External Opening Research Articles

TU1.12 Video Presentation: The OVESCO Clip for Endoscopic Treatment of Gastrocutanoeus Fistula

Abstract Background Percutaneous endoscopic gastrostomy (PEG) is an important route of nutrition in many patients. PEG removal usually leads to spontaneous closure in a few days. Gastrocutaneous fistula (GCF) after PEG removal is an uncommon complication occurring in 2% of patients. Despite its rarity, it is responsible for significant morbidity and reduced quality of life. Treatment is initially focused on medical management and endoscopic clipping, with advanced endoscopic techniques and surgery reserved for selected cases. Method We present a video presentation demonstrating successful endoscopic treatment of GCF using the OVESCO Over the Scope clip with resolution of symptoms and closure of the fistula tract. The device is a novel innovation designed to achieve tissue apposition and compression without ischaemia. It is licensed for Gastrointestinal iatrogenic defects, endoscopic perforation, bleeding and GCF. The 72 year old patient had debilitating symptoms of gastric leakage for over a year despite previous attempts at endoscopic clipping, fibrin glue and curettage of the fistula tract. Results As shown in the video, the clip achieved good opposition with no post procedural leak. The patient was reviewed at 3 and 12 months with no recurrence of their symptoms. The external cutaneous opening had closed at 3 months. The patient reported an increase in weight, improved mood and a greater quality of life following the intervention. Conclusion The OVESCO clip has been proven to facilitate successful endoscopic closure of GCF in selected patients in whom initial treatment measures have failed. This mitigates the need and risks of surgical closure.

A vidian neurectomy approach with the sphenoid process of the palatine bone as a landmark

Objective:To explore a safe and effective surgical approach to locate and cut the vidian nerves with the sphenoid process of the palatine bone as a landmark. Methods: The landmarks of locating the external opening of the vidian canal were confirmed by the dissection of the cadaveric heads, and the feasibility of locating the vidian nerves with the determined landmarks was verified during operation. Results:The anatomical landmarks, which are the anterior opening of palatovaginal canal, the posterior opening of palatovaginal canal, palatovaginal canal and the nasal pharyngeal crest of the root of the pterygoid process can be used as the important landmarks of locating vidian nerve. In the cases of 10 patients with refractory allergic rhinitis and vasomotor rhinitis, the vidian nerves were successfully located and sectioned, and one patient was complicated with short-term unilateral palatal numbness after surgery. Conclusion:The anterior opening of palatovaginal canal, the posterior opening of palatovaginal canal, palatovaginal canal and the nasal pharyngeal crest of the root of the pterygoid process can be used as surgical markers for vidian neurectomy with the sphenoid process of the palatine bone as landmarks.

A Preclinical Validation of Iron Oxide Nanoparticles for Treatment of Perianal Fistulizing Crohn's Disease.

Fistulizing anoperineal lesions are severe complications of Crohn’s disease (CD) that affect quality of life with a long-term risk of anal sphincter destruction, incontinence, permanent stoma, and anal cancer. Despite several surgical procedures, they relapse in about two-thirds of patients, mandating innovative treatments. Ultrasmall particles of iron oxide (USPIO) have been described to achieve in vivo rapid healing of deep wounds in the skin and liver of rats thanks to their nanobridging capability that could be adapted to fistula treatment. Our main purpose was to highlight preclinical data with USPIO for the treatment of perianal fistulizing CD. Twenty male Sprague Dawley rats with severe 2,4,6-trinitrobenzenesulfonic acid solution (TNBS)-induced proctitis were operated to generate two perianal fistulas per rat. At day 35, two inflammatory fistulas were obtained per rat and perineal magnetic resonance imaging (MRI) was performed. After a baseline MRI, a fistula tract was randomly drawn and topically treated either with saline or with USPIO for 1 min (n = 17 for each). The rats underwent a perineal MRI on postoperative days (POD) 1, 4, and 7 and were sacrificed for pathological examination. The primary outcome was the filling or closure of the fistula tract, including the external or internal openings. USPIO treatment allowed the closure and/or filling of all the treated fistulas from its application until POD 7 in comparison with the control fistulas (23%). The treatment with USPIO was safe, permanently closed the fistula along its entire length, including internal and external orifices, and paved new avenues for the treatment of perianal fistulizing Crohn’s disease.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula.

Valve and ‘Stigma’ Structure and Phylogeny of an Enigmatic Cymbelloid Diatom Karthickia verestigmata Glushchenko, Kulikovskiy & Kociolek

The epilithic diatom Karthickia verestigmata Glushchenko et al. was described from North Viet Nam and Laos. Karthickia is a monotypic genus characterized by a unique ‘stigma’ located on the secondary side of the valve with an external circular opening and opening internally by two elongated slits. In 2012 we collected a diatom population consistent with the description of K. verestigmata from the Wang Kaew Waterfall on the upper Wang River in Doi Luang National Park, Thailand. This study details its internal ‘stigma’ structure utilizing sections made with a focused ion beam and observed with a scanning electron microscopy. From the bottom of external circular hole two narrowly flat spaces expanded from the bottom of the external opening down to each inner slit, lying in a trough that is a partial extension of a stria. A phylogenetic hypothesis for Karthickia was created using multiple genes. The taxonomic status of Karthickia is discussed in the context of other genera in the Cymbellales.

Rimocostatus bugojnicus gen.et. sp. nov. (Coscinodiscophyceae, Bacillariophyta) – a new fossil diatom genus from Gračanica, Bugojno palaeolake in Bosnia and Herzegovina

A new freshwater fossil diatom taxon Rimocostatus bugojnicus gen. et sp. nov, from Miocene sediments at the Gračanica site, Bugojno palaeolake in Bosnia and Herzegovina, is described. The main morphological feature of the genus is the presence of marginal rimoportulae with simple, round external openings positioned on interfascicles on the valve mantle and stalked, large, wide internal slits, positioned on every costa. Marginal and valve face fultoportulae are absent. With these characteristics, the species shows similarities to both marine and freshwater species, known from recent, and primarily from fossil, diatom deposits. Thus, Rimocostatus bugojnicus gen. et sp. nov. is an important find for understanding the evolution of centric diatom species.

Colorectal carcinoma presenting as spontaneous colocutaneous fistula - A rare case report and review of literature.

Introduction and importanceColon cancer presenting as spontaneous enterocutaneous fistula are rare with only few cases reported in the literature. Such presentation signifies locally advanced disease with poorer outcomes. Enterocutaneous fistula increases morbidity and mortality in cancer and may potentially delay the definitive care. It poses a difficulty in management in terms of patient optimization, determining the type of resection (palliative or curative) and the operative timeline.Case presentationA 47 years old female presented with complaints of foul smelling discharge from a fistulous opening in right iliac fossa with occasional per rectal bleeding for the past six months. Imaging showed ascending colon mass breaching the peritoneum with fistulous tract opening into subcutaneous plane. Exploratory laparotomy with extended right hemicolectomy and en bloc resection was performed.Clinical discussionCutaneous fistula can be caused by traumatic, postoperative etiologies and about 20 % are of spontaneous etiologies. Colon cancer has the ability to mimic any abdominal disease with a wide spectrum of presentations. The locoregional extension from the bowel creates a passage of colonic contents to evacuate from the external opening. The fistulous tract of colon cancer is less likely to close spontaneously and may require surgical intervention following appropriate resuscitation. Due to features suggestive of bowel obstruction an early single stage surgery was performed in our case.ConclusionThere are no existing guidelines for colon cancer with colocutaneous fistula because they are the same for benign fistulas (resuscitation, control of output, eradication of the infection, nutritional optimization, surgery) along with a multidisciplinary oncology team approach.

Treatment of cryptoglandular fistulas with the fistula tract laser closure (FiLaC™) method in comparison with standard methods: first results of a multicenter retrospective comparative study in the Netherlands.

Current surgical closure techniques for sphincter-sparing treatment of high cryptoglandular fistulas in the Netherlands include the mucosal advancement flap procedure (MAF) and ligation of the intersphincteric fistula tract (LIFT). A relatively novel treatment is the fistula tract laser closure (FiLaC™) method. The aim of this study was to investigate the differences in healing and recurrence rates between FiLaC™ and current standard practices. This multicenter retrospective cohort study included both primary and recurrent high cryptoglandular anorectal fistulas, treated with either FiLaC™ or standard methods (MAF or LIFT) between September 2015 and July 2020. Patients with extrasphincteric fistulas, Crohn's disease, multiple fistulas, age < 18years or missing data regarding healing time or recurrence were excluded. The primary outcomes were the clinical primary and secondary healing and recurrence rates. Primary healing was defined as a closed external opening without fluid discharge within 6months of treatment on examination, while secondary healing was the same endpoint after secondary treatment. Secondary outcomes included healing time and complaints. A total of 162 high fistulas from 3 Dutch hospitals were included. Ninety-nine high fistulas were treated with FiLaC™ and 63 with either MAF or LIFT. There were no significant differences between FiLaC™ and MAF/LIFT in terms of clinical healing (55.6% versus 58.7%, p = .601), secondary healing (70.0% versus 69.2%, p = .950) or recurrence rates (49.5% versus 54%, p = .420), respectively. Median follow-up duration was 7.1months in the FiLaC™ group (interquartile range [IQR] 4.1-14.4months) versus 6months in the control group (IQR 3.5-8.1months). FiLaC™ treatment of high anorectal fistulas does not appear to be inferior to MAF or LIFT. Based on these preliminary results, FiLaC™ can be considered as a worthwhile treatment option for high cryptoglandular fistulas. Prospective studies with a longer follow-up period and well-determined postoperative parameters such as complication rates, magnetic resonance imaging for confirmation of fistula healing, incontinence and quality of life are warranted.

Management of high anal complex Fistula by modified Kshar Sutra therapy

Fistula-in-ano is an inflammatory track which has an external opening in the perianal skin and internal opening in the anal canal or rectum. The track is lined by unhealthy granulation tissue and fibrous tissue. As per Ayurvedic perspective the condition can be corelated with Bhagandara. Acharya Sushruta has described Bhagandara in Ashtomahagada as it is difficult to cure. According to Charak Samhita Kshar sutra ligation is one of the effective procedures for Fistula-in-ano. A single case study of 38 years old male patient, suffering from Fistula-in-ano since 2 months has been illustrated here. Patient had complaints of mild pain at perianal region, P/R bleeding on and off, pus discharge on and off and boil at perianal region. After taking detailed history and thorough examination, we decided to treat the patient with Nadi puran (irrigation with medicated oil) using Saindhavadi taila along with internal medications i.e Kaishore guggul and Shanshamani vati for six days. Kshar sutra and non-cutting plain thread (seton) ligation was done on 7th day along with internal medications. Kshar sutra changing was repeated 4 times i.e., on day 14, day 23, day 33 and day 43 till the tract was completely cut and healed.

Higher infliximab and adalimumab trough levels are associated with fistula healing in patients with fistulising perianal Crohn's disease.

BACKGROUNDTumor necrosis factor-alpha inhibitors, including infliximab and adalimumab, are effective medical treatments for perianal fistulising Crohn’s disease (CD), but not all patients achieve fistula healing.AIMTo determine the correlation between perianal fistula healing and closure with infliximab and adalimumab trough levels.METHODSIn this multicentre retrospective study conducted across four tertiary inflammatory bowel disease centres in Australia, we identified CD patients with perianal fistulae on maintenance infliximab or adalimumab who had a trough level within twelve weeks of clinical assessment. Data collected included demographics, serum infliximab and adalimumab trough levels (mg/L) within 12 wk before or after their most recent clinical assessment and concomitant medical or surgical therapy. The primary outcome was fistula healing, defined as cessation in fistula drainage. The secondary outcome was fistula closure, defined as healing and closure of all external fistula openings. Differences between patients who did or did not achieve fistula healing were compared using the chi-square test, t test or Mann-Whitney U test.RESULTSOne hundred and fourteen patients (66 infliximab, 48 adalimumab) were included. Forty-eight (72.7%) patients on maintenance infliximab achieved fistula healing and 18 (27.3%) achieved fistula closure. Thirty-seven (77%) patients on maintenance adalimumab achieved fistula healing and 17 (35.4%) achieved fistula closure. Patients who achieved fistula healing had significantly higher infliximab and adalimumab trough levels than patients who did not [infliximab: 6.4 (3.8-9.5) vs 3.0 (0.3-6.2) mg/L, P = 0.003; adalimumab: 9.2 (6.5-12.0) vs 5.4 (2.5-8.3) mg/L, P = 0.004]. For patients on infliximab, fistula healing was associated with lower rates of detectable anti-infliximab antibodies and younger age. For patients on adalimumab, fistula healing was associated with higher rates of combination therapy with an immunomodulator. Serum trough levels for patients with and without fistula closure were not significantly different for infliximab [6.9 (4.3-10.2) vs 5.5 (2.5-8.3) mg/L, P = 0.105] or adalimumab [10.0 (6.6-12.0) vs 7.8 (4.2-10.0) mg/L, P = 0.083].CONCLUSIONHigher maintenance infliximab and adalimumab trough levels are associated with perianal fistula healing in CD.

A novel variant luteinizing hormone receptor in the first transmembrane helix of two homozygous Iranian patients: case report

BackgroundLeydig cell hypoplasia (LCH) is a rare autosomal recessive endocrine syndrome that affects the normal development of male external genitalia in 46, XY individuals and is one of the causes of disorder of sexual differentiation (DSD) in males. The responsible gene of LCH is LHCGR which is located on the chromosome 2 and its various mutations lead to different degrees of the disease ranging from micropenis to complete XY DSD.Case presentationIn this study, we have investigated the clinical presentation and molecular findings of two siblings with complete male LCH and XY DSD. This is the first detailed report of individuals with LCH from Iran. It aimed to study the molecular and clinical characteristics of two sisters with type 1 LCH. Whole exome sequencing was used for these patients to find the underlying genetic cause of the disease. Our Iranian DSD patients had external genitalia (normal labia major and minor, the external opening of the urethra beneath the clitoris) and bilateral testicular tissues in the inguinal region, which were removed by surgical exploration.ConclusionsGenetic sequencing showed the homozygous variants of the LHCGR gene in the patients, a novel duplication variant in exon 11, c.1091dupT -or pLeu365Profs*5. This mutation is described as likely pathogenic. We think that this case report can widen the genotypic spectrum of the LHCGR variants. Moreover, this study emphasizes the significant rule of Whole Exome Sequencing in differentiating various causes of disorder of sexual differentiation.

Short-term stretched penile length analysis for subsequent erectile dysfunction after robotic-assisted radical prostatectomy with bilateral neurovascular bundle preservation

ABSTRACT Introduction Stretched Penile Length (SPL) is observed to shrink after radical prostatectomy (RP) and has chances resuming the length as long as 12 months. Objective To assess the short-term SPL change from patients after robotic-assisted radical prostatectomy (RARP) with bilateral neurovascular bundle (NVB) preservation and experiencing subsequent erectile dysfunction (ED). Effects from tadalafil, post-operative androgen deprivation therapy (ADT), and no medication or intervention are compared. Methods From April to December 2018, patients developing ED (IIEF-5&amp;lt;22) after RARP with bilateral NVB preservation were included. SPL was measured as length from pubic symphysis to external urethral opening. Tadalafil 5 mg once daily (Group 1), postoperative ADT (Group 2) and control group (Group 3) were classified. Postoperative ADT was prescribed during the whole periods of 6 months for surgical adverse effects in group 2. Follow-ups were arranged 2 weeks after operation in the first time, and then every month up to 6 months. Student t test, chi-square test and SAS 9.4 were utilized to see if significant difference when p&amp;lt;0.05. Results With 64 men, 1 was excluded for preoperative ADT use. SPL-related comparisons were listed at Table 1. Preoperative SPL was measured without differences. Generally, in 6-month span, more men were with increased SPL in group 1 than in group 3, and also more with deterioration compared to group 3 (p=0.048). Same trend was observed in group 2 compared to group 3 (p=0.036). Men in group 1 (at the time deciding to take tadalafil) experienced a worse shortening SPL than group 3 (the 30–day change after operation) (p&amp;lt; 0.0001). Significantly improvement on SPL between before (7.93±1.89 (median: 7.5) cm) and after (8.59±2.17 (median:9) cm) tadalafil in group 1 (p=0.037) and also significantly improved against the SPL change from post-operative 30-day to 5-month of group 3 (p=0.004). Conclusions In our analysis, 63.7% of subsequent ED after RARP with bilateral NVB preservation would experience SPL shortening around 3 cm (around 30% of preoperative SPL) if only observation in 6 months after operation. Postoperative ADT for 6 months would contribute to approximately additional 15% shortening rates with the same degree. Significant improvement around 1 cm (around 10% of the preoperative SPL) on SPL was observed after tadalafil 5 mg once daily with median 4-month prescription. Disclosure Work supported by industry: no.

Probable cross-corridor transmission of SARS-CoV-2 due to cross airflows and its control

A COVID-19 outbreak occurred in May 2020 in a public housing building in Hong Kong – Luk Chuen House, located in Lek Yuen Estate. The horizontal cluster linked to the index case’ flat (flat 812) remains to be explained. Computational fluid dynamics simulations were conducted to obtain the wind-pressure coefficients of each external opening on the eighth floor of the building. The data were then used in a multi-zone airflow model to estimate the airflow rate and aerosol concentration in the flats and corridors on that floor. Apart from flat 812 and corridors, the virus-laden aerosol concentrations in flats 811, 813, 815, 817 and 819 (opposite to flat 812, across the corridor) were the highest on the eighth floor. When the doors of flats 813 and 817 were opened by 20%, the hourly-averaged aerosol concentrations in these two flats were at least four times as high as those in flats 811, 815 and 819 during the index case's home hours or the suspected exposure period of secondary cases. Thus, the flats across the corridor that were immediately downstream from flat 812 were at the highest exposure risk under a prevailing easterly wind, especially when their doors or windows that connected to the corridor were open. Given that the floorplan and dimension of Luk Chuen House are similar to those of many hotels, our findings provide a probable explanation for COVID-19 outbreaks in quarantine hotels. Positive pressure and sufficient ventilation in the corridor would help to minimise such cross-corridor infections.

An Evaluation of The Various Modalities Used for Treatment of Low Fistulas and Their Outcome at a Tertiary Care Center

A fistula-in-ano is an abnormal hollow tract or cavity that is lined with granulation tissue and that connects a primary opening inside the anal canal to a secondary opening in the perianal skin; secondary tracts may be multiple and can extend from the same primary opening. Anal fistula is a common peri-anal surgical problem with which the patient presents the clinician. The study was done at in the department of General Surgery in father muller Medical College Hospital during the period from October 2018 - October 2020. Data was collected from the operated cases of all types of peri-anal fistula above 18 years and below 60 whose follow up was done for at least 6 months. In the study of 50 cases were randomly selected patients of fistula in ano, 84% of them had only one external opening, while 10% had 2 external opening and another 6% had more than 2 openings, hence fistula in ano with a single external opening is commonest in occurrence.

Endoscopic Treatment of Enterocutaneous Fistulas in Crohn's Disease.

Management of enterocutaneous fistulas in Crohn's disease is challenging. Most patients still need intestinal resection in the biologic era. The aim of this study was to evaluate the efficacy of endoscopic treatment for enterocutaneous fistulas. This is a retrospective study of medical records. This study was conducted in a single institution. All consecutive patients with Crohn's disease with an enterocutaneous fistula who underwent endoscopic fistula closure with the use of an over-the-scope clip or a hemostatic clip were included. The main outcome measured was the clinical success 3 months after the procedure, which was defined as the complete closure of all fistulas at physical examination and complete cessation of the drainage from the external opening, without surgery. Eight patients (men, 25%; median age 45 years [interquartile range, 33-51]) were followed. Fistulas were localized at the ileocolonic or colocolonic anastomosis in 7 patients and at the stomach in 1 patient. Seven patients were treated with an over-the-scope clip, and one was treated with a hemostatic clip. Technical success was achieved in all cases. Clinical success at 3 months was achieved in 75% of cases (6/8 patients). After a median 16-month (interquartile range, 13-23) follow-up, 3 of 8 (37.5%) patients had enterocutaneous fistula closure and 2 of 8 (25%) needed intestinal resection. No complications were observed. The retrospective nature, the small sample size of the study, and the heterogeneity of the population limit the interpretation of the results. Endoscopic treatment of enterocutaneous fistulas is feasible with a short-term effectiveness. Additional studies are needed to confirm these results. See Video Abstract at http://links.lww.com/DCR/B614. ANTECEDENTES:Es desafiante el manejo de las fístulas enterocutáneas en enfermedad de Crohn. En la era biológica, la mayoría de los pacientes todavía requieren de resección intestinal.OBJETIVO:Evaluar la eficacia por tratamiento endoscópico de fístulas enterocutáneas.ENTORNO CLINICO:Estudio retrospectivo de registros médicos.AJUSTE:Realizado en una sola institución.PACIENTES:Se incluyeron todos los pacientes consecutivos con fístula enterocutánea en enfermedad de Crohn, sometidos a cierre endoscópico de la fístula con clip sobre el endoscopio o clip hemostático.PRINCIPALES MEDIDAS DE VALORACION:El éxito clínico a los 3 meses después del procedimiento. Definido al examen físico, como el cierre completo de todas las fístulas y cese completo del drenaje por la abertura externa, sin cirugía.RESULTADOS:Se estudiaron a ocho pacientes (hombres, 25%, mediana de edad de 45 años (rango intercuartílico, 33-51)). En 7 pacientes, las fístulas se localizaron en la anastomosis ileocolónica o colocolónica y un paciente, en el estómago. Siete pacientes fueron tratados con clip sobre el endoscopio y uno con clip hemostático. Se logró éxito técnico en todos los casos. Se logró éxito clínico a los 3 meses en 75% de los casos (6/8 pacientes). Después de una mediana de 16 meses (rango intercuartílico, 13-23), de seguimiento 3/8 (37,5%) pacientes presentaron cierre de fístulas enterocutáneas y 2/8 (25%) requirieron resección intestinal. No se observaron complicaciones.LIMITACIONES:Estudio retrospectivo, pequeño tamaño de la muestra y heterogeneidad de la población, limitaron la interpretación de los resultados.CONCLUSIONES:Es posible el tratamiento endoscópico de fístulas enterocutáneas con efectividad a corto plazo. Se requieren nuevos estudios para confirmar estos resultados. Consulte Video Resumen en http://links.lww.com/DCR/B614. (Traducción-Dr. Fidel Ruiz Healy).

Evaluation of cross-sectional area and morphological value of external auditory meatus in concha plasty with I shaped incision

Objective:To evaluate the preliminary value of the cross-sectional area and morphological changes of the external ear canal opening after the two-flap auriculoplasty through the I shaped posterior incision. Methods:One hundred and thirty-seven patients（a total of 155 ears） who received open radical mastoidectomy in the department of otolaryngology in the First Affiliated Hospital of Kunming Medical University were treated with I shaped incision and two-flap auriculoplasty. Vertical diameter（D1） and horizontal diameter（D2） of the external ear canal were measured at the completion of surgery, 1 month and 6 months post-operation, respectively. The cross-sectional area（S=1/4πD1×D2） of the external ear canal was calculated according to the two diameters. The dry ear time and intraoperative lumen epithelialization time were observed after operation. At 6 months after operation, the morphology of the external ear canal opening was analyzed. Results:The postoperative dry ear duration was 18-61 days（27.32±7.52） days. The time to complete epithelialization of the operative cavity was 24-70 days（32.18±10.36） days. Six months after the operation, the morphological classification of 155 outer ear meatal openings was as follows: 117 ears（ 75.48%） were round（the difference between vertical diameter and horizontal diameter was within 2 mm）; Oval（oval appearance, difference between vertical diameter and horizontal diameter greater than 2 mm） 35 ears（22.58%）, triangle 3 ears（1.94%）; Irregular ear canal orifice was not observed in all cases. During the operation, and at 1 month and 6 months after the operation, the cross-sectional area of the external ear canal was（2.51±0.48） cm², （2.45±0.35） cm², （2.41±0.43） cm², respectively. And no significant differences were observed. （P>0.05）. Conclusion:The I shaped posterior auricular incision and two-flap auricular lumenoplasty is not compex and easy to perform. The morphology of the external ear opening is regular after the operation, which can effectively match the ventilation of the operative cavity.

A New and Easier Approach to Preserflo MicroShunt Implantation.

PRESERFLO™ MicroShunt is a new minimally invasive glaucoma surgical (MIGS) device, implanted with an ab externo approach, which drains the aqueous humor to the subconjunctival space. It has been designed as a safer and less invasive approach for treating medically uncontrolled primary open-angle glaucoma (POAG) patients. The classic way of MicroShunt implantation involves different key steps, which includes creating a small scleral pocket with a 1mm blade; passing a 25-gauge (25G) needle through the scleral pocket into the anterior chamber (AC); and subsequently flushing the stent with a 23-gauge (23G) thin-wall cannula. However, sliding the needle into the scleral pocket can create false passages, thus making the device’s threading more difficult. The purpose of the current paper is to propose a simplified implantation approach. Our method proposes to make the scleral tunnel by using directly the 25G needle and, at the limbus, this 25G needle is used to slightly depress the sclera and enter into the AC. The MicroShunt is subsequently assembled on a 23G cannula mounted on a 1mL syringe. The syringe can then be used to flush the device. Outflow can thus be confirmed immediately by seeing drops of aqueous humor leaking from the external opening of the stent. This new approach may have different potential advantages, such as better control of the site of entry, avoids wrong passages, reduces or eliminates the risk of aqueous humor sideway flow, facilitates a parallel path to the iris plane, and it is faster.

Intraoperative visualization of urethra using illuminating catheter in laparoscopy-assisted anorectoplasty for imperforated anus-A novel and safe technique for preventing urethral injury.

In this study, we used a near-infrared ray catheter (NIRC) to visualize the urethral line. We herein report our intraoperative visualization technique of the urethra using an illuminating catheter in laparoscopy-assisted anorectoplasty (LAARP) for imperforated anus. A 3.0-kg term male neonate with anorectal malformation was delivered. An invertogram revealed the type as intermediate. Transverse colostomy was performed at the left upper abdomen. A recto-bulbar urethral fistula (RBUF) was diagnosed via distal colostogram and voiding cystourethrogram. LAARP was planned at 6 months of age. We performed the operation with four trocars. A 45° 5-mm scope was used to clearly view the deep pelvic space. Before starting rectal dissection, a 6-Fr pig-tail-type NIRC was inserted through the external opening of the urethra to visualize the urethra during the laparoscopic procedure. The catheter tip was placed in the bladder, and excretion of urine was maintained through the NIRC during the procedures. While dissecting the deep pelvic space between the posterior wall of the urethra and anterior wall of the rectum, the exact line of the urethra was clearly confirmed by overlay images of the NIRC. The RBUF was dissected safely using this innovative image-guided technique. Anoplasty was performed between the rectal stump and perineal skin. The postoperative course was uneventful. Oral intake was started on postoperative day 1. Postoperative dynamic urography showed no complications. An NIRC is useful for detecting the urethra during LAARP.

One new species of Achnanthidium Kützing (Bacillariophyta, Achnanthidiaceae) from Tibet, China

Tibet is a very important biodiversity hot spot in China and the diatom flora of this region has drawn a lot of attention. Diatom samples were collected from several places across Tibet. During research on the biodiversity of diatoms from Tibet, one Achnanthidium species showed unique features compared with other known taxa. It has linear-lanceolate valves with rounded apices, tear-drop shaped proximal raphe ends and ?-shaped distal raphe ends. The most distinctive character of this species, however, is the shape of areolae; since this species has nearly round external areolar openings on the valve face but more typical slit-like areolae present on the mantle. Here we describe it as new to science as Achnanthidium tibeticum Y. Liu &amp; Kociolek. We compare this new species with other, similar taxa within the genus.

Abstract 82: Rare case of 46XY OVO testicular DSD

A 5-month-old term baby was referred for ambiguous genitalia. Examination showed a right descended gonad, and an empty scrotum and an inguinal swelling on the left, no phallus and single external urogenital opening in the perinium with an EMS score of 2.5. Possibilities considered included ovo-testicular DSD, PAIS and testosterone biosynthetic defects. Beta HCG Stimulation test ruled out synthetic defects and with good testosterone response. USG abdomen/scrotum showed left inguinal undescended testes. Post Acton prolongatum stimulated cortisol was 43 mcg/dL and the Karyotyping was 46 XY. Diagnostic laparoscopy showed a left sided ovotestes with fallopian tube-like structure attached; and biopsy of gonad confirmed both ovarian and testicular tissue. Hence diagnosis of 46 XY Ovo testicular DSD was made; one which accounts for 3-10% of total DSD. We report this instance where absence of phallic structure is a rare presentation among cases of 46XY Ovo testicular DSD.