Postoperative Stenosis Research Articles

MODERN METHODS OF PREVENTION AND TREATMENT OF COMPLICATIONS OF CERVICAL ESOPHAGO-ORGAN ANASTOMOSIS AT ESOPHAGOPLASTY

The aim: To improve the results of operative treatment of esophageal strictures by decreasing the rate of failure and stricture of cervical esophago-organ anastomoses. Materials and methods: There were 45 patients with post-burn corrosive gullet strictures, 17 patients with postoperative corrosive strictures, 10 patients with peptic strictures secondary to reflux-esophagitis, 42 patients with esophageal cancer strictures. The patients were divided into two groups: the comparison group - 55 persons and the main group - 59 persons. Patients of comparison group underwent surgical treatment of esophageal strictures according to classic protocols and standards. In the main group of patients we applied proposed diagnostic algorithm with prediction of complication risk and the designed method of esophago-organ anastomosis formation. Results: The results of operative treatment in patients with esophageal strictures showed the development of early postoperative complications in 59 individuals (51.75 %). In the postoperative period six patients died: four - in the comparison group and two - in the main group. Failure of cervical esophago-organ anastomosis and esophageal strictures occurred in 7 patients (11.86 %) of main group and 20 patients (36.36 %) of the comparison group (p<0.05). Conclusions: Application of method predicting the risk of complications of cervical anastomosis, treatment program and instrumental method of formation anastomosis resulted in reduced incidence of failure and strictures of esophago-organ anastomosis from 36.36 % to 11.86 % (p<0.05); decreased time of hospitalization - from 28.2 ± 1.1 to 21.5 ± 0.5 bed-days (p<0.001), postoperative period - from 20.5 ± 1.1 to 16.1 ± 0.7 bed-days (p<0.01); decreased postoperative mortality - from 7.27 % to 3.39 %.

Staged resection and local intralesional triamcinolone acetonide injection to prevent postoperative stricture for multiple superficial hypopharyngeal cancer : a case report

頭頸部表在癌治療は主に経口的切除術と放射線療法である。治療方針は年齢，既往歴，病変の部位，深達度，範囲等を鑑みて決定するが，多発・広範な場合は特に慎重な検討が必要である。症例は胸部食道表在癌に対して内視鏡治療歴のある78歳男性で，下咽頭の両側梨状陥凹と後壁に表在癌を認めた。放射線療法も検討されたが，多発・重複癌であり，今後の再発・新規病変への対応を考慮して経口的切除術を選択した。広範かつ複数亜部位の切除になることから術後瘢痕狭窄予防として段階的切除とトリアムシノロンアセトニドの局所注射を実施し，局所制御および常食摂取を達成している。多発下咽頭表在癌の対応について重要な示唆を得たので報告する。

Diagnosis and Management of Choledochal Cyst : A Single Center Experience

Objective: Choledochal cyst is cystic dilatation of intrahepatic and/ or extrahepatic bile duct. Its incidence is 1 in 1000 in Asian population. The objective of the study was to study the presentation, diagnosis, treatment and postoperative outcome of choledochal cyst operated in Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal.&#x0D; Methods: This retrospective study was done by reviewing all the records of patients with choledochal cyst who underwent operative treatment in Dhulikhel Hospital from January 2015 to July 2019.&#x0D; Results: We analyzed twenty cases of Choledochal cyst. It was found to be common in age group (21-30 ) years with female preponderance (85%). Most common presenting symptom was abdominal pain. Abdominal Ultrasonography was the initial diagnostic tool. Todani type I choledochal cyst was the commonest type. All the cases underwent complete excision of extrahepatic biliary tree followed by hepato-jejunostomy. There was no post-operative anastomosis stricture in follow up period.&#x0D; Conclusion: Choledochal cyst presents commonly with abdominal pain. It can be diagnosed with abdominal ultrasonography. It has good outcome if treated adequately with good surgical technique.

Efficacy of hydrocortisone sodium succinate and aluminum phosphate gel for stricture prevention after ≥3/4 circumferential endoscopic submucosal dissection.

ObjectiveEndoscopic submucosal dissection (ESD) is widely used in early-stage esophageal cancer, but the quality of life of patients with postoperative stricture is markedly reduced, requiring long-term repeat, periodic endoscopic balloon dilatation. We evaluated the combination of hydrocortisone sodium succinate and aluminum phosphate gel administered orally for stricture prevention.MethodsWe retrospectively assigned 27 patients who underwent ≥3/4 circular ESD for esophageal superficial squamous cell cancer to one of two groups according to the preventative strategy: endoscopic intralesional steroid injection and systemic steroid (IT+ST group) and oral combination of hydrocortisone sodium succinate and aluminum phosphate gel (OHA group). Stricture rate was compared between the two groups.ResultsThere were six and seven complete and ≥3/4 circular ESD cases, respectively, in the IT+ST group and four and ten cases in the OHA group. Stricture rates in the IT+ST and OHA groups were 53.8% and 7.1%, respectively. Nine patients in each group developed hypokalemia after glucocorticoid administration.ConclusionsOHA is a promising treatment strategy for stricture prevention following large-circumference ESD in patients with early stage esophageal carcinoma.

Two types of autologous cells in stricture development prevention after complete circular endoscopic dissection in minipig.

Complete circular endoscopic dissection (CED) is frequently accompanied with post-operative strictures formation in the esophagus. Various types of therapeutic approaches have recently been tested to prevent these strictures, e.g. cell therapy or stenting. Miniature pigs of Gottingen/Minnesota origin (n=10) were used in the study. First, we made the complete CED in the mid esophagus; next, the defect was left untreated or covered with mesenchymal stem cells (MSCs) or amixture of MSCs and primary oral keratinocytes (pOKs) suspension without/with fully covered self-expandable metallic stent (SEMS). Consequently, we performed acontrol endoscopy with astent removal, and necropsy was performed 17-36 days after cells application. All CED procedures were completed successfully without serious complications. Although we were able to detect MSCs or pOKs in the post-CED defects up to the 36th day after transplantation, the combination of MSCs or MSCs/pOKs with or without SEMS application did not prevent post-CED strictures development. The mixture of MSCs and pOKs resulted in the formation of cellular aggregates, which were mainly observed in submucosa, and the post-CED defect was covered with collagen fibers containing athin scarred epithelium, accompanied by various degrees of reconstruction and integrity. Suspension application of autologous MSCs alone or in combination with pOKs with or without SEMS was ineffective in the prevention of strictures formation after complete CED. Nevertheless, the presence of MSCs or pOKs in the post-CED defect was confirmed even 5 weeks after transplantation.

P183 NEW METHOD OF ESOPHAGO-GASTRO ANASTOMOSIS WITHIN MINIMALLY INVASIVE HYBRID IVOR LEWIS PROCEDURE

Abstract Aim Improve the results of surgical treatment of esophageal cancer by developing and implementing a new method for the formation of invagination mechanical esophagogastoanastomosis. Material and methods Reconstruction after esophagectomy together with the reliability of the esophagus-gastric anastomosis (EGA) constitute some of the most important problems in the surgery of the esophagus, because anastomosis leakage is one of the main reasons of lethal surgery. The research included 60 patients who anderwent the minimally invasive hybrid Ivor Lewis procedure for malignant tumors of esophagus in Shalimov National Institute of Surgery and Transplantation (1 group comprised 30 patients with mechanical EGA end-to-side; 2 group comprised 30 patients with invaginated mechanical EGA). The objects for estimation included post-operative mortality as well as the number of post-operative anastomosis complications: the number of EGA leakages in the early post-operative period and the number of post operative strictures in the EGA area three, six and twelve months after the surgery. All patients underwent a course of neoadjuvant chemo/RT in accordance with NCCN guidelines. Data processing was done by means of Statistic - licensed application programs for Windows. Results and discussion Patients belonging to both groups were comparable according to their age, sex, weight, height and surgery duration. Research group did not register a single case of EGA leakage while 2 patients in control group (р&lt;0,05). had the leakage which was stopped by means of “Endovac” system. There were 2 cases of esophagus post-operative strictures which developed 3 months after the surgery in the research group which was less than in the control group which saw 6 cases of strictures of EGA (р&lt;0,05). 6 months after surgery, the number of post-operative strictures increased in both groups, but was lower in the research group and amounted to 4 cases in the research group and 11 cases in the control group (р&lt;0,05). There were 5 cases of esophagus post-operative strictures which developed 12 months after the surgery in the research group which was less than in the control group which saw 13 cases of strictures of EGA (р&lt;0,05). Neither of the groups had any cases of post-operative mortality. Conclusion The study found that invaginated mechanical EGA within minimally invasive hybrid Ivor Lewis procedure reduces EGA leakages as well as EGA benign strictures.

P74 A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS OF ANASTOMOTIC TECHNIQUES FOR OESOPHAGECTOMY FOR MALIGNANCY

Abstract Aims This systematic review and network meta-analysis evaluates the evidence for the techniques for oesophagogastric (OG) anastomosis and their impact on perioperative outcomes. Background Current evidence on the benefits of different anastomotic techniques (hand-sewn (HS), circular stapled (CS), triangular stapler (TS) or linear stapler/semi-mechanical (LSSM) techniques after oesophagectomy is conflicting. Methods A systematic literature search was conducted to identify randomised and non-randomised studies reporting techniques for the OG anastomosis. Network meta-analysis of postoperative anastomotic leaks and strictures was performed. Results This study included 15 randomised and 22 non-randomised studies (n=8,618). LSSM (OR: 0.49, CI95%: 0.33 - 0.74, p=0.001) and CS (OR: 0.68, CI95%: 0.48 - 0.95, p=0.027) and anastomoses were associated with lower anastomotic leak rates than HS anastomosis. LSSM anastomosis was found to be superior to CS (OR: 0.15, CI95%: 0.08 - 0.28, p &lt;0.001), TS (OR: 0.32, CI95%: 0.19 - 0.54, p &lt;0.001) and HS (OR: 0.15, CI95%: 0.05 - 0.46, p=0.001) anastomoses respectively in anastomotic stricture rates. LSSM was ranked the best technique with high probability for anastomotic leaks and strictures. Conclusions Stapled anastomoses, specifically LSSM were associated with lower anastomotic leaks and strictures rates following oesophagectomy. Therefore, current evidence suggests superiority of the LSSM technique for OG anastomosis.

Laparoscopic surgery for colorectal cancer with persistent descending mesocolon

BackgroundPersistent descending mesocolon (PDM) is caused by the absence of fusion of the descending colon to the retroperitoneum. We herein report two colorectal cancer cases with PDM that were treated with laparoscopic surgery.Case presentationCase 1: a 50-year-old man with sigmoid colon cancer and synchronous liver metastasis. After neoadjuvant chemotherapy, he underwent laparoscopic sigmoidectomy with lymph node dissection cutting the root of the inferior mesenteric artery (IMA) and synchronous liver resection. He experienced postoperative stenosis of the reconstructed colon possibly due to an impaired arterial blood flow in the reconstructed colon.Case 2: a 77-year-old man with rectal cancer. Laparoscopic low anterior resection preserving the left colic artery (LCA) was performed. Intraoperative infrared ray (IR) imaging using indocyanine green (ICG) showed good blood flow of the reconstructed colon. He had no postoperative complications. In cases of PDM, the mesentery of the descending and sigmoid colon containing the LCA is often shortened, and the marginal artery of the reconstructed colon is located close to the root of the LCA. Lymph node dissection accompanied by cutting the LCA carries a risk of marginal artery injury. Therefore, we recommend lymph node dissection preserving the LCA in colorectal cancer patients with PDM in order to maintain the blood flow of the reconstructed colon. If the IMA and LCA absolutely need to be cut for complete lymph node dissection, the marginal artery should be clearly identified and preserved. In addition, intraoperative IR imaging is extremely useful for evaluating colonic perfusion and reducing the risk of anastomotic complications.ConclusionIn colorectal cancer surgery in patients with PDM, surgeons should be aware of these tips for maintaining the blood flow of the reconstructed colon and thereby avoid postoperative complications caused by an impaired blood flow.

Complication management after bile duct surgery

Bile leakage and postoperative bile duct strictures or anastomotic stenosis after bilioenteric anastomosis are complex surgical complications, which are associated with increased morbidity and mortality. Detailed diagnostics and sophisticated decision-making is always requiered. Complex liver surgery (redo procedures, nonanatomic resections, etc.) and surgery involving the liver hilum or exposure of the intraparenchymal Glissonean sheath are risk factors for postoperative bile leakage. Bile leakage is defined as a bilirubin concentration at least three times greater than the serum bilirubin measured in an abdominal drainage on or after the third postoperative day or as the need for radiologic intervention because of biliary collection or relaparotomy for bile peritonitis. Therapeutic strategies for bile leakage comprise conservative watch and wait, interventional procedures (endoscopic or percutaneous biliary drainage) and relaparotomy and are selected based on the postoperative onset, output volume and anatomic localization of the bile leak. Conservative treatment and interventional procedures show ahigh success rate and should therefore be considered as the treatment of choice in most cases. In contrast to bile leakage, bile duct strictures and anastomotic stenosis are rarely observed after surgery and can usually be treated by interventional procedures. This review article discusses situation-dependent specific treatment of postoperative bile leakage as well as bile duct strictures and anastomotic stenosis in detail.

Laparoscopic ureterolithotomy versus ureteroscopic laser lithotripsy for large proximal ureteral stones: a systematic review and meta-analysis.

To review current studies and conduct a meta-analysis on the topic of laparoscopic ureterolithotomy (LU) versus ureteroscopic lithotripsy (URSL) with holmium laser for large proximal ureteral stones. A systematic research of PubMed, Ovid, Scopus (up to March 2019), and citation lists was performed to identify eligible comparative studies. All studies comparing LU versus URSL with holmium laser in proximal ureteral stones were included. Statistical analyses were performed using the Cochrane Collaboration's Review Manager (RevMan) 5.3 software. Overall, seven studies were included in analysis involving 884 patients (LU 387; URSL 497). Our meta-analysis showed that LU group had bigger stone size than URSL group (WMD 0.19 cm; P=0.001). LU group was associated with longer operative time (WMD 36.29 min; P<0.001), and length of hospital stay (WMD 1.24 d; P=0.04). However, LU group showed better initial stone-free rate (OR 11.03; P<0.001), and final stone-free rate (OR 22.37; P<0.001). There were no significant differences in all complications (RR 1.06; P=0.76). While, LU group had fewer Clavien Dindo score ≥3 complications (RR 0.21; P=0.002), fewer ureteral stricture (RR 0.26; P=0.04), and lower need of auxiliary procedures (RR 0.09; P<0.001) compared with URSL group. LU could provide a higher stone-free rate and fewer severe complications compared with URSL with holmium laser for large proximal ureteral stones. More importantly, LU could also reduce the postoperative ureteral stricture rate.

Post-Operative Urethral Stricture after Holmium Laser Enucleation of the Prostate

Holmium laser enucleation of the prostate (HoLEP) is a safe and effective surgical procedure for patients suffering from comparatively larger benign prostatic hyperplasia. However, the rate of postoperative urethral stricture (POUS) is relatively high, which can render further invasive intervention. Here we assessed the POUS rate, riskfactors and outcomes in 206 patients with benign prostatic hyperplasia who underwent HoLEP at our hospital between January 2006 and December 2015. POUS was observed in 24 patients (11.7%). The rate of intraoperative urethral stricture was significantly higher in the patients with POUS (8 out of 24 patients, 33.3%) than in those without POUS (12 out of 186 patients, 6.6%). The odds ratio was 7.08, 95% and combination index (CI) was 2.53-19.9, p<0.001). The relative riskfor POUS based on intraoperative urethral stricture was 4.65 (95% CI : 2.28-9.48). The most common POUS site was external urethral orifice (12 out of 24 cases). The POUS onset was significantly earlier in patients with external urethral orifice than the other sites (p=0.0389). The site of postoperative stricture concurred with that of intraoperative stricture at a high rate (7 out of 8 patients). Significant differences were observed between patients with and without POUS within one month in international prostate symptom score, quality of life score and in Qmax after the operation, while they were improved by simple interventions such as bougie. In conclusion, we should consider the possibility of POUS when the patient had an intraoperative stricture in HoLEP.

1736 Mega Esophageal Diverticulum Complicated by Post-Operative Esophageal Stricture

INTRODUCTION: Esophageal diverticulae are rare outpouchings of the esophagus that occur secondary to underlying motility disorders. On average they measure approximately 7 cm. Here we present a case of mega diverticulum measuring 8.5 cm, complicated by post-operative esophageal stricture. CASE DESCRIPTION/METHODS: Patient is a 58-year old female with a medical history of gastroesophageal reflux disease who presented to our gastroenterology clinic complaining of progressively worsening reflux and weight loss. Given these symptoms, an esophagogastroduodenoscopy (EGD) was scheduled. This was done and showed a large esophageal diverticulum with luminal distortion and retained food in the lower third of the esophagus. Subsequently a barium swallow was ordered to better evaluate the esophagus. This was done and showed an 8.5 × 6.0 cm diverticulum from the right side of the distal esophagus with slight irregularity of the mucosa superior to the diverticulum (Figure 1). The patient was then referred the surgical clinic for possible intervention. After discussing the risks and benefits of treatment the patient agreed to undergo surgical repair consisting of a diverticulectomy. This was done successfully with no postoperative complications. Five days after the procedure a repeat barium swallow was done and showed resolution of the diverticulum with no leakage of barium, but did reveal lower esophageal narrowing with a dilated thoracic esophagus (Figure 2). Following these findings a repeat endoscopy was done which showed a lower esophageal stricture that was treated with balloon dilation (Figure 3). After the procedure the patient was able to tolerate oral intake and was safely discharge home. DISCUSSION: Management of esophageal diverticula depends on the severity of symptoms. In asymptomatic patients a conservative approach may be employed. In symptomatic patients who present with dysphagia, regurgitation, vomiting or chest pain, surgery is the mainstay of treatment. Surgical management consists of diverticulectomy with long myotomy and subsequent fundoplication. Postoperative complications include pulmonary edema, pneumonia, and leakage of barium swallow into the thoracic cavity. Rarely will esophageal narrowing resulting in persistent dysphagia occur. In these cases an endoscopic treatment with balloon dilation should be pursued. Our case highlights a rare presentation of a mega esophageal diverticulum complicated by a post-operative esophageal stricture that was successfully treated with balloon dilation.

P026 - Retrograde holmium: YAG laser endoureterotomy in the treatment of postoperative ureteral strictures following endoscopic stone surgery

P026 - Retrograde holmium: YAG laser endoureterotomy in the treatment of postoperative ureteral strictures following endoscopic stone surgery

Early prediction of complex benign anastomotic stricture after esophagectomy using early postoperative endoscopic findings.

Benign anastomotic stricture after esophagectomy and reconstruction adversely affects oral intake and can increase the risk of aspiration pneumonia. Some patients experience relapse that requires frequent endoscopic dilatations. This study aimed to investigate whether the endoscopic appearance of anastomosis during the early postoperative period is associated with the complexity of subsequent anastomotic strictures. Data of 213 patients who underwent esophagectomy with gastric tube reconstruction and early postoperative endoscopy between July 2008 and September 2018 were prospectively collected. Relationships among various risk factors, including the severity of mucosal degeneration of the anastomosis and complexity of anastomotic stricture, were studied using multivariate logistic regression analysis. Fifty-three patients (25%) developed anastomotic strictures at a median of 55days after surgery, requiring a median of 5 endoscopic dilations. In multivariate analysis, severe mucosal degeneration was the only significant risk factor for any type of anastomotic stricture (P < 0.001). Twenty-seven patients (51%) developed refractory anastomotic strictures. In multivariate analysis, younger age (< 65years) (P = 0.01), lack of neoadjuvant therapy (P = 0.02), severe mucosal degeneration (P = 0.03), and stricture development within 55days (P = 0.01) were the risk factors for refractory stricture. The analysis of the risk factors for severe mucosal degeneration revealed that comorbidities and anastomotic techniques were independently correlated (P < 0.01). Early postoperative severe mucosal degeneration of esophagogastrostomy was the only predictor of strictures, regardless of their type. Mucosal degeneration, early postoperative stricture, younger age, and front surgery were associated with refractory anastomotic strictures.

Comparison of Short-Term Efficacy Between Endoscopic Submucosal Tunnel Dissection and Endoscopic Submucosal Dissection in Treatment of Wide Esophageal Squamous Cell Carcinoma of Early Stage.

The goal of this study was to compare the efficacy and safety of endoscopic submucosal tunnel dissection (ESTD) with endoscopic submucosal dissection (ESD) for the removal of early-stage esophageal squamous cancer wider than or equal to one half the circumference of the esophagus. Although ESD has been successfully applied for resection of early-stage esophageal cancer, there are still technical challenges and postoperative stenosis when it is applied to treat large lesions. A total of 40 patients with early-stage esophageal cancer wider than or equal to one half its circumference were enrolled in this study and randomly assigned to an ESTD or ESD group for treatment of esophageal superficial squamous cell carcinoma. All of the patients received oral steroids after endoscopic dissection. We then compared the 2 groups in terms of average operating time, dissection speed, en bloc resection rate, R0 resection rate, and complications during a 1-year follow-up period. The dissection speed in the ESTD group was significantly faster than that in the ESD group (P=0.047). There were no significant differences in operating time, en bloc resection rates, or R0 resection rates between the ESTD and ESD group (P=0.319, 1.000, 1.000, respectively). There were also no significant differences in perforation, bleeding, or stenosis rates between the ESTD and ESD group (P=1.000, 0.748, 1.000, respectively). Both ESTD and ESD are safe and effective therapies for early-stage esophageal cancer wider than or equal to one half the esophageal circumference. The dissection speed of ESTD is faster than that of ESD.

Techniques for successful vaginal anastomosis in the uterine transplant patient

To demonstrate our techniques for successful vaginal anastomosis in the uterine transplant patient. We report the case of a recent uterine transplant from a decease multi-organ donor and highlight the vaginal anastomosis portion of this multi-step surgery. This video uses live action footage from surgery and detailed descriptions review our techniques for successful vaginal anastomosis in the uterine transplant patient. Following uterine transplantation, access to the donor allograft cervix is important for many reasons. Vaginal strictures pose a unique problem in this surgical population. We believe strictures result from difficult in approximating donor vaginal mucosa to recipient vaginal mucosa, and that this is paramount in reducing this untoward postop complication. Given the difficulty of surgery and tendency for the recipient vaginal mucosa to retract, our teams has employed techniques from vaginal reconstructive surgery to reduce the occurrence of postoperative vaginal strictures.

Radiological Intervention and Imaging Procedures in Management of Patients with Malignant Obstructive Jaundice

AbstractBackground: Malignant biliary obstruction has a bad prognosis and adverse effect on the quality of life, with most of those patients are inoperable at time of diagnosis. Patients who underwent whipple operation may develop anastomotic site (choledocho-jujenostomy) stenosis with subsequent ele-vated bilirubin level and related complications.Aim of Study: This prospective study will be conducted to evaluate the efficacy of different modalities of interventional radiological and imaging procedures as Percutaneous Trans hepatic Cholangiography (PTC), Percutaneous Trans hepatic Drainage (PTD) and biliary stenting in management of patients with malignant obstructive jaundice.Patients and Methods: This study was conducted on 30 patients (19 males and 11 females) with mean age of 56 years, 28 of 30 patients (93.3%) are non operable and the other 2 of 30 patients (6.7%) operated patients for choledocho-jujenostomy stenosis were subjected to intervention techniques. 10 of 30 patients (33.3%) underwent percutaneous external biliary drainage, 15 of 30 patients (50%) underwent percuta-neous stent insertion (8 of 30 patients (26.7%) with metallic stents & 7 of 30 patients (23.3%) with plastic stents), 3 of 30 patients (10%) underwent internal external drainage and 2 of 30 patients (6.66%) underwent biliary drainage through combined (randez-voux) technique.Results: High success rate (86.6%) with reduction of total bilirubin level was observed in metallic stenting group of patients.Conclusion: Biliary intervention procedures help to reduce high bilirubin level, bypass obstruction level and help in dilatation of post-operative stenosis site.

Endoscopic Balloon Dilation for Benign Bilioenteric Stricture: Outcomes and Factors Affecting Recurrence.

Balloon dilation (BD) is a simple, effective procedure for postoperative benign bilioenteric strictures (BBESs). Factors associated with BBES recurrence after endoscopic BD have not been studied adequately. This study examined the outcomes and 1-year recurrence factors in patients with BBES who underwent endoscopic BD. Patients who underwent endoscopic BD as an initial treatment between April 2008 and March 2017 were retrospectively assessed. The median time to recurrence of BBES (RBBES) and recurrence factors were evaluated. The study group comprised 55 patients (median age 72years). The rate of RBBES was 52.7% (29/55), and the median time to RBBES was 2.78years (95% confidence interval [CI] 1.17-4.40). RBBES was observed in 32.7% (18/55) within 1year after endoscopic BD. The significant factors associated with recurrence within 1year, revealed by multivariate analysis, were: postoperative bile leak (p = 0.001; hazard ratio [HR] 10.94; 95% CI 2.47-48.39); BBES onset within 6months, postoperatively (p = 0.013; HR 6.18; 95% CI 1.46-26.21); no intrahepatic stones (p = 0.049; HR 3.05; 95% CI 1.01-9.22); and remaining balloon waist (p = 0.005; HR 5.71; 95% CI 1.69-19.31). The median time to RBBES was significantly shorter in patients with these recurrence factors (0.88years vs. not reached, p = 0.004). Patients exhibiting at least two recurrence factors were significantly more likely to experience recurrence (p < 0.001). Endoscopic BD is effective for BBES, especially for patients with no recurrence factors. Consideration of endoscopic BD and additional treatment may be necessary for patients with recurrence factors.

Risk factors of coloanal anastomotic stricture after laparoscopic intersphincteric resection for low rectal cancer

Objective: To evaluate the risk factors of coloanal anastomotic stricture after laparoscopic intersphincteric resection (Lap-ISR) for patients with low rectal cancer. Methods: A retrospective case-control study was performed to collect clinicopathological data from a prospective database (registration number: ChiCTR-ONC-15007506) at the Department of Colorectal Surgery, the Characteristic Medical center of PLA Rocket Force. From June 2011 to August 2018, a total of 144 consecutive patients with low rectal cancer who underwent Lap-ISR were enrolled in the study. Inclusion criteria: (1) reconstruction of digestive tract by end-to-end hand-made coloanal anastomosis (HCAA); (2) distance from lower tumor margin to anorected sphincter ring < 1 cm and distance from lower tumor margin to intersphincteric groove ≥ 1 cm; (3) T1-3 stage tumor with expected negative circumferential resection margin evaluated by preoperative MRI or 3D endoanal ultrasound; (4) rectal cancer confirmed as well- or moderately-differentiated adenocarcinoma; (5) preoperative Wexner incontinence score >10 points. Exclusion criteria: (1) follow-up period less than 3 months; (2) multiple primary cancers; (3) undergoing colonic J-pouch, coloplasty or reconstruction of end-to-side coloanal anastomosis; (4) death within perioperative period (within 3 months after surgery). Coloanal anastomotic stricture was diagnosed if the index finger or 12 mm electronic colonoscope had obvious resistance through the anastomosis or new rectum, or could not pass, accompanied by clinical symptoms such as difficult defecation and anal incontinence. Degree of anastomotic stricture was divided into 3 grades: grade A required anal enlargement, laxative or enema to assist defecation without active surgical treatment; grade B required surgery or endoscopic intervention; grade C required definitive ostomy, including unreducible preventive ileostomy or permanent colostomy. Univariate and multivariate analysis were used to evaluate the effects of 28 variables, including baseline data (age, gender, body mass index, neoadjuvant therapy, etc.), tumor-related factors (distance between tumor low margin and anal edge, maximum diameter of tumor, TNM staging, etc.), surgery-related factors (operation time, intraoperative blood loss, ISR procedure, anastomotic height, etc.) and anastomotic leakage, on the postoperative coloanal anastomotic stricture. Univariate analysis used χ(2) test or Fisher's exact test, then factors with P<0.05 were further included in multivariate analysis using logistic regression. Results: A total of 144 patients were enrolled in the study, including 90 males and 54 females with a median age of 59 years and median BMI of 24.88 kg/m(2). R0 resection rate was 96.5% (139/144). Median tumor distal resection margin was 1.5 (0.5 to 3.0) cm. Median follow-up was 31.5 (4 to 86) months. Coloanal anastomotic stricture was observed in 19 patients (13.2%), including 3 cases (2.1%) of grade A, 9 cases (6.2%) of grade B, and 7 cases (4.9%) of grade C. The median interval from the initial surgery to diagnosis of anastomotic stricture was 7 (1 to 31) months. Univariate analysis showed that male (χ(2)=6.795, P=0.009), radiotherapy (χ(2)=13.330, P=0.001), operation type of ISR (χ(2)=7.996, P=0.013), and anastomotic leakage (χ(2)=10.198, P=0.004) were associated with the postoperative coloanal anastomotic stricture. Multivariate analysis further indicated that male (OR=5.975, 95% CI: 1.209-29.534, P=0.028), postoperative radiotherapy (OR=8.748, 95% CI: 2.397-31.929, P=0.001), and anastomotic leakage (OR=6.313, 95% CI: 1.834-21.734, P=0.003) were independent risk factor of postoperative coloanal anastomotic stricture. Conclusion: For male patients, or patients with postoperative radiotherapy or anastomotic leakage, close follow-up should be carried out to prevent postoperative coloanal anastomotic stricture following Lap-ISR.

Thermal effect of holmium laser lithotripsy under ureteroscopy.

Thermal effect of holmium laser lithotripsy under ureteroscopy.