Endoscopic treatment of extreme esophageal stenosis complicated with esophagotracheal fistula: A case report.

BACKGROUND: At present, there is no unified and effective treatment for extreme corrosive esophageal stenosis (CES) with esophagotracheal fistula (ETF). This case had extreme and severe esophageal stenosis (ES) and ETF after ingesting an enzyme-based chemical detergent, resulting in a serious pulmonary infection and severe malnutrition. Upper gastrointestinal imaging showed that he had an ETF, and endoscopy showed that he had extreme and severe esophageal stricture. This case was complex and difficult to treat. According to the domestic and foreign literature, there is no universal treatment that is low-risk. CASE SUMMARY: A patient came to our hospital with extreme ES, an ETF, and severe malnutrition complicated with pulmonary tuberculosis 1 mo after the consumption of an enzyme-based detergent. The ES was serious, and the endoscope was unable to pass through the esophagus. We treated him by endoscopic incision method (EIM), esophageal stent placement (ESP), and endoscopic balloon dilation (EBD) by using the bronchoscope and gastroscope. This treatment not only closed the ETF, but also expanded the esophagus, with minimal trauma, greatly reducing the pain of the patient. According to the literature, there are no similar reported cases. CONCLUSION: We report, for the first time, a patient with extreme CES complicated with ETF, where the endoscope could not be passed through his esophagus but he could be examined by bronchoscopy and treated by EIM, ESP, and EBD.

[Application Progress of Arterial Spin Labeling Magnetic Resonance Imaging in Renal Perfusion Analysis].

Arterial spin labeling is a noninvasive,quantitative method for perfusion imaging,which does not need any contrast media.This technique has been used in the renal perfusion analysis.In this article,we briefly introduced this technique and summarized its application in healthy volunteers,acute kidney injury,chronic kidney diseases,renovascular diseases,renal tumors,and renal transplantation.

[Latest Progresses in Surgical Treatment of Median Arcuate Ligament Syndrome].

Median arcuate ligament syndrome(MALS)is compression of the celiac trunk by the median arcuate ligament.Median arcuate ligament release is the corner stone for the surgical treatment of MALS.Open surgery,laparoscopic surgery,and robot-assisted surgery have been developed,among which laparoscopic surgery has been proposed as the preferred approach in view of its minimal trauma and short hospital stay.Auxiliary celiac plexus neurolysis could further alleviate the patient's discomfort.Moreover,vascular reconstitution is of vital importance in the case of persistent stenosis in the celiac artery despite of median arcuate ligament decompression.Vascular reconstruction has satisfactory long-term patency rate,while endovascular treatment is less invasive.This article aims to summarize the consensuses and advances and shed light on the surgical treatment of MALS.

[Clinical Analysis of the Treatment of Iliac Limb Occlusion Following Endovascular Abdominal Aortic Aneurysm Repair].

Objective To explore the cause and the treatment strategies of iliac limb occlusion after endovascular abdominal aortic aneurysm repair(EVAR). Methods The patients receiving EVAR in PUMC Hospital from January 2015 to December 2020 were retrospectively analyzed.Sixteen(2.7%)cases of iliac limb occlusion were identified,among which 6,9,and 1 cases underwent surgical bypass,endovascular or hybrid procedure,and conservative treatment,respectively. Results Fifteen cases were successfully treated.During the 10.6-month follow-up,2 cases receiving hybrid treatment underwent femoral-femoral bypass due to re-occlusion of the iliac limb. Conclusions Iliac limb occlusion mostly occurs in the acute phase after EVAR,and endovascular or hybrid treatment can be the first choice for iliac limb occlusion.It is suggested to focus on the risk factors for prevention.

[Femoral-popliteal Arteriosclerosis Obliterans:Review of Evidence-based Studies on Drug-eluting Endovascular Treatment].

Atherosclerosis-related diseases have increasingly become health concerns with the increased living conditions and aging.Globally,about 200 million people have suffered from arteriosclerosis obliterans(ASO),which can even be life-threatening in some cases.The past seven decades have witnessed the rapid advances in the treatment of ASO,which has developed from surgery to endovascular interventions including plain balloon angioplasty,bare metal stent placement,drug-coated balloon,and drug-eluting stent.However,the roles of these new techniques for femoral-popliteal lesions,especially their real-world clinical outcomes and indications,remain unclear.This article reviews the latest evidences on the use of drug-eluting devices in treating femoral-popliteal arteriosclerosis obliterans.

[Correlation of Matrix Metalloproteinases-9 with Microemboli Shedding in Carotid Endarterectomy].

Objective To investigate the change of serum matrix metalloproteinases-9 (MMP-9) expression before,during,and after carotid endarterectomy (CEA) and to investigate the prognostic role of MMP-9. Methods Forty carotid stenosis patients who underwent CEA in the Department of Vascular Surgery,Peking Union Medical College Hospital from February to September 2012 were enrolled in this study. Based on the findings of transcranial doppler monitoring,patients were divided into embolic-positive group and emboli-negative group. Serum samples were obtained from 40 consecutive patients undergoing CEA before operation (pre-op),before de-clamping,30 minutes after de-clamping,and 12 hours after operation (12-h post-op). MMP-9 expression was quantified using enzyme-linked immunosorbent assay and gelatin zymography. Student's t-test and chi-square test were used to compare the differences between these two groups. Results Of these 40 patients,microemboli were detected in 8 patients. The 12-h post-op MMP-9 level was significantly higher than the pre-op level in the emboli-positive group [(904.27±369.47)ng/ml vs. (333.88±126.32) ng/ml,t=4.132,P=0.001].However,there was no difference between pre-op and 12-h post-op MMP-9 levels in the emboli-negative group [(375.83±194.36) ng/ml vs. (472.74±271.21) ng/ml,t=-1.643,P=0.081]. Gelatin zymography also showed higher MMP-9 activity in the emboli-positive group than in the emboli-negative group. Conclusion Serum MMP-9 concentration remarkably increases 12 hours after CEA in patients with microemboli shedding,suggesting MMP-9 may be a potential biomarker for CEA-related cerebral ischemic injury.

Role of perivascular adipose tissue in nicotine­induced endothelial cell inflammatory responses.

Smoking is considered to be one of the primary causes of atherosclerosis and vascular injury. Previous studies have shown that nicotine in tobacco can lead to vascular inflammation and endothelial dysfunction. Perivascular adipose tissue (PVAT) is known to secrete various types of adipokines to maintain vascular homeostasis. The present study investigated whether nicotine­induced PVAT malfunction can accelerate endothelial inflammation and eventually lead to endothelial dysfunction. The levels of inflammatory adipokines, including nuclear factor (NF)­κB, interleukin (IL)­1ß, IL­6 and tumor necrosis factor (TNF)­α, the ICAM­1 and VCAM­1 adhesion molecules and secretion of adiponectin were assessed in mature adipocytes and endothelial cells cultured alone or in co­culture under nicotine stimulation. It was found that nicotine reduced the secretion of adiponectin and stimulated secretion of the NF­κB, IL­1ß, IL­6 and TNF­α inflammatory adipokines in mature adipocytes. Although nicotine stimulated endothelial cells to secrete IL­1ß and IL­6, no significant increase in the secretion of TNF­α was observed. The co­culture of mature adipocytes with endothelial cells markedly augmented the expression of the NF­κB, IL­1ß, IL­6 and TNF­α inflammatory adipokines and the ICAM­1 and VCAM­1 adhesion molecules, and significantly lowered the levels of adiponectin. These findings suggested that nicotine induced mature adipocyte dysfunction, which caused the abnormal secretion of adiponectin and inflammatory adipokines, and exacerbated endothelial inflammation. These findings also suggested a mechanism whereby nicotine induced the secretion of adiponectin and inflammatory cytokines by adipocytes. The results of the present study elucidated a novel pathway induced by cigarette smoke, which contributed to atherosclerosis and vascular injury.

[Logistic Regression Analysis of Depression in Arteriosclerosis Obliterans Patients and Its Risk Factors].

OBJECTIVE: To investigate the depression in arteriosclerosis obliterans (ASO) patients and its risk factors. METHODS: The self-rating depression scale (SDS) was applied in 228 ASO patients hospitalized in the vascular surgery department of Peking Union Medical College Hospital from March 2010 to October 2011. The risk factors of depression were analyzed by using univariate and multivariate Logistic regression analysis. RESULTS: Of these 228 ASO patients, 133 (58.3%) were found to be depressive. Univariate and multivariate analysis showed that female (OR=0.15,95% CI:0.05-0.45), hypertension (OR=4.63,95% CI:1.90-11.29), coronary heart disease (OR=3.62,95%CI:1.43-9.18), as well as Fontaine 2a (OR=20.76,95% CI:3.21-134.28), 2b (OR=26.34,95% CI:4.20-164.97), 3(OR=192.28,95% CI:25.97-1423.51), and 4(OR=291.41,95% CI:28.67-2962.21) were the risk factors of depression in ASO patients. CONCLUSIONS: ASO patients can easily develop depression. Female, hypertension, coronary heart disease, and Fontaine 2a, 2b,3,and 4 are the risk factors of depression in ASO patients.

Prediction of Cerebral Hyperperfusion Syndrome with Velocity Blood Pressure Index.

BACKGROUND: Cerebral hyperperfusion syndrome is an important complication of carotid endarterectomy (CEA). An >100% increase in middle cerebral artery velocity (MCAV) after CEA is used to predict the cerebral hyperperfusion syndrome (CHS) development, but the accuracy is limited. The increase in blood pressure (BP) after surgery is a risk factor of CHS, but no study uses it to predict CHS. This study was to create a more precise parameter for prediction of CHS by combined the increase of MCAV and BP after CEA. METHODS: Systolic MCAV measured by transcranial Doppler and systematic BP were recorded preoperatively; 30 min postoperatively. The new parameter velocity BP index (VBI) was calculated from the postoperative increase ratios of MCAV and BP. The prediction powers of VBI and the increase ratio of MCAV (velocity ratio [VR]) were compared for predicting CHS occurrence. RESULTS: Totally, 6/185 cases suffered CHS. The best-fit cut-off point of 2.0 for VBI was identified, which had 83.3% sensitivity, 98.3% specificity, 62.5% positive predictive value and 99.4% negative predictive value for CHS development. This result is significantly better than VR (33.3%, 97.2%, 28.6% and 97.8%). The area under the curve (AUC) of receiver operating characteristic: AUC(VBI) = 0.981, 95% confidence interval [CI] 0.949-0.995; AUC(VR) = 0.935, 95% CI 0.890-0.966, P = 0.02. CONCLUSIONS: The new parameter VBI can more accurately predict patients at risk of CHS after CEA. This observation needs to be validated by larger studies.

Comparison of endovascular aortic repair and open surgical repair for ruptured abdominal aortic aneurysm.

OBJECTIVE: To compare the clinical efficacies of endovascular aortic repair(EVAR)and open surgical repair(OSR)for ruptured abdominal aortic aneurysm(rAAA). METHODS: The clinical data of 28 rAAA patients undergoing emergent treatment between February 2002 and February 2013 in PUMC Hospital were retrospectively reviewed. Among them 13 cases were treated by EVAR and 15 cases by OSR. RESULTS: Before the surgery,the general conditions,comorbidities,and hemodynamics were not significantly different between these two groups(all P>0.05),although the EVAR group had significantly higher mean age than OSR group(P=0.041). In the perioperative period,the EVAR group showed significantly lower 30-day mortality(P=0.044),less blood loss(P=0.005),less blood transfusion(P=0.003),less infusion quantity(P=0.000),shorter length of procedure(P=0.001),and shorter hospital stay(P=0.020). Also,the EVAR group had no severe perioperative complications and showed superior 1-year follow up survival(P<0.05). CONCLUSIONS: EVAR is an effective treatment for rAAA and can improve the clinical outcomes. EVAR may be adopted as the first-line treatment for rAAA,especially for the aged.

[Risk analysis for cerebral hyperperfusion syndrome after carotid endarterectomy].

OBJECTIVE: To analyze risk factors for cerebral hyperperfusion syndrome (CHS) after carotid endarterectomy (CEA). METHODS: From September 2010 to September 2012, 183 consecutive patients with carotid artery stenosis who had indications for CEA entered the study. There were 149 male and 34 female patients, aged from 38 to 83 years with an average of (66 ± 9) years. Intracranial blood flow changes were monitored through transcranial Doppler routinely. Pre- and post-operative middle cerebral artery velocity (VMCA) were recorded. CHS was diagnosed by the combination of hyperperfusion syndrome and 100% increase of VMCA after operation compared with pre-operative baseline values. The patients who had CHS during hospitalization were recorded. Pre-operative and operative related factors were analyzed by univariate analysis, followed by Logistic regression model, to identify the risk factors of CHS. RESULTS: Overall, CHS occurred in 15 patients (8.2%) after CEA. The average onset time was (2.6 ± 0.2) days after surgery. By decreasing blood pressure and using dehydration medicine, all the patients with CHS recovered before discharge. None of them developed to intracranial hemorrhage. On univariate analysis, significant risk factors for CHS were history of stoke, symptomatic carotid artery stenosis and shunting during operation. On Logistic regression model, independent risk factor was symptomatic carotid artery stenosis (OR = 6.733, 95%CI: 1.455-31.155, P = 0.015), while shunting during operation (OR = 0.252, 95%CI: 0.067-0.945, P = 0.041) was a protective factor. CONCLUSIONS: Symptomatic carotid artery stenosis is an independent risk factor for CHS after CEA and shunting during operation is a protective factor. Using shunt may be an effective method of preventing CHS after CEA.

[New method to predict cerebral hyperperfusion syndrome after carotid endarterectomy by transcranial Doppler].

OBJECTIVE: To determine the diagnostic value for predicting cerebral hyperperfusion syndrome (CHS) by adding a transcranial Doppler (TCD) measurement at the end of the carotid endarterectomy (CEA) at the operating room. METHODS: Patients who underwent CEA between August 2009 and December 2011 of the prospective clinical trial in whom both intra- and post-operative TCD monitoring were performed were included. The middle cerebral artery velocities pre-clamping, post-declamping and post-operatively were measured by TCD. The intra-operative velocity increase ratio (VR1) was compared to the postoperative velocity increase ratio(VR2) in relation to CHS by calculating the sensitivity,specificity, positive predictive value, negative predictive value. The receiver operating characteristic curve (ROC) were also performed. The area under the curve (AUC) of ROC of VR1 and VR2 were compared.All the data were analyzed using SPSS 20.0 software. RESULTS: VR1 > 100% was identified in 6 patients, while VR2 > 100% was identified in 18 patients, respectively. Ten patients were diagnosed with CHS. The AUC of VR2 (0.728) was higher than AUC of VR1 (0.636). The best fit cutoff point of VR2 was 100%. The sensitivity, specificity, positive predictive value, negative predictive value were 70%, 83%, 39%, 95%, respectively, which demonstrates a better predictive power than VR1. CONCLUSION: Besides the commonly used intra-operative TCD monitoring, additional TCD measurement at the end of the carotid endarterectomy at the operating room is more useful to more accurately predict CHS.

[Shunting during carotid endarterectomy prevents postoperative cerebral hyperperfusion syndrome].

OBJECTIVE: To assess if shunting during carotid endarterectomy (CEA) can lower the risk of postoperative cerebral hyperperfusion (CH) and cerebral hyperperfusion syndrome (CHS). METHODS: This study was a prospective non-randomized controlled trial which approved by human rights committee of our hospital. From August 2009 to August 2012, 180 eligible patients with carotid arterial stenosis who had indication for CEA entered our study. 146 patients were males and 34 patients were females. Their age range was 38 - 83 years. Average age was (66 ± 9) years. Cerebral blood flow changes were monitored through Transcranial Doppler routinely. There were 81 cases with shunting and 99 without shunting. We compared the rate of CH, CHS and other complications between two groups. RESULTS: No patient died or suffered hemorrhagic stroke. There were no significant difference in average operation time between two groups ((144 ± 25) min vs (139 ± 34) min, P > 0.05), but the clamping time of shunting group was significantly shorter than no shunting group ((4 ± 4) min vs (26 ± 14) min, P < 0.05). The rate of CH and CHS of shunting group is lower than no shunting group (7.4% vs 18.2%, P < 0.05; 3.7% vs 12.1%, P < 0.05). There were no differences in other complications between two groups. CONCLUSION: Shunting during CEA can lower the rate of CH and CHS by shortening the time of intraoperative cerebral ischemia, but didn't increase the rate of other complications. Using shunt may be an effective method of preventing CHS after CEA, especially for the high risk patients according to preoperative evaluation.

Measurement and analysis of facial nerve on fully displayed multislice computed tomographic multiplanar reconstruction image.

The objectives of this study were to measure the length of horizontal segment of facial nerve (HFN), the length of vertical segment of facial nerve (VFN), and the angle between these 2 segments on a fully displayed multislice computed tomographic multiplanar reconstruction (MPR) images of HFN and VFN and to analyze the data with respects to side, sex, and age. Parameters of 234 patients (468 observations, 118 men and 116 women, aged 4-70 years) with intact temporal bone were measured on multislice computed tomographic multiplanar reconstruction images. The data gained were analyzed by statistical method. The left and right lengths of VFN were significantly different (P < 0.05). And the length of HFN, the length of VFN, and the angle between males and females were significantly different (P < 0.05). We divided the data into 3 groups to study correlations between measurements and age. In underaged group, there was a strong positive correlation between the length of VFN and age; the value of Pearson correlation was 0.645. And there was a weak correlation between the angle and the age; the value of Pearson correlation was 0.270. In older-aged group, there was a moderate negative correlation between the length of VFN and age; the value of Pearson correlation was -0.408. Our results are of high potential to expand the visual field to facial nerve and may provide more detailed information to surgeries of facial nerve, middle ear, and temporal bone.

[Expressions of p-c-jun and cyclinD1 between vascular smooth muscle cells and endothelial cells exposured to cigarette smoke extract].

OBJECTIVE: To investigate the cell viabilities of vascular smooth muscle cells and vascular endothelial cells stimulated by cigarette smoke extract(CSE) . METHODS: The CSE was prepared by smoke-bubbled phosphate buffered saline(PBS) generation.After culturing cells with different concentrations of CSE, we used the cell counting kit-8 to determine the cell viability.The expression levels of c-jun and cyclinD1 were analyzed through Western blot.The c-jun plasmid was transfected to detect the change of cyclinD1 expression. RESULTS: The smooth muscle cell viability increased when the CSE concentration ranged 0.625%-10%, whereas the endothelial cells viability decreased when exposed to the CSE concentration. After exposure to CSE for 48 hours, there was no difference in c-jun expression between toxin group and PBS group;however, the expression of p-c-jun in the smooth muscle cells significantly increased in the toxin groups than in the PBS group(P<0.05) and the expression of p-c-jun in the vascular endothelial cells significantly decreased(P<0.05) . The level of cyclinD1 significantly increased after exposed to CSE, and its expression level also increased in respond to the c-jun overexpression. CONCLUSION: CSE can enhance the proliferation of vascular smooth muscle cells and decrease in the activity of endothelial cells proliferation, which may be explained by the phosphorylation of c-jun and the expression of cyclinD1.