Assessment of colorectal anastomosis perfusion with confocal laser endomicroscopy − an experimental study

Introduction: Early diagnosis of complicated healing of colorectal anastomosis can increase the chance for salvage surgery and thus reduce overall morbidity. Confocal laser endomicroscopy (CLE) enables in vivo assessment of tissue perfusion without disturbing its integrity. This experimental study evaluates the potential of CLE for postoperative monitoring of colorectal anastomosis. Methods: A hand-sewn colorectal anastomosis was performed in 9 pigs. The animals were subsequently divided into groups with normal (N=3) and ischemic anastomosis (N=6). Microscopic signs of hypoperfusion were evaluated postoperatively at regular intervals using CLE. Results: Uneven saturation of the images was evident in the group with ischemic anastomosis. The epithelium had inhomogeneous edges and more numerous crypt branching was visible. Tissue oedema quantified as the number of crypts per visual field was already more extensive at the first measurement after induction of ischemia. There was also a significant difference between the values measured before and 10 minutes after ischemia ­ 8.7±1.9 vs. 6.0±1.1 (p=0.013). Conclusion: Postoperative monitoring of the colorectal anastomosis using CLE enables prompt detection of perfusion disorders.

Migration of a mesh into the colon after inguinal hernia repair - a case report.

INTRODUCTION: Mesh migration is one of the least common complications that arise after inguinal hernia repair with a mesh. Only small case series have been reported, and an understanding of this issue is limited due to a lack of data. Most of the cases were treated surgically. In this paper, we wish to present the potential of treating this condition using endoscopic techniques. CASE REPORT: A male patient underwent transabdominal preperitoneal repair of a primary inguinal hernia in 1999. In 2003, the patient required the same procedure for a recurrent inguinal hernia. Twenty years after the primary hernia repair, the patient had a positive faecal occult blood test but was completely asymptomatic. A colonoscopy revealed mesh migration into the sigmoid colon. Despite multiple attempts to remove the mesh endoscopically, endoscopic treatment was unsuccessful. The migrated mesh was surgically removed and obligatory resection of the sigmoid colon was carried out. Apart from wound infection (Clavien-Dindo IIIb), the postoperative course was uneventful. CONCLUSION: In our case, the mesh that had penetrated the colon could not be removed endoscopically. Despite our experience, it is advisable to attempt endoscopic removal of mesh that has migrated into a hollow intra-abdominal viscus.

Real world analysis of high-cut-off (HCO) hemodialysis with bortezomib-based backbone therapy in patients with multiple myeloma and acute kidney injury.

BACKGROUND: In patients with multiple myeloma (MM) free light chain-induced cast nephropathy is a serious complication associated with poor survival. High-cut-off (HCO) hemodialysis can reduce the amount of serum free light chains (sFLC), but data on its impact on clinical outcome is limited and contradictory. To gain further insights we collected real world data from two major myeloma and nephrology centers in Austria and the Czech Republic. METHODS: Sixty-one patients with MM and acute kidney injury, who were treated between 2011 and 2019 with HCO hemodialysis and bortezomib-based MM therapy, were analyzed. RESULTS: The median number of HCO hemodialysis sessions was 11 (range 1-42). Median glomerular filtration rate at diagnosis was 7 ± 4.2 ml/min/1.73m2. sFLC after the first HCO hemodialysis decreased by 66.5% and by 89.2% at day 18. At 3 and 6 months, 26 (42.6%) and 30 (49.2%) of patients became dialysis-independent. CONCLUSION: The widely used strategy combining HCO hemodialysis and bortezomib-based antimyeloma treatment is dissatisfactory for half of the patients undergoing it and clearly in need of improvement.

Confocal laser endomicroscopy in diagnosing indeterminate biliary strictures and pancreatic lesions a prospective pilot study.

INTRODUCTION: An accurate histopathological diagnosis of indeterminate biliary strictures and pancreatic lesions is challenging because of insufficient quali-ty of tissue specimen taken during ERCP (brush cytology), cholangioscopy (biopsies) or endosonography (EUS, FNAB). Confocal laser endomicroscopy (CLE) allows virtual histopathological diagnosis with the potential to either replace or increase the diagnostic yield of standard histopathological diagnosis in patients presenting with biliary strictures and pancreatic lesions. The aims of our prospective pilot study were to: 1. Assess the diagnostic yield of standard histopathology compared to CLE in patients referred for cholangioscopy or for EUS of the pancreas; 2. Evaluate the cost of CLE in these indications. METHODS: CLE was performed (during cholangioscopy or EUS), followed by standard tissue sampling. CLE-based diagnosis was compared with standard histopathology/cytology. CLE probe was introduced through the working channel of the cholangioscope or through the FNAB needle. RESULTS: A total of 23 patients were enrolled (12 women, mean age 61 years); 13 patients underwent cholangioscopy and 10 patients underwent EUS. Cholangioscopy: CLE diagnosed correctly all 4 malignant strictures (histology 2 of them only as 2 patients had insufficient quality of the tissue specimen). Agreement between standard histopathology and CLE was achieved in 85 %. EUS: All 3 cases of pancreatic cancer were correctly diagnosed by both CLE and FNAB. All remaining (premalignant and benign) lesions were also correctly diagnosed by both methods. The cost of CLE examination is higher compared to FNAB but comparable with tissue sampling during digital cholangioscopy. CONCLUSION: CLE demonstrated sufficient diagnostic accuracy in patients with indeterminate biliary strictures or pancreatic lesions and, therefore, might improve diagnostic accuracy or even replace standard histopathology in these indications.

Two types of autologous cells in stricture development prevention after complete circular endoscopic dissection in minipig.

INTRODUCTION: Complete circular endoscopic dissection (CED) is frequently accompanied with post-operative strictures formation in the esophagus. Various types of therapeutic approaches have recently been tested to prevent these strictures, e.g. cell therapy or stenting. METHODS: Miniature pigs of Gottingen/Minnesota origin (n=10) were used in the study. First, we made the complete CED in the mid esophagus; next, the defect was left untreated or covered with mesenchymal stem cells (MSCs) or a mixture of MSCs and primary oral keratinocytes (pOKs) suspension without/with fully covered self-expandable metallic stent (SEMS). Consequently, we performed a control endoscopy with a stent removal, and necropsy was performed 17-36 days after cells application. RESULTS: All CED procedures were completed successfully without serious complications. Although we were able to detect MSCs or pOKs in the post-CED defects up to the 36th day after transplantation, the combination of MSCs or MSCs/pOKs with or without SEMS application did not prevent post-CED strictures development. The mixture of MSCs and pOKs resulted in the formation of cellular aggregates, which were mainly observed in submucosa, and the post-CED defect was covered with collagen fibers containing a thin scarred epithelium, accompanied by various degrees of reconstruction and integrity. CONCLUSION: Suspension application of autologous MSCs alone or in combination with pOKs with or without SEMS was ineffective in the prevention of strictures formation after complete CED. Nevertheless, the presence of MSCs or pOKs in the post-CED defect was confirmed even 5 weeks after transplantation.

Confocal laser endomicroscopy in the diagnostics of gastrointestinal lesions literary review and personal experience.

INTRODUCTION: Confocal laser endomicroscopy (CLE) is a new method enabling real-time histopathological diagnosis. Two platforms of CLE are used standardly: the so called probe-based CLE in which an endomicroscopic probe is inserted through an endoscope, and so-called needle-based CLE inserted through a needle. METHODS: CLE enables evaluation of epithelial and subepithelial structures with 1000x magnification in any part of the gastrointestinal system. The main advantage over conventional biopsies can be immediate diagnosis and larger area evaluated. CLE might play a promising role in indeterminate biliary lesions where biopsies are often not sufficient and fail to allow for accurate diagnosis. CLE can also have a promising potential in pancreatic lesions where it is used along with the needle designed for tissue aspiration during endosonography. It is also possible to use CLE in other organ systems and medical specialties, e.g. in pneumology, neurosurgery, ENT and others. CONCLUSION: CLE is a promising diagnostic method; however, it is unlikely to replace standard biopsies currently since these are still considered a gold standard of histopathological diagnosis. High purchase price is a main disadvantage of the method, hampering its expansion in medicine. Key words: confocal laser endomicroscopy CLE biliary strictures pancreatic lesions esophageal carcinoma Rozhl Chir 2018;97:531-538.

Molecular profiling in IgA nephropathy and focal and segmental glomerulosclerosis.

The aim of the study was to characterize by molecular profiling two glomerular diseases: IgA nephropathy (IgAN) and focal segmental glomerulosclerosis (FSGS) and to identify potential molecular markers of IgAN and FSGS progression. The expressions of 90 immune-related genes were compared in biopsies of patients with IgAN (n=33), FSGS (n=17) and in controls (n=11) using RT-qPCR. To identify markers of disease progression, gene expression was compared between progressors and non-progressors in 1 year follow-up. The results were verified on validation cohort of patients with IgAN (n=8) and in controls (n=6) using laser-capture microdissection, that enables to analyze gene expression separately for glomeruli and interstitium. In comparison to controls, patients with both IgAN and FSGS, had lower expression of BAX (apoptotic molecule BCL2-associated protein) and HMOX-1 (heme oxygenase 1) and higher expression of SELP (selectin P). Furthermore, in IgAN higher expression of PTPRC (protein-tyrosine phosphatase, receptor-type C) and in FSGS higher expression of BCL2L1 (regulator of apoptosis BCL2-like 1) and IL18 compared to control was observed. Validation of differentially expressed genes between IgAN and controls on another cohort using laser-capture microdissection confirmed higher expression of PTPRC in glomeruli of patients with IgAN. The risk of progression in IgAN was associated with higher expression EDN1 (endothelin 1) (AUC=0.77) and FASLG (Fas ligand) (AUC=0.82) and lower expression of VEGF (vascular endothelial growth factor) (AUC=0.8) and in FSGS with lower expression of CCL19 (chemokine (C-C motif) ligand 19) (AUC=0.86). Higher expression of EDN1 and FASLG along with lower expression of VEGF in IgAN and lower expression of CCL19 in FSGS at the time of biopsy can help to identify patients at risk of future disease progression.

Liver resection for recurrent sarcoma with allogenic aortic patch as partial inferior vena cava replacement - case report and review of literature.

In this case report, we discuss the topic of hepatic sarcomas, their occurrence and treatment options. We present a case of successful radical resection in a young man with recurrent sarcoma of the liver with inferior vena cava infiltration. We describe the surgical procedure in steps and point out the severity of the disease with frequent recurrences. We also review evidence behind the topic aimed to support our treatment approach.Key words: hepatectomy - sarcoma - inferior vena cava - blood vessel prosthesis - allograft.

A comparison of two endoscopic closures: over-the-scope clip (OTSC) versus KING closure (endoloop + clips) in a randomized long-term experimental study.

BACKGROUND: Both over-the-scope clip (OTSC) and KING (endoloop + clips) closures provide reliable and safe full-thickness endoscopic closure. Nevertheless, OTSC clip demonstrated significantly inferior histological healing in the short-term follow-up. AIM: To compare OTSC versus KING closure of a perforation with regard to long-term effectiveness and macroscopic and histological quality of healing. METHODS: We performed a randomized experimental study with 16 mini-pigs (mean weight 43.2 ± 11.2 kg). A standardized perforation was performed on the anterior sigmoid wall. KING closure (n = 8) was attained by approximation of an endoloop fixed to the margins of a perforation with endoclips. OTSC closure (n = 8) was performed by deploying OTSC (OVESCO) over the defect. Pigs underwent a control sigmoidoscopy 8 months after the closure to assess the macroscopic quality of healing. Then, autopsy was performed and the rectosigmoid was sent for histopathological assessment. RESULTS: All closures were completed successfully without air leaks. The duration of closure was similar in both techniques (OTSC 17.8 ± 7.6 min vs. KING 19.6 ± 8.8 min). At autopsy, all KING closures (100 %) were healed with a flat scar without signs of leakage. Microscopically, no inflammatory changes were observed after KING closure. In the OTSC group, microscopic ulcers were present in two pigs (25 %), cryptal abscesses in three pigs (38 %) and significant neutrophil accumulation in all eight pigs (P < 0.01). Giant cell granulomas, dysplasia or abundant scarification was not observed in either group. CONCLUSIONS: Both OTSC and KING closures offer a long-term reliable seal of a gastrointestinal perforation without stenosis or fistulas. KING closure provides long-term histologically superior healing.

An alternative method for electrophoretic gel image analysis in the GelMaster software.

A novel methodology of electrophoretic gel image analysis has been proposed that is based on two-dimensional image processing methods instead of previously used one-dimensional Gaussian deconvolution. The crucial problem of the analysis of imperfect gels, that consists in band detection, is solved using the algorithms of band boundary detection and intensity homogeneity indication. The template approach represents the core element of the developed algorithms. The GelMaster software system has been developed in which the novel algorithms are implemented. It involves two-stage interaction with the user: detection of the true bands and deleting the false band detections. The main features of the GelMaster system and the most important algorithms are described.

EEG analysis with simulated neuronal cell models helps to detect pre-seizure changes.

OBJECTIVES: To test if a method for real-time detection of epileptic seizures based on electroencephalographic (EEG) analysis with simulated neuronal cell models can be modified to identify pre-seizure changes. METHODS: Our EEG analysis method consists of two simulated leaky integrate and fire units (LIFU) connected to a signal preprocessing stage that marks parts of the EEG signals with slopes larger than a preset threshold Hth with unit pulses. The LIFUs change their spiking frequency depending on the rate and the synchrony of the impinging pulse trains. Here, we use our method in a high-sensitivity mode by setting Hth to low values, which causes the LIFUs to continuously spike during the interictal state. We test if the LIFUs spiking rates change before seizure onset. RESULTS: We used 9 long-term EEGs (16+/-7 h) of 7 patients with drug resistant epilepsy. Fifteen seizures were analyzed and all were preceded by an increase of the time-averaged spiking rates SR(av) of the LIFUs. We defined a function F(Sz), which quantifies the changes of SR(av). F(Sz) increased and stayed above an individually set and fixed threshold 83+/-91 min (range: 4-330 min) before EEG seizure onset. Only two false alarms occurred. CONCLUSIONS: We conclude that EEG analysis with simulated neuronal cell models may be used to detect pre-seizure changes with high sensitivity and specificity.

Hyperperfusion of anterior cingulate gyrus in a case of paroxysmal nocturnal dystonia.

The authors report the clinical, EEG, and SPECT findings of a patient with nocturnal paroxysmal dystonia. Ictal and interictal scalp EEG showed epileptiform activity over both frontal lobes. Subtraction ictal SPECT co-registered to MRI indicated a bilateral significant hyperperfusion in the anterior part of the cingulate gyrus. These results support earlier electrophysiologic investigations by others suggesting that anterior cingulate epilepsy may manifest as nocturnal paroxysmal dystonia, and illustrate the usefulness of computer-assisted SPECT analysis.

Using simulated neuronal cell models for detection of epileptic seizures in foramen ovale and scalp EEG.

OBJECTIVE: To demonstrate a novel approach for real-time and automatic detection of epileptic seizures in EEG recorded with foramen ovale (Fov) or scalp electrodes. METHODS: Our seizure detection method is based on simulated leaky integrate and fire units (LIFU), which are classical simple neuronal cell models. The LIFUs are connected to a signal preprocessing stage and increase their spiking rates in response to rhythmic and synchronous EEG signals as typically occur at the onset and during seizures. RESULTS: We analyzed 22 short-term (10+/-3 min) and 4 long-term (18+/-7 h) Fov or scalp EEGs of 10 patients with drug resistant partial epilepsy. Seizures (n=36) were marked by increases of the LIFUs spiking rates above a preset threshold. The durations of increased spiking rates due to seizures were always longer than 10 s (36+/-21 s) and allowed separation from artifacts, which caused only short durations (1.2+/-0.6 s) of high spiking rates. The LIFUs correctly detected all the seizures and produced no false alarms. In the long term Fov EEGs seizure detection occurred before the onset of clinical signs (41+/-22 s). CONCLUSIONS: By using simulated neuronal cell models it is possible to automatically detect epileptic seizures in scalp and Fov EEG with high sensitivity and specificity.

Epigastric sensations as an unusual manifestation of adult absence epilepsy.

We report the case of a 39-year-old woman with onset of daily epigastric sensations associated with brief episodes of unresponsive blank stare, which have been interpreted as complex partial seizures with occasional secondary generalisation. Phenytoin as monotherapy and in combination with valproate had not been effective. During video-EEG we recorded typical absences with brief 3 second spike, and slow-wave discharges of up to 5 seconds, which were recognized by the patient herself. All absences were preceded by epigastric sensations. There was no indication of focal epilepsy. Monotherapy with valproate substantially decreased the frequency of the absences. In conclusion, this case is peculiar for several reasons: 1) late onset of absence epilepsy, 2) epigastric sensation at onset of absence seizures, 3) recognition of brief "phantom" absences and 4) presumable adverse effects of phenytoin.

Rotatory seizures in a patient with tuberous sclerosis.

We present an 11-year-old girl with tuberous sclerosis who developed seizures characterized by circling behavior. Rotatory seizures are uncommon and occur mainly secondary to a focal pathology. Our patient had a right temporal epileptic focus, confirmed by magnetic resonance imaging (MRI) to be a subcortical lesion in the right temporal region. This case is probably the first reported case of tuberous sclerosis associated with rotatory seizures with an ictal EEG.

A user-friendly instrument for rating agitation in dementia patients.

There are many rating instruments designed to assess symptoms of agitation in patients with dementia. Most scales require that raters assess multiple specific behaviors over several days, limiting the use of such scales to clinical staff who have direct contact with patients but do not have the time to complete a comprehensive assessment following each period of observation. Also, scales that assess behavior over several days must rely on "secondhand" information describing behaviors not directly observed by the rater. The Pittsburgh Agitation Scale (PAS) is an easy-to-use instrument, based on direct observations of the patient, that was developed to monitor the severity of agitation associated with dementia. Interrater reliability and measures of validity have been established with clinical staff on a busy psychogeriatric inpatient unit and with research personnel in a nursing home setting.

Adolescent anger: a developmental study.

This research examined adolescent anger in a cohort of adolescents measured twice, once during the freshman year and again in the senior year of high school. Anger was measured by the Anger Index, a questionnaire developed by Siegel (1984). The purpose of the research was to determine if adolescent anger changed over time and if there were gender differences. Results of the study indicated that anger scores appeared to be stable over time for both boys and girls. There were gender and time differences on individual responses for several items, indicating that certain dimensions of anger may differ over time and by gender. It also appeared possible that the interpretation of certain questions on the anger index was different for the adolescents at the two time intervals.

Perfusate oncotic pressure during cardiopulmonary bypass. Optimum level as determined by metabolic acidosis, tissue edema, and renal function.

Current practice with respect to the use of a dilutional prime for cardiopulmonary bypass (CPB) varies widely, and the safe lower limit of perfusate protein content has not been defined. We studied this question in 75 rabbits subjected to a 1-hour CPB with a perfusate colloid osmotic pressure (COP) ranging from 26 to 4 mm Hg. Metabolic acidosis was inversely related to COP; acid-base equilibrium is thus best maintained with a high perfusate protein content. Tissue edema rapidly increased at COP levels below 16 mm Hg, i.e. with a protein level less than 4.2 g%. Urinary excretion during CPB was antagonized by the COP, the reason being that glomerular filtration rate was proportional to the difference between perfusion pressure and COP. The safety margin for renal function during CPB thus widens with a decreasing perfusate protein content. We conclude that the optimum levels of perfuste oncotic pressure and protein content during experimental cardiopulmonary bypass are 16 mm Hg and 4.2 g%.

Acute hypoproteinemic fluid overload: its determinants, distribution, and treatment with concentrated albumin and diuretics.

We simulated the use of massive volumes of crystalloid fluids as a treatment of acute plasma loss in a standardized experimental model and studied the factors determining the retention or excretion of the resulting acute hypoproteinemic fluid overload, its distribution within the body, and its treatment with concentrated albumin and diuretics. In accordance with the classic Starling concept, the serum protein level, i.e. the serum colloid osmotic pressure, determined the excretion/retention ratio of a given water and sodium load. Of the total fluid retention, fat and muscle each accommodated 25%, whereas the skin, which contributes only 7% to the total body weight, accounted for 37% and increased its volume by roughly one third. Concentrated albumin promoted fluid excretion in direct proportion to the achieved increment of the serum protein level and abolished the edema of fat, muscle and skin. Furosemide was virtually ineffective. The implications of these results for the 'adult respiratory distress syndrome' and disturbed wound healing are discussed and related to the concept of a critical threshold of the serum protein level.