Covered self-expanding stent treatment for anastomotic leakage: outcomes in esophagogastric and esophagojejunal anastomoses

Background

Anastomotic leakage of esophagogastric and esophagojejunal anastomoses is a severe complication after esophagectomy and gastrectomy associated with a high mortality. We conducted this non-randomized observational study to evaluate the outcomes and clinical effectiveness of covered self-expanding stents (CSESs) in treating esophageal anastomotic leakage.

Methods

From 2002 to 2013, consecutive patients with anastomotic leakage after esophagogastrostomy or esophagojejunostomy who received CSESs were analyzed concerning leakage characteristics, leakage sealing rate, success and failure rates of CSES treatment, stent-related complications, and mortality.

Results

In 35 patients, anastomotic leakage originating from 5 cervical esophagogastrostomies, 6 thoracic esophagogastrostomies, 12 mediastinal esophagojejunostomies and 12 abdominal esophagojejunostomies were treated with 48 CSESs (16 fully CSES, 32 partially CSES). Of 35 patients, 24 received one stent, 9 received two consecutive stents, and 2 received three consecutive stents. Stent-related complications occurred in 71 % of patients (25/35). The most frequent complications were leakage persistence (44 %) and stent dislocation (19 %). Sealing of the anastomotic leakage was achieved in 24 (69 %) patients after a median (range) stenting time of 19 (1–78) days. Sealing rates differed significantly with 20 % (cervical esophagogastrostomies), 50 % (thoracic esophagogastrostomies), 92 % (mediastinal esophagojejunostomies) and 67 % (abdominal esophagojejunostomies) of patients (p = 0.023). Moreover, clinical success rates differed among these groups (60 vs. 67 vs. 92 vs. 58 %; p = 0.247). Clinical failure of stent treatment was more likely to be recognized in early postoperative leakage (median postoperative day 3 vs. 8; p = 0.098) compared with successful treatment, whereas no difference for clinical success rates was found comparing leakage ≤10 versus >10 mm (68 vs. 64 %; p = 0.479).

Conclusion

CSESs are an effective treatment for anastomotic leakage in patients with esophagogastrostomies and esophagojejunostomies. Best results can be achieved in patients with anastomotic leakages following mediastinal esophagojejunostomy, and in leakages occurring after the very early postoperative phase.     

Gastric band is safe and effective at three years in a national study subgroup of non-morbidly obese patients

Aim

To analyze the 3-year outcomes of lower body mass index (BMI) (<35 kg/m²) adjustable gastric band (AGB) recipients across multiple sites in the French health insurance system.

Methods

From prospectively collected data on a cohort of 517 morbidly obese Swedish Adjustable Gastric Band^® (SAGB) patients (Clinical Trials Web database, #{"type":"clinical-trial","attrs":{"text":"NCT01183975","term_id":"NCT01183975"}}NCT01183975), a retrospective analysis of a subgroup of 29 low-BMI patients was conducted. Patients had a severe obesity-related comorbidity, had undergone a prior bariatric procedure requiring reintervention, or had a maximum adult BMI≥40. Safety (mortality, adverse events) and effectiveness (BMI change, excess weight loss [EWL, %], total body weight loss [%TBWL], quality of life [QoL], and comorbidities) were evaluated.

Results

Multiple surgical teams/sites enrolled patients and performed SAGB procedures between September 2, 2007 and April 30, 2008. Of 29 low-BMI patients (mean age, 41.3 ± 10.3 years), 89.7% were female, and obesity duration was 13.6 ± 7.3 years. Mean BMI was 31.5 ± 3.7; there were 37 comorbidities in 15/29 patients. At 3-year follow-up, BMI was 29.4 ± 4.9 (mean change, -2.3 ± 6.2; P = 0.069); total cohort EWL, 7.3 ± 74.8%; TBWL, 6.2 ± 18.8%; BMI≥30 to <35 EWL, 38.8 ± 48.0%; there were 7 comorbidities in 15/29 patients (P < 0.031). There were 20 adverse events in 13 patients (44.8%); SAGBs were retained in 25/29 (86.2%) at 3 years.

Conclusions

In a retrospective analysis of a subgroup of BMI<35 kg/m² patients, some following a prior bariatric procedure, SAGB was found to be safe and effective at 3-year follow-up.For over 2 decades, since publication of the 1991 National Institutes of Health (NIH) consensus conference statement (1), the cutoff point for bariatric surgery has been morbid obesity (body mass index [BMI, kg/m²]≥40 or ≥35 with comorbidities), also termed class II obesity by the World Health Organization (WHO) (2). This demarcation of access to bariatric surgery was based on the observation that an increase in BMI leads to an increase in the risk of comorbid illness and premature death. Yet, investigation of the potential value of bariatric surgery as a safe and effective treatment for overweight (BMI 25-<30) and obesity class I (BMI≥30 to <35) patients has been under way since the publication of the NIH statement. In 1992 and 1995 landmark studies (3,4), Pories et al theorized that bariatric procedures might be safe and as beneficial for weight loss and comorbidity reduction in non-morbidly obese patients as it was in the morbidly obese (5). In the last half decade, the least-invasive, lowest-risk restrictive procedures, such as adjustable gastric banding (AGB), have been employed at the forefront of exploring surgical options for the <35 BMI patient.Adjustable gastric banding comprised the vast majority, nearly 90%, of bariatric procedures performed in morbidly obese patients in France prior to 2008 (6). To assess the national social insurance-supported use of the Swedish Adjustable Gastric Band (SAGB) (7,8), the French government commissioned a prospective, 31-center, “real-life,” observation of SAGB safety and effectiveness in class II and III obese patients (9). Between September 2, 2007 and April 30, 2008, patients were selected and underwent SAGB implantation in rural and urban centers. SAGB weight-loss effectiveness analyzed on an intent-to-treat basis at the 3-year study endpoint was comparable to that of AGB findings summarized by global meta-analyses (10,11). Under the “real-world” SAGB study protocol requirement of consecutive recruitment and surgeon discretion, 29 patients (5.6% of 517) were included in the national SAGB study who presented with a BMI<35 and a severe obesity-related comorbidity, and/or had experienced a prior complicated bariatric surgery requiring revision, and/or had previously sustained a maximum adult BMI≥40. With the aim of contributing safety and effectiveness findings to the growing <35 BMI evidence base, we report 3-year outcomes for the French low-BMI SAGB study group.     

Contractile reserve assessed by dobutamine test identifies super-responders to cardiac resynchronization therapy

Introduction

In this study, we sought to determine whether myocardial contractile reserve (CR) assessed by dobutamine stress echocardiography (DSE) can identify patients who experience nearly complete normalization of left ventricular (LV) function after the implantation of a cardiac resynchronization therapy (CRT) pacemaker.

Material and methods

The study group consisted of 55 consecutive patients with non-ischemic dilated cardiomyopathy, LV ejection fraction (LVEF) < 35%, and prolonged QRS complex duration, who were scheduled for CRT pacemaker implantation. The DSE (20 µg/kg/min) was performed in all patients. The CR assessment was based on a change in the wall motion score index (ΔWMSI) and ΔLVEF during DSE. Super-response was defined as an increase in LVEF to > 50% and reduction in left ventricular end-systolic dimension to < 40 mm 12 months following the CRT implantation.

Results

A total of 7 patients (12.7%) were identified as super-responders to CRT. When compared to non-super-responders, these patients had significantly higher values of the dobutamine-induced change in ΔWMSI (1.031 ±0.120 vs. 0.49 ±0.371, p < 0.01), and ΔEF (17.9 ±2.2 vs. 8.8 ±6.2, p < 0.01). Receiver operating characteristic analysis showed that dobutamine-induced changes in ΔWMSI ≥ 0.7 and ≥ 14% for ΔEF are the best discriminators for a super-response. Patients with ΔWMSI ≥ 0.7 and ΔEF ≥ 14% are significantly less often hospitalized (p < 0.01) for worsening of heart failure during 28.5 ±3.0 months of the follow-up.

Conclusions

Contractile reserve assessed by DSE can identify patients with dilated cardiomyopathy who are likely to experience near normalization of LV function following CRT.     

Chemoselective synthesis of multifunctional ferrocene-containing derivatives by the cross Rauhut–Currier reaction

A simple protocol has been developed for the chemoselective synthesis of ferrocene-containing Rauhut–Currier adducts from 1-ferrocenyl-2-nitroethene and vinyl ketones using 20 mol% of triphenylphosphine. Multifunctional ferrocene derivatives were obtained in moderate to high yields (51–92%) by the coupling between the α-position of vinyl ketones and the β-position of the nitroalkene. The study of the Rauhut–Currier reaction under the described conditions showed that the strong electron-donating group at the β-position of nitroalkenes plays a significant role in the reaction outcome due to prevention of polymerization and stabilization of the zwitterionic intermediate. Additionally, a preparative synthesis of 4-ferrocenyl-3-methylene-5-nitropentan-2-one was carried out and its synthetic transformations showed easy conversion to other useful building blocks.

A simple method has been developed for the chemoselective synthesis of ferrocene-containing Rauhut–Currier adducts from 1-ferrocenyl-2-nitroethene and vinyl ketones catalyzed by triphenylphosphine.     

Fertility-sparing surgery for patients with malignant ovarian germ cell tumors: 10 years of clinical experience from a tertiary referral center

Archives of Gynecology and Obstetrics - To describe a case series of patients with malignant ovarian germ cell tumors (MOGCT) treated exclusively with fertility-sparing surgery (FSS) with or...     

Revealing the Pb Whisker Growth Mechanism from Al-Alloy Surface and Morphological Dependency on Material Stress and Growth Environment

Spontaneous metallic Pb whisker formation from Pb and Bi containing Al-alloy’s surfaces is a newly discovered phenomenon. The whiskers display unique formations, growth and morphology, which give the opportunity to be applied for specialized sensor and electronics applications. Within this work, the impact of environmental conditions (gas composition and moisture) is investigated and correlated with the modification of whisker evolution and growth dynamics. Furthermore, the residual stress state of the aluminum matrix using deep cryogenic treatment is modified and used to further increase whisker nucleation and growth by up to three- and seven-fold, respectively, supported by quantitative results. The results of this paper indicate the possibility to manipulate the whisker not only in terms of their kinetics but also their morphology (optimal conditions are 20% O₂ and 35% humidity). Such features allow the tailoring of the whisker structure and surface to volume ratio, which can be optimized for different applications. Finally, this research provides new insight into the growth dynamics of the whiskers through in situ and ex situ measurements, providing further evidence of the complex nucleation and growth mechanisms that dictate the spontaneous growth of Pb whiskers from Al-alloy 6026 surfaces with growth velocities up to 1.15 µm/s.     

The Dose-Response Effects of Consuming High Fructose Corn Syrup-Sweetened Beverages on Hepatic Lipid Content and Insulin Sensitivity in Young Adults

Increased hepatic lipid content and decreased insulin sensitivity have critical roles in the development of cardiometabolic diseases. Therefore, our objective was to investigate the dose-response effects of consuming high fructose corn syrup (HFCS)-sweetened beverages for two weeks on hepatic lipid content and insulin sensitivity in young (18–40 years) adults (BMI 18–35 kg/m²). In a parallel, double-blinded study, participants consumed three beverages/day providing 0% (aspartame: n = 23), 10% (n = 18), 17.5% (n = 16), or 25% (n = 28) daily energy requirements from HFCS. Magnetic resonance imaging for hepatic lipid content and oral glucose tolerance tests (OGTT) were conducted during 3.5-day inpatient visits at baseline and again at the end of a 15-day intervention. During the 12 intervening outpatient days participants consumed their usual diets with their assigned beverages. Significant linear dose-response effects were observed for increases of hepatic lipid content (p = 0.015) and glucose and insulin AUCs during OGTT (both p = 0.0004), and for decreases in the Matsuda (p = 0.0087) and Predicted M (p = 0.0027) indices of insulin sensitivity. These dose-response effects strengthen the mechanistic evidence implicating consumption of HFCS-sweetened beverages as a contributor to the metabolic dysregulation that increases risk for nonalcoholic fatty liver disease and type 2 diabetes.