Safety and usability of an endo staple line reinforcement device for pulmonary resections.

Background: Pulmonary resection can present technical challenges for surgeons due to the dissection and closure of tissues, which vary in thickness and elastic properties, occasionally leading to prolonged air leaks. Staple line reinforcements (SLRs) are widely utilized tools for fortifying the stability and integrity of closures in thoracic surgery, however, materials available and ease of use for both surgeon and scrub nurse have been suboptimal. A novel "click-and-go" device pre-loaded with bioabsorbable buttress material was recently developed, the Echelon Endopath SLR (ESLR, Ethicon, Inc., Cincinnati, OH, USA). This prospective study examines the safety and efficacy of this novel device in lung resections. Methods: Adult surgical candidates undergoing primary pulmonary resection (both open and thoracoscopic) where the ESLR would be used were enrolled. Exclusion included reoperation/revision in same anatomical location, hypersensitivity to polyglactin or related products, and body mass index (BMI) ≥46.0 kg/m2. The primary endpoint assessed the incidence of specific device-related adverse events (AEs): prolonged air leak and empyema. Additional endpoints included number of devices replaced during surgery due to slippage or bunching, and surgeon-reported usability responses. Data was summarized for AEs deemed device-related and usability questionnaire responses. Results: A total of 131 subjects were included in the primary endpoint analysis data set with 120 subjects completing the study (91.6%). The mean age at consent was 62.8±12.0 years and 55.7% were female. The most common primary indication for the procedure was malignancy 61.1%, and primary non-malignant lung disease (non-chronic obstructive pulmonary disease) 12.2%. Common procedures performed were wedge resection (58.0%) and lobectomy (34.4%). There were zero reported device-specific/-related AEs which counted toward the primary endpoint. Responses from a usability questionnaire found all surgeons (100.0%) reported the ease of setup was superior to previous devices utilized. Surgeons expressed greater confidence in the buttress material of the ESLR than that of previous SLR devices (strongly agree 88.9%; slightly agree 11.1%). Most also felt that there was less wastage with the click-and-go ESLR (strongly agree 77.8%, slightly agree 11.1%, neutral 11.1%). Conclusions: The ESLR device demonstrates safe and effective performance in this post-market study of specific thoracic procedures. Furthermore, surgeons found this was easier to use.

K-RAS Mutant Gene Found in Pancreatic Juice Activated Chromatin From Peri-ampullary Adenocarcinomas.

External pancreatic duct stents inserted after resection of pancreatic head tumors provide unique access to pancreatic juice analysis of genetic and metabolic components that may be associated with peri-ampullary tumor progression. For this pilot study, portal venous blood and pancreatic juice samples were collected from 17 patients who underwent pancreaticoduodenectomy for peri-ampullary tumors. Portal vein circulating tumor cells (CTC) were isolated by high-speed fluorescence-activated cell sorting (FACS) and analyzed by quantitative reverse transcription polymerase chain reaction (RT-PCR) for K-RAS exon 12 mutant gene expression (K-RASmut). DNA, chromatin, and histone acetylated active chromatin were isolated from pancreatic juice samples by chromatin immunoprecipitation (ChIP) and the presence of K-RASmut and other cancer-related gene sequences detected by quantitative polymerase chain reaction (PCR) and ChIP-Seq. Mutated K-RAS gene was detectable in activated chromatin in pancreatic juice secreted after surgical resection of pancreatic, ampullary and bile duct carcinomas and directly correlated with the number of CTC found in the portal venous blood (P = .0453). ChIP and ChIP-Seq detected acetylated chromatin in peri-ampullary cancer patient juice containing candidate chromatin loci, including RET proto-oncogene, not found in similar analysis of pancreatic juice from non-malignant ampullary adenoma. The presence of active tumor cell chromatin in pancreatic juice after surgical removal of the primary tumor suggests that viable cancer cells either remain or re-emerge from the remnant pancreatic duct, providing a potential source for tumor recurrence and cancer relapse. Therefore, epigenetic analysis for active chromatin in pancreatic juice and portal venous blood CTC may be useful for prognostic risk stratification and potential identification of molecular targets in peri-ampullary cancers.

Pancreatic and bile duct cancer circulating tumor cells (CTC) form immune-resistant multi-cell type clusters in the portal venous circulation.

Circulating tumor cells (CTC) enter the blood from many carcinomas and represent a likely source of metastatic dissemination. In contrast to the peripheral circulation, KRAS mutation- positive CTC thrive in the portal venous blood of patients with pancreatic ductal adenocarcinoma (PDAC). To analyze the essential interactions that contribute to carcinoma CTC growth and immune resistance, portal venous blood was collected during pancreatico-duodenectomy in 41 patients with peri-ampullary pathologies (PDAC = 11; ampullary adenocarcinoma (AA) = 15; distal cholangiocarcinoma (CC) = 6; IPMN = 7; non-malignant pancreatitis = 2). FACS-isolated cell populations from the portal circulation were reconstituted ex vivo using mixed cell reaction cultures (MCR). During the first 48hr, PDAC, AA, and CC patient CTC were all highly proliferative (mean 1.7 hr/cell cycle, 61.5% ± 20% growing cells) and resistant to apoptosis (mean 39% ±  25% apoptotic cells). PDAC CTC proliferation and resistance to T cell cytotoxicity were decreased among patients who received pre-operative chemotherapy (p = 0.0019, p = 0.0191, respectively). After 7 days in culture, CTC from PDAC, CC, and AA patients recruited multiple immune cell types, including CD105 + CD14 + myeloid fibroblasts, to organize into spheroid-like clusters. It was only in PDAC and CC-derived MCR that cluster formation promoted CTC survival, growth, and fibroblast differentiation. FACS depletion of CTC or myeloid fibroblast cells eliminated cluster network formation, and re-introduction of these cell populations reconstituted such ability. Our findings suggest that PDAC and CC CTC survival within the portal venous circulation is supported by their interactions with immune cells within multi-cell type clusters that could represent vectors of local recurrence and metastatic progression.

Portal Venous Blood Circulation Supports Immunosuppressive Environment and Pancreatic Cancer Circulating Tumor Cell Activation.

OBJECTIVES: Aggressive spread and liver metastases are predominant features of pancreatic ductal adenocarcinoma (PDAC). This study investigates activation of PDAC circulating tumor cells (CTC) and immunosuppression in the portal venous system. METHODS: Portal venous and peripheral blood were collected during pancreaticoduodenectomy from patients with PDAC (n = 21) or other non-PDAC pancreatic conditions (n = 20). Circulating tumor cells were isolated by fluorescence-activated cell sorting and characterized for messenger RNA (mRNA) expression and acetylated chromatin encoding K-RAS exon 12 mutation (K-RASmut). Myeloid-derived suppressor cells (MDSC) were identified using flow cytometry. RESULTS: Pancreatic ductal adenocarcinoma K-RASmut mRNA expression in portal venous blood CTC was significantly elevated compared with preoperative and postoperative peripheral blood (P = 0.0123 and P = 0.0246, respectively). There was no significant variation in total CTC numbers between portal and peripheral blood.Portal venous M-MDSC were elevated compared with peripheral blood in PDAC patients (P = 0.0065). M-MDSC increases correlated with K-RASmut mRNA-expressing CTC present in PDAC portal blood (P < 0.0001). CONCLUSIONS: Association of MDSC with active CTC in portal venous blood may support immunosuppression within the portal venous circulation to promote PDAC CTC survival.

Acupuncture for ovulation induction in polycystic ovary syndrome: a randomized controlled trial.

Acupuncture has been demonstrated to improve menstrual frequency and to decrease circulating testosterone in women with polycystic ovary syndrome (PCOS). Our aim was to investigate whether acupuncture affects ovulation frequency and to understand the underlying mechanisms of any such effect by analyzing LH and sex steroid secretion in women with PCOS. This prospective, randomized, controlled clinical trial was conducted between June 2009 and September 2010. Thirty-two women with PCOS were randomized to receive either acupuncture with manual and low-frequency electrical stimulation or to meetings with a physical therapist twice a week for 10-13 wk. Main outcome measures were changes in LH secretion patterns from baseline to after 10-13 wk of treatment and ovulation frequency during the treatment period. Secondary outcomes were changes in the secretion of sex steroids, anti-Müllerian hormone, inhibin B, and serum cortisol. Ovulation frequency during treatment was higher in the acupuncture group than in the control group. After 10-13 wk of intervention, circulating levels of estrone, estrone sulfate, estradiol, dehydroepiandrosterone, dehydroepiandrosterone sulfate, androstenedione, testosterone, free testosterone, dihydrotestosterone, androsterone glucuronide, androstane-3α,17ß-diol-3-glucuronide, and androstane-3α,17ß-diol-17-glucuronide decreased within the acupuncture group and were significantly lower than in the control group for all of these except androstenedione. We conclude that repeated acupuncture treatments resulted in higher ovulation frequency in lean/overweight women with PCOS and were more effective than just meeting with the therapist. Ovarian and adrenal sex steroid serum levels were reduced with no effect on LH secretion.

AutoDecon, a deconvolution algorithm for identification and characterization of luteinizing hormone secretory bursts: description and validation using synthetic data.

Hormone signaling is often pulsatile, and multiparameter deconvolution procedures have long been used to identify and characterize secretory events. However, the existing programs have serious limitations, including the subjective nature of initial peak selection, lack of statistical verification of presumed bursts, and user-unfriendliness of the application. Here we describe a novel deconvolution program, AutoDecon, which addresses these concerns. We validate AutoDecon for application to serum luteinizing hormone (LH) concentration time series using synthetic data mimicking real data from normal women and then comparing the performance of AutoDecon with the performance of the widely employed hormone pulsatility analysis program Cluster. The sensitivity of AutoDecon is higher than that of Cluster ( approximately 96% vs. 80%, P=0.001). However, Cluster had a lower false-positive detection rate than did AutoDecon (6% vs. 1%, P=0.001). Further analysis demonstrated that the pulsatility parameters recovered by AutoDecon were indistinguishable from those characterizing the synthetic data and that sampling at 5- or 10-min intervals was optimal for maximizing the sensitivity rates for LH. Accordingly, AutoDecon presents a viable nonsubjective alternative to previous pulse detection algorithms for the analysis of LH data. It is applicable to other pulsatile hormone concentration time series and many other pulsatile phenomena. The software is free and downloadable at http://mljohnson.pharm.virginia.edu/home.html.

Leptin secretory burst mass correlates with body mass index and insulin in normal women but not in women with polycystic ovary syndrome.

Leptin secretion exhibits a pulsatile, circadian pattern and may play a role in reproduction. No previous studies have compared leptin secretory burst characteristics in normal eumenorrheic women and women with polycystic ovary syndrome (PCOS) who are appropriately matched for body mass index (BMI). To determine if leptin secretory burst characteristics and/or the relationships of BMI, insulin, or testosterone to these characteristics differ between PCOS and normal women, we studied 9 normal eumenorrheic women and 9 women with PCOS. Each woman underwent blood sampling every 10 minutes for 24 hours to measure leptin and insulin under controlled conditions. Leptin secretory bursts were identified and characterized using multiparameter deconvolution procedures (Deconv), and the 24-hour periodicity of leptin was characterized with cosinor analysis. Relationships between BMI, area under the curve (AUC) insulin, and testosterone and leptin secretory burst characteristics in PCOS and normal women were sought using linear regression. There were no significant differences in mean serum leptin concentrations or in secretory burst characteristics between PCOS and normal women. Although the 24-hour serum leptin concentration correlated with BMI in both normal and PCOS women, leptin secretory burst mass correlated with BMI only in normal women. Similarly, the 24-hour serum leptin concentration correlated with serum insulin AUC in both normal and PCOS women; but insulin AUC correlated with leptin burst mass only in normal women. Although there was a strong trend toward a correlation between both mean 24-hour serum leptin concentration and leptin secretory burst mass with the serum testosterone concentration in normal women, such trends were not seen in PCOS women. Both normal and PCOS women exhibited a diurnal rhythm of leptin secretion with the peak occurring at night. However, neither the peak amplitude nor the timing of the peak amplitude differed between normal and PCOS women. The presence of strong relationships between BMI and insulin with both mean serum leptin and leptin secretory burst mass in normal women as opposed to PCOS women suggests that the mechanisms subserving leptin secretion differ in these 2 groups.