Dilation Procedures Research Articles

A case of esophageal squamous cell carcinoma with epidermization showing a unique morphology.

An 80-year-old woman with a history of endoscopic balloon dilation for esophageal stricture caused by accidental ingestion of caustic soda during infancy presented with dysphagia. Upper gastrointestinal endoscopy revealed a 10-cm-long, highly white, elevated lesion with a feathered appearance. This lesion was determined to be the cause of dysphagia and was completely resected via endoscopic submucosal dissection. Histopathological examination revealed a thick keratin layer on the surface of the stratified squamous epithelium, with a prominent granular layer underneath and some areas showing nuclear atypia. The lesion was diagnosed as a well-differentiated squamous cell carcinoma, pT1a-LPM, derived from epidermoid metaplasia. Cancer genome analysis revealed mutations in TP53 as well as amplification of MYC, FGFR1, chromosome 7, and chromosome 20q. This case suggests that epidermoid metaplasia caused by chronic irritation from an esophageal stricture may have been exacerbated by the dilation procedure.

S625 Safety of Esophageal Dilation Procedures in Patients on Antithrombotic Therapy: A US Collaborative Network Cohort Study

S625 Safety of Esophageal Dilation Procedures in Patients on Antithrombotic Therapy: A US Collaborative Network Cohort Study

Surgical abortion service reorganization in response to the COVID-19 pandemic: a unique experience of attending second trimester D&E procedures under spinal anesthesia as emergency procedures.

The COVID-19 pandemic created a massive shift in how health care systems interact with COVID testing for patients. To avoid delay in accessing second trimester surgical abortion at our hospital (St. Paul's Hospital Millennium Medical College) during this pandemic, dilation and evacuation (D&E) procedures were attended as emergency cases, instead of as elective surgical procedures, which then required adherence to the universal preoperative COVID-19 testing protocol. This study aimed at documenting the experience of this unique abortion service adjustment in response to the COVID-19 pandemic. This was a retrospective descriptive study conducted at St. Paul's Hospital Millennium Medical College (SPHMMC) in Addis Ababa, Ethiopia, from April 1, 2021 to July 31, 2021. We reviewed second trimester surgical abortion cases managed with D& E procedures, performed under spinal anesthesia using the emergency COVID-19 pre-operative testing protocol. Data were analyzed using SPSS version 23 and simple descriptive statistics were applied. Percentages and proportions were used to present the results. Nineteen cases of second trimester D&E cases were reviewed. The median gestational age of the abortion clients was 21.57 weeks. Eight of 19 cases had cervical preparation with overnight intra-cervical Foley catheter placement while the rest 11 (57.9%) cases had their cervical preparation with Laminaria. The median time interval from initial evaluation of the abortion client to time of doing D& E procedure was 21.83 h. Surgical abortion service reorganization enabled abortion clients to access dilation and evacuation procedures within 24 h of their initial presentation. This prevented significant delays in accessing abortion care that could otherwise have occurred as a result of adhering to the preoperative COVID-19 testing protocols applied to elective surgeries.

The value of cesarean scar diverticulum in diagnosis of adverse events during dilatation and curettage in patient with cesarean scar pregnancy.

The aim of the present study was to explore the relationship between the size of cesarean scar diverticulum (CSD) measured on preoperative magnetic resonance imaging (MRI) and adverse events during dilatation and curettage (D&C) procedure in patients with cesarean scar pregnancy (CSP). The MRI of 197 CSP patients from October 2019 to August 2023 were retrospectively reviewed. The volume, area, and depth of CSD, residual myometrium thickness (RMT), and gestational sac diameter were recorded and tested for correlation with intraoperative estimated blood loss (EBL), and operation time and for any association with the intraoperative adverse events (intraoperative massive hemorrhage [39 cases] and D&C procedure failure [15 cases]). The Spearman test was used to characterize the correlation between the five MRI variables and both the EBL and operation time. The correlation between the five MRI variables and intraoperative adverse events was evaluated with student's t test and Mann-Whitney U test. Diagnostic power of the MRI variables was evaluated by the area under receiver operating characteristic curve (AUC). The volume, area, and depth of CSD and gestational sac diameter were positively correlated with both EBL and operation time, with the CSD volume having the highest correlation with them (r = 0.543 and 0.461, respectively). Conversely, the RMT displayed a negative correlation with the EBL and operation time. All five MRI variables were significantly associated with both intraoperative massive hemorrhage and D&C failure (all P < 0.001). The CSD volume demonstrated the highest AUC for diagnosing intraoperative massive hemorrhage and D&C failure at 0.893 (95% CI: 0.82-0.92) and 0.901 (95% CI: 0.85-0.94), respectively. The optimal cutoff values for CSD volume in predicting massive hemorrhage and D&C failure were determined to be 5.41 and 8.92 cm3, respectively, with corresponding sensitivities/specificities of 92.31/74.68 and 93.33/82.42, respectively. Quantifying the size of CSD based on preoperative MRI could aid in evaluating risk during D&C in CSP patients, with CSD volume possessing higher diagnostic efficacy than the other four MRI indicators.

Transurethral balloon dilation safety and efficacy in patients with recurrent bladder neck contracture after transurethral interventions

Introduction. Currently, urologists are divided on which method is most effective for treating bladder neck contracture (BNC) after surgery: transurethral resection (TUR) or incision.Objective. The study aimed to assess the balloon dilation safety and success in patients with recurrent bladder neck contracture (BNC) after endoscopic surgery for benign prostatic hyperplasia (BPH).Materials &amp; Methods. This study involved 110 patients with recurrent BNC after transurethral interventions for BPH. All patients underwent TUR of the bladder neck and were divided into 2 groups: group A (n = 45) included men who, after TUR, additionally underwent repeated balloon dilation, while the control group B (n = 65) included men who were treated with alpha-blockers alone.Results. In 9 months after TUR and 3 months after the fourth balloon dilation procedure in group A, the mean international prostate symptom score (IPSS) decreased from 20.1 ± 8.4 to 17.2 ± 7.4, and the IPSS-quality of life (QoL) was 4.2 ± 1.2 (p &gt; 0.05). In group B, they were 21.7 ± 7.7 and 4.7 ± 1.1 (p &gt; 0.05), respectively. Additionally, the mean flow rate in group A was 13.2 ± 5.4 ml/s, while in group B, it was 8.7 ± 4.9 ml/s (p &lt; 0.05). There was a significant decrease in the post-void residual urine volume (PVR) from 76.2 ± 96.1 ml to 37.6 ± 55.1 ml in group A, whereas, in group B, it increased from 63.0 ± 36.9 ml to 79.4 ± 71.6 ml (p &gt; 0.05). Also, 28.0% of patients of group B, and 13.3% of patients of group A underwent repeated TUR of the bladder neck in 9 months follow-up period (p &lt; 0.05).Conclusion. Balloon dilation procedure is a relatively safe less invasive procedure and can reduce the BNC recurrence rate and consequently the rate of repeated transurethral interventions.

Unravelling supravalvular aortic stenosis in a young patient: look beyond the valve.

A 16-year-old adolescent girl was referred to our tertiary care center for management of a failed aortic valve balloon dilatation procedure for congenital valvular aortic stenosis. The medical records revealed a residual peak-to-peak gradient of 80 mm Hg after 2 dilations with 16 x 6-mm Tyshak balloon (NuMed Inc.).

Recurrent Esophageal Stricture in a Child Post Steven-Johnson Syndrome: A Case Report

Background: Esophageal stricture is an abnormal narrowing of the esophageal lumen, resulting in dysphagia. Despite its rarity, this condition could be caused by various etiologies, including Steven-Johnson Syndrome (SJS). In some cases, stricture could recur, which complicates the management. This case report presented a rare case of refractory esophageal stricture in children with Steven-Johnson Syndrome. Case: A 5-years-old boy with a prior history of SJS presented with dysphagia for one month. The patient experienced choking, blood vomiting, stomatitis, swelling on the lips, and difficulty in swallowing solid food. Barium meal and EGD test confirmed the diagnosis of esophageal strictures. The patient then underwent dilation using bougie dilator. However, he continued to experience dysphagia, resulting in a total of 15 serial dilation sessions. Discussion: Esophageal dysphagia is observed in patients who experience difficulty swallowing solid food. SJS can contribute to the development of esophageal dysphagia by causing inflammation of the esophageal mucosa, resulting in lesions and strictures. In patients with esophageal strictures, two types of dilation methods are available: bougie dilator with wire guidance (Savary-Gilliard) and balloon dilator, with the current consensus for dilation procedures supporting the rule of three. For patients with refractory strictures, other modalities such as mitomycin-C injection and stent placement are also available. Esophageal replacement surgery is considered as the last resort for refractory stricture patients who have not responded to previous treatments. Conclusion: Steven-Johnson Syndrome is a rare cause of esophageal strictures. The management of refractory esophageal stricture requires a comprehensive subspecialty care and long-term monitoring.

Predictive factors for esophageal stenosis in patients receiving prophylactic steroid therapy after endoscopic submucosal dissection for esophageal squamous cell carcinoma.

Methods to prevent esophageal stenosis (ES) after endoscopic submucosal dissection (ESD) for superficial esophageal squamous cell carcinoma (ESCC) have received increasing attention. Although steroid administration is a prophylactic treatment, the risk factors for ES during prophylactic steroid therapy remain unknown. Therefore, this study aimed to retrospectively evaluate the risk factors for refractory ES in patients administered prophylactic steroids after ESD for ESCC. Among 795 patients with ESCC (854 lesions), 180 patients (211 lesions) administered local triamcinolone acetonide (TrA) and/or oral prednisolone were recruited for this study. We compared the total number of endoscopic balloon dilatation (EBD) procedures performed for post-ESD ES and clinical findings (tumor size, ESD history or chemoradiation therapy [CRT], entire circumferential resection, muscle layer damage, supplemental oral prednisolone administration, EBD with TrA injection, and additional CRT) between patients with refractory and non-refractory ES. EBD was continued until dysphagia resolved. We categorized cases requiring ≥ 8 EBD procedures as refractory postoperative stenosis and divided the lesions into two groups. Multivariate logistic regression analysis revealed that factors such as ESD history, CRT history, tumor size, and entire circumferential resection were independently associated with the development of refractory ES. The withdrawal rates of EBD at 3years were 96.1% (52/53) and 58.5% (39/59) in the non-refractory and refractory groups, respectively. Our data suggest that entire circumferential resection and CRT history are risk factors for refractory post-ESD ES in ESCC, even with prophylactic steroid administration.

Efficacy and safety of endoscopic ultrasound-guided gallbladder drainage without dilation by using a 0.035-inch stiff guidewire.

Endoscopic ultrasound-guided gallbladder drainage for patients with cholecystitis and high surgical risk is commonly performed by dilating the fistula before inserting the delivery sheath; however, this carries an increased risk of peritonitis. To overcome this problem, we developed a new technique that did not require dilation, using a 0.035-inch stiff guidewire, and retrospectively evaluated the efficacy and safety of this technique. This retrospective case series report collected data on non-surgical patients who underwent endoscopic ultrasound-guided gallbladder drainage for various indications at Steel Memorial Muroran Hospital between November 2020 and October 2022. A total of 71 patients were included (mean age 83 ± 7.6 years; 33 women and 38 men). Breakthrough of the delivery sheath without dilation of the fistula was successful in 97.2% (n = 69) of patients. The success rate of stent placement was 98.6% (n = 70), as was the clinical success rate. Complications occurred in 2.8% (n = 2) of patients. Early and late adverse events occurred in 2.8% (n = 2) and 12.7% (n = 9) of patients, respectively. The mean procedure time was 24.8 ± 9.3 min. If a 0.035-inch stiff guidewire is used, the dilation procedure can be omitted in the endoscopic ultrasound-guided gallbladder drainage using self-expandable metal stents.

Percutaneous Dilatational Tracheostomy; Diagnosis and Mortality Rate in Intensive Care Saiful Anwar Hospital

Introduction: Tracheostomy is a common surgical procedure performed on critically ill intensive care patients. Reports have documented considerable associated morbidity, with complication rates varying from 6 to 66%. The reports on mortality associated with tracheostomy range from 0 to 5%. Since its introduction, percutaneous dilatational tracheostomies (PDT) have gained increasing popularity. The most commonly cited advantages are the ease of the familiar technique and the ability to perform the procedure at the bedside.7 This paper aims to study the mortality rate and diagnosis of patients who performed the percutaneous dilatational tracheostomy procedure in the ICU of Saiful Anwar Malang Hospital.&#x0D; Methods: Observational analytical research is carried out cross-sectionally. Data was collected from the medical records of patients undergoing PDT for the period July 2022 – October 2022. Statistical analysis using the Chi-square test.&#x0D; Results: From 39 subjects, 34 (87.2%) subjects experienced respiratory failure. The most common cause was HAP pneumonia (61.5%), followed by CVA (17.9%) and CAP pneumonia (12.8%); the rest were EDH, SAH, and ASD secundum, as much as 2.6%. The outcome was that 13 (33.3%) subjects died, and the rest survived and were transported to a care ward. Correlation between patient outcomes with respiratory failure p=0.735, with diagnosis p=0.309.&#x0D; Conclusion: The most common diagnosis of PDT is HAP pneumonia. There was no significant correlation between diagnosis and mortality of patients performed by PDT.

Dilation of benign esophageal strictures with balloon/bougie; a single center experience

Objective: Narrowing in the esophagus caused by benign conditions such as peptic injury, surgical anastomosis, radiation therapy, Schatzki rings, esophageal webs, erosive injury and eosinophilic esophagitis are called benign esophageal strictures. In the treatment of benign esophageal stricture, endoscopic dilation with balloon or bougie is the first priority. Method: The study included a total of 96 patients who were diagnosed with a benign stricture at the gastroenterology clinic of our university from May 2009 to October 2023. All patients were symptomatic, and their main complaint was dysphagia. The benign stricture was diagnosed through clinical examination, radiological imaging and endoscopy. Patient data were scanned retrospectively. The dilation method (bougie, balloon), the number of times the procedure was permormed and any potential complications were recorded. Stents were applied to patients who did not provide adequate dilatation. Results: A total of 96 patients were included in the study. 47 (49%) of them were women and 49 (51%) were men. The average age was 48±17 years (the youngest was 18, the oldest was 81). A total of 198 dilation procedures were performed on 96 patients. The average follow-up period was 79±54 (1-179) months. Srictures were divided into 4 groups according to etiology as anastomotic stricture, peptic stricture, caustic stricture and post-radiotherapy stricture. Of the cases with stricture, 76 (79.2%) underwent bougie dilation, 26 (27.1%) underwent balloon dilation, 5 (5.2%) underwent bougie and then balloon dilation, and in 5 (5.2%) cases, metallic stent was placed due to failed dilations. Conclusion: This study shows the effectiveness of bougie and/or balloon dilation in treating most of the patients with benign esophageal strictures, with a low complication rate. It is less invasive, comfortable and cost-effective than the alternative surgical approach.

Subglottic stenosis as an early presentation of DiGeorge Syndrome

&lt;b&gt;&lt;br&gt;Introduction:&lt;/b&gt; DiGeorge Syndrome, a microdeletion on chromosome 22q11.2, encompasses a myriad of congenital abnormalities. These often include cardiac malformations, velopharyngeal insufficiency, immune deficiency, parathyroid hypoplasia, and hypocalcemia. Although congenital defects of the larynx are quite well acknowledged in the literature, their presence and prevalence in this syndrome remain unknown.&lt;/br&gt; &lt;b&gt;&lt;br&gt;Aim:&lt;/b&gt; We present a case report describing an infant whose initial presentation and symptoms were not suggestive of DiGeorge Syndrome. We also discuss the prevalence of subglottic stenosis among young patients diagnosed with DiGeorge Syndrome.&lt;/br&gt; &lt;b&gt;&lt;br&gt;Case report:&lt;/b&gt; A two-month-old infant was admitted to the Pediatric Otolaryngology Department after difficulties with intubation and extubation during surgical repair of intestinal malrotation. Laryngoscopic examination revealed stage III subglottic stenosis. Laryngotracheoplasty with anterior costal cartilage graft was performed, followed by a series of balloon dilation procedures due to postoperative adhesions and recurrent subglottic stenosis. A comprehensive postsurgical evaluation of the patient confirmed the diagnosis of DiGeorge Syndrome.&lt;/br&gt; &lt;b&gt;&lt;br&gt;Conclusions:&lt;/b&gt; The presented case underscores the broad clinical presentation of DiGeorge Syndrome and emphasizes the importance of maintaining a high index of suspicion in patients demonstrating an unusual confluence of symptoms. Detailed investigation and early diagnosis can significantly contribute to appropriate management, thereby potentially improving outcomes in this patient population.&lt;/br&gt;

Mifepristone Use Among Obstetrician-Gynecologists in Massachusetts: Prevalence and Predictors of Use

ObjectivesWe estimated the prevalence of mifepristone use for evidence-based indications among obstetrician-gynecologists in independent practice in Massachusetts and explored the demographic and practice-related factors associated with use. MethodsWe used data from a cross-sectional survey administered to Massachusetts obstetrician-gynecologists identified from the American Medical Association Physician Masterfile. We measured the prevalence of mifepristone use for four clinical scenarios: early pregnancy loss, medication abortion, cervical preparation before dilation and evacuation procedures, and cervical preparation before induction of labor. Multivariate regression was used to calculate the odds of mifepristone use for these scenarios based on practice type, years in practice, physician sex, and history of medication abortion training. ResultsA total of 198 obstetrician-gynecologists responded to the survey (response rate = 29.0%); this analysis was limited to 158 respondents who were not in residency or fellowship. Overall, 46.0% used mifepristone for early pregnancy loss and 38.6% for medication abortion. Fewer used mifepristone for cervical preparation before dilation and evacuation (26.0%) or before induction of labor (26.4%). Respondents in academic practice settings, with more years in practice, of female sex, and with sufficient medication abortion training were significantly more likely to use mifepristone for one or more evidence-based clinical indications. ConclusionsSufficient medication abortion training during residency significantly predicts whether obstetrician-gynecologists use mifepristone in practice. The U.S. Supreme Court's overturning of Roe v. Wade will allow state-level abortion bans and restrictions to be in effect, which will reduce exposure to abortion training during residency. Increasing training in and utilization of mifepristone are critical for equitable access to reproductive health services. Further interventions may need to be developed to increase mifepristone use in nonacademic practice settings.

Lung functions pre- and post-endoscopic balloon dilation treatment among patients with subglottic stenosis.

Subglottic stenosis (SGS) is an unusual clinical condition of mucosal wounding, compromising the extra-thoracic part of the tracheal airway below the vocal folds. The diagnosis of SGS is established with a detailed clinical examination and a direct endoscopic examination, and the role of spirometry is also often acknowledged. This study aimed to investigate the impact of SGS on lung functions before and after the balloon dilation procedure. The respiratory functions were performed in the Department of Clinical Physiology and the Department of Otolaryngology College of Medicine, King Saud University, Riyadh, Saudi Arabia. In this study, 50 patients with SGS were referred from the Department of Otolaryngology, and lung functions before and after the balloon dilation procedure among patients with SGS were performed using an electronic spirometer. The results revealed that the mean values for lung function test parameters VC (p=0.01), FVC (p=0.01), FEV1 (p=0.004), FEV1/FVC Ratio (p=0.01), PEFR (p=0.01), FEF-25% (p=0.01), FEF-50% (p=0.01), and FEF-75%, (p=0.01) were significantly improved in both male and female patients with SGS on one month after the balloon dilation procedure. It is concluded that the lung function test parameters were increased after the balloon dilation procedure among patients with SGS. The findings showed the impact of SGS on lung function test parameters. Spirometry is a valuable test in patients with SGS and is an appropriate marker to reveal post-airway outcomes. Physicians must suggest lung function tests in patients with SGS before and after the balloon dilation procedure.

Favorable surgical and obstetrical outcomes in pre- and postconceptional laparoscopic abdominal cerclage: a large multicenter cohort study

BackgroundCervical incompetence is an important cause of extreme preterm delivery. Without specialized treatment, cervical incompetence has a 30% chance of recurrence in a subsequent pregnancy. Recently the first randomized controlled trial showed significant superiority of the abdominal cerclage compared to both a high and low vaginal cerclage in preventing preterm delivery <32 weeks of gestational age and fetal loss in patients with a prior failed vaginal cerclage. Objective(s)To assess surgical and obstetric outcomes in patients with pre- and postconceptional laparoscopic abdominal cerclage placement. Furthermore, to perform subgroup analysis based on the indication for cerclage placement in order to identify patients that benefit the most from an abdominal cerclage. Study designA retrospective multicenter cohort study with consecutive inclusion of all eligible patients from 1997 onwards in the Dutch cohort (104 patients) and from 2007 onwards in the Boston cohort (169 patients) was conducted. Eligible patients suffered from at least one second- or third-trimester fetal loss because of cervical incompetence and/or a short or absent cervix after cervical surgery. This includes loop electrosurgical excision procedure (LEEP), conization or trachelectomy. Patients were divided into subgroups based on the indication for cerclage placement: 1) prior failed vaginal cerclage 2) prior cervical surgery 3) other indications. This third group consisted of patients with a history of multiple second- or early third-trimester fetal losses based on cervical incompetence (without a failed vaginal cerclage) and/or multiple dilation and curettage procedures. The primary outcome measure was delivery at ≥34 weeks of gestation with neonatal survival at hospital discharge. Secondary outcome measures included surgical and obstetric outcomes, such as pregnancy rates after preconceptional surgery, obstetric complications and fetal survival rates. ResultsA total of 273 patients were included; 250 patients in the preconceptional cohort and 23 patients in the postconceptional cohort. Surgical outcomes of 273 patients were favorable with six minor complications (2.2%). In the postconceptional cohort we had one patient (0.4%) with hemorrhage of 650 ml, resulting in conversion to laparotomy. After preconceptional laparoscopic abdominal cerclage (n=250) the pregnancy rate was 74.1% (n=137) with a minimal follow-up of 12 months. Delivery at ≥ 34 weeks of gestation occurred in 90.5% of all ongoing pregnancies. Four patients (3.3%) suffered from a second-trimester fetal loss. The indication for the cerclage in all four patients was a prior failed vaginal cerclage. The other subgroups showed fetal survival rates of 100% in ongoing pregnancies with a total fetal survival rate of 96%. After postconceptional placement, 94.1% of all patients with an ongoing pregnancy delivered at ≥ 34 weeks of gestation with a total fetal survival rate of 100%. Thus second-trimester fetal losses did not occur in this group. Conclusion(s)Pre- and postconceptional laparoscopic abdominal cerclage is a safe procedure with favorable obstetric outcomes in patients with an increased risk of cervical incompetence. All subgroups show high fetal survival rates. Second-trimester fetal loss only occurred in the group of patients with a cerclage placed for the indication prior failed vaginal cerclage, but also in this group the chance was low.

OGC P56 Preliminary results from the use of a symptom response questionnaire following pyloric dilatation for delayed gastric emptying post-oesophagectomy

Abstract Background Patient symptom burden following oesophago-gastrectomy is high with numerous potential underlying causes which can often overlap. Diagnostic test results and the symptom response to a given intervention may provide important insights, yet there are no validated questionnaires to support the latter. Delayed gastric emptying is a common problem after oesophagectomy, significantly affecting patients' quality of life. The most common treatment option is to perform an endoscopic pyloric dilatation. However, there is no tool available to measure its effect on patient's quality of life. We have developed a symptom response questionnaire to evaluate the impact of the pyloric dilatation procedure. Methods With patient involvement, a symptom response to treatment questionnaire was developed based on validated EORTC symptom questions. Although designed to assess symptom response to any intervention, consecutive patients referred for suspected delayed gastric emptying who received an endoscopic pyloric dilatation from a single center were included in this study. Patients were contacted by telephone at two and four weeks after the procedure to complete the symptom response questionnaire. The investigators contacting the patients were neither their surgeon nor the one who performed the endoscopic procedure. We excluded all patients receiving other endoscopic treatment than a pyloric dilatation. Results 27 patients responded to the questionnaire at 2 and 4 weeks. The main reported symptoms were dysphagia in 15 patients (58%) and reflux in 6 patients (21%). An improvement in symptom frequency was noted in 23 patients (85%) at two weeks. A subsequent worsening in the patient symptom frequency was noted in 3 patients (8.8%) between two and four weeks. Regarding the severity of the symptom, an improvement was observed in 24 out of 27 patients (88%) after two weeks, and no patients reported a worsening of symptom severity at the four-weeks call. Conclusions The symptom response questionnaire aimed at evaluating the impact of pyloric dilatation was easily implemented and well-received by the patients for completion. By providing a structured and patient-centred approach, this questionnaire can serve as a basis for monitoring and understanding the effectiveness of endoscopic interventions in improving the quality of life for patients with delayed gastric emptying. An electronic version of the questionnaire has been developed and will be tested in the near future.

Abstract 241: Outcomes of Statins Post‐Endovascular Thrombectomy in Ischemic Stroke

Introduction Acute large vessel occlusions (LVOs) represent one‐third of acute ischemic strokes (AIS). LVOs are associated with high mortality and severe functional deficits. Several factors have been reported to play a role in improving outcomes after Endovascular Thrombectomy (EVT). Previous animal studies indicated that statins may have a protective effect on vessel wall injury caused by mechanical thrombectomy. We conducted a retrospective study to analyze whether pretreatment with statins influence the clinical and safety outcomes of EVT in AIS. Methods We conducted a retrospective observational study using the TriNetX database, a global health research network that provides access to electronic medical records retrieved from multiple international healthcare organizations but predominantly from the United States. We collected data about patients' diagnoses (using ICD‐10‐CM codes), medical procedures, medications, and demographics. Investigators were blinded to patients’ personal information or identification of participating healthcare organizations. Our study included adult patients with AIS who received EVT treatment (either extirpation or dilation procedure) between January 4, 2018, and December 31, 2022. The study patients were categorized into two groups based on whether or not they were on statins (Rosuvastatin, Simvastatin, Pravastatin, Atorvastatin, Lovastatin or Pitavastatin) during 3 months prior to hospitalization for AIS. Thirty‐day timepoint assessment was chosen to analyze the primary outcome (all‐cause mortality) and secondary outcomes [intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), decompressive hemicraniectomy procedure (DHC), and aspiration pneumonia]. The chi‐square χ2 test was used to analyze baseline characteristics for categorical variables and the independent‐sample t‐test was used for continuous variables. Matching propensity scores (with a tolerance level of 0.01 and the difference between propensity scores ≤ 0.1) were used to control differences in the comparison cohorts. Results We identified 11,972 patients who received EVT for LVO ischemic stroke. A total of 5,839 patients were on statins during 3 months prior to EVT and 6,133 were not on statins. After 1:1 propensity matching, 1,602 patients were included in each group. Kaplan‐Meier survival analysis showed the 30‐day mortality rates were significantly less for patients who were on statins compared to those who were not and with higher survival probability [87.2% vs. 77.5%, hazard ratio 0.54; confidence interval (CI): 0.45,0.64]. In comparison to EVT patients who were not on statins, those who were on statins had significantly lower rates of ICH [9.9 vs 14.1%; odds ratio (OR) 0.67; 95% CI (0.53,0.84)], lower rates of SAH [4.1 vs. 6.3%; OR 0.64; 95% CI (0.46,0.89)] and lower rates of aspiration pneumonia [5.6 vs 8.3%; OR 0.66; 95% CI (0.50,0.88)]. There was no significant difference in rates of DHC in the statins group in comparison to patients who were not on statins [1.8 vs 2.4%; OR 0.74; 95% CI (0.45,1.22)]. Conclusion Pretreatment with statins was associated with significantly better survival, less bleeding risks, and lower complication rates in LVO ischemic strokes post‐EVT. Future studies may help examine the differential effects of statin type and dose intensity on LVO strokes treated with EVT.

Repair of Isthmocele Following Embolization of Uterine Arteriovenous Malformation

To present a case of concurrent uterine arteriovenous malformation (AVM) and isthmocele, treated with ethylene vinyl alcohol copolymer (EVAC) embolization of the AVM followed by robotic isthmocele repair. A stepwise video demonstration with narration. A tertiary care academic hospital. Patient is a 37-year-old with one previous cesarean section who presented with persistent heavy vaginal bleeding after a dilation and evacuation procedure. Imaging showed evidence of an isthmocele and an iatrogenic uterine AVM secondary to the dilation and evacuation procedure. Both entities are morbid conditions associated with significant operative blood loss. Embolization of the acquired AVM was first performed to stabilize bleeding. In addition, owing to the extensive uterine defect and history of infertility, surgical repair of the isthmocele was recommended. A multidisciplinary approach combining interventional radiology and gynecologic surgery expertise, implementing several strategies to minimize blood loss: 1. Image-guided uterine AVM embolization with EVAC [1] 2. Hysteroscopic identification of isthmocele and residual EVAC in the cavity, with fluorescence transillumination to clearly delineate isthmocele borders 3. Robot-assisted laparoscopic approach for bladder flap creation, as well as retroperitoneal space dissection to skeletonize uterine arteries 4. Transient occlusion of uterine arteries using vascular clamps to minimize operative blood loss given the isthmocele size and its proximity to the left uterine artery 5. Resection of the isthmocele and removal of residual intracavitary EVAC 6. Multilayer, bidirectional hysterotomy closure and vascular clamp removal to restore uterine blood supply CONCLUSIONS: Successful multidisciplinary treatment of concurrent uterine AVM and isthmocele. Cesarean delivery at 36 to 37 weeks' gestational age was recommended for future deliveries.

Utility of Office Hysteroscopy in Diagnosing Retained Products of Conception After Early Pregnancy Loss After In Vitro Fertilization.

To evaluate the utility of office hysteroscopy in diagnosing and treating retained products of conception in patients with infertility who experience early pregnancy loss (EPL) after in vitro fertilization (IVF). We evaluated a retrospective cohort of 597 pregnancies that ended in EPL in patients aged 18-45 years who conceived through fresh or frozen embryo transfer at an academic fertility practice between January 2016 and December 2021. All patients underwent office hysteroscopy after expectant, medical, or surgical management of the EPL. The primary outcome was presence of retained products of conception at the time of office hysteroscopy. Secondary outcomes included incidence of vaginal bleeding, presence of intrauterine adhesions, treatment for retained products of conception, and duration of time from EPL diagnosis to resolution. Log-binomial regression and Poisson regression were performed, adjusting for potential confounders including oocyte age, patient age, body mass index, prior EPL count, number of prior dilation and curettage procedures, leiomyomas, uterine anomalies, and vaginal bleeding. Of the 597 EPLs included, 129 patients (21.6%) had retained products of conception diagnosed at the time of office hysteroscopy. The majority of individuals with EPL were managed surgically (n=427, 71.5%), in lieu of expectant management (n=140, 23.5%) or medical management (n=30, 5.0%). The presence of retained products of conception was significantly associated with vaginal bleeding (relative risk [RR] 1.72, 95% CI 1.34-2.21). Of the 41 patients with normal pelvic ultrasonogram results before office hysteroscopy, 10 (24.4%) had retained products of conception detected at the time of office hysteroscopy. When stratified by EPL management method, retained products of conception were significantly more likely to be present in individuals with EPL who were managed medically (adjusted RR 2.66, 95% CI 1.90-3.73) when compared with those managed surgically. Intrauterine adhesions were significantly less likely to be detected in individuals with EPL who underwent expectant management when compared with those managed surgically (RR 0.14, 95% CI 0.04-0.44). Of the 127 individuals with EPL who were diagnosed with retained products of conception at the time of office hysteroscopy, 30 (23.6%) had retained products of conception dislodged during the office hysteroscopy, 34 (26.8%) chose expectant or medical management, and 63 (49.6%) chose surgical management. The mean number of days from EPL diagnosis to resolution of pregnancy was significantly higher in patients who elected for expectant management (31 days; RR 1.18, 95% CI 1.02-1.37) or medical management (41 days; RR 1.54, 95% CI 1.25-1.90) when compared with surgical management (27 days). In patients with EPL after IVF, office hysteroscopy detected retained products of conception in 24.4% of those with normal pelvic ultrasonogram results. Due to the efficacy of office hysteroscopy in diagnosing and treating retained products of conception, these data support considering office hysteroscopy as an adjunct to ultrasonography in patients with infertility who experience EPL after IVF.

Predictors of response to endoscopic management of subglottic/tracheal stenosis in patients without tracheostomy

IntroductionSubglottic and tracheal stenosis (SGTS) in adults is an acquired or idiopathic condition that can lead to dyspnea, and even life-threatening airway obstruction. Endoscopic techniques have advanced and largely eclipsed open surgery, with open surgery now reserved for refractory cases (Hseu et al., 2013; Feinstein et al., 2017). Currently, there is no accepted guideline for the endoscopic treatment of SGTS. Thus, the aim of the present study is to examine the impact of various clinical and pathological characteristics on outcomes to endoscopic treatment in a cohort of SGTS patients. DisclosureNone of the authors have any financial or personal relationship that could cause a conflict of interest regarding this article. MethodsRetrospective chart review was performed for 41 patients presenting with SGS without a tracheostomy over a 4-year-period (2018–2022), within a single tertiary care center. Quantitative outcomes including number of dilation procedures undergone and need for open procedures were examined. The qualitative variables included a history of pulmonary disease, prior tracheostomy/tracheal resection, presence of tracheomalacia, granulation tissue, excessive dynamic airway collapse (EDAC), and etiology of idiopathic subglottic stenosis. ResultsThe presence of granulation tissue seen on tracheoscopy was associated with a higher number (4+) of dilation procedures (p = 0.01). A history of pulmonary disease (p = 0.037), the presence of tracheomalacia (p = 0.039), and the presence of granulation tissue (0.003) were all associated with a need for open procedures. ConclusionPatients with the presence of granulation tissue, tracheomalacia, and a history of pulmonary disease were more associated with more severe disease requiring either a higher number of endoscopic procedures or need for open procedures.