Intraoperative Stent Research Articles

The Role of Narrow Aortic Bifurcation in Affecting EVAR Treatment and Outcomes

The narrow aortic bifurcation (NAB) is considered a risk factor for endograft thrombosis after aorto-biiliac endovascular aneurysm repair (EVAR) for aortic or iliac aneurysm. Nowadays, no consensus on the threshold diameter for the definition of NAB is reached and other aortic bifurcation features are rarely considered. The aim of the study is to assess the EVAR outcomes using bifurcated endograft according to anatomical characteristics of aortic bifurcation. The study included patients treated with primary EVAR from 2016 to 2022. A retrospective analysis of single-center prospectively collected database was performed. Patients were classified in standard aortic bifurcation (SAB) (aortic bifurcation diameter >20mm), NAB (≤20mm and >16mm), and extremely NAB (eNAB) (≤16mm). The 3 groups were compared in terms of patient demographics, risk factors, procedure setting (elective or urgent/emergent), and type of deployed endograft. In NAB and eNAB groups, severe calcification (SC) and length of stenotic aortic bifurcation >10mm (long-NAB) were assessed from preoperative imaging. In SAB, NAB, and eNAB groups, following outcomes were evaluated: rate of intraoperative iliac endograft stenting (unilateral or kissing stenting), primary patency (PP), freedom from endograft-related reintervention, and overall survival during follow-up. The total number of deployed aorto-biiliac endografts was 365 (mean age: 76.6±7.4 years; male 89.3%): SAB 298 (81.6%), NAB 57 (15.6%), and eNAB 10 (2.7%) cases. Female gender, chronic obstructive pulmonary disease patients, and active smokers were more frequent in patients with smaller aortic bifurcation diameter (P=0.002, 0.039, and 0.010, respectively). In NAB and eNAB groups, SC was reported in 18/67 cases (26.9%) and long-NAB in 15/67 cases (25.4%). Patients with eNAB have more frequent SC of aortic bifurcation (60% vs. NAB 21.1%, P=0.018) and long-NAB (50% vs. NAB 17.5%, P=0.023). In SAB, NAB, and eNAB, intraoperative iliac endograft stenting was performed in 34/298 (11.4%), 9/57(15.8%), and 5/10 (50%), respectively (P=0.001). Kissing stenting was performed more frequently in groups with smaller aortic bifurcation diameter (P=0.010). Mean follow-up was 30.2±21.5 months. At 1, 3, and 5years, PP was 98.5%, 96.6%, and 95.6%, respectively. eNAB had lower rate of PP compared to NAB group (P=0.030). Long-NAB had lower rate of PP (P=0.035). At 1, 3, and 5years, endograft-related reintervention was 96.8%, 86.7%, and 76.7%, respectively, with no differences between 3 groups (P=0.423). At 1, 3, and 5years, survival was 92.5%, 77.6%, and 58.1%, respectively, with no difference between SAB, NAB, and eNAB (P=0.673). Female gender, chronic obstructive pulmonary disease patients, and active smokers have more frequently smaller aortic bifurcation diameter. eNAB patients have more challenging anatomical characteristics compared with NAB group, requiring higher rate of intraoperative stenting, especially kissing stenting. Mid-term PP seems to be negatively influenced by aortic bifurcation ≤16mm and long-NAB.

Safety and efficacy of ureteroscopy for the treatment of large impacted proximal ureteralstones

Introduction and objective: Management of large impacted proximal ureteral stones is often challenging due to the presence of mucosal edema, inflammation and angulations of the ureter. Improvements in ureteroscopic technology increased the efficacy and safety of ureteroscopy (URS) as a first-line treatment in large impacted stones in the proximal ureter. The objective of this retrospective study is to evaluate the efficacy and safety of URS for the management of impacted proximal ureteral stones ≥ 10 mm. Material and methods: The medical records of 700 patients with ureteral stones, who underwent ureteroscopy and intracorporeal lithotripsy between January 2016 and Аpril 2024 were retrospectively reviewed. 179 patients had impacted stones ≥ 10 mm located in the proximal ureter – 125 (70%) were stones sized 10÷15 mm and 54 (30%) – stones ≥ 15 mm. URS was performed with 8.6 or 6.4Fr semirigid ureteroscope and Holmium laser. Flexible URS was performed in cases with tortuous ureter or stone retropulsion. Data on patients‘ preoperative characterstics, stone-free rates, operating times, intra- and postoperative complications were analyzed. Results: Patients’mean age was 54.1±12.3 years and mean stone size – 14.7±.4.8 mm. 30 % of the patients had previous unsuccessful shock- wave lithotripsy of the stone. Mean operative time was 45.1±15.7 min min and overall success rate – 85.3%. 66.2% of patients were treated with semirigid URS and 33.8% – with flexible URS. On subgroup analysis patients with stones 10÷15 mm and patients with stones ≥ 15 mm had similar preoperative characteristics. Success rate after a single procedure was higher and operating times significantly shorter in the subgroup of stones sized 10÷15 mm (87.1% vs 71.3%, p=0.159 and 41.3±12.9 vs 53.3±21.3 min, p=0.040,respectively). There were no statistically significant differences between the two subgroups in intraoperative stent JJ placement (34.1% vs 50.0%, p=0.400), stone retropulsion (21.3% vs 23.1%, p=0.847) and overall postoperative complications rate (9.3% vs 0%, p=0.161). Conclusion: The results of this study suggest that URS is a safe and effective treatment for management of patients with large impacted proximal ureteral stones. Larger stone size was a predictor of lower success rate after a single procedure.

Искусственный интеллект для персонализированного подхода к перкутанной нефролитотрипсии.

Introduction. In recent years, there has been more and more research on the creation of artificial intelligence (AI) to help diagnose and treat patients in various fields of medicine. The use of algorithms allows us to reduce the time for processing large volumes of information and give a «second opinion» to a specialist in complex and non-standard clinical cases. In order to increase the effectiveness of percutaneous nephrolithotripsy, we have created an AI algorithm to personalize approach in the surgical treatment of nephrolithiasis. Purpose. To develop a universal tool for predicting the most optimal tactics of percutaneous nephrolithotripsy depending on the clinical case. Materials and methods. The total number of patients treated at N. Lopatkin Scientific Research Institute of Urology and Interventional Radiology and those who took part in the study amounted to 1000 people. The number of men was 419 (41.9%), women 581 (58.1%). The age of patients included in the studies ranged from 18 to 88 years (52.3±13.47). The division into Training and Holdout partitions varied depending on the target variable to obtain the most accurate result. The maximum difference in the samples was 600n and 400n (60% and 40%), the minimum 800n and 200n (80% and 20%). Data processing was carried out using IBM SPSS Statistics and Modeler programs using the neural network modeling method. Results. The accuracy of prediction for the choice of nephroscope size was 82.2%, requirement for intraoperative stent placement 93.9%, requirement for ureteroscopy or contact ureterolithotripsy 98.5%. The accuracy of the forecast for the number of puncture accesses was 92.6%, for access through the upper group 95%, for access through the middle group 91.2%, for access through the lower group 91.2%. The algorithm allows us to predict the presence of residual stones with an accuracy of 84.1%, the duration of surgical intervention is 87.3%.The number of test observations was 30. The algorithm demonstrated high accuracy of prediction (from 73.8% to 94.5%) of surgical tactics in complex clinical cases. Conclusion. The results of using the algorithm for personalized prognosis in the surgical treatment of nephrolithiasis showed high accuracy and efficiency. Further development of technology to create algorithms for each nosology and surgical interventions will reduce the time of data analysis by the attending physician, provide a «second opinion» to young specialists and standardize the approach to treatment in rare and complex clinical cases.

Transbrachial Artery as Single or Combined Approach for Complex Interventions in Patients with Peripheral Artery Disease

This study aimed to assess the safety and efficacy of the transbrachial approach as a single or combined procedure for complex interventions in peripheral artery disease (PAD). Between March 2011 and April 2021, 169 patients with PAD underwent endovascular therapy via the transbrachial approach as a single or dual procedure. Univariate and multivariate analyses were performed to evaluate the predictors of adverse events at the brachial puncture site. All demographic, clinical, and perioperative data were acquired from electronic medical records and retrospectively analyzed. Brachial artery access was used alone and in combination in 87 and 82 patients, respectively. Patients in the combined-approach group underwent more intraoperative stent implantations and had more vascular closure devices (VCD). Multivariate logistic regression analysis revealed that hypertension was an independent factor for higher rates of brachial puncture site adverse events (odds ratio, 4.76; 95% confidence interval, 1.33-16.97; P=0.016). Brachial artery access-site complications occurred in 26 patients, including 6 (23.1%) major and 20 (76.9%) minor entry-site complications. Entry-site complications were observed in 21 (16.8%) and 5 (11.4%) patients assigned to manual compression and VCD groups, respectively. There were no significant intergroup differences in the incidence of major or minor complications. Interestingly, patients assigned to the VCD group did not experience major entry-site complications. The transbrachial approach, as a single or combined procedure, is a safe alternative to complex interventions in patients with PAD. Complications of brachial access progressively decrease with improved blood pressure control.

Short-term efficacy of stenting as a rescue therapy for acute atherosclerotic occlusion in anterior cerebral circulation.

The study aimed to explore the efficacy and safety of the Neuroform EZ stent in treating acute anterior circulation large artery occlusion. The clinical data of 42 consecutive patients with acute anterior circulation large atherosclerotic occlusion who were treated with the Neuroform EZ stent from January 2018 to August 2019 in our stroke care center, including baseline characteristics, images, therapeutic condition, and follow-up data were retrospectively analyzed. There were 42 mechanical thrombectomy (MT) failure cases of intracranial atherosclerotic stenosis with rescue Neuroform EZ stent implantation, of which 78.6% (33/42) had a good prognosis and 88.1% (37/42) showed no re-stenosis at follow-up. The average time from puncture to recanalization is 79.50 ± 14.19 min. The successful rate of intraoperative stent release is 97.6%, while there is one case of stent displacement, three cases of thrombus escape, and six cases of hemorrhage. Rescue therapy of the Neuroform EZ stent for acute anterior circulation large atherosclerotic occlusion can archive good short-term imaging and clinical results, while long-term follow-up is still needed to verify.

External ureteric stent versus internal double J stent in kidney transplantation: a retrospective analysis on the incidence of urological complications and urinary tract infections.

Urologic complications (UCs) and urinary tract infections (UTIs) are common after kidney transplantation. Intraoperative stent placement at the vesicoureteric anastomosis reduces UC risk, but increases UTI risk. In 2014 our stenting protocol changed from external ureteric stent (ES) to internal double J stent (DJ). We retrospectively studied the occurrence of UCs and UTIs in relation to ES or DJ in 697 kidney recipients. An ES was used in 403 patients (57.8%), in 294 (42.2%) a DJ. ES was removed 7-12 days and DJ 3-4 weeks post-operative. Induction immunosuppression was the same in both groups. Primary outcomes at 6 months follow-up were UC (urinary leakage/ureter stenosis) and UTI; they were related to stenting procedure and clinical and transplant characteristics. The incidence of UCs was similar for ES (8.4%) and DJ (6.8%), p=0.389. ES use was a significant risk factor for UTI (OR 1.69 (1.15-2.50), p=0.008). Post-transplant hospitalization was significantly shorter in the DJ group. Despite more acute rejection episodes with ES (ES/DJ: 16.4%/6.1%, p<0.001), no clinical relevant differences in graft outcomes existed. A DJ is, compared to ES, associated with a lower incidence of UTIs and comparable occurrence of UCs and is therefore the preferred technique for stenting the vesicoureteric anastomosis.

Long-Term Results of Autologous Bifurcated Carotid Artery Reconstructions

Carotid bifurcation revascularization using interposition grafts is rare. While internal carotid artery (ICA) revascularization is regarded as mandatory, the external carotid artery (ECA) is severed in most instances. Long-term results of an autologous bifurcated carotid artery reconstruction are discussed. Single centre, retrospective analysis of a consecutive series of patients treated at an academic vascular surgery center. From 12/2006 to 11/2019, fifty-one patients underwent reconstruction of the carotid artery using an autologous bifurcated interposition graft (38 male, 75%; median age: 68.7 years; IQR: 60.2-76.5). Thirty-eight patients were asymptomatic (74.5%). Indication for reconstruction was recurrent carotid stenosis unfavourable for endovascular treatment/redo patchplasty (n=32, symptomatic: n=7), carotid aneurysm (n=11, symptomatic: n=5), neck tumor with vascular involvement (n=7), trauma (n=1). Non-reversed valve depleted saphenous vein y-graft from the groin was used in 49 (94.2%) and reversed cubital vein bifurcation in three (5.8%) procedures. Median ICA cross-clamp time was 15 minutes (IQR: 13-20 minutes). In four procedures (7.7%), a shunt was inserted because of significant decrease of cerebral perfusion. In one patient, additional intraoperative stent placement of a proximal common carotid artery (CCA) stenosis was performed. Six patients suffered from ischemic neurological deficits (11.5%), all but 1 recovered with no or moderate symptoms. After a median follow-up of 5.2 years (IQR: 1.1-8.7 years), 7 significant asymptomatic stenoses (13.5%) and 2 occlusions (3.8%, one symptomatic) of the ICA, two significant asymptomatic CCA stenoses (3.8%), five significant stenoses (9.6%) and seven asymptomatic occlusions (13.5%) of the ECA were observed. This prompted 7 re-redo-interventions in 5 patients. Twenty-eight patients (54.9%) died after a median follow up of 3.3 years (IQR: .5-5.6 years). Two of these patients died due to conditions related to the performed carotid artery reconstruction. Autologous bifurcated carotid artery interposition graft provides results comparable to other complex ICA-revascularizations. Overall survival in this heterogeneous patient cohort is poor. Due to high risk of stroke and poor long-term outcome, this procedure should be reserved for symptomatic patients with no other option for revascularization.

Discussion

Discussion

A prospective randomized study evaluating the necessity of narcotics following ureteroscopy for urinary stone disease.

To evaluate the efficacy of non-narcotic analgesics and preoperative counseling in managing postoperative pain and narcotic use following ureteroscopic laser lithotripsy (URS). Adult patients at a single academic center undergoing URS for nephrourolithiasis were recruited. After informed consent, subjects were randomized into three groups: NARC-15 tablets oxycodone-acetaminophen 5/325mg (A-OXY), 2. NSAID-15 tablets ibuprofen (IBU) 600mg, 3. CNSL-15 tablets A-OXY, 15 tablets IBU, and preoperative counseling from the surgeon to avoid narcotic if possible. Patients who did not receive an intraoperative stent were excluded. At the time of stent removal subjects completed the Universal Stent Symptom Questionnaire (USSQ), and a pill count was performed. USSQ pain indices were the primary study endpoint. Of 115 patients enrolled, 104 met the primary endpoint and were included in the analysis. No significant differences were noted in patient demographic, clinical, or operative characteristics. No differences were noted in median USSQ pain indices. The CNSL group used a significantly lower median number of A-OXY pills compared to the NARC group (2.4 vs. 5.4, p = 0.001) and less IBU compared to the NSAID group (3.1 vs. 5.9, p = 0.008). No differences in median total pill count, office calls, medication requests, nor ED visits were noted. Our data suggest that patients can achieve equivalent postoperative analgesic satisfaction with non-narcotics compared to opiates following URS. Further, counseling patients on postoperative pain before surgery can reduce the total number of postoperative narcotic and non-narcotic medications taken. We suggest surgeons strongly consider omission of narcotic prescriptions following non-complicated URS.

Deep Learning–Based Intraoperative Stent Graft Segmentation on Completion Digital Subtraction Angiography During Endovascular Aneurysm Repair

Purpose: Modern endovascular hybrid operating rooms generate large amounts of medical images during a procedure, which are currently mostly assessed by eye. In this paper, we present fully automatic segmentation of the stent graft on the completion digital subtraction angiography during endovascular aneurysm repair, utilizing a deep learning network. Technique: Completion digital subtraction angiographies (cDSAs) of 47 patients treated for an infrarenal aortic aneurysm using EVAR were collected retrospectively. A two-dimensional convolutional neural network (CNN) with a U-Net architecture was trained for segmentation of the stent graft from the completion angiographies. The cross-validation resulted in an average Dice similarity score of 0.957 ± 0.041 and median of 0.968 (IQR: 0.950 – 0.976). The mean and median of the average surface distance are 1.266 ± 1.506 mm and 0.870 mm (IQR: 0.490 – 1.430), respectively. Conclusion: We developed a fully automatic stent graft segmentation method based on the completion digital subtraction angiography during EVAR, utilizing a deep learning network. This can provide the platform for the development of intraoperative analytical applications in the endovascular hybrid operating room such as stent graft deployment accuracy, endoleak visualization, and image fusion correction.

Comparison of Outcome of Renal Transplant with and Without Double J Stenting

Background: Renal transplant is definitive treatment for chronic renal disease. Renal transplant involves three anastomosis, renal artery, vein and ureter. Some surgeons prefer urinary stenting for prevention of urinary complication like urinary leakage, while others do not. Still there is controversy whether to use or not use intraoperative stenting. The purpose of this study is to share experience of renal transplant with and without stenting. Objective: To compare the outcome of renal transplant with and without intraoperative placement of Double J Stent Study Design: Comparative study. Place and Duration of Study: Department of Urology and Kidney Transplantation, Shaikh Zaid Hospital, Lahore from 1st January 2014 to 31st December 2015. Methodology: One hundred and eight patients with chronic kidney disease had renal transplant. Randomly, 54 patients transplant was done with stenting and in 54 patients transplant was done without stenting. The patients were followed up for presence of urinary leakage. Results: Among 54 renal transplants with stenting, no urinary leakage was found (0%), while in 54 patients without stent placement, urinary leakage was observed in 2 (3.7%) patients. (p=0.153, i.e. &gt;0.05) Conclusion: Ureteric stenting is not mandatory for renal transplantation. Frequency of urinary leakage among patients with renal transplant with stent was low while no leakage was seen with stenting. Difference in rate of urinary leakage with and without stenting was not statistically significant. Keywords: Live related renal transplant; Intraoperative DJ stenting; Urinary leakage

A Novel Suction-Irrigation Cannula-Guided Hydrophilic Tip Guidewire Technique of Intraoperative Ureteral Stent Placement During Robot-Assisted Radical Prostatectomy

Background: Patients with large median lobe, history of pelvic radiotherapy, or transurethral resection of the prostate are on the verge of ureteral orifice (UO) injury during robot-assisted radical prostatectomy (RARP). Not all aforementioned patients require ureteral stent placement. Intraoperative findings justify whether to proceed with ureteral stent placement or not. Previously described techniques of intraoperative stent placement involve use of transurethral cystoscopy or suprapubic skin incision, which makes procedure further difficult especially with robotic arms in place.1 Herein, we describe a simple and efficacious method Suction-Irrigation cannula-Guided Hydrophilic Tip guidewire (SIGHT) technique for intraoperative ureteral stent placement. Technique: The case shown here is a 64-year-old gentleman with Gleason 8 prostate cancer and opted for RARP. After division of bladder neck, the interior of the bladder was routinely inspected and the UOs were found too close to the bladder margins. The decision was made to proceed with bilateral ureteral stents placement. To facilitate stent placement, bladder margin is held up using 4th arm of the robot. The bedside assistant inserted laparoscopic suction irrigation cannula from 5 mm assistant trocar. Cannula tip was held a couple of centimeters away from respective UO. A 0.038 Inch diameter, 150 cm long hydrophilic straight tip guidewire is fed into the abdomen through shaft of the cannula. The surgeon on console (A.T.) places the wire into UO and feeds it proximally until the resistance is met. The bedside assistant (R.B.) then feeds the stent over the wire into the abdomen, and the surgeon threads the stent over the wire. The assistance held back-tension on the wire. A pusher is then guided over the wire in similar manner and stent is advanced until distal end of the stent is seen. The wire is pulled out by the bedside assistant, and the distal end of the stent is confirmed with use of robot and secure inside the bladder. Surgery proceeded as usual. Stent placement was verified postoperatively by plain kidney, ureter and bladder radiograph. Patient was discharged next day. Catheter removal was done at postoperative day 7. Ureteral stents were removed under local anesthesia in the office at 4 weeks postoperative visit without complication. Conclusions: Our SIGHT technique is safe, effective, and easily adaptable method for intraoperative ureteral stent placement during robotic procedures. It avoids intraoperative cystoscopy or suprapubic skin incision or use of additional guidewires thereby saving time during which patient is under anesthesia during surgery. Patient Consent Statement: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Music Source:www.epidemicsound.com Copyright: Author owns copyright/license for the music used in the video. A.T. has served as a site-PI on pharma/industry-sponsored clinical trials from Kite Pharma, Lumicell Inc., Dendreon, and Oncovir Inc. He has received research funding (grants) to his institution from Department of Defence, National Institute of Health, Axogen, Intuitive Surgical, Arthur M. Blank Family Foundation, and other philanthropy. A.T. has served as an unpaid consultant to Roivant Biosciences and advisor to Promaxo. He owns equity in Promaxo. Rest of the authors do not have conflict of interests. Runtime of video: 3 mins 21 secs

Combined surgical and intraoperative endoscopic rescue of a biliary incarcerated balloon dilator: a successful rescue in a fortunate patient

BackgroundEndoscopic papillary balloon dilatation (EPBD) is the second proposed maneuver for the endoscopic retrieval of common bile duct stones after endoscopic sphincterotomy (EST). Being less traumatic, EPBD is acknowledged for fewer procedure-related complications compared to (EST).Case presentationWe present a 55-year-old lady, who was referred to the pancreato-biliary division, Gastrointestinal Endoscopy Unit, National Liver Institute, Menoufia University, for endoscopic management of a high likelihood of choledocholithiasis. Unfortunately, during the procedure, the balloon dilator was incarcerated inside the common bile duct (CBD) with failure of all endoscopic extraction trials. Because of the resultant cholangio-pancreatitis, the incarcerated inflated balloon had to be removed immediately. Open surgical rescue of the case in conjunction with the intraoperative endoscopic biliary stent deployment had made it possible to save the patient.ConclusionThis case is one of the few reports of incarcerated balloon dilator during EPBD and failure of endoscopic retrieval, with subsequent acute pancreatitis/hepato-cholangitis, and gall bladder mucocele. Despite being a critical surgical candidate and owing to the attentive timely surgical intervention collaborated with the intra-operative endoscopic management, the case was fortunate.

Эндоваскулярная имплантация стент-графта в аорту в условиях гибридной операционной при помощи современной мобильной рентгеновской С-дуги: клинический случай

Thanks to the development of modern mobile imaging devices, the treatment of such a serious pa-thology as aortic aneurysm has become more accessible. Thoracic aortic aneurysms are the most common pathology of the thoracic aorta. It occurs with increasing frequency (10 cases per 100,000 people per year). The most common cause of the disease is atherosclerosis. To date, the treat-ment of this serious pathology has become more accessible due to the development of modern mobile imaging devices. As compared to stationary devices, the portable devices for angiography of the latest generation are movable and can be moved from site to site quickly and easily they produce high quality angiograms, the system can be accessible to any health-care institutions. The paper presents the first in Russia successful case of endoprosthetics of the thoracic aorta using mobile C-arm RFD Ziehm Vision. A 75-year-old man was found to have a symptomatic thoracic aortic aneurysm up to 67 mm in diameter, complicated by intramural (1.2 cm thick) and periaortic hematomas and compression atelectasis of the lower lobe of the left lung. The patient underwent prosthetics of the root, ascending part and arch of the aorta with a 30x8 (mm) synthetic prosthesis and intraoperative stenting of the descending thoracic aorta on a mobile C-arm. Our clinical expe-rience shows that difficult hybrid interventions can be successful if they are carried out in a surgical operating room with the use of a high-power C-arm with angiography function. This approach al-lows specialists to obtain image of required quality, with low exposure of a patient to ionizing radia-tion. The method can be used in the absence of stationary angiographs.

Lateral ventricular stenting as a method of preventing trapped temporal horn following resection of lateral ventricular trigone tumor. Case report and review of literature

Resection of lateral ventricular trigone tumor can lead the development of specific complication like a trapped temporal horn. Secretion of cerebrospinal fluid from the choroid plexus in closed space leads to progressive enlargement of the temporal horn. The enlargement of the temporal horn leads to lateral transtentorial herniation with brain steam compression, which manifested by disorders of consciousness, hemiparesis, memory impairment and loss of visual fields. The proposed stenting technique allows to prevent the development of extended temporal horn and excludes the requirement its treatment in the long-term period. Over the past year, intraoperative stenting have been performed in five cases. In the long-term period none of the patients have had trapped temporal horn. There was no case of stent dysfunction.The article presents a clinical case of ventricular stenting following resection of lateral ventricular trigone tumor.

Modified Meso-Rex bypass with umbilical vein recanalization and intra-operative stenting.

The aim of the study was to evaluate the usefulness of a novel modified Meso-Rex bypass surgical technique with umbilical vein recanalization and intra-operative stenting to treat portal vein cavernous transformation. In total, 13 portal vein cavernous transformation patients underwent Meso-Rex bypass surgery, consisting of bypassgrafts between the superior mesenteric vein (SMV) and the recess of Rex as well as through the ligamentum teres hepatis without stent implantation (Group A, n = 9) and umbilical vein recanalization with intra-operative stent implantation (Group B, n = 4). In Group A, the bypass diameter was 0-6mm (median 3mm) and blood flow velocity 25-115cm/s (median 72cm/s) 1month after Meso-Rex bypass surgery, with open bypass times of 0-67months (median 6months); 6 patients in this group developed postoperative Meso-Rex bypass occlusions. A patient in Group A treated with ligamentum teres hepatis recanalization needed a thrombectomy and stent implantation during a second surgery 2days after the Meso-Rex bypass, because of bypass thrombosis and umbilical vein stenosis. In Group B, the average modified Meso-Rex bypass diameter was 5.5-6.5mm (median 6mm), and the bypass vessels remained open in all patients, with blood flow rates of 45-100cm/s (median 76.5cm/s) 1month after the modified Meso-Rex bypass, up to the endpoint (15-33months, median 24months). The rate of bypass occlusions in Group A and Group B were 22.2% and 0%, 30.0% and 0%, and 55.6% and 0% at 1month, 3months, and 1year, respectively, after bypass surgery. Our novel modified Meso-Rex bypass approach for portal vein cavernous transformation treatment was effective with excellent long-term bypass patency.

Urgent intraoperative endovascular stent placement to resolve acute hepatic or portal venous obstruction during liver surgery: a case series

BackgroundAcute obstruction of the hepatic vein (HV) or the portal vein (PV), particularly when it occurs during liver surgery, is potentially fatal unless repaired swiftly. As surgical interventions for this problem are technically demanding and potentially unsuccessful, other treatment options are needed.Case presentationWe report two cases of acute, surgically uncorrectable HV or PV obstruction during liver resection or living donor liver transplantation (LDLT), which was successfully treated with urgent intraoperative placement of endovascular stents using interventional radiology (IVR). In Case 1, a patient with colonic liver metastases underwent a non-anatomic partial hepatectomy of the segments 4 and 8 with middle hepatic vein (MHV) resection. Additionally, the patient underwent an extended right posterior sectionectomy with right hepatic vein (RHV) resection for tumors involving RHV. Reconstruction of the MHV was needed to avoid HV congestion of the anterior section of the liver. The MHV was firstly reconstructed by an end-to-end anastomosis between the MHV and RHV resected stumps. However, the reconstruction failed to retain the HV outflow and the anterior section became congested. Serial trials of surgical revisions including re-anastomosis, vein graft interposition and vein graft patch-plasty on the anastomotic wall failed to recover the HV outflow. In Case 2, a pediatric patient with biliary atresia underwent an LDLT and developed an intractable PV obstruction during surgery. Re-anastomosis with vein graft interposition failed to restore the PV flow and elongated warm ischemic time became critical. In both cases, the misalignment in HV or PV reconstruction was likely to have caused flow obstruction, and various types of surgical interventions failed to recover the venous flow. In both cases, an urgent IVR-directed placement of self-expandable metallic stents (SEMS) restored the HV or PV perfusion quickly and effectively, and saved the patients from developing critical conditions. Furthermore, in Cases 1 and 2, the SEMS placed were patent for a sufficient period of time (32 and 44 months, respectively).ConclusionsThe IVR-directed, urgent, intraoperative endovascular stenting is a safe and efficient treatment tool that serves to resolve the potentially fatal acute HV or PV obstruction that occurs in the middle of liver surgery.

Technical features of esophageal stent deployment

To work out the optimal technique of endoscopic stenting of the esophagus (ESE) using various delivery devices (DD); to analyze immediate and long-term results of stenting depending on the type of DD. ESE results were studied in 83 patients. Group 1 included 41 patients with implantation of metal stents delivered on a knitted tubular casing (21 stents with proximal opening and 20 stents with distal opening). Group 2 consisted of 42 patients who underwent ESE using a DD in the form of a contracting outer shell. In the 1st group, DD «stumbling» in 6 cases (14.6%) required additional tubular hollow rigid conductor. In the 2nd group, there was no need for additional conductor (p=0.011). Intraoperative stent repositioning after its initial installation was required in 7 cases (17.1%) of the 1st group and 16 cases (38.1%) of the 2nd group (p=0.033). Higher likelihood of stent repositioning was observed in distal stent opening. Technical success rate was 100% in both groups. Clinical success rate was 100% in the 1st group and 97.6% in the 2nd group (p>0.05). Incidence of early and long-term postoperative complications was similar (p>0.05). ESE with various DDs is safe and effective in patients with malignant unresectable esophageal tumors and symptoms of dysphagia. However, certain features of stent installation should be considered. In our opinion, DD with proximal disclosure is more convenient due to better visual positioning of stent.

Intraoperative Ureteral Stent Use at Radical Cystectomy is Associated with Higher 30-Day Complication Rates.

Radical cystectomy/urinary diversion is a high risk procedure. Intraoperative stents are commonly utilized to decrease ureteroenteric anastomosis related complications. Institutionally some surgeons routinely use intraoperative stents while others do not, providing an opportunity to compare complication differences. We queried a prospective database of 283 patients enrolled in a randomized controlled trial evaluating 30-day perioperative complications with goal directed fluid therapy following open radical cystectomy/urinary diversion between 2014 and 2018. Ureteroenteric anastomosis specific complications (ureteral obstruction, urinary leak, urinary infections/sepsis and intra-abdominal abscess) were compared between groups (intraoperative stent vs nonintraoperative stent group) using Fisher exact test and quantified using logistic regression. The nonintraoperative stent group (77 of 283 patients, 27%) was older (median 72 vs 69 years) and was more likely to receive neoadjuvant chemotherapy (53% vs 40%), have baseline renal insufficiency (43% vs 30%) and undergo an ileal conduit (92% vs 53%). However, despite higher comorbidity, the nonintraoperative stent group had a significantly lower rate of ureteroenteric anastomosis complications (14% vs 32%, p=0.004). Since continent diversions may be associated with higher complications, the nonintraoperative stent group with ileal conduit was also compared to intraoperative stent cohorts with ileal conduit, and ureteroenteric anastomosis complications remained lower in the nonintraoperative stent group (14% vs 28%, p=0.043). Multivariable logistic regression showed significantly increased odds of urinary complications with intraoperative stent use (OR 3.55, 95% CI 2.93-4.31; p <0.0001). Importantly there was no obstruction and only 1 leak (1.3%) in the nonintraoperative stent group. Contrary to conventional belief, we found intraoperative stent use in radical cystectomy/urinary diversion was associated with significantly higher infectious complications and urgent care visits, and significantly increased the odds of 30-day ureteroenteric anastomosis associated complications.

Variations in Perioperative Antibiotic Prescriptions Among Academic Urologists After Ambulatory Endoscopic Urologic Surgery: Impact on Infection Rates and Validation of 2019 Best Practice Statement

ObjectiveTo evaluate adherence to the American Urologic Association (AUA) best practice statement guidelines regarding antibiotic duration in the perioperative setting for endoscopic urologic surgery. We assessed concordance to these guidelines among adult urologists at a single academic institution and its correlation with postoperative positive urine cultures as it relates to the revised 2019 best practice statement. MethodsWe performed a retrospective review of all adult endoscopic ambulatory urologic surgeries performed over an 18-month period by urologists at our institution. Patient demographics, pre- and postoperative urine cultures, operative details, stent or foley use, and antibiotic prescriptions were reviewed. Chi-squared and linear regression analyses were done. ResultsThree hundred thirty patients were included for analysis. Sixty-two percent of patients were prescribed postoperative antibiotics, for an average of 4 days. Trimethoprim/Sulfamethoxazole and fluroquinolones were most often prescribed (43% and 38%, respectively). Intraoperative stent placement, positive urine culture within 30 days prior to surgery, and a positive urine culture within 1 year prior to surgery predicted antibiotic prescription. No significant differences were seen in rates of positive postoperative urine culture rates between cohorts that received antibiotics postoperatively vs those who did not. ConclusionsAt our academic institution, we observed poor concordance with the AUA best practice statement for perioperative antibiotic prescription after ambulatory endoscopic urologic surgery. Rates of positive postoperative cultures were low and not associated with receipt or duration of antibiotic prescription at the time of surgery, supporting minimal use of antibiotics for most endoscopic cases.