Efficacy of Gastric Balloon Dilatation and/or Retrievable Stent Insertion for Pyloric Spasms after Pylorus-Preserving Gastrectomy: Retrospective Analysis

<div><p>Purpose</p><p>We retrospectively investigated the feasibility and clinical efficacy of balloon dilatation and subsequent retrievable stent insertion, when necessitated, for pyloric spasms after pylorus-preserving gastrectomy (PPG).</p><p>Materials and Methods</p><p>Forty-five patients experiencing pyloric spasms after PPG underwent fluoroscopic balloon dilations to alleviate obstructive symptoms due to delayed gastric emptying. Patients showing poor response to balloon dilation underwent subsequent retrievable stent insertion. Safety of the procedures was analyzed, and subjective symptoms and objective signs of pyloric spasms were analyzed and compared before and after treatment.</p><p>Results</p><p>Thirty-three patients (73.3%, 33/45) showed good response to balloon dilatation requiring no further treatment (balloon group). Conversely, 12 patients (26.7%, 12/45) showed poor or no response after balloon dilation requiring subsequent stent insertion (stent group). Balloon dilations and/or stent insertions were safely performed in all patients except one patient who suffered a transmural tear after balloon dilatation. In both groups, mean subjective symptom score was significantly improved and mean pyloric canal-to-height of the adjacent vertebral body ratio was significantly increased after the procedures (P <.05).</p><p>Conclusion</p><p>Balloon dilation is a safe and effective treatment for patients with pyloric spasms after PPG. In patients refractory to balloon dilations, retrievable stent placement can be a safe alternative tool.</p></div

Graphs showing the results of subjective and objective analyses in the stent group.

<p>(A) Plotting of subjective symptom scores before and after balloon dilatation and after stent insertion. In all patients, subjective symptom scores were not improved after balloon dilatation. However, it was significantly improved after stent insertion. (B) Plotting of the pyloric canal-to-height of vertebral body ratio before and after balloon dilatation and after stent insertion. In all patients, the ratio of the pyloric canal-to-height of the vertebral body increased after stent insertion compared to both before and after balloon dilatation. (C) Plotting of the grade for residual food stagnation before and after balloon dilatation and after stent insertion. In all patients, the grade of residual food stagnation improved after stent insertion compared to both before and after balloon dilatation.</p

Images of a 60-year-old woman with impaired pyloric function after laparoscopy-assisted pylorus-preserving gastrectomy (PPG).

<p>(A) On the scout image obtained 13 days after PPG, approximately 1/2~3/4 of the stomach (S) is filled with residual food material, resulting in a semi-quantitative score for residual food of 2. (B) On upper gastrointestinal series (UGIS), the pyloric canal is severely narrowed (arrow) and the width of the pyloric canal and the height of the adjacent vertebral body are 1.5 and 24.87, respectively, with a pyloric canal-to-height of vertebral body ratio of 6.03. A = antrum, D = duodenum. (C), (D) Fluoroscopic images show dilatation of the stenotic pyloric canal with a 25 mm x 4 cm long balloon until the balloon deformity disappears. (E) The scout image of UGIS obtained 11 months after balloon dilatation shows no residual food material within the stomach, resulting in a markedly improved semi-quantitative score for residual food of 5. (F) UGIS shows a dilated pyloric canal (arrow), and the width of the pyloric canal and the height of the adjacent vertebral body are 11.33 and 27.71, respectively. Therefore, the pyloric canal-to-height of vertebral body ratio was also markedly increased to 40.89. Finally, her subjective symptom score of post-prandial discomfort was also markedly decreased from 10 to 3 after the balloon procedure.</p

Graphs showing the results of subjective and objective analyses in the balloon group.

<p>(A) Plotting of subjective symptom scores before and after balloon dilatation. In all patients, subjective symptom scores improved after balloon dilatation. (B) Plotting of the pyloric canal-to-height of vertebral body ratio before and after balloon dilatation. In all patients except one (arrow), the pyloric canal-to-height of vertebral body ratio increased after balloon dilatation. (C) Plotting of the grade for residual food stagnation before and after balloon dilatation. In 26 of 33 patients, the grade of residual food stagnation improved. The grade of residual food stagnation was the same after balloon dilatation in four patients (arrows) (2 to 2 in three and 1 to 1 in one) and became worse in the remaining three (arrowheads) (2 to 1, 3 to 2, and 4 to 2).</p

Images of a 56-year-old man with impaired pyloric function after laparoscopy-assisted pylorus-preserving gastrectomy (PPG).

<p>The patient underwent balloon dilatation and subsequent stent insertion 21 and 23 days after PPG, respectively. (A) On the scout image obtained after stent insertion, the stent (arrowheads) is well placed extending from the stomach (S) to the duodenum (D) with its center located at the pyloric canal. (B) On plain abdominal radiograph obtained after 1 day, the stent (arrowheads) has migrated proximally and is located within the remnant stomach. (C) Fluoroscopic guided stent removal was done using an angiographic catheter (arrows). Note the collapsed proximal end (arrowhead) of the stent.</p

A flow diagram of our study population.

<p>A flow diagram of our study population.</p

Semi-quantitative grading for the degree of residual food stagnation within the remnant stomach.

<p>Grade 1 is defined as when more than 3/4 of the remnant stomach is filled with residual food; grade 2 when 3/4 ~ 1/2 of the residual stomach is filled; grade 3 when 1/2 ~ 1/4 of the residual stomach is filled; grade 4 when less than 1/4 of the residual stomach is filled; grade 5 when the entire stomach is empty on the scout image of the upper gastrointestinal series.</p

Additional file 1: of Incidence and risk factors of subsyndromal delirium after curative resection of gastric cancer

Table S1. Preoperative laboratory values of participants, Table S2. Preoperative psychiatric variables of participants, Table S3. Correlations among DRS scores and other continuous variables, Table S4. Univariate logistic regression analysis to examine risk factors as continuous variables of subsyndromal delirium, Table S5. Multivariate logistic regression analysis to determine the independent risk factors as continuous variables of postoperative subsyndromal delirium, Figure S1. Histogram of pre-op DRS and post-op DRS. (DOCX 44 kb

Near-Infrared Emitting Polymer Nanogels for Efficient Sentinel Lymph Node Mapping

Sentinel lymph node (SLN) mapping has been widely used to predict the metastatic spread of primary tumor to regional lymph nodes in clinical practice. In this research, a new near-infrared (NIR)-emitting polymer nanogel (NIR-PNG) having a hydrodynamic diameter of about 30 nm, which is optimal for lymph node uptake, was developed. The NIR-emitting polymer nanoprobes were designed and synthesized by conjugating IRDye800 organic dye to biodegradable pullulan-cholesterol polymer nanogels. The NIR-PNG nanoprobes were found to be photostable compared with the IRDye800-free dye at room temperature. Upon intradermal injection of the NIR-PNG into the front paw of a mouse, the nanoprobes entered the lymphatic system and migrated to the axillary lymph node within 2 min. The NIR fluorescence signal intensity and retention time of NIR-PNG in the lymph node were superior to the corresponding properties of the IRDye800-free dye. A immunohistofluorescence study of the SLN resected under NIR imaging revealed that the NIR-PNG nanoprobes were predominantly co-localized with macrophages and dendritic cells. Intradermal injection of NIR-PNG nanoprobes into the thigh of a pig permitted real-time imaging of the lymphatic flow toward the SLN. The position of the SLN was identified within 1 min with the help of the NIR fluorescence images. Taken together, the experimental results demonstrating the enhanced photostability and retention time of the NIR-PNG provide strong evidence for the potential utility of these polymer probes in cancer surgery such as SLN mapping

Near-Infrared Emitting Polymer Nanogels for Efficient Sentinel Lymph Node Mapping

Sentinel lymph node (SLN) mapping has been widely used to predict the metastatic spread of primary tumor to regional lymph nodes in clinical practice. In this research, a new near-infrared (NIR)-emitting polymer nanogel (NIR-PNG) having a hydrodynamic diameter of about 30 nm, which is optimal for lymph node uptake, was developed. The NIR-emitting polymer nanoprobes were designed and synthesized by conjugating IRDye800 organic dye to biodegradable pullulan-cholesterol polymer nanogels. The NIR-PNG nanoprobes were found to be photostable compared with the IRDye800-free dye at room temperature. Upon intradermal injection of the NIR-PNG into the front paw of a mouse, the nanoprobes entered the lymphatic system and migrated to the axillary lymph node within 2 min. The NIR fluorescence signal intensity and retention time of NIR-PNG in the lymph node were superior to the corresponding properties of the IRDye800-free dye. A immunohistofluorescence study of the SLN resected under NIR imaging revealed that the NIR-PNG nanoprobes were predominantly co-localized with macrophages and dendritic cells. Intradermal injection of NIR-PNG nanoprobes into the thigh of a pig permitted real-time imaging of the lymphatic flow toward the SLN. The position of the SLN was identified within 1 min with the help of the NIR fluorescence images. Taken together, the experimental results demonstrating the enhanced photostability and retention time of the NIR-PNG provide strong evidence for the potential utility of these polymer probes in cancer surgery such as SLN mapping