Portal Infusion Research Articles

Application of three fingers to pinching needle method in infusion port

Objective To explore the advantages of the three-finger method of pinching the needle infusion port. Methods A total of forty three patients who underwent intracranial vein infusion port implantation between January 2018 and June 2018 were enrolled. The self-control method was divided into the test group and the control group, and both groups of patients used a safe butterfly wing non-destructive needle. The control group used the traditional needle insertion method from July 1st to July 31st. The experimental group used the three-finger needle-to-needle method from August 1st to August 31st to compare the two groups of patients in one-time injection. Different results in terms of local skin bleeding and patient satisfaction. Results The one-time injection rate and non-bleed rate of the control group were both 25.6%(11/43) and the satisfaction rate was 20.9%(9/43). There was one case of pedicle turnover, one case of clipping syndrome, and one case of local infection; no other complications. The one-time injection rate and non-bleed rate of the test group were both 90.7%(39/43) and the satisfaction rate was 90.7%(39/43); there was one case of clipping syndrome; no other complications. The difference of one-time injection rate, local non-bleed rate and satisfaction rate between the two groups was statistically significant (χ2=37.45, 37.45,42.43, both P<0.05). Conclusions The three-finger method of pinching the needle can improve the one-time injection rate of the nurse, improve the patient's satisfaction and reduce the complications. This aspect deserves to be promoted in the clinic. Key words: Three-finger pinch; Needle; Port

Peripherally delivered hepatopreferential insulin analog insulin-406 mimics the hypoglycaemia-sparing effect of portal vein human insulin infusion in dogs.

We previously quantified the hypoglycaemia-sparing effect of portal vs peripheral human insulin delivery. The current investigation aimed to determine whether a bioequivalent peripheral vein infusion of a hepatopreferential insulin analog, insulin-406, could similarly protect against hypoglycaemia. Dogs received human insulin infusions into either the hepatic portal vein (PoHI, n = 7) or a peripheral vein (PeHI, n = 7) for 180 minutes at four-fold the basal secretion rate (6.6 pmol/kg/min) in a previous study. Insulin-406 (Pe406, n = 7) was peripherally infused at 6.0 pmol/kg/min, a rate determined to decrease plasma glucose by the same amount as with PoHI infusion during the first 60 minutes. Glucagon was fixed at basal concentrations, mimicking the diminished α-cell response seen in type 1 diabetes. Glucose dropped quickly with PeHI infusion, reaching 41 ± 3 mg/dL at 60 minutes, but more slowly with PoHI and Pe406 infusion (67 ± 2 and 72 ± 4 mg/dL, respectively; P < 0.01 vs PeHI for both). The hypoglycaemic nadir (c. 40 mg/dL) occurred at 60 minutes with PeHI infusion vs 120 minutes with PoHI and Pe406 infusion. ΔAUCepinephrine during the 180-minute insulin infusion period was two-fold higher with PeHI infusion compared with PoHI and Pe406 infusion. Glucose production (mg/kg/min) was least suppressed with PeHI infusion (Δ = 0.79 ± 0.33) and equally suppressed with PoHI and Pe406 infusion (Δ = 1.16 ± 0.21 and 1.18 ± 0.17, respectively; P = NS). Peak glucose utilization (mg/kg/min) was highest with PeHI infusion (4.94 ± 0.17) and less with PoHI and Pe406 infusion (3.58 ± 0.58 and 3.26 ± 0.08, respectively; P < 0.05 vs Pe for both). Peripheral infusion of hepatopreferential insulin can achieve a metabolic profile that closely mimics portal insulin delivery, which reduces the risk of hypoglycaemia compared with peripheral insulin infusion.

Reconsidering the “MR Unsafe” breast tissue expander with magnetic infusion port: A case report and literature review

Breast tissue expanders (TEs) with magnetic infusion ports are labeled “MR Unsafe.” Therefore, patients with these implants are typically prevented from undergoing magnetic resonance imaging (MRI). We report a patient with a total submuscular breast TE who inadvertently underwent an MRI exam. She subsequently developed expander exposure, requiring explantation and autologous reconstruction. The safety profile of TEs with magnetic ports and the use of MRI in patients with these implants is surprisingly controversial. Therefore, we present our case report, a systematic literature review, and propose procedural guidelines to help ensure the safety of patients with TEs with magnetic ports that need to undergo MRI exams.

Abstract 3981: Exosomal microRNA profiles in peritoneal fluids as a therapeutic biomarker for peritoneal metastasis of gastric cancer

Abstract Objectives: Peritoneal metastasis (PM) frequently occurs in patients with gastric cancer and has poor prognosis even with systemic chemotherapy. Intraperitoneal chemotherapy (IPC) using paclitaxel (PTX) combined with systemic chemotherapy has demonstrated a remarkable clinical efficacy for gastric cancer with PM. However, there is no reliable biomarker to reflect the response of peritoneal lesions as well as to predict the outcome of the patients receiving IPC. Although peritoneal fluids are considered to contain many factors derived from disseminated tumor cells in peritoneal cavity, little information is available so far. In this study, we examined exosomal miRNA profiles derived from peritoneal fluids in patients with gastric cancer and explored possible biomarkers useful for IPC of the patients with PM. Methods: Peritoneal fluids were collected from 2 groups; with or without PM. Peritoneal fluids were obtained either laparoscopically, during open surgery or from subcutaneous infusion port connected to an intraperitoneal catheter. Exosomal fractions were isolated using ultracentrifuge method (150,000 xg, 70 min, 4°C) and the presence of exosome was confirmed with nanotracking analysis. Total RNA including small RNA was extracted from exosomal fractions and expression analyses of miRNAs were performed using RT-PCR. Results: At first, we comprehensively analyzed the expression of miRNAs between 11 samples with PM and 14 samples without PM and identified 11 miRNAs which showed particularly different expression pattern between the 2 groups. Among them, 4 miRNAs (miR-21-5p,miR-223-3p, miR-342-3p and miR-92a-3p) were selected and further analysed using 51 samples derived from the peritoneal fluids of gastric cancer. Expression of these 4 miRNAs were significantly up-regulated in samples with PM which was consistent with formeranalysis. Moreover, expression of miR-21-5p was significantly upregulated in in samples fromT4 tumor (invaded serosa or adjacent structure) as compared with those from T1 to T3 tumor. Conclusion: We identified several dysregulated exsosomal miRNAs derived from peritoneal fluids of the patients with PM from gastric cancer, which were supposed to reflect the tumor burden on peritoneum. Exosomal miRNA profiles might be useful biomarkers to determine the presence of PM as well as the response to IPC. Citation Format: Hideyuki Ohzawa, Akira Saito, Yuko Kumagai, Hironori Yamaguchi, Yoshinori Hosoya, Naohiro Sata, Joji Kitayama. Exosomal microRNA profiles in peritoneal fluids as a therapeutic biomarker for peritoneal metastasis of gastric cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3981.

Glucose mediates insulin sensitivity via a hepatoportal mechanism in high-fat-fed rats.

Poor nutrition plays a fundamental role in the development of insulin resistance, an underlying characteristic of type 2 diabetes. We have previously shown that high-fat diet-induced insulin resistance in rats can be ameliorated by a single glucose meal, but the mechanisms for this observation remain unresolved. To determine if this phenomenon is mediated by gut or hepatoportal factors, male Wistar rats were fed a high-fat diet for 3 weeks before receiving one of five interventions: high-fat meal, glucose gavage, high-glucose meal, systemic glucose infusion or portal glucose infusion. Insulin sensitivity was assessed the following day in conscious animals by a hyperinsulinaemic-euglycaemic clamp. An oral glucose load consistently improved insulin sensitivity in high-fat-fed rats, establishing the reproducibility of this model. A systemic infusion of a glucose load did not affect insulin sensitivity, indicating that the physiological response to oral glucose was not due solely to increased glucose turnover or withdrawal of dietary lipid. A portal infusion of glucose produced the largest improvement in insulin sensitivity, implicating a role for the hepatoportal region rather than the gastrointestinal tract in mediating the effect of glucose to improve lipid-induced insulin resistance. These results further deepen our understanding of the mechanism of glucose-mediated regulation of insulin sensitivity and provide new insight into the role of nutrition in whole body metabolism.

Management of Port Occlusions in Adults: Different-Site Replacement versus Same-Site Salvage

PurposeTo compare the safety and effectiveness of different-site port placement versus same-site port salvage in adult patients with occluded ports. Materials and MethodsNinety-five occluded subcutaneous infusion ports (ports) in 95 patients presenting between July 1, 2002, and June 30, 2017, were retrospectively reviewed: 48 (51%) different-site placements (replacements; same-day indwelling port removal and different-site new port placement) and 47 (49%) same-site salvages (salvages; 35 fibrin sheath strippings, 12 over-the-wire exchanges). Demographic information, indication for initial placement and replacement or salvage, procedural details, post-intervention primary catheter patency, and post-intervention port sequelae were recorded. Post-intervention primary catheter patency, and malfunction and infection rates were compared with Kaplan-Meier estimation and the log-rank test, and Fisher exact test, respectively. The association of patient risk factors and port patency was assessed with Cox regression. ResultsMedian primary catheter patency after replacement was 254 days (interquartile range [IQR], 297) and after salvage was 391 days (IQR, 906) (P = .25). Within the salvage group, median primary catheter patency after stripping was 391 days (IQR, 658) and after exchange was 666 days (IQR, 1412) (P = .08). There was no statistical difference in malfunction (P = .12) and infection (P = .74) rates between the replaced and salvaged groups or in malfunction (P = .09) and infection (P = .1) rates between the exchanged and stripped subgroups. None of the patient or catheter characteristics assessed were significantly associated with primary catheter patency. ConclusionsThere was no statistical difference between patency, malfunctions, or infections after replacement and salvage, or after stripping and exchange, so technique selection should be based on the patient’s estimated lifetime venous access requirements, cost, and physician preference.

A modified approach for ultrasound-guided axillary venipuncture in the infraclavicular area: A retrospective observational study.

Catheterization of the axillary vein in the infraclavicular area has important advantages in patients with long-term, indwelling central venous catheters. The two most commonly used ultrasound-guided approaches for catheterization of the axillary vein include the long-axis/in-plane approach and the short-axis/out-of-plane approach, but there are certain drawbacks to both approaches. We have modified a new approach for axillary vein catheterization: the oblique-axis/in-plane approach. This observational study retrospectively collected data from patients who underwent ultrasound-guided placement of an axillary vein infusion port in the infraclavicular area at the Central Venous Access Clinics of Zhongshan Hospital at Fudan University between March 2014 and May 2017. The patients' demographic data, success rate of catheterization, venous catheterization site, and immediate complications associated with catheterization were recorded. Between March 2014 and May 2017, a total of 858 patients underwent placement of an axillary vein infusion port in the infraclavicular area at our center. The ultrasound-guided oblique-axis/in-plane approach was used for all patients, and the venipuncture success rate was 100%. Two cases of accidental arterial puncture and one case of local hematoma formation were reported, and no other complications, such as pneumothorax or nerve damage, were reported. The ultrasound-guided oblique-axis/in-plane approach is a safe and reliable alternative to the routine ultrasound-guided approach for axillary venous catheterization.

Sandwich Technique with Anterior Silicone Oil and Posterior Perfluorocarbon Liquid for Intraoperative Retinal Stabilization in Eyes with Large Retinal Breaks.

During retinal surgeries, the presence of large retinal defects or breaks (giant retinal tears or retinotomies ≥3 clock hours) requires the use of perfluorocarbon liquid (PFCL) to stabilize the posterior retina. Thereafter, direct PFCL-oil exchange is preferred to avoid posterior slippage of the retina. However, in an eye filled with PFCL, fluid currents at the surface of the PFCL pose a few problems when laser is attempted. Multiple bubbles are formed due to fluid currents, and the fluid jet from the infusion port may continually dislodge the free end of the retina despite the presence of PFCL. This effect is accentuated when instruments are exchanged or if the active port is unoccluded. On the other hand, if laser is postponed until the eye is filled with oil, fluid accumulation may occur under the macula, as posterior tamponade is absent. We present a modified technique that entails the use of a “sandwich” of anterior SO and posterior PFCL to comfortably perform laser in a well-formed closed vitreous chamber with continuous maintenance of retinal attachment.

Clinical and laboratory outcomes of stem cell transplantation in patients with decompensated liver cirrhosis: single-arm pilot trial

Introduction The high prevalence of hepatitis C virus-associated liver disease has led to increasing number of Egyptian patients having end-stage liver disease and requiring liver transplantation. Because of several limitations of liver transplantation, new alternative treatment modalities are required for patients with liver cirrhosis. Many study results encourage the use of autologous bone marrow-derived mesenchymal stem cells (MSCs) for liver diseases. Aim The aim of this study was to assess the efficacy of using bone marrow-derived MSC on clinical manifestations, liver function, Child–Pugh score, and Model for End-stage Liver Disease score in patients with decompensated liver cirrhosis. Patients and methods This is a pilot single-arm prospective trial that included 13 patients with hepatitis C virus-associated liver cirrhosis who received transdifferentiated MSC via ultrasound-guided percutaneous portal vein infusion plus regular conventional treatment for patients with cirrhosis. Patients were followed up weekly for the first month and monthly for 6 months. Results There was significant improvement in some clinical manifestations, including frequency of attacks of hematemesis, ascites, and lower limb edema after MSC infusion compared with baseline data. Moreover significant increase was detected in mean serum albumin level as it began with 24.62 ± 3.93 and became 27.81 ± 4.14 (P = 0.009) after 6 months of follow-up. Moreover, the results showed improvement in Child–Pugh, but no changes were detected in Model for End-stage Liver Disease score after MSC infusion compared with baseline. Conclusion Our data show that transdifferentiated MSC injection may improve some clinical manifestations and some indices of liver function in patients with decompensated liver cirrhosis with successful tolerability.

Current strategy for ABO incompatible liver transplantation in Kyoto University

Introduction: Although the prognosis for ABO-blood-type-incompatible living-donor liver transplantation (ABO-I LDLT) is poorer than identical/compatible LDLT, it is inevitable when only the ABO-I donor is available. We evaluated our current strategy for ABO-I LDLT. Method: From April 2006 to October 2018, a total 107 ABO-I LDLT was performed in Kyoto University. Rituximab (RIX) prophylaxis was performed in all cases before LDLT. The strategy for ABO-I LDLT has changed; Era1. 2006.4∼2009.6: RIX with hepatic arterial infusion; Era2. 2009.7∼2013.7: RIX with portal venous infusion; Era3. 2013.8∼: RIX without local therapy. Characteristics: median (range): Male/female; 59/48, Recipient age; 53 (17∼69) y/o, Donor age; 47(21∼66) y/o, MELD; 18(8-55), Graft weight; 530(230∼1025)g, GRWR; 0.85 (0.54∼1.55)%. Splenectomy was performed in 61cases(57%). Result: Patients with AMR(n=28) showed lower survival. Era3 achieved the best overall survival. Splenectomy did not have any impact on survival after ABO-I LDLT. One patient was introduced Bortezomib, who showed uncontrollable AMR on POD 7, and was rescued without any complication. Pretransplant anti-AB antibody (IgG)≥32, and posttransplant anti-AB antibody (IgG and IgM)≥16 showed significantly higher rate of AMR. Eight cases showed ischemic cholangiopathy, in which 6 cases(75%) showed graft failure. RIX administration within one week before LDLT showed higher rate of AMR. Conclusion: Besides the results of our current strategy against ABO-I LDLT is not satisfactory, followings are recommended; (1) Reduce pretransplant anti-ABO antibody IgG< 32titer (2) In case of the anti-AB antibody ≥16titer after LDLTx, beware AMR (3) Against uncontrollable AMR, consider to use Bortezomib. (4) Posttransplant cholangiography is important to check the ischemic cholangiopathy.

Analysis of the reasons and influencing factors of unplanned removal of implantable venous access port in tumor patients

Objective To explore the reasons and influencing factors of unplanned removal of implantable venous access port (IVAP) in tumor patients, and analyze its influencing factors, so as to explore the corresponding clinical interventions. Methods A total of 1 029 cases of tumor patients who were implanted IVAP in Zhejiang Cancer Hospital from January 1st, 2009 to December 31st, 2016 were recruited by convenience sampling method. Univariate analysis and Logistic regression analysis were applied to analyze the influencing factors of unplanned port-taking. Results Finally 1 002 tumor patients were recruited excluding patients who died or lost follow-up. Excluding patient's subjective factors, catheter-related blood stream infection (CRBSI) , catheter clamping syndrome, and pain around infusion seat were the main causes of unplanned removal of IVAP. Univariate analysis revealed that there were significant differences in unplanned port removal among patients with different catheterization veins, infection and coagulation function (χ2=15.691, 14.425, 16.732; P<0.001) . Logistic regression analysis showed that internal jugular vein catheterization (OR=8.272) , infection (OR=2.592) and coagulation (OR=2.709) were the main factors. Conclusions Medical staff should strictly control the causes and influencing factors of unplanned removal of IVAP when implanting and maintaining the use of IVAP for patients, so as to prolong the use time of infusion port. Key words: Neoplasms; Implantable venous access port; Influencing factors; Unplanned port removal

Comparative effects of proximal and distal small intestinal administration of metformin on plasma glucose and glucagon-like peptide-1, and gastric emptying after oral glucose, in type 2 diabetes.

The gastrointestinal tract, particularly the lower gut, may be key to the anti-diabetic action of metformin. We evaluated whether administration of metformin into the distal, vs the proximal, small intestine would be more effective in lowering plasma glucose by stimulating glucagon-like pepetide-1 (GLP-1) and/or slowing gastric emptying (GE) in type 2 diabetes (T2DM). Ten diet-controlled T2DM patients were studied on three occasions. A transnasal catheter was positioned with proximal and distal infusion ports located 13 and 190 cm beyond the pylorus, respectively. Participants received infusions of (a) proximal + distal saline (control), (b) proximal metformin (1000 mg) + distal saline or (c) proximal saline + distal metformin (1000 mg) over 5 minutes, followed 60 minutes later by a glucose drink containing 50 g glucose and 150 mg 13 C-acetate. "Arterialized" venous blood and breath samples were collected over 3 hours for measurements of plasma glucose, GLP-1, insulin and glucagon, and GE, respectively. Compared with control, both proximal and distal metformin reduced plasma glucose and augmented GLP-1 responses to oral glucose comparably (P < 0.05 each), without affecting plasma insulin or glucagon. GE was slower after proximal metformin than after control (P < 0.05) and tended to be slower after distal metformin, without any difference between proximal and distal metformin. In diet-controlled T2DM patients, glucose-lowering via a single dose of metformin administered to the upper and lower gut was comparable and was associated with stimulation of GLP-1 and slowing of GE. These observations suggest that the site of gastrointestinal administration is not critical to the glucose-lowering capacity of metformin.

Intraportal therapy of autologous bone marrow mononuclear cells in patients on the waiting list for liver transplantation

This study was carried out to explore the methodology of intraportal infusion of autologous bone marrow mononuclear cells in patients in the waiting list for liver transplantation. The study included eight patients. The Model for End-Stage Liver Disease (MELD) score as a predictor of hepatic failure exceeds 10 points, i.e., 12-22 points. According to Child-Turcotte-Pugh (CTP) classification, the severity of cirrhosis ranged from class B to C. The bone marrow volume of 224-320 ml was harvested by bilateral aspiration from the posterior iliac crest. The total volume of the mononuclear cells (MNC) was 47.1-58.3 ml (median, 47 ml). The absolute viable count of isolated MNC was 1.24 · 109-5.84 · 109 and CD34+ cells 2.54 · 106-48.20 · 106. After portal vein catheterization, direct transhepatic portography was performed, and portosystemic collaterals were found in all cases. Portal flowmetry was performed to determine the optimal selective perfusion rate of the segmental branches of the portal vein. Portal vein infusion was performed at 0.3-1.5 ml/sec. Serious side effects were not detected during bone marrow harvesting and MNC infusion. All patients had stable condition (no deterioration was initially noticed) after MNC infusion according to the MELD score and CTP criteria during a 3-month observation. Moreover, improvement in physical health status was observed and obtained using the SF-36 questionnaire. This study confirmed the safety of using intraportal therapy of autologous bone marrow MNC in patients on the waiting list for liver transplantation. Herein, we presented the technique of target delivery of autologous bone marrow MNC to the liver to minimize their loss during intraportal infusion. Prolonged follow-up time and improvement of the present technique are needed for further evaluation of the efficiency of autologous bone marrow MNC.

Preliminary Safety and Tolerability of a Novel Subcutaneous Intrathecal Catheter System for Repeated Outpatient Dosing of Nusinersen to Children and Adults With Spinal Muscular Atrophy.

Many patients with spinal muscular atrophy (SMA) who might benefit from intrathecal antisense oligonucleotide (nusinersen) therapy have scoliosis or spinal fusion that precludes safe drug delivery. To circumvent spinal pathology, we designed a novel subcutaneous intrathecal catheter (SIC) system by connecting an intrathecal catheter to an implantable infusion port. Device safety and tolerability were tested in 10 SMA patients (age, 5.4 to 30.5 y; 80% with 3 copies of SMN2); each received 3 sequential doses of nusinersen (n=30 doses). Pretreatment disease burden was evaluated using the Revised Hammersmith Scale, dynamometry, National Institutes of Health pegboard, pulmonary function testing, electromyography, and 2 health-related quality of life tools. Device implantation took ≤2 hours and was well tolerated. All outpatient nusinersen doses were successfully administered via SIC within 20 minutes on the first attempt, and required no regional or systemic analgesia, cognitive distraction, ultrasound guidance, respiratory precautions, or sedation. Cerebrospinal fluid withdrawn from the SIC had normal levels of glucose and protein; cerebrospinal fluid white blood cells were slightly elevated in 2 (22%) of 9 specimens (median, 1 cell/µL; range, 0 to 12 cells/µL) and red blood cells were detected in 7 (78%) specimens (median, 4; range, 0 to 2930 cells/µL). Preliminary observations reveal the SIC to be relatively safe and well tolerated in SMA patients with advanced disease and spinal fusion. The SIC warrants further study and, if proven effective in larger trials of longer duration, could double the number of patients able to receive nusinersen worldwide while reducing administration costs 5- to 10-fold.

Hepatocyte spheroids as an alternative to single cells for transplantation after ex vivo gene therapy in mice and pig models

BackgroundAutologous hepatocyte transplantation after ex vivo gene therapy is an alternative to liver transplantation for metabolic liver disease. Here we evaluate ex vivo gene therapy followed by transplantation of single-cell or spheroid hepatocytes. MethodsPig and mouse hepatocytes were isolated, labeled with zirconium-89 and returned to the liver as single cells or spheroids. Biodistribution was evaluated through positron emission tomography–computed tomography. Fumarylacetoacetate hydrolase–deficient pig hepatocytes were isolated and transduced with a lentiviral vector containing the Fah gene. Animals received portal vein infusion of single-cell or spheroid autologous hepatocytes after ex vivo gene delivery. Portal pressures were measured and ultrasound was used to evaluate for thrombus. Differences in engraftment and expansion of ex vivo corrected single-cell or spheroid hepatocytes were followed through histologic analysis and animals’ ability to thrive off 2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione. ResultsPositron emission tomography–computed tomography imaging showed spheroid hepatocytes with increased heterogeneity in biodistribution as compared with single cells, which spread more uniformly throughout the liver. Animals receiving spheroids experienced higher mean changes in portal pressure than animals receiving single cells (P < .01). Additionally, two animals from the spheroid group developed portal vein thrombi that required systemic anticoagulation. Immunohistochemical analysis of spheroid- and single-cell–transplanted animals showed similar engraftment and expansion rates of fumarylacetoacetate hydrolase–positive hepatocytes in the liver, correlating with similar weight stabilization curves. ConclusionEx vivo gene correction of autologous hepatocytes in fumarylacetoacetate hydrolase–deficient pigs can be performed using hepatocyte spheroids or single-cell hepatocytes, with spheroids showing a more heterogeneous distribution within the liver and higher risks for portal vein thrombosis and increased portal pressures.

On the distribution and metabolism of Fusarium-toxins along the gastrointestinal tract of endotoxaemic pigs

ABSTRACTThe aim of this study was to investigate the potential modulatory effect of E. coli lipopolysaccharides (LPS) on residues of deoxynivalenol (DON), de-epoxy-deoxynivalenol (DOM-1), zearalenone (ZEN) and its metabolites α-zearalenol (α-ZEL), β-zearalenol (β-ZEL), zearalanone (ZAN), α-zearalanol (α-ZAL) and β-zearalanol (β-ZAL) after pre- or post-hepatic administration along the gastrointestinal axis. Fifteen barrows were exposed to a naturally mycotoxin contaminated diet (4.59 mg DON/kg feed and 0.22 mg ZEN/kg feed) and equipped with jugular (ju) and portal (po) catheters. On sampling day (day 29), the barrows were infused with LPS or a control fluid (LPS, 7.5 µg/kg body weight; control, 0.9% NaCl) either pre- or post-hepatically, resulting in three infusion groups: CONju-CONpo, CONju-LPSpo and LPSju-CONpo. At 195 min relative to infusion start (210 min post-feeding), pigs were sacrificed and content of stomach and small intestine (proximal, medial and distal part) as well as faeces were collected. In all LPS-infused animals, higher amounts of dry matter were recovered irrespective of LPS entry site suggesting a reduced gastric emptying and a decreased gastrointestinal motility under endotoxaemic conditions. DON metabolism in the gastrointestinal tract (GIT) remained unaltered by treatments and included an increase in the proportion of DOM-1 along the GIT, particularly from distal small intestine to faeces. Variables describing ZEN metabolism suggest a stimulated biliary release of ZEN and its metabolites in LPS-infused groups, particularly in the LPSju-CONpo group. In conclusion, the GIT metabolism of ZEN was markedly influenced in endotoxaemic pigs whereby a jugular induction of an acute phase reaction was more effective than portal LPS infusion hinting at a strong hepatic first-pass effect.

Morning Hyperinsulinemia Primes the Liver for Glucose Uptake and Glycogen Storage Later in the Day.

We observed that a 4-h morning (AM) duodenal infusion of glucose versus saline doubled hepatic glucose uptake (HGU) and storage during a hyperinsulinemic-hyperglycemic (HIHG) clamp that afternoon (PM). To separate the effects of AM hyperglycemia versus AM hyperinsulinemia on the PM response, we used hepatic balance and tracer ([3-3H]glucose) techniques in conscious dogs. From 0 to 240 min, dogs underwent a euinsulinemic-hyperglycemic (GLC; n = 7) or hyperinsulinemic-euglycemic (INS; n = 8) clamp. Tracer equilibration and basal sampling occurred from 240 to 360 min, followed by an HIHG clamp (360-600 min; four times basal insulin, two times basal glycemia) with portal glucose infusion (4 mg ⋅ kg-1 ⋅ min-1). In the HIHG clamp, HGU (5.8 ± 0.9 vs. 3.3 ± 0.3 mg ⋅ kg-1 ⋅ min-1) and net glycogen storage (6.0 ± 0.8 vs. 2.9 ± 0.5 mg ⋅ kg-1 ⋅ min-1) were approximately twofold greater in INS than in GLC. PM hepatic glycogen content (1.9 ± 0.2 vs. 1.3 ± 0.2 g/kg body weight) and glycogen synthase (GS) activity were also greater in INS versus GLC, whereas glycogen phosphorylase (GP) activity was reduced. Thus AM hyperinsulinemia, but not AM hyperglycemia, enhanced the HGU response to a PM HIHG clamp by augmenting GS and reducing GP activity. AM hyperinsulinemia can prime the liver to extract and store glucose more effectively during subsequent same-day meals, potentially providing a tool to improve glucose control.

The Anatomy Features and Variations of the Point Where Right Gastroepiploic Vein Flows into Superior Mesenteric Vein/Portal Vein: Anatomical Study of Catheterization of Portal Vein Infusion Chemotherapy.

To study the anatomical features and classification of the angle between the right gastroepiploic vein (RGEV) and superior mesenteric vein/portal vein (SMV/PV) and to guide the catheterization of intraportal infusion chemotherapy through RGEV and reduce surgical complications. A retrospective three-dimensional (3D) computed tomography study was undertaken on 200 consecutive subjects with or without hepatic malignant tumors with a dedicated workstation 3D-MIA (the improved MI-3DVS workstation) developed by ourselves to determine the prevalence of surgically significant angle between RGEV and SMV/PV anatomic variations and its classification. The mean value of the angles between the end of RGEV and SMV/PV (AERS/P) (200 cases) was 84.2° ± 23.8 (31.4°-151.5°): 40.6° ± 92.3 (-177.9° to 178.0°) (sagittal angle), 81.7° ± 29.8 (-79.3° to 160.7°) (coronal angle), and 10.5° ± 94.3 (-178.7° to 175.8°) (horizontal angle). The mean value of the angles between the right bend of RGEV and SMV/PV (ARRS/P) (168 cases) was 104.8° ± 26.1 (20.5°-159.7°):49.3° ± 117.8 (-175.3° to 179.5°) (sagittal angle), 103.5° ± 37.7 (-178.8° to 168.9°) (coronal angle), and 12.6° ± 102.8 (-179.9° to 179.2°) (horizontal angle). The AERS/P were classified into large angle group (32 cases, 16%), middle angle group (113 cases, 56.5%), and small angle group (55 cases, 27.5%) based on angle variations and risks of catheterization. Precognition of the variations of AERS/P and ARRS/P before surgery is useful during chemotherapy pump catheterizing through RGEV in reduction of surgical complications by modulating the angle and direction of RGEV running into SMV/PV properly.

Gallbladder cancer with tumor thrombus in the portal vein

Rationale:Gallbladder cancer (GBC) is a highly fatal malignancy. Due to its invasiveness and delayed diagnosis, many GBC patients are diagnosed with synchronous liver and hepatoduodenal ligament involvement. In our case, we report a gallbladder cancer with portal vein thrombus.Patient concerns:A 60-year-old woman presented with persistent upper abdominal dull pain for 2 months.Diagnoses:Ultrasound examination showed gallbladder carcinoma invading liver segment IV, and a tumor thrombus in the left and right main portal trunk. Ultrasonography and contrast-enhanced magnetic resonance imaging (MRI) showed gallbladder carcinoma with invasion of adjacent liver, and tumor thrombus in the right branch of the portal vein and intrahepatic bile duct. Abdominal computed tomography angiography (CTA) revealed no hepatic artery invasion.Interventions:We made a decision to perform extended right lobectomy. Twenty-six days later, the patient underwent intravenous infusion port implantation for S-1 plus oxaliplatin (SOX) therapy.Outcomes:After treatment, the patient has been doing very well and no recurrence has been found for 5 months.Lessons:The patient with gallbladder cancer and tumor thrombus in the portal vein described in this report provides a reminder for surgeons of the importance of early diagnosis, and adequate surgical and adjuvant treatment. Multi-disciplinary treatment is significantly beneficial for the overall survival of patients with advanced GBC.

Patient-Specific Atrial Hemodynamics of a Double Lumen Neonatal Cannula in Correct Caval Position.

Clinical success of pediatric veno‐venous (VV) extracorporeal membrane oxygenation (ECMO) is associated with the double lumen cannula cardiovascular device design as well as its anatomic orientation in the atrium. The positions of cannula ports with respect to the vena cavae and the tricuspid valve are believed to play a significant role on device hemodynamics. Despite various improvements in ECMO catheters, especially for the neonatal and congenital heart patients, it is still challenging to select a catalogue size that would fit to most patients optimally. In effect, the local unfavorable blood flow characteristics of the cannula would translate to an overall loss of efficiency of the ECMO circuit. In this study, the complex flow regime of a neonatal double lumen cannula, positioned in a patient‐specific right atrium, is presented for the first time in literature. A pulsatile computational fluid dynamics (CFD) solver that is validated for cardiovascular device flow regimes was used to perform the detailed flow, oxygenated blood transport, and site‐specific blood damage analysis using an integrated cannula and right atrium model. A standard 13Fr double lumen cannula was scanned using micro‐CT, reconstructed and simulated under physiologic flow conditions. User defined scalar transport equations allowed the quantification of the mixing and convection of oxygenated and deoxygenated blood as well as blood residence times and hemolysis build‐up. Site‐specific CFD analysis provided key insight into the hemodynamic challenges encountered in cannula design and the associated intra‐atrial flow patterns. Due to neonatal flow conditions, an ultra high velocity infusion jet emanated from the infusion port and created a zone of major recirculation in the atrium. This flow regime influenced the delivery of the oxygenated blood to the tricuspid valve. Elevated velocities and complex gradients resulted in higher wall shear stresses (WSS) particularly at the infusion port having the highest value followed by the aspiration hole closest to the drainage port. Our results show that, in a cannula that is perfectly oriented in the atrium, almost 38% of the oxygenated blood is lost to the atrial circulation while only half of the blood from inferior vena cava (IVC) can reach to the tricuspid valve. As such, approximately 6% of venous blood from superior vena cava (SVC) can be delivered to tricuspid. High values of hemolysis index were observed with blood damage encountered around infusion hole (0.025%). These results warrant further improvements in the cannula design to achieve optimal performance of ECMO and better patient outcomes.