A transanal procedure using an endoscopic linear stapler for obstructed defecation syndrome: the first Chinese experience

BACKGROUND

Transanal surgery using an endoscopic linear stapler is a recognized, but not widely performed technique for the treatment of obstructed defecation syndrome (ODS). A study of consecutive patients was conducted to evaluate the safety and effectiveness of the technique for the treatment of ODS in Chinese patients.

METHODS

From November 2008 to December 2010, 43 female patients with ODS caused by rectocele and/or rectal intussusception underwent transanal surgery using an endoscopic linear stapler in three Chinese hospitals. Clinical and functional data including the Wexner constipation score and outcome classification were analyzed retrospectively.

RESULTS

The average duration of surgery was 23 ± 4 min (range 15-30 min). Blood loss was 10 ± 2 ml (range 5-15 ml). The average postoperative hospital stay was 5 days (range 4-6 days). The pathologic findings showed that the specimen contained rectal muscle in all patients. Postoperative complications included 4 patients with transient fecal urgency, 3 patients with anorectal pain, and one patient with mild bleeding from the stapled suture line. Three patients reported minor fecal incontinence (Wexner score less than 3). During a median follow-up of 12 months (range, 3-26 months), the mean constipation score improved from preoperative 13.56 to postoperative 5.07 at 1 year (P < 0.05). The outcome at 1 year was excellent in 18 of 43 patients, good in 13, fairly good in 7, and poor in 5. Postoperative defecography was performed in 28 patients. Rectocele disappeared in 15 patients. Rectocele depth was reduced from 34 ± 4 mm preoperatively to 17 ± 3 mm postoperatively (P < 0.05).

CONCLUSION

The transanal procedure using an endoscopic linear stapler is an easy, safe, and effective option for selected patients with ODS. Long-term prospective, randomized, controlled studies are needed to confirm the advantages of this procedure in comparison with the traditional transanal and stapled transanal rectal resection (STARR) techniques.

The miRNA-17∼92 cluster mediates chemoresistance and enhances tumor growth in mantle cell lymphoma via PI3K/AKT pathway activation

The median survival of patients with mantle cell lymphoma (MCL) ranges from 3 to 5 years with current chemotherapeutic regimens. A common secondary genomic alteration detected in MCL is chromosome 13q31-q32 gain/amplification, which targets a microRNA (miRNA) cluster, miR-17∼92. On the basis of gene expression profiling, we found that high level expression of C13orf25, the primary transcript from which these miRNAs are processed, was associated with poorer survival in patients with MCL (P=0.021). We demonstrated that the protein phosphatase PHLPP2, an important negative regulator of the PI3K/AKT pathway, was a direct target of miR-17∼92 miRNAs, in addition to PTEN and BIM. These proteins were down-modulated in MCL cells with overexpression of the miR-17∼92 cluster. Overexpression of miR-17∼92 activated the PI3K/AKT pathway and inhibited chemotherapy-induced apoptosis in MCL cell lines. Conversely, inhibition of miR-17∼92 expression suppressed the PI3K/AKT pathway and inhibited tumor growth in a xenograft MCL mouse model. Targeting the miR-17∼92 cluster may therefore provide a novel therapeutic approach for patients with MCL.

Endovascular treatment of ruptured and unruptured vertebral artery aneurysms

This paper analyzes the success of endovascular management of ruptured and unruptured vertebral artery aneurysms. Sixty-three patients with 65 vertebral (both acute dissection and chronic larger aneurysms are included) treated at our hospital form the basis of the analysis. Clinical outcome was evaluated using the modified Rankin Scale. Angiographic follow-up data was obtained for 44 patients (69.8%) for periods ranging from three to 16 months (mean, eight months). Based on the Hunt and Hess grading scale, the patient population included 34 patients (54.0%) with unruptured aneurysms, 28 (44.4%) with Grade 1 aneurysms, one (1.6%) with Grade 2 aneurysms. The locations of the aneurysms included 25 (38.5%) at the distal to posterior inferior cerebellar artery (PICA), 22 (33.8%) at the proximal to PICA and 18 (27.7%) at the vertebral artery-posterior inferior cerebellar artery (VA-PICA). Of the 63 patients, 12 (19%) were women and 51 (81%) were men. The mean age at treatment was 41.7 years (range, six-77 yrs). Follow-up angiograms were obtained in 44 (69.8%) out of 63 patients. Complete or virtually complete thrombosis was confirmed on early posttreatment angiography in 39 (88.6%) out of 44 patients. A slight reduction in the size of the lesion was noted in three patients and there was a significant residual lesion in two (4.5%) patients. Clinical follow-up revealed 90.5% patients in the mRS 0-2 category, 4.8% patients in the mRS>2 category, and 4.8% patients had died (mRS 6). Three patients died of rebleeding (n=1) or progressive mass effect/brainstem ischemia (n=2). Ruptured and unruptured aneurysms of the vertebral artery can be well treated using endovascular techniques, overall long-term results were good in 90.5% of patients.

Association study of myelin transcription factor 1-like polymorphisms with schizophrenia in Han Chinese population

Schizophrenia (SZ) is characterized by a variety of complex positive, negative and cognitive symptoms that are differentially expressed in individual patients. Variability in symptom presentation indicates that multiple genes, many involved in neurodevelopment, contribute to the etiology of SZ. The myelin transcription factor 1-like (MYT1L) gene encodes the MYT1L protein that participates in several neurodevelopment pathways. The copy number variant of MYT1L gene is associated with SZ, and single-nucleotide polymorphisms (SNPs) of MYT1L contribute to major depressive disorder. To explore the association of MYT1L polymorphisms with SZ, we examined six SNPs of MYT1L in a Han Chinese population consisting of 528 paranoid schizophrenic patients and 528 healthy subjects. Our results showed that rs17039584 was significantly associated with SZ (A>G), even after Bonferroni correction. When subjects were divided by gender, the rs10190125 allele and genotype remained significantly associated with SZ in female patients. Moreover, we found that rs6742365 was associated with a family history of SZ in females. Other SNPs did not achieve statistical significance for SZ but were associated with individual phenotypes, as measured by the Positive and Negative Syndrome Scale (PANSS) inventory. Our findings suggest that MYT1L may represent a susceptibility gene for SZ in the Han Chinese population and show that a specific SNP may increase susceptibility in females.

cDNA cloning, genomic structure and mRNA expression pattern of porcine type I interferons receptor 2 gene

Type I interferons (IFN) are important mediators of the host defence against viruses through binding to the cell surface receptors, among which the binding to type I IFN receptor 2 (IFNAR2) is the very first step initiating a complex signal transduction cascade. By using RT-PCR and 5' RACE approaches, we obtained porcine IFNAR2 cDNA, the nucleotide identity of its coding region is 57.53%, 67.45%, 74.07% and 74.63% to those of mouse, human, sheep and cattle, respectively; and the deduced protein of which shares 38.18%, 55.29%, 62.01% and 63.39% identity to those of mouse, human, sheep and cattle, respectively. The genomic structure of porcine IFNAR2 gene consists of nine exons and eight introns. Porcine IFNAR2 mRNA expression was detected in all tissues examined, being strong in the spleen, small intestine, cerebrum and uterus tissues and relatively weak in the stomach tissues. As compared with piglets, the expression of IFNAR2 mRNA was significantly higher in both liver and spleen of Laiwu adult pigs (P < 0.01); in Duroc pigs, however, significantly higher IFNAR2 mRNA expression was only found in adult liver (P < 0.05). In Duroc × Landrace × Yorkshire commercial pigs infected with porcine reproductive and respiratory syndrome virus (PRRSV), the expression of IFNAR2 mRNA in lung tissue was significantly down-regulated as compared to uninfected ones (P < 0.05).

Deliberate parent artery occlusion for non-saccular posterior cerebral artery aneurysms

Posterior cerebral aneurysms are rare vascular lesions and usually present as non-saccular or dissecting in nature. We present a retrospective review of our experience in the deliberate parent artery occlusion of posterior cerebral artery (PCA) aneurysms.From June 2006 to June 2010, 12 patients (seven men, five women) with posterior cerebral artery non-saccular aneurysms presented to our department and were treated by parent artery occlusion. There were eight (66.7%) aneurysms located at the P2 segment, two (16.7%) at the P2-3 junction, one (8.3%) at the P1-2 junction and one (8.3%) at the P3 segment. Ten of the 12 patients were treated by aneurysm together with parent artery occlusion and two were treated by proximal occlusion.The procedure was technically successful in all cases. Angiography was performed immediately after the procedure in all patients and showed occlusion of the parent vessel with no filling of the aneurysm. Only one patient (8.3%) developed procedure-related transient hemianopsia and recovered within one month. The other 11 patients showed no additional neurological symptoms after procedure. Deliberate parent artery occlusion by detachable coils appears to be well tolerated for P2 or distal segment of PCA in our limited case series. We propose that this technique could be a good treatment option in treating non-saccular aneurysms in this location.

Low agreement between the T-SPOT®.TB assay and the tuberculin skin test among college students in China

T-SPOT®.TB and the tuberculin skin test (TST) were used to screen for latent tuberculosis infection among 899 Chinese college students. The positivity rates for T-SPOT®.TB and TST were respectively 13.0% (95% confidence interval [CI] 10.4-15.9) and 24.9% (95%CI 21.5-28.6) among students with a bacille Calmette-Guérin (BCG) scar (agreement of both tests 72.3%; 95%CI 68.6-75.8; κ = 0.118), and respectively 17.3% (95%CI 11.7-24.2) and 23.7% (95%CI 17.3-31.2) among those without a BCG scar (agreement 73.1%; 95%CI 65.4-79.9; κ = 0.179). These results demonstrate low agreement between the TST and T-SPOT.TB in the Chinese population studied.

Treatment of a fusiform vertebral aneurysm with double stent placement. A technical case report and review of the literature

A 34-year-old man admitted to another hospital presented with sudden onset of headache. The CT scan was unremarkable, but magnetic resonance angiography revealed a fusiform aneurysm in the left vertebral artery. Six days later, the patient was sent to our institution for further diagnosis and treatment. Cerebral angiography confirmed a fusiform aneurysm located in the right vertebral artery. At first, we placed a neuroform-3 stent and could see contrast medium stasis in the aneurysm, so we did not fill coils into the aneurysm. Four months later, the patient was admitted for rechecking. DSA showed the aneurysm remained and we placed a LEO stent in the lumen of the Neuroform stent. A control DSA eight months later showed the aneurysm had almost healed. Overlapping stents may induce spontaneous thrombosis of vertebral artery aneurysms and facilitate parent artery reconstruction through flow remodeling and stent endothelialization. This technique may be an option in treating dissecting or fusiform intracranial aneurysms that are not amenable to open surgical treatment or endovascular coil embolization.

Genomic structure and characterization of mRNA expression pattern of porcine interferon gamma receptor 1 gene

Interferon gamma receptor (IFNGR) plays an important role in the biological effects of IFN-γ. In this study, porcine IFNGR1 cDNA was cloned and two transcripts both having a coding region of 1413 bp were identified. Porcine IFNGR1 cDNA shares 62.95%, 63.73%, 72.90% and 81.10% identity in nucleotide sequence; and 45.64%, 46.69%, 58.04% and 72.55% homology in amino acid sequence to those of rat, mouse, human and cattle, respectively. The porcine IFNGR1 genomic structure consists of seven exons and six introns and is located on porcine chromosome 1. The mRNA expression of porcine IFNGR1 gene is detected in all tissues examined, with strong expression in spleen and liver tissues and weak expression in cerebrum, cerebellum and uterus tissues, respectively. A different developmental pattern in IFNGR1 mRNA expression between Laiwu and Duroc breeds was revealed by real-time quantitative RT-PCR: in Duroc pigs, a significantly higher expression was found in the tissues of heart (P<0.05), liver (P<0.01), kidney (P<0.01) and skeletal muscle (P<0.05) of adult pigs compared to piglets. In porcine reproductive and respiratory syndrome virus (PRRSV)-infected Dapulian pigs, compared to the uninfected ones, the expression level of IFNGR1 mRNA in spleen was significantly up-regulated (P<0.05), whereas its expression in the lymph node was significantly down-regulated (P<0.05); in PRRSV-infected Duroc × Yorkshire × Landrace commercial pigs, however, the differences both in spleen and lymph node tissues were not significant.

A p1 aneurysm and diabetes insipidus caused by traumatic brain injury

We describe a patient with a P1 aneurysm of the posterior cerebral artery (PCA) with diabetes insipidus (DI) caused by traumatic brain injury. A 21-year-old woman presented with epidural hematoma, left temporal contusion and subarachnoid hemorrhage caused by head trauma. DI occurred with normal anterior hypophyseal function on the second day after admission and cerebral angiography demonstrated an aneurysm at the right P1 portion after one month. DI was treated with administration of desmopressin and the aneurysm and P1 portion of the right PCA were occluded completely. After three months, her DI recovered and decompressin was discontinued. The six month follow-up angiogram confirmed cure of the P1 aneurysm. P1 aneurysm and DI can be caused by traumatic brain injury. Cranial DI caused by head injury with perturbations in water balance may be transitory and resolve.

Endovascular treatment for cerebral aneurysms using stents

Endovascular stent placement combined with coil embolization is an established procedure for the treatment of intracranial aneurysms. We describe lesion outcome using stents for the treatment of intracranial aneurysms. Sixty-nine patients (30 females and 39 males; age range 12-78 years) treated with stent placement at Beijing Tiantan Hospital over a six-year period. Seventy- six cerebral aneurysms were encountered and 74 lesions were treated with 79 stents. Outcome was evaluated using the Glasgow Outcome Scale (GOS) score during a mean follow-up period of 32 months. Of the 74 stented aneurysms, 34 (45.9%) were located in the anterior circulation and 40 (54.1%) in the posterior circulation. Forty-eight (64.9%) aneurysms were small and 26 (35.1%) were large or giant. In 67 (90.5%) aneurysms embolization was completed by packing the aneurysm sac with platinum coils. In five small fusiform and four saccular aneurysms, the stent was used alone. Six procedure-related complications were observed and a cause of death in 7.2% of the patients. Follow-up angiography obtained at three months to one year in 68 (91.9%) aneurysms demonstrated complete occlusion in 43 aneurysms with a progressive thrombosis rate of 19.4% (six out of 31 aneurysms). Aneurysm recurrence occurred in four (5.8%) patients, three were treated with coil embolization and one with placement of another stent. Overall long-term outcome was good (GOS Score 4 or 5) in 92.8%, and fatal (GOS Score 1) in 7.2% of the patients. Intracranial stents can be a useful addition to coil embolization for complex broad-based aneurysms. Favorable overall long-term outcome can be achieved in 92.8% of patients when using endovascular stent placement techniques.

Giant vertebrobasilar aneurysm treated with bilateral vertebral artery occlusion. Two case reports

Giant vertebrobasilar aneurysms constitute a relatively uncommon subgroup of aneurysms with a high mortality rate. These aneurysms are often difficult to treat with conventional clipping or coiling because of their location and their morphology. Here we describe two patients with giant vertebrobasilar aneurysms, both of which were successfully treated with bilateral vertebral artery occlusion. This approach is suggested as a definitive treatment for vertebrobasilar aneurysms in appropriate circumstances.

Endovascular treatment for complex intracranial aneurysms: lessons learnt in five patients

We describe our experience in five cases of endovascular treatment for complex intracranial aneurysms. The senior author (ZW) has clinical experience with more than 6000 cases of brain aneurysms treated with endovascular techniques. Multiple endovascular therapies, such as treatment with Onyx, parent vessel occlusion, stent-assisted coiling, covered stent, can be used in an attempt to provide a solution to various clinical dilemmas associated with the management of these difficult lesions. Here, we focus on the latest five patients and lessons learnt in endovascular techniques for complex intracranial aneurysms.On the basis of the knowledge obtained over the years, multimodality endovascular techniques should be re-evaluated to improve patient outcomes.

Transarterial and transvenous embolization for cavernous sinus dural arteriovenous fistulae

We report on the safety and efficacy of trans-arterial and transvenous Onyx embolization in the treatment of dural arteriovenous fistulae (DAVFs) of the cavernous sinus. We reviewed the findings from a retrospectively database for 22 patients with cavernous sinus DAVFs who were treated with either transarterial Onyx embolization alone (n = 8) or transarterial and transvenous Onyx embolization (n = 14) over a four year period. The mean follow-up period after endovascular treatment was 21.6 months (range 3-42 mths). Total number of embolizations was 27 for 22 patients. Two patients were treated transvenously after transarterial embolization. All 22 patients (100%) experienced improvement of their clinical symptoms. All 22 patients (100%) experienced total obliteration of their DAVFs, as documented by angiography performed at a mean follow-up of 5.8 months after the last treatment. No patient experienced a recurrence of symptoms after angiography showed DAVF obliteration. One patient exhibited temporary deterioration of ocular symptoms secondary to venous hypertension after near total obliteration; one had transient V cranial nerve deficit related to transarterial embolization, and two patients exhibited transient III and VI cranial nerve weakness related to transvenous embolization. Two patients experienced recurrent symptoms after incomplete transarterial embolization and underwent transvenous embolization at three and four months. Both patients achieved clinical and angiographic cures. Transarterial and transvenous embolization with Onyx, whenever possible, proved to be a safe and effective management for patients with cavernous sinus DAVFs.

Role of neurocrine somatostatin on sphincter of Oddi contractility and intestinal ischemia reperfusion-induced acute pancreatitis in macaques

BACKGROUND

Intestinal ischemia-reperfusion (IIR) is implicated in the pathogenesis of severe acute pancreatitis (SAP). This study investigates the impact of neurocrine somatostatin (SST) on the contraction of sphincter of Oddi (SO) during IIR.

METHODS

Intestinal ischemia-reperfusion model in macaques was induced by occluding the superior mesenteric artery. Pancreatitis was confirmed by pancreatic histology and serum levels of amylase and lipase. SST and its receptors (SSTRs) in SO were visualized by immunohistochemistry. Effects of SST on the contraction of the isolated SO were recorded in vitro.

KEY RESULTS

Inflammatory scores of the pancreas and serum levels of amylase or lipase in the macaques that underwent IIR were significantly higher than those in the control group. The frequency and amplitude of phasic contraction of the circular muscle in SO was increased by SST in a concentration-dependent manner. Compared with the control group, SST innervation or SSTR2 expression in SO of macaques treated with IIR was increased 5.2 fold or 5.6 fold respectively. Prophylactic infusion of SST before IIR significantly reduced SST immunoreactive fibers in SO as compared to those in the IIR group and remarkably alleviated the pathophysiologic changes due to IIR.

CONCLUSIONS & INFERENCES

Increased SST innervation in SO during the early phase of IIR associated with the contraction of circular muscle of SO, which might be one of the promoting factors associated with the development of SAP. Prevention of IIR or intervention of SO contraction after occurrence of acute pancreatitis might be beneficial for preventing SAP.