Atlas for Cholangioscopy and Cholecystoscopy: A Primer for Diagnostic and Therapeutic Endoscopy in the Biliary Tree and Gallbladder.

Percutaneous endoscopy of the biliary system (cholangioscopy) and gallbladder (cholecystoscopy) has significantly impacted diagnostic and therapeutic approaches to many diseases in interventional radiology, overcoming previous challenges related to scope size and rigidity. The current endoscopes offer enhanced maneuverability within narrow tubular structures such as bile ducts. Before endoscopy, reliance on 2D imaging modalities limited real-time visualization during percutaneous procedures. Percutaneous endoscopy provides 3D perspectives, enabling a better appreciation of normal structures, targeted biopsy of lesions, and accurate deployment of therapeutic interventions. This review aims to explore percutaneous endoscopic findings across various biliary and gallbladder pathologies.

Genicular Artery Embolization: Embolic Material and Imaging Review.

Osteoarthritis (OA) of the knee is a degenerative condition impacting numerous individuals globally. Genicular artery embolization (GAE) has emerged as an effective minimally invasive therapy for managing medically refractory OA-related pain in patients who are not eligible for surgery. This intervention works by disrupting the inflammatory and neoangiogenic pathways that contribute to pain. The efficacy of GAE has been demonstrated in various clinical trials, yielding promising results. This review aims to explore recent advancements in the embolic materials used during GAE, examining their properties and potential benefits. Additionally, it will describe the use of pre-, intra-, and postprocedural imaging-particularly magnetic resonance imaging and other modalities-to optimize GAE outcomes.

Combined Percutaneous Transhepatic Lymphatic Embolization and Peroral Duodenal Mucosal Radiofrequency Ablation to Manage Protein-Losing Enteropathy.

Percutaneous transhepatic lymphatic embolization (PTLE) and peroral esophagogastroduodenoscopy (EGD) duodenal mucosal radiofrequency (RF) ablation were performed to manage protein-losing enteropathy (PLE) in patients with congenital heart disease. Five procedures were performed in 4 patients (3 men and 1 woman; median age, 49 years; range, 31-71 years). Transhepatic lymphangiography demonstrated abnormal periduodenal lymphatic channels. After methylene blue injection through transhepatic access, subsequent EGD evaluation showed methylene blue extravasation at various sites in the duodenal mucosa. Endoscopic RF ablation of the leakage sites followed by PTLE using 3:1 ethiodized oil-to-n-butyl cyanoacrylate glue ratio resulted in improved symptoms and serum albumin levels (before procedure, 2.6 g/dL [SD ± 0.2]; after procedure, 3.5 g/dL [SD ± 0.4]; P = .004) over a median follow-up of 16 months (range, 5-20 months). Transhepatic lymphangiography and methylene blue injection with EGD evaluation of the duodenal mucosa can help diagnose PLE. Combined PTLE and EGD-RF ablation is an option to treat patients with PLE.

Factors influencing pregnancy rate and loss after laparoscopic artificial insemination with frozen-thawed semen in Lohi sheep under sub-tropical conditions.

This study evaluates factors influencing pregnancy rates per artificial insemination (P/AI) and pregnancy loss in Lohi ewes undergoing laparoscopic AI with frozen-thawed semen under sub-tropical conditions. Data from three experiments comprising ewes (n = 358) of mixed parity (nulliparous; NP and parous; P), various body condition score (BCS) and assigned to long-term (LTP, 11 days) and short-term (STP, 5 days) oestrus synchronization regimen across high breeding season (HBS) and low breeding season (LBS) were analysed. Laparoscopic insemination was conducted 54 h post-sponge removal. Pregnancy diagnosis and loss were evaluated on days 35 and 90 post-insemination via ultrasonography. Results showed parity significantly influenced P/AI, with nulliparous ewes achieving higher pregnancy ratios than parous ewes (p = .001). BCS significantly influenced P/AI (p < .05), with a quadratic relationship observed between BCS and season (BCS*BCS*Season; p = .07). Progestin treatment did not significantly influence the ratio of pregnant ewes (p = .07). Pregnancy losses were significantly higher during LBS than HBS (p < .05), irrespective of progestin treatment. In conclusion, parity and BCS significantly influenced P/AI, with BCS demonstrating a quadratic association with season. Ewes bred during LBS experienced higher pregnancy losses than HBS, irrespective of progestin treatment.

Percutaneous Endoscopy and Image-guided Retrieval of Dropped Gallstones - A Case Series.

BACKGROUND: Recurrent abscesses can happen due to dropped gallstones (DGs) after laparoscopic cholecystectomy (LC). Recognition and appropriate percutaneous endoscopy and image-guided treatment options can decrease morbidity associated with this condition. MATERIALS AND METHODS: We report a minimally invasive endoscopy and image-guided technique for retrieval of dropped gallstones in a series of 6 patients (M/F=3/3; median age: 75.5 years [68 to 82]) presenting with recurrent or chronic intra-abdominal abscesses secondary to dropped gallstones. Technical success was defined as the visualization and retrieval of all stones. DGs were identified on pre-procedure imaging. Number of abscesses recurrence was 12 (1/6), 1 (3/6), and 0 (2/6) with a median interval of 2 months (1 to 21) between cholecystectomy and abscess development. RESULTS: Percutaneous endoscopy and fluoroscopy guidance were utilized in all cases. Technical success was achieved in 4 patients (66%). The median procedure time was 65.8 minutes (39 to 136). The median fluoroscopy time and dose were 12.6 min (3.3 to 67) and 234 mGy (31 to 1457), respectively. There were no intraprocedure and postprocedure complications. No abscess recurrence was reported among successful procedures during a median follow-up of 193 days (51 to 308). CONCLUSION: Percutaneous image and endoscopy-guided lithotripsy/lithectomy are safe and effective. This technique is a suitable alternative to open surgery for dropped gallstones. LEVEL OF EVIDENCE: Level 4, Case Series.

Future of Artificial Intelligence in Surgery: A Narrative Review.

Artificial intelligence (AI) is the capability of a machine to execute cognitive processes that are typically considered to be functions of the human brain. It is the study of algorithms that enable machines to reason and perform mental tasks, including problem-solving, object and word recognition, and decision-making. Once considered science fiction, AI today is a fact and an increasingly prevalent subject in both academic and popular literature. It is expected to reshape medicine, benefiting both healthcare professionals and patients. Machine learning (ML) is a subset of AI that allows machines to learn and make predictions by recognizing patterns, thus empowering the medical team to deliver better care to patients through accurate diagnosis and treatment. ML is expanding its footprint in a variety of surgical specialties, including general surgery, ophthalmology, cardiothoracic surgery, and vascular surgery, to name a few. In recent years, we have seen AI make its way into the operating theatres. Though it has not yet been able to replace the surgeon, it has the potential to become a highly valuable surgical tool. Rest assured that the day is not far off when AI shall play a significant intraoperative role, a projection that is currently marred by safety concerns. This review aims to explore the present application of AI in various surgical disciplines and how it benefits both patients and physicians, as well as the current obstacles and limitations facing its seemingly unstoppable rise.

The Efficacy of Ketoconazole Containing Regimens in Castration-Resistant Prostate Cancer: A Systematic Review and Meta-Analysis.

Castration resistant prostate cancer (CRPC) is a challenging subset of prostate cancer associated with an extensive metastatic profile and high mortality. Ketoconazole is a nonselective steroid 17α-hydroxylase/17,20 lyase (CYP17A1) inhibitor and is employed as a second line treatment option for CRPC with an established efficacy profile in patients. The aim of this study is to assess the efficacy of ketoconazole containing regimens for CRPC in terms of prostate specific antigen (PSA) decline rate using a systematic review and meta-analysis. In this review, an electronic search was carried out on PubMed, Cochrane CENTRAL, Scopus, and Google Scholar to find relevant literature. Random effects model was used to assess pooled PSA decline rate and 95% CIs. Publication bias was assessed using the funnel plot symmetry and one-tailed Egger's and Begg's test. In all cases, P-value <.05 was indicative of significant results. The review is registered with PROSPERO: CRD42023466536. A total of 483 articles were retrieved after database searching, out of which 23 studies (having a total of 1315 patients) were included in the review based on prespecified criteria. The PSA decline rate was reported in the 14 observational studies (having 964 patients) and 9 experimental studies (having 351 patients). Pooled results revealed that 48.6% (95% CI 43.1-54.2; P-value <.001; I2 = 73.24%) of participants achieved more than 50% decline in PSA (602/1315 participants). Sensitivity analysis using the leave-one-out method revealed no substantial change in pooled effect estimates; (Risk Ratio) RR 47.2% to RR 49.8% demonstrating the robustness of our results. There was no evidence of publication bias as assessed from the funnel plot symmetry. Ketoconazole containing regimens have shown moderate efficacy in high risk CRPC patients as demonstrated by the pooled results. Hence, a ketoconazole based chemotherapy can be added to patients' regimen if there is a persistent rise in PSA levels after androgen deprivation therapy.

Rathke's cleft cyst abscess from Klebsiella.

Pituitary abscesses are uncommon lesions accounting for <1% of all pituitary diseases. We report a case of a female microbiology technician with a rare congenital heart disease who developed an Rathke's Cleft Cyst abscess from Klebsiella. A 26-year-old female biotechnician with a history of congenital heart disease and subclinical immunosuppression presented with a 10-month history of weight loss, amenorrhea, and visual deterioration. There was a history of previous unsuccessful transsphenoidal surgery. Radiology revealed a cystic lesion in the sellar region. The patient underwent an endoscopic endonasal intervention and the cystic cavity was washed with gentamicin, and the patient received meropenem postoperatively. The patient was followed up and had gradual improvement in her overall health, complete normality of her menstrual cycle, her visual field recovering to near normal and improving, no recurrence, and a stable cyst on magnetic resonance imaging.

Histiocytic Sarcoma Secondary to Gastrointestinal Stromal Tumors: A Literature Review.

Histiocytic sarcoma (HS) is a rare tumor that may result from the transdifferentiation of preexisting hematolymphoid neoplasms in a subset of patients. There are instances of correlation or concurrence between HS and a number of cancers, particularly B-cell-associated hematopoietic tumors. Only three cases of HS occurring subsequent to or concurrently with gastrointestinal stromal tumors (GIST) have been recorded. Our main objective was to give an overview of demographics, clinical signs and symptoms, histopathological findings, and immunohistochemical and molecular analysis when HS develops secondary to or concurrently with GIST. A search of PubMed, Google Scholar, and ScienceDirect was undertaken using Medical Subject Headings (MeSH) keywords. According to the findings of our review, there were two males (66.6%) and one female (33.3%). The average age of patients at presentation was 59.6 years. On the immunohistochemistry, three patients were positive for cluster of differentiation (CD) 68 (100%), two patients were positive for CD 163 (67%), one patient was positive for leukocyte common antigen (LCA) (33%), and only one patient was positive for CD 4, CD 10, CD 31, CD 45, human leukocyte antigen (HLA)-DR, lysozyme, and vimentin (33%). On molecular investigation, the gastric mass of only one patient (33.33%) contained a KIT mutation on exon 11. Emperipolesis was observed in one patient (33.33%) on histological examination. Our study provides an important overview of the available literature and gives insight into important diagnostic markers of HS when it occurs secondary to or concurrently with GIST.

Effect of plasma progesterone on oocyte recovery, oocyte quality, and early in-vitro developmental competence of embryos in Bos indicus dairy cows.

The objective of present study was to determine the effect of plasma progesterone (P4) on oocyte recovery, oocyte quality, and early in-vitro developmental competence of embryos in Bos indicus dairy cows. The ovaries were collected in an abattoir. These ovaries (n = 750) were divided into two groups: 1) estrous CYCLIC (n = 318), and 2) estrous ACYCLIC (n = 432). Mean serum concentrations of P4 in a subset of (n = 85; 4.21 ± 0.4 ng/ml compared with 0.5 ± 0.2 ng/ml; P < 0.05) were greater in estrous CYCLIC as compared to ACYCLIC cows, respectively. The mean number of oocytes recovered per ovary (6.5 ± 0.5 compared with 4.0 ± 0.2; P < 0.05) was greater for estrous CYCLIC than ACYCLIC cows, respectively. The oocytes with grade I_+_II quality (55.3% compared with 47.6%; P < 0.05) were greater, whereas, there was lesser percentage with grade III_+_IV quality (44.5% compared with 52.4%; P < 0.05) from estrous CYCLIC as compared with ACYCLIC cows, respectively. Cleavage rate (70.9% compared with 52.8%; P < 0.05) was greater for embryos derived from estrous CYCLIC than ACYCLIC cows, respectively. Similarly, the embryo developmental rates to the 8- (38.5% compared with 20.8%; P < 0.05) and 16- (20.0% compared with 10.9%; P < 0.05) cell stage were greater for embryos derived from estrous CYCLIC as compared to ACYCLIC cows, respectively. In conclusion, the presence of greater plasma P4 has a beneficial effect on oocyte recovery, oocyte quality, and early IVEP outcomes in Bos indicus dairy cows.

Equine chorionic gonadotropin (eCG) enhances reproductive responses in CIDR-EB treated lactating anovular Nili-Ravi buffalo during the breeding season.

The objective of this study was to evaluate the effect of equine chorionic gonadotropin (eCG) on the estrous response, ovulatory follicle development, ovulation rate, corpus luteum (CL) diameter, concentrations of progesterone (P4) and pregnancy per AI (P/AI) in CIDR-EB treated lactating anovular Nili-Ravi buffalo during the breeding season. Buffalo (n = 87), 60 to 200 Days postpartum were treated with CIDR at a random stage of the estrous cycle (Day 0) and assigned to two groups; with eCG (+eCG; n = 44), or without eCG (-eCG; n = 43). In both groups, each animal received 2 and 1 mg estradiol benzoate (EB) on Day 0 and then on Day 8, respectively. On Day 6, eCG and PGF2α were administered. On Day 7, CIDR were removed and FTAI was performed at 48 and 60 h later and pregnancy was diagnosed 35 Days post AI. The results revealed that eCG treatment increased (P <  0.05) the CL diameter on 15, 18, and 21 after the ovulation that resulted from imposing the estrous synchronization protocol than when eCG was not administered. Similarly, treatment with eCG resulted in an increased (P <  0.05) mean concentration of P4 as compared with animals not treated with eCG on Days 18 and 21 after the ovulation that occurred subsequent to imposing the estrous synchronization protocol. The ovulation rate was greater in eCG-treated buffalo as compared with those not treated with eCG (93% compared with 74%, respectively; P < 0.05). The P/AI was greater in buffalo treated with eCG than those not treated with eCG (56% compared with 31%, respectively; P < 0.05). In conclusion, the addition of eCG along with EB and P4 based treatments enhanced the estrous response, follicular and luteal function, ovulation rate, concentrations of P4, and P/AI in lactating anovular Nili-Ravi buffalo.

Effect of resynchronization with GnRH or progesterone (P4) intravaginal device (CIDR) on Day 23 after timed artificial insemination on cumulative pregnancy and embryonic losses in CIDR-GnRH synchronized Nili-Ravi buffaloes.

The objective of the present study was to determine the effect of resynchronization on Day 23 with either GnRH or P4 (controlled internal drug release device containing progesterone; CIDR) on pregnancy rate, cumulative pregnancy, and embryonic and fetal losses in CIDR-GnRH synchronized Nili-Ravi buffaloes. Buffaloes (n = 181) of mixed parity, lactating, 181 ± 73 days postpartum, a body condition score (BCS) of 3.2 ± 0.5 (scale of 1-5), and 450-600 kg weight were subjected to synchronization and resynchronization. All buffaloes received CIDR on Day -9.5. In addition, GnRH was injected 36 h after CIDR removal, and timed artificial insemination (TAI) was performed 18 h later (Day 0). On Day 23, buffaloes were randomly assigned to receive one of the following treatments: 1) CON (n = 63), 2) P4 (n = 55), and 3) GnRH (n = 63) for resynchronization (2nd AI). Pregnancy rate, and embryonic and fetal losses were monitored by serial ultrasonography on Days 30, 45, 60, and 90 after synchronization (1st TAI), respectively. The pregnancy rate in GnRH-treated buffaloes remained significantly and consistently higher (P < 0.05) than in the CON group at Days 30, 45, 60, and 90 after 1st TAI. Based on the pregnancy diagnosis, on Day 30 post 1st TAI, buffaloes that remained non-pregnant in the CON, P4, and GnRH groups received: 1) Artificial insemination on detected estrus (AIDE; n = 37), 2) CIDR-GnRH protocol (CIDR; n = 27), and 3) Ovsynch protocol (OVS; n = 23), respectively. The pregnancy rate in resynchronized buffaloes did not differ (P > 0.05) between the OVS and CIDR groups; whereas the, cumulative pregnancy rate in GnRH + OVS buffaloes (81%) after 1st and 2ndAI when determined on Day 64 was higher (P < 0.05) than that in CON + AIDE (59%) buffaloes. The embryonic losses were significantly lower (P < 0.05) in GnRH-treated (18%) buffaloes, than in CON (42%) buffaloes on Day 45 post 1st TAI. Fetal losses were fewer and did not differ (P > 0.05) due to treatments on Day 60 or 90 post 1st AI. In conclusion, 1) the pregnancy rate and cumulative pregnancy rate in GnRH-treated buffaloes were higher than in CON buffaloes on Day 64 after synchronization and resynchronization, and 2) embryonic and fetal losses were lower in GnRH-treated buffaloes than in CON buffaloes when determined from Day 31-90 post 1st TAI.

Effect of ovsynch versus prostaglandin F2α protocol on estrus response, ovulation rate, timing of ovulation and pregnancy per artificial insemination in Sahiwal cows.

Sahiwal cow is Bos indicus which is an important dairy breed of tropical and sub-tropical region. Research on reproduction is rare in this breed. The objectives of the present study were to determine the effect of Ovsynch (OVS) versus prostaglandin F2α (PG) protocol on estrus response and its intensity, ovulation rate, timing of ovulation and pregnancy per artificial insemination (AI) in Sahiwal cows. Experimental cows (n = 80) were of mixed parity, lactating, suckled, ≥120 days postpartum with body condition score 3.08 ± 0.34 and 375-475 kg of body weight which were randomly assigned to receive either OVS (n = 46) or PG (n =34) protocol. Cows were inseminated twice at 12 and 24 h after second gonadotropin releasing hormone in the OVS group, and 72 and 84 h after administration of prostaglandin F2α in PG group, respectively. The results revealed that estrus response did not differ (P > 0.05) and was 87% in OVS and 78% in PG cows. Ovulation rate did not differ (P > 0.05) and was 50% in both, OVS and PG cows. The pregnancy per AI did not differ (P > 0.05) and was 43% in OVS compared to 31% in PG cows. It is concluded that estrus response, ovulation rate and pregnancy per AI of OVS protocol is the same as PG in Sahiwal cows.

Effect of oestradiol benzoate on oestrus intensity and pregnancy rate in CIDR treated anoestrus nulliparous and multiparous buffalo.

The objective of the present study was to examine if administration of oestradiol benzoate (OEB) after removal of control internal drug releasing device (CIDR) could enhance oestrous intensity and pregnancy rate in anovular nulliparous and multiparous Nili-Ravi buffalo. For this, a total of 298 nulliparous (n=91) and multiparous (n=207) buffaloes received a CIDR on Day 0, and were administered PGF2α on Day 6 followed by removal of CIDR on Day 7. At Day 8, OEB was administered in approximately half of nulliparous (n=45/91) and multiparous (n=100/207) buffalo. All animals were fixed time inseminated 48 and 60h after CIDR removal, respectively. The results showed that administration of OEB but not the parity, improved oestrous intensity (3.15±0.05 vs 2.99±0.05; P=0.0026) compared to those not received OEB, respectively. However, OEB did not affect (46.2 vs 44.1; P=0.8) pregnancy per AI (P/AI). In addition, P/AI was greater (50.7 vs 39.6; P=0.036) in multiparous compared to nulliparous buffalo, respectively. The oestrous intensity (P=0.025) and response to OEB (P=0.0002) was greater in buffalo having a greater body condition (>3.0). Though, non significant, timing of ovulation was more synchronous (62.9±1.8 vs 72.4±3.6h; P>0.05) and ovulation rate was greater (91% vs 64%; P>0.05) in buffalo after OEB administration. It is concluded that administration of OEB in conjunction with the CIDR improves oestrous intensity without affecting P/AI in nulliparous and multiparous anovular buffalo.