Reanastomosis Research Articles

Endoscopic submucosal dissection of rectal lesion recurrence at the anastomosis site: when the staples lead the way.

A 75-year-old man underwent an anterior rectum resection due to an early neoplastic rectal lesion. On surveillance endoscopy 4 years later, the surgical anastomosis was identified at 8 cm from the anal margin and was associated with a 35-mm lateral spreading tumor (LST), compatible with neoplastic recurrence. The LST reached the anastomosis as well as an adjacent pseudodiverticular recess ([Fig. 1]). White-light and narrow-band imaging evaluation looking for signs of invasive disease were unremarkable, so endoscopic submucosal dissection (ESD) was decided upon.

Lower Extremity Reconstruction with Anterolateral Thigh Free-Flap Anastomoses: A Computational Fluid Dynamic Analysis.

The anterolateral thigh free flap is an option for repairing soft tissue defects of the distal lower extremity. This flap uses the descending branch of the lateral circumflex femoral (LCF) artery as the flap vessel. The recipient vessel in these flaps is often the anterior tibial (AT), posterior tibial (PT), or peroneal (P) arteries. Computational fluid dynamic (CFD) evaluation of anastomoses between these vessels can optimize outcomes. Thirty-eight CFD models were created to model end-to-side (ETS) and end-to-end (ETE) anastomoses for lower extremity reconstruction. Seven out of thirty-eight models represented ETS anastomoses between the LCF and AT arteries with varying anastomotic angles. Nine out of thirty-eight models represented 45-degree ETS anastomoses between varying diameters of the LCF and AT, PT, and P arteries. Nine out of thirty-eight models represented stenosis on the flap vessel and recipient vessel, pre- and post-bifurcation. Nine out of thirty-eight models represented ETE anastomoses, rather than ETS, with varying vessel diameters. Four out of thirty-eight models represented ETE anastomoses with varying regions and levels of stenosis. Stasis of blood flow in ETS models increased as anastomotic angle increased in a logarithmic relationship (R 2 = 0.918). Flow was optimized overall as flap and recipient vessel diameters approached one another. In ETS models, flap vessel and postbifurcation recipient vessel stenosis were found to substantially increase stasis. Selection of flap and recipient vessels with similar diameters can optimize outcomes in microvascular anastomoses. In the context of lower extremity reconstruction with the ALT flap, the PT artery can be recommended as a first-line recipient vessel due to its similar vessel caliber to the LCF and relative ease of surgical access compared with the P artery. Avoidance of areas of stenosis is recommended to ensure laminar flow and reduce the operative difficulty associated with performing anastomoses on nonpliable arteries. Striving for increased acuity of anastomotic angles is recommended to optimize the flow in ETS microvascular anastomoses.

Venous outflow obstruction in pediatric left lateral segment split liver transplantation.

Venous outflow obstruction (VOO) is a known cause of graft and patient loss after pediatric liver transplantation (LT). We analyzed the incidence, risk factors, diagnosis, management, and outcome of VOO in a large, consecutive series of left lateral segment (LLS) split LT with end-to-side triangular venous anastomosis. We evaluated data collected in our prospective databases relative to all consecutive pediatric liver transplants performed from January 2006 to December 2021. We included in this study children undergoing LLS split liver transplant with end-to-side triangular anastomosis. Diagnosis of VOO was based on clinical suspicion and radiological confirmation. VOO occurred in 24/279 transplants (8.6%), and it was associated with lower graft weight (p=.04), re-transplantation (p=.008), and presence of two hepatic veins (p<.0001). In presence of two segmental veins' orifices, the type of reconstruction (single anastomosis after venoplasty or double anastomosis) was not significantly related to VOO (p=.87). Multivariable analysis indicated VOO as a risk factor for graft lost (hazard ratio 3.21, 95% confidence interval 1.22-8.46; p=.01). Percutaneous Transluminal Angioplasty (PTA) was effective in 17/22 (77%) transplants. Surgical anastomosis was redone in one case. Overall six grafts (25%) were lost. VOO after LLS split LT with end-to-side triangular anastomosis is an unusual but critical complication leading to graft loss in a quarter of cases. The occurrence of VOO was associated with lower graft weight, re-transplantation, and presence of two hepatic veins. PTA was safe and effective to restore proper venous outflow in most cases.

Widespread Emphysema After Elective Colonoscopy

CASE REPORT Perforation in colonoscopy occurs in 5.8 procedures per 10,000,1 and 52% are detected within 1 hour.2 Common signs include subcutaneous emphysema of the face, neck, or upper chest,3 but the growing complexity and demand for colonoscopy increase the incidence and severity of complications. A 72-year-old man with a medical history of pneumoconiosis and colorectal cancer status post right hemicolectomy complicated by anastomotic leakage resulting in temporary diverting ileostomy presented for colon cancer surveillance and precolonic reconstruction evaluation. One year before, the patient was submitted to right hemicolectomy for colon cancer therapy. As early surgical anastomosis leakage occurred, a temporary diverting ileostomy was performed. Ten minutes after colon inflation with room air, the patient became hemodynamically unstable witch precluded the polypectomy. Computed tomography showed subcutaneous emphysema (Figure 1), pneumoretroperitoneum (Figure 2), pneumothorax, pneumopericardium (Figure 3), and extra peritoneum fistula (Figure 4).Figure 1.: (A) Facial subcutaneous emphysema after intubation and (B) normal face at discharge.Figure 2.: Computed tomography abdomen: pneumoperitoneum and pneumoretroperitoneum.Figure 3.: Computed tomography chest: bilateral pneumothorax and pneumopericardium.Figure 4.: Abdominal wall with ileostomy bag in place. White arrow: extra peritoneum fistula.Anatomical alterations resulting from past abdominal surgeries favored gas spreading through the fistula. Positive pressure ventilation and lung disease led to hypertensive pneumothorax generating hemodynamic instability. The use of low solubility room air and the ileostomy bag acted as emphysema catalyzers. To prevent life-threatening complications, it is important to know the underlying pathophysiological framework, the patient's risk factors, and adapt to each individual patient. DISCLOSURES Author contributions: AM Pinto: writing of the manuscript and literature review, and is the article guarantor. P. Sarrmento, A. Fonte, and R. Cerqueira: literature review, review of intellectual content, and manuscript final approval. Financial disclosure: None to report. Informed consent was obtained for this case report.

COMPARISON OF PREOPERATIVE BOWEL PREPARATION MODELS OF PATIENTS WHO UNDERWENT SURGERY FOR COLORECTAL CANCER

Background&#x0D; The most prevalent cancer in society is colorectal cancer (CRC). Studies aiming to lower surgical morbidity and mortality have found a significant contribution from preoperative bowel preparation. Models for bowel preparation included mechanical cleaning, the use of antibiotics, and control groups. We compared preoperative bowel preparation for elective colorectal cancer and evaluated its effects in this study.&#x0D; Material and Methods&#x0D; Preoperative bowel preparation model was used to prospectively split 144 patients (n=144) with colorectal cancer into four groups. Patients in the first group (Group I) underwent mechanical bowel preparation (MBP), followed by oral antibiotic therapy (OAB) and MBP in the second group (Group II), intravenous antibiotic therapy (IVAB), MBP, and OAB in the third group (Group III), and no bowel preparation in the fourth group (Group IV). Demographic information, anastomotic leakage, surgical site infection, intraabdominal abscess, postoperative ileus, and death were compared between patients.&#x0D; Results&#x0D; Groups I, II, III, and IV of the study each had 35 patients, 38 patients, 35 patients, and 36 patients, respectively. There was no statistically significant difference between the four groups when the groups were evaluated by age, gender, and ASA (American Society of Anesthesiologists) score (p&gt; 0.05). There were significant differences between surgical site infection (SSI), intraabdominal abscess, and anastomosis leaking (p0.05). Mortality and postoperative ileus did not differ significantly (p &gt; 0.05).&#x0D; Conclusion&#x0D; We consider that the bowel preparation approach of mechanical colon cleansing and antibiotic administration is appropriate for patients who have had surgery owing to elective CRC.

A129 A RETROSPECTIVE ANALYSIS OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN PATIENTS WITH PANCREATICODUODENECTOMY

Abstract Background Surgically altered anatomy remains a challenge when performing advanced endoscopic procedures including endoscopic retrograde cholangiopancreatography (ERCP). Post-surgical anatomy frequently encountered in clinical practice that affects ERCP success includes Billroth II, roux-en-y gastric bypass, roux-en-y hepaticojejunostomy and pancreaticoduodenectomy (PD). While ERCP has a success rate of 90-95% in patients with native anatomy, the data is less robust in patients with PD anatomy. Advancement of the endoscope to the surgical anastomoses remains challenging as PD anatomy requires accurate identification of the afferent limb, and encourages acute bowel angulation and loop formation. In addition, navigation to the anastomosis may be more challenging with a sideviewing endoscope. Although forward viewing endoscopes may more readily reach the surgical anastomosis, cannulation may be difficult without an elevator or device-appropriate instruments. As a result, a retrospective analysis of technical and clinical success rates in ERCP was analyzed in post-PD patients. Purpose The purpose of this study was to evaluate the technical and clinical success of ERCP in patients with post-PD anatomy. Method A retrospective analysis was conducted on all patients with post-PD anatomy referred to our institution between 2006 to 2021 for ERCP. Demographic and procedural details including gender, age, indications, primary malignancy, and anastomosis identification were collected. Major outcomes included technical success (TS) rate (successful biliary or pancreatic intervention) and clinical success (CS) rate (improvement in patient symptomatology or normalization of bilirubin level). Result(s) A total of 47 patients underwent 102 ERCPs for biliary (n = 98; 96.1%) and pancreatic (n = 4; 3.9%) indications. There were 31 (66.0%) male patients and 16 (34.0%) female patients. The average age of patients was 61.5 years. The most common primary malignancies included pancreatic adenocarcinoma (n = 26; 55.3%), pancreatic neuroendocrine tumour (n = 5; 10.6%), and ampullary adenocarcinoma (n = 4; 8.5%). The most common indications for ERCP included obstructive jaundice (n = 22; 21.6%), stent evaluation (n = 30; 29.4%), and cholangitis (n = 35; 34.3%). Surgical anastomosis was identified in 90 (88.2%) patients. The overall TS and CS rates were 82.4% and 75.5%, respectively. When adjusted for anastomosis identification, the overall TS and CS rates were 93.3% and 82.2%. Conclusion(s) Despite the challenges of conducting ERCP in patients with post-PD anatomy, this retrospective analysis demonstrates an adequate overall TS and CS rate. Although endoscope advancement to the surgical anastomoses may be challenging, TS and CS rates improved if the anastomosis was reached and identified. The advent of endoscopic enteroenterostomy formation, balloon-assisted enterscopy, and rigidizing overtubes may assist in reaching surgical anastomoses. As a result, consideration should be undertaken to attempt ERCP in post-PD patients. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

A121 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN PATIENTS WITH PANCREATICODUODENECTOMY USING DYNAMIC RIGIDIZING OVERTUBE

Abstract Background Dynamic rigidizing overtubes have recently been described as a useful tool in challenging endoscopic procedures. These devices have the ability to dynamically rigidize, which stabilizes endoscope position, reduce loop formation and assist in the traversal of acute angulation. Its use has been best described in difficult colonoscopies by preventing loop formation and subsequently facilitating cecal intubation. However, the use of rigidizing overtubes for endoscopic retrograde cholangiopancreatography is sparsely described in the literature. In particular, rigidizing overtubes may be beneficial in patients with surgically-altered anatomy, including post-pancreaticoduodenectomy (PD) patients, as traversal to the surgical anastomosis is often challenging because of loop formation and acute angulation. In this study, a retrospective analysis was conducted on post-PD patients undergoing ERCP with dynamic rigidizing overtube. Purpose The purpose of this study was to evaluate the technical and clinical success of post-PD patients undergoing ERCP with rigidizing overtube. Method A retrospective analysis was conducted on all post-PD patients who underwent ERCP with rigidizing overtube between 2006 and 2021. Demographic information including age, gender and primary malignancy was collected. Pertinent procedure-related information including indication and anastomosis identification was obtained. The primary outcomes evaluated included technical and clinical success rate. Technical success (TS) was defined as the ability to perform an intended therapeutic intervention (stent insertion, cannulation, etc). Clinical success (CS) was operationalized as improvement in patient symptoms or normalization of bilirubin. Result(s) A total of 5 patients underwent 11 ERCPs with rigidizing overtube for biliary indications. There was a total of 3 (60.0%) male and 2 (40.0%) female patients. The average age of the patients was 62.5 years of age. There were 3 (60.0%) patients with pancreas cancer, 1 (20.0%) with metastatic renal cell carcinoma, and 1 (20.0%) with duodenal adenoma with high grade dysplasia. The indications for ERCP included stent evaluation (n = 6; 54.5%), obstructive jaundice (n =3; 27.3%), cholangitis (n = 1; 9.1%), and stricture evaluation (n = 1; 9.1%). The surgical anastomosis was identified in all patients (n = 11; 100%). The overall technical and clinical success rates were both 90.9%. Conclusion(s) The use of rigidizing overtubes in ERCP may be beneficial in patients with surgically altered anatomy. In this small sample, technical and clinical success rates were excellent in post-PD patients. However, additional studies need to be conducted to validate these findings further. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Percutaneous Creation of Dialysis Arteriovenous Fistula: Patient Selection and Ultrasound Mapping.

Approximately, 550,000 patients with end-stage kidney disease rely on maintenance dialysis in the United States, and nearly 90% receive hemodialysis.[1] Providing hemodialysis requires a conduit to the bloodstream (vascular access) that can reliably deliver a high blood flow into the extracorporeal dialysis circuit. A surgical arteriovenous fistula (AVF) is created by a direct surgical anastomosis between a peripheral artery and vein. AVFs are considered the preferred type of vascular access, because they have better survival and require fewer interventions to maintain long-term patency for dialysis, once they are successfully cannulated for dialysis.[2] [3] [4]

Impact of Antifibrotic Treatment on Postoperative Complications in Patients with Interstitial Lung Diseases Undergoing Lung Transplantation: A Systematic Review and Meta-Analysis.

Antifibrotic treatment has been approved for reducing disease progression in fibrotic interstitial lung disease (ILD). As a result of increased bleeding risk, some experts suggest cessation of antifibrotics prior to lung transplantation (LT). However, extensive knowledge regarding the impact of antifibrotic treatment on postoperative complications remains unclear. We performed a comprehensive search of several databases from their inception through to 30 September 2021. Original studies were included in the final analysis if they compared postoperative complications, including surgical wound dehiscence, anastomosis complication, bleeding complications, and primary graft dysfunction, between those with and without antifibrotic treatment undergoing LT. Of 563 retrieved studies, 6 studies were included in the final analysis. A total of 543 ILD patients completing LT were included, with 161 patients continuing antifibrotic treatment up to the time of LT and 382 without prior treatment. Antifibrotic treatment was not significantly associated with surgical wound dehiscence (RR 1.05; 95% CI, 0.31-3.60; I2 = 0%), anastomotic complications (RR 0.88; 95% CI, 0.37-2.12; I2 = 31%), bleeding complications (RR 0.76; 95% CI, 0.33-1.76; I2 = 0%), or primary graft dysfunction (RR 0.87; 95% CI, 0.59-1.29; I2 = 0%). Finally, continuing antifibrotic treatment prior to LT was not significantly associated with decreased 1-year mortality (RR 0.80; 95% CI, 0.41-1.58; I2 = 0%). Our study suggests a similar risk of postoperative complications in ILD patients undergoing LT who received antifibrotic treatment compared to those not on antifibrotic therapy.

URETHRAL STRICTURE MANAGED WITH HOMEOPATHIC MEDICINE: A STUDY OF FOUR CASES

Urethral stricture is the narrowing of the urethral mucosa, commonly resulting from trauma followed by inflammation and fibrous changes of the corpus spongiosum along the male urethra. Clinical manifestation contains gradual deterioration of hesitancy, intermittency, dribbling of urine, and in association with a sensation of incomplete voiding of the bladder, increased frequency, urgency, straining, and urethralgia during micturition. A low Qmax in Uroflowmetry will give a primary idea of stricture; however, a Retrograde Urethrography (RUG) confirms the stricture location, length, and other identifiable pathology affecting the urethra. In this particular disease, the scope of conventional medicinal treatment is limited, however, there transurethral (dilation, internal urethrotomy) and open surgical (stricture resection and anastomosis, urethroplasty, and perineal urethrostomy) procedures are available, and recurrence is common. Homeopathic medicine is mostly an individualized medicine with a minimum number and high dilution. The use of homeopathic medicine for urological diseases is an opportunistic option. However, a group of patients with similar set of symptoms might be treated with a specific homeopathic medicine. The author is reporting a study of four urethral stricture cases treated with homeopathic medicines, namely Clematis erecta, Medorrhinum, and Aurum metallicum; within 6-24 weeks of homeopathic medicine treatment, all four patients experienced improved uroflowmetry and RUG. The current study results shows homeopathic medicine helped the patients in a harmless, cost-effective way which might encourage awareness among the medical practitioners regarding the available homeopathic medicinal treatment of urethral stricture. Bioresearch Commu. 9(1): 1245-1251, 2023 (January)

Aortic tissue pathology in reoperative post-dissection repair following prior use of BioGlue.

The benefits of BioGlue as a surgical adjunct in aortic procedures have been demonstrated in several studies, but limited information is available regarding the associated histopathological findings of aortic tissue at the time of reoperation. The objective of this study was to assess, at reoperation, the histopathological characteristics of aortic tissue which has had BioGlue applied during a previous surgery. This prospective, single-center, single-arm study enrolled patients who were undergoing aortic reoperation and who had BioGlue used during previous aortic surgery. Histopathological assessment of aortic specimens obtained intraoperatively was performed on tissue that would have been removed independent of subject participation in the study. A total of 11 patients were enrolled and based on gross assessment, excessive amounts of BioGlue had been applied during the initial surgery in 36.4% of cases. The samples with the greatest amount of residual BioGlue demonstrated moderate to marked inflammatory responses, while the remaining samples demonstrated minimal to moderate inflammatory responses. Calcification of residual BioGlue was noted in 4 cases. Substantial medial degeneration was associated with suture line dehiscence in 4 cases, some of which had a large quantity of residual BioGlue. No evidence of suture degradation was observed. Cases with surgical anastomosis dehiscence were associated with substantial medial degeneration. While no histologic findings directly linked BioGlue to these degenerative changes, a contributory role cannot be excluded. Following the manufacturer's instructions for appropriate application of BioGlue is crucial to prevent potential complications.

Study protocol for comparing the efficacy of left-open single-flap technique versus double-flap technique after proximal gastrectomy: A multicenter randomized controlled trial.

Proximal gastrectomy has gradually gained more attention due to its superiority in retaining the function of part of the stomach. The inevitable loss of the antireflux barrier and postoperative complications resulting from proximal gastrectomy can severely affect the quality of life. Continuous improvements in digestive tract reconstruction after proximal gastrectomy have yielded the development of a variety of methods with antireflux functions. Recently, our center attempted the left-open single-flap technique and initiated a multicenter, prospective, randomized controlled trial for patients undergoing proximal gastrectomy to reduce the difficulty of surgical anastomosis and the incidence of perioperative complications compared with the double-flap technique. These findings will provide more evidence-based medical research for the development of clinical guidelines. This study is a prospective, multicenter, randomized controlled clinical trial. We plan to recruit 250 patients who are eligible for proximal gastrectomy. After informed consent is obtained, patients will be randomly assigned to the trial group (left-open single-flap technique) and the control group (double-flap technique) in a 1:1 allocation ratio. Increasingly, clinical studies have focused on the improvement of reconstruction modalities after proximal gastrectomy. Among these methods, the double-flap technique is a clinically effective method. The purpose of this study is to establish a prospective randomized controlled trial to compare the efficacy of the left-open single-flap technique versus the double-flap technique after proximal gastrectomy, aiming to provide more evidence-based medical studies for digestive tract reconstruction in proximal gastrectomy. ClinicalTrials.gov, identifier [NCT05418920].

Incidence and causes of failure in various anatomical pouch designs 20years after surgical primary ileal-pouch anal anastomosis construction.

Since the introduction of ileo-pouch anal anastomosis (IPAA) surgery, various pouch designs have been applied. Recently, there has been renewed interest in creating larger pouch designs to reduce defecation frequency after pouch surgery. The aim of this study was to assess chronic pouch failure (PF) rates and causes in alternative S or septated (SP) pouches when compared to J pouches and B- shaped adaptations. This retrospective cohort study included patients that underwent primary IPAA construction surgery from 1978-2000. Pouch designs were subdivided in J and B (J/B), and larger pouches (S/SP). PF included need for a pouch excision, redo pouch procedure, revisional pouch surgery, or permanent ileostomy surgery. Outcomes of this study were incidence and causes for PF per pouch design group. Out of 200 patients who underwent IPAA surgery, 19 had an S/SP design and 181 had a J/B design. After a follow-up of 27.0 (IQR 23.3 - 29.0) years, 45/200 (22.5%) patients who underwent IPAA surgery between 1975-2000 developed PF. Some 78.9% of patients with an S/SP pouch developed PF, compared to 16.7% of patients with a J/B pouch (p < 0.01). Mechanical outlet issues occurred more often in S/SP pouches when compared to J/B (42.1% vs. 1.1%, p < 0.01), and were predominantly caused by septal- or pouch wall intussusception and efferent loop kinking (S-pouch). Despite an inevitable proportion of bias, the current study revealed that S/SP pouches were characterized by an increased PF incidence due to emptying problems after long-term follow-up when compared to J/B pouches. Constructing an S pouch or large septated reservoir at index surgery should therefore be questioned because of a shorter longevity.

Pictorial review: radiological diagnosis of anastomotic leakage with water-soluble contrast enema after anterior resection of the rectum.

For patients who have undergone colorectal surgery, anastomotic leakage is a serious and challenging complication with a variable rate ranging between 1.8% and 19.2%. Postoperative anastomotic leaks after colorectal surgery can have severe consequences for patients, particularly ones who present with few or no symptoms. Computed tomography and/or water-soluble contrast enema (WSE) are the most frequently utilized imaging methods to identify and diagnose anastomotic leaks early. WSE is a safe and complication-free procedure that allows to identify the presence of otherwise unrecognized anastomotic leaks, both in asymptomatic and symptomatic patients. Fluoroscopic rectal examination using a water-soluble contrast agent for postoperative patients is never an easy examination to perform since it requires careful preparation, skill, and knowledge. Four morphological types of anastomotic dispersion have been described: "saccular type", "horny type", "serpentine type" and "dendritic type". Among 4 types of leakage, dendritic and serpentine types are more frequently followed by clinical symptoms and none of the dendritic type resolves spontaneously. On the other hand, the saccular and horny types have a better prognosis after healing of the loss and subsequent restoration of the ostomy as they consist of a cavity that provides a sort of physical barrier to the spread of inflammation. The aim of this pictorial essay was to illustrate the spectrum of imaging findings of morphological types of radiologic leakages on WCE in patients with colorectal surgical anastomosis. We have also tried to provide tips and tools to enable identification of radiological leakages on retrograde WCE, particularly of the smallest leaks which can be more easily missed.

External Iliac Artery Anastomosis and Internal Iliac Artery Anastomosis for Artery anastomosis in Deceased-donor Kidney Transplantation and Multifactorial Analysis of Graft Survival.

To determine the effects of surgical techniques applied to arterial anastomosis for kidney transplantation on the graft outcome. Observational study. Organ Transplantation Center, Ataturk University Research Hospital and School of Medicine, Erzurum, Turkey, from January 2010 to January 2020. In total, 143 consecutive patients who underwent deceased-donor-donor kidney transplantation during a 10-years period were retrospectively analysed. All patients were divided into two groups according to the vascular anastomosis techniques (end-to side external iliac and end-to-end internal iliac). The two groups were compared in terms of urine volume on postoperative days 1 and 7; blood creatinine levels on postoperative days 1, 2, and 7; complications; and graft survival. The mean patient age was 42.04 ± 11.1 years. No significant difference was observed between creatinine values ​​and urine amounts for both surgical techniques (p >0.05). Only the amount of urine on the postoperative 7th day had a significant effect on graft survival (p <0.05). There was no significant difference between the two anastomosis techniques in terms of graft survival (p >0.05). Both surgical techniques can be used safely in renal transplantation and arterial anastomosis. Also, decreased urine volume during follow-up can be considered as an early indicator of graft loss in the long-term. Kidney transplantation, Surgical anastomosis, Delayed graft function, Graft survival.

S2876 To the Duodenum, and Beyond! Using the BougieCap for Duodenal Stricture Dilation

Introduction: Benign duodenal strictures are typically caused by peptic ulcer disease, caustic ingestion, surgical anastomoses, or inflammatory bowel disease. Treatment of benign strictures usually involves endoscopic dilation using through-the-scope (TTS) balloon dilators with or without fluoroscopy. TTS balloon dilators allow visualization during dilation, but they do not provide haptic feedback. The BougieCap dilator is a newer device that attaches to the endoscope and allows direct visual and haptic feedback during dilation. While it is generally used for dilation of esophageal strictures, this report describes its use for dilation of a benign duodenal stricture. Case Description/Methods: A 75-year-old male with stage IV non-small cell lung cancer on immunotherapy was found to have biliary dilation on imaging. He subsequently underwent endoscopic ultrasound which incidentally revealed a duodenal stricture at the junction of the first and second portions of the duodenum. The stricture was unable to be traversed with the linear echoendoscope or an adult upper endoscope. TTS balloon dilation from 8 to 12 mm was performed, however, the adult upper endoscope was still unable to traverse the stricture. Biopsies of the stricture were obtained and were negative for malignancy and gastric biopsies did not reveal any evidence of Helicobacter pylori infection. Approximately 4 months later, the patient developed progressive nausea and vomiting. Upper endoscopy again showed the duodenal stricture which was unable to be traversed. The decision was made to use the BougieCap device for dilation. The stricture was then sequentially dilated from 10 to 12 mm using the BougieCap with direct visualization of mucosal disruption during dilation as expected (Figure). The adult upper endoscope was then able to traverse the stricture easily. There were no procedural complications or adverse effects and the patient reported improvement in his symptoms. Discussion: Benign duodenal strictures are typically treated with endoscopic dilation using TTS balloon dilators, although this method is limited by the lack of haptic feedback or complete visualization in some cases. In this case, TTS balloon dilation was ineffective for initial stricture dilation, thus the BougieCap was used for more precise dilation under direct visualization. While the BougieCap is generally used for esophageal stricture dilation, it may also serve as a safe and effective method to dilate refractory benign duodenal strictures.Figure 1.: Endoscopic image of BougieCap dilation of the duodenal stricture.

End-to-side Anastomosis on Digital Arteries: Just a Technical Choice or a Real Benefit?

Background:High-quality evidence is currently poor regarding the benefits of end-to-end (ETE) or end-to-side (ETS) anastomosis in arterial and venous anastomoses, despite being postulated as a potential influence on outcomes. A sufficient microvascular anastomosis is indispensable for the success of any free tissue transfer. ETS microvascular anastomoses have been becoming increasingly important as they allow reconstruction even in patients with impaired vascular status. To the authors’ knowledge, no studies have examined the choice of ETE or ETS anastomoses specifically for digital arteries.Methods:We conducted a retrospective study of ETE and ETS anastomosis cases; the only inclusion criteria was that digital arteries (proper, common) were the recipient vessels.Results:Fifty-seven cases met the inclusion criteria. All the venous anastomoses were ETE. Of these cases, four total intraoperative complications (immediate thrombosis) and only one case of complete failure were registered. The ETE group consisted of 49 patients and the ETS group of eight patients. A comparison of the mean ischemia time in the two groups showed no statistically significant difference (P = 0.121).Conclusions:We observed no difference in the reconstructive outcomes of hand free-flaps and reconstruction between ETE or ETS digital arteries anastomoses. The successful microsurgical reconstruction was independent of anastomotic technique. In particular, the results of our study demonstrated no statistically significant increase of the ischemia time; thus, no prolongation of operative time can be attributed to the higher technical challenge of the anastomosis.

Hepatic Abscess following Yttrium-90 Radioembolization in Patients with Surgical Bilioenteric Anastomosis or Compromised Sphincter of Oddi: A Tertiary Cancer Center Experience.

Purpose: We describe our experience with the development of hepatobiliary infection in patients with prior surgical, percutaneous, or endoscopic biliary interventions who are receiving transarterial radioembolization (TARE) with yttrium-90 (90Y) for primary or metastatic hepatobiliary lesions. Methods: Records of 15 patients with a history of prior biliary intervention and liver malignancy subsequently treated with TARE at the participating medical center from November 2009 to September 2015 were reviewed. The primary endpoint was the development of a hepatic abscess or cholangitis in a patient after radioembolization. Results: A total of 15 patients comprising 9 men and 6 women, with a median age of 49 years (range 30–73), underwent 17 TARE with 90Y procedures. Of the 15 patients, 2 (13.3%) of them developed a hepatobiliary infection. A single patient (6.6%) developed a hepatobiliary abscess. Conclusion: Our study shows a low incidence rate of hepatic abscess following TARE in patients with prior biliary intervention.

242.12: The Outcome of the Inferior Epigastric Artery as a Donor Vessel for Managing Accessory Renal Arteries in Renal Transplantation: A Systematic Review and Meta-Analysis

Background: Utilisation of renal allografts with multiple renal arteries (MRA) has always been considered a technical challenge during implantation of renal allografts. There is sparse literature comparing the implantation technique of MRA and allograft outcomes. The aim of this study was to perform systematic review and meta-analysis of literature comparing inferior epigastric artery (IEA) to other surgical anastomosis techniques in renal allografts with MRA. Methodology: The database MEDLINE was searched via PubMed, EMBASE, The Cochrane Library. Grey literature search was utilised including GoogleScholar. We appraised the studies using Keywords and MeSH were utilised, including: “epigastric artery” AND “kidney transplant”. The studies were appraised using Newcastle-Ottawa scale and meta-analysed using random-effects model. Results: A total of eight studies met the inclusion and exclusion criteria for analysis. Five studies were included in the quantitative analysis. Majority of the studies were poor (n=4) or fair (n=4). There were a total of n=846 patients in the studies, with n=161(19.0%) undergoing inferior epigastric artery anastomosis. Other anastomosis techniques consisted of: side-to-side with single anastomosis, long or modified carrell patch, end to side to main renal artery with single anastomosis. Nearly all of the renal allografts in the study population consisted of living donation kidney allografts. In meta-analysis: there was no statistical difference in urological complication rate between IEA versus other techniques, O.R. 0.82 (CI 0.21, 3.24). There was a trend towards lower delayed graft function (DGF) in IEA versus other anastomosis techniques but it did not reach statistical significance (O.R. 0.45, CI 0.10, 2.02). In qualitative analysis, vascular complications were largely reported in one paper, with 3 in IEA vs 6 in other anastomosis group. Long-term graft function was only reported in one paper, with 2 (9.5%) in IEA vs 47(16.2%) in other anastomosis group. Overall follow-up ranged from 12 months to 10 years, with none reporting long-term patient survival. Conclusion: Utilisation of recipient inferior epigastric artery for accessory polar vessels is an acceptable technique in renal transplantation. Whilst no short-term differences were shown in peri-procedural vascular or urological complication, there was a trend towards reduced delayed graft function. Long-term impact on graft function remains to be determined.

3D laparoscopic-assisted vs open gastrectomy for carcinoma in the remnant stomach: A retrospective cohort study

BACKGROUNDThree-dimensional (3D) laparoscopic technique has gradually been applied to the treatment of carcinoma in the remnant stomach (CRS), but its clinical efficacy remains controversial.AIMTo compare the short-term and long-term results of 3D laparoscopic-assisted gastrectomy (3DLAG) with open gastrectomy (OG) for CRS.METHODSThe clinical data of patients diagnosed with CRS and admitted to the First Medical Center of Chinese PLA General Hospital from January 2016 to January 2021 were retrospectively collected. A total of 84 patients who met the inclusion and exclusion criteria were enrolled. All their clinical data were collected and a database was established. All patients were treated with 3DLAG or OG by experienced surgeons and were divided into two groups based on the different surgical methods mentioned above. By using outpatient and telephone follow-up, we were able to determine postoperative survival and tumor status. The postoperative short-term efficacy and 1-year and 3-year overall survival (OS) rates were compared between the two groups.RESULTSAmong 84 patients with CRS, 48 were treated with OG and 36 with 3DLAG. All patients successfully completed surgery. There was no significant difference between the two groups in terms of age, gender, body mass index, ASA score, initial disease state (benign or malignant), primary surgical anastomosis method, interval time of carcinogenesis, and tumorigenesis site. Patients in the 3DLAG group experienced less intraoperative blood loss (188.33 ± 191.35 mL vs 305.83 ± 303.66 mL; P = 0.045) and smaller incision (10.86 ± 3.18 cm vs 20.06 ± 5.17 cm; P < 0.001) than those in the OG group. 3DLAGC was a more minimally invasive method. 3DLAGC retrieved significantly more lymph nodes than OG (14.0 ± 7.17 vs 10.73 ± 6.82; P = 0.036), whereas the number of positive lymph nodes did not differ between the two groups (1.56 ± 2.84 vs 2.35 ± 5.28; P = 0.413). The complication rate (8.3% vs 20.8%; P = 0.207) and intensive care unit admission rate (5.6% vs 14.5%; P = 0.372) were equivalent between the two groups. In terms of postoperative recovery, the 3DLAGC group had a lower visual analog score, shorter indwelling time of gastric and drainage tubes, shorter time of early off-bed motivation, shorter time of postoperative initial flatus and initial soft diet intake, shorter postoperative hospital stay and total hospital stay, and there were significant differences, showing better short-term efficacy. The 1-year and 3-year OS rates of OG group were 83.2% [95% confidence interval (CI): 72.4%-95.6%] and 73.3% (95%CI: 60.0%-89.5%) respectively. The 1-year and 3-year OS rates of the 3DLAG group were 87.3% (95%CI: 76.4%-99.8%) and 75.6% (95%CI: 59.0%-97.0%), respectively. However, the 1-year and 3-year OS rates were similar between the two groups, which suggested that long-term survival results were comparable between the two groups (P = 0.68).CONCLUSIONCompared with OG, 3DLAG for CRS achieved better short-term efficacy and equivalent oncological results without increasing clinical complications. 3DLAG for CRS can be promoted safely and effectively in selected patients.