Outflow Obstruction Research Articles

Hypoplastic Left Heart Syndrome Across the Lifespan: Clinical Considerations for Care of the Fetus, Child, and Adult.

Hypoplastic left heart syndrome (HLHS) is the most common anatomic lesion in children born with single-ventricle physiology and is characterised by the presence of a dominant right ventricle and a hypoplastic left ventricle along with small left-sided heart structures. Diagnostic subgroups of HLHS reflect the extent of inflow and outflow obstruction at the aortic and mitral valves, specifically stenosis or atresia. If left unpalliated, HLHS is a uniformly fatal lesion in infancy. Following introduction of the Norwood operation, early survival has steadily improved over the past 4 decades, mirroring advances in operative and perioperative management as well as reflecting refinements in patient surveillance and interstage clinical care. Notably, survival after staged palliation has increased from 0% to a 5-year survival of 60%-65% for children in some centres. Despite the prevalence of HLHS in childhood with relatively favourable surgical outcomes in contemporary series, this cohort is only now reaching early adult life and longer-term outcomes have yet to be elucidated. In this article we focus on contemporary clinical management strategies for patients with HLHS across the lifespan, from fetal to adult life. Nomenclature and diagnostic considerations are discussed and current literature pertaining to putative genetic etiologies is reviewed. The spectrum of fetal and paediatric interventional strategies, both percutaneous and surgical, is described. Clinical, patient-reported, and neurodevelopmental outcomes of HLHS are delineated. Finally, note is made of current areas of clinical uncertainty, and suggested directions for future research are highlighted.

How provocative tests in addition to wet swallows during high-resolution manometry can direct clinical management.

Provocative tests have been advocated to address limitations of high-resolution manometry (HRM) with wet swallows. We describe the commonly used provocative manometric manoeuvres [rapid drink challenge (RDC), multiple rapid swallows (MRS), solid swallows and the solid test meal (STM)], compare their diagnostic yield and accuracy to wet swallows, and outline their role in directing clinical management. Provocative testing with RDC and STM identifies a proportion of achalasia cases missed by standard testing, and RDC can play a similar role to radiology in the evaluation of treatment response. In EGJOO, provocative testing with RDC and STM not only increase the diagnostic yield, but can also help differentiate between spurious cases and those representing true outflow obstruction likely to respond to achalasia-type therapies. MRS and STM can help determine the clinical relevance (or otherwise) of ineffective oesophageal motility, and in this setting, MRS may predict the likelihood of postfundoplication dysphagia. RDC and STM can help identify cases of postfundoplication dysphagia more likely to respond to dilatation. Provocative testing has been shown to increase diagnostic yield of HRM, clarify inconclusive diagnoses, allows corroboration of dysmotility with patient symptoms and helps direct clinical management.

Rapid Onset Ascites: A Rare Case Report of Budd-Chiari Syndrome

Budd-Chiari Syndrome is an uncommon condition characterized by clinical features related to hepatic venous outflow obstruction resulting either from thrombotic or non-thrombotic causes. Presentations may vary from asymptomatic to acute fulminant hepatic failure. A meticulous history, examination and imaging studies are invaluable for a prompt diagnosis and initiation of time-sensitive treatment. This report presents a case of a young female with rapid onset ascites due to prothrombotic state of unknown cause with occlusion of all hepatic veins on doppler ultrasonography, without liver impairment.

Hepatic Venous Stenting in a case of Budd-Chiari Syndrome: A Case report

Budd-Chiari syndrome (BCS) results from hepatic venous outflow obstruction at the level of the hepatic veins or inferior vena cava.There is increasing number of successful reports of BCS therapy have involved endovascular techniques, including angioplasty and stent placement. Case Presentation : 22 Years old female patient presented to IR OPD with complaints of chronic abdominal pain and distension and decreased energy. The patient had no history of jaundice, bruising, or acholic stools. ChildPugh Score was 6 point and Child Class A. On Ultrasonography and CT scan, diagnosis of Budd chiari syndrome due to narrowing of IVC in its hepatic portion with occlusion of hepatic veins ostia was kept.Endovascular management was done. Conclusion : BCS denotes a heterogeneous group of diseases characterized by hepatic venous outflow obstruction at the level of hepatic veins or inferior vena cava resulting in portal hypertension.CT and MR angiography provide noninvasive anatomical definition of the hepatic artery that may be important for operative or interventional planning.

Functional luminal imaging probe in the evaluation of esophago-gastric junction outflow obstruction.

Esophagogastric junction outflow obstruction (EGJOO) comprises a heterogeneous group of conditions that demonstrate impaired deglutitive relaxation of the esophagogastric junction (EGJ) with intact esophageal peristalsis on high-resolution manometry. Functional luminal imaging probe (FLIP) panometry is a powerful tool that can help to clarify the etiology of this manometric diagnosis. The aim of this review is to summarize the use of FLIP for the evaluation and management of EGJOO. FLIP panometry provides measures of esophageal compliance at the EGJ and information on esophageal body contractile responses to balloon distention that have important implications for the management of patients with EGJOO. After excluding anatomic causes of impaired EGJ distensibility, FLIP panometry is useful in differentiating true lower esophageal sphincter dysfunction from manometric artifact. FLIP panometry has been shown to be useful in determining the need for invasive treatment in patients with EGJOO, and in intraoperative tailoring of myotomy procedures. FLIP panometry is easy to perform during endoscopy and provides useful information for characterizing the EGJOO population. FLIP panometry can be used to guide treatment and improve outcomes in the management of patients with EGJOO.

Patients with active venous leg ulcers at the time of iliac vein stenting require more reoperations

ObjectiveAn active venous leg ulcer (VLU) caused by lower extremity venous insufficiency is challenging to treat and will often recur after initially healing. In the present study, we compared the symptomatic outcomes and need for reoperation after iliac vein stenting (IVS) in patients with an active VLU (VLU+) and those without an active VLU (VLU−). MethodsA single-institution database of patients with chronic venous outflow obstruction who underwent IVS from August 2011 to June 2021 was analyzed. Symptoms were quantified using the venous clinical severity score. The patients were divided into two cohorts: those with (VLU+) and without (VLU−) VLUs. ResultsA total of 872 patients (71 VLU+ and 801 VLU−) were identified. Many of the demographics and comorbidities differed between the two cohorts, and these variables were included in the multivariable analysis. On univariate analysis, the VLU+ cohort was more likely to need a major reoperation (odds ratio, 1.94; 95% confidence interval, 1.01-3.52; P = .036). However, on multivariable analysis, the difference was not statistically significant (odds ratio, 1.17; 95% confidence interval, 0.55-2.40; P = .667). Additionally, the VLU+ cohort required a significantly greater mean total of reoperations (1.4 vs 1.0; P = .006) than the VLU− cohort. Comparatively, for patients who underwent at least one reoperation, the difference in the mean total number of reoperations was even greater for the VLU+ cohort (2.6 vs 1.8; P = .001). The results from the Kaplan-Meier log-rank test revealed no differences in the reintervention-free survival time (P = .980). Both cohorts experienced a durable mean reduction in the venous clinical severity score. The ulcer healing rates for the VLU+ cohort at 6, 12, 24, and 36 months were 38%, 47%, 52%, and 59%, respectively. The ulcer recurrence rates for the VLU+ cohort were 4%, 10%, 19%, and 30% at 6, 12, 24, and 36 months, respectively, with a median time to recurrence of 1.2 years. ConclusionsPatients with active VLUs who underwent a first reintervention after initial IVS, on average, required an additional reintervention.

Chicago classification v4.0 protocol improves specificity and accuracy of diagnosis of oesophagogastric junction outflow obstruction.

SummaryBackgroundChicago classification version 4.0 (CCv4.0) introduced stringent diagnostic criteria for oesophagogastric junction outflow obstruction (EGJOO), in order to increase the clinical relevance of the diagnosis, although this has not yet been demonstrated.AimsTo determine the prevalence of EGJOO using CCv4.0 criteria in patients with CCv3.0‐based EGJOO, and to assess if provocative manoeuvres can predict a conclusive CCv4.0 diagnosis of EGJOO.MethodsClinical presentation, high resolution manometry (HRM) with rapid drink challenge (RDC), and timed barium oesophagogram (TBE) data were extracted for patients diagnosed with EGJOO as per CCv3.0 between 2018 and 2020. Patients were then re‐classified according to CCv4.0 criteria, using clinically relevant symptoms (dysphagia and/or chest pain), and abnormal barium emptying at 5 min on TBE. Receiver operating characteristic (ROC) analyses identified HRM predictors of EGJOO.ResultsOf 2010 HRM studies, 144 (7.2%) fulfilled CCv3.0 criteria for EGJOO (median age 61 years, 56.9% female). Upon applying CCv4.0 criteria, EGJOO prevalence decreased to 1.2%. On ROC analysis, integrated relaxation pressure during RDC (RDC‐IRP) was a significant predictor of a conclusive EGJOO diagnosis by CCv4.0 criteria (area under the curve: 96.1%). The optimal RDC‐IRP threshold of 16.7 mm Hg had 87% sensitivity, 97.1% specificity, 95.7% negative predictive value and 91.3% positive predictive value for a conclusive EGJOO diagnosis; lower thresholds (10 mmHg, 12 mmHg) had better sensitivity but lower specificity.ConclusionCCv4.0 criteria reduced the prevalence of EGJOO by 80%, thereby refining the diagnosis and identifying clinically relevant outflow obstruction. Elevated RDC‐IRP can predict conclusive EGJOO per CCv4.0.

Symptom Relief and Reintervention after Iliac Vein Stenting Stratified by CEAP Clinical Classification

This study sought to evaluate long-term symptom relief and reintervention rates after iliac vein stenting (IVS) in patients with chronic venous outflow obstruction. A single-institution database of patients undergoing IVS from August 2011 to June 2021 was analyzed. Patients were stratified into three cohorts based on the clinical component of the clinical, etiology, anatomical, and pathophysiology (CEAP) classification: C3, C4, and C5/6. Symptoms were quantified using the venous clinical severity score (VCSS). Reintervention was defined as any procedure using venography. Edema, pigmentation, and ulceration progression-free survival as well as reintervention-free survival were assessed with Kaplan Meier analysis. Among 737 total patients, there were 435 C3, 206 C4, and 96 C5/6 patients. The C5/6 cohort had the highest percentage of patients undergo reoperation (36.4%). C5/6 patients yielded the poorest ulceration progression-free survival (P<0.001) while C3 patients had the poorest skin pigmentation progression-free survival (P=0.009). On adjusted analysis there was no significant difference in odds of reintervention between study cohorts. Mean composite VCSS scores were significantly different at each yearly post-operative follow-up visit up to 6 years. The present study is one of the largest investigations of long-term outcomes in IVS patients. Most patients with long-term follow-up experienced an improvement in their composite VCSS. CEAP clinical classification at the time of IVS had a significant influence on the likelihood and quantity of reintervention.

A Clinical Trial of Venous Stent Placement for Post-thrombotic Syndrome: Current Status and Pandemic-related Changes.

Patients with post-thrombotic syndrome (PTS) and iliac vein obstruction have lower extremity symptoms, activity limitation and impairment of health-related quality of life. Preliminary studies suggest that iliac vein stent placement, which eliminates venous outflow obstruction, may reduce the clinical severity of PTS. However, stent placement is associated with patient risk, inconvenience and cost. Therefore, the Chronic Venous Thrombosis - Relief with Adjunctive Catheter-directed Therapy (C-TRACT) trial was launched to rigorously assess the risk-benefit ratio of stent placement for the treatment of moderate or severe PTS. In the trial, patients in both treatment groups receive a high quality of multimodality PTS care that includes medical, compressive, and ulcer therapies. Due to the COVID-19 pandemic, the trial protocol and practices were modified to enhance the study feasibility while preserving its ability to answer its primary question. This review summarises the current status of the trial and the potential impact of the pandemic-related adaptations to future venous clinical practice and research.

Algorithm of surgical tactics and surgical treatment of cholelithiasis complicated by multiple choledocholithiasis

Objective: Biliary stone disease is now one of the most common diseases, affecting 10-20% of the world's population. One of the most important problems in biliary tract surgery is the treatment of choledocholithiasis, which occurs in 10 to 38% of biliary stone disease according to different authors. Our research has allowed us to outline the most rational ways of treating patients in modern conditions. In our research, we focus on “the golden mean'” - a combination of staged minimally invasive interventions and standard interventions. Aim of our study was to evaluate the results of postoperative complications using the developed algorithm of surgical tactics and choledochoduodenoanastomosis from a minimally invasive approach. Methods: Overall, 35 patients who underwent surgical treatment of cholelithiasis, cholangitis, benign genesis obstructive jaundice (BGOJ) were included to the study. All patients were divided into two groups (main group and comparison group) depending on the method of treatment used. The study group consisted of 17 (48.6%) patients who underwent bile outflow restoration of choledochal outflow obstruction of the terminal section (choledochodenoanastamosis according to the developed by us procedure (Kazakhstan patent №108142, Algorithm of diagnostics and surgical treatment tactics of benign genesis obstructive jaundice - Author's certificate № 24754. Control group consisted of 18 (51.4%) patients who underwent cholecystectomy, choledocholithiasis by Jurash-Vinogradov and applied conventional algorithm of diagnostics and treatment of multiple choledocholithiasis with benign genesis obstructive jaundice. We assessed complications of procedures according to Clavien-Dindo and pain intensity level using visual analog score in both groups. Results: When using the proposed algorithm and new methods of surgical treatment in patients in the study group the rate of complication was lower in the study group as compared to control group (p=0.04): there was no deficiency and bleeding from the anastomosis, while in control group they turned out to be in 1 case. Complications in the form of seroma in 2 cases and bleeding into the subcutaneous tissue of the postoperative wound were in 1 case, being the same as in control group. No mortality was recorded in any group. The pain level was lower in the study group as compared to control group (p&amp;lt;0.05). Conclusions: Thus, the application of our algorithm for the diagnosis and surgical tactics of treatment of obstructive jaundice of benign genesis makes it possible to determine the tactics of surgical treatment of patients with obstructive jaundice. The developed technique for the surgical treatment of choledocholithiasis in cholelithiasis ensures the restoration of bile outflow in the duodenum, normalizes its morphofunctional state, prevents the development of various postoperative complications, in particular, there was no leakage and bleeding from the choledochoduodenoanastomosis in the main group.

Very low birth weight infants with congenital heart disease: A multicenter cohort study in Japan

BackgroundThe frequency, mortality, and morbidity of very low birth weight (VLBW) infants with congenital heart disease (CHD) in Asian countries are limited. In addition, little is known about the risk factors of death in these infants. MethodsA retrospective, multicenter cohort study was conducted. VLBW infants with CHD born between 2006 and 2010, and followed to 5 years of age, were included in the analysis. Multiple logistic regression analysis was performed to identify the risk factors of death. ResultsAmong 3247 VLBW infants, 126 various CHDs (3.9 %) were identified. The most common lesions were ventricular septal defect, tetralogy of Fallot (TOF), and coarctation of the aorta/interrupted aortic arch, in that order. The proportions of left-sided and right-sided outflow obstruction (TOF, pulmonary stenosis) were 15.1 % and 15.9 %, respectively. Trisomy 18 and trisomy 13 were present in 32 (25.4 %) of 126 VLBW infants with CHD. Nine patients were lost to follow-up. Overall, 45 patients (35.7 %) died up to 5 years of age. Serious CHD [odds ratio (OR), 19.2; 95 % confidential interval (CI), 3.94–93.11; p < 0.0001], sepsis (OR, 42.3; 95 % CI, 5.39–332.22; p < 0.0001), chromosomal /named anomalies (OR, 7.50; 95%CI, 2.09–26.94; p = 0.001), and no-invasive treatments (OR, 9.89; 95%CI, 2.28–42.91; p = 0.001) were associated with death. On excluding chromosomal anomalies, twelve of 71 patients (16.9 %) died, and only sepsis (OR, 35.5, 95%CI, 2.63–477.1; p = 0.0008) was an independent risk factor. ConclusionsTrisomy 18 and trisomy 13 of chromosomal anomalies are frequently associated with VLBW infants with CHD. The mortality of VLBW infants with CHD is high, even when chromosomal anomalies are excluded. Sepsis has a significant impact on death in VLBW infants with CHD.

Ultrasound biomicroscopy of the equine iridocorneal angle.

The iridocorneal angle (ICA) is the major pathway of aqueous humour outflow from the anterior chamber of the eye. Ultrasound biomicroscopy (UBM) has been utilised to characterise the morphology of this drainage pathway in numerous species. UBM may allow for early recognition of aqueous humour outflow obstructions in horses, allowing for earlier recognition of risk for glaucoma, a vision-threatening and painful disease. UBM morphology of the normal equine ICA has yet to be described. To determine the ultrasonographic morphology of the equine ICA by UBM in standing sedated horses. In vivo experimental study. Thirty healthy adult horses underwent UBM of the ICA at four locations (superior, temporal, inferior, nasal) of each eye utilising standing sedation, topical anaesthesia and auriculopalpebral perineural anaesthesia. Anatomic structures were defined on ultrasound images through comparison to published histologic photomicrographs of the equine ICA. Ultrasound imaging of the ICA at all four locations was easily performed in standing, sedated horses. High-resolution images of the ICA allowed for identification of the pectinate ligament, corneoscleral trabecular meshwork (TM), uveal TM and supraciliary TM. Pupil size was midrange in all eyes, but was not strictly controlled. Lighting conditions not controlled. Various breeds included. In vivo UBM of the equine ICA is feasible and provides high-resolution images of the structures of the aqueous humour outflow pathway.

Urgent decompression of tension pneumomediastinum in a patient to relieve elevated intracranial pressure: a case report

Background: Timely recognition and intervention for venous outflow obstruction due to intrathoracic pathology are critical for controlling elevated intracranial pressure.Case Report: A 26-year-old man with pectus excavatum and a posterior fossa tumor requiring biopsy, decompression, and cerebrospinal fluid diversion developed pneumomediastinum following intubation with tension physiology and progressive elevation of intracranial pressure. Emergent tracheostomy was performed to decompress intrathoracic pressure, augment venous return, and ultimately expedite the patient’s definitive cancer therapy. Conclusion: Recognition of the mediastinal pathology leading to venous obstruction may be required for the management of malignant intracranial hypertension. Tracheostomy may be a means to decompress mediastinal pressure and augment venous outflow in rare cases of pneumomediastinum with tension physiology.

ESOPHAGEAL MANOMETRY PROFILE IN PATIENTS OF UPPER GASTROINTESTINAL SYMPTOMS IN WESTERN INDIA: A RETROSPECTIVE COHORT STUDY

INTRODUCTION: High-resolution esophageal manometry (HREM) is a technique to determine the pressure pattern which is a function of esophageal musculature and integrity of LES. The indications for HREM evaluation include evaluation of nonobstructive dysphagia, symptoms of regurgitation and noncardiac or atypical chest pain unexplained by endoscopic evaluation To analyse profile of esophageal motility disorders in patient presenting with refractoryAIM: gastroesophageal reflux disease (GERD), dysphagia and atypical chest pain in tertiary care centre in Western India METHODS: We enrolled patient presented with refractory GERD, dysphagia and atypical chest pain from Jan 2020 to March 2022 at Department of gastroenterology, National Institute of Medical College &amp; R, Jaipur. Upper GI endoscopy and high-resolution esophageal manometry was done in all patients Ineffective esophageal peristalsis,RESULTS: achalasia cardia, hypercontractile esophagus, fragmented peristalsis and esophagogastric junction outflow obstruction were common diagnosis made by high resolution esophageal manometry In our study ineffectiveConclusion: esophageal motility most common and achalasia cardia second most common diagnosis identified on esophageal manometry

Assessing the Hemodynamic Impact of Anterior Leaflet Laceration in Transcatheter Mitral Valve Replacement: An in silico Study.

BackgroundA clinical study comparing the hemodynamic outcomes of transcatheter mitral valve replacement (TMVR) with vs. without Laceration of the Anterior Mitral leaflet to Prevent Outflow Obstruction (LAMPOON) has never been designed nor conducted.AimsTo quantify the hemodynamic impact of LAMPOON in TMVR using patient-specific computational (in silico) models.MaterialsEight subjects from the LAMPOON investigational device exemption trial were included who had acceptable computed tomography (CT) data for analysis. All subjects were anticipated to be at prohibitive risk of left ventricular outflow tract (LVOT) obstruction from TMVR, and underwent successful LAMPOON immediately followed by TMVR. Using post-procedure CT scans, two 3D anatomical models were created for each subject: (1) TMVR with LAMPOON (performed procedure), and (2) TMVR without LAMPOON (virtual control). A validated computational fluid dynamics (CFD) paradigm was then used to simulate the hemodynamic outcomes for each condition.ResultsLAMPOON exposed on average 2 ± 0.6 transcatheter valve cells (70 ± 20 mm2 total increase in outflow area) which provided an additional pathway for flow into the LVOT. As compared to TMVR without LAMPOON, TMVR with LAMPOON resulted in lower peak LVOT velocity, lower peak LVOT gradient, and higher peak LVOT effective orifice area by 0.4 ± 0.3 m/s (14 ± 7% improvement, p = 0.006), 7.6 ± 10.9 mmHg (31 ± 17% improvement, p = 0.01), and 0.2 ± 0.1 cm2 (17 ± 9% improvement, p = 0.002), respectively.ConclusionThis was the first study to permit a quantitative, patient-specific comparison of LVOT hemodynamics following TMVR with and without LAMPOON. The LAMPOON procedure achieved a critical increment in outflow area which was effective for improving LVOT hemodynamics, particularly for subjects with a small neo-left ventricular outflow tract (neo-LVOT).

Isolated posterior mitral leaflet elongation-related dynamic left ventricular outflow obstruction.

Isolated posterior mitral leaflet elongation-related dynamic left ventricular outflow obstruction.

Endovascular treatment of proximal venous outflow obstructions in patients with arteriovenous fistula: Our single-center experience

Endovascular treatment of proximal venous outflow obstructions in patients with arteriovenous fistula: Our single-center experience

Evaluation of Lower Urinary Tract Symptoms suggestive of Benign Enlargement of the Prostate by Uroflowmetry and American Urological Association Symptom Score

Background: Uroflowmetry study is a non-invasive, simple, and inexpensive preliminary the diagnostic tool of various lower urinary tract diseases like benign prostatic hyperplasia, stricture the urethra, neurogenic bladder, etc. American Urological Association Symptom Score is the single a most important tool used in the evaluation of patients with Benign prostatic hyperplasia (BPH) and is recommended for all patients before initiation of therapy. Objectives: To evaluate lower urinary tract symptoms suggestive of Benign Enlargement of Prostate by Uroflowmetry study, measuring American Urological Symptom Score, Quality of life, and to find out correlation among Uroflowmetry parameters, age. Materials and Methods: This is a prospective study to evaluate 13 patients with lower urinary tract symptoms suggestive of benign enlargement of the prostate by performing a Uroflowmetry test. We also measured the level of symptoms by American Urological Association Symptom Score and quality of life of age group 48 to 71 years. Selected patients have gone under Uroflowmetry study recorded American Urological Association Symptom Score and quality of life by few questionnaires. Results: The mean age of the patients was 58.92+/-6.93 SD year. The mean maximum flow rate and average flow rate were found to be 16.44 and 6.99 ml/sec respectively. Voiding time and voided volume of urine was 74.53+/-44.94 SD sec, and 412.38+/- 255.66 SD ml respectively. The maximum flow rate and age were negatively correlated(R=-0.551). Time of maximum flow rate and amount of voided urine was strong positively correlated(R=0.8717, p&lt;0.05). Voiding time and voided volume were positively correlated (p&lt;0.05).Regarding American Urological Association Symptom Score, 53.85% of patients had severe symptoms. The mean American Urological Association Symptom Score of severe and moderate symptomatic patients were 25.14+/-3.48 SD, and 14.67+/-3.77 SD respectively. For patients of Uroflowmetry studied, 76.92% had prolonged voiding time, and 23% had normal voiding time in comparison with a normal nomogram.14 Conclusions: The uroflowmetry test and American Urological Association Symptom Score are helpful for preliminary evaluation of lower urinary tract symptoms suggestive of benign enlargement of the prostate and for further treatment. Prolong voiding time and decrease maximum flow rate can give clues for outflow obstruction for benign enlargement of the prostate. KYAMC Journal Vol. 13, No. 01, April 2022: 45-49

Complex case of granulomatosis with polyangiitis involving the urethra and prostate causing outflow obstruction and ano-urethral fistula

Granulomatosis with polyangiitis (GPA) is an autoimmune small to medium vessel inflammatory vasculitis that can affect multiple organ systems, with predominantly pulmonary, renal and musculoskeletal manifestations. Rarely, there have been cases involving the genitourinary system, particularly causing urethritis and prostatitis. In some incidences, this may mimic prostate abscess or malignancy. We present a case of a 36-year-old man with refractory urinary retention secondary to prostate abscess due to GPA. This case necessitated transurethral resection of the prostate (TURP) and supra-pubic catheterisation, later complicated by a peri-anal abscess and severe urethritis. A potential recto-urethral fistula was noted on magnetic resonance imaging (MRI) and cystourethroscopy, which was managed conservatively with long-term catheter drainage until resolution. The patient ultimately displayed many severe clinical manifestations of a systemic vasculitis and this case report emphasises the importance of considering autoimmune vasculitis conditions as a differential diagnosis when managing inflammatory genitourinary conditions. This case report highlights the importance of obtaining sufficient tissue to make a timely diagnosis in order to initiate immunosuppressant therapy and disease-modifying anti-rheumatic drugs (DMARDs).

Hepatic Venous Outflow Obstruction in Adult Deceased Donor Liver Transplantation: Classic Piggyback Implantation Versus a Modified Technique that Widens the Ostium of the Recipient's Left and Middle Hepatic Veins

The classic piggyback technique uses the union of the 3 hepatic veins to perform the cavo-caval anastomosis. However, due to the lateral localization of the right hepatic vein, the partial clamping of the vena cava in this technique significantly reduces the venous return to the right atrium. To avoid this, we adopted in 2015 a modified piggyback technique, in which we use the common trunk of the middle and left hepatic veins and also perform a lateral incision toward the right in the anterior wall of the vena cava in order to widen the final ostium of the cavo-caval anastomosis. The aim of the study was to analyze the incidence of hepatic venous outflow obstruction between those 2 techniques. Retrospective study of liver transplant recipients undergoing venography for suspected hepatic venous outflow obstruction from January 2009 to June 2021. Patients undergoing transplantation with living donors or split grafts and pediatric cases were excluded from the study. From January 2009 to December 2014 and from January 2015 to June 2021, 587 (group 1) and 730 (group 2) deceased-donor liver transplants were performed with the classic and the modified piggyback techniques, respectively. The incidence of cases with suspected hepatic venous outflow obstruction in groups 1 and 2 were 1.87% (n=11) and 0.95% (n=7), respectively (P=0,15). The number of confirmed patients with outflow blockage that required endovascular treatment during venography in groups 1 and 2 were 4 (0.68%) and 5 (0.68%), respectively (P=0,31). This modified piggyback technique did not increase the incidence of hepatic venous outflow obstruction at our service.