Postoperative Medical Treatment Research Articles

Targeted surgery combined with postoperative medical therapy for residual disease for severe and multifocal Crohn’s disease

In patients with multifocal intestinal Crohn disease requiring surgery for complication or uncontrolled disease, resection of all the lesions may lead to diarrhea and malnutrition. This is a single-center retrospective review of all patients undergoing targeted surgery for multifocal Crohn disease with at least one residual Crohn disease location left behind. The primary endpoint was the rate of insufficient control of residual Crohn disease lesions requiring redo-surgery targeting these lesions. The rate of clinical remission defined by Harvey-Bradshaw index <4 was studied over time. From January 2012 to August 2022, among 320 patients undergoing surgery for intestinal Crohn disease, 30 metall criteria. Before surgery, patients had received a mean of 3 medical treatment lines; 83% (n= 25) had a clinically active Crohn disease (Harvey-Bradshaw index ≥4). Surgery consisted in ileocolonic (n= 14;47%), small bowel (n= 5;17%) or colonic resection (n= 12;40%) and strictureplasty (n= 4;13%). Operative mortality was nil. Overall postoperative and severe morbidity rates were 15 of 30 (50%) and 3 of 30. Residual lesions were in the small bowel (n= 15;50%), the colon (n= 16;53%), and/or the rectum (n= 16;53%). Twenty-five patients (83%) had postoperative medical therapy. Median follow-up was 65. Six patients (20%) required reoperation for insufficient control of residual lesions at index surgery after a mean of 98±8months. The clinical remission rate increased from 17% before surgery to 59% at 6-12months and 71% at 24months. In patients with multifocal Crohn disease, surgery targeted to severe and complicated lesions combined with postoperative medical treatment is a safe and effective strategy.

Validity of the I‑FEED classification in assessing postoperative gastrointestinal impairment in patients undergoing elective lumbar spinal surgery with general anesthesia: a prospective observational study

BackgroundThe I-FEED classification, scored 0–8, was reported to accurately describe the clinical manifestations of gastrointestinal impairment after colorectal surgery. Therefore, it is interesting to determine whether the I-FEED scoring system is also applicable to patients undergoing lumbar spine surgery.MethodsAdult patients undergoing elective lumbar spine surgery were enrolled, and the I-FEED score was measured for 4 days after surgery. The I-FEED scoring system incorporates five elements: intake (score: 0, 1, 3), feeling nauseated (score: 0, 1, 3), emesis (score: 0, 1, 3), results of physical exam (score: 0, 1, 3), and duration of symptoms (score: 0, 1, 2). Daily I-FEED scores were summed, and the highest overall score is used to categorize patients into one of three categories: normal (0–2 points), postoperative gastrointestinal intolerance (POGI; 3–5 points), and postoperative gastrointestinal dysfunction (POGD; 6 + points). The construct validity hypothesis testing determines whether the I-FEED category is consistent with objective clinical findings relevant to gastrointestinal impairment, namely, the longer length of hospital stay (LOS), higher inhospital medical cost, more postoperative gastrointestinal medical treatment, and more postoperative non-gastrointestinal complications.ResultsA total of 156 patients were enrolled, and 25.0% of patients were categorized as normal, 49.4% POGI, and 25.6% POGD. Patients with higher I-FEED scores agreed with the four validity hypotheses. Patients with POGD had a significantly longer length of hospital stay (1 day longer median stay; p = 0.049) and more inhospital medical costs (approximately 500 Taiwanese dollars; p = 0.037), and more patients with POGD required rectal laxatives (10.3% vs. 32.5% vs. 32.5%; p = 0.026). In addition, more patients with POGD had non-gastrointestinal complications (5.1% vs. 11.7% vs. 30.0%; p = 0.034).ConclusionThis study contributes preliminary validity evidence for the I-FEED score as a measure for postoperative gastrointestinal impairment after elective lumbar spine surgery.

P263 Clinical-Endoscopic Correlation of Postoperative Recurrence in Surgically Treated Crohn's Disease Patients

Abstract Background The majority of patients with Crohn's disease (CD) require surgical intervention at some point in their disease course, particularly ileocolic resection. However, the average rate of clinical postoperative relapse is 30% at 3 years and 60% at 10 years. Endoscopic postoperative recurrence precedes clinical recurrence, highlighting the importance of conducting a colonoscopy 6 to 12 months postoperatively to establish the Rutgeerts score,which predicts the risk of clinical recurrence. The aim of this study is to correlate endoscopic findings with the clinical symptoms of these patients. Methods We retrospectively analyzed clinical symptoms and Rutgeerts scores of Crohn's disease patients who underwent ileocolic resection during the course of their disease, and followed at the Hepato-Gastroenterology Department of MOHAMMED VI university hospital in Oujda, Morocco, during the period [2018-2023] Results Sixty Crohn's disease patients underwent at least one surgical operation during the course of their disease, comprising 25 females and 35 males with a sex ratio (M/F: 1.4). The average age of our patients was 35 years [20-73]. The average time between diagnosis and the first surgery was 4 years. All these patients received postoperative medical treatment before colonoscopy, including azathioprine or methotrexate in 26 patients (43%) and anti-TNF in 34 cases (56%), with an average time of 8 months between surgery and the start of treatment. According to the Montreal classification, the ileocolic form dominated in 88% of cases, with a penetrating phenotype in 40% and a structuring phenotype in 60%. The operative indication was primarily obstructive syndromes in 85% of cases and collections in15%. The average time to perform colonoscopy after surgery was 10 months. During follow-up, 80% of patients were asymptomatic post-surgery, with Rutgeerts scores of I0-I1 in 11(23%) patients, I2 in 13 (27%) cases, I3 in 9 (19%) cases, and I4 in 15 (31%) cases.However, clinical recurrence, characterized by diarrhea, abdominal pain, or Koenig's syndrome, was observed in 20% of patients, with an average postoperative clinical recurrence time of 2 years. The endoscopic findings in these patients revealed Rutgeerts scores of I2 in 4 cases (33%), I3 in 3 cases (25%), and I4 in 5 cases (41%). Conclusion In summary, despite postoperative medical management, the risk of clinical recurrence isnotable. Early postoperative colonoscopy, assessing Rutgeerts scores, proves crucial inpredicting clinical recurrence risk. The observed clinical-endoscopic discordance emphasizes the need for a comprehensive approach to monitoring postoperative outcomes in Crohn's disease.

P866 Management of fistulizing Crohn's Disease in a moroccan population: about 125 cases

Abstract Background Crohn's disease is an inflammatory enterocolitis, which may be complicated by enteroenteric, enterovesical, rectovaginal, enterocutaneous and anoperineal fistulas. This is a retrospective study of fistulizing Crohn's disease cases followed in our gastroenterology department. Methods We report a retrospective and descriptive study, covering all cases of fistulizing Crohn's disease, collected in the hepato-gastroenterology department at our university hospital center during a 9-year study period, from 2015 to 2023. All patients with digestive and/or anal crohn's fistula were included. Comparison of categorical variables was performed with Fisher's exact test using SPSS 10.0 software. The significance level was p &amp;lt; 0.05. Results 125 patients had a fistulizing form of Crohn's disease. The location of fistulas was represented by anoperineal fistulas (32.6%), followed by enteroenteral (22.9%) and enterocutaneous (23%) fistulas, then enterovesical (9%) and rectovaginal (3.8%) fistulas. Surgical treatment was immediately indicated in all cases of enterocutaneous and enterovesical fistulas, and 66.7% of rectovaginal fistulas. Proctological drainage was performed in 57.1% of cases of anoperineal fistulas. 33 cases of anoperineal fistulas and one case of recto-vaginal fistulas were treated with infliximab. Clinical remission was also significantly associated with medical treatment with biologics versus immunosuppressants (P=0.0018). Surgical treatment remains indicated in the majority of cases of fistulizing Crohn's disease. Conclusion Fistulizing Crohn's disease poses a problem for medical and surgical management. Surgical treatment remains indicated in the majority of Crohn's fistula cases. This study also showed that endoscopic recurrence and clinical remission were significantly associated with the type of postoperative medical treatment.

Prophylactic versus endoscopy-driven treatment of Crohn's postoperative recurrence: A retrospective, multicentric European study (PORCSE study).

No consensus exists on optimal strategy to prevent postoperative recurrence (POR) after ileocecal resection (ICR) for Crohn's disease (CD).We compared early medical prophylaxis versus expectant management with treatment driven by findings at elective endoscopy 6-12 months after ICR. A retrospective, multicentric, observational study was performed. CD-patients undergoing first ICR were assigned to cohort1 if a biologic or immunomodulator was (re)started prophylactically after ICR, or to cohort2 if no postoperative prophylaxis was given and treatment was started as reaction to elective endoscopic findings. Primary endpoint was rate of endoscopic POR (Rutgeerts>i1). Secondary endpoints were severe endoscopic POR (Rutgeerts i3/i4), clinical POR, surgical POR and treatment burden during follow-up. Of 346 included patients, 47.4% received prophylactic postoperative treatment (proactive/cohort1) and 52.6% did not (reactive/cohort2).Endoscopic POR (Rutgeerts>i1) rate was significantly higher in cohort2 (41.5% vs 53.8%, OR1.81, P=0.039) at endoscopy 6-12 months after surgery. No significant difference in severe endoscopic POR was found (OR1.29, P=0.517). Cohort2 had significantly higher clinical POR rates (17.7% vs 35.7%, OR3.05, P=0.002) and numerically higher surgical recurrence rates (6.7% vs 13.2%, OR2.59, P=0.051). Cox proportional hazards regression analysis showed no significant difference in time to surgical POR of proactive versus expectant/reactive approach (HR2.50, P=0.057). Quasi-Poisson regression revealed a significantly lower treatment burden for immunomodulator use in cohort2 (mean ratio 0.53, P=0.002), but no difference in burden of biologics or combination treatment. The PORCSE study showed lower rates of endoscopic POR with early postoperative medical treatment compared to expectant management after first ileocecal resection for Crohn's disease.

Mid-term results of combined medical and popliteal artery endarterectomy treatment in Buerger's disease

Aim: Our aim in this article is to present the mid-term results of the best preoperative and postoperative medical treatment and analgesia treatment in patients with advanced Buerger's disease who underwent saphenous patchplasty and saphenous distal bypass after endarterectomy to the popliteal artery or trifurcation area. Material and Methods: Between 2015 and 2023, we operated on 83 patients, diagnosed with Buerger's disease, who were in the chronic stage of the disease, and whose advanced imaging was performed. Preoperative, postoperative, and 1st year control evaluations were determined according to Rutherford, Fontaine classification, and Ankle-Brachial Indexes. Medical treatments of the patients were organized by the vascular surgery team and algology department. After determining the surgical approach strategy according to the imaging of the patients, saphenous patchplasty and anatomical bypass were performed. Results: The mean preoperative ankle-brachial index was 0.305, the mean postoperative ankle-brachial index was 0.644, and the mean 1-year ankle-brachial index was 0.629 in 83 patients included in the study. Statistically significant improvements were observed in the Rutherford and Fontaine classifications. (p-value &lt; 0,001) Amputation was performed in 9.6% of patients within 1 year. Conclusion: Good clinical results and limb salvage can be achieved with a combined medical and surgical treatment approach in advancedstage patients who do not respond despite optimal medical treatment. Provided that patients quit smoking, good determination of the target surgical site, Saphenous patchplasty, and Saphenous distal bypass applied after endarterectomy in suitable patients are supported with good medical and analgesia treatment, the results will improve further.

Various Postoperative Medical Lines for Management of Allegic Fungal Rhinosinusitis (Meta-Analyical Study)

Abstract Background Allergic fungal rhinosinusitits (AFRS) is a subset of polypoid chronic rhinosinusitis that is characterized by the presence of eosinophilic mucin with fungal hyphae within the sinuses and a type I hypersensitivity to fungi. The treatment of allergic fungal rhinosinusitis usually involves surgery in combination with medical therapies to keep the disease in a dormant state. However, what constitutes an optimal post-operative medical regimen is still controversial. Hence, the purpose of this study is to assess the efficacy of various postoperative medical lines for management of AFRS. Objective To find out the role and efficacy of various medical therapies for postoperative treatment of allergic fungal rhinosinusitis (through a systematic review study). Materials and Methods Fifty studies were included in the present systematic review and meta-analysis, the total number of patients included in all studies (No = 1,655 patients). Our review has investigated the literature on 5 medical therapies (steroids, antifungal, immunotherapy, mepolizumab, and omalizumab) concerning the management of postoperative AFRS patients. Results The results showed that the recurrence rate after postoperative systemic steroids was 26.3%, topical steroids was 38.4%, antifungals therapy was 32.1%, immunotherapy was 17.4%, the percentage of recurrence after combination of antifungal and steroids was 9.6%, recurrence risk difference between antifungal and placebo was 18.2%, recurrence risk difference between steroids and placebo was 6.5%. Base on the above results, the combination of steroids and antifungal therapy is the best treatment for postoperative patients with AFRS. Conclusion This review investigated the literature on 5 medical therapies (steroids, antifungal, immunotherapy, mepolizumab, and omalizumab) concerning the management of postoperative AFRS, and provided an evidence-based review with recommendations, the use of steroids alone or antifungals as well, resulted in some degree of recurrence reduction in disease, the evidence supports the use of postoperative combination (oral steroids and systemic antifungal) as a better line of post-operative medical treatment in AFRS patients.

Comparison of postoperative exercise capacity of patients who underwent sternal closure with SternaLock Blu and those with traditional sternal wire closure following cardiovascular surgery via sternotomy

PurposeThis study aimed to evaluate the efficacy of postoperative exercise capacity of SternaLock Blu (Zimmer Biomet, USA) for post-sternotomy patients who underwent cardiovascular surgery.MethodsWe investigated 116 patients, including 35 women (mean age 70.3 ± 10.0 years), who underwent cardiovascular surgery by median sternotomy. Patients were candidate for using SternaLock Blu, such as obesity (body mass index > 30/kg/m2), insulin-dependent diabetes mellitus, steroid administrating, undergoing coronary bypass artery grafting used bilateral internal thoracic artery. These patients were categorized into those with SternaLock Blu (S group, n = 47) or with sternal wires only (N group, n = 69) for closing sternotomy, and their data were analyzed.ResultsMax Prince Henry Pain Scale (PHPS) was significantly low in the S group than in the N group (N vs. S = 2.7 ± 1.4 vs. 1.6 ± 1.7%, p < 0.001). Postoperative 6-min walk was significantly longer in the S group than in the N group (N vs. S = 346.2 ± 101.6 vs. 408.6 ± 104.6 m, p = 0.018). The length of intensive care unit (N vs. S = 4.9 ± 0.9 vs. 4.0 ± 1.2 days, p < 0.001) and hospitalization (N vs. S = 18.0 ± 5.0 vs. 15.2 ± 3.8 days, p = 0.006) were significantly shorter in the S group than in the N group.ConclusionsSternaLock Blu could keep exercise capacity, and might help reduce postoperative pain and medical treatment period for patients who underwent cardiovascular surgery.

Effect of dienogest on serum anti-Mullerian hormone level after laparoscopic cystectomy of ovarian endometrioma

ObjectiveThis comparative study aimed to evaluate the effect of postoperative dienogest treatment on serum anti-Mullerian hormone (AMH) levels in patients undergoing laparoscopic cystectomy of ovarian endometriomas. Materials and methodsA total of 71 patients with ovarian endometriomas treated at our department were enrolled. After surgery, 54 patients received oral dienogest 2 mg daily continuously for 6 months (dienogest group). The other 17 patients did not receive postoperative medical treatment (control group). Serum AMH levels were measured before surgery, at 3-month period after surgery, and at the end of 6-month follow-up period. Serial changes of AMH levels were compared between the two groups. ResultsThe age, endometrioma size, and serum AMH level before surgery were comparable between the dienogest group and the control group. The AMH levels decreased significantly at 3-month period after surgery in the dienogest group (a decrease of 65.5%; p < 0.001) and the control group (a decrease of 64.8%; p = 0.018). The AMH levels increased gradually from the nadir at 3-month period after surgery and recovered partially at the end of 6-month follow-up period in both groups. There were no statistically significant differences in the rate of reduction of serum AMH levels between the two groups (p = 0.707). ConclusionLaparoscopic cystectomy of ovarian endometrioma causes a significant decrease in serum AMH levels. The rates of reduction of AMH levels are similar regardless of dienogest treatment. Postoperative dienogest treatment for 6 months has no rescue effect on serum AMH levels in these patients.

Unpredictable post-laparoscopic bleeding in essential thrombocytosis: a call for additional safety measures

Patients with essential thrombocythemia (ET) can undergo laparoscopy without international precautions. This case report describes an ET with a mild increase in the platelet count that developed after laparoscopic surgery and prolonged intraperitoneal bleeding. The patient underwent intensive postoperative medical and surgical treatments until cured. Patients with ET should provide informed consent for post-laparoscopic bleeding. Surgeons should perform optimal hemostasis. Further studies are required to provide clear guidelines for both medical and surgical interventions aimed at preventing thrombo-hemorrhagic complications associated with ET. A preoperative study of platelet function and the selection of the best cytotoxic drug for the perioperative period are mandatory.

Effectiveness of laparoscopic removal of isolated superficial peritoneal endometriosis for the management of chronic pelvic pain in women (ESPriT2): protocol for a multi-centre randomised controlled trial

BackgroundEndometriosis affects 190 million women and those assigned female at birth worldwide. For some, it is associated with debilitating chronic pelvic pain. Diagnosis of endometriosis is often achieved through diagnostic laparoscopy. However, when isolated superficial peritoneal endometriosis (SPE), the most common endometriosis subtype, is identified during laparoscopy, limited evidence exists to support the common decision to surgically remove it via excision or ablation. Improved understanding of the impact of surgical removal of isolated SPE for the management of chronic pelvic pain in women is required. Here, we describe our protocol for a multi-centre trial to determine the effectiveness of surgical removal of isolated SPE for the management of endometriosis-associated pain.MethodsWe plan to undertake a multi-centre participant-blind parallel-group randomised controlled clinical and cost-effectiveness trial with internal pilot. We plan to randomise 400 participants from up to 70 National Health Service Hospitals in the UK. Participants with chronic pelvic pain awaiting diagnostic laparoscopy for suspected endometriosis will be consented by the clinical research team. If isolated SPE is identified at laparoscopy, and deep or ovarian endometriosis is not seen, participants will be randomised intraoperatively (1:1) to surgical removal (by excision or ablation or both, according to surgeons’ preference) versus diagnostic laparoscopy alone. Randomisation with block-stratification will be used. Participants will be given a diagnosis but will not be informed of the procedure they received until 12 months post-randomisation, unless required. Post-operative medical treatment will be according to participants’ preference. Participants will be asked to complete validated pain and quality of life questionnaires at 3, 6 and 12 months after randomisation. Our primary outcome is the pain domain of the Endometriosis Health Profile-30 (EHP-30), via a between randomised group comparison of adjusted means at 12 months. Assuming a standard deviation of 22 points around the pain score, 90% power, 5% significance and 20% missing data, 400 participants are required to be randomised to detect an 8-point pain score difference.DiscussionThis trial aims to provide high quality evidence of the clinical and cost-effectiveness of surgical removal of isolated SPE.Trial registrationISRCTN registry ISRCTN27244948. Registered 6 April 2021.

Incidence of Intrauterine Adhesions After Hysteroscopic Myomectomy in Patients Seeking Fertility

To study the incidence of intrauterine adhesions (IUAs) after hysteroscopic myomectomy. Previous studies report a range of incidence for IUAs after hysteroscopic myomectomy. A retrospective review study. An academic community hospital in the Boston metropolitan area. Patients undergoing hysteroscopic myomectomy at our institution from January 2019 to February 2022. Patients were excluded if they did not have plans for future fertility or had a new diagnosis of cancer. All patients underwent hysteroscopic myomectomy using bipolar resectoscope without postoperative medical or barrier treatment. All procedures were performed by 1 of 4 fellowship-trained high-volume gynecologic surgeons with resident and fellow assistance. Incidence of postoperative IUAs was assessed and treated using second-look office hysteroscopy. A total of 44 patients without preoperative IUAs underwent hysteroscopic myomectomy during our study period, and 4 patients (9.1%) developed new IUAs. Among 9 patients who were found to have preoperative IUAs and underwent concurrent hysteroscopic myomectomy and lysis of adhesions, we found a recurrence of IUAs in 5 patients (55.6%). We found the number, size, and deepest type of myoma removed were not correlated to an increased risk of new IUA formation. In addition, removing myomas on opposing walls during the same operation did not increase the incidence of new IUAs. Formation of IUAs after hysteroscopic myomectomy is a well-documented consequence. Our reported incidence of 9.1% of new IUAs that are not affected by the number, size, deepest type of myoma resected, and resection of myomas on opposing uterine walls contributes to the current literature. In addition, our finding of 55.6% of recurrent IUAs in patients undergoing both hysteroscopic myomectomy and lysis of adhesions highlights a high-risk population requiring additional study.

The Clinical Picture and Fecundity of Primary and Recurrent Ovarian Endometriosis with Family History: A Retrospective Analysis

This study aims to evaluate the role of endometriosis family history on the clinical manifestation and fertility performance of primary and recurrent endometriosis. In total, 312 primary and 323 recurrent endometrioma patients with a histological diagnosis were included in this study. Family history was significantly correlated with recurrent endometriosis (adjusted OR: 3.52, 95% CI: 1.09-9.46, p = 0.008). Patients with a family history showed a significantly higher proportion of recurrent endometriosis (75.76% vs. 49.50%), higher rASRM scores, higher incidence of severe dysmenorrhea, and severe pelvic pain than the sporadic cases. Recurrent endometrioma showed statistical increase in rASRM scores, percentage of rASRM Stage IV, dysmenorrhea, dyschezia, those undergoing semi-radical surgery or unilateral oophorosalpingectomy, postoperative medical treatment, e with a positive family history, while a decrease in the incidence of asymptomatic phenomena and those undergoing ovarian cystectomy compared to those with primary endometriosis. The naturally conceived pregnancy rate was higher in primary endometriosis compared to recurrent endometriosis. Compared to recurrent endometriosis with a negative family history, recurrent endometriosis with a positive family history had a higher incidence of severe dysmenorrhea, chronic pelvic pain, a higher spontaneous abortion rate, and a lower natural pregnancy rate. Primary endometriosis with a family history presented a higher incidence of severe dysmenorrhea than those without a family history. In conclusion, endometriosis patients with a positive family history presented a higher pain severity and lower conception probability compared to the sporadic cases. Recurrent endometriosis showed further-exacerbated clinical manifestations, more pronounced familial tendency, and lower pregnancy rates than primary endometriosis.

DOP77 Is durable remission achievable after ileocolic resection for Crohn’s disease ? Long-term results of a prospective multicentric cohort study of the GETAID Chirurgie

Abstract Background Most of the patients undergoing bowel resection for Crohn’s disease (CD) develop postoperative recurrence requiring medical treatment intensification or surgery. Is there a subgroup of patients for which surgery allows durable remission? Methods In this retrospective follow-up study, we collected data from 592 patients undergoing ileocolic resection for CD who were included from 2013 to 2015 in a prospective nation-wide cohort of the GETAID Chirurgie group. Patients with follow-up superior to 36 months were included. Primary outcome was durable remission, defined as the absence of endoscopic recurrence (Rutgeerts ≥i2) and/or absence of medical treatment intensification. Uni- and multivariate analyses of the predictive factors for durable remission were carried out. Results Among 268 included patients, 158 (59%) had a B2 stricturing phenotype, 92 (34%) had a B3 penetrating phenotype and 18 (7%) had a non-stricturing non-perforating phenotype (Montreal classification). One hundred and eighty-eight patients (70%) had a primary ileocolic resection. One hundred and sixty-seven patients (66%) had postoperative medical treatment to prevent postoperative recurrence (Table 1). After a median follow-up of 85 (36-104) months, 52 patients (19%) had a durable remission, among which 24 (46%) had no medical treatment and 28 (54%) maintained the same postoperative prophylactic treatment, including anti-TNF therapy in 15 patients (54%) (Table 2). Durable remission rate was significantly increased in B1 phenotype vs B2/B3 (n=7/18 ;39% vs n=45/250; 18%, p=0.030) and in primary ileocolic resection vs redo ileocolic resection (n=43/184 ; 23% vs n=9/80 ; 11%, p=0.023). In multivariate analysis, B1 phenotype was an independent predictive factor for durable remission (OR=3.59, IC95%[1.13-11.37], p=0.030) (Table 3). Conclusion These long-term data obtained from a nation-wide prospective cohort are in line with those of a randomised controlled trial (LIR!C) and show that durable remission is obtained in nearly 40% of CD patients with non-stricturing non-penetrating phenotype operated for CD refractory to medical treatment. This important result should be considered when medical treatment intensification versus surgery is discussed in these patients.

Sinonasal Outcomes Using Oral Corticosteroids in Patients with Chronic Rhinosinusitis with Nasal Polyps and Positive Sinonasal Cultures.

Introduction Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) and positive sinonasal bacterial cultures may be recalcitrant to topical therapy alone due to the additional local inflammatory burden associated with bacterial infection/colonization. Objective To evaluate sinonasal outcomes in CRSwNP patients with a positive perioperative bacterial culture, who were treated with postoperative intranasal corticosteroids (INCS) alone versus INCS in combination with a short-term course of oral corticosteroids (OCS). Methods This is a retrospective chart review of CRSwNP patients. A total of 59 patients met inclusion criteria, including positive perioperative bacterial culture and treatment with INCS with or without concomitant use of OCS. Two cohorts were formed based on the chosen postoperative medical treatment; 32 patients underwent postoperative INCS alone, while 27 underwent INCS plus a ≤ 2-week course of OCS. The 22-item sinonasal outcome test (SNOT-22) scores and Lund-Kennedy scores (LKS) were assessed preoperatively, and at 2-week, 4-week, and 4 to 6 months after endoscopic sinus surgery (ESS). Results There were no statistically significant differences in postoperative sinonasal symptoms or endoscopic scores between the cohorts treated with INCS plus OCS versus those prescribed INCS alone ( p > 0.05). Our regression model failed to demonstrate a relationship between the use of OCS and better sinonasal outcomes at 2-week, 4-week, and 4 to 6 months after ESS ( p > 0.05). Conclusion Our study suggests that in a cohort of CRSwNP patients with recent bacterial infections, the postoperative use of combined OCS and INCS did not result in a statistical improvement of endoscopic and symptomatic outcomes over INCS irrigation alone. However, both treatment groups had a clinically significant improvement based on the Minimal Clinically Important Difference.

The role of large cavity sinus surgery in the management of chronic rhinosinusitis in N-ERD: a single-centre experience and long-term outcomes.

This study aimed to discuss the role of large cavity functional endoscopic sinus surgery in the management of chronic rhinosinusitis with nasal polyps in patients with non-steroidal anti-inflammatory drug exacerbated respiratory disease. This was a retrospective review of patients undergoing large cavity functional endoscopic sinus surgery for non-steroidal anti-inflammatory drug exacerbated respiratory disease from January 2016 to March 2022. Population characteristics, pre- and post-operative number of functional endoscopic sinus surgical procedures, endoscopic polyp grade, Lund-Mackay score and nasal symptoms were recorded. Thirteen consecutive patients with a median age of 47 years were included. They all failed maximal medical treatment and/or conservative functional endoscopic sinus surgery and underwent large cavity sinus surgery followed by post-operative maximal medical therapy. All patients showed an improvement in nasal symptoms with improved Lund-Mackay scores post-operatively. The median length of follow up was 1.5 years. Large cavity functional endoscopic sinus surgery seems to halt the progression of chronic rhinosinusitis with nasal polyps in non-steroidal anti-inflammatory drug exacerbated respiratory disease. In this case series, large cavity functional endoscopic sinus surgery combined with optimal post-operative medical treatment appeared to switch off chronic rhinosinusitis with nasal polyps in patients with non-steroidal anti-inflammatory drug exacerbated respiratory disease.

Cluster analysis of patients with chronic rhinosinusitis and asthma after endoscopic sinus surgery

BackgroundPatients with chronic rhinosinusitis with nasal polyps and asthma (CRSwAS) are highly heterogenous in severity and prognosis. The clinical phenotypes and inflammatory endotypes of CRSwAS and their association with outcomes of endoscopic sinus surgery (ESS) have not been fully studied yet. ObjectiveWe aimed to find out the clinical phenotypes of CRSwAS and explore their relationship with ESS outcomes using cluster analysis. MethodsWe recruited 103 consecutive adult patients with CRSwAS who had undergone ESS and been followed up for more than 1 year. For cluster analysis, we collected the data from 63 variables pertaining to demographic characteristics, preoperative disease status, surgical techniques, postoperative medical treatment, and outcomes. Eosinophilic CRS was defined as greater than or equal to 10 eosinophils/high-power field, and sinus computed tomography was evaluated by Lund-Mackay sinus computed tomography score (LM score). ResultsWe screened 92 eligible patients and 13 preoperative variables for balanced iterative reducing and clustering using hierarchies cluster analysis. Patients with CRSwAS were divided into 4 clusters with distinct ESS outcomes: (1) cluster 1, characterized by aspirin-exacerbated respiratory disease, eosinophilic CRS, high preoperative LM score, moderate-to-severe asthma, and uncontrolled CRS after ESS; (2) cluster 2, characterized as having female dominance (66.67%), non–aspirin-exacerbated respiratory disease, eosinophilic CRS, high preoperative LM score, moderate-to-severe asthma, and uncontrolled CRS after ESS; (3) cluster 3, characterized as having female dominance (95.83%), noneosinophilic CRS, low preoperative LM score, moderate asthma, and controlled CRS after ESS; and (4) cluster 4, characterized as men-only, smoker, noneosinophilic CRS, low preoperative LM score, mild asthma, and controlled CRS after ESS. ConclusionCRSwAS has distinct clusters, each corresponding to unique clinical and inflammatory characteristics and ESS outcomes.

Endoscopic outcomes in patients with AERD treated with topical antibiotics and intranasal corticosteroids.

BackgroundIdentifying effective therapy for recalcitrant chronic rhinosinusitis with nasal polyposis (CRSwNP) is a major challenge; and subtypes such as aspirin-exacerbated respiratory disease (AERD) are even more difficult to treat. Evidence on topical antibiotics use in (CRSwNP) is lacking. Current consensus guidelines recommend against its routine use, but recent reviews show some benefit when managing recalcitrant disease after endoscopic sinus surgery (ESS).ObjectiveEvaluate the effect of culture-directed topical antibiotics on sinonasal outcomes in AERD patients with a positive perioperative sinonasal bacterial culture who have undergone ESS.MethodsA retrospective cohort study of AERD patients with positive sinonasal culture, who underwent ESS from 2016 to 2021 was performed. Forty-four patients were identified and stratified based on their postoperative medical treatment. Twenty-six underwent postoperative intranasal corticosteroids (INCS) alone, while eighteen underwent INCS plus a 4-weeks treatment with topical antibiotics. SNOT-22 and Lund-Kennedy score (LKS) were assessed preoperatively and at 4-weeks and 4-6 months after ESS.ResultsA statistically significant improvement in the 4-weeks and 4-6 months postoperative SNOT-22 and LKS were noted within both groups (p<0.05). However, only a statistically significant difference was found in the 4-weeks postoperative LKS when comparing between treatment groups (p=0.01). Our linear regression model demonstrated a relationship between the use of combined therapy with INCS and topical antibiotics and the LKS 4-weeks post ESS (p=0.015).ConclusionIn AERD patients with a confirmed sinus infection, the combination of culture-directed topical antibiotics and intranasal corticosteroid irrigations in the postoperative period can provide a short-term improvement in endoscopic scores.

The classification, diagnosis, and treatment of rhinosinusitis

Background: Rhinosinusitis, one of the most common conditions encountered by clinicians, affects quality of life and reduces work productivity. Despite its high prevalence and economic burden, there are considerable differences in practice regarding the management of rhinosinusitis. Based on many studies, including the updated guidelines, classifications have been subdivided, and new treatments have been added.Current Concepts: Rhinosinusitis can be classified as acute rhinosinusitis (ARS) or chronic rhinosinusitis (CRS) with a cut-off duration of 12 weeks. It is diagnosed based on subjective symptoms and objective findings on computed tomography or endoscopy. Viral infections account for the majority of the causes of ARS, with watchful waiting without antibiotics as its important initial management. Meanwhile, CRS is divided into primary and secondary CRS, which is further subdivided by anatomic distribution and endotype. Particularly, the Type 2 endotype is characterized by a high recurrence rate and high resistance to current therapies. Biologics using monoclonal antibodies could therefore be used as new therapeutic options for the treatment of primary type 2 CRS. Furthermore, given the chronicity of CRS, it is important to recognize that endoscopic sinus surgery and continuous postoperative medical treatment are important for its management.Discussion and Conclusion: Accurate diagnoses based on diagnostic criteria and subdivided classifications are necessary to determine the treatment plan and prognosis. In particular, it is important to differentiate the endotype of CRS and provide appropriate treatments to improve the patient’s symptoms and quality of life.

MP13-15 THE ROLE OF PERITONEAL CAVITY SPARING IN THE REDUCTION OF RADICAL CYSTOPROSTATECTOMY (RCP) POSTOPERATIVE COMPLICATION RATES

You have accessJournal of UrologyBladder Cancer: Invasive I (MP13)1 Sep 2021MP13-15 THE ROLE OF PERITONEAL CAVITY SPARING IN THE REDUCTION OF RADICAL CYSTOPROSTATECTOMY (RCP) POSTOPERATIVE COMPLICATION RATES Guram Karazanashvili, Nika Gagoshidze, and Nino Karazanashvili Guram KarazanashviliGuram Karazanashvili More articles by this author , Nika GagoshidzeNika Gagoshidze More articles by this author , and Nino KarazanashviliNino Karazanashvili More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001994.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical cystectomy remains the gold standard for the management of invasive bladder cancer. However, postoperative complications of this complex surgery still remain the major problem, which ranges between 30-64%. Neobladder extra-peritonization as a method for reduction of postoperative complications was discussed by few authors, showing that it has the potential to reduce the complication rate. In 2018 a video-description of the new technique of peritoneal cavity sparing (Karazanashvili, G. (2018)) was presented at AUA annual congress. We aimed to investigate the role of this new technique in the reduction of the RCP postoperative complications. METHODS: In 2011-2016 years 98 RCP were performed using the standard transperitoneal descending approach, leaving just a partially extra-peritonized neobladder in the peritoneal cavity. In 2016-2020 years 60 patients underwent RCP using the new technique - peritoneal cavity sparing extraperitoneal RCP with extraperitoneal orthotopic neobladder formation: RCP was performed in a retrograde manner, from apex prostate to the bladder pedicles and the dome; peritoneum was detached from bladder wall and peritoneal cavity hermeticism was kept until complete removal of the specimen and until completion of extended lymphadenectomy. So the peritoneal cavity remained untouched for the most part of the operation. After the creation of the neobladder, it was completely extra-peritonized; the peritoneal cavity was closed almost hermetically (hiatus was left only for neobladder mesentery) without drains. Complication rates after the operations were calculated according to the Clavien-Dindo scale. RESULTS: The retrospective analysis of complication rates has revealed that Clavien-Dindo Grade 1 to 3 intestinal complications significantly decreased using the new RCP technique compared to the old - standard one: Postoperative ileus medical treatment rate decreased from 3% to 0%; Intra-abdominal urine leakage - from 2.2%to 1.69%; Ileus surgical intervention - from 10.8% to 5.08%; Ileal anastomosis leakage from 5.7 to 0%; Evisceration - from 2.7% to 0%. Thus Intestinal Grade 1 complications decreased from 5.2% to 1.69 and Grade 3 complications - from 18.7% to 5.08%; totally the intestinal complication rate decreased by 17.22% (from 23.9% to 6.77%), however prolonged lymphorrhea rate increased by 12.54% (from 7.8 % to 20.34%). CONCLUSIONS: Peritoneum cavity sparing extraperitoneal RCP and extraperitoneal orthotopic neobladder formation can lead to notable reduction of RCP postoperative intestinal complication rate in price of prolonged lymphorrhea. Source of Funding: No funding was available © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e249-e249 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Guram Karazanashvili More articles by this author Nika Gagoshidze More articles by this author Nino Karazanashvili More articles by this author Expand All Advertisement Loading ...