Delayed gastric emptying after classical Whipple or pylorus-preserving pancreatoduodenectomy: a randomized clinical trial (QUANUPAD).

PURPOSE: Pylorus-preserving pancreatoduodenectomy (PPPD) has been the gold standard for pancreatic head lesion resection for several years. Some studies have noted that it involves more delayed gastric emptying (DGE) than classical Whipple (i.e., pancreatoduodenectomy with antrectomy). Our working hypothesis was that the classical Whipple has a lower incidence of DGE. We aimed to compare the incidence of DGE among pancreatoduodenectomy techniques. METHODS: This pragmatic, randomized, open-label, single-center clinical trial involved patients who underwent classical Whipple (study group) or PPPD (control group). Gastric emptying was clinically evaluated using scintigraphy. DGE was defined according to the International Study Group of Pancreatic Surgery (ISGPS) criteria. The secondary endpoints were postoperative morbidity, length of hospital stay, anthropometric measurements, and nutritional status. RESULTS: A total of 84 patients were randomized (42 per group). DGE incidence was 50% (20/40, 95% confidence interval (95% CI): 35-65%) in the study group and 62% (24/39, 95% CI: 46-75%) in the control group (p = 0.260). No differences were observed between both groups regarding postoperative morbidity or length of hospital stay. Anthropometric measurements at 6 months post-surgery: triceps fold measurements were 12 mm and 16 mm (p = 0.021). At 5 weeks post-surgery, triceps fold measurements were 13 mm and 16 mm (p = 0.020) and upper arm circumferences were 26 cm and 28 cm (p = 0.030). No significant differences were observed in nutritional status. CONCLUSION: DGE incidence and severity did not differ between classical Whipple and PPPD. Some anthropometric measurements may indicate a better recovery with PPPD. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03984734.

Effectiveness and safety of perampanel as early add-on treatment in patients with epilepsy and focal seizures in the routine clinical practice: Spain prospective study (PERADON).

OBJECTIVE: Perampanel (PER) has been shown to be effective as an adjunctive therapy for controlling refractory focal-onset seizures (FOS). However, the information as early add-on for the treatment of FOS in the clinical practice is still scarce and must be further assessed. METHODS: An observational prospective study was conducted to evaluate the effectiveness of early add-on PER, assessed as 50% responders (seizure frequency reduced by at least 50% during the last 3 months as compared with baseline) rate at 6 and 12 months, in patients with FOS in the routine clinical practice of Spain. RESULTS: One hundred and thirteen patients (mean age: 40.3 years, 51.3% male) with FOS received PER as early add-on (1st add-on: 37.2% and 2nd: 62.8%) for a mean exposure of 11 months (mean PER dose: 6.3 mg/day at month 12). At 6 months, 50.4% and 20.4% of the patients were responders and seizure-free (respectively) relative to baseline (3 months prior to PER initiation), and at 12 months, 68.1% and 26.5% of the patients were responders and seizure-free (respectively), relative to baseline (3 months prior to PER initiation). The retention rate at 6 and 12 months was 83.2% and 80.5%, respectively. The percentage of seizure-free patients at 12 months was significantly (p = 0.033) higher when PER was added as first vs. second add-on. The number of concomitant antiepileptic drugs (AEDs) was significantly reduced from baseline to 6 and 12 months (p = 0.001). Treatment was simplified in 23.9% of patients at the end of the observation period. Drug-related adverse events (AEs), most mild or moderate, were reported in 30.1% of patients, with irritability (8%) and dizziness (7.1%) as the most frequent ones. CONCLUSIONS: This is the first observational, prospective study to evaluate efficacy and safety of early adjunctive treatment with PER in patients with focal epilepsy at 12 months. Perampanel demonstrated a good efficacy and safety profile when used at a median dose of 6 mg/day, regardless of the combination with other AEDs. Adverse events were mild or moderate, with dizziness being the most frequent one.

Randomized trial of two types of gastrojejunostomy after pancreatoduodenectomy and risk of delayed gastric emptying (PAUDA trial).

BACKGROUND: Delayed gastric emptying (DGE) is the most important cause of an extended hospital stay after pancreatoduodenectomy. Reports suggest that a Roux-en-Y gastroenteric anastomosis may have lower incidence of DGE than a Billroth II reconstruction. The primary aim of this RCT was to compare Billroth II (single loop) and Roux-en-Y (double loop) after pancreatoduodenectomy to determine whether Roux-en-Y reconstruction is associated with a lower incidence of DGE. Secondary endpoints were postoperative complications. METHODS: This was a randomized unblinded single-centre trial without masked evaluation of the main outcome. Patients undergoing pancreatoduodenectomy between 2013 and 2015 were randomized to undergo one of two types of gastroenteric anastomosis for reconstruction. RESULTS: A total of 80 patients were randomized, 40 in each group. The incidence of DGE was the same in patients undergoing Billroth II or Roux-en-Y gastroenteric anastomosis (both 18 of 40 patients; P = 1·000). The grade of DGE was also similar in the Billroth II and Roux-en-Y groups (grade A, both 10 of 40; grade B, 5 of 40 versus 6 of 40; grade C, 3 of 40 versus 2 of 40; P = 0·962). The mortality rate was 3 per cent, with no significant difference between the two groups. There were no differences in the overall rate of postoperative morbidity, relaparotomy rate or duration of hospital stay. CONCLUSION: The incidence and severity of DGE does not differ between single- or double-loop gastroenteric anastomosis performed after pancreatoduodenectomy. Registration number: NCT00915863 (http://www.clinicaltrials.gov).

Study of risk factors for delayed gastric emptying after partial pancretoduodenectomy.

INTRODUCTION: Delayed gastric emptying is one of the most frequent complications after pancreatoduodenectomy. METHODS: We performed an analysis of risk factors for delayed gastric emptying on a prospective database of 390 patients operated on between 2013 and 2021. A comparative retrospective study was carried out between patients with and without delayed gastric emptying and subsequently a study of risk factors for delayed gastric emptying using univariate and multivariate logistic regression models. RESULTS: The incidence of delayed gastric emptying in the overall series was 28%. The morbidity of the group was 63%, and postoperative mortality was 3.1%. Focusing on delayed gastric emptying, the median age (73 years vs 68 years, P < 0.001) and preoperative creatinine (75 vs 65.5, P < 0.001) were higher in the group with this complication. The study of risk factors showed that age over 60 years (P = 0.002) and pancreatic fistula (P < 0.001) were risk factors for delayed gastric emptying. CONCLUSION: The presence of pancreatic fistula is confirmed as a risk factor for slow gastric emptying after pancreaticoduodenectomy. In addition, age over 60 years is shown to be a risk factor for slow gastric emptying.

Preproenkephalin mRNA is expressed by C1 and non-C1 barosensitive bulbospinal neurons in the rostral ventrolateral medulla of the rat.

The autonomic regions of the thoracolumbar spinal cord receive a dense enkephalinergic (ENK) innervation from supraspinal sources, including the rostral ventrolateral medulla (RVLM). In the present study, we sought to determine whether the barosensitive bulbospinal (BSBS) neurons of the RVLM express preproenkephalin (PPE) mRNA. After injection of Fluoro-Gold (FG) into the upper thoracic spinal cord, neurons with PPE mRNA (PPE(+) neurons) were retrogradely labeled throughout the ventrolateral medulla. At the most rostral RVLM level, 29% of bulbospinal PPE+ cells were tyrosine hydroxylase-immunoreactive (TH-ir) and the latter constituted 19.4% of the bulbospinal TH-ir cells. We determined whether the bulbospinal PPE(+) RVLM neurons are barosensitive in two ways. First, we examined Fos production by FG-labeled RVLM neurons after 2 hours of hydralazine-induced hypotension (to 73 +/- 2 mm Hg) in conscious rats. Hydralazine (10 mg/kg i.v.) increased the number of Fos-ir neurons by two- to eightfold at all levels of the ventrolateral medulla examined. In the RVLM, 54% of bulbospinal PPE(+) neurons were Fos-ir, whereas such cells were more rarely found at caudal ventrolateral medullary levels. Second, we recorded individual BSBS RVLM units extracellularly in anesthetized rats and filled them juxtacellularly with biotinamide. Most biotinamide-filled neurons were PPE(+) (10 of 17), and the PPE(+) BSBS cells had a faster axonal conduction velocity than those without PPE mRNA (4.2 vs. 0.67 m/sec). Four of the 10 PPE(+) BSBS RVLM neurons were TH-ir. In summary, PPE mRNA is predominantly expressed by RVLM BSBS neurons with lightly myelinated spinal axons. PPE mRNA is present in most noncatecholaminergic BSBS neurons and also in approximately 20% of the bulbospinal C1 neurons. BSBS RVLM neurons most likely provide a major ENK input to sympathetic preganglionic neurons and PPE mRNA is the first identified positive phenotype of the non-C1 BSBS RVLM neurons.

[Adherence and fidelity in patients treated with intragastric balloon]. / Adherencia y fidelidad en el paciente tratado con balon intragastrico.

A correct treatment of obesity needs a program of habits modification regardless of the selected technique, especially if it is minimally invasive as the intragastric balloon (BIG). The adherence of the obese patients with regard to recommended drugs measures to medium- and long-term is less than 50%. Given that the results obtained using the technique of gastric balloon must be seen influenced by adherence to the modification of habits program and its fulfillment, we reviewed series published in attention to the program proposed with the BIG. The series published to date provide few details about the used Therapeutic Programs as well as the adherence of patients to them, and even less concerning the Monitoring Plan and the loyalty of the patient can be seen. We conclude the convenience to agree on a follow-up strategy, at least the 6 months during which the BIG remain in the stomach.

Drosophila Eye Nuclei Segmentation Based on Graph Cut and Convex Shape Prior.

The rapid advance in three-dimensional (3D) confocal imaging technologies is rapidly increasing the availability of 3D cellular images. However, the lack of robust automated methods for the extraction of cell or organelle shapes from the images is hindering researchers ability to take full advantage of the increase in experimental output. The lack of appropriate methods is particularly significant when the density of the features of interest in high, such as in the developing eye of the fruit fly. Here, we present a novel and efficient nuclei segmentation algorithm based on the combination of graph cut and convex shape prior. The main characteristic of the algorithm is that it segments nuclei foreground using a graph cut algorithm and splits overlapping or touching cell nuclei by simple convex and concavity analysis, using a convex shape assumption for nuclei contour. We evaluate the performance of our method by applying it to a library of publicly-available two-dimensional (2D) images that were hand-labeled by experts. Our algorithm yields a substantial quantitative improvement over other methods for this benchmark. For example, our method achieves a decrease of 3.2 in the Hausdorff distance and an decrease of 1.8 per slice in the merged nuclei error.

[Minimally invasive emergent techniques in obesity treatment]. / Técnicas mínimamente invasivas emergentes en el tratamiento de la obesidad.

INTRODUCTION: Obesity is a chronic disease for which several modalities of treatment are investigated today. One of them is the set of minimally aggressive techniques that have been added to the intragastric balloon. OBJECTIVE: To review the minimally invasive techniques described in the last years for the treatment of obesity. MATERIAL AND METHOD: It consisted in reviewing the bibliography through the habitual finders, in addition to the obtained data of the companies. They are classified in restrictive and malabsortive, and the restrictive are divides in mechanical or functional restriction. RESULT: Between mechanical restrictive the classified as we included in the restrictive emergent techniques the adjustable intragastric balloon, the intragastric prosthesis, the vertical endoluminal gastroplasty and the transoral gastroplasty. In order to obtain a functional restriction, we have the gastric pacemaker and the botulinic toxin. And finally, the endoluminal duodenojejunal bypass is described as a malabsortive technique. DISCUSSION: With less than 10 years of existence, it seems that the described techniques compensate their smaller effectiveness compared to the surgical techniques, with the absence of substantial modifications in the anatomy of the alimentary tract. None of these techniques is free of risks and complications.

[Informed consent in the intragastric balloon supported by SENPE, SEEDO, SEN and SECO: legal aspects]. / Consentimiento informado en el balón intragástrico avalado por SENPE, SEEDO, SEN y SECO: aspectos médico-legales.

INTRODUCTION: Intra-gastric balloon (IGB) is an invasive, temporary, non-surgical technique for the treatment of obesity. Its outcomes mainly depend on the patient's collaboration. OBJECTIVE: The aim was to adapt the informed consent used for bariatric surgery to a method that has especial characteristics. MATERIALS AND METHODS: We used the informed consent proposed by ASAC for bariatric surgery and 8 statements related to IGB included in the WESTLAW ES database. RESULTS: The review of the statements defines the IGB treatment as a curative-intended and non-satisfactive therapy with an obligation of the means used, but not the outcomes, by the treating physician. Moreover, the obligations of providing a correct and complete information -which includes the dietary regime- should be observed, as well as the possible therapeutic alternatives and finally, the proceeding used should be in written. CONCLUSIONS: The informed consent is a medico-legal document which content should consider the latest jurisprudence on the minimally invasive techniques for the treatment of obesity.

Estrogen protects against hypertension in the spontaneously hypertensive rat, but its protective mechanism is unrelated to impaired arterial muscle relaxation.

OBJECTIVES: To determine if estrogen acutely and directly alters arterial muscle relaxation, if estrogen is responsible for gender dichotomy in hypertension, and if arterial muscle from female spontaneously hypertensive rats (SHR) is slow to relax as is muscle from male SHR compared with arterial muscle of normotensive Wistar-Kyoto rats (WKY). METHODS: Relaxation rates of isometrically contracted arterial muscle from male rats were measured before and after addition of beta-estradiol. Blood pressure (BP) was monitored in intact male and female SHR and WKY and in ovariectomized and estrone-treated ovariectomized SHR and WKY. Relaxation rates of maximum isometric contractions of arterial muscle excised from male SHR and WKY and female SHR and WKY with varying chronic estrogen status were measured. RESULTS: Beta-estradiol had no direct, acute effect on arterial muscle force or relaxation. Intact and estrone-implanted SHR females had significantly lower BP than males. Ovariectomized SHR developed high BP equivalent to that of males. Arterial relaxation was slower in both male and female SHR compared with WKY. CONCLUSIONS: Estrogen lowers BP in female SHR. Strain differences in relaxation rates are independent of gender and estrogen status. Estrogen has no effect on arterial muscle relaxation, suggesting another mechanism for the protective effect of estrogen in hypertension.

H(2)O(2) mediates Ca(2+)- and MLC(20) phosphorylation-independent contraction in intact and permeabilized vascular muscle.

One purpose of the current study was to establish whether vasoconstriction occurs in all vessel types in response to H(2)O(2). Isometric force was measured in pulmonary venous and arterial rings, and isobaric contractions were measured in mesenteric arteries and veins in response to H(2)O(2). A second purpose was to determine whether H(2)O(2)-induced contraction is calcium independent. The addition of H(2)O(2) to calcium-depleted (using the Ca(2+) ionophore ionomycin in zero calcium EGTA buffer) muscle caused contraction. Furthermore, permeabilized muscle contracted in response to H(2)O(2) even in zero Ca(2+). The final purpose was to determine whether the 20-kDa regulatory myosin light chain (MLC(20)) phosphorylation plays a role in H(2)O(2)-induced contraction. Pulmonary arterial strips were freeze-clamped at various time points during H(2)O(2)-induced contractions, and the relative amounts of phosphorylated MLC(20) were measured. H(2)O(2) caused dose-dependent contractions that were independent of MLC(20) phosphorylation. ML-9, a myosin light chain kinase inhibitor, had no effect on the H(2)O(2) contractile response. In conclusion, H(2)O(2) induces Ca(2+)- and MLC(20) phosphorylation-independent contraction in pulmonary and systemic arterial and venous smooth muscle.

MAPK and PKC activity are not required for H(2)O(2)-induced arterial muscle contraction.

H(2)O(2)-induced pulmonary arterial smooth muscle (PASM) contractions are independent of Ca(2+) and myosin light chain phosphorylation. The purpose of this study was to determine whether mitogen-activated protein kinase (MAPK), extracellular signal-regulated kinase (ERK) 1 and ERK2, or protein kinase C (PKC) activation is required for H(2)O(2)-induced contraction. Porcine PASM strips were stimulated with 1 mM H(2)O(2), 120 mM KCl, or 10 microM phorbol myristic acetate and freeze clamped at various times during the contractions. Changes in relative amounts of tyrosine/threonine phosphorylated MAPK compared with total MAPK were measured. MAPK tyrosine phosphorylation levels increased in correlation with tension development. However, 50 microM PD-98059, a MAPK/ERK kinase-MAPK kinase blocker, reduced MAPK phosphorylation below resting levels, even though the magnitude of the isometric tension development was unaltered. Freeze-clamped PASM strips were placed in a PKC activity assay buffer containing (32)P and CaCl(2) to measure the total myelin basic protein phosphorylation. The data show that: 1) the time courses of PKC activity and force produced in response to H(2)O(2) do not correlate, and 2) MAPK activation may be a concurrent event with, or a consequence of, tension development in response to a variety of agonists but is not responsible for contractions to H(2)O(2), high K(+), or phorbol esters.

Intracellular and extracellular calcium utilization during hypoxic vasoconstriction of cyclostome aortas.

Hypoxic vasoconstriction (HV) is an intrinsic response of mammalian pulmonary and cyclostome aortic vascular smooth muscle. The present study examined the utilization of calcium during HV in dorsal aortas (DA) from sea lamprey and New Zealand hagfish. HV was temporally correlated with increased free cytosolic calcium (Ca2+c) in lamprey DA. Extracellular calcium (Ca2+o) did not contribute significantly to HV in lamprey DA, but it accounted for 38.1 +/- 5.3% of HV in hagfish DA. Treatment of lamprey DA with ionomycin, ryanodine, or caffeine added to thapsigargin-reduced HV, whereas HV was augmented by BAY K 8644. Methoxyverapamil (D600) in zero Ca2+o did not affect HV in lamprey DA, nor did it prevent further constriction when Ca2+o was restored during hypoxia in hagfish DA. Removal of extracellular sodium (Na+o) caused a constriction in both species. Lamprey DA relaxed to prehypoxic tension following return to normoxia in zero Na+o, whereas relaxation was inhibited in hagfish DA. Relaxation following HV was inhibited in lamprey DA when Na+o and Ca2+o were removed. These results show that HV is correlated with [Ca2+]c in lamprey DA and that Na+/Ca2+ exchange is used during HV in hagfish but not lamprey DA. Multiple receptor types appear to mediate stored intracellular calcium release in lamprey DA, and L-type calcium channels do not contribute significantly to constriction in either cyclostome.