Tract Drainage Research Articles

Urinary Tract Drainage Selection in Case of Pyelonephritis in Pregnant Women

The article presents an analysis of the treatment results of 1122 patients with pyelonephritis in pregnancy at different gestational periods (from 6 to 39-40 weeks of pregnancy). The age of the patients was from 16 to 41 years, the average age was 26.15 ± 7 years. The indications and methods of urinary tract drainage in pregnant women were analyzed depending on the causes of urodynamic disturbances (kidney stone disease, decreased urinary tract tone, ureters compression by the uterus, vesico-urethral reflux) pregnancy term; pyelonephritis in pregnancy stage (serous/ purulent). Errors in the patients’ management after purulent pyelonephritis in pregnancy are considered. The expediency of examining and treating patients with risk factors for urinary tract infections during pregnancy were indicated at the stage of preparing a woman for pregnancy. Antegrade draining of the urinary tract is indicated for pregnant women from the 31st pregnancy week (and even shorter periods with a pronounced violation of urodynamics) with the presence of knee-shaped deviation in the ureter`s upper third and with suspected purulent process. Therefore, nephrostomy draining provides a more adequate outflow of urine from the affected kidney and makes it possible to control daily diuresis. It is necessary to conduct active monitoring of pregnant women with the presence of internal ureteral stents and their timely replacement. It is advisable to remove the drainage 3-4 weeks after birth, depending on the causes of the urodynamics` disorders. Symptom build-up dynamics, severity of intoxication, multi-organ lesion, the possibility of antenatal death of the fetus require urgent choice of the method of urinary tract drainage and the early initiation of intensive therapy in patients with suspected purulent process. Antimicrobial therapy should be carried out in accordance with the Russian guidelines on Urinary tract infections.TThe study did not have sponsorship. The authors have declared no conflicts of interest.

IR-guided endoscopic pancreaticojejuostomy for post-whipple pancreaticocutaneous fistula

Presenter: Elliot Scott MD | Virginia Mason Medical Center Background: A 67yF presented with biliary obstruction and computed tomography (CT) suggested a distal bile duct tumor. She underwent an ERCP with brushings for stenting and to but unfortunately developed severe acute pancreatitis (SAP). Although technically resectable after complete staging without evidence of distant disease, she was not felt to be a surgical candidate and was referred for neoadjuvant chemotherapy while. Unfortunately, after one cycle of gemcitabine and cisplatin, her SAP progressed to walled-off necrosis (WOPN) requiring percutaneous and endoscopic drainage. Therefore, after a period of recovery, she was taken to the operating room for an attempt at curative resection. A pylorus-preserving pancreaticoduodenectomy (PD) was performed, however, the pancreas was scarred without a visible duct and adherent to a thrombosed splenic vein with sinistral portal hypertension form WOPN. Decision was made to suture the pancreatic remnant without an anastomosis. The patient did well until POD#4 when a CT performed for abdominal pain revealed a large fluid collection. This was drained percutaneously and was consistent with a pancreatic leak. The patient convalesced from her operation but was left with a pancreaticocutaneous fistula. Methods: Since transgastric internalization was not feasible post-PD, a combined interventional radiology (IR) and gastroenterology (GI) rendezvous approach was utilized. An endoscopic ultrasound (EUS) scope was passed into the afferent limb while a balloon catheter was passed through the drain tract. The balloon was visualized by EUS and punctured in order to grab an IR wire and pass it into the afferent jejunal limb. Two pigtail stents were then deployed in order to create a pancreaticojejunostomy (See Figure). Results: The patient did well post procedure and deemed ready for adjuvant therapy for her T2N1 distal cholangiocarcinoma. Conclusion: This challenging case highlights the multidisciplinary strategy required not only for optimal oncologic treatment of biliary tumors but also to manage the complications of therapy.

Biliary decompression in patients with obstructive jaundice

Aim. Evaluation of the biliary tract decompression methods and their use results, in patients with obstructive jaundice of various etiologies on the basis of our own clinical material.Material and Methods. A retrospective analysis of the biliary tract drain results in 6935 patients with obstructive jaundice with benign and tumor etiology. In 87% cases there was B Class of obstructive jaundice. In 93% we observed mild (A Class) obstructive jaundice. For the biliary tract drainage we used laparoscopic or open surgical access. The retrograde drain we used in sixty-seven percent cases with obstructive jaundice B Class. In sixty-six percent cases of obstructive jaundice C Class, we used antegrade drain.Results. The biliary decompression was effective in 98%. Regarding the rate and timing of bilirubin reduction, all the applied methods showed a similar result, however, the greatest number of complications and fatalities we recorded in patients after antegrade percutaneous drain of the biliary tract and transabdominal access. In 36% the performed interventions became the final treatment option, and the sixty-one percent of patients underwent two-stage treatment. The overall mortality rate was 3%.Conclusion. The use of percutaneous drainage is justified for obstructive jaundice with tumor origin, and possible radical surgical treatment. Transabdominal access drainage for benign etiology of obstructive jaundice in compensated patients can be safely used. Transduodenal endoscopic drain is an alternative to other methods biliary tract drain in severe and medium obstructive jaundice of benign etiology. The same drain method can be used for drainage of biliary tract in patients with tumors of the hepatopancreatobiliary zone organs, as a palliative treatment.

The New Strategy for the Treatment of Cerebrospinal Fluid Leak Following Lumbar Surgery.

Introduction Cerebrospinal fluid (CSF) leak is a common complication of surgery involving the lumbar spine. However, although there are various therapeutic options for CSF leak, there is currently no optimal technique, and the choice of therapy often depends on the surgeon's cumulative experience. The aim of this study was to describe the successful treatment of CSF leakage using blood injection therapy along the drain removal tract. Technical Note We enrolled 7 consecutive patients who underwent lumbar surgery at our institute. The surgeries performed included decompression in two patients (one microendoscopic surgery), fusion in four, and an epidural cyst resection in one. After finding a CSF leak, we injected about 10 ml of blood from the patient into the drain tract. CSF leak did not recur after the blood injection in any of the seven patients. Following just one day of bed rest, the symptoms of intracranial hypotension disappeared with no instances of worsened symptoms of back pain, lower limb pain or fever. Conclusions We propose this route of blood injection therapy as a novel method for the treatment of CSF leak after lumbar surgery.

Pyelonephritis in Pregnancy: modern draining tactics

Many publications in foreign and domestic papers are devoted to pyelonephritis in pregnancy. At the same time, aspects of the upper urinary tract (UUT) drainage, indications / lack of indications, and the duration of UUT drainage during kidney infections in pregnant women are bypassed. Etiological treatment of this pathology is well described in the European Association of Urology guidelines and American Urological Associations guidelines in accordance with the recommendations of the Food and Drug Administration (FDA). However, there are no references to the management of patients with UUT dilatation, associated with pyelonephritis in pregnant women. The Russian Clinical Guidelines for Urology (2018) also contains very brief information on this issue. Thus, each urological clinic of the Russian Federation has formed its own views on the draining tactics for pyelonephritis in pregnant women, which our colleagues have been following for years and decades. This publication presents an analysis of the literature sources focusing on the current state of the problem of pyelonephritis in pregnancy and the «neсessity» of the UUP drainage. It is intended to initiate a review of the established «tradition» and avoid a significant number of catheter and stent-related complications.

Causes and Treatment of Bile Leaks at the Puncture Site After Percutaneous Transhepatic Biliary Decompression

Introduction: Bile leaks at the puncture site after percutaneous transhepatic biliary decompression (PTBD) are not uncommon and cause a lot of problems for patients with non-resectable biliary malignant obstruction. However, to the best of the authors’ knowledge, no study is conducted to establish the causes and to find an appropriate treatment. The current study was conducted on 264 patients who underwent PTBD for a malignant biliary obstruction. Material and Methods: This retrospective study reviewed 264 patients with non-resectable malignant biliary obstruction requiring PTBD. A two-stage biliary decompression is done. An 8Fr pigtail catheter is placed for PTBD, the patients would return after two days for stent placement. After stent placement, an 8 Fr pigtail catheter (internal – external) would be placed for flushing, and also for cholangiography. The patients are then observed for another two days. Patients who have persistent puncture site bile leakage after 24 hours are considered to have a bile leak. In these patients, cholangiography is performed. If cholangiography reveals stent occlusion, stent reopening by irrigation/ballooning is done. For those with patent stents and bile leakage, an internal-external biliary drain is placed which does not solve the problem, and a cholangiography is done into the drain tract via a syringe. Results: Sixteen of 264 patients who underwent percutaneous biliary decompression developed bile leakage at the puncture site. Twelve of these patients demonstrated an occluded biliary stent and their bile leak resolved after irrigation/ballooning. Four patients with bile leak demonstrated patent biliary stents and persistent leakage despite internal-external biliary drain placement. Cholangiograms in these patients demonstrated connections from the stented biliary system (the ipsilateral system), branches of a different occluded biliary system (the contralateral biliary tract), and the drain tract. All four patients underwent PTBD of the contralateral biliary system with subsequent resolution of their bile leak. Discussion: One of the complications of PTBD is bile leakage at the puncture site which could have two reasons. The most common is stent occlusion by clot and debris which can be managed by irrigation/ stenting. The second mechanism of bile leakage, not reported previously, was a fistulous connection between the drained biliary system (the ipsilateral system) and a separate obstructed biliary system (the contralateral system). We would like to refer to this mechanism of bile leak “Yo-Yo reflux” for its specific pattern of cholangiography. The Yo-Yo reflux mechanism of bile leaks occurs when a small branch from the adjacent separated contralateral system is transgressed inadvertently during ipsilateral biliary drainage. High-pressure bile fluid from the obstructed system flows through the lower pressure ipsilateral system and through the cannulation tract and onto the skin surface. In the Yo-Yo mechanism, stenting of the contralateral side is the only treatment. Conclusion: Bile leakage at the puncture site after PTBD has two major causes. The most common is stent occlusion by clot/debris which is diagnosed by cholangiography and treated by irrigation/ballooning. The second cause is Yo-Yo reflux which is diagnosed by cholangiography injecting directly into the orifice of skin fistula and treated by contralateral stenting.

Evolution of upper urinary tract drainage method

Despite the achievements of modern medicine, the method of drainage of the upper urinary tract with obstruction remains an urgent problem in urgent urological practice. The article presents a brief literature review of classical methods of upper urinary tract drainage, such as open nephrostomy and ureteral catheter installation. Special attention is paid to modern methods of drainage of the upper urinary tract. Percutaneous puncture nephrostomy today is one of the most frequently performed operations for the purpose of upper urinary tract drainage in urology, which is used both for medical and diagnostic purposes, which characterizes it as a fairly simple operation and safe for the patient, which has a number of significant drawbacks (wearing a urinal, possible purulent-septic complications, traumatization of the renal parenchyma). In contrast to percutaneous puncture nephrostomy, the urethral stent is devoid of the above disadvantages, however, it has no less significant disadvantages in use (migration, inlay, reflux).

The Effect of Treatment Timing and Urinary Drainage on the Outcome of Urinary Tuberculosis

Background: Urinary tuberculosis (TB) has a variety of clinical manifestations and is a diagnostic challenge for urologists. Delayed treatment can lead to loss of renal function and structural destruction. In this study, we analyzed the relationship between the timing of treatment and outcomes in patients with urinary TB. Methods: We performed a retrospective chart review of all patients with urinary TB from 1978 to 2016 at our hospital and analyzed the patients' symptoms, diagnostic methods, imaging studies, time to diagnosis, treatment methods, and follow-up. Results: Twenty-one patients (median age: 49 years) had urinary TB, of whom 18 had hydronephrosis and hydroureter. No bilateral renal involvement was noted. The median duration from symptom onset to anti-TB treatment was 78.5 days. There was no significant relationship between symptom-to-treatment time and posttreatment changes in renal function (Pearson's r = 0.103, P > 0.05); however, the symptom-to-treatment time was linearly associated with pre- and posttreatment hydronephrosis grade (Pearson's r = 0.667, P= 0.03, and r = 0.710, P= 0.007, respectively). In multivariate analysis, the symptom-to-treatment time was found to be an independent predictor of improvements in hydronephrosis but was not associated with renal function change. Of nine patients with upper urinary tract drainage, hydronephrosis improved in three and was stable in five patients. Of 12 patients without drainage, four experienced renal loss. Conclusion: Urinary TB has vague clinical manifestations and is prone to a delayed diagnosis. Early diagnosis and prompt internal ureteral stenting may prevent renal loss in certain patients.

310. Assessment of MSIS Diagnostic Criteria as Predictors of Treatment Success in Total Knee Arthroplasty (TKA) Infections Treated With Two-Stage Exchange

BackgroundProsthetic joint infection (PJI) is a grave complication of total knee arthroplasty (TKA); predicting outcome is difficult. Musculoskeletal Infection Society (MSIS) criteria are sensitive and specific for the diagnosis of PJI. In prior work, we systematically studied the value of each MSIS criterion as a prognostic marker among a large cohort of patients with infected hip and knee arthroplasty treated with debridement, antibiotics, and implant retention (DAIR) at our specialized orthopedic hospital. We found that sinus tract drainage and culture positivity predicted explantation within two years of DAIR; the minor MSIS criteria were not predictive. Here, we sought to evaluate the utility of MSIS criteria in predicting outcomes of infected TKR PJI treated with two-stage exchange arthroplasty. We sought to evaluate whether MSIS criteria can predict the outcome of infected TKR PJI treated with two-stage exchange arthroplasty.MethodsA retrospective cohort of TKA PJI treated with two-stage exchange was identified by query of hospital coding records from 2009 to 2014, with subsequent chart review. Collected data included demographics and comorbidities, duration of symptoms, implant age, and pathogen. All cases met Musculoskeletal Infection Society International Consensus criteria for PJI. The primary endpoint was defined as prosthesis retention for 2 years from reimplantation. Descriptive statistics were completed using the Fisher’s exact test for categorical variables and the Mann–Whitney U test for continuous variables.Results159 patients who underwent 2-stage exchange for TKA PJI meeting MSIS criteria were identified. 116 patients (73%) remained infection-free after two years of observation. Neither of the major criteria [presence of sinus drainage (P = 0.6); >1 positive culture (P = 1.0)], nor any of the minor criteria (individually or in composite) reached statistically significant association with treatment outcome.ConclusionIndividual MSIS diagnostic criteria, which have prognostic utility in TKA PJI treated with DAIR, are not powerful predictors of outcome of TKA PJI after two-stage exchange.Disclosures All authors: No reported disclosures.

Return to emergency department after pediatric urology procedures

Unplanned postoperative return visits to the emergency department (ED) and readmission represent a quality bench outcome and pose a considerable cost burden to health-care systems. The aim of this study is to evaluate ED return visits after pediatric urology procedures in a tertiary care children's hospital, trying to identify potential causes. This may constitute a platform for future improvement areas. A Quality Board-approved retrospective study was performed identifying all urologic cases completed between October 2012 and September 2015. Baseline demographics, American Society of Anesthesia class, operating surgeon, type of admission, type and duration of surgical procedure, and type of anesthesia given were evaluated. Patients who returned to the ED within 30 days of the surgery date were identified. The ED records were reviewed for time of return, etiology for visit, and management received. Univariate and subsequent multivariate logistic regression statistical analyses were performed to identify variables associated with ED return. Odds ratio (OR) and 95% confidence intervals (95% CIs) were generated to determine the significance of relationships. Total of 4125 cases was identified. Median age was 32.9 months, with 85.1% of them being male. 349 (8.5%) cases returned to the ED within 30 days of the surgery. The majority of the returned patients, 295 (84.5%), managed conservatively with medications or reassurance, whereas 54 (15.5%) required readmission, and of those readmitted, 15 (4.3%) cases needed further surgical interventions, mainly urinary tract drainage procedures. Multivariate logistic regression analysis identified that the age, residence, admission type, inguinoscrotal surgery, and duration of surgical procedure were significantly associated with ED return (Table). The most common reason for the ED visit was UTI in 17.2%, followed by stentand catheterissues in 14.3%, wound-related in 14.3%, and bleeding in 11.7%. Pediatric literatureshow varying rates of ED return ranging from 2.4% to 2.6% after urologic procedures. Our return to ED rate exceeds that found in US studies, which can perhaps be attributed to the differences between the Canadian and US health-care systems. As found with other studies, age, inpatient admission, procedure type, and increased operative time were related to ED returns, possibly because of the difficulty of young children expressing themselves and the presumed complex nature of longer operations that mostly need inpatient admission. The most common reason for ED return in this study as in others was presumptive UTI. A known limitation of this study is its retrospective nature, along with the possible missed visits of patients who presented to outside hospitals. We present an account of the status of ED return visits after pediatric urology procedures in our institute. The majority of ED returns can be managed conservatively and are probably preventable.

Author Reply

The primary objective of our analysis was to demonstrate that patients with simultaneous bilateral ureteral calculi (SBUC) do not all have exactly the same initial clinical presentation. Therefore, a tailored approach should be applied to their management just as in any other clinical condition. Traditionally, patients with SBUC undergo immediate upper tract drainage and deferred definitive stone treatment. As emphasized in our study and the Editorial Comment, 1 Peter L.S. Simultaneous bilateral ureteral calculi: A new paradigm for management [Editorial Comment]. Urology. Google Scholar this staged approach remains the standard of care in patients with SBUC who present with true emergencies including infection, significant renal injury, or electrolyte abnormalities. However, this represents less than a third of patients with SBUC in our series.

Mo1310 CHOLECYSTOENTEROSTOMY AS AN ALTERNATIVE TO CONVENTIONAL TREATMENT FOR CHOELCYSTITIS AND THE ROLE OF SEROTROPIC STENTS

Laparoscopic cholecystectomy for cholecystitis is the standard of care . Percutaneous cholecystostomy is used in patients deemed unfit for surgery . Endoscopic interventions include natural orifice trans-luminal endoscopic surgery (NOTES), per-oral endoscopic trans-papillary drainage and endoscopic ultrasound- guided endoluminal gallbladder drainage. There are a few EUS- specific stents that have shown promise through decreased tissue ingrowth, leakage and migration yet ensure drainage through apposition of lumens. Our index case highlights one stent but autopsy findings did not demonstrate apposition. A 26-year-old female presented with decompensated alcoholic cirrhosis with ascites, abdominal pain and hyperbilirubinemia. After a negative serologic evaluation, we requested a magnetic resonance cholangiopancreatography (MRCP) which demonstrated multiple gallstones and a mildly thickened gallbladder wall. We performed an endoscopic ultrasound which confirmed cholelithiasis, gallbladder distention and estimated the gall bladder wall thickness to be 2.4 mm. We then performed a cholecystoduodenostomy using the AXIOS™ stent and electrocautery enhanced delivery system (AXIOS, Boston Scientific, Natick, MA). Within 24 hours, the patient showed significant improvement in her abdominal pain. Second-look esophagogastroduodenoscopy 48 hours after the initial procedure to evaluate post procedural anemia was unrevealing. Two weeks after gallbladder drainage her hepatic status worsened and she expired. We participated in a limited autopsy to evaluate the effect of the stent invivo and reviewed the histological properties of the lumen. There was evidence of focal adherence of the gallbladder to the duodenum at the site of stent deployment with circumferential serosal formation. Figure 1. The diameter of the tract was 15 mm which was the diameter of the stent used. Histology demonstrated gallbladder serosa continuous with the neo-serosa of the tract and there was no evidence of significant adhesions. Figure 2. The AXIOS™ stent is FDA approved for trans-enteric drainage of pancreatic pseudocysts but recently has been used successfully for gallbladder drainage. Data describing adherence of the gallbladder to the duodenal wall in human subjects using the AXIOS™ stent is limited. Animal model studies have shown serosal adhesion of the stomach to gallbladder at 4 weeks. We observed serosal formation rather than adhesion after two weeks. Studies indicate that adhesions occur after disruption of serosal surfaces and tissue apposition. If tissue apposition does not occur, a new serosal surface will be formed similar to cutaneous wound healing. Trans-luminal stents likely decompress and drain but also are a conduit for serosal formation without direct tissue apposition. We refer to this process as “serotropism.”Figure 2. Histology showing continuation of gallbladder serosa with neo-serosa of the drainage tract created by the stent.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Does Retrograde Treatment of Upper Urinary Tract Stones Necessitate Postoperative Upper Urinary Tract Drainage? Conclusions from More Than 500 Single Center Consecutive Cases.

Temporary drainage of the upper urinary tract after ureterorenoscopy for the treatment of urinary stones is almost a routine in endourologic practice. In these cases, a Double-J stent (DJS) is left for 7 or more days. In borderline cases, a ureteral catheter attached to the urethral catheter may be left for 24-48 hours. In some situations, tubeless approach is possible. The purpose of this study was to evaluate the necessity and immediate postoperative implications of upper tract drainage by comparing complications and symptoms at the immediate postoperative period in these three groups of patients. A database of 516 consecutive patients who underwent ureterorenoscopy for ureteral and/or renal stones between October 2014 and September 2016 was retrospectively evaluated. The cohort was divided according to postoperative drainage type of the upper urinary tract. The data consisted of demographic parameters, stone location, number and burden, severity of preoperative obstruction, and postoperative complications. Symptoms at the immediate postoperative period, assessed by visual analog scale (VAS) score, frequency, and type of analgesics used, were evaluated and compared. Categorical dependent variables were evaluated using chi-square or Spearman's correlation tests, whereas continuous dependent variables were analyzed using Pearson correlation analysis. There were 196 (38%) tubeless, 214 (41%) UC, and 106 (21%) DJS cases. Patients who were drained with DJS at the end of the procedure were significantly with higher stone volume (p < 0.005), higher stone density (p < 0.005), and with more severe preoperative obstruction (p < 0.005). Postoperative complications (infection, stone-street, and acute renal failure), mean VAS score, or analgesics used were not different in the three subgroups. A tubeless approach is safe in properly selected cases. There is no difference in postoperative course compared with drained groups. Tubeless procedures may facilitate an outpatient approach for treatment of upper urinary tract stones.

MP25-05 IS SYSTEMATIC EARLY DRAINAGE RELEVANT TO TREAT URINARY TRACT RUPTURE IN NON-PENETRATING RENAL TRAUMA? RESULTS FROM A MULTICENTER STUDY

MP25-05 IS SYSTEMATIC EARLY DRAINAGE RELEVANT TO TREAT URINARY TRACT RUPTURE IN NON-PENETRATING RENAL TRAUMA? RESULTS FROM A MULTICENTER STUDY

Abstract No. 561 Percutaneous endoluminal brush cytology in patients suspected of malignant biliary obstruction: Experience from a tertiary cancer center in India

To evaluate endoluminal brush cytology during percutaneous biliary drainage in patients suspected of malignant biliary obstruction. From January 2010 to December 2016, 106 consecutive patients with obstructive jaundice secondary to suspected malignant biliary obstruction underwent 136 endoluminal brush cytology procedures, during or after percutaneous transhepatic biliary drainage in presence of on-site cytologist. The data was collected retrospectively and analysed. The lesions involved the common bile duct (n-21), common hepatic duct (n-22) and hilum with right or left intrahepatic ducts (n-63). In each patient, upto three (mean-1.3) brush cytology specimens were taken with 8F double lumen brush. Definitive diagnosis in each case was established by the Brush cytology, exploratory laparotomy, biopsy/cytology from any other metastatic site or combination of tumour markers, radiological or clinical suspicion and increase in size or metastasis in follow-up. Statistical analysis was performed using chi-square test and Z-test of significance to compare sensitivity and p-value ≤0.05 was considered statistically significant. 66 out of 106 patients had correct diagnoses of malignancy on brush cytology. 3 diagnoses proved to be true-negative & 37 were false-negative. 9 out of 22 patients (40.1%) had malignancy diagnosed in 2nd attempt and 1 of 3 patients (33.3%) had malignancy diagnosed with 3rd attempt. Diagnostic sensitivity and specificity brush cytology for malignant nature of biliary strictures was 64.1% and 100% respectively with accuracy of 65.1%. The sensitivity of brush cytology was highest in proximal hilar block 67.8% as against 38.5% noted for lower CBD block, this difference was statistically significant (p-value ≤0.034). Anastomotic site recurrence had a sensitivity of 46.1% in diagnosing malignant nature of disease. No complications were related to the procedure. Percutaneous endoluminal brush cytology is relatively accurate procedure that is safe & easy to perform through a transhepatic biliary drainage tract. Sensitivity to diagnose malignant stricture was higher in primary and proximal hilar block as against lower CBD block & anastomotic site strictures.

Minimally Invasive Retroperitoneal Approach for Pancreatic Necrosectomy via a Percutaneous Drainage Tract

Aim-Background Infected pancreatic necrosis (IPN) develops in approximately one third of patients with necrotizing pancreatitis (NP). In the past, open necrosectomy (ON) was the standard treatment for this condition, but it carried significant morbidity and mortality. Currently, minimally invasive procedures (MIPs) have been established for the management of IPN, decreasing the risk of complications compared with ON.

Deep tissue analysis of distal aqueous drainage structures and contractile features

Outflow resistance in the aqueous drainage tract distal to trabecular meshwork is potentially an important determinant of intraocular pressure and success of trabecular bypass glaucoma surgeries. It is unclear how distal resistance is modulated. We sought to establish: (a) multimodal 2-photon deep tissue imaging and 3-dimensional analysis of the distal aqueous drainage tract (DT) in transgenic mice in vivo and ex vivo; (b) criteria for distinguishing the DT from blood and lymphatic vessels; and (c) presence of a DT wall organization capable of contractility. DT lumen appeared as scleral collagen second harmonic generation signal voids that could be traced back to Schlemm’s canal. DT endothelium was Prox1-positive, CD31-positive and LYVE-1-negative, bearing a different molecular signature from blood and true lymphatic vessels. DT walls showed prominent filamentous actin (F-actin) labeling reflecting cells in a contracted state. F-actin co-localized with mesenchymal smooth muscle epitopes of alpha-smooth muscle actin, caldesmon and calponin, which localized adjacent and external to the endothelium. Our findings support a DT wall organization resembling that of blood vessels. This reflects a capacity to contract and support dynamic alteration of DT caliber and resistance analogous to the role of blood vessel tone in regulating blood flow.

Treatment of Walled-off Pancreatic Necrosis by Percutaneous Endoscopic Necrosectomy

Walled-off pancreatic necrosis (WOPN) consists of a mature collection of pancreatic necrotic tissue within a well-defined inflammatory wall. Treatment involves drainage and debridement of the necrotic material. Modalities such as laparoscopic, endoscopic, and video-assisted retroperitoneal debridement are effective, and have less morbidity than open surgery. Percutaneous endoscopic necrosectomy (PEN) is a novel technique that allows the operator to use conventional endoscopes to perform necrosectomy via a percutaneous tract in patients with WOPN that is difficult to access via the stomach or duodenum. A 44-year old male with newly diagnosed diabetes mellitus presented with severe abdominal pain and sepsis secondary to a peripancreatic fluid collection that developed after an episode of acute pancreatitis. On arrival, his vitals were: Temp 100.4 F, BP 100/63 mm Hg, HR 129 beats/min, RR 20 breaths/min, and SPO2 96% room air. Abdominal examination revealed mild distension and severe epigastric tenderness. A percutaneous drain was placed via the left flank into the fluid collection at another facility. However, the collection persisted and grew E. Coli and K. Pneumoniae. Endoscopic ultrasound showed a debris-filled cavity abutting the pancreatic tail without close approximation to the gastric wall. Following upsizing of the percutaneous drain, three sessions of PEN were performed via the drain tract. Ongoing drainage was found to originate from a colonic fistula and pancreatic duct leak, which were treated with a diverting loop colostomy and endoscopic retrograde cholangiopancreatogram (ERCP) with pancreatic duct stent placement, respectively. The patient's condition improved with and resolution of the duct leak, confirmed on repeat ERCP performed two months later. His percutaneous drainage eventually stopped and the external drain was removed. PEN is a safe and effective minimally invasive technique that can be used to treat WOPN. It may be the procedure of choice in instances where necrosis cannot be accessed through the stomach or duodenum. Recent studies have shown that PEN has superior safety profile compared to the existing endoscopic (e.g. transgastric endoscopic necrosectomy) or surgical interventions. Additionally, percutaneous access along a predefined tract avoids inherent complexities of the transluminal approach. This novel technique may also be utilized for other intra-abdominal fluid collection accessible to interventional radiologists.

Assessment of Musculoskeletal Infection Society (MSIS) Diagnostic Criteria as Predictors of Treatment Success in Hip Arthroplasty Infections Treated with Two-Stage Exchange

Background Prosthetic joint infection (PJI) is a grave complication of total hip arthroplasty (THA). Predicting outcome is difficult. Musculoskeletal Infection Society (MSIS) criteria are sensitive and specific for the diagnosis of PJI. In prior work, we systematically studied the value of each MSIS criterion as a prognostic marker among a large cohort of patients with infected hip and knee arthroplasty treated with debridement, antibiotics, and implant retention (DAIR) at our specialized orthopedic hospital. We found that sinus tract drainage and culture positivity predicted explantation within 2 years of DAIR; the minor MSIS criteria were not predictive. Here, we sought to evaluate the utility of MSIS criteria in predicting outcomes of infected THR PJI treated with two-stage exchange arthroplasty. We sought to evaluate whether MSIS criteria can predict outcome of infected THR PJI treated with two-stage exchange arthroplasty.Methods A retrospective cohort of PJI from 2007 to 2014 treated with two-stage exchange was identified via an administrative database. Two-year implant retention was the primary outcome. Collected data included demographics and comorbidities, duration of symptoms, implant age, and pathogen. Continuous variables were assessed using the Mann–Whitney U-tests and categorical variables using the χ 2 test and Fisher’s exact test when appropriate.ResultsOne hundred and thirty patients who underwent two-stage exchange for THA PJI meeting MSIS criteria were identified. Ninety percent remained infection free after 2 years of observation. Neither of the major criteria [the presence of sinus drainage[(P = 0.5416), and >1 positive culture (P = 0.1052)], nor any of the minor criteria, reached statistically significant association with treatment outcome.Conclusion Individual MSIS diagnostic criteria, which do have prognostic utility in hip and knee PJI treated with DAIR, may not be powerful predictors of outcome of hip PJI after two-stage exchange, likely in part because of the high success rate of this procedure.Disclosures All authors: No reported disclosures.

Comparative evaluation of pin-in-fiberglass cast and Kirschner-Ehmer external fixative in the management of radius-ulna fractures in dogs

Four adult (two males and two females) dogs were used to comparatively evaluate the effectiveness of pin-in-fiberglass cast with Kirschner-Ehmer type I external skeletal fixative in the management of surgically created radius-ulna fractures in dogs. These dogs were assigned to two groups (A and B) with each group made up of two dogs. The radius-ulna fracture was created in all the dogs under general anaesthesia as follows: Group A, pin-in-fiberglass casting; and Group B, Kirschner-Ehmer type I external fixation. Post-operatively, minimal increase in vital parameters were observed, but were not significant (P&gt;0.05) when compared with pre-operative values in both groups. The haematological indices were within acceptable normal limits for both group (P&gt;0.05). Dogs in both groups bore weight on the operated limb and could walk within 24 hours post-operative. Radiographic evaluation revealed minimal soft tissue swelling and minimal periosteal tissue reaction in both groups. The Kirschner-Ehmer external fixative group attained the faster fracture healing time (7 weeks) compared to the pin-in-fiberglass group (8 weeks). Functional and cosmetic appearances were graded as excellent for both groups. Complications associated with the two techniques were cast sores in the pin-in-fiberglass group while pin loosening and serous pin tract drainage were observed in the Kirschner-Ehmer external fixative group. Thus, it was concluded that pin-in-fiberglass cast could be used as a satisfactory substitute to Kirschner-Ehmer type I external fixative in the management of simple radius-ulna fractures in dogs.Keywords: Bone, Dog, Fracture, Kirschner-Ehmer external fixative, Pin-in-fiberglass cast, Radius-ulna