Site Of Leak Research Articles

Laparoscopic minigastric bypass as a revisional choice for failed restrictive bariatric procedure and its metabolic impact

Background Restrictive bariatric procedures, like laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG), are associated with an increased risk of long-term failure. The efficacy of One-anastomosis gastric bypass (OAGB) has been described in primary and revisional settings, with a lack of Egyptian studies regarding OAGB as a revisional surgery. Herein, we describe our experience regarding 1-year outcomes of OAGB as a revisional surgery after failed LSG or LAGB. Patients and methods Fifty patients with failed LSG or LAGB were enrolled in this prospective study. All cases underwent laparoscopic OAGB, and its effects on weight loss and obesity-related comorbidities were noticed after 3, 6, and 12 months. Results The duration of the operation ranged between 45 and 120 min Postoperative complications included leakage (2%), hemorrhage (2%), and port site infection (2%). OAGB as a revisional surgery led to a significant and effective weight loss, as the percent of excess weight loss (%EWL) had mean values of 23.72%, 51.54%, and 80.25% at the scheduled visits, respectively. The procedure was associated with a significant rise in hemoglobin and albumin, significant decline in blood sugar, glycosylated hemoglobin, vitamin B12, and most lipid profile parameters, with no significant changes in serum calcium and high-density lipoproteins. Beneficial effects (remission or improvement) were noticed in 88.9% of diabetic cases, 80% of hypertensive cases, and 100% of reflux cases at one-year follow-up visit. Conclusion Laparoscopic OAGB as a revisional surgery is a safe and efficacious procedure in the management of patients with failed previous restrictive procedures like LSG and LAGB.

S4143 The Resolution of Gastrostomy Site Leakage After the Conversion from a Balloon to Non-balloon Based Gastrostomy Tube for Gastric Venting in a Patient with Gastrointestinal Dysmotility: A Case Report

S4143 The Resolution of Gastrostomy Site Leakage After the Conversion from a Balloon to Non-balloon Based Gastrostomy Tube for Gastric Venting in a Patient with Gastrointestinal Dysmotility: A Case Report

"Sealing the Gap" : CSF Leakage Demystified-A Comprehensive Analysis of our Experience in CSF Rhinorrhea Management.

CSF (Cerebro Spinal Fluid) rhinorrhoea occurs when the fluid leaks from subarachnoid space into the nasal cavity. The study aims to find out the prevalence and demographic distribution of CSF leak and to describe the site of the CSF leak along with the management. We did a prospective study on 180 patients admitted with head injury in neurosurgery department, along with the patients who came to ENT department with unilateral nasal discharge during the time period from March 2017 to March 2021. A total of 36 cases of CSF leak were obtained during the time period. The etiology in 18 cases was head injury & the other 18 cases were either due to infectious or nontraumatic causes. In our study, 26(72.22%) patients were aged less than 50 years. Incidence was more among males compared to females. The most common etiology was head injury - 18(50%) patients followed by the spontaneous leak- 16 (44.44%) patients with the most common site as the cribriform plate. Endoscopic repair using a hadad flap was done in most of the patients. Trauma due to head injury is the most common etiology in CSF rhinorrhea with more number of patients aged less than 50 years. Most of the leaks can be repaired successfully with the use of endoscope with excellent illumination & localizing the exact site of the leak.

The NADase CD38 may not dictate NAD levels in brain mitochondria of aged mice but regulates hydrogen peroxide generation

Aging is a time-related functional decline that affects many species. One of the hallmarks of aging is mitochondrial dysfunction, which leads to metabolic decline. The NAD decline during aging, in several tissues, correlates with increase in NADase activity of CD38. Knock out or pharmacological inhibition of CD38 activity can rescue mitochondrial function in several tissues, however, the role of CD38 in controlling NAD levels and metabolic function in the aging brain is unknown. In this work, we investigated CD38 NADase activity controlling NAD levels and mitochondrial function in mice brain with aging. We demonstrate that NADase activity of CD38 does not dictate NAD total levels in brain of aging mice and does not control mitochondrial oxygen consumption nor other oxygen parameters markers of mitochondrial dysfunction. However, for the first time we show that CD38 regulates hydrogen peroxide (H2O2) generation, one of the reactive oxygen species (ROS) in aging brain, through regulation of pyruvate dehydrogenase and alfa-ketoglutarate dehydrogenase, as mitochondria H2O2 leakage sites. The effect may be related to mitochondrial calcium handling differences in CD38 absence. Our study highlights a novel role of CD38 in brain energy metabolism and aging.

Construction and validation of infection risk model for patients with external ventricular drainage: a multicenter retrospective study.

External ventricular drainage (EVD) is a life-saving neurosurgical procedure, of which the most concerning complication is EVD-related infection (ERI). We aimed to construct and validate an ERI risk model and establish a monographic chart. We retrospectively analyzed the adult EVD patients in four medical centers and split the data into a training and a validation set. We selected features via single-factor logistic regression and trained the ERI risk model using multi-factor logistic regression. We further evaluated the model discrimination, calibration, and clinical usefulness, with internal and external validation to assess the reproducibility and generalizability. We finally visualized the model as a nomogram and created an online calculator (dynamic nomogram). Our research enrolled 439 EVD patients and found 75 cases (17.1%) had ERI. Diabetes, drainage duration, site leakage, and other infections were independent risk factors that we used to fit the ERI risk model. The area under the receiver operating characteristic curve (AUC) and the Brier score of the model were 0.758 and 0.118, and these indicators' values were similar when internally validated. In external validation, the model discrimination had a moderate decline, of which the AUC was 0.720. However, the Brier score was 0.114, suggesting no degradation in overall performance. Spiegelhalter's Z-test indicated that the model had adequate calibration when validated internally or externally (P = 0.464 vs. P = 0.612). The model was transformed into a nomogram with an online calculator built, which is available through the website: https://wang-cdutcm.shinyapps.io/DynNomapp/ . The present study developed an infection risk model for EVD patients, which is freely accessible and may serve as a simple decision tool in the clinic.

364. A CASE OF SEVERE REFRACTORY MASSIVE MASTOID ASCITES AFTER THORACIC DUCT LIGATION FOR POSTOPERATIVE MASTOIDECTOMY

Abstract The patient, a male in his 70s, was referred to our hospital after an upper gastrointestinal endoscopy revealed esophageal cancer. After a close examination, he was diagnosed with esophageal squamous cell carcinoma T3, N2, M0, Stage III. After preoperative chemotherapy, he underwent thoracoscopic esophagectomy and gastric tube reconstruction. Intraoperatively, the thoracic duct was injured on the cranial side of the aortic arch and was ligated with a clip. When tube feeding was started postoperatively, a pleural effusion was observed, and the patient was treated with central venous nutrition. The effusion did not improve, so thoracoscopic surgery was performed on the postoperative day 12, and the thoracic duct was ligated just above the diaphragm. Postoperatively, the patient developed ascites in addition to pleural effusion, and continued to totally drain 3000 mL of thoracoabdominal fluid every day. Lymphangiography showed that lymphatic flow was interrupted at the site of thoracic duct ligation, but the site of leakage was unknown. Based on previous reports, octreotide 300 μg and etilefrine 100 mg was administered continuously, and pleural drainage decreased, and ascites drainage increased. Ascites volume exceeded 3000 mL in three days and was treated with a single puncture, but no improvement was observed. Tolvaptan 3.75 mg was started, and ascites decreased gradually. Patient’s general condition improved with nutrition and rehabilitation, and he was discharged on the day 189. We report a very rare case of refractory massive ascites following thoracic duct ligation for postoperative chylothorax, along with a discussion of the relevant literature.

Rainbow-Colored Carbon Nanotubes via Rational Surface Engineering for Smart Visualized Sensors.

Surface engineering is effective for developing materials with novel properties, multifunctionality, and smart features that can enable their use in emerging applications. However, surface engineering of carbon nanotubes (CNTs) to add color properties and functionalities has not been well established. Herein, a new surface engineering strategy is developed to achieve rainbow-colored CNTs with high chroma, high brightness, and strong color travel for visual hydrogen sensing. This approach involved constructing a bilayer structure of W and WO3 on CNTs (CNT/W/WO3 ) and a trilayer structure of W, WO3 , and Pd on CNTs (CNT/W/WO3 /Pd) with tunable thicknesses. The resulting CNT/W/WO3 composite film exhibits a wide range of visible colors, including yellow, orange, magenta, violet, blue, cyan, and green, owing to strong thin-film interference. This coloring method outperforms other structural coloring methods in both brightness and chroma. The smart CNT/W/WO3 /Pd films with porous characteristics quickly and precisely detectthe hydrogen leakage site. Furthermore, the smart CNT/W/WO3 /Pd films allow a concentration as low as 0.6% H2 /air to be detected by the naked eye in 58 s, offering a very practical and safe approach for the detection and localization of leaks in onboard hydrogen tanks.

Mini-versus standard percutaneous nephrolithotomy in pediatric population: A randomized controlled trial

Mini PCNL has gained popularity in adult patients due to reduction in the complication rate with comparable stone free rate. There is paucity of level 1 evidence regarding the benefit of mini PCNL in the pediatric group. We performed a randomised study to compare mini PCNL (mPCNL) with standard PCNL (sPCNL) for the management of renal calculi in patients less than 18 years of age in terms of safety, efficacy, and stone-free rate (SFR). A randomised controlled trial was performed on 50 children who underwent PCNL from June 2015 to March 2021, who were divided into two groups. Group I had 25 patients managed with mPCNL (sheath size 16.5 Fr) and Group II had 25 patients who underwent sPCNL (sheath size 26 Fr). Primary outcomes including stone free rates (SFR) and hemoglobin drop and secondary outcomes like operative time, complications, pain score, need of analgesia, incidence of nephrostomy site leak, hospital stay in days were compared between the two groups. The mean age of patients in groups I and II was 9.4±2.6 and 10.4±2.26 years, respectively (p=0.15). The mean stone sizes in both groups I and II were 18.6±2.56 and 20.2±3.58mm, respectively (p>0.05). The stone free rate for group I was 88% and for group II, 92% (p=0.64). The average drop in hemoglobin was higher in group II compared to group I (1.1±0.31g/dl and 1.7±0.23g/dl respectively; p<0.0001), however the mean blood transfusion rate was not significantly different in both groups. The operating time was shorter in group II compared to group I (p-value - 0.0030). The pain scores were lesser for the group I. Grade I complications were higher in group II as compared to group I (p-0.047); however, grade II complications were comparable in both groups. The mean hospital stay was not significantly different in both groups. This study confirms the role of mini PCNL in pediatric patients with renal stones. The stone clearance rate of mini PCNL is equivalent to standard PCNL, with lesser blood loss and postoperative complications, however with longer operative time during mPCNL. The small number of the participants in both arms is a limitation of this study and may also reflect fewer children with urolithiasis being treated surgically even in a tertiary care referral centre. Mini-PCNL offers equivalent stone free outcome with lower complications rate compared to the standard PCNL for all types of renal stones.

Cervical Epidural Blood Patch for Spontaneous Intracranial Hypotension-A Case Report

Spontaneous intracranial hypotension (SIH) is an uncommon disorder caused by cerebrospinal fluid (CSF) leaks in the spine. Treatment is directed at sealing the site of leak, which is often difficult to localize. We present a case of near fatal SIH that was treated with cervical epidural blood patch (EBP) and burr hole drainage of the hematoma. A 41-year old male presented with severe headache after drinking alcohol over several weeks. Brain magnetic resonance imaging (MRI) showed features typical of SIH. But, further imaging with MR myelography and radionuclide cisternography failed to identify a precise site of leak. Despite lumbar EBP, the patient’s orthostatic headache recurred and developed acute subdural hematoma(SDH) to require burr hole drainage for hematoma evacuation. After surgery, the patient’s mental state improved, and the amount of SDH decreased, but he still complained of severe orthostatic headache. We performed EBP at cervico-thoracic junction level. The headache was rapidly relieved and the SDH was completely absorbed. In this case, we aim to remind clinicians that cervical EBP should be considered management for SIH as an alternative to the repeated lumbar blood patch.

Conventional Percutaneous Nephrolithotomy (PCNL) Complications Rate in a Tertiary Care Center.

Background: Assess The Complication Rate Of Conventional Percutaneous Nephrolithotomy In A Tertiary Care Hospital (PCNL). Study design: A Retrospective observational study. Place and duration of study: Department Urology Lady Reading Hospital In Peshawar, Pakistan, From 05-January 2016 To 05- January 2020 MATERIALS AND METHODS: The following research was carried out by the urologist department of Lady Reading Hospital in Peshawar, Pakistan, from January 2016 to January 2020. Four hundred thirty-nine individuals with normal-panel underwent the study. Before non- contrast, C.T. kub was done on all subjects. The patient was lying flat after the 6fr ureteric catheter was inserted in the lithotomy position. All prone procedures using 30fr am plating sheaths were directed by fluoroscopy. Hydraulic lithoclasts broke the stone. All nephrostomy tubes were foley devices with a 16-fr size. Six physicians performed these operations with four years of penal experience. Postoperative problems were evaluated using an adapted Cloven rating method. Results: There were problems with 46.9%. 54 (12%) and (120) grade I and II clavier problems were discovered. 67 (15%) stage I patients with transient temperature were treated with antipyretics. 53 (12%) patients used supine pressure bands to treat nephrostomy site leakage. 9 (2%) of the grade II issues needed IV antibiotics for sepsis, and 45 (10%) required blood transfusions. Extended haemorrhage occurred in 4 (0.8%) patients who underwent percutaneous angioembolization and 6 (1.2%) patients who underwent perinephric collection drainage. One (0.2%) patient had a colostomy, and 24 (5.3%) patients with persistent nephrostomy leakage or PCS injury underwent D.J. stenting. I was alright with Intensity IV. 0.4% of fatalities were due to severe bleeding. Conclusion: The procedure of percutaneous nephrolithotomy is economical, risk-free, and well-tolerated. Most of the time, minor problems like brief temperature and nephrostomy site leaks go away independently. The degree of complexity has been reduced to almost nothing due to the shrinking size of Pcnls from conventional to mini, ultra mini, and micro. Keywords: Complications, Territorial Care, Conventional, PCNL

Successful Cervical Epidural Blood Patch as a Treatment of Spontaneous Intracranial Hypotension - A Case Report

Background: Spontaneous intracranial hypotension can be a source of headache due to a continuous cerebrospinal fluid leakage. Case: A 33-year-old male patient with unremarkable history was presented with a headache, accompanying posterior neck stiffness and tinnitus lasting for 4 days. The opening pressure from cerebrospinal fluid tapping was 60mmH2O. Magnetic resonance imaging of the neck showed fluid collection at right C1-2 level, suggesting spontaneous intracranial hypotension. The headache did not respond to conservative treatments. Epidural blood patch was performed at C4-5 level. On postoperative day 1, remnant headache was only 20 percent and patient was discharged the day after. Conclusions: In spontaneous intracranial hypotension with leakage site at high cervical level, an epidural blood patch at a different cervical level can be safely performed to relieve the symptoms.

Postoperative constrictive pericarditis caused rupture of lymphatic collaterals: a rare etiology of chylothorax

BackgroundChylothorax after cardiovascular surgery is primarily caused by direct injury to the thoracic duct or its branches, and occurs in early postoperative period. In the present case, we describe a rare case of chylothorax manifesting three months after surgery secondary to constrictive pericarditis.Case presentationA 71-year-old man underwent mitral valve replacement, tricuspid valve annuloplasty, and the maze procedure. He developed acute perioperative myocardial infarction on postoperative day one due to plaque rupture in the left anterior descending artery and underwent percutaneous coronary intervention. Although the patient was discharged on postoperative day 36, he required readmission on postoperative day 83 because of right side chylothorax associated with constrictive pericarditis. Lymphangiography revealed thoracic duct interruption and development of lymphatic collateral vessels via the right hilum. Single-photon emission computed tomography revealed abnormal tracer accumulation in the right hilum, suggesting a lymphatic leakage site. A catheter study indicated biventricular dip and plateau patterns with a reduced cardiac index (1.6 L/min/m2) and elevated central venous pressure (18 mmHg). Conservative treatment for chylothorax, including a low-fat diet and continuous drainage with chest tube, was unsuccessful. Drainage of chyle at approximately 500 mL/day continued. On hospitalization day 50, complete pericardiectomy via median sternotomy was performed because the patient’s cardiac function deteriorated. The central venous pressure dramatically decreased, and the chylothorax gradually subsided. There was no recurrence of symptoms 1 year postoperatively.ConclusionsChylothorax associated with constrictive pericarditis subsequent to cardiac surgery is extremely rare. Although conservative management failed, the present case was successfully treated via pericardiectomy alone and did not require any additional precedures, such as thoracic duct ligation via a right thoracotomy.

Application of the ALOHA simulation model to assess Ammonia leakage from the coal-fired power station of Duyen Hai 2 Thermal Power Plant

The widespread use of hazardous chemicals in industrial activities can cause chemical accidents in which Ammonia gas leaks are one of the most concerning issues due to their toxic nature and adverse impacts on workers and the working environment. Therefore, accident risk prediction is essential to reduce the extent of damage and develop plans in place for minimizing and controlling unexpected hazards. This paper aims to provide an estimation of Ammonia leakage by ALOHA simulation software with scenarios for Ammonia leakage escaping from storage tanks of a coal-fired power station at Duyen Hai 2 Thermal Power Plant, Tra Vinh province. Three scenarios of chemical (Ammonia) incidents were simulated to assess the degree and extent of the impacts of chemical leakage on humans and the environments, including monthly, seasonally scenarios (for single chemical tank incidents) and two-tank incident scenario. The results show that the monthly scenario in April (29°C; 80,4%; 3,4m/s) and November (27,14°C; 87,2%; 2,9m/s) have the largest influence and the worst effects with the radius of red zone damage of 3.3km from the leakage site. The scenario of the dry season has much higher damage than the rainy one with the red zone is 4.6km. Meanwhile, the damage area of red zone caused by chemical incidents from two tanks leakage is 5.3km. This finding provide the top management level of the factory with a critical view of damage extent caused by chemical incidents for which a proactive plan should be available to prevent from the risks of explosion.

The Etiology, Diagnosis, and Management of Cerebrospinal Fluid Rhinorrhea: A Tertiary Center Experience.

Introduction The aim of the present study was to describe our institution's nine years of experience in the endoscopic endonasal management of cerebrospinal fluid (CSF) rhinorrhea and to discuss the causes, sites, and outcomes. Methodology The medical records of patients diagnosed with CSF rhinorrhea in King Abdulaziz Medical City-Jeddah (KAMC-J) between 2014 and 2023 were retrospectively reviewed, and all relevant information including body mass index, medical and surgical history, and postoperative outcomes were obtained. Results A total of 20 cases were included in the present study, sixteen (80%) of which were females and four (20%) were males. The mean age of participants was 42.59±13.9 years. Nine cases (45%) were spontaneous CSF rhinorrhea and 11 (55%) were traumatic; within the traumatic group, six cases (54%) were iatrogenic either following previous neurosurgery or functional endoscopic sinus surgery, while the remaining five cases were related to motor vehicle accidents. The mean body mass index for the spontaneous CSF leak was 32 Kg/m2, and 33 Kg/m2 for the traumatic leaks, no statistically significant difference was noted. The cribriform plate was the most common site of leakage (65%). A multilayer surgical technique using facia lata graft with nasoseptal flap was the most common choice for reconstruction with a first-attempt success rate approximating 90%. A recurrence was observed in two patients only. No major complications were reported. The average length of stay was nine days. Conclusion The endoscopic endonasal repair of CSF leak is a safe and reliable procedure and is associated with high success rates and low risk of complications. Therefore, it should be preferred as a first-line treatment for CSF rhinorrhea.

Long-term outcome of transcatheter repair of paravalvular leak post surgical mitral valve replacement

Objective: To explore the long-term clinical efficacy of transcatheter repair of mitral paravalvular leak (PVL) post surgical mitral valve replacement. Methods: This study is a retrospective study. Patients who completed transcatheter repair of paravalvular leak after surgical mitral valve replacement at Shanghai Chest Hospital, Shanghai Jiaotong University School of Medicine from March 2010 to December 2018 were included. Technical success was defined as the occluder being stably implanted in the paravalvular leak site without affecting the function of the mitral valve and surrounding tissues; and there were no intervention-related complications, such as new hemolysis or aggravated hemolysis, and echocardiography confirmed mitral paravalvular regurgitation reduced by more than 1 grade. Patients were followed up at 30 days, 1, and 3 years after the intervention. The main endpoints were all-cause death and re-surgery due to interventional failure or serious complications. The occurrence of occluder-mediated hemolysis and chronic renal insufficiency was recorded, and patients were monitored with echocardiography during follow up. Results: A total of 75 patients were included, aged (54.3±22.9) years old, and 38 patients were males. All patients had decreased cardiac function and/or hemolysis before intervention. Procedural success was achieved in 54 patients (72.0%). Incidence of device-mediated hemolysis was 18.7% (14/75). During the follow-up period, all-cause death occurred in 7 patients (9.3%), and 3 were cardiac deaths.The 3-year event-free survival rate was 81.3% (61/75). The need for cardiac surgery was 9.3% (7/75): 3 cases due to severe device-mediated hemolysis, 2 cases due to prosthetic valve failure and 2 cases due to moderate to severe residual regurgitation. The echocardiography follow-up results showed that the position of the occluder was stable, there was no impact on the artificial valve function and surrounding structures, and the residual regurgitation was stable without progressive increase in event-free patients. Compared with pre-intervention, the left ventricular end systolic diameter ((33.9±7.4)mm vs. (38.3±8.9) mm, P=0.036), end diastolic diameter ((53.7±8.3) mm vs. (58.4±9.1) mm, P=0.045) and left atrial diameter (59.3 (44.5, 90.7) mm vs. 64.3 (44.8, 96.6) mm, P=0.049) were significantly reduced, pulmonary artery systolic pressure was also significantly decreased ((36.5±15.8) mmHg vs. (46.3±14.9) mmHg, P=0.022, 1 mmHg=0.133 kPa). There was no significant difference between 3 years and 1 year after transcatheter repair of mitral paravalvular leak post surgical mitral valve replacement (all P>0.05). Conclusion: Transcatheter repair of mitral paravalvular leak post surgical mitral valve replacement is an effective treatment option in selective patients.

Peroxidase-encapsulated Zn/Co-zeolite imidazole framework nanosheets on ZnCoO nanowire array for detecting H2O2 derived from mitochondrial superoxide anion

In this work, we have developed a nanocomposite consisting of horseradish peroxidase (HRP)-encapsulated 2D Zn–Co zeolite imidazole framework (ZIF) nanosheets strung on a ZnCoO nanowire array on a Ti support (denoted as 2D-Zn/Co-ZIF(HRP)|ZnCoO|Ti). This nanocomposite was then applied to constructing an electrochemical biosensor for detecting H2O2 derived from O2∙− released by mitochondria in living cells. This sensing platform shows excellent catalytic performance towards H2O2, attributable to the enzyme/metal-catalytic effect of HRP and Zn/Co-ZIF. The unique nano-string structure alleviates the aggregation of Zn/Co-ZIF nanosheets, readily exposes the catalytic active sites, protects the bioactivity of HRP, and reduces the charge/mass transfer pathway within Zn/Co-ZIF. The 2D-Zn/Co-ZIF(HRP)|ZnCoO|Ti biosensor offers two linear ranges of 0.2–10 μ M and 10–1100 μ M, a limit of detection of 0.082 μ M, a sensitivity of 3.3 mA mM−1 cm−2, good selectivity and stability over 40 days for H2O2 detection. After treating with specific mitochondrial complex inhibitors, the chronoamperometric results at the 2D-Zn/Co-ZIF(HRP)|ZnCoO|Ti confirmed complex I and III within the mitochondria electron transfer chain as the main electron leakage sites. This biosensor may contribute to the development of diagnostic health-care devices that shed light on the precaution and even treatment of oxidative stress diseases.

Novel endoscopic management of gastroenterological anastomosis leakage by injecting gel-forming solutions: an experimental animal study.

Anastomotic leakage (AL) after gastrointestinal surgery remains a challenging complication that requires surgical or non-surgical treatment. Although various therapeutic endoscopic techniques are available, no definitive interventions exist. We developed a therapeutic endoscopic submucosal injection method using novel gel-forming mixed solutions to close AL and evaluated the elasticity of the developed hydrogel. The safety and efficacy of the injection method were explored in porcine AL models. We developed a novel gel-forming solution, and the formed gel lasted approximately oneweek within the gastrointestinal wall. An indentation test evaluated the elasticity of the novel hydrogel. After the confirmation of AL on porcine anterior gastric walls, sodium alginate was endoscopically injected into the submucosal layer around the leakage site circularly, followed by a calcium lactate/chitosan-based solution. After that, the outcomes data were collected, and histopathological effectiveness was evaluated. The increased sodium alginate elasticity with the addition of calcium lactate/chitosan-based solution facilitated long-lasting gel formation. Four pigs with AL underwent this intervention consecutively. Each endoscopic injection was completed in less than 5min. No significant complications were observed for 3weeks after the intervention. All AL sites were macroscopically healed. Histopathologic findings at 3weeks showed that the wall defect was filled with collagen fibers that had grown around the site of the muscle layer tear. No tissue necrosis was observed. This preclinical study demonstrated that the therapeutic injection method for gastroenterological AL using gel-forming solutions could be an alternative endoscopic treatment, especially in patients with severe conditions or comorbidities. The optimal target of this treatment is small size and early AL without poor blood flow or intense hypertrophic scar lesions.

Foveal neovascularization in proliferative diabetic retinopathy: Characterization with OCTA

Foveal neovascularization (FNV) is a rare clinical finding in conditions with vascular compromise, leading to ischemia of the retina. We present a case of proliferative diabetic retinopathy (PDR) with FNV, where optical coherence tomography angiography (OCTA) confirmed the architecture, extent, activity, and origin of a hemorrhage-like clump at the fovea. Digital Florescein Angiography (DFA) showed PDR (both eyes), but intra-retina microvascular abnormalities (IrMAs) or FNV could not be differentiated at the site of leak in right eye fovea. OCTA confirmed a FNV breaching the internal limiting membrane (ILM), protruding into vitreous, and determined its origin from superficial vascular plexus (SVC). Also, segmentation revealed flow voids in choriocapillaris slab, suggesting choroidal ischemia.

Innovations in Combined Surgery of Endoscopic Transsphenoidal Surgery and Craniotomy

Combined endoscopic transsphenoidal surgery and craniotomy may be useful for tumors extending into the suprasellar region or ventricles and for tumors extending simultaneously into the nasal sinuses and intracranial space. This method allows two surgeons to share the surgical field while compensating for each other's blind spots and allows for safe tumor removal by separating the normal structure from the tumor and protecting the normal structure. Simultaneous combined endoscopic transsphenoidal surgery and craniotomy require a lot of equipment; however, by devising the layout of the equipment in the operating room, the staff involved in the surgery can perform their roles more effectively. However, this method results in extensive dural and cranial defects, and prevention of cerebrospinal fluid leakage and perioperative surgical site infection is essential. Skull base reconstruction using autologous tissues and medical materials at appropriate locations can reduce the risk of postoperative cerebrospinal fluid leakage and surgical site infection. Furthermore, multilayered reconstruction using restorative medical materials eliminates the need for autologous tissue, is minimally invasive, shortens the operative time, reduces postoperative stress, and shortens the length of hospital stay. A combination of endoscopic transsphenoidal surgery and craniotomy will contribute to the improvement of the safety of highly difficult tumorectomies under a reliable skull base reconstruction method.

Spontaneous Intracranial Hypotension Treated with Epidural Blood Patch: A Case Report

Spontaneous intracranial hypotension (SIH) is a condition caused by spontaneous cerebrospinal fluid (CSF) leakage, resulting in orthostatic headache as the main symptom, but other symptoms such as memory loss, nausea, and tinnitus may also be present. Various imaging techniques are used to diagnose SIH, with magnetic resonance imaging myelography being an important tool for detecting the leakage site of CSF. Conservative treatments including hydration, bed rest, and intravenous caffeine have been tried with limited success. Epidural blood patch (EBP) is the most commonly performed treatment for SIH after the failure of conservative management. There are different opinions about the EBP procedure (e.g., blind EBP vs. targeted EBP). This report describes the treatment of SIH with targeted EBP according to imaging diagnosis after the failure of initial blind lumbar EBP.