Meyer, Alyssa J.

Abstract Background and study aims Management of malignant gastrointestinal obstruction (MGIO) is more challenging in the presence of peritoneal carcinomatosis (PC). Outcomes data to guide the management of MGIO with PC are lacking. We aimed to compare the clinical outcomes and adverse events between endoscopic and surgical palliation and identify predictors of stent success in patients with MGIO with PC. Patients and methods Consecutive inpatients with MGIO with PC between 2000 and 2018 who underwent palliative surgery or enteral stenting were included. Clinical success was defined as relief of obstructive symptoms. Results Fifty-seven patients with enteral stenting and 40 with palliative surgery were compared. The two groups did not differ in rates of technical success, 30-day mortality, or recurrence. Clinical success from a single intervention (63.2 % versus 95 %), luminal patency duration (27 days vs. 145 days), and survival length (148 days vs. 336 days) favored palliative surgery (all P < 0.05) but the patients in the surgery group had a trend toward better Eastern Cooperative Oncology Group (ECOG) status. The rate of adverse events (AEs) (10.5 % vs. 50 %), the severity of AEs, and length of hospital stay (4.5 days vs. 9 days) favored enteral stenting (P < 0.05). The need for more than one stent was associated with a higher likelihood of stent failure. Conclusions Our study suggests that enteral stenting is safer and associated with a shorter hospital stay than palliative surgery, although unlike other MGIOs, clinical success is lower in MGIO with PC. Identification of the right candidates and potential predictors of clinical success in ECOG-matched large-scale studies is needed to validate these results.

Replication of negative-strand RNA viruses relies on two components: a helical ribonucleocapsid and an RNA-dependent RNA polymerase composed of a catalytic subunit, the L protein, and a cofactor, the P protein. We show that the measles virus (MeV) C protein is an additional component of the replication complex. We provide evidence that the C protein is recruited to the ribonucleocapsid by the P protein and map the interacting segments of both C and P proteins. We conclude that the primary function of MeV C is to improve polymerase processivity and accuracy, rather than uniquely to antagonize the type I interferon response. Since most viruses of the Paramyxoviridae family express C proteins, their primary function may be conserved.

Abstract Background Proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the surgical procedure of choice for medically refractory ulcerative colitis and familial adenomatous polyposis. While rare, a pouch volvulus can occur. We aimed to determine the frequency, presentation, and management approach of pouch volvulus in patients with IPAA. Methods A systematic search of published literature was performed by a medical reference librarian on 10 August 2018 and two independent reviewers identified relevant publications, extracted data, and assessed the methodological quality based on a validated tool. A retrospective review of the Mayo Clinic electronic medical records identified one case of pouch volvulus between January 2008 and August 2018. Results The frequency of pouch volvulus from one large published study reporting long-term outcomes of IPAA was 0.18% (3/1,700). A total of 22 patients (18 ulcerative colitis) were included (median age 32 years, 73% females). Median time to volvulus after IPAA was 36 months while median interval to volvulus diagnosis from symptom onset was 24 hours. Abdominal pain was the most commonly reported symptom (76%). The diagnosis was made primarily by abdominal computed tomography (13/17 patients, 76%). Endoscopic treatment was successful in 1 of 11 patients (9%). Surgery was performed in 20 patients and pouch-pexy and pouch excision were the most frequent surgical operations. A redo IPAA was performed in five patients (25%). Conclusion Pouch volvulus is a rare but serious complication of IPAA and should be suspected even in the absence of obstruction symptoms. Endoscopic treatment often fails and surgery is effective when performed early.

Abstract Background Post-surgical complications such as leaks are the source of considerable morbidity and mortality. Success of conservative interventions is highly variable. Recurrence after surgical repair is also not uncommon. Our aim was to develop novel endoscopic strategies to maximize negative intracavitary pressure to manage leaks in cases where conventional management either failed or were not feasible. Methods We have used transluminal locking loop drains with low intermittent suction in the management of non-healing leaks in various areas. An example presented here illustrates this concept where a 68-year-old male patient underwent paraesophageal hernia repair with Nissen fundoplication. Patient presented 3 weeks later with fistula leading to a 13 cm meditational abscess. Patient developed right hemiparesis requiring tissue plasminogen activator (tPA). Post-tPA patient developed hemoptysis and hematemesis requiring emergency intubation. The defect in the esophagus was 6–8 mm. Endoscopic repair with stitching or clipping would have left a large undrained cavity with a potential to expand. Endoscopic repair with transcutaneous drain placement was challenging due to recent tPA and a difficult location. Moreover there was potential to develop esophago- pleural- broncho- cutaneous fistula. Endoscopic vacuum therapy was felt to be a suboptimal choice. Patient was high-risk surgical candidate as it would have required radical surgery in the setting of tPA.Upper endoscopy was performed and the cavity was debrided. No direct communication with bronchopulmonary tree noted. A transnasal guidewire assisted 16 Fr, 60 cm locking loop drain was placed and connected to low intermittent suction that was switched to bulb based suction. Results The output from naso-cavity drain decreased nearly 100 cc per day in the first 5 days and the size reduced by 30, 50 and 80% by day 5, 9 and 12 respectively. Near complete elimination of the cavity was observed on day 15. Esophagogram showed complete resolution of the leak and computerized tomography revealed no residual cavity Conclusion Developing transluminal endoscopic strategies to maximize negative intracavitary pressure helps expedite the healing of resistant postsurgical leaks. This technique avoids the need for frequent drain changes that remains a challenge for vacuum therapy. Disclosure All authors have declared no conflicts of interest.