Inflammatory Stenosis Research Articles

Colon Involvement in Necrotizing Pancreatitis: Incidence, Risk Factors, and Outcomes.

To investigate the incidence, risk factors, and outcomes of colon involvement in patients with necrotizing pancreatitis. Necrotizing pancreatitis is characterized by a profound inflammatory response with local and systemic implications. Mesocolic involvement can compromise colonic blood supply leading to ischemic complications; however, few data exist regarding this problem. We hypothesized that the development of colon involvement in necrotizing pancreatitis (NP) negatively affects morbidity and mortality. Six hundred forty-seven NP patients treated between 2005 and 2017 were retrospectively reviewed to identify patients with colon complications, including ischemia, perforation, fistula, stricture/obstruction, and fulminant Clostridium difficile colitis. Clinical characteristics were analyzed to identify risk factors and effect of colon involvement on morbidity and mortality. Colon involvement was seen in 11% (69/647) of NP patients. Ischemia was the most common pathology (n = 29) followed by perforation (n = 18), fistula (n = 12), inflammatory stricture (n = 7), and fulminant C difficile colitis (n = 3). Statistically significant risk factors for developing colon pathology include tobacco use (odds ratio (OR), 2.0; 95% confidence interval (CI), 1.2-3.4, P = 0.009), coronary artery disease (OR, 1.9; 95% CI, 1.1-3.7; P = 0.04), and respiratory failure (OR, 4.7; 95% CI, 1.1-26.3; P = 0.049). When compared with patients without colon involvement, NP patients with colon involvement had significantly increased overall morbidity (86% vs 96%, P = 0.03) and mortality (8% vs 19%, P = 0.002). Colon involvement in necrotizing pancreatitis is common; clinical deterioration should prompt its evaluation. Risk factors include tobacco use, coronary artery disease, and respiratory failure. Colon involvement in necrotizing pancreatitis is associated with substantial morbidity and mortality.

Stenosis and stenosis-like lesions in the submandibular duct: Detailed clinical and sialendoscopy-based analysis and proposal for a classification

The aim of this study was to perform a detailed analysis of submandibular duct stenoses and propose a classification for them. This retrospective study covering the period 2001-2019 included 314 patients with 370 submandibular duct stenoses, assessed sialendoscopically for number, grade of narrowing, length, tissue type, and underlying main cause/associated diseases. In the included patients, 58.9% of the stenoses were at the papilla, 89.2% were short, and 61.6% were of high grade. Predominantly inflammatory stenoses (type 1) differed from fibrotic stenoses (type 2). Detailed analysis identified stenosis-like lesions caused by anatomic duct narrowing and/or duct variations (type 3), differing significantly from type 2 stenoses in location, length, and bilaterality (each P=.0001) and from type 1 stenoses in location (P=.0001). Compared with type 2, type 1 stenoses were bilateral significantly more often and shorter (each P=.0001). Frequencies of the main causes of stenosis-anatomic narrowness/duct variation and chronic sialadenitis-differed significantly in the different locations (P=.0001). There were no significant differences in frequencies of associated diseases/conditions for the different stenosis types. Three types of stenosis/stenosis-like lesions were distinguished. In view of these results and the findings from a review of the literature, the location and type of stenoses were found to be more important parameters, whereas number, grade, and length were less important. The underlying cause may be useful for assessing the prognosis.

Surgical treatment of intestinal stricture in inflammatory bowel disease.

Fibroblast infiltration and collagen deposition result in structural changes in the bowel wall, and lead to strictures in intestinal inflammatory disease. While strictures can also occur in other contexts, such as malignancy, this review focuses on the surgical treatment of stricture secondary to inflammatory bowel disease. Distinguishing between predominantly inflammation vs established fibrosis as the cause of a stricture can be challenging. While inflammatory strictures may be responsive to medication, predominantly fibrotic strictures usually need surgical intervention. Both endoluminal and extraluminal approaches are described in this review. Endoscopic dilatation of strictures is suitable for short-segment isolated small bowel strictures. Other options are to divide the stricture surgically but preserve the length, performing a strictureplasty or resecting the strictured segment. The mesentery is increasingly recognized as playing a role in stricture recurrence. In a relapsing-remitting disease such as Crohn's disease, the preservation of intestinal length is essential and balance is needed between this and a complete resection to reduce the risk of recurrence. Pre- and postoperative involvement of the multidisciplinary team is essential to improve outcomes in this challenging clinical scenario.

Contrast-Enhanced Ultrasound as a Diagnostic Tool in Diseases of the Digestive Tract

Contrast-Enhanced Ultrasound as a Diagnostic Tool in Diseases of the Digestive Tract Abstract. Contrast-enhanced ultrasound is a good diagnostic tool in certain gastrointestinal diseases. Inflammation of the gastric and the bowel wall can often be distinguished from neoplastic alterations. Gastric and duodenal stenosis can be depicted with the use of oral contrast, and after stenting the patency can be documented. Abscesses are perfectly delineated, and after drainage the exact location of the tube and possible complications can be documented. In patients with Crohn's disease inflammatory activity and complications such as abscesses, fistulas and stenotic areas can be depicted. Distinction of fibrotic from inflammatory stenosis may help to look for surgical intervention in due time. Acute ischemic colitis has a typical perfusion pattern, and a control after a few days may show an increased vascularity.

M2 Macrophages and Phenotypic Modulation of Intestinal Smooth Muscle Cells Characterize Inflammatory Stricture Formation in Rats

The progression of Crohn disease to intestinal stricture formation is poorly controlled, and the pathogenesis is unclear, although increased smooth muscle mass is present. A previously described rat model of trinitrobenzenesulfonic acid-induced colitis is re-examined here. Although inflammation of the mid-descending colon typically resolved, a subset showed characteristic stricturing by day 16, with an inflammatory infiltrate in the neuromuscular layers including eosinophils, CD3-positive T cells, and CD68-positive macrophages. Closer study identified CD163-positive, CD206-positive, and arginase-positive cells, indicating a M2 macrophage phenotype. Stricturing involved ongoing proliferation of intestinal smooth muscle cells (ISMC) with expression of platelet-derived growth factor receptor beta and progressive loss of phenotypic markers, and stable expression of hypoxia inducible factor 1 subunit alpha. In parallel, collagen I and III showed a selective and progressive increase over time. A culture model of the stricture phenotype of ISMC showed stable hypoxia inducible factor 1 subunit alpha expression that promoted growth and improved both survival and growth in models of experimental ischemia. This phenotype was hyperproliferative to serum and platelet-derived growth factor BB, and unresponsive to transforming growth factor beta, a prominent cytokine of M2 macrophages, compared with control ISMC. We identified a hyperplastic phenotype of ISMC, uniquely adapted to an ischemic environment to drive smooth muscle layer expansion, which may reveal new targets for treating intestinal fibrosis.

<p>Anterior Segment Optical Coherence Tomography (AS-OCT) Guided Reversal of Edematous Punctal Occlusion</p>

AimTo evaluate the role of anterior segment–optical coherence tomography (AS-OCT) in the diagnosis of punctal stenosis and to compare punctal parameters before and after medical treatment.Patients and MethodsThe study was conducted on 40 eyes of 24 patients who had acquired inflammatory punctal stenosis and had persistent epiphora (persistent epiphora group – PEG), and 20 eyes of 10 subjects with normal punctal openings as a control group (control group – CG). We measured the outer punctal diameter (OPD), recorded the visibility of the internal punctum and punctal depth (PD) using AS-OCT, before and 1 month after treatment with preservative free methylprednisolone 5% eye drops. Punctal diameter, tear meniscus height (TMH) and Munk’s score were compared to the control group before and after treatment.ResultsThe mean OPD of the PEG before treatment (455.5 ± 174 µm) was significantly smaller than that of the CG (590.9 ± 106.6 µm) (P= 0.002). The mean OPD of the PEG significantly increased to 484.6 ± 175.5 µm after treatment (P <0.001). Also, the visibility of vertical canaliculus lumen and PD were restored in 70% of eyes. The TMH was much higher in the PEG than in the CG before treatment (P<0.05). However, after treatment the difference was not statistically significant.ConclusionAS-OCT parameters were useful in monitoring and measuring the efficacy of medical treatment in relieving punctal edema, which subsequently resulted in reducing the epiphora symptoms.

Differentiation of fibrotic and inflammatory component of Crohn's disease-associated strictures.

Patients with Crohn’s disease (CD) commonly develop bowel strictures, which may contain various degrees of inflammation and fibrosis. While predominantly inflammatory strictures may benefit from a medical anti-inflammatory treatment approach, fibrotic strictures would require endoscopic balloon dilation or surgery. Cross-sectional imaging surpasses endoscopy for characterization of stenotic segments and potentially may contribute to the optimal clinical management of these patients. This short review aims to discuss the potentialities and limitations of cross-sectional imaging techniques for assessing bowel fibrosis in patients with CD.

Focal Cerebral Arteriopathy in Young Adult Patients With Stroke.

Background and Purpose- Focal cerebral arteriopathy is monophasic inflammatory stenosis of the distal internal carotid artery or the proximal segment of the middle cerebral artery. It is one of the most common causes of acute arterial ischemic stroke in young children but is a less familiar entity for adult neurologists. Methods- We retrospectively reviewed stroke service radiology records at a tertiary referral center from January 2013 to December 2014. Focal cerebral arteriopathy was defined as nonprogressive unifocal and unilateral stenosis/irregularity of the distal internal carotid artery or its proximal branches. Only patients aged 16 to 55 years with stroke were included. Results- There were 5 cases of focal cerebral arteriopathy: 2 males and 3 females. Three cases were from the cohort of 123 acute presentations of young stroke, and 2 cases were outpatient referrals. The mean age (range) was 43 (32-55) years. The majority presented with recurrent transient ischemic attacks/minor strokes within a single vascular territory over days to weeks. All cases had characteristic radiological features. Interval imaging demonstrated resolution in 1 case and improvement in 3 cases. Functional outcome was excellent with discharge modified Rankin Scale score ranging from 0 to 1. Recurrence occurred in 1 case. Conclusions- Focal cerebral arteriopathy is a rare cause of arterial ischemic stroke in young adults. Follow-up intracranial imaging is essential to differentiate from progressive arteriopathies. Evidence-based treatment warrants further investigation. Prognosis is favorable.

Role of preservative free steroids in treatment of inflammatory punctal stenosis guided by Anterior Segment Optical Coherence Tomography

Abstract Background Acquired inflammatory punctual stenosis is a disease commonly presented with epiphora and most common cause is long term treatment with preservative containing topical eye drops. The inflammation causes a decrease in the clearance of the medication and preservative, and their continued use will result in more inflammation and stenosis, and therefore a longer clearance time resulting in a higher concentration and longer transit time, leading to a vicious cycle. Objective This study was conducted to compare between the effectiveness of topical preservative free steroids eye drops and preservative free artificial tears in treatment of punctal edema in Egypt. Methods This prospective comparative study comprised 40 eyes with punctal edema. Group A: 20 eyes Patients in this group received preservative free hydrocortisone 2.5% eye drops 4 times daily for 1 week with tapering over 3 weeks and followed up after 1 month. And after 3 months. Group B: 20 eyes Patients in this group received one of the preservative free artificial tears available in market 4 times/day for 1 month. All subjects were subjected to history taking, slit lamp examination, Flourescene dye disappearance test for diagnosis and follow up once/month for 3 months and measuring the punctual diameter pretreatment, after 1 month and after 3 months. From treatment. Results Comparing the two groups, the study found that there was no statistically significant difference found between the two studied groups regarding punctual diameter pretreatment, at 1 month and at 3 months and a highly statistically significant symptomatic improvement after 3 months in preservative free steroids group more than the preservative free artificial tears group. Conclusion The present study compared the effectiveness of topical preservative free steroid eye drops and preservative free artificial tears as regards increase in punctual diameter and symptomatic improvement and found a statistically significant increase in symptomatic improvement in preservative free steroid group more than the preservative free artificial tears group as after 3 months and statistically significant increase in punctual diameters in both groups in comparison to control group.

Therapeutic resolution of focal, predominantly anastomotic Crohn’s disease strictures using removable stents: outcomes from a single-center case series in the United Kingdom

Intestinal and anastomotic strictures in Crohn's disease (CD) produce considerable morbidity. The development of surgery-sparing, endoscopic modalities for stricture resolution is essential. Removable stent therapy is emerging as an efficacious and safe means of stricture resolution. We present outcomes from the largest, single-center series of patients with CD undergoing removable self-expanding metal stent (SEMS) therapy to resolve focal intestinal strictures. Patients with symptomatic CD were assessed with magnetic resonance enterography. Short (≤6 cm), fibrostenotic strictures of the terminal ileum or ileocolonic anastomoses were considered by a multidisciplinary team and put forward for stent therapy. Strictures were examined endoscopically and impassable strictures were treated with SEMSs. The Hanaro HRC-20-080-230 partially covered SEMS was used for all patients. Endoscopically inaccessible or inflammatory strictures were excluded. Stent retrieval was scheduled for 7 days after insertion. Therapeutic benefit was assessed with validated inflammatory bowel disease scoring tools. Twenty-one patients underwent 23 stent episodes, with 2 patients requiring repeat therapy in the follow-up period. Most treated strictures were anastomotic (19 of 21); 2 of 21 were de novo. Of those patients attending follow-up, 81% (13 of 16) reported symptom improvement or resolution; 88% (14 of 16) were in clinical remission at follow-up. Across all stent episodes, only 5 adverse events were noted (2 episodes of stent-related discomfort, 3 asymptomatic stent migrations). There were no direct stent-related adverse events such as perforation, impaction, or bleeding. No patient has required stricture-related surgery in the follow-up period (range, 3-50 months). In this series, removable SEMS therapy for ileal and anastomotic strictures was found to be clinically efficacious. The absence of perforation events and need for stricture-related surgery are noteworthy. These results suggest that the efficacy of stent therapy in this context merits powered, head-to-head investigation with other modalities for stricture resolution.

P638 Stenotic Crohn’s disease

Abstract Background The treatment of Crohn’s stenosis appears to be codified and complex, it depends on the inflammatory or fibrous type of stenosis. The purpose of our study was to describe the clinical, epidemiological and therapeutic characteristics of Crohn’s disease in its stenotic form and to determine the failure factors for the treatment of stenotic CD. Methods This is a descriptive and analytical monocentric retrospective study, involving 900 Crohn’s patients, 189 of whom had stenotic CD. The statistical analysis is performed using the SPSS 22.0 software. Results The average age was 32± 11 years. Followed for an average of 48 months[12–96].Sex ratio=1.14F/1H. 44(23.3%) were smokers and 29(15.3%) had a previous of appendectomy.Symptomatology was Koenig syndrome in 107 cases(56.6%), occlusive syndrome in 40 cases(21.2%), constipation in 31 cases(16.4%), vomiting in 7 cases(3.7%) and 4 cases(2.2%) asymptomatic.The localisation of stenosis was ileocaecal in 118 patients(62.4%), hail in 32 patients(16.9%), colic in 17 cases(9%), anal in 15 cases(7.9%) and high in 7 cases(3.7%).Stenosis was unique in 160 cases(84.7%) and multiple in 29 cases(15.3%). 117 patients (62%) had a short stenosis &amp;lt;5 cm and 72 patients (38%) had a stenosis &amp;gt;5 cm. The fibrous nature of stenosis was in 86 patients (45.5%) and inflammatory in 103 (54.5%). 40 patients (21.2%) had an associated fistulizing behaviour. Anoperineal manifestations (MAP) in 58 cases (30.7%). Therapeutically speaking:80 patients (42.3%) were treated with corticosteroids, 10 patients (5.3%) with anti-TNFa, 3 patients (1.6%) with immunosuppressants (IS), 12 cases (6.3%) with endoscopic dilation and 84 cases (44.4%) were operated. The course was marked by a good response in 53 cases (28%), the appearance of fistula± abscess in 25 cases (13.2%), intestinal obstruction in 13 cases (6.9%) and recurrence of stenotic disease in 98 cases (51.9%).There is a difference in management between fibrous and inflammatory stenosis:corticosteroids(1.2%vs98.8%),anti-TNF(10%vs90%), dilation(100%vs0%), surgery(84.5%vs15.5%), this difference is statistically significant(p &amp;lt; 0.001). In multivariate analysis and by adjusting for confounding parameters, it appears that only MAP, ileocaecal location and fistulizing behavior are associated with treatment failure with [OR = 3.2; IC = 1.4–7.7; p = 0.005], [OR = 0.17; IC = 0.3–0.9; p = 0.037], [OR = 2.6; IC = 1.02–6.6; p = 0.04]. Conclusion There was a statistically significant difference (p &amp;lt; 0.001) in terms of response to corticosteroid and anti-TNF treatments, as well as the use of surgery and dilatation between fibrous and inflammatory stenosis. And treatment failure was related to: MAP association [OR = 3.2; IC = 1.4–7.7; p = 0.005], ileocaecal localisation of stenosis [OR = 0.17; IC=0.3–0.9; p = 0.037] and fistulizing behavior[OR = 2.6;IC = 1.02–6.6;p = 0.04]

P346 Single-centre experience of ustekinumab: Therapeutic drug monitoring in Crohn’s disease patients

Abstract Background Therapeutic drug monitoring (TDM) is a diagnostic tool in the monitoring of anti-TNF therapies. Yet, the benefit for TDM of new biologics such as ustekinumab (USK) is still controversial in real-world experiences. Methods This monocentric retrospective study aims to correlate USK trough levels (TLs) with clinical and endoscopic data. All patients have given written consent to the Biobank (B2011/005). Endoscopic disease was defined as quiescent in absence of endoscopic lesions, mild disease in presence of few superficial ulcerations, moderate in presence of several ulcers and severe in presence of numerous deep ulcers and/or inflammatory stenosis. 313 serum USK samples from 67 Crohn’s disease patients were used to measure USK TL (USK ELISA, apDia) while 88 samples (at week 16, and before and after optimisation) were used to measure anti-drug antibody (ADA), using a drug-tolerant affinity capture elution anti-ustekinumab assay Results Demographic and baseline data of our population are presented in Table 1. The median follow-up was 73 weeks (IQR 39–92). An optimisation due to loss of response was required in 44.8% of patients (n = 30) after a median time of 38 weeks (IQR 24–55). To evaluate the drug efficacy, an endoscopy was performed in 61% of cases at a median time of 35 weeks (IQR 27–47). TLs were 5.2 µg/ml (IQR 2.1–8.8), 1.7 µg/ml (IQR 0.3–4.3) and 2.6 µg/ml (IQR 0.6–4.1) at week 8, 16 and 24, respectively. TLs at week 8 were correlated to the induction IV dose administrated (r = 0.3, p = 0.03). At week 16, low TLs were associated with higher endoscopic activity in the follow-up (p = 0.02), although this was not the case at week 8 (p = 0.5) (Figure 1). Patients not requiring an optimisation had higher TLs in maintenance than patients requiring optimisation (2.45 µg/ml (IQR 1.3–4.4) vs. 1.15 µg/ml (IQR 0.1–2.24), p = 0.008). Obviously, optimisation significantly increased TLs (1.15 µg/ml (IQR 0.1–2.24) vs. 6.6 µg/ml (IQR 2.3–11.3), p &amp;lt; 0.001). ADA were undetectable in all the measured samples in maintenance. Conclusion This real-world experience confirms a drug exposure-endoscopic response relationship. Week 16 seems to be an appropriate time point to monitor drug exposure. Earlier USK TLs, at week 8, appear less valuable to be monitored due to the influence of initial IV dose. The absence of immunogenicity suggests that it is not a key driver in the loss of response.

Role of Leptin in Neoplastic and Biliary Tree Disease.

Leptin is a small hormone of protein nature, it is strongly involved in the regulation of lipid metabolism and its functioning mechanism is not yet well known or whether or not it is actually secreted by cholangiocytes, nor if the biliary tree expresses its receptors. In the past, various studies have tried to correlate leptin levels with certain neoplasms. The aim of this study was to demonstrate that serum leptin values can become a new sensitive and specific serum marker for cholangiocarcinoma. Seventy-two patients with gallbladder stones, hepatolithiasis with benign biliary stenosis, cholangiocarcinoma, and a group of patients without hepato-biliary diseases were enrolled in the study. In all cases blood and bile samples were collected for evaluation of leptin levels and liver biopsies were performed to confirm diagnosis. In all patients, both ultrasound and cholangio-magnetic resonance imaging (MRI) were performed to complete the diagnostic procedure. Twenty-two patients were affected by cholangiocarcinoma, 50 by benign biliary disease (35 cholelithiasis and 6 hepatolithiasis and 9 by inflammatory biliary stenosis). The mean values of serum leptin in patients with cholangiocarcinoma were 19.28±8.76 ng/ml, significantly higher than those observed in non-neoplastic biliary diseases. Serum leptin levels might be a useful marker to differentiate patients with cholangiocarcinoma from those with biliary lithiasis and inflammatory stenosis.

Endoscopic ultrasonography in the differential diagnosis of biliopancreatoduodenal tumors

Objective . Todeterminethe role ofendoscopicultrasonography in preoperative differentialdiagnosis of bilio pancreatoduodenal tumorsand choice of further treatment strategy. Material and methods . A retrospective analysis included medical records of 89 patients hospital-ized with suspected biliopancreatoduodenal tumor.Pancreatic head tumor was diagnosed in 41(46.1%) patients, tumorof major duodenal papilla – in 15 patients (16.9%), tumor of distal seg-ment of common bile duct – in 10 patients (11.2%), cicatricial and inflammatory strictures of distal segment of common bile duct – in 19 patients (21.3%), post-necroticpseudocysts of pancreatic head – in 4 patients (4.5%). Results . Sensitivity ofendoscopic ultrasonography for tumors of pancreatic head, major duodenal papilla, distal common bile duct, cicatricial and inflammatory strictures of distal segment of com-mon bile duct and postnecroticpseudocysts of pancreatic head was 90.2%, 100%, 80%, 94.7% and 100%, respectively. Specificity was 97.9%, 94.6%, 98.7%, 98.6% and 100%, respectively. Overall accuracy was 94.4%, 95.5%, 96.6%, 97.8% and 100%, respectively. False-negative results were obtained in 7 cases. Tumor was not excluded in these patients, but there was a conclusion about an-other primary source of growth. Conclusion . Endoscopic ultrasonography is associated with high accuracy of preoperative differen-tial diagnosis of malignant and benign biliopancreatoduodenaltumors and useful to clarify diagnosis in patients with mechanical jaundice syndrome. These data are usedas an objective criterion to de-termine further treatment strategy depending on the results of endoscopic ultrasonography.

Single-stage buccal mucosal graft urethroplasty for meatal stenoses and fossa navicularis strictures: a monocentric outcome analysis and literature review on alternative treatment options.

To describe the operative technique and report outcomes from the largest series of patients who underwent single-stage dorsal inlay buccal mucosal graft urethroplasty (BMGU) for isolated meatal stenoses and fossa navicularis strictures. First, we evaluated patients who underwent single-stage BMGU for distal urethral strictures (meatus and fossa navicularis) between 2009 and 2016 at our department. Clinical and surgical characteristics were prospectively collected in an institutional database. Recurrence was defined as symptomatic need of any instrumentation during follow-up, was retrospectively assessed by patient interview, and recurrence-free survival was plotted using Kaplan-Meier curves. Second, a systematic literature review was performed through Medline to summarize the available evidence on distal urethroplasty using flaps or grafts. Of 32 patients, 16 (50%) presented with a hypospadias-associated stricture, followed by seven (22%), five (16%), and four (13%) patients with iatrogenic, inflammatory, and congenital strictures, respectively. At a median follow-up of 42months (IQR 23-65), single-stage dorsal inlay BMGU was successful in 22 patients (69%), and estimated recurrence-free survival rates were 79% and 74% at 12 and 24months, respectively. Overall, 62 patients from five studies in the literature review underwent BMGU for isolated distal strictures and success rates ranged from 56 to 100%. Recurrent meatal stenoses and fossa navicularis strictures represent some of the most complex uro-reconstructive challenges. Inlay BMGU proves to be a valid and efficient last-resort single-stage technique. However, higher recurrence risk must be considered and staged urethroplasty should be discussed individually. Prospective randomized controlled trials are needed to prove the superiority of flaps, grafts or staged approaches over each other in this context.

Outcome determinants of urethroplasty in the management of inflammatory anterior urethral strictures.

Limited data are available on outcomes of the surgical management of inflammatory urethral strictures secondary to infection, a major cause of stricture. Several shortcomings that need to be addressed have been identified in the past. To determine the impact of stricture length, position and degree of obliterative urethral lumen on the surgical outcomes of corrective procedures for inflammatory anterior urethral strictures. This retrospective analysis used the records of patients who presented with proven infective anterior urethral strictures at an academic hospital from 2007 to 2010. All patients were followed up after 48 months. Urethroplasty outcomes were analysed according to stricture location and length and effect of urethral obliteration. The median age of the 174 patients in the study was 47 (range 21 - 86) years. Anastomotic urethroplasty was successful in 59/99 (59.6%) patients. Augmented anastomotic urethroplasty was successful in 11/15 (73.3%) patients. Dorsal onlay buccal mucosa graft urethroplasty was successful in 23/32 (71.9%) patients, significantly higher than in 2/9 (22.2%) patients who underwent ventral onlay buccal mucosa graft urethroplasty (p=0.017; hazard ratio 3.4; 95% confidence interval 1.29 - 9.40). The one-stage circular pedicled penile skin-flap urethroplasty was successful in 1/12 (8.3%) patients. Two-stage urethroplasty was successful in 5/7 (71.4%) patients. A primary component analysis of the 73 failed procedures showed that stricture length was the main contributor to failure (eigenvalue 1.79; 45%). Urethroplasty remains a challenge in inflammatory urethral strictures, where stricture length was the main reason for treatment failure.

Non Transecting Dorsal Onlay and Ventral Inlay Buccal Mucosal Substitution Urethroplasty for Obliterative Bulbar Urethral Strictures

Background: Dorsal or ventral single layer repair can be impractical when there is an inadequate strip of urethra. Staged urethroplasty and non-transecting bilayer substitution urethroplasty are the other alternatives. Objectives: To assess the safety and outcome of non-transecting dorsal onlay and ventral inlay buccal mucosal substitution urethroplasty technique. Method: Between January 2014 and December 2018, 21 patients underwent non-transecting, double-layer, buccal mucosal urethroplasty for inflammatory bulbar urethral strictures. Four weeks after surgery, foley catheters were removed and voiding trial was given. Clinical examination and uroflowmetry (UFM) were done at 1, 3, and 6 months after surgery. Annual follow-up with flow rate and post-void residual assessment were also recorded. Failure was defined as a condition when there was flow rate deterioration (<15 mL/s) or when there is stricture recurrence (<20 Fr). Results: The mean age was 49.5 years. There was no significant difference in comorbidities among the patients. The mean duration of operative time was 259 min. The mean blood loss was 190 mL. The follow-up duration ranged from 12 to 66 months. The average length of stricture was 3.9 cm. The mean diameter of stricture segment was 1.96 mm. Comparison of UFM trend during follow-up was statistically significant (p = 0.05). One patient had Clavien-dindo grade 1, while 2 patients had grade 3b complications. Two patients had soft anastomotic site stricture and were treated successfully with endoscopic internal urethrotomy. The success rate was 90.47%. Conclusions: Non-transecting bilayer substitution urethroplasty is safe and has better short-term outcome in case of obliterative inflammatory urethral strictures.

Usefulness of dedicated forceps for digital single-operator cholangioscopy for the treatment of inflammatory biliary stricture

Usefulness of dedicated forceps for digital single-operator cholangioscopy for the treatment of inflammatory biliary stricture

1412 A Rare Case of Post-ERCP Panniculitis

INTRODUCTION: Pancreatic panniculitis affects 0.3-3% of patients with a wide variety of pancreatic disorders. It is characterized by subcutaneous fat necrosis following the release of pancreatic enzymes into the circulation. Endoscopic retrograde cholangiopancreatography (ERCP) is a rare cause of panniculitis. Based on our literature review, this is the fourth case report of post-ERCP panniculitis. CASE DESCRIPTION/METHODS: An 80-year-old female with a history of choledocholithiasis with biliary stent placement presented for elective ERCP. The procedure demonstrated a moderate, inflammatory distal biliary stricture, a migrated biliary stent and choledocholithiasis. A biliary sphincterotomy, cholangioscopy and laser lithotripsy and stent exchange was performed with approximately 80% of stone removal. Post- procedure the patient noted tender erythematous raised nodules on her legs. Skin biopsy was performed with findings consistent with pancreatic pannicultitis. Follow-up ERCP was normal with trace sludge and removal of the biliary stent. At follow-up she was improved without abdominal pain and reported healing of the lower extremity cutaneous lesions. DISCUSSION: Pancreatic panniculitis is a rare skin finding that is independent of disease severity and can occur at any point during the disease process. Post-ERCP panniculitis is rare and only reported in three other cases. Pancreatic panniculitis is typically tender, ill-defined, red-brown nodules located in the lower extremities. The gold standard for diagnosis is biopsy with histopathology significant for a mostly lobular panniculitis without vasculitis with the presence of the typical ghost cells, necrotic and calcified adipocytes. Treatment is aimed at addressing the underlying pancreatic disease and the lesions typically resolve with improvement in pancreatic inflammation.

3008 Painless Jaundice, Sclerosing Cholangitis, and IgG-4 Related Disease

INTRODUCTION: IgG4-RD can mimic PSC and Cholangiocarcinoma when presenting in the hepatobiliary system, and should be placed high on the differential diagnosis when there is multi-organ system involvement and negative workup for malignancy. CASE DESCRIPTION/METHODS: A 58 year-old male presented to the ED with painless jaundice and 6 months of episodic RUQ pain, cervical lymphadenopathy, increased anorexia, weight loss, and fatigue. Prior work-up included a CT abdomen/pelvis that showed intra-hepatic ductal dilation and possible stricture/mass at the common hepatic duct, as well as FNA biopsies of lymph nodes negative for malignancy. Initial lab work was significant for T bili of 8.5, AST of 289, AST of 231, and alkaline phosphatase of 1033, and lipase of 26. Physical exam was notable for scleral icterus, cervical lymphadenopathy, and jaundiced skin. Patient was admitted and underwent ERCP with findings of strictures with PSC-like beading; a stent was placed with improvement in his biliary obstruction. Brushings were obtained for cytology, which were negative for malignancy. Given concern for malignancy, further evaluation was performed including tumor markers which revealed an elevated CA 19-9. Staging chest CT revealed adenopathy concerning for metastases. Subsequent excisional biopsy of an enlarged cervical node was negative for malignancy but revealed a non-caseating granuloma. A second ERCP revealed an inflammatory stricture with brushings again negative for malignancy. Given lack of evidence of malignancy, an IgG4 level was checked which was elevated at 386. His presentation was thus thought to be most consistent with IgG4 sclerosing cholangitis, and he was started on systemic corticosteroids. DISCUSSION: IgG4-RD is characterized as a chronic relapsing fibro-inflammatory syndrome. Increased serum levels of IgG4 and infiltration of tissue by IgG4+ plasma cells are typical of IgG4-RD. Common histological findings include dense lymphoplasmacytic infiltrate with IgG4+ plasma cells, storiform fibrosis, and obliterative phlebitis. The above serological and histological findings together make a diagnosis of IgG4-RD likely. IgG4-RD can occur in multiple organ systems, with typical presentation in the pancreatico-hepatobiliary system as Autoimmune Pancreatitis or Autoimmune Sclerosing Cholangitis. Steroids are first-line treatment, with refractory cases requiring more aggressive immunosuppressive agents, such as Rituximab, to decrease the recurrence of inflammation seen in patients.