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BACKGROUND AND AIMS: Lumen-apposing metal stents (LAMSs) have proven to be effective for drainage of pancreatic walled-off necrosis (WON), although associated adverse events (AEs) have been reported. Anchoring coaxial double-pigtail plastic stents (DPSs) within LAMSs have been proposed to prevent LAMS-related AEs but have not been assessed in prospective studies. We aimed to evaluate the utility of such measures with a randomized controlled trial. METHODS: We randomly assigned consecutive patients with WON indications for drainage to EUS-guided transluminal drainage using LAMSs with (group A) or without (group B) DPSs. All LAMSs were to be removed after 3 weeks had elapsed from the index procedure with a preceding CT to decide whether additional steps needed to be taken (eg, transluminal necrosectomy or placing transluminal plastic stents in patients with incomplete resolution of WON). The main outcomes were failure of the index method, defined as necessity of reintervention (endoscopic, percutaneous, or surgical) before LAMS removal because of LAMS-related AEs and/or clinical deterioration; AE rates; and mortality with the LAMS in place. Variables were evaluated using the Mann-Whitney U test, χ2 test, or Fisher exact test as appropriate. P < .05 was considered significant. RESULTS: Sixty-seven patients (37.3% women; mean age, 54 ± 14.4 years) underwent LAMS placement with (n = 34) or without (n = 33) DPS placement in 2 tertiary centers. Baseline characteristics including demographics, etiology, comorbidity, and clinical presentation (sterile vs infected necrosis) were comparable between both groups. The technical success rate in placing LAMSs and DPSs was 100%. The global rate of AEs was significantly lower in group A versus group B (20.7% vs 51.5%, respectively; P = .008). Stent occlusion was the most frequently observed AE (14.7% vs 36.3%, P = .042). Failure of the index method was lower in group A versus group B (29.4% vs 48.5%, respectively; P = .109); however, the difference did not achieve statistical significance. The same applied to the mortality rate with LAMSs in place (2.9% vs 12.1%, P = .197). CONCLUSIONS: The addition of a coaxial DPS within a LAMS was associated with a significantly lower global rate of AEs and stent occlusion rate in EUS-guided drainage of WON. (Clinical trial registration number: NCT03923686.).
Subject(s)
Pancreatitis, Acute Necrotizing , Stents , Humans , Female , Adult , Middle Aged , Aged , Male , Prospective Studies , Treatment Outcome , Retrospective Studies , Stents/adverse effects , Pancreatitis, Acute Necrotizing/surgery , Drainage/methods , Plastics , Necrosis/etiology , EndosonographyABSTRACT
INTRODUCTION: Percutaneous endoscopic cecostomy (PEC) is a viable treatment option for patients with persistent or recurrent acute colonic pseudo-obstruction (ACPO; Ogilvie's syndrome). It should be generally considered in patients that are refractory to pharmacologic and endoscopic decompression, especially those not amenable to surgical intervention due to an increased perioperative risk. Physicians are rather unfamiliar with this approach given the limited number of reports in the literature and paucity of guideline resources, although guidelines concerning ACPO and covering the role of endoscopy were recently published by three major expert societies, all within the last 2 years. PATIENTS AND METHODS: We retrospectively identified three consecutive patients who underwent PEC placement at a Czech tertiary referral center between May 2018 and December 2021: all for recurrent ACPO. In addition, we summarized the current guidelines in order to present the latest knowledge related both to the procedure and management approach in patients with ACPO. RESULTS: The placement of PEC was successful and resulted in clinical improvement in all cases without any adverse events. CONCLUSION: The results of our experience are in line with previous reports and suggest that PEC may become a very useful tool in the armamentarium of modalities utilized to treat ACPO. Furthermore, the availability of guideline resources now offers comprehensive guidance for informed decision-making and the procedural aspects.
Subject(s)
Cecostomy , Colonic Pseudo-Obstruction , Humans , Colonic Pseudo-Obstruction/surgery , Decompression, Surgical/methods , Endoscopy, Gastrointestinal , Lumbar Vertebrae/surgery , Retrospective StudiesABSTRACT
INTRODUCTION AND PURPOSE: With current imaging modalities and diagnostic tests, identifying pain generators in patients with non-specific chronic low back pain (CLBP) is difficult. There is growing evidence of the effectiveness of SPECT/CT examination in diagnosing the source of pain in the spine. The study aims to investigate the effect of posterior interbody fusion on a single-level SPECT/CT positive lumbar degenerative disc disease (DDD). MATERIAL AND METHODS: This is a prospective study of patients with chronic low back pain (CLBP) operated on for a single-level SPECT/CT positive DDD. Primary outcomes were changes in visual analogue scale (VAS) scores and the Oswestry Disability Index (ODI). Secondary outcomes were complications, return to work, satisfaction and willingness to re-undergo surgery. RESULTS: During a 3-year period, 38 patients underwent single-level fusion surgery. The mean preoperative VAS score of 8.4 (± 1.1) decreased to 3.2 (± 2.5, p < 0.001) and the mean preoperative ODI of 51.5 (± 7.3) improved to 20.7 (± 14.68, p < 0.001) at a 2-year follow-up. A minimum clinically important difference (30% reduction in VAS and ODI) was achieved in 84.2% of patients. Some 71% of patients were satisfied with the surgery results and 89.4% would undergo surgery again. There were four complications, and two patients underwent revision surgery. Some 82.9% of patients returned to work. CONCLUSION: Fusion for one-level SPECT/CT positive lumbar DDD resulted in substantial clinical improvement and satisfaction with surgical treatment. Therefore, SPECT/CT imaging could be useful in assessing patients with CLBP, especially those with unclear MRI findings. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04876586.
Subject(s)
Intervertebral Disc Degeneration , Low Back Pain , Spinal Fusion , Humans , Intervertebral Disc Degeneration/diagnostic imaging , Intervertebral Disc Degeneration/surgery , Low Back Pain/diagnostic imaging , Low Back Pain/etiology , Low Back Pain/surgery , Lumbar Vertebrae/diagnostic imaging , Lumbar Vertebrae/surgery , Prospective Studies , Retrospective Studies , Spinal Fusion/methods , Tomography, Emission-Computed, Single-Photon , Tomography, X-Ray Computed , Treatment OutcomeABSTRACT
Pancreatic ductal adenocarcinoma (PDAC) is a dreaded malignancy with a dismal 5-year survival rate despite maximal efforts on optimizing treatment strategies. Currently, early detection is considered to be the most effective way to improve survival as radical resection is the only potential cure. PDAC is often divided into four categories based on the extent of disease: resectable, borderline resectable, locally advanced, and metastatic. Unfortunately, the majority of patients are diagnosed with locally advanced or metastatic disease, which renders them ineligible for curative resection. This is mainly due to the lack of or vague symptoms while the disease is still localized, although appropriate utilization and prompt availability of adequate diagnostic tools is also critical given the aggressive nature of the disease. A cost-effective biomarker with high specificity and sensitivity allowing early detection of PDAC without the need for advanced or invasive methods is still not available. This leaves the diagnosis dependent on radiodiagnostic methods or endoscopic ultrasound. Here we summarize the latest epidemiological data, risk factors, clinical manifestation, and current diagnostic trends and implications of PDAC focusing on serum biomarkers and imaging modalities. Additionally, up-to-date management and therapeutic algorithms are outlined.
Subject(s)
Carcinoma, Pancreatic Ductal , Pancreatic Neoplasms , Humans , Pancreatic Neoplasms/diagnosis , Carcinoma, Pancreatic Ductal/diagnosis , Carcinoma, Pancreatic Ductal/surgery , Pancreatic NeoplasmsABSTRACT
BACKGROUND AND AIMS: Necrotizing pancreatitis has a variable clinical course and it is essential to identify determinants associated with high risk of mortality and poor clinical outcomes. The aim of this study is to evaluate the association between CT-assessed body composition parameters such as visceral fat area (VFA), skeletal muscle index (SMI) and skeletal muscle density (SMD) and inpatient mortality in NP patients. Secondary outcomes include organ failure on admission, persistent organ failure, length of stay (LOS), need for ICU admission, need for endoscopic, percutaneous or surgical interventions for NP and 30-day unplanned readmission. METHODS: All NP patients managed at a single center between 2009 and 2019 with a CT scan within a week of admission were included. SMI, SMD and VFA was calculated from CT imaging at the third lumbar vertebra and multivariable analysis was performed after correcting for age, sex, BMI, ASA classification, multi- organ failure on admission to determine independent association with inpatient mortality and secondary outcomes. RESULTS: 507 NP patients [males = 349 (68.8%), median age 53 (IQR 37-65) years were included in this study. The lowest tertile SMD was independently associated with inpatient mortality on multivariable analysis: adjusted OR 3.36 (1.57-7.2), P = 0.002. The lowest SMI tertile and highest VFA tertile were not independently associated with mortality. Lowest tertile SMD was significantly associated with persistent organ failure (OR 2.01, 95% CI 1.34-3.01, p = 0.001), need for percutaneous drainage (OR 1.84, 95% CI 1.21-2.8, p = 0.004), need for ICU admission (OR 2.32, 95% CI 1.59-3.38, p < 0.0001) and LOS. CONCLUSION: Low SMD was independently associated with in-hospital mortality in NP patients and can be usefully incorporated in CT based predictive scoring models as a prognostic marker.
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OBJECTIVE: The main aim of this study was to analyse the compex clinical and radiographic findings in a group of RA patients with atlanto-axial slip (AAS) treated with free-hand short C1 lateral mass and C2 trans-pedicular screw fixation. The surgical technique used and the pathology treated were the same in all patients, producing a very homogeneous cohort of patients This allowed the study and measurement of radiographic parameters and fusion process. METHODS: Twenty-nine patients (21 female, 8 male, mean age 54.9 years, duration of RA 17.3 years) with AAS and without CS were treated by short C1/2 fixation. Mean follow-up was 4.5 years. Pain intensity was monitored using VAS. Radiographic assessment consisted of lateral cervical radiographs in neutral and dynamic views, MR and CT of the cervical spine. The AADI, PADI, AAA, sub-axial cervical Cobb angle and canal-clivus angle (CCA) were measured pre-operatively and during the follow-up. RESULTS: Significant malposition was recorded in 4 (3.4%) out of 116 inserted screws. AADI, PADI, AAA and CCA values changed significantly after surgery and remained stable during follow-up. The Cobb C angle value showed no significant change after surgery. There was a significant decrease of the VAS after the surgery. Fusion or a stable situation was achieved in all patients at 2-year follow-up. Pannus regression was observed in the vast majority of patients; only in two cases was rheumatic tissue detected on MR at 2 years post-operatively. CONCLUSION: C1 lateral mass and C2 trans-pedicular fixation with polyaxial screws followed by an autograft between C1 and C2 lamina allowed, with an acceptable complication rate and favourable clinical results, adequate slip reposition, introduction of optimal sagittal alignment in terms of the final AAA with no radiographic consequences for the sub-axial cervical spine and assurance of long-term stability.
Subject(s)
Arthritis, Rheumatoid/complications , Atlanto-Axial Joint/surgery , Joint Dislocations/surgery , Postoperative Complications/epidemiology , Spinal Fusion/methods , Adult , Aged , Bone Screws/adverse effects , Female , Humans , Joint Dislocations/etiology , Male , Middle Aged , Postoperative Complications/diagnostic imaging , Spinal Fusion/adverse effectsABSTRACT
OBJECTIVES: CT angiography (CTA) is recommended as a standard of stroke imaging. We investigated accuracy and precision of standard or single-phase CTA as compared with novel technique or multiphase CTA in clot detection in the middle cerebral artery. METHODS: Twenty single-phase CTA and twenty multiphase CTA with prevailing M2 occlusion were assessed by 10 radiologists and 10 neurologists blinded to clinical information (7 less experienced and 3 experienced). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated as compared with reading by two seniors. Reliability was calculated using Krippendorff's alpha (K-alpha). RESULTS: Sensitivity, specificity, PPV, and NPV of single-phase CTA compared with multiphase CTA for M2 clot presence were, respectively, .86, .75, .90, and .67 versus .88, .82, .92, and .72. For secondary or distal clots, sensitivity, specificity, PPV, and NPV of single-phase CTA compared with multiphase CTA were .41, .83, .50, and .78 versus .65, .77, .71, and .67. Agreement increased significantly in favor of multiphase CTA for detection of primary clots from moderate (.43) to substantial (.65) in less experienced radiologists and from slight (.10) to moderate (.30) in less experienced neurologists. Agreement significantly increased for distal or secondary clot detection in favor of multiphase CTA from fair (.24) to moderate (.49) in experienced radiologists and from slight (.12) to moderate (.46) in experienced neurologists. CONCLUSIONS: Multiphase CTA is a reliable imaging tool in M2 clot detection and might represent a beneficial imaging tool in clot detection for less experienced physicians.
Subject(s)
Computed Tomography Angiography/methods , Intracranial Thrombosis/diagnostic imaging , Middle Cerebral Artery/diagnostic imaging , Neurologists/psychology , Radiologists/psychology , Cohort Studies , Female , Humans , Intracranial Thrombosis/etiology , Male , Sensitivity and Specificity , Stroke/complications , Time FactorsABSTRACT
PURPOSE: Mucopolysaccharidosis IVA (MPS IVA) is a multisystemic storage disorder. Patient's disability and life expectancy depends upon skeletal complications, including cervical myelopathy due to upper cervical compression or instability. Posterior decompression followed by occipitocervical fixation or C1-2 fusion are the most frequently recommended surgical interventions. The bony elements of C1 and C2 are often inadequately developed making routine screw insertion difficult. The main purpose of this work was to present novel technique of occipitocervical fixation using two C2 laminar screws. METHODS: Four children with MPS IVA underwent decompression and C0-C2 instrumented fusion using two C2 bilateral laminar screws. The dimensions of the C2 lamina were measured. Clinical and radiological results were monitored prospectively for a minimum 3 years. RESULTS: The mean laminar length was 24 ± 1.15 mm, width 6.15 ± 0.55 mm and height 7.4 ± 0.6 mm. Patients remained in a stable neurological condition. The mean antero-posterior diameter of the spinal canal on the pre-operative MR was 6.2 ± 0.74 mm and it was enlarged to 11.4 ± 0.8 mm after 3 years. All screws were placed adequately. In all patients, the control CT scan 2 years post-operatively revealed a stable position of the treated segments, but solid bony fusion was not registered in any patient. CONCLUSIONS: Decompression and fusion of the upper cervical spine is a generally accepted approach to treat upper cervical spine instability and myelopathy in MPS IVA patients. The feasibility and the suitability of the technique of C0-C2 stabilization using bilateral C2 laminar screws have been presented.
Subject(s)
Atlanto-Occipital Joint/surgery , Bone Screws , Cervical Vertebrae/surgery , Joint Instability/surgery , Mucopolysaccharidosis IV/complications , Spinal Fusion/instrumentation , Adolescent , Child , Decompression, Surgical/instrumentation , Decompression, Surgical/methods , Feasibility Studies , Female , Humans , Magnetic Resonance Imaging/methods , Male , Spinal Cord Compression/diagnosis , Spinal Cord Compression/etiology , Spinal Cord Compression/surgery , Spinal Fusion/methods , Tomography, X-Ray Computed/methodsABSTRACT
In a subset of patients with acute necrotizing pancreatitis, segmental necrosis affecting the main pancreatic duct may result in a discontinuity between the left-sided pancreas and the duodenum. Such an interruption in the setting of a viable upstream portion of the gland can give rise to the disconnected pancreatic duct syndrome (DPDS). By maintaining its secretory function, the disconnected segment may lead to persistent external pancreatic fistulae, recurrent pancreatic fluid collections, and/or obstructive recurrent acute or chronic pancreatitis of the isolated parenchyma. There are currently no universally accepted guidelines for the diagnosis or treatment of DPDS, and because the condition is underrecognized, the diagnosis is often delayed. DPDS is associated with a prolonged disease course and poses a burden on patients' quality of life as well as high health care resource utilization. The aim of our review is to summarize current knowledge, discuss diagnostic approaches, outline management options, and raise awareness of this challenging complication of necrotizing pancreatitis.
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Background and aims: Diagnosis of the biliary stricture remains a challenge. In view of the low sensitivity of brush cytology (BC), fluorescence in situ hybridization (FISH) has been reported as a useful adjunctive test in patients with biliary strictures. We aimed to determine performance characteristics of BC and FISH individually and in combination (BC + FISH) in the primary diagnosis of biliary strictures. Methods: This single-center prospective study was conducted between April 2019 and January 2021. Consecutive patients with unsampled biliary strictures undergoing first endoscopic retrograde cholangiopancreatography in our institution were included. Tissue specimens from two standardized transpapillary brushings from the strictures were examined by routine cytology and FISH. Histopathological confirmation after surgery or 12-month follow-up was regarded as the reference standard for final diagnosis. Results: Of 109 enrolled patients, six were excluded and one lost from the final analysis. In the remaining 102 patients (60.8% males, mean age 67.4, range 25-92 years), the proportions of benign and malignant strictures were 28 (27.5%) and 74 (72.5%), respectively. The proportions of proximal and distal strictures were 26 (25.5%) and 76 (74.5%), respectively. In comparison to BC alone, FISH increased the sensitivity from 36.1% to 50.7% (p = 0.076) while maintaining similar specificity (p = 0.311). Conclusions: Dual-modality tissue evaluation using BC + FISH showed an improving trend in sensitivity for the primary diagnosis of biliary strictures when compared with BC alone.
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Bobble-head doll syndrome (BHDS) is a complex syndrome with the dominant symptom of repetitive anteroposterior head movement. Only 57 patients are quoted in the literature. The etiology of this syndrome remains unknown and no standard treatment has yet been established. We hereby report four cases treated at our department. All the patients presented a psychomotor retardation due to an obstructive hydrocephalus. All the patients were treated using neuroendoscopic techniques: two with ventriculocystostomy, and two with ventriculocystocisternostomy. Cyst decompression was achieved in all four cases and clinical recovery was evident in three of the four patients observed. After surgery, BHDS persisted longer the more the subsequent treatment was delayed. In this article, we provide a concise overview of the theories of pathogenesis, presentation, and management of this syndrome. Based on our own experience, we state that the method of choice should be the neuroendoscopy and this must be performed promptly after diagnosis is made.
Subject(s)
Arachnoid Cysts/surgery , Dyskinesias/surgery , Hydrocephalus/surgery , Arachnoid Cysts/complications , Child , Dyskinesias/complications , Female , Follow-Up Studies , Head Movements/physiology , Humans , Hydrocephalus/etiology , Neuroendoscopy/methods , Syndrome , Third Ventricle/abnormalities , Third Ventricle/surgery , Treatment OutcomeABSTRACT
Pancreatic ductal adenocarcinoma (PDAC) is a dreaded malignancy with a dismal 5-year survival rate despite maximal efforts on optimizing treatment strategies. Radical surgery is the only potential curative procedure. Unfortunately, the majority of patients are diagnosed with locally advanced or metastatic disease, which renders them ineligible for curative resection. Early detection of PDAC is thus considered to be the most effective way to improve survival. In this regard, pancreatic screening has been proposed to improve results by detecting asymptomatic stages of PDAC and its precursors. There is now evidence of benefits of systematic surveillance in high-risk individuals, and the current guidelines emphasize the potential of screening to affect overall survival in individuals with genetic susceptibility syndromes or familial occurrence of PDAC. Here we aim to summarize the current knowledge about screening strategies for PDAC, including the latest epidemiological data, risk factors, associated hereditary syndromes, available screening modalities, benefits, limitations, as well as management implications.
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This video case report presents a patient with an invasive pancreatic mass and a history of Roux-en-Y gastric bypass surgery who underwent single-session endoscopic ultrasound-directed transgastric ERCP for tissue sampling and biliary stenting with subsequent maintenance of the newly established gastrogastrostomy. The demonstrated technique enables spectrum of endoscopic interventions in gastric bypass patients by facilitating a direct endoscopic passage through the reconnected stomach. Importantly, the method carries a risk of weight regain by essentially reversing the bypass. However, this can be an actual desire in selected cases, e.g., oncologic patients, making it a favorable choice over other alternatives.
Subject(s)
Cholestasis , Gastric Bypass , Obesity, Morbid , Cholangiopancreatography, Endoscopic Retrograde , Endosonography , Humans , Obesity, Morbid/surgeryABSTRACT
BACKGROUND: Anterior sacral meningocele (ASM) is characterized by a herniation of the dural sac through a bony defect of the anterior sacral wall. Symptoms of ASMs are usually directly related to their mass effect on the adjacent pelvic structures, often causing chronic constipation and urinary disturbances. The low-dysplastic spondylolisthesis results from congenital abnormalities of the upper sacral facets or the neural arch of L5. Its symptoms are related to neural compression and/or segmental instability. The main aim of this case report is to present a patient who underwent surgery for low dysplastic spondylolisthesis combined with an ASM that were both considered symptomatic. CASE DESCRIPTION: A 23-year-old male patient, with no medical history, no signs of neurologic deficit was admitted for lower back pain and irritation, numbness and paresthesia in the L5 dermatomes bilaterally, together with alternating constipation and diarrhea with no response to conservative treatment. Computed tomography and magnetic resonance imaging of the lumbar spine and pelvis showing a large retroperitoneal mass with fluid contend causing compression and displacement of the pelvic structures, in particular the bladder and the colon and there was also a low-dysplastic spondylolisthesis of L5/S1 with pressure on both L5 nerve roots. Surgery was done in one session purely from a posterior approach with no complications. CONCLUSIONS: In the present case, we have demonstrated the suitability of a standard midline posterior approach in the treatment not only for ASM itself, but also for a low-dysplastic spondylolisthesis in 1 session.
Subject(s)
Meningocele/complications , Meningocele/surgery , Spondylolisthesis/etiology , Spondylolisthesis/surgery , Decompression, Surgical/methods , Humans , Male , Spinal Cord , Spinal Fusion/methods , Young AdultABSTRACT
STUDY DESIGN: Consecutive case-series. OBJECTIVE: The main purpose of this study was to analyze the relationship between the preoperative neurological status and subsequent survival of patients undergoing surgical treatment for symptomatic spinal metastases. SUMMARY OF BACKGROUND DATA: The survival of cancer patients has increased over recent years with improvements in oncologic therapy. As many as 70% of cancer patients develop spinal metastases and â¼10% of all cancer patients are treated for metastatic spinal cord compression. METHODS: We retrospectively analyzed 166 patients who underwent surgery for symptomatic spinal metastases in our department between 2005 and 2012. The evaluated factors were age, primary tumor aggressiveness (slow, moderate, rapid growing), spinal location (cervical, thoracic, lumbar, and sacral), operation type (posterior decompression, anterior or posterior instrumented procedure, and radical combined instrumented surgery), preoperative evaluation using the revised Tokuhashi scoring system (<9, 9-11, and 12-15), pre- and postoperative neurological status according to the Frankel score (A-C and D-E), and the site of the main spinal cord compression (anterior, posterior, or combined). Postoperative complication and recurrence rate were also monitored. RESULTS: The mean age of the patients was 62â±â12 years. The median survival time after surgery was 16.0 months. Preoperative neurological status influenced survival time significantly; the median survival was 5.1 months in Frankel A-C and 28.2 months in Frankel D-E (Pâ<â0.001). Improvement on the Frankel scale did not influence the survival time (Pâ=â0.131). When the patients' age was <65 years this related to a significantly longer survival time (Pâ=â0.046). The Tokuhashi score predicted patient's survival independently (Pâ<â0.001). The other factors had no statistical significance. CONCLUSION: The most important factors influencing postoperative survival time of these patients with symptomatic spinal metastases was the preoperative neurological condition and the Tokuhashi scoring system, which together represents a useful tool for planning the extent of surgical treatment.