Diameter Of Anastomosis Research Articles

ThP3.13 - Impact of gastrojejunostomy anastomosis diameter on weight loss following laparoscopic gastric bypass: a systematic review

Abstract Introduction Laparoscopic Roux-en-Y Gastric Bypass (RYGB) is a preeminent procedure for achieving significant weight reduction and alleviating obesity-related comorbidities. However, the influence of gastrojejunostomy (GJ) anastomosis diameter on weight loss is not well-elucidated. This review examines the effect of GJ diameter on post-RYGB weight loss outcomes. Methods A meticulous systematic search of the literature, limited to English-language publications, was executed with the assistance of an expert librarian. The search encompassed all studies available up to 3 August 2023, the date of the last search. Study quality was evaluated utilizing the Newcastle-Ottawa Scale. Due to the heterogeneity of the outcomes, a narrative synthesis approach was adopted. Results From 1,026 records screened, 6 studies met the inclusion criteria, demonstrating a range of GJ diameters and follow-up durations (1-5 years). Generally, smaller GJ diameters were associated with more significant weight loss in the short to medium term. There appears to be a threshold for the reduction in diameter; beyond this, the risk of complications such as stenosis may escalate. The studies indicated a moderate to low risk of bias and underscored the importance of accurate GJ area quantification post-operation. Conclusion This review identifies a negative correlation between smaller GJ diameters and weight loss after RYGB. Future investigations should prioritize the standardization of measurement techniques and investigate the potential of intra-operative and artificial intelligence-based methodologies for optimal GJ diameter determination, with the aim of augmenting patient outcomes in bariatric surgery.

Long-term results after transoral outlet reduction (TORe) of the gastrojejunal anastomosis for secondary weight regain and dumping syndrome after Roux-en-Y gastric bypass.

Bariatric surgery has been proven to be the most effective therapy for obesity and Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed procedure. However, weight regain and dumping syndrome occur over time. The transoral outlet reduction (TORe) procedure using an endoscopic suturing device may be an option to treat these conditions. We aimed to analyze outcome parameters and long-term results for this endoscopic technique. A retrospective data analysis of patients who underwent TORe using an endoscopic suturing system at our institution from January 2015 to December 2020 was performed. A total of 71 subjects were included. Forty-five patients received the intervention for weight regain, 9 for dumping syndrome and 17 for both. The primary endpoint was weight stabilization or weight loss for subjects with weight regain, and resolution of symptoms for those with dumping syndrome. Secondary endpoints were intraoperative complications, procedure time, length of hospital stay and diameter of gastrojejunal anastomosis 1year post-intervention. The median size of the gastrojejunal anastomosis was estimated at 30mm before intervention, and after performing a median of 3 endoscopic sutures, the median estimated gastrojejunal anastomosis width was reduced to 9.5mm. Eight perioperative complications occurred. Overall mean follow-up was 26.5months. All interventions achieved weight stabilization or weight loss or resolution of dumping symptoms within the first 3months, 98.2% at 12months, 91.4% at 24months and 75.0% at 48months. In 22/26 subjects a persisting improvement of dumping syndrome was achieved. TORe is a safe and effective procedure in the treatment of patients with dumping syndrome after laparoscopic RYGB, the effect on weight stabilization is less significant. A prospective randomized trial should be conducted to compare the effects of TORe with other surgical methods like banding the gastrojejunal anastomosis.

Effect of tissue tension on magnetic compression anastomosis of digestive tract

With the increasing application of magnetic compression anastomosis (MCA) in gastrointestinal anastomosis, we identified an interesting phenomenon that an anastomosis is more prone to stenosis after endoscopic gastrointestinal MCA. We hypothesized that the increase in tissue tension during endoscopic procedures is the cause of anastomotic stenosis. In this study, we investigated the effect of tissue tension on gastroduodenal bypass MCA in Sprague–Dawley (SD) rats. Twenty SD rats were divided into the study group (high-tension group, n = 10) and control group (no tension group, n = 10), wherein the rats underwent complete gastroduodenal bypass magnetic anastomosis under high tension and no tension of the digestive tract, respectively. Anastomotic specimens were obtained 4 weeks after the operation, and anastomotic diameters of the two groups were observed and measured. The histological difference was observed by hematoxylin & eosin and Masson staining. The operation was successfully completed in all rats, and all survived until 4 weeks postoperatively. Anastomotic measurements revealed that the anastomosis diameter was significantly smaller in the study group than in the control group, and there were three cases of severe anastomotic stenosis. Histological observation showed that the amount of collagen fibers in the anastomosis was greater in the study group than in the control group. The results suggest that the high-tension state of the digestive tract is an important factor leading to anastomotic stenosis, and thus, we put forward the Yan-Zhang’s Tissue Tension Theory of MCA to explain this phenomenon.

Influence of different magnetic forces on the effect of colonic anastomosis in rats.

Despite much work having been conducted on magnetic compression anastomosis (MCA) in the digestive tract, there are no reports on the influence of magnetic force on the anastomosis. To investigate the effect of different magnetic force magnets on the MCA of the digestive tract. Two groups of magnets of the same sizes but different magnetic forces were designed and produced. A total of 24 Sprague-Dawley rats were randomly assigned into two groups (powerful magnet group and common magnet group), with 12 rats in each group. Two types of magnets were used to complete the colonic side-to-side anastomosis of the rats. The operation time and magnet discharge time were recorded. The anastomotic specimens were obtained 4 wk after the operation and then the burst pressure and diameter of the anastomosis were measured, and the anastomosis was observed via the naked eye and subjected to histological examination. The magnetic forces of the powerful and common magnet groups at zero distance were 8.26 N and 4.10 N, respectively. The colonic side-to-side anastomosis was completed in all 24 rats, and the operation success rate and postoperative survival rate were 100%. No significant difference was noted in the operation time between the two groups. The magnet discharge time of the powerful magnet group was slightly longer than that of the common magnet group, but the difference was not statistically significant (P = 0.513). Furthermore, there was no statistical difference in the burst pressure (P = 0.266) or diameter of magnetic anastomosis (P = 0.095) between the two groups. The gross specimens of the two groups showed good anastomotic healing, and histological observation indicated good mucosal continuity without differences on healing. In the rat colonic side-to-side MCA model, both the powerful magnet with 8.26 N and the common magnet with 4.10 N showed no significant impact on the anastomosis establishment process or its effect.

Correlation Between Gastrojejunal Anastomosis Diameter, Distensibility Index, and Weight Regain After Roux-en-Y Gastric Bypass.

Gastrojejunal anastomosis (GJA) dilation is an independent predictor of weight regain (WR) after Roux-en-Y gastric bypass (RYGB). However, the role of planimetric measurements in this context remains unknown. This is a retrospective cohort study including adult RYGB patients who underwent a diagnostic endoscopy withEndoflip assessment of the GJA. We excluded patients in the early postoperative period and those with abnormal endoscopic findings (marginal ulcers and gastro-gastric fistulas). Thirty-four patients were initially included. Endoscopic GJA diameter had a moderate positive correlation with WR (r=+0.438, p=0.011). However, after excluding the 7 patients with GJA> 30 mm, there was no significant correlation. There was a moderate agreement between the EndoFLIP-GJA diameter at 60mL and endoscopic diameter (ICC=0.576, p=0.049). The distensibility index (DI) showed a consistent moderate negative correlation with WR. Considering the maximum DI at 40 ml, we found a cutoff of DI = 7 mm2/mmHg that split the sample in two significantly different populations in terms of WR (67.4% vs. 43.2%, p=0.04). Visual estimation of the GJA diameter correlates with EndoFLIP at 60mL. In the subset of patients with GJA ≤ 30 mm, more distensible GJAs are associated with lower rates of WR. Larger studies are needed to confirm this correlation and to validate its utility for clinical management.

SP7.1 Effect of gastrojejunal anastomosis diameter in laparoscopic one-anastomosis gastric bypass for the treatment of morbid obesity and related disorders: a comparative study

Abstract Background One-anastomosis gastric bypass (OAGB) is a safe and effective bariatric procedure that employs a long gastric pouch with antecolic loop gastrojejunal (GJ) anastomosis. The optimum anastomosis diameter is still unclear, as there are many differences in the literature. Aim This study aims to evaluate the short-term effect of different GJ anastomosis diameters in patients offered laparoscopic OAGB regarding weight loss, bile reflux, and nutritional and metabolic effect. Patients and methods A total of 59 patients were included in this study, and they were divided into two groups: group A included patients with GJ anastomosis made by a 45-mm stapler reload, and group B included patients with GJ anastomosis made by 20 mm of the stapler reload. Results There was no statistically significant difference between groups regarding postoperative mean BMI at 3, 6, 9 months, and 1 year; excess weight loss (EWL%); remission of comorbidities; and bile reflux (P>0.05). Hypoalbuminemia was significantly more evident in group B at 3, 9 months, and 1 year, with P values of less than 0.001, 0.035, and 0.031, respectively. Moreover, group B patients had more iron-deficiency anemia, which was statistically significant at 3, 6, and 9 months (P<0.05), whereas there was no significant difference at 1 year (P=0.128). Conclusion OAGB is an effective bariatric procedure, but the use of a 45-mm stapler reload for GJ anastomosis may be associated with less nutritional deficiencies than using 20 mm of the reload. Further studies are needed on a larger number of patients with long-term follow-up.

Factors Associated with Weight Loss After Endoscopic Transoral Outlet Reduction (TORe)

IntroductionEndoscopic transoral outlet reduction (TORe) has emerged as a safe and effective treatment option for weight regain after Roux-en-Y Gastric Bypass (RYGB). Factors that predict successful weight loss after TORe are incompletely understood. The aims of this study were to evaluate procedural factors and patient factors that may affect percent total body weight loss (%TBWL) after TORe. MethodsA retrospective cohort study was performed on patients after TORe. The primary outcomes were %TBWL at 6 and 12 months based on four procedural factors: purse-string (PS) vs. non-purse-string (NPS) suture pattern, gastric pouch sutures (N), change in the diameter of the gastrojejunal anastomosis, and change in the length of the gastric pouch. Secondary outcomes included patient factors that affected weight loss. ResultsFifty-one patients underwent TORe. Weight loss for completers was 11.3 ± 7.6% and 12.2 ± 9.2% at 6 and 12 months. There was a correlation between %TBWL and change in pouch length at 6 and 12 months and number of sutures in the pouch at 6 months. The difference in %TBWL between PS and NPS groups at 6 months (PS, n=21, 12.3 ± 8.5% and NPS, n=8, 8.7 ± 3.7%) and 12 months (PS, n=21, 13.5 ± 9.2% and NPS, n=5, 7.0 ± 7.9%) did not reach statistical significance. For secondary outcomes, depression was associated with %TBWL. ConclusionChange in pouch length and number of sutures in the pouch correlated positively while depression correlated negatively with weight loss after TORe. Further studies are needed to understand these effects.

The Impact of Hepatic Artery Thrombosis on the Outcome of Pediatric Living Donor Liver Transplantations

The aim of our study was to assess risk factors for hepatic artery thrombosis (HAT) and to evaluate the impact of HAT management on long-term outcomes after pediatric living donor liver transplantation (LDLT). We retrospectively analyzed 400 patients who underwent primary LDLT between 1999 and 2020. We compared preoperative data, surgical factors, complications, and patient and graft survivals in patients with HAT (HAT Group) and without HAT (non-HAT Group). A total of 27 patients (6.75%) developed HAT. Acute liver failure, a hepatic artery (HA) anastomosis diameter below 2 mm, and intraoperative HA flow dysfunction were significantly more common in the HAT Group (p < 0.05, p = 0.02026, and p = 0.0019, respectively). In the HAT Group, 21 patients (77.8%) underwent urgent surgical revision. The incidence of biliary stenosis and retransplantation was significantly higher in the HAT Group (p = 0.00002 and p < 0.0001, respectively). Patient and graft survivals were significantly worse in the HAT Group (p < 0.05). The close monitoring of HA flow with Doppler ultrasound during the critical period of 2 to 3 weeks after LDLT and the immediate attempt of surgical revascularization may attenuate the elevated risk of biliary stenosis, graft loss, and the need for retransplantation due to HAT.

Factors predicting surgical difficulties in congenital biliary dilatation in pediatric patients.

The effects of disease classification and the patient's preoperative condition on the difficulty of performing a laparotomy for pediatric congenital biliary dilatation (CBD) have not been fully elucidated. The present study retrospectively analyzed 46 pediatric CBD laparotomies performed at the study center between March 2010 and December 2021 and predictors of operative time. The patients were separated into a short operative time group (SOT) (≤ 360min, n = 27) and a long operative time group (LOT) (> 360min, n = 19). The preoperative AST and ALT values were higher, and the bile duct anastomosis diameter was larger, in the LOT. Correlation analysis demonstrated that the maximum cyst diameter, preoperative neutrophil-to-lymphocyte ratio, AST, ALT, AMY, and bile duct anastomosis diameter correlated positively with operative time. Multivariate analysis identified the maximal cyst diameter, preoperative AST, and bile duct anastomosis diameter as significant factors affecting surgical time. Postoperatively, intrapancreatic stones and paralytic ileus were observed in one patient each in the SOT, and mild bile leakage was observed in one patient in the LOT. The maximum cyst diameter, preoperative AST, and bile duct anastomosis diameter have the potential to predict the difficulty of performing a pediatric CBD laparotomy.

Transoral Outlet Reduction (TORe) for the Treatment of Weight Regain and Dumping Syndrome after Roux-en-Y Gastric Bypass

Obesity is a chronic relapsing disease of global pandemic proportions. In this context, an increasing number of patients are undergoing bariatric surgery, which is considered the most effective weight loss treatment for long-term improvement in obesity-related comorbidities. One of the most popular bariatric surgeries is the Roux-en-Y gastric bypass (RYGB). Despite its proven short- and long-term efficacy, progressive weight regain and dumping symptoms remain a challenge. Revisional bariatric surgery is indicated when dietary and lifestyle modification, pharmaceutical agents and/or psychological therapy fail to arrest weight regain or control dumping. However, these re-interventions present greater technical difficulty and are accompanied by an increased risk of peri- and postoperative complications with substantial morbidity and mortality. The endoscopic approach to gastrojejunal anastomotic revision, transoral outlet reduction (TORe), is used as a minimally invasive treatment that aims to reduce the diameter of the gastrojejunal anastomosis, delaying gastric emptying and increasing satiety. With substantial published data supporting its use, TORe is an effective and safe bariatric endoscopic technique for addressing weight regain and dumping syndrome after RYGB.

Efficacy of the argon plasma coagulation in patients with weight regain after gastric bypass: a randomized control trial.

Background and study aims Endoscopic procedure using argon plasma coagulation (APC) promotes a progressive reduction in gastrojejunal anastomosis diameter. The present study aimed to evaluate the efficacy of the APC in patients with weight regain in the postoperative periods of gastric bypass. Patients and methods This was a randomized controlled trial conducted with 66 patients who were randomly assigned selected (using lottery method) and divided into two groups: study group (SG), 38 patients (APC treatment); and control group (CG), 28 patients (only endoscopy procedure). We considered 30 days,180 days, and one year as short-term, medium-term, and long-term, respectively. The parameters analyzed were total weight loss (TWL), excess weight loss (%EWL), total weight loss (%TWL), and reduction of weight regain (%RWR). Furthermore, a biopsy for neoplastic histological changes was carried out for the APC group. For statistical analysis, values of P < 0.05 were considered significant. Results The %TWL and %RWR were higher in the SG in short, medium, and long terms, when compared to the same periods in the CG ( P < 0.001). One year after follow-up, the final weight did not reach the statistical difference between groups. Biopsy performed in SG 1 year after APC did not reveal neoplastic histological changes. Conclusions APC effectively treats weight regain after bariatric surgery in the short and medium-term. An important "new" weight gain was observed in the long-term, showing that obesity is a chronic disease that requires multidisciplinary and family care for life. Also, APC is a safe procedure with low adverse event rates.

Association between brachial artery peak systolic velocity and ipsilateral radio-cephalic arteriovenous fistula maturation.

To evaluate the association between brachial artery blood velocity by color Doppler flow imaging (CDFI) and primary maturation of radio-cephalic autologous arteriovenous fistula (RC-AVF). Clinical data from patients who underwent end-to-side cephalic-radial anastomosis were collected from December 2015 to December 2020. The anastomosis diameter (mm), blood velocity (cm/s), and brachial artery diameters (mm) 7 cm proximal to the elbow pre- and postoperation were measured by GE LOGIC-E9 ultrasound. The AVF was mature if it could be cannulated successfully and the blood flow was >200 ml/min during dialysis. A total of 197 patients were included in our statistical analysis. A total of 163 patients had mature AVFs, and 34 patients had poor maturity (assisted and failed maturation). There were no significant differences in the clinical characteristics, peak systolic velocity (PSV) of the brachial artery, diameter of the radial artery or cephalic vein measured by CDFI preoperatively. The diameter of the brachial artery (5.41 ± 0.77 vs 4.89 ± 0.90, p = 0.00) and the fistula anastomosis (2.79 ± 0.78 vs 2.45 ± 0.85, p = 0.02) and PSV of the brachial artery (123.58 ± 37.11 vs 89.63 ± 28.31, p = 0.00) in the mature group were higher than those in the immature group. Brachial artery PSV and increased brachial artery PSV could be used to detect RC-AVF maturation in the early stage.

Arteriovenous Fistula Anastomosis Diameter Association with the Ischemic Steal Syndrome Occurrence

OBJECTIVE: Symptomatic Steal syndrome is one of the major complications following arteriovenous access fistula (AVF). The aim of this study is to investigate the association between AVF anastomosis diameter and the incidence of symptomatic steal syndrome.&#x0D; METHODS: A total of 103 patients with AVF were enrolled retrospectively in the study. There were two groups in the study, 77 patients with clinical symptomatic steal syndrome and 26 control with mature AVF with no symptoms. Anastomosis diameter was measured at the site of anastomosis and recorded at different fistula locations. Patient demographic, risk factors and access characteristics were recorded.&#x0D; RESULTS: Symptomatic Steal syndrome was more common among female patients (75.4%). Symptomatic Steal syndrome was more prevalent in patients with diabetes mellitus (DM), 77.8%, p&lt;0.001. The mean anastomosis diameter in patients with Symptomatic steal syndrome was 3.74(±1.47) mm and in the control group 4.07(±1.79) mm, which indicates no significant difference in the anastomosis diameter, p=0.425. Analysis of covariance (ANCOVA) indicated that cardiovascular disease [F (1,94) =15.691, p=0.008] and peripheral vascular diseases [F (1,94) =13.059, p=0.016] are associated with steal syndrome incidence.&#x0D; CONCLUSION: The findings of this study conclude that there is no significant association between increased anastomosis diameter and the incidence of AVF steal syndrome.&#x0D;

Resizing of the Gastric Pouch for Weight Regain after Laparoscopic Roux-en-Y Gastric Bypass and One-Anastomosis Gastric Bypass: Is It a Valid Option?

The laparoscopic resizing of the gastric pouch (LPR) has recently been proposed as a revisional technique in the case of weight regain (WR) after gastric bypass procedures. The aim of this study was to report our experience with LPR for WR. All patients with WR ≥ 25% after gastric bypass and with a dilated gastric pouch and/or gastrojejunal anastomosis who underwent LPR between January 2017 and January 2022 were retrospectively reviewed. From a radiological point of view, a gastric pouch was considered dilated when its volume was calculated at &gt;80 cm3 for LRYGB and &gt;200 cm3 for OAGB upon a 3D-CT scan. The endoscopic criterion considered both the diameter of the gastrojejunal anastomosis and the gastric pouch volume. All anastomoses &gt; 20 mm for LRYGB and &gt;40 mm for OAGB were considered dilated, while a gastric pouch was considered endoscopically dilated when the retrovision maneuver with the gastroscope was easily performed. These selection criteria were arbitrarily established on the basis of both our personal experience and literature data. Twenty-three patients had LPR after a Roux-en-Y gastric bypass or one-anastomosis gastric bypass. The mean BMI at LPR was 36.3 ± 4.7 kg/m2. All patients underwent LPR, while the resizing of the GJA was also performed in 3/23 (13%) cases, and hiatoplasty was associated with the resizing of the pouch in 6/23 cases (26.1%). The mean BMI at the last follow-up was 29.3 ± 5.8 kg/m2. The difference between the BMI before resizing and the BMI at the last follow-up visit was statistically significant (p = 0.00005). The mean %TWL at 24.2 ± 16.1 months was 19.6 ± 9%. Comorbidities had an overall resolution and/or improvement rate of 47%. The mean operative time was 71.7 ± 21.9 min. The conversion rate was nil. Postoperative complications occurred in two cases (8.7%). In our series, LPR for WR showed good results in weight loss and in improvement/resolution of comorbidities, with an acceptable complication rate and operative time. Only further studies with a greater cohort of patients and a longer postoperative follow-up will be able to highlight the long-term benefits of this technique.

628. THE BEST METHOD OF THE GASTRIC TUBE RECONSTRUCTION AFTER ESOPHAGECTOMY

Abstract As a postoperative complication of esophageal cancer, anastomotic leakage (AL) is a serious complication that affects not only the delay in the start of oral intake but also the prognosis. Anastomotic stenosis (AS) also has a significant effect on postoperative quality of life. The blood flow evaluation of gastric tube was introduced for the purpose of improving these, and then the anastomosis method was changed from hand-sewn to Collard's modified method. Esophageal cancer patients who underwent gastric tube reconstruction as a radical operation for esophageal cancer during the period from January 2017 to November 2021 were included (n=120). The blood flow evaluation of gastric tube using the ICG was started in 2019, and the anastomosis method was changed from hand-sewn to Collard modified method from April 2021. These patients were divided into 3 groups and the surgical results were compared and examined. Group A (without blood flow evaluation, hand-sewn): 55 cases, Group B (with blood flow evaluation, hand-sewn): 42 cases, Group C (with blood flow evaluation, modified Collard method): 23 cases. In the blood flow evaluation of gastric tube, the A and B groups were compared, and the AL incidence rate tended to be higher in the B group (A/B: 18.2%/33.3%, p=0.087). The incidence of AS was significantly higher in group B (A/B: 32.7%/66.7%, p=0.001). There was no difference in the incidence of AL between groups B and C (B/C: 33.3%/26.0%, p=0.586). The incidence of AS was significantly lower in group C (B/C: 66.7%/5.9%, p&amp;lt;0.001). The incidence of AL was compared by anastomotic method, but no difference was observed (P = 0.444). In addition, there was no difference in postoperative complications. It is considered that the modified Collard method could reduce AS because a constant anastomosis diameter could be maintained even when a difference in diameter between the esophagus and the gastric tube was observed during the anastomosis. However, both AL and AS have increased due to the evaluation of gastric tube blood flow, and it is necessary to review the blood flow evaluation method.

Arterial diameter ratio as a reliable predictor for upper limb steal syndrome in patients with arteriovenous fistula for hemodialysis.

The aim of this study is to assess the association between the anastomosis diameter enlargement and steal syndrome incidence in patients with upper limb arteriovenous fistula using ratios as reliable predictors. An analytical cross-sectional prospective study was conducted. A total of 49 patients with AVF hemodialysis access were recruited. Twenty-four participants with positive steal syndrome and 25 control were enrolled in the study. Anastomosis diameter, anastomosis diameter ratio, and volume flow ratio were measured ultrasonographically by two expert vascular sonographers. These clinical parameters were recorded and analyzed to assess the difference and association. Patient risk factors and steal syndrome association were emphasized. The study analysis indicates a strong association in the anastomosis diameter and anastomosis diameter ratio between steal and non-steal patients with a p-value ≤0.05. Additionally, there was a significant increase in the volume flow ratio in the patients with steal syndrome compared to the control group (p-value ≤0.05). There was a strong relationship between steal syndrome and the presence of peripheral arterial disease (73.9%, p = 0.001). The ICC index of absolute agreement between the two observers was ICC= 0.99 (95% CI 0.99-0.99, n = 10), indicating excellent agreement between observers. Anastomosis diameter and volume flow ratio strongly suggest that steal syndrome is associated with the increased diameter of anastomosis. Patients with a≥1.05 anastomosis diameter ratio have a greater risk of developing steal syndrome than those with an anastomosis ratio of ≤0.8. In addition, patients with a volume flow ratio ≥0.98 have an increased risk of developing steal syndrome than those with a volume flow ratio of ≤0.75.

Рентген-эндоскопическое лечение облитерации уретерорезервуароанастомоза после перенесенной ортотопической пластики мочевого пузыря

Strictures and obliterations of ureteral anastomosis after radical cystectomy with orthotopic neobladder reconstruction occur in 8-13% of cases, mainly in the first 2 years after surgery. According to the European Association of Urology guidelines, open reconstruction is considered the "gold standard" for the treatment of those patients. At the same time, according to various publications, X-ray endoscopic treatment of ureteral anastomotic strictures can be performed, especially in patients who have undergone orthotopic neobladder reconstruction.Three clinical cases of endoscopic treatment of ureteral anastomotic obliteration after orthotopic neobladder formation are presented. In all patients, nephrostomy tube was initially put due to acute pyelonephritis. Obliteration of the ureteral anastomosis was diagnosed by contrast-enhanced multispiral computed tomography and antegrade pyelography. The length of obliteration in all patients did not exceed 1.0 cm. The recurrence of the bladder cancer was excluded. After percutaneous opacification of the pelvicalyceal system and advancement of two guidewires ("working" and "safety") to the level of ureteral obliteration, a catheter with a built-in fiber optic light source was put in antegrade fashion along the "working" guidewire to the area of obliteration. During transurethral inspection of the reservoir, the distal end of the light source was visualized and the reservoir wall was cut "to the light" using electrosurgery (n=2) and a thulium fiber laser (one case). For adequate kidney drainage, two internal stents of 6 Fr were put for a period of 6 months in two patients and for 2 months in another case.All patients had an adequate diameter of the ureteral anastomosis after removal of the stents. In two cases, an adequate passage of the contrast agent through both ureters was maintained for 42 and 37 months after procedure (according to the follow-up computed tomography and excretory urography). One patient had an attack of acute pyelonephritis 2 months after the removal of internal stents due to recurrent stricture. After repeated endoscopic ureteral recanalization with putting of two internal stents for a period of 6 months, no recurrence of the stricture was observed during 28 months of follow-up.Endoscopic treatment of both primary and recurrent short ureteral anastomotic obliterations in patients with orthotopic neobladder allows for adequate ureteral patency, provided that two internal stents are left in place for 6 months.

Impact of placental sharing and large bidirectional anastomoses on birthweight discordance in monochorionic twins: a retrospective cohort study in 449 cases

In monochorionic twin pregnancies, the fetuses share a single placenta. When this placenta is unequally shared, a discordant antenatal growth pattern ensues resulting in high rates of perinatal morbidity and mortality. Understanding placental pathophysiology is paramount in devising feasible antenatal management strategies. Unequal placental sharing is not the sole determinant of birthweight discordance as there is no one-to-one relationship with placental share discordance. Placental angioarchitecture, especially the presence of large bidirectional anastomoses, is thought to affect this relationship by allowing for a compensatory intertwin blood flow. This study aimed to assess whether placental angioarchitecture can affect birthweight discordance in live-born monochorionic twins, the aim of our study was 2-fold: (1) to assess the relationship between birthweight discordance and placental share discordance and (2) to examine to what extent large bidirectional anastomoses can compensate for the effect of unequal placental sharing on birthweight discordance, with a subgroup analysis for umbilical artery Doppler flow patterns in cases with a birthweight discordance of ≥20%. This was a retrospective cohort study that included monochorionic twin pregnancies observed in our center between March 2002 and June 2021, in which twins with a birthweight discordance of ≥20% were classified according to umbilical artery Doppler flow patterns of the smaller twin. We excluded cases with twin-twin transfusion syndrome and twin anemia polycythemia sequence. Monochorionic placentas of live-born twins were injected with dye, and images were saved for computer measurements of placental sharing and the diameter of anastomoses. Univariate linear regressions of the relationship between placental share discordance and birthweight discordance (both calculated as weight or share larger twin-weight or share smaller twin/weight or share larger twin×100%) and the relationship between arterioarterial and venovenous diameters and birthweight ratio/placental territory ratio were performed. A total of 449 placentas were included in the analysis. Placental share discordance was positively correlated with birthweight discordance (β coefficient, 0.325; 95% confidence interval, 0.254-0.397; P<.0001). The arterioarterial diameter was negatively correlated with birthweight ratio/placental territory ratio (β coefficient,-0.041; 95% confidence interval,-0.059 to-0.023; P<.0001), meaning that an increase in arterioarterial diameter leads to less birthweight discordance than expected for the amount of placental share discordance. There was no relationship between venovenous diameter and birthweight ratio/placental territory ratio (β coefficient,-0.007; 95% confidence interval,-0.027 to 0.012; P=.473). Birthweight discordance in monochorionic twins was strongly associated with placental share discordance. Large arterioarterial anastomoses can mitigate the effect of unequal placental sharing.

Comparison Between Modified Lateral Arm Free Flap and Traditional Lateral Arm Free Flap for the Reconstruction of Oral and Maxillofacial Soft Tissue Defects.

ObjectiveThe traditional lateral arm free flap (tLAFF) has the disadvantages of short vascular pedicle, small vascular diameter, and non-perforator flap. We used a new method to prepare modified LAFF (mLAFF) and evaluate its application value in the repair of oral and maxillofacial soft tissue defects.MethodsThe anatomical features of the flap were recorded and compared between the tLAFF group and the mLAFF group. All the flaps in the modified group were perforator flaps. Statistical analysis was performed on the data using ANOVA on SPSS 22.0 statistical software package.ResultsForty-five mLAFFs were prepared as eccentric design rotation repair perforated flap, or multi-lobed or chimeric perforator flaps. Compared with the tLAFF, the vascular pedicle length of the mLAFF was increased, and the outer diameter of the anastomosis was thickened. The damage to the donor site was less. The difference was statistically significant.ConclusionThe mLAFF can effectively lengthen the vascular pedicle length and increase the anastomosis diameter. Perforator LAFFs in the repair of oral and maxillofacial defects have good application value.

MO779: Benefits of a Nefrovascular Ultrasound Consultation: Results of 2 Years of Follow-Up

Abstract BACKGROUND AND AIMS The main vascular access for haemodialysis patients is the arteriovenous fistula (AVF). There is a high rate of early primary failure and loss of primary patency, therefore, vascular access monitoring is essential for the early diagnosis of complications and prolonging their survival. Our objective is to analyse the results of a consultation for the review and follow-up of AVFs using colour-Doppler ultrasound, performed by the nephrologist. METHOD Retrospective descriptive study of vascular ultrasounds performed from January 2019 to January 2021. Including clinical and demographic variables of the patients, as well as ultrasound parameters. Data from the Review group were compared; ultrasounds performed 3–4 weeks after performing vascular access; versus Dysfunction group; whose patients were referred from the advanced chronic kidney disease (ACKD) consultations or from the different dialysis centres upon detecting any data of suspected vascular access dysfunction. RESULTS A total of 166 vascular ultrasounds were performed: 106 (64%) in the Review group and 60 (36%) in the Dysfunction of the AVF group. A higher proportion of women was found in the Dysfunction group and upper mean age, close to the significance, P = 0.06 and P = 0.059 respectively. No significant differences were found with respect to other demographic characteristics in both groups (hypertension, diabetes, anticoagulant treatment and aetiology of kidney disease). Regarding the type of vascular access, a lower proportion of radiocephalic AVFs was observed in the Revision group (65% versus 50%) and a greater number of elbow AVFs (humero cephalic, humero basilic and humero median) in the Dysfunction group (35% versus 50%) with differences close to significance, P = 0.057. In the Review group, in 70.8% the findings were normal, in 24.5% lack of development was found, thrombosis in 9.4%, stenosis 6.6%, aneurysm 6%, oedema 17% and haematoma 6.6%. A 43% of the patients did not require to implement measures, in 42% exercise was recommended, in 6% repose of the AVF and 6 patients were requested fistulography and 3 were referred to cardiovascular surgery (CCV). In the Access Dysfunction group, the ultrasound diagnosis was normal in 28%, thrombosis was objective in 25%, stenosis 37%, aneurysm 42%, oedema 17%, haematoma 22%. 37% were referred for fistulography and 15% for revision by CCV. Regarding the ultrasound parameters, significant differences (P &amp;gt; 0.05) were found in terms of AVF flow, proximal and distal resistance index and vein calibre, but not in terms of vein depth and anastomosis diameter. A total of 28 fistulograms were performed, finding 86% agreement with the ultrasound findings. And in 93% the intervention was successful. Only 24% of the patients referred to the consultation required some type of intervention, and up to 65% were able to save the AVF, avoiding the realization of a new vascular access. CONCLUSION The systematic review after performing the vascular access made it possible to diagnose complications early and allow early intervention. It might be necessary to establish predictive criteria for vascular access dysfunction to individualize the follow-up for each patient, such as age, sex, or type of vascular access. Systematized vascular ultrasound by the nephrologist is very useful to preserve the functionality of the vascular access. On the other hand, the Vascular Nephrodiagnosis Consultation can avoid performing invasive and unnecessary procedures for the patient.