Circumferential Incision Research Articles

Efficacy of a novel traction method: outside-lesion clip-thread method for gastric endoscopic submucosal dissection of lesions of the greater curvature of the upper/middle stomach (with video).

Gastric endoscopic submucosal dissection (ESD) for lesions located on the greater curvature of the upper and middle (U/M) third of the stomach remains challenging, even for experienced endoscopists. Accordingly, we have developed a novel traction technique, termed the outside-lesion clip-thread method (O-CTM). In this method, a clip thread is attached to the healthy mucosa outside the circumferential incision line, and traction is applied to bring the scope and lesion into proximity for ESD. Here, we assessed the efficacy of ESD using the O-CTM compared to ESD without the O-CTM. We retrospectively reviewed data from 63 consecutive patients who underwent gastric ESD for 63 lesions located on the greater curvature of the U/M third of the stomach between September 2015 and April 2024. The primary outcome was the operation time, and secondary outcomes were resection speed, en bloc resection, R0 resection and complications in the O-CTM and without O-CTM ESD groups. Of the 63 included lesions, 37 were resected without the O-CTM between September 2015 and June 2022 (without O-CTM group), and 26 lesions were resected using the O-CTM between July 2022 and April 2024 (O-CTM group). The O-CTM group had significantly shorter operation times (40min vs. 77min, p = 0.01) than the without O-CTM group. The resection speed was also significantly faster (20.1 mm2/min vs. 11.3 mm2/min, p = 0.02). No significant differences in en bloc resection rate, R0 resection rate, and complications were observed. Gastric ESD using O-CTM is beneficial when compared with the ESD without O-CTM in reducing operation time and improving resection speeds for treating lesions located on the greater curvature of the U/M region.

Case Report: Management of Penile Fracture with Urethral Injury in Two Patients

Penile fracture is a trauma accompanied by sudden pain, swelling, loss of erection, deviation, and ecchymosis along with a breaking sound in the penis. It can be accompanied by urethral injuries in 11-22% of patients, occurring due to force/blunt trauma to the erect penis. In this case report, we present two cases of penile fracture with accompanying urethral injury, occurring approximately one month apart. In our first case, surgical repair was performed approximately 1 hour after the incident, and in the second case, it was performed approximately 2 hours after the incident. Ultrasound (USG) was used as radiological imaging in both cases. In the second case, suspicion of urethral injury was mentioned in the USG. In both cases, a subcoronal circumferential incision was made, and the penile skin was degloved up to the radix. Damaged areas in the intraoperative tunica albuginea and urethra were observed in both cases. Postoperatively, the penile bandage of the first case was removed on the 4th day, and that of the second case was removed on the 6th day. The catheter was removed on the 20th day in both cases. In both cases, no loss of erection or penile deviation was observed at the 3-month postoperative follow-up. No clinical or uroflowmetric findings compatible with urethral stenosis were found in the 2nd and 3rd months post-op. The current approach to penile fractures is emergency surgical decompression and repair.

Endoscopic mucosal resection with a circumferential incision in the removal of colon neoplasms. Results of a randomized trial.

Endoscopic mucosal resection with a circumferential incision in the removal of colon neoplasms. Results of a randomized trial.

Outcome of vesicovaginal fistula repair by vaginal approach.

Objectives: To evaluate success of vesicovaginal fistula repair by vaginal approach with secondary objective to assess the limitations of repair by vaginal route. Study Design: Retrospective & Descriptive study. Setting: Department of Urology and Renal Transplantation, Faisalabad Medical University, Faisalabad. Period: January 2017 to December 2020. Material & Methods: In which 42 patients were included in the study. All patients were submitted for VVF repair by vaginal approach. Procedure was done under spinal anesthesia in all patients. Operation was done in lithotomy position. Circumferential incision was made around the fistula. Vagina and bladder were separated. Urinary bladder was repaired in two layers and vagina by perpendicular stitching technique. Foley catheter was passed. Urinary leakage was seen by instillation of normal saline and Gentian Violet. Vaginal packing was done at the end of the procedure which was removed after 1 day of surgery and patient post operative data was noted. Results: 42 patients were included. There mean age was 27 years. 45.23% patients came with history of prolonged labor, 30.95% patients presented after transabdominal hysterectomy, 21.42% after lower segment secession section and 2.38% patients came after operation for cystocele. Infra-trigonal VVF was present in 59.53% patients and supra-trigonal in 40.47% cases. Our success rate was 85.71% and we faced failure in 14.28% of patients. Lower urinary tracts symptoms were seen in 30.95%, hematuria in 9.25%, stress incontinence in 11.9%, symptoms like over active bladder in 7.14% and urinary tract infection in 14.28%. Conclusion: VVF repair by vaginal approach is safe and successful with less morbidity than abdominal approach.

Preserved mucosa unroofing facilitated closure of a large gastric defect after endoscopic full-thickness resection.

A 58-year-old woman was found to have a submucosal bulging lesion in the anterior wall of the gastric fundus during a screening esophagogastroscopy. Endosonographic evaluation revealed it to be a 3.1×2.5cm, hypoechoic mass originating from muscularis propria (MP). Endoscopic full-thickness resection (EFR) was attempted. After submucosal injection, a four-fifth circumferential mucosal incision was made around the lesion. Submucosal dissection was performed to unroof the overlying mucosa, which was preserved via the remaining one-fifth circumferential mucosal edge. Thus a mucosal flap was created and turned aside to expose the mass. En bloc resection of the lesion resulted in a 3.5*3.0cm full-thickness defect . The mucosal flap was flipped back and the defect was almost fully covered. Therefore, closure of the defect was accomplished by simply clipping the two edges of the initially incised mucosa. The patient was discharged 2 days later without discomfort. Histopathology confirmed a gastrointestinal stromal tumor (GIST), prognostic group 1.

Curative endoscopic full-thickness resection of a fundic gland-type gastric adenocarcinoma

Video 1Summary of the presented case. Macroscopic images of the lesion in a white-light endoscopy and narrow-band imaging and in an underwater view followed by scenes from the resection with circular marking, submucosal injection, circumferential incision, and submucosal dissection using a multi-bend double-channel endoscope, as well as clip traction, controlled full-thickness dissection, and inspection of the defect plus closure of the defect with the clip-and-loop technique.

Preoperative H. pylori Eradication Therapy Facilitates Precise Delineation in Early Gastric Cancer with Current H. pylori Infection

Introduction: Early gastric cancer with current Helicobacter pylori infection (HpC-EGC) is common, but it is still unclear whether H. pylori eradication therapy (Hp-ET) or endoscopic submucosal dissection (ESD) should be performed first. We evaluated Hp-ETs short-term effects on horizontal boundary delineations of HpC-EGC in ESD. Methods: Prospectively enrolled HpC-EGC patients were randomly assigned to eradication or control groups. Operation scopes of HpC-EGC lesions were delineated with marking dots at 5 mm out of the endoscopic demarcation line by an independent endoscopist, unaware of eradication status, before formal circumferential incision. As representatives, precise delineation rate, the shortest distance of all marking dots to the pathological demarcation line in all slices of one intact resected specimen (D_min), and negative marking dot specimen rate were examined. Results: Twenty-three HpC-EGC patients (25 lesions) were allocated to eradication group and 26 patients (27 lesions) were allocated to the control group with similar eradication success rates and all were differentiated type. With improving background mucosa inflammation after Hp-ET and similar gastritis-like epithelium rates, 10 lesions (40.0%) in the eradication group were of precise delineation compared to control group with 2 lesions (7.4%) (relative risk = 5.40, 95% CI 1.31–22.28). D_min of eradication and control groups were 4.17 ± 2.52 mm and 2.67 ± 2.30 mm (p = 0.029), accompanied by 4 (14.8%) and none (0.0%) specimens that exhibited positive marking dots (p = 0.11), respectively. Conclusion: For HpC-EGC patients, administrating eradication medication before ESD is beneficial for the precise delineation of lesions and reducing the risk of positive horizontal resection margins.

Scanning Electron Microscopy Analysis of Lymphatic Regeneration in a Secondary Lymphedema Mouse Model: A Preliminary Study

Under inflammatory conditions including lymphatic disorders, bone marrow-derived myeloid cells often express lymphatic endothelial cell (LEC) markers, and these cells are then called LEC progenitor cells, which extend lymphatic vessels by fusing with existing lymphatic vessels. However, studies on the mechanism of lymphatic regeneration using three-dimensional images of lymphatic structures are limited. In this study, scanning electron microscopy (SEM) was used to observe the three-dimensional structure of lymphangiogenesis in a mouse model of secondary lymphedema. The model was established in C57BL/6J mice via circumferential incision in the inguinal region of the left hind limb. Skin samples were obtained from the lymphedema region on days 2, 5, and 8 after surgery. To determine lymphatic vessel positions using SEM analysis, we detected anti-lymphatic vessel endothelial hyaluronan receptor 1 (LYVE-1) immunoreactivity in serial sections and overlaid them during SEM observation. On days 2 and 5, spherical cells, probably myeloid cells, were attached and fused to the LYVE-1-positive lymphatic vessel walls. On day 8, spherical cells were converted to string-shaped cells, forming a new lymphatic vessel wall resembling an intraluminal pillar. Our results showed the newly formed lymphatic vessel wall extended into the lumen, suggesting intussusceptive lymphangiogenesis.

Gastrogastric intussusception and acute pancreatitis caused by a large pyloric gland adenoma treated with endoscopic submucosal dissection

Video 1Gastrogastric intussusception and acute pancreatitis caused by a large pyloric gland adenoma treated with endoscopic submucosal dissection: A 75-year-old woman with a several-week history of intermittent postprandial nausea and vomiting presented to the emergency room after experiencing syncope, following several hours of persistent abdominal pain, nausea, and vomiting. A contrast-enhanced CT scan of the abdomen and pelvis was arranged. Axial images show gastrogastric intussusception with the intussusceptum, indicated by the dashed lines, telescoping into the intussuscipiens indicated by the arrowheads. There is a lobulated mass indicated by the asterisk, serving as the lead point for the intussusception, and there is also a small volume of fluid indicated by the arrow, which delineates the mass from the duodenum. In the coronal images, we can again see a long-segment intussusception indicated by the dashed line with a lobulated mass indicated by the asterisk serving as the lead point and extending into the proximal duodenum. Then the lobulated mass occupying and expanding the duodenal lumen can be seen, indicated by the asterisk. Upon entry into the stomach through endoscopy, the gastrogastric intussusception can be seen. The lobulated mass serving as the lead point can be seen being pulled distally. With air insufflation, the intussusception spontaneously resolved. With continued insufflation, within a few minutes, the native confirmation of the polyp was established. It was located in the proximal body along the greater curve with a lobulated appearance with a Paris 1sp morphology. In addition, there was panatrophy in the background mucosa, which was consistent with autoimmune atrophic gastritis that was subsequently confirmed on histopathology and positive anti-parietal cell antibiotics. An EUS was performed and did not show any evidence of T2 disease. Doppler showed large central feeding vessel. A plan was made for endoscopic submucosal dissection (ESD). The strategy for the ESD was an initial circumferential incision and trimming with subsequent application of multipoint traction. After a circumferential incision, a rich vascular supply is seen. After completion of the incision and trimming, the snare was advanced over the scope and the clip advanced through the instrument channel. Multiple clips were then used to secure the snare to the distal end of the lesion. With traction applied, access to the submucosa became much easier and the ESD proceeded easily. For the final remnant of submucosa, it was more easily dissected in a forward view. Chess is one of the merits of multipoint traction in that traction can be applied both proximally and distally to the lesion. The lesion was resected en bloc. The specimen was retrieved using the attached snare, but unfortunately, some of the friable head was fragmented because of its large size, yet the base remained intact. Final pathology demonstrated PGD+HGD with clear margins vertically and laterally along the base. This case of gastrogastric intussusception, causing gastric outlet obstruction and acute pancreatitis secondary to a large pyloric gland adenoma, highlights several rare clinical entities. First, gastrogastric intussusception in adults is an exceptionally rare phenomenon, with only a few documented cases reported in the literature. Second, in the case of large gastric neoplasms causing intussusception, rarely the neoplasm may extend down into the duodenum and obstruct the ampulla of Vater causing acute pancreatitis. Furthermore, pyloric gland adenomas are rare gastric neoplasms that tend to be polypoid in morphology and are associated with autoimmune gastritis, predominantly occurring in female patients, as in this case. Lastly, the traditional management for lesions causing gastroduodenal intussusception is surgical because of the risk of malignancy. However, in this case, the patient underwent successful curative and therapeutic endoscopic resection with ESD.

Establishment of a Simple, Reproducible, and Long-lasting Hind Limb Animal Model of Lymphedema.

Lymphedema is an intractable disease for which there is currently no established curative therapy. A reliable and long-lasting lymphedema model is essential for development of better treatments. In this study, we aimed to establish a simple, reproducible and long-lasting mouse model of lymphedema. Our model is characterized by a combination of a circumferential skin incision in the femoral region, complete dissection of regional lymph nodes, and ablation of the inguinal route in the femoral region. The characteristics of the lymphedema were evaluated and compared with those of two other models. One of these models involved dissection of the subiliac, popliteal, and sciatic lymph nodes (model A) and the other excision of the subiliac, popliteal, and sciatic lymph nodes with cauterization of lymphatic vessels and closure without a skin excision (model B). Although the lymphedema in models A and B resolved spontaneously, that in the new model lasted for a month with increases in femoral circumference and hind limb volume, thickening of the skin, especially subcutaneous tissue, and congestion of peripheral lymphatic vessels. Furthermore, this model could be used for assessing the therapeutic effects of syngeneic mesenchymal stem cell transplantation. The average operation time for the new model was 14.4 ± 1.3 minutes. Long-lasting lymphedema can be achieved by our new model, making it suitable for assessing therapies for lymphedema.

321. ESD AND ELPS A NOVEL MINIMALLY INVASIVE TREATMENT FOR MULTI-EPISODE SUPERFICIAL ESOPHAGEAL SCC AND 2ND PRIMARY HYPOPHARYNGEAL SCC:A CASE REPORT

Abstract Background Esophageal SCC is a common cancer worldwide. Major risk factors were tobacco and alcohol use. It’s also a cause of head and neck cancers, particularly hypopharyngeal SCC. ESD was established as standard procedure for curative early esophageal SCC. However, conventional ESD for hypopharyngeal lesions is technically difficult. This report describes a patient who had superficial hypopharyngeal SCC following multiple esophageal ESD sessions. This VDO presentation shows how to perform safe ELPS and achieve oncological purposes. Methods A 77-year-old Thai man. He had primary cervical esophageal SCC and 1 month after complete response from definite CCRT, he began presenting four other recurrent episodes of superficial esophageal SCC in the lower, middle, and two times of cervical regions over a 3-year period. ESD and APC were applied and showed a complete response. The last endoscopic finding also revealed of superficial hypopharyngeal SCC and ELPS was decided by the following step: curve laryngoscope placement, laryngeal packing, lesion identification and marking, submucosal injection, circumferential incision, submucosal dissection, and bleeding control. The specimen was removed transorally and sent for pathological examination. Result The operation was successful without complications. The patient was able to start a liquid diet on day 1 and a soft meal on second day post operation. He was discharged on 3rd day without any complications. The pathological report was moderated differentiate SCC with positive deep margin, so he was planned for further RT. Conclusion ELPS provided good visualization, which led to a sufficient working space for resection. The procedure was safe and feasible for superficial hypopharyngeal lesions and exhibited good oncological outcomes, preserving both swallowing and phonation functions.

Endoscopic Resection with One-Port Placement: A Newly Developed Technique for the Safe Management of Advanced Endoscopic Resection for Gastric Gastrointestinal Stromal Tumors

Introduction: Endoscopic full-thickness resection (EFTR) without laparoscopic assistance (pure EFTR) is an emerging, less invasive treatment for gastrointestinal stromal tumors (GISTs). However, the technique has seldom been performed outside China because of concerns regarding pneumoperitoneum, maintenance of endoscopic view, and endoscopic suturing. This study aimed to evaluate the efficacy and safety of endoscopic resection with one-port placement (EROPP) for gastric GISTs. Methods: This retrospective study included 17 patients with gastric GISTs originating from the muscularis propria who underwent EROPP between 2019 and 2022. One camera port was inserted in the umbilicus before initiating the endoscopic procedure to maintain intra-abdominal pressure, which was monitored and adjusted via this port. While allowing for conversion to laparoscopic surgery if needed, EFTR was performed as follows: (1) circumferential incision of the mucosal and submucosal layers around the lesion was performed by typical endoscopic submucosal dissection; (2) an intentional perforation and subsequent seromuscular resection was made using dental floss and an endo-clip for traction; and (3) closure of the gastric full-thickness defect was performed with an over-the-scope clip (OTSC) after peroral retrieval of the specimen. We retrospectively assessed the short-term outcomes and safety. Results: All procedures were completed successfully without conversion to laparoscopic surgery. The median size of the resected tumors was 23 mm (range, 8–35 mm), the median resection time was 36 min (range, 22–95 min), and closure time was 18 min (range, 10–45 min). The rates of en bloc and complete resection were 100% and 88%, respectively. In 2 cases, another port was added to aspirate the leaking fluid or check the condition of the endoscopic closure. All gastric defects were endoscopically closed, mainly using OTSCs. The recovery course for all patients was uneventful, and no adverse events were reported. Conclusions: EROPP is a safe and minimally invasive treatment for gastric GISTs and appears to be suitable for introducing EFTR procedures.

A study of the histopathology of collagen fleece (TachoSil) patching of tunica albuginea in the rat penis and a literature review of penile graft materials in experimental animals.

A penile tunica defect may arise during surgery in patients with Peyronie's disease. Collagen fleece (TachoSil) has recently gained popularity in penile surgery to cover the tunica albuginea (TA) defect associated with clinical success. However, it is not known what the histological outcomes of these grafts are in the penis. We aimed to study the histopathology of the TachoSil graft in an experimental animal model for the regeneration of TA, inflammation, fibrosis, and the underlying cavernous tissue. Six adult male Sprague Dawley rats were used. The penis was degloved through a circumferential subcoronal incision. A longitudinal 1 mm × 10 mm defect was created at the base of the lateral aspect of the penis. A TachoSil patch (Takeda, Japan) was applied to the defect. The penile skin covering was then restored. At 2 months, the rat penis was excised and examined with hematoxylin, eosin, and trichrome stains. We conducted a literature review of penile grafts in animals for comparison. Rats weighed 369.2 gm (standard deviation: 31.5). At 2 months, all rats showed normal-looking penis with complete healing, no scaring, tethering, or gross inflammatory features. Histopathology of the patch site showed fibrosis, chronic inflammation, and foreign body giant cell reaction. There was no generation of a new TA, or new vascularity. No inflammatory or pathological reaction affected the underlying corpus cavernous tissue. One rat died on the 6th postoperative day. Postmortem showed massive multiorgan hemorrhage consistent with disseminated intravascular coagulopathy (DIC). Unlike some other reported grafts, there is no TA regeneration. TachoSil patching of penile TA defect forms a distinctive barrier against inflammation, protecting the underlying corpus cavernosum. However, no regeneration of the tunica defect is observed at 2 months. DIC is a potential complication of systemic absorption of TachoSil.

Penile fracture in burkina faso: our experience on the management of 21 cases

BackgroundPenile fracture is relatively a rare urological emergency and has been the topic of a few publications in the literature through clinical cases or case series. Despite this relative scarcity, it is increasingly reported as one of the andrological emergencies in Burkina Faso. The purpose of this study was to report our experience of the management of such andrological emergency in the two main university teaching hospitals of Burkina Faso.MethodsThis was a cross-sectional study, including retrospectively patients managed for a penile fracture between January 2016 and September 2021, and having a minimum postoperative follow-up of 6 months. The literature review was performed by analyzing the content of the following documents: consultation logs, patient records, operative report protocol. The parameters studied were age, mechanism of occurrence, clinical data, delay of management, operative technique and functional and morphological results after surgery. Erectile function was assessed by the IIEF5 score and rigidity by the EHS scale.ResultsAmong the 24 cases of penile fracture, 21 patients were included with a median age of 32.7 ± 5.74 years (23–43 years). The most common mechanism was a coital misstep or coitus interruptus (14 patients or 66.7%). Forced self-manipulation/masturbation was noted in 4 cases (19%), and direct trauma to the penis was noted in 3 cases (14.3%). Urethrorrhagia was reported by 5 patients. The mean delay of management was 65 h (6–432 h). The main sign found was the painful swelling of the penis with an “eggplant” appearance. The surgical approach was a circumferential balanopreputial incision in all our patients. Involvement of the spongy body and urethra associated with involvement of the cavernous body was noted in 4 patients, with a single case of spongy body and urethral involvement. The mean length of hospital stay was 3 days. Postoperatively, erectile dysfunction was noted in 6 patients. A palpable nodule at the penis was observed in 12 patients. No patient reported curvature of the penis.ConclusionPenile fracture is a clinical diagnosis requiring early exploration and surgical repair to ensure better functional and morphological outcomes.

Multicenter evaluation of recurrence in endoscopic submucosal dissection and endoscopic mucosal resection in the colon: A Western perspective.

While colon endoscopic mucosal resection (EMR) is an effective technique, removal of larger polyps often requires piecemeal resection, which can increase recurrence rates. Endoscopic submucosal dissection (ESD) in the colon offers the ability for en bloc resection and is well-described in Asia, but there are limited studies comparing ESD vs EMR in the West. To evaluate different techniques in endoscopic resection of large polyps in the colon and to identify factors for recurrence. The study is a retrospective comparison of ESD, EMR and knife-assisted endoscopic resection performed at Stanford University Medical Center and Veterans Affairs Palo Alto Health Care System between 2016 and 2020. Knife-assisted endoscopic resection was defined as use of electrosurgical knife to facilitate snare resection, such as for circumferential incision. Patients ≥ 18 years of age undergoing colonoscopy with removal of polyp(s) ≥ 20 mm were included. The primary outcome was recurrence on follow-up. A total of 376 patients and 428 polyps were included. Mean polyp size was greatest in the ESD group (35.8 mm), followed by knife-assisted endoscopic resection (33.3 mm) and EMR (30.5 mm) (P < 0.001). ESD achieved highest en bloc resection (90.4%) followed by knife-assisted endoscopic resection (31.1%) and EMR (20.2%) (P < 0.001). A total of 287 polyps had follow-up (67.1%). On follow-up analysis, recurrence rate was lowest in knife-assisted endoscopic resection (0.0%) and ESD (1.3%) and highest in EMR (12.9%) (P = 0.0017). En bloc polyp resection had significantly lower rate of recurrence (1.9%) compared to non-en bloc (12.0%, P = 0.003). On multivariate analysis, ESD (in comparison to EMR) adjusted for polyp size was found to significantly reduce risk of recurrence [adjusted hazard ratio 0.06 (95%CI: 0.01-0.57, P = 0.014)]. In our study, EMR had significantly higher recurrence compared to ESD and knife-assisted endoscopic resection. We found factors including resection by ESD, en bloc removal, and use of circumferential incision were associated with significantly decreased recurrence. While further studies are needed, we have demonstrated the efficacy of ESD in a Western population.

(112) An Experimental Animal Study of the Histopathological Effect of Collagen Fleece (TachoSil) Patch of Tunica Albuginea Defects Associated with Penile Surgery

Abstract Introduction A penile tunica defect may arise during penile prosthesis surgery or reconstruction of the penis in patients with Peyronie’s disease. Collagen fleece (TachoSil) was recently reported in penile surgery to cover the tunica defect with reported clinical success. However, it is not known what the histological outcomes of these grafts are in the penis. Objective We study the novel application of TachoSil graft in an experimental animal model. We looked at the regeneration of tunica albuginea, development of inflammation and fibrosis, and histopathological effect on the underlying cavernous tissue. Methods Seven adult male Sprague Dawley rats were used. All procedures were carried out under general inhalation anesthesia. The penis was degloved through a circumferential subcoronal incision. A longitudinal 1x10 mm defect was created at the base of the lateral aspect of the penis. A TachoSil patch (Takeda, Japan) was applied to the defect in six rats and Surgicel (Ethicon) in one. The penile skin covering is then restored and fixed with interrupted 5-6 zero absorbable sutures. At two months, the rat penis was evaluated for excision. Euthanasia was carried out with an overdose of inhalation anesthesia and chest opening. The excised penis was examined by hematoxylin and eosin and trichrome stains. Results At the time of surgery, the rats’ weight was 390 gm (SD 33.8). All rats with TachoSil showed normal-looking penis at two months with complete healing, no scaring, tethering, or gross inflammatory features. The penis of three rats with a Tachosil patch was harvested at two months postoperatively. It showed histopathology of fibrosis, chronic inflammation, and foreign body giant cell reaction at the site of the patch. There was no generation of a new tunica albuginea, no new vascularity or distinct fibrous layer development. The underlying corpus cavernous tissue was not affected by any inflammatory or pathological reaction. One rat died on the 6th postoperative day. Postmortem showed massive gastrointestinal bleeding, intraperitoneal hemorrhage, and punctate hemorrhages of the parenchyma of both suprarenal glands, both kidneys, and the liver. A clinical diagnosis of DIC was made. Histopathology of the penis, however, did not show micro thrombosis. The fifth rat with a Surgicel patch showed immediate hematoma of the penis controlled by compression. After two months, during harvesting of the penis, large pockets of pus were seen spreading from the site of the patch to surrounding structures. Histopathology showed chronic inflammation and fibrosis extending into the corpus cavernosum. The sixth and seventh rats showed normal penis external appearance at two months and were left surviving for harvest at four months. Conclusions Tachosil patching of penile tunica albuginea defect forms a distinctive barrier against inflammation protecting the underlying corpus cavernosum. However, no regeneration of tunica defect is observed at two months. DIC is a potential complication of systemic absorption of TachoSil. Disclosure No

Epidemioclinical and Therapeutic Study of Fractures of the Penis at the Csréf of Markala

The aim was to carry out an epidemioclinical and therapeutic study of fractures of the penis at the Csréf in Markala. Patients and methods: This is a retrospective prospective descriptive study of 13 cases of fracture of the penis during four years at the Csréf of Markala from 01 January 2019 to 01 January 2023. All patients who had a treated penis fracture were included in our study. All patients who had other forms of trauma to the penis other than a penis fracture were excluded. Results: The frequency of fracture of the penis was 14.8% compared to other urological injuries. The average age of our patients was 36.30 years with extremes ranging from 25 to 54 years. 53.8% of our patients were single. The average consultation time was 14.8 hours, with extremes ranging from 3 hours to 47 hours. The approach was longitudinal in some cases and in other cases a circumferential incision or at the level of the balano preputial fold. The most frequent complications were penis bending, with 15.5% (2 patients), urethral fistula was observed in one patient (7.7%), and we also noted cases of fibrosis of the erectile bodies (23.1%). Conclusion: The fracture of the penis is a real uro-andrological emergency, and the treatment must be rapid and effective in order to avoid irreversible after-effects, which may even lead to erectile dysfunction or urethral stricture in these patients. The approach must be appropriate in order to prevent short, medium and late complications.

A modified exposed endoscopic full-thickness resection: Traction-assisted resection while defect closing.

Exposed endoscopic full-thickness resection (Eo-EFTR) has proven effective and economical for patients with gastric submucosal tumors (SMTs), showing great prospects. However, the poor operative field of view, the risk of tumors falling into the peritoneal cavity, especially the difficulties in defect closure, have limited its widespread application. Herein, we described a modified traction-assisted Eo-EFTR technique aimed at simplifying both the dissection and defect closure procedures. Nineteen patients who underwent the modified Eo-EFTR for gastric SMTs in the Chinese People's Liberation Army General Hospital were enrolled in the study. Following a 2/3 circumferential full-thickness incision, a clip with dental floss was anchored to the resected part of the tumor surface. With the dental floss traction, the gastric defect was reshaped into a V shape, which facilitated the deployment of clips to close the defect. The defect closure and tumor dissection procedures were then performed alternately. Patients' demographics, tumor characteristics, and therapeutic outcomes were evaluated retrospectively. All tumors had an R0 resection. The median procedure time was 43 min (range 28-89 min). No severe perioperative adverse events occurred. Two patients experienced transient fever, and three patients complained of mild abdominal pain on the first day after the operation. All patients recovered on the next day with conservative management. No residual lesion or recurrence was reported during the follow-up period of 30.1 months. The safety and practicability of the modified technique might allow for wide clinical applications of Eo-EFTR in gastric SMTs.

Comparison of Needle Knife versus Scissors Forceps for Colorectal Endoscopic Submucosal Dissection: A Prospective Randomized Study

To evaluate the efficacy and safety of a grasping-type knife, called Clutch Cutter (CC), for colorectal endoscopic submucosal dissection (C-ESD). This was a randomized prospective study. Patients who underwent C-ESD for colorectal neoplasms >20 mm and <50 mm in size were enrolled, dividing into two groups: ESD using needle type of dual knife alone (D-group) and circumferential incision using dual knife followed by submucosal dissection using CC (CC-group). The primary outcome was the self-completion rate. The secondary outcomes were intraoperative complication rate, procedure time, and en bloc resection rate. A total of 45 patients were allocated to the D-group and 43 to the CC-group were allocated. The self-completion rate was higher in the CC-group (87% [39/45] vs. 98% [42/43]). All of the six patients with an incomplete procedure in the D-group were completely resected with CC use. The intraoperative complication rate was not significant in either group (D vs. CC: 2% vs. 0%). The mean procedure time was significantly shorter in the D-group than that in the CC-group (62.0 vs. 81.1 min; p = 0.0036). The en bloc resection rate was 100% in the D-group and 98% in the CC-group. While dual knife use is superior to CC in terms of time efficiency, the use of CC may be a safe and efficacious option for achieving complete C-ESD.

Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review.

ESGE suggests conventional endoscopic submucosal dissection (ESD; marking and mucosal incision followed by circumferential incision and stepwise submucosal dissection) for most esophageal and gastric lesions. ESGE suggests tunneling ESD for esophageal lesions involving more than two-thirds of the esophageal circumference. ESGE recommends the pocket-creation method for colorectal ESD, at least if traction devices are not used. The use of dedicated ESD knives with size adequate to the location/thickness of the gastrointestinal wall is recommended. It is suggested that isotonic saline or viscous solutions can be used for submucosal injection. ESGE recommends traction methods in esophageal and colorectal ESD and in selected gastric lesions. After gastric ESD, coagulation of visible vessels is recommended, and post-procedural high dose proton pump inhibitor (PPI) (or vonoprazan). ESGE recommends against routine closure of the ESD defect, except in duodenal ESD. ESGE recommends corticosteroids after resection of > 50 % of the esophageal circumference. The use of carbon dioxide when performing ESD is recommended. ESGE recommends against the performance of second-look endoscopy after ESD. ESGE recommends endoscopy/colonoscopy in the case of significant bleeding (hemodynamic instability, drop in hemoglobin > 2 g/dL, severe ongoing bleeding) to perform endoscopic hemostasis with thermal methods or clipping; hemostatic powders represent rescue therapies. ESGE recommends closure of immediate perforations with clips (through-the-scope or cap-mounted, depending on the size and shape of the perforation), as soon as possible but ideally after securing a good plane for further dissection.