The efficacy and safety of biliary stenting alone versus stenting combined with iodine-125 seed strand implantation for the treatment of cholangiocarcinoma with malignant obstructive jaundice: a prospective, nonrandomized, controlled clinical study.

BACKGROUND: Many patients with cholangiocarcinoma also present with malignant obstructive jaundice (MOJ), which requires biliary drainage and stent placement. Recently, clinicians have tried to implant iodine-125 seeds into the biliary tract. However, we know very little about this treatment. This study aimed to compare biliary stenting alone and stenting combined with iodine-125 seed strand implantation to evaluate the safety and efficacy of this technique. METHODS: Sixty patients of cholangiocarcinoma with MOJ were enrolled into the study. According to voluntary choices, 30 received biliary stenting combined with iodine-125 seed strand implantation (study group), and 30 received biliary stent implantation alone (control group). Various biochemical indicators and the manifestation of computed tomography (CT) or magnetic resonance imaging (MRI) were compared before and after operation. We evaluated the safety and efficacy of these treatments by observing patients' symptoms, biochemical indicators and imaging data. Individualized antitumor therapy and regular follow-up were given according to the patients' condition. RESULTS: All 60 patients successfully completed operation. There were no statistically significant differences in baseline data between two groups (P>0.05). Before and 4 weeks after operation, the average total bilirubin levels decreased from 268.14±114.97 to 54.00±80.78 µmol/L in study group, and decreased from 228.89±162.04 to 58.80±61.14 µmol/L in control group. The difference between two groups was not statistically significant (P=0.796). Before and 4 weeks after operation, the average Child-Pugh scores decreased from 7.83±0.59 to 6.20±1.03 points in study group, and decreased from 7.93±1.08 to 7.07±1.39 points in control group, with a statistically significant difference between two groups (P=0.008). The median patency time of stents was 41.71±3.46 weeks in study group and 29.00±5.81 weeks in control group, with a statistically significant difference between the two groups (P=0.037). A statistically significant difference in disease control rate (DCR) was observed between the two groups (P=0.045). CONCLUSIONS: This study demonstrated biliary stenting combined with iodine-125 seed strand implantation may be consider as a safe treatment option for the patients of cholangiocarcinoma with MOJ, and this treatment may improve liver function, reduce the incidence of in-stent restenosis, and improve DCR.

LncRNA TUG1 Promotes Growth and Metastasis of Cholangiocarcinoma Cells by Inhibiting miR-29a.

BACKGROUND: As a highly malignant tumor, cholangiocarcinoma poses a serious threat to human life and health, so exploring the mechanisms of its development and progression at a molecular level is of great significance to the diagnosis and treatment of the disease. OBJECTIVE: This study was aimed at investigating the effects and related mechanisms of LncRNA TUG1 on cholangiocarcinoma cells. METHODS: Cholangiocarcinoma tissues and adjacent tissues (n=82 each), human cholangiocarcinoma cell lines (RBE, QBC939, HuH28), and a human normal biliary epithelial cell line (HIBE) were collected. miR-29a-mimics, miR-29a-inhibitor, miR-NC, si-TUG1, pcDNA3.1 TUG1, and NC were transfected into the cholangiocarcinoma cells. qRT-PCR was performed to detect TUG1 and miR-29a expression in the cholangiocarcinoma tissues and cells. Western blotting (WB) was conducted to detect the expression of Bax, Caspase-3, and Bcl-2 in the cells. CCK-8 assay, Transwell, and flow cytometry were carried out to detect cell proliferation, invasion, and apoptosis. Dual luciferase reporter gene assay (DLRGA) was performed to confirm the correlation of TUG1 with miR-29a. RESULTS: TUG1 was highly expressed while miR-29a was poorly expressed in cholangiocarcinoma cells. TUG1 expression was negatively correlated with miR-29a expression, and TUG1 had a relatively high diagnostic value for cholangiocarcinoma. Cell experiments showed that inhibiting TUG1 expression or up-regulating miR-29a expression could inhibit cholangiocarcinoma cells from proliferation and invasion, and promote their apoptosis, while up-regulating TUG1 or inhibiting miR-29a could promote the proliferation and invasion but inhibit the apoptosis. Rescue experiment showed that overexpressing miR-29a could reverse the effects of high TUG1 expression on cholangiocarcinoma cells. DLRGA confirmed that there was a regulatory relationship between TUG1 and miR-29a. CONCLUSION: TUG1 is highly expressed in cholangiocarcinoma tissues. It can promote the growth and metastasis of cholangiocarcinoma cells by inhibiting miR-29a, so it may be a new target for diagnosing and treating cholangiocarcinoma.

Multimaterial and multicolor 3D-printed model in training of transnasal endoscopic surgery for pituitary adenoma.

OBJECTIVE: The aim of the present study was to investigate the practical value of a multimaterial and multicolor 3D-printed model in anatomical teaching, surgical training, and preoperative planning of transnasal endoscopic surgery for pituitary adenoma. METHODS: Multimodality neuroimaging data were obtained in a 42-year-old healthy male volunteer and a 40-year-old female patient with an invasive nonfunctional pituitary adenoma. Three 3D-printed models were produced: a monomaterial and monocolor model, a monomaterial and multicolor model, and a multimaterial and multicolor model. The effects on anatomical teaching and surgical training for exposing the vidian nerve were assessed by 12 residents, and the training effect was validated on cadavers. The practical values for preoperative planning were evaluated by 6 experienced neurosurgeons. All evaluations were based on 5-point Likert questionnaires. RESULTS: The multimaterial and multicolor model was superior to the monomaterial models in surgical training for exposing the vidian nerve (Fisher test; p < 0.05). In addition, the multimaterial and multicolor model was superior to the monomaterial models in anatomical teaching and preoperative planning (Friedman test; p < 0.05). CONCLUSIONS: Multimaterial and multicolor 3D printing technology makes it convenient and efficient to produce a practical model for simulating individualized and complex anatomical structures in the sellar region. Furthermore, the multimaterial model can provide a more realistic manipulative experience for surgical training and facilitate the preoperative planning.

Three-Dimensional Printed Skull Base Simulation for Transnasal Endoscopic Surgical Training.

OBJECTIVE: Transnasal endoscopic skull base surgery (SBS) presents a major challenge for inexperienced neurosurgeons because of the complicated anatomic structures, 2-dimensional endoscopic view, limited operative field, and required skills. We designed a personalized multimaterial and multicolor three-dimensional (3D)-printed SBS simulation to reproduce the complex anatomy of the skull base. The fidelity and feasibility for anatomic education and surgical training were assessed. METHODS: Two-dimensional computer tomography and magnetic resonance images were collected from a 42-year-old healthy male volunteer. After 3D modeling and spatial alignment, personalized SBS simulations were produced using a multimaterial 3D printer. The fidelity of the models was assessed by 3 experienced neurosurgeons, and the effects for anatomic education and surgical training were evaluated by 10 resident trainees. Both evaluations were based on 5-point Likert questionnaires. RESULTS: The mean scores for fidelity of tissue structure ranged from 3.7 to 4.7, and scores for aid in anatomic education and surgical training ranged from 3.5 to 4.9. CONCLUSION: The 3D-printed SBS simulation is a practical, economical, high-fidelity model. It has great potential for anatomic education and operative training in transnasal endoscopic surgery.

Evaluation of efficacy of transcatheter arterial chemoembolization combined with computed tomography-guided radiofrequency ablation for hepatocellular carcinoma using magnetic resonance diffusion weighted imaging and computed tomography perfusion imaging: A prospective study.

BACKGROUND: The purpose of this study is to evaluate the efficacy of transcatheter arterial chemoembolization (TACE) combined with computed tomography-guided radiofrequency ablation (CT-RFA) in the treatment of hepatocellular carcinoma (HCC) using magnetic resonance diffusion weighted imaging (MR-DWI) and CT perfusion imaging (CT-PI). METHODS: From January 2008 to January 2014, a total of 522 HCC patients receiving TACE combined with CT-RFA were included in this study. All patients underwent TACE followed by CT-RFA, and 1 day before treatment and 1 month after treatment they received MR-DWI and CT-PI. Enzyme-linked immunosorbent assay (ELISA) was performed to detect the concentration of alpha-fetoprotein (AFP). Tumor response was evaluated using the revised RECIST criteria. One-year follow-up was conducted on all patients. Receiver-operating characteristic (ROC) curve was drawn to evaluate the efficacy of TACE combined with CT-RFA for HCC using MR-DWI and CT-PI. RESULTS: Total effective rate (complete remission [CR] + partial remission [PR]) of TACE combined with CT-RFA for HCC was 82.95%. HCC patients of CR + PR had lower hepatic blood flow (HBF), hepatic blood volume (HBV), permeability surface (PS), hepatic arterial perfusion (HAP), and hepatic perfusion index (HPI) levels than those of SD + PD, but HCC patients of CR + PR had higher mean transit time (MTT) level than those of SD + PD. The patients of PR + CR had higher apparent diffusion coefficient (ADC) values than those of SD + PD. The patients of PR + CR showed lower AFP concentration than those of SD + PD. ROC curve analysis indicated that the area under the curve (AUC) of AFP, HBV, PS, HAP, HPI, and ADC was more than 0.7, but the AUC of HBF, MTT, and PVP were less than 0.7. After treatment, the AFP, HBF, HBV, PS, HAP, and HPI in the HCC patients with recurrence were higher than those in the HCC patients without, but MTT and ADC in the HCC patients with recurrence were lower than those in the HCC patients without. CONCLUSION: These findings indicate that MR-DWI and CT-PI can effectively evaluate the efficacy of TACE combined with CT-RFA and postoperative recurrence of HCC.

Anatomical partition of the clival region and adjacent structures via extended endoscopic endonasal approach.

OBJECTIVES: To explore the anatomy of the ventral clivus and adjacent structure in the endoscopic surgery through the anterior approach, particularly in accurate locating lesions in transnasal endoscopic surgery. PATIENTS AND METHODS: A total of 9 formalin-fixed adult cadaver heads were injected with red and blue latex to observe the arteries and veins, respectively. The relationships between various parts of internal carotid artery (ICA) and anatomic structures of clivus were investigated, followed by the measurement of the posterior pharyngeal wall, anterior wall and posterior wall of clivus, cerebral dura mater, subdural space and adjacent regions to determine their correlations, as well as the clivus and adjacent structures. RESULTS: The clivus structure was divided into the bone segment, the ICA segment and subdural segment for anatomic division according to the anatomic landmarks in the anatomic process. The clivus can be classified in a shape of '' with the ICA, including the middle superior region, middle inferior region, bilateral lateral superior and lateral inferior regions. CONCLUSION: The ICA is closely related to the ventral clivus and adjacent structure, which can be used as the basis of anatomic division via anterior approach.

Endoscopic approach to the trigeminal nerve: an anatomic study.

OBJECTIVE: To describe an endoscopic perspective of the surgical anatomy of the trigeminal nerve. METHODS: Nine adult cadaveric heads were dissected endoscopically. RESULTS: Opening the pterygopalatine fossa is important because many key anatomical structures (V2, pterygopalatine ganglion, vidian nerve) can be identified and traced to other areas of the trigeminal nerve. From the pterygopalatine ganglion, the maxillary nerve and vidian nerve can be identified, and they can be traced to the gasserian ganglion and internal carotid artery. An anteromedial maxillectomy increases the angle of approach from the contralateral nares due to an increase in diameter of the piriform aperture, and provides excellent access to the mandibular nerve, the petrous carotid, and the cochlea. CONCLUSIONS: Identification of key anatomical structures in the pterygopalatine fossa can be used to identify other areas of the trigeminal nerve, and an anteromedial maxillectomy is necessary to expose the ipsilateral mandibular nerve and contralateral cranial level of the trigeminal nerve.

Arterial compression of nerve is the primary cause of trigeminal neuralgia.

Whether arterial or venous compression or arachnoid adhesions are primarily responsible for compression of the trigeminal nerve in patients with trigeminal neuralgia is unclear. The aim of this study was to determine the causes of trigeminal nerve compression in patients with trigeminal neuralgia. The surgical findings in patients with trigeminal neuralgia who were treated by micro vascular decompression were compared to those in patients with hemifacial spasm without any signs or symptoms of trigeminal neuralgia who were treated with microvascular decompression. The study included 99 patients with trigeminal neuralgia (median age, 57 years) and 101 patients with hemifacial spasm (median age, 47 years). There were significant differences between the groups in the relationship of artery to nerve (p < 0.001) and the presence of arachnoid adhesions (p < 0.001) but no significant difference in relationship of vein to nerve. After adjustment for age, gender, and other factors, patients with vein compression of nerve or with artery compression of nerve were more likely to have trigeminal neuralgia (OR = 5.21 and 42.54, p = 0.026 and p < 0.001, respectively). Patients with arachnoid adhesions were less likely to have trigeminal neuralgia (OR = 0.15, p = 0.038). Arterial compression of the trigeminal nerve is the primary cause of trigeminal neuralgia and therefore, decompression of veins need not be a priority when performing microvascular dissection in patients with trigeminal neuralgia.

[Clinical observation of remifentanyl and propofol injection in total intravenous anesthesia for percutaneous radiofrequency ablation].

OBJECTIVE: To explore the efficacy and safety of remifentanyl and propofol injection in total intravenous anesthesia for percutaneous radiofrequency ablation. METHODS: 60 patients scheduled for PRFA were divided randomly into two groups:group A and group B. Each group contained 30 patients. Those in group A received remifentanyl and propofol injection, and the patients in group B were given oxycodone hydrochloride. The mean arterial pressure (MAP), heart rate (HR) and pulse oxygen saturation (SPO2) were measured and recorded by monitor during the operation. The chest muscle rigidity, respiratory depression, nausea and vomitting, hypotensio and VAS were also recorded. RESULTS: Compared with the preoperative,MAP, HR in group A decreased significantly during the operation, increased in group B (P < 0.05). VAS was significantly lower in group A than that in group B (P < 0.05). 2 patients had respiratory depression, 1 patient had nausea and vomiting reaction in group A.2 patients had vagus reflex, 3 patient had nausea and vomitting reaction in group B. CONCLUSION: Total intravenous anesthesia with remifentanyl and propofol for PRFA is safe and reliable. Respiratory and circulation should be monitored instantly and strictly.

[Feasibility study on CT guided percutaneous incisional needle biopsy for deep pelvic masses by different puncture approaches].

OBJECTIVE: To explore the feasibility of CT guided percutaneous incisional needle biopsy (PINB) for deep pelvic masses at different locations via various puncture approaches. METHODS: PINBs under CT guidance were performed in 70 patients with 72 pelvic lesions through different puncture approaches. Their pathological findings and safety were evaluated after follow-up of a period of 1-34 months. RESULTS: PINBs were performed through transpiriform-muscle in 27 cases, 16 through transgluteal approach, 5 through posterior oblique approach in prone position, 8 by anterior or lateral transabdominal route, 8 through iliopsoas muscle and 8 by direct transosseous approach, respectively. Sixty-four malignant lesions were confirmed by pathology, including 30 adenocarcinomas, 19 squamous cell carcinomas, 5 unclassified malignant tumors, 3 small cell carcinomas, 2 malignant giant cell tumors of bone, 2 hepatocellular carcinomas and 3 false negative lesions which were confirmed at the second PINBs as malignant tumors, respectively. Benign neoplasms were confirmed in 8 cases, including fibrosis tissue in 6 lesions, bone tuberculosis in 1 and ovarian cyst in 1. The sensitivity, specificity, and accuracy rate were 95.3% (61/64), 100% (8/8), and 95.8% (69/72), respectively. Twenty-two cases via transpiriform-muscle approach suffered from transient deep pelvic pain which radiated to the lower limbs of the same side. No hematoma, nerve damage, infection, and tumor transplantation in pelvic cavity developed after the PINB procedure. CONCLUSION: CT guided percutaneous incisional needle biopsy through different puncture approaches is safe and feasible for the patients with deep masses at different locations in the pelvic cavity.

[Application of topical intranasal fluorescein in endoscopic endonasal repair of cerebrospinal fluid leakage].

OBJECTIVE: To investigate the effects of topical fluorescein on the preoperative diagnosis of rhinorrhea of cerebrospinal fluid (CSF) and intraoperative localization of CSF fistula. METHODS: Cotton pads soaked with 5% fluorescein were placed in the middle turbinate meatus, roof of ethmoid plate, and sphenoethmoidalis recesses via endoscopic endonasal technique of 15 patients with CSF rhinorrhea, 5 caused by accidental trauma and 10 spontaneous. Change of the color of fluorescein from yellow to green fluorescence denoted the presence of CSF, and thus the site of the leak could be traced. The accuracy rates of diagnosis and leak site identification by this technique were compared with those by glucose analysis, intraoperative findings, and follow-up. RESULTS: The preoperative diagnosis rate of CSF rhinorrhea and the CSF fistula site localization rate by fluorescein-soaked cotton pad were both 100%. No recurrence was found during the follow-up for 2 - 24 months. No complication had been reported. CONCLUSIONS: Application of topical fluorescein is an easy, sensitive, safe, and highly accurate tool in the intraoperative localization of the site and extent of CSF fistulas and should be considered a viable noninvasive alternative to intrathecal fluorescein technique.

[Investigation of CT guided percutaneous incisional needle biopsy in parapharyngeal region for suspicious nasopharyngeal carcinoma].

OBJECTIVE: To investigate the safety and efficacy of percutaneous incisional needle biopsy (PINB) in the parapharyngeal region under CT guide for highly suspicious nasopharyngeal carcinoma (NPC) or recurrence of NPC after radiotherapy. METHODS: PINB under CT guide was performed in 32 highly suspicious NPC or recurrence of NPC after radiotherapy through three puncture routes: posterolateral maxillary sinus fatty area, mandibular fossa area, and anterior-mastoid area. Specimens were fixed by 95% alcohol and then underwent pathologic examination. RESULTS: CT guided PINB was successfully performed in every patients with a technical successful rate of 100%. Definitive histopathologic diagnosis was obtained in 30 patients: squamous-cell carcinoma 21, undifferentiated carcinoma 5 and adenocarcinoma 4. The remaining two negative cases were confirmed as fibrosis after radiotherapy. Complications included persistent bleeding of puncture point in one patient and bloody sputum in 3 patients which subsided after symptomatic management. None of these patients was found to have symptoms of nerve injury caused by PINB procedure. CONCLUSION: The CT guided percutaneous incisional needle biopsy in parapharyngeal region through the above three puncture routes for highly suspicious nasopharyngeal carcinoma is safe, rapid and effective.