The Clinical Impact of Different Types of Preoperative Biliary Intervention on Postoperative Biliary Tract Infection of Patients Undergoing Pancreaticoduodenectomy.

Background: For patients with obstructive jaundice and who are indicated for pancreaticoduodenectomy (PD) or biliary intervention, either endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography and drainage (PTCD) may be indicated preoperatively. However, the possibility of procedure-related postoperative biliary tract infection (BTI) should be a concern. We tried to evaluate the impact of ERCP and PTCD on postoperative BTI. Methods: Patients diagnosed from June 2013 to March 2022 with periampullary lesions and with PD indicated were enrolled in this cohort. Patients without intraoperative bile culture and non-neoplastic lesions were excluded. Clinical information, including demographic and laboratory data, pathologic diagnosis, results of microbiologic tests, and relevant infectious outcomes, was extracted from medical records for analysis. Results: One-hundred-and-sixty-four patients from the cohort (164/689) underwent preoperative biliary intervention, either ERCP (n = 125) or PTCD (n = 39). The positive yield of intraoperative biliary culture was significantly higher in patients who underwent ERCP than in PTCD (90.4% vs. 41.0%, p < 0.001). Although there was no significance, a trend of higher postoperative BTI (13.8% vs. 2.7%) and BTI-related septic shock (5 vs. 0, 4.0% vs. 0%) in the ERCP group was noticed. While the risk factors for postoperative BTI have not been confirmed, a trend suggesting a higher incidence of BTI associated with ERCP procedures was observed, with a borderline p-value (p = 0.05, regarding ERCP biopsy). Conclusions: ERCP in patients undergoing PD increases the positive yield of intraoperative biliary culture. PTCD may be the favorable option if preoperative biliary intervention is indicated.

Prognostic Factors and the Role of Adjuvant Chemotherapy in Pathological Node-Negative T3 Gastric Cancer.

The role of adjuvant chemotherapy in pathological T3N0M0 (pT3N0M0) gastric cancer (GC) remains unclear. The aim of this study was to analyze the prognostic factors of patients with pT3N0M0 GC and to clarify which ones could benefit from adjuvant chemotherapy. A total of 137 patients with pT3N0M0 GC were recruited between 1994 and 2020. Clinicopathological factors and adjuvant chemotherapy regimens were retrospectively collected. Prognostic factors of disease-free survival (DFS) and cancer-specific survival (CSS) were determined using univariate and multivariate analyses. The chemotherapy group was younger (p = 0.012), had had more lymph nodes retrieved (p = 0.042) and had higher percentages of vascular invasion (p = 0.021) or perineural invasion (p = 0.030) than the non-chemotherapy group. There were no significant differences in DFS (p = 0.222) and CSS (p = 0.126) between patients treated with or without adjuvant chemotherapy. Stump cancer, tumor size and perineural invasion were associated with higher rates of recurrence. Tumor size was an independent prognostic factor for DFS (hazard ratio, 4.55; confidence interval, 1.59-12.99; p = 0.005) and CSS (hazard ratio, 3.97; confidence interval, 1.38-11.43; p = 0.011). Tumor size independently influenced survival outcomes in pT3N0M0 patients who underwent radical surgery with and without adjuvant chemotherapy.

Risk factors of recurrent secondary hyperparathyroidism after adequate primary surgical treatment.

Background: Secondary hyperparathyroidism (SHPT) is a common condition in patients with end-stage renal disease (ESRD) who are on dialysis. Parathyroidectomy is a treatment for patients when medical therapy has failed. Recurrence may occur and is indicated for further surgery in the era of improved quality of care for ESRD patients. Methods: We identified, 1060 patients undergoing parathyroidectomy from January, 2011 to June, 2020. After excluding patients without regular check-up at our institute, primary hyperparathyroidism, or malignancy, 504 patients were enrolled. Sixty-two patients (12.3%, 62/504) were then excluded due to persistent SHPT even after the first parathyroidectomy. We aimed to identify risk factors for recurrent SHPT after the first surgery. Results: During the study period, 20% of patients who underwent parathyroidectomy at our institute (in, 2019) was due to recurrence after a previous parathyroidectomy. There were 442 patients eligible for analysis of recurrence after excluding patients with the persistent disease (n = 62). While 44 patients (9.95%) had recurrence, 398 patients did not. Significant risk factors for recurrent SHPT within 5 years after the first parathyroidectomy, including dialysis start time to first operation time < 3 years (p = 0.046), postoperative PTH >106.5 pg/mL (p < 0.001), and postoperative phosphorus> 5.9 mg/dL (p = 0.016), were identified by multivariate analysis. Conclusions: The starting time of dialysis to first operation time < 3 years in the patients with dialysis, postoperative PTH> 106.5 pg/mL, and postoperative phosphorus> 5.9 mg/dL tended to have a higher risk for recurrent SHPT within 5 years after primary treatment.

Metabolism of Proteins and Amino Acids in Critical Illness: From Physiological Alterations to Relevant Clinical Practice.

The clinical impact of nutrition therapy in critically ill patients has been known for years, and relevant guidelines regarding nutrition therapy have emphasized the importance of proteins. During critical illness, such as sepsis or the state following major surgery, major trauma, or major burn injury, patients suffer from a high degree of stress/inflammation, and during this time, metabolism deviates from homeostasis. The increased degradation of endogenous proteins in response to stress hormones is among the most important events in the acute phase of critical illness. Currently published evidence suggests that adequate protein supplementation might improve the clinical outcomes of critically ill patients. The role of sufficient protein supplementation may even surpass that of caloric supplementation. In this review, we focus on relevant physiological alterations in critical illness, the effects of critical illness on protein metabolism, nutrition therapy in clinical practice, and the function of specific amino acids.

Impact of the highest amylase level in drain fluid on surgical outcomes and postoperative interventions in patients undergoing pancreaticoduodenectomy.

OBJECTIVES: The clinical significance of the highest drain fluid amylase (DFA) level beyond pancreaticoduodenectomy (PD) postoperative day three (POD 3) remains unclear. This study investigated the impact of highest DFA level beyond POD 3 on postoperative pancreatic fistula (POPF) severity and outcomes of patients undergoing PD with POPF. METHODS: Patient demographics of biochemical POPF and clinically relevant POPF (CR-POPF) were compared. Predictive factors were assessed using binary logistic regression. Receiver operating characteristic curve analysis was performed to determine the optimal cutoff value of highest DFA (beyond POD 3). We compared length of hospital stay, surgical mortality rates, and need for postoperative interventions by highest DFA level. RESULTS: Patients with CR-POPF had an older age (p = 0.039), required intraoperative blood transfusion (p = 0.006), and had greater highest DFA levels (p = 0.001) than those with biochemical POPF. The optimal highest DFA cutoff was 2014.5 U/L. Multivariate analysis showed that percentage of patients with intraoperative blood transfusion (p = 0.011; odds ratio, 3.716) and a highest DFA > 2014.5 U/L beyond POD 3 (p = 0.001; odds ratio, 5.722) was predictive of CR-POPF. CONCLUSION: Highest DFA > 2014.5 U/L beyond POD 3 is an independent predictor for CR-POPF. At a highest DFA >2014.5 U/L, 30-day surgical mortality rate, length of stay, and need for postoperative interventions did not differ.

Alternative application of percutaneous cholecystostomy in patients with biliary obstruction.

PURPOSE: Percutaneous cholecystostomy (PC) is an important modality for acute cholecystitis and has been applied for other clinical scenarios as well. In the present study, we aimed to investigate an alternative use of PC for obstructive jaundice. METHODS: From January 2012 to December 2018, eligible subjects were selected from patients undergoing PC in our institute. The characteristics, spectrum of underlying disease, indication for PC performance, details of the procedure, and treatment effect were all investigated. RESULTS: During the study period, 1364 patients underwent PC. Seventy patients fulfilled the defined inclusion criteria. While 47 patients were diagnosed with malignant biliary obstruction with or without cholangitis, 23 patients were diagnosed with nonmalignant biliary obstruction and acute cholangitis. There were 63 patients (90%) diagnosed with acute cholangitis. Pancreatic cancer (n = 24, 51%) and advanced malignancy (n = 28, 59%) were noted mostly in the group with malignant biliary obstruction. Treatment effects were proven by laboratory data, including the white blood cell count, C-reactive protein level, and hepatic function. CONCLUSION: PC can temporize definitive therapies and serve as an alternative treatment for patients with nonmalignant conditions. For patients with advanced malignancy, PC can serve as a palliative procedure that has a high success rate and low complication rate and effectively relieves biliary obstruction.

Surgical options for submucosal tumors near the esophagogastric junction: does size or location matter?

BACKGROUND: Submucosal tumors (SMTs) of different etiologies exist from esophagus to rectum. Esophagogastric junction (EGJ) is one of the known difficult locations for tumor resection. Although minimally invasive surgery (MIS) is a well-established approach for gastrointestinal surgery, there is no consensus that MIS for resection of SMTs around EGJ is superior to laparotomy. We tried to clarify the factors that determine the surgeons' choices between these two approaches. METHODS: From January 2002 to June 2016, 909 patients with SMTs underwent resection in our department. Among them, 119 patients (13%) had SMTs around EGJ were enrolled by retrospective review. The clinicopathological features and tumor-related parameters were reviewed and analyzed. RESULTS: The cohort was stratified into three groups according to the extent of gastrectomy and surgical approaches. The three groups are as following: major gastrectomy (n = 13), minor gastrectomy by laparotomy (n = 51), and minor gastrectomy with MIS (n = 55). The average tumor size was significantly larger in the major gastrectomy group than in the two minor gastrectomy groups; however, there was no difference between the two minor gastrectomy groups (5.33 cm, 4.07 cm, and 3.69 cm, respectively). The minor gastrectomy with MIS required least hospital stay and operation duration also. We re-stratify the two minor gastrectomy groups (n = 106) according to the orientation of SMTs around the EGJ into 4 zones. Most of SMTs located on the greater curvature side of the EGJ were resected with MIS (82% versus 18%), whereas SMTs in the other zones were resected more often by laparotomy (59% versus 41%). There was no surgical mortality within the cohort, while minor gastrectomy with MIS yielded least number of leakages among the three groups. CONCLUSIONS: For SMTs around the EGJ, larger tumors (diameter of more than 5 cm) are more likely to be resected with major gastrectomy. To resect SMTs around the EGJ in a wedge-like (minor gastrectomy) fashion, tumors located other than the greater curvature side were more often resected by laparotomy. However, MIS yielded acceptable safety and surgical outcomes compared to conventional laparotomy for SMTs around the EGJ of the same size.

Modification and Compounding of CaMgAl-Layered Double Hydroxides and Their Application in the Flame Retardance of Acrylonitrile-Butadiene-Styrene Resin.

CaMgAl-layered double hydroxides (CaMgAl-LDHs) were synthesized by a co-precipitation method to prepare sodium oleate-modified, borate-intercalated CaMgAl-LDHs (O-CaMgAl-LDHs) using in-situ intercalation and modification, and the LDHs samples were characterized by X-ray diffraction (XRD), Fourier transform infrared spectroscopy (FT-IR), field emission scanning electron microscopy (FESEM), and thermal gravimetric analysis (TGA). The FESEM observations showed that the as-prepared CaMgAl-LDHs had a lamellar structure with a particle size of 200~500 nm, while the O-CaMgAl-LDHs had a plate-like structure with a particle size of about 100 nm. TGA showed that O-CaMgAl-LDHs resulted in higher thermal stability at high temperature compared to CaMgAl-LDHs. O-CaMgAl-LDHs/ABS composites were prepared by adding O-CaMgAl-LDHs to acrylonitrile-butadiene-styrene resin (ABS) to test the resulting flame retardancy and mechanical properties, and the results showed that the limiting oxygen index (LOI) could increase from 18% to 26%, while the mechanical properties decreased significantly when the added fraction was 40% (relative to ABS). O-CaMgAl-LDHs, ammonium polyphosphate (APP) and expandable graphite (EG) were added into the ABS to prepare ABS composites, and the effects of different compositions on the flame retardancy and mechanical properties of the ABS composites were investigated. The results showed that, when adding 5 g of O-CaMgAl-LDHs, 1 g of APP, and 14 g of EG into 40 g of ABS, the LOI of the ABS composite reached 28.8%, and the composite prepared could meet the V-0 grade requirements of the UL-94 combustion test, while the flexural strength decreased only 21.9% compared to pure ABS, the smallest decrease compared to all of the other composites.

Transdermal Delivery of Luteinizing Hormone-releasing Hormone with Chitosan Microneedles: A Promising Tool for Androgen Deprivation Therapy.

Long-term administration of luteinizing hormone-releasing hormone analogs (LHRHa) is the main type of androgen-deprivation therapy (ADT) for lethal prostate cancer. A fully insertable microneedle system, composed of embeddable chitosan microneedles and a dissolvable polyvinyl alcohol/polyvinyl pyrrolidone supporting array, was developed for sustained delivery of LHRHa to the skin. A porcine cadaver skin test showed that chitosan microneedles can be fully embedded within the skin and microneedle-created micropores reseal within 7 days. The measured LHRHa loading amount was 73.3±2.8 µg per microneedle patch. After applying goserelin-containing microneedles to mice, serum LH levels increased initially and then declined below baseline at day 7. In contrast, serum testosterone levels increased to reach a peak at day 14 and then declined to a castration level at day 21. Additionally, such a castration level was maintained for 2 weeks. Therefore, transdermal delivery of goserelin with embeddable chitosan microneedles can produce a castrated state in mice. Such a system is a promising, feasible means of delivering ADT.

Efficacy of External Beam Radiation-Based Treatment plus Locoregional Therapy for Hepatocellular Carcinoma Associated with Portal Vein Tumor Thrombosis.

Background. Portal vein tumor thrombosis (PVTT) is a common event in advanced hepatocellular carcinoma (HCC). The optimal treatment for these patients remains controversial. Methods. A retrospective review of 149 patients who had unresectable HCC associated with PVTT between January 2005 and December 2012 was performed. Outcomes related to external beam radiation-based treatment were measured, and clinicopathological features and parameters affecting prognosis were analyzed as well. Results. The radiotherapeutic response of PVTT was an important element that affected the overall treatment response of HCC. Serum α-fetoprotein < 400 ng/mL, the presence of a radiotherapeutic response on PVTT, and receiving additional locoregional therapy were significant prognostic factors affecting the survival of patients. Patients who had received additional locoregional therapy obtained a better outcome, and six of them were eventually able to undergo surgical management with curative intent. Conclusion. The outcome of HCC associated with PVTT remains pessimistic. In addition to the current recommended treatment using sorafenib, a combination of external beam radiotherapy targeting PVTT and locoregional therapy for intrahepatic HCC might be a promising strategy for patients who had unresectable HCC with PVTT. This approach could perhaps offer patients a favorable outcome as well as a possible cure with following surgical management.

Genome-based expression profiling as a single standardized microarray platform for the diagnosis of endometrial disorder: an array of 126-gene model.

OBJECTIVE: To assess the molecular signatures underlying endometrial disorder using cDNA microarray. DESIGN: Gene expression-based oligonucleotide array of the normal endometrium. SETTING: University hospital. PATIENT(S): Humans. INTERVENTION(S): Endometrial tissues were obtained from 28 normal cycling women undergoing endometrial biopsy. RNA was extracted from each tissue and all labeled samples were hybridized to Affymetrix Human U133 plus 2.0 array. MAIN OUTCOME MEASURE(S): Transcriptional response. RESULT(S): Hierarchical cluster analysis with the Mahalanobis distance revealed a "126-gene" model, which are up-regulated at mid-secretory phase, moderately expressed at late-secretary phase, and down-regulated at late-secretory phase. Furthermore, the mechanisms underlying the receptivity of human endometrium at mid-secretary phase can be summarized: first, complex metabolic reactions are involved. Second, the activation of complement and coagulation cascades promotes muscle contraction, chemotaxis, phagocyte recruitment, and peritoneal inflammation. Third, Ephrin A-mediated axon guidance promotes retrograde menstruation. Fourth, autophagic degradation is suggested to be responsible for the new blood vessel formation. In addition, DKK1 is up-regulated, indicating that WNT signaling pathway may contribute to the development of endometrial disorders. CONCLUSION(S): The success of this innovation has supported the use of microarray-based genome expression profiling as a single standardized platform for diagnosis of endometrial disorders.

Genome-based expression profiles as a single standardized microarray platform for the diagnosis of bladder pain syndrome/interstitial cystitis: an array of 139 genes model.

INTRODUCTION AND HYPOTHESIS: The aim of the study was to investigate the molecular signatures underlying bladder pain syndrome/interstitial cystitis (BPS/IC) using cDNA microarray. METHODS: Microarray gene expression profiles were [corrected] studied in a matched case-control study [corrected] by using a system of conditional regression modeling. RESULTS: The main [corrected] findings are summarized as follows: Firstly, a "139-gene" model was discovered to contain high expressions of bladder epithelium, which feature in BPS/IC. Secondly, complex metabolic reactions, including carbohydrate, lipid, cofactors, vitamins, xenobiotics, nucleotide, and amino acid metabolisms, were [corrected] found to have a strong relationship with bladder smooth muscle contraction through IC status. Thirdly, we [corrected] found the transcriptional regulations of IC-induced bladder smooth muscle contraction status, including the level of contractile force, tissue homeostasis, energy homeostasis, and the development of the [corrected] nervous system. In addition, our study suggested the mast-cell activation mediated by the high-affinity receptor of Fc epsilon [corrected] RI triggering allergic inflammation through IC status. Such genetic changes, jointly termed "bladder remodeling," [corrected] can constitute an important long-term consequence of BPS/IC. [corrected]. CONCLUSIONS: The success of this innovation has supported the use of microarray-based expression profiling as a single standardized platform for diagnosis of PBS/IC and offers [corrected] drug discovery.

Genome-based expression profiles as a single standardized microarray platform for the diagnosis of experimental interstitial cystitis: an array of 75 genes model.

INTRODUCTION AND HYPOTHESIS: To investigate the molecular signature underlying experimental interstitial cystitis (IC) using cDNA microarray. METHODS: Microarray gene expression profiles are studied in bladder epithelium of C57BL/6 mice with ovalbumin or substance P-induced experimental IC versus Escherichia coli lipopolysaccharide-induced bacterial cystitis. RESULTS: Main findings are summarized as follows: firstly, a "75-gene" model was discovered to contain high expressions of bladder epithelium which feature in experimental IC. Secondly, glucose, lipid, nucleotide, xenobiotics, and amino acid metabolisms are involved in. Thirdly, T-cell-mediated immune and inflammatory responses are observed. Fourthly, Wnt, Tgf-beta, Mapk, and insulin growth factor receptor signaling pathways are also involved in. In addition, experimental IC leads to Ephrin- and Semaphorin-mediated axon guidance promoting parasympathetic inflammatory reflexes. CONCLUSIONS: Further characterization of human IC-induced gene expression profiles would enable the use of genome-based expression profiling for the therapeutic targets and diagnosis of IC.