Endoscopic management of bariatric complications: A review and update

With over a third of Americans being considered obese, bariatric procedures have now become the most performed operation be general surgeons in the United States. The most common operations are the Laparoscopic Roux-en-Y Gastric Bypass, the Laparoscopic Sleeve Gastrectomy, and the Laparoscopic Adjustable Gastric Band. With over 340000 bariatric procedures preformed worldwide in 2011, the absolute number of complications related to these operations is also increasing. Complications, although few, can be life threatening. One of the most dreaded acute complication is the anastomotic/staple line leak. If left undiagnosed or untreated they can lead to sepsis, multi organ failure, and death. Smaller or contained leaks can develop into fistulas. Although most patients with an acute anastomotic leak return to the operating room, there has been a trend to manage the stable patient with an endoscopic stent. They offer an advantage by creating a barrier between enteric content and the leak, and will allow the patients to resume enteral feeding much earlier. Fistulas are a complex and chronic complication with high morbidity and mortality. Postoperative bleeding although rare may also be treated locally with endoscopy. Stenosis is a more frequent late complication and is best-managed with endoscopic therapy. Stents may not heal every fistula or stenosis, however they may prevent certain patients the need for additional revisional surgery.

Laparoscopic resection of pancreatic adenocarcinoma: Dream or reality?

Laparoscopic pancreatic surgery is in its infancy despite initial procedures reported two decades ago. Both laparoscopic distal pancreatectomy(LDP) and laparoscopic pancreaticoduodenectomy(LPD) can be performed competently; however when minimally invasive surgical(MIS) approaches are implemented the indication is often benign or low-grade malignant pathologies. Nonetheless, LDP and LPD afford improved perioperative outcomes, similar to those observed when MIS is utilized for other purposes. This includes decreased blood loss, shorter length of hospital stay, reduced post-operative pain, and expedited time to functional recovery. What then is its role for resection of pancreatic adenocarcinoma? The biology of this aggressive cancer and the inherent challenge of pancreatic surgery have slowed MIS progress in this field. In general, the overall quality of evidence is low with a lack of randomized control trials, a preponderance of uncontrolled series, short follow-up intervals, and small sample sizes in the studies available. Available evidence compiles heterogeneous pathologic diagnoses and is limited by case-by-case follow-up, which makes extrapolation of results difficult. Nonetheless, shortterm surrogate markers of oncologic success, such as margin status and lymph node harvest, are comparable to open procedures. Unfortunately disease recurrence and long-term survival data are lacking. In this review we explore the evidence available regarding laparoscopic resection of pancreatic adenocarcinoma, a promising approach for future widespread application.

Crohn's disease genotypes of patients in remission vs relapses after infliximab discontinuation

AIM： To investigate genetic differences between Crohn＇s disease （CD） patients with a sustained remission vs relapsers after discontinuing infliximab while in cortico- steroid-free remission. METHODS： Forty-eight CD patients received infliximab and were in full corticosteroid-free clinical remission but then discontinued infliximab for reasons other than a loss of response, were identified by review of an electronic database and charts. Infliximab-associated remis- sion was defined as corticosteroid-free plus normaliza- tion of clinical disease activity [CD activity index （CDAI） 〈 150] during follow-up visits based on physician global assessments. A CD relapse （loss of infliximab-induced remission） was clinically defined as a physician visit for symptoms of disease activity （CDAI 〉 220） and a thera- peutic intervention with CD medication（s）, or a hospital- ization with complications related to active CD. Genetic analyses were performed on samples from 14 patients （n = 6 who had a sustained long term remission after stopping infliximab, n -- 8 who rapidly relapsed after stopping infliximab）. Nucleotide-binding oligomerization domain 2 （NOD2）/caspase activation recruitment do- main 15 （CARD15） polymorphisms （R702W, G908R and L1007fs） and the inflammatory bowel disease 5 （IBDS） polymorphisms （IGR2060a1 and IGR3081a1） were ana- lyzed in each group. RESULTS： Five single nucleotide polymorphisms of IBD5 and NOD2/CARD15 genes were successfully analyzed for all 14 subjects. There was no signifcant increase in frequency of the NOD2/CARD15 polymor- phisms （R702W, G908R and L1007fs） and the IBD5 polymorphisms （IGR2060al and IGR3081a1） in either group of patients; those whose disease relapsed rap- idly or those who remained in sustained long term remission following the discontinuation of infliximab. Nearly a third of patients in full clinical remission who stopped infliximab for reasons other than loss of re- sponse remained in sustained clinical remission, while two-thirds relapsed rapidly. There was a marked dif- ference in the duration of clinical remission following discontinuance of infliximab between the two groups. The patients who lost remission did so after 1.0 years 4- 0.6 years, while those still in remission were at the time of this study, 8.1 years 4- 2.6 years post-discon- tinuation of infliximab, P 〈 0.001. The 8 patients who had lost remission after discontinuing infiiximab had a mean number of 5 infusions （range 3-7）, with a mean treatment time of 7.2 mo （range 1.5 mo-15 mo）. The mean duration of time from the last infusion of inflix- imab to the time of loss of remission was 382 d （range 20 d-701 d）. The 6 patients who remained in remission after discontinuing infliximab had a mean number of 6 infusions （range 3-12）, with a mean treatment dura- tion of 12 mo （range 3.6 mo-32 too） （P = 0.45 relative to those who lost remission）. CONCLUSION： There are no IBD5 or NOD2/CARD15 mutations that predict which patients might have sus- tained remission and which will relapse rapidly after stopping infliximab.

Status Epilepticus in Children: A Study of 54 Cases

Objectives: To review the clinical character, the management and outcome of status epilepticus in children. Methodology: We conducted a retrospective review of 54 cases treated between 1996 and 1997 at the Royal Alexandra Hospital for Children, Sydney, Australia. Among the variables collected for analysis in this study were age, sex, etiology of status epilepticus, median length of Paediatric Intensive Care Unit (PICU) stay and days of mechanical ventilation, and mortality of status epilepticus. Results: Of the patients with status epilepticus, 61% were male and 39% female, with an age range of 3 months to 15 years (mean 5.3 years). The etiology of status epilepticus is largely age related, with acute causes common in 1 - 3 year and 4 - 7 year ages, 44 cases (81.5%). The etiology of status epilepticus included febrile (35.18%), acute symptomatic (27.58%) and idiopathic (16.6%), total was 44 cases (81.4%). Median length of PICU stay and days of mechanical ventilation were 3.02 ± 1.6 days and 1.24 ± 0.5 days respectively. Mortality was 5.3%. Most patients were treated with diazepam and phenytoin. The total number of the patients with a favorable outcome was 41 (75.89%). Conclusions: One of the most common neurologic emergencies in children of status epilepticus remains a major problem in morbidity and mortality. There are multiple causes of status epilepticus that include the categories of idiopathic, febrile, acute symptomatic and remote symptomatic. Intravenously administered phenytoin and diazepam remains the first-line therapy for status epilepticus. Most of the patients will respond to this treatment. The etiology of status epilepticus included febrile (35.18%), acute symptomatic (27.58%), idiopathic (16.6%) and total was 44 (81.4%).

膀胱输尿管反流现象的存在并不能说明首次泌尿道感染后肾脏瘢痕形成患病风险增加

Background: Childhood urinary tract infection (UTI) with or without vesicoureteric reflux (VUR) may predispose to renal scarring. There is no clear consensus in the literature regarding imaging following UTI in infancy. Aims: To define the role of cystography following a first UTI in children aged under 1 year, when urinary tract ultrasonography (US) is normal. Methods: Retrospective data collection of 108 children (216 renal units)-aged under 1 year at the time of a bacteriologically proven UTI. All had a normal US and underwent both catheter cystogram and DMSA test. Sensitivity, specificity, likelihood ratios positive and negative, and diagnostic odds ratio were calculated for VUR on cystography versus scarring on DMSA. Results: VUR was shown in 25 (11.6%) renal units. Scarring on DMSA was seen in 8 (3.7%) kidneys. Only 16%of kidneys with VUR had associated scarring; 50%of scarred kidneys were not associated with VUR. The likelihood ratio positive was 4.95 (95%CI 2.22 to 11.05) and the likelihood ratio negative was 0.56 (95%CI 0.28 to 1.11). The diagnostic odds ratio was 8.9, suggesting that cystography provided little additional information. Conclusion: Since only 16%of children with VUR had an abnormal kidney, the presence of VUR does not identify a susceptible population with an abnormal kidney on DMSA. In the context of a normal ultrasound examination, cystography contributes little to the management of children under the age of 1 year with a UTI. In this context, a normal DMSA study reinforces the redundancy of cystography.

Reactive Oxygen Species and Oxidative Stress in the Pathogenesis of MAFLD

The pathogenesis of metabolic-associated fatty liver disease(MAFLD)is complex and thought to be dependent on multiple parallel hits on a background of genetic susceptibility.The evidence suggests that MAFLD progression is a dynamic two-way process relating to repetitive bouts of metabolic stress and inflammation interspersed with endogenous anti-inflammatory reparative responses.In MAFLD,excessive hepatic lipid accumulation causes the production of lipotoxins that induce mitochondrial dysfunction,endoplasmic reticular stress,and over production of reactive oxygen species(ROS).Models of MAFLD show marked disruption of mitochondrial function and reduced oxidative capacitance with impact on cellular processes including mitophagy,oxidative phosphorylation,and mitochondrial biogenesis.In excess,ROS modify insulin and innate immune signaling and alter the expression and activity of essential enzymes involved in lipid homeostasis.ROS can also cause direct damage to intracellular structures causing hepatocyte injury and death.In select cases,the use of anti-oxidants and ROS scavengers have been shown to diminish the proapoptopic effects of fatty acids.Given this link,endogenous anti-oxidant pathways have been a target of interest,with Nrf2 activation showing a reduction in oxidative stress and inflammation in models of MAFLD.Thyroid hormone receptorβ(THRβ)agonists and nuclear peroxisome proliferationactivated receptor(PPAR)family have also gained interest in reducing hepatic lipotoxicity and restoring hepatic function in models of MAFLD.Unfortunately,the true interplay between the clinical and molecular components of MAFLD progression remain only partly understood.Most recently,multiomics-based strategies are being adopted for hypothesis-free analysis of the molecular changes in MAFLD.Transcriptome profiling maps the unique genotype-phenotype associations in MAFLD and with various single-cell tran scriptome-based projects underway,there is hope of novel physiological insights to MAFLD progression and uncover therapeutic targets.

Different approaches for patent ductus arteriosus in premature infants using acetaminophen

Background Acetaminophen use for pharmacological treatment of hemodynamically significant patent ductus arteriosus(hsPDA)in preterm infants is becoming more popular with emerging evidence that it is effective as well as safe alternative for other agents used to close hsPDA.Data sources We performed a narrative review of literature about pharmacological treatment of PDA using acetaminophen.Results Acetaminophen was used as a prophylaxis,symptomatic,targeted,and a rescue approach.Conclusions It appears that acetaminophen could be used in different approaches to close the hsPDA.Long-term outcomes of acetaminophen exposure early in life still lack certainty.