Prolonged Dilatation Research Articles

Su1806 Endolumenal Stent Suture-Fixation Compared to Endoscopic Clips for Prevention of Esophageal Stent Migration During Prolonged Dilatation in Recurrent Achalasia

Su1806 Endolumenal Stent Suture-Fixation Compared to Endoscopic Clips for Prevention of Esophageal Stent Migration During Prolonged Dilatation in Recurrent Achalasia

Successful conservative management of coronary artery rupture: role of post pericardiotomy adhesions as a protective barrier

Coronary artery rupture is a rare but potentially life-threatening complication of percutaneous coronary interventions (PCI). Grade III perforation and coronary artery rupture invariably results in pericardial effusion and tamponade requiring urgent pericardiocentesis. We report an elderly male with post coronary artery bypass status, who developed right coronary artery rupture during PCI with massive extravasation, however post pericardiotomy adhesions resulted in contained collection, thus preventing tamponade and need for pericardiocentesis. The coronary artery rupture was successfully manages with prolonged balloon dilatation followed by stenting.

Minimal invasive pyeloplasty technique with vertical surgical approach: An alternative to laparoscopic pyeloplasty

This retrospective clinical study presents pyeloplasty results following a muscle-splitting dissection, with mini-flank incision, using instruments held in a vertical position. Between 2004 and 2010, dismembered pyeloplasty (Anderson-Hynes) was performed in 37 cases (32 males and 5 females) with an average age of 26 years (range, 20–56 years). The technique was carried out through a window opened by separating the lateral abdominal muscles. Operation duration, length of incision, postoperative pain, complications, and radiological and clinical results were discussed. The operation duration was between 50 and 90 minutes (average=65 minutes), the incisional length 5 and 7cm (average=5.2cm), and visual pain scale was 4.1±3.1 and 3.3±3.4 at 4 and 24 hours after the operation, respectively. The duration of hospitalization was between 30 and 120 hours (average=42 hours). In a retrospective analysis of our study, one case was reoperated on, following recurrence with obstruction, there were 9 cases with prolonged dilation in response to diuretics and 29 cases with complete recovery. Pyeloplasty operations, with a vertical surgical approach through smaller incisions and muscle separation, offered shorter periods of hospitalization, less postoperative pain, acceptable cosmetic results and higher rates of functional recovery.

Headache and prolonged dilatation of the middle meningeal artery by PACAP38 in healthy volunteers

To explore a possible relationship between vasodilatation and delayed headache we examined the effect of pituitary adenylate cyclase-activating polypeptide-38 (PACAP38) on the middle meningeal artery (MMA) and middle cerebral artery (MCA) using high resolution magnetic resonance angiography (MRA). In a double-blind, randomized, placebo-controlled study 14 healthy volunteers were scanned repeatedly after infusion (20 min) of 10 pmol/kg/min PACAP38 or placebo. In addition, four participants were scanned following subcutaneous sumatriptan (6 mg). We found significant dilatation of the MMA (p = 0.00001), but not of the MCA (p = 0.50) after PACAP38. There was no change after placebo (p > 0.40). Vasodilatation (range 16-23%) lasted more than 5 h. Sumatriptan selectively contracted the MMA by 12.3% (p = 0.043). PACAP38-induced headache is associated with prolonged dilatation of the MMA but not of the MCA. Sumatriptan relieves headache in parallel with contraction of the MMA but not of the MCA.

Labial flap vaginoplasty with sacrospinous fixation

We present a case of congenital absence of Vagina which was treated by reconstruction of the vagina using vascular labial flaps. Furthermore, we anchored the neo-vagina to the Sacro-spinous ligament on either side. The aim of the attachment to the sacro-spinous ligament is to provide a durable apical support and to give an immediate, good vaginal length. Various techniques have been described for the construction of Neo-vagina. Except for sigmoid vaginoplasty, most other procedures are associated with a significant risk of post-operative restenosis, for which prolonged dilatation is necessary. Attaching to the sacro-spinous ligament gives the vagina good depth and, to some extent, decreases the risk of re-stenosis. This technique is simpler, does not require sophisticated instruments or prolonged post operative dilatation and is particularly suitable for under-developed countries.

Prevalence of preoperative arrhythmias in children with delayed treatment of severe congenital heart disease

Aim — Our aim was to determine the real importance of rhythm and conduction disorders in children with unoperated severe congenital heart disease.Methods — Consecutive children with delayed treatment of severe congenital heart disease were prospectively studied for the occurrence of arrhythmias before any invasive investigation or surgical procedure was performed.Results — All 168 children were in sinus rhythm. One hundred and fifty-eight patients (94%) had no significant preoperative findings. One child with double discordance had an intermittent complete atrioventricular block, and another one had a long QT syndrome. Children with severe ventricular dysfunction had paroxysmal atrioventricular re-entry tachycardia in 3 cases and abnormally frequent premature ventricular complexes in 3 other cases. Children with severe left atrial dilatation had periods of atrial ectopic tachycardia in one case and atrial fibrillation in another case.Conclusions — The prevalence of rhythm and conduction disorders is relatively low in children with delayed treatment of severe congenital heart disease. Only those with congenital heart disease classically combined with such disorders and those with prolonged severe ventricular dysfunction and/or atrial dilatation are at risk of developing significant arrhythmias and should undergo a preoperative assessment of arrhythmias.

Vaginal agenesis: Experience with sigmoid colon neovaginoplasty

Aim:Objective of this study is to report our experience with sigmoid vaginoplasty in adolescents.Materials and Methods:A retrospective study of children with vaginal atresia and Mayer–Rokitansky–Kuster–Hauser syndrome. The sigmoid segment was used for vaginoplasty in all the cases.Results:Eight children were studied over a period of 7 years. The postoperative complications were ileus in 2, mucosal prolapse of the neovagina in 1, and minor wound infection in 1 patient. Seven patients are on regular follow-up. All the neovaginas were patent and functional. One patient had unacceptable perineal appearance, that is, badly scarred perineum as a late complication. None of the patients had vaginal stenosis or excessive mucus discharge, during follow-up visits. Out of the 7 patients, 2 patients are sexually active and satisfied.Conclusions:Sigmoid vaginoplasty is a safe and acceptable procedure for vaginal agenesis with good cosmetic results and acceptable complications rate. Sigmoid colon vaginoplasty is the treatment of choice because of its large lumen, thick walls resistant to trauma, adequate secretion allowing lubrication, not necessitating prolonged dilatation, and short recovery time.

Stenting Refractory Esophageal Strictures

For most patients with benign esophageal strictures, dilation with bougies or balloons for only a few seconds will relieve dysphagia. This observation suggests that prolonged dilation via esophageal stenting might create a more durable effect in strictures that are highly resistant to standard endoscopic dilation, such as those associated with radiation therapy, caustic ingestion, or surgical anastomosis. To evaluate this possibility, investigators conducted a …

Self-Expanding Stents in Benign Esophageal Strictures

Self-expanding metal stents (SEMS) have gained a wide consensus in the treatment of malignant dysphagia. The small diameter of the delivery system has reduced the morbidity related to their placement. These stents could be a reasonable option also in patients with benign refractory esophageal strictures. Two types of stents have been used: self-expandable plastic stent (SEPS; Polyflex ® ) and SEMS. Fluoroscopy is recommended, and predeployment dilation should be performed when a SEPS is placed. SEMS should be completely covered with a silicone layer that opposes the granulomatous ingrowth through the meshes, which prevents imbedding and allows easy retrieval. Migration represents the most frequent complication and is due to the lack of imbedding of these stents. The techniques of stent placement are similar to those when stents are placed for malignant disease. Dilation is not advisable before placing a SEMS, but may be performed after its release. The prolonged and stable dilation of the endoprosthesis is believed to work in some patients by prevention of the scarring process and avoiding the adhesion of damaged areas (such as after extensive endoscopic mucosal resection). Remodeling of scar tissue by the indwelling stent is believed to occur in chronic strictures but is difficult to obtain in patients with refractory hypopharyngeal strictures following radiation therapy. Stents need to be removed, the timing of which is variable but usually more than 4 to 8 weeks after placement. Prolonged placement may lead to complications such as reactive overgrowth and result in a new stricture. This review analyses the risk and benefits of self-expandable stents in the management of dysphagia for benign esophageal strictures.

Visual Diagnosis

1. Lopa Shah, MD* 2. Gita Balakumar, MD* 1. *University of Nevada School of Medicine, Las Vegas, Nev A 3-week-old girl presents to the clinic for a persistent rash that has been present since birth. Following an uncomplicated term gestation, the infant was born by cesarian section due to prolonged dilation and failure to progress. She weighed 3.2 kg. A rash was noted at birth on her left lower extremity, and her parents were reassured that the rash would resolve. However, the rash now extends over both lower extremities. The mother has not applied any creams, lotions, or topical medications to the infant’s skin. The family history is noncontributory; there is no history of nervous system or skin disorders. The infant is well-appearing, comfortable, and afebrile. She weighs 3.54 kg (25th percentile). Skin examination reveals red, hyperpigmented streaks and plaques on the upper part of her lower extremities (Fig. 1), with occasional vesicles distributed linearly (Fig. 2). An accessory nipple is noted on the right chest wall. The infant is active, there is no evidence of scratching, and her muscle strength and tone are normal for age. The remaining physical findings are normal. Figure 1. Red, hyperpigmented streaks and plaques on left lower extremity. Figure 2. Vesicles on left lower extremity. A complete blood count demonstrates: hemoglobin, 12.5 g/L (125 g/L); white blood cell count, 46.3×103/mcL (46.3×109/L) with 14% neutrophils, 2% bands, 33% lymphocytes, 44% eosinophils, and 1% myelocytes; and platelet count, 560.0×103/mcL (560.0×109/L). Peripheral blood smear reveals a slight normochromic, normocytic anemia with erythropenia, normal red cells with a few teardrop cells, moderately increased number of platelets, and a mild-to-moderate increase of white blood cells with relative and absolute eosinophilia. A clinical diagnosis is made. The presence of vesicular and hyperpigmented linear skin lesions since birth, their distribution over lines of Blaschko, and the laboratory finding of …

Valoración de las alteraciones de la función anorrectal en el postoperatorio inmediato y tardío tras la microcirugía transanal endoscópica

Transanal endoscopic microsurgery (TEM) is a new technique for local excision of benign and incipient malignant rectal lesions. This technique offers technological advantages over other procedures and is associated with lower morbidity and mortality. TEM involves prolonged dilatation of the anal sphincter with a large-diameter (4 cm) operating rectoscope. The aim of the present study was to assess the effects of TEM on anorectal function. All patients undergoing TEM were included. Continence was scored by a numeric scale and anorectal manometry before surgery and 3 weeks and 4 months after surgery. Variations in anal resting pressure, maximal anal resting pressure and the anal continence questionnaire were evaluated. Sixty-eight patients underwent TEM between June 2004 and August 2006. Mean anal resting pressure (ARP) and maximal anal resting pressure (MARP) were significantly reduced at 3 weeks after surgery (ARP/MARP before surgery: 38.89/126.28; 3 weeks after surgery: 26.61/104.75). No significant change was found in the mean continence score. No association was found between variation in pressures and operating time. TEM produced statistically significant alterations in anorectal physiology studies which returned to normal at 4 months. The technique did not affect continence scores in the immediate or late postoperative period and consequently can be considered a safe procedure that does not produce significant alterations in anorectal function.

Therapeutic Gains of Prolonged Bronchial Dilatation in Chronic Obstructive Pulmonary Disease

The clinical spectrum of chronic obstructive pulmonary disease (COPD) includes chronic bronchitis, emphysema, and refractory asthma. Other important features are airway obstruction and clinical exa...

Intestinal vaginoplasty: is it optimal treatment of vaginal agenesis? A pilot study

The outcome of 11 cases with vaginal agenesis who underwent intestinal vaginoplasties are presented. Patients were between 18 and 37 years old. Ileum vaginoplasty and sigmoid colon vaginoplasty were carried out in two and nine cases, respectively. Ileum necrosis at donor site requiring ileum resection and bilateral ileostomy encountered in one of the cases was the major complication. Mild stenosis responsive to finger dilatation had been detected in two women with sigmoid vaginoplasty. Excess mucous production, long operation time, and shortness of mesentery of ileum led us to abandon ileum vaginoplasty, and sigmoid colon vaginoplasty was performed in the following cases with vaginal agenesis. All of the neovaginas were patent and functional. We suggest sigmoid colon vaginoplasty as the treatment of choice because of its large lumen, thick walls resistant to trauma, adequate secretion allowing lubrication, not necessitating prolonged dilatation, short recovery time compared with ileum vaginoplasties; and in patients reluctance to prolonged use of dilatators or in those who experienced previous failure of the other treatment modalities.

Endoscopic management of the liver transplant patient

Endoscopic management of the liver transplant patient

Success of Endoscopic Therapy in Traumatic Bile Duct Lesions

Introduction: For endoscopic diagnosis and treatment of bile duct lesions due to blunt abdominal traumata especially in cases of traffic accidents (e.g. by steering-wheel or belt) there are no standardized guidelines. The delimitation from surgical procedures is unclear. Methods: From 8598 ERCPs performed in the time between November 1st, 1998 and October 31st, 2003 in our endoscopic unit in 12 patients (8m, 4f, mean age: 47 years, min. 12 to max.79 years) retrograde bile duct opacifications due to blunt abdominal traumata were performed. The indication was biliary leakage with peritonitis or cholestasis and cholangitis. Results: By ERC in 6 patients a rupture of the common bile duct or a main hepatic branch with a diameter less than 5 mm was found and in 3 patients with a diameter more than 5 mm. In further 3 patients stenoses in the central bile duct system occured. The leakages less than 5 mm were primarily splinted and stented after sphincterotomy. Stenoses resulting from scarification processes were balloon-dilatated. Afterwards parallelstenting with three 10 F stents over one year as a prolonged dilatation procedure was performed. In the long term follow-up period (32 months in the mean, min. 14 to max. 45 months) these patients were symptom-free. In the 3 patients with leakages wider than 5 mm surgery had to be performed at once. These patients had longer stays at the intensive care unit also due to septic complications or other severe organ failures. In the meantime they are also symptom-free. Conclusions: In bile duct injuries due to blunt abdominal traumata endoscopic retrograde cholangiography should be performed at once to define the type of lesion. In short leakages and scarred stenoses an endoscopic therapy should be intended. In leakages with diameters more than 5 mm initial surgery is indicated.

Endoscopic stenting for postoperative biliary strictures due to hepatic hydatid disease: effectiveness and long-term outcome.

Postoperative strictures due to hepatic hydatid disease caused by Echinococcus surgery is considered to be a rare cause of benign bile duct strictures, especially in the Western world. The aim of this retrospective study is to demonstrate possible characteristics of the strictures as well as the effectiveness of long-term endoscopic stenting. Between 1994 and 2001, we treated 10 of these cases in our clinic. All patients had surgery for hepatic Echinococcus disease one or more times. These types of benign biliary strictures, secondary to surgery of hepatic hydatid disease, were multiple and located in the proximal common bile duct. Endoscopic stent therapy was carried out in all cases containing transpapillary approach with plastic prostheses (7.5-11 French) or transhepatic approach with Yamakawa prostheses (16 French). Nine patients were available for follow-up. In 6 patients (66%), the stents were removed after a median period of 22.5 months with radiologic and clinical signs of improvement. Three patients required prolonged dilatation therapy because of stricture-recurrence. There was low overall morbidity and we recognized no therapy-associated mortality. Endoscopic stent therapy is a safe nonoperative method for the treatment of postoperative benign biliary strictures due to hepatic hydatid disease.

Failure of Prolonged Dilation to Improve Long-term Patency of Femoropopliteal Artery Angioplasty: Results of a Prospective Trial

To determine long-term patency of femoropopliteal artery percutaneous transluminal angioplasty (PTA) in a prospective trial during which prolonged balloon inflation was used for optimization of initial results. Femoropopliteal PTA was performed in 112 limbs of 97 patients. The mean total length of the treated segments was 7.2 cm (95% CI: 5.99-8.46; median: 5.5 cm). In cases of unsatisfactory primary results after standard dilation for 1-3 minutes, the procedure was continued with prolonged dilation (93 limbs; mean balloon inflation time: 31 min; 95% CI: 24.2-37.7; median: 15 min) with use of the same balloon catheter (77 limbs) or a perfusion balloon catheter (35 limbs). Thirty-four proximal infrapopliteal artery stenoses were treated to improve peripheral runoff and 12 short stents were placed because of flow-limiting dissections. Primary hemodynamic success established by Doppler ultrasound (US) criteria was achieved in 92.9% (104 of 112) of the limbs. Three major complications were encountered; none were related to prolonged balloon inflation. The primary patency rate according to Kaplan-Meier analysis was 42% (+/-5% SE) at 1 year and 39% (+/-5%) at 2 and 3 years. The corresponding secondary patency rates were 51% (+/-5%) and 47% (+/-5%). Large numbers of diseased vessels in the treated limb (four to 10 instead of one to three), eccentric lesions (as opposed to concentric morphology), and additional treated segments (instead of only femoropopliteal lesions) were associated with poorer long-term patency. The duration of balloon dilation was not a determinant of long-term patency. Although prolonged dilation is safe and feasible in femoropopliteal artery PTA, its routine use is not warranted because it does not result in superior long-term patency rates.

Transcatheter thrombolysis with high-dose bolus tissue plasminogen activator in iatrogenic arterial occlusion after femoral arterial catheterization.

To assess the efficacy of percutaneous local thrombolysis with high-dose bolus recombinant tissue plasminogen activator (rt-PA) in patients with acute limb ischemia due to arterial thrombosis after cardiac catheterization. We treated eight patients (7 men; mean age 56 years) with thrombotic occlusion of both the common femoral artery (CFA) and external iliac artery (EIA) in six patients and of the CFA only in two patients. Two 5 mg boluses of rt-PA were injected into the proximal clot through a 5 Fr end-hole catheter and subsequently two additional boluses of 5 mg rt-PA were given through a catheter with multiple side-holes. In case of a significant amount of residual thrombus, a continuous infusion of 2.5 mg/hr of rt-PA was started. Successful lysis was achieved in all patients. The mean duration of lysis was 2 hr 41 min. The mean total amount of rt-PA delivered was 23.16 mg. In four patients unmasked flow-limited dissections confined to the CFA were managed by prolonged balloon dilatation, while in the remaining four patients with extension of the dissection to the external iliac artery one or two Easy Wallstents were implanted. There was prompt relief of lower limb ischemic symptoms and signs in all patients. Two groin hematomas were conservatively treated. Clinical and color Doppler flow imaging follow-up with a mean duration of 15 months, showed no reappearance of ischemic symptoms or development of restenosis in any of the patients. One patient died 6 months after thrombolysis. Transcatheter thrombolysis with high-dose bolus rt-PA is a safe and effective treatment in patients with iatrogenic arterial occlusion after femoral catheterization. Underlying dissections should be treated by prolonged balloon dilatation but stent implantation is often required.

Immediate stent implantation versus conventional techniques for the treatment of abrupt vessel closure or symptomatic dissections after coronary balloon angioplasty

Background Coronary stenting was initially designed to treat a bailout scenario. Prospective randomized trials comparing stent implantation with standard techniques, including emergency coronary artery bypass grafting, are lacking. The aim of this trial was to test the superiority of immediate stent implantation compared with standard techniques for the treatment of abrupt or threatening closure after coronary balloon angioplasty. Methods In a prospective trial, 100 patients with abrupt vessel closure or symptomatic dissections causing objective signs of ischemia were randomly assigned to treatment with immediate placement of stents (n = 51) versus standard techniques such as prolonged dilatation or emergency bypass surgery (n = 49). The primary end point was the achievement of successful stabilization not requiring crossover to the other study group. Secondary end points included event-free survival and restenosis. Results Successful stabilization was achieved in 94% of patients in the stent group compared with 78% of patients in the standard treatment group (P =.038). Two patients died in each group, and there was a trend toward a higher incidence of myocardial infarction (16% vs 8%; P =.163) and a significantly increased creatine phosphokinase level (245 IU/L [95% confidence interval, 217-265 IU/L] vs 179 IU/L [confidence interval 140-212 IU/L]; P =.0002) in the standard treatment group. Event-free survival after 250 days was 72% in the stent group compared with 29% in the standard treatment group (P =.001). The angiographic restenosis rate was 30% in the stent group versus 59% in the standard treatment group (P =.01). Conclusions Immediate stenting, if technically feasible, shows superior short- and long-term results compared with standard treatment options. (Am Heart J 2000;140:e26.)

Temporary implantation of a metal stent in Vater's ampulla. Evaluation of early changes of the bile ducts in an animal study

Evaluation of temporary stent implantation in the papilla of vater and the subsequent alterations of the bile ducts in a controlled animal study. In seven domestic pigs the papilla of vater was stented with a nitinolelastalloy-strecker stent over a period of three days. The microscopic and macroscopic changes of the biliary tract and the serologic parameters were judged. In three cases a slight widening of the peripheric bile ducts was found. With the exception of a mild elevation of lactate dehydrogenase the serological parameters remained normal. The explantation of the stent two possible in six cases. A thickening of the outer layers of the bile ducts and a low to middle grade injury of the mucosa were found histologically. A temporary stent implantation in the papilla of vater is feasible. The mucosal injuries caused by the temporary stent placement may be fully repairable. The method seems to be suitable for prolonged dilatation of benign stenoses.