EUS-Guided Bile Duct Drainage (EUBD) in 95 Patients

PURPOSE

Bile duct stenting during ERCP has long been established as the gold standard for the treatment of biliary obstruction. However, when the ampulla cannot be reached or bile duct cannulation fails, percutaneous or surgical drainage is performed. The study aimed to investigate the feasibility and long-term outcome of a potential alternative intervention, EUS-guided transluminal biliary drainage (EUBD), in a representative number of patients.

MATERIALS AND METHODS

All patients undergoing EUBD were included in a prospectively collected single-center database over a 10-year period. Feasibility was characterized by technical and clinical success, including long-term follow-up data.

RESULTS

From IV/2002 - XI/2012, 10 832 EUS and 8756 ERCP procedures were performed. Simultaneously, 223 PTCD and 95 EUBD were performed. Cholangiography was achieved in 93/95 patients (97.9 %). However, in one patient stone extraction was executed by means of the rendezvous technique. Therefore, drainage was not necessary. Intention to treat with EUS-guided drainage was given in 80/94 patients (86.9 %) using different techniques depending on anatomical variations and requirements. The cause of bile duct obstruction could not be cured in 77 patients (malignancy). In 18 patients, a benign (n = 15) or unknown etiology (n = 3) of bile duct stenosis was found. The complication rate was 15.7 % (mortality, 1.1 %; n = 1/95). The follow-up ranged from 3 - 60 months with reintervention in 3 patients.

CONCLUSION

EUBD is a promising therapy for bile duct obstruction in patients predominantly with malignant diseases. Using EUBD, an excellent interventional approach is available for long-term internal drainage to prevent percutaneous drainage (PTCD). EUS-guided drainage is challenging and needs extraordinary interventional expertise, preferentially in tertiary gastroenterological and endoscopic centers.

Cytokeratin 19-fragments (CYFRA 21-1) as a novel serum biomarker for response and survival in patients with advanced pancreatic cancer

Background:

CYFRA 21-1 serves as biomarker in several epithelial malignancies. However, its role in pancreatic cancer (PC) has not yet been investigated.

Methods:

Within a prospective single-centre study serial blood samples were collected from patients with confirmed advanced PC. Pre-treatment values and weekly measurements of CYFRA 21-1, carbohydrate antigen 19-9 (CA 19-9) and carcinoembryonic antigen (assessed by Elecsys 2010, Roche Diagnostics) during palliative first-line chemotherapy were obtained. Biomarker data were correlated with objective response (determined by RECIST) as well as time to progression (TTP) and overall survival (OS) using uni- and multivariate analyses.

Results:

Seventy-eight patients were included, 45% of these received treatment in prospective clinical trials. Median TTP was 3.9 months, median OS 7.7 months. Pre-treatment CYFRA 21-1 levels were significantly associated with performance status (P=0.0399) and stage of disease (P=0.0001). Marker values before chemotherapy and at the 2-month staging of all three markers were considered significant predictors for objective treatment response. Pre-treatment CYFRA 21-1 levels, as well as CA 19-9 values, could be applied to define subgroups (categorised by tertiles) with a different OS outcome (CYFRA: 14.8 vs 7.1 vs 4.8 months, CA 19-9: 14.2 vs 7.1 vs 5.2 months; P<0.0001). CYFRA 21-1 and CA 19-9 (both as categorised and as continuous variables) showed a highly significant correlation with TTP and OS at nearly all-time points assessed in univariate analysis. In multivariate analysis, only CYFRA 21-1 and performance status were independent predictors for OS.

Conclusions:

CYFRA 21-1 may serve as a valuable tool for monitoring treatment response and assessing prognosis in advanced PC.

Trehalose-6-phosphate synthase from the cat flea Ctenocephalides felis and Drosophila melanogaster: gene identification, cloning, heterologous functional expression and identification of inhibitors by high throughput screening

Trehalose phosphate synthase (EC 2.4.1.15; TPS) is the crucial enzyme for the biosynthesis of trehalose, the main haemolymph sugar of insects, and therefore a potential insecticidal molecular target. In this study, we report the functional heterologous expression of Drosophila melanogaster TPS, the gene identification, full length cDNA cloning and functional expression of cat flea (Ctenocephalides felis) TPS, and the Michaelis-Menten constants for their specific substrates glucose-6-phosphate and uridinediphosphate-glucose. A novel high throughput screening-compatible TPS assay and its use for the identification of the first potent insect TPS inhibitors from a large synthetic compound collection (>115 000 compounds) is described. One compound class that emerged in this screening, the 4-substituted 2,6-diamino-3,5-dicyano-4H-thiopyrans, was further investigated by analysing preliminary structure-activity relationships. Here, compounds were identified that show low µM to high nM half maximal inhibitory concentrations on insect TPS and that may serve as lead compounds for the development of insecticides with a novel mode of action.

Effects of different extraction buffers on peanut protein detectability and lateral flow device (LFD) performance

The accidental uptake of peanuts can cause severe health reactions in allergic individuals. Reliable determination of traces of peanuts in food products is required to support correct labelling and therefore minimise consumers' risk. The immunoanalytical detectability of potentially allergenic peanut proteins is dependent on previous heat treatment, the extraction capacity of the applied buffer and the specificity of the antibody. In this study a lateral flow device (LFD) for the detection of peanut protein was developed and the capacity of 30 different buffers to extract proteins from mildly and strongly roasted peanut samples as well as their influence on the test strip performance were investigated. Most of the tested buffers showed good extraction capacity for putative Ara h 1 from mildly roasted peanuts. Protein extraction from dark-roasted samples required denaturing additives, which were proven to be incompatible with LFD performance. High-pH buffers increased the protein yield but inhibited signal generation on the test strip. Overall, the best results were achieved using neutral phosphate buffers but equal detectability of differently altered proteins due to food processing cannot be assured yet for immunoanalytical methods.

Evaluation of the GlideScope for tracheal intubation in patients with cervical spine immobilisation by a semi-rigid collar

Application of cervical collars may reduce cervical spine movements but render tracheal intubation with a standard laryngoscope difficult if not impossible. We hypothesised that despite the presence of a Philadelphia Patriot cervical collar and with the patient's head taped to the trolley, tracheal intubation would be possible in 50 adult patients using the GlideScope and its dedicated stylet. Laryngoscopy was attempted using a Macintosh laryngoscope with a size 4 blade, and the modified Cormack-Lehane grade was scored. Subsequently, laryngoscopy with the GlideScope was graded and followed by tracheal intubation. All patients' tracheas were successfully intubated with the GlideScope. The median (IQR) intubation time was 50 s (43-61 s). The modified Cormack-Lehane grade was 3 or 4 at direct laryngoscopy. It was significantly reduced with the GlideScope (p < 0.0001), reaching grade 2a in most patients. Tracheal intubation in patients wearing a semi-rigid collar and having their head taped to the trolley is possible with the help of the GlideScope.

Ex utero intrapartum treatment (EXIT), a resuscitation option for intra-thoracic foetal pathologies

The ex utero intrapartum treatment (EXIT) procedure is designed to guarantee sufficient oxygenation for a foetus at risk of airway obstruction. This is achieved by improving lung ventilation, usually by establishing an airway during caesarean delivery whilst preserving the foetal-placental circulation temporarily. Indications for the EXIT procedure have extended from its original use in reversing iatrogenic tracheal obstruction in congenital diaphragmatic hernia to naturally occurring upper airway obstructions. We report our experience with a new and rarely mentioned indication for the EXIT procedure, intra-thoracic volume expansions. The elaboration of lowest risk scenarios through balancing risks with alternative options, foetal or neonatal intervention and coordination between professionals from various disciplines are the most important conditions for a successful EXIT procedure. The EXIT procedure requires a caesarean section that specifically differs from the traditional caesarean section during which uterine tone is maintained to minimize maternal bleeding. To guarantee foetal oxygenation during the EXIT procedure, profound uterine relaxation is desired. To gain time with optimal placental oxygenation in order to safely perform an airway intervention in a baby at risk of hypoxia may require deep inhalation anaesthesia and/or tocolytic agents. We review the EXIT procedure and present a case series from the University Hospital of Geneva that contrasts with the common indication for the EXIT procedure usually based on upper airway obstruction by its exclusive indication for intra-thoracic malformations/diseases.

Ex utero intrapartum treatment (EXIT), a resuscitation option for intra-thoracic foetal pathologies

The ex utero intrapartum treatment (EXIT) procedure is designed to guarantee sufficient oxygenation for a foetus at risk of airway obstruction. This is achieved by improving lung ventilation, usually by establishing an airway during caesarean delivery whilst preserving the foetal-placental circulation temporarily. Indications for the EXIT procedure have extended from its original use in reversing iatrogenic tracheal obstruction in congenital diaphragmatic hernia to naturally occurring upper airway obstructions. We report our experience with a new and rarely mentioned indication for the EXIT procedure, intra-thoracic volume expansions. The elaboration of lowest risk scenarios through balancing risks with alternative options, foetal or neonatal intervention and coordination between professionals from various disciplines are the most important conditions for a successful EXIT procedure. The EXIT procedure requires a caesarean section that specifically differs from the traditional caesarean section during which uterine tone is maintained to minimize maternal bleeding. To guarantee foetal oxygenation during the EXIT procedure, profound uterine relaxation is desired. To gain time with optimal placental oxygenation in order to safely perform an airway intervention in a baby at risk of hypoxia may require deep inhalation anaesthesia and/or tocolytic agents. We review the EXIT procedure and present a case series from the University Hospital of Geneva that contrasts with the common indication for the EXIT procedure usually based on upper airway obstruction by its exclusive indication for intra-thoracic malformations/diseases.

Microarray analysis reveals influence of the sesquiterpene lactone parthenolide on gene transcription profiles in human epithelial cells

Sesquiterpene lactones are known for their anti-inflammatory activity which has been proven in various assays on DNA, mRNA and protein level. Here we report on the change in the gene expression profile in TNF-alpha stimulated human 293 cells after treatment with parthenolide using a cDNA microarray analysis. Twenty-one of 7028 genes were found to be up- and 18 down-regulated. They encode for chemoattractants, immune system proteins, glycoproteins, metabolism, serine proteinases, and transcription factors. Confirmatory analyses were carried out using quantitative real-time RT-PCR (TaqMan). Additional studies with selected genes revealed the concentration-dependent influence of parthenolide on the expression of these genes.