Postoperative Stenosis Research Articles

WITHDRAWN: Prerectal-transperineal approach for treatment of recurrent vesico-urethral anastomotic stenosis after radical prostatectomy

Abstract Vesico-urethral anastomotic stenosis (VUAS) after radical prostatectomy is a narrowing of the vesicourethral anastomosis after radical prostatectomy. We aim to describe a safe re-anastomotic procedure for recurrent bladder neck contracture following radical prostatectomy (RP). This technique allows an easier access to the stenotic vesico-urethral anastomosis, a better mobilization of the bladder neck and a tension free re-anastomosis. Twelve patients suffering from VUAS after radical prostatectomy were enrolled between May 2014 and September 2018. We describe our approach to the disease. The evaluated outcomes were intra- and post-operative complications, stricture recurrence, and postoperative stress incontinence. Average operative time was 3 h. No major intraoperative complications or bleeding occurred. Patients were discharged after 72 h. At the time of catheter removal, 3 weeks after surgery, 9 out of twelve patients developed stress urinary incontinence, requiring 4 pads/day. Two patients with history of pelvic radiotherapy developed a surgical site abscess that required toilette and external urinary diversion. One recurrence occurred and was treated with internal urethrotomy before sphincter placement. No patient reported significant postoperative pain or fecal incontinence. Our approach allows direct access to the posterior urethra, and we demonstrate the advantages for treatment of VUAS to achieve a tension free anastomosis. All patients need to be informed of subsequent urinary incontinence to be treated with artificial sphincter placement. Patients with a history of pelvic radiotherapy show very poor preoperative conditions of the tissues and must be informed about the possibility of an external urinary diversion.

GreenLight Laser™ Photovaporization versus Transurethral Resection of the Prostate: A Systematic Review and Meta-Analysis.

GreenLight laser™ photovaporization of the prostate (GLL-PVP) has become a valid alternative to traditional transurethral resection of the prostate (TURP) in men requiring surgery for benign prostatic hyperplasia. We aimed to review systematically the safety and efficacy of studies comparing GLL PVP and TURP in the medium-term. A comprehensive literature search was performed. Twelve studies were identified for meta-analysis. Meta-analyses showed a longer postoperative catheterization time (risk ratio (RR): 1.12, 95% CI:1.09–1.14, p<0.00001) and length of stay (RR: 1.16, 95% CI:1.12–1.19, p<0.00001) in the TURP group; higher risk of transfusion in the TURP group (RR: 6.51, 95% CI: 2,90–14,64 p<0.00001); no difference in the risk of urinary tract infections (RR: 0.83, 95% CI: 0.58–1.18, p=0.30) and transient re-catheterization (RR: 1.11, 95% CI: 0.76–1.60, p=0.60). Regarding reoperation rate, no difference was found in term of postoperative urethral stricture (RR: 1.13, 95% CI: 0.73–1.75, p=0.59) and bladder neck contracture (RR: 0.66, 95% CI: 0.31–1.40, p=0.28). A significantly higher incidence in reoperation for persistent/regrowth adenoma was present in the GLLL-PVP (RR: 0.64, 95% CI: 0.41–0.99, p=0.05). Data at 2-year follow-up showed significant better post-voiding residual (PVR) (MD: -1.42, 95% CI: -2.01, -0.82, p<0.00001) and International Prostate Symptom Score (IPSS) (MD: -0.35, 95% CI: -0.50, -0.20, p<0.00001) after TURP. No difference was found in the mean PVR at 2 years after TURP, in the mean maximum flow rate (Qmax) (MD: 0.30, 95% CI: -0.02–0.61, p=0.06) and quality of life QoL score (MD: 0.05, 95% CI: -0.02–0.42, p=0.13). At 5-year follow-up, data showed better IPSS (MD: -1.70, 95% CI: -2.45,-0.95, p<0.00001), QoL scores (MD: -0.35, 95% CI: -0.69, -0.02, p=0.04) and Qmax (MD: 3.29, 95% CI: 0.19–6.38, p=0.04) after TURP. Data of PVR showed no significant difference (MD: -11.54, 95% CI: -29.55–6.46, p=0.21). In conclusion, our analysis shows that GLL-PVP is a safer and more efficacious procedure than standard TURP in the early and medium-term. However, in the long term period GLL-PVP showed a higher incidence of reoperation rate due to incomplete vaporization/regrowth of prostatic adenoma.

Side-to-side esophagogastric anastomosis for minimally invasive Ivor-Lewis esophagectomy: operative technique and short-term outcomes

Totally minimally invasive Ivor-Lewis esophagectomy (TMIIL) is associated to lower rate of post-operative complication, decreases length of hospital stay and improves quality of life compared to open approach. Nevertheless, adaptation of TMIIL still proceeds at slow pace, mainly due to the difficulty to perform the intra-thoracic anastomosis and heterogeneity of surgical techniques. We present our experience with TMIIL utilizing a stapled side-to-side anastomosis. We retrospectively evaluated 36 patients who underwent a planned TMIIL from January 2017 to September 2020. Esophagogastric anastomoses were performed using a 3-cm linear-stapled side-to-side technique. General features, operative techniques, pathology data and short-term outcomes were analyzed. The median operative time was 365 min (ranging from 240 to 480 min) with a median blood loss of 100 ml (50–1000 ml). The median overall length of stay was 13 (7–64) days and in-hospital mortality rate was 2.8%. Two patients (5.6%) had an anastomotic leak, without need for operative intervention and another patient developed an anastomotic stricture, resolved with a single endoscopic dilation. Chylothorax occurred in three patients; two of these required a surgical intervention. Pulmonary complications occurred in six patients (16.7%). Based on Comprehensive Complications Index (CCI), median values of complications were 27.9 (ranging from 20.9 to 100). The results of our study suggest that TMIIL with a 3-cm linear-stapled anastomosis seems to be safe and effective, with low rates of post-operative anastomotic leak and stricture.

Wide-field endoscopic submucosal dissection for the treatment of Barrett's esophagus neoplasia.

Background and study aims Implementation of endoscopic submucosal dissection (ESD) for the treatment of Barrett’s esophagus neoplasia (BEN) has been hampered by high rates of positive margins and complications. Dissection with wider margins was proposed to overcome these problems, but was never tested. We aim to compare Wide-Field ESD (WF-ESD) with conventional ESD (C-ESD) for treatment of BEN. Patients and methods This was a cohort study of all ESDs performed in our center during 2011 to 2018. C-ESD was the only technique used before 2014, with WF-ESD used beginning in 2014. In WF-ESD marking was performed 10 mm from the tumor margin compared to 5 mm with C-E. Results ESD was performed in 90 cases, corresponding to 74 patients, 84 % male, median age 69. Of these, 22 were C-ESD (24 %) and 68 were WF-ESD (76 %). The en bloc resection rate was 95 vs 100 % (ns), the positive lateral margin rate was 23 % vs 3 % ( P < 0.01), the R0 rate was 73 % vs 90 %, and the curative resection rate was 59 % vs 76 % in the C-ESD and WF-ESD groups, respectively, (both P > 0.05). The procedure speed was 4.4 and 2.3 (min/mm) in the C-ESD and WF-ESD groups ( P < 0.01), respectively. WF-ESD was associated with less post-operative strictures, 6 % vs 27 % ( P = 0.01), with no local recurrence but no significantly reduced risk of metachronous recurrence (Hazard Ratio = 0.46, 95 %CI = 0.14–1.46), during a follow-up of 13.4 and 9.4 months in the C-ESD and WF-ESD cohorts, respectively. Conclusions WF-ESD is associated with a reduction in positive lateral margins, faster dissection, and lower stricture rates. Further prospective, multicenter studies are warranted to evaluate its role in clinical practice.

Image-Guided Percutaneous Pancreatic Duct Drainage: A 10-Year Observational Study

PurposeTo study the safety, efficacy, and long-term outcomes of percutaneous pancreatic duct drainage (PPDD) for treating pancreatic duct (PD) obstruction. Materials and MethodsThis prospective observational cohort study included 73 patients with PD obstruction between December 2010 and June 2020. Patients underwent PPDD under ultrasound and fluoroscopy guidance, computed tomography (CT) and fluoroscopy guidance, or CT guidance only. They were categorized into 2 groups: nonmalignant (26 patients with PD obstruction due to acute and chronic pancreatitis or postoperative stricture) and malignant (47 patients with pancreatic head and ampullary tumors). ResultsThe overall technical success rate was 98.6% (72/73). No major complications were encountered; however, severe weakness, lack of appetite, and tachycardia were observed in 4.1% (3/73) of patients, managed with intravenous resuscitation. Multivariate analysis demonstrated that diagnosis type (pancreatic head tumor: P = .049; odds ratio = 1.95 [1.11–2.25], and chronic pancreatitis: P = .048; odds ratio = 6.25 [1.74–22.22]) was associated with mortality. The median survival time was 16.3 months. Moreover, 15.1% (11/73) of the patients were alive 4 years after the PPDD procedure, and the mean overall survival time of nonmalignant and malignant patients was 35.1 and 21.4 months, respectively. ConclusionsImage-guided PPDD appears to be feasible and safe and provides a valuable therapeutic option for managing patients with PD obstruction.

Ureteral distal ends combined and inserted into the ileum: a novel anastomotic technique for urinary diversion

BackgroundThis study aimed to introduce a novel method for ureteroileal anastomosis, explore its clinical effectiveness, observe the incidence of postoperative anastomotic stricture, and compare the postoperative complications with those of other types of ureteroileal anastomosis reported in the literature.MethodsBoth ureters were first anastomosed at their distal ends and then inserted into the proximal end of the ileal loop. A postoperative follow-up analysis was performed to evaluate major complication indicators, including anastomotic stricture, anastomotic leak, and hydroureteronephrosis.ResultsWe successfully performed ureteral distal ends anastomosis combined with end-to-end insertion into the ileum for 143 patients. The mean postoperative follow-up lasted 37 months (range: 10–68 months). There was no occurrence of an anastomotic leak. The incidence of anastomotic stricture combined with hydronephrosis, ileal conduit stones, urinary tract infection, and renal dysfunction were 2.1%, 0.7%, 2.1%, and 4.2%, respectively.ConclusionUreteral distal ends combined and inserted into the ileum were simple to perform and helped achieve precise anastomosis with fewer postoperative complications.

T-tube vs no T-tube for biliary tract reconstruction in adult orthotopic liver transplantation: An updated systematic review and meta-analysis.

BACKGROUNDWhether to use a T-tube for biliary anastomosis during orthotopic liver transplantation (OLT) remains a debatable question. Some surgeons chose to use a T-tube because they believed that it reduces the incidence of biliary strictures. Advances in surgical techniques during the last decades have significantly decreased the overall incidence of postoperative biliary complications. Whether using a T-tube during OLT is still associated with the reduced incidence of biliary strictures needs to be re-evaluated.AIMTo provide an updated systematic review and meta-analysis on using a T-tube during adult OLT. METHODSIn the electronic databases MEDLINE, PubMed, Scopus, ClinicalTrials.gov, the Cochrane Library, the Cochrane Hepato-Biliary Group Controlled Trails Register, and the Cochrane Central Register of Controlled Trials, we identified 17 studies (eight randomized controlled trials and nine comparative studies) from January 1995 to October 2020. The data of the studies before and after 2010 were separately extracted. We chose the overall biliary complications, bile leaks or fistulas, biliary strictures (anastomotic or non-anastomotic), and cholangitis as outcomes. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to describe the results of the outcomes. Furthermore, the test for overall effect (Z) was used to test the difference between OR and 1, where P ≤ 0.05 indicated a significant difference between OR value and 1.RESULTSA total of 1053 subjects before 2010 and 1346 subjects after 2010 were included in this meta-analysis. The pooled results showed that using a T-tube reduced the incidence of postoperative biliary strictures in studies before 2010 (P = 0.012, OR = 0.62, 95%CI: 0.42-0.90), while the same benefit was not seen in studies after 2010 (P = 0.60, OR = 0.76, 95%CI: 0.27-2.12). No significant difference in the incidence of overall biliary complications (P = 0.37, OR = 1.41, 95%CI: 0.66-2.98), bile leaks (P = 0.89, OR = 1.04, 95%CI: 0.63-1.70), and cholangitis (P = 0.27, OR = 2.00, 95%CI: 0.59-6.84) was observed between using and not using a T-tube before 2010. However, using a T-tube appeared to increase the incidence of overall biliary complications (P = 0.049, OR = 1.49, 95%CI: 1.00-2.22), bile leaks (P = 0.048, OR = 1.91, 95%CI: 1.01-3.64), and cholangitis (P = 0.02, OR = 7.21, 95%CI: 1.37-38.00) after 2010. A random-effects model was used in biliary strictures (after 2010), overall biliary complications (before 2010), and cholangitis (before 2010) due to their heterogeneity (I2 = 62.3%, 85.4%, and 53.6%, respectively). In the sensitivity analysis (only RCTs included), bile leak (P = 0.66) lost the significance after 2010 and a random-effects model was used in overall biliary complications (before 2010), cholangitis (before 2010), bile leaks (after 2010), and biliary strictures (after 2010) because of their heterogeneity (I2 = 92.2%, 65.6%, 50.9%, and 80.3%, respectively).CONCLUSIONIn conclusion, the evidence gathered in our updated meta-analysis showed that the studies published in the last decade did not provide enough evidence to support the routine use of T-tube in adults during OLT.

Novel hybrid endoscopy-assisted larynx-preserving esophagectomy for cervical esophageal cancer (with video)

Hybrid endoscopy-assisted larynx-preserving esophagectomy is developed for cervical esophageal squamous cell carcinoma encroaching or extending above the upper esophageal sphincter. First, a cervical incision was surgically performed followed by cervical lymph node dissection. Second, the margin of cervical esophageal squamous cell carcinoma was endoscopically identified with iodine staining and marked endoscopically followed by semi-circumferential or circumferential endoscopic full-thickness excision around the lumen of the esophagus. The distal margin was surgically resected and reconstruction was performed. Among six consecutive patients with cervical esophageal squamous cell carcinoma undergoing hybrid endoscopy-assisted larynx-preserving esophagectomy, proximal surgical margin was histologically negative in five patients. During a median follow-up period of 15.5months, all patients tolerated oral intake and were alive without evidence of recurrence. None of the patients experienced aspiration pneumonia, vocal disorder or postoperative anastomotic stricture. Hybrid endoscopy-assisted larynx-preserving esophagectomy could be a clinically feasible treatment for cervical esophageal squamous cell carcinoma providing accurate proximal resection margin with the benefit of laryngeal function preservation.

AB174. SOH21AS184. Biodegradable polydioxanone stenting: a useful tool in the management of recurrent colorectal anastomotic strictures failing to respond to endoscopic balloon dilation

Background: Post-operative anastomotic stricture is a common complication of colorectal surgery. It is well established that endoscopic dilation is the first line option in managing these colorectal strictures. However, it is unclear what is the most suitable management of strictures not responding to endoscopic dilation.

Manual and mechanical cervical esophagogastric anastomosis after esophageal Resection: A comparison

Anastomotic complications after esophagectomy continue to be a burden jeopardizing the quality of life and of swallowing. However, incidence, mortality and morbidity of anastomotic complications have substantially decreased in recent years. It seems that this is not so much related to the use of a particular conduit, approach or route for reconstruction, but rather related to refinement in anastomotic techniques and perhaps even more to progress in modern perioperative management. Knowledge of surgical anatomy and meticulous technique are of paramount importance and obviously related to individual expertise. Aims 1. To compare the rates of anastomotic leaks after cervical esophagogastric anastomosis (CEGA) done by hand-sewn (end-to-side) technique and by linear stapled anastomosis (side-to-side) technique. 2. To compare the rates of postoperative anastomotic stricture after cervical esophagogastric anastomosis (CEGA) done by hand-sewn (end-to-side) technique and by linear stapled anastomosis (side-to-side) technique. Index terms: Cervical Esophagogastric Anastomosis (CEGA), Esophagectomy, Esophageal Resection, Anastomotic leaks, Hand sewn anastomosis, Stapled anastomosis, gastrostomy.

Тулиевая и гольмиевая уретеролитотрипсия: оценка термического воздействия на мочеточник путем измерения температуры ирригационной жидкости в условиях in vitro

Introduction. Urolithiasis refers to one of the most common diseases of the genitourinary system, which the urologist meets in his daily practice. When a stone is located in the ureter, surgical intervention is often required to restore the passage of urine and prevent the development of obstructive pyelonephritis. Currently, the holmium or thule laser ureterolithotripsy is condidered the «gold standard» of surgical treatment of ureteral calculi. The thermal effect on the ureteral wall when using a laser may be one of the reasons for the postoperative ureteral strictures development. The aim of our study is to compare in vitro thermal effects of these types of laser on the ureter wall by evaluating the change in the temperature of the irrigation fluid when they are used. Materials and methods. A tube with a diameter of 5 mm, which imitated the ureter, was placed in an aqueous medium with a temperature of 36°C. A temperature sensor (HI 98509 Checktemp 1) was installed in its lumen, at a 3 mm distance from the laser fiber. The time when the irrigation fluid reaches a temperature of 43°C, as well as its temperature at a pulse duration of 3 seconds at an irrigation rate of 25 and 50 ml/sec in the dusting and fragmentation modes, were recorded. Results and discussion. It was found that when using a thulium laser, regardless of the flow rate of the irrigation fluid, an increase in its temperature to 43°C is achieved for a longer time. Also, a lower temperature of the irrigation fluid with a pulse duration of 3 second is recorded using thulium laser. The obtained data allow us to assume that the use of a thulium laser is accompanied by a lower thermal effect on the ureter wall. Conclusion. In this study, we found that when using a thulium laser (Fiberlase U2) in the fragmentation and sputtering modes, a slower increase in the temperature of the irrigation liquid is observed than when using a holmium laser (Lumenis VersaPulse 100W), regardless of the irrigation speed. At a 3 second pulse , a lower temperature of the irrigation fluid was recorded during the use of the thulium laser.

Successful transition from open to minimally invasive approach in Ivor Lewis esophagectomy: a single-center experience in Japan.

This study evaluates surgical outcomes of Ivor Lewis esophagectomy (ILE) in our institution, with the transition from open ILE to hybrid or totally minimally invasive ILE (MI-ILE). Selected patients who underwent ILE for esophageal cancer between 2013 and 2020 were included. We retrospectively investigated the patients' background characteristics and the short-term surgical outcomes. In this period, among a total of 858 esophagectomies, selected seventy-one patients (8.3%) underwent ILE, consisted of 17 cases with completely open procedures, 27 with hybrid MI-ILE, and 27 with total MI-ILE. The major indications for ILE were adenocarcinoma of the distal esophagus or esophagogastric junction (33.8%) and patients with prior treatment of head and neck cancer (31.0%). Among these approaches, there were no significant differences in the characteristics including age, body mass index (BMI), tumor location, preoperative therapy, and clinical TNM stage, except for histology. Compared to the completely open and hybrid groups, incidences of both total and severe complications in the total MI-ILE group were significantly lower (total 70.6 vs. 66.6 vs. 37.0%, p=0.036; severe 35.3 vs. 44.4 vs. 11.1%, p=0.023), and also, those of pneumonia (41.2 vs. 29.6 vs. 7.4%, p=0.026) and postoperative stricture (11.8 vs. 18.5 vs. 0%, p=0.001) were significantly fewer in the total MI-ILE group. We have been able to achieve the transition from completely open to total MI-ILE with better short-term outcomes. Total MI-ILE with linear-stapled anastomosis can be a good alternative to open procedures for the selected patients with reducing the incidence of postoperative pneumonia and anastomotic stricture.

Appropriate duration of endoscopic dilation for postoperative benign esophageal strictures.

Benign esophageal strictures are a frequent complication after esophageal surgery or extensive endoscopic submucosal dissection. Endoscopic dilation is the preferred treatment in clinical practice. However, the allocation of time for each dilation is unclear. The aim of this study was to evaluate the appropriate duration of endoscopic dilation for benign esophageal strictures after esophageal surgery or endoscopic submucosal dissection. Patients with benign esophageal strictures after esophageal surgery or endoscopic submucosal dissection between July 2010 and July 2018 were retrospectively included in this study. According to the dilation time (1, 3, 5min), patients were divided into three groups. The clinical effects and adverse events were compared among the three groups. Altogether, 57 patients, including 21 in the 1-min group, 18 in the 3-min group and 18 in the 5-min group, were included. All patients underwent endoscopic treatment successfully. The stricture recurrence rate was 76.19% in the 1-min group, 55.56% in the 3-min group and 61.11% in the 5-min group. The median overall dysphagia-free period was 2.60 (range, 0.80-12.00) months in the 1-min group, 6.60 (range, 1.80-12.00) months in the 3-min group and 6.25 (range, 2.40-12.00) months in the 5-min group (P < 0.05). For patients who developed stricture recurrence, the mean dysphagia-free periods were 2.26 ± 1.27months, 4.00 ± 1.76months and 4.23 ± 1.63months, respectively (P < 0.05). The dysphagia-free periods were comparable between the 3- and 5-min groups and were longer than those in the 1-min group. Muscle layer damage occurred in two patients (11.11%) in the 5-min group and in no patients in the other two groups. Three minutes was considered a safe and effective dilation duration for benign esophageal strictures after esophageal surgery or endoscopic submucosal dissection.

The safety and efficacy of the trans-umbilical approach for pyloroplasty in the management of post-acid corrosive gastric outlet obstruction in children

BackgroundGastric outlet obstruction (GOO) may follow acid corrosive ingestion. Several surgical techniques have been reported after the failure of endoscopic dilatation. The aim of this study was to evaluate the feasibility and safety of Heinecke-Mikulicz pyloroplasty (HMP) through a circum-umbilical skin incision in children with pyloric stricture after accidental acid corrosive ingestion.ResultsSeven patients were males and 4 were females, their ages ranged from 17 months to 6 years at the time of definitive treatment. The surgery was completed successfully in all patients through the circum-umbilical incision. Vertical extension of skin incision was needed in one patient. The pylorus was grossly affected in 9 patients. Both pylorus and gastric antrum were involved in 2 patients. Nine patients had an excellent postoperative course with the cessation of vomiting and progressive weight gain. One patient developed postoperative recurrent stricture treated by gastrojejunostomy. Another patient with associated esophageal stricture responded to repeated endoscopic dilatation for the esophageal stricture and pyloroplasty for the pyloric stricture. No surgical site infection or wound dehiscence occurred in any patient.ConclusionHeinecke-Mikulicz pyloroplasty through a circum-umbilical approach is both feasible and safe in the majority of children with post-acid corrosive GOO. It is associated with satisfactory wound healing and excellent cosmetic outcome. Different techniques are recommended in cases of severe pyloric stricture associated with significant proximal gastric antral scarring.

Assessment of long-term results of repeated dilations and impact of a scheduled program of dilations for refractory esophageal strictures: a retrospective case-control study.

In patients with benign and refractory esophageal strictures (BES), repeating initial dilations in short intervals could be recommended, but little data are available to validate this strategy. Our aim was to evaluate long-term results of a scheduled program of repeated and sustained esophageal dilations in patients with refractory strictures. Patients with BES requiring five or more dilations were retrospectively included and divided in two groups for analysis: a SCHEDULED group (SDG) where patients were systematically rescheduled for the 5 first dilations; ON-DEMAND group (ODG) where patients were dilated only in case of recurrence of the dysphagia. Comparison between SDG and ODG was done with a 1:1 matching analysis and etiology of stricture. Clinical success was defined as the absence of dysphagia for more than a year. 39 patients with refractory BES were included with post-operative stenosis in 51.2% and post-caustic injury 28.2%; 10 were in SDG and 29 in ODG. In overall analysis (39 patients), the follow-up was 64.4 ± 32months, success rate was 79.5% and duration of treatment was 27.3 ± 20months, and mean number of dilations was 11.7 per patient. The need for dilations decreased significantly after 18months of treatment with an average of 0.56 dilations per semester. Self-expandable metallic stent insertion was associated with an increased rate of complications (5.9% vs 59.1% p = 0.001). In matched analysis (10 ODG vs 10 SDG patients), the duration of treatment was lower in SDG (18.8 vs 41.4months, p = 0,032) with a higher probability of remission (survival analysis, Log-rank: p = 0,019) and the success rate did not differ between ODG and SDG patients (80% vs 90%; NS). Overall, long-term esophageal dilations resulted in a 79.5% success rate and the need for further dilatations decreased significantly in both groups after 18-month follow-up. A scheduled dilation program was associated with a higher probability of final success and lower treatment duration.

Thulium-laser retrograde intra renal ablation of upper urinary tract transitional cell carcinoma: an ESUT Study.

Background Radical nephroureterectomy (RNU) is the gold standard treatment for upper urinary tract urothelial carcinoma (UTUC); however, patients presenting with small low-grade UTUC have been treated by flexible ureteroscopic laser ablation with good outcomes. Different types of laser have been discussed in the literature including Holmium and Neodymium lasers. We aimed to assess the safety and efficacy of Thulium laser (Tm:YAG) in the ureteroscopic ablation of UTUC. Methods A retrospective observational multicentre study of patients diagnosed with papillary UTUC between January 2015 and December 2016 was carried out. All patients underwent ureteroscopic biopsy of the UTUC followed by Tm:YAG ablation. Based on the histopathological grade of the tumor, patients were counseled to undergo either RNU (high-grade tumors) or conservative managementand follow-up (low-grade tumor). Results RNU was performed in 31 patients, while the remaining 47 patients (undergone ™:YAG ablation only) were followed up for a mean of 11.7 months with only 19.2% of patients showing upper tract recurrence and no patients showed postoperative ureteral strictures. Limitations include the short follow-up and retrospective nature of the study. Conclusions On the short term, thulium Laser ablation of UTUC is safe and feasible especially in lowgrade UTUC.

Reconstruction of full-length ureter defects by laparoscopic bladder flap forming

To evaluate the safety and efficacy of laparoscopic bladder muscle flap reconstruction in the treatment of extensive ureteral avulsion. Patients with full-length (re length > 20 cm) and upper ureteral (avulsion length > 10 cm) defects were eligible. All patients were treated with laparoscopic bladder muscle flap reconstruction. Peri-operative information and post-operative complications were recorded. The kidney function, urinary ultrasound or computed tomography (CT), sun-renal function tests emission computed tomography (ECT) and cystography after operation were recorded. Ten patients were included (7 with full-length and 3 with upper ureteral defects). Median age was 56 years and 70% of them were female. The average operation time and blood loss was 124 min and 92.2 ml. There was no treatment-related adverse effects including urinary leakage, renal colic, fever, etc. The median follow-up was 18.5 months (3–39 months). The surgery did not significantly alter the renal function and separation degree of the renal pelvis during long-term follow-up. Double J stents were removed in nine patients (90%) within six months after operation. Only one case was diagnosed with post-operative anastomotic stricture, and subsequently received laparoscopic ipsilateral nephrectomy one year after the reconstruction operation. All cases had normal voiding and pear-shaped cystography. Laparoscopic bladder flap repair is a safe and effective treatment approach together with several advantages for patients with full-length or upper ureteral avulsion.

Biological testing of chitosan-collagen-based porous scaffolds loaded with PLGA/Triamcinolone microspheres for ameliorating endoscopic dissection-related stenosis in oesophagus.

ObjectivesEndoscopic submucosal dissection (ESD), a preferential approach for early oesophageal neoplasms, inevitably results in oesophageal strictures in patients. Clinical use of glucocorticoids through submucosal injection is beneficial for inhibiting oesophageal stricture following injury; however, it also has limitations, such as dose loss and perforation. Hence, alternatives to glucocorticoid therapy should be developed.MethodsA novel porous composite scaffold, ChCo‐TAMS, composed of chitosan, collagen‐I and triamcinolone acetonide (TA) loaded into poly (lactic‐co‐glycolic) acid (PLGA) microspheres (TAMS), was successfully constructed and subjected to biological testing to ameliorate oesophageal ESD‐related stenosis.ResultsThe synthesized biomaterials displayed unique properties in inhibiting the activation of macrophages, chemokine‐mediated cell recruitment and fibrogenesis of fibroblasts. Further application of the scaffolds in the rat dermal defect and porcine oesophageal ESD model showed that these novel scaffolds played a robust role in inhibiting wound contracture and oesophageal ESD strictures.ConclusionsThe developed composite scaffolds provide a promising clinical medical device for the prevention of post‐operative oesophageal stricture.

Inhibition of Lysyl Oxidase with β-aminopropionitrile Improves Venous Adaptation after Arteriovenous Fistula Creation.

The arteriovenous fistula (AVF) is the preferred hemodialysis access for end-stage renal disease (ESRD) patients. Yet, establishment of a functional AVF presents a challenge, even for the most experienced surgeons, since postoperative stenosis frequently occludes the AVF. Stenosis results from the loss of compliance in fibrotic areas of the fistula which turns intimal hyperplasia into an occlusive feature. Fibrotic remodeling depends on deposition and crosslinking of collagen by lysyl oxidase (LOX), an enzyme that catalyzes the deamination of lysine and hydroxylysine residues, facilitating intra/intermolecular covalent bonds. We postulate that pharmacological inhibition of lysyl oxidase (LOX) increases postoperative venous compliance and prevents stenosis in a rat AVF model. LOX gene expression and vascular localization were assayed in rat AVFs and human pre-access veins, respectively. Collagen crosslinking was measured in humans AVFs that matured or failed, and in rat AVFs treated with β-aminopropionitrile (BAPN), an irreversible LOX inhibitor. BAPN was either injected systemically or delivered locally around rat AVFs using nanofiber scaffolds. The major endpoints were AVF blood flow, wall fibrosis, collagen crosslinking, and vascular distensibility. Non-maturation of human AVFs was associated with higher LOX deposition in pre-access veins (N=20, P=0.029), and increased trivalent crosslinks (N=18, P=0.027) in human AVF tissues. Systemic and local inhibition of LOX increased AVF distensibility, while reducing wall fibrosis and collagen crosslinking in rat fistulas. Our results demonstrate that BAPN-mediated inhibition of LOX significantly improves vascular remodeling in experimental fistulas.

The Circular Stapled Esophagogastric Anastomosis in Esophagectomy: No Differences in Anastomotic Insufficiency and Stricture Rates Between the 25 mm and 28 mm Circular Stapler

BackgroundFor patients undergoing an Ivor Lewis esophagectomy with a circular stapled anastomosis, the optimal diameter of the used circular stapler to restore continuity is unknown. The aim of this study was to compare the 25 mm stapled versus the 28 mm stapled esophagogastric anastomosis after Ivor Lewis esophagectomy, focusing on anastomotic insufficiency and postoperative anastomotic strictures. MethodsBetween February 2008 and June 2019, 349 consecutive patients underwent Ivor Lewis esophagectomy with gastric conduit reconstruction and circular stapled anastomosis. Patient characteristics and postoperative results, such as anastomotic insufficiency rates, postoperative anastomotic stricture rates, time to anastomotic stricture rate, and the number of dilatations, were recorded in a prospective database and analyzed. ResultsIn 222 patients (64%), the 25 mm circular stapler was used and in 127 patients (36%) the 28 mm circular stapler was used. There were no differences in baseline characteristics. Anastomotic insufficiency rates were comparable between the 25 mm (12%) and the 28 mm groups (11%) (p = 0.751). There were no differences between postoperative anastomotic strictures in the 25 mm (14%) and the 28 mm groups (14%) (p = 0.863). Within patients with postoperative anastomotic strictures, a median number of 2 dilatations were observed in each group (p = 0.573) without differences in the time to first diagnosis (p = 0.412). ConclusionThere were no differences in anastomotic insufficiency and postoperative anastomotic stricture rates between the 25 mm and the 28 mm circular stapled esophagogastric anastomosis after Ivor Lewis esophagectomy. Both the 25 mm and 28 mm stapler can be safely used to create a circular stapled esophagogastric anastomosis to restore continuity after esophagectomy.