Incidence Of Perforation Research Articles

Tu1174 CLICICAL AND ENDOSCOPIC PREDICTORS FOR INTRAPROCEDURAL MUCOSAL PERFORATION DURING PERORAL ENDOSCOPIC MYOTOMY: A RETROSPECTIVE SINGLE CENTER STUDY

Mucosal perforation is the most critical perioperative adverse event of peroral endoscopic myotomy (POEM). Severe mucosal perforation may cause contamination of the tunnel and lengthen hospital stay. This study explored the characteristics, predictors, and management approaches for Mucosal Perforation. POEM was successfully performed in 211 patients. A total of 44 patients experienced mucosal perforation, for an overall frequency of 20.8% (44/211). On multivariable analysis, Mucosal perforation was associated with previous POEM history (odds ratio [OR], 9.343; P = 0.04), submocosal fibrosis (OR, 6.3; P=0.084), Intraprocedure bleeding (OR, 16.904; P<0.001), large-caliber endoscope (OR, 3.772; P =0.035), and long procedure duration (OR, 0.016; P<0.034). Mucosal perforation is a significant complication encountered during POEM procedure. Previous POEM, Procedure duration, Intraprocedure bleeding and caliber diameter were significant predictors of Mucosal perforation. As endoscopists give more attention to the bleeding and use small diameter endoscope, the incidence of mucosal perforation may be reduced.

Management of coronary perforations during angioplasty

Coronary perforation represents a terrible complication of percutaneous coronary intervention (PCI) which, if not promptly recognized and treated, can lead to catastrophic consequences for the patient. Hence, acquisition of the basic techniques for the treatment of coronary perforations is critical for the interventional cardiologist in order to safely perform PCIs. Although the incidence of coronary perforations remains low during PCI, it is possible to recognize some subgroups of patients and some types of coronary lesions, such as chronic coronary total occlusions, that are associated with increased risk. The treatments currently available depend on the type and site of coronary perforation, therefore timely recognition is of paramount importance in order to be able to quickly establish the most appropriate treatment.

Short- and long-term outcomes of endoscopic submucosal dissection for superficial esophageal squamous cell cancer in patients with prior gastrectomy.

The surgery for esophageal cancer arising after prior gastrectomy is technically difficult with high morbidity and mortality. Endoscopic submucosal dissection (ESD) is a minimally invasive endoscopic treatment for superficial SCC with high curative resection rate. But few studies are concerned about ESD under these circumstances. The aim of this study was to elucidate the short- and long-term outcomes of ESD for superficial esophageal squamous cell cancer (SCC) in patients with prior gastrectomy. From January 2009 to January 2019, 37 patients with prior gastrectomy who underwent ESD for superficial esophageal SCC were retrospectively enrolled at the Zhongshan Hospital, Fudan University in Shanghai, China. Rates of en bloc resection, complete resection, curative resection, incidence of postoperative bleeding, perforation and postoperative stricture were evaluated as short-term outcomes. Overall survival, and local recurrence-free survival were evaluated as long-term outcomes. The rate of en bloc resection, complete resection and curative resection were 94.6%, 86.5% and 78.4%, respectively. No perforation was observed. 1 (2.7%) patient experienced postoperative bleeding. During the median observation of 43months, 3 (8.6%) patients experienced esophageal stricture, successfully managed by balloon dilation. 3(8.6%) patients had local recurrence after ESD with 5-year local recurrence-free survival rate of 91.4%. During the observation period, 4 patients died of other reasons. The 1, 3, 5-year overall survival rates were 97.1%, 97.1% and 91.4%. The short-term outcomes indicate ESD is technically difficult with lower resection completeness in patients after gastrectomy, while the long-term outcomes are rather favorable.

Bevacizumab-related gastrointestinal perforation in patients with three or more prior chemotherapy regimens: A real-world experience

ObjectiveAssociations between the number of prior chemotherapy (CT) regimens and gastrointestinal (GI) perforation in patients receiving bevacizumab treatment has not been fully investigated. The aim of the study was to investigate the impact of ≥3 prior CT regimens on GI perforation. Materials and methodsWe retrospectively investigated the medical records of 133 patients with gynecological cancer who received bevacizumab-containing treatment. Bevacizumab was intravenously administered at a dose of 15 mg/kg every 4 weeks. Incidence of GI perforation was compared between ≤2 and ≥3 prior CT groups. ResultsTwenty-three (17.3%) patients had a history of ≥3 CT; these patients received bevacizumab at 4-week intervals. The percentage of patients with prior surgery was significantly higher in the ≥3 prior CT group (95.7% vs. 70.0%, P = 0.008), while those with prior bowel resection was significantly higher in the ≥3 prior CT group (30.4% vs. 12.7%, P = 0.034). There was no significant difference in the mean number of bevacizumab cycles between the two groups (10.7 vs. 8.9, P = 0.19). While GI perforation was observed in three (2.7%) patients in the ≤2 prior CT group, no GI perforation was found in the ≥3 prior CT group (P > 0.99). ConclusionA history of ≥3 prior CT did not increase the risk for GI perforation when bevacizumab is administered at a dose of 15 mg/kg every 4 weeks in our cases.

Intraoperative Ultrasound Guidance During Curettage After Second-Trimester Delivery is Associated With a Higher Rate of Complications.

The use of intraoperative ultrasound guidance for second-trimester elective dilation and curettage reduces the incidence of uterine perforation. However, the role of intraoperative ultrasound guidance during curettage following second-trimester delivery has not been evaluated. We aim to evaluate the effect of intraoperative ultrasound guidance during curettage following second-trimester delivery. We conducted a retrospective cohort study that included patients who had a second-trimester delivery at up to 236/7 weeks gestation and underwent uterine curettage after the fetus was delivered. Overall, 273 patients were included. Of them, 194 (71%) underwent curettage without intraoperative ultrasound guidance, while 79 (29%) underwent the procedure utilizing intraoperative ultrasound guidance. The overall rate of a composite adverse outcome was higher among those undergoing curettage under intraoperative ultrasound guidance compared with no ultrasound guidance (31 [39.2%] vs. 40 [20.6%]; OR 2.4; 95% CI 1.4-4.4, P = 0.002). Placental morbidity (10 [12.6%] vs. 11 [5.6%]; OR 1.9; 95% CI 1.01-5.9, P = 0.04) and infectious complications (6 [7.5%] vs. 5 [2.5%]; OR 3.1; 95% CI 1.01-10.4, P = 0.05) were more frequent among those undergoing curettage with intraoperative ultrasound guidance. In a multivariate logistic regression analysis, intraoperative ultrasound guidance was the only independent factor positively associated with the occurrence of an adverse outcome (adjusted OR 1.93; 95% CI 1.1-3.4, P = 0.02). Procedure time was longer when ultrasound guidance was used (9:52 vs. 6:58 min:s; P < 0.001). Intraoperative ultrasound guidance during curettage after second-trimester delivery is associated with a higher complication rate than no guidance.

Incidence and management of intestinal perforation in typhoid: a prospective, observational study

Background: Intestinal perforation is a common surgical problem, which need proper attention. Typhoid is the most common cause of bowel perforation. With the concept of a correct diagnosis of perforation in reference to its etiology and further study of etiological factor (typhoid) in relation to epidemiology, surgical treatment and outcome, the present study has been undertaken.Methods: It is a prospective, observational study in which 50 cases of enteric perforation admitting in SMS Hospital at JAIPUR were observed. All patients of enteric perforation peritonitis were evaluated by detailed history, clinical examination and radiological as well as laboratory investigations. After initial resuscitation patient were treated by operative procedures. Postoperatively progress report, morbidity and mortality data were observed.Results: Mean age of patients was 26.38 years. Male to female ratio was 4:1. Enteric perforation is more common in patients with poor nutritional status and rural area. Primary repair of perforation was done in patient with small perforation with relatively healthy bowel, while ileostomy was done in patients with large perforation of longer duration, multiple perforations and edematous bowel with necrotic patches. Mortality was highest in patients who underwent primary repair and proximal loop ileostomy (33.3%) and lowest in patients in which exteriorization of the perforation as loop ileostomy was done (10.3%).Conclusions: The time interval between occurrence of perforation and starting of specific therapy is the most important factor in deciding the ultimate outcome of the typhoid perforation patient and operative procedure is another important factor in deciding the outcome.

Safety and efficacy of bipolar versus monopolar transurethral resection of bladder tumor: a systematic review and meta-analysis.

Transurethral resection of bladder tumor is the standard of care for the management of patients with bladder mass. Primary objective of this study was to compare safety and efficacy of the two energy modalities used for TURBT (monopolar and bipolar). Systematic literature search of various electronic databases was conducted to include all the randomized studies comparing two groups. Standard PRISMA (Preferred reporting Items for Systematic reviews and Meta-analysis) guidelines were pursued for this review and study protocol was registered with PROSPERO (CRD42019139987). In the present review, eight RCTs including 1147 patients were included. Resection time, hospital stay and catheter duration were significantly shorter with bipolar group. There was no significant difference in incidence of obturator reflex (OR 0.65, CI [0.35, 1.2], p = 0.17), whereas incidence of bladder perforation was significantly higher in the monopolar group (6.4% versus 3.3%, p = 0.01. However, sensitivity analysis including 3 high quality studies revealed equal incidence of bladder perforations. Need for blood transfusion was similar in the two groups but fall in hemoglobin was significantly lower in bipolar group (MD - 0.45 CI [- 0.72, - 0.18], p = 0.0009). Bipolar group was found to have significantly lower incidence of tissue artifacts due to thermal energy on pathological examination (OR 0.27 CI [0.15, 0.47], p < 0.00001). Bipolar and monopolar devices are equally safe in terms of obturator jerk and bladder perforation. Bipolar group was significantly better as compared to monopolar for hospital stay, catheter duration and fall in hemoglobin; however, the clinical relevance of most of these parameters is little.

Early versus delayed appendectomy for uncomplicated acute appendicitis.

Study Design: Sectional study. Setting: Madina Teaching Hospital Faisalabad. Period: July 2018 to June 2019. Material &amp; Methods: A sample of 107 patients was selected using non-probability purposive sampling out of all the patients presenting with acute appendicitis. Study population was divided into Groups A and B, former undergoing appendectomy within 8 hours of admission and later undergoing surgery more than 8 hours after admission. Spinal and general anesthesia was used and both Laparoscopic and open surgical techniques were employed. Results: Out of total 107 patients, 62 (57.94%)were placed in group A and 45 (42.06%) in group B. Age and gender related distribution in both groups were similar. 5 patients in group A had perforated appendix and 3 patients in Group B were found to have perforated appendix. The difference between incidence of perforation between the two groups was not statistically significant. Conclusion: in-hospital delay before appendectomy does not significantly increase the risk of perforation in uncomplicated acute appendicitis.

Intralesional Steroid Injection Therapy for Esophageal Anastomotic Stricture Following Esophageal Atresia Repair.

The role of intralesional steroid injection (ISI) in the treatment of anastomotic stricture in patients with esophageal atresia remains unclear. The aim of this study was to evaluate the efficacy and safety of ISI. A total of 158 patients with esophageal atresia with at least 1 ISI for the treatment of esophageal anastomotic stricture between 2010 and 2017 were identified. The change in stricture diameter (ΔD) was compared between procedures with dilation alone (ISI-) and dilation with steroid injection (ISI+). A total of 1055 balloon dilations were performed (452 ISI+). The median ΔD was significantly greater in the ISI+ group: 1 mm (interquartile range [IQR] 0, 3) versus 0 mm (IQR -1, 1.5) (P < 0.0001). The ISI+ group had greater percentage of improved diameter (P < 0.0001) and lesser percentages of unchanged and decreased diameters at subsequent endoscopy (P = 0.0009, P = 0.003). Multivariable logistic regression confirmed the significance of ISI on increasing the likelihood of improved stricture diameter with an adjusted odds ratio of 3.24 (95% confidence interval: 2.15-4.88) (P < 0.001). The ΔD for the first 3 ISI+ procedures was greater than the ΔD for subsequent ISI+ procedures: 1 mm (IQR 0, 3) versus 0.5 mm (IQR-1.25, 2) (P = 0.001). There was no difference in perforation incidence between ISI+ and ISI- groups (P = 0.82). ISI with dilation was well tolerated and improved anastomotic stricture diameter more than dilation alone. The benefit of ISI over dilation alone was limited to the first 3 ISI procedures.

Clinical outcome of open reduction and internal fixation of proximal humerus fractures with proximal humerus locking plates

Background and Objective: Proximal humerus fractures are one of the commonly encountered fractures in an orthopaedic setup comprising nearly 4% of all fractures. Achieving a stable fixation in three and four part fractures have always been a challenge. There is also a debate about the ideal method to treat such fractures. We undertook the present study to assess the functional outcome following proximal humerus fixation with proximal humerus locking plates. Methods: This is a prospective study of 30 cases of proximal humerus fractures operated by ORIF with Proximal humerus locking plate from January 2018 to May 2019 at Sanjay Gandhi Institute of Trauma and Orthopaedics, Bengaluru. The cases were evaluated radiologically and functionally assessed using the Constant Murley score at the end of study. Results: In our case series of patients, majority were males, with RTA being the commonest mode of injury in young population and domestic fall being the most common mode of injury in elderly. All the fractures united with a good to excellent outcome in 76% of the patients. Malunions were the only complications and there were no incidences of screw perforation, AVN, plate impingement and infection. Conclusion: In conclusion locking compression plate is an advantageous implant in proximal humeral fractures due to angular stability, particularly in comminuted osteoporotic bones in elderly patients, thus allowing early mobilization.

Rectal perforation following endorectal prostate MRI: an unexpected complication

BackgroundProstate cancer is a common cancer among men in developed countries. Prostate magnetic resonance imaging (MRI) has been widely employed for early diagnosis of prostate cancer and recommending a treatment plan. The incidence of rectal perforation during endorectal prostate MRI is rare and has never been reported before. Herein, we present a case of rectal perforation after a prostate MRI examination that was subjected to emergency surgical intervention because of the acute presentation of generalized peritonitis. Patients with systemic comorbidities are reportedly at greater risks of encountering colonoscopic perforation. Endorectal prostate MRI is a safe diagnostic modality, but inadequate lubrication of the endorectal coil or over-insufflation of the balloon during the procedure may also lead to serious complications such as hollow organ perforation. Early surgery will be necessary should peritoneal symptoms persist.Case presentationIn 2015, a 56-year-old man came to our ER due to acute abdominal pain after he finished his MRI exam. The exam indicated diffuse tenderness over his abdomen and at the ER, his abdominal CT (computerized tomography) was checked. The images revealed extraluminal air in the perirectal fat and the pneumoperitoneum. In response, exploratory laparotomy, simple closure of rectal perforation, and loop-S colostomy were performed and the patient was discharged 1 month after operation.ConclusionsProstate MRI is a secure procedure with few complications. Clinicians must keep in mind the possibility of perforation when using ultrasound probe. Hollow organ perforation can result in serious morbidity or death. As a result, patients need to be informed of the complications of prostate MRI. When performing the procedure, clinicians must be cautioned about the potential problems for patients with high-anesthetic risk.

The Use of Harmonic Scalpel for Laparoscopic Clip less Cholecystectomy

BACKGROUND: Laparoscopic cholecystectomy (LC) is accepted as the ‘‘gold standard’’ surgical treatment of gallstones. Although surgical clip (SC) is known to be a safe closure method for cystic duct and artery, bile leakage due to clip displacement from the cystic duct stump is a potential complication. In recent years, some energy sources have been tried for the closure of the cystic duct. After the beginning of the use of a harmonic scalpel (HS) for sealing of the cystic artery, surgeons started to investigate the role of HS for sealing the cystic duct. The aim of this study was to assess the efficacy and safety of the use of HS in performing LC.&#x0D; OBJECTIVE: To assess the safety and efficacy of HS, as an effective alternative to clipping, for achieving perfect haemobilliary stasis in LC.&#x0D; MATERIAL AND METHODS: This study was carried out on 70 patients over a period of 2 years. It included 29 males and 41 females with a mean age of 40.6±12.3 years. Most of the cases (42.9%) were operated within 35-44 minutes with a range of 25-64 minutes.&#x0D; RESULTS: LC was successful in all patients, with no need to convert into open technique. Gall bladder (GB) perforation occurred in 8.6% of cases. None of the patients had intraoperative cystic duct leaks. Postoperative drainage was haemoserous in all patients with no bile or frank blood. The mean hospital stay was 1.3±0.72 days.&#x0D; CONCLUSION: Harmonic scalpel is a safe and effective alternative to clipping for LC, ensuring perfect haemobilliary stasis. It has the advantages of a lower incidence of GB perforation and shorter operative time. The major limitation is its cost and apprehension of insecurity in using it in mega cystic duct &gt;6 mm.

Effect of Medical-Grade Polyurethane Sponges on Sinus Membrane Perforation With a Lateral Window Approach.

The most commonly reported complication during the sinus elevation surgical procedure is the perforation of the Schneiderian membrane. The aim of this retrospective study was to compare the rate of sinus membrane perforation during lateral window augmentation using either conventional sinus curettes or medical-grade polyurethane sponges. This retrospective study included patients who received a lateral window approach for sinus floor elevation. The sinus elevation procedures using medical-grade polyurethane sponges (test) or conventional curettes (control) were recorded and analyzed. All subjects' demographic data and preexisting conditions were evaluated. A total of 38 procedures met inclusion criteria, and those data were evaluated for analysis. There were no statistically significant differences in demographic data or preexisting conditions including age, sex, treatment location, presence and absence of septum, Schneiderian membrane thickness, and residual bone height between test and control groups. The membrane perforation rate was 7% in the test group and 43% in the control group; however, this difference did not reach statistical significance (P = .064). Within the limitations of this study, although there was no statistically significant reduction of sinus membrane perforation with the use of medical-grade polyurethane sponges, the decreased incidence of perforation might be of clinical significance.

A141 ENDOSCOPIST PROCEDURAL VOLUME AND COLONOSCOPY OUTCOMES: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Background In addition to monitoring adverse events (AEs) and post-colonoscopy colorectal cancers (PCCRC), several indicators are used to assess the overall quality of colonoscopy performance, including adenoma detection rate (ADR) and cecal intubation rate (CIR). It is unclear whether there is an association between an endoscopist’s annual colonoscopy volumes and ADR, CIR, AEs or PCCRC. Aims We performed a systematic review and meta-analysis to determine whether there is an association between annual colonoscopy volume and colonoscopy quality indicators, or between annual volume and colonoscopy outcomes. Methods A comprehensive electronic search was performed through March of 2019 for any studies assessing the potential association between annual colonoscopy volume and outcomes, or quality indicators, including ADR, CIR, AEs or PCCRC. Pooled odds ratios (OR) were calculated using DerSimonian and Laird random effects models. Subgroup and sensitivity analyses were also performed to assess for any potential methodological or clinical factors associated with outcomes. These included dividing procedural volume into total procedures or screening procedures performed. Results Out of an initial 9,235 studies, 27 were included in our systematic review, representing 11,276,244 colonoscopies performed by over 530 endoscopists. There was no association between procedural volume and ADR (OR 1.00, 95% confidence intervals, CI, 0.98 to 1.02 per additional 100 annual total colonoscopy procedures performed by an endoscopist). CIR was improved with each additional 100 annual colonoscopy procedures (OR 1.17, 95% CI 1.08 to 1.28). There was a trend toward decreased overall adverse events per additional 100 annual procedures that did not meet significance (OR 0.95, 95% CI 0.90 to 1.00), although there was a decreased incidence of colonic perforations with increasing colonoscopy volume. Figure 1 - Forest plots demonstrating the odds of A) detecting an adenoma, B) intubating the cecum, and C) incurring an overall or specific adverse event, per additional 100 annual procedures, for total and screening procedures. Conclusions In this meta-analysis, higher annual colonoscopy volumes correlated with higher CIR, but not with ADR or PCCRC. Trends toward lower AE rates were also demonstrated with higher volumes. All studies included in this review examined endoscopists performing above respective recommended minimum volume thresholds for their health region. Thus, data are lacking on endoscopists performing very low numbers or very high numbers of colonoscopies annually. Future studies should focus on measuring colonoscopy quality metrics and outcomes among these extreme performers to more clearly determine associations between annual volume and colonoscopy outcomes. Funding Agencies Alberta Health Services Digestive Health Strategic Care Network

Randomized controlled trials for comparison of laparoscopic versus conventional open catheter placement in peritoneal dialysis patients: a meta-analysis

BackgroundThe application of laparoscopic catheterization technology in peritoneal dialysis (PD) patients has recently increased. However, the advantages and disadvantages of laparoscopic versus conventional open PD catheter placement are still controversial. The aim of this meta-analysis is to assess the complications of catheterization in PD patients and to provide a reference for choosing a PD-catheter placement technique in the clinic.MethodsWe searched numerous databases, including Embase, PubMed, CNKI and the Cochrane Library, for published randomized controlled trials (RCTs).ResultsEight relevant studies (n = 646) were included in the meta-analysis. The pooled results showed a lower incidence of catheter migration (OR: 0.42, 95% CI: 0.19 to 0.90, P: 0.03) and catheter removal (OR: 0.41, 95% CI: 0.21 to 0.79, P: 0.008) but a higher incidence of bleeding (OR: 3.25, 95% CI: 1.18 to 8.97, P: 0.02) with a laparoscopic approach than with a conventional approach. There was no significant difference in the incidence of omentum adhesion (OR: 0.32, 95% CI: 0.05 to 2.10, P: 0.24), hernia (OR: 0.38, 95% CI: 0.09 to 1.68, P: 0.20), leakage (OR: 0.69, 95% CI: 0.38 to 1.26, P: 0.23), intestinal obstruction (OR: 0.96, 95% CI: 0.48 to 1.91, P: 0.90) or perforation (OR: 0.95, 95% CI: 0.06 to 15.42, P: 0.97). The statistical analysis showed no significant difference in early (OR: 0.44, 95% CI: 0.15 to 1.33, P: 0.15), late (OR: 0.89, 95% CI: 0.41 to 1.90, P: 0.76) or total (OR: 0.68, 95% CI: 0.42 to 1.12, P: 0.13) peritonitis infections between the 2 groups, and there are no no significant difference in early (OR: 0.39, 95% CI: 0.06 to 2.36, P: 0.30), late (OR: 1.35, 95% CI: 0.78 to 2.33, P: 0.16) or total (OR: 1.20, 95% CI: 0.71 to 2.02, P: 0.17) tunnel or exit-site infections between the 2 groups.ConclusionLaparoscopic catheterization and conventional open catheter placement in PD patients have unique advantages, but laparoscopic PD catheterization may be superior to conventional open catheter placement. However, this conclusion needs to be confirmed with further large-sample-size, multi-centre, high-quality RCTs.

Adverse events after biliary sphincterotomy: Does the electric current mode make a difference? A systematic review and meta-analysis of randomized controlled trials

Biliary sphincterotomy is an invasive method that allows access to the bile ducts, however, this procedure is not exempt of complications. Studies in the literature indicate that the mode of electric current used for sphincterotomy may carry different incidences of adverse events such as pancreatitis, hemorrhage, perforation, and cholangitis. To evaluate the safety of different modes of electrical current during biliary sphincterotomy based on incidence of adverse events. We searched articles for this systematic review in Medline, EMBASE, Central Cochrane, Lilacs, and gray literature from inception to September 2019. Data from studies describing different types of electric current were meta-analyzed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The following electric current modalities were evaluated: endocut, blend, pure cut, pure cut followed by blend, monopolar, and bipolar. A total of 1791 patients from 11 randomized clinical trials evaluating the following comparisons: 1. Endocut vs Blend: No statistical difference in the incidence of bleeding (7% vs 13.4%; RD: -0.11 [-0.31, 0.08], P=0.27, I2=86%), pancreatitis (4.4% vs 3.5%; RD: 0.01 [-0.03, 0.04], P=0.62, I2=48%) and perforation (absence of cases in both arms). 2. Endocut vs Pure cut: Higher incidence of mild bleeding (without drop in hemoglobin levels, clinical repercussion or need for endoscopic intervention) in the pure cut group (9.2% vs 28.8%; RD: -0.19 [-0.27, -0.12], P<0.00001, I2=0%). No statistical difference regarding pancreatitis (5.2% vs 0.9%; RD: 0.05 [-0.01, 0.11], P=0.12, I2=57%), perforation (0.4% vs 0%; RD: 0.00 [-0.01, 0.02], P=0.7, I2=0%) or cholangitis (1.8% vs 3.2%; RD: -0.01 [-0.09, 0.06], P=0,7). 3. Pure cut vs blend: higher incidence of mild bleeding in the pure cut group (40.4% vs 16.7%; RD: 0.24 [0.15, 0.33], P<0.00001, I2=0%). No statistical difference concerning incidence of pancreatitis or cholangitis. 4. Pure cut vs Pure cut followed by Blend: No statistical difference regarding incidence of bleeding (22.5% vs 11.7%; RD: -0.10 [-0.24, 0.04], P=0.18, I2=61%) and pancreatitis (8.9% vs 14.8%; RD 0.06 [-0.02, 0.13], P=0.12, I2=0%). 5. Blend vs pure cut followed by blend: no statistical difference regarding incidence of bleeding and pancreatitis (11.3% vs 10.4%; RD -0.01 [-0.11, 0.09], P=0.82, I2=0%). 6. Monopolar vs bipolar: higher incidence of pancreatitis in the monopolar mode group (12% vs 0%; RD 0.12 [0.02, 0.22], P=0.01). Pure cut carries higher incidences of mild bleeding compared to endocut and blend. However, this modality might present a lower incidence of pancreatitis. The monopolar mode elicits higher rates of pancreatitis in comparison with the bipolar mode. There is no difference in incidence of cholangitis or perforation between different types of electric current. There is a lack of evidence in the literature to recommend one method over the others, therefore new studies are warranted. As there is no perfect electric current mode, the choice in clinical practice must be based on the patient risk factors.

A new intravascular ultrasound-guided stenting strategy compared with angiography on stent expansion and procedural outcomes in patients with positive lesion remodeling.

We investigated the role of a new intravascular ultrasound (IVUS)-guided stenting strategy versus angiography on optimal stent expansion (OSE) and procedural outcomes in patients with positive lesion remodeling. There are no IVUS criteria on how to achieve OSE. A total of 100 patients were assigned to a new IVUS-guided stenting strategy (IVUS group) versus angiography-guided stenting (Angio group). In the IVUS group, among patients with positive lesion remodeling, defined as a remodeling ratio (RR; lesion external elastic membrane (EEM) area/distal reference EEM area) >1.05, the stent was expanded with a balloon sized to the distal reference EEM diameter. In the Angio group, the stent was expanded by visual estimation. In both groups, IVUS was performed after postdilation. Minimum stent area (MSA) and stent volume index were significantly larger in the IVUS versus Angio group (7.1 ± 1.9 vs. 5.9 ± 1.5 mm2 , and 8.7 ± 2.1 vs. 7.5 ± 1.8 mm3 /mm, respectively; p < .01). The percentages of OSE, defined as an MSA ≥5.4 mm2 , MSA ≥90% of distal reference lumen area (DRLA), or MSA > DRLA, were significantly higher in the IVUS versus Angio group (80 vs. 56%, 78 vs. 54%, and 71 vs. 38%, respectively; p < .01). Stent underexpansion, malapposition, and residual reference segment stenosis were significantly higher in the Angio versus IVUS group (44 vs. 12%, 16 vs. 4%, and 12 vs. 0%, respectively; p < .05). In the IVUS group, owing to positive remodeling, there was no incidence of dissection or perforation. This new strategy of IVUS-guided stenting in patients with positive lesion remodeling, compared with angiography, significantly increased stent expansion and decreased stent underexpansion, malapposition, and residual reference segment stenosis with no complications.

Pediatric bladder augmentation - Panacea or Pandora's box?

Bladder augmentation is a surgery that can increase bladder capacity and compliance. The objective of this study was to provide a longitudinal review of pediatric bladder augmentation at a tertiary Canadian center. A retrospective review was performed on patients who underwent bladder augmentation at a tertiary pediatric hospital between 1986 and 2014. The primary objective was short- and long-term complications of augmentation. Secondary objectives were to review number of augmentation procedures performed over time and the utility of routine postoperative cystograms. A total of 56 procedures were performed on 54 patients (28 males, 26 females) of mean age 10 years (standard deviation [SD] 5) and mean followup eight years (SD 5). The most common bowel segment used was ileum (87.5%). Twenty-eight patients (50%) received catheterizable channels. Overall complication rate was 15% and the most common complications were urinary tract infections (68.5%), worsening hydronephrosis (14.8%), bladder stone formation (14%), and hematuria (13%). In total, 19 of 54 (35.2%) patients returned to the operating room. The incidence of bladder perforation was 3.6%. Complications with the catheterizable channel occurred in 13 of 28 (46.4%), of which 10 were related to stomal stenosis. Forty patients had postoperative cystograms and extravasation was seen in three (7.5%). There was no malignancy during the followup. Only four augmentations were performed from 2008-2014. Bladder augmentation likely represents a safe surgical treatment option. Extravasation on postoperative cystogram was uncommon and, thus, it may not be indicated routinely. The number of augmentation procedures performed has declined in recent years.

Incidence and risk factors of colonoscopic post-polypectomy bleeding and perforation in patients with end-stage renal disease.

Colonoscopic polypectomy in end-stage renal disease (ESRD) patients are at risks of post-polypectomy bleeding and perforation, but evidences are limited. This study aimed to determine the incident polypectomy complications among ESRD patients. In the nationwide ESRD cohort, a propensity score matched case-control study design was conducted to assess risk associated with post-polypectomy bleeding and perforation using the Taiwanese National Health Insurance Research Database from 1997 to 2013 for adults aged 40years and older; 7011 ESRD and 19118 non-ESRD patients met the study criteria. A total of 5302 patients in each group were matched for further analyses. The primary endpoint was post-polypectomy bleeding or bowel perforation in 30days. The secondary endpoint was mortality and length of hospital stay for the bleeding complications requiring hospitalization. Overall incidences of post-polypectomy bleeding or perforation in patients with ESRD was higher than the non-ESRD group (5.83% vs 1.78%, P<0.0001) in the matched cohort. High risk of adverse outcomes was associated with ESRD (adjusted odds ratio [aOR], 2.38, 95% confidence interval [CI], 1.85-3.05), female patient (aOR, 1.7, 95% CI, 1.37-2.11), history of acute myocardial infarction (aOR, 1.91, 95% CI, 1.1-3.32), liver disease (aOR, 1.79, 95% CI, 1.37-2.34), diabetes (aOR, 1.45, 95% CI, 1.16-1.82), cancer (aOR, 1.4, 95% CI, 1.09-1.81), inpatient setting (aOR, 13.19, 95% CI, 9.73-17.88), and prior use of clopidogrel (aOR, 1.61, 95% CI, 1.03-2.52) and warfarin (aOR, 2.03, 95% CI, 1.21-3.41). End-stage renal disease was associated with approximately twofold higher risk of colonoscopic post-polypectomy bleeding or perforation and should be cautiously performed in this special population cohort.

The necessity of nighttime appendectomies: Is appendicitis an emergency?

Background:In our institution, we avoid emergency nighttime appendectomies, instead performing the surgery during daylight hours the following day. We examined whether emergency or early appendectomies affect the outcome of patient morbidity.Materials and Methods:Medical records of children treated for appendicitis between 2010 and 2012 were retrospectively reviewed. Outcomes were compared between Group 1, defined as those patients who presented to the hospital during the day and underwent appendectomy on the same day and Group 2, defined as those patients who presented to the hospital at night and underwent appendectomy the next day. Incidences of perforation at surgery, operative time, complications and length of stay were analysed. Cases with perforation were also analysed to determine if the perforations could have been identified preoperatively.Results:A total of 74 patients met the study criteria, including 41 and 33 in Groups 1 and 2, respectively. There were no significant differences in the incidence of perforation at surgery, operative time, complications and length of stay. A total of nine cases of perforation were identified during surgery, and there were no significant differences in the pre-operative characteristics between perforated and non-perforated cases.Conclusions:The results of this study indicate that early appendectomy is safe and did not increase patient morbidity. We, therefore, recommend performing appendectomies in the daytime.