Failure Of Endoscopic Dilation Research Articles

The Efficacy and Safety of Endoscopic Balloon Dilatation in the Treatment of Functional Post-Sleeve-Gastrectomy Stenosis

Background and Objectives: Functional gastric stenosis, a consequence of sleeve gastrectomy, is defined as a rotation of the gastric tube along its longitudinal axis. It is brought on by gastric twisting without the anatomical constriction of the gastric lumen. During endoscopic examination, the staple line is deviated with a clockwise rotation, and the stenosis requires additional endoscopic manipulations for its transposition. Upper gastrointestinal series show the gastric twist with an upstream dilatation of the gastric tube in some patients. Data on its management have remained scarce. The objective was to assess the efficacy and safety of endoscopic balloon dilatation in the management of functional post-sleeve gastrectomy stenosis. Patients and Methods: Twenty-two patients with functional post-primary-sleeve-gastrectomy stenosis who had an endoscopic balloon dilatation between 2017 and 2023 were included in this retrospective study. Patients with alternative treatment plans and those undergoing endoscopic dilatation for other forms of gastric stenosis were excluded. The clinical outcomes were used to evaluate the efficacy and safety of balloon dilatation in the management of functional gastric stenosis. Results: A total of 45 dilatations were performed with a 30 mm balloon in 22 patients (100%), a 35 mm balloon in 18 patients (81.82%), and a 40 mm balloon in 5 patients (22.73%). The patients’ clinical responses after the first balloon dilatation were a complete clinical response (4 patients, 18.18%), a partial clinical response (12 patients, 54.55%), and a non-response (6 patients, 27.27%). Nineteen patients (86.36%) had achieved clinical success at six months. Three patients (13.64%) who remained symptomatic even after achieving the maximal balloon dilation of 40 mm were considered failure of endoscopic dilatation, and they were referred for surgical intervention. No significant adverse events were found during or following the balloon dilatation. Conclusions: Endoscopic balloon dilatation is an effective and safe minimally invasive procedure in the management of functional post-sleeve-gastrectomy stenosis.

The safety and efficacy of the trans-umbilical approach for pyloroplasty in the management of post-acid corrosive gastric outlet obstruction in children

BackgroundGastric outlet obstruction (GOO) may follow acid corrosive ingestion. Several surgical techniques have been reported after the failure of endoscopic dilatation. The aim of this study was to evaluate the feasibility and safety of Heinecke-Mikulicz pyloroplasty (HMP) through a circum-umbilical skin incision in children with pyloric stricture after accidental acid corrosive ingestion.ResultsSeven patients were males and 4 were females, their ages ranged from 17 months to 6 years at the time of definitive treatment. The surgery was completed successfully in all patients through the circum-umbilical incision. Vertical extension of skin incision was needed in one patient. The pylorus was grossly affected in 9 patients. Both pylorus and gastric antrum were involved in 2 patients. Nine patients had an excellent postoperative course with the cessation of vomiting and progressive weight gain. One patient developed postoperative recurrent stricture treated by gastrojejunostomy. Another patient with associated esophageal stricture responded to repeated endoscopic dilatation for the esophageal stricture and pyloroplasty for the pyloric stricture. No surgical site infection or wound dehiscence occurred in any patient.ConclusionHeinecke-Mikulicz pyloroplasty through a circum-umbilical approach is both feasible and safe in the majority of children with post-acid corrosive GOO. It is associated with satisfactory wound healing and excellent cosmetic outcome. Different techniques are recommended in cases of severe pyloric stricture associated with significant proximal gastric antral scarring.

Endoscopic balloon dilatation of primary obstructive megaureter: method standardization and predictive prognostic factors.

The management of congenital primary obstructive megaureter (POM) is usually conservative, especially during the first year of life. Endoscopic high-pressure balloon dilatation (EHPBD) is indicated when symptoms, increasing dilatation and progressive renal damage are recorded, particularly in children younger than one year of age. We identified and described endoscopic prognostic factors predicting the success or failure of endoscopic dilatation. Thirty-eight patients (33 M;5 F) with POM from 2005-2018 were included. Diagnosis was based on US distal ureter dilatation (>7 mm), obstructive MAG-3 diuretic renogram and absence of vesicoureteral reflux (cystography). 24 patients were under 1 year of age. All patients underwent cystoscopy and high-pressure balloon dilatation with 3,5 Fr dilating balloon, after ascending pyelography. Median follow-up was of 6.5 years. We identified characteristics with poor prognosis: stenotic punctiform ureteral ostium and/or ostium located in a bladder diverticulum (9 pts) and stenotic tract longer than 1 cm (5 pts). The patients with a stenotic tract shorter than 1 cm (18 pts) were divided into two groups: <5 mm (5 pts) and between 5 and 10 mm (13 pts) showed a good response to dilatation. Endoscopic evaluation of ureteral ostium with pneumatic dilatation when possible is a useful diagnostic and therapeutic solution for POM treatment, especially under one year of age. EHPBD is effective in short stenotic tracts (<5 mm). It may also be repeated with good results in intermediate stenotic sections (5 mm-1 cm). According to our preliminary results, the procedure is more effective if performed earlier (3-7 months of life). Greater cohort and longer follow-up are needed to verify the stability of these results.

Robot-Assisted Ureteroileal Reimplantation for Postcystectomy Anastomotic Stricture

Introduction and Objectives: Ureteroileal anastomatic strictures after robot-assisted radical cystectomy (RARC) occur at a rate of 4% to 9% and pose a challenge in management. Although open surgical repair remains the standard treatment for anastomotic strictures, we present a case of effective postcystectomy robot-assisted laparoscopic ureteroileal reimplantation. Materials and Methods: Our patient is a 65-year-old woman with high-grade muscle-invasive urothelial carcinoma who underwent RARC and intracorporeal ileal conduit urinary diversion. Three months postoperatively, the patient developed recurrent urinary tract infections that necessitated hospital admission for left pyelonephritis. CT scan displayed left hydronephrosis and hydroureter. Antegrade nephrostogram revealed a complete ureteroileal anastomatic stricture, with confirmed severe obstruction on MAG-3 renal scan and left differential renal function of 16%. After failure of endoscopic dilation, the patient underwent exploratory laparoscopy and robot-assisted left ureteral reimplantation. Laparoscopic ports were placed similarly to RARC. We performed a lysis of adhesions and identified the proximal end of the ileal conduit, where the distal ureters were identified among significant fibrosis. We isolated each ureter separately and mobilized the left ureter posterior to the sigmoid colon using sharp dissection. We incised into the proximal end of the ileal conduit and confirmed identification of the left ureter through the protruding preplaced stent. We then ligated the distal most aspect of the left ureter after a frozen section confirmed no recurrence of tumor and advanced a guidewire through the conduit into the left distal ureter and renal pelvis. The ureter was spatulated and we completed a new left ureteroileal anastomosis over a Double-J stent using two running 4-0 Vicryl sutures. Results: Our operative time was just under 4 hours with an estimated blood loss of 100 mL. Jackson–Pratt (JP) drain was maintained until discharge on postoperative day 4. There were no intraoperative or postoperative complications. Five-month follow-up revealed marked improvement of left hydronephrosis on renal ultrasound and absence of obstruction on MAG-3 renal scan with a t½ of 8 minutes. Left renal function stabilized at 19%. Conclusions: Robot-assisted ureteral reimplantation for management of postcystectomy ureteroileal anastomatic stricture is feasible and safe in experienced hands. No competing financial interests exist. Runtime of video: 7 mins 56 secs

V10-10 ROBOT-ASSISTED URETEROILEAL REIMPLANTATION FOR POST-CYSTECTOMY ANASTOMOTIC STRICTURE.

INTRODUCTION AND OBJECTIVES: Ureteroileal anastomatic strictures after robot-assisted radical cystectomy (RARC) occur at a rate of 4-9%, and pose a challenge in management. While open surgical repair remains the standard treatment for anastomotic strictures, we present a case of successful post-cystectomy robot-assisted laparoscopic ureteroileal reimplantation. METHODS: Our patient is a 65 year old woman with high grade muscle invasive urothelial carcinoma who underwent RARC and intracorporeal ileal conduit urinary diversion. Three months post-operatively, the patient developed recurrent urinary tract infections and required hospital admission for left pyelonephritis. CT scan displayed left hydronephrosis and hydroureter. Antegrade nephrostogram revealed a complete ureteroileal anastomatic stricture, with confirmed severe obstruction on MAG-3 renal scan and left differential renal function of 16%. After failure of endoscopic dilation, the patient underwent exploratory laparoscopy and robot-assisted left ureteral reimplantation. Laparoscopic ports were placed similarly to RARC. We performed a lysis of adhesions and identified the proximal end of the ileal conduit, where the distal ureters were identified amongst significant fibrosis. We isolated each ureter separately and mobilized the left ureter posterior to the sigmoid colon using sharp dissection. We incised into the proximal end of the ileal conduit and confirmed identification of the left ureter via the protruding pre-placed stent. We then ligated the distal most aspect of the left ureter after a frozen section confirmed no recurrence of tumor and advanced a guide wire through the conduit into the left distal ureter and renal pelvis. The ureter was spatulated and we completed a new left ureteroileal anastomosis over a double-J stent using two running 4-0 Vicryl sutures. RESULTS: Our operative time was just under 4 hours with an estimated blood loss of 100ml. JP drain was maintained until discharge on postoperative day 4. There were no intraoperative or postoperative complications. Five month follow up revealed marked improvement of left hydronephrosis on renal ultrasound and absence of obstruction on MAG3 renal scan with a t1/2 of 8 minutes. Left renal function stabilized at 19%. CONCLUSIONS: Robot-assisted ureteral reimplantation for management of post-cystectomy ureteroileal anastomatic stricture is feasible and safe in experienced hands.

Combined pedicled antropyloroplasty and gastric pull-up reconstruction for corrosive esophagogastric stricture

Combined pedicled antropyloroplasty and gastric pull-up reconstruction for corrosive esophagogastric stricture