Analysis of safety and efficacy of laparoscopic radical gastrectomy combined with or without indocyanine green tracer fluorescence technique in treatment of gastric cancer: a retrospective cohort study

BackgroundAn adequate resection margin and lymph node dissection are important factors for successful radical gastrectomy. The presence of near-infrared camera imaging with indocyanine green (ICG) gives new insight into radical gastrectomy. Laparoscopic radical gastrectomy with ICG is still in its initial stages and requires more evidence-based medical research. The aim of the present study was to evaluate the safety and availability of lymph node dissection and precise gastrectomy for gastric cancer patients undergoing radical resection under laparoscope with ICG, in the hope of providing evidence of application of ICG tracer fluorescence technique in radical gastrectomy.MethodsA retrospective cohort study was performed with 56 patients who underwent laparoscopic radical gastrectomy. The patients were categorized into the ICG (n=18) or the non-ICG (n=38) group based on whether preoperative endoscopic mucosal ICG injection was performed. Their clinical characteristics (age, tumor size, location, TNM stage and so on) were compared as baseline data. Perioperative outcomes (blood loss, time of first intestinal exhaust, early or long-term complications and so on) were used to assess safety. The status of lymph node dissection and tumor localization were analyzed to testify efficacy. SPSS version 26.0 was used for the statistical analysis.ResultsThere was no difference in clinical data at baseline. From the safety point of view, there was no difference in perioperative outcomes (operative time, blood loss, time of first intestinal exhaust and so on) between the two groups (all P>0.05). From the efficacy point of view, the number of lymph nodes <5 mm (21.84±1.86 vs. 16.24±2.10, P<0.001), the total number of lymph nodes (34.61±5.87 vs. 29.92±5.27, P=0.004), the number of lymph nodes dissected in perigastric regions (groups 1–7, 22.89±3.64 vs. 20.29±3.00, P=0.007), and the number of lymph nodes in extraperigastric regions (groups 8–12, 11.72±3.06 vs. 9.61±3.18, P=0.022) were greater in ICG group compared with non-ICG group. In ICG group, the average vertical distances between the top and bottom of the fluorescent edge and neoplastic edge were 2.65±0.58 and 2.67±0.65 cm, respectively. Fluorescent edge pathology was negative.ConclusionsICG fluorescence could be conducive to lymph node dissection and precise gastrectomy in laparoscopic radical gastrectomy.     

Uncovering the high prevalence of bacterial burden in surgical site wounds with point‐of‐care fluorescence imaging

Detection of bacterial burden within or near surgical wounds is critical to reducing the occurrence of surgical site infection (SSI). A distinct lack of reliable methods to identify postoperative bioburden has forced reliance on clinical signs and symptoms of infection (CSS). As a result, infection management has been reactive, rather than proactive. Fluorescence imaging of bacterial burden (FL) is positioned to potentially flip that paradigm. This post hoc analysis evaluated 58 imaged and biopsied surgical site wounds from the multi‐centre fluorescence imaging assessment and guidance clinical trial. Diagnostic accuracy measures of CSS and FL were evaluated. A reader study investigated the impact of advanced image interpretation experience on imaging sensitivity. Forty‐four of fifty‐eight surgical site wounds (75.8%) had bacterial loads >10⁴ CFU/g (median = 3.11 × 10⁵ CFU/g); however, only 3 of 44 were CSS positive (sensitivity of 6.8%). FL improved sensitivity of bacterial detection by 5.7‐fold compared with CSS alone (P = .0005). Sensitivity improved by 11.3‐fold over CSS among clinicians highly experienced with FL interpretation (P < .0001). Surgical sites that reach the stage of referral to a wound specialist frequently harbour asymptomatic high bacterial loads that delay healing and increase infection risk. Advanced imaging of pathological bacterial burden improves surgical site monitoring and may reduce the rate of SSIs.     

Collateral Flow in Magnetic Resonance Angiography: Prognostic Value for Vertebrobasilar Stenosis With Stroke Recurrence

Background and PurposeIntracranial vertebrobasilar atherosclerotic stenosis (IVBAS) is a major cause of posterior circulation stroke. Some patients suffer from stroke recurrence despite receiving medical treatment. This study aimed to determine the prognostic value of a new score for the posterior communicating artery and the P1 segment of the posterior cerebral artery (PCoA-P1) for predicting stroke recurrence in IVBAS.MethodsWe retrospectively enrolled patients with severe IVBAS (70%–99%). According to the number of stroke recurrences, patients were divided into no-recurrence, single-recurrence, and multiple-recurrences groups. We developed a new 5-point grading scale, with the PCoA-P1 score ranging from 0 to 4 based on magnetic resonance angiography, in which primary collaterals were dichotomized into good (2–4 points) and poor (0 or 1 point). Stroke recurrences after the index stroke were recorded. Patients who did not experience stroke recurrence were compared with those who experienced single or multiple stroke recurrences.ResultsFrom January 2012 to December 2019, 176 patients were enrolled, of which 116 (65.9%) had no stroke recurrence, 35 (19.9%) had a single stroke recurrence, and 25 (14.2%) had multiple stroke recurrences. Patients with single stroke recurrence (odds ratio [OR]=4.134, 95% confidence interval [CI]=1.822–9.380, p=0.001) and multiple stroke recurrences (OR=6.894, 95% CI=2.489–19.092, p<0.001) were more likely to have poor primary collaterals than those with no stroke recurrence.ConclusionsThe new PCoA-P1 score appears to provide improve predictions of stroke recurrence in patients with IVBAS.     

Usefulness of 3-Dimensional Reconstruction Images of Coronary Computed Tomography Angiogram in Percutaneous Coronary Intervention After Bentall Operation

Anastomotic complications of the coronary arteries were observed in approximately 5% of patients undergoing Bentall-type surgery. Given the high surgical risk of reoperation, percutaneous coronary intervention could be a treatment for anastomotic complications but is challenging because of the complicated anatomy after Bentall-type surgery. Here, a 70-year-old man underwent a Bentall operation during which the left main coronary artery was accidentally injured. Therefore, coronary artery bypass using a saphenous vein graft was performed. The saphenous vein graft was anastomosed from the right side of the aortic graft to the left main coronary artery. Three years later, the patient presented with an anterior non–ST-segment elevation myocardial infarction. Because his unusual anatomy, the saphenous vein graft could not be cannulated with diagnostic catheters, even after perusing the surgical record of the Bentall surgery. Subsequently, coronary computed tomography angiography was performed. Three-dimensional reconstructed images visualized the positional relationship between the saphenous vein graft and anatomical landmarks, such as the implanted surgical valve prosthesis. The angiogram angle was adjusted using these landmarks and projection angles estimated by the images. Then, the ASAHI Hyperion Judkins right 4 catheter could be easily inserted, and percutaneous coronary intervention was successfully performed. Three-dimensional reconstruction images were useful for performing percutaneous coronary intervention by aiding in the identification of the anatomic location of the saphenous vein graft and the positional relationship between the saphenous vein graft and anatomic landmarks. In patients with unusual anatomy, as in this case, coronary computed tomography angiography should be strongly considered.     

Circadian rhythm and clinical characteristics in patients with acute myocardial infarction combined with obstructive sleep apnea

ObjectiveThe present study aimed to investigate the circadian rhythm and clinical characteristics of patients with acute myocardial infarction (AMI) combined with obstructive sleep apnea (OSA).MethodsPatients with AMI combined with OSA were enrolled in the study, and those that met the inclusion criteria were divided into three time‐period groups based on their sleep–wake rhythm (22:00–5:59, 6:00–13:59, and 14:00–21:59). The differences between the three groups of patients in sleep‐monitoring data, blood routine, biochemical indicators, and coronary angiographic parameters were analyzed and compared. Count data were expressed as the number of cases, and the chi‐square test was used for statistical analysis. Continuous data were expressed as mean ± standard deviation, and analysis of variance was used for the statistical analysis of these data. The characteristics of circadian rhythm and clinical features in patients with AMI combined with OSA were analyzed.ResultsOf the 148 patients, 90/148 (61%) had chest pain and 58/148 (39%) had non‐chest pain symptoms. In the 22:00–05:59 group, there were 70/148 (47%) patients with AMI (of these, 46/70 [66%] had chest pain). In the 06:00–13:59 period group, there were 44/148 (30%) patients with AMI (of these, 26/44 [60%] had chest pain). In the 14:00–21:59 period group, there were 34/148 (23%) patients with AMI (of these, 17/34 [50%] had chest pain). There was no statistically significant difference in the apnea–hypopnea index (AHI) and SYNTAX score between patients in the 22:00–5:59 and 6:00–13:59 groups. However, the AHI and SYNTAX scores in the 22:00–5:59 and 6:00–13:59 groups were higher than those in the 14:00–21:59 group, and the differences were statistically significant. In patients in the 22:00–5:59 group, the levels of serum D‐dimer (DD), hemoglobin (Hb), and oxygen desaturation index (ODI3) were higher, the sleep mean oxygen saturation (MeanSaO₂) was lower and the percentage of nighttime spent with oxygen saturation of less than 90% (Tsat₉₀) and less than 85% (Tsat₈₅) was longer.ConclusionThe peak period for the onset of AMI in patients with OSA was 22:00–5:59, and the incidence of chest pain was high. During this period, patients had higher DD and Hb, higher ODI3, lower MeanSaO₂ during sleep, and longer TSat₉₀ and TSat₈₅. During the 22:00–5:59 and 6:00–13:59 periods, patients had higher AHI and a higher SYNTAX score.     

Near-infrared fluorescence guided laparoscopic cholecystectomy in the spectrum of complicated gallstone disease

ICG fluorescence (ICGF) guidance during laparoscopic cholecystectomy (LC) is gaining wider acceptance. While the accruing data largely addresses ICGF guidance during LC in patients with uncomplicated gallstone disease (UGS) and acute cholecystitis, there is a paucity of data related for complicated gall stone disease (CGS) such as choledocholithiasis, bilio-enteric fistula, remnant gall bladder, etc. The purpose of this study was to evaluate the role of ICGF during LC in the spectrum of CGS with state of the art 4 chip camera system. Retrospective review from a prospectively maintained database of all patients who underwent ICGF guided LC during the period June 1^st, 2019 till December 30^th, 2021 formed part of the study. Clinical profile and findings on ICGF during LC for CGS were studied. The data was studied to evaluate the potential roles of ICGF during LC for CGS. Of 68 patients, there were 29 males and 39 females. Among them were 32 and 36 in the uncomplicated and complicated gallstone disease groups, respectively. ICGF showed CBD visualization in 67(98.5%) and cystic duct in 62(91%). ICGF guidance helped in management of CGS, prior to, during and after completion of LC. It had novel application in patients undergoing CBD exploration. In our small series of patients with CGS, ICGF guidance enabled a LC and laparoscopic subtotal cholecystectomy in 94% and 6% of patients respectively. The study highlights potential roles and advantages with ICGF guided laparoscopic management for CBD stones, bilioenteric fistula, completion cholecystectomy and cystic duct stones. Large scale multicenter prospective studies are required to clarify the role of ICGF in the wide spectrum of CGS.     

CT angiograms for lower GI bleeding: the experience of a large UK teaching hospital

IntroductionThe clinical presentation of lower gastrointestinal bleeding (LGIB) is variable in severity, cause and potential investigations. The British Society of Gastroenterology recently published LGIB guidelines, recommending CT angiography (CT-A) for haemodynamically unstable patients, defined by shock index (SI) greater than 1. The aim of this study was to assess the use and role of CT-A in diagnosing LGIB, by assessing the pickup rate of active LGIB defined by contrast extravasation or ‘blush’ and to determine any association between positive CT-A with various patient and clinical characteristics.MethodsA retrospective analysis was carried out of 4 years of LGIB admissions. Demographics, inpatient observations and use of blood products were acquired. Vital signs nearest the time of CT-A plus abnormal vital signs preceding imaging were used to calculate SI, Age SI, National Early Warning Score 2 (NEWS2) and Standardised Early Warning Score (SEWS). A consultant gastrointestinal radiologist further reviewed all consultant-reported scans.ResultsIn total, 930 patients were admitted with LGIB. Median age was 71 years and 51% were male; 179 (19.2%) patients received red blood cell transfusion and 93 patients (10%) underwent CT-A, who were older and were likely to be hypotensive and receive red cell transfusions. Following exclusions, 92 CT-As were included in the analysis. Nine (9.8%) were positive. Univariate analysis showed no association between positive CT-A and any scoring system. A multivariate analysis, including age and gender, showed association between both NEWS2 and SEWS scores with positive CT-A.ConclusionIn our analysis of the typical LGIB population, CT-A has shown relatively low pick up rate of active bleeding. CT-A clearly has a role in the investigation of LGIB, but selection remains challenging.     

Positron emission tomographic studies of the association between atherogenesis and aortitis among psoriatic patients

IntroductionThere is increased interest in the use of positron emission tomography (PET) in psoriatic patients. We used PET induced with tracer fluorine-18 (¹⁸F) fluorodeoxyglucose (FDG) to study the association between the process of early-atherogenesis (eAg) and aortitis by quantifying enhanced aortic vascular inflammation along with calculation of total coronary plaque load (TCPL) and non-calcified atherosclerotic plaque load (NcAPL). In order to study the utility of aortitis in capturing eAg, we also assessed luminal stenosis atherosclerosis (LSA) and high-risk coronary plaques (HrCP).Material and methodsThe study was conducted at our hospital between 1 April 2014 and 31 December 2017, and the analysis was done in July 2018. We recruited 180 consecutive psoriatic patients and subjected them to ¹⁸F-FDG PET. However, in order to characterise eAg, 160 out of 180 patients were also subjected to coronary angiographic computed tomographic studies (CACTS).ResultsAmong 180 psoriatic patients (76 women, 42%) (mean [SD] age, 51.1 [13.2] years), greater prevalence values of LSA (odd ratio [OR], 3.71; 95% confidence interval [CI], 1.84–7.89; p = 0.001) and HrCP (OR, 3.11; 95% CI: 1.54–6.51; p = 0.003) along with enhanced TCPL (standardised β = 0.44; p < 0.001) were observed in patients with enhanced aortitis. However, the association between aortitis and HrCP was controlled by low-attenuation plaque (LAP), while the same between aortitis and TCPL was controlled by NcAPL (β = 0.45; p < 0.001).ConclusionsAssociation between aortitis and broad coronary angiographic indices was achieved and hence predicted the possibility of a surrogate role of aortitis in eAg.     

非小细胞肺癌ALK基因重排检测

目的 通过荧光原位杂交(FISH)方法检测非小细胞肺癌(NSCLC)患者间变性淋巴瘤激酶(ALK)基因重排.方法 根据ALK断裂重排方式及特点,设计并制备红/绿双色荧光探针.以人外周血培养细胞为检测对象评价ALK融合基因检测探针的敏感性和特异性,以NSCLC石蜡组织样本为对象进行ALK基因重排检测以评价探针的性能.结果 本研究制备的荧光探针在EB病毒(EBV)转化的人淋巴细胞检测中的特异性和敏感性均可达到100％.在对2例NSCLC患者石蜡包埋组织样本检测中,检测阴性、阳性各1例,检测结果与免疫组织化学检测结果一致.结论 本研究中制备的双色荧光探针可用于NSCLC ALK基因重排的检测.