Stepwise Algorithmic Approach to Endoscopic Removal of Biliary Partially Covered and Uncovered Self-Expanding Metal Stents

Self-expanding metal stents play a crucial role in the management of patients with biliary obstruction. Endoscopic extraction of uncovered metal stents (UCMSs) and partially covered metal stents (PCMSs) could be challenging because of tissue ingrowth. No standardized technique can guarantee universal success. We present our technique and experience of endoscopic extraction of biliary stents in two patients with a UCMS and three patients with a PCMS. Three of the five patients had a previous failed attempt of stent extraction at an outside hospital. Overall, our composite success rate was 80% (4/5). The individual success rate was 100% (3/3) for PCMSs and 50% (1/2) for UCMSs. The stent-in-stent technique, in which a fully covered metal stent is placed through an existing UCMS/PCMS, was used in 60% (3/5) of the cases, with a success rate of 66.7% (2/3). We share our algorithmic approach to each case, with detailed emphasis on the technical aspects of the procedure.

Antidiabetic Activity of Momordica charantia L. and Mechanism of Insulin Secretion of 1-Butanol Soluble Part on Type 2 Diabetic Model Rats

The in vivo effects of fruit pulp juice (MC-PJ) of Momordica charantia and its 1-butanol soluble part (MC-BP) and aqueous soluble part (MC-AP) on blood glucose of type 2 diabetic rats were studied. In vitro insulin secretion in response to MC-BP and MC-AP from whole perfused pancreas was measured. For elucidating the mechanism of insulinotropic action, the insulin secretory activity of MC-BP in the presence of 11 mM glucose, 50 μM verapamil (Ca++ channel blocker), 8 mM diazoxide (K+ ATP channel opener) and 10 mM theophylline (cAMP phosphodiesterase inhibitor) were studied. Serum glucose was measured by glucose oxidase-peroxidase method and rat insulin was assayed by specific ELISA. In the in vivo study, MC-BP significantly opposed the rise of serum glucose compared to control at 105 min (p<0.05). Although the MC-AP and MC-PJ lowered the serum glucose both at 60 and 105 min, these were not statistically significant. In the in vitro study, only MC-BP produced 22-fold increase in insulin secretion from the perfused pancreas at nonstimulatory glucose level, which was significant (basal vs. MC-BP, 0.071±0.009 vs. 1.563±0.150 ng/ml, p<0.001). The MC-BP also enhanced the insulin secretion from the glucose-stimulated pancreas (p<0.001). The MC-BP induced insulin secretion was not affected in presence of diazoxide and verapamil. The obtained results also showed that MC-BP enhanced the insulin secretory effect of theophylline (p<0.001). The findings indicate that MC-BP has stimulatory effects on physiological pathways of insulin secretion which may underlie its reported antidiabetic action. Dhaka Univ. J. Pharm. Sci. 19(2): 111-117, 2020 (December)

Prevalence and types of genetic polymorphisms of CYP2C19 and their effects on platelet aggregation inhibition by clopidogrel

OBJECTIVE

The current study was conducted to determine the distribution of genetic polymorphisms in CYP2C19 in Iraqi patients and their role in inter-individual variability of clopidogrel efficacy.

PATIENTS AND METHODS

A prospective controlled study was done on 100 patients under high risk of cardiovascular diseases who started clopidogrel prophylactic therapy. Polymerase chain reaction-restriction fragment length polymorphism method was used to determine the existence of the CYP2C19 gene mutation. Vasodilator-stimulated phosphoprotein (VASP) index baseline besides one-month post-therapy was analyzed by dual-color flow cytometry analysis.

RESULTS

Eight gene mutations of CYP2C19 were found (*1/*1), (*1/*2), (*1/*3), (*1/*8), (*1/*17), (*2/*2), (*2/*4), and (*3/*3) with higher prevalent CYP2C19*1 gene. Homozygous CYP2C19*1 allele was shown to be the rapid metabolizer comparing to the heterozygous CYP2C19*1 allele, whereas, CYP2C19*2 and CYP2C19*3 were resistant alleles and were present in 28% of patients. The analysis of VASP phosphorylation produces accurate inter-individual response variability in platelets inhibition by antiplatelet drugs.

CONCLUSIONS

In vitro gene analysis and VASP index improve the clinical outcome of a patient candidate to clopidogrel as prophylaxis in cardiovascular events.

Study on Precipitating Factor of Chronic Hepatic Encephalopathy

Hepatic encephalopathy (HE) is a neuro-psychiatric manifestation of chronic liver disease causing significant morbidity and mortality worldwide. Though the exact mechanism is unknown but it is well accepted that various precipitating factors are involved in hepatic encephalopathy. Aim of the study was explore the precipitating factors of chronic hepatic encephalopathy. This cross sectional descriptive study was conducted in the Department of Medicine and Department of Hepatology, Mymensingh Medical College Hospital, Mymensingh, Bangladesh during the period from April 2016 to October 2016. One hundred patients with hepatic encephalopathy fulfilling the inclusion and exclusion criteria were enrolled. Inclusion criteria were designed for all diagnosed cases of hepatic encephalopathy associated with cirrhosis of liver aged 18 years or above irrespective of sex. Patients with acute fulminant hepatitis and non-cirrhotic hepatic encephalopathy were excluded. The result of the study was mean age of hepatic encephalopathy was 52.81±8.15 years and 94.0% patients were above 40 years. Male (66.0%) were predominant over female (34.0%). HBsAg and Anti HCV were positive in 49.0% and 11.0% patients respectively. Stage of hepatic encephalopathy was stage-I in 8.0%, stage-II in 37.0%, stage-III in 39.0% and stage-IV in 16.0% patients. Changes of biochemical parameters were low haemoglobin level (70.0%), raised total count of leukocyte (25.0%), low platelet count (68.0%), low serum albumin (98.0%) raised prothrombin time (60.0%), low serum sodium (34.0%) and low serum potassium (63.0%). The recoded precipitating factors were gastrointestinal bleeding (14.0%), constipation (37.0%), hyponatremia (34.0%), hypokalemia (28.0%) infections (20.0%), use of diruretics (8.0%), use of sedatives (4.0%) and excess intake of protein (6.0%). While precipitating factor was absent in 11.0% of cases. In conclusion there are different factors which play a key role in precipitating hepatic encephalopathy but electrolytes imbalance, constipation, infections, Upper GI bleed, diuretics are the most common precipitating factors.

Concomitant neuroendocrine tumor and gastrointestinal stromal tumor in a duodenal fine needle aspiration: A cytologic clue for neurofibromatosis type 1

The identification of two cell populations displaying different cytologic characteristics in the same fine needle aspiration (FNA), one with an epithelioid appearance and the other spindle cell morphology, is an extremely rare phenomenon and potentially represents a source of diagnostic confusion. Depending on the lineage and relationship of the two cell types, the differential diagnosis is broad and encompasses a wide spectrum of entities. The current case describes the presence of nests and clusters of neuroendocrine cells associated with rare spindle cell fragments of gastrointestinal stromal tumor (GIST) in the same fine needle aspiration of a duodenal mass. Our literature analysis revealed that such combined cytologic findings were hitherto never reported and the concurrence of well-differentiated neuroendocrine tumor (NET) and GIST is almost pathognomonic for neurofibromatosis type 1 (NF-1).

Effects of Blended (Yellow) vs Forced Coagulation (Blue) Currents on Adverse Events, Complete Resection, or Polyp Recurrence After Polypectomy in a Large Randomized Trial

BACKGROUND & AIMS

There is debate over the type of electrosurgical setting that should be used for polyp resection. Some endoscopists use a type of blended current (yellow), whereas others prefer coagulation (blue). We performed a single-blinded, randomized trial to determine whether type of electrosurgical setting affects risk of adverse events or recurrence.

METHODS

Patients undergoing endoscopic mucosal resection of nonpedunculated colorectal polyps 20 mm or larger (n = 928) were randomly assigned, in a 2 × 2 design, to groups that received clip closure or no clip closure of the resection defect (primary intervention) and then to either a blended current (Endocut Q) or coagulation current (forced coagulation) (Erbe Inc) (secondary intervention and focus of the study). The study was performed at multiple centers, from April 2013 through October 2017. Patients were evaluated 30 days after the procedure (n = 919), and 675 patients underwent a surveillance colonoscopy at a median of 6 months after the procedure. The primary outcome was any severe adverse event in a per patient analysis. Secondary outcomes were complete resection and recurrence at first surveillance colonoscopy in a per polyp analysis.

RESULTS

Serious adverse events occurred in 7.2% of patients in the Endocut group and 7.9% of patients in the forced coagulation group, with no significant differences in the occurrence of types of events. There were no significant differences between groups in proportions of polyps that were completely removed (96% in the Endocut group vs 95% in the forced coagulation group) or the proportion of polyps found to have recurred at surveillance colonoscopy (17% and 17%, respectively). Procedural characteristics were comparable, except that 17% of patients in the Endocut group had immediate bleeding that required an intervention, compared with 11% in the forced coagulation group (P = .006).

CONCLUSIONS

In a randomized trial to compare 2 commonly used electrosurgical settings for the resection of large colorectal polyps (Endocut vs forced coagulation), we found no difference in risk of serious adverse events, complete resection rate, or polyp recurrence. Electrosurgical settings can therefore be selected based on endoscopist expertise and preference. Clinicaltrials.gov ID NCT01936948.

A newly designed uncovered biliary stent for palliation of malignant obstruction: results of a prospective study

Background

Biliary decompression can reduce symptoms and improve quality of life in patients with malignant biliary obstruction. Endoscopically placed stents have become the standard of care for biliary drainage with the aim of improving hepatic function, relieving jaundice, and reducing adverse effects of obstruction. The purpose of this study was to evaluate the performance characteristics of a newly-designed, uncovered metal biliary stent for the palliation of malignant biliary obstruction.

Methods

This post-market, prospective study included patients with biliary obstruction due to a malignant neoplasm treated with a single-type, commercially available uncovered self-expanding metal stent (SEMS). Stents were placed as clinically indicated for palliation of jaundice and to potentially facilitate neo-adjuvant chemotherapy. The main outcome measure was freedom from recurrent biliary obstruction (within the stent) requiring re-intervention within 1, 3, and 6 months of stent insertion. Secondary outcome measures included device-related adverse events and technical success of stent deployment.

Results

SEMS were placed in 113 patients (73 men; mean age, 69); a single stent was inserted in 106 patients, and 2 stents were placed in 7 patients. Forty-eight patients survived and/or completed the 6 month study protocol. Freedom from symptomatic recurrent biliary obstruction requiring re-intervention was achieved in 108 of 113 patients (95.6, 95%CI = 90.0–98.6%) at study exit for each patient. Per interval analysis yielded the absence of recurrent biliary obstruction in 99.0% of patients at 1 month (n = 99; 95%CI = 97.0–100%), 96.6% of patients at 3 months (n = 77; 95%CI = 92.7–100%), and 93.3% of patients at 6 months (n = 48; 95%CI = 86.8–99.9%). In total, only 5 patients (4.4%) were considered failures of the primary endpoint. Most of these failures (4/5) were due to stent occlusion from tumor ingrowth or overgrowth. Overall technical success rate of stent deployment was 99.2%. There were 2 cases of stent-related adverse events (1.8%). There were no cases of post-procedure stent migration, stent-related perforation, or stent-related deaths.

Conclusions

This newly designed and marketed biliary SEMS system appears to be effective at relieving biliary obstruction and preventing re-intervention within 6 months of insertion in the overwhelming majority of patients. The device has an excellent safety profile, and associated high technical success rate during deployment.

Trial registration

The study was registered on clinicaltrials.gov on 14 October 2013 and the study registration number is NCT01962168. University of Massachusetts Medical School did not participate in the study.

Demography and Symptom Profile of Tetanus: A Cross-sectional Observation in an Infectious Disease Hospital of Bangladesh

Tetanus is a potentially preventable neurological infectious disorder with paucity of literature in Bangladesh. We aimed to see the demography and symptom profile of tetanus cases managed at the Infectious disease Hospital Sylhet. This hospital based cross-sectional descriptive study was conducted within the time period of January to December 2012 among 50 consecutive admitted patients in the Infectious Disease Hospital, Sylhet, Bangladesh who were diagnosed as a case of tetanus and fulfilling the inclusion criteria and exclusion criteria. Neonatal tetanus was considered as exclusion criteria and clinical diagnosis of tetanus was considered as the tetanus. Data were collected purposively with pretested predesigned questionnaire. Data were processed manually and analyzed with the help of SPSS Version 16.0. The mean±SD age was 33.00±16.8 years, ranging from 10 to 70 years. Among the 50 respondents, 72.0% were male, 50% from lower class, 34% were students and 30.0% had their educational status of primary level, 60.0% from rural social background. Trismus was found in 98.0% of the cases, rigidity in 96.0% cases, body ache in 94.0% cases, dysphagia in 92.0% cases, neck pain in 78.0% cases, dysarthria in 92.0% cases, reflex spasm in 66.0% cases, opisthotonus in 46.0% cases and urinary retention in 26.0% cases. In this study rural male people with lower socioeconomic status individuals were mostly affected with trismus, rigidity, body ache and dysphagia symptoms.

Gender Difference of Common Risk Factors and in Hospital Outcome of Acute Ischaemic Stroke

This was an observational study with cross-sectional comparison of risk factors between sexes in the distribution of common risk factors and in hospital outcome of acute ischaemic stroke with the purpose of developing optimal strategies for the prevention and care of this disease. This study was conducted in the Department of Medicine and Department of Neurology, Sylhet MAG Osmani Medical College Hospital, Sylhet, Bangladesh from March 2013 to August 2013. Patients were divided in Group A- male patients with acute ischaemic stroke (n=47) and Group B- female patients with acute ischaemic stroke (n=47), were included according to inclusion and exclusion criteria. Male were more frequently diabetic [19(40.4%) vs. 10(21.3%), p=0.044] and smoker [41(87.2%) vs. 18 (38.3%); p<0.001] than that of female. Female were older [67.4±8.9 years vs. 62.2±8.1 years; p<0.05]; more frequent hypertensive [36(76.6%) vs. 26(55.3%); p=0.030] than that of male but no gender differences in atrial fibrillation, ischemic heart disease, dyslipidaemia. In-hospital functional outcome (p=0.039) was significantly better in male than that of female patients with acute ischaemic stroke. Characterization of risk factors for acute ischaemic stroke in both sexes may aid in developing prevention strategies to reduce stroke incidence.

Clip Closure Prevents Bleeding After Endoscopic Resection of Large Colon Polyps in a Randomized Trial

BACKGROUND & AIMS

Bleeding is the most common severe complication after endoscopic mucosal resection of large colon polyps and is associated with significant morbidity and cost. We examined whether prophylactic closure of the mucosal defect with hemoclips after polyp resection reduces the risk of bleeding.

METHODS

We performed a multicenter, randomized trial of patients with a large nonpedunculated colon polyp (≥20 mm) at 18 medical centers in North America and Spain from April 2013 through October 2017. Patients were randomly assigned to groups that underwent endoscopic closure with a clip (clip group) or no closure (control group) and followed. The primary outcome, postprocedure bleeding, was defined as a severe bleeding event that required hospitalization, a blood transfusion, colonoscopy, surgery, or another invasive intervention within 30 days after completion of the colonoscopy. Subgroup analyses included postprocedure bleeding with polyp location, polyp size, or use of periprocedural antithrombotic medications. We also examined the risk of any serious adverse event.

RESULTS

A total of 919 patients were randomly assigned to groups and completed follow-up. Postprocedure bleeding occurred in 3.5% of patients in the clip group and 7.1% in the control group (absolute risk difference [ARD] 3.6%; 95% confidence interval [CI] 0.7%-6.5%). Among 615 patients (66.9%) with a proximal large polyp, the risk of bleeding in the clip group was 3.3% and in the control group was 9.6% (ARD 6.3%; 95% CI 2.5%-10.1%); among patients with a distal large polyp, the risks were 4.0% in the clip group and 1.4% in the control group (ARD -2.6%; 95% CI -6.3% to -1.1%). The effect of clip closure was independent of antithrombotic medications or polyp size. Serious adverse events occurred in 4.8% of patients in the clip group and 9.5% of patients in the control group (ARD 4.6%; 95% CI 1.3%-8.0%).

CONCLUSIONS

In a randomized trial, we found that endoscopic clip closure of the mucosal defect following resection of large colon polyps reduces risk of postprocedure bleeding. The protective effect appeared to be restricted to large polyps located in the proximal colon. ClinicalTrials.gov no: NCT01936948.

Endoscopic ultrasound-guided liver biopsy using a 22-G fine needle biopsy needle: a prospective study

BACKGROUND

Endoscopic ultrasound-guided liver biopsy (EUS-LB) using a 19-gauge (19-G) EUS needle is becoming increasingly popular. We evaluated the efficacy and safety of a 22-G EUS fine needle biopsy (FNB) needle for performing EUS-LB.

METHODS

Patients referred for evaluation of elevated liver enzymes and without obstructive disease requiring endoscopic retrograde cholangiopancreatography (ERCP) were included. Using a 22-G FNB needle, two passes were made from the left lobe and one from the right. The main outcome measure was adequacy of the specimen for histology interpretation, and the secondary outcome was the safety of EUS-guided liver biopsy with a 22-G FNB needle. Patients were followed for post-procedure complications for 30 days.

RESULTS

40 patients (median age 61 years; 26 women) underwent EUS-LB. Analyzing by needle passes, the median longest core fragment was 12 mm (1st quartile - 3rd quartile 10 mm - 16.25 mm, interquartile range [IQR] 6.25 mm) from the left lobe and 11 mm (10 mm - 15.75 mm, IQR 5.75 mm) from the right lobe. The median cumulative core length per patient was 55 mm (44.5 mm - 68 mm, IQR 23.5 mm). The median cumulative number of complete portal triads (CPTs) per patient was 42 (28.5 - 53, IQR 24.5). The specimen was considered adequate in all 40 patients (100 %). Self-limiting abdominal pain was reported in 6 patients (15 %).

CONCLUSIONS

EUS-LB using a 22-G FNB needle is a safe and viable alternative to the use of larger gauge needles, yielding adequate tissue for evaluation of parenchymal disease in 100 % of the patients.

Non-superiority of lumen-apposing metal stents over plastic stents for drainage of walled-off necrosis in a randomised trial

OBJECTIVE

Although lumen-apposing metal stents (LAMS) are increasingly used for drainage of walled-off necrosis (WON), their advantage over plastic stents is unclear. We compared efficacy of LAMS and plastic stents for WON drainage.

DESIGN

Patients with WON were randomised to endoscopic ultrasound-guided drainage using LAMS or plastic stents. Primary outcome was comparing total number of procedures to achieve treatment success defined as symptom relief in conjunction with WON resolution on CT at 6 months. Secondary outcomes were treatment success, procedure duration, clinical/stent-related adverse events, readmissions, length of hospital stay (LOS) and costs.

RESULTS

60 patients underwent LAMS (n=31) or plastic stent (n=29) placement. There was no significant difference in total number of procedures performed (median 2 (range 2-7) LAMS vs 3 (range 2-7) plastic, p=0.192), treatment success, clinical adverse events, readmissions, LOS and overall treatment costs between cohorts. Although procedure duration was shorter (15 vs 40 min, p<0.001), stent-related adverse events (32.3% vs 6.9%, p=0.01) and procedure costs (US$12 155 vs US$6609, p<0.001) were higher with LAMS. Significant stent-related adverse events were observed ≥3 weeks postintervention in LAMS cohort. Interim audit resulted in protocol amendment where CT scan was obtained at 3 weeks postintervention followed by LAMS removal if WON had resolved. After protocol amendment, there was no significant difference in adverse events between cohorts.

CONCLUSION

Except for procedure duration, there was no significant difference in treatment outcomes between LAMS and plastic stents. To minimise adverse events with LAMS, patients should undergo follow-up imaging and stent removal at 3 weeks if WON has resolved.

TRIAL REGISTRATION NUMBER

NCT02685865.

An Endoscopic Transluminal Approach, Compared With Minimally Invasive Surgery, Reduces Complications and Costs for Patients With Necrotizing Pancreatitis

BACKGROUND & AIMS

Infected necrotizing pancreatitis is a highly morbid disease with poor outcomes. Intervention strategies have progressed from open necrosectomy to minimally invasive approaches. We compared outcomes of minimally invasive surgery vs endoscopic approaches for patients with infected necrotizing pancreatitis.

METHODS

We performed a single-center, randomized trial of 66 patients with confirmed or suspected infected necrotizing pancreatitis who required intervention from May 12, 2014, through March 24, 2017. Patients were randomly assigned to groups that received minimally invasive surgery (laparoscopic or video-assisted retroperitoneal debridement, depending on location of collection, n = 32) or an endoscopic step-up approach (transluminal drainage with or without necrosectomy, n = 34). The primary endpoint was a composite of major complications (new-onset multiple organ failure, new-onset systemic dysfunction, enteral or pancreatic-cutaneous fistula, bleeding and perforation of a visceral organ) or death during 6 months of follow-up.

RESULTS

The primary endpoint occurred in 11.8% of patients who received the endoscopic procedure and 40.6% of patients who received the minimally invasive surgery (risk ratio 0.29; 95% confidence interval 0.11-0.80; P = .007). Although there was no significant difference in mortality (endoscopy 8.8% vs surgery 6.3%; P = .999), none of the patients assigned to the endoscopic approach developed enteral or pancreatic-cutaneous fistulae compared with 28.1% of the patients who underwent surgery (P = .001). The mean number of major complications per patient was significantly higher in the surgery group (0.69 ± 1.03) compared with the endoscopy group (0.15 ± 0.44) (P = .007). The physical health scores for quality of life at 3 months was better with the endoscopic approach (P = .039) and mean total cost was lower ($75,830) compared with $117,492 for surgery (P = .039).

CONCLUSIONS

In a randomized trial of 66 patients, an endoscopic transluminal approach for infected necrotizing pancreatitis, compared with minimally invasive surgery, significantly reduced major complications, lowered costs, and increased quality of life. Clinicaltrials.gov no: NCT02084537.

Abstract P2-01-10: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Hasan MK, Widhopf II GF, Zhang S, Shen Z, Briggs SP, Kipps TJ. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-01-10.

Utility of rapid onsite evaluation of touch imprint cytology from endoscopic and cholangioscopic forceps biopsy sampling (with video)

BACKGROUND AND AIMS

Rapid onsite evaluation of touch imprint cytology (ROSE-TIC) is a simple and rapid method used for the diagnosis of benign and malignant lesions. We evaluated the diagnostic accuracy of ROSE-TIC for advanced intestinal luminal and indeterminate pancreatobiliary lesions during endoscopy.

METHODS

This is a retrospective descriptive study of patients who underwent endoscopy or ERCP between January 1, 2014 and December 31, 2016. It included patients who were referred for the treatment of intestinal luminal lesions or evaluation of indeterminate pancreatobiliary lesions. The slides were prepared by gently touching the specimen onto a glass slide and were examined under the microscope. The main outcome measure was to determine the diagnostic accuracy of ROSE-TIC by comparing the onsite cytology findings with the corresponding off-site histologic diagnosis.

RESULTS

All 222 patients (106 pancreatobiliary and 116 GI lesions) had a prior benign diagnosis of intestinal luminal lesions or indeterminate diagnosis of pancreatobiliary lesions. The overall sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of ROSE-TIC were 97%, 85%, 83%, 97.2%, and 90%, respectively. The accuracy varied with the site of the biopsy sample. The accuracy was lowest for upper GI tract, where it was 85.2% but was 95% for lower GI tract lesions.

CONCLUSIONS

By establishing a rapid onsite diagnosis, ROSE-TIC expedites decision-making on patient management. Prospective studies are needed to confirm these preliminary findings.

Anterior Mediastinal Teratoma- A Rare Variety

Anterior mediastinal teratomas are rare germ cell tumors. We report a case of such rare tumor in a 16 years old boy who presented with sudden severe right sided abdominal pain which radiating to chest for one day. CT scan of the chest was suggestive of anterior mediastinal teratoma. Patient underwent Clamshell thoracotomy. Peroperatively a large mass was found in the anterior mediastinum containing huge amount of sebum like material. It was adherent to mediastinal surface of right & left lung, pericardium and great vessels (SVC, Aorta). The tumor and was resected out except part of its posterior surface which was adherent to pericardium and great vessels and was left in situ. He had a smooth & uneventful post-operative recovery. Histopathology reported as mature (benign) teratoma with no evidence of malignancy.Pulse Vol.10 January-December 2017 p.52-56

Surgical Management of Large Mediastinal Masses–12 Years’ Experience in Apollo Hospitals Dhaka

Objective: The aim of this study was to evaluate the role of surgical treatment for large mediastinal tumors. A retrospective study was done from 6.8.2005 to 11.5.2017. Total 39 patients were included in this study. Age range was from 7 months to 70 years. Male was 24 and female was 15.Background: Most of the tumours were thymoma (12 cases). Others were thymoma with myasthenia gravis in 3 cases, Thymic carcinoma 2 cases, Nodular sclerosing Hodgkin’s lymphoma in 1 case, Schwannoma in 3 cases, Cystic mass in 5 cases, Schwannoma with cystic degeneration in 1 case, Fibromyxoma in 1 case, Dermoid in 4 cases, Teratoma in 3 cases, Fibrosing mediastinitis in thymic mass in 1 case, Lymphoid hyperplasia in 1 case, Malignant Mesenchymal tumour in 1 case, Myxoid Liposarcoma in 1 case.Method: Surgical exposure varies from sternotomy in 22 cases, to clamshell incision in 1 case, posterolateral thoracotomy in 14 cases and anterolateral thoracotomy in 2 cases. Superior Venacava was injured in 1 case, repaired successfully by 6/0 prolene controlled by partial clamp. Some of the mediastinal mass needed careful dissection from lung, pleura, encircling distal aortic arch and proximal part of left subclavian artery, encircling left brachiocephalic vein. 1 case needed reconstruction of sternum with prolene mesh, marsupialization was done in 2 cases, adjacent pleura, fatty tissue, part of pericardium was removed in 5 cases. Lobectomy was needed in 1 case. In 1 case, recurrence of fibrosing mediastinitis needed steroid therapy. Extensive growth of the tumour which involved surrounding vital structures was decided not to proceed for excision in 2 cases.Results: Overall five-years survival rate was 94.87% .2 patients of the series died due to disease process as they were cases of advanced malignant mediastinal mass.Conclusion: Surgical treatment for mediastinal mass specially involving surrounding structures though challenging, gives good outcome.Pulse Vol.10 January-December 2017 p.12-17

Left Atrial Myxoma with Mild Left Ventricular Dysfunction— A Case Report

Atrial Myxoma is the most common primary cardiac tumors accounting for about 50% of benign primary cardiac tumors, with the majority located in the left atrium. This is a case of large left atrial (LA) myxoma presented with features of mitral stenosis associated with moderate left ventricular failure (LVF) and mild pulmonary artery hypertension (PAH) The patient improved markedly after tumor excision.Pulse Vol.10 January-December 2017 p.29-33

Socio-economic performance of Bt eggplant cultivation in Bangladesh

A study was conducted in 35 districts of Bangladesh during 2016-17 winter season for assessing the farm level performance of Bt eggplant in reducing pesticide use, cultivation cost and increase farm income. Five hundred five Bt eggplant farmers were selected purposively and 350 non-Bt eggplant farmers were selected randomly for the study. Net returns per hectare were Tk. 179,602/ha for Bt eggplant as compared to Tk. 29,841/ha for non-Bt eggplant. Pesticides were applied 11 times to Bt eggplant where as it was 41 times to non-Bt eggplant for controlling sucking pests. The Bt eggplant farmers saved 61 percent of the pesticide cost compared to non-Bt eggplant farmers, experienced no losses due to fruit and shoot borer, and received higher net returns. The experience with Bt eggplant technology was good for most of the locations and up to the mark and off course this technology will be significantly improved to their socio-economic conditions in future as reported by the Bt respondents. All Bt and 86% non-Bt farmers wanted to cultivate Bt eggplant in the next year if they can obtain the seeds/seedlings from the research station. For getting higher yield and economic benefits, in the course of technology dissemination, the importance of good production practices must be emphasized.Bangladesh J. Agril. Res. 43(2): 187-203, June 2018

Comparative Study between the Use of Multidose Standard Cardioplegia and Long Acting Del Nido Cardioplegia during Intracardiac Repair for Tetralogy of Fallot in Pediatric Patients

Pediatric myocardium is unique from mature myocardium; thus, the use of adult cardioplegia for pediatric cardiac operations may provide suboptimal myocardial protection. It is found that children undergoing heart surgery show evidence of less myocardial damage when del Nido cardioplegia is used instead of a standard cardioplegic solution. Del Nido cardioplegia solution provides a depolarized hyperkalaemic arrest lasting up to 60 minutes, reduces spontaneous and inducible activity during arrest, and prevents hyper contraction during early reperfusion. In this single blind randomized trial, a total of 60 patients underwent intra cardiac repair for TOF in National Institute of Cardiovascular Diseases, Dhaka, Bangladesh from July 2014 to January 2016 fulfilling inclusion and exclusion criteria. They were randomly assigned in two groups- 30 patients in Del Nido group (Group A) and 30 patients in standard group (Group B). Comparison between groups was done by Chi square test and Student's test. All data were analyzed by SPSS 20.0 for windows. P value less than 0.05 was considered as significant. There was statistically significant difference among the patients in terms of mean total initial cardioplegia volume, mean number of additional dose, mean additional dose amount, mean cross clamp time, mean CPB time (331.67±188.07 vs. 458.67±226.62, p=0.022; 0.13±0.35 vs. 1.27±0.89, p=0.000; 23.33±60.76 vs. 336.83±259.6, p=0.000; 45.10±10.35 vs. 59.23±23.21, p=0.003; 89.30±15.73 vs. 111.10±29.23, p=0.001 respectively). Mean post operative serum troponin I level at arrival in ICU and after 24 hours between two groups were statistically significantly different (55.60±32.91 vs. 83.5±58.99; p=0.024 and 13.01±5.84 vs. 18.16±9.51; p=0.014 respectively). The mean ventilation duration, mean ICU stay were also statistically significant. This study showed that cardiac arrest with Del Nido cardioplegia during intra cardiac repair for TOF was associated with improved myocardial protection over standard cardioplegia in terms of reduced CPB and cross clamp times, lower total volume of cardioplegia.

Randomized trial comparing the Franseen and Fork-tip needles for EUS-guided fine-needle biopsy sampling of solid pancreatic mass lesions

BACKGROUND AND AIMS

Recently, a 3-plane symmetric needle with Franseen geometry and a Fork-tip biopsy needle have been developed for histologic tissue procurement. We compared 22-gauge Franseen and 22-gauge Fork-tip needles in patients undergoing EUS-guided sampling of pancreatic masses.

METHODS

Fifty patients underwent sampling using both 22-gauge Franseen and 22-gauge Fork-tip needles, with randomization of needle order. Two dedicated passes were performed using both needles for cell block. Subsequent passes were performed for rapid onsite evaluation (ROSE) using both needles alternately until diagnosis was established. The main outcome was to evaluate for histologic core tissue by comparing area of total tissue, tumor, desmoplastic fibrosis, and rate of retained tissue architecture between cohorts. Other outcomes were rates of diagnostic cell block and diagnostic adequacy at ROSE.

RESULTS

Final diagnosis was pancreatic cancer in 44 patients, neuroendocrine tumor in 2, lymphoma in 1, and chronic pancreatitis in 3. There was no significant difference in area of total tissue (median 6.1 [interquartie range {IQR}, 3.5-10.5] vs 8.2 mm² [IQR, 4.0-13.0], P = .50), tumor (median .9 [IQR .3-2.8] vs 1.0 mm² [IQR .4-2.7], P = .33), desmoplastic fibrosis (median 4.3 [IQR, 2.0-6.7] vs 5.2 mm² [IQR, 1.7-6.1], P = .71), retained architecture (100% vs 83%, P = .25), diagnostic cell block (96.0% vs 92.0%, P = .32), and diagnostic adequacy at ROSE (94.0% vs 98.0%, P = .32) between Franseen and Fork-tip needles, respectively.

CONCLUSIONS

There was no significant difference between Franseen and Fork-tip needles in yielding histologic tissue. Given their ability to yield diagnostic cell block in greater than 90% of patients, the new-generation fine-needle biopsy needles may obviate the need for ROSE. (Clinical trial registration number: NCT02910960.).