Long-term Resolution Of Symptoms Research Articles

Long-term symptom resolution following the surgical management of chronic pancreatitis

BackgroundPervasive symptoms from chronic pancreatitis despite noninvasive management is an indication for surgical intervention. Frey and Whipple procedures are appropriate options for proximal pancreas disease; however, data are limited on symptomatic outcomes. MethodsWe conducted a retrospective analysis of patients who underwent surgical intervention for chronic pancreatitis of the proximal pancreas from 2005 to 2019. Preoperative patient characteristics and postoperative outcomes were evaluated. ResultsOne hundred forty patients underwent surgical intervention for chronic pancreatitis, 91 Whipple and 49 Frey procedures. Mean age was 53 years (SD 12), and mean BMI 24 (SD 5.6). At post-operative follow-up, 74 ​% were asymptomatic, and 84 ​% at average follow-up of 2 years. Groove pancreatitis, lack of post-operative delayed gastric emptying, and decreased length of stay were predictive of symptom resolution. ConclusionsWhipple and Frey procedures are appropriate surgical options for chronic pancreatitis affecting the proximal pancreas. Both lead to sustained symptom resolution for most patients.

Optimizing surgical technique in microvascular decompression for hemifacial spasm - Results from a surgical series with contemporary use of neuronavigation and intraoperative neuromonitoring.

Microvascular decompression (MVD) through a retrosigmoid approach is considered the treatment of choice in cases of hemifacial spasm (HFS) due to neurovascular conflict (NVC). Despite the widespread of neuronavigation and intraoperative neuromonitoring (IONM) techniques in neurosurgery, their contemporary application in MVD for HFS has been only anecdotally reported. Here, we report the results of MVD performed with a combination of neuronavigation and IONM, including lateral spread response (LSR) in 20 HFS patients. HFS clinical outcome and different surgical-related factors, such as craniotomy size, surgical duration, mastoid air cell (MAC) opening, postoperative cerebral spinal fluid (CSF) leakage, sinus injury, and other complications occurrence, and the length of hospitalization (LOS) were studied. Postoperatively, residual spasm persisted only in two patients, but at the latest follow-up (FU) (mean: 12.5 ± 8.98 months), all patients had resolution of symptoms. The mean surgical duration was 103.35 ± 19.36 min, and the mean LOS was 2.21 ± 1.12 days. Craniotomy resulted in 4.21 ± 1.21 cm2 in size. Opening of MAC happened in two cases, whereas no cases of CSF leak were reported as well as no other complications postoperatively and during FU. MVD for HFS is an elective procedure, and for this reason, surgery should integrate all technologies to ensure safety and efficacy. The disappearance of LSR is a crucial factor for identifying the vessel responsible for NVC and for achieving long-term resolution of HFS symptoms. Simultaneously, the benefits of using neuronavigation, including the ability to customize the craniotomy, contribute to reduce the possibility of complications.

OGBN P04 Achalasia: A single-centre experience of surgical management over 14 years

Abstract Background Achalasia is a rare motility disorder of the oesophagus with likely autoimmune aetiology, characterised by absent oesophageal peristalsis and impaired lower oesophageal sphincter relaxation. Typical symptoms include dysphagia, regurgitation and weight loss. Different treatment modalities are available, predominantly aimed at improving quality of life. No UK guidelines currently exist for the management of achalasia; the US-based SAGES guidelines (2011) do however provide evidence-based recommendations, albeit of varying strength. A published survey of UK surgeons revealed variation in certain aspects. We sought to explore our institution's experience in management of achalasia, primarily focusing on surgery (laparoscopic Heller’s cardiomyotomy). Methods An electronic database search was performed to identify all patients either newly diagnosed with achalasia and / or who received treatment for achalasia at our institution between 2009 and 2022. Patients who had already received endoscopic, radiological or surgical treatment prior to 2000, or at another institution at any time were excluded. Demographics, diagnostic investigations, treatment (Botox injection, dilatation, cardiomyotomy) and surgical outcomes were retrospectively recorded in a database and analysed. Results 128 patients met the inclusion criteria above; 127 were adults, 66 male. 70 patients (54.7%) underwent laparoscopic Heller’s cardiomyotomy with anterior fundoplication. All patients had OGD, 63 (90.0%) barium swallow and 54 (77.1%) high resolution manometry pre-operatively. Major intra-operative bleeding occurred in one patient from lower oesophageal ulceration. 12 patients had mucosal breaches, repaired intra-operatively. Iatrogenic oesophageal perforations occurred in two patients requiring return to theatre. No mortalities occurred. 31 patients (44.3%) experienced long-term symptom resolution post-operatively. 8 patients (20.5%) with recurrent symptoms had laparoscopic re-do surgery, 11 Botox (28.2%) and 11 dilatation (28.2%) - several had combination of modalities. Conclusions Access to regional, then latterly local, high resolution manometry has facilitated full diagnostic assessment, as SAGES strongly recommends all patients undergo along with OGD and barium swallow. Surgical management of achalasia at our institution over this 14-year period has been very standardised, owing to the operations being performed by two consultant surgeons only. A good proportion of operated patients had a successful outcome with long-term resolution of symptoms. Serious complications in our cohort were rare; these patients required re-operation and ultimately recovered. Laparoscopic Heller’s cardiomyotomy with anterior fundoplication can be a safe and effective management option for achalasia.

Ten-step minimally invasive slalom unilateral laminotomy for bilateral decompression (sULBD) with navigation

BackgroundUnilateral laminotomy for bilateral decompression (ULBD) is a MIS surgical technique that offers safe and effective decompression of lumbar spinal stenosis (LSS) with a long-term resolution of symptoms. Advantages over conventional open laminectomy include reduced expected blood loss, muscle damage, mechanical instability, and less postoperative pain. The slalom technique combined with navigation is used in multi-segmental LSS to improve the workflow and effectiveness of the procedure.MethodsWe outline ten technical steps to achieve a slalom unilateral laminotomy for bilateral decompression (sULBD) with navigation. In a retrospective case series, we included patients with multi-segmental LSS operated in our institution using the sULBD between 2020 and 2022. The primary outcome was a reduction in pain measured by Visual Analogue Scale (VAS) for back pain and leg pain and Oswestry Disability Index (ODI).ResultsIn our case series (N = 7), all patients reported resolution of initial symptoms on an average follow-up of 20.71 ± 9 months. The average operative time and length of hospital stay were 196.14 min and 1.67 days, respectively. On average, VAS (back pain) was 4.71 pre-operatively and 1.50 on long-term follow-up of an average of 19.05 months. VAS (leg pain) decreased from 4.33 to 1.21. ODI was reported as 33% pre-operatively and 12% on long-term follow-up.ConclusionThe sULBD with navigation is a safe and effective MIS surgical procedure and achieves the resolution of symptoms in patients presenting with multi-segmental LSS. Herein, we demonstrate the ten key steps required to perform the sULBD technique. Compared to the standard sULBD technique, the incorporation of navigation provides anatomic localization without exposure to radiation to staff for a higher safety profile along with a fast and efficient workflow.

Operative Outcomes for Polycystic Liver Disease: Results of a Large Contemporary Series

IntroductionPersistent symptoms of pain, early satiety, dyspnea, and gastrointestinal reflux due to significant liver enlargement are indications for surgical debulking in patients with polycystic liver disease (PCLD) due to the lack of effective medical therapies; however, few data exist on outcomes of surgical intervention for PCLD. MethodsWe conducted a retrospective analysis of consecutive patients who underwent operative intervention due to persistent symptoms secondary to PCLD. Preoperative patient characteristics, 30-day postoperative outcomes, and long-term postoperative outcomes, including complications and symptom resolution, were analyzed. ResultsWe identified 50 patients who underwent hepatic resection for symptomatic PCLD. Nine patients (19%) had concomitant polycystic kidney disease, and 14 (28%) had previously undergone interventions for PCLD management. The overall complication rate was 30%, with 8 patients (16%) experiencing Clavien-Dindo Grade III-V complications and no mortalities. The median relative reduction in liver volume was 41%. At a median follow-up of 2 years, 94% has sustained symptom resolution. ConclusionsThis is among the largest case series exploring PCLD operative outcomes, revealing that surgical intervention for debulking for advanced PCLD is safe and effective for symptom management. Furthermore, patients with PCLD undergoing hepatectomy tolerate significant liver volume loss without evidence of impaired hepatic function.

Evidence in treatment of trigger finger: a review

Sclerosing flexor tenosynovitis (commonly known as “trigger finger”) is one of the main causes of pain and disability in the hand for which patients attend reconstructive and orthopedic surgery. The pathophysiology of this affectation is based on the presence of repetitive trauma that generates an inflammatory process in the sheath of the flexor tendon of the fingers, which eventually generates an alteration in the hand pulley system and produces all the manifestations characteristics of this disease. First and second author independently searched databases using the following databases: Medline, Cinhal, Pubmed, Cochrane Library, and Clinicaltrials.gov, using the keywords: trigger finger conservative and surgical management. Publications that evaluated the effectiveness and provided comparative and conclusive information on the results of surgical and conservative management for carrying out this work were reviewed and considered. The usefulness of 3 therapeutic methods for managing trigger finger was reviewed, identifying a success rate of 56% with isolated steroid injection and up to 79.6% when used serially; in the use of orthoses, a reduction in the symptom score was identified in all cases, although there is no conclusive evidence on long-term results and complete resolution of the condition; Regarding surgical treatment, it was determined that it represents the best alternative for long-term symptom resolution, with a higher rate of sequelae such as pain within the first week or nerve injury. Intrafascial steroid-based injection represents the initial technique of choice in the management of trigger finger. The use of orthoses may represent an alternative in patients who have no impediment for their use for a fairly long time. Open surgical treatment continues being the therapeutic measure to be overcome, with a high symptom resolution rate 1 year after the procedure.

Acute versus late endoscopic dacryocystorhinostomy in treatment of acute dacryocystitis: A prospective randomised trial with an 18-month follow-up.

To compare the long-term symptom resolution and use of resources of performing endoscopic dacryocystorhinostomy (enDCR) in acute or delayed phase in patients with acute dacryocystitis (AD). This prospective, randomised controlled trial was conducted in Helsinki University tertiary Eye and Ear, Nose and Throat (ENT) Hospitals between September 2013 and January 2019. Fifty patients aged 18 and above presenting with AD in the emergency care were randomised into acute and delayed enDCR surgery groups, performed in 1 week or 4 months from the diagnosis of AD. The follow-up time was 18 months. Outcome measures were subjective epiphora, lacrimal symptoms and visual analogue scale (VAS) pain scores, the number of hospitalised and unhealthy days, use of medication and openness in lacrimal syringing and dye test. EnDCR was performed on 24 patients in the acute and 19 in the delayed group. There were no significant differences between the groups in follow-up lacrimal symptoms, syringing test, dye test or use of resources. At the 18 months' follow-up, 21/23 (91.3%) in the acute group and 12/13 (92.3%) in the delayed group had no disturbing lacrimal symptoms. When reoperations and dropouts are considered, beneficial outcome was 22/24 (91.7%) in the acute and 12/16 (75%) (p = 0.195) in the delayed group. The acute group had significantly fewer pain medication days than the delayed group, 3 versus 10.5 (p = 0.03). Acute enDCR is associated with fewer pain medication days and equal resolution of lacrimal symptoms and use of resources.

Prostatic Artery Embolization (PAE)

Benign prostatic hyperplasia (BPH) is a common condition affecting the majority of men over 60 years of age. BPH incidence increases with age and often leads to lower urinary tract symptoms including frequency, urgency, and straining. In patients that do not respond to pharmacological therapy, options include transurethral procedures such as transurethral resection (TURP) or photovaporization, surgical prostatectomy and prostate artery embolization (PAE). The goal of PAE is to occlude arterial supply to the prostate by selective catheterization and subsequent embolization, most commonly with spherical tris-acryl gelatin microspheres. Over weeks to months, reduced blood flow leads to necrosis of prostatic adenomatous tissue, resulting in reduction of prostate size and decreased urethral impingement, eventually allowing for long-term resolution of symptoms in a majority of patients. Advantages of this technique compared with the standard surgical option, TURP, include faster recovery times, fewer side effects, and lower complication rates with near equal efficacy.

Emergency Department Treatment Provides Immediate and Durable Relief Following Vaccine Injury: A Case Report.

Intramuscular administration of vaccines into the deltoid muscle is the recommended route for most vaccines in adults. Ectopic injection into the subdeltoid/subacromial bursa can produce an inflammatory bursitis that is associated with significant long-term morbidity. We describe a novel approach to treatment of this condition: ultrasound-guided administration of dexamethasone by the emergency physician within six hours of vaccine administration. This approach resulted in complete and durable long-term resolution of symptoms with no functional impairment. This outcome is superior to that described for usual care, and the approach is well-suited to emergency physicians.

S1132 Real World Outcomes of Transoral Incisionless Fundoplication at a Tertiary Academic Center

Introduction: Transoral incisionless fundoplication (TIF) is a minimally invasive procedure for treatment of gastroesophageal reflux disease (GERD). Although studies have reported long-term durability and resolution of symptoms, the procedure carries a wide range of adverse events from mild to life-threatening. This study aims to evaluate the short-term outcomes of consecutive TIF procedures in a tertiary academic center. Methods: This is a retrospective study of patients who underwent TIF procedure by a single experienced gastroenterologist at a tertiary center in the United States from January 2018 to December 2021. Clinical success was defined as the ability to create a >=270° partial wrap with estimated longitudinal length of >=2cm. Short-term outcomes including patient symptoms or procedure related adverse events immediately to two months post-op were collected retrospectively. Results: Overall, 68 patients underwent 77 consecutive TIF procedures. The average age of patients was 52.35 ± 15.74 years (67.6% female). Technical success was achieved in 100% of the patients. 10.3% of the patients had a history of prior anti-reflux surgery. Chronic GERD was the main indication for TIF procedure. The majority of patients underwent TIF for Hill grade II and III flap valves, present in 62.5% and 25%, respectively. 50.6% of patients had post-procedure symptoms up to 2 months post-procedure including abdominal pain (28%), nausea/vomiting (14.3%), chest pain (10.4%), dysphagia/odynophagia (6.5%). There was a positive correlation between number of fasteners used and immediate abdominal pain (p=0.003), sore throat (p=0.024), and nausea/vomiting (p=0.046). Two patients developed major adverse events: one developed pneumoperitoneum and the second aspiration pneumonia complicated by flash pulmonary edema. Of the 29 patients with follow-up EGDs, 62.1% had an intact wrap (Hill I). There was no significant difference in the average number of fasteners in those with intact or loose wrap on follow up EGD (21.67 ± 5.1 vs. 22.8 ± 5.2, p=0.57). 9 patients (13.2%) underwent redo TIF and 2 (2.9%) proceeded with surgical fundoplication for persistent symptoms. (Table) Conclusion: Outcomes of TIF performed on a heterogeneous population in a tertiary academic center are comparable to outcomes reported from original randomized trials of TIF. Immediate adverse effects are common after TIF, but typically improve on long-term follow-up. Table 1. - Baseline patient characteristics and short-term post-TIF outcomes Patient summary characteristics: Gender (Female) 67.6% (n=46) Age [mean ± SD 52.35 ± 15.74 Race White 79.41% (n=54) Non-Hispanic 67.65% (n=46) BMI [mean ± SD] 27.7 ± 5.1 ASA Score II 69.1% (n=47) III 29.4% (n=20) IV 1.5% (n=1) Prior history of Barrett’s ablation 4.4% (n=3) Prior esophageal surgical intervention Nissen Fundoplication 8.8% (n=6) POEM- Nissen Fundoplication 1.5% (n=1) POEM 2.9% (n=2) Indication for TIF GERD 83.82% (n=57) Chronic cough +/- GERD 16.17% (n=11) Hernia HILL grade (if available): 1 25% (n=14) 2 62.5% (n=35) 3 8.9% (n=5) 4 3.6% (n=1) PH impedance or Bravo test (uninterpreTable (n=1); not performed due to presence of BE/esophagitis (n=5)) Acid 82.26% (n=51) Non-acid 17.74% (n=11) Procedure characteristics: Number of fasteners [mean ± SD] 23.1 ± 6.2 Median Hospital LOS (days) [min, max] 1 [0,10] Immediate outcomes post procedure-2 months(%): Immediate adverse events 50.6% (n=39) Immediate abdominal pain 28.6% (n=22) Immediate chest pain 10.4% (n=8) Immediate dysphagia/odynophagia 6.5% (n=5) Immediate sore throat 7.8% (n=6) Immediate Nausea/vomiting 14.3% (n=11) Follow-up Procedural outcomes (%): Post-TIF EGD performed 42.6% (n=29) Time interval between TIF and Follow up EGD 269.8 ± 205.1 Days Esophagitis on post-TIF EGD 10.3% (n=3) Intact wrap on post-TIF EGD 62.1% (n=18) >95% SAP on follow up PH testing (out of 18) 50% (n=9) Post-TIF surgical fundoplication (n) 2.9% (n=2) Repeat TIF patient characteristics: Repeat TIF required (n) 13.2% (n=9) Female Gender (%) 66.7% (n=6) BMI at initial TIF [mean ± SD] 29.4 ± 3.7 Age at initial TIF (median) [min,max] 53 [25,65] ASA score at initial TIF (median) [min,max] 2 [2,3] Number of fasteners (median) [min, max] Initial TIF 20 [14,34] Re-Do TIF 22 [8,28] Procedure length (median) [min, max] Initial TIF 47 [36,89] Re-Do TIF 45 [29,56]

Pediatric Normokinetic Biliary Dyskinesia: Pain with Cholecystokinin on Hepatobiliary Iminodiacetic Acid Scan Predictive of Symptom Resolution After Cholecystectomy.

Introduction: Biliary dyskinesia is typically defined as a gallbladder ejection fraction (EF) <35% on hepatobiliary iminodiacetic acid scan with cholecystokinin stimulation (CCK-HIDA) testing. Cholecystectomy often leads to resolution of associated biliary colic symptoms. Alternatively, there is a subset of symptomatic patients with normal gallbladder EF on CCK-HIDA. It has been proposed that pain with CCK injection is more predictive of symptom resolution after cholecystectomy than low gallbladder EF. We reviewed our experience with pediatric patients with positive CCK provocation testing and a normal gallbladder EF in the absence of gallstones. Materials and Methods: We retrospectively reviewed the records of all pediatric patients with normal hepatobiliary iminodiacetic acid EFs (35%-80%) and pain with CCK injection at a tertiary care center between 2016 and 2020. Age, gender, body mass index (BMI), CCK-HIDA results, and pathology analysis were noted. Short- and long-term resolution of symptoms was determined by patient self-reporting at a mean of 3 weeks and 46 months, respectively. Results: Seventeen patients met inclusion criteria. Average age was 15.1 years (range, 12-17 years) with median BMI 24.9 (± 4.9 kg/m2). Mean CCK-HIDA EF was 56.3% (± 11.4%). In total, 62.5% of patients had evidence of chronic cholecystitis and/or cholesterolosis on pathology analysis. Of patients available for short-term and long-term postoperative follow-up, 80% and 83% reported complete or near complete resolution of symptoms, respectively. Conclusions: Normokinetic biliary dyskinesia is poorly understood but appears to be associated with chronic inflammation and cured by surgical intervention. Laparoscopic cholecystectomy results in resolution of symptoms for a majority of patients and should be considered in those with pain with CCK injection despite normal imaging studies. Clinical Trial Registration Number: 1657640-2.

Eosinophil Progenitors in Patients With Non-Asthmatic Eosinophilic Bronchitis, Eosinophilic Asthma, and Normal Controls.

ObjectiveThis study aims to explore the potential of in situ airway differentiation of eosinophil progenitors (EoPs) and hematopoietic progenitor cells (HPCs) in sputum and peripheral blood from patients with non-asthmatic eosinophilic bronchitis (NAEB), eosinophilic asthma (EA), and healthy controls (HC).MethodsUsing flow cytometry, we enumerated sputum and blood HPCs and EoPs in patients with NAEB (n=15), EA (n=15), and HC (n=14) at baseline. Patients with NAEB and EA were then treated for 1 month with budesonide (200 μg, bid) or budesonide and formoterol (200/6 μg, bid), respectively. HPCs and EoPs in both compartments were re-evaluated.ResultsAt baseline, NAEB and EA both had significantly greater numbers of sputum but not blood HPCs and EoPs (p<0.05) compared to HC. There were no differences between NAEB and EA. After 1 month of inhaled corticosteroid (ICS) treatment, NAEB patients showed a significant improvement in cough symptoms, but the attenuation of sputum HPC and EoP levels was not significant.ConclusionsNAEB patients have increased airway levels of HPCs and EoPs. One-month treatment with ICS did not fully suppress the level of EoPs in NAEB. Controlling in situ airway differentiation of EoPs may control airway eosinophilia and provide long-term resolution of symptoms in NAEB.

Iliac vein stenting is safe when performed in an office based laboratory setting

BackgroundVenous stenting for iliac vein outflow obstruction is associated with excellent long-term stent patency and symptom resolution. However, the safety of iliac vein stenting performed in an office-based laboratory (OBL) setting is not well-defined. The purpose of our investigation was to determine the safety profile of iliac vein stenting in an OBL setting. MethodsData were prospectively collected in the Center for Vascular Medicine electronic medical record system (NextGen Healthcare Information System, Irvine, Calif) and retrospectively analyzed. Standardized patient safety and sedation protocols were used in accordance with the accreditation standards of the Joint Commission for Accreditation of Hospital Organizations for office-based surgery centers. Patient consultations, interventions, and follow-up at 1 to 6 weeks were included in the present analysis. All the patients had received moderate sedation during their procedure. Complications requiring hospitalization were classified as major complications. Minor complications consisted of bleeding, hematoma, vasovagal response, in-stent thrombosis resulting in complete occlusion of the iliac vein stent, an allergic reaction, hematemesis, hypotension, pelvic discomfort, and pseudoaneurysm. ResultsBetween January 2015 and January 2019, 1223 iliac vein stents were placed in 1104 patients (23.7% male; 76.3% female). A total of 90 minor complications (7.36%) and 5 major complications (0.41%) were observed. The major complications included the following: one allergic reaction, one episode of atrial fibrillation, one episode of supraventricular tachycardia, one episode of chest pain, and one case of acute stent occlusion. The minor complications were primarily insertion site hematomas. No complications were related to sedation or acute renal failure. No patient died. ConclusionsMajor complications were rare after iliac vein stenting in an OBL setting. Minor complications were primarily insertion site hematomas, which did not require inpatient hospitalization. Our analysis has shown that iliac vein stenting in an OBL setting is a safe and well-tolerated procedure.

A systematic review of the efficacy of surgical intervention in the management of symptomatic Tarlov cysts: a meta-analysis

Introduction: Tarlov cysts (TC) are sacral perineural cysts that are often found incidentally during spinal imaging. In a small fraction, symptomatic TC can cause pain, bowel, bladder and/or sexual dysfunction, as well as motor and sensory deficits. While many surgeons regard TCs as a non-operative entity, there have been suggestions that operative intervention in carefully selected symptomatic patients may be beneficial. The aim of this meta-analysis is to identify whether surgical treatment for symptomatic TCs is beneficial with an acceptable complication profile. Materials and methods: The authors conducted a systematic outcome analysis of symptomatic TCs treated either with surgery or conservatively managed. Results: Sixteen studies (N = 238) met the inclusion criteria for final meta-analysis. The literature search was performed using PubMed, Ovid MEDLINE, CINAHL, and EMBASE databases up to September 2017 and with an updated search in April 2019. The post-operative complication rate in patients undergoing surgical intervention was 16.9 (11.8 to 22.7) and cyst recurrence was 8.5 (3.5 to 15.4). When a complication occurred, the most frequent complication of surgical intervention was the development of a surgical site infection and/or CSF leak. Of the 15 studies reporting long-term follow-up, 81.0 (74.0–88.0) of patients remained symptom-free for more than 1 year (Mean: 27.5 months, SD = 11.5). Conclusion: We rigorously analyse the efficacy of open surgical decompression and repair of symptomatic TCs and corroborate the findings of sustained long-term resolution of symptoms.

Endoscopic transmural drainage is associated with improved outcomes in disconnected pancreatic duct syndrome: a systematic review and meta-analysis

BackgroundDisconnected pancreatic duct syndrome (DPDS) is a complication of acute necrotizing pancreatitis in the neck and body of the pancreas often manifesting as persistent pancreatic fluid collection (PFC) or external pancreatic fistula (EPF). This systematic review and pairwise meta-analysis aimed to review the definitions, clinical presentation, intervention, and outcomes for DPDS.MethodsThe PubMed, EMBASE, MEDLINE, and SCOPUS databases were systematically searched until February 2020 using the PRISMA framework. A meta-analysis was performed to assess the success rates of endoscopic and surgical interventions for the treatment of DPDS. Success of DPDS treatment was defined as long-term resolution of symptoms without recurrence of PFC, EPF, or pancreatic ascites.ResultsThirty studies were included in the quantitative analysis comprising 1355 patients. Acute pancreatitis was the most common etiology (95.3%, 936/982), followed by chronic pancreatitis (3.1%, 30/982). DPDS commonly presented with PFC (83.2%, 948/1140) and EPF (13.4%, 153/1140). There was significant heterogeneity in the definition of DPDS in the literature. Weighted success rate of endoscopic transmural drainage (90.6%, 95%-CI 81.0–95.6%) was significantly higher than transpapillary drainage (58.5%, 95%-CI 36.7–77.4). Pairwise meta-analysis showed comparable success rates between endoscopic and surgical intervention, which were 82% (weighted 95%-CI 68.6–90.5) and 87.4% (95%-CI 81.2–91.8), respectively (P = 0.389).ConclusionsEndoscopic transmural drainage was superior to transpapillary drainage for the management of DPDS. Endoscopic and surgical interventions had comparable success rates. The significant variability in the definitions and treatment strategies for DPDS warrant standardisation for further research.

Efficacy of medical and ablation therapy for inappropriate sinus tachycardia: A single-center experience.

Effective therapy for inappropriate sinus tachycardia (IST) remains challenging with high rates of treatment failure and symptom recurrence. It is uncertain how effective pharmacotherapy and procedural therapy are long-term, with poor response to medical therapy in general. We retrospectively reviewed all patients with the diagnosis of IST at a tertiary academic medical center from 1998 to 2018. We extracted data related to prescribing patterns and symptom response to medical therapy and sinus node modification (SNM), assessing efficacy and periprocedural complication rates. A total of 305 patients with a formal diagnosis of IST were identified, with 259 (84.9%) receiving at least one prescription medication related to the condition. Beta-blockers were the most commonly used medication (n = 245), with a majority of patients reporting no change or worsening of symptoms, and poor response was seen to other medication classes. Improvement was seen significantly more often with ivabradine than beta blockers, though the sample size was limited (p = .003). Fifty-five patients (18.0% of all IST patients), mean age 32.0 ± 9.1 years, underwent a SNM procedure, with an average of 1.8 ± 0.9 procedures per patient. Acute symptomatic improvement (<6 months) was seen in 58.2% of patients. Long-term complete resolution of symptoms was seen in 5.5% of patients, modest improvement in 29.1%, and no long-term benefit was seen in 65.5% of patients. Among all medical therapies, there were high rates of treatment failure or symptom worsening in over three-quarters of patients in our study. Ivabradine was most beneficial, though the sample size was small. While most patients receiving SNM ablation for IST perceive an acute symptomatic improvement, almost two-thirds of patients have no long-term improvement, and resolution of symptoms is quite rare. AV node ablation with pacemaker implantation following lack of response to SNM offered increased success, though the sample size was limited.

Endoscopic transmural drainage is associated with improved outcomes in disconnected pancreatic duct syndrome: a systematic review and meta-analysis

Purpose: Disconnected pancreatic duct syndrome (DPDS) is a complication of acute necrotizing pancreatitis in the neck and body of the pancreas often manifesting as persistent pancreatic fluid collection (PFC) or external pancreatic fistula (EPF). This systematic review and pairwise meta-analysis aim to review the definitions, clinical presentation, intervention, and outcomes for DPDS. Method: The PubMed, EMBASE, MEDLINE, and SCOPUS databases were systematically searched until February 2020 using the PRISMA framework. A meta-analysis was performed to assess the success rates of endoscopic and surgical interventions for the treatment of DPDS. Success of DPDS treatment was defined as long-term resolution of symptoms without recurrence of PFC, EPF, or pancreatic ascites. Results: Thirty studies were included in the quantitative analysis comprising 1355 patients. Acute pancreatitis was the most common etiology (95.3%, 936/982), followed by chronic pancreatitis (3.1%, 30/982). DPDS commonly presented with PFC (83.2%, 948/1140) and EPF (13.4%, 153/1140). There was significant heterogeneity in the definition of DPDS in the literature. Weighted success rate of endoscopic transmural drainage (90.6%, 95%-CI 81.0-95.6%) was significantly higher than transpapillary drainage (58.5%, 95%-CI 36.7-77.4). Pairwise meta-analysis showed comparable success rates between endoscopic and surgical intervention, which were 82% (weighted 95%-CI 68.6-90.5) and 87.4% (95%-CI 81.2-91.8), respectively (P=0.389). Conclusion: Endoscopic transmural drainage was superior to transpapillary drainage for the management of DPDS. Endoscopic and surgical interventions had comparable success rates. The significant variability in the definitions and treatment strategies for DPDS warrant standardisation for further research.

Letter to the Editor Regarding “Reversible Severe Brainstem Herniation and Obstructive Hydrocephalus from Cystoperitoneal Shunt Overdrainage”

Suprasellar arachnoid cysts are a rare but important pediatric neurosurgical pathology with unknown ideal management. They have been previously managed with techniques including open craniotomy with microsurgical fenestration, cystoperitoneal shunting, endoscopic ventriculocystostomy, and endoscopic ventriculocystocisternostomy (VCC), without a consistent consensus on the best surgical approach. We present an overview of the literature on surgical management of suprasellar arachnoid cysts.A literature search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted for all articles evaluating treatment modalities for suprasellar arachnoid cysts, using PubMed, OVID, and Web of Science.Twenty-five articles on management of suprasellar arachnoid cysts in children were identified. Few published studies exist that examine different types of surgical management across a single institution. The majority of studies reported best clinical outcomes in patients treated with endoscopic approaches when compared with microsurgical fenestration or cystoperitoneal shunting, reporting lower rates of infection, shunt dependence, and need for revision in addition to better resolution of clinical symptoms. Furthermore, most studies argue that VCC is superior to ventriculocystostomy, offering better long-term improvement of clinical symptoms and lower rates of failure.This study examines the current literature on suprasellar arachnoid cyst surgical management to conclude that an endoscopic approach in comparison with other approaches has the best outcomes. Of the endoscopic options available, VCC provides patients with the best long-term resolution of symptoms and the lowest need for revision. These findings should be further investigated with larger multicenter studies to further compare different surgical techniques and outcomes.

In Reply to the Letter to the Editor Regarding “Reversible Severe Brainstem Herniation and Obstructive Hydrocephalus from Cystoperitoneal Shunt Overdrainage”

Suprasellar arachnoid cysts are a rare but important pediatric neurosurgical pathology with unknown ideal management. They have been previously managed with techniques including open craniotomy with microsurgical fenestration, cystoperitoneal shunting, endoscopic ventriculocystostomy, and endoscopic ventriculocystocisternostomy (VCC), without a consistent consensus on the best surgical approach. We present an overview of the literature on surgical management of suprasellar arachnoid cysts.A literature search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted for all articles evaluating treatment modalities for suprasellar arachnoid cysts, using PubMed, OVID, and Web of Science.Twenty-five articles on management of suprasellar arachnoid cysts in children were identified. Few published studies exist that examine different types of surgical management across a single institution. The majority of studies reported best clinical outcomes in patients treated with endoscopic approaches when compared with microsurgical fenestration or cystoperitoneal shunting, reporting lower rates of infection, shunt dependence, and need for revision in addition to better resolution of clinical symptoms. Furthermore, most studies argue that VCC is superior to ventriculocystostomy, offering better long-term improvement of clinical symptoms and lower rates of failure.This study examines the current literature on suprasellar arachnoid cyst surgical management to conclude that an endoscopic approach in comparison with other approaches has the best outcomes. Of the endoscopic options available, VCC provides patients with the best long-term resolution of symptoms and the lowest need for revision. These findings should be further investigated with larger multicenter studies to further compare different surgical techniques and outcomes.

Percutaneous Cryoablation of Symptomatic Abdominal Wall Endometriosis at a Military Treatment Facility

Study Objective To describe a case of symptomatic abdominal wall endometriosis treated with cryoablation Design Case report Setting Academic military hospital Patients or Participants A 31 year-old active duty female with one prior cesarean section reported 7 years of cyclic pain at her cesarean scar that was nonresponsive to trigger point injections or oral contraceptives. The pain resolved with leuprolide, however, it was stopped due to intolerable side effects. She was initially scheduled for excision of her abdominal wall endometriosis (AWE), but the procedure was cancelled due to a year-long military deployment. Interventions Two years later the patient presented to our facility with cyclic pain and enlarging cesarean scar mass. An MRI revealed 5.5 × 3.1cm left rectus muscle AWE. General surgery recommended against surgical excision as rectus resection and reconstruction could impact her military readiness with a high risk of medical discharge. Interventional Radiology was consulted and recommended minimally invasive percutaneous cryoablation. Percutaneous cryoablation was performed outpatient under local and moderate sedation with ultrasound- and CT-guidance. Image-guided hydrodissection was used to protect the skin, abdominal wall, and underlying bowel from ice. Appropriate cytotoxic temperatures were monitored and achieved throughout the mass. Periodic CT evaluation confirmed the ablation margin of ice extended just beyond the tumor margin. The patient tolerated the procedure well and was discharged home same-day. Measurements and Main Results Patient noted complete resolution of pain at 6 weeks post-procedure without residual AWE on follow-up MRI. Norethindrone was continued for endometriosis suppression and physical therapy initiated for core strengthening with continued absence of symptoms at 6 months post-procedure. Conclusion Surgical resection of large AWE may not be feasible given the physical demands of military servicewomen. Percutaneous cryoablation provides a minimally invasive and less morbid treatment option with long-term resolution of pain symptoms in this patient.