Benign Strictures Research Articles

Fluorescence In Situ Hybridization in Primary Diagnosis of Biliary Strictures: A Single-Center Prospective Interventional Study

Background and aims: Diagnosis of the biliary stricture remains a challenge. In view of the low sensitivity of brush cytology (BC), fluorescence in situ hybridization (FISH) has been reported as a useful adjunctive test in patients with biliary strictures. We aimed to determine performance characteristics of BC and FISH individually and in combination (BC + FISH) in the primary diagnosis of biliary strictures. Methods: This single-center prospective study was conducted between April 2019 and January 2021. Consecutive patients with unsampled biliary strictures undergoing first endoscopic retrograde cholangiopancreatography in our institution were included. Tissue specimens from two standardized transpapillary brushings from the strictures were examined by routine cytology and FISH. Histopathological confirmation after surgery or 12-month follow-up was regarded as the reference standard for final diagnosis. Results: Of 109 enrolled patients, six were excluded and one lost from the final analysis. In the remaining 102 patients (60.8% males, mean age 67.4, range 25-92 years), the proportions of benign and malignant strictures were 28 (27.5%) and 74 (72.5%), respectively. The proportions of proximal and distal strictures were 26 (25.5%) and 76 (74.5%), respectively. In comparison to BC alone, FISH increased the sensitivity from 36.1% to 50.7% (p = 0.076) while maintaining similar specificity (p = 0.311). Conclusions: Dual-modality tissue evaluation using BC + FISH showed an improving trend in sensitivity for the primary diagnosis of biliary strictures when compared with BC alone.

Efficacy and safety of repeated endoscopic radial incision and cutting procedure for benign esophageal stricture.

Background and study aims: Radial incision and cutting (RIC) is indicated for refractory benign esophageal strictures after curative treatment for esophageal cancer and has shown favorable short-term outcomes. However, re-stricture after RIC may occur in the long term, and RIC is performed repeatedly in such cases, but the efficacy and safety of repeated RIC are unclear. Therefore, we aimed to demonstrate the efficacy and safety of the repeated RIC for refractory benign esophageal strictures after surgical and non-surgical treatment. Patients and methods: Between April 2008 and September 2019, we enrolled patients who were treated with the first RIC for benign esophageal strictures. The RIC was indicated for the refractory stricture and repeatedly performed for re-refractory esophageal stricture after RIC. We retrospectively evaluated the 6-month refractory stricture-free rate, and adverse events (AEs) in the first RIC and repeated RICs. Results: Forty-six patients (39 men, 7 women; median age, 71 years, range 49-85) were included. RIC was performed once in 24 patients (non-repeated RIC group) and two or more times in 22 patients (repeated RIC group). In all patients, the 6-month refractory stricture-free rate after the first RIC were 42.3 %. In the repeated RIC group, the 6-month refractory stricture-free rate after the first and repeated RICs were 18.2 % vs 18.2 %, respectively. No AEs were noted. Conclusions: Repeated RIC could be effective in the short-term and safe even for patients with refractory benign esophageal stricture after the first RIC. However, it cannot be considered curative treatment for refractory stricture because of poor long-term results.

EVALUATION OF PANCREATOBILIARY PATHOLOGIES USING MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY

Introduction: Pancreato-biliary diseases are commonly observed in the population that can have adverse outcome if not diagnosed or managed correctly and in time. It is divided into intraductal and extraductal obstruction. Biliary strictures, choledocholithiasis, malignant strictures as well as conditions such as primary sclerosing cholangitis constitute the most signicant reasons of intraductal obstruction. Extraductal reasons for obstruction consist of compression of biliary channels by neoplasms, cystic duct stones and pancreatitis. Benign as well as malignant biliary obstructions are not easy to distinguish with only imaging clinical correlation is also important. A total of 70 patients were enrolled Methodology: in the study. MRI was done with 3 Tesla GE machine using body coil. T2-weighted and diffusion-weighted sequences were routinely obtained. Examination was performed after the patient has fasted for minimum 4 hours to promote gall bladder lling. Males were Result And Discussion: slightly more in proportion than females (52.86% vs 47.14%) in study, The commonest clinical feature noted in the study was abdominal pain (55.71%), followed by jaundice (17.14%) and epigastric pain in 10% cases. The common ndings noted were calculus cholecystitis (21.43%), cholelithiasis (18.57%), choledocholithiasis (17.14%), IHBR dilatation (15.71%) and benign stricture in (14.29%). Acute and chronic pancreatitis was noted in 8 cases each (11.43% each). Pseudocyst of pancreas and hepatic cysts or abscess was also noted in 10% and 7.14% cases respectively. Overall, 11% of the cases had neoplastic or malignant nding on MRCP assessment. MRCP was found to be 93 % accurate in Conclusion: identifying the pancreaticobiliary disorders with its underlying cause in present study. The present study shows that MRCP is excellent modality of choice for the detecting of pancreaticobiliary pathologies in the symptomatic patients. Thereby helping in quick diagnosis, treatment planning and better prognosis

Abstract No. 55 Evaluating Percutaneous Transhepatic Biliary Drainage (PTBD) Factors Associated with Better Outcomes in the Treatment of Post-Surgical Benign Biliary Strictures

To report outcomes of post-surgical benign biliary strictures treated with percutaneous transhepatic biliary drainage (PTBD) and balloon dilation. Patients with a history of surgery and who developed a benign biliary stricture were included in this retrospective, IRB-approved study (n = 44). Patients having biliary leaks, or with complete occlusion of the bile duct due to surgical clips were excluded (n = 28). Drain size, type (internal-external or external), balloon dilation, and type and size of balloon used was evaluated for all biliary procedures. These characteristics were compared between patients needing (n = 8) and not needing (n = 36) surgical revision. Continuous variables are reported as median (IQR) and compared with Wilcoxon rank sum test, categorical variables as numbers with percentages and compared using chi-square test. Patients were 59 (42-67) years old with 67% being female. Hepaticojejunostomy was the most common surgery (30%) followed by Roux-en-Y gastric bypass (16%), pancreaticoduodenectomy (14%), transplant (14%), Billroth II (9%), cholecystectomy (7%) and others (9%). Duct to enteric anastomosis was present in 52%, duct to duct in 11% and no anastomosis in 36%. Prior non-PTBD interventions included ERCP dilation and stent placement in 9 (20%) and failed ERCP in 10 (23%) patients. The first PTBD was done 28 (6-98) months after surgery, with a drain size of ≥10F in 20 (45%) and < 10F in 24 (55%) patients. The drain was internal-external in 41 (93%) patients. Patients underwent a total of 4 (3-8) procedures before drain removal, with drain upsizing performed in 23 (52%) patients, leading to a largest drain size of ≤8F in 10 (23%), 10F in 17 (39%), 12F in 14 (32%) and ≥14F in 3 (6%) patients. Balloon dilation was performed in 40 (91%) patients, with the largest balloon size being ≤8 mm in 13 (30%), 10 mm in 20 (45%), 12 mm in 6 (14%), and 14 mm in 1 (2%) patient. A cutting balloon was used in 19 (43%) patients. Surgical revision was needed in 8 (18%) patients, with a repeat PTBD performed in 5 (11%) patients. The rate of surgical revision was lower in patients who received a largest drain of ≥10F (12%) compared with those who received a largest drain of <10F (40%, P = 0.042). The rate of surgical revision was 7.4% in patients who were dilated with a balloon of ≥10 mm compared with 30.7% in those who were dilated with a balloon of <10 mm (P = 0.053). The median drain-free survival was 41 (11-57) months for the entire cohort. Postsurgical benign biliary strictures treated with PTBD with a drain of ≥10F and dilated with a balloon of ≥10 mm are less likely to need surgical revision.

Abstract No. 56 Comparing Outcomes of Percutaneous Biliary Drainage Catheters in Right versus Left Hepatic Approaches

Determine if there is a difference in complications associated with right or left hepatic percutaneous biliary drain placement in patients with benign or malignant biliary etiology. This retrospective study included patients with benign or malignant biliary stricture and treated with percutaneous biliary drainage at a single institution from 7/28/2004 to 3/30/2021. Three hundred fifty-seven patients met inclusion criteria, seventy-seven on the left and two hundred and eighty on the right, with a mean age of 65.1 years. Complications associated with the initial drain placement or during subsequent intervention were collected and categorized. Perioperative complications included surgery, infection, hemorrhage, and drain failure. Complications during treatment with a percutaneous biliary drain included death, chills, catheter displacement, cholangitis, biliary stones, drain malfunction, fever resolving without treatment, and pericatheter leakage. Complications were also grouped as major or minor. Statistical analyses were performed using logistic regression analysis and P values less than 0.05 were considered significant. Major interventional and treatment complication rates showed no statistical significance between left and right drains. The rate of minor interventional and treatment complications also showed no statistical significance between right and left drains. However, when cholangitis was analyzed individually, right sided hepatobiliary drains demonstrated a statistically significant increase in complication rates. Current literature describes safety of right biliary drain placement when compared with left, despite current equivocal study analyses. This large group analysis describes no statistically significant difference in complications between right and left hepatobiliary drains aside from slightly higher incidence of cholangitis for right sided drains.

Abstract No. 54 Percutaneous Endobiliary Radiofrequency Ablation for Benign and Malignant Strictures

Abstract No. 54 Percutaneous Endobiliary Radiofrequency Ablation for Benign and Malignant Strictures

The role of tracheal wall injury in the development of benign airway stenosis in rabbits

To investigate the role of tracheal wall injury in the development of benign airway stenosis in rabbits. Prospective study. We injured the tracheal walls of 28 New Zealand white rabbits using four different methods. Experimental group: Group A (n = 7, mild injury of tracheal mucosa by ordinary brush under bronchoscopy); Group B (n = 7, severe injury of tracheal mucosa by nylon brush under tracheotomy); Group C (n = 7, tracheal cartilage was injured by vascular clamp after tracheotomy); Group D (n = 7, the tracheal cartilage was injured with vascular forceps and the tracheal mucosa was injured with a nylon brush after tracheotomy). Bronchoscopy was performed on each experimental rabbit at 1, 2, 3 and 4 weeks after operation. High-resolution computed tomography (HRCT) and endobronchial optical coherence tomography (EB-OCT) were performed at 4 weeks, and the rabbits were sacrificed after the examination. Their gross and histological findings were comparatively determined whether the experimental rabbit stenosis was established. No airway stenosis was observed in group A. In group B, 28.57% of experimental rabbits developed tracheal stenosis (granulation tissue proliferation was observed in rabbits No. 2 and No. 6 at 1, 2 and 3 weeks after operation, and the tracheal scar contracture was observed in No.6 rabbit at 4 weeks after operation). Fourteen rabbits in group C and group D had tracheal stenosis caused by granulation tissue proliferation at 1, 2 and 3 weeks after operation. At the fourth week after operation, 71.43% of experimental rabbits had tracheal stenosis due to granulation tissue hyperplasia, 7.14% of experimental rabbits had tracheal stenosis due to scar contracture and granulation hyperplasia, and 21.43% of experimental rabbits had tracheal stenosis due to scar contracture. EB-OCT scan showed that the cartilage layer with low signal reflection band was discontinuous. The injury of cartilage is the key factor of benign airway stenosis. Acute injury of airway mucosa alone is unlikely to cause airway stenosis, but combined with cartilage injury may aggravate airway stenosis. EB-OCT can clearly identify the airway layers of rabbits, which is helpful to evaluate the damage of tracheal cartilage and mucosa. The diagnostic potential of this technique makes EB-OCT a promising approach for the study and monitoring of airway diseases.

Successful retrieval of migrated and embedded fully covered self-expanding metal stent using "snare and lithotripter" technique.

A 52-year-old woman with benign perihilar left intrahepatic duct stricture underwent repeated stricture dilation and multiple plastic stent placements. Subsequently, an 8 mm × 12 cm multi-hole fully covered self-expanding metal stent (MH-FCSEMS) was inserted. Six months later, she had abnormal liver biochemistry. Endoscopic retrograde cholangiography (ERC) revealed supra-papillary stent migration and tissue ingrowth at the proximal end ([Fig. 1]). Cholangioscopy (SpyGlass System; Boston Scientific Corp., Marlborough, Massachusetts, USA) showed that the stent lumen was obliterated by stone cast ([Fig. 2]). Stent removal with forceps and snare failed. The patient was referred to our center for a second opinion.

Comparison of statins with steroids and botulinum toxin A in the prevention of benign strictures after esophageal endoscopic submucosal dissection: a retrospective cohort study.

Preventing benign strictures following esophageal endoscopic submucosal dissection (ESD) remains difficult, and finding a safe, effective, and simple management method is vital. We previously reported that rosuvastatin significantly reduced the incidence and severity of strictures in a rabbit model of esophageal stricture. Accordingly, in this study, we compared the effects of statins, steroids, and botulinum toxin A (BTX-A) on stricture prevention after ESD involving more than three-fourths of the luminal circumference. Of the 1019 ESD cases treated between January 2015 and December 2020, 246 met the inclusion criteria, with 21 cases excluded due to loss to follow-up, tumor recurrence, death, or need for additional surgery, radiotherapy, and/or chemotherapy. Of the 225 included cases, 145 received no intervention, while the remaining 80 were treated: 16 with oral steroids, 20 with topical triamcinolone acetonide (TA) injection, 21 with topical BTX-A injection, and 23 with statins. The occurrence stricture rate in the statins group (17.4%, 4/23) was significantly lower than in the non-intervention (75.2%, 109/145, P = 0.000), oral steroids (56.3%, 9/16, P = 0.011) and TA injection (50%, 10/20, P = 0.023) groups, but comparable to in the BTX-A injection (38.1%, 8/21, P = 0.124) group. The dysphagia score was lower in the statin than non-intervention group (P = 0.000). Although there was no significant difference in the number of required dilations between groups, the maximum number of dilations in the statins group was only six. Statins may be a potential treatment to prevent esophageal strictures after extensive ESD; however, clinical trials should be conducted to validate this.

Optimizing decision-making process of benign uretero-enteric anastomotic stricture treatment after radical cystectomy.

To identify preoperative predictors of endo-urological treatment (EUT) failure while promoting a new diagnostic and therapeutic pathway for benign uretero-enteric anastomosis stricture (UES) management after radical cystectomy (RC). We relied on a prospectively maintained database including 96 individuals (122 renal units) who developed a benign UES at our institution between 1990 and 2018. UES was classified into two different types according to morphology: FP1 (i.e., sharp or duckbill) and FP2 (i.e., flat or concave). EUT feasibility, success rate, as well as intra and postoperative complications were recorded. Uni- and multivariable logistic regression analysis (MVA) assessed for predictors of EUT failure. Overall, 78 (63.9%) and 32 (26.3%) cases were defined as FP1 and FP2, respectively. EUT was not feasible in 33 (27.1%) cases. After a median follow-up of 50 (IQR 5-240) months, successful treatment was reached only in 15/122 (12.3%) cases. EUT success rates raised when considering short (< 1cm) (16.8%), FP1 morphology (16.7%) strictures, or the combination of these characteristics (22.4%). Overall, 5 (5.2%) cases had CD ≥ III complications. FP2 (OR: 1.91, 95%CI 1.21-5.31, p = 0.03) and stricture length ≥ 1cm (OR: 9.08, 95%CI 2.09-65.71, p = 0.009) were associated with treatment failure at MVA. Endoscopic treatment for benign UES after RC is feasible but harbors a low success rate. Stricture length and radiological morphology of the stricture are related to endoscopic treatment failure. Surgeons should be aware of the stricture features during the preoperative decision-making process to choose the optimal candidate for endoscopic treatment.

Risk factors for benign ureteroenteric anastomosis strictures in patients undergoing Bricker urinary diversion for bladder cancer

Risk factors for benign ureteroenteric anastomosis strictures in patients undergoing Bricker urinary diversion for bladder cancer

Diagnostic Accuracy of Magnetic Resonance Cholangiopancreatography in Comparison With Endoscopic Retrograde Cholangiopancreatography for Detection of the Etiology of Obstructive Jaundice.

Despite technological advances, obstructive jaundice has significant morbidity and mortality rates. When studying obstructive jaundice, endoscopic retrograde cholangiopancreatography (ERCP), the "gold standard" for biliary obstruction identification, might be replaced with magnetic resonance cholangiopancreatography (MRCP), which is a non-invasive procedure. Diagnostic accuracy of MRCP in comparison with ERCP for the detection of the etiology of obstructive jaundice. This prospective, observational study included 102 patients who presented with obstructive jaundice as proven by liver function tests. The MRCP was conducted within 24 to 72 hours before the ERCP. A torso phased-array coil (Siemens, Germany) was used for the MRCP. The duodeno-videoscope and general electric fluoroscopy were used to perform the ERCP. The MRCP was evaluated by a classified radiologist who was blinded to the clinical details. An experienced consultant gastroenterologist who was blinded to the results of the MRCP assessed the cholangiogram of each patient. The hepato-pancreaticobiliary system results from both procedures were compared based on the pathology observed, such as choledocholithiasis, pancreaticobiliary strictures, and dilatation of biliary strictures. We determined the sensitivity, specificity, and negative and positive predictive values with 95% confidence intervals. The statistical significance was set at p<0.05. The most commonly reported pathology was choledocholithiasis, and MRCP diagnosed 55 patients, of which 53 were true positive cases when compared with the ERCP results of the same patients. MRCP demonstrated greater sensitivity and specificity (respectively) for screening choledocholithiasis (96.2, 91.8), cholelithiasis (100, 75.8), pancreatic duct stricture (100, 100), and hepatic duct mass (100, 100) and showed statistically significant values. The sensitivity of MRCP is lower for identifying benign and malignant strictures, but its specificity was observed to be reliable. When it comes to determining the severity of obstructive jaundice, both in its early and later stages, the MRCP technique is widely regarded as a reliable means of diagnostic imaging. The diagnostic function of ERCP has been significantly reduced as a result of the precision of MRCP as well as its non-invasive nature. In addition to being a helpful non-invasive method to identify biliary diseases and avoid unnecessary ERCPs and their risks, MRCP offers good diagnostic accuracy for obstructive jaundice.

The Practical Multidisciplinary Management of the Indeterminate Biliary Stricture and/or Dilatation -Radiological Differential Diagnosis: Challenging but Essential-

The most important aspect of the imaging role for indeterminate bile duct stricture is to make a differential diagnosis on whether the stricture is highly likely to be malignant or benign. Compared to benign stricture, malignant stricture is longer, thicker, and has indistinct outer border and irregularity of the lumen in contrastenhanced computed tomography and magnetic resonance (MR). Also, in the contrast-enhanced portal phase, malignant stricture has a stronger enhancement than the liver parenchyma. There are studies to differentiate between malignant and benign stricture in diffusion weighted image, a functional MR image, but there remains controversial. Sometimes, malignant biliary stricture may be caused by bile duct invasion of gallbladder cancer, pancreatic cancer, hepatocellular carcinoma, biliary metastasis, and lymphoma. Among the potential causes of indeterminate biliary stricture, the characteristics of multifocal biliary stricture mainly suggest benign sclerosing cholangitis, and various external compression factors that cause biliary stricture can be differentiated by radiologic imaging. There are causes of biliary dilatation without obstructive lesion, radiologic diagnosis can be made by considering various characteristics.

Etiological Spectrum of Obstructive Jaundice: "Our Experience in Two University Hospitals in Yemen"

Background: Obstructive jaundice is a surgical emergency with preoperatively uncertain diagnosis. Its early diagnosis and treatment is important to avoid fatal complications.&#x0D; Objective: to determine the etiology of obstructive jaundice.&#x0D; Patients and methods: The data of patients, who were operated for obstructive jaundice at department of Surgery in Sana'a University Hospital and Thamar University Hospital between January 2004 and December 2008, were prospectively analyzed in relation to the causes of obstructive jaundice. The study included 134 patients (91 females and 43 males). Their ages varied from 8-90 years. &#x0D; Results: Among 9 underlying causes of obstructive jaundice, the common bile duct stones were the most common cause, 68 patients (50.7%). Malignancies of pancreas and hepatobiliary tract came in the second place, 33 patients (24.6%), followed by 13 patients with stenosis of papilla of Vater (9.7%) and benign strictures of extrahepatic biliary ducts, 10 patients (7.4%).&#x0D; Ascaris in common bile duct was found in 3 patients. Mirrizi's syndrome was found in 2 patients. Obstruction due to ruptured hydatid cyst was found in 2 patients. Two patients had amoebic liver abscesses One patient had pancreatic pseudocyst. &#x0D; Conclusion: Obstructive jaundice of Yemeni patients in our series was most often due to common bile duct stones followed by malignancy of pancreas and hepatobiliary tract. Cancer of the pancreas was the most common malignant cause. Rare causes such as ascaris in common bile duct was detected. Cooperation between surgeon and radiologist is highly recommended &#x0D;

Post cholecystectomy benign biliary stricture-isolated hepatic duct stricture: a proposed modification of the BISMUTH classification.

Post-cholecystectomy, benign biliary strictures are challenging for both patients and surgeons. Bismuth classified benign biliary strictures into 5 types. This study aimed to review these isolated hepatic duct strictures which were not included in Bismuth classification. The case records of all patients who presented with post-cholecystectomy benign biliary strictures between January 2005 and December 2020 at our centre were reviewed. Data regarding demography, type of stricture, and treatment strategy were entered into the standard proforma. There were 242 patients [type I-3.7%, type II-41.7%, type III-38.0%, type IV-6.6%, and type V-7.8%]. Five (2.1%) patients did not fit the Bismuth classification and were the focus of this study. In each of these patients, an isolated hepatic duct stricture (first-or second-order hepatic duct) was present, with no involvement of the common hepatic duct or hilar confluence. The addition of isolated hepatic duct stricture [type VI] to the Bismuth classification will enhance the original classification, help in reporting and management of this sub-set of patients.

A retrospective comparison between laparoscopic and open ureteroneocystostomy for management of benign lower ureteral strictures: An experience in tertiary care centre of Eastern India.

The objective is to discover the etiopathogenesis of benign lower ureteric stricture in Eastern India and compare the outcome of open versus laparoscopic ureteroneocystostomy. Retrospectively 52 patients who underwent laparoscopic (n = 28) or open ureteroneocystostomy (n = 24) for lower ureteral stricture between January 2018and December 2021 were included. The demography, aetiology, radiologic imaging, intraoperative & postoperative outcomes and follow-up data were collected and analysed. The mean duration of follow up was 14.3 months. Lower ureteric stricture were common in females. The most common cause of the stricture was iatrogenic injury (42%). Other causes were tuberculosis, post-endourological surgery, obstructing mega ureter, endometriosis and idiopathic. Laparoscopic surgery had longer mean operative time (228 vs 171 min), less blood loss (166 vs 246 ml), lower VAS score (6.1 vs 7.22) and less need of post-operative analgesia (1.86 vs 2.36 days). The hospital stay (5.36 vs 6.77 days) and post-operative complications (none vs 3) were also significantly lower in laparoscopic group. Open surgery and laparoscopic surgery had success rate of 100% and 96.6% each. Iatrogenic injury are the most common cause of ureteric stricture followed by tuberculosis. Laparoscopic approach is a feasible option in treatment of lower ureteric stricture as it offer comparable outcome to open procedure while offering the advantage of a minimal invasive technique. Stricture secondary to iatrogenic injury poses a different challenge due to presence of hard dense fibrosis. This is a complex reconstructive procedure and has a steep learning curve and demands high level of laparoscopic skill.

DNA Methylation Dynamics During Esophageal Epithelial Regeneration Following Repair with Acellular Silk Fibroin Grafts in Rat.

Esophageal pathologies such as atresia and benign strictures often require surgical reconstruction with autologous tissues to restore organ continuity. Complications such as donor site morbidity and limited tissue availability have spurred the development of acellular grafts for esophageal tissue replacement. Acellular biomaterials for esophageal repair rely on the activation of intrinsic regenerative mechanisms to mediate de novo tissue formation at implantation sites. Previous research has identified signaling cascades involved in neoepithelial formation in a rat model of onlay esophagoplasty with acellular silk fibroin grafts, including phosphoinositide 3-kinase (PI3K), and protein kinase B (Akt) signaling. However, it is currently unknown how these mechanisms are governed by DNA methylation (DNAme) during esophageal wound healing processes. Reduced-representation bisulfite sequencingis performed to characterize temporal DNAme dynamics in host and regenerated tissues up to 1 week postimplantation. Overall, global hypermethylation is observed at postreconstruction timepoints and an inverse correlation between promoter DNAme and the expression levels of differentially expressed proteins during regeneration. Site-specific hypomethylation targets genes associated with immune activation, while hypermethylation occurs within gene bodies encoding PI3K-Akt signaling components during the tissue remodeling period. The data provide insight into the epigenetic mechanisms during esophageal regeneration following surgical repair with acellular grafts.

Dilatation of the main pancreatic duct of unknown origin: causes and risk factors of pre-malignancy or malignancy.

A dilatation of the main pancreatic duct (MPD) is mainly due to obstructive causes (pancreatic tumor, chronic pancreatitis) or intraductal papillary mucinous neoplasm (IPMN). This study aims to assess the risk of pre-malignancy or malignancy in case of MPD dilatation with no visible mass nor obstructive calcification on computed tomography scan (CT-scan) in a population operated for it. All patients operated on from November 2015 to December 2019 in our center for a significant dilatation of the MPD without visible obstructive cause on CT-scan were included. Preoperative work-up included at least CT-scan, magnetic resonance imaging (MRI), and endoscopic ultrasonography (EUS). Primary endpoint was the final pathological diagnosis. Secondary endpoints were predictive factors of malignancy. 101 patients were included, mean age 68years-old. Final pathological data were pancreatic adenocarcinoma (n = 2), IPMN with high-grade dysplasia (n = 37), high-grade Pancreatic Intraepithelial Neoplasia (PanIN) (n = 2) (total of pre-malignant or malignant lesions: n = 41), neuroendocrine tumor (n = 6), IPMN with low-grade dysplasia (n = 45), low-grade PanIN (n = 5), chronic pancreatitis (n = 3), and benign stenosis (n = 1). On preoperative explorations, the median diameter of MPD was 7mm [3-35]. MRI and/or EUS showed intraductal material, nodule, or cyst in 22, 32, and 52 patients, respectively; 22 patients without nodule visible on MRI or EUS had still a pre-malignant or malignant lesion. In multivariate analysis, predictive factors forpre-malignancy or malignancy were symptoms before surgery (p = 0.01), MPD dilatation without downstream stenosis (p = 0.046), and the presence of nodule (p = 0.009). A dilatation of the MPD without detectable mass or obstructive calcification on CT-scan was associated with a pre-malignant or malignant lesion in 41 patients. Symptoms before surgery, MPD dilatation without duct narrowing, and the presence of nodules on MRI/EUS were associated with the risk of pre-malignancy ormalignancy.

Endoscopic management of benign and malignant hilar stricture.

Management of hilar strictures pose a significant challenge for endoscopists. Several strategies have been demonstrated in the last decade beyond decompression, however, there remains controversy and minimal consensus in the literature. This review seeks to summarize the current literature and discuss emerging therapies, such as photodynamic therapy and radiofrequency ablation.

Robot-assisted complex urinary tract reconstruction using intestinal segments: redefining the paradigm.

Complex urinary tract reconstruction has significantly advanced with the increasing use of robot-assisted procedures. Robotic surgery aims to achieve the same outcomes as open surgery while minimizing morbidity by causing less blood loss, faster postoperative recovery, and reducing complications.This article shares our technique, challenges encountered, and experience of robot-assisted complex urinary tract reconstruction using intestinal segments.Between January 2020 to March 2022, 6 patients who underwent robot-assisted complex urinary tract reconstruction using intestinal segments at our centre were retrospectively reviewed. Demographic, clinical, and operative data were recorded. Patients underwent renal function tests, blood gas analysis, and radiographic imaging in the follow-up. Symptomatic and radiologic relief were the criteria for success. Out of 6 cases, three patients underwent ileal ureter replacement, two combined ileal ureter with augmentation ileo-cystoplasty and one augmentation ileo-cystoplasty alone. The mean age, estimated blood loss, length of hospital stay, and follow-up period were 32.6years, 110 ± 13.1mL, 7.0 ± 1.1days, and 11.3months, respectively. The indications for surgery were either benign ureteral stricture following lithotripsy or sequelae of genitourinary tuberculosis. No intra-operative complications were found. Clavien-Dindo grade-II and Grade-IIIa were found in three and one patient, respectively. During follow-up, none had compromised renal function or acidosis. Robot-assisted complex urinary tract reconstruction using intestinal segments is safe and offers the advantages of minimally invasive techniques. Techniques demonstrated in this article make these reconstructions feasible with good surgical and clinical outcomes.