Occlusion Of Tract Research Articles

"Efficacy of needle tract embolization using gelfoam in reducing incidence of Pneumothorax in CT-guided transthoracic Lung Biopsies: A Systematic Review and Meta-analysis."

Transthoracic CT-guided lung biopsy is associated with risk of pneumothorax, requiring chest tube placement at times. From available literature, we tried to compare the incidence rate of pneumothorax in cases undergoing CT-guided lung biopsy with versus without use of gelfoam slurry for tract occlusion. Databases like SCOPUS, PubMed, Google Scholar and EMBASE were searched for original studies analyzing the efficacy of gelfoam for needle tract embolization following CT-guided lung biopsy till September 2023. Bias in the selected studies was assessed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. Pooled odds ratio of the effect of gelfoam slurry on the rate of pneumothorax and chest tube placement following CT-guided lung biopsy was calculated and represented with 95% confidence intervals (95% CI) and Prediction interval (PI). Pooled analysis of six studies, revealed that patients undergoing needle tract embolization when compared to non-embolized patients had a significantly decreased risk of pneumothorax with odds reduced by 59% (OR = 0.41, 95% CI = 0.25-0.66, p = 0.01; PI=-1.694-0.094). Also, it led to a significant reduction in severe pneumothorax requiring chest tube placement with reduced odds by 63% (OR = 0.37, 95%CI= 0.20-0.69, p = 0.01; PI=-1.855-0.115). Needle tract embolization using gelfoam has a significant protective effect against pneumothorax as well as chest tube insertion in patients undergoing CT-guided lung biopsy. Gelfoam needle tract embolization can effectively reduce the risk of pneumothorax and chest tube requirement after lung biopsy.

339. MANAGEMENT OF OESOPHAGO-PLEURAL FISTULAS WITH ENDOSCOPIC VACUUM THERAPY: A PROMISING APPROACH

Abstract Background Boerhaave syndrome is a rare and serious condition requiring prompt management to prevent severe complications and improve patient outcomes. One significant complication is an oesophago-pleural fistula. These fistulas often result in aspiration pneumonia, empyema, and mediastinitis. Conventional management with surgery has high complication and mortality rates. Endoscopic vacuum therapy (EVT) is a less invasive technique for the management of oesophageal fistulas, involving endoscopic placement of a vacuum-assisted sponge within the oesophageal defect, promoting healing via continuous wound drainage and tissue granulation. Methods We report the case of a gentleman who initially presented with Boerhaave syndrome, was treated with open oesophageal repair, and was re-admitted 3 weeks later for an oesophago-pleural fistula with pleural collections. EVT was administered to the oesophageal defect twice weekly for 29 days and the effectiveness of therapy was monitored with serial oesophagogastroduodenoscopies, contrast studies, and computed tomography scans of the thorax to monitor the resolution of the pleural collections. During this period, the fistula defect showed gradual granulation tissue growth, resulting in full closure of the mucosal defect. Results The use of EVT has shown to result in successful closure of fistulas, resolution of sepsis with reduced need for surgical intervention, and shorter hospital stays. EVT combines coverage of the oesophageal defect and adequate drainage of the cavity behind the defect, often without the need for additional external drain placement. These findings highlight the role of EVT as a valuable adjunct in the management of oesophageal fistulas, particularly in cases requiring rescue therapy. Limitations of EVT include risk of bleeding, fistula formation/recurrence, need for frequent endoscopic interventions, stricture formation, and inability for oral intake due to occlusion of the gastrointestinal tract. Conclusion EVT represents a paradigm shift in the management of oesophageal fistulas, offering a less invasive alternative with the ability to promote wound healing, control sepsis, and reduce the need for high-risk redo oesophageal surgery. Further prospective studies and trials are needed to reach a consensus about its technical aspects, such as pressure settings and procedure intervals; as well as to evaluate its efficacy as a potential first-line treatment for oesophageal fistulas.

Allogenic Stem Cells in Anal Fistulas of Crohn's Disease: From Promising Premises to Real Life Experience.

Allogenic adipocyte stem cells represent an unprecedented opportunity for regenerative therapy to treat Crohn anal fistulas. Apart from the results of one 8-year-old trial, scientific evidence remains scarce. Data from consecutive patients treated with darvadstrocel for Crohn anal fistulas were reviewed at 6 first tertiary reference centers. The judgment criteria combined asymptomatic status plus clinical occlusion of the fistula tract and MRI-confirmed healing of the tract (no inflammation and/or disappearance of the tract). Both clinical and MRI-confirmed healing of the tract defined a deep remission. Clinical remission was defined by an absence of complaint, occlusion of all external openings, and no fistula discharge. A total of 116 patients were extracted (median follow-up after cell stem injection: 11 [6-14] months). No severe adverse events were reported after surgery except for subsequent anal surgery in 29 (25%) patients. Fifty-one (44%) patients had clinical remission defined by the absence of complaints, the occlusion of all external openings, and the presence of no fistula discharge. Deep remission was observed in 23 (29%) patients. Patients with clinical remission more often received combined therapy (immunosuppressant antitumor necrosis factors) than those with no improvement (31 of 51 [61%] vs 23 of 65 [35%]; P = .007). Regression analysis showed that high fistulas (odds ratio, 3.8 [1.1-12.5]; P = .03) and younger age (<38 years, odds ratio, 2.3 [1.0-58;4]; P = .02) were associated with a better outcome. Allogeneic stem cell treatment of Crohn's anal fistulas results in complete remission in less than half of patients, with a significant reintervention rate.

Outcomes following transcatheter closure or surgical repair of coronary-left ventricular fistula: A single-center study with 10-year experience

BackgroundCoronary arteries drain into the left ventricle, known as coronary-left ventricular fistula (CLVF), an extremely rare anomalous coronary artery disease. Little is known about the outcomes following transcatheter closure (TC) or surgical closure (SC) of CLVF. MethodThis was a single-center retrospective study including 42 consecutive patients who underwent either the TC or SC procedure from January 2011 to December 2021. The baseline and anatomic characteristics of the fistulas, procedural outcomes, and late outcomes were summarized and analyzed. ResultsThe mean age was 31.6 ± 16.2 years, with 28 male patients (66.7%). Fifteen patients underwent SC group and the remaining received TC group. There were no differences in age, comorbidities, clinical presentations, and anatomic characteristics between the 2 groups. The procedural success rate was similar (93.3% vs. 85.2%, P = 0.639) without operative and in-hospital mortality in both groups. Notably, patients who underwent TC had a significantly shorter postoperative in-hospital length of stay (2.11 ± 1.49 vs. 7.73 ± 2.37 days, P<0.001). The median follow-up time was 4.6 years (2.5-5.7 years, TC group) and 3.98 years (0.42-7.15 years, SC group), respectively. No difference was observed in the incidence of recanalization of the fistula (7.4% vs. 6.7%, P = 1) and myocardial infarction (0% vs. 0%). Cerebral infarction due to discontinuation of anticoagulants happened to two patients in the TC group. Importantly, thrombotic occlusion of the fistulous tract with patent parent coronary artery was found in 7 patients of the TC group. ConclusionBoth transcatheter and SC are safe and effective for patients with CLVF. Thrombotic occlusion is a noteworthy late complication, and its presence indicates the use of anticoagulants lifelong.

Traumatic Subdural Hygroma Due to Injury of an Ommaya Reservoir: A Case Report

A 68-year-old male patient was transferred to the emergency department after a passerby found him lying on the road with a bicycle. He had been diagnosed with neurolymphomatosis in 2006 and had an Ommaya reservoir targeted to the right lateral ventricle via the right Kocher’s point for chemotherapy. His initial mental status was stuporous. Brain computed tomography (CT) showed multiple traumatic injuries. Seven days after admission, bilateral subdural hygroma (SDG) developed. We performed CT cisternography. The contrast was directly injected into the Ommaya reservoir and CT images were obtained. On cisternography, contrast leakage points were identified from the Ommaya reservoir. The patient underwent surgery for Ommaya reservoir removal and occlusion of the permanent tract of the Ommaya reservoir. This case shows a rare etiology of traumatic SDG and demonstrates the usefulness of CT cisternography to determine cerebrospinal fluid leakage from an implant.

Hybrid Revascularization for Extensive Iliofemoral Occlusive Disease

Total occlusion of the iliac-femoral tract can cause a variety of life-limiting symptoms ranging from mild claudication to chronic limb-threatening ischemia. Efforts should be made to revascularize the symptomatic ischemic limb. Currently there are different options in the vascular surgeon's armamentarium to achieve this. The aim of the study was to verify the feasibility and outcomes of inflow hybrid revascularizations combining femoral endarterectomy and recanalization of iliac atherosclerotic occlusion. A retrospective review was conducted of all hybrid revascularizations involving femoral endarterectomy and endovascular treatment of iliac occlusion. The operations were performed in Helsinki University Hospital between January 2013 and December 2018. First, information about patients' baseline characteristics, indications and details of surgery and technical/hemodynamic success, and complications and mortality were obtained from the vascular registry and patients records. Secondarily, a prospective assessment of mid-term patency was performed through follow-up in November 2019. Immediate technical success, 30-day mortality, complications, and patency were considered major outcomes. Hemodynamic improvement, amputation rate, and overall mortality were also assessed. One hundred sixty three iliofemoral occlusions were performed on 147 patients during the period studied. Six patients (3.6%) had infrarenal aortic occlusion, 86 (52.7%) had common iliac, and 128 (78.5%) had external iliac artery occlusion. Technical success rate was 88.3% (n=144 occlusions recanalized). Primary technical success was somewhat lower in lesions ≥ 90mm (87.1%) compared to lesions shorter than 90mm (95.7%; χ2P=0.06). Iliac stent was deployed in 141 (94.6%) cases, 51 (34.3%) of which were covered stents. Significant residual stenosis remained in 1.2% of cases. Median operative time was 4hr 34min (interquartile range 2 hr 43min) and median estimated blood loss was 743mL (interquartile range 500mL). Five patients (3.0%) developed a deep groin infection and 12 (8.1%) suffered any major cardiovascular event or stroke perioperatively. Primary patency at 30day, 6months, 1 year, and 2years was 98.7%, 98.1%, 96.6%, and 93.7%, respectively. Hemodynamic success was documented in 107 patients (73%). By the end of the follow-up, 7 iliofemoral tracts (11.1%) reoccluded, 2 limbs (1.2%) required amputation, and 50 patients (3.0%) died. Good immediate success rate and mid-term patency can be achieved by hybrid revascularization of iliofemoral occlusions. Careful patient selection is mandatory because this population often suffers from universal atherosclerosis. The involvement of the aorta represents a significant determinant of worse long-term patency, although it did not preclude technical success.

Electroacupuncture treatment of benign prostatic hyperplasia: A case report

Benign prostatic hyperplasia (BPH) is characterized by symptoms such as frequent urination and difficulty in urination. Currently, treatment is mainly carried out using medications and surgery, but all of these methods can lead to certain adverse effects. In this case, a ninety-year-old male elderly patient came to our acupuncture clinic for treatment of urinary tract occlusion due to BPH. According to the patient's condition, we adopted the eletroacupuncture treatment protocol of Prof. Zhanglian Wang, a famous experienced Chinese medicine doctor. After six weeks of acupuncture treatment, the patient's urinary status improved significantly. This case suggests that acupuncture may be an effective complementary alternative therapy for BPH.

A Modified Surgical Technique for Kidney Transplantation in Mice

Kidney transplantation in mice is a complicated and challenging surgery procedure. There are very few publications demonstrating the key steps of this operation. Therefore, this article introduces the technique and points out the surgical caveats associated with this operation. In addition, important modifications in comparison to the conventional procedure are demonstrated. Firstly, a patch of the abdominal aorta is cut and prepared so that the proximal bifurcations of the renal artery, including the ureteral artery are transected together with the donor kidney en bloc. This reduces the risk of a ureter necrosis and avoids the development of a urinary tract occlusion. Secondly, a new method of the vascular anastomosis is demonstrated that allows the operator to flexibly increase or decrease the size of the anastomosis after renal transplant reperfusion has already been initiated. This avoids the development of vessel strictures and intraabdominal bleeding. Thirdly, a technique that enables the anastomosis of the delicate donor ureter and the recipient bladder that does not cause a trauma is shown. Adopting this protocol can shorten the operation time and reduces the damage to the recipient's bladder, thereby significantly increasing the operation success rate for the recipient mice.

P194 AN UNUSUAL PRESENTATION OF ST–SEGMENT ELEVATION MYOCARDIAL INFARCTION: LEFT VENTRICULAR THROMBOSIS AND ISCHEMIC STROKE

Abstract Background Patients with large anterior MI associated with a reduced systolic function are at increased risk for developing left ventricular thrombosis. Stasis of blood in the ventricular cavity and the inflammation associated with ischemic injury are the causes of left ventricular thrombosis and increased risk of stroke. It usually develops within the first week and often the first day after infarction. Embolization takes place during the first 1 to 3 months. Our patient presented a very early embolization. Case Report A 70–year–old smoker man, without other cardiovascular risk factors, presented at the emergency department of our hospital with acute aphasia and right facio–brachio–crural hemiparesis. The 12–lead ECG revealed ST–elevation in V2–V5 and Q waves in V1–V3. Patient was asymptomatic for angina at the time of presentation and the days before. He performed an urgent head–CT that revealed proximal occlusion of the M2 tract of left middle cerebral artery cause of ischemic stroke (NIHSS 13). Then, he underwent per–cutaneous mechanical thrombectomy with complete re–canalization of the vessel. Immediately after he performed coronary angiography that showed the occlusion of anterior inter–ventricular artery treated by angioplasty and implant of drug eluting stent. Both procedures have been well tolerated by the patient without complications. Measurements of high–sensitivity cardiac Troponin demonstrated a peak and following fall of the values. A two–dimensional echo–cardiogram showed akinesia of anterior wall and apical segments of LV with EF &amp;lt; 40% and ventricular thrombus. A multidisciplinary team evaluated evolution of cerebral ischemic lesion and patient’s clinical conditions and established the correct time and management of therapy with DAPT (aspirin+clopidogrel) and VKA. It has been prescribed three months DAPT+VKA therapy and later DAT (aspirin+VKA) for one year. Patient has been discharged with minor aphasia, without cardiac symptoms and good hemodynamic status. Conclusion Left ventricular thrombosis is a frequent complication of anterior MI. The optimal frequency of follow–up imaging and time of treatment are not known. Our patient had a very early presentation. It should be useful to have guidelines to prevent and treat left ventricular thrombosis. Despite common use of anticoagulant drugs in the treatment of left ventricular thrombosis, there aren‘t randomized clinical trials evaluating the safety and efficacy of this strategy.

Feasibility and safety of guidewire-balloon entrapment technique for recanalization of thoracic central vein occlusion in hemodialysis patients.

To explore the feasibility and safety of Guidewire-Balloon Entrapment Technique (GBET) for the recanalization of thoracic central vein occlusions (TCVOs) in hemodialysis patients. A retrospective observational study was conducted using data from 28 patients who required the establishment or maintenance of hemodialysis access and were treated with GBET for the recanalization of right-sided TCVOs from January 2017 to April 2021. Of the patients, 27 required tunneled cuffed catheter (TCC) placement or exchange, and 1 had an outflow tract occlusion of the Brescia-Cimino radio cephalic arteriovenous fistula (AVF). A total of 26 patients successfully underwent TCC exchange and placement using GBET; 1 patient underwent successful recanalization of an occlusion of the outflow tract of the right Brescia-Cimino AVF; and 1 patient underwent successful TCC placement in the left internal jugular vein (LIJV) after the failure of TCC placement in the right internal jugular vein (RIJV). The success rate for GBET was 27/28 (96.43%), and there were no major complications. GBET is a safe and effective method for the recanalization of right-sided TCVOs, especially for TCC exchange and placement, and can be used as a safe and easy approach for TCVO recanalization.

The use of modified Montgomery T-tubes as frontal sinus stents: how I do it.

Frontal sinus surgery is challenging as the frontal recess is prone to re-stenosis and there is subsequent occlusion of the frontal sinus outflow tract. In an attempt to maintain the frontal recess calibre and reduce frontal sinus re-stenosis, frontal sinus stents have been used with different materials and varying results. This paper presents the technique of using a modified Montgomery T-tube as a frontal sinus stent. The use of a soft, self-retaining and non-absorbable stent that can be used for stenting of the frontal sinus is described. Our technique is safe, effective, inexpensive and well tolerated.

Vocal Fold Vibration Characteristics during SOVTE using a Vibration Simulator and Digital Kymography

Objectives: The purpose of this study is to investigate the characteristics of vocal fold vibration during sustained vowel /a/ phonation and various semi-occluded vocal tract exercise (SOVTEs) using a vibration simulator and digital kymography (DKG).Methods: A total of 12 normal young speakers (6 males, 6 females) aged 20-30 years participated in the study. They phonated a sustained /a/ vowel and performed SOVTE. The vocal fold vibration characteristics were measured according to the number of vibration sources (single vs. double), and vocal tract occlusion degree using a vibration simulator and DKG. Glottal gap quotient (GQ, %), speed quotient (SQ, %) and amplitude (pixel) were estimated quantitatively from the DKG image.Results: The results showed that significantly higher GQ (p = .000) and SQ (p = .000) were observed in the humming and bilabial fricative /β/ compared to open vowels. The amplitude was significantly higher in the open vowel /a/ than in humming (p = .018) and bilabial fricative /β/ (p = .003). Also, when comparing the vocal fold vibration parameters according to vibration type (single source: straw phonation vs. double source: straw phonation with water), the double source presented a significantly higher GQ (p = .000) as well as SQ (p = .008) in comparison with a single source.Conclusion: SOVTE showed a glottal gap that is different from the opened vowel /a/. It also had a longer opening of the vocal fold and a smaller amplitude than the vowel. This suggests that SOVTE may be helpful for facilitating vocal fold vibration and good voice quality in clinical practice. The current study can be meaningful in providing theoretical and clinical evidence for SOVTE.

Mortality among involuntary inpatients of psychiatric hospital

BackgroundMortality is often used as an indicator of public health efforts. Even if mortality in psychiatric hospitals decreased since the introduction of modern treatment, the death toll is still high. The authors have analyzed the forensic autopsy data and the medical documentation regarding 115 death cases from psychiatric hospitals in south-eastern Romania during the period of 2000–2020.ResultsThe average annual mortality rate was 5.13‰, the necropsy data corroborated with those from the medical documentary material indicates acute myocardial infarction as the dominant cause, with 65 (56.5%) cases, followed by upper respiratory tract occlusion with 23 cases (20%) and pulmonary thromboembolism in 4 cases (12.2%). Furthermore, in 6 cases (5.2%) the cause of death was traumatic: 4 cases of cranio-cerebral trauma and 2 cases of hanging.ConclusionsIn the mortality structure of psychiatric patients, cardiac death predominated, being influenced by the cardiotoxic effect of medication administered for the specific pathology; hence, an early involvement of cardiologists in the follow-up of patients and the finding of treatment schemes with a reduced cardiotoxic effect are required.

Gelfoam slurry tract occlusion after computed tomography-guided percutaneous lung biopsy: Does it prevent major pneumothorax?

Computed tomography (CT)-guided lung biopsy is a frequently performed procedure in the diagnostic workup for suspicious lung nodules that can be complicated by pneumothorax. This retrospective study assessed the efficacy of biopsy tract occlusion with a gelatin sponge slurry for preventing post-biopsy pneumothorax. Retrospective analysis was conducted on consecutive adult patients who underwent CT-guided lung biopsy over a 10-year period. Age, gender, existing chronic obstructive pulmonary disease (COPD), evidence of emphysema on CT, location of the lesion and the presence of pneumothorax on post-procedure CT and 4-h chest radiograph were recorded. Two hundred and ninety-six patients were included (126 patients in the non-gelfoam group and 170 in the gelfoam group). When gelfoam was used, risk of developing an immediate pneumothorax was lower (P=0.032). Patients with emphysema were 2.4 times more likely to develop a delayed pneumothorax without gelfoam (P=0.034). There was a significantly higher risk of both immediate and delayed pneumothorax in non-peripheral lesions without gelfoam (P=0.001 and P=0.002, respectively). The frequency of requiring a chest tube to treat a pneumothorax was 86% lower when gelfoam was used (P=0.012). Gelfoam is effective in preventing immediate pneumothorax. In patients with emphysema, there was a significantly higher risk of delayed pneumothorax without gelfoam. Additionally, non-peripheral lesions were more likely to develop pneumothorax when gelfoam was not used. The use of gelfoam was especially important in preventing the development of major pneumothoraces that would require drainage with a chest tube.

Inhibition of heat shock protein 90 alleviates cholestatic liver injury by decreasing IL-1β and IL-18 expression.

Severe cholestatic liver injury diseases, such as obstructive jaundice and the subsequent acute obstructive cholangitis, are induced by biliary tract occlusion. Heat shock protein 90 (HSP90) inhibitors have been demonstrated to be protective for various organs. The potential of HSP90 inhibitors in the treatment of cholestatic liver injury, however, remains unclear. In the present study, rat models of bile duct ligation (BDL) were established, the HSP90 inhibitor 17-dimethylamino-ethylamino-17-demethoxygeldanamycin (17-DMAG) was administered, and its ability to ameliorate the cholestasis-induced liver injuries was evaluated. In the BDL rat models and clinical samples, increased HSP90 expression was observed to be associated with cholestatic liver injury. Furthermore, 17-DMAG alleviated cholestasis-induced liver injury in the rat models, as revealed by the assessment of pathological changes and liver function. In addition, 17-DMAG protected hepatocytes against cholestatic injury in vitro. Further assays indicated that 17-DMAG administration prevented cholestasis-induced liver injury in the rats by decreasing the expression of interleukin (IL)-1β and IL-18. Moreover, 17-DMAG also decreased the cholestasis-induced upregulation of IL-1β and IL-18 in liver sinusoidal endothelial cells in vitro. In conclusion, the HSP90 inhibitor 17-DMAG is able to prevent liver injury in rats with biliary obstruction, and this phenomenon is associated with the reduction of IL-1β and IL-18 expression.

Malignant obstructive jaundice: justification of the method of biliary decompression

Aim. To show the optimal algorithm of diagnostic and treatment of malignant obstructive jaundice, which allows to increase the effectiveness of primary surgery, reducing the number of complications and mortality in the operated patients.Materials and methods. The results of examination and surgical treatment of 325 patients with malignant obstructive jaundice who underwent minimally invasive decompression of the biliary tract were studied. Based on the results of treatment, an algorithm for examining and treating patients with malignant obstructive jaundice has been formed and tested.Results. Using such criterial like severity of obstructive jaundice by E.I. Galperin, anatomical level of biliary tract occlusion and staging oncology process by TNM classification could help to choose the rational method for its surgical treatment and determine the risk of complications and mortality. At the level of biliary occlusion I and II, endoscopic stenting is a fairly successful inter-vention with a minimum of complications. For a level III block, the operation of choice is percutaneous transhepatic drainage. Cholecystostomy is advisable in case of level I block below the cystic duct in flow level and class “C” obstructive jaundice or for technical impossibility to apply a different method.Realization of the developed algorithm allowed resolving obstructive jaundice in a palliative option in 71.4% of patients and preparing 28.6% for surgical treatment.Conclusion. Implementation of an improved algorithm for the diagnosis of malignant obstructive jaundice makes it possible to justify the choice of a rational option for its surgical treatment, increase the effectiveness of interventions and reduce postoperative mortality.

The Compensatory Reserve Index Responds to Acute Hemodynamic Changes in Patients with Congenital Heart Disease: A Proof of Concept Study.

Patients with congenital heart disease (CHD) who undergo cardiac procedures may become hemodynamically unstable. Predictive algorithms that utilize dense physiologic data may be useful. The compensatory reserve index (CRI) trends beat-to-beat progression from normovolemia (CRI = 1) to decompensation (CRI = 0) in hemorrhagic shock by continuously analyzing unique sets of features in the changing pulsephotoplethysmogram (PPG) waveform. We sought to understand if the CRI accurately reflects changing hemodynamics during and after a cardiac procedure for patients with CHD. A transcatheter pulmonary valve replacement (TcPVR) model was used because left ventricular stroke volume decreases upon sizing balloon occlusion of the right ventricular outflow tract (RVOT) and increases after successful valve placement. A single-center, prospective cohort study was performed. The CRI was continuously measured to determine the change in CRI before and after RVOT occlusion and successful TcPVR. Twenty-six subjects were enrolled with a median age of 19 (interquartile range (IQR) 13-29) years. The mean (± standard deviation) CRI decreased from 0.66 ± 0.15 1-min before balloon inflation to 0.53 ± 0.16 (p = 0.03) 1-min after balloon deflation. The mean CRI increased from a pre-valve mean CRI of 0.63 [95% confidence interval (CI) 0.56-0.70] to 0.77 (95% CI 0.71-0.83) after successful TcPVR. In this study, the CRI accurately reflected acute hemodynamic changes associated with TcPVR. Further research is justified to determine if the CRI can be useful as an early warning tool in patients with CHD at risk for decompensation during and after cardiac procedures.

Radiofrequency thermocoagulation for high transphincteric fistulae, Merlini l'Héritier et al.

Obliteration of the internal opening has long been held as the key resolution of high transsphincteric fistulae. This month's Editor's Choice by Merlini l'Héritier et al. evaluated ablation of the tract by applying radiofrequency thermocoagulation 1. They used a control group, selected from a prospective database consisting of patients who underwent occlusion of the fistula tract by a rectal advancement flap, paired-matched for sex, age and the presence of Crohn's disease. The healing rate was only 26% at 5 months after radiofrequency thermocoagulation, vs 68% after flap repair, and dropped further to 10% after 21 months. These findings suggest that obliteration of the fistula tract is not enough to accomplish healing of perianal fistulae in most cases. The authors must be congratulated on publishing these findings. Negative findings provide much needed feedback on the effectiveness of treatment after introducing a new technique or pursuing new indications for a known technique. Radiofrequency thermocoagulation has become common practice as the primary treatment of varicose veins. Recently, new indications for the radiofrequency technique have been defined. For example, obliteration of the sinus in simple pilonidal disease with radiofrequency has been shown to be highly successful 2. We now know that pilonidal disease is caused by loose hairs entering the pits in the intergluteal cleft by their root ends, where a foreign body reaction creates the pilonidal sinus. Consequently, it is understandable that after removing the hairs from the pilonidal cavity, obliteration of the pits by thermocoagulation in order to avoid future potential ports of hair re-entry is a sound treatment principle. The pathophysiology of cryptoglandular and Crohn's fistulae has not been conclusively established. Crohn's disease is thought to be caused by a failure of the intestinal mucosal immune system to tolerate commensal bacteria. The highest healing rates in the featured study were achieved in patients with Crohn's disease (overall success 64 percent) 1. All these patients were on anti-tumour necrosis factor alpha therapy. There is now growing evidence that in patients with Crohn's fistulae, it is essential to combine surgery with biologic agents 2, 3. When managing Crohn's fistulae, combining a surgical procedure, which prevents entry of bacteria to the fistula, with immunotherapy seems to be the logical approach. The overall healing rate in patients with cryptoglandular fistulae was only 41% at 5 months follow-up 1. The persistent inflammation in the anal crypt is nowadays believed to occur as a result of a defective local immune system. Hence, before introduction of new surgical techniques, a better understanding of what process drives this ongoing perianal sepsis is recommended.

Development of a New Local Therapeutic Approach for BOS: Efficacy of Imatinib Loaded -antiCD44 Coated Gold Nanoparticles In Vitro and In Vivo

Purpose The use of gold nanoparticles (GNPs) as local targeted drug delivery system are a promising issue for several orphan diseases. Bronchiolitis obliterans syndrome (BOS) represents about 70% of cases of chronic lung allograft dysfunction limiting long term survival after lung transplant, and occurs also as chronic pulmonary involvement in the context of GVHD. To now treatment strategies in BOS are scarce and poorly effective. In the present work, we investigated the effect of GNP decorated with the half chain of monoclonal antibody against CD44 (GNP-HC), surface receptor overexpressed by primary BOS derived mesenchymal cells (MCs) that cause the partial or total occlusion of alveolar tract. We loaded GNP-HC with imatinib (GNP-HCim), an cAbl inhibitor used in the management of chronic GVHD. Methods In vitro experiments were performed on MCs derived from BOS patients evaluating cell cytotoxicity after incubation with GNP-HC, GNP-HCim and Imatinib alone. We further performed a mouse heterotopic trachea transplantation model modified by the subcutaneous placement of Alzet Model 2004 miniosmotic pumps used to deliver into the trachea different solutions at a constant rate for 28 days. This was performed in order to assess the efficacy of the local intratracheal administration of our nanovectors. Results Thanks to MTT and apoptosis assay we observed that GNP-HCim decrease MCs viability more than GNP-HC and Imatinib alone, due to an induction of apoptosis (50 ± 0.5 % for GNP-HCim in contrast to GNP-HC 40 ± 0.35 % and Imatinib alone 30 ± 1.2 %). Moreover, animal model data confirmed the in vitro results: GNP-HCim significantly reduced the percentage of tracheal obliterative area (12.99 ± 2.5%) respect to GNP-HC (46.79± 5.7%) and vehicle treated mice (30.92 ± 5.8%). Conclusion We conclude that this approach by newly developed nano-based strategies for BOS treatment and especially targeted imatinib gold nanoparticles are promising candidates for further development.

Malignant obstructive jaundice: rational method of surgical treatment

Background: Aim of the study is to choose rational method of biliary decompression in patients with malignant obstruction. 260 patients had biliary decompression for the 6 year period Methods: We focused on the anatomical level of biliary tract occlusion. Obstruction at the level of the common bile duct(CBD) was detected in 78.8% cases , common hepatic duct(CHD) with untouched confluence in 8,3% , confluence and above on lobal and segmental level of occlusion in 12,9 % Results: Cholecystostomy (CS) was performed in 24.2% cases, Percutaneous biliary drainage (PBD) in - 13.2%, Endoscopic stenting (ES) in - 47.6%, In 14% of cases we had to combine the two different methods of draining jaundice because of the inefficiency one of them. ES was successful in 91.3% cases with an occlusion at the level of CBD, in 72.0% at the level of the CHD In cases with occlusion above confluence ES was not applied. PBD was successfully in 87.5% cases with obstruction at the level of the CBD, at the level of CHD - 90%, at the level of lobal and segmental hepatic ducts - 88.2%. CS was effective in 77.9%, in cases with obstruction below the mouth of the cystic duct.Complications occurred in 13% of cases. After ES leading complication was cholangitis. The main complications after PBD and CS was bile leakage into the peritoneal or pleural cavity. Conclusion: ES has priority in cases with an occlusion level of the CBD and CHD with untouched confluence, PHD in cases with occlusion level of lobal and segmental ducts.