Performance characteristics of retrograde single-balloon endoscopy: A single center experience

AIM: To evaluate the technical success, diagnostic yield(DY) and therapeutic potential of retrograde single balloon enteroscopy(rS BE). METHODS: A retrospective review of 136 rS BE procedures performed at a tertiary academic referral center from January 2006 and September 2013 was completed. Patient characteristics including age, gender and inpatient status were collected. The indication for the procedure was categorized into one of three groups: Obscure gastrointestinal bleeding(GIB), evaluation for Crohn's disease and abnormal imaging. Procedural characteristics including insertion depth(ID), procedure time, concordance with pre-procedural imaging and complications were also recorded. Lastly, DY, defined as the percentage of cases producing either a definitive diagnosis or findings that could explain clinical symptoms and therapeutic yield(TY), defined as the percentage of cases in which a definitive intervention was performed, were determined. Mucosal tattooing and biopsy alone were not included in the TY. RESULTS: A total of 136 rS BE procedures were identified. Mean patient age was 57.5(± 16.2) years, 67(49.2%) were male, and 110(80.9%) procedures were performed on an outpatient basis. Indications for rS BE included GIB in 55(40.4%), evaluation of inflammatory bowel disease(IBD) in 29(21.3%), and imaging suggestive of pathology other than GIB or IBD in 43(31.6%). Nine(6.6%) rS BEs were performed for other indications. Mean ID was 68.3(± 39.3) cm proximal to the ileocecal valve and mean time to completion was 41.7(± 15.5) min. Overall, 73(53.7%) cases were diagnostic and 25(18.4%) cases were therapeutic in which interventions(argon plasma coagulation, stricture dilatation, polypectomy, etc.) were performed. Pre-procedural imaging was performed in 88(64.7%) patients. Endoscopic concordance of positive imaging findings was seen in 31(35.2%) cases. Follow up data was available in 93(68.4%) patients; 2(2.2%) reported post-procedural abdominal pain within 30 d following rS BE. There were no other reported complications. CONCLUSION: rS BE exhibits an acceptable diagnostic and TY, rendering it a safe and effective procedure for the evaluation and treatment of small bowel diseases.

The effect of wilderness and medical training on injury and altitude preparedness among backcountry hikers in Rocky Mountain National Park

BACKGROUND:The purpose of this study was to document the correlation between medical and wilderness training with levels of preparedness for acute mountain sickness(AMS),illness,and injury among backcountry hikers.METHODS:We conducted a cross-sectional,convenience survey in Rocky Mountain National Park in July and August 2015.The study group consisted of 380 hikers who completed a written survey that collected information about demographics,wilderness experience,altitude experience,hiking equipment,communications devices,and trip planning.RESULTS:Factors such as wilderness training(wilderness first aid[WFA],wilderness first responder[WFR],or wilderness emergency medical technician[WEMT]),wilderness experience,and altitude experience all affected hikers’emergency preparedness.Respondents with medical training were more prepared to avoid or respond to AMS(62.3%vs.34.3%[P<0.001]).They were also more prepared to avoid or manage injury/illness than hikers without medical training(37.7%vs.20.7%[P=0.003]).Participants with wilderness training were more likely to be prepared to avoid or respond to AMS(52.3%vs.36.8%[P=0.025])but not significantly more likely to be prepared to manage illness/injury(31.8%vs.22.0%[P<0.11]).Adjusting for experience,wilderness training,age,and gender,we found that medical training was associated with increased preparedness for AMS(OR2.72;95%CI 1.51–4.91)and injury/illness(OR 2.71;95%CI 1.5–4.89).CONCLUSION:Medically trained hikers were more likely to be prepared to avoid or manage AMS,medical emergencies,and injuries than their non-medically trained counterparts.Wilderness training increased hikers’preparedness for AMS but did not significantly alter preparedness for illness/injury.

<i>Ex vivo</i>evaluation of a prototype submucosal biopsy forceps for the diagnosis of gastric gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) account for approximately 2% of gastric cancers and can be challenging to diagnose due to the difficulty sampling tissue from these lesions. Current biopsy methods are inadequate for determining the mitotic index, a major prognostic factor of these tumors. We sought to evaluate the ability of a prototype submucosal biopsy forceps to make a histologic diagnosis and mitotic index determination in cases of resected gastric GISTs. After obtaining informed consent and surgical resection of three gastric GISTs, an investigational submucosal biopsy forceps and sheath was passed under direct visualization into the central portion of the tumors (in the ex vivo setting) and biopsies were obtained. The tumor was then processed for standard histology. A gastrointestinal pathologist, blinded to the mitotic index of the full specimen, evaluated the research biopsies. The results from the submucosal forceps biopsies were then compared with the standard histology results. n all 3 cases, the submucosal forceps biopsies confirmed the diagnosis of a GIST. In two out of three cases, the submucosal forceps biopsies accurately classified the risk for progressive disease (based on the mitotic index) when compared to standard histology. In one case, the research biopsy mitotic index would have resulted in an underestimation of tumor risk (biopsies categorized the lesion as “very low” rather than “moderate” risk).

Diabetic Ketoacidosis in Type 1 DM: A Novel Presentation of CML

Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes characterized by metabolic acidosis, hyperglycemia, and ketosis. It most commonly occurs secondary to a precipitating event such as an infection, non-infectious illness, or insulin non-compliance. We report a case of a 28-year-old male with a history of well-controlled type 1 diabetes mellitus who began having frequent and repeated episodes of DKA. Evaluation for compliance lapses was negative. The further review noted a worsening white blood cell count over the same period, despite repeated negative infectious workups. A bone marrow biopsy revealed a hypercellular marrow with granulocyte and megakaryocyte proliferation. Testing for the BCR-ABL fusion gene was positive in 92% of cells. This led to a final diagnosis of chronic myeloid leukemia as the precipitator for repeated presentation with DKA. The two diseases do not commonly present simultaneously due to differences in median age. No previous reports of adults with DKA precipitated by CML are present in the literature. However, worsening hyperglycemia has been reported with other hematologic malignancies, particularly in the setting of acute lymphoblastic leukemia in the pediatric population. This is thought in some instances to be due to the leukemic process itself, potentially through cytokine release.

Changing paradigms in lower extremity reconstruction in war-related injuries

Background: Ballistic high-energy trauma has substantially increased the severity of non-fatal extremity injuries incurred in modern warfare. Expedient medical care, refinement in surgical techniques, and soft tissue coverage have brought about a paradigm shift in the management of lower extremity wounds during the last decade with an increased emphasis on limb salvage.Methods: A literature-based study was conducted to analyze reconstructive modalities based on the location, depth, and severity of wounds, as well as mechanism of injury, concomitant vascular injuries and open fractures, choice of flap, timing of definitive reconstruction, and complications.Results: Extremity injuries account for over 60% of injuries in the recent conflicts in Iraq and Afghanistan, with the majority secondary to explosive devices. The severity of these injuries is profound compared with civilian registries, and conventional injury scoring systems have failed to accurately predict outcomes in combat trauma. The mainstay of treatment is serial debridement, negative pressure therapy, fracture stabilization, and treatment of concomitant injuries by the forward medical teams with subsequent definitive reconstruction after transport to an advanced military treatment facility. Autologous reconstruction with free tissue transfer and pedicled flaps remains the primary modality for soft tissue coverage in limb salvage. Adjunct innovative modalities, such as external tissue expansion, dermal substitutes, and regenerative matrices, have also been successfully utilized for limb salvage.Conclusion: Lower extremity injuries account for the vast majority of injuries in modern warzones. Explosive devices represent the most common mechanism of injury, with blast impact leading to extensive soft tissue injuries necessitating complex reconstructive strategies. Serial debridement, negative pressure therapy, and autologous reconstruction with free tissue transfer and pedicled flaps remain the mainstay of treatment in recent conflicts.

Is endoscopic retrograde appendicitis therapy a better modality for acute uncomplicated appendicitis? A systematic review and metaanalysis

BACKGROUND Previous studies had shown endoscopic retrograde appendicitis therapy(ERAT)is an effective treatment for acute appendicitis.However,different studies reported conflicting outcomes regarding the effectiveness of ERAT in comparison with laparoscopic appendectomy(LA).AIM To compare the effectiveness of ERAT with LA.METHODS Randomized controlled trials(RCTs)and retrospective studies of ERAT for acute uncomplicated appendicitis were searched in PubMed,Cochrane Library,Web of Science,Embase database,China National Knowledge Infrastructure(CNKI),the WanFang Database,and Chinese Scientific Journals Database(VIP)from the establishment date to March 12021.Heterogeneity was assessed using the Isquared statistic.Pooled odds ratios(OR),weighted mean difference(WMD),and standard mean difference(SMD),with 95%confidence intervals(CI)were calculated through either fixed-effects or random-effects model.Sensitivity analysis was also performed.Publication bias was tested by Egger's test,and Begg’s test.The quality of included RCT were evaluated by the Jadad scale,while Newcastle-Ottawa scale is adopted for assessing the methodological quality of case-control studies.All statistical analysis was performed using Stata 15.1 statistical software.All statistical analysis was performed using Stata 15.1 statistical software.This study is registered with PROSPERO,CRD42021243955.RESULTS After screening,10 RCTs and 2 case-control studies were included in the current systematic review.Firstly,the length of hospitalizations[WMD=-1.15,95%CI:-1.99,-0.31;P=0.007]was shorter than LA group.Secondly,the level of postoperative CRP[WMD=-10.06,95%CI:(-17.39,-2.73);P=0.007],TNF-α[WMD=-7.70,95%CI:(-8.47,-6.93);P<0.001],and IL-6 Levels[WMD=-9.78,95%CI:(-10.69,-8.88);P<0.001;P<0.001]in ERAT group was significantly lower than LA group.Thirdly,ERAT group had a lower incidence of intestinal obstruction than LA group.[OR=0.19,95%CI:(0.05,0.79);P=0.020].Moreover,the quality of 10 RCTs were low with 0-3 Jadad scores,while the methodological quality of two case-control studies were fair with a score of 2(each).CONCLUSION Compared with LA,ERAT reduces operation time,the level of postoperative inflammation,and results in fewer complications and shorter recovery time,with preserving the appendix and its immune and biological functions.

A Case Report: Calciphylaxis Presenting as Digital Ischemia in Patient with End Stage Kidney Disease on Peritoneal Dialysis

Calciphylaxis also known as Calcific uremic arteriolopathy (CUA), is a fatal disease with high mortality that mostly affects patients with end stage kidney disease (ESKD) on dialysis. In recent years the incidence of CUA has been increasing among patients on peritoneal dialysis (PD). The exact mechanism and risk factors are not well described.

Ciliated Hepatic Foregut Cyst: 103 Cases in the World Literature

Ciliated hepatic foregut cysts (CHFC) are rare, typically benign, lesions whose incidence has been increasing recently. Despite this increase in incidence, they remain rare and several key characteristics remain poorly understood, including the range of presentation and the risk of malignant conversion. To better understand CHFC, an extensive review of the international literature was performed. Characteristics including size, location, contents, presenting symptoms, and risk of malignancy were analyzed. In addition, an illustrative case is presented to highlight a potential pitfall in diagnosis: Although the presentation is thought to be typically painless or vaguely painful, these lesions may also present with hemorrhage and sudden severe abdominal pain. Importantly, although malignant degeneration is uncommon, analysis revealed that malignancy is significantly associated with size, which was significantly larger (median 10 cm) in malignant CHFC compared with the typical benign CHFC (3 cm) (P < 0.01). Large or symptomatic cysts, or small asymptomatic cysts that are atypical, should be resected.

Cholangioscopy-assisted guidewire placement in a malignant biliary stricture: A case report

BACKGROUND Cholangioscopy has been described in case reports and series to facilitate guidewire placement in difficult benign biliary strictures.Specifically,it has been infrequently used in difficult benign anastomotic liver transplant biliary strictures to visualize the stricture orifice for guidewire placement.Here we describe a case of guidewire placement through a difficult malignant biliary stricture using single operator cholangioscopy.CASE SUMMARY A 74-year-old female presented with jaundice and weight loss.Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography(ERCP)by other endoscopists demonstrated pancreatic adenocarcinoma with a dilated cystic duct(CD)and proximal common bile duct(CBD).The associated distal CBD stricture was dilated and stented with a plastic stent.However she subsequently developed cholangitis,prompting referral for a repeat ERCP.The stent was found to have migrated distally to the confluence of the dilated CD and CBD stricture.Despite using multiple hydrophilic guidewires,the stricture could not be traversed due to preferential wire passage into the dilated CD.SpyGlass DS(Boston Scientific Corp,Marlborough,MA,United States)was then used to visualize the orifices of the CD and CBD stenosis,enabling the guidewire to be placed directly through the stricture into the proximal CBD.A WallFlex covered metal stent(Boston Scientific Corp,Marlborough,MA,United States)was successfully placed,resulting in resolution of her cholangitis.CONCLUSION To our knowledge,this is one of the first cases to describe successful cholangioscopic guidewire placement for malignant biliary strictures.

A Long Right Atrial Thrombus Intermittently Prolapsing into Right Ventricle in a Patient with Recurrent Ischemic Stroke: An Image Report

A 39-year-old male was admitted for recurrent ischemic strokes. TEE was performed to detect the potential intra-cardiac thrombi and right-to-left shunts. A large hypermobile, echodense, irregular mass was found in the right atrium, which looked like a cluster of grapes. The motion of the components of the mass was synchronized, prolapsing into right ventricle in an octopus-like fashion during diastole. There was no evidence for PFO or other intra-cardiac shunts by color flow Doppler. The patient was referred to surgery and a continuous 30 cm long thrombus spanning from the inferior vena cava to the right ventricle was discovered.

Paenibacillus Infection in a Pediatric Patient on ECMO

Paenibacillus is a spore forming gram positive rod that is usually found in the environment. We describe a case of a patient who contracted this organism having never left the hospital after birth. This neonate contracted Paenibacillus septic shock requiring support with venous-arterial extracorporeal membrane oxygenation (ECMO) while still admitted to the hospital after birth. This patient initially presented in severe septic shock due to a Streptococcus agalactiae infection requiring hemodynamic support with ECMO. Following treatment for the Streptococcus agalactiae infection, and while still on ECMO support, the blood culture became positive for Paenibacillus. Given that our patient had never left the hospital after birth, the finding of this organism in the blood is unique. The primary defense against this bacterium is usually the skin. The only invasive procedure this patient had was ECMO cannulation which is done in a sterile fashion. Most species are susceptible to vancomycin, clindamycin, fluoroquinolones, aminoglycosides, carbapenems, penicillin, and cephalosporins. This patient was treated with penicillin G for 14 days for the S. agalactiae infection prior to the blood culture being positive for Paenibacillus. More than a hundred species had been identified in the genus Paenibacillus, however, few found to cause human infection. This case is unique as it is the first pediatric case with a Paenibacillus infection and the first pediatric case where this organism which rarely causes human infection was found in the blood culture of a patient on ECMO.

对医师进行ERCP荧光镜透视检查时间培训的效果

Our purpose was to compare fluoroscopy time during endoscopic retrograde cholangiopancreatography(ERCP) between endoscopists with different levels of experience.We performed a cross-sectional analysis of 269 consecutive ERCPs at an academic hospital during 1 year.Median fluoroscopy time was significantly longer in more complex cases,such as in therapeutic(406.5 s [IQR,235.5-685]) compared to diagnostic(202 s [IQR,141-481];P = 0.002) procedures.The experience(number of prior ERCPs) of gastroenterology fellows involved in procedures was an independent predictor of shorter fluoroscopy time when controlling for patient and procedure characteristics(P < 0.0001) .Median fluoroscopy time was 2.73 min shorter after at least 50 procedures had been performed(P = 0.039) .Time for ERCPs involving fellows was not significantly longer than cases by attending physicians alone(P = 0.23) .Increased experience is associated with lower radiation exposure during ERCP training.Radiation reduction methods should be prospectively investigated and integrated into training programs.

放置胰导管支架有助于解决胆总管插管困难

Background: Cannulation of the common bile duct can be difficult in certain instances. Difficult cannulation has been demonstrated to be a risk factor for post-ERCP pancreatitis. We report a technique to facilitate difficult cannulation that uses a pancreatic-duct stent to guide biliary cannulation. Methods: A retrospective review of all ERCPs performed at our institution from October 1, 2000 to June 30, 2004 (1638) was performed to identify all cases in which a pancreatic-duct stent was placed to guide common bile duct cannulation. Charts on these patients then were reviewed to assess cannulation success and complications. In addition, indications for the ERCP and previously failed cannulation attempts by outside physicians were documented. Observations: Thirty-nine patients had pancreatic-duct stents placed as an aid to guide common bile duct cannulation. Successful cannulation of the bile duct was achieved in 38 of the 39 patients (97.4% ) Procedure-related pancreatitis occurred in two patients and was mild in both. There were no procedure-related deaths. Conclusions: In cases of difficult common bile duct cannulation, placement of a pancreatic-duct stent as a guide to aid common bile duct cannulation appears to be an effective and safe technique.

美国结直肠外科医师协会2019版肠道准备在择期结直肠手术中的应用临床实践指南

美国结直肠外科医师协会(The American Society of Colon and Rectal Surgeons,ASCRS)于2019年1月公布了最新的肠道准备在择期结直肠手术中的应用临床实践指南。该指南是由国际知名结直肠外科专家组成的临床实践指南委员会修订,对肠道准备的一些争议进行了汇总和分析。

Learning curve for magnetic resonance imaging/ultrasound fusion prostate biopsy in detecting prostate cancer using cumulative sum analysis

Background:Targeted magnetic resonance(MR)with ultrasound(US)fusion-guided biopsy has been shown to improve detection of prostate cancer.The implementation of this approach requires integration of skills from radiologists and urologists.Objective methods for assessment of learning curves,such as cumulative sum(CUSUM)analysis,may be helpful in identifying the presence and duration of a learning curve.The aim of this study is to determine the learning curve for MR/US fusion-guided biopsy in detecting clinically significant prostate cancer using CUSUM analysis.Materials and methods:Retrospective analysis was performed in this institutional review board-approved study.Two urologists implemented an MR/US fusion-guided prostate biopsy program between March 2015 and September 2017.The primary outcome measure was cancer detection rate(CDR)stratified by Prostate Imaging Reporting and Data System(PI-RADS)scores assigned on the MR imaging.Cumulative sum analysis quantified actual cancer detection versus a predetermined target satisfactory CDR of MR/US fusion biopsies in a sequential case-by-case basis.For this analysis,satisfactory performance was defined as>80%CDR in patients with Pl-RADS 5,>50%in PI-RADS 4,and<20%in Pl-RADS 1-3.Results:Complete data were available for MR/US fusion-guided biopsies performed on 107 patients.The CUSUM learning curve analysis demonstrated intermittent underperformance until approximately 50 cases.After this inflection point,there was consistently good performance,evidence that no further learning curve was being encountered.Conclusions:At a new center implementing MR/US fusion-guided prostate biopsy,the learning curve was approximately 50 cases before a consistently high performance for prostate cancer detection.