Postoperative Stenosis Research Articles

Indications and endonasal treatment of petrous apex cholesterol granulomas

Lesions of the petrous apex of the temporal bone can be challenging to access and approaches laterally through the mastoid as well as medially through an endonasal approach are utilized to access this region while preserving function of adjacent structures. Cholesterol granulomas of the petrous apex requiring surgery are marsupialized to prevent expansion of the inflamed cyst and relieve associated clinical symptoms. The endonasal approach to the petrous apex has in the past been limited to lesions medial to the internal carotid artery. Endoscopic approaches have been developed to expand the range of petrous apex lesions that are accessible endonasally. These endonasal corridors include a nasopharyngeal/transclival corridor, lateralization of the internal carotid artery to create an expanded medial window, a pterygopalatine infrapetrosal approach, and a contralateral maxillary approach, which allow improved access to the inferior and lateral petrous apex. Nasoseptal flaps may reduce the risk of postoperative stenosis of the drainage tract. Endoscopic endonasal approaches can be used safely to address both medial and lateral/inferior petrous apex lesions. Morbidity of these procedures is low and use of a nasoseptal flap may limit restenosis of the drainage pathway.

VIRTUAL BRONCHOSCOPY OF MULTISPIRAL COMPUTED TOMOGRAPHY WITH TRAUMATIC INJURIES OF THE MAIN BRONCHUS

The aim of the study was to evaluate the role of virtual bronchoscopy (VB) in traumatic rupture of the main bronchus Material and methods. Тhe data of virtual bronchoscopy of multispiral computed tomography (MSCT) with multiplanar and 3D reconstructions of 10 patients with traumatic separation of the main bronchus were analyzed. MSCT was carried out by the computer tomograph AquilionONE (320-slice) according to the previously described technique. Results of the study. VB MSCT allowed to determine the presence of a complete or partial rupture of the main bronchus, its distance to the bifurcation of the trachea, the state of the collapsed lung, the presence of fluid in the hemithorax, secondary changes in the bone structures of the chest. The World Bank played an important role in monitoring the adequacy of reconstructive measures on the damaged bronchus, excluding the occurrence of postoperative stenosis. The conclusion. Virtual bronchoscopy of multispiral computed tomography with the capabilities of multiplanar and volumetric reconstructions, postprocessing image processing is an optimal non-invasive method for determining the traumatic lesion of the main bronchi and monitoring the success of the reconstructive surgical manual.

Triangulating stapling vs functional end-to-end stapling for cervical esophagogastric anastomosis after esophagectomy for thoracic esophageal cancer: study protocol for a randomized controlled trial

BackgroundSeveral studies have reported that the triangulating stapling method decreases the incidence of anastomotic stricture after esophagectomy. Our previous randomized controlled trial, however, could not confirm the superiority of the triangulating stapling (TS) method over the circular stapling (CS) method in terms of postoperative anastomotic stricture rate. Recently, the functional end-to-end stapling (FEES) method for cervical anastomosis after esophagectomy was developed, and lower anastomotic stricture rates with FEES have been reported than for our previously experienced anastomotic methods. To investigate the optimal anastomotic method, we now compare the TS method with the FEES method for cervical anastomosis regarding decrease in anastomotic stricture after esophagectomy for thoracic esophageal cancer.MethodsThis is a randomized, single-center clinical trial designed to examine the superiority of the FEES method over the TS method for esophageal cancer patients. The primary endpoint is reduction of anastomotic stricture of cervical esophagogastric anastomosis within 12 months after esophagectomy. Secondary endpoints include overall postoperative morbidity within the first 12 months after esophagectomy, incidence of anastomotic leakage, aspiration pneumonia, or reflux esophagitis, and quality of life assessment as measured by the FACT-E at 12 months after esophagectomy. The incidence rate of anastomotic stricture of the TS method was 20% and this rate of the FEES method was estimated to be 4% in our preliminary study. We calculated sample size with a beta error of 0.20 and an alpha error of 0.05. We have been enrolling 125 patients in this trial to either the TS group or the FEES group since January 2017.DiscussionThis study should help to define the optimal anastomotic method for cervical esophagogastric anastomosis after esophagectomy in patients with esophageal cancer.The FEES method, if proven to be superior to the TS method, can be implemented routinely for esophageal cancer patients with gastric-conduit reconstruction after esophagectomy.Trial registrationUniversity Hospital Medical Information Network Clinical Trial Registry (UMIN 000025632). Registered on 13 January 2017.

A clinical study of endoscopic balloon dilation in treatment of esophageal stenosis after neonatal esophageal atresia surgery

Objective To explore the feasibility and efficacy of endoscopic balloon dilation in treatment of esophageal stenosis caused by operation of congenital esophageal atresia. Methods A retrospective analysis was performed on data of 218 children with type Ⅲ esophageal atresia, who underwent surgery in Zhengzhou Children′s Hospital from January 2009 to December 2017. The occurrence of postoperative complications and efficacy of endoscopic balloon dilation in treatment of esophageal stenosis was analyzed. Results Among the 218 patients with congenital esophageal atresia, 92 were type Ⅲa and 126 were type Ⅲb. Postoperative anastomotic leakage occurred in 46 cases (21.1%), including 29 (31.5%) of type Ⅲa and 17 (13.5%) of type Ⅲb. Postoperative anastomotic stenosis occurred in 53 cases (24.3%), including 29 (31.5%) of type Ⅲa and 24 (19.0%) of type Ⅲb. The incidence of anastomotic leakage and anastomotic stenosis in different types was significantly different (χ2=10.383, P=0.001; χ2=4.497, P=0.034). The 53 cases of anastomotic stenosis underwent 123 times of endoscopic balloon dilation, with mean time of 3.5±1.6, and were finally clinically recovery. No esophagus perforation occurred. Among them, 29 cases of type Ⅲa underwent 73 times with mean of 4.0±1.8, and 24 cases of type Ⅲb underwent 50 times with mean of 2.5±0.7. The difference between the two types was statistically significant (t=-4.053, P=0.027). Conclusion Children with type Ⅲa esophageal atresia has a higher incidence of anastomotic stenosis and leakage, and more times of esophageal dilation. Endoscopic balloon dilation is safe and effective in treatment of esophageal stenosis after surgery for patients with congenital esophageal atresia. Key words: Child; Esophageal atresia; Esophageal stenosis; Endoscopic balloon dilation

Efficacy and safety of steroid in the prevention of esophageal stricture after endoscopic submucosal dissection: A network meta‐analysis

Even though endoscopic submucosal dissection is an important endoscopic resection technique for gastrointestinal neoplasms, there are chances that postoperative esophageal stricture might take place as a side effect. Steroid applications were reported to be effective for the prevention of stricture formation. Therefore, this study aims to evaluate the efficacy and safety of different steroid applications. Eligible studies published on PubMed, the Cochrane Library, Embase, Web of Science, and Chinese Biomedical Literature Database before August 2018 were reviewed. The preventions were divided as placebo/no treatment, long-term oral steroid (LOS), median-term oral steroid, short-term oral steroid, single-dose steroid injection, multiple-dose steroid injection, topical superficial steroid, steroid injection combined with oral steroid, and preemptive endoscopic balloon dilatation. The primary outcomes were postoperative esophageal stricture rate and endoscopic balloon dilatation sessions required. Complications were also analyzed. A total of 19 studies were included. The network meta-results illustrated that compared with the placebo, all kinds of steroid interventions were associated with lower rates of postoperative esophageal stenosis and less number of endoscopic balloon dilatation sessions. Moreover, combined therapy was no better than single regimen therapy. No significant differences between various steroid applications in the incidence of complications were spotted during this study. Based on the results of the network and clustered ranking, LOS might be the superior prevention for postoperative stricture with satisfying efficacy. The present study showed that LOS appears to be the optimal prevention method for postoperative stricture formation.

Predictive Value of Anastomotic Blood Supply for Anastomotic Stricture After Esophagectomy in Esophageal Cancer.

Insufficient blood supply in the gastric tube is considered as a risk factor for postoperative anastomotic strictures in patients receiving esophagectomy, but the direct evidence is lacking. We aimed to investigate the correlation between perioperative blood supply in the anastomotic area of the gastric tube and the formation of anastomotic strictures in the patients undergoing esophagectomy. This prospective study included 60 patients with esophageal squamous cell carcinoma undergoing Ivor Lewisesophagectomy between March 2014 and February 2016, which were divided into stricture group (n = 13) and non-stricture group (n = 47) based on their severity of anastomotic strictures at 3months post-operation. The perioperative anastomotic blood supply was measured using a laser Doppler flowmetry. The gastricintramucosalpH (pHi) was measured by a gastric tonometer within 72h post-operation. The perfusion index and gastric pHi were compared between groups. The stricture group had a significantly lower blood flow index (P < 0.001) and gastric pHi values from day 1 to day 3 post-operation than the non-stricture group (all P < 0.001). In addition, Pearson correlation analysis showed that both the perfusion index and gastric pHi were significantly correlated with stricture size and stricture scores, respectively (r = 0.65 - 0.32, all P < 0.05). Furthermore, the multivariate logistic regression analysis showed that perfusion index was an influential factor associated with postoperative anastomotic strictures (OR 0.84. 95% CI 0.72-0.98, P = 0.026). These results suggested that poor blood supply in the anastomotic area of the gastric tube in the perioperative period was a risk factor for postoperative anastomotic strictures.

Effect of Early Endoscopic Evaluation With Balloon Dilatation on Preventing Esophagojejunal Strictures Following Total Gastrectomy for Gastric Cancer

Background: The present study aims to evaluate the efficacy of early endoscopic evaluation with balloon dilatation performed during non-symptomatic post-operative period with the intent of preventing benign post-operative esophagojejunal anastomotic strictures in patients who receive total gastrectomy for gastric cancer. Methods: First, we retrospectively compared the prevalence of benign esophagojejunal anastomotic stricture occurred 1 month after total gastrectomy for gastric cancer in early endoscopic evaluated group using balloon dilatation (n = 61) with non-evaluated group (n = 148); and then we reviewed the relationship between benign anastomotic stricture and other clinicopathological parameters, including gender, age, body mass index (BMI), and tumor, node, metastasis (TNM) stage. Results: The total number of patients was 209, with 139 men and 70 women, and with an average age of 57.8 years. The endoscopic evaluation with or without balloon dilatation on the 10th post-operative day (POD) was performed in 61 out of 209 patients. Of them, benign post-operative anastomotic stricture was found in 17 patients (27.9%). In the remaining 148 patients, benign post-operative anastomotic stricture occurred in 14 (9.5%) patients. In the 61 patients who received early endoscopic evaluation, 16 received preventive balloon dilatation at the same time and four of them showed benign stricture (4/16, 25%). Of the remaining 45 patients who was endoscopically evaluated without balloon dilatation, 13 had benign strictures (13/45, 28.9%). Preventive endoscopic balloon dilatation (EBD) on the 10th POD was not statistically related to post-operative stricture in a total of 209 patients (P = 0.260) and in early gastrofiberscopy (GFS) sub-group (P = 1.000). A multivariable logistic regression analysis showed that pre-operative BMI (P = 0.014) and endoscopy on the 10th POD (P = 0.001) were independent predictors of post-operative anastomotic stricture. Conclusions: Endoscopic procedure with balloon dilatation, which we had expected to prevent stenosis by widening the internal diameter of the anastomosis site in early post-operative period after total gastrectomy, does not prevent stenosis but rather promotes post-operative stricture. In addition, the lower the pre-operative BMI is, the more frequent post-operative benign anastomotic stricture will be. J Curr Surg. 2019;000(000):000-000 doi: https://doi.org/10.14740/jcs370

Outcomes of Early Primary Endoscopic Realignment and Delayed Reconstruction in the Management of Posterior Urethral Injury in Male

Background: Posterior urethral injury usually occurs in male patients with pelvic fractures. Posterior urethral injuries are associated with considerable morbidity including urinary incontinence, erectile dysfunction and urethral stricture. Objective: To compare the outcomes between early primary endoscopic realignment and delayed reconstruction in the management of male patients of posterior urethral injury. Methodology: This prospective study was conducted in the department of urology and department of casualty, Dhaka Medical College Hospital, Dhaka, Bangladesh from July 2015 to June 2017 among 50 male patients with posterior urethral injury. Fifty patients were randomly allocated into two groups; the group A consisted of 24 patients underwent early primary endoscopic realignment within 10 days after posterior urethral injury and the group B consisted of 26 patients underwent delayed reconstruction in form of anastomotic urethroplasty after 3 months. All patients were followed up at 3rd, 6th and 9th month after the procedure. Outcome variables were post-operative urethral stricture, urinary incontinence and erectile dysfunction. Data were analyzed and compared by statistical tests. Results: The mean (±SD) age of the study patients was almost similar between the groups (28.8 ± 8.4 vs. 27.4 ± 7.2 years, p = 0.486). In group A, 83.33% patients developed postoperative urethral stricture, none of them developed urinary incontinence and 20.83% developed erectile dysfunction; On the other hand, in group B, these rates were 38.46%, 23.07% and 38.46% respectively. Postoperative urethral stricture formation was significantly higher in Group A (p = 0.0012) but urinary incontinence and erectile dysfunction rates were significantly higher in Group B (p = 0.018 and p = 0.042 respectively). Conclusion: Early primary endoscopic realignment is better than delayed reconstruction in the management of male patients with posterior urethral injury. It provides less postoperative complications like urinary incontinence and erectile dysfunction, though postoperative urethral stricture formation is higher but amenable to be corrected endoscopically.

Surgical repair for bile duct injuries after cholecistectomy in a tertiary referral center: long term results

Background: Bile duct injuries (BDI) after laparoscopic cholecistectomy commonly occur close to the hilar plate. Hepatico-jejunostomy (HJ) according to Hepp-Couinaud (HC) technique in referral centers remains the best surgical treatment. Methods: 186 patients (pts) referred for BDI between 1994 and 2014, 163 pts (87.6%) for major BDI. Eighty-nine (47.8%) underwent surgical repair: 82 HJHC and 7 multiple-HJ. Aims of this study were: evaluate predictive factors of failure of biliary recostruction, long term results after surgery and after percutaneous stenting (PTC) in postoperative strictures. Repair was defined successful when no further treatment was required. Symptom-free Survival (SFS) after surgery and Progression Symptom-free Survival (PSFS) after PTC of stricture were evaluated. Results: Postoperative morbidity was 34.8% with no mortality. After a mean follow-up of 96 months, 76 pts (85,4%) had excellent/good outcome. Thirteen pts (14.6%) developed anastomotic stricture treated with PTC. Post-operative bile leakage was the only factor significantly related to a failure of biliary reconstruction (p = 0.03; HR:4.963). Ten-years SFS was 82%. At the end of PTC treatment 8 pts (61%) reached excellent/good results with 10-years PSFS of 92.4% (p = 0.049%). Conclusion: Success of biliary reconstruction after BDI is related to development of postoperative bile leakage. Ten-year survival without symptoms was 82% after surgery and it was significantly increased to more than 92% after PTC management of failed repairs.

Surgical repair for bile duct injuries after cholecistectomy in a tertiary referral center: long term results

Background: Bile duct injuries (BDI) after laparoscopic cholecistectomy commonly occur close to the hilar plate. Hepatico-jejunostomy (HJ) according to Hepp-Couinaud (HC) technique in referral centers remains the best surgical treatment. Methods: 186 patients (pts) referred for BDI between 1994 and 2014, 163 pts (87.6%) for major BDI. Eighty-nine (47.8%) underwent surgical repair: 82 HJHC and 7 multiple-HJ. Aims of this study were: evaluate predictive factors of failure of biliary recostruction, long term Results after surgery and after percutaneous stenting (PTC) in postoperative strictures. Repair was defined successful when no further treatment was required. Symptom-free Survival (SFS) after surgery and Progression Symptom-free Survival (PSFS) after PTC of stricture were evaluated. Results: Postoperative morbidity was 34.8% with no mortality. After a mean follow-up of 96 months, 76 pts (85,4%) had excellent/good outcome. Thirteen pts (14.6%) developed anastomotic stricture treated with PTC. Post-operative bile leakage was the only factor significantly related to a failure of biliary reconstruction (p=0.03; HR:4.963). Ten-years SFS was 82%. At the end of PTC treatment 8 pts (61%) reached excellent/good results with 10-years PSFS of 92.4% (p=0.049%). Conclusion: Success of biliary reconstruction after BDI is related to development of postoperative bile leakage. Ten-year survival without symptoms was 82% after surgery and it was significantly increased to more than 92% after PTC management of failed repairs.

Buccal mucosal graft versus penile skin flap urethroplasty for long segment penile urethral stricture: a prospective randomized study.

IntroductionThe aim of this study was to analyze the outcomes of dorsolateral onlay buccal mucosal graft (BMG) and ventral onlay local penile skin flap (LPF) urethroplasty in the management of long segment penile urethral stricture (PUS).Material and methodsThrough a prospective study conducted between October 2014 and May 2018, 84 patients with long segment PUS were randomly assigned to receive either dorsolateral onlay BMG (Group 1 which included 42 patients) or ventral onlay PSF urethroplasty (Group 2 which included 42 patients). The success rate and surgical outcomes were compared in both groups.ResultsThe success rate was 92.9% in Group 1 and 85.7% in Group 2 (p = 0.5). Postoperative short segment urethral stricture at the site of proximal anastomosis was reported in 3 patients in Group 1. Six patients in Group 2 were considered as a treatment failure, 3 of them due to recurrence of long segment urethral stricture after 6 months, and 3 patients developed ring urethral stricture at the site of proximal anastomosis managed by direct vision internal urethrotomy.ConclusionsOn an intermediate term follow-up, dorsolateral onlay BMG and ventral onlay LPF provide similar success rates in penile urethroplasty, with essentially comparable postoperative morbidity. However, further studies with bigger sample sizes and longer follow-up periods may be required to determine subtle differences between both techniques.

Mitomycin in Choanal Atresia Repair

Background: choanal atresia is one of congenital anomalies that needs surgical repair. Nasal re-stenosis and obstruction are side effects of endoscopic repair. Mitomycin was proposed to decrease postoperative stenosis and/or obstruction. Aim of the Work: it was to address the efficacy of adjuvant mitomycin therapy application in providing the postoperative patency in choanal atresia. Patients and Methods: this study is a record analysis of surgical outcomes of transnasal endoscopic surgical choanal atresia repair in Al-Azhar University Hospitals (Cairo and Damietta). The study included records of 30 children with either uni- or bi-lateral choanal atresia. Eighteen (18) children of themwereoperated upon with adjuvant mitomycin therapy. Meanwhile, records of 12 children were operated uponwithout adjuvant mitomycin andconsidered as a comparison group. Postoperative stenting was carried out in all participants. The collected information included demographic information, associated co-morbidities, operative details, and endoscopic findings. The outcome measures were: granulation tissue formation, need for postoperative dilation and need for revision surgical intervention. Results: re-stenosis was reported in 11 (28.9%) patients. The need for revision surgery was reported in 10.3%. The postoperative dilatation was required in 10 (25.6%) patients, and there was no significant difference between mitomycin and comparison groups. Conclusion and Recommendation: the use of adjunctive mitomycin therapy with endoscopic repair of choanal atresia seems to be effective and safe approach. Multicenter follow up trials should be done to fully evaluate the value (benefits) of adjuvant mitomycin therapy in choanal atresia repair.

Mitomycin in Choanal Atresia Repair

Background: choanal atresia is one of congenital anomalies that needs surgical repair. Nasal re-stenosis and obstruction are side effects of endoscopic repair. Mitomycin was proposed to decrease postoperative stenosis and/or obstruction. Aim of the Work: it was to address the efficacy of adjuvant mitomycin therapy application in providing the postoperative patency in choanal atresia. Patients and Methods: this study is a record analysis of surgical outcomes of transnasal endoscopic surgical choanal atresia repair in Al-Azhar University Hospitals (Cairo and Damietta). The study included records of 30 children with either uni- or bi-lateral choanal atresia. Eighteen (18) children of themwereoperated upon with adjuvant mitomycin therapy. Meanwhile, records of 12 children were operated uponwithout adjuvant mitomycin andconsidered as a comparison group. Postoperative stenting was carried out in all participants. The collected information included demographic information, associated co-morbidities, operative details, and endoscopic findings. The outcome measures were: granulation tissue formation, need for postoperative dilation and need for revision surgical intervention. Results: re-stenosis was reported in 11 (28.9%) patients. The need for revision surgery was reported in 10.3%. The postoperative dilatation was required in 10 (25.6%) patients, and there was no significant difference between mitomycin and comparison groups. Conclusion and Recommendation: the use of adjunctive mitomycin therapy with endoscopic repair of choanal atresia seems to be effective and safe approach. Multicenter follow up trials should be done to fully evaluate the value (benefits) of adjuvant mitomycin therapy in choanal atresia repair.

Reconstruction of the larynx with unipedicled sternohyoid myofascial flap following open extended vertical partial laryngectomy

&lt;p class="abstract"&gt;The extent of resection during open vertical partial laryngectomy may vary considerably and even an experienced surgeon may encounter difficulties in reconstructing the larynx to preserve laryngeal function and to prevent stenosis. Different local flaps were proposed for reconstruction; however, the ideal technique is still under development. A simple modification to the technique originally described by Calcaterra (1983) is presented. The unipedicled sternohyoid myofascial flap consists of the unsplit sternohyoid muscle with all three overlying fasciae harvested as a whole. The flap is rotated 90° and horizontally sutured in position to supply the necessary bulk to the entire neocord to produce a functional voice. Completely filling the mucosal defect USMF-flap allows laryngeal structures to maintain their native position and retain protective function of the larynx. The thick multilayered fascia covering facilitates rapid epithelization and prevents excessive granulation and secondary stenosis. The technique is indicated in glottic cancer patients treated by open extended vertical partial laryngectomy when the laryngeal mucosa defect is too extensive for primary closure and poses significant risk of developing postoperative stenosis.&lt;/p&gt;

Evaluating the Outcome of Direct Repair of Bile Duct Injury

AbstractBackground: Bile duct injury (BDI) during laparoscopic cholecystectomy is a surgical catastrophe with an incidence ranging. Between 0.3 to 1,4%. Many surgeons think that direct repair of BDI carries a high risk of stricture that is why the bilioenteric reconstruction is more popular.Aim of Study: Evaluating the results of direct repair in selected cases and compare it to the classic bilioenteric reconstruction.Methods: We had 2 groups, group A had direct bile duct repair and group B had bilioenteric reconstruction. The choice of doing the direct repair was based on the absence of risk factors for biliary complications. Both are compared as regards the presence of postoperative complications either leakage or stricture and hospital stay. All cases were done in Ain Shams university hospitals during the period between January 2013 until December 2017.Results: Bile leakage had happened in one case of group A (11%) and 2 cases of group B (16.7%) with no statistically significant difference, (p-value is 0.72). One case of group A (11.1%) had biliary stricture which was presented at 6 months follow up, managed first by ERCP and stent twice and required reconstruction by Roux en Y after 15 months. For group B, 2 cases had anastomotic strictures presented at 9 and 12 months. They were managed by PTC, dilatation, and stenting and followed by redo reconstruction of the anastomosis at 15 and 17 months after the surgery.Conclusions: Direct repair of the Bile duct can be safely done in properly selected patients with comparable results to bilioenteric reconstruction and no increase in the incidence of postoperative complications.

Surgical repair of partial anomalous pulmonary venous return with intact atrial septum in a 65-year-old woman: a case report

BackgroundPartial anomalous pulmonary venous return is a rare congenital cardiac anomaly that usually involves the right pulmonary vein and an atrial septal defect. Isolated partial anomalous pulmonary venous return with an intact atrial septum is even rarer, and this condition is usually treated surgically in younger patients. We describe isolated partial anomalous pulmonary venous return in a 65-year-old woman who was treated by caval division with pericardial patch baffling through a surgically created atrial septal defect and reconstruction of the superior vena cava using a prosthetic graft.Case presentationA 65-year-old Asian woman who presented with exertional dyspnea was diagnosed with isolated partial anomalous pulmonary venous return. The surgical indications and strategy were controversial because of the rarity of this pathology. She had an indication for surgery because she was symptomatic and had a high ratio of pulmonary to systemic blood flow. We considered that surgical procedures should avoid postoperative stenosis of a reconstructed flow tract, sinus node dysfunction, and thrombogenesis. We created a caval division with pericardial patch baffling through a surgically created atrial septal defect and reconstructed the superior vena cava using a prosthetic graft for the isolated partial anomalous pulmonary venous return. She has since remained free of exertional dyspnea, arrhythmia, and thrombotic complications. This surgical strategy is safe and effective for treating isolated partial anomalous pulmonary venous return in older symptomatic adults.ConclusionsThe long-term outcome of surgical repair of partial anomalous pulmonary venous return with an intact atrial septum in our patient, a symptomatic 65-year-old woman, was excellent.

Efficiency and safety of endoscopic therapy for early esophageal cancer and precancerous lesions with length more than 5 cm

Objective To compare the effectiveness and safety of endoscopic submucosal dissection (ESD) with endoscopic piecemeal mucosal resection (EPMR) for early esophageal cancer and precancerous lesions with length more than 5 cm. Methods A retrospective analysis was performed on data of 85 patients diagnosed as early esophageal cancer and precancerous lesions with length more than 5 cm in Fujian Medical Association of Early Esophageal Carcinoma from January 2012 to July 2017. The patients were divided into ESD group (52 cases) and EPMR group (33 cases), and the effectiveness and safety between the two groups were compared. Results There was no significant difference on the complete resection rate between the two groups[86.5% (45/52) VS 87.9% (29/33), P>0.05]. The operative time (58.53±30.50 min VS 32.06±9.12 min), postoperative fasting time (4.18±1.30 d VS 3.67±0.96 d), postoperative hospital-stay time (7.45±2.44 d VS 6.54±1.73 d), and postoperative antibiotics using time (3.48±2.33 d VS 1.96±2.20 d) in ESD group were higher than those in EPMR group (all P 0.05). But the postoperative stricture rate of ESD group was higher than that of EPMR group[23.1% (12/52) VS 6.1% (2/33), P 0.05). Conclusion ESD and EPMR have equivalent efficacy and safety on the treatment of early esophageal cancer and precancerous lesion. EPMR has a shorter operative time, lower rate of post-operative stricture, and is easier to master. Key words: Esophageal neoplasms; Endoscopic piecemeal mucosal resection; Endoscopic submucosal dissection; Efficiency; Safety

Endoscopic Management of Gastrointestinal Complications

AbstractDespite improvements in preoperative patient optimization, refinements in surgical methodology and technology, and the implementation of enhanced recovery protocols, complications following gastrointestinal (GI) surgery remain a fact of life. As the rates of GI surgical procedures increase worldwide, so will the volume of complications. The surgical management of complications is often not ideal, as some (such as acute staple line bleeding or the development of an anastomotic stricture) are luminal-based processes that are difficult to approach from an extraluminal (i.e., surgical) perspective. Endoscopy has largely replaced surgery for the management of such postoperative problems. Leak, the most feared complications of GI surgery, can result from intestinal resection, anastomosis formation, or from iatrogenic injury. With advancements in both diagnostic and therapeutic endoscopy, novel endoluminal and transluminal management options for leak continue to evolve. In centers where these interventions are readily available, they are becoming a first-line treatment option. This article will review the endoscopic management of GI complications with a particular focus on the management of postoperative strictures and of full-thickness GI tract defects (perforations, acute leaks, and chronic fistulae).

Local Thymosin β4 Gel Injection Prevents Esophageal Stricture after Circumferential Endoscopic Submucosal Dissection in a Porcine Model

Background: Endoscopic submucosal dissection (ESD) is widely used in the treatment of early esophageal cancer. However, the incidence of postoperative esophageal stricture is relatively high, especially after full circumferential ESD. Previous studies have shown that thymosin β4 (Tβ4) has anti-fibrotic activity and prevents scar formation. In this study, we investigated the safety and therapeutic effect of Tβ4 injection in preventing esophageal stricture after circumferential ESD in a porcine model. Methods: A total of 8 Bama pigs underwent esophageal circumferential ESD under anesthesia (n = 4 for experimental and control group). Local injection of Tβ4 gel was administered in the experimental group. Follow-up endoscopy was conducted, and balloon dilation (EBD) was performed to prevent the occurrence of esophageal stricture. Results: Esophageal stricture developed after circumferential ESD in all pigs. Local Tβ4 gel injection has shortened resolution of the stricture (p = 0.012) and was associated with a lesser number of EBD sessions (p = 0.002). The severity of esophageal stricture was milder in the experimental group (p = 0.046 vs. control group). No adverse events occurred in the study. Conclusions: Local Tβ4 gel injection appeared to be safe and effective for the prevention of esophageal stricture after circumferential ESD in a porcine model.

Clinical efficacy of basiliximab-induced glucose-free corticosteroid immunosuppressive regimen after liver transplantation

Objective To investigate the clinical efficacy of basiliximab-induced glucose-free corticosteroid immunosuppressive regimen after liver transplantation. Methods The retrospective cohort study was conducted. The clinicopathological data of 227 patients with liver transplantation who were admitted to Bayi Hospital affiliated to Nanjing University of Traditional Chinese Medicine from January 2010 to October 2016 were collected. Of the 227 patients, 125 who postoperatively received a glucose-free corticosteroid immunosuppressive regimen using a monoclonal antibody + tacrolimus + mycophenolate mofetil tablets were allocated into the hormone-free group, and 102 who were postoperatively treated with the immunosuppressive regimen using glucocorticoid steroid + tacrolimus + mycophenolate mofetil tablets were allocated into the hormone group. Observation indicators: (1) comparison of follow-up and survival; (2) comparison of postoperative infection, rejection and biliary stenosis between groups. Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival, infection, rejection and biliary stenosis up to June 2017. The measurement data with normal distribution were represented as ±s, and comparison between groups was done by the t test. Measurement data with skewed distribution were described as M (P25, P75) and M (range), and comparison between groups was analyzed using the rank sum test. The count data were compared by the chi-square test. Kaplan-meier method was used to draw survival curve and calculated survival rate. Log-rank test was used for survival analysis. Results (1) Comparison of follow-up and survival: patients between groups were followed up for 9-89 months, with a median time of 45 months. The 1- and 3-year overall survival rates were respectively 93.25%, 85.24% in the hormone-free group and 89.89 %, 74.22% in the hormone group, with a statistically significant difference (χ2=8.450, P 0.05). The rejection of both groups occurred within 1 week postoperatively. Two patients in the hormone group were treated with glucocorticoid hormonal shock. The other patients in the 2 groups were improved by adjusting the amount of tacrolimus and mycophenolate mofetil tablets. ③ The cases with postoperative biliary stenosis in the hormone-free group and the hormone group were 32 and 8 respectively, with a statistically significant difference (χ2=12.200, P<0.05). In the hormone group, biliary stenosis occurred after stopping glucocorticoids. The patients with biliary stenosis were improved after biliary stent implantation by endoscopic retrograde cholangio pancreatography (ERCP). Conclusion The basiliximab-induced glucose-free corticosteroid immunosuppressive regimen after liver transplantation is safe and feasible, and it can significantly reduce the incidence of postoperative infection and improve long-term overall survival compared with the conventional glucocorticoid immunosuppressive regimen, but increased postoperative biliary stenosis. Key words: Liver transplantation; Immunosuppression; Basiliximab; Glucocorticoid hormone; Rejection; Biliary stenosis