Definitive Management Research Articles

Surgeon-Performed Percutaneous Endoscopic Biliary Lithectomy: Description of a Novel Technique and Initial Results.

Introduction: Percutaneous endoscopic biliary lithectomy (PEBL) can be performed through preexisting drain tracts, offering ductal clearance and definitive management for patients with complicated gallstone disease unable to undergo conventional therapy. The technique has not been widely adopted by general surgeons. Herein, we describe our technique with surgeon-performed PEBL and present initial results. Materials and Methods: A single institutional retrospective review of the electronic medical record was performed for patients who underwent percutaneous choledochoscopy between February 2019 and November 2020. All operations were performed by 1 of 2 board-certified general surgeons with fellowship training in surgical endoscopy. Preoperative, operative, and postoperative variables were analyzed using descriptive statistics. Results: Thirteen patients underwent PEBL. Seventeen total procedures were performed; 4 patients underwent repeat intervention. The diagnoses leading to PEBL were: cholelithiasis (8), choledocholithiasis (4), and recurrent pancreatitis (1). Complete ductal clearance was achieved in 9 patients (69.2%) during the initial procedure. The remaining 4 patients (30.8%) underwent repeat PEBL, at which point complete ductal clearance was then achieved. The percutaneous drain was removed at the time of final procedure in 5 patients (38.5%) or within 5 weeks in the remaining 8 (61.5%). No intraoperative complications occurred, and no pancreatic or biliary postoperative complications or recurrences were noted with a mean follow-up of 279 ± 240 days. Conclusion: Surgeon-performed PEBL is a safe and effective method of achieving biliary ductal clearance. The technique is readily achieved following basic endoscopic and fluoroscopic principles and should be understood by all physicians managing gallstone disease.

A Case Report of a Rare Aetiology of a Sigmoid Volvulus Involving a Congenital Omental Defect

Sigmoid volvulus is a rare form of large bowel obstruction and makes up < 5% of all colonic obstruction. The commonest aetiologies include a lead point involving an intra or extra luminal mass such as a malignancy or a benign stricture or colonic dysmotility especially in the geriatric population. Rare aetiologies include a mesenteric defect, or as in this case report, a congenital omental defect acting as the lead point. This makes for an increasingly unusual case report, and we believe that this is the first such report in English language literature. The management remains the same, irrespective of the aetiology. Endoscopic bowel decompression in the acute phase is followed by definite surgical management with or without a primary surgical anastomosis.

Non-syndromic oropharyngeal hamartoma: A case report

This case report details the presentation, investigation, management, and histopathological examination of a rare occurrence – non-syndromic oropharyngeal hamartomas in a 2-year-old child. The child presented with a substantial orofacial mass on the dorsum of the tongue, causing significant functional impairments. Notably, the mass measured 8×4 cm and protruded outside the oral cavity. Additional findings included a nodular mass at the tongue tip, a lobulated mass on the right buccal mucosa (3×4 cm), cleft palate, microphthalmos of the right eye, and an accessory pinna on the right cheek. Diagnostic investigations, including ultrasound, revealed irregular soft tissue lesions with hypoechoic areas and vascular channels, indicative of hemangioma. Blood parameters were within normal limits. Due to the size and symptomatic nature of the mass, surgical intervention was planned and executed under general anesthesia with nasal intubation. The procedure involved complete dissection and excision of the masses from the tongue and buccal mucosa. The surgical site was meticulously closed in layers using 4-O vicryl. Postoperatively, the child resumed oral feeds on the third day, and the recovery period was uneventful. Histopathological examination of the excised specimen depicted a hamartomatous lesion of the tongue characterized by stratified squamous epithelial lining, admixture of blood vessels, adipose tissue, fibrocollagenous tissue, cartilaginous tissue, nerve bundles, adnexal structures, and minor salivary glands. The report concludes by highlighting the rarity of lingual hamartomas, emphasizing the exceptional size and vascularity of the presented case. It stresses the necessity of considering hamartomas in the differential diagnosis of tongue lesions in pediatric patients. The definitive management approach discussed is complete surgical excision, with the importance of confirming the diagnosis through histopathological examination of the excised specimen. This case contributes with valuable insights into the clinical presentation and management of non-syndromic oropharyngeal hamartomas in pediatric patients.

Significant improvement in hydronephrosis with pyeloplasty prior to 3 months of age in patients with antenatal severe hydronephrosis.

Pyeloplasty is the definitive management of ureteropelvic junction obstruction (UPJO). One of the challenging questions is when to perform pyeloplasty. We studied if improvement post-pyeloplasty in the first 3 months of life could show greater improvement in hydronephrosis than surgery at an older age. Patients with postnatally diagnosed UPJO and underwent pyeloplasty in the first year of life were retrospectively reviewed. We excluded patients with concomitant vesicoureteral reflux, and patients who had pyeloplasty because of UTI or missed follow-up. Patients were divided into two groups, according to the age at pyeloplasty, before and after the age of 3 months. We collected patients' demographics, anteroposterior diameter of the renal pelvis (APD), SFU grade, renogram data, perioperative data (surgery duration, hospital stay, and ureteral stent duration) and postoperative ultrasound changes. The percentage of change of APD (Δ%APD) was calculatedusing the formula: Δ%APD = [ (initial APD-last APD)/initial APD] *100. We included 90 patients (93 renal units). 36 patients had pyeloplasty during the first 3 months of life and 57 patients at 3 -12 months. Patients' characteristics were similar in both groups except APD which was higher when pyeloplasty was done < 3 months of age (p = 0.02). Both groups had comparable perioperative parameters. After almost similar follow-up period of both groups. The Δ%APD was 58% when pyeloplasty was done < 3 months compared to 33% when was performed > 3 months (p = 0.009). Using Kaplan-Meier analysis, APD significantly improved when pyeloplasty was performed before the age of 3 months (p = 0.001). Early pyeloplasty, in the first 3 months of life, showed a significant improvement of APD postoperatively than those had surgery later. It is unclear if this will relate to less loss of renal function yet certainly this would be suspected and feel this finding provides some evidence for early intervention.

A Single-Institution Review of the Use of Radiation in the Adjuvant and Definitive Management of Keloids

AimsMany individuals suffer from keloids that are refractory to standard treatment modalities, including surgical excision alone. Radiation therapy can be used to reduce the risk of recurrent keloids post-operatively, as well as be used as primary treatment for keloids not amenable to surgical resection. The purpose of this study was to review our institutional experience of radiation therapy for keloid management. Materials and methodsA retrospective review of patients treated with radiation therapy for keloids between 2014 and 2020 at our institution was performed. ResultsA total of 70 keloids in 41 patients were treated. For the 55 keloids treated with post-operative radiation therapy (16Gy delivered in 2 fractions), 82.5% (33/40) of evaluable lesions did not recur. Among the 15 keloids treated with definitive radiation therapy (24Gy delivered in 3 fractions), 78.6% (11/14) of evaluable keloids showed complete flattening, and 14.3% (2/14) had partial flattening. Both acute and late toxicities were mild, with only a single instance of grade 3 toxicity (dermatitis). ConclusionOur study confirms that radiation therapy has a role in reducing the risk of keloid recurrence post-operatively, and plays an important role in the definitive management of unresectable keloids.

Incidental but Not Insignificant: Thyroid Cancer in Patients with Graves Disease.

Graves disease is the most common cause of hyperthyroidism in the US. Treatment with antithyroid drugs and radioactive iodine is more commonly used than surgical management with total thyroidectomy (TTx). However, incidentally discovered thyroid cancer (TC) has been described on surgical pathology from patients who underwent surgical treatment of Graves disease, which would be missed with these other treatment strategies. We sought to determine the incidence rate of TC among patients with surgically treated Graves disease. We retrospectively reviewed patients with Graves disease who underwent TTx at a single institution from 2011 to 2023. Pathology reports were reviewed for TC. Patient demographics, preoperative laboratory and radiological evaluations, preoperative medical management, and surgical outcomes were compared between patients with and without incidental TC. There were 934 patients, of whom 60 (6.4%) patients had incidentally discovered TC on pathology. The majority (58.3%) of patients had papillary thyroid carcinoma, followed by 33.3% with papillary microcarcinoma. Preoperative ultrasound (US) was obtained in 564 (60.4%) of patients, with 44.3% with nodules, but only 34 (13.7%) of those with nodules had TC on final pathology. Preoperative fine needle aspiration was obtained in 15 patients with TC, and 8 patients (53.3%) were reported as benign lesions, which ultimately had TC on final pathology. There was no difference in sex, race or ethnicity, preoperative medical management, and postoperative outcomes between the 2 groups. Incidental TC was found on surgical pathology in 6.4% of patients undergoing TTx for Graves disease. Preoperative imaging with US and fine needle aspiration were often unreliable at predicting TC. The incidence of TC should not be underestimated when counseling patients on definitive management for Graves disease.

Long-term oncological outcomes for endoscopic endonasal versus open surgical approaches for anatomically matched, locally advanced stage T4 sinonasal malignancies with skull base involvement.

Expanded endoscopic approaches (EEAs) are increasingly used for the definitive management of sinonasal malignancies. EEAs, in appropriately selected cases, provide similar oncological outcomes but are associated with lower complication rates compared with open surgical approaches. Selection bias is a limitation reported in previous studies comparing EEAs and open surgical approaches for the management of sinonasal malignancies. To address this issue, in this study the authors compared the long-term oncological outcomes of an anatomically matched cohort of patients with locally advanced sinonasal malignancies with skull base involvement (T4 stage). The specific objective of this study was to investigate the extent of resection (EOR), overall survival (OS), and disease progression between the EEA and open surgical cohorts. A cohort of 42 patients with locally advanced sinonasal malignancies and skull base involvement (stage T4) and operated on via an EEA was matched anatomically with a cohort of 54 patients who had undergone open surgery. A retrospective chart review was conducted on these 96 patients who were treated between September 1993 and June 2020. All patients in the cohort were eligible for either an EEA or open surgery according to anatomical criteria. Patients of all ages were included, and the minimum follow-up required for eligibility was 4 months. Patients were excluded if surgery was not offered for curative intent and preoperative imaging did not demonstrate that gross-total resection was achievable. There were more complications in the conventional surgery cohort than in the EEA cohort (33.33% vs 14.29%, p = 0.033). There was no significant difference in the EOR between the EEA and conventional surgery cohorts, as demonstrated by comparable rates of positive margins in both groups (5.56% vs 2.38%, respectively). Disease progression (hazard ratio [HR] 0.47, 95% CI 0.17-1.27, p = 0.137) was lower and OS (HR 0.58, 95% CI 0.26-1.29, p = 0.183) was higher in the EEA cohort, but these findings did not reach statistical significance. The EEA was found to be associated with lower risks of complications than conventional craniofacial surgical approaches. There were no significant differences in OS and progression-free survival between the EEA and conventional surgical cohorts when comparing anatomically matched cohorts of patients with stage T4 sinonasal malignancies and skull base involvement.

DRESS syndrome: More than just a rash.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is rare but carries significant mortality and morbidity, making early identification and definitive management crucial. The diagnosis of DRESS is made clinically and involves consideration of a broad list of differential diagnoses. Given variable clinical presentations among patients with DRESS syndrome, clinicians should look for common findings and other hallmarks of the syndrome while monitoring for known complications. Additionally, clinicians should maintain a high index of suspicion to avoid missing more mild presentations, such as in this case patient with DRESS syndrome minor.

Management of High-velocity Firearms Injury in Counterinsurgency Area: A Single-Center Study

Abstract Background: High-velocity firearms injuries in counterinsurgency (CI) areas are different from civilian injuries in terms of mechanism of injury, pathophysiology, management, and outcome. Hostile environments and difficult terrain are the main roadblocks in providing quality first aid and timely evacuation, which leads to compromised outcomes. This study was designed to analyze the epidemiology, management modalities, and complications of firearm injuries referred to a trauma care center in a counterinsurgency (CI) area. Methodology: This is a single-center prospective observational study over 3 years at a trauma care hospital in the Union Territory of Kashmir in India. All patients with firearm injuries sustained during CI operations were part of the study cohort. Patient profile, evacuation modalities, time elapsed since injury, and treatment modalities, including complications, were analyzed. Results: Four hundred and eighty patients were admitted over 3 years. The mean time elapsed in reaching the hospital was 7 h. Gunshot injury was the most common mechanism in 58% of the patients. 21.3% were priority I, 45.0% were priority II, whereas 33.7% were priority III. One hundred and fifty-four patients required definitive operative management. Lower extremity was the most common site. Sixty (12.5%) had penetrating abdominal trauma and 27 (5.6%) had vascular injury. Six patients succumbed to death postoperative due to various reasons. Conclusions: High-velocity firearms injury is a common cause of morbidity and mortality in military combat operations. This study highlights the challenges faced in managing high-velocity firearm injuries in such a large cohort of injured patients.

Upadacitinib as Rescue Therapy for the Treatment of Acute Severe Colitis in an Acute Care Setting.

Inflammatory bowel disease is a chronic, relapsing, and remitting inflammatory disorder that despite advances in medical therapy often requires hospitalization for treatment of acute flares with intravenous corticosteroids. Many patients will not respond to corticosteroids and require infliximab or cyclosporine as rescue therapy. If medical therapy fails, definitive surgical management is required. Recently, Janus Kinase inhibitors, including upadacitinib, have been proposed as an alternative rescue therapy. We hypothesized that upadacitinib may be effective in treating acute severe colitis. A retrospective review of 12 inflammatory bowel disease patients admitted for acute severe colitis who received upadacitinib induction therapy was performed. The rates of surgery, repeat or prolonged steroid use, and re-admission within 90days of index hospitalization were measured. The need for re-induction with upadacitinib, change in medical therapy, rates of clinical remission, change in 6-point partial Mayo score, and laboratory markers of inflammation were measured as secondary outcomes. Five patients met the primary composite endpoint including four patients requiring surgery and one additional patient being unable to withdraw steroids within 90days of hospital discharge. One patient required re-induction with upadacitinib within 90days and no patients required change in medical therapy within 90days. Most patients who did not undergo surgery were in clinical remission within 90days and showed clinical improvement with decreased 6-point partial Mayo scores. Upadacitinib may be effective salvage therapy for acute severe colitis, but larger controlled trials are required to validate these results.

Burn Wound Care Strategies for the Battlefield and Austere Settings

Burns are commonly encountered in the battlefield environment; however, the availability of burn expertise and specialized supplies is variable. Initial burn care should remain focused on cooling the burn, preventing hypothermia, basic wound cleansing, and evacuation. Key ongoing burn wound management principles include wound debridement, accurate burn size and depth estimation, wound care, ongoing wound evaluation, and treatment of suspected Gram-negative wound infection. Operative management should be limited to urgent procedures, and definitive burn management should be performed only after evacuation to a higher level of care. Flexibility, creativity, and the ability to adapt care to the tactical environment are key to the successful management of burn injuries in battlefield and austere settings.

Considerations for instituting pediatric pulmonary embolism response teams: A tool kit

The incidence of pediatric pulmonary embolism (PE) has increased by 200 % in the last decade, but at a single center, it is still infrequent. Given the unique epidemiologic features of pediatric PE, diagnosis is often delayed, and the management is empiric, based on individual physician experience or preference. Thus, there is a strong need for center-specific uniform management of pediatric PE patients. In adults, the development of pulmonary embolism response teams (PERTs) or PE critical care pathways has shortened the time to diagnosis and the initiation of definitive management. Evidence to support an improvement in PE outcomes after the development of PERTs does not exist in children. Nonetheless, we have summarized the practical practice guidelines that physicians and institutions can adopt to establish their institutional PERTs or critical pathways. We also provide strategies for resource-challenged institutions for partnering with centers with expertise in the management of pediatric PE.

Adult case of slipped capital femoral epiphysis initially requiring in situ fixation with revision to total hip arthroplasty after failure of index surgery

Introduction: Slipped capital femoral epiphysis (SCFE) is a disorder classically associated with pediatric patients in which the femoral head is displaced through the physis. In rare cases of metabolic and hormonal disorders, SCFEs can be identified in adult patients as a result of persistent growth plates. Optimal definitive surgical management of these patients is still unknown and more information is needed in order to provide appropriate care for these patients. Case Report: A 31-year-old male with past medical history of hypopituitarism presented with left hip pain after a seizure. He was found to have a left slipped capital femoral epiphysis on initial radiographs for which he was taken to the operating room for open treatment of the left SCFE with in situ screw fixation. Approximately four weeks later he returned to the hospital after a fall with left hip pain and inability to ambulate. Radiographs demonstrated cutout of the cannulated screw in the setting of a SCFE with further displacement. He returned to the operating room for conversion to an uncemented total hip arthroplasty. His post-op course was uneventful and he was discharged home in stable condition. Conclusion: This cases highlights a condition uncommonly identified in adult patients which was further complicated by failure of the initial surgical repair and need for revision surgery. This case is unique in that total hip arthroplasty as a definitive treatment for acute SCFE, rather than treatment for end stage arthritis secondary to chronic SCFE, has not been reported upon this author’s review.

Does prior ipsilateral steroid injection affect outcomes after shoulder arthroplasty?

BackgroundSteroid injections are a well-known first-line treatment for glenohumeral osteoarthritis; however, many patients eventually require definitive management with surgery. Recent literature has called into question the safety of steroid injections before shoulder surgery due to increased infections and revisions. Conclusive data regarding the relationship between preoperative injection and postoperative outcomes is lacking. This study aimed to determine the impact of ipsilateral injections on clinical outcomes following shoulder arthroplasty (SA). MethodsA retrospective study was performed on patients who underwent SA by a single fellowship-trained orthopedic surgeon from 2017 to 2021. Patients were divided into two cohorts based on preoperative corticosteroid injection: (1) injection group (IG) and (2) no injection (control group (CG)). The IG was further stratified based on number of injections (1 vs. ≥2 injections) and timing of injections relative to surgery (<3 months, 3-12 months, and >12 months). Patient-reported pain and satisfaction, simple shoulder test, shoulder pain and disability index, visual analog scale for pain, University of California-Los Angeles score, American Shoulder and Elbow Surgeons score, Constant-Murley score, range of motion, complications, and reoperations were collected preoperatively and at final follow-up. Comparisons were made between groups and the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) were calculated for each score. Results421 patients (IG = 98 patients, CG = 323 patients) were included, with mean follow-up of 22 months. The IG had more females (69.1% vs. 48.9%; P < .001) and older age (75 vs. 70; P < .001). There was significantly greater preoperative range of motion in the IG for forward elevation (80° vs. 70°; P = .025) and abduction (70° vs. 60°; P = .004). At final follow-up, all groups had a high percentage (mean 80.26%) of patients exceeding both MCID and SCB for all measures. More patients in the IG exceeded MCID and SCB for visual analog scale for pain (P = .009 and P = .007, respectively), and MCID for American Shoulder and Elbow Surgeons (P = .046) compared to the CG. The group with ≥2 injections reported worse shoulder pain and disability index scores (P = .024). Complication and reoperation rates were comparable between groups. ConclusionOur study indicates that a single ipsilateral shoulder injection did not worsen postoperative outcomes or complication rates following SA. However, patients who received two or more injections had inferior patient-reported outcomes. Surgeons can continue to use injections as a viable first-line management option before shoulder arthroplasty for reliable pain relief without concerns for increased complications.

Outcomes of Percutaneous Image-Guided and Laparoscopic Cholecystostomies in High-Risk Patients With Acute Calculus Cholecystitis: A Five-Year District General Hospital Experience.

Introduction Acute cholecystitis (AC), inflammation of the gall bladder, is one of the most common emergency surgical presentations. In the UK, approximately 15% of the population is estimated to have gallstones, and approximately 20% of them can develop AC. Laparoscopic cholecystectomy (LC) is considered the definitive management of AC. However, cholecystectomy carries a very high risk of morbidity and mortality in high-risk frail patients with multiple comorbidities who are deemed unfit for surgery. Percutaneous cholecystostomy (PC), both image-guided and laparoscopic, is generally acknowledged as an interim treatment measure before definitive management, which is the LC. Materials and methods This is a retrospective study from the Royal Albert Edward Infirmary, a district general hospital (DGH) based in Wigan, UK. The medical records of all the patients whowere admitted to the surgical department and underwent PC between January 2017 and December 2022 were analyzed. Patients with previous hepato-pancreato-biliary (HPB) malignancy, who underwent open cholecystostomy, or those withabdominal ascites were excluded from the study. Information was collected regarding the age, gender, American Society of Anaesthesiologists(ASA) grades, success rates of both procedures as temporary or definitive management, duration of hospital stay, 30-day and 1-year mortality after the procedure, timing of the procedure,and long-term complications after the procedure, particularly those related to cholecystostomy tube dislodgment or blockage. Results Twenty-seven patients who underwent PCwere divided into two groups: group A, consisting of 10 patients who underwent laparoscopic cholecystostomies, and group B, consisting of 17 patients who had ultrasound (US)-guided cholecystostomies.The mean age of the patients in group A was 66.7 as compared to 75.1 in group B.Most of the patients were in ASAgroups III (14) and IV (10). About 74% of patients had procedures done during the day and 26% had PC at night time. The mean hospital stay was 13.5 days. About 55% of patients had planned elective LC as a definitive management. Following the treatment, two patients died within 30 days, and eight patients passed away within a year. About 40% of the patients had complications related to the tube dislodgment and blockage. Conclusion This study concludesthat PC, using both laparoscopic and US-guided techniques, can serve as an interim as well as a definitive measure,particularly in patients who are at high risk for anesthesia and the procedure itself and have multiple comorbidities.

A299 ACUTE TUMOUR RUPTURE POST-TRANSARTERIAL CHEMOEMBOLIZATION IN A PATIENT WITH HEPATOCELLULAR CARCINOMA

Abstract Background Hepatocellular carcinoma (HCC) is the most common primary liver malignancy, with increasing worldwide incidence. Transarterial chemoembolization (TACE) is an interventional radiological (IR) therapy used largely in intermediate stage HCC, which can provide successful bridge or downstaging to liver transplantation and increased survival rates. Tumour rupture is a very rare complication of TACE, with an estimated incidence of 0.68%. Potential risk factors include tumour size ampersand:003E 10 cm, and location of lesions in the right lobe or near the liver capsule. However, the pathophysiology of post-TACE tumour rupture is still not fully understood. Aims We aim to describe a case of HCC tumour rupture that occurred in the first 30 hours post-TACE. We also aim to highlight the extent of multiorgan ischemia associated with this tumour-related arterial bleed. Methods A PubMed literature review was done to ensure that post-TACE tumour rupture was a rare and sparsely reported event. Subsequently, inpatient notes, laboratory and imaging data were obtained from the patient's medical record in an anonymized manner. Results A 66-year-old male with alcohol-related liver cirrhosis (MELDNa 7; Child-Pugh Class A) was diagnosed with a 3.3 cm HCC, spanning segments 5 and 8. Six months later, after multidisciplinary discussion, he underwent successful elective TACE of a segment 8 artery that was supplying the HCC, as a bridge to liver transplantation. The next day, he developed diffuse abdominal pain, emesis, tachycardia, and abdominal firmness and tenderness. Labs showed a 45 g/L drop in hemoglobin (121 g/L to 76 g/L), leukocytosis (27.0 x109/L), and an elevated lactate (4.4 mmol/L). Computed tomography (CT) scan confirmed tumour rupture, with moderate-to-large hemoperitoneum with active bleeding from the embolized region of the HCC, and associated gas. Emergent IR-guided embolization was performed to the bleeding segment 8 artery. CT scan two days later revealed interval ischemic infarction of the spleen, pancreatic tail, and stomach. This widespread ischemia was suspected to be due to hypovolemic hypoperfusion vs. post-TACE embolic phenomena. Aggressive supportive measures, antibiotics, and anticoagulation were implemented. Due to tumour rupture, the patient was deemed no longer a suitable candidate for liver transplantation. Futility of definitive management was discussed, and the patient opted for medical care without resuscitation. After optimization of nutritional and physical functioning parameters, he was discharged home with medical management for pain and ascites. Conclusions Post-TACE tumour rupture is a rare occurrence for which the pathophysiology is not fully understood. This case provides an important reminder of this potential adverse event. Early detection and management are imperative to facilitating a favourable outcome in this life-threatening condition. Funding Agencies None

Factors associated with unplanned clinical encounters for ureteral stent-related symptoms.

Ureteral stent-related symptoms (USRS) often result in unplanned phone calls and ER visits. We hypothesize that patient factors can be identified to predict these unplanned encounters. Retrospective analysis of indwelling ureteral stent placements from 2014 to 2019 at a single institution by CPT code was performed. Patient demographics, discharge medications, and clinical factors were evaluated using multiple logistic regression with respect to postoperative telephone and emergency room (ER) encounters for USRS. Of 374 patients, 75 (20.1%) had one or more encounters for USRS: 48 (12.8%) called the clinic and 39 (10.4%) returned to the ER. Chronic opioid use was predictive of calls to clinic and ER visits (OR 3.21 [CI 1.42-6.97], p < 0.01 and OR 3.64 [CI 1.45-8.98], p < 0.01). Survival analysis stratified by history of chronic opioid use and discharge opioid prescriptions demonstrated that opioid naïve patients receiving opioids at discharge had unplanned encounters sooner and more often [Calls p = 0.025, ER p = 0.041]), whereas patients with chronic opioid usereturned to the ER sooner and more frequently when prescribed additional opioids (Calls p = 0.4, ER p = 0.002). Patients with a history of chronic opioid use may experience more intense USRS or have a lower threshold to seek medical care than opioid naïve patients and tend to bypass calling the clinic for the ER. Given that none of the studied medications reduced unplanned patient contact for USRS, urologists should consider upfront definitive management of urinary obstruction when appropriate.

Percutaneous management of Lutembacher’s syndrome: A case report

The definitive percutaneous management of Lutembacher&amp;rsquo;s syndrome (LS) is a recognized alternative to surgery in selected cases. This intervention involves balloon mitral valvuloplasty (BMV) followed by device closure of the atrial septal defect (ASD). However, despite its recognition, certain challenges inherent to the procedure have not been highlighted in the majority of earlier case reports. The subject of the present case is a 30-year-old male diagnosed with LS who underwent definitive percutaneous treatment. The coexisting ASD required improvisation to facilitate balloon insertion across the mitral valve using the modified Inoue technique. Furthermore, the ASD device was deliberately oversized to prevent device embolization. This case highlights that percutaneous management of LS is not merely a combination of BMV and device closure procedures. Instead, the unique anatomic and hemodynamic features of LS should be considered when formulating treatment strategies for these patients.

Female Bladder Dysfunction Following Boari Bladder Flap Ureteral Reconstruction

ObjectivesTo describe our institution’s experience with Boari flap ureteral reconstruction, specifically focusing on the development of postoperative lower urinary tract symptoms (LUTS). MethodsA retrospective review of all Boari flaps performed at our institution between 2013 and 2023 was performed, excluding patients with urothelial carcinoma and males, given the frequency of LUTS from benign prostatic hyperplasia. Primary outcome was the development of new onset LUTS and subsequent treatment. Secondary outcomes included postoperative infections and ureteral stricture. Results29 total patients were identified. Mean age was 52.2 years (Standard deviation (SD) 13.1). Mean follow-up was 22.3 months (SD 25.3). Primary reasons for ureteral reconstruction were radiation damage (37.9%) and iatrogenic surgical injury (37.9%). A concurrent psoas hitch was performed in 18/29 (62%) cases, nephropexy was utilized in 1/29 (3.4%) cases, and contralateral bladder pedicles were ligated in 10/29 (34.5%) for increased bladder mobilization. Postoperatively, 8 patients (27.6%) developed new-onset LUTS, effectively managed with oral anticholinergics. Recurrent UTIs occurred in 5 patients (17.2%) and pyelonephritis in one (3.4%) patient. Two patients (6.9%) developed ureteral strictures, one treated with ileal ureter replacement and the other with ureteral balloon dilation. ConclusionsBoari bladder flap ureteral reconstruction leads to moderate rates of new onset LUTS postoperatively, which is important information when counseling women on reconstructive options. Boari flap ureteral reconstruction has a high success rate and serious complications are rare. In the setting of ureteral injury, reconstruction using Boari flaps with or without psoas hitch should be considered for definitive management.

Management of rhino-orbito-cerebral mucormycosis: a clinico-radiological study—an institutional experience

BackgroundMucormycosis in the setting of COVID-19 has given rise to the concept of “epidemic within a pandemic.” Once known to be a rare fungal disease, mucormycosis has now been regrouped under emerging pathogens. It has got special affinity for the immunocompromised, which is one of the main reasons for the flare up of the fungus during the second wave of COVID. The burden of the disease was felt globally, and India is facing the major brunt owing to our population and healthcare services ratio.ObjectiveIn our study, we have made an attempt to evaluate the clinical and radiological findings in patients of rhino-orbito-cerebral mucormycosis (ROCM) and to formulate a management protocol which will benefit such patients in forthcoming years.MethodsThis is a retrospective single-center study in Northern India. A total of 350 patients, affected by ROCM, were included in the study. Medical records of these patients were reviewed. Their clinical manifestations, nasal endoscopic findings, microbiological and radiological records, extent of disease, treatment profile, surgical interventions, and outcomes were analyzed. Nasal swab which was sent for KOH mount/fungal culture revealed broad aseptate filamentous fungi branching at right angles. All patients received intravenous amphotericin B and had undergone extensive surgical debridement endoscopically. The maxillary sinus was the commonest paranasal sinus involved followed by the ethmoid sinuses. Tissue sent for histopathological examination confirmed mucormycosis, except for 3 cases.ResultsThe commonest presenting symptoms were cheek swelling with ophthalmoplegia, diminution of vision, and headache. The mean duration of follow-up was 8 months.The maxillary sinus was found to be involved in around 71% of the cases followed by the ethmoids and sphenoid. Thirty percent of the cases had visual complaints including diplopia and vision loss, whereas the palate was involved in around 35%. Nine patients had no perception of light in one eye on presentation, whereas 21 patients had perception of light only; 24 patients could count fingers close to face, and the rest had ambulatory vision. Three patients presented with facial palsy. All patients had favorable outcome except six who succumbed due to cerebral involvement and uncontrolled blood glucose levels.ConclusionA definite management protocol was formulated for ROCM which requires a multidisciplinary approach.