Peripherally inserted central catheters: guidance with use of US versus venography in 2,650 patients

PURPOSE: To compare technical success and initial complication rates of peripherally inserted central catheters (PICCs) by interventional radiologists using ultrasound (US) or venographic guidance. MATERIALS AND METHODS: With use of a computer database, the authors retrospectively reviewed 2,650 procedures, 2,126 of which were performed with US and 524 with venography. Technical success was defined as placement of a PICC. Initial complications were defined as development of a hematoma, inadvertent arterial puncture, or neuropathy. Statistical significance was assessed using the chi2 test. RESULTS: During 33 consecutive months, 2,650 procedures were performed with a complication rate of 1.0%. The technical success rate was 95.8% for venography and 99.6% for US. The initial complication rate was 0.75% for venography and 1.08% for US. There was no statistically significant difference in immediate complication rates (P = .50); however, there is statistical significance in regard to technical success (P < .001). CONCLUSION: There is no difference in initial complication rates when comparing US and venographic guidance for PICC insertion. The decision to use either method can be based on clinical grounds and/or physician preference, although US has a higher initial success rate.     

Renal cell carcinoma with unusual metastasis to the gallbladder

Gallbladder involvement in patients with renal cell carcinoma (RCC) is extremely rare. We present a report of a 61-year-old man with a synchronous RCC metastasis to the gallbladder presenting as an intraluminal polypoid mass simulating primary gallbladder carcinoma. Enhanced abdominal computed tomography demonstrated a well-enhanced polypoid lesion in the gallbladder. Intraoperative rapid pathological examination of the gallbladder tumor showed clear cell-type cancerous cells. Microscopically, tumor cells of both the resected kidney and gallbladder had round uniform nuclei, clear cytoplasm, and well-defined cytoplasmic borders, forming alveolar patterns. Immunohistochemically, the tumor cells were negative for cytokeratin 7 (CK7) and carcinoembryonic antigen (CEA), which is usually positive in primary clear cell carcinoma of the gallbladder. Therefore, the final diagnosis was RCC with a synchronous gallbladder metastasis.     

The mouse as a model for the study of penile erection: moving towards a smaller animal

We evaluated erectile haemodynamics in mice and characterized the corpus cavernosum morphologically. Four-month-old male BALB/c mice and Sprague-Dawley rats were used. The following stimulation parameters were tested to achieve maximal erectile responses: voltage, 1-6 V; frequency, 6-24 Hz; pulse width, 1 msec; duration, 1 min (n = 7 per group). In a separate group of mice and rats (n = 10 per group), we measured systemic arterial pressure by use of either a 24-gauge angiocatheter or smaller calibre PE-10 tubing. Cavernous tissues from mice, rats or patients with psychogenic erectile dysfunction were stained for factor VIII, alpha-actin and Masson trichrome. Electrical stimulation of the cavernous nerve in mice produced voltage-dependent erectile responses of up to 5 V, with the highest response at a frequency of 12 Hz. The maximal intracavernous pressure recorded at this stimulation parameter was comparable with that in rats. A PE-10 catheter was more reliable for measuring systemic arterial pressure in mice than was a 24-gauge angiocatheter, and the values recorded were similar between mice and rats. The content of endothelial cells, smooth muscle cells and collagen was similar between mice and rats. However, the cavernous tissue of both animals contained lesser amounts of smooth muscle cells and greater amounts of collagen than that of humans (p < 0.01). These results suggest that the mouse is a useful and technically feasible model for the study of penile erection and has functional and structural properties similar to those of rats.     

Surgical Indication for Non-curative Endoscopic Resection in Early Gastric Cancer

Background Endoscopic resection (ER) is an effective treatment for early gastric cancer (EGC) without lymph node metastasis. However, after ER additional surgery may be needed to manage the risks presented by residual cancer or lymph node metastasis. Methods ER was performed on 344 gastric adenocarcinomas between November 2001 and April 2006 at the Korean National Cancer Center under the strict pre-procedural indication. The authors performed operations in 43 patients due to: residual mucosal cancer, a mucosal cancer larger than 3 cm, or a submucosal cancer regardless of size or margin involvement. ER and surgical specimens were reviewed and analyzed for residual cancer and lymph node metastasis. Results Based on examinations of ER specimens, cancer was confined to the mucosal layer in 15 patients (34.9%) and invaded the submucosal layer in 28 patients (65.1%). Surgical specimens showed residual cancer in 17 patients (39.5%) and lymph node metastasis in four (9.3%). Neither residual cancer nor lymph node metastasis was found in patients with less than 500 μm submucosal invasion without margin involvement in ER specimens. In three of four patients with lymph node metastasis, the depth of submucosal invasion was 500 μm or more; the remaining patient had a 4-cm-sized differentiated mucosal cancer. Conclusions When a pathologic evaluation of an ER specimen reveals more than 500 μm of submucosal invasion or a mucosal cancer of larger than 3 cm, surgery should be considered due to the risk of lymph node metastasis.     

Bedside prediction of the central venous catheter insertion depth

BACKGROUND: The carina level has been shown to be near the pericardial reflectionand can easily be identified as a landmark on a routine chestradiography. The purpose of this study was to reveal a simplemethod to predict the adequate central venous catheter (CVC)depth, hereby facilitating safe positioning of the CVC tip. METHODS: Central venous catheterization was performed via the right internaljugular vein (IJV) or the right subclavian vein (SCV). The CVCwas placed at a depth derived by adding the length between theneedle insertion point and the clavicular notch and the verticallength between the clavicular notch and the carina on the chestradiograph. The distance between the CVC tip and the carinawas measured on the postoperative chest radiograph. RESULTS: The tip position of 100 CVCs placed via the right IJV was 0.1(1.1) cm [mean (SD)] below the carina (95% CI: 0.3 cm belowcarina–0.2 cm above carina) and the tip positionof 153 CVCs placed via the right SCV was 0.0 (1.2) cm [mean(SD)] below the carina (95% CI: 0.2 cm below carina–0.2 cmabove carina). There were nine outliers (two in IJV group andseven in SCV group). CONCLUSIONS: When CVCs are inserted to a depth derived by adding the lengthbetween the needle insertion point and the clavicular notchand the vertical length between the clavicular notch and thecarina, the CVC tip can be reliably placed near the carina level.     

Activation of the renin-angiotensin system within podocytes in diabetes

The autocrine and paracrine activation of the renin-angiotensin system (RAS) within cells of the kidney plays a role in the overall pathophysiology of the renal disease due to diabetes. In this study, we focus on components of the RAS in the podocyte as these cells are important in the pathogenesis of glomerulosclerosis and proteinuria. Immortalized mouse podocytes were exposed to media containing normal glucose (NG) or high glucose (HG) for in vitro studies. In vivo studies utilized kidney tissue obtained from rats treated for 3 months with streptozotocin to induce diabetes. Angiotensinogen (AGT) and the angiotensin II (AII) type 1 receptor mRNA and protein were significantly increased in the podocytes cultured under the high glucose conditions. Both angiotensins I and II levels were significantly higher in cell lysates and the conditioned media of cells grown in high glucose. There were no differences in renin activity, angiotensin-converting enzyme level, or AII type 2 receptor level. Glomerular AGT and AII type 1 receptor assessed by means of immunohistochemistry were increased in diabetic rats compared with the control rats. Other measured components of the RAS within the glomeruli were not different. We suggest that increased AGT, an attendant increase in AII and increased AII type 1 receptor in podocytes experiencing diabetic conditions play an important role in the pathogenesis of diabetic nephropathy.     

Ovine forestomach matrix biomaterial is a broad spectrum inhibitor of matrix metalloproteinases and neutrophil elastase

Proteases play a critical role in the ordered remodelling of extracellular matrix (ECM) components during wound healing and tissue regeneration. However, the usually ordered proteolysis is compromised in chronic wounds due to over‐expression and high concentrations of matrix metalloproteinase's (MMPs) and neutrophil elastase (NE). Ovine forestomach matrix (OFM) is a decellularised extracellular matrix‐based biomaterial developed for tissue regeneration applications, including the treatment of chronic wounds, and is a heterogeneous mixture of ECM proteins and proteoglycans that retains the native structural and functional characteristics of tissue ECM. Given the diverse molecular species present in OFM, we hypothesised that OFM may contain components or fragments that inhibit MMP and NE activity. An extract of OFM was shown to be a potent inhibitor of a range of tissue MMPs (IC₅₀s = 23 ± 5 to 115 ± 14 µg/ml) and NE (IC₅₀ = 157 ± 37 µg/ml), and was more potent than extracts prepared from a known protease modulating wound dressing. The broad spectrum activity of OFM against different classes of MMPs (i.e. collagenases, gelatinases and stromelysins) may provide a clinical advantage by more effectively addressing the protease imbalance seen in chronic wounds.     

Long-term surgical outcomes of cervical myelopathy with athetoid cerebral palsy

Purpose

To understand the long-term surgical outcomes and prognostic factors for the operative treatment of cervical myelopathy (CM) in patients with athetoid cerebral palsy (ACP).

Methods

We retrospectively reviewed 24 patients with ACP who underwent surgery for CM at our hospital between March 2002 and June 2008. All patients had more than 5 years follow-up. Anterior fusion (11 patients), posterior fusion (1 patient), or combined anterior and posterior (AP) fusion (7 patients) and C1-2 fusion (5 patients) surgeries were performed. Surgical outcomes (average follow-up 102 months), as assessed using modified JOA (mJOA) scores, the Neck Disability Index (NDI), and a visual analog scale (VAS) were compared between the preoperative and postoperative states.

Results

Preoperatvie cervical kyphosis decreased mJOA scores significantly. Long-term follow-up clinical outcomes demonstrated that 10 patients showed favorable (excellent and good) outcomes and 11 patients had non-favorable (fair and worse) outcomes. According to the mJOA scores, patients showed postoperative improvement (7.10–10.45). NDI decreased from 68.46 to 31.66. A second operation was done in seven cases due to instrument failure, progressive kyphotic deformities and adjacent segment degeneration. A preoperative botulinum toxin injection significantly decreased (p < 0.05) the incidence of a second operation.

Conclusions

Patients with ACP have high incidence of instrument failure. Strong surgical fixation, bone fusion and perioperative immobilizations using botulinum toxin injection should be carefully planned preoperatively.     

A Body Shape Index Has a Good Correlation with Postoperative Complications in Gastric Cancer Surgery

Background

The relationship between obesity and surgical complications has been controversial. A Body Shape Index (ABSI) is a newly developed anthropometric index based on waist circumference adjusted for height and weight. The aim of this study was to investigate the relationship between ABSI and surgical complications.

Methods

From November 2001 to September 2012, 4,813 patients underwent curative resection for gastric cancer. ABSI was defined as waist circumference divided by (BMI^2/3height^1/2). Data of clinicopathologic characteristics and morbidity were collected by retrospective review. Binary logistic regression was used for multivariable analyses to determine whether ABSI was independently associated with postoperative complications.

Results

The incidence of overall surgical complications was 13.4 %, and the most common complication was ileus (2.8 %). In the multivariable analysis, ABSI was an independent factor for overall complications [odds ratio (OR), 1.22; 95 % confidence interval (CI) 1.01–1.48; P = 0.041). However, BMI showed no statistical significance (OR, 1.03; 95 % CI 1.00–1.06; P = 0.063). In the subgroup analyses, ABSI was significantly associated with overall complications regarding open gastrectomy (OR, 1.26; 95 % CI 1.01–1.57; P = 0.039). Regarding laparoscopy-assisted gastrectomy, ABSI had no significant effect on overall complications (P = 0.844).

Conclusions

ABSI shows good correlation with surgical complications in patients with gastric cancer. Further studies are needed for the various clinical roles of ABSI, and the results could be helpful to determine the effect of abdominal obesity on gastric cancer surgery and the clinical usefulness of ABSI.     

Proposal of the Surgical Options for Primary Tumor Control During Sentinel Node Navigation Surgery Based on the Discrepancy Between Preoperative and Postoperative Early Gastric Cancer Diagnoses

Background

There is no consensus on the optimal method of primary tumor control, determined by preoperative clinical factors, during sentinel node (SN) navigation surgery for early gastric cancer (EGC). In this study, we investigated the accuracy of clinical diagnosis based on preoperative examination in patients with EGC and proposed surgical options for primary tumor control during SN navigation surgery.

Methods

We analyzed 815 patients with clinical stage IA gastric cancer who underwent gastrectomy at the National Cancer Center in Korea between March 2001 and February 2011. The clinical stage was determined by endoscopy, endoscopic ultrasonography, and abdominal computed tomography.

Results

The preoperative assessment of tumor depth and tumor size was accurate in 57.5 and 70.8 % of patients, respectively. Tumor depth and size were underestimated in 8 and 25.3 % of patients. The overall accuracy of histologic diagnosis by endoscopic biopsy was 87.2 %. Of those tumors diagnosed preoperatively as differentiated, 20.5 % revealed mixed histology of undifferentiated type.

Conclusions

The recommendation for SN biopsy may be limited to tumors sized 3 cm or smaller to avoid positive lateral margins and to minimize the risk of skip metastases. Endoscopic resection may safely be applied to small mucosal cancers, but other surgical options should be employed for undifferentiated large mucosal lesions, given their tendency for diffuse invasion. Full-thickness resection is preferable for submucosal cancers, to secure clear vertical margins.