Additional modifications to the Blumgart pancreaticojejunostomy: Results of a propensity score-matched analysis versus Cattel-Warren pancreaticojejunostomy

BackgroundPostoperative pancreatic fistula continues to occur frequently after pancreatoduodenectomy.MethodsWe have described a modification of the Blumgart pancreaticojejunostomy. The modification of the Blumgart pancreaticojejunostomy was compared to the Cattel-Warren pancreaticojejunostomy in cohorts of patients matched by propensity scores based on factors predictive of clinically relevant postoperative pancreatic fistula, which was the primary endpoint of this study. Based on a noninferiority study design, 95 open pancreatoduodenectomies per group were needed. Feasibility of the modification of the Blumgart pancreaticojejunostomy in robotic pancreatoduodenectomy was also shown. All pancreaticojejunostomies were performed by a single surgeon.ResultsBetween October 2011 and May 2019, there were 415 pancreatoduodenectomies with either a Cattel-Warren pancreaticojejunostomy (n = 225) or a modification of the Blumgart pancreaticojejunostomy (n = 190). There was 1 grade C postoperative pancreatic fistula in 190 consecutive modification of the Blumgart pancreaticojejunostomies (0.5%). Logistic regression analysis showed that the rate of clinically relevant postoperative pancreatic fistula was not affected by consecutive case number. After exclusion of robotic pancreatoduodenectomies (the Cattel-Warren pancreaticojejunostomy: 82; modification of the Blumgart pancreaticojejunostomy: 66), 267 open pancreatoduodenectomies were left, among which the matching process identified 109 pairs. The modification of the Blumgart pancreaticojejunostomy was shown to be noninferior to the Cattel-Warren pancreaticojejunostomy with respect to clinically relevant postoperative pancreatic fistula (11.9% vs 22.9%; odds ratio: 0.46 [0.21–0.93]; P = .03), grade B postoperative pancreatic fistula (11.9% vs 18.3%; P = .18), and grade C postoperative pancreatic fistula (0 vs 4.6%; P = .05) as well as to all secondary study endpoints. The modification of the Blumgart pancreaticojejunostomy was feasible in 66 robotic pancreatoduodenectomies. In this subgroup with 1 conversion to open surgery (1.5%), a clinically relevant postoperative pancreatic fistula occurred after 9 procedures (13.6%) with no case of grade C postoperative pancreatic fistula and a 90-day mortality of 3%.ConclusionThe modification of the Blumgart pancreaticojejunostomy described herein is noninferior to the Cattel-Warren pancreaticojejunostomy in open pancreatoduodenectomy. This technique is also feasible in robotic pancreatoduodenectomy.     

Early outcome prediction on 18F-fluorocholine PET/CT in metastatic castration-resistant prostate cancer patients treated with abiraterone

Objective: We investigated the role of 18F-fluorocholine positron emission tomography/computed tomography (FCH-PET/CT) in the early evaluation of abiraterone and outcome prediction in patients with metastatic castration-resistant prostate cancer (CRPC).Patient and methods: Forty-three patients with metastatic CRPC progressing after docetaxel received abiraterone 1,000 mg daily with prednisone 5 mg twice daily. Patients were evaluated monthly for serological PSA response and safety. FCH-PET/CT was done at baseline and after 3 to 6 weeks. Univariate and multivariate Cox regression models addressed potential predictors of progression-free survival (PFS) and overall survival (OS).Results: Declines in PSA level of ≥50% were seen in 21 of 43 (49%) patients. Forty-two patients were evaluable for FCH-PET/CT response. FCH-PET/CT bone flare was observed in 4 of 42 (10%) evaluable patients. In univariate analysis, PSA decline and FCH-PET/CT response predicted PFS, while PSA decline and FCH-PET/CT (progression vs non progression) predicted OS. In multivariate analysis, only FCH-PET/CT (progression vs nonprogression) remained significant for PFS and OS (p = 0.022 and p = 0.027, respectively).Conclusion: Early FCH-PET/CT can predict clinical outcome in CRPC beyond PSA response. These data support further studies on FCH-PET/CT for abiraterone monitoring and outcome prediction in patients with CRPC.     

Fish tolerance to organophosphate-induced oxidative stress is dependent on the glutathione metabolism and enhanced by N-acetylcysteine

Dichlorvos (2,2-dichlorovinyl dimethyl phosphate, DDVP) is an organophosphorus (OP) insecticide and acaricide extensively used to treat external parasitic infections of farmed fish. In previous studies we have demonstrated the importance of the glutathione (GSH) metabolism in the resistance of the European eel (Anguilla anguilla L.) to thiocarbamate herbicides. The present work studied the effects of the antioxidant and glutathione pro-drug N-acetyl-L-cysteine (NAC) on the survival of a natural population of A. anguilla exposed to a lethal concentration of dichlorvos, focusing on the glutathione metabolism and the enzyme activities of acetylcholinesterase (AChE) and caspase-3 as biomarkers of neurotoxicity and induction of apoptosis, respectively. Fish pre-treated with NAC (1 mmol kg(-1), i.p.) and exposed to 1.5 mg l(-1) (the 96-h LC85) of dichlorvos for 96 h in a static-renewal system achieved an increase of the GSH content, GSH/GSSG ratio, hepatic glutathione reductase (GR), glutathione S-transferase (GST), glutamate:cysteine ligase (GCL), and gamma-glutamyl transferase (gammaGT) activities, which ameliorated the glutathione loss and oxidation, and enzyme inactivation, caused by the OP pesticide. Although NAC-treated fish presented a higher survival and were two-fold less likely to die within the study period of 96 h, Cox proportional hazard models showed that hepatic GSH/GSSG ratio was the best explanatory variable related to survival. Hence, tolerance to a lethal concentration of dichlorvos can be explained by the individual capacity to maintain and improve the hepatic glutathione redox status. Impairment of the GSH/GSSG ratio can lead to excessive oxidative stress and inhibition of caspase-3-like activity, inducing cell death by necrosis, and, ultimately, resulting in the death of the organism. We therefore propose a reconsideration of the individual effective dose or individual tolerance concept postulated by Gaddum 50 years ago for the log-normal dose-response relationship. In addition, as NAC increased the tolerance to dichlorvos, it could be a potential antidote for OP poisoning, complementary to current treatments.     

Safety,tolerability, and efficacy evaluation of the SlimME device for circumference reduction

Objective

To assess the short‐ and long‐term thermal impact of subclinical and clinical regimens of a single, non‐invasive uniform ultrasound treatment session on subcutaneous adipose tissue (SAT).

Study Design

Prospective, open‐label, single‐arm, split‐side study.

Methods

Patients (n = 17) were subjected to uniform ultrasound treatment, delivered in a single session with the SlimME device. The device was set to one of four treatment regimens, which differed in their durations and energy fluences during the raise and maintenance phases. Up to six abdominal regions were treated, with six patients receiving a different treatment on each side of the abdomen. Safety was assessed by measuring skin surface temperature, evaluating expected skin responses immediately and 30 min after treatment and via patient ratings of pain and discomfort. Efficacy of raising and then maintaining SAT temperatures at 48°C, was determined by routinely measuring SAT temperatures during the treatment session and by histological analysis of samples collected 7 (n = 13) or 90 (n = 4) days after treatment.

Results

Trace to mild erythema was observed in up to 48% of the treated zones, which, in most cases, resolved within 30 minutes. No significant rise in mean skin surface temperature (≤26.5°C) was recorded following any of the four tested regimens. Overall, patients reported tolerability to treatment, with the highest mean pain score registered for the moderate and high intensity regimens (4.4 ± 1.5 and 4.9 ± 1.4, respectively). Mean SAT temperatures did not exceed 48.4 ± 2.5°C and were effectively maintained throughout the maintenance phase of the treatment session. Low‐energy fluence led to localized fat coagulative necrotic lesions, surrounded by subacute rim of inflammation, while high‐energy fluence induced fat coagulative necrosis alongside granulomatous panniculitis, which resolved within 90 days.

Conclusion

The tested uniform ultrasound regimens elicited SAT temperature elevations, with a subsequent energy‐dependent increase in degree of fat necrosis. At the same time, the unique design spared the surrounding tissue from thermal damage and was associated with minimal discomfort. Taken together, the SlimME device constitutes an effective tool for destruction of stubborn hypodermal fat deposits. Lasers Surg. Med. 50:745–754, 2018. © 2018 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.     

Influence of videogames and musical instruments on performances at a simulator for robotic surgery

Objective: To assess if exposure to videogames, musical instrument playing, or both influence the psychomotor skills level, assessed by a virtual reality simulator for robot-assisted surgery (RAS).

Materials and methods: A cohort of 57 medical students were recruited: playing musical instruments (group 1), videogames (group 2), both (group 3), and no activity (group 4); all students executed four exercises on a virtual simulator for RAS.

Results: Subjects from group 3 achieved the best performances on overall score: 527.09?±?130.54 vs. 493.73?±?108.88 (group 2), 472.72?±?85.31 (group 1), and 403.13?±?99.83 (group 4). Statistically significant differences (p?p?=?.009) and for time of completion (p?=?.044). As regards experience with the piano, subjects from group 3 outperformed those from group 1 on overall score (496.98?±?122.71 vs. 470.25?±?92.31), but without statistically significant difference (p?=?.646).

Conclusions: The present study suggests that the level of psychomotor skills in subjects exposed to both musical instrument playing and videogames is higher than that in those practicing either one alone. The effect of videogames appears negligible in individuals playing the piano.