Zhonggao Wang

Endovascular Stenting vs. Extrathoracic Surgical Bypass for Symptomatic Subclavian Steal Syndrome

Purpose To analyze the immediate and long-term outcomes of endovascular stenting vs. extrathoracic surgical bypass for subclavian steal syndrome. Methods From 1989 to 2010, 252 consecutive patients (173 men; mean age 62 years) with vertebrobasilar and upper extremity symptoms of subclavian steal were treated with balloon-expandable stents (n = 148) or extrathoracic surgical bypasses (n = 104: 71 axilloaxillary and 33 carotid-subclavian) using polytetrafluoroethylene grafts. Results The technical success rate was 97.3% in the stent group vs. 99.0% for the bypass group (p=0.605). There was no perioperative mortality or any permanent neurological deficit in either group. The overall perioperative complication rate was 6.1% in the stent group vs. 9.6% in the bypass group (p=0.295). The 10-year target vessel revascularization rate was 46.6% for stenting vs. 5.8% for bypass (p<0.001). The cumulative primary patency rates at 1, 3, 5, and 10 years were 91%, 78%, 67%, and 49% for the stent group vs. 99%, 97%, 95%, and 89% for the bypass group (p<0.001). The cumulative secondary patency rates were 95%, 91%, 86%, and 64%, respectively, for the stent group vs. 99%, 99%, 98%, and 94% for the bypass group (p=0.001). No difference was detected in overall survival curves between the groups (p=0.527). Conclusion Both endovascular stenting and extrathoracic surgical bypass are safe and effective treatments for subclavian steal syndrome in the short and medium term; however, extrathoracic surgical bypasses are more durable in the long term.

A meta-analysis of long follow-up outcomes of laparoscopic Nissen (total) versus Toupet (270°) fundoplication for gastro-esophageal reflux disease based on randomized controlled trials in adults

BackgroundLaparoscopic Nissen fundoplication (LNF) is the most common surgical procedure for the surgical management of gastro-esophageal reflux disease (GERD). Laparoscopic Toupet fundoplication (LTF) has been reported to have a lower prevalence of postoperative complications yet still obtain a similar level of reflux control. We conducted a meta-analysis to confirm the value of LNF and LTF.MethodsPubMed, Medline, Embase, Cochrane Library and Springerlink were searched for randomized controlled trials (RCTs) comparing LNF and LTF. Data regarding the benefits and adverse results of two techniques were extracted and compared using a meta-analysis.ResultsEight eligible RCTs comparing LNF (n = 625) and LTF (n = 567) were identified. There were no significant differences between LNF and LTF with regard to hospitalization duration, perioperative complications, patient satisfaction, postoperative heartburn, regurgitation, postoperative DeMeester scores, or esophagites. A shorter operative time and higher postoperative lower esophageal sphincter pressure were associated with LNF. Prevalence of postoperative dysphagia, gas-bloating, inability to belch, dilatation for dysphagia and reoperation were higher after LNF, but subgroup analyses showed that differences with respect to dysphagia between LNF and LTF disappeared over time. Subgroup analyses did not support “tailored therapy” according to preoperative esophageal motility.ConclusionsLNF and LTF have equivalently good control of GERD and result in a similar prevalence of patient satisfaction. Based on current evidence, it is not rational or advisable to abandon LNF when choosing a surgical procedure for GERD.

Angioplasty for pediatric renovascular hypertension: a 13-year experience.

PURPOSE We aimed to evaluate the long-term outcome and efficacy of percutaneous transluminal renal angioplasty (PTRA) for pediatric renal artery stenosis (RAS), which is an important cause of medication-refractory pediatric hypertension. MATERIALS AND METHODS We retrospectively evaluated 22 hypertensive children (age range, 3-17 years) who underwent PTRA from February 2000 to July 2012. Sixteen patients had Takayasu arteritis and six fibromuscular dysplasia. Five were not included in the statistical analysis due to loss to follow-up. RESULTS Technical success was achieved in 32 of 34 procedures (94.1%). The stenosis rate decreased from 84.5% before PTRA to 20.1% after PTRA. Treatment was effective in 72.7% (16/22) of patients, including complete cure in 27.3% (6/22) and improvement in 45.5% (10/22). Systolic and diastolic blood pressures decreased from 153 ± 19.1 to 131.7 ± 21.4 mmHg and from 97.9 ± 14.2 to 83.6 ± 19.3 mmHg, respectively (P <0.01). Number of antihypertensive agents decreased from 2.7 to 0.5 per patient. Restenosis was detected in 40.9% (9/22) of patients, with a restenotic interval of 11.8 months (range, 3-47 months). Lesion length was strongly correlated with clinical success (cure and improvement) (independent-sample t test, P <0.001; binary logistic regression, P = 0.040). CONCLUSION Lesion length is an important determination of clinical success with PTRA for pediatric RAS. PTRA is an appropriate treatment option for pediatric renovascular hypertension due to Takayasu arteritis and fibromuscular dysplasia.

Early and Midterm Outcome After Laparoscopic Fundoplication and a Minimally Invasive Endoscopic Procedure in Patients with Gastroesophageal Reflux Disease: A Prospective Observational Study.

BACKGROUND AND AIMS Although the minimally invasive endoscopic Stretta procedure is being increasingly used as an alternative strategy to manage gastroesophageal reflux disease (GERD), the benefits of this procedure have to be further evaluated in clinical settings. This prospective observational study assessed the short-term and midterm outcomes associated with laparoscopic Toupet fundoplication (LTF) and the Stretta procedure. PATIENTS AND METHODS From January 2011 to January 2012, we allocated 80 patients to LTF and 85 to the Stretta procedure. Primary outcome measures, including symptom scores of heartburn, regurgitation, chest pain, belching, hiccup, cough, and asthma, as well as proton pump inhibitor (PPI) use, were analyzed at midterm follow-up (1-3 years). RESULTS Of the 165 patients, 125 patients following LTF (n=65) or the Stretta procedure (n=60) completed the designated 3-year follow-up and were included in the final analysis. At the end of the 3-year follow-up, the symptom scores were all significantly decreased compared with the corresponding values before the two procedures in both groups (P<.05). After LTF and the Stretta procedure, 47/65 (72.3%) and 41/60 (68.3%) patients, respectively, achieved complete PPI therapy independence (72.3% versus 68.3%, P=.627). Comparing with LTF, however, the Stretta procedure had less effect on improving typical symptoms of heartburn, regurgitation, and chest pain and reducing the rate of re-operation (11.8% versus 0%, P=.006). CONCLUSIONS LTF and the Stretta procedure were equally effective in controlling GERD symptoms and reducing PPI use. However, LTF can achieve more improvement on typical symptoms and has a lower rate of re-operation.

Comparison of Stretta procedure and toupet fundoplication for gastroesophageal reflux disease-related extra-esophageal symptoms

AIM To compare the outcomes between the Stretta procedure and laparoscopic toupet fundoplication (LTF) in patients with gastroesophageal reflux disease (GERD)-related extra-esophageal symptoms. METHODS From January 2011 to February 2012, a total of 98 patients diagnosed with GERD-related extra-esophageal symptoms who met the inclusion criteria were enrolled in this study. All patients who either underwent the Stretta procedure or LTF treatment have now completed the 3-year follow-up. Primary outcome measures, including frequency and severity of extra-esophageal symptoms, proton pump inhibitor (PPI) use, satisfaction, and postoperative complications, were assessed. The results of the Stretta procedure and LTF therapy were analyzed and compared. RESULTS There were 47 patients in the Stretta group and 51 patients in the LTF group. Ninety patients were available at the 3-year follow-up. The total of the frequency and severity scores for every symptom improved in both groups (P < 0.05). Improvement in symptom scores of cough, sputum, and wheezing did not achieve statistical significance between the two groups (P > 0.05). However, the score for globus hysterics was different between the Stretta group and the LTF group (4.9 ± 2.24 vs 3.2 ± 2.63, P < 0.05). After the Stretta procedure and LTF treatment, 29 and 33 patients in each group achieved PPI therapy independence (61.7% vs 64.7%, P = 0.835). The patients in the LTF group were more satisfied with their quality of life than those in the Stretta procedure group (P < 0.05). Most complications resolved without intervention within two weeks; however, two patients in the LTF group still suffered from severe dysphagia 2 wk after the operation, and it improved after bougie dilation treatment in both patients. CONCLUSION The Stretta procedure and LTF were both safe and effective for the control of GERD-related extra-esophageal symptoms and the reduction of PPI use.

A preliminary investigation of laparoscopic fundoplication treatment on gastroesophageal reflux disease-related respiratory symptoms.

Background: Extraesophageal syndromes are more difficult to identify and treat than the usual esophageal symptoms. The current study explores the efficacy of laparoscopic Nissen fundoplication (LNF) on gastroesophageal reflux disease (GERD)-related respiratory symptoms (RSs) during a 12-month follow-up observation. Methods: From April 2008 to September 2009, LNF was performed on 198 patients (107 men and 91 women) with GERD-related RSs according to underlying esophageal motility. A questionnaire form ranging from 0 to 5 was the basic requirement for recording pretreatment and posttreatment and for making detailed evaluation of the symptoms. All scores of GERD-related RSs, such as heartburn, regurgitation, coughing, breathe holding, wheezing, shortness of breath, and choking, significantly decreased at the 12th month. Results: All the patients who participated in the current study were adults and elders aged 22 to 84 years with a mean age of 49±12.89. The median length of stay was 4.3 days with a range of 2 to 8 days. The median score of heartburn, regurgitation, coughing, wheezing, shortness of breath, choking, and chest pain decreased from 4.92±1.99, 4.98±1.81, 7.23±1.87, 7.50±1.88, 5.83±2.13, 5.94±2.22, and 4.92±1.88 to 1.62±2.33, 0.64±1.43, 2.79±2.82, 2.53±2.96, 1.37±2.10, 1.28±2.09, and 1.57±2.55 (P<0.01), respectively. A total of 173 patients had various relieved symptom scores, 16 patients (8.1%) had different scale recurrence of symptoms after laparoscopic fundoplication treatment, and 13 patients had to retreat to omeprazole as an auxiliary medical therapy. Three other patients rejected any therapy, and no deaths occurred. A single patient converted from laparoscopic surgery to open surgery. Several short-term symptoms included retrosternal uneasiness or pain (n=63; 31.8%), dysphagia (n=45; 22.7%), abdominal distension (n=87; 43.9%), and diarrhea (n=23; 11.6%). Early dysphagia lasting <6 weeks was common, and 45 patients (22.7%) underwent an early esophagogastroduodenoscopy or contrast swallow. Five patients (2.5%) who had prolonged dysphagia during the 6-month clinical review required esophageal dilatation, and the outcomes were successful. Conclusions: LNF can be an effective means for treating RSs in patients with GERD.

Surgical treatment of carotid body tumor: case report and literature review.

Carotid body tumors (CBT) are rare chemical receptor tumors. We report nine cases of CBT who were diagnosed at our center during 2004 to 2008 with a literature review. Of these nine patients, eight underwent complete resection, one received palliative resection due to the malignant nature of the tumor, and the other one refused surgery. No perioperative mortality and stroke occurred. During a mean follow up of 2.2 years, no deaths related to CBT occurred. Surgical treatment for CBT is relatively safe. The surgeon should be careful to maintain the integrity of carotid artery, and prevent cerebral ischemia and cranial nerve injuries in order to improve outcome.

Management of Complex Patients with Budd–Chiari Syndrome

Therapy for patients with Budd-Chiari syndrome is well established. For those with commonly seen localized lesions, percutaneous transluminal angioplasty or stenting is the first-line treatment. Treatment methods for severely ill patients in whom intervention has failed, or those in a poor general condition, are worth exploring. From February 2002 to July 2008, 31 patients were referred to us. Eighteen patients had a failed intervention, 4 had undergone surgery, and 10 had conservative therapy. All had intractable ascites or/and hematemesis. The procedures carried out in this series included mesocavoatrial shunt in 10 patients, radical correction in 9, mesocavojugular shunt in 7 (including 2 mesojugular shunts), mesocaval shunt in 2, cavoatrial shunt in 2 (including a revision of cavoatrial shunt), and cavojugular shunt in 1. Surgical mortality and postoperative complications were both 3.2%. Twenty-eight patients had a mean follow-up of 40 months. Outcome of follow-up was measured as excellent, good, fair, poor, and death (28.6%, 53.6%, 10.7%, 3.6%, and 3.6%, respectively). The total mortality of the group is 6.5%. After appropriate preoperative evaluation and preparation, active and cautious treatment individualized to the underlying disease may help severely ill patients with Budd-Chiari syndrome.

Preliminary investigation of seeding mesenchymal stem cells on biodegradable scaffolds for vascular tissue engineering in vitro.

We used &egr;-caprolactone/l-lactide (PCLA) as a biodegradable scaffold and bone marrow (BM) mesenchymal stem cells (MSCs) as seeding cells for vascular tissue engineering: we expected MSCs to grow in the scaffolds in a bioreactor. The MSCs we used were from the BM of dogs, and vascular scaffolds were carried out on the electrospinning process of PCLA copolymers. MSCs expressed CD44 and CD105 but did not express CD34 or CD14 at an identical time point. Scaffolds were nontoxic to cells and were favorable for the growth and migration of MSCs. After culture in a bioreactor with mechanical stimulation, cells completely covered the surfaces of PCLA scaffolds and penetrated or infiltrated into the inside of the scaffold structure.

Diagnosis and Anti-Reflux Therapy for GERD with Respiratory Symptoms: A Study Using Multichannel Intraluminal Impedance-pH Monitoring

Background/Aims Respiratory symptoms are often associated with gastroesophageal reflux disease (GERD). Although the role of multichannel intraluminal impedance–pH (MII-pH) monitoring in GERD is clear, little is known regarding the characteristics of patients with respiratory symptoms based on MII-pH monitoring and anti-reflux therapy. We evaluated a cohort of GERD patients to identify the MII-pH parameters of GERD-related respiratory symptoms and to assess the anti-reflux therapy outcomes. Methods We undertook a prospective study of patients who were referred for GERD evaluation from January 2011 to January 2012. One hundred ninety-five patients underwent MII-pH monitoring and esophageal manometry, and one hundred sixty-five patients underwent invasive anti-reflux therapy that included laparoscopic Toupet fundoplication (LTF) and the Stretta procedure. The patient characteristics and MII-pH parameters were analyzed, and the symptom scores were assessed at baseline and at 1- and 3-year follow-up evaluations. Results Of the 195 patients, 96 (49.2%) exhibited respiratory symptoms and significantly more reflux episodes (70.7±29.3) than patients without respiratory symptoms (64.7±24.4, p = 0.044) based on the MII-pH monitoring results. Moreover, the group of patients with respiratory symptoms exhibited more proximal reflux episodes (35.2±21.3) than the non-respiratory symptomatic group (28.3±17.9, p = 0.013). One hundred twenty-five patients following the Stretta procedure (n = 60, 31 with respiratory symptoms) or LTF (n = 65, 35 with respiratory symptoms) completed the designated 3-year follow-up period and were included in the final analysis. The symptom scores after anti-reflux therapy all decreased relative to the corresponding baseline values (p<0.05), and there were no significant differences in the control of respiration between the Stretta procedure and LTF (p>0.05). However, LTF significantly reduced the recurrence (re-operation) rate compared with the Stretta procedure (0 vs. 19.4%, p = 0.006). Conclusions MII-pH monitoring effectively detected respiratory-related predictive parameters, including total/proximal reflux episodes and symptom correlations. We found that GERD patients with respiratory symptoms exhibited more proximal and total reflux episodes but not more acid-related episodes, as determined by MII-pH monitoring. Thus, such monitoring could be useful for diagnosing atypical GERD patients with respiratory symptoms. Furthermore, LTF exhibited a more significant effect on controlling typical symptoms in all GERD patients and reducing the recurrence rate than the Stretta procedure in patients with respiratory symptoms.