Should Silicone Lacrimal Stenting be a Better Choice for Primary Endoscopic Powered Dacryocystorhinostomy?

Objective: To compare endoscopic dacryocystorhinostomy (EnDCR) with and without silicone lacrimal stenting through subjective (patients’) and objective (surgeons’) outcome parameters. Methodology: Following defined selection criteria, EnDCR was performed on patients with primary chronic dacryocystitis with post-saccal stenosis. Every alternate patient had silicone lacrimal stenting (group A: no stenting; group B: with stenting); stents were removed at three months. At six months (minimum follow-up period), patients’ responses on symptom relief (through a five-point score) and naso-endoscopic evaluation (visualization of rhinostome; presence of granulations and synechiae; lacrimal drainage patency by estimating methylene blue flow pattern) were compared between the groups. Results: Each group had 20 patients. There was no statistically significant difference in group-wise follow-up periods. Five-point score at six months revealed 85% and 95% of patients in groups A and B, respectively, experienced “success”; among them, 60% and 75% were “symptom-free”. The majority (75%) in group B experienced no discomfort from stenting. Naso-endoscopy revealed 80% patients in group A and 65% in group B had well-delineated rhinostome, albeit with granulations in 25% and 50%, respectively. Spontaneous dye flow was achieved, respectively, in 75% and 90%. The difference in none of the subjective and endoscopic parameters achieved statistical significance. None had synechia; fibrosis was seen in the four patients with no dye flow even with pressure/massaging. Conclusion: There was no statistically significant difference in EnDCR with and without silicone lacrimal stenting in the overall outcome of symptomatic improvement and endoscopic assessment of the surgical site.     

Management of refractory ascites

The development of refractory ascites in approximately 10% of patients with decompensated cirrhosis heralds the progression to a more advanced stage of cirrhosis. Its pathogenesis is related to significant hemodynamic changes, initiated by portal hypertension, but ultimately leading to renal hypoperfusion and avid sodium retention. Inflammation can also contribute to the pathogenesis of refractory ascites by causing portal microthrombi, perpetuating the portal hypertension. Many complications accompany the development of refractory ascites, but renal dysfunction is most common. Management starts with continuation of sodium restriction, which needs frequent reviews for adherence; and regular large volume paracentesis of 5 L or more with albumin infusions to prevent the development of paracentesisinduced circulatory dysfunction. Albumin infusions independent of paracentesis may have a role in the management of these patients. The insertion of a covered, smaller diameter, transjugular intrahepatic porto-systemic stent shunt (TIPS) in the appropriate patients with reasonable liver reserve can bring about improvement in quality of life and improved survival after ascites clearance. Devices such as an automated low-flow ascites pump may be available in the future for ascites treatment. Patients with refractory ascites should be referred for liver transplant, as their prognosis is poor. In patients with refractory ascites and concomitant chronic kidney disease of more than stage 3b, assessment should be referred for dual liver-kidney transplants. In patients with very advanced cirrhosis not suitable for any definitive treatment for ascites control, palliative care should be involved to improve the quality of life of these patients.     

Meta-Analysis of Short vs. Prolonged Dual Antiplatelet Therapy after Drug-Eluting Stent Implantation and Role of Continuation with either Aspirin or a P2Y12 Inhibitor Thereafter

Aim: The optimal duration of dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation is an ongoing debate and novel data has emerged. The aim of this meta-analysis was to assess outcomes of short vs. control DAPT duration. In addition, the role of single antiplatelet therapy (SAPT) after DAPT with either aspirin or P2Y₁₂ inhibitor monotherapy was analyzed. Methods: The authors searched MEDLINE and Cochrane databases and proceedings of international meetings for randomized controlled trials (RCT) comparing ≤ 3 months with ≥ 6 months DAPT after DES implantation. The primary and co-primary outcomes of interest were definite or probable stent thrombosis (ST) and bleeding. In addition, we performed an analysis on studies who continued with either aspirin or P2Y₁₂ monotherapy after DAPT. Results: 9 RCTs comprising 41,864 patients were included and we analyzed a short DAPT duration of median 1.5 months vs. 12.1 months in the control group. The risk for ST was similar with short vs. control DAPT duration (0.5 vs. 0.5%; hazard ratio 1.17[95% CI 0.89-1.54];p=0.26). Bleeding was significantly reduced with short vs. control DAPT duration (1.9 vs. 3.0%; 0.65[0.54-0.77];p＜0.0001). ST was not different between short vs. control DAPT duration in the analysis of the 4 RCTs who continued with aspirin after DAPT and the 5 P2Y₁₂ RCTs, respectively, and no heterogeneity was detected (p=0.861). Bleeding was also reduced with short vs. control DAPT in both the aspirin (1.2 vs. 1.7%; 0.71[0.51-0.99];p=0.04) and P2Y₁₂ inhibitor studies (2.1 vs. 3.4%; 0.62[0.47-0.80];p=0.0003) and no heterogeneity was detected (p=0.515). Conclusions: Our meta-analysis shows that short DAPT ≤ 3 months followed by SAPT reduces bleeding and is not associated with an increase in ST. The results were consistent within the aspirin and P2Y₁₂ SAPT studies.     

血管内支架置入术前后动态血压变化

目的探讨血管内支架置入术前后患者动态血压的变化。方法使用动态血压监测仪测量7例血管内支架置入术患者支架置入前后的动态血压值，计算变异系数。结果血管内支架置入后，7例患者的血压均有不同程度下降；颈内动脉支架置入患者血压变异系数减小；椎一基底动脉支架置入患者血压变异系数增大。结论支架置入术对血管狭窄患者血压的影响尚不明确。     

Stent implantation and balloon angioplasty for treatment of branch pulmonary artery stenosis in children

OBJECTIVES: Comparison of the results of branch pulmonary artery stenosis treated with balloon angioplasty (BA) or stent implantation (SI) in children. BACKGROUND: Branch pulmonary artery stenosis may be treated with BA or SI. METHODS: We compared the results of 147 interventions of branch pulmonary artery stenosis in 87 children (median age 3.6 years). Patients were treated during 1989-2000 with BA and during 2001-2004 with SI. Primary endpoints were acute complications and reintervention during follow up. Secondary variables were age, vessel diameter increase, acute success rate, balloon/vessel diameter ratio, pulmonary artery hypoplasia indices, and procedure related factors. RESULTS: The acute vessel diameter increase with BA (4.31 +/- 1.98 vs. 7.15 +/- 2.31 mm) and SI (3.71 +/- 1.58 vs. 6.97 +/- 2.68 mm) was significant within both groups (P < 0.001), but not between both groups. The reintervention rate was comparable between both groups, but median time to reintervention was shorter after SI in infants compared to BA. The balloon/vessel diameter ratio was on average higher in BA than the stent/vessel diameter ratio in SI (3.49 +/- 2.16 vs. 2.42 +/- 0.56; P < 0.05) and was a significant risk factor (P < 0.01) for the higher complication rate after BA (BA: 14.1% vs. SI: 4.8%). No mortality occurred in both groups. CONCLUSION: BA and SI are safe interventional catheter therapies of branch pulmonary artery stenosis. The immediate results of BA and SI are comparable. The higher complication rate after BA, especially in infants, was associated with a higher balloon/vessel diameter ratio. SI seems to be a safe permanent alternative with foreign material, but requires more reinterventions in infants due to its therapeutic strategy.     

Acute Mediastinitis – Outcomes and Prognostic Factors of Surgical Therapy (A Single-Center Experience)

Purpose: The aims of this work were the retrospective analysis of a cohort of patients with acute mediastinitis treated at the authors’ worksite over a 15-year period and the identification of factors that significantly affect the outcomes of the therapy.Methods: During the period 2006–2020, 80 patients with acute mediastinitis were treated. Within the cohort, the following were observed: the causes and the type of acute mediastinitis, length of anamnesis, comorbidities, diagnostic methods, time from the diagnosis to surgery, types and number of surgical procedures, results of microbiological tests, complications, and outcomes of the treatment.Results: The most common type of acute mediastinitis was descending mediastinitis (48.75%). A total of 116 surgical procedures were performed. Ten patients in the cohort died (12.5%). Patients older than 60 years were at a 6.8 times higher risk of death. Patients with more than two comorbidities were at a 14.3 times higher risk of death. The presence of yeasts in the culture material increased the risk of death by 4.4 times.Conclusion: Early diagnosis, removal of the cause of mediastinitis, sufficient mediastinal debridement, and multiple drainage thereof with the possibility of continual postoperative lavage are essential for the successful treatment of acute mediastinitis.     

国产胆道金属支架的临床应用

目的探讨国产胆道金属支架应用的安全性及临床疗效。方法对72例(70例恶性,2例良性)阻塞性黄疸患者施行经皮经肝穿刺植入国产胆道金属支架75枚。结果66例胆道金属支架植入成功,技术成功率92．7％(66／72)。支架植入术后1个月内黄疸缓解率97．0％(64／66),30d内死亡2例,早期并发症发生率7．6％(5／66)。44例随访2～24个月,随访率66．7％。42例恶性患者,随访5～16个月(平均11．6个月),9例存活,33例死亡;生存时间2～23个月,中位生存期5．3个月。随访3、6、12个月的支架通畅率分别为92．8％、89．9％、79．4％。支架再阻塞率14．3％(6／42),中位阻塞期3个月。2例良性梗阻患者,1例支架术后24个月仍通畅,1例术后3个月因其他原因死亡。结论国产胆道金属支架使用方便,临床应用安全可靠,具有临床推广价值。     

Clinical characteristics,aetiology and mortality/recurrence risk factors of acute cholangitis in patients with and without biliary stent

ObjectivesAcute cholangitis is one of the most frequent complications in patients carrying biliary stents. The aim of our study is to analyze the demographic and clinical characteristics, as well as the microbiological profile and evolution of patients with acute bacteremic cholangitis, comparing them based upon they were or not biliary stent carriers.MethodsWe performed a retrospective analysis of all consecutive patients over 18 years-old with a stent placement in our center between 2008 and 2017 were included. We compared them with our prospective cohort of patients with a diagnosis of acute bacteremic cholangitis. Primary outcome was 30-day mortality. Secondary outcome was clinical cure at day 7, 14-day mortality and 90-day recurrence.ResultsTwo hundred and seventy-three patients were analyzed, including 156 in the stent-related (SR) and 117 in the stent not-related (SNR) group, respectively. Stent-related colangitis patients were younger, with more comorbidities and with a greater severity of infection. Escherichia coli and Klebsiella pneumonia were the most frequent isolation. Enterococcus spp. was the third most frequent isolation in SR group but were uncommon in SNR patients; where E. coli was the most prevalent microorganism. Septic shock (HR 3.44, 95% [CI 1.18–8.77]), inadequate empirical treatment (HR 2.65, 95% CI [1.38–.7.98]) and advanced neoplasia (HR 2.41, 95% CI [1.55–6.44]) were independent 30-day mortality risk factors. The 90-day recurrence rate significantly higher in those patients with stent-related cholangitis (29% vs. 13%, p = 0.016) and stent replacement was associated with lower recurrence rate (HR 0.38, 95% CI [0.11–0.77]).ConclusionsClinical and microbiological profile, as well as outcome of patients with SR and SNR cholangitis were different. In SR group, recurrence rate was high and stent replacement was associated with a lower risk.     

A study of unprotected left main intervention in the ACS population 2013–2018

ObjectivesOur objectives were to evaluate the outcomes of left main percutaneous coronary interventions in Acute Coronary Syndrome population.MethodsThis is a retrospective& observational study. Primary endpoint is a composite of death, stent thrombosis/MI, target lesion revascularization. Secondary endpoints include individual components of the primary events analyzed separately.ResultsSeventy five patients, two year follow – up data was analyzed. The primary event analysis showed that the Elective Double Stent (EDS) group had a higher primary events (36% vs. 14%, p value – 0.008, Hazard ratio – 0.76 (0.51–1.15, 95% CI), in secondary event analysis stent thrombosis (ST)/Myocardial infarction (MI) rates were higher in EDS group (8% Vs 36%, p Value – 0.008, Hazard ratio- 0.63(0.35–1.14, 95%CI), there is no difference in target lesion revascularization (TLR)and death rates in both the groups.ConclusionsThe provisional strategy is better than EDS in treatment of left main bifurcation lesions in the ACS population.