Enteral stenting for gastric outlet obstruction and afferent limb syndrome following pancreaticoduodenectomy.

BackgroundObstruction of the afferent or efferent limbs of a gastrojejunal anastomosis is a potential complication after pancreaticoduodenectomy (PD) resulting in either gastric outlet obstruction or afferent limb syndrome. The use of self-expanding metal stents for the management of anastomotic strictures after resection of pancreatic cancer has not been well studied. We present four such cases and review published data regarding this population.MethodsRetrospective chart review and literature search. Outcomes were summarized with descriptive statistics.ResultsAt our institution, 4 patients underwent metal stent placement for gastrojejunal obstruction after PD for pancreatic cancer. Enteral stents were placed in two patients across the afferent limb, in one patient across the efferent limb, and in another patient across both limbs. Similar cases in the literature revealed that the anastomotic stricture was malignant in 26 of 27 cases. Clinical improvement occurred in 88%. Afferent limb syndrome was successfully treated in 5 of 6 cases. Median survival was 3.5 months after stent placement.ConclusionsEffective palliation of both gastric outlet obstruction and afferent limb syndrome after PD can be provided with enteral stenting. Gastrojejunal strictures after PD for pancreatic cancer are usually malignant with median survival of 3.5 months after stent placement

Comparative efficacy of first-line therapeutic interventions for achalasia: a systematic review and network meta-analysis

BackgroundSeveral interventions with variable efficacy are available as first-line therapy for patients with achalasia. We assessed the comparative efficacy of different strategies for management of achalasia, through a network meta-analysis combining direct and indirect treatment comparisons.MethodsWe identified six randomized controlled trials in adults with achalasia that compared the efficacy of pneumatic dilation (PD; n = 260), laparoscopic Heller myotomy (LHM; n = 309), and peroral endoscopic myotomy (POEM; n = 176). Primary efficacy outcome was 1-year treatment success (patient-reported improvement in symptoms based on validated scores); secondary efficacy outcomes were 2-year treatment success and physiologic improvement; safety outcomes were risk of gastroesophageal reflux disease (GERD), severe erosive esophagitis, and procedure-related serious adverse events. We performed pairwise and network meta-analysis for all treatments, and used GRADE criteria to appraise quality of evidence.ResultsLow-quality evidence, based primarily on direct evidence, supports the use of POEM (RR [risk ratio], 1.29; 95% confidence intervals [CI], 0.99-1.69), and LHM (RR, 1.18 [0.96-1.44]) over PD for treatment success at 1 year; no significant difference was observed between LHM and POEM (RR 1.09 [0.86-1.39]). The incidence of severe esophagitis after POEM, LHM, and PD was 5.3%, 3.7%, and 1.5%, respectively. Procedure-related serious adverse event rate after POEM, LHM, and PD was 1.4%, 6.7%, and 4.2%, respectively.ConclusionsPOEM and LHM have comparable efficacy, and may increase treatment success as compared to PD with low confidence in estimates. POEM may have lower rate of serious adverse events compared to LHM and PD, but higher rate of GERD

Bio-Convection Effects on Prandtl Hybrid Nanofluid Flow with Chemical Reaction and Motile Microorganism over a Stretching Sheet

This study aims to determine the heat transfer properties of a magnetohydrodynamic Prandtl hybrid nanofluid over a stretched surface in the presence of bioconvection and chemical reaction effects. This article investigates the bio-convection, inclined magnetohydrodynamic, thermal linear radiations, and chemical reaction of hybrid nanofluid across stretching sheets. Also, the results are compared with the nanofluid flow. Moreover, the non-Newtonian fluid named Prandtl fluid is considered. Microfluidics, industry, transportation, the military, and medicine are just a few of the real-world applications of hybrid nanofluids. Due to the nonlinear and convoluted nature of the governing equations for the problem, similarity transformations are used to develop a simplified mathematical model with all differential equations being ordinary and asymmetric. The reduced mathematical model is computationally analyzed using the MATLAB software package’s boundary value problem solver, Runge-Kutta-fourth-fifth Fehlberg’s order method. When compared to previously published studies, it is observed that the acquired results exhibited a high degree of symmetry and accuracy. The velocity profiles of basic nanofluid and hybrid nanofluid are increased by increasing the Prandtl parameters’ values, which is consistent with prior observations. Additionally, the concentration and temperature of simple and hybrid nanofluids increase with the magnetic parameter values