Segmental Obstruction Research Articles

External extension of double-J ureteral stent during pyeloplasty: inexpensive stent and non-cystoscopic removal

The purpose of the study is to describe our experience with the application of externalized double-J ureteral stent (DJUS) during pyeloplasty for correction of ureteropelvic junction obstruction (UPJO) in order to avoid cystoscopy for stent removal. Pyeloplasty was performed in 523 infants with UPJO using miniature pyeloplasty technique. After removing the obstructed segment, a 3-Fr. DJUS was placed into the ureter. In order to avoid cystoscopy for the removal of the stent, a feeding tube was passed through the skin and renal pelvis via a separate stab incision, connected to the DJUS and secured to the external body surface (skin), and the pyeloplasty was completed. The feeding tube along with the stent was removed after 3-4 weeks, respectively. Postoperative follow-up visits were performed 1, 3, and 6 months after the procedure. The mean operative time was 49 min (range 41-79). Patients were discharged after 17 ± 2 h (mean ± SD). No patient experienced bladder spasm or anticholinergic administration. Forty-four patients (8.4 %) experienced minor complications including non-febrile urinary tract infections and mild hematuria. No major complication including urinoma, leakage, and stent migration or displacement was observed during the follow-up period. Stent removal was tolerated by 99.8 % of patients in an outpatient setting with minimal discomfort without performing cystoscopy. Using external DJUS along with a pyelocutaneous stent extension during pyeloplasty is a safe, feasible, and beneficial technique. This technique resulted in high success rate with minimal cost and no renal injury. The non-cystoscopic stent removal and elimination of urethral catheterization following pyeloplasty are the other advantages of this technique.

Incremental prognostic value of coronary computed tomographic angiography over coronary artery calcium score for risk prediction of major adverse cardiac events in asymptomatic diabetic individuals

BackgroundCoronary artery disease (CAD) diagnosis by coronary computed tomographic angiography (CCTA) is useful for identification of symptomatic diabetic individuals at heightened risk for death. Whether CCTA-detected CAD enables improved risk assessment of asymptomatic diabetic individuals beyond clinical risk factors and coronary artery calcium scoring (CACS) remains unexplored. MethodsFrom a prospective 12-center international registry of 27,125 individuals undergoing CCTA, we identified 400 asymptomatic diabetic individuals without known CAD. Coronary stenosis by CCTA was graded as 0%, 1–49%, 50–69%, and ≥70%. CAD was judged on a per-patient, per-vessel and per-segment basis as maximal stenosis severity, number of vessels with ≥50% stenosis, and coronary segments weighted for stenosis severity (segment stenosis score), respectively. We assessed major adverse cardiovascular events (MACE) – inclusive of mortality, nonfatal myocardial infarction (MI), and late target vessel revascularization ≥90 days (REV) – and evaluated the incremental utility of CCTA for risk prediction, discrimination and reclassification. ResultsMean age was 60.4 ± 9.9 years; 65.0% were male. At a mean follow-up 2.4 ± 1.1 years, 33 MACE occurred (13 deaths, 8 MI, 12 REV) [8.25%; annualized rate 3.4%]. By univariate analysis, per-patient maximal stenosis [hazards ratio (HR) 2.24 per stenosis grade, 95% confidence interval (CI) 1.61–3.10, p < 0.001], increasing numbers of obstructive vessels (HR 2.30 per vessel, 95% CI 1.75–3.03, p < 0.001) and segment stenosis score (HR 1.14 per segment, 95% CI 1.09–1.19, p < 0.001) were associated with increased MACE. After adjustment for CAD risk factors and CACS, maximal stenosis (HR 1.80 per grade, 95% CI 1.18–2.75, p = 0.006), number of obstructive vessels (HR 1.85 per vessel, 95% CI 1.29–2.65, p < 0.001) and segment stenosis score (HR 1.11 per segment, 95% CI 1.05–1.18, p < 0.001) were associated with increased risk of MACE. Beyond age, gender and CACS (C-index 0.64), CCTA improved discrimination by maximal stenosis, number of obstructive vessels and segment stenosis score (C-index 0.77, 0.77 and 0.78, respectively). Similarly, CCTA findings improved risk reclassification by per-patient maximal stenosis [integrated discrimination improvement (IDI) index 0.03, p = 0.03] and number of obstructive vessels (IDI index 0.06, p = 0.002), and by trend for segment stenosis score (IDI 0.03, p = 0.06). ConclusionFor asymptomatic diabetic individuals, CCTA measures of CAD severity confer incremental risk prediction, discrimination and reclassification on a per-patient, per-vessel and per-segment basis.

A novel animal model of gastrointestinal obstruction for the development of stent

BackgroundThe need for newer gastrointestinal (GI) stents has been continuously raised. Newly developed stents are generally tested for physical properties in vitro and directly introduced to clinical practice because there is no reliable animal model of GI obstruction. The aim of this study was to establish an animal model both that can represent obstruction of the GI tract and be used to develop new stents. Material and methodsSurgical obstruction of the descending colon by wrapping with a nonabsorbable synthetic mesh and rubber bands was made in 17 healthy mongrel dogs. Four days later, a covered self-expanding metallic stent was placed for the obstructed segment in each dog under fluoroscopic guidance. Patency and migration of the inserted stents were evaluated clinically on a daily basis and fluoroscopically on a weekly basis. After sacrifice of the dogs, the degree and extent of residual colonic obstruction were assessed fluoroscopically. The specimen of the colonic obstructed segment was examined microscopically. ResultsIn all 17 mongrel dogs, segmental obstruction in the descending colon was successfully created and confirmed with fluoroscopic examination using a contrast medium. The percentage of luminal narrowing ranged from 99%–100%. Stent placement was technically successful in all 17 dogs. During the follow-up period, stent migration occurred in 12 dogs and indwelling time of a stent ranged from 0–95 d (mean 29.2 ± 38.8 d). On postmortem pathologic examination, it was found that fibrosis had newly formed outside the colonic longitudinal muscle layer in all dogs. ConclusionsOur canine colonic obstruction model is the first animal model that can be feasible for developing a new design of stent and provide in vivo data on complications, particularly stent migration.

Intraoperative underwater colonoscopy with a laparoscope following in-sleeve on-table colonic irrigation in obstructed left colon

Aim The aim of the present study was to describe intraoperative underwater colonoscopy (IUC) and recommend the use of this new technique in emergency settings for the management of acute left-sided colonic obstruction. Patients and Methods IUC was performed with a laparoscope attached to a video-camera system after in-sleeve, on-table colonic irrigation. The colon was transected proximally to the tumour, and a nylon camera drape was sutured tightly to the proximal colonic end. Following colonic irrigation, the washout was stopped, and IUC was accomplished by introducing a laparoscope into the bowel. Finally, the laparoscope was withdrawn and formal surgery was performed. Results IUC was successfully used in nine patients who underwent emergency colon surgery; eight patients had colonic obstructions due to adenocarcinomas, and one patient had colonic perforation. IUC revealed three synchronous lesions in the obstructed colonic segments which one of them was an adenocarcinoma in three patients. Another patient had a polyp located distally to the tumour, which was determined preoperatively. Primary resection and stapling anastomosis were performed in all cases. Postoperative complications were atelectasis and delay of intestinal motility in two patients; both recovered well. There was no complication due to IUC or primary operation; for example, anastomotic leakage or wound infection. During the follow up, one patient died 10 months after primary operation due to a cardiac event. Conclusion IUC following in-sleeve, on-table irrigation is safe and quick to perform, and enables the assessment of colonic mucosa with good visibility. This method was found to be helpful to perform intraoperative colonoscopy when indicated in the emergency surgery of the obstructed left-sided colon when conventional endoscopy was not available at the theatre.

Value and limitation of interventional recanalization for infertility induced by fallopian tube obstruction

Objective To explore the value and limitation of interventional recanalization for infertility induced by fallopian tube obstruction.Methods The X-ray appearances and clinical efficacies of hysterosalpingography and interventional recanalization for infertility induced by fallopian tube obstruction in 160 patients were retrospectively analyzed.Results Of the 160 patients,72 patients had bilateral tubal obstruction and 88 had unilateral obstruction,accounting for 45.0% and 55.0%,respectively.232 of the 320 fallopian tubes showed different degrees of obstruction; 105 tubes （45.3%） occurred interstitial obstruction,70 （30.2%） occurred isthmus obstruction,22 （9.5%） developed ampullary obstruction,and 35 （15.1%） developed umbrella end obstruction （some with hydrosalpinx）.Recanalization was successful in 197 tubes,with a total recanalization rate of 85.0%; 98 of which were successful for interstitial recanalization,with a rate of 93.3%,65 were successful for isthmus recanalization,with a rate of 92.9%,19 were successful for ampullary recanalization,with a rate of 86.4%,and 15 were successful for fimbria recanalization,with a rate of 42.9%.During the period of one-year follow-up,64 were pregnant,with a pregnancy rate of 40.0%; 9 developoed ectopic pregnancy after recanalization,with a rate of 5.6%.40 fallopian tube re-obsturcted,with a rate of 20.3%.Conclusions Interventional recanalization is an effective method for obstructive infertility induced by the three segment （interstitial,isthmus,and pot belly） obstruction of the fallopian tube; but it is not suitable for umbrella end obstruction complicated by hydrosalpinx. Key words: Interventional recanalization; Fallopian tube obstruction; Infertility; Value and limitation

Endovascular treatment of central venous stenosis and obstruction in hemodialysis patients

Background Central venous stenosis and obstruction (CVD) is a serious and prevalent challenge to both resolve the venous hypertension symptoms and maintain the pantency of the ipsilateral hemodialysis access in hemodialysis patients. This study aimed to summarize our experience of the endovascular management of the central venous stenosis or obstruction in hemodialysis patients. Methods Twenty-four haemodialysis cases of central vein stenosis or obstruction with ipsilateral functional vascular access in our hospital between July 2006 and February 2012 were treated by interventional therapy and the data were analyzed retrospectively. Results Eighteen males and six females with mean age of (66.4±13.8) years and manifesting with arm swelling and venous hypertension were enrolled; 62.5% of them had a history of catheterization. Venography showed stenotic lesion in 10 cases including eight cases of brachiocephalic vein stenosis and two cases of subclavian vein stenosis and 14 cases of obstruction lesions including seven cases of short brachiocephalic obstruction and seven cases of long segment obstruction. Interventional therapy was performed and the technique success rate was 83.3%. Percutaneous transluminal angioplasty (PTA) was performed in nine cases and stent was performed in 11 cases firstly. The symptoms of venous hypertension were resolved after intervention in all the cases. There was no major complication and death perioperatively. During follow-up, reintervention was done, the primary patency rates were (88.9±10.5)%, (64.8±10.5)% and (48.6±18.7)% at 3 months, 6 months and 1 year after treatment in the PTA group; (90.0±9.5)% and (77.1±14.4)% at 6 months and 1 year after treatment in the stent group, respectively. The secondary patency rates were (48.6±18.7)% in the PTA group and (83.3±15.2)% in the stent group 1 year after treatment, respectively. There was no significant difference between the two groups (primary patency, P=0.20; secondary patency, P=0.10). Conclusions The endovascular intervention is a safe and effective method for CVD in short term; enhanced follow-up and repeated interventions are required to maintain patency for long term. The prevention is most important. Avoiding and minimizing the placement of the central venous catheter may be the key point for the prevention.

Lymphovenous Microsurgical Shunts in Treatment of Lymphedema of Lower Limbs: A 45-year Experience of One Surgeon/One Center

RationaleThe use of microsurgical lymphovenous shunts is one of the generally accepted treatments for limb lymphedema. AimThe 45-year personal experience of one surgeon in indications, technique and results of lymphovenous shunt operations in lower limb lymphedema of varying etiology is presented. MaterialOne thousand three hundred patients were followed up in the period 1966–2011. Patients were classified into groups according to the etiology of lymphedema as postinflammatory/posttraumatic, postsurgical, idiopathic and hyperplastic. Decrease in limb circumference, heaviness and pain, and increase in joint flexing were evaluated. ResultsThe most satisfactory results, reaching 80–100% improvement, were obtained in the congenital non-hereditary hyperplastic lymphedema group, with large lymphatics not previously damaged by infection. Results were also satisfactory in the group of cancer patients after iliac lymphadenectomy, reaching 80%. A less satisfactory outcome was observed in the postinflammatory group, not exceeding 30–40%. In idiopathic lymphedema results were satisfactory in only a few cases. ConclusionsPatients with lymphedema with local segmental obstruction but still partly patent distal lymphatics and without an active inflammatory process in the skin, subcutaneous tissue and lymph vessels present satisfactory results.

Comparing Ways of Assessing Tongue Base Obstruction in Obstructive Sleep Apnea

Objective: To determine if awake clinical evaluation methods like Friedman’s Tongue Position (FTP), endoscopic assessment of the hypopharynx using Mueller maneuver (MM), and during end expiration (EEPBOT) to assess tongue-base obstruction correlate well with tongue-base obstruction seen during drug-induced sleep endoscopy (DISE). Method: Pilot prospective study of 16 patients with moderate to severe OSA recruited over 1 year at a tertiary care center. These patients were evaluated in the clinic with the flexible nasendoscope and subsequently underwent full PSG and DISE with midazolam. Results: The 16 patients studied had a mean AHI of 65 (range, 18.8 to 129). Fifteen out of 16 patients (93.7%) were found to have multi segment obstruction on DISE according to the original grading proposed by Pringle and Croft. Comparing the various awake dynamic maneuvers against DISE as a gold standard, MM was found to have sensitivity of 53%, FTP had a sensitivity of 80%, and EEPBOT had a sensitivity of 93%. Because of the skewed nature of the results (only 1 out of 16 patients [6.3%] was classified as not having obstruction), specificity results had no statistical value. Conclusion: This small pilot study showed a good correlation between EEPBOT, FTP, and DISE. A poorer correlation between MM and DISE is seen. Our results suggest that EEPBOT and FPP are superior to MM in evaluating tongue-base obstruction in OSA; however, further research is required to support these findings.

A Technique for the Surgical Treatment of Distal Intestinal Obstructive Syndrome by Hand-assisted Laparoscopy

Distal intestinal obstructive syndrome (DIOS) is the partial or complete obstruction of the colon or the terminal ileum by abnormally viscous intestinal contents and is a common sequela of cystic fibrosis (CF) in adults. Medical management of this entity is well described, but often falls short for those with signs of peritonitis or bowel ischemia. Current surgical options are not widely reported. These procedures usually require laparotomy, occasionally with enterotomy, and are complicated by the typically poor medical condition of patients with DIOS. A minimally invasive approach to the surgical care of CF patients with DIOS could effectively relieve obstruction refractory to medical management. A 39-year-old woman with CF presented with nausea, severe abdominal pain, and obstipation. She was diagnosed with DIOS and underwent aggressive medical management unsuccessfully. The patient underwent successful hand-assisted laparoscopic antegrade milking of a 15-cm obstructive segment of the small bowel into the colon and placement of an appendicostomy tube. This was followed by postoperative administration of antegrade enemas and nasogastric osmotic cathartics. The patient had resumption of bowel function and was subsequently discharged to her home. This is a reported case of laparoscopic exploration and treatment for DIOS, and provides a minimally invasive alternative to laparotomy and enterotomy in the treatment of DIOS.

A high loading dose of clopidogrel reduces myocardial infarct size in patients undergoing primary percutaneous coronary intervention: A magnetic resonance imaging study

We sought to determine whether a 600-mg loading dose of clopidogrel reduces myocardial infarct size compared with a 300-mg dose using contrast-enhanced magnetic resonance imaging in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). In 198 patients undergoing primary PCI for STEMI, contrast-enhanced magnetic resonance imaging was performed a median of 7 days after the index event. Infarct size was measured on delayed-enhancement imaging, and area at risk (AAR) was quantified on T2-weighted images. Baseline characteristics were not significantly different between the 600-mg clopidogrel loading group (n = 117) and the 300-mg group (n = 81). The median infarct size was significantly smaller in the 600-mg group than in the 300-mg group (17.3% [8.9%-26.2%] vs 21.7% [12.9%-30.0%], P = .03). Myocardial salvage index ([AAR - infarct size] × 100/AAR) was greater in the 600-mg group than in the 300-mg group (47.7 [33.7-60.9] vs 32.0 [23.6-51.5], P < .01). Patients in the 600-mg group also had a significantly lower extent of microvascular obstruction and smaller number of segments with >75% of infarct transmurality than did those in the 300-mg group. After propensity score matching, the 600-mg group had smaller infarct size and greater myocardial salvage index compared with the 300-mg group. In multivariate analysis, the use of a 600-mg clopidogrel loading dose significantly reduced the risk of a large infarct (odds ratio 0.53, 95% CI 0.29-0.98, P = .04). In patients undergoing primary PCI for STEMI, a 600-mg loading dose of clopidogrel reduced myocardial infarct size and improved myocardial salvage compared with a 300-mg loading dose.

Incomplete mechanical recanalization of middle cerebral artery occlusions facilitates endogenous recanalization within 5 h

Background and purposeSuccessful revascularization can often improve functional outcome after large intracranial arterial occlusions. However, incomplete or unsuccessful recanalization is often the end result after attempted mechanical thrombectomy. A study...

Usefulness of sum of the thickness of plaque in the carotid artery for predicting the presence and the extent of the coronary artery disease in patients with type 2 diabetes mellitus without known coronary artery disease

AimsThe usefulness of the sum of plaque thickness in the carotid artery (plaque score; PS), as a prediction of coronary artery disease (CAD) was investigated in patients with type 2 diabetes mellitus. MethodsB mode ultrasonographic scanning of the carotid artery and multislice computed tomography (MSCT) coronary angiography were performed in 227 diabetic patients without known cardiac disease. ResultsThe PS was useful to predict the presence of diseased [nonobstructive and obstructive] CAD (≧3 segments) and obstructive (≧50%) CAD with cut-off value of 3.5mm (area under curve: 0.745 and 0.782, respectively), according to a receiver operating characteristics curve analysis. A multivariate logistic analysis of baseline risk factors showed that the PS was independent risk factor for the prediction of diseased and obstructive coronary artery disease (R2=0.2165, p<0.0001 and R2=0.2265, p<0.0001, respectively). The PS was most significant predictor of the number of diseased and obstructive segments of the coronary artery in a multiple regression analysis (R2=0.2022, p<0.0001 and R2=0.2209, p<0.0001, respectively). ConclusionsThe PS in the carotid artery was useful for the prediction of the presence and the extent of CAD, and was most important as a screening test for the identification of a high risk group of asymptomatic diabetic patients.

Enteral Feeding Patients With Gastric Outlet Obstruction

Patients with upper gastrointestinal obstructions were previously managed with gastric decompression and parenteral feeding. The authors present their experience in 50 patients with obstructions chiefly due to complicated severe acute (n = 31) or chronic cystic pancreatitis (n = 11) using a double-lumen nasogastric decompression and jejunal feeding tube system (NGJ) held in place with a nasal bridle that passes through the obstructed gastroduodenal segments, allowing distal jejunal feeding, and at the same time decompresses the stomach to prevent vomiting and aspiration. The tip of the jejunal tube was placed approximately 40 cm down the jejunum to maintain pancreatic rest. Duration of feeding ranged from 1-145 days (median 25 days); 19 patients were discharged home with tube feeds. Only 1 patient could not tolerate feeding and needed to be converted to parenteral feeding. Average tube life was 14 days, with replacement being needed most commonly for kinking or clogging of the jejunal tube (56%) or accidental dislodgement (24%). The obstruction resolved spontaneously in 60%, allowing resumption of normal eating. Of the patients with severe acute pancreatitis or pancreatic pseudocysts, pancreatic rest resulted in resolution of the disease without surgery in 87%, and need for surgery in the remainder was put off for 31-76 days. Seven patients died predominantly of complications of acute pancreatitis between 1 and 31 days. In conclusion, NGJ feeding provides a relatively safe conservative management for critically ill patients with upper gastrointestinal obstructions, reducing the need for surgery and parenteral feeding.

Pilot study comparing SPECT perfusion scintigraphy with CT pulmonary angiography in chronic thromboembolic pulmonary hypertension

The management of chronic thromboembolic pulmonary hypertension (CTEPH) is dependent on the extent of pulmonary artery obstruction, which is usually evaluated by planar perfusion scanning and CT pulmonary angiography (CTPA). We previously reported that SPECT perfusion scanning is more sensitive than planar scanning for detecting vascular obstruction in CTEPH. The purpose of this study is to compare SPECT with CTPA for detecting segmental pulmonary artery obstruction in CTEPH. SPECT and CTPA were carried out before pulmonary endarterectomy in 12 CTEPH patients. Field experts documented the anatomical distribution of perfusion defects disclosed by SPECT, the anatomical distribution of pulmonary arterial filling defects disclosed by CTPA and the segmental anatomy of the vascular obstructions based on a review of clinical and pathology records, without knowledge of scan results. Clinical/pathological evaluation disclosed 140 obstructed (15.5 ± 2.5 per patient) and 40 unobstructed lung segments. SPECT scanning identified 87/140 (62%) of the obstructed and 29/40 (72%) of the unobstructed segments. By comparison, CTPA identified 67/140 (47.8%) of the obstructed and 32/40 (80%) of the unobstructed segments. Sensitivity for detecting obstructed segments was significantly higher for SPECT compared with CTPA (62 ± 4.1% vs 47.8 ± 2.9%, respectively; P = 0.03). SPECT is more sensitive than CTPA for identifying obstructed segments in this small sample of CTEPH patients. However, even SPECT under-represents the extent of vascular obstruction from this disease.

Abstract 9883: Comparison of Magnetic Resonance Imaging Findings in Non-ST-Segment Elevation versus ST-Segment Elevation Myocardial Infarction Patients Undergoing Early Invasive Intervention

Background To define causes and pathophysiological mechanisms underlying differences in clinical outcomes, we compared the findings of contrast-enhanced magnetic resonance imaging (CE-MRI) between patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) who received early invasive intervention. Methods In 168 patients undergoing early invasive intervention for STEMI (n=113) and NSTEMI (n=55), CE-MRI was performed a median of 6 days after the index event. Infarct size was measured on delayed-enhancement imaging and area at risk (AAR) was quantified on T2-weighted images. Results The median infarct size was significantly smaller in the NSTEMI group than in the STEMI group (10.7% [5.6-18.1] versus 19.2% [10.3-30.7], P &lt;0.001). Although there was a trend of greater myocardial salvage index ([AAR - infarct size] × 100/ AAR) in the NSTEMI group than the STEMI group (48.2 [30.4-66.8] versus 40.5 [24.8-53.5], P =0.056), myocardial salvage index was similar between the groups in patients with anterior infarction (39.6 [20.0-54.9] versus 35.5 [23.2-53.4], P =0.96). The NSTEMI group also had a significantly lower extent of microvascular obstruction and smaller number of segments with &gt;75% of infarct transmurality relative to the STEMI group (0% [0-0.6] versus 0.9% [0-2.3], P &lt;0.001 and 3.0±2.3 versus 4.6±2.9, P =0.001, respectively). Myocardial hemorrhage was detected less frequently in the NSTEMI group than the STEMI group (22.6% versus 43.8%, P =0.029). In multivariate analysis, baseline Thrombolysis In Myocardial Infarction flow grade 3 and hemorrhagic infarction were closely associated with ST-segment elevation (OR 0.32, 95% CI 0.13-0.81, P =0.017; OR 5.66, 95% CI 1.77-18.12, P =0.003, respectively). Conclusions In vivo pathophysiological differences revealed by CE-MRI assessment include more favorable infarct size, AAR, myocardial salvage and reperfusion injury in patients with NSTEMI than in those with STEMI undergoing early invasive intervention.

Laparoscopic management of primary pelvi-ureteric junction obstruction: Single-centre experience

ObjectiveTo evaluate the effect and safety of laparoscopic pyeloplasty in the treatment of pelvi-ureteric junction obstruction (PUJO). Patients and methodsIn 34 patients, laparoscopic dismembered pyeloplasty was used to treat primary PUJO. Information was obtained for symptoms, results of a nuclear scan before and after surgery, intraoperative blood loss, operative duration, stenting method, and hospital stay. Under general anaesthesia and in the flank position, a 10mm trocar was first placed above the umbilicus; three 5mm working ports were then placed. The ureter and pelvis were freed from surrounding adhesions. The obstructive pelvi-ureteric segment was then excised, and the opened point of the ureter spatulated. Ureteropyeloplasty between the lower pole, pelvis and spatulated ureter was made using a 4-0 polyglactin suture around a JJ stent. ResultsThe mean (SD) preoperative nuclear scan result was 23.6 (6.4)mL/min, with retention of tracer. The median operative duration was 200min, and the median blood loss 120mL. All patients were stented with a JJ stent. The mean hospital stay was 5 days. The final results were assessed at 6 months after surgery, when the mean (SD) nuclear scan result was 30 (7.4)mL/min. ConclusionLaparoscopic pyeloplasty is a safe and effective option which can produce satisfactory results both clinically and radiologically.

The Use of 125I Seed Strands for Intraluminal Brachytherapy of Malignant Obstructive Jaundice

This study is sought to evaluate the feasibility and safety of using ¹²⁵I seed strands for intraluminal brachytherapy (ILBT) in the treatment of malignant obstructive jaundice (MOJ), and its clinical effect on stent patency. A total of 34 patients found to have MOJ were randomly assigned to an ILBT treatment group or a control group before biliary stent insertion. For the ILBT group, ¹²⁵I seed strands were implanted into the obstructive segment of the bile duct after stent insertion. For the control group, only the biliary stent was inserted. Alimentary and hematologic complications were examined for patients in the ILBT group. The stent patency of the two groups were compared. In the ILBT group, the number of ¹²⁵I seeds per strand varied from 6 to 16 (mean, 10.9), and were successfully implanted in 17 patients. Serum levels of bilirubin, alanine aminotransferase, granulocytes, and platelets assayed 2 and 4 weeks following the procedure demonstrated no significant difference between the ILBT group and the control group. The mean stent patency for ILBT group (10.2 months) was significantly longer than that of the control group (7.2 months, p=0.032). ¹²⁵I seed strands for ILBT is a feasible and safe palliative therapy for the treatment of MOJ, and may prolong stent patency.

Transcatheter device closure of a residual postmyocardial infarction ventricular septal defect

Postmyocardial infarction ventricular septal defect (VSD) carries a high mortality and, even after successful surgery, residual defect is common. A 75-year-old woman was admitted with the diagnosis of hyperacute anterior myocardial infarction. Primary percutaneous intervention was performed by stenting of a totally obstructed segment in the proximal left anterior descending artery. The patient's condition deteriorated on the second postprocedural day with a 3/6 pansystolic murmur at the mesocardium. Echocardiography revealed an apical anteroseptal VSD and moderate pulmonary hypertension. She underwent surgical VSD closure with a Gore-Tex patch and coronary artery bypass grafting to the left anterior descending and circumflex arteries. The patient's condition continued to be unstable due to septicemia and hemodynamically significant residual VSD. After medical management of septicemia, the residual defect was successfully closed using a 10-mm Cardio-O-Fix septal occluder under fluoroscopic and transesophageal echocardiographic guidance. The clinical condition of the patient was then stabilized and there was no significant residual shunt on echocardiography on the third postprocedural day.

Collagen levels are normalized after decompression of experimentally obstructed colon

Our aim was to define the dynamics in collagen concentrations in the large bowel wall following decompression of experimental obstruction. Colonic obstruction was created in 28 male rats by the placement of a silicone ring around the distal colon. The ring was removed after 4 days to mimic endoscopical decompression by stent deployment. Colon circumference and collagen concentration were measured proximal to the obstructed segment immediately and at 3 and 10 days after decompression. The corresponding colonic sites of 23 sham-operated and eight nonoperated control animals were subjected to identical analyses. Four days of obstruction resulted in a more than twofold increase in colonic circumference (20 vs 8 mm), with a concomitant 43% reduction (P = 0.001) in collagen concentration in the bowel wall proximal to the obstruction compared with sham animals. Three days after decompression, collagen concentrations remained reduced (P < 0.05), while there was no significant difference after 10 days with either sham-operated or nonoperated controls. Colonic circumference of the obstructed colon remained slightly distended (11 mm) on day 10 and tended to correlate (r(S) = 0.51, P = 0.053) with total matrix metalloproteinase activity. The marked reduction in collagen concentration in an experimentally obstructed colon is normalized 10 days after decompression. These findings may have clinical implications for the timing of surgical resection.

Meningiomas of the transverse – sigmoid sinus junction area

Meningiomas with exclusive or prevalent dural attachment over the transverse-sigmoid sinus junction area represent a well-defined subgroup of posterior fossa meningiomas. This study reports 13 cases of this localisation (10.8% of all infratentorial meningiomas). In this series, six patients (46%) were discovered as an incidental MR finding. One patient with a small (1.5 cm) meningioma presented with an intracranial hypertension syndrome due to severe obstruction of the unique transverse-sigmoid sinus junction. A MR angiography was performed in 11 patients; it showed intraluminal tumour in two cases with dominant and unique transverse sinus, respectively. Tumour removal with excision of the outer dural layer and coagulation of the dural attachment (Simpson II) was performed in 11 cases; in two others with focal sinus invasion, removal of the small intravenous tumour fragment was not performed (Simpson III). No post-operative complications occurred. Remission of pre-operative symptoms was obtained in all symptomatic cases. The management of the transverse-sigmoid sinus junction is the main problem of meningiomas of this region. Excision of the outer dural layer and coagulation of the dural attachment are in our opinion sufficient in most cases, even when there is tumour invasion of the patent venous lumen. The resection of the sinus wall should be reserved to cases with a totally obstructed segment and symmetrical or asymmetrical but present transverse and sigmoid sinuses.