Initial Conservative Management Research Articles

Factors Associated With Coronary Angiography Performed Within 6 Months of Randomization to the Conservative Strategy in the ISCHEMIA Trial.

ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) did not find an overall reduction in cardiovascular events with an initial invasive versus conservative management strategy in chronic coronary disease; however, there were conservative strategy participants who underwent invasive coronary angiography early postrandomization (within 6 months). Identifying factors associated with angiography in conservative strategy participants will inform clinical decision-making in patients with chronic coronary disease. Factors independently associated with angiography performed within 6 months of randomization were identified using Fine and Gray proportional subdistribution hazard models, including demographics, region of randomization, medical history, risk factor control, symptoms, ischemia severity, coronary anatomy based on protocol-mandated coronary computed tomography angiography, and medication use. Among 2591 conservative strategy participants, angiography within 6 months of randomization occurred in 8.7% (4.7% for a suspected primary end point event, 1.6% for persistent symptoms, and 2.6% due to protocol nonadherence) and was associated with the following baseline characteristics: enrollment in Europe versus Asia (hazard ratio [HR], 1.81 [95% CI, 1.14-2.86]), daily and weekly versus no angina (HR, 5.97 [95% CI, 2.78-12.86] and 2.63 [95% CI, 1.51-4.58], respectively), poor to fair versus good to excellent health status (HR, 2.02 [95% CI, 1.23-3.32]) assessed with Seattle Angina Questionnaire, and new/more frequent angina prerandomization (HR, 1.80 [95% CI, 1.34-2.40]). Baseline low-density lipoprotein cholesterol <70 mg/dL was associated with a lower risk of angiography (HR, 0.65 [95% CI, 0.46-0.91) but not baseline ischemia severity nor the presence of multivessel or proximal left anterior descending artery stenosis >70% on coronary computed tomography angiography. Among ISCHEMIA participants randomized to the conservative strategy, angiography within 6 months of randomization was performed in <10% of patients. It was associated with frequent or increasing baseline angina and poor quality of life but not with objective markers of disease severity. Well-controlled baseline low-density lipoprotein cholesterol was associated with a reduced likelihood of angiography. These findings point to the importance of a comprehensive assessment of symptoms and a review of guideline-directed medical therapy goals when deciding the initial treatment strategy for chronic coronary disease. URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.

Infected pancreatic necrosis-Current trends in management.

Acute necrotizing pancreatitis is a common gastrointestinal disease requiring hospitalization and multiple interventions resulting in higher morbidity and mortality. Development of infection in such necrotic tissue is one of the sentinel events in natural history of necrotizing pancreatitis. Infected necrosis develops in around 1/3rd of patients with necrotizing pancreatitis resulting in higher mortality. So, timely diagnosis of infected necrosis using clinical, laboratory and radiological parameters is of utmost importance. Though initial conservative management with antibiotics and organ support system is effective in some patients, amajority of patients still requires drainage of the collection by various modalities. Mode of drainage of infected pancreatic necrosis depends on various factors such as the clinical status of the patient, location and characteristics of collection and availability of the expertise and includes endoscopic, percutaneous and minimally invasive or open surgical approaches. Endoscopic drainage has proved to be a game changer in the management of infected pancreatic necrosis in the last decade with rapid evolution in procedure techniques, development of novel metal stent and dedicated necrosectomy devices for better clinical outcome. Despite widespread adoption of endoscopic transluminal drainage of pancreatic necrosis with excellent clinical outcomes, peripheral collections are still not amenable for endoscopic drainage and in such scenario, the role of percutaneous catheter drainage or minimally invasive surgical necrosectomy cannot be understated. In a nutshell, the management of patients with infected pancreatic necrosis involves a multi-disciplinary team including a gastroenterologist, an intensivist, an interventional radiologist and a surgeon for optimum clinical outcomes.

NanoScope wrist arthroscopy under wide-awake local anesthesia with no tourniquet: A prospective series of 30 consecutive patients

IntroductionWrist arthroscopy is an evolving procedure. The purpose of this study was to report the outcome of diagnostic arthroscopy of the wrist using a new tool, the NanoScope, under wide-awake local anesthesia with no tourniquet (WALANT). Patients and methodsThis was a prospective study of 30 consecutive patients with suspected ligament tear after wrist trauma and remaining symptoms after initial conservative management. All patients had an MRI prior to the NanoScope procedure. ResultsThe patients comprised 17 men and 13 women, with a mean age of 31 years. One patient declined the NanoScope procedure following their MRI. In the remaining 29 patients, NanoScope wrist arthroscopy revealed 19 cases of triangular fibrocartilaginous complex (TFCC) tears and 11 tears of the scapholunate (SL) or lunotriquetral (LT) ligaments. The correlation between preoperative MRI and the findings from NanoScope arthroscopy was poor. Six patients had additional surgery after the NanoScope arthroscopy, comprising three TFCC sutures, one SL and one LT ligament reconstruction respectively, and one wrist arthrodesis. No complications related to the NanoScope arthroscopies were noted. ConclusionNanoScope arthroscopy of the wrist is safe, is well-suited for surgery in WALANT, and has superior diagnostic capacity compared to MRI. Further studies are warranted to determine the role of the NanoScope in the management of wrist ligament pathologies. Level of evidenceThis is a level 4 study.

Endoscopic Resection of Horseshoe Ganglion of the Lateral Midfoot

A ganglion is the most common soft-tissue mass in the foot and can cause pain, paresthesia, or footwear problems. A ganglion can extend from the dorsum into the plantar compartment of the foot in the form of a horseshoe at the borders of the foot or in the form of an hourglass through the intermetatarsal space. Initial conservative management of a ganglion may entail observation and the use of padding for comfort, manual rupture, aspiration of the cyst contents, and steroid injection or sclerotherapy into the cyst. When the lesion is recurrent or painful, surgical excision is recommended. The purpose of this Technical Note is to describe the details of endoscopic resection of a horseshoe ganglion of the lateral midfoot. This technique has the advantages of being minimally invasive, with better cosmetic results and less surgical trauma to the soft tissue.

Basilar artery perforator aneurysms: a comparison with non-perforator saccular aneurysms.

Basilar artery perforator aneurysms (BAPAs) are rare. There is no systematic description of their presentation, imaging, natural history and outcomes and how these compare to conventional non-perforator aneurysms. Thus, the authors in this study aimed to compare BAPAs to non-perforator aneurysms. Cases were identified from a prospective neurovascular database, notes and imaging retrospectively reviewed and compared to a consecutive series of patients with non-perforator aneurysms. Blood volume on CT and vessel wall imaging (VWI) were compared to controls. 9/739 patients with aneurysmal subarachnoid haemorrhage (aSAH) harboured BAPAs. Compared to 103 with aSAH from posterior circulation aneurysms, they were more likely to be male (6/9, p = 0.008), but of equal severity (4/9 poor grade, p = 0.736) and need of CSF drainage (5/9, p = 0.154). Blood volume was similar to controls (30.2ml vs 26.7ml, p = 0.716). 6/9 BAPAs were initially missed on CTA. VWI showed thick (2.9mm ± 2.7) bright enhancement (stalk ratio 1.05 ± 0.12), similar to controls with ruptured aneurysms (0.95 ± 0.23, p = 0.551), and greater than unruptured aneurysms (0.43 ± 0.11, p < 0.001). All were initially managed conservatively. Six thrombosed spontaneously. Three grew and had difficult access with few good endovascular options and were treated through a subtemporal craniotomy without complication. None rebled. At 3months, all presenting in poor grade were mRS 3-4 and those in good grade mRS 1-2. Despite their small size, BAPAs present with similar volume SAH, WFNS grade and hydrocephalus to other aneurysms. They are difficult to identify on CTA but enhance strikingly on VWI. The majority thrombosed. Initial conservative management reserving treatment for growth was associated with no rebleeds or complications.

Sex Differences in Revascularization, Treatment Goals, and Outcomes of Patients With Chronic Coronary Disease: Insights From the ISCHEMIA Trial.

Women with chronic coronary disease are generally older than men and have more comorbidities but less atherosclerosis. We explored sex differences in revascularization, guideline-directed medical therapy, and outcomes among patients with chronic coronary disease with ischemia on stress testing, with and without invasive management. The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial randomized patients with moderate or severe ischemia to invasive management with angiography, revascularization, and guideline-directed medical therapy, or initial conservative management with guideline-directed medical therapy alone. We evaluated the primary outcome (cardiovascular death, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest) and other end points, by sex, in 1168 (22.6%) women and 4011 (77.4%) men. Invasive group catheterization rates were similar, with less revascularization among women (73.4% of invasive-assigned women revascularized versus 81.2% of invasive-assigned men; P<0.001). Women had less coronary artery disease: multivessel in 60.0% of invasive-assigned women and 74.8% of invasive-assigned men, and no ≥50% stenosis in 12.3% versus 4.5% (P<0.001). In the conservative group, 4-year catheterization rates were 26.3% of women versus 25.6% of men (P=0.72). Guideline-directed medical therapy use was lower among women with fewer risk factor goals attained. There were no sex differences in the primary outcome (adjusted hazard ratio [HR] for women versus men, 0.93 [95% CI, 0.77-1.13]; P=0.47) or the major secondary outcome of cardiovascular death/myocardial infarction (adjusted HR, 0.93 [95% CI, 0.76-1.14]; P=0.49), with no significant sex-by-treatment-group interactions. Women had less extensive coronary artery disease and, therefore, lower revascularization rates in the invasive group. Despite lower risk factor goal attainment, women with chronic coronary disease experienced similar risk-adjusted outcomes to men in the ISCHEMIA trial. URL: http://wwwclinicaltrials.gov. Unique identifier: NCT01471522.

Multi-modal conservative management of intra-abdominal collections in fistulising Crohn’s disease

Background and Objectives: The management of intra-abdominal collections in fistulising Crohn’s disease (CD) has traditionally involved surgery. However, conservative management is a potential alternative. In this study, we report our experience with multi-modal conservative management of intra-abdominal collections secondary to perforating CD. Methods: Medical records of CD patients with a history of intra-abdominal collections or fistulas over the past five years were reviewed retrospectively. Patients were included if they were initially managed conservatively using any combination of antibiotics, exclusive enteral nutrition (EEN), percutaneous drainage of collections, endoscopic dilatation of associated strictures and medical therapy for IBD with steroids, immunomodulators and/or biologics. Results: Eleven participants were included. All participants had penetrating CD affecting the terminal ileum. Nine participants had intra-abdominal collection on cross-sectional imaging whilst the remaining two participants had fistulising disease and sepsis without a discrete collection. Eight participants completed a 6–8 weeks course of EEN. All participants were treated with antibiotics and a thiopurine. Steroids were used in eight participants and biological agents in six. Six participants underwent endoscopic dilatation of small bowel strictures. After a median follow up of 20 months [range: 3–210] nine participants had evidence of adequate clinical, biochemical, radiological and endoscopic improvement. Complete resolution of abscess was seen in 4/7 participants and a significant reduction in abscess size was seen in 2/7. Two participants had complete endoscopic and histological remission and complete resolution of abscess. Both participants with fistulising disease (without a collection) had evidence of healed fistula tract on progress imaging and endoscopy. Two participants underwent surgery after failure of initial conservative management. Conclusion: Intra-abdominal collections in fistulising CD can be managed successfully in appropriately selected patients using a multi-modal approach incorporating antibiotics, EEN, endoscopic dilatations of culprit strictures and optimised medical management using steroids (for induction of remission), immunomodulators and biologics.

Height Restoration for Vertebra Plana Using a Mechanical Lamellar Vertebral Body Reduction Device: 2-Dimensional Operative Video.

Compression fractures of thoracolumbar vertebra are the most common vertebral fracture.1 Associated with osteoporosis, the compression can progress until reach vertebra plana and cause a kyphosis.2 The reduction of the fresh fracture and restoration of the height are the purposes of the kyphoplasty.3 We present a modified technique adapted for the treatment of vertebral plana using a mechanical flexible lamellar vertebral body reduction device (Tektona, Spinart).4 We present the case of a 77-year-old woman with back pain after a fall. The radiological investigations show a compressive fracture type AO A1 of T7. After an initial conservative management, the patient presented persistence of the pain with a visual analog scale of 9/10 and progression of the fracture at the 2-week follow-up. On the x-ray, focal kyphosis with vertebra plana was observed. A kyphoplasty for pain management and kyphosis correction was performed. The patient consented to the procedure. A bipedicular approach to the vertebra was performed. The correction of the height was done using 2 mechanical devices. The lamellar device allowed a progressive height restoration of the fracture. On one side, the cannula was used as a support to maintain the correction during the contralateral cementing. The postoperative imaging confirmed a maintained vertebral restoration with kyphosis correction. At 1 year, the patient reported a pain at 1 of 10 on the visual analog scale. In our opinion, this technique is adapted for fresh osteoporotic vertebral compression fractures. Surgical experience in osteoporotic fracture treatment and kyphoplasty is recommended before the management of vertebra plana.

A77 COMPLICATIONS OF DUODENAL DIVERTICULA: A SYSTEMATIC REVIEW ON CLINICAL PRESENTATION AND MANAGEMENT OF ENTEROLITH ILEUS SECONDARY TO DUODENAL DIVERTICULA FORMATION

Abstract Background Duodenal diverticula (DD) are relatively common findings in the gastrointestinal (GI) tract with their presence noted in up to 20% of the population. Rarely, however, these diverticula predispose to enterolith formation which can lead to small bowel obstruction, a phenomenon termed “enterolith ileus”. Both surgical and non-surgical approaches have been espoused in tackling this complication but definitive literature on optimal management is lacking and is limited to scattered case reports and case series. With this phenomenon carrying significant morbidity and mortality, we have conducted a comprehensive review of all available case reports to summarize our understanding of this condition. Aims To investigate the prevalance and clinical presentation of enterolith ileus secondary to duodenal diverticula and their optimal management whether that be medical or surgical. Methods A comprehensive search of PubMed, OVID, CINAHL, and Cochrane databases up to February 2023 was conducted to identify all studies reporting clinical information on enterolith formation in DD leading to small bowel obstruction. Each article was qualitatively assessed, and relevant data were extracted from selected studies to determine clinical courses and optimal management. Results Our literature review identified 17 case reports of enterolith ileus secondary to DD. The mean age of the patients was 72 years (SD 11.43), with 59% of them being female. Three patients had previously undergone Roux-en-Y gastric bypass, while one patient had undergone a distal gastrectomy. The most common symptoms reported were abdominal pain, nausea, and vomiting (88%), followed by abdominal distension (47%). Dilated bowel loops was the most common finding on X-rays, while CT scans revealed signs of small bowel obstruction and DD with an endoluminal mass in most of the cases. Upper GI series was performed in five cases, revealing multiple duodenal diverticula. Despite initial conservative management, 16 out of 17 patients eventually required surgical intervention. Enteroliths were extracted via enterotomy in 14 out of 17 cases, while surgical resection of the bowel was performed in three cases due to suspicion of tumor or perforation. Conclusions Our findings highlight the importance of prompt diagnosis and management of DD leading to enterolith ileus, particularly in elderly patients and those with a history of gastric surgery. Surgical intervention is almost always required and therefore early recognition and intervention can help minimize the risk of morbidity and mortality associated with this condition. Funding Agencies None

A103 A COMPREHENSIVE REVIEW OF ENTEROLITH ILEUS SECONDARY TO COMPLICATIONS OF ILEAL DIVERTICULA AND INVESTIGATIONS INTO OPTIMAL MANAGEMENT

Abstract Background Acquired ileal diverticula are rarely found in adults and are only apparent in 1.9% of small bowel contrast studies. Even more rarely, these diverticula can lead to enterolith formation which can obstruct the bowel, a term coined “enterolith ileus”. Both surgical and non-surgical approaches have been espoused in tackling this complication but definitive literature on optimal management is lacking and is limited to scattered case reports and case series. With this phenomenon carrying significant morbidity and mortality, we have conducted a comprehensive review of all available case reports to summarize our understanding of enterolith ileus secondary to ileal diverticula. Aims To understand the varying clinical presentations of enterolith ileus from ileal diverticula complications and understanding optimal management for the pathology. Methods A comprehensive search of PubMed, OVID, CINAHL, and Cochrane databases up to February 2023 was conducted to identify all studies reporting clinical information on enterolith formation in ileal diverticula leading to small bowel obstruction. Relevant data were extracted from selected studies to determine clinical courses and optimal management. Results Our literature review identified 61 case reports of enterolith ileus secondary to complications of ileal diverticula. The mean age of the patients was 51.64 years (SD 20.9), with 27% of them being female. The most common symptoms reported were abdominal pain (87%), nausea, and vomiting (51%), followed by constipation (18%) and melena (5%). Notably, localized abdominal tenderness was a common finding, observed in 74% of cases across 29 out of 34 studies reporting physical examination findings. Diagnostic investigations, including abdominal X-rays and CT scans, consistently revealed dilated bowel loops and signs of bowel obstruction. Surgical intervention was eventually required for almost all patients (97%), with diverticulectomy performed in 47%, enterectomy in 12%, and surgical resection of the bowel in 32% of cases respectively. These surgical interventions demonstrated high success rates, effectively resolving the condition in most cases. Complications, such as wound infection (2 cases), postoperative ileus (3 cases), anastomotic leak, and wound dehiscence (1 case each) were observed in a limited number of patients. Conclusions Our findings highlight the critical importance of prompt diagnosis and management of enterolith ileus secondary to complications of ileal diverticula. We recommend avoidance of initial conservative management as surgical intervention has proven almost always necessary and is highly successful in tackling this pathology. Early recognition and intervention can help minimize the risk of morbidity and mortality associated with this condition. Funding Agencies None

(222) Simultaneous Inflatable Penile Prosthesis and Adjustable Male Sling: A Step-by-Step Surgical Technique

Abstract Introduction Erectile dysfunction (ED) and urinary incontinence (UI) are common complications following radical prostatectomy (1). At twenty-four months post-surgery, approximately 43% of men experience some degree of ED, while UI affects around 15% of patients between twelve to twenty-four months (2, 3). Notably, nearly 20% of patients experience both ED and UI complications (4). Initial conservative management strategies include the use of PDE-5 inhibitors, intercavernosal injections, or a vacuum erectile device for ED and pelvic floor muscle training for UI (5). However, symptoms that persist or worsen beyond six months can be considered for surgical intervention (6). Surgical options include penile prosthesis implantation for ED and diverse techniques such as the Artificial Urinary Sphincter (AUS) or adjustable male urethral sling, depending on symptom severity, for UI management. Limited evidence suggests that a simultaneous surgical approach addressing both conditions can be a cost-effective and a safe alternative to separate surgeries (7, 8). Objective In this context, the objective of this video presentation is to illustrate a detailed, step-by-step technique for the simultaneous implantation of an inflatable penile prosthesis (IPP) and an adjustable male sling (AMS), while also discussing its feasibility, safety, and functional outcomes. Methods The combined IPP and AMS surgery is a safe, viable, and cost-effective option for patients who need to address both ED and UI. Rhee (2005) initially described the concurrent placement of a penile prosthesis (PP) and male sling (MS) in a series of four post-prostatectomy patients. Results The results demonstrated successful restoration of erections and complete continence in all patients, with no postoperative complications. Our previous systematic review, comparing the outcomes of simultaneous surgical placement of PP and MS versus PP and artificial urethral sphincter (AUS), found no clinically significant differences in outcomes between the two groups (Raheem 2021). Therefore, the simultaneous placement of IPP and AMS should be considered an option for patients, as it shows comparable effectiveness to other concurrent surgical interventions. Dual implantation of PP and male sling have also demonstrated cost savings of approximately $9,000 for patients, further enhancing its advantages in managing both ED and UI (Gorbatiy 2010). Ultimately, a collaborative discussion between patients and their urologist is crucial in determining the most suitable approach for patient individual needs. Conclusions The simultaneous surgical placement of an inflatable penile prosthesis (IPP) and adjustable male sling (AMS) presents a favorable and viable solution for managing erectile dysfunction (ED) and urinary incontinence (UI) in patients who exhibit an inadequate response to conservative management following prostatectomy. Disclosure No.

Cervical corpectomy in a pediatric patient with chondrodysplasia punctata and C5 dysplasia with spinal cord compression: illustrative case.

Chondrodysplasia punctata (CDP) describes skeletal dysplasia secondary to a variety of genetic underpinnings characterized by cartilaginous stippling from abnormal calcium deposition during endochondral bone formation. Approximately 20%-38% of patients with CDP have cervical spine abnormalities, resulting in stenosis and cord compression. However, approaches to management differ among patients. The authors present an 18-year-old male with a known history of CDP and cervical kyphosis with worsening paresthesias and increased spasticity. Imaging confirmed dysplastic C4 and C5 vertebra with focal kyphosis, bony retropulsion, spinal cord compression, and myelomalacia. To treat the stenosis and deformity, the patient underwent C4 and C5 vertebrectomies with C3 to C6 anterior fusion with resolution of symptoms. Despite many CDP patients having cervical deformities with spinal cord compression and associated neurological symptoms, there is a paucity of data on surgical management and outcomes. There are only scattered reports, and most authors recommend initial conservative management because of the high risk of operative morbidity and mortality secondary to comorbidities. When surgery is performed, long-term follow-up is recommended because of the high rates of progression of deformity, requiring subsequent operations. The authors hope that their experience adds to the literature describing the surgical management of cervical deformities in these patients.

Abstract 18958: Management of Patients With Suspected Left-Sided Prosthetic Valve Endocarditis According to Myocardial FDG-PET CT Results

Introduction: Accurate diagnosis of prosthetic valve endocarditis (PVE) is challenging because echocardiography (Echo) can be limited by artifact from prosthetic material. Myocardial FDG-PET (PET) can improve diagnostic accuracy; however, little is known about its effect on patient management. Research Question: Does PET affect management of patients with suspected left-sided PVE? Methods: A retrospective, single-center study was conducted on all admitted patients with a history of aortic valve replacement (AVR) or mitral valve replacement (MVR) or repair who underwent a myocardial PET for suspected endocarditis between April 2016 to December 2022. PET was defined as positive, negative, or indeterminate based on signal intensity/pattern at valve prosthesis. For this analysis, patients with indeterminate results were included with negative results, resulting in four groups PET+, PET-, Echo+ and Echo-. Patients were followed up to twelve months. Data were obtained from chart review and supplemented with national death index data. Results: Of a total of 146 included patients, 68% had a surgical AVR, 14% had a transcatheter AVR and 21% had an MVR. Median age was 63 years and 30% of patients were female. Most patients had positive blood cultures on admission (66%). The Echo+/PET+ group had a high rate of definite PVE (95%). PVE was rejected in 58% of those in the Echo-/PET- group. PET+ patients were more likely to undergo surgery in both the Echo- (24% for PET+ vs. 12% for PET-) and Echo+ (62% for PET+ vs. 20% for PET-) groups. High rates of prolonged antibiotic courses (73%) were seen across all groups; PET- groups had lower rates of prolonged antibiotics. Conclusions: Although most patients with suspected PVE underwent initial conservative management, PET+ patients had higher rates of surgical management. Negative PET results may help to identify patients with suspected PVE that may not require prolonged antibiotics.

Feasibility and safety of percutaneous nephrolithotomy in the management of renal stones with emphysematous pyelonephritis following control of infection

Abstract Background Management of renal calculi in the presence of emphysematous pyelonephritis (EPN) is challenging. The optimal management strategy for patients with EPN and renal calculi remains unclear. This study aimed to evaluate the safety and efficacy of percutaneous nephrolithotomy (PCNL) in the management of these patients and to provide insights into the postoperative outcomes and complications of PCNL according to the modified Clavien-Dindo classification. Materials and methods This retrospective study included patients with EPN and renal stones who underwent PCNL, after initial conservative management, between January 2012 and December 2021. Patient demographics, presenting symptoms, features of septicemia, preoperative drainage, postoperative complications, and outcomes were recorded. Postoperative complications were categorized according to the modified Clavien-Dindo classification. Results A total of 48 patients with EPN and renal calculi were included in this study. Percutaneous nephrolithotomy was performed 4–6 weeks later after obtaining a negative urine culture or under appropriate antibiotic coverage if the culture was unsterile. Of the total, 39 (81.25%) patients had postoperative complications, but only 9 (18.75%) patients had grade III or higher complications. Of these, 3 (6.25%) patients had grade IIIa complications, 3 (6.25%) had grade IIIb complications, 2 (4.1%) had grade IVa complications, and 1 (2.08%) had grade IVb complications and was admitted to the intensive care. No mortality was observed during the postoperative period. Conclusions Initial conservative management of EPN followed by PCNL after initial infection control is an effective strategy for managing these patients. Patients with higher EPN grades have a higher risk of major postoperative complications after PCNL for renal stones. Specifically, patients with an EPN class 3 or 4 had a higher risk of complications than those with an EPN class 2 or lower. Patients with EPN class 1 have a relatively uncomplicated postoperative course after PCNL.

Management of enterocutaneous fistulas in UMAE Hospital de Especialidades Dr. Antonio Fraga Mouret La Raza hospital of specialties

Background: Describes the management of enterocutaneous fistulas in UMAE specialty hospital "Dr Antonio Fraga Mouret La Raza". Methods: Descriptive, observational, retrospective and cross-sectional study, records were reviewed describing the management of patients with enterocutaneous fistulas, period from 01/01/2017 to 12/31/2021, each qualitative variable described in frequency and percentages, data processed by SPSS, quantitative variables described with measures of central tendency and dispersion. Results: The 90 patients were included, 76.7% male and 23.3% female, median age 56 years. Anatomical location with greater frequency (42.2%) in ileum; 98.8% of the fistulas were surgical etiology, 100% operated by open procedure, 51.1% of the patients did not present comorbidities prior to the condition, 37.5% received definitive conservative management and 62.2% definitive surgical treatment, 36.7% presented definitive cure and 27.8% were recurrent, 35.6% presented chronicity. Conclusions: Male sex was most affected, 58.9% received initial conservative management and 41.1% surgical treatment, so 37.5% received definitive conservative management and 62.2% definitive surgical management, of which 36.7% were cured compared to the 35.6% who cornified; which reflects that there is no high significance between cure and chronicity of patients treated with definitive management, either conservative or surgical, it is undoubtedly concluded that the most prevalent intrahospital treatment is definitive surgical.

Jejunal stenosis as a sequela after laparoscopic sleeve gastrectomy for morbid obesity: a case series

Porto-mesenteric venous thrombosis (PMVT) is a rare complication that is encountered in less than 1% of patients following laparoscopic sleeve gastrectomy (LSG). This condition could be conservatively managed in stable patients with no evidence of peritonitis or bowel wall ischemia. Nonetheless, conservative management may be followed by ischemic small bowel stricture, which is poorly reported in the literature. Herein, we present our experience regarding three patients who presented with manifestations of jejunal stricture after initial successful conservative management of PMVT. Retrospective analysis of patients who developed jejunal stenosis as a sequela after LSG. The three included patients had undergone LSG with an uneventful post-operative course. All of them developed PMVT that was conservatively managed mainly by anticoagulation. After they were discharged, all of them returned with manifestations of upper bowel obstruction. Upper gastrointestinal series and abdominal computed tomography confirmed the diagnosis of jejunal stricture. The three patients were explored via laparoscopy, and resection anastomosis of the stenosed segment was performed.Bariatric surgeons should be aware of the association between PMVT, following LSG, and ischemic bowel strictures. That should help in the rapid diagnosis of the rare and difficult entity.

P137 STEMI IN YOUNG MAN: A "CHALLENGE" CASE OF SPONTANEOUS CORONARY DISSECTION

Abstract A 21–years old male patient presented to the emergency department complaining chest pain in the night. There was no family history of cardiovascular events; he did not have any known risk factors and denied drug abuse. Pathological history was positive for allergic asthma. On admission, he was paucisyntomatic. The physical examination was normal. Blood pressure was slightly elevated. The EKG showed sinus rhythm, ST segment elevation in high lateral leads and reciprocal ST depression in inferior leads. The echocardiogram showed anterolateral and mid–apical septal akinesia of the left ventricle with ejection fraction of 45%. The urgent coronary angiography showed suspected coronary artery dissection of the first diagonal branch with TIMI flow grade 2 and myocardial brigde of the middle segment of the left anterior descending artery (fig.1). An initial conservative management with beta–blockers, dual antiplatelet therapy, statin and ACE–inhibitors was adopted: the patient was asymptomatic and the EKG became normal during the coronary angiography. In addition the young age, the suspicion of Spontaneous Coronary Artery Dissection (SCAD) and TIMI flow grade 2 in the culpit vessel provided support of conservative treatment. The hospital stay was unremarkable. Troponin T peak value was 1542 pg/ml (n.v. &amp;lt; 13 pg/ml). Thrombophilia screening showed mild hyperhomocysteinemia and homozygous MTHFR mutation. Autoimmunity screening was negative. The subsequent echocardiogram showed mid–distal hypokinesia of the anterolateral, inferolateral and anterior wall of the left ventricle with normal ejection fraction. The CT angiography of the cerebral and abdominal vessels was normal. The cardiac magnetic resonance imaging (MRI) confirmed a recent acute myocardial infarction of the mid–apical portions of the anterior and anterolateral wall and normal global contractile function of the left ventricle (fig. 2, 3). At 30 days follow up, the echocardiogram remained unchanged; the coronary AngioCT scan confirmed the dissection of the ostium and proximal section of the first diagonal branch; the cardiac MRI showed transmural fibrosis of the anterolateral wall with normal left ventricular ejection fraction. SCAD is an under–reported pathology. It can lead to acute coronary syndromes and life–threatening consequences. Diagnosis and treatment are still under debate. The presented clinical case, effectively treated with conservative therapy, represented a "challenge" in the acute phase.

Long-term follow-up after invasive or conservative management of stable coronary disease: the ISCHEMIA-EXTEND study.

The ISCHEMIA trial found no statistical difference in the primary endpoint between initial invasive and conservative management of patients with chronic coronary disease and moderate-to-severe ischaemia on stress testing. However, an invasive strategy increased peri-procedural myocardial infarction (MI) but decreased spontaneous MI with continued separation of curves over time. Thus, in order to assess the long-term effect of invasive management strategy on mortality, the ISCHEMIA-EXTEND observational study was planned including surviving participants from the initial phase of the ISCHEMIA trial with a projected median follow-up of nearly 10 years. Recently, an interim report of 7-year all-cause, cardiovascular (CV), and non-CV mortality rates has been published showing no difference in all-cause mortality between the two strategies, but with a lower risk of CV mortality and higher risk of non-CV mortality with an initial invasive strategy over a median follow-up of 5.7 years. The trade-offs in CV and non-CV mortality observed in ISCHEMIA-EXTEND raise many important questions regarding the heterogeneity of treatment effect, the drivers of mortality, and the relative importance and reliability of CV vs. all-cause mortality. Overall, findings from ISCHEMIA and ISCHEMIA-EXTEND trials might help physicians in shared decision-making as to whether to add invasive management to guideline-directed medical management in selected patients with chronic coronary artery disease and moderate or severe ischaemia.

Conservative Versus Endovascular Treatment for Spontaneous Isolated Superior Mesenteric Artery Dissection: A Clinical and Imaging Follow-up Study.

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare vascular disease, the treatment strategies for which remain debated. This retrospective study aimed to compare the outcomes of conservative and endovascular treatments in patients with SISMAD. Fifty-eight patients with SISMAD confirmed by computed tomography angiography admitted to our hospital between November 2017 and May 2021 and received confirmed conservative (n=43) or endovascular (n=15) treatment. The patient demographics, imaging analysis, and follow-up results were analyzed and compared. The cohort included 54 males and 4 females with a mean age of 52 years. Abdominal pain was the major complaint (49/58, 84.5%), followed by chest pain (2/58, 3.4%). The mean follow-up was 9.1±7.9 months. The 2 main Sakamoto types were type III (27/58, 46.6%) and type IV (16/58, 27.6%). Most patients in both groups had angle 1 (aortomesenteric angle) and angle 2 (superior mesenteric artery [SMA] course) of over 80°. About 67.3% of patients had long length of dissection (>60 mm). The median distance between the SMA root and the dissection entry site was 1.5 cm, mostly (84.5% of the patients) in the curved segment of the SMA. Telephone follow-ups found that most patients survived pain-free, and none underwent intestinal resection. Only 4 patients, 2 in each group, had recurrent abdominal pain during follow-up and received stenting treatment to achieve complete vascular remodeling. Importantly, we found that the conservative and endovascular therapies achieved similar high remodeling rates (94% and 100%, respectively; p=0.335). The conservative group achieved satisfying vascular remodeling (partial, 35%; complete, 59%), making it as safe and effective a treatment as endovascular therapy. Initial conservative management is safe and effective in patients with SISMAD. A high technical success rate and favorable short-term outcomes were associated with endovascular procedures as secondary interventions. It would be helpful to conduct large-scale, prospective, randomized controlled trials with long-term follow-up for SISMAD. 1. This research provided more detail clinical information, such as evaluation of abdominal pain and measurements of SMA angles, which is all relevant to treatment. 2. What's more, the most surprising results of follow-up part shown that conservative treatment could reached the remodeling rate as high as endovascular treatment, which was relatively low in other studies. It helps us share our treatment experience with clinicians. 3. In addition, we get limited knowledge about this rare disease, it's encouraging us to do more researches based on the results we had.

Long term outcome of multidisciplinary management of urethro-rectal fistula after urologic surgery

We retrospectively collected the records of patients with URF operated on at the University Hospital of Tours between January 1, 2000 and January 1, 2020. Short-term and long-term results according to management are reported. The study included 20 patients. As an initial gesture, 11 patients underwent bladder catheterization and colostomy, seven underwent bladder catheterization alone, one underwent graciloplasty, and one, a York Mason procedure. The success rate of initial conservative management was only 5% (1/20). As a secondary or tertiary intervention, ten patients underwent a York Mason procedure and nine underwent graciloplasty. At the end of the study period, with a median follow-up of 50 months, 19 had been effectively treated for URF, 16 were able to have colostomy closure with restoration of digestive continuity while four had a permanent stoma. One patient had anal incontinence, 14% had major stress urinary incontinence. Multidisciplinary care remains a cornerstone of the treatment of URF because iterative surgeries may be required, with an overall success rate of up to 95% at the end of follow-up.