Postoperative Stenosis Research Articles

Functional Outcome Analysis After Anterolateral Thigh Flap Reconstruction of Pharyngoesophageal Defect

Pharyngoesophageal defects are traditionally reconstructed with jejunal or radial forearm flaps. Recently, anterolateral thigh flaps have served for pharyngoesophageal reconstruction. We tell of our experience with anterolateral thigh flap for the reconstruction of pharyngoesophageal defect for the past 5 years. This study presents another modified flap design and refinement of surgical techniques. In all, 45 pharyngoesophageal reconstructions were performed during 2006 to 2011, namely patch (n = 18), near-circumferential (n = 8), and circumferential defect (n = 19) reconstructed by 2 plastic surgeons with the same trapezoid anterolateral thigh flap design. Total flap loss occurred in 2 patients (4%). Two patients experienced partial flap necrosis. Fistulas occurred in 8 patients, but only 5 of these needed further suture ligation or local flap treatment. Postoperative strictures without tumor recurrence were identified in 4 patients (9%). Forty patients (88.9%) could tolerate oral diet; 34 of these ate soft or solid food. Anterolateral thigh flap offers good coverage and swallowing function in the reconstruction of hypopharyngeal defect. Trapezoid drawing of anterolateral thigh flap makes the design simplified, with an accepted complication rate.

A video demonstration of the Li's anastomosis-the key part of the "non-tube no fasting" fast track program for resectable esophageal carcinoma.

The main obstacle of fast track surgery for esophagectomy is early oral feeding. The main concern of early oral feeding is the possibility of increasing the incidence of anastomotic leakage. Dr. Yin Li used the Li's anastomosis to ensure oral feeding at will the first day after esophagectomy. This safe and efficient anastomosis method significantly reduced the anastomotic leak rate, the number of post-operative days and stricture. Importantly, the "non-tube no fasting" fast track program for esophageal cancer patients was conducted smoothly with Li's anastomosis. This article was focused on the surgical procedure of Li's anastomosis.

Management of benign biliary strictures: current status and perspective.

Benign biliary strictures are common and occur either from hepato-biliary surgery or from diseases including chronic pancreatitis and primary sclerosing cholangitis, among others. The treatment of many such strictures is endoscopic with evolving new approaches especially with fully covered metal stents. The only classification system available is for postoperative strictures with the intention to guide surgical correction. There is no useful classification system to guide both assessment and management of benign biliary strictures. This proposed classification is relevant to patient care in assisting diagnosis and endoscopic management.

Percutaneous treatment of symptomatic superior mesenteric vein stenosis using self-expanding nitinol stents

PurposeTo evaluate the technical and clinical success of percutaneous superior mesenteric vein (SMV) stenting in symptomatic patients using self-expanding nitinol stents. MethodsWe retrospectively analyzed the technical and clinical success of percutaneous SMV stenting of 6 symptomatic patients (3 men, mean age 67 years, range 48–81 years). Stenosis of the SMV was caused by postoperative stricture (n=3), pancreas carcinoma (n=1) and pancreatitis (n=2). As a result of the stenosis, 3 patients had symptomatic ascites, 2 patients showed signs of mesenteric ischemia and 1 patient had recurrent gastrointestinal bleeding. Stenting was performed by a percutaneous transhepatic approach using self-expanding nitinol stents. ResultsStenting of the SMV was technically and clinically successful in all patients. No peri-interventional complications occurred. The stent diameters ranged from 6 to 14mm. During the mean follow-up of 6 months (range, 2–10 months) 1 patient presented early stent occlusion 2 weeks after placement. ConclusionStenting of a symptomatic SMV stenosis using self-expanding nitinol stents is feasible and clinically effective.

Effect of Continuous Urethro-Vesical Anastomosis Technique in Incontinence After Radical Retropubic Prostatectomy, 1:1 Matching Study.

Purpose:Vesicourethral anastomosis (VUA) is an important step in radical prostatectomy and can affect clinical course in hospital. However, few studies comparing VUA by standard interrupted and continuous suturing techniques in radical retropubicprostatectomy (RRP) have been reported. We compared the postoperative outcomes and continence recovery rates of patients undergoing these two variations of VUA using 1:1 propensity score matching.Methods:From January 2008 to January 2014, a total of 188 patients underwent RRP. We conducted 1:1 propensity score matching based on age, prostate volume, pathological stage, status of nerve sparing, and two baseline characteristics (preoperative prostate-specific antigen [PSA] level and Gleason score determined by pathology). Patients were assigned to two groups based on the suturing method used (interrupted or continuous). After RRP, incontinence levels were assessed at 1, 3, 6, and 12months based on pad usage per day (0, dry; ≤1, social continence; ≥2, incontinence).Results:Each group consisted of 47 patients. The continuous group had a lower incidence of VUA site leakage (0% vs. 10.6%, P=0.022), but there were no significant differences in the rates of postoperative urethral stricture (6.4% vs. 6.4%, P=1.00) andpyuria (43.6% vs. 45.0%, P=0.770) between the two groups. The rate of recovery to social continence was greater in the continuous group at postoperative 3 months (85.1% vs. 66.0%, P=0.031). About 50% of patients had no incontinence (pad perday=0) after 6 months (59.6% in the continuous group and 51.1% in the interrupted group, P=0.407) and at postoperative 12 months, the dry rate 61.7% in the interrupted group and 80.4% in the continuous group (P=0.047). The times required toreach social continence (3.21 months vs. 3.77 months, P=0.056) and no incontinence (7.23 months vs. 7.63 months, P=0.132) were also shorter in the continuous group, but these differences were not statistically significant.Conclusions:The results of this study suggest that earlier recovery to social continence and a higher rate of complete recovery (dry) could be expected with VUA by continuous suturing. Furthermore, if adequate surgical experience is accumulated, VUAwith continuous suturing could be performed without difficulty.

Bricker versus Wallace anastomosis: A meta-analysis of ureteroenteric stricture rates after ileal conduit urinary diversion

Data comparing the incidence of ureteroenteric strictures for Bricker and Wallace anastomoses are limited. This study compares both anastomotic techniques in terms of ureteroenteric stricture rates after radical cystectomy and ileal conduit urinary diversion. Electronic databases (Medline, EMBASE, and Cochrane database) were searched for studies comparing Bricker and Wallace ureteroeneteric anastomoses for ileal conduit urinary diversion after radical cystectomy. Meta-analyses were performed using the random effects method. The primary outcome measure was to determine differences in postoperative ureteroenteric stricture rates for both surgical techniques. Four studies describing 658 patients met the inclusion criteria. The total number of ureters used for ureteroeneteric anastomoses was 1217 (545 in the Bricker group and 672 in the Wallace group). There were no significant differences in age (p = 0.472), gender (p = 0.897), duration of follow-up (p = 0.168), and duration to stricture development between groups (p = 0.439). The overall stricture rate was 29 of 1217 (2.4%); 16 of 545 ureters (2.9%) in the Bricker group and 13 of 672 ureters (1.9%) in the Wallace group. The Bricker anastomosis was not associated with a significantly higher overall stricture rate compared to the Wallace ureteroenteric anastomosis (odds ratio: 1.393, 95% confidence interval: 0.441-4.394, p = 0.572). Accepting limitations in the available data, we found no significant difference in the incidence of ureteroenteric stricture for Bricker and Wallace anastomoses.

经尿道输尿管镜下微创治疗儿童输尿管术后再次狭窄 12例回顾分析

Objective: To explore the clinical efficacy of the minimally-invasive treatment of ureteral postoperative stenosis with self-made electrotome, ureteroscope hard expansion and ureteral stents indwelled. Methods : A retrospective analysis of 12 cases with ureteral postoperative strictures (10 in the upper, 1 in the middle, 1 in the lower ureters, 10 cases of male, female 2 cases, average 2.1 years) from June 2012 to April 2014 was made, the length from 0.2cm to 1.5 cm, with an average of 0.5 cm. Renal function were moderately impaired in 6 cases, severely impaired in 6 cases, underwent the therapy of ureteral stenosis with self-made micro-probe electrotome and ureteroscope hard expansion, postoperatively, one 4.7 or 6F ureteral stents were remained indwelling for 6～8 weeks. Results : 12 cases completed the operation smoothly, the operative duration was 35～65 minutes (average 46 minutes). No severe complications were accompanied. Postoperative hospital stays for 7～9 days, an average of 8.3 days. with a median follow-up 8 months (ranging form 1～20 months), success was achieved in 10 of the 12 children, 2 cases were unsuccessful so as to undergo pyeloureteroplasty on open surgery once again because of the long ureteral narrow（the length over 1.2cm）and recovered eventually. Conclusion : Minimally-invasive ureteroscopy combined with self-made electrotome ureteroscope hard expansion and ureteral stents indwelled is one of the effective methods for treatment of ureteral postoperative stenosis which worth further promotion clinical application, the operation effect is exact, little pain and quick recovery, it can be used to short period ( 1.2cm ) that requires to open surgery.

Reoperation After Holmium Laser Enucleation of the Prostate for Management of Benign Prostatic Hyperplasia: Assessment of Risk Factors with Time to Event Analysis.

To determine risk factors of reoperation after holmium laser enucleation of the prostate (HoLEP) for management of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) with time to event analysis. A prospectively maintained database was reviewed for patients undergoing HoLEP. Baseline and follow-up data were compared in terms of International Prostate Symptoms Score, quality of life, peak flow rate, residual urine, and prostate-specific antigen (PSA) at 1, 6, and 12-months and then annually. Perioperative and late adverse events were recorded. Reoperation was defined as the need for any surgical intervention to relieve bothersome LUTS after HoLEP. Multivariate logistic regression was used to determine covariates associated with reoperation and the Kaplan-Meier curve assessed the time to reoperation. A total of 1216 HoLEP procedures were performed between March 1998 and October 2013 with a mean prostate volume of 94.8 ± 52.7 cc. Catheter time and hospital stay were 1.4 ± 1.9 and 1.3 ± 1.6 days, respectively. After a median follow-up of 7.6 years (1-14 years), 52 (4.3%) patients needed reoperation for recurrent LUTS, including 13 (1.07%) for residual/recurrent adenoma, 14 (1.15%) for bladder neck contracture (BNC), and 25 (2.05%) for de novo urethral stricture. In multivariate regression, smaller prostate size (< 62 cc), PSA reduction < 50%, and history of previous prostate surgery were significantly associated with recurrence of adenoma. BNC was significantly associated with smaller glands (< 54 cc) while longer operative time and postoperative catheterization were significantly associated with urethral stricture. Kaplan-Meier curve demonstrates post-HoLEP freedom from reoperation of 96.9% at 5 years and 95.1% at 10 years. In a single center large series, HoLEP has 95% reoperation-free probability at 10 years. Relatively small-size prostate may have an impact on recurrence of adenoma and bladder neck contracture. PSA reduction < 50% was significantly associated with recurrence of adenoma while longer operative time and postoperative catheterization were significantly associated with postoperative urethral stricture.

Clinical outcomes of endoscopic submucosal dissection for superficial esophageal neoplasms: a multicenter retrospective cohort study.

The safety and efficacy of endoscopic submucosal dissection (ESD) for superficial esophageal neoplasms (SENs) have not been evaluated in a multicenter survey. The aim of this study was to investigate the clinical outcomes in a multicenter study that included municipal hospitals. Of 312 consecutive patients with 373 esophageal lesions treated by ESD at 11 hospitals from May 2005 to December 2012, a total of 368 SENs in 307 patients were retrospectively analyzed. The median tumor size was 18 mm (range 2 - 85 mm). The median procedure time was 90 minutes (range 12 - 450 minutes). The en bloc resection and complete resection rates were 96.7 % (95 % confidence interval [CI] 94.4 % - 98.1 %) and 84.5 % (95 %CI 80.5 % - 87.8 %), respectively. Perforation (including mediastinal emphysema), postoperative pneumonia, bleeding, and esophageal stricture, occurred in 5.2 % (95 %CI 3.3 % - 7.9 %), 1.6 % (95 %CI 0.7 % - 3.5 %), 0 %, and 7.1 % (95 %CI 4.9 % - 10.2 %) of patients, respectively. All of these complications were cured conservatively. No procedure-related mortality occurred. Early treatment periods (odds ratio [OR] = 4.04; P < 0.01) and low volume institutions (OR = 3.03; P = 0.045) were significantly independent risk factors for perforation. The circumference of the lesion was significantly associated with postoperative stricture (OR = 32.3; P < 0.01). The procedure times significantly decreased in the later period of the study (P < 0.01). Follow-up data (median 35 months; range 4 - 98 months) showed significant differences in overall survival (P = 0.03) and recurrence-free survival (P < 0.01) rates between patients with curative and noncurative resections. Esophageal ESD has become feasible with acceptable complication risks and favorable long term outcomes.

A New Flap Technique for Reconstruction of Microtia and Congenital Aural Atresia.

Atresiaplasty is still a challenge for otolaryngologist, although the operation technique has been modified several times over the past decades. This study describes a reliable flap technique for combining atresiaplasty with total auricular reconstruction by performing the total auricular reconstruction with the MEDPOR framework at the same time as the atresiaplasty for patients with microtia and congenital aural atresia. We performed a prospective study of the medical records of 18 consecutive patients with congenital aural atresia. All the patients had a Jahrsdoerfer grade of 6 or higher, and the mean age was 9.7years. Atresiaplasty with the new flap technique was performed in 19 ears in our department from January 1, 2011, through July 31, 2013. Among the postoperative ears, 17 ears (89.5%) had the excellent outcomes, without infections and stenosis. Only two ears (10.5%) had postoperative stenosis and atresia after infection, respectively. There were no other complications. We concluded that the new flap technique combining atresiaplasty and total auricular reconstruction yielded satisfactory canal patency, low infection rates, and favorable cosmetic results, with acceptable rates of complications. This novel flap technique is a valuable option in the armamentarium of microtia and atresia surgeons.

Retroperitoneal laparoscopic ureterolithotomy in comparison with ureteroscopic lithotripsy in the management of impacted upper ureteral stones larger than 12 mm.

To compare the results of ureteroscopic lithotripsy (URSL) with retroperitoneal laparoscopic ureterolithotomy (RPLU) as two minimally invasive techniques in the management of proximal ureteral stones larger than 12 mm. From January 2009 to October 2013, patients with impacted unilateral upper ureteral stones larger than 12 mm were enrolled including 182 males and 93 females with a medium age of 40 years (22-72 years). Patients were randomized to receive URSL (139 cases) with semirigid ureteroscope or RPLU (136 cases). Stone size was similar in RPLU and URSL groups (13.8 ± 1.9 vs 13.6 ± 1.4 mm, P = 0.312). Operating time and hospitalizing days in URSL group were significantly shorter than those in RPLU group (P < 0.001), whereas stone clearance rate was significantly higher in RPLU group (97.1 vs 89.9 %, P = 0.017). Ureteral strictures happened higher in URSL group (5 patients, 3.6 %) than RPLU group (2 patients, 1.5 %) with no statistical significance, while the strictures requiring surgical intervention were significantly higher in URSL group (4 cases) (2.9 vs 0 %, P = 0.046). RPLU could provide better stone clearance rate than semirigid URSL for upper ureteral impacted stones larger than 12 mm. It may also reduce the chance of surgical intervention for postoperative ureteral stricture.

Initial experience with the new Pul-Stent in treating postoperative branch pulmonary artery stenosis

The Pul-stent is a new cobalt alloys stent, specially licensed for pulmonary artery stenosis. The aim of this study was to investigate the value of the stent implantation as the treatment of postoperative pulmonary artery stenosis. Clinical practice was carried out to evaluate effectiveness, safety and maneuverability of Pul-stent in the defined clinical setting. Transthoracic echocardiography, chest roentgenography and electrocardiography were carried out as follow-up studies at 1 and 3 months after procedures. Ten patients (7 males and 3 females) received Pul-stent implantation in left or right pulmonary arteries (9 stents in left and 1 stent in right). For 9 cases transcatheter stent implantation was performed and in I case hybrid procedure. The median age was 7. 9 years (range 3. 4 - 13. 7 years). The median weight was 22. 3 kg (range 13 - 32 kg). Among them 6 cases were post surgical repair of tetralogy of Fallot, 2 cases were after Fontan procedures, 1 patient was post surgical repair of pulmonary atresia with ventricular septal defect, and 1 patient had stenosis at Glenn pathway. The pressure gradient at the stenosis decreased from (31. 6 ± 10. 2) mmHg(1 mmHg =0. 133 kPa) to (7. 3 ± 10. 3) mmHg, and the diameter of the narrowest segment increased from (4. 0 ± 2. 3) mm to (9. 6 ± 2. 7) mm, the right ventricle to aortic pressure ratio decreased from 0. 54 to 0. 36, all of these improvements were statistically significant (t = 3. 9, -9. 7, 4. 5; P =0. 008, 0. 000, 0. 004). The total procedure time ranged from 55 to 220 min (median 117 min) , and the fluoroscopy time ranged from 9 to 67 min (median 26 min). There were 2 cases of post-stenting pneumorrhagia. No stent fracture, stent malposition and other severe complications were observed. Initial follow-up of 1 and 3-months showed good results with maintenance of improved caliber of the stented vessel, and the gradient across the stenosis area measured by echocardiography was (32. 0 ± 14. 6) mmHg after 3 months. Compared with before stentifng ((40.6 ± 15. 2) mmHg) and 1 month later ((30. 6 ± 13. 6) mmHg), the difference was not statistically significant (t =2. 2,1. 76; P =0. 07, 0. 10). Pul-Stent tracking and delivery was excellent, the initial experience has shown that Pul-stent implantation was effective and safe in treating post-operative branch pulmonary artery stenosis. Further follow-up study should be conducted to make sure whether those good results would be kept constant.

Balloon Dilation of the Ureter: A Contemporary Review of Outcomes and Complications

During ureteroscopy ureteral balloon dilation may be necessary to allow for passage of endoscopic instruments or access sheaths. We assessed the efficacy and complications associated with ureteral balloon dilation. We retrospectively reviewed the records at 2 institutions from 2000 to 2012 to identify patients who underwent ureteral balloon dilation during ureteroscopic treatment of upper tract stones. An 18Fr balloon dilator was used in all cases. Patients with documented ureteral stricture, radiation therapy or urothelial cancer were excluded from analysis. Primary outcomes were the stone-free rate, operative complications, balloon dilation failure and the postoperative ureteral stricture rate. Complications were divided into intraoperative and postoperative groups according to the Satava and Clavien-Dindo classifications, respectively. A total of 151 patients fulfilled study criteria. Median followup was 12 months. The stone-free rate was 72% and median time to first postoperative imaging was 2.8 months. Balloon dilation failed in only 8 patients (5%). Eight intraoperative ureteral perforations (5%) were identified, which were managed by a ureteral stent in 7 patients and a percutaneous tube in 1. Endoscopic re-treatment was required in 4 patients with Satava 2b postoperative complications. The postoperative complication rate was 8% (11 cases). A single ureteral stricture was attributable to balloon dilation. In this contemporary review balloon dilation of the ureter before endoscopic treatment of stone disease was associated with a high success rate and few complications. Ureteral balloon dilation may decrease the need for a secondary procedure in patients undergoing ureteroscopy to manage proximal ureteral and intrarenal stones.

Liver resection for the treatment of post-cholecystectomy biliary stricture with vascular injury.

To report experience with liver resection in a select group of patients with postoperative biliary stricture associated with vascular injury. From a prospective database of patients treated for benign biliary strictures at our hospital, cases that underwent liver resections were reviewed. All cases were referred after one or more attempts to repair bile duct injuries following cholecystectomy (open or laparoscopic). Liver resection was indicated in patients with Strasberg E3/E4 (hilar stricture) bile duct lesions associated with vascular damage (arterial and/or portal), ipsilateral liver atrophy/abscess, recurrent attacks of cholangitis, and failure of previous hepaticojejunostomy. Of 148 patients treated for benign biliary strictures, nine (6.1%) underwent liver resection; eight women and one man with a mean age of 38.6 years. Six patients had previously been submitted to open cholecystectomy and three to laparoscopic surgery. The mean number of surgical procedures before definitive treatment was 2.4. All patients had Strasberg E3/E4 injuries, and vascular injury was present in all cases. Eight patients underwent right hepatectomy and one underwent left lateral sectionectomy without mortality. Mean time of follow up was 69.1 mo and after long-term follow up, eight patients are asymptomatic. Liver resection is a good therapeutic option for patients with complex postoperative biliary stricture and vascular injury presenting with liver atrophy/abscess in which previous hepaticojejunostomy has failed.

The use of an interposed graft during portal vein and/or superior mesenteric vein reconstruction in pancreatic resection for pancreatic cancer.

482 Background: Combined portal vein and/or superior mesenteric vein (PV/SMV) resection with pancreatectomy sometimes leads to prolonged survival for patients with periampullary tumors. In this study, we evaluated outcomes of patients with PV/SMV reconstruction, and we considered indications for the use of a graft during this procedure. Methods: We performed PV/SMV resection with pancreatectomy in 128 patients with periampullary tumors, including 14 using grafts. Short and long-term outcomes associated with PV/SMV reconstruction and harvesting venous grafts and reconstructed PV/SMV patency during follow-up were assessed. Results: Of the 128 patients with periampullary tumors, 5 underwent total pancreatectomy, 99 pancreaticoduodenectomy, and 24 distal pancreatectomy. In the 14 patients who underwent PV/SMV reconstruction with grafts, the grafts were harvested from external iliac vein in 10 patients and internal jugular vein in the other 4. Five patients (3.9%) had intraoperative or postoperative acute thrombus or stenosis of reconstructed PV/SMV after direct end-to-end anastomosis. However, PV/SMV patency was excellent after reconstruction using grafts. Among 228 patients with common pancreatic cancer, there were no significant differences in overall survival (OS) between the patients with PV/SMV resection (n=99) and without PV/SMV resection (n=206) (P=0.354), although the lymph node metastasis rates in the patients with PV/SMV resection were higher than those without PV/SMV resection (78.8 vs. 64.6%, P=0.012). Furthermore, the tumor size in the patients with the use of a graft was larger than that without a graft (Mean size; 40.5 vs. 29.3 mm, P=0.047), and the R0 rates and OS were not different between the patients with and without a graft (R0 rates; 50 vs. 73%, P=0.129 and OS; 23.4 vs. 16.6 months, P=0.323). Conclusions: Depending on the length and/or position of the removed PV/SMV segment, an interposed graft may be required for reconstruction in some patients.

Effect of endoscopic submucosal dissection for superficial esophageal neoplasms and risk factors for postoperative stricture.

Endoscopic submucosal dissection (ESD) enables wider tumor resection compared with endoscopic mucosal resection and en bloc resection of superficial esophageal neoplasms. However, ESD may cause difficult-to-treat stricture of the esophagus, and therefore, prediction of and measures against postoperative esophageal stricture are critical. The aim of this study was to evaluate the effect of ESD on superficial esophageal neoplasms and identify risk factors associated with esophageal stricture after ESD.This study included 165 lesions in 120 patients with superficial esophageal neoplasms, including cancer and neoplasia, who underwent ESD from 2009 to 2013.The complete resection rate of superficial esophageal neoplasms by ESD was 90.9%. After ESD, 22 subjects (18.3%) had symptomatic esophageal stricture, 12 (10.0%) had aspiration pneumonia of grade 2, and 7 (5.8%) had mediastinal emphysema of grade 2. Comparison of the 22 subjects with stricture with the 98 subjects without stricture showed significant differences in the rate of resection of >75% of the esophageal circumference, rate of whole circumference resection, and the required time for resection. The tumor size and the size of the resected tissue sample also differed between the 2 groups. The groups did not differ in age, sex, alcohol intake, and smoking; location, macroscopic, and histological tumor findings; chest pain; or use of anticoagulants for comorbidities. In multivariate analysis, tumor size and whole circumference resection were independent risk factors for stricture. Furthermore, in 45 subjects with resection of >75% of the esophageal circumference, whole resection of the esophagus was the only independent risk factor for stricture.This study suggests that ESD has a strong therapeutic effect on superficial esophageal neoplasms; however, a greater extent of resection of the esophagus increases the risk of postoperative esophageal stricture. Preventive measures against development of postoperative stricture require further study.

Impact of Fully Covered Metal Stent Placement in Refractory Postoperative Hilar and Anastomotic Strictures

Introduction: Biliary stricture can occur following surgeries of the biliary tract and can cause biliary congestion and cholangitis. Recently, fully covered self-expandable metal stent (FCSEMS) has been utilized for postoperative hilar and anastomotic strictures that have conventionally been considered difficult to treat. On the other hand, there is no solid evidence regarding optimal metal stent placement period. Method: Retrospective review of patients treated for postoperative benign biliary stricture using a FCSEMS at our hospital between 2013 and 2015. Results: We performed a total of 14 metal stent placements for 12 patients with postoperative benign biliary stricture. In all the patients, the metal stents were placed endoscopically and removed safely after the placement. The mean duration of stent placement was 47.9 days (28-144), and there was no retrograde cholangitis observed during metal stent placement. Following metal stent removal, the stricture improved in 9 patients. Recurrence developed in 3 patients, recurring bile duct stones in 2 patients, and cholangitis in 1 patient. Adverse events included post-ERCP pancreatitis in 2 patients, which was alleviated by stent removal the following day and conservative treatment in 1 patient, and conservative treatment only in the other patient. Distal stent migration was observed in 2 patients. Conclusion: The present results suggest that stricture improvement can be expected in a shorter period by metal stent placement in patients with refractory postoperative biliary stricture. In patients with bile duct stones, lithectomy can be safely and effectively performed following metal stent expansion; however, further studies are required.

Corrosive injury of the upper gastrointestinal tract: review of surgical management and outcome in 14 adult cases.

Caustic ingestion is responsible for a spectrum of upper gastrointestinal tract injury from self-limited to perforation. This study conducted to evaluate clinical characteristics as well as surgical outcomes in patients with caustic ingestion. Between Nov1993 to march 2011, 14 adults with a clinical evidence of corrosive ingestion were admitted into our institutions (Omid and Ghaem hospitals). Patients evaluated for etiology of erosion, location, type of surgery, morbidity and mortality after surgery. 14 patients (10men and 4 women) with a age range between18-53 years were evaluated. In 6 patients, the injury was accidental and in 8 patients ingestion was a suicide attempt. Ingested agent included nitric acid in 4 patients, hydrochloric acid in 7 patients, sulfuric acid in 2 patients and strong alkali in one patient. The location and extent of lesion varied included esophagus in 13 cases, stomach in 7 cases and the pharynx in 3 cases. Acute abdomen was developed In 2 patients and a procedure of total gasterectomy and blunt esophagectomy was performed. In the remaining patients, substernal esophageal bypass in 2 patients, esophageal resection and replacement surgery in 9 patients and gastroenterostomy in one patient performed to relieve esophageal stricture. Two patients died of mediastinitis after esophageal replacement surgery. Postoperative strictures were developed in 2 survived patients with hypopharyngeal reconstruction that was managed by per oral bougienage in one patient and KTP Laser and stenting in the other patient. Esophageal resection with replacement was safe and good technique for severe corrosive esophageal stricture with low mortality and morbidity.

The roles of connective tissue growth factor in the development of anastomotic esophageal strictures.

IntroductionThe aim of this study was to investigate the roles of connective tissue growth factor (CTGF) in the development of anastomotic strictures after surgical repair of the esophagus.Material and methodsTissues collected from the patients were divided into three groups based on the results of endoscopy and clinical grading. Patients without dysphagia after esophagectomy were used as the control population. The protein levels of CTGF, TGF-β1, Smad2, and Smad4 were determined by immunohistochemistry (IHC) and western blot analyses, while the mRNA levels of the two growth factors were evaluated by real-time polymerase chain reaction.ResultsCompared with the control group, significantly increased (p < 0.01) levels of CTGF and TGF-β1 protein were observed in the anastomotic stenosis (AS) group, and levels of the two proteins detected by the IHC and western blot analyses were also significantly increased with the increasing severity of stenosis (p < 0.05). The mRNA levels of CTGF and TGF-β1 in the tissues collected from the patients with stenosis were significantly up-regulated (p < 0.05) as compared with those from the control group. In addition, the levels of Smad2 and Smad4 protein were also significantly increased (p < 0.05) with the increasing severity of stenosis, and the protein levels were positively correlated with the levels of CTGF (r = 0.59, p < 0.05) and TGF-β1 (r = 0.63, p < 0.05).ConclusionsInhibition of CTGF protein or mRNA expression may be a distinctive and effective therapy for the treatment of postoperative anastomotic strictures.

Endoscopic Management of Benign Biliary Strictures

Benign biliary stricture result from different group of diseases with variable natural history. Table 1 lists the common causes of benign biliary stricture. Post-operative and inflammatory stricture are the most common. Endoscopic retrograde cholangiopancreatography (ERCP) has become a golden standard for treating benign biliary strictures. ERCP for the treatment of BBS is preferred over surgery and the percutaneous approach due to its low invasiveness, because it is safer and repeatable. Percutaneous approach can be useful in case of failure of ERCP for “rendezvous” techniques, in patients with surgically modified anatomy and non-accessible papilla. Multistenting procedure has been proven efficacy and safe treatment for benign biliary strictures. Despite significant advances in endoscopic techniques, differentiating malignant from benign strictures can still be challenging and chronic pancreatitis as well as non-anastomotic stricture post liver transplantation as cause of benign biliary strictures remain resistant to endoscopic treatments. The short term outcome following endoscopic treatment of benign biliary stricture is excellent but long-term outcome is poor mainly for high rate of recurrence. The use of covered metallic stents for the treatment of benign biliary strictures is still under investigation, clinical trials are underway to establish the best approach to the treatment of the benign biliary stricture. This article focuses on the endoscopic management of benign biliary strictures and elaborates on optimal treatments strategies for the more common causes.