Trans-Colostomy Placement of a Button Gastrostomy Tube for Malignant Bowel Obstruction in Patients with Peritoneal Carcinomatosis

Purpose The aim of the study is to evaluate the feasibility, safety, and efficacy of the trans-colostomy placement of a button gastrostomy tube for patients with malignant bowel obstruction due to peritoneal carcinomatosis. Material and Methods Data from seven consecutive patients who presented with malignant bowel obstruction due to peritoneal carcinomatosis involving the colostomy site and underwent trans-colostomy button gastrostomy tube placement between 2013 and 2020 were retrospectively reviewed. We assessed technical and clinical success rate, procedure time, duration of improvement, and complication rate. Results The technical success rate of the trans-colostomy button gastrostomy tube placement was 100%, and average procedure time was 25 minutes. Clinical symptoms of malignant bowel obstruction resolved in four out of seven (57%) patients. Average duration of improvement in the four patients with clinical success was 170.8 days. There were no complications associated with the procedure. Conclusion Trans-colostomy button gastrostomy tube placement might be a safe and feasible treatment option for patients with malignant bowel obstruction due to peritoneal carcinomatosis.

Tumor-Infiltrating Lymphocytes in Colorectal Cancer: The Fundamental Indication and Application on Immunotherapy

The clinical success of immunotherapy has revolutionized the treatment of cancer patients, bringing renewed attention to tumor-infiltrating lymphocytes (TILs) of various cancer types. Immune checkpoint blockade is effective in patients with mismatched repair defects and high microsatellite instability (dMMR-MSI-H) in metastatic colorectal cancer (CRC), leading the FDA to accelerate the approval of two programmed cell death 1 (PD-1) blocking antibodies, pembrolizumab and nivolumab, for treatment of dMMR-MSI-H cancers. In contrast, patients with proficient mismatch repair and low levels of microsatellite stability or microsatellite instability (pMMR-MSI-L/MSS) typically have low tumor-infiltrating lymphocytes and have shown unsatisfied responses to the immune checkpoint inhibitor. Different TILs environments reflect different responses to immunotherapy, highlighting the complexity of the underlying tumor-immune interaction. Profiling of TILs fundamental Indication would shed light on the mechanisms of cancer-immune evasion, thus providing opportunities for the development of novel therapeutic strategies. In this review, we summarize phenotypic diversities of TILs and their connections with prognosis in CRC and provide insights into the subsets-specific nature of TILs with different MSI status. We also discuss current clinical immunotherapy approaches based on TILs as well as promising directions for future expansion, and highlight existing clinical data supporting its use.

Midterm osteolysis-induced aseptic failure of the M6-C™ cervical total disc replacement secondary to polyethylene wear debris

Background According to published meta-analyses, cervical total disc replacement (CTDR) seems to be superior to anterior cervical decompression and fusion (ACDF) in most clinical parameters. Despite short-term clinical success of CTDR, there are concerns regarding long-term durability of these prostheses. Methods This prospective study involved 382 patients who received standalone CTDR or a hybrid procedure (ACDF/CTDR). A retrospective comparison between different CTDR devices was conducted regarding patient-reported outcome measures (PROMs), failure scenarios, and revision surgeries. The M6-C™ Artificial Cervical Disc (Orthofix, Lewisville, Texas) cohort was compared to the other CTDR devices clinically. Etiological reasons for revision, and the surgical technique of the revision was investigated. Results Fifty-three patients received M6-C CTDR. Eighteen patients (34%) were revised at an average of 67 months postoperatively for wear-induced osteolysis. There were three additional cases of pending revision. The PROMs of the two groups were similar, indicating that the failure mode (wear-induced osteolysis) is often asymptomatic. The demographics of the two groups were also similar, with more women undergoing revision surgery than men. There were three one-level CTDR, four two-level hybrids, seven three-level hybrids, and three four-level hybrids revised anteriorly. Sixteen patients underwent removal of the prosthesis and were treated according to the extent of osteolysis. There were four vertebrectomies, six revisions to ACDF, and six revisions to another CTDR. One patient underwent supplemental fixation using a posterior approach. The other CTDR cohort had an incidence of 3.3% at the equivalent time, and none of these were due to osteolysis or wear-related events. Conclusions There is a concerning midterm failure rate related to ultra-high-molecular-weight-polyethylene wear-induced osteolysis in the M6-C. Patients implanted with the M6-C prosthesis should be contacted, informed, and clinically and radiologically assessed.

Percutaneous Cryoablation of Renal Tumors: Initial Indian Experience

Objective The purpose of this study was to report short-term outcomes of cryoablation of early-stage renal tumors (T1a and T1b) at a tertiary hospital in India. Methods This was a retrospective study of consecutive patients who underwent cryoablation for renal cell carcinoma (RCC) from November 2018 to June 2020. Cryoablation was performed under combined ultrasound and computed tomography guidance using a helium-argon cryoablation system. Tumor number, size, location, nephrometry score, relationship of the tumor with pelvicalyceal system, and adjacent organs were tabulated, and technical and clinical success evaluated. Early and late recurrence and complications were also assessed. Results Eleven patients (median age: 62 years) with 11 tumors underwent cryoablation. The mean tumor size was 2.58 cm (range: 1.62–5.62 cm) with 10 lesions being T1a and one lesion T1b. Tissue sampling was done in 9/11 patients, 3 were papillary RCC and the rest, clear cell RCC. In two patients, the tumor was completely endophytic, three patients had partially endophytic tumors while 6 patients had exophytic lesions. The median nephrometry score was 6 (range: 4–11, Mode 4). Technical success was achieved in all patients. Complete response was achieved in 81% (9/11) of the patients at 1-month follow-up. Median follow-up period was 6 months. Two patients showed residual disease on follow-up imaging at 1 and 3 months, respectively. Conclusion Cryoablation is a promising, relatively new minimally invasive therapy for treating small renal tumors in India. It is safe, technically feasible, and shows excellent short-term efficacy.

Early endoscopic treatment of symptomatic pancreatic necrotic collections

EUS-guided transmural endoscopic drainage is commonly used in the treatment of WOPN in the late phase of ANP. The role of endoscopic intervention remains unclear in the early phase of ANP. This study aimed to prospectively evaluate early endoscopic treatment of ANCs compared with endoscopic drainage of WOPN. Overall, 71 patients with ANP who underwent transmural endoscopic drainage for necrotic collections were included. Endoscopic intervention was performed within the first four weeks of ANP in 25 (35.21%) patients with ANC (Group 1) and in 46 (64.79%) patients after four weeks since the onset of ANP with WOPN (Group 2). The overall mean age of patients was 49.9 (22–79) years and 59 of them were males. The mean time of active drainage and duration of total endoscopic treatment was 26.8 and 16.9 days (P = 0.0001) and 270.8 and 164.2 days (P = 0.0001) in Groups 1 and 2, respectively. The average total number of endoscopic interventions was 9.5 and 4.5 in Groups 1 and 2, respectively (P = 0.0001). The clinical success rate, frequency of complications of endoscopic interventions, long-term success rate, and recurrence rate were not significantly different between the groups (P > 0.05 for each). Transmural endoscopic drainage is effective method of treatment of early ANCs within the first four weeks of ANP. However, compared with endoscopic intervention in WOPN, more interventions and longer duration of drainage are required.

Safety and efficacy of emergency transarterial embolization for mesenteric bleeding

Background Patients with spontaneous or traumatic active mesenteric bleeding cannot be treated endoscopically. Transarterial embolization can serve as a potential alternative to emergency surgery. Literature on transarterial embolization for mesenteric bleeding remains very scarce. The objective of this study was to evaluate the safety and efficacy of transarterial embolization for mesenteric bleeding. We reviewed all consecutive patients admitted for mesenteric bleeding to the interventional radiology department, in a tertiary center, between January 2010 and March 2021. Mesenteric bleeding was defined as mesenteric hematoma and contrast extravasation and/or pseudoaneurysm visible on pre-operative CT scan. We evaluated technical success, clinical success, and complications. Results Among the 17 patients admitted to the interventional department for mesenteric bleeding, 15 presented with active mesenteric bleeding requiring transarterial embolization with five patients with hemodynamic instability. Mean age was 67 ± 14 years, including 12 (70.6%) males. Technical success was achieved in 14/15 (93.3%) patients. One patient with technical failure was treated by percutaneous embolization with NBCA-Lipiodol mixture. Three patients (20%) had early rebleeding: two were treated by successful repeat embolization and one by surgery. One patient (6.7%) had early death within 30 days and two patients (13.3%) had late death after 30 days. Mean length of hospitalization was 12.8 ± 7 days. There were no transarterial embolization-related ischemic complications. Conclusion Transarterial embolization is a safe and effective technique for treating mesenteric bleeding even in patients with hemodynamic instability. Transarterial embolization doesn’t close the door to surgery and could be proposed as first intention in case of mesenteric bleeding.

The Challenge of Converting “Failed Spinal Cord Stimulation Syndrome” Back to Clinical Success, Using SCS Reprogramming as Salvage Therapy, through Neurostimulation Adapters Combined with 3D-Computerized Pain Mapping Assessment: A Real Life Retrospective Study

While paresthesia-based Spinal Cord Stimulation (SCS) has been proven effective as treatment for chronic neuropathic pain, its initial benefits may lead to the development of “Failed SCS Syndrome’ (FSCSS) defined as decrease over time related to Loss of Efficacy (LoE) with or without Loss of Coverage (LoC). Development of technologies associating new paresthesia-free stimulation waveforms and implanted pulse generator adapters provide opportunities to manage patients with LoE. The main goal of our study was to investigate salvage procedures, through neurostimulation adapters, in patients already implanted with SCS and experiencing LoE. We retrospectively analyzed a cohort of patients who were offered new SCS programs/waveforms through an implanted adapter between 2018 and 2021. Patients were evaluated before and at 1-, 3-, 6- and 12-month follow-ups. Outcomes included pain intensity rating with a Visual Analog Scale (VAS), pain/coverage mappings and stimulation preferences. Last follow-up evaluations (N = 27) showed significant improvement in VAS (p = 0.0001), ODI (p = 0.021) and quality of life (p = 0.023). In the 11/27 patients with LoC, SCS efficacy on pain intensity (36.89%) was accompanied via paresthesia coverage recovery (55.57%) and pain surface decrease (47.01%). At 12-month follow-up, 81.3% preferred to keep tonic stimulation in their waveform portfolio. SCS conversion using adapters appears promising as a salvage solution, with an emphasis on paresthesia recapturing enabled via spatial retargeting. In light of these results, adapters could be integrated in SCS rescue algorithms or should be considered in SCS rescue.

Does General and Specific Traits of Personality Predict Students’ Academic Performance?

Background and Objectives. This study examines whether personality profiles, personality factors, or clusters of personality factors are associated with academic success. Methods. The study includes all fifth-year dental students registered at the College of Dentistry, Ajman University, in 2019/2020. One hundred and seventy students were invited to complete personality and performance measures using the Big Five Inventory (BFI) scale; the weighted grade point average (GPA) was used to assess students’ academic performance. Results. Of the 170 participants, 60% were female and 40% were male. Participants ranged in age from twenty-four to twenty-seven years, with an average age of twenty-four years. There was a relationship between personality scores obtained for the students and their subsequent academic performance. The broad conscientiousness, competence, achievement, and dutifulness predicted academic and clinical success. The prediction accuracy of conscientiousness was improved by the inclusion of dutifulness, self-discipline, and deliberation. Conclusion. This study confirms that the students’ personality profile is a substantial predictor of academic performance and likely to help select future intakes of students, although a prospective study would be required for a definite answer to this question.

Gallbladder Cryoablation: Clinical and Technical Considerations

As many as 500,000 cholecystectomies are performed per year in the United States. Frail patients are at higher risk from cholecystectomy, with reported postoperative complication and mortality rates as high as 31 and 5% in patients older than 75 years. Percutaneous cholecystostomy drainage is commonly employed in high-risk patients with cholecystitis, with over 12,000 cases performed annually. Cholecystostomy, however, is not a definitive treatment, with up to 30% of patients having a recurrent episode of cholecystitis within 4 months after tube removal. Gallbladder cryoablation has emerged as a minimally invasive procedure that achieves transmural gallbladder wall necrosis in a single session resulting in gallbladder fibrosis and involution. Early clinical data have been promising, with reported technical success of 86% and clinical success of 100% at up to 500 days of follow-up. Several challenges and unknowns remain, however, including optimal patient selection and procedural technique, the potential need for adjunct procedures to occlude the cystic duct, the implications of the immunostimulatory effects of cryoablation, and the impact of the presence of gallstones on outcomes. This article reviews the rationale behind gallbladder cryoablation, updates early clinical outcomes, and discusses the challenges that remain for the adoption of the technique for the treatment of benign gallbladder disease.

Surgical Treatment of Iatrogenic Low Variety Anal Stenosis with Diamond Flap Anoplasty – A Prospective Study

Background: Anal stenosis results from loss of anoderm with subsequent fibrosis and scarring of underlying tissue. The condition represents a technical challenge in terms of surgical management. It is a serious complication of anorectal surgery, most commonly seen after surgical haemorrhoidectomy. However, stenosis can also occur after perianal circumferential burn due to application of herbal medicine by village doctors. Objective: This study was conducted to see the outcome of diamond-flap anoplasty for the treatment of moderate to severe anal stenosis. Patients and interventions: Unilateral diamond flaps anoplasty was performed for moderate to severe anal stenosis. Final anal calibre of 25 to 26 mm was targeted. The demographic characteristics, causes of anal stenosis, number of previous surgeries, anal stenosis severity, postoperative complications and the time of return to work were recorded. Results: From July 2012 to January 2017, 18 patients (12 males, 67% and 6 female patients, 33%) with a mean age of 34 years (range, 25-52) were treated. 15 of the patients had a history of previous haemorrhoidectomy and 3 had circumferential perianal chemical burn due to application of herbal medicine by village doctors. Five patients (28%) had moderate anal stenosis and 13 (72%) had severe anal stenosis. Preoperative, intraoperative, and 12-month postoperative anal calibration values were 9 ± 3 mm (range, 5-15), 25 ± 0.75 mm (range, 24- 26), and 25 ± 1 mm (range, 23-27). The clinical success rate was 98.9%. No severe postoperative complications were observed. Conclusion: Diamond-flap anoplasty is a highly successful method for the treatment of anal stenosis caused by previous haemorrhoidectomy and perianal circumferential chemical burn by herbal medicine. J Shaheed Suhrawardy Med Coll 2020; 12(2): 67-71