Objectives
Disconnected pancreatic duct syndrome (DPDS) is the most common cause of pancreatic fluid collection (PFC) recurrence. While long‐term transmural drainage with plastic stents is the ...preferred endoscopic approach, there is a paucity of literature on patients undergoing initial drainage with lumen‐apposing metal stents (LAMS). We describe our experience managing patients with DPDS.
Methods
A retrospective review of a prospectively maintained database (November 2015–September 2020) was performed looking at clinical outcomes and overall survival for patients undergoing endoscopic management of PFCs using LAMS. The primary outcome was to assess recurrence‐free survival in PFC patients with DPDS managed with or without double pigtail stents (DPS) replacement after LAMS removal.
Results
Of 96 patients with PFCs, 48 with DPDS were included in the study. The median follow‐up was 20.1 months. LAMS replacement with DPS was successful in 21/48 (43.8%) patients. Recurrence was seen in 1/21 (5%) patients with DPS replacement and 10/27 (37%) without DPS replacement. In multivariable models, a longer duration of LAMS placement was negatively associated with successful DPS replacement (odds ratio 1.33, 95% confidence interval CI 1.11, 1.59, P = 0.0019) and successful LAMS replacement with DPS in patients with DPDS improved recurrence‐free survival (hazard ratio 0.09, 95% CI 0.01, 0.83, P = 0.033).
Conclusion
In patients with PFCs and DPDS, early replacement of LAMS with DPS improves the likelihood of successful long‐term transmural drainage and decreases recurrences.
Objectives
Advancements in the endoscopic management of walled‐off necrosis using lumen apposing metal stents have improved outcomes over its surgical and percutaneous alternatives. The ideal ...procedural technique and timing of direct endoscopic necrosectomy (DEN) have yet to be clarified.
Methods
From November 2015 to June 2021, a retrospective comparative cohort analysis was performed comparing clinical outcomes for patients undergoing immediate DEN (iDEN) versus delayed DEN (dDEN). Subgroups were identified based on the quantification of necrosis. Wilcoxon two‐sample tests were used to compare continuous variables and Fisher's exact test was used to compare categorical variables.
Results
A total of 80 patients underwent DEN for management of walled‐off necrosis (iDEN = 43, dDEN = 37). Technical success was achieved in all patients. Clinical success was seen in 39 (91%) patients in the iDEN group and 34 (92%) in the dDEN group. Amongst iDEN patients, the mean number of necrosectomies was 2.5 (standard deviation SD 1.4) in comparison to 1.5 (SD 1.0) for dDEN (p‐value = 0.0011). The median index hospital length of stay was longer with iDEN than dDEN (7.5 days vs. 3.0 days respectively, p‐value = 0.010). Subgroup analysis was performed based on the percentage of necrosis (<25% vs. >25% necrosis). iDEN was associated with more necrosectomies than dDEN regardless of the percentage of necrosis (p = 0.017 and 0.0067, respectively).
Conclusion
Patients undergoing dDEN had a shorter index hospital stay and fewer necrosectomies than iDEN. The large diameter of lumen apposing metal stents permits adequate drainage allowing a less aggressive approach thereby improving clinical outcomes and avoiding unnecessary interventions.
Retinal detachment (RD) is one of the most frequently diagnosed ophthalmologic conditions requiring prompt surgical intervention. Combination of proper surgical technique and new diagnostic markers, ...both clinical and molecular, can help improve the diagnosis and prognosis of RD treatment.
12 patients with rhegmatogenous RD (rRD) were included into the study after obtaining patient consent and Regional Ethical Approval (average age: 58.1 ± 17.4 years). OCT was performed before and after 23G vitrectomy for RD. Pure subretinal fluid (SRF) was collected during surgery and analyzed by protein array profiling on a panel of 105 inflammatory cytokines (Human XL Cytokine Array), while the effect of SRF upon human macrophages-driven phagocytosis of apoptotic retinal pigment epithelial (RPE) cells ex vivo was quantified by flow cytometry. Immunohistochemistry (IHC) of retinectomized tissue due to PVR caused by RD was performed to determine presence of markers for microglial cells (CD34), macrophages and activated microglia (CD68), regulator of the immune response to infection (NFkB), progenitor and stem cell marker (Sox2), pluripotency marker (Oct4) and intermediate filament markers (GFAP and Nestin).
OCT of fresh RD patients contained pre-operatively hyper reflective points (HRPs) at the detached neuroretina border and proximal to the RPE layer-their size and number decreased following successful reattachment surgery. IHC of the retinectomized tissue from detached retina due to severe PVR showed presence of cell conglomerates at the detached neuroretina border which were positive for CD68, NFkB, Sox2 and GFAP, less positive for CD47 and Nestin and negative for Oct4 and CD34. The SRF contained at least 37 cytokines with higher, and 4 cytokine with lower concentration compared to that in vitreous from non-RD pathology; when used as conditional medium to human macrophages ex vivo, the SRF doubled their capacity for engulfing dying RPEs.
Fresh RD can be hallmarked by presence of HRPs at the detached neuroretina border on OCT; the HRPs decrease in size and number after successful reattachment surgery, and likely resemble the macrophage conglomerates seen by IHC. The neuroretina in RD contains progenitor/stem-like cells and signs of inflammatory reaction, while the SRF contains inflammatory cytokines and other factors which increase the ability of professional phagocytes to engulf dying RPE, or for that matter, other dying cells in the retina.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract
Background and study aims Innovations in endoscopic management of pancreatic fluid collections (PFCs) using lumen apposing metal stents (LAMS) have rendered it a preferred approach for ...drainage of PFCs. These advances have not come without concern for adverse events (AEs). We present our experience with LAMS for drainage of PFCs and analyze factors that contribute to LAMS-related AEs.
Patients and methods From November 2015 to October 2021, a retrospective analysis was performed of patients undergoing endoscopic management of PFCs using LAMS. All AEs were classified as either early (<48 hours) or late (>48 hours). Univariate and multivariate analysis were performed using logistic regression to assess the relationship between independent variables and AEs.
Results A total of 119 patients with symptomatic PFCs underwent
endoscopic drainage with LAMS. There were 16 AEs (12.4%). These included systemic inflammatory
response syndrome (SIRS) (n=2), stent occlusion (n=5), bleeding (n=7), and stent migration
(n=2). Univariate analysis of risk of AEs showed that no variables approached statistical
significance. Of the seven patients who developed bleeding, five had pseudoaneurysms following
LAMS placement and underwent angioembolization by an interventional radiologist. The average
time to bleeding was 9.3 days (standard deviation 7.3) with all bleeding events occurring
within 3 weeks. In a multivariate model, pseudocysts and presence of paracolic gutter
extension were associated with an increased risk of bleeding.
Conclusions Endoscopists should be aware of the risk factors for LAMS-related bleeding and tailor their drainage strategy, including utilization of plastic stents for drainage of pseudocysts and adherence to a strict imaging interval and follow-up protocol.
Objectives
Malignant gastric outlet obstruction (GOO) has traditionally been managed with enteral stenting and surgical gastrojejunostomy. Our study aimed to compare outcomes between endoscopic ...ultrasound‐guided gastrojejunostomy (EUS‐GJ) using a lumen‐apposing metal stent and robotic GJ (R‐GJ) for unresectable malignant GOO.
Methods
Patients undergoing EUS‐GJ or R‐GJ for unresectable malignant GOO were retrospectively analyzed. The primary outcome was clinical success defined by the ability to tolerate oral intake at the time of discharge. Secondary outcomes included technical success, procedure duration, adverse events, and post‐procedure length of stay (LOS).
Results
A total of 44 patients met the inclusion criteria. Of the 44, 29 underwent EUS‐GJ and 15 underwent R‐GJ. Age, gender, malignant etiology, and presence of ascites were similar between the two groups. Patients treated with EUS‐GJ had a higher mean Charlson comorbidity index (10.3 vs. 7.0; p ≤ 0.0001) and a lower preoperative body mass index (22.3 vs. 27.2; p = 0.007). Technical and clinical success was achieved in 100% of patients in both groups (p > 0.99). EUS‐GJ was associated with shorter procedure duration (57.5 vs. 146.3 min; p < 0.0001), hospital LOS (4.3 vs. 8.2 days, p = 0.0009), and time to oral intake (1.0 vs. 5.8 days; p < 0.0001) when compared to R‐GJ. Adverse events occurred in 5 of the R‐GJ patients and none of the EUS‐GJ patients (p = 0.003).
Conclusions
EUS‐GJ has similar efficacy and superior clinical outcomes compared to R‐GJ in the management of malignant GOO. Prospective studies with longer follow‐up duration are needed to validate these findings.
Elderly patients require tunneled central vein dialysis catheters more often than younger patients. Little is known about the risk of catheter-related bloodstream infection in this population.
This ...study identified 464 patients on hemodialysis with tunneled central vein dialysis catheters between 2005 and 2007 and excluded patients who accrued <21 catheter-days during this period. Outpatient and inpatient catheter-related bloodstream infection data were collected. A Cox proportional hazards regression analysis adjusting for sex, ancestry, comorbidites, dialysis vintage, dialysis unit, immunosuppression, initial catheter site, and first antimicrobial catheter lock solution was performed for risk of catheter-related bloodstream infection between nonelderly (18-74 years) and elderly (≥ 75 years) patients.
In total, 374 nonelderly and 90 elderly patients with mean (SD) ages of 54.8 (12.3) and 81.3 (4.9) years and dialysis vintages of 1.8 (3.3) and 1.5 (2.9) years (P=0.47), respectively, were identified. Mean at-risk catheter-days were 272 (243) in nonelderly and 318 (240) in elderly patients. Between age groups, there were no significant differences in initial catheter site, type of catheter lock solution, or microbiology results. A total of 208 catheter-related bloodstream infection events occurred (190 events in nonelderly and 18 events in elderly patients), with a catheter-related bloodstream infection incidence per 1000 catheter-days of 1.97 (4.6) in nonelderly and 0.55 (1.6) in elderly patients (P<0.001). Relative to nonelderly patients, the hazard ratio for catheter-related bloodstream infection in the elderly was 0.33 (95% confidence interval, 0.20 to 0.55; P<0.001) after multivariate analysis.
Elderly patients on hemodialysis using tunneled central vein dialysis catheters are at lower risk of catheter-related bloodstream infection than their younger counterparts. For some elderly patients, tunneled central vein dialysis catheters may represent a suitable dialysis access option in the setting of nonmaturing arteriovenous fistulae or poorly functioning synthetic grafts.
Objectives
Hemorrhagic pancreatic fluid collections (hPFC) are a complication of pancreatitis with an unknown influence on prognosis. Advancements in endoscopic management of PFC have improved ...results over their surgical and percutaneous alternatives. We performed a propensity‐matched analysis comparing clinical outcomes in hemorrhagic and non‐hemorrhagic PFC (nhPFC).
Methods
From November 2015 to November 2021, a retrospective comparative cohort analysis was performed comparing clinical outcomes for patients with hPFC and nhPFC managed with lumen‐apposing metal stents. Propensity score matching was used to balance the two subgroups. Wilcoxon two‐sample tests were used to compare continuous variables and Fisher's exact test was used to compare categorical variables. Kaplan‐Meier method was used to estimate overall survival.
Results
Fifteen patients with hPFC were matched with 30 nhPFC patients. Technical and clinical success was similar in both groups. The median length of hospitalization was 6 days in the hPFC group and 3 days in the nhPFC group (p = 0.23); however, more hPFC patients required intensive care unit admission post‐procedure (33.3% vs. 16.7%, p = 0.26). Patients with hPFC were more likely to be readmitted to the hospital within 30 days (33.3% vs. 6.7%, p = 0.032). Mortality at 3 months (13% vs 3%, p = 0.25) and 6 months (27% vs. 7%, p = 0.09) was higher in the hPFC cohort. The 1‐year survival estimate was 73.3% (standard error = 11.4) in the hPFC group and 88.9% (6.1) in the nhPFC group (p = 0.16).
Conclusions
Patients with hPFC are more likely to be readmitted to the hospital within 30 days and have worse clinical outcomes.
Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an alternative to surgery for acute cholecystitis (AC) in poor operative candidates. However, the role of EUS-GBD in non-cholecystitis ...(NC) indications has not been well studied. We compared the clinical outcomes of EUS-GBD for AC and NC indications. Consecutive patients undergoing EUS-GBD for all indications at a single center were retrospectively analyzed. Fifty-one patients underwent EUS-GBD during the study period. Thirty-nine (76%) patients had AC while 12 (24%) had NC indications. NC indications included malignant biliary obstruction (
= 8), symptomatic cholelithiasis (
= 1), gallstone pancreatitis (
= 1), choledocholithiasis (
= 1), and Mirizzi's syndrome (
= 1). Technical success was noted in 92% (36/39) for AC and 92% (11/12) for NC (
> 0.99). The clinical success rate was 94% and 100%, respectively (
> 0.99). There were four adverse events in the AC group and 3 in the NC group (
= 0.33). Procedure duration (median 43 vs. 45 min,
= 0.37), post-procedure length of stay (median 3 vs. 3 days,
= 0.97), and total gallbladder-related procedures (median 2 vs. 2,
= 0.59) were similar. EUS-GBD for NC indications is similarly safe and effective as EUS-GBD in AC.
Abstract
Background and study aims Percutaneous transhepatic biliary drainage (PTBD) is the traditional second-line option after unsuccessful endoscopic retrograde cholangiopancreatography (ERCP). ...Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HG) is a viable alternative to PTBD. Our study aimed to compare outcomes of EUS-HG and PTBD for benign and malignant biliary diseases following failed ERCP.
Patients and methods This single-center study retrospectively analyzed patients undergoing EUS-HG and PTBD for benign and malignant biliary disorders. A propensity score-matched analysis was performed using age, sex, and Charlson Comorbidity Index. The primary outcome was clinical success, which we defined as a decrease in total bilirubin by ≥ 50% at 2 weeks for malignant disease and resolution of the biliary disorder for benign disease.
Results In total, 41 patients underwent EUS-HG and 138 patients
underwent PTBD. After propensity score matching in a 1:2 ratio, 32 EUS-HG patients were
matched with 64 PTBD. Technical success was achieved in 29 of 32 (91%) for EUS-HG and 63 of 64
(98%) for PTBD (P=0.11). Clinical success was 100% for EUS-HG and
75% for PTBD (P=0.0021). EUS-HG was associated with a lower adverse
event rate (EUS-HG 13% vs. PTBD 58%, P <0.0001), shorter
procedure duration (median 60 vs. 115 minutes, P <0.0001),
shorter post-procedure length of stay (median 2 vs. 4 days, P
<0.0001), and fewer reinterventions (median 1 vs. 3, P
<0.0001).
Conclusions Our results suggest that EUS-HG is superior to PTBD in the treatment of benign and malignant biliary disorders after failed ERCP.
Atypical meningiomas have poor local control with emerging literature indicating the use of radiosurgery in treatment. The purpose of this study was to evaluate clinical outcomes including local ...control and failure pattern after Gamma Knife radiosurgery (GKRS) and factors that may affect these outcomes. Between 1999 and 2008, 24 patients were treated with GKRS as either primary or salvage treatment for pathologically proven atypical meningiomas. Treatment failures were determined by serial magnetic resonance imaging. A median marginal dose of 14 Gy was used (range 10.5–18 Gy). Overall local control rates at 1, 2, and 5 years were 75, 51, and 44%, respectively. With median follow-up time of 42.5 months, 14 of 24 patients experienced a treatment failure at time of last follow-up. Eight recurrences were in-field, four were marginal failures, and two were distant failures. Wilcoxon analysis revealed that the conformality index (CI) was a significant predictor of local recurrence (
P
= 0.04). CI did not predict for distant recurrences (
P
= 0.16). On multivariate analysis evaluating factors predicting progression free survival, dose >14 Gy was found to be statistically significant (
P
= 0.01). There appears to be a dose response using GKRS beyond 14 Gy but given the suboptimal local control rates in this study, higher doses may still be needed to obtain better local control.
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