Endoscopic treatment of biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants: Lessons learned from single-balloon enteroscopy-assisted ERCP

Background: Endoscopic treatment of biliopancreatic pathology is challenging due to surgically altered anatomy after Whipple's pancreaticoduodenectomy. This study aimed to evaluate the feasibility and safety of single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography(SBE-ERCP) to treat biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants. Methods: We retrospectively analyzed 106 SBE-ERCP procedures in 46 patients with Whipple's variants. Technical and clinical success rates and adverse events were evaluated. Results: Biliary SBE-ERCP was performed in 34 patients and pancreatic SBE-ERCP in 17, including 5 with both indications. From a total of 106 SBE-ERCP procedures, 76 were biliary indication with technical success rate of 68/76(90%) procedures and clinical success rate of 30/34(88%) patients. Mild adverse event rate was 8/76(11%), without serious adverse events. From a total of 106 SBE-ERCP procedures, 30 were pancreatic indication with technical success rate of 24/30(80%) procedures( P = 0.194 vs. biliary SBEERCP) and clinical success rate of 11/17(65%) patients( P = 0.016 vs. biliary SBE-ERCP). Mild adverse event rate was 6/30(20%)( P = 0.194 vs. biliary SBE-ERCP), without serious adverse events. After SBE-ERCP failure, endoscopic ultrasound-guided drainage, percutaneous drainage and redo surgery were alternative therapeutic options. Conclusions: Biliopancreatic pathology after Whipple's pancreaticoduodenectomy variants can be treated using SBE-ERCP without serious adverse events. Technical and clinical success rates are high for biliary indications, whereas clinical success rate of pancreatic indications is significantly lower. SBE-ERCP can be considered as first-line treatment option in this patient group with surgically altered anatomy.

Correlation of MRI-determined small bowel Crohn’s disease categories with medical response and surgical pathology

AIM: To determine whether magnetic resonance imaging (MRI) can be used to categorize small bowel Crohn's disease (SB CD) into groups that correlate with response to medical therapy and surgical pathology.METHODS: Data was collected from all patients with MRI evidence of SB CD without significant colonic disease over a 32-mo period. Two radiologists, blinded to clinical findings, evaluated each MRI and grouped them based on bowel wall thickness and wall enhancement. These categories were: (1) "fibrosis", (2) "mild segmental hyper-enhancement and mild wall thickening", (3) "mild segmental hyper-enhancement and marked wall thickening", (4) "marked segmental transmural hyper-enhancement". Patient response to additional medical therapy post-MRI was prospectively determined at 8-wk. Non-responders underwent endoscopy and were offered therapeutic endoscopy or surgery. Surgical pathology was assessed against the MRI category. RESULTS: Fifty-five patients were included. Females and category "2" patients were more likely, and patients with luminal narrowing and hold-up less likely, to respond to medical therapy (P < 0.05). Seventeen patients underwent surgery. The surgical pathologicalfindings of fibrosis and the severity of inflammation correlated with the MRI category in all cases.CONCLUSION: Our fi ndings suggest that SB CD can be grouped by the MRI f indings and that these groups are associated with patients more likely to respond to continued medical therapy. The MRI categories also correlated with the presence and level of intestinal inflammation and fibrosis on surgical pathology, and may be of prognostic use in the management of CD patients.

Comparative Analysis of the Value of Gastroscopic Biopsy and Surgical Pathology in the Diagnosis of Gastric Cancer

Objective:To explore and analyze the diagnostic value of gastroscopic biopsy and surgical pathology in improving the diagnostic accuracy of gastric cancer.Methods:From May 2019 to June 2020,80 patients with gastric cancer treated in Shuyang Xiehe Hospital were selected and divided into two groups,a control group and a study group,with 40 cases in each group,based on the examination method individually selected by the patients.The patients in the control group were investigated via gastroscopy,while those in the study group were investigated by surgical pathology.The diagnostic values of the two methods were compared and analyzed.Results:The diagnostic accuracy of patients in the study group was 100%,which was higher than that of the control group.The tissue type,lesion morphology,and cancer differentiation of the study group were better than those of the control group.There was significant difference between the two methods(P<0.05).Conclusion:Surgical and pathological examination can improve the diagnostic accuracy of gastric cancer,comprehensively analyze the patient’s condition,and provide corresponding theoretical basis for follow-up treatment,so that patients can obtain more active and effective treatment,reduce pain,and improve their quality of life.

Amyloid-beta pathology-induced nanoscale synaptic disruption:the case of the GABA_B-GIRK assembly

Alzheimer's disease (AD) is characterized by an imbalance between excitatory and inhibitory brain networks,leading to aberrant homeostatic synaptic plasticity.AD has progressively been recognized as syna ptopathy and syna ptic dysfunction has been identified as a key component of its pathogenesis (Schirinzi et al.,2020).Syna ptic dysfunction is believed to precede synapse loss,a primary biological correlate of cognitive decline in AD,inevita bly associated with neuronal death.

Navigating medial patellotibial ligament reconstruction:Clinical perspectives and surgical strategies

The surgical approach for patellar instability usually refers to reconstruction of the medial patellofemoral ligament associated with an osteotomy of the tibial tuberosity or a trochleoplasty when required.The medial patellotibial ligament and the medial patellomeniscal ligament are secondary stabilizers of the patella.Despite this,both the medial patellotibial and patellofemoral ligaments aid in patellar rotation and tilt when the knee is flexed beyond 45°.The medial patellotibial ligament plays a particularly important role in the final stages of stretching in extension and between 40 degrees to 90 degrees of flexion.The clinical relevance and surgical indications for medial patellotibial ligament reconstruction associated with medial patellofemoral ligament reconstruction are still controversial.This editorial explores the surgical indications and clinical results for medial patellotibial ligament reconstruction to improve readers’understanding of this technique,especially because reported clinical outcomes have remained sparse.

Expanding role and scope of artificial intelligence in the field of gastrointestinal pathology

Digital pathology(DP)and its subsidiaries including artificial intelligence(AI)are rapidly making inroads into the area of diagnostic anatomic pathology(AP)including gastrointestinal(GI)pathology.It is poised to revolutionize the field of diagnostic AP.Historically,AP has been slow to adopt digital technology,but this is changing rapidly,with many centers worldwide transitioning to DP.Coupled with advanced techniques of AI such as deep learning and machine learning,DP is likely to transform histopathology from a subjective field to an objective,efficient,and transparent discipline.AI is increasingly integrated into GI pathology,offering numerous advancements and improvements in overall diagnostic accuracy,efficiency,and patient care.Specifically,AI in GI pathology enhances diagnostic accuracy,streamlines workflows,provides predictive insights,integrates multimodal data,supports research,and aids in education and training,ultimately improving patient care and outcomes.This review summarized the latest developments in the role and scope of AI in AP with a focus on GI pathology.The main aim was to provide updates and create awareness among the pathology community.

NLRP3-mediated autophagy dysfunction links gut microbiota dysbiosis to tau pathology in chronic sleep deprivation

Emerging evidence indicates that sleep deprivation(SD)can lead to Alzheimer’s disease(AD)-related pathological changes and cognitive decline.However,the underlying mechanisms remain obscure.In the present study,we identified the existence of a microbiota-gut-brain axis in cognitive deficits resulting from chronic SD and revealed a potential pathway by which gut microbiota affects cognitive functioning in chronic SD.Our findings demonstrated that chronic SD in mice not only led to cognitive decline but also induced gut microbiota dysbiosis,elevated NLRP3 inflammasome expression,GSK-3βactivation,autophagy dysfunction,and tau hyperphosphorylation in the hippocampus.Colonization with the“SD microbiota”replicated the pathological and behavioral abnormalities observed in chronic sleep-deprived mice.Remarkably,both the deletion of NLRP3 in NLRP3-/-mice and specific knockdown of NLRP3 in the hippocampus restored autophagic flux,suppressed tau hyperphosphorylation,and ameliorated cognitive deficits induced by chronic SD,while GSK-3βactivity was not regulated by the NLRP3 inflammasome in chronic SD.Notably,deletion of NLRP3 reversed NLRP3 inflammasome activation,autophagy deficits,and tau hyperphosphorylation induced by GSK-3βactivation in primary hippocampal neurons,suggesting that GSK-3β,as a regulator of NLRP3-mediated autophagy dysfunction,plays a significant role in promoting tau hyperphosphorylation.Thus,gut microbiota dysbiosis was identified as a contributor to chronic SD-induced tau pathology via NLRP3-mediated autophagy dysfunction,ultimately leading to cognitive deficits.Overall,these findings highlight GSK-3βas a regulator of NLRP3-mediated autophagy dysfunction,playing a critical role in promoting tau hyperphosphorylation.

Digital pathology-based artificial intelligence models for differential diagnosis and prognosis of sporadic odontogenic keratocysts

Odontogenic keratocyst(OKC)is a common jaw cyst with a high recurrence rate.OKC combined with basal cell carcinoma as well as skeletal and other developmental abnormalities is thought to be associated with Gorlin syndrome.Moreover,OKC needs to be differentiated from orthokeratinized odontogenic cyst and other jaw cysts.Because of the different prognosis,differential diagnosis of several cysts can contribute to clinical management.We collected 519 cases,comprising a total of 2157 hematoxylin and eosinstained images,to develop digital pathology-based artificial intelligence(AI)models for the diagnosis and prognosis of OKC.The Inception_v3 neural network was utilized to train and test models developed from patch-level images.Finally,whole slide imagelevel AI models were developed by integrating deep learning-generated pathology features with several machine learning algorithms.The AI models showed great performance in the diagnosis(AUC=0.935,95%CI:0.898–0.973)and prognosis(AUC=0.840,95%CI:0.751–0.930)of OKC.The advantages of multiple slides model for integrating of histopathological information are demonstrated through a comparison with the single slide model.Furthermore,the study investigates the correlation between AI features generated by deep learning and pathological findings,highlighting the interpretative potential of AI models in the pathology.Here,we have developed the robust diagnostic and prognostic models for OKC.The AI model that is based on digital pathology shows promise potential for applications in odontogenic diseases of the jaw.

Going straight for the gut:gut-brain axis pathology and treatment of Parkinson's disease

This perspective focuses on the recent literature regarding the role of the gut-brain axis(GBA) in fecal microbiota transplantation(FMT) and stem cell therapy(SCT) in Parkinson's disease(PD).PD is the second most common neurodegenerative disease in the United States,yet therapies remain limited.Current research suggests that the GBA may play a role in the pathogenesis of PD.GBAbased FMT as well as SCT offer promising new avenues for PD treatment.Pro bing the interactions between FMT and SCT with the GBA may reveal novel therapeutics for PD.

Hysterectomies for Gynaecological Pathology: 56 Cases at the Segou Regional Hospital in Mali

Introduction: Hysterectomy is a surgical procedure involving partial or total removal of the uterus. It is the most common gynaecological surgery in the world. Objective: To describe the epidemio-clinical and prognostic aspects of gynaecological hysterectomies. Patients and methods: This was an 18-month retrospective prospective descriptive study with a six-month follow-up period from 1 December 2020 to 31 May 2022 carried out in the gynaecology department of the Segou regional hospital. Results: Fifty-six (56) hysterectomies were performed out of 118 gynaecological surgical procedures (47.45%). The mean age was 47 ± 11.77 years. Large multiparous women were the most common (50%), with an average parity of 4.58. The main indications were uterine fibroids (30.4%), precancerous lesions of the cervix (17.85%) and uterine prolapse (17.85%). The abdominal route was the most commonly used surgical route (82.14%). Hysterectomy was total in 100% of cases and associated with bilateral adnexectomy in 48.2% of cases. The intra- and post-operative prognosis was satisfactory in 94.6% of cases. No deaths were recorded. The average length of stay was 3.28 days, irrespective of the surgical approach. Three cases of dyspareunia were noted among those who had resumed sexual activity.

Defining minimal invasive surgical therapy for benign prostatic obstruction surgery: Perspectives from a global knowledge, attitude, and practice survey

Objective:To scrutinize the definitions of minimal invasive surgical therapy(MIST)and to investigate urologists’knowledge,attitudes,and practices for benign prostatic obstruction surgeries.Methods:A 36-item survey was developed with a Delphi method.Questions on definitions of MIST and attitudes and practices of benign prostatic obstruction surgeries were included.Urologists were invited globally to complete the online survey.Consensus was achieved when more than or equal to 70%responses were“agree or strongly agree”and less than or equal to 15%responses were“disagree or strongly disagree”(consensus agree),or when more than or equal to 70%responses were“disagree or strongly disagree”and less than or equal to 15%responses were“agree or strongly agree”(consensus disagree).Results:The top three qualities for defining MIST were minimal blood loss(n=466,80.3%),fast post-operative recovery(n=431,74.3%),and short hospital stay(n=425,73.3%).The top three surgeries that were regarded as MIST were Urolift®(n=361,62.2%),Rezum®(n=351,60.5%),and endoscopic enucleation of the prostate(EEP)(n=332,57.2%).Consensus in the knowledge section was achieved for the superiority of Urolift®,Rezum®,and iTIND®over transurethral resection of the prostate with regard to blood loss,recovery,day surgery feasibility,and post-operative continence.Consensus in the attitudes section was achieved for the superiority of Urolift®,Rezum®,and iTIND®over transurethral resection of the prostate with regard to blood loss,recovery,and day surgery feasibility.Consensus on both sections was achieved for EEP as the option with the better symptoms and flow improvement,lower retreatment rate,and better suitable for prostate more than 80 mL.Conclusion:Minimal blood loss,fast post-operative recovery,and short hospital stay were the most important qualities for defining MIST.Urolift®,Rezum®,and EEP were regarded as MIST by most urologists.

Using MsfNet to Predict the ISUP Grade of Renal Clear Cell Carcinoma in Digital Pathology Images

Clear cell renal cell carcinoma(ccRCC)represents the most frequent form of renal cell carcinoma(RCC),and accurate International Society of Urological Pathology(ISUP)grading is crucial for prognosis and treatment selection.This study presents a new deep network called Multi-scale Fusion Network(MsfNet),which aims to enhance the automatic ISUP grade of ccRCC with digital histopathology pathology images.The MsfNet overcomes the limitations of traditional ResNet50 by multi-scale information fusion and dynamic allocation of channel quantity.The model was trained and tested using 90 Hematoxylin and Eosin(H&E)stained whole slide images(WSIs),which were all cropped into 320×320-pixel patches at 40×magnification.MsfNet achieved a micro-averaged area under the curve(AUC)of 0.9807,a macro-averaged AUC of 0.9778 on the test dataset.The Gradient-weighted Class Activation Mapping(Grad-CAM)visually demonstrated MsfNet’s ability to distinguish and highlight abnormal areas more effectively than ResNet50.The t-Distributed Stochastic Neighbor Embedding(t-SNE)plot indicates our model can efficiently extract critical features from images,reducing the impact of noise and redundant information.The results suggest that MsfNet offers an accurate ISUP grade of ccRCC in digital images,emphasizing the potential of AI-assisted histopathological systems in clinical practice.

Estimation of Physiologic Ability and Surgical Stress scoring system for predicting complications following abdominal surgery: A metaanalysis spanning 2004 to 2022

BACKGROUND Postoperative complications remain a paramount concern for surgeons and healthcare practitioners.AIM To present a comprehensive analysis of the Estimation of Physiologic Ability and Surgical Stress(E-PASS)scoring system’s efficacy in predicting postoperative complications following abdominal surgery.METHODS A systematic search of published studies was conducted,yielding 17 studies with pertinent data.Parameters such as preoperative risk score(PRS),surgical stress score(SSS),comprehensive risk score(CRS),postoperative complications,post-operative mortality,and other clinical data were collected for meta-analysis.Forest plots were employed for continuous and binary variables,withχ2 tests assessing heterogeneity(P value).RESULTS Patients experiencing complications after abdominal surgery exhibited significantly higher E-PASS scores compared to those without complications[mean difference and 95%confidence interval(CI)of PRS:0.10(0.05-0.15);SSS:0.04(0.001-0.08);CRS:0.19(0.07-0.31)].Following the exclusion of low-quality studies,results remained valid with no discernible heterogeneity.Subgroup analysis indicated that variations in sample size and age may contribute to hetero-geneity in CRS analysis.Binary variable meta-analysis demonstrated a correlation between high CRS and increased postoperative complication rates[odds ratio(OR)(95%CI):3.01(1.83-4.95)],with a significant association observed between high CRS and postoperative mortality[OR(95%CI):15.49(3.75-64.01)].CONCLUSION In summary,postoperative complications in abdominal surgery,as assessed by the E-PASS scoring system,are consistently linked to elevated PRS,SSS,and CRS scores.High CRS scores emerge as risk factors for heightened morbidity and mortality.This study establishes the accuracy of the E-PASS scoring system in predicting postoperative morbidity and mortality in abdominal surgery,underscoring its potential for widespread adoption in effective risk assessment.

Emerging molecules,tools,technology,and future of surgical knife in gastroenterology

The 21^(st) century has started with several innovations in the medical sciences,with wide applications in health care management.This development has taken in the field of medicines(newer drugs/molecules),various tools and technology which has completely changed the patient management including abdominal surgery.Surgery for abdominal diseases has moved from maximally invasive to minimally invasive(laparoscopic and robotic)surgery.Some of the newer medicines have its impact on need for surgical intervention.This article focuses on the development of these emerging molecules,tools,and technology and their impact on present surgical form and its future effects on the surgical intervention in gastroenterological diseases.

A Multi-Task Deep Learning Framework for Simultaneous Detection of Thoracic Pathology through Image Classification

Thoracic diseases pose significant risks to an individual's chest health and are among the most perilous medical diseases. They can impact either one or both lungs, which leads to a severe impairment of a person’s ability to breathe normally. Some notable examples of such diseases encompass pneumonia, lung cancer, coronavirus disease 2019 (COVID-19), tuberculosis, and chronic obstructive pulmonary disease (COPD). Consequently, early and precise detection of these diseases is paramount during the diagnostic process. Traditionally, the primary methods employed for the detection involve the use of X-ray imaging or computed tomography (CT) scans. Nevertheless, due to the scarcity of proficient radiologists and the inherent similarities between these diseases, the accuracy of detection can be compromised, leading to imprecise or erroneous results. To address this challenge, scientists have turned to computer-based solutions, aiming for swift and accurate diagnoses. The primary objective of this study is to develop two machine learning models, utilizing single-task and multi-task learning frameworks, to enhance classification accuracy. Within the multi-task learning architecture, two principal approaches exist soft parameter sharing and hard parameter sharing. Consequently, this research adopts a multi-task deep learning approach that leverages CNNs to achieve improved classification performance for the specified tasks. These tasks, focusing on pneumonia and COVID-19, are processed and learned simultaneously within a multi-task model. To assess the effectiveness of the trained model, it is rigorously validated using three different real-world datasets for training and testing.

Standardizing R-E-NSM Surgical Protocols: A Critical Appraisal for Breast Cancer Patients

To the editors:We read with interest the article by Jiao ZHOU et al,which introduces a novel technique of reverse-sequence endoscopic nipple-sparing mastectomy(R-E-NSM)with direct-to-implant breast reconstruction(DIBR)for breast cancer patientsll.While the study presents a promising approach,the interpretation of its findings warrants careful consideration owing to several methodological and clinical aspects:(1)Table 1 presents the lymph node status following propensity score matching but does not detail the total number of lymph nodes resected.

Assessment of the effectiveness of weight-adjusted antibiotic administration,for reduced duration,in surgical prophylaxis of primary hip and knee arthroplasty

BACKGROUND Prophylactic antibiotics have significantly led to a reduction in the risk of postoperative surgical site infections(SSI)in orthopaedic surgery.The aim of using antibiotics for this purpose is to achieve serum and tissue drug levels that exceed,for the duration of the operation,the minimum inhibitory concentration of the likely organisms that are encountered.Prophylactic antibiotics reduce the rate of SSIs in lower limb arthroplasty from between 4%and 8%to between 1%and 3%.Controversy,however,still surrounds the optimal frequency and dosing of antibiotic administration.AIM To evaluate the impact of introduction of a weight-adjusted antibiotic prophylaxis regime,combined with a reduction in the duration of administration of post-operative antibiotics on SSI incidence during the 2 years following primary elective total hip and knee arthroplasty METHODS Following ethical approval,patients undergoing primary total hip arthroplasty(THA)/total knee arthroplasty(TKA)with the old regime(OR)of a preoperative dose[cefazolin 2 g intravenously(IV)],and two subsequent doses(2 h and 8 h),were compared to those after a change to a new regime(NR)of a weight-adjusted preoperative dose(cefazolin 2 g IV for patients<120 kg;cefazolin 3g IV for patients>120 kg)and a post-operative dose at 2 h.The primary outcome in both groups was SSI rates during the 2 years post-operatively.RESULTS A total of n=1273 operations(THA n=534,TKA n=739)were performed in n=1264 patients.There was no statistically significant difference in the rate of deep(OR 0.74%(5/675)vs NR 0.50%(3/598);fishers exact test P=0.72),nor superficial SSIs(OR 2.07%(14/675)vs NR 1.50%(9/598);chi-squared test P=0.44)at 2 years postoperatively.With propensity score weighting and an interrupted time series analysis,there was also no difference in SSI rates between both groups[RR 0.88(95%CI 0.61 to 1.30)P=0.46].CONCLUSION A weight-adjusted regime,with a reduction in number of post-operative doses had no adverse impact on SSI incidence in this population.

Response to Comment“Standardizing R-E-NSM Surgical Protocols:A Critical Appraisal for Breast Cancer Patients”

To the editors:We appreciate the detailed and constructive comments provided by the commenters.We adopted some suggestions and responded to all comments.The responses are as follows.1.Table 1 presents lymph node status following PSM but does not detail the total lymph nodes resected.

Results of Open Surgical Treatment of Humeral Paddle Fractures about 63 Cases

Fractures of the humeral paddle, common to young adults, are most often complex, linked to violence and an increase in road accidents. The objective of our work is to evaluate our functional results, in the medium term, correlated with a review of the literature. This is a retrospective study of 63 patients, carried out in the traumatology-orthopedics department 1 of the IBN EL JAZZAR hospital in KAIROUAN, over a period of 7 years from January 2015 to December 2021. The average age of patients was 39 years (17 - 68 years). Predominantly male. The etiologies are dominated by falls and accidents on public roads. Fractures are classified according to the Müller and Allgöwer classification where type C is found in 51% of cases. All our patients undergo an olecranon osteotomy in 71% of cases. Osteosynthesis using a Lecestre plate combined with screwing or plugging is used in 84% of cases. The evolution is marked by complications observed in eight patients (16%), including two cases of sepsis, four cases of elbow stiffness (8%), one case of joint callus and one case of pseudarthrosis. Our results are evaluated according to the Mayo Elbow Performance Score, they are excellent and good in 71% of cases, average in 18% of cases and poor in 11% of cases. Fractures of the humeral paddle are fractures with a satisfactory functional prognosis, requiring ad integrum anatomical restoration and solid osteosynthesis allowing early rehabilitation of the elbow. One case of joint callus and one case of pseudarthrosis.

Incidences and Risk Factors for Surgical Site Infections in Koutiala, Mali

Purpose: This paper aims to assess the incidences and risk factors for surgical site (ISO) infections in the general surgery department of the Koutiala District Hospital. Patients and Methods: This was a prospective and descriptive study from August 1, 2017 to October 31, 2020 involving all patients who underwent laparotomy in the general surgery department of the Koutiala District Hospital. Patients who were not operated on and who did not have a laparotomy were not included. Age, sex, frequency, patient history, National Nosocomial Infections Surveillance (NNIS) index, time to occur, bacteriological test results and course of infection were analyzed. Results: Fifty patients were registered. The average age was 34.2 ± 21.2 years old. Eleven patients were 60 years old or older. The hospital incidence rate was 4.3% and the community incidence rate was 6.1 cases per 100,000 population. The concept of smoking was noted in 15 patients. Patients were operated on in emergency 84% of cases. Peritonitis was the most common initial lesion with 32% of cases. Our patients had an NNIS index greater than 0 in 84% of cases. The time to develop infection from the surgical site was less than 3 days in 8 patients (16% of cases). Depending on the depth of the infection, it was superficial (cutaneous) in 39 patients (78%) and deep (subcutaneous and organic) in 11 patients (22%). Escherichia coli was the most common germ with 72% followed by staphylococcus aureus at 24%. We noted 22% morbidity. The median length of hospitalization was 9 ± 2.2 days. Conclusion: ISO is common in our service. Prevention and mastery require knowledge of risk factors.