Open Surgical Treatment Research Articles

Coagulation Factor Activity and Hemostatic Markers of Endothelial Dysfunction in Patients with Peripheral Arterial Disease.

PurposeWe aimed to evaluate the impact of intrinsic coagulation factors and hemostatic markers of endothelial dysfunction on complications in patients with atherosclerotic peripheral arterial disease (PAD).MethodsMaterials and This prospective study enrolled 120 PAD patients at Fontaine stages 2b to 3 who underwent open surgical, endovascular, or conservative treatment. Coagulation factors (FVIII, FIX, and FXI) and endothelial hemostatic markers, including von Willebrand factor (vWF) activity and level, soluble endothelial protein C receptor, and plasminogen activator inhibitor-1 (PAI-1) levels, were assessed.ResultsAt 3 months after open bypass grafting, activity of FVIII significantly increased from a median of 175% to 233% (P<0.001). At 3 months after endovascular treatment, the activities of FVIII, FIX, and FXI significantly increased from medians of 157%, 180%, and 156% to 184%, 218%, and 181%, respectively (P<0.05). Six patients with increased FVIII activity developed bypass graft thrombosis. Four patients in the endovascular group and three patients in the conservative treatment group with increased activity of vWF developed myocardial infarction (P=0.049). The subjects who developed restenosis had increased vWF activity (P=0.023) and decreased nitric oxide metabolite levels (P=0.003). Three subjects who received conservative treatment and developed PAD progression at 12 months had increased PAI-1 activity (P=0.028).ConclusionPatients with advanced PAD had a hypercoagulable status, and performance of open or endovascular revascularization was associated with further hypercoagulability. Increased activity of coagulation factors and altered levels of hemostatic markers of endothelial dysfunction were associated with PAD complications such as graft thrombosis, myocardial infarction, disease progression, and restenosis.

Open Surgical Secondary Interventions are More Durable than Endovascular Interventions for Lower Extremity Bypass Stenosis or Occlusion.

Objectives: Lower extremity bypasses often require secondary interventions to maintain patency. Our objectives were to characterize effectiveness of secondary interventions to maintain or restore bypass graft patency, and to compare outcomes of open and endovascular interventions. Methods: We reviewed patients who underwent lower extremity bypass at our institution from 2007 to 2010. We recorded the index bypass and subsequent ipsilateral interventions performed through 2018 or until loss of secondary patency. Patient, procedure, and anatomic data were collected. Endovascular intervention was compared with open/hybrid intervention. For outcome analysis, patency measures were defined relative to the time of the secondary intervention rather than the time of the index bypass. Results: 174 secondary interventions (56 open/hybrid, 118 endovascular; 42 for graft occlusion, and 132 for stenosis) treating 228 lesions in 97 bypasses were available for study. The index bypass was most commonly performed for tissue loss (71.1%), utilized a tibial artery target (57.7%), and used single-segment great saphenous vein (59.8%) rather than alternative vein (32.0%) or prosthetic (8.2%). A higher portion of open/hybrid interventions (51.8%) were done for graft occlusion than endovascular interventions (11.0%, P < .001). Mean follow-up for secondary interventions was 3.5years. A multivariate Cox proportional hazards model identified female gender, prior MI, anticoagulation, occlusion, and endovascular intervention as predictors of loss of primary patency. Intervention for occlusion predicted poorer primary and secondary patency. Endovascular intervention was associated with poorer primary patency as compared to open intervention and a trend toward poorer secondary patency. Conclusions: Both open and endovascular secondary interventions on lower extremity bypasses are low-risk procedures that offer acceptable patency. Although more commonly performed in the setting of graft occlusion, open surgical interventions show improved durability compared to endovascular interventions. Some patients, including those with occluded grafts, may benefit from more liberal use of open surgical intervention to restore bypass patency.

Posterior nut-cracker syndrome: Urologist’s perspective – A mini review

Posterior Nut Cracker Syndrome (PCNS) is a rare clinical condition that occurs when the left renal vein gets compressed between the abdominal aorta and vertebral body. Posterior nutcracker phenomenon is a common anatomical abnormality, which is totally asymptomatic and diagnosed in a routinely performed abdominal imaging. The pressure gradient that develops between the renal vein and the inferior vena cava is the basic reason for all the features associated with this condition. Left renal venous entrapment would result in stagnation of blood in gonadal vessels that results in cascading effect resulting in a venous congestion and increased resistance to arterial blood flow in the kidney. Patients with pelvic congestion syndrome present with left loin pain and unilateral left varicocele. Gastrointestinal symptoms and arterial hypertension may also be the presenting symptoms. The symptoms depend upon the degree of pressure in renal veins and gonadal veins. When the dilated veins communicate with renal calyx, haematuria occurs. PNCS is best managed based on the severity of symptoms and the extent of clinical manifestations. Treatment options include conservative treatment, intra-vascular stents, chemical cauterisation, open surgical intervention and finally if everything fails, nephrectomy. PCNS is a rare entity that affects mostly females and can present with a variety of signs and symptoms. A high index of clinical suspicion is needed to achieve a prompt diagnosis. Conservative treatment is recommended for patients with mild symptoms. Severely symptomatic patients might benefit from endovascular treatment.

A retrospective comparison of outcomes for open vs. laparoscopic surgical techniques in pediatric ulcerative colitis.

Ulcerative colitis (UC) is an aggressive disease in the pediatric population and a cause of significant, lifelong morbidity. The aim of this study is to compare surgical complications in pediatric patients undergoing laparoscopic vs. open surgical treatment for UC. We queried the Kids' Inpatient Database (KID) for all cases of UC undergoing surgical treatment in 2009 and 2012. We identified patients who received total colectomy without proctectomy (n=413) or total proctocolectomy (n=196) and performed univariate and multivariate analyses comparing laparoscopic vs. open procedures. In pediatric UC patients undergoing total colectomy without proctectomy, open procedures were associated with more complications than laparoscopic, including fluid and electrolyte disorders (40% vs. 28%), surgical wound dehiscence (6% vs. 2%), septicemia (18% vs. 2%), and gastrointestinal disorders (16% vs. 7%) among others, all P<0.05. Likewise, in patients with UC undergoing total proctocolectomy, there were more complications in open vs. laparoscopic technique, including increased transfusion requirements (25% vs. 7%, P=0.001) and significantly more gastrointestinal upset, including nausea, vomiting, and diarrhea (11% vs. 1%, P=0.003). In multivariate analysis, patients who underwent total colectomy with or without proctectomy had an increased risk of experiencing any complication when their procedure was performed in an open or non-elective fashion (all odds ratio >2.4; all P<0.001). The laparoscopic approach was associated with significantly lower rates of surgical complications in pediatric patients undergoing total colectomy with or without proctectomy for UC. These findings demonstrate that laparoscopic technique compares favorably, and may be preferable, to the open approach in selected pediatric patients with UC.

Robotic revision surgery for type IV choledochal cyst

Complete excision of the cyst with Roux-en-Y hepaticojejunostomy (RYHJ) is the standard treatment for a choledochal cyst (CDC). Incomplete cyst excision and anastomotic stricture are the common causes of recurrent symptoms. The use of the robotic platform for re-operation after open surgical treatment of the CDC has not been previously reported. The technique of robotic revision surgery using the daVinci®XiTM robotic surgical system is described in this report. A 24-year-old female with a history of open CDC excision and choledochoduodenostomy at three months of age, presented with intermittent fever and abdominal pain for ten years duration. Preoperative evaluation with upper gastrointestinal endoscopy and magnetic resonance imaging revealed choledochoduodenostomy stricture with cystic dilatation of biliary radicals predominantly in the left lobe liver suggestive of type IVa choledochal cyst. The patient underwent robotic dismantling of strictured choledochoduodenostomy, left hepatectomy and Roux-en-Y right hepaticojejunostomy. The procedure was performed with four 8 mm robotic trocars placed at the umbilicus level and one infraumbilical assistant trocar. Key steps are intra-abdominal adhesiolysis, dismantling of the choledochoduodenostomy, inflow control to the left hemiliver, parenchymal transection to the left of the middle hepatic vein, division of left hepatic duct, intraparenchymal transection of the left hepatic vein and Roux-en-Y right hepaticojejunostomy. The operative time, blood loss, and postoperative hospital stay were 410 minutes, 200 mL, and four days, respectively. At seven months follow-up, the patient is asymptomatic with normal liver function test. Robotic revision surgery for CDC is safe and the feasibility reported in the present patient needs to be documented in a large case series.

Comparison of Surgical Outcomes between Robotic Transaxillary and Conventional Open Thyroidectomy in Pediatric Thyroid Cancer.

Simple SummaryThyroid cancer is rare in the pediatric population, but in comparison to thyroid carcinomas in adults, those occurring in children present with aggressive and advanced features. Recent innovations in the surgical technique of robotic thyroidectomy for young patients have offered the opportunity to improve cosmetic effects and oncologic outcomes. The aim of our retrospective study was to conduct a review of the pediatric population who underwent robotic trans-axillary thyroidectomy or conventional open thyroidectomy between February 2008 and December 2019. In the hands of an experienced surgeon, robotic thyroidectomy is a feasible and safe option for pediatric patients.Thyroid cancer in children is very uncommon. For pediatric thyroid cancer, robotic surgery has served as a minimally invasive surgical alternative to conventional open surgery. Our study aimed to evaluate the results of robotic versus open surgical treatment for patients with thyroid cancer younger than 20 years of age at the time of diagnosis. This retrospective review included 161 pediatric patients who underwent robotic transaxillary or conventional open thyroidectomy at our institution from 2008 to 2019. Of these patients, 99 comprised the robotic group and 62 the open group. Patient demographics, surgical outcomes, and disease-free survival rates were compared between the two groups. Patients in the open group were more likely to have advanced stage diseases with a larger tumor size and higher tumor-node-metastasis stage than those in the robotic group. Operation time and follow-up period were similar in both groups. Patients in the robotic group had a lower rate of postoperative complications and a shorter length of hospital stay, but they also had a lower average number of retrieved central lymph nodes. However, there were no significant between group differences in recurrence rates and disease-free survival. In the hands of an experienced surgeon, robotic thyroidectomy is a feasible and safe option for pediatric patients.

Interventional management of peripheral vascular injuries : From the exclusion indication to the procedure of first choice

Approximately one third of all traumatic peripheral artery injuries affect the upper extremities, while two thirds involve the arteries of the lower extremities. Historically, these injuries were treated by open surgical repair. Nowadays, interventional treatment, such as embolization or stent grafting are increasingly used to treat peripheral artery injuries. Determination of the current state of interventional treatment options for injuries of peripheral arteries. Selective literature review on the current state of interventional management of peripheral artery injuries. Although scarce, the available data confirm the efficacy of interventional techniques for managing peripheral artery injuries; however, despite improvements in treatment techniques and interventional devices, not all patients are equally well suited for endovascular or open surgical treatment. Consequently, amultidisciplinary decision on the best treatment has to be made on acase by case basis. According to the promising clinical data, interventional treatment should be considered more often. Diagnostic algorithms need to be adapted accordingly.

High-pressure balloon dilatation for the treatment of primary obstructive megaureter: is it the first line of treatment in children and infants?

To evaluate the efficacy of high-pressure balloon dilatation (HPBD) as treatment of primary obstructive megaureter (POM) in paediatric patients, we analysed the data of our institute from June 2018 to September 2019. 14 patients, aged 5 months to 5 years, with POM were treated with HPBD. All patients had a distal ureter dilatation greater than 7 mm associated with obstructive features on a mercaptoacetyl triglycine-3 diuretic renogram scan, and a voiding cystourethrogram without vesicoureteral reflux. HPBD was performed in 12 patients, whereas 2 patients (14%), aged 5 and 6 months, required open surgical treatment because of failure to pass the balloon catheter through the vesicoureteral junction. The procedure was performed with a 5 Fr balloon catheter for two cycles of 5 minutes each at 17 atm. A double-J stent and a urinary catheter were inserted at the end of procedure in all patients. No operative complications or symptoms or recurrence were recorded in our series. The patients were generally discharged 24 hours after surgery. All the patients showed an improvement on ultrasonography at the postoperative follow-up, with no evidence of obstruction. During the procedure a clear stenotic ring was identified in 10 of the 12 patients, which disappeared in all 10 cases after the HPBD technique. Based on our experience, HPBD may be considered the first-line surgical approach in the treatment of POM in children, avoiding bladder surgery in most cases.

Outcomes of different acute mesenteric ischemia therapies in the last 20 years: A meta-analysis and systematic review.

Acute mesenteric ischemia is a disease with high morbidity and mortality, and it is traditionally treated with open surgery. Endovascular therapy and hybrid techniques are alternative treatments that are also currently available. We performed a meta-analysis to evaluate the outcomes of the different treatment approaches in the last 20years. Studies on acute mesenteric ischemia that were indexed in PubMed, Embase, and MEDLINE databases (from January 1, 2000, to April 1, 2021) were reviewed. All related retrospective observational studies and case series were included. A random-effects model was used to calculate pooled estimates, and the results were reported as proportions and 95% confidence intervals (CIs). In our study, a total of 2369 patients (in 39 studies) underwent endovascular, open surgery, or retrograde open mesenteric stenting. The pooled mortality estimates for open surgery, endovascular therapy, and retrograde open mesenteric stenting were 40% (95% CI, 0.33-0.47; I2 = 84%), 26% (95% CI, 0.19-0.33; I2 = 33%), and 32% (95% CI, 0.21-0.44; I2 = 26%), respectively. The mortality associated with open surgical treatment, endovascular therapy, and retrograde open mesenteric stenting tend to be similar in the last 20years.

Perilunate Dislocations and Fracture-Dislocations: A Retrospective Study of 11 Cases

Perilunate dislocations (PD) and perilunate fracture-dislocations (PFD) of the carpus are rare but important entity in so far as it presents a high risk of after-effects and post-traumatic osteoarthritis. We report a retrospective, monocentric and multioperator series of 11 patients with a mean follow-up of 24 months over a -year period from 2016 to 2020. The objective of our study was to establish an epidemiological profile and to study the clinical, functional and radiological results of PD and PFD of the carpus while underlining the interest of early management. There were 3 pure PDs and 8 trans-scaphoid PFDs with 10 dorsally displaced forms and only one ventrally displaced form. Clinical and functional evaluation was based on mobilities, strength, pain, Cooney Score, Quick-DASH, and PRWE. Radiological abnormalities were analyzed with the Herzberg classification. All patients were treated surgically after closed reduction, with a dorsal approach in 3 cases, and a palmar approach in 8 patients. Early diagnosis and anatomical reduction provide a satisfactory functional result to avoid complications. This implies an emergency open surgical treatment, a close follow-up and a postoperative rehabilitation in the shortest possible time.

Comparison of Early-Late Results and Cost Effectivity of Open Surgical Treatment and Endovascular Interventions in Abdominal Aortic Aneurysms

Objective: In this study, we aimed to compare early and late outcomes of patients with abdominal aortic aneurysm (AAA) treated using an endovascular approach and open aneurysm repair technique. Method: A total of 171 patients who were undergoing EVAR and open surgical therapy were retrospectively analyzed under elective conditions due to abdominal aortic aneurysm via Hospital Info Management System and archive files within May 2006 and June 2014, in the Ankara University Cardiovascular Department. 126 of the patients (73,7%) were treated by endovascular (group 1) and 45 of them (26,3%) were treated with open surgery (group 2) technique. Patients with 5,5 cm or large asymptomatic aneurysms and symptomatic patients with diameter smaller than 5,5 cm are classified by aneurysm morphology evaluating preoperative CT angiography images and risk scores were made and considering the other comorbidities early and late morbidity mortality, reintervention rates, transfusion needs, hospital stay and cost effectiveness of EVAR were compared. Results: The mortality rate for patients undergoing EVAR was 2,4%, while in patients undergoing open surgical repair was found 8,9% (p <0.05). The mean length of ICU, and hospital stay were significantly lower in the patients undergoing EVAR, in comparison with open surgery. The amount of blood transfusion in patients undergoing EVAR was significantly lower than in patients treated with open surgery. It can be observed an increase in early endoleak (leakage) rates constituting 9,5% in EVAR patients, which was dropped to 3,2% in sixthmonth control. According to the consequences of cost effectiveness, it was obtained that endovascular group is considerably expensive treatment than open surgery. It should be pointed out that the post implantation syndrome rates were 14,2% and there was not noted any change on mortality outcomes. Conclusions: EVAR is a safe in early and long term follow-up that reduces mortality range in all age groups, especially over 70 years old, and in patients with comobrid factors. Therefore, EVAR treatment should be considered as a priority in anatomically suitable patients despite its high cost effectiveness.

The Utility of Brain Magnetic Resonance Imaging/Angiography and Neck Magnetic Resonance Angiography in Patients with Suspected Acute Stroke

In our health maintenance organization, we have seen a trend among our referring physicians to order simultaneous brain magnetic resonance imaging (MRI), head magnetic resonance angiography (MRA), and neck MRA in the evaluation of patients for acute stroke. However, there are little data to demonstrate any improvement in patient care resulting from ordering this triple study. The objective of this study was to analyze the utility of the triple MRI/MRA study for patients who experience stroke-like symptoms. We reviewed all triple-study cases between January 1, 2013 and December 31, 2016. We recorded whether or not an acute stroke occurred, the presence or absence of a major stenosis in the intracranial and/or neck arteries, subsequent percutaneous endovascular or open surgical intervention within 90 days, and any follow-up computed tomography angiography or carotid ultrasound studies within 30 days. During the studied period, 591 triple studies were ordered, and 162 patients (27.4%) were found to have moderate or severe stenosis. Of the patients who had an acute stroke, 100 (48.3%) also had a major stenosis. Of 591 patients, only 15 (2.5%) underwent percutaneous endovascular or open surgical intervention within 90 days. Of these, 4 patients had an intervention in less than a week; in all of the cases, the triple study did not need to be ordered simultaneously to achieve the same clinical outcome. Brain MRI, head MRA, and neck MRA studies should not be ordered simultaneously as a generalized response to patients presenting with acute stroke-like symptoms.

The benefits of vestibular schwannoma treatment by the means of gamma knife radiosurgery. Literature review

Domantas Jakštas1, Gabija Pajedienė1, Monika Martusevičienė2 1Lithuanian University of Health Sciences, Medical Academy, Faculty of Medicine 2Lithuanian University of Health Sciences, Kaunas Hospital Abstract Vestibular schwannoma (VS), also known as acoustic neuroma, is a benign, slow-growing tumor that develops due to hyperproduction of Schwan‘s cells surrounding the balance and auditory nerves in the inner ear. Symptoms such as asymmetric hearing loss, tinnitus, dizziness, and imbalance occur as the tumor grows. Significant enlargement of the tumor may exhibit pressure on the surrounding brain structures, leading to various neurological deficits and life-threatening damage to the brain stem. Due to the complex localization of the tumor, surgical treatment is associated with a high risk of complications and more difficult recovery, leading to the increasing use of radiosurgical treatments. Gamma knife stereotaxic radiosurgery is a promising and effective treatment method that is increasingly used to treat VS. Aim: to collect publications on the treatment of vestibular schwannoma with stereotaxic radiosurgery using Gamma knife and to systematically evaluate the benefits provided by this method over traditional microsurgery. Methods. A comprehensive search of English-language literature in the PubMed database was performed. The search was performed using MeSH terms: Gamma knife, radiosurgery, stereotactic radiosurgery, vestibular schwannoma, acoustic neuroma. Article inclusion criteria: Article was published in English Article was not older than 15 years Article was describing the results of vestibular schwannoma treatment by the means of Gamma knife (LINAC radiosurgery and CyberKnife were excluded) Exclusion criteria: Articles, describing the use of other radiosurgery modalities, such as LINAC and CyberKnife Results: with the use of chosen keywords, 60 studies were found. After implementing inclusion and exclusion criteria, 31 articles were selected for further evaluation. After analyzing the information, presented in these articles, we have come to conclusion that Gamma Knife is an effective method of VS treatment, with an advantage as this method can avoid many of the complications associated with open surgical treatment, such as hearing loss, facial or trigeminal nerve dysfunction. Keywords: vestibular schwannoma, gamma knife, stereotactic radiosurgery. https://doi.org/10.53453/ms.2021.06.12

Inter Maxillary Fixation Versus Open Reduction for the Treatment of Mandibular Condyle Fractures: A Comparative Evaluation.

Background:The treatment for fractured mandibular condyles aims at restoring the masticatory ability, occlusion, symmetry, and function as the bit were before the trauma. The treatment of the mandibular condylar fracture can be done based on the two protocols.Aims:The present clinical trial was conducted to collate aftertreatment upshot of closed treatment and open surgical treatment for mandibular condyle fractures.Materials and Methods:Forty-two patients were divided into two groups (n = 12) which were treated with either the closed reduction using intermaxillary fixation or open reduction and internal fixation. The following clinical parameters were assessed at 1st and 3rd day and at 1, 3, and 6 weeks: lateral excursion and protrusion, occlusion; interincisal opening, mandibular ramus height, deviation/deflection during jaw opening, and pain assessment using visual analog score. The collected data were subjected to statistical evaluation.Results:Interincisal opening was found to be 8.125 ± 0.3467 mm and 6.016 ± 0.1528 mm, respectively, for Group I and Group II which was statistically significant (P < 0.00001). At the 3 months and 6th week postoperatively, it was increased in the surgical groups to 17.433 ± 0.3822 mm and 19.175 ± 0.3696 mm, respectively.Conclusion:The present trial suggests surgical open reduction and internal fixation treatment of the mandibular condylar fracture is better than the nonsurgical closed reduction in terms of interincisal opening, lateral excursion, and protrusive mandibular movement range.

Percutaneous, PMMA-augmented, pedicle screw instrumentation of thoracolumbar ankylotic spine fractures

IntroductionFractures in the ankylotic spine may have an insidious presentation but are prone to displace with devastating consequences. The long lever arm of ankylosed spine fragments may lead to pulmonary and great vessel injury and is difficult to adequately immobilize. Conservative treatment will produce in many cases poor outcomes with high morbidity and mortality. Open surgical treatment is also fraught with technical difficulties and can lead to major blood loss and prolonged operative times.In recent years, percutaneous instrumentation of non-ankylotic spine fractures has gained popularity, producing similar outcomes to open surgery with shorter operative times and reduced blood loss and hospital length of stay. We describe our experience implementing these techniques in ankylotic spine patients.MethodsWe retrospectively retrieved from our hospital’s electronic health records all patients treated for thoracolumbar spine fractures between 2008 and 2015 with a diagnosis of ankylosing spondylitis (AS) or diffuse idiopathic skeletal hyperostosis (DISH). Operative and postoperative data, results, and complications were tabulated, and radiographic parameters were evaluated.ResultsTwenty-four patients with ankylotic spine disease underwent percutaneous augmented instrumentation between 2008 and 2015. The mean age was 76. All patients had at least one comorbidity. The mean number of ankylosed levels was 14. Mean operative time was 131 min. The average postoperative hemoglobin decrease was 1.21 gr/%, with only 4 patients requiring blood transfusion.45.8% of the patients had postoperative medical complications. One patient (4.2%) had a superficial postoperative infection, and one patient died in hospital. The average hospital length of stay was 14.55 days.All patients retained their preoperative ASIA grades, and 3 improved one grade. All patients united their fractures without losing reduction.ConclusionsPMMA-augmented percutaneous instrumentation is an attractive surgical option for this difficult patient subset, especially when compared to other available current alternatives.

A comparative evaluation of laser hemorrhoidoplasty versus open surgical hemorrhoidectomy treatment of grade III and IV hemorrhoids. A prospective observational study

The aim of the present study was to evaluate and compare the efficacy and outcomes of laser hemorrhoidoplasty with that of open surgical hemorrhoidectomy. This prospective observational study consists of 50 subjects in each group. The open surgery group underwent a standardized Milligan-Morgan technique, and the laser group underwent laser hemorrhoidoplasty with a diode laser of 1470 nm (LASOTRONIX), 8.5 watts with a continuous pulse. Postoperative pain was considered as the primary outcome and was evaluated in both groups using the visual analog scale. There was a statistically significant difference between the two groups in VAS score at different follow-up period, with a mean score of 2.3±1.05 and 5.1±1.11 (24 hours) for the laser hemorrhoidoplasty group and open surgery group, respectively (p value &lt; 0.008). There was an improvement in VAS score in the laser hemorrhoidoplasty group compared to the conventional open surgical group in 1, 7, 14, 21, and 30 days follow up.

Learning from Our Complications Will Be Rewarding

Atherosclerotic disease of mesenteric arteries is a relatively rare disorder. This is the reason why it is so difficult to produce high quality evidence for its treatment. According to multicentre studies and a recent meta-analysis, endovascular revascularisation seems to offer advantages over open surgical treatment in atherosclerotic acute mesenteric ischaemia (AMI). Reflecting on these data, the European Society for Vascular Surgery’s mesenteric guidelines suggest that endovascular therapy should be considered as the first line treatment in patients with acute thrombotic occlusion of the superior mesenteric artery (SMA).

Successful Surgical Removal of Firmly Impacted Pancreatic Duct Stent: Two Case Report

Successful surgical removal of firmly impacted pancreatic duct stent: Two case report Recently, the self-expandable metallic and plastic stents are increasingly being used for management of different pancreatic disorders. The major indications for pancreatic stent placement are: pancreatic duct stones, chronic pancreatitis, pancreatic strictures, unresectable pancreatic cancer, preventing POPF and post-ERCP pancreatitis, papillary adenoma. Stent placement or retrieval and exchange is difficult process and sometimes it could be the serious clinical challenge. We report two cases of successful removal of firmly impacted pancreatic duct stent by open surgical intervention and transduodenal approach with lateral “side-to-side” pancreaticojejunostomy to prevent the risk of main pancreatic duct restenosis in the first case and with the sphincteroplasty in the second. Therefore, in these challenging cases of firmly impacted pancreatic duct stents, our choice seems to be the most optimal and effective surgical procedure, which could be considered like “parachute” option after failed attempts of stents removal by endoscopic and radiological procedures.

Successful Surgical Removal of Firmly Impacted Pancreatic Duct Stent: Two Case Report

Successful surgical removal of firmly impacted pancreatic duct stent: Two case report Recently, the self-expandable metallic and plastic stents are increasingly being used for management of different pancreatic disorders. The major indications for pancreatic stent placement are: pancreatic duct stones, chronic pancreatitis, pancreatic strictures, unresectable pancreatic cancer, preventing POPF and post-ERCP pancreatitis, papillary adenoma. Stent placement or retrieval and exchange is difficult process and sometimes it could be the serious clinical challenge. We report two cases of successful removal of firmly impacted pancreatic duct stent by open surgical intervention and transduodenal approach with lateral “side-to-side” pancreaticojejunostomy to prevent the risk of main pancreatic duct restenosis in the first case and with the sphincteroplasty in the second. Therefore, in these challenging cases of firmly impacted pancreatic duct stents, our choice seems to be the most optimal and effective surgical procedure, which could be considered like “parachute” option after failed attempts of stents removal by endoscopic and radiological procedures.

A Simple Target Will Save the Day and the Kidney: This Is How We Perform Our Endovascular Fenestrated Graft Procedure.

With the advent of state-of-the-art imaging modalities, increasing population age, and advanced preventive medical treatments, medical device design attempts to keep up with procedural demand. An abdominal aortic aneurysm (AAA) is a recognized, potentially fatal disease process where strides have been made in screening, detection, and treatment since its discovery. With the introduction of percutaneous endograft procedures in 1991, open surgical treatment is nearly a lost art. Endovascular aortic repair is now the gold standard. However, short landing zone necks, hostile angulation, and markedly dilated seal zones present challenges for one size fits all endovascular aortic devices. Suprarenal and juxtarenal fenestrated aortic grafts are the most advanced individually customized grafts invented to date. Subsequently, proper placement of these complex devices still presents challenges. We present a method for preoperative renal stent placement for target purposes. This article includes a pictorial guide and describes the tips and pitfalls for easy proper AAA exclusion with a fenestrated aortic graft. We were successful in the deployment of the fenestrated graft device and the exclusion of an aortic aneurysm while preserving the patency of the renal arteries. The patient had no postoperative complications. During 18-month postoperative surveillance, imaging demonstrated proper graft positioning without evidence of an endoleak. In fenestrated endovascular aortic repair, preoperative renal stenting is paramount for targeting purposes. This allows for the precise and timely deployment of the renal limbs through the fenestrations while minimizing the risk of postoperative complications, including renal artery occlusion.