Hepaticoduodenostomy versus hepaticojejunostomy after resection of choledochal cyst: A systematic review and meta-analysis

Background

Excision has been established as a standard management practice for choledochal cysts in the last few decades. The two most commonly performed methods of reconstruction after excision are hepaticoduodenostomy (HD) and Roux-en-Y hepaticojejunostomy (HJ), of which the HJ is favored by most surgeons. Evidence concerning the optimal method of reconstruction is, however, sparse.

Materials and Methods

Studies comparing outcomes from HD and HJ after choledochal cyst excision were identified by searching Medline, Ovid, Search Medica, Elsevier Clinicalkey, Google Scholar and Cochrane library. Suitable studies were chosen and data extracted for meta-analysis. Outcomes evaluated included operative time, hospital stay and incidence of postoperative bile leak, cholangitis, reflux/gastritis, anastomotic stricture, bleeding, intestinal obstruction and re-operative rate. Pooled odds ratios (OR) were calculated for dichotomous variables; pooled mean differences (MD) were measured for continuous variables.

Results

Six retrospective studies were included in this meta-analysis, comprising a total of 679 patients, 412 of whom (60.7%) underwent HD, and the remainder, 267(39.3%) underwent HJ. Although, HD group had slightly shorter hospital stay (MD: 0.30; 95% CI: −0.22–0.39; P < 0.00001) it showed a higher incidence of postoperative reflux/gastritis (OR: 0.08; 95% CI: − 0.02–0.39; P = 0.002). However, the other outcomes such as bile leak, cholangitis, anastomotic stricture, bleeding, operative time, reoperation rate and adhesive intestinal obstruction did not differ between HD and HJ groups.

Conclusions

HD shows higher postoperative reflux/gastritis than HJ but a shorter hospital stay. There are few good-quality studies that compare the outcomes from HD and HJ, meaning that caution should be exercised in the generalization of the results of this meta-analysis, which suggests HD to be comparable with HJ in terms of other complications, operative benefits and outcomes.     

High condom use but low HIV testing uptake reported by men who purchase sex in Bali,Indonesia

Men who purchase sex (MWPS) have long been considered as one of the population groups at risk of HIV transmission. However, while HIV-related interventions have been targeted towards this group, few studies have directly recruited MWPS to measure the impact of such interventions. This study aimed to fill the gap for Indonesia by identifying the level and predictors of condom use and HIV testing among MWPS, to inform prevention strategies. A cross-sectional study was conducted by surveying 200 MWPS in Bali, Indonesia in 2015. A structured questionnaire was administered to collect the data. Self-reported condom use on the occasion of last paid sex was very high (88.5%), while a history of HIV testing was low (8.1%). None of the variables identified in this study were associated with condom use at last paid sex. Men were more likely to report a history of HIV testing if they: perceived themselves to be at high risk of HIV, had a higher level of HIV-related knowledge, reported a history of genital ulcers or urethral discharge in the past 12 months, or were aware that confidential HIV testing was available. Implications and limitations of this study are discussed.     

Even a single third trimester antenatal fetal screening for congenital anomalies can be life saving

We report two cases of malrotation with extremely different outcomes based on the availability and non-availability of antenatal scanning. The first one had a single third trimester ultrasound which detected malrotation and helped in saving baby’s life whereas the second baby without antenatal screening succumbed to midgut volvulus and its sequelae because of delayed presentation. In developing countries where most of the pregnancies may go unsupervised, a single third trimester scan for fetal anomalies by an experienced sonologist, in areas where routine antenatal screening program has failed or not feasible can help save the baby’s life at least in surgically correctable anomalies. This may be an important strategy to reduce the infant mortality rate in the country.     

Sequential Co-infection of Heligmosomoides polygyrus and Mycobacterium tuberculosis Determine Lung Macrophage Polarization and Histopathological Changes

BackgroundTuberculosis is a chronic infection caused by Mycobacterium tuberculosis (M.tb), which needs proper macrophage activation for control. It has been debated whether the co-infection with helminth will affect the immune response to mycobacterial infection.ObjectiveTo determine the effect of sequential co-infection of Heligmosomoides polygyrus (H.pg) nematodes and M.tb on T cell responses, macrophages polarization and lung histopathological changes.MethodThis study used 49 mice divided into 7 treatment groups, with different sequence of infection of M.tb via inhalation and H.pg via oral ingestion for 8 and 16 weeks. T cells response in the lung, intestine, and peripheral blood were determined by flow cytometry. Cytokines (IL-4, IFN-γ, TGB-β1, and IL-10) were measured in peripheral blood using ELISA. Lung macrophage polarization were determined by the expression of iNOS (M1) or Arginase 1 (M2). Mycobacterial count were done in lung tissue. Lung histopathology were measured using Dorman’s semiquantitative score assessing peribronchiolitis, perivasculitis, alveolitis, and granuloma formation.ResultM.tb infection induced Th1 response and M1 macrophage polarization, while H.pg infection induced Th2 and M2 polarization. In sequential co-infection, the final polarization of macrophage was dictated by the sequence of co-infection. However, all groups with M.tb infection showed the same degree of mycobacterial count in lung tissues and lung tissue histopathological changes.ConclusionSequential co-infection of H.pg and M.tb induces different T cell response which leads to different macrophage polarization in lung tissue. Helminth infection induced M2 lung macrophage polarization, but did not cause different mycobacterial count nor lung histopathological changes.     

Angiotensin-converting enzyme gene polymorphism in North-west Indian children with posterior urethral valves

PurposeTo investigate the association of angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism and other risk factors with renal scarring in patients with posterior urethral valves (PUV).Materials and methodsForty consecutive patients from North-west India were treated for PUV in 1997–2004. The patients were divided into group 1 (no renal scarring, n = 12) and group 2 (renal scars present, n = 28) based on dimercato-succinic acid scans. ACE I/D polymorphism was determined by polymerase chain reaction in PUV patients and unrelated healthy controls (n = 100).ResultsMean age at presentation was 23.7 ± 37.2 months and mean follow up was 4.8 ± 1.5 years. Preoperative mean serum creatinine levels for group 1 (non-scarred) and group 2 (scarred) were 1.1 ± 1.6 mg/dl and 1.7 ± 1.6 mg/dl, respectively. One year after treatment, the serum creatinine levels had decreased to 0.6 ± 0.1 mg/dl and 0.8 ± 0.3 mg/dl in group 1 and group 2, respectively. ACE genotype distribution in children with PUV was no different from that of controls. The occurrence of D allele was significantly (p = 0.04) higher in patients of group 2. Multivariate logistic regression analysis showed that D allele had a significant impact on renal scar formation, introducing a 4.6-fold risk (odds ratio 4.6, 95% confidence interval 1.03–20.38, p = 0.04). A highly significant correlation between the occurrence of renal scarring and presence of breakthrough urinary tract infection (odds ratio = 7.5, 95% confidence interval 1.60–35.07, p = 0.006) and serum creatinine at follow up (odds ratio = 0.6, 95% confidence interval 0.47–0.81, p = 0.03) was observed. The mean values for glomerular filtration rate (GFR) after 1 year of treatment (p = 0.006) and at follow up (p = 0.027) were significantly different between the patients with II genotype and ID/DD genotype. Hypertension was observed in 13 patients and proteinuria in nine patients with no significant difference between the patients having II/I D/DD genotypes.ConclusionThe presence of D allele is associated with progression of renal scarring and reduced GFR in PUV patients.     

Cancer stem cell theory in gastrointestinal malignancies: recent progress and upcoming challenges

A growing body of evidence supports the notion that malignant tumors are heterogeneous and contain diverse subpopulations of cells with unique characteristics including the ability to initiate a tumor and metastasize. This phenomenon might be explained by the so-called cancer stem cell (CSC) theory. Recent technological developments have allowed a deeper understanding and characterization of CSCs. Even though the application of this theory to hematopoietic malignancies and solid tumors holds promise for new ways to treat cancer, it also brings some skepticism. Efficacious therapeutic approaches targeting the CSC population should be explored to overcome therapeutic failure and improve patient outcomes. This review will focus on the intrinsic and extrinsic regulation of CSCs, as well as the development of therapeutic approaches against CSCs, predominantly focusing on gastrointestinal malignancies.