Blind Pouch Research Articles

Novel microarchitecture of human endometrial glands: implications in endometrial regeneration and pathologies.

BACKGROUNDHuman endometrium remains a poorly understood tissue of the female reproductive tract. The superficial endometrial functionalis, the site of embryo implantation, is repeatedly shed with menstruation, and the stem cell-rich deeper basalis is postulated to be responsible for the regeneration of the functionalis. Two recent manuscripts have demonstrated the 3D architecture of endometrial glands. These manuscripts have challenged and replaced the prevailing concept that these glands end in blind pouches in the basalis layer that contain stem cells in crypts, as in the intestinal mucosa, providing a new paradigm for endometrial glandular anatomy. This necessitates re-evaluation of the available evidence on human endometrial regeneration in both health and disease in the context of this previously unknown endometrial glandular arrangement.OBJECTIVE AND RATIONALEThe aim of this review is to determine if the recently discovered glandular arrangement provides plausible explanations for previously unanswered questions related to human endometrial biology. Specifically, it will focus on re-appraising the theories related to endometrial regeneration, location of stem/progenitor cells and endometrial pathologies in the context of this recently unravelled endometrial glandular organization.SEARCH METHODSAn extensive literature search was conducted from inception to April 2021 using multiple databases, including PubMed/Web of Science/EMBASE/Scopus, to select studies using keywords applied to endometrial glandular anatomy and regeneration, and the references included in selected publications were also screened. All relevant publications were included.OUTCOMESThe human endometrial glands have a unique and complex architecture; branched basalis glands proceed in a horizontal course adjacent to the myometrium, as opposed to the non-branching, vertically coiled functionalis glands, which run parallel to each other as is observed in intestinal crypts. This complex network of mycelium-like, interconnected basalis glands is demonstrated to contain endometrial epithelial stem cells giving rise to single, non-branching functionalis glands. Several previous studies that have tried to confirm the existence of epithelial stem cells have used methodologies that prevent sampling of the stem cell-rich basalis. More recent findings have provided insight into the efficient regeneration of the human endometrium, which is preferentially evolved in humans and menstruating upper-order primates.WIDER IMPLICATIONSThe unique physiological organization of the human endometrial glandular element, its relevance to stem cell activity and scarless endometrial regeneration will inform reproductive biologists and clinicians to direct their future research to determine disease-specific alterations in glandular anatomy in a variety of endometrial pathological conditions.

S1998 Two Scopes Are Better Than One: Esophageal Recanalization With the Rendezvous Procedure

Introduction: Esophageal strictures can occur in patients with head & neck cancers treated with radiotherapy. Rate of stricture in these cases is estimated to be between 2-16%. We present a case of severe esophageal stricture treated with combined antegrade-retrograde endoscopic dilation and biliary stent placement. Case Description/Methods: 76-year-old female with squamous cell carcinoma of the hypopharynx, with PEG tube for nutrition, presented with persistent dysphagia following completion of radiotherapy. Barium esophagram showed severe pharyngeal dysphagia with esophageal backflow and aspiration. Laryngoscopy and transnasal esophagoscopy revealed a blind ending pouch in the proximal esophagus. After unsuccessful attempts to pass a guidewire through the stenosis under direct visualization, we were consulted to discuss a combined approach. Rendezvous recanalization with access through both the mouth and gastrostomy site was planned. An endoscope was passed through the mouth to the level of the esophagus, revealing severe stenosis with complete obstruction in the hypopharynx. Under fluoroscopic guidance, we attempted to advance a guidewire through the stenosis, but were unsuccessful. An endoscope was then reintroduced through the mature gastrostomy. The scope was advanced to the esophageal stricture in retrograde. A transnasal esophagoscope was used through the mouth for antegrade access. From the retrograde endoscope, a guidewire was passed through the stenosis and captured through the mouth. Under fluoroscopy, a 6-7-8mm x 5.5cm CRE balloon dilator was passed over guidewire through the mouth, and dilation was performed to 6mm. We decided to use a biliary stent given the location of the stricture in the hypopharynx where placement of a larger esophageal stent is not feasible and would cause severe discomfort given the larger diameter. A 10mm x 60mm WallFlex biliary stent was successfully deployed across the stenosis. After repeat dilation was performed twice more 2 weeks apart, her esophagus remains patent at 18mm. On latest follow-up, she is able to tolerate PO liquids and pureed food. Discussion: High-grade stenosis is difficult to treat, often requiring a multidisciplinary approach. In cases of high-grade esophageal stenosis, an antegrade-retrograde endoscopic approach can be employed to dilate the esophageal segment. Recent meta-analysis shows esophageal recanalization using the rendezvous procedure to have a technical success rate >85%, dysphagia improvement rate >55%, and PEG-tube free rate >40%.Figure 1.: Endoscopic view of esophageal stricture (a), fluoroscopic image of antegrade and retrograde scope with wire passing through the stricture (b), endoscopic view of biliary stent in place (c), fluoroscopic image of biliary stent in place (d). Watch the video at https://bit.ly/3eNvMxi.

Detail correction for Gross classification of esophageal atresia based on 434 cases in China.

Detail correction for Gross classification of esophageal atresia based on 434 cases in China.

Candy cane syndrome at jejunojejunostomy causing small bowel obstruction following revisional laparoscopic gastric bypass: A case report and review of literature.

Introduction and importanceThe literature described Candy cane syndrome (CCS) as causing various symptoms and affecting patients' quality of life. Most of the literature described this syndrome occurrence at gastrojejunostomy (GJ) anastomosis. The literature lacks data on this syndrome occurring at the jejunojejunostomy (JJ).Case presentationWe describe a patient who underwent revision of laparoscopic gastric bypass (LGB) due to weight regain and presented three days after the procedure with small bowel obstruction (SBO). The patient was admitted as she demonstrated a picture of SBO. A complete workup and contrast study was done and showed dilated bowel loops. The patient was taken for exploratory laparoscopy, which revealed dilated 10–15 cm candy cane near the JJ, causing and obstruction. Resection of the elongated blind pouch was done, and the patient tolerated the surgery with improvement in her symptoms. Preoperative imaging, perioperative management, procedure videos, and follow-up were used to describe the case.Clinical discussionAfter reviewing the literature, eight papers reported CCS, 7 of those articles mentioned the syndrome located at the GJ. CCS located near the JJ can lead to symptoms including SBO. Management is mainly surgical, and prevention of occurrence can be achieved by limiting unnecessary elongated blind pouches.ConclusionCCS is a well-established condition occurring at the GJ following LGB, but it can manifest similarly if an elongated blind limb is left unresected at the JJ.

Relations between left atrial appendage contrast retention and thromboembolic risk in patients with atrial fibrillation.

Left atrial appendage (LAA), a blind pouch, accounts for more than 90% of the source of cardiac thrombus formation. Contrast retention (CR) in the LAA has been frequently observed during left atrial appendage occlusion (LAAO) procedures, especially in patients with stroke history. This study was designed to assess the relations between LAA contrast retention and thrombogenesis risk of the LAA in patients with non-valvular atrial fibrillation. A total of 132 consecutive patients who underwent LAAO were enrolled. The data collected from computed tomography (CT), transthoracic echocardiography (TTE), transesophageal echocardiography (TEE) and blood samples were analyzed. Univariate and multivariate logistic regression models were constructed to assess the association between CR, left atrial appendage thrombus (LAAT) and other factors. Contrast retention was observed in 33 patients, accounting for 25% of the population. Compared to the non-CR group, patients in the CR group had a larger left atrium anteroposterior diameter (49.64 ± 11.57 vs. 42.42 ± 7.04, P = 0.002), higher CHADS2 (3.88 ± 0.99 vs. 2.97 ± 1.35, P = 0.001) and CHA2DS2-VASc scores (5.79 ± 1.14 vs. 4.89 ± 1.56, P = 0.003), a higher rate of prior stroke (90.9% vs. 66.7%, P = 0.007), more LAA lobes (3.13 ± 1.18 vs. 2.64 ± 1.12, P = 0.038), and a higher prevalence of LAAT (63.6% vs. 13.1%, P < 0.001). After having adjusted the logistic model, only contrast retention, LAA cauliflower morphology and left ventricular ejection fraction (LVEF) were independently associated with LAAT. Patients with LAA contrast retention have a higher risk of left atrial appendage thrombosis. Contrast retention may be a cardiac factor strongly associated with cardiogenic stroke.

Congenital and acquired tracheoesophageal fistulas in children

Tracheoesophageal fistulas (TEF) are an anomalous communication between airway and esophagus. There are several types of TEF. Congenital are mainly associated to an esophageal atresia. The type III or C, in which the upper segment of the esophagus ends in a blind pouch and there is distal tracheoesophageal fistula above the carina, accounts for 85% of esophageal atresias. The other are extremely infrequent. H-type or N-type TEF, classified as type 5 or E, is an uncommon variant and accounts for less than 4%.Recurrent TEF is a serious complication after first surgery of esophageal atresia and TEF. The rate of recurrence of TEF is estimated between 3-15%. The treatment is a challenge with a high rate of recurrence after surgery.Classical symptoms of RTEF include coughing especially after drinking, abdominal distension, repeated cyanosis, and respiratory infections. In the case of H-type fistula the symptoms are similar but appear during the first month of life.In this chapter we presented the management and alternative treatments of the congenital and acquired TEF.

Pituitary Stalk Interruption Syndrome in a 40-Year-Old Female With Absent Uterus and Ovaries

Background: A patient with multiple pituitary hormone deficiencies due to a rare congenital pituitary defect also presented with an absent uterus and ovaries. Coexisting Müllerian agenesis was suspected, however hormone replacement unraveled a different story. Case Presentation: A 40-year-old female presented with generalized body weakness and euvolemic hyponatremia. She also had cold intolerance, constipation, primary amenorrhea and dyspareunia. As a child, she was worked up for short stature but was lost to follow up. Physical examination showed Tanner stage 1 breast and pubic hair, and absence of axillary hair. She had no facial anomalies, visual abnormalities or anosmia. Hormone panel was consistent with panhypopituitarism: ACTH 5.69 pg/mL (<46 pg/mL), cortisol 1.9 ug/dL (4.30-22.40 μg/dL), TSH 3.375 uIU/mL (0.55-4.78 uIU/mL), FT4 0.51 ng/dL (0.55-4.78 uIU/mL), FT3 1.79 pg/mL (2.30-4.20 pg/mL), LH <0.07 mIU/mL (1.9-12.5 mIU/mL), FSH 0.95 mIU/mL (2.5-10.2 mIU/mL) and IGF-1 40.8 ng/dL (109-284 ng/mL). Bone age was delayed (16-year-old) but with most ossification centers fused. Pituitary MRI showed hypoplastic anterior pituitary, ectopic posterior pituitary and absent pituitary stalk suggestive of Pituitary Stalk Interruption Syndrome (PSIS). Low estradiol 19.35 pg/mL (19.5-144.2 pg/mL) in the setting of low LH and FSH was compatible with hypogonadotrophic hypogonadism. She had female-range serum testosterone level <0.007 ng/mL (0.1209-0.5946 ng/mL) and karyotype of 46XX. Transvaginal ultrasound revealed a blind vaginal pouch with absent uterus, fallopian tubes and ovaries; hence Müllerian agenesis was also considered. Hormonal replacement with prednisone, levothyroxine and conjugated equine estrogen was started. Secondary osteoporosis was treated with alendronate, calcium and vitamin D on top of estrogen therapy. Six months after initiation of estrogen, there was appearance of a small anteverted uterus and atrophic right ovary. Müllerian agenesis was ruled out and hypogonadotropic hypogonadism was proved to be the cause of the initial absence of the uterus and ovaries on imaging. Conclusion: Increased awareness of PSIS is important since early and accurate diagnosis is crucial for timely initiation of hormone replacement. This case also demonstrates the need for reassessment after hormonal replacement in patients with severe estrogen deficiency and apparent Müllerian agenesis.

Construct validation of a 3D printed neonatal thoracoscopic simulator: Can it measure expertise?

Backgroundacquiring technical expertise for neonatal thoracoscopy is challenging. To address this, we designed a fully synthetic thoracoscopic simulator for which we established its construct validity. Methodsthree thoracoscopic tasks were assessed: ring transfer, needle pass and incision of a blind upper esophageal pouch (EA cut). Participants watched instructional videos with accompanying written instructions for each task before having their attempt video recorded. All tasks were marked by three blinded pediatric surgeons using a modified Objective Structured Assessment of Technical Skills (OSATS). Scores were assessed using appropriate statistical analysis and inter-rater reliability was analyzed by interclass correlation coefficient (ICC). Results23 participants completed the ring transfer and needle pass and 21 the EA cut: 5 experts (consultant surgeons), 5 intermediate (registrars on a training program) and 13 novices (medical students, house surgeons or non-training registrars). All three tasks distinguished between novice and intermediate/expert (ring transfer p = 0.00001, needle pass p = 0.0004 and EA cut p = 0.0014, respectively). Interrater reliability was good for ring transfer and needle pass but poor for EA cut. Conclusionthe tasks distinguished between novice and intermediate/expert but not between expert and intermediate. In needle pass and EA cut, there was a trend for the experts to score higher than intermediate participants. Ring transfer and needle pass tasks achieved construct validity, had good interrater reliability and were found to be useful in assessing a novice surgeon's progression towards the intermediate level. Distinguishing between intermediate and expert may require assessment of more complex tasks such as intracorporeal suturing and tying. Level of evidenceII

The Root of All Thrombi: Coronary Artery Thromboembolism Post Heartmate3

<h3>Introduction</h3> Aortic root thrombosis (ART) is a rare complication of left ventricular assist device (LVAD) therapy and can cause thromboembolic events. We present a case of ART complicated by coronary artery occlusion, myocardial infarction and recurrent ventricular tachycardia (VT) 2 months after HM3 implantation. <h3>Case Report</h3> 62 year old female with non-ischemic cardiomyopathy and HM3 presented 2 months post-implant with chest pain, low flow alarms, and ICD shock. Exam showed MAP 55 mm hg, pump flow 3.4 LPM, speed 5200 RPM, pulsatility index 5.2. LVAD interrogation showed multiple PI events. Her left ventricle was 5.2 cm with closed aortic valve and midline septum. TAPSE was 1.1cm. ECG showed new RBBB. Troponin T peaked at 9035 ng/dL. LDH peaked at 1361 U/L. BNP was 2194 pg/mL. INR range was 2.4-2.7 the month prior. VT initially resolved after decreasing VAD speed to 4800 suggesting suction as a trigger. She received fluids, antiarrhythmics and developed right ventricular dysfunction requiring inotrope support. Persistent chest pain and recurrent VT led to coronary angiography, which showed occlusive thrombus from aortic root to left main and left anterior descending arteries. Using embolic protection devices, clot was mechanically aspirated (Fig 1). Eleven days later, she developed an acute left posterior cerebral and basilar artery stroke. Attempted clot aspiration was complicated by intracranial hemorrhage. <h3>Summary</h3> Hemocompatibility related adverse events remain an issue with the HM 3. Lower rates of pump thrombosis were reported in the MOMENTUM trials, but thrombi can form at other sites such as outflow graft and aortic root, causing embolic complications. Closed aortic valves form a blind pouch, increasing the risk of ART especially if INR is subtherapeutic. Early imaging of the aortic root and coronary arteries should be considered for unexplained VT irrespective of coronary anatomy and risks and benefits of intervention using embolic protection devices can be considered after careful multidisciplinary evaluation.

Comparative study of malformed atresia ani et recti with or without customized stent in new born calf

Introduction: Atresia ani is a congenital condition commonly seen in young animals such as calves, lambs, and kids. Anatomically, atresia ani has been classified into four types, namely, I, II, III, and IV (Vianna and Tobias, 2005). Type I atresia ani is defined as a congenital stenosis of a patent anus. Type II has a persistent complete anal membrane alone or a combination of an anal membrane with the rectum ending as a blind pouch cranial to the membrane. Type III has an imperforate anus with rectum terminating further cranially. Type IV has a normal ending of the terminal rectum and anus, while the cranial rectum terminates as a blind pouch within the pelvis. Aim of the Study: The aim of the study was to compare the use of customized stent-based correction over the routine pattern followed for the correction of atresia ani et recti. Materials and Methods: Two 3 days old calves with atresia ani et recti were subjects for the study. Both cases were surgically corrected by routine standard surgical technique. Furthermore, in second case, a customized stent was used to prevent stricture of anoplasty. Results: Customized stent used here was successful in preventing the anoplasty stricture as well as this prevented soiling the suture site with feces, which is very common after anoplasty procedure. Conclusion: This case report suggests that use of a sterile syringe, which can be customized, may be used as a stent to prevent stricture of anoplasty as well as reduce wound contamination, thus providing better and faster wound healing and reduces the postoperative complications.

A rare report on 18-month survival of a dog born with multiple anomalies including atresia ani

Long term survival of animals with major congenital anomalies is very rare. This report documents the 18-month survival of a dog with multiple anomalies including atresia ani. An 18-month-old black Cocker Spaniel bitch was presented for evaluation of prolapsed glands of the third eyelid involving both the eyes. Clinical examination revealed a single perineal opening, fecal matter in the vestibule, distended abdomen, hypoplastic vulva, and the absence of a tail without any neurological deficits. Abdominal contrast radiography revealed a distended colon with fecal stasis, rectovestibular fistula, termination of the rectum as a blind pouch, lumbar scoliosis due to block vertebrae, and the presence of only two hypoplastic coccygeal vertebrae. The case was diagnosed as atresia ani type II with rectovestibular fistula, hypoplastic vulva, lumbar scoliosis, and anury, in the global context of a caudal regression syndrome. The wide aperture fistula, connected to the vestibule, undamaged spinal cord and sacrum without any neurological deficits were the favorable prognostic factors that maintained continence and allowed the dog to survive to adult life with these anomalies. Thus, an appropriate bowel management program and specialty care can improve the quality of life and longevity of this animal.

Endograft exclusion of the false lumen restores local hemodynamics in a model of type B aortic dissection

ObjectiveEndovascular intervention in uncomplicated type B dissection has not been shown conclusively to confer benefit on patients. The hemodynamic effect of primary entry tear coverage is not known. Endovascular stent grafts were deployed in a model of aortic dissection with multiple fenestrations to study these effects. It is hypothesized that endograft deployment will lead to restoration of parabolic true lumen flow as well as elimination of false lumen flow and transluminal jets and vortices locally while maintaining distal false lumen canalization. MethodsThoracic stent grafts were placed in silicone models of aortic dissection with a compliant and mobile intimal flap and installed in a flow loop. Pulsatile fluid flow was established with a custom positive displacement pump, and the models were imaged by four-dimensional flow magnetic resonance imaging. Full flow fields were acquired in the models, and velocities were extracted to calculate flow rates, reverse flow indices, and oscillatory shear index, the last two of which are measures of stagnant and disturbed flows. ResultsComplete obliteration of the false lumen was achieved in grafted aorta, with normal parabolic flow profiles in the true lumen (maximal velocity, 30.4 ± 8.4 cm/s). A blind false lumen pouch was created distal to this with low-velocity (5.8 ± 2.7 cm/s) and highly reversed (27.9% ± 13.9% reverse flow index) flows. In distal free false lumen segments, flows were comparable to ungrafted conditions with maximal velocities on the order of 7.0 ± 2.1 cm/s. Visualization studies revealed forward flow in these regions with left-handed vortices from true to false lumen. Shear calculations in free false lumen regions demonstrated reduced oscillatory shear index. ConclusionsPer the initial hypothesis, endovascular grafting improved true lumen hemodynamics in the grafted region. Just distally, a prothrombotic flow regimen was noted in the false lumen, yet free false lumen distal to this remained canalized. Clinically, this suggests a need for advancing endovascular intervention beyond sole entry tear coverage to prevent further false lumen canalization through uncovered fenestrations.

Abstract WP261: The Left Atrial Septal Pouch: A New Stroke Risk Factor?

Background: The left atrial septal pouch (LASP) is a common anatomic variant produced by the incomplete fusion of septa primum and secondum at the inter-atrial septum, thus creating a potential embolic source from an open flap or blind pouch in the left atrium. Our prior work demonstrated increased prevalence of LASP in cryptogenic strokes (Frontiers Neurology 3-24-15). The aim of the current study was to examine the prevalence of LASP in a separate, more recent group of stroke patients and control subjects who underwent transesophageal echocardiography (TEE). Methods: We examined consecutive TEE studies performed between July, 2011 and December, 2018 at UC Irvine Medical Center. Prevalence of LASP was determined in TEE studies referred for ischemic stroke or TIA (“stroke subjects”), and compared to LASP prevalence in patients undergoing TEE for other reasons (“control subjects”). Stroke subtyping was performed using TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. Results: TEE studies were performed on 221 cerebrovascular cases and 164 control subjects. Age and sex were 57±1 years (mean±SE) and 53% male for stroke subjects, and 56±1 years and 62% male for control subjects. Prevalence of LASP was 24% (40/164) in control subjects, 17% (24/138) in non-cryptogenic stroke subjects, and 36% (30/83) in cryptogenic stroke subjects. LASP prevalence was significantly higher for cryptogenics compared to the other groups (p=0.007). There was no significant difference between LASP prevalence in controls vs non-cryptogenic stroke. Elimination from analysis of subjects with other inter-atrial septal abnormalities (ie, patent foramen ovale or atrial septal defect) did not significantly change results. Conclusions: These findings demonstrate an increased prevalence of LASP in cryptogenic stroke, confirming our prior published findings. Given the plausibility of LASP acting as a thromboembolic nidus, additional studies are needed to determine the generalizability of these findings and their therapeutic implications.

Guidelines of the Italian Society of Videosurgery in Infancy for the minimally invasive treatment of the esophageal atresia.

Esophageal Atresia (EA) is defined as an interruption in esophageal continuity that results in a proximal tract that ends in a blind pouch in 98% of cases, and a distal tract that in 87% of cases arises via a Fistula from the Trachea (TEF). (...).

Colpolithiasis: A mini review

Objective: Vaginal calculus is an unusual finding. In this study we describe a case of primary vaginal calculus in a rather rare urogenital anomaly- Obstructed hemivagina with ipsilateral renal agenesis (OHVIRA) syndrome. This syndrome is shrouded in controversies. Here we present a mini review about vaginal calculus and theory of embryological development of female genital tract as related to OHVIRA syndrome. Case: A 50 years-old unmarried lady with primary amenorrhoea presented with pain abdomen. She was found to have calculus in the pelvis by x-ray which was thought to be bladder calculus initially. On local examination the vaginal opening was absent. Imaging studies such as NCCT and MRI confirmed that it is a vaginal calculus, located below the uterine cervix, with absent right kidney. She was diagnosed with OHVIRA syndrome with colpolithiasis. On laparotomy she was detected to have unicornuate uterus with absence of right Mullerian structures. The calculus occupied the whole of upper part of vagina, which was a blind pouch. The patient underwent total abdominal hysterectomy, left salpingo-ophorectomy with removal of calculus after opening the vaginal vault. Postoperative recovery was uneventful. Chemical analysis of the calculus revealed calcium magnesium oxalate which is of hematic origin. Keywords: Primary vaginal calculus, Mullerian duct anomaly, Obstructed hemivagina, OHVIRA syndrome, Herlyn-Werner-Wunderlich syndrome.

Development and Preliminary Validation of a Rabbit Model of Duodenal Atresia for Training in Pediatric Surgical Skills

Duodenal atresia is a congenital defect that requires advanced surgical skills. The objective of this study is to present an anatomical defect of duodenal atresia using a rabbit model and evaluate the preliminary experience for the training of surgical skills with pediatric surgeons. Adult white New Zealand male rabbits weighing 3.0 to 4.5 kg were used to create the defect. To simulate the bottom of the dilated blind pouch, the gastric antrum of the rabbit was obliterated using a 2-0 Prolene suture, and the cecal appendix was dissected to simulate the continuation of the duodenum. Participants performed laparoscopic duodenal atresia repair in this animal model using the iPhone trainer. Thirteen pediatric surgeons with experience in laparoscopic duodenal atresia repair assessed this model with a questionnaire on 5-point Likert-type scale. Overall, the simulated model of duodenal atresia obtained a general average score of 4.39. The highest observed average was for its physical realism, whereas the lowest score was in surgical experience. The global opinion of the model obtained a score of 4.40. In addition, all surgeons answered that this rabbit model showed the same complexity as newborns and young children in the repair of this type of defect. The inclusion of new models through rabbits in pediatric surgery programs will allow the development of advanced skills of pediatric residents and surgeons.

2190 A Unique Case Demonstrating the Endoscopic Management of a Duodenal Stump Fistula

INTRODUCTION: Medical procedures continue to evolve towards being more minimally invasive leading to significant advances in the endoscopic management of transmural defects of the gastrointestinal (GI) tract. These are typically divided into three primary types; anastomotic leaks, perforations and fistulas. Once the site of injury has been identified, basic management involves surgical debridement and drainage with subsequent closure, diversion or both. We present a case of a complicated fistula and a novel approach to closing it. CASE DESCRIPTION/METHODS: A 35 year old female presented to the emergency room following blunt abdominal trauma from a horse kick. She sustained significant injuries to the small bowel requiring emergent surgical intervention and ultimately a duodenectomy with gastrojejunostomy. She was left with a 6cm blind limb of native post pyloric duodenum that was drained percutaneously with a 32Fr Malecot catheter. Gastroenterology was consulted to assist with endoscopic drain removal and management of the residual fistula tract. The Malecot was replaced with a 24Fr percutaneous gastrostomy tube with subsequent downsizing procedures every 2-3 weeks. The end result was a 3-4mm duodenal-cutaneous fistula with persistent output. After fulguration of the surrounding area with Argon plasma coagulation a single running suture of 5 stitches was placed using the OverStitchTM device and the external opening was allowed to close by secondary intention. At a 2 week clinic follow up she had returned to her usual activities and a barium upper GI series at 4 weeks post closure confirmed no stump leak. DISCUSSION: There is a paucity of data to guide the gastroenterologist on duodenal stump defects. In the setting of a planned surgical fistula such as in our patient, the most appropriate treatment option was successive downsizing of the tract with definitive closure via endoscopic suturing. The unique location of the fistula in a blind pouch precluded the use of a self-expanding metal stent, the defect was too large to close with a through-the-scope clip, and there was a theoretical concern of retention in the stump if a larger over-the-scope clip was employed. The high volume of bilious output through the fistula precluded the use of tissue adhesives as a monotherapy. Despite the desired outcome being achieved in our case we suspect this method of closure would be less successful in fistulas complicated by chronic inflammation, infection, or malignancy.

1630 Rectal Duplication in a Middle-Aged Adult Presenting With Constipation and Abdominal Mass After Hysterectomy

INTRODUCTION: Alimentary tract duplications are rare congenital malformation that usually presented since childhood. CASE DESCRIPTION/METHODS: A 43–year-old female presented with constipation and progressive enlargement of abdominal mass for 4 years. Her constipation symptoms started after she underwent hysterectomy for myoma uteri. She had straining and fecal soiling that was refractory to laxatives. Physical examination revealed a 25-cm non-tender hard mass at mid-lower abdomen. Digital rectal examination showed anal wink, normal sphincter tone, and empty rectum. Paradoxical anal sphincter contraction was presented while pushing. Other physical findings were unremarkable. CT abdomen showed marked dilatation of rectosigmoid colon with feces content with an abrupt change of caliber at upper rectum. Small bowel was not dilated. Barium enema study was shown in Figure 1. Colonoscopy showed a 1.5-cm opening of a large blind pouch at 10 cm above anal verge. Anorectal manometry revealed dyssynergic defecation type II with rectal hyposensitivity with delayed balloon expulsion time. The patient underwent a complete transabdominal resection of the duplication with temporary loop sigmoid colostomy. Gross findings showed a large uniloculated cyst (Figure 2). Pathological findings showed a cystic lesion lined by complete colonic wall (Figure 3). DISCUSSION: Rectal duplications are rare congenital anomalies (1/200,000 live births) and seventy percent of them are diagnosed before the age of two. They can be classified as type I (cystic) and type II (tubular) with or without communication to rectum or perineum. The wall of the duplications is typically lined with complete rectal wall. Surgical removal is indicated as it prevents septic and carcinogenic complications [1]. Our patient’s symptoms interestingly occurred late in adulthood after surgery. Removal of uterus and myoma uteri might change the angle of the duplication’s opening. Also, the presence of dyssynergic defecation might contribute and cause gradual accumulation of fecal content inside. Three months post-operative anorectal manometry still showed dyssynergia but improved rectal sensitivity. At present, our patient has bowel movement every 1-2 days per colostomy with minimal usage of laxative and is currently undergoing biofeedback training before colostomy closure.

Perineal hypospadias repair with preservation of a coincidental vagina or perineal utricle in boys with disorders of sex development

An enlarged utricle in patients with proximal hypospadias or disorders of sex development (DSD) is common. The utricle orifice is usually in the posterior urethra near the verumontanum, but in exceptional cases located on the perineum. Concurrence of a perineal hypospadias and perineal utricle or vagina is also known as male vagina, pseudovagina, or blind vaginal pouch. The utricle in such cases is usually excised either before or concomitant with hypospadias repair. The authors developed an alternative approach in which the vagina or perineal utricle is retained during hypospadias repair and report on the results in four patients. To report a novel technique for perineal hypospadias repair while retaining a concurrent vagina or perineal utricle. Between 1999 and 2014, four neonates presented with perineal hypospadias. In all patients, a second perineal opening providing access to either an enlarged utricle or a vagina was identified. Karyotype in peripheral blood was in two patients 46,XY and in the other two 45,X/46,XY of which one showed a complex mosaicism in gonadal tissue. No genetic cause was identified on DNA evaluation in the two patients with 46,XY DSD. All patients were raised as boys. Hypospadias repair was performed in two stages at prepubertal age. During the second stage of surgery, performed between the age of 1.5 and 5 years, the vagina or utricle orifice was incorporated into the neo-urethra, resulting in a retained 'built-in' vagina or utricle. Surgical procedures were uneventful, and patients remained asymptomatic during a mean postoperative follow-up of 8.5 (range 2-13.5) years. One patient was lost to follow-up after the age of 8 years. At their last visit, the remaining patients, at the age of 4, 15, and 17 years, were able to void in standing position without dribbling. Both adolescent patients reported erections without ejaculations and identified themselves as males without signs of gender dysphoria. Hypospadias repair in boys with perineal hypospadias while leaving a male vagina or perineal utricle in situ has not been reported previously, and the study's preliminary results are favorable. One of the benefits of this approach is that inadvertent injury to adjacent anatomic structuressuch as urethral sphincter, neurovascular bundles, ureters, vas deferens, and rectum is avoided. The main rationale for adopting this conservative approach however is to minimize genital tissue removal in children with a not yet definite gender identity, which will certainly facilitate unforeseen future gender reassignment surgery.

Lumen-apposing metal stent creating jejuno-jejunostomy for blind pouch syndrome in patients with esophago-jejunostomy after gastrectomy: a novel technique

Lumen-apposing metal stent creating jejuno-jejunostomy for blind pouch syndrome in patients with esophago-jejunostomy after gastrectomy: a novel technique