A nomogram for prediction of ERCP success in patients with bile duct leaks: a multicenter study.

BACKGROUND: Bile duct leaks (BDLs) are serious complications that occurs after hepatobiliary surgery and trauma, leading to rapid clinical deterioration. Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment for BDLs, but it is not clear which patients will respond to this therapy and which patients will require additional surgical intervention. The aim of our study was to explore the predictors of successful ERCP for BDLs. METHODS: A retrospective analysis was conducted using data from six centers' databases. All consecutive patients who were clinically confirmed as BDLs were included in the study. Collected data were demographics, disease severity, and ERCP procedure characteristics. Univariate and multivariate analysis were used to select independent predictive factors that affect the outcome of ERCP for BDLs, and a nomogram was established. Calibration and ROC curves were used to evaluate the models. RESULTS: Four hundred and forty-eight consecutive patients were clinically confirmed as BDLs and 347 were excluded. In the 101 patients included patients, clinical success was achieved in 78 patients (77.2%). In logistic multivariable regression, two independent factors were negatively associated with the success of ERCP: SIRS (OR, 0.183; 95% CI 0.039-0.864; P = 0.032) and high-grade leak (OR 0.073; 95% CI 0.010-0.539; P = 0.010). Two independent factors were positively associated with the success of ERCP: leak-bridging drainage (OR 4.792; 95% CI 1.08-21.21; P = 0.039) and cystic duct leak (OR 6.193; 95% CI 1.03-37.17; P = 0.046). The prediction model with these four factors was evaluated using a receiver-operating characteristic (ROC) curve, which demonstrated an area under the curve of 0.9351. The calibration curve showed that the model had good predictive accuracy. CONCLUSION: Leak-bridging drainage and cystic duct leak are positive predictors for the success of ERCP, while SIRS and high-grade leak are negative predictors. This prediction model with nomogram has good predictive ability and practical clinical value, and may be helpful in clinical decision-making and prognostication.

Risk factors for complications in elderly patients aged 85 years and over undergoing endoscopic biliary stone removal.

Background and aim: The number of elderly patients with biliary stones is increasing. Endoscopic retrograde cholangiography (ERCP) is considered to be an effective treatment for biliary stones. Having a sound knowledge of the risk factors can help reduce the incidence and severity of complications for ERCP. Furthermore, limited research has been published on patients aged over 85 years undergoing endoscopic biliary stone removal. This study aims to determine the risk factors that lead to complications of ERCP in patients over 85 years of age. Methods: This was a single-center retrospective study. We analyzed 156 patients aged ≥ 85 years with biliary stones who underwent their first ERCP at Chinese PLA General Hospital from February 2002 to March 2021. Logistic regression models were employed to identify the independent risk factors for complications. Results: A total of 13 patients (8.3%) had complications. Thereinto, pancreatitis, cholangitis, bleeding, and other complications occurred in 4 cases (2.6%), 1 cases (0.6%), 4 cases (2.6%), and 4 cases (2.6%), respectively. There was no perforation or death related to ERCP. Independent risk factors for complications were acute biliary pancreatitis (ABP) (P = 0.017) and Charlson Comorbidity Index (CCI) (P = 0.019). Significantly, reasons for incomplete stone removal at once were large stone (>10 mm) (P < 0.001) and higher acute physiology and chronic health evaluation scoring system (APACHE-II) (P = 0.005). Conclusions: ERCP was recommended with caution in patients ≥ 85 years of age with ABP or higher CCI undergoing endoscopic biliary stone removal. In patients with ABP without cholangitis or biliary obstruction we recommend against urgent (within 48 h) ERCP. Patients with higher CCI who can tolerate ERCP can undergo rapid ERCP biliary stenting or nasobiliary implantation with later treatment of stones, and patients who cannot tolerate ERCP are treated promptly with PTCD and aggressive conservative treatment.

Safety and efficacy of therapeutic endoscopic retrograde cholangiopancreatography for patients over 90 years of age.

AIMS: This study aimed to explore the safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP) in patients over 90 years of age. METHODS: The study included 176 patients aged over 85 years who received their ERCP from February 2002 to January 2021. In the case group (super-elderly group), 44 patients were 90 years old or above. In the control group (younger group), there were 132 patients aged 85-89 years. The control group was matched according to patient gender and the same indications of ERCP at a 1:3 ratio. Logistic regression models were employed to evaluate all complications. RESULTS: The case group had higher acute physiology and chronic health evaluation scoring system (APACHE-II) scores and rate of hypoalbuminemia. APACHE-II scores (≥6 or 7) were significantly more common in the case group. The rates of technical success and complete success in the case group were 100% and 100% respectively, which were similar to the rates in the control group, namely a technical success rate of 98.5% and a complete success rate of 98.5%. The rate of complication in the case group was 9.1%, which was slightly lower than that of the control group (15.2%, P > 0.05). ERCP-related death occurred in one patient in the control group, who had malignant biliary obstruction and died from cholangitis. There was no significant difference in the incidence of complications such as pancreatitis, hemorrhage, and infection between the two groups. In the multivariate analysis, the independent risk factor was Charlson Comorbidity Index (CCI) for overall complication. CONCLUSIONS: ERCP can be performed safely and successfully in patients aged ≥90 years. Geriatr Gerontol Int 2022; 22: 50-55.

Effect of Acupuncture on the Notch Signaling Pathway in Rats with Brain Injury.

OBJECTIVE: To observe the effect of acupuncture on the Notch signaling pathway in rats with traumatic brain injury and to explore the pathogenesis of acupuncture intervention on traumatic brain injury. METHODS: Feeney's freefall epidural impact method was used to establish a traumatic brain injury model in rats; the rats were randomly divided into a normal group, sham operation group, model group and acupuncture group. Acupuncture was performed in the Baihui (DU 20), Shuigou (DU 26), Fengfu (DU 16), Yamen (DU 15) and Hegu (LI 4) acupoints in the rat, and Yamen was punctured via Fengfu. Then, the rats in each group were randomly divided into three subgroups, namely the day 3 subgroup, day 7 subgroup and day 14 subgroup according to treatment duration. The modified neurological severity scores (mNss) method was used to perform neurobehavioral scoring for evaluating the degree of injury in the rats. The hematoxylin-eosin (HE) staining method was used to observe the pathological change in the brain tissue of rats in each group. Real-time fluorescent quantitative polymerase chain reaction (Q-PCR) technology was used to detect changes in the Notch1, Hes1 and Hes5 gene expression levels in the cortex on the injured side. Western blot was used to detect the protein expression changes. RESULTS: One day after modeling, the mNss scores in the model group and in the acupuncture group were significantly higher than those in the normal and sham operation groups (P<0.01) ; there was no statistically significant difference between the normal group and the sham operation group. The scores decreased with increased treatment time, and the scores in the acupuncture group decreased more significantly than those in the model group (P<0.01). The pathological examination by the HE staining method demonstrated that the brain tissue of the rats in the acupuncture and model groups relatively significantly changed. The Notch1 gene expression level in the acupuncture group was significantly higher than the level in all of the other groups (P<0.01) ; the Hes1 and Hes5 gene expression levels were also higher in the acupuncture group. The expression changes of the Notch1 and Hes1 protein were consistent with that of mRNA. In each experimental group, the mNss score and the pathological results by the HE staining method were consistent with the mRNA results. CONCLUSION: Acupuncture could significantly promote high expression levels of Notch1, Hes1 and Hes5 in the brain tissue of traumatic brain injury rats. Therefore, acupuncture might be an important intervention for inducing endogenous stem cell proliferation and for promoting nerve repair.

Effects of acupuncture on cortical expression of Wnt3a, ß-catenin and Sox2 in a rat model of traumatic brain injury.

OBJECTIVE: To observe the effects of acupuncture treatment on the expression of Wnt/ß-catenin signalling pathway-related genes (Wnt3a, ß-catenin and Sox2) in the injured cerebral cortex of rats with traumatic brain injury (TBI). METHODS: A controlled impact model of TBI was established using Feeney's free-drop method. Seventy-eight Sprague-Dawley rats were randomly divided into the following three groups: a normal group (n=18) that was left untreated; a model group (n=30) that received no treatment after TBI; and an acupuncture group (n=30) that received acupuncture (at LI4, GV20, GV26 and GV16) after TBI. Rats in each group were randomly and equally divided into 3-day, 7-day and 14-day subgroups according to the duration of therapy. Real-time fluorescence quantitative PCR (RT-qPCR) was used to measure mRNA expression of Wnt3a, ß-catenin and Sox2. Western blots were performed to determine the expression levels of WNT3a, ß-Catenin and SOX2. RESULTS: Wnt3a mRNA was upregulated in the 7-day and 14-day acupuncture subgroups compared with the corresponding model subgroups (p<0.05). ß-catenin expression was significantly increased in the 7-day and 14-day acupuncture subgroups compared with the corresponding model subgroups (p<0.01). In the 3-day and 7-day acupuncture subgroups, Sox2 expression was significantly higher than that in the normal and model groups (p<0.01 each). The levels of WNT3a, ß-catenin and SOX2 were generally consistent with the corresponding mRNA levels. CONCLUSIONS: Acupuncture exerts a regulatory effect on the Wnt/ß-catenin signalling pathway, which may in turn influence the proliferation and differentiation of endogenous neural stem cells.

[Clinical observation on electroacupuncture for arousing consciousness of comatose patients with severe trauma brain injury].

OBJECTIVE: To observe the arousal effect of electroacupuncture (EA) stimulation of Baihui (GV 20), Shuigou (GV 26), etc. on severe craniocerebral injury patients. METHODS: A total of 90 cases of severe craniocerebral injury were randomly allocated to routine medication, naloxone and EA groups, with 30 cases in each group. For patients of the routine medication group, mild hypothermia therapy, medicines for dehydration, hormonal therapy, vascular dilation, cerebral nutrition supporting, anti-inflammation, etc. were given. For patients of the naloxone group, intravenous drip of naloxone 0.4 mg/kg in the first 3 days, 0.2 mg/kg for 7 days and 0. 1 mg/kg afterwards. For patients of the EA group, EA (1 Hz/50 Hz) was given for 30 min once daily. All the treatments were conducted once a day for 14 days. The Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) were used for assessing the therapeutic effect. RESULTS: In comparison with pre-treatment in each one of the routine medication, naloxone and EA groups, GCS scores were all obviously increased in the 3 groups following the treatment, and one month's follow-up (P<0. 05). The GCS scores of both naloxone and EA groups were significantly higher than those of the routine medication group (P<0.05). No significant difference was found between the naloxone group and EA group in GCS scores (P>0. 05). According to the GOS, one month's follow-up showed that of the three 30 cases in the routine medication, naloxone and EA groups, 6, 12 and 14 were improved, 8, 10 and 10 moderate handicap, 8, 3 and 2 severe handicap, 5, 3 and 2 vegetative state, and 3, 2 and 2 dead, with the arousal rates being 46. 66% , 73. 33% and 80. 00%, respectively. The therapeutic effects of both naloxone and EA groups were significantly superior to those of the routine medication group (P<0.05). CONCLUSION: EA intervention at early stage can promote the recovery of neurological function, accelerate the consciousness from coma and improve the outcomes of patients with severe traumatic brain injury.

Effect of acupuncture on proliferation and differentiation of neural stem cells in brain tissues of rats with traumatic brain injury.

OBJECTIVE: To observe the effect of acupuncture on proliferation and differentiation of neural stem cells in brain tissues of rats with traumatic brain injuny. METHODS: Thirty SD rats were randomly and equally allocated to the sham-operated, the model and the acupuncture groups. The traumatic brain injury model was established by the free drop method. For the rats in the acupuncture group, acupuncture was applied once a day for 7 days. Brain histotomy was carried out when treatments were completed. Immunohistochemical techniques were adopted to detect the cells that express nestin, neurofilament proteins (NF)-200 and glial fibrillary acidic proteins (GFAP), the markers of neural stem cells, neurons, astrocytes respectively. RESULTS: Compared to the sham-operated group, the number of nestin-positive cells and NF-200-positive cells in brain tissues was decreased significantly in the model group (P < 0.01), whereas the number of GFAP-positive cells was significantly increased P<0.01). Compared to the model group, the positive cells of nestin, NF-200, GFAP in brain tissues in the acupuncture group were increased obviously (P<0.01). CONCLUSIONS: Acupuncture can significantly increase the number of nestin-positive cells, NF-200-positive cells and GFAP-positive cells, indicating the significant increase of neural stem cells, neurons and astrocytes in number. Acupuncture can improve neuranagenesis by promoting the proliferation and differentiation of neural stem cells in brain tissues. This might be one of the mechanisms for acupuncture to treat traumatic brain injury and to promote the repair of nervous function.