Postoperative Obstruction Research Articles

Augmentation of the posterior pharyngeal wall with autologous tragal cartilage for management of velopharyngeal valve insufficiency in adults

ObjectiveThe study aims to evaluate posterior pharyngeal wall augmentation using autologous tragal cartilage graft in adults with velopharyngeal valve insufficiency (VPI). MethodsThe study included 23 patients with VPI (grade I, II, III), with ages ranging from 19 to 45 years. Six patients had previously undergone simple palatoplasty for cleft palate, 8 patients had previously undergone adenotonsillectomy and 9 patients had previously undergone uvulopalatopharyngoplasty (UPPP). The procedure was done by implanting a piece of autologous tragal cartilage in the posterior pharyngeal wall. Patients were followed up for 24 months postoperatively. The evaluation of percent of speech intelligibility and grade of the closure of the velopharyngeal valve using video-nasopharyngoscopy was evaluated preoperatively and postoperatively. ResultsHighly statistically significant improvement in the grade of the closure of the velopharyngeal valve (P = 0.009) and percent of intelligibility (P = 0.001) was found after surgery. There were no postoperative airway obstruction or sleep apnea. ConclusionAugmentation of the posterior pharyngeal wall using tragal cartilage is an effective, safe and physiological surgical procedure in the management of VPI in adults who suffered hypernasality following palatal and oropharyngeal surgeries.

Ethmoid Sinus Mucosal and Lacrimal Sac Flap Anastomosing in Patients With Failed Dacryocystorhinostomy.

The aim of this work is to demonstrate the outcomes of endonasal dacryocystorhinostomy (En-DCR) with anterior ethmoid sinus mucosal and posterior lacrimal sac flap anastomosing in patients with previous failed DCR. The clinical data of patients who suffered from recurrent epiphora after failed DCR between September 2014 and March 2018 were reviewed retrospectively. Among them, those who received the second En-DCR procedure were enrolled in this study. During the surgery, anterior ethmoidectomy was performed. Posterior lacrimal sac flap was apposed closely to the mucosal of anterior ethmoid sinus instead of nasal flap at end of the surgery. Patients were followed up more than 12 months were included, the success rate and complications were recorded. Sixty-one eyes of 61 patients were enrolled in the study. The success rate of our modified En-DCR was 83.6% (51/61). Among 10 eyes with postoperative obstruction, 4 eyes caused by granuloma, 2 eyes caused by scar synechia, 2 eyes caused by membranous obstruction, and 2 eyes caused by common canalicular stenosis. No serious complications such as orbital fat prolapse, cerebrospinal fluid leak, sinusitis, or visual impairment were occurred in this study. Endoscopic approach with anterior ethmoid sinus mucosal and posterior lacrimal sac flap anastomosing is a good choice for patients with recurrent epiphora after previous failed DCR.

Comparative Analysis of Semi Rigid Ureterolithotripsy and Extracorporeal Shock Wave Lithotripsy for the Treatment of Upper Ureteric Calculi

Objectives: To find out the better treatment option between semi rigid ureteroscopy with ICPL and ESWL for upper ureteric calculi. To compare stone free rate, complications and re treatment between ureterolithotripsy and ESWL in upper ureteric calculi. Materials and Method: This prospective comparative study was conducted in the department of urology BSMMU and Kidney and urology hospital, Dhaka from June 2009 to May 2010. Fifty patients were enrolled and 25 on each group as ESWL and ICPL Inclusion criteria was adult patients with single radiopaque stone of 06-15 mm, and no obstruction distal to stone. We exclude Stone size > 1.5cm, PUJ stone, patients with DJ stent and nephrostomies, infection, pregnancy, hemostatic, disorders, and morbid obesity. Identified postoperative urological complications pain, haematuria, fever, stone migration, obstruction, infections, and postoperative hospital stays recorded accordingly. X- ray KUB and in some cases ultrasound of kidney ureter and bladder with prostate with PVR were done. Those with residual calculi sized less than 2 mm were considered stone free. Those patients whom stone not cleared or stone migrated they again sent for ESWL or ureterolithotripsy. Stone free patient of ureterolithotripsy sent for removal of Double J stent under local anesthesia at 4 weeks. Results: Three months postoperatively, 21 out of 25 Patients (85%) in the ureterolithotripsy group were stone free. In ureterolithotripsy group, all failures were due to upward calculus migration. After calculus migration, this was mandated double- J stenting and send for ESWL. These patients were referred for ESWL, all of whom were stone free after this procedure. DJ stent removed under local anesthesia. 22 out of 25 Patients (88%) in the ESWL group were stone free and 10 patients need two sessions. Re-ESWL had done after 3 weeks. All failures in ESWL group were due to hard in constancy and small stone size. Failed cases were referred for ureterolithotripsy and DJ stenting, all of whom were stone free after this procedure. Using statistical data by chi square test and analytical test level of significance as set at 0.05 and p< 0.05 was consider significant. Conclusion: Upper ureteral calculi up to 1.5 cm can be safely and effectively managed by using semi rigid ureteroscopy and pneumatic lithotripsy. However, the ESWL approach has still its role in treating upper ureteric calculi. Finally, postoperative home rest in the ESWL group was more due to the repeated treatment. Bangladesh Journal of Urology, Vol. 20, No. 2, July 2017 p.54-60

Predictive Nomogram for the Necessity of Tracheotomy During Oral and Oropharyngeal Cancer Surgery.

The individualized risk of airway obstruction after head and neck cancer surgery is unclear, especially oral and oropharyngeal cancer. The study aimed to establish an individualized predictive model for the necessity of temporary tracheotomy in these patients. Patients who underwent oral and oropharyngeal cancer surgery from 1999 to 2019 were retrospectively reviewed. A nomogram was developed and validated in patients treated from 1999 to 2009 and 2010 to 2019, respectively. In total, 1551 patients were included. Oropharyngeal cancer, large tumor, midline crossing, preoperative radiation, mandibulectomy, flap reconstruction, and neck dissection were independent risk factors of postoperative airway obstruction in the training group (n = 707). A nomogram incorporating these factors had a C-index of 0.931 and was validated in the testing group (n = 844) (C-index, 0.918). Good calibration curves were observed in both groups. The nomogram successfully predicted the individual risk of postoperative airway obstruction for patients with oral and oropharyngeal cancer. 4. Laryngoscope, 131:E1489-E1495, 2021.

Non-invasive evaluation of obstruction after ureteroscopic stone removal: Role of renal resistive index assessment

The aim of this study is to evaluate prediction of postoperative ureteral obstruction needing ureteral stent insertion by evaluating the resistive index (RI) values and the grade of hydronephrosis. A total of 66 adult patients undergoing stentless endoscopic ureteral stone treatment (URS) between January 2018 and January 2019 were included in this prospective study. Preoperative patient and stone characteristics were noted. All patients were evaluated with renal Doppler ultrasonography study to assess degree of hydronephrosis and RI values. A renal Doppler ultrasonography was repeated at postoperative 1st, 3rd and 7th days. Changes in both RI and hydronephrosis levels before and after the procedures were noted. On the postoperative 7th day, patients were divided into two groups including obstructive and non-obstructive cases according to RI values assessed where a RI value of 0.7 was accepted as the cut-off for obstruction. The preoperative and perioperative characteristics of both groups were evaluated in a comparative manner. The mean patient age was 43.6 ± 1.72 years. Significant improvements were noted in RI and grade of hydronephrosis after the operation. The grade of hydronephrosis and RI values were found to improve more significantly on postoperative 3rd day when compared to the postoperative 7th day (p < 0.01 and p < 0.01). A significant correlation was detected between the grade of hydronephrosis (>grade 2) and obstructive RI values (> 0.7) in each postoperative visits (p: 0.001). RI values (> 0.7) at postoperative seventh days were correlated with larger mean stone size, increased ureteral wall thickness, increased diameter of the ureter proximal to the stone, and longer duration of the operation. Preoperative high-grade hydronephrosis indicated obstructive RI values at postoperative seventh day (p = 0.001) Conclusion: Changes in RI values on Doppler sonography and the grade of hydronephrosis may be a guiding parameter in assessing postoperative ureteral obstruction.

Analysis of surgical effect on middle ear cholesterol granuloma

Objective:To evaluate surgical effects on middle ear cholesterol granuloma（CG）. Method:The patients receiving surgery due to middle ear CG were retrospectively analyzed. The choice of operative methods was made according to medical history, endotoscope, pure-tone audiometry and temporal bone CT. Tympanostomy tube（TT） insertion was performed on 12 patients; canal wall up（CWU） tympanoplasty combined with tympanostomy tube was performed on 40 patients, and canal wall down（CWD） tympanoplasty combined with TT on 14 cases. The pre-and postoperative audiometric results（500, 1000, 2000 and 4000 Hz） were evaluated for each patient. Then the average air-bone gap（ABG） was analyzed. Result:One patient had postoperative tube obstruction. One patient who performed only TT insertion recurred. Secretory otitis media occurred in one case undergoing CWU tympanoplasty after removal of the ventilation tube. For TT insertion group, pre-and postoperative ABG levels were （21.25±5.96） dB and （8.85±6.49） dB, respectively（P<0.01）. For CWU+TT group, pre-and postoperative ABG levels were （34.19±10.43） dB and （23.55±12.48） dB, respectively（P<0.01）. For CWD+TT group, pre-and postoperative ABG levels were （36.43±12.11） dB and （25.71±13.50） dB, respectively（P<0.01）. Conclusion:The aim of surgical treatment for middle ear CG includes thorough removal of lesions, improvement of ventilation and drainage of middle ear. Individualized surgical strategy should be adopted according to the patients' conditions. And long-term follow-up should be done after operation.

S2046 Pseudo Pseudo? Chronic Intestinal Pseudo-Obstruction Presenting as Mechanical Obstruction and Recurring Despite Surgery

INTRODUCTION: Chronic intestinal pseudo-obstruction (CIPO) is a rare, characterized by chronic abdominal pain with intermittent exacerbations of bowel obstruction. An attempt to surgically remove an apparent involved segment is often not recommended and is associated with potentially worse long term outcomes. CASE DESCRIPTION/METHODS: A 72 year old man, with a history of pre-diabetes and chronic constipation had first presented 5 years ago with abdominal pain. CT showed evidence of marked redundancy and gaseous distention of the sigmoid colon without evidence of mechanical obstruction. He was diagnosed with sigmoid volvulus and laparoscopic sigmoid colectomy was performed. Thereafter, he was presumably thought to have an acute exacerbation of colonic pseudo-obstruction, for which he had an elective subtotal colectomy performed. 4 months after surgery, the patient presented to our ER with abdominal pain and distention. CT showed marked gaseous distention of small bowel loops and the stomach with no evidence of structural obstruction. The patient was kept NPO and was decompressed with a nasogastric and rectal tube. Prokinetic erythromycin was started. Interval CT documented decompressed stomach, improvement in gaseous distention of small bowel loops although measuring up to 6.1 cm. DISCUSSION: CIPO is rare, with prevalence and incidence estimated to be 0.9 and 0.23 cases per 100,000, respectively. Either secondary or idiopathic, 3 underlying pathologic entities suggested for CIPO: neuropathic, myopathies or mesenchymopathy. Imaging revealing dilated small or large bowels in the abscess of anatomical obstruction is required for the diagnosis. Impaired motility supports the diagnosis. Rarely, CIPO might present with an actual anatomical obstruction, especially in the setting of previous abdominal surgeries, masking or delaying the diagnosis. Proper diagnosis of CIPO is crucial, as the mainstay of management remains treating the underlying primary condition. Despite segmental appearing disease, an attempt to selectively remove the affected area is ill-advised, as it might promote post-operative mechanical obstruction, proven inefficacious in preventing pseudo-obstruction of other segments with a probabilities of CIPO-related re-operation of 66% after 5 years. This case demonstrates the complexity of CIPO diagnosis when newly presenting with mechanical obstruction and the ineffectiveness of colectomy in preventing further exacerbations.Figure 1.: CT showing gastric pneumatosis and marked distention of the stomach containing fluid, debris, and gas with no evidence of structural obstruction from the stomach.Figure 2.: CT showing gaseous distention of small bowel loops without sharp transition point.

Laparoscopic Versus Open Pyeloplasty for Management of Secondary Ureteropelvic Junction Obstruction

Background: Ureteropelvic junction obstruction (UPJO) causes hydronephrosis and progressive renal impairment may ensue if left uncorrected. Open pyeloplasty remains the standard against which new techniques must be compared. Objective: To evaluate the laparoscopic management of secondary pelvi-ureteric junction obstruction regarding the operative time. Bleeding requiring blood transfusion intraoperative complication, hospital stays short- and long- term complication, and the rate of success in comparison to open repair in literature. Patients and methods: This study was conducted at the Urology Department of Aswan and Sohag University Hospitals. In the period from April 2016 to April 2020, a total of forty-five patients with secondary PUJ obstruction fulfilling the inclusion criteria were admitted for undergoing laparoscopic pyeloplasty. Results: The median follow-up period was 24 months (6-36 months). The mean of operative time (LPP) was 154.9± 25.4 minutes, ranged from 80 to 185 minutes, and the mean of blood loss was 77.8±32.8 ml, ranged from 30 to 190 ml. The mean value of hospital stay of our patients was 3.8±1.2 days, ranging from 2 to 7 days, and the mean of follow-up was 5.6±2.15 months, ranged from 3 to 24 months. During the follow up there were three patients who experienced postoperative obstruction, our success rate was 93.3%. Conclusion: Laparoscopic pyeloplasty regarding cost-effectiveness, success rate, complications, and outcome the disadvantages of longer operative time of laparoscopi pyeloplasty, and the long learning curve, is more superior to open pyeloplasty in shorter hospital stay, early convalescence, and low postoperative analgesic requirements.

Laparoscopic Versus Open Pyeloplasty for Management of Secondary Ureteropelvic Junction Obstruction

Background: Ureteropelvic junction obstruction (UPJO) causes hydronephrosis and progressive renal impairment may ensue if left uncorrected. Open pyeloplasty remains the standard against which new techniques must be compared. Objective: To evaluate the laparoscopic management of secondary pelvi-ureteric junction obstruction regarding the operative time. Bleeding requiring blood transfusion intraoperative complication, hospital stays short- and long- term complication, and the rate of success in comparison to open repair in literature. Patients and methods: This study was conducted at the Urology Department of Aswan and Sohag University Hospitals. In the period from April 2016 to April 2020, a total of forty-five patients with secondary PUJ obstruction fulfilling the inclusion criteria were admitted for undergoing laparoscopic pyeloplasty. Results: The median follow-up period was 24 months (6-36 months). The mean of operative time (LPP) was 154.9± 25.4 minutes, ranged from 80 to 185 minutes, and the mean of blood loss was 77.8±32.8 ml, ranged from 30 to 190 ml. The mean value of hospital stay of our patients was 3.8±1.2 days, ranging from 2 to 7 days, and the mean of follow-up was 5.6±2.15 months, ranged from 3 to 24 months. During the follow up there were three patients who experienced postoperative obstruction, our success rate was 93.3%. Conclusion: Laparoscopic pyeloplasty regarding cost-effectiveness, success rate, complications, and outcome the disadvantages of longer operative time of laparoscopi pyeloplasty, and the long learning curve, is more superior to open pyeloplasty in shorter hospital stay, early convalescence, and low postoperative analgesic requirements.

Success of Custommade Transobturator Slings Prepared From Conventional Polypropylene Mesh in the Treatment of Stress Urinary Incontinence in Women

Objective: To observe the outcome of the transobturator tape, using custommade slings prepared from conventional polypropylene mesh in women in management of SUI. Materials and Methods: This prospective observational study was carried out from June 2010 to April 2015 among 35 patients who underwent the TOT procedure using handmade (polypropylene monofilament) slings; and complete at least the 12 month follow up period. Medical history, demographic characteristics, body mass indexes (BMI), menopausal status of patients, operation time, cost of sling, success of operation and complications were recorded. Before the operation, all patients were confirmed SUI through physical examination, urinalysis, urodynamic studies and ultrasonography. Placement of the sling to the midurethra was done in manner as described by Delorme. All the data were analyzed. Results: There were 35 patients with mean age 51.23 ± 5.63years, BMI 26.14 ± 3.70 kg/m². Twenty of the patients post were menopausal. The cost of the sling was 1200 BDT (15 USD). The success rate of TOT 12 months after surgery and at the last follow up was 91.5% and 88.6% respectively. Postoperative obstruction was noted in 2 patients, vaginal extrusion occurred in one case, de novo urgency and urinary tract infection (UTI) occurred in 2 patients. All of them were managed successfully with conservative treatments. There was no other early or late postoperative complication. There was significant improvement of the QoL and statistically no significant decrease in the Q max during the follow up period. Conclusion: Custommade mesh is a reasonable option in TOT surgery with good efficacy and cost effectiveness and complication like vaginal extrusion is also minimum. Bangladesh Journal of Urology, Vol. 18, No. 2, July 2015 p.49-55

Solving the problem of post-operative airway obstruction in Nasal/Sinus Surgery

Sinus surgery, septoplasty—with or without turbinate reduction—and rhinoplasty are among the most common surgical procedures performed by our specialty.

Mid-term results of modified L-shaped incision technique for supracardiac total anomalous pulmonary venous connection.

Surgical outcomes of supracardiac total anomalous pulmonary venous connection (TAPVC) repair by the posterior technique (PT) remain unsatisfactory. This study aimed to compare the outcomes of the modified L-shaped incision technique with the PT for supracardiac TAPVC repair. From January 2009 to December 2019, 121 consecutive patients with supracardiac TAPVC undergoing surgical repair in our institution were included (L-group, n = 53; PT group, n = 68). A propensity score-matched analysis was performed. Patients with single-ventricle physiology or atrial isomerism were excluded. All clinical data were retrospectively analysed. In the unmatched cohort, the median follow-up duration was 33 months (interquartile range 26-65 months). There were 5 operative mortalities (4.1%) and 12 late mortalities (9.9%). Postoperative pulmonary venous obstruction (PVO) was documented in 21 patients. After matching (52 pairs), the overall survival rate in the L-group was 88.2% at both 3 and 5 years. For the propensity score-matched patients with preoperative PVO (n = 20), statistically significant differences (P = 0.002) were found by Kaplan-Meier curves with freedom from death and postoperative PVO at 1 and 3 years of 100% and 85.7% [standard deviation (SD): 13.2%] in the L-group and 90% (SD: 9.5%) and 22.9% (SD: 14.1%) in the PT group, respectively. Multivariable analysis revealed that the use of the PT was an independent risk factor for death and postoperative PVO (hazard ratio 4.12, 95% confidence interval 1.12-15.16; P = 0.03). The modified L-shaped incision technique provided an acceptable outcome for supracardiac TAPVC repair. Compared with PT, the modified L-shaped incision technique was significantly associated with decreased death and postoperative PVO in patients with obstructed supracardiac TAPVC.

Transhepatic stent placement for portal vein obstruction after hepatobiliary and pancreatic surgery: long-term efficacy and risk factor for stent failure.

To evaluate the long-term efficacy of transhepatic portal vein (PV) stent placement in patients with postoperative PV obstruction and to identify risk factors for stent failure. Between January 2007 and October 2019, percutaneous transhepatic PV stent placement was attempted in 60 patients with postoperative PV obstruction. Technical and clinical success, complications, and stent patency were retrospectively evaluated. Thirteen clinical variables were analyzed to determine risk factors for stent failure. Stent placement was technically successful in all patients. Thromboaspiration (n = 19) and jejunal variceal embolization (n = 7) were performed in the same session. Clinical symptoms related to portal hypertension were resolved in 54 patients (90.0%). There was no procedure-related complication. During the follow-up period (mean 630 days), stent failure occurred in 13 patients. One- and 5-year stent patency rate was 74.8% and 64.9%, respectively. The presence of a pancreatic fistula was the only independent risk factor associated with stent failure (HR 7.54; 95% CI 2.02-28.10, p = 0.003). Percutaneous transhepatic PV stent placement is a technically feasible and effective treatment for postoperative PV obstruction. The pancreatic fistula is a risk factor for stent failure. • Percutaneous transhepatic stent placement is an effective treatment to improve portal hypertension-related symptoms in patients with portal vein obstruction after hepatobiliary and pancreatic surgery. • The pancreatic fistula is an independent risk factor for portal vein stent failure.

Bilateral mucosal flap septal perforation repair in the adolescent

IntroductionPerforations of the nasal septum are rare in the pediatric age group. High success rates for attempted perforation closure utilizing mucosal flap techniques in adults are frequently reported. This study reviews our experience with pediatric patients diagnosed with a septal perforation who underwent attempted closure during adolescence. Our endonasal bilateral mucosal flap technique is present. MethodsThis study is an observational case series with retrospective chart review of a single surgeon's experience of attempted septal perforation repair utilizing bilateral mucosal flaps with an interposition graft in patients diagnosed with a perforation prior to age 19. The study period was from November 1991 to April 2019. Patient demographics, perforation characteristics (etiology, symptoms and size), surgical closure technique and outcomes are presented. ResultsTwenty-three patients (13 females) met the study criteria. Mean age at diagnosis was 14.3 (range, 3–18) years. Crusting (82.6%), nasal obstruction/congestion (60.9%) and epistaxis (47.8%) were the most frequent reported symptoms at presentation. Fourteen patients who underwent attempted closure during adolescence had a minimum of three months follow-up. Mean age at the time of bilateral mucosal flap repair was 17.4 (range, 13–19) years. Mean perforation length was 14.2 (range, 8-22) mm and mean height 10.6 (range, 5-15) mm. Complete closure was noted in all but one patient (92.8%) at the time of last follow-up, mean 16.9 (range, 3–92) months. Every patient noted partial to complete resolution in presenting symptoms. Four patients required revision surgery to address persistent postoperative obstruction. ConclusionOur experience demonstrates septal perforation repair utilizing a bilateral mucosal flap technique can be successfully employed in the adolescent patient.

Straws Don't Suck: Are Straws Dangerous after Endoscopic Skull Base Surgery?

Objective Patients undergoing endoscopic endonasal surgery have historically been restricted from using straws postoperatively, due to the concern that this activity generates negative pressure. The objective of this study is to evaluate the pressure dynamics in the sinonasal cavity associated with the use of a straw. Methods Intracranial pressure catheters were placed in the nasal cavity of 20 healthy individuals. Pressure measurements were then recorded while participants drank liquids of different viscosities from a cup and from a straw. Measurements were recorded with and without subjects occluding their nose to simulate postoperative nasal obstruction. Results The average pressure in the nasal cavity while drinking water from a cup was -0.86 cmH 2 O, from a straw was -1.09 cmH 2 O, and while occluding the nose and using a straw was -0.81 cmH 2 O. The average pressure in the nasal cavity while drinking a milkshake from a cup was -0.98 cmH 2 O, from a straw was -1.88 cmH 2 O, and while occluding the nose and using a straw was -1.37 cmH 2 O. There was no statistically significant difference in pressure measurements when comparing either task or consistency ( p > 0.05). Conclusion Straw use is not associated with the generation of significant negative pressure in the nasal cavity. The pressure generated when drinking from a straw is not significantly different from that of drinking from a cup. This data suggest that straw use may be safe for patients following endoscopic skull base surgery, but further investigation is warranted.

Scimitar syndrome: A new multipatch technique and incidence of postoperative pulmonary vein obstruction.

ObjectiveA review of our center's experience before March 2011 showed that one half of 36 patients who had a baffling or reimplantation procedure to repair scimitar syndrome developed pulmonary vein obstruction. We analyzed the results of a new operation that enlarges the left atrium and avoids circuitous pathways or tension on the scimitar pulmonary vein.MethodsBetween April 2011 and November 2018, 22 patients underwent scimitar vein surgery; 11 had baffling or reimplantation and 11 only had the new operation that included resection of the atrial septum with removal of the muscular limbus. The left atrium was pulled down toward the scimitar vein and a V-shaped incision made at the scimitar vein atrial junction with the space filled with a pulmonary homograft. If the scimitar vein coursed adjacent to the atrium, a V-shaped incision was made into the scimitar vein and directly anastomosed to the atrium. A patch of autologous pericardium was used to septate the atrium and an additional patch placed anteriorly to augment the inferior vena cava.ResultsOf the 11 patients who had baffling or reimplantation, 5 developed pulmonary vein obstruction between 45 days and 9.5 months after surgery associated with baffle thrombosis or tension on the pulmonary vein. None of the 11 patients who only had the new procedure developed pulmonary vein obstruction during postoperative monitoring up to 3.6 years.ConclusionsPatients having only the multipatch procedure for repair of scimitar syndrome have not developed postoperative pulmonary vein obstruction in the short to intermediate term.

Transcatheter mitral valve replacement (TMVR): annular or apical fixation?

The aim of this study was to evaluate the impact of two different transcatheter mitral valve replacement (TMVR) fixation strategies on the neo left ventricular outflow tract (neo-LVOT) and aorto-mitral angulation (AMA) after TMVR. Two different self-expanding nitinol valved stents were developed for transapical TMVR. In one group, the stents were fixed with an annular fixation system (ANN group, n=6). These prototypes were compared with an apical tether fixation TMVR system (AP group, n=11) in another group. Echocardiographic evaluation of the AMA and the neo-LVOT was conducted before and one hour after implantation. Maximal and minimal AMA (AMAmax and AMAmin) during the cardiac cycle of the AP group were significantly narrower than those of the ANN group (AMAmax: 39±8° vs 67±15°, p<0.001, AMAmin: 33±10° vs 56±22°, p=0.009). More severe reduction of the neo-LVOT diameter was observed in the ANN group (60±11% vs 26±14%, p<0.001). The ANN group had a higher peak velocity through the neo-LVOT post implantation (200±52 cm/s vs 108±15 cm/s, p<0.001). The apical fixation system maintains a smaller and more stable aorto-mitral angulation and a larger neo-LVOT, thereby reducing the risk of postoperative neo-LVOT obstruction in this experimental setting.

Evaluation of urethral orifice cross-section dimensions following perineal urethrostomy in male cats.

The aims of this study were: (1) To evaluate the urethral orifice cross-section size immediately and 12 days post-operatively following a perineal urethrostomy procedure. (2) To assess the correlation between the cross-section size and stricture formation during a 6-month period following the perineal urethrostomy. Twenty-four male cats with feline lower urinary tract disease that failed to respond to medical treatment and underwent perineal urethrostomy. The urethral orifice cross-section size was estimated by the largest size of the urinary catheter that was possible to insert facilely through the urethrostomy site. The urethral orifice cross-section size was measured in three different times: Pre-operative (LUCpr), immediately post-operative (LUCi) and 12 days post-operative (LUCp). Urinary obstruction recurrence and urethrostomy site stricture formation were documented for 6months after the surgical procedure. The probabilities for obstruction recurrence in cases of LUCi ≤ 8Fr and LUCi> 8Fr were calculated. Urinary obstruction and urethrostomy site stricture occurred in 5 of 24 (~20%) of the operated cats at an average of 92 ± 25 days post-perineal urethrostomy. LUCi ranged from 6 to 10 (median 10) Fr and the LUCp ranged from 4 to 10 (median 8) Fr. There was a significant decrease of 0.15 ± 0.09 mm2 of the urethral orifice cross-section area 12 days post-operative compared to the measurements taken immediately post-operative. The probabilities for post-operative urinary obstruction of the LUCi ≤ 8Fr cases (intra-operative urethral orifice cross-section area equal or larger than 5.5 mm2 ) and in the LUCi> 8Fr cases were 44 and 6%, respectively. Recurrence of obstruction was documented in all cases (three cats) in which LUCi was 6Fr. The largest size of the urinary catheter that is possible to insert during surgery is a simple method to evaluate urethrostomy cross-section size. Contraction of the urethral orifice diameter is expected during the wound healing phase. Post-operative urinary obstruction is more likely in cases where LUCi < 8Fr.

Functional Outcomes of Septal Extension Grafting in Aesthetic Rhinoplasty: A Cohort Analysis.

Background: Septal extension grafts (SEGs) are used widely in rhinoplasty as a means of controlling tip position. Grafts positioned in a side-to-side configuration may cause nasal airway obstruction. Methods: Retrospective cohort analysis of patients undergoing cosmetic rhinoplasty. Patients undergoing SEG placement were grouped according to completion of the Nasal Obstruction Symptom Evaluation (NOSE) or Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS). The latter has a cosmetic (C) and functional (O) domain. Each group was matched to a cohort that did not undergo SEG placement using criteria: preoperative NOSE or SCHNOS-O score, age, and gender. Patient demographics and outcomes, including NOSE, SCHNOS, and visual analog scale (VAS) scores, were compared between SEG and no-SEG groups using univariate and multivariate analyses. If patients underwent placement of an SEG and complained of obstruction, the laterality of the graft in relation to the complaint was examined. Results: SEGs were placed in 79 patients, of whom 77 completed the NOSE survey and 37 completed the SCHNOS-O both pre- and postoperatively. These patients were matched to patients without SEGs. For both the SCHNOS and NOSE-matched cohorts, functional outcomes (NOSE, SCHNOS-O, and VAS-F) did not significantly differ between SEG and no-SEG groups. These findings were also observed when patients were stratified by cosmetic surgery alone versus combined functional and cosmetic surgery. On multivariate linear regression analysis, when accounting for intraoperative techniques, there was no difference in postoperative NOSE or SCHNOS-O outcomes between the SEG and no-SEG cohorts. Side of postoperative nasal obstruction did not correlate with side of SEG placement. Conclusion: SEGs, when used in a unilateral side-to-side configuration, yield excellent aesthetic results without compromising functional outcomes.

Natural History of the Standardized Cosmesis and Health Nasal Outcomes Survey After Rhinoplasty.

To explore the natural history of nasal obstruction and cosmesis following rhinoplasty by utilizing the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS). Retrospective chart study. This study was carried out at a tertiary referral center, preoperative and postoperative Nasal Obstruction Symptom Evaluation (NOSE), SCHNOS-Obstruction (SCHNOS-O), and SCHNOS-Cosmesis (SCHNOS-C) scores in patients who underwent rhinoplasty for functional, cosmetic, or both reasons from June 2017 to May 2019 were reviewed and analyzed. Postoperative intervals were defined as <2 months, 2 to 5 months, 5 to 8 months, 8 to 12 months, and >12 months. A total of 302 patients (67% women), with a mean age (standard deviation [SD]) of 35 (13) years, who underwent rhinoplasty for functional (90, 30%), cosmetic (124, 41%), and combined functional and cosmetic (88, 29%) reasons, met inclusion criteria. The mean follow-up period (SD, range) was 5 months (4.2 months, 13 days-1.8 years). Compared to the preoperative mean NOSE score, SCHNOS- O, and SCHNOS-C scores, postoperative mean scores for the functional and combined subgroup were significantly lower (P < .05) across all five postoperative intervals. In the cosmetic subgroup, postoperative mean SCHNOS-C scores were significantly lower (P < .05) across all postoperative intervals compared to the mean preoperative scores. The natural history of the SCHNOS-O and SCHNOS-C score in patients who underwent rhinoplasty demonstrates 1) after functional rhinoplasty, an improvement in nasal breathing symptoms is attained as early as <2 months postoperatively; and 2) after cosmetic rhinoplasty, an improvement in nasal cosmesis is seen as early as <2 months postoperatively. These improvements in nasal breathing and cosmesis are sustained through a follow-up interval >12 months. 4 Laryngoscope, 131:E116-E123, 2021.