Economic Burden of Endoscopic Vacuum Therapy Compared to Alternative Therapy Methods in Patients with Anastomotic Leakage After Esophagectomy

Background!#!Endoscopic vacuum therapy (EVT) has become a promising option in the management of anastomotic leakage (AL) after esophagectomy. However, EVT is an effortful approach associated with multiple interventions. In this study, we conduct a comparative cost analysis for methods of management of AL.!##!Methods!#!All patients who experienced AL treated by EVT, stent, or reoperation following Ivor Lewis esophagectomy for esophageal cancer were included. Cases that were managed by more than one modality were excluded. For the remaining cases, in-patient treatment cost was collected for material, personnel, (par)enteral nutrition, intensive care, operating room, and imaging.!##!Results!#!42 patients were treated as follows: EVT n = 25, stent n = 13, and reoperation n = 4. The mean duration of therapy as well as length of overall hospital stay was significantly shorter in the stent than the EVT group (30 vs. 44d, p = 0.046; 34 vs. 53d, p = 0.02). The total mean cost for stent was €33.685, and the total cost for EVT was €46.136, resulting in a delta increase of 37% for EVT vs. stent cost. 75% (€34.320, EVT), respectively, 80% (€26.900, stent) of total costs were caused by ICU stay. Mean pure costs for endoscopic management were relatively low and comparable between both groups (EVT: €1.900, stent: €1.100, p = 0.28).!##!Conclusion!#!Management of AL represents an effortful approach that results in high overall costs. The expenses directly related to EVT and stent therapy were however comparatively low with more than 75% of costs being attributable to the ICU stay. Reduction of ICU care should be a central part of cost reduction strategies

MicroRNA Profiling Implies New Markers of Gemcitabine Chemoresistance in Mutant p53 Pancreatic Ductal Adenocarcinoma.

No reliable predictors of susceptibility to gemcitabine chemotherapy exist in pancreatic ductal adenocarcinoma (PDAC). MicroRNAs (miR) are epigenetic gene regulators with tumorsuppressive or oncogenic roles in various carcinomas. This study assesses chemoresistant PDAC for its specific miR expression pattern.Gemcitabine-resistant variants of two mutant p53 human PDAC cell lines were established. Survival rates were analyzed by cytotoxicity and apoptosis assays. Expression of 1733 human miRs was investigated by microarray and validated by qRT-PCR. After in-silico analysis of specific target genes and proteins of dysregulated miRs, expression of MRP-1, Bcl-2, mutant p53, and CDK1 was quantified by Western blot.Both established PDAC clones showed a significant resistance to gemcitabine (p<0.02) with low apoptosis rate (p<0.001) vs. parental cells. MiR-screening revealed significantly upregulated (miR-21, miR-99a, miR-100, miR-125b, miR-138, miR-210) and downregulated miRs (miR-31*, miR-330, miR-378) in chemoresistant PDAC (p<0.05). Bioinformatic analysis suggested involvement of these miRs in pathways controlling cell death and cycle. MRP-1 (p<0.02) and Bcl-2 (p<0.003) were significantly overexpressed in both resistant cell clones and mutant p53 (p = 0.023) in one clone.Consistent miR expression profiles, in part regulated by mutant TP53 gene, were identified in gemcitabine-resistant PDAC with significant MRP-1 and Bcl-2 overexpression. These results provide a basis for further elucidation of chemoresistance mechanisms and therapeutic approaches to overcome chemoresistance in PDAC

Protein target expression.

<p>Protein expression of MRP-1, mutant p53 (mt p53 R273H and mt p53 R248W), CDK1, Bcl-2, and actin (loading control) in parental (PANC-1, MIA-PaCa-2) and gemcitabine resistant PDAC cell clones (PANC-1-GR, MIA-PaCa-2-GR) by Western blot.</p

In-silico target analysis.

<p>Overview of selected and highly predicted gene targets of dysregulated miRs in chemoresistant PDAC cell clones. (N.A., not available)</p

Establishment of chemoresistant PDAC cell clones.

<p>Generation of chemoresistant PDAC cell clones by repeated pulsatile treatment over 3 days with constant sublethal concentrations of 0.4μM (A) or 0.06μM (D) gemcitabine followed by recovery-periods and quantification of cell viability by MTT assay as well as apoptosis assay in parental vs. chemoresistant PANC-1 (A, B, C) and MIA-PaCa-2 (D, E, F) cell clones.</p

Interaction of mutant TP53 and microRNA signaling pathways in chemoresistant pancreatic cancer.

<p>Target analysis was performed by Ingenuity Pathway Analysis and DIANA-mirPath.</p

MicroRNA profiling.

<p>Procedure and results of miR expression profiling by GeneChip microarray and qRT-PCR validation in parental and gemcitabine resistant PANC-1 and MIA-PaCa-2 cell clones.</p

MicroRNA heat mapping.

<p>Hierarchical cluster heat maps of significantly dysregulated miRs in PANC-1-GR late and early cell passage (A) as well as in PANC-1-GR and MIA-PaCa-2-GR late cell passage (B). Each row shows the relative expression level for a single miR and each column shows the expression level for a single sample; fold change greater than ±2 (p<0.05). The red or green color indicates low or high expression, respectively.</p

Protein densitometry.

<p>Adjusted relative density of MRP-1, mutant p53 (mt p53 R273H and mt p53 R248W), CDK1, Bcl-2, and their loading controls measured by ImageJ densitometry software. Asterisks indicates to a significant difference of p<0.05, respectively.</p

Morphologic changes in parental and chemoresistant PANC-1 and MIA-PaCa-2.

<p>Representative attached epithelial cells with spindle-shaped cells in untreated MIA-PaCa-2 (A) and PANC-1 cells (B) compared to more plump rounded morphology and enhanced formation of pseudopodia in their chemoresistant cell clones (C, D).</p