Recurrent Obstructive Symptoms Research Articles

Endoscopic ultrasonography-guided gastroenterostomy versus surgical gastrojejunostomy for palliation of malignant gastric outlet obstruction (ENDURO): study protocol for a randomized controlled trial

BackgroundMalignant gastric outlet obstruction (GOO) is a debilitating condition that frequently occurs in patients with malignancies of the distal stomach and (peri)ampullary region. The standard palliative treatment for patients with a reasonable life expectancy and adequate performance status is a laparoscopic surgical gastrojejunostomy (SGJ). Recently, endoscopic ultrasound-guided gastroenterostomy (EUS-GE) emerged as a promising alternative to the surgical approach. The present study aims to compare these treatment modalities in terms of efficacy, safety, and costs.MethodsThe ENDURO-study is a multicentre, open-label, parallel-group randomized controlled trial. In total, ninety-six patients with gastric outlet obstruction caused by an irresectable or metastasized malignancy will be 1:1 randomized to either SGJ or EUS-GE. The primary endpoint is time to tolerate at least soft solids. The co-primary endpoint is the proportion of patients with persisting or recurring symptoms of gastric outlet obstruction for which a reintervention is required. Secondary endpoints are technical and clinical success, quality of life, gastroenterostomy dysfunction, reinterventions, time to reintervention, adverse events, quality of life, time to start chemotherapy, length of hospital stay, readmissions, weight, survival, and costs.DiscussionThe ENDURO-study assesses whether EUS-GE, as compared to SGJ, results in a faster resumption of solid oral intake and is non-inferior regarding reinterventions for persistent or recurrent obstructive symptoms in patients with malignant GOO. This trial aims to guide future treatment strategies and to improve quality of life in a palliative setting.Trial registrationInternational Clinical Trials Registry Platform (ICTRP): NL9592. Registered on 07 July 2021.

P178 OCCASIONAL ECHOCARDIOGRAPHIC DIAGNOSIS OF BRONCHOGENIC CYST

Abstract Bronchogenic cysts (BCs) are abnormal rounded formations associated with the tracheobronchial tree, that can cause recurrent infections or obstructive respiratory symptoms. They are often asymptomatic and can be discovered on occasional cardiac imaging. The treatment of bronchogenic cyst is controversial; some clinicians recommend surgical resection or transbronchial needle aspiration, others prefer a conservative attitude, reserving treatment for the possible appearance of symptoms or complications. We describe the case of a 54–year–old male patient which came to our observation in 2005, for the onset of intermittent angina pectoris. The first tests showed: no ECG alterations, mild hypokinesia of the inferolateral wall of the left ventricle with preserved systolic function on the echocardiogram, a modest increase in myocardial enzymes: total CK 731 U/L, CK–MB 40 U/L, CK–MB/CK ratio 5,4. The next day, the patient underwent coronary angiography and ramus intermedius PCI. However, the echocardiogram showed a rounded, anecogenic formation, 52 x 49 mm, behind the left atrium (Fig.1–2), which CT and MRI of the chest (Fig.3) diagnosed as BC in mediastinal location. Excluding the presence of neoplastic cells in the bronchoalveolar lavage fluid, a conservative strategy was agreed with the pulmonologists, choosing echocardiogram for follow–up. In the 17–year observation period, BC remained clinically silent, with no increase in size. Bronchogenic cysts are caused by an abnormal branching of the respiratory airways, that leads to the formation of segments separated from the tracheobronchial tree. About 80% of BCs are localized in the mediastinum, the remainder in the lung parenchyma. Unlike lung BCs, mediastinal BCs rarely communicate with the tracheobronchial tree and therefore usually do not undergo infectious processes. Mediastinal BCs localized near the carina of the trachea can cause compression symptoms (cough, dysphagia, dyspnoea). The other mediastinal BCs usually do not cause disorders. Knowledge of this rare congenital pulmonary disease is useful for echocardiographic differential diagnosis. Sometimes the cardiologist can play a role in the follow–up of this pathology.

Bilateral Supernumerary Teeth Presenting as Nasal Masses and Recurrent Rhinitis: An Interesting Case Report.

The presence of a tooth inside the nasal cavity is a rare clinical entity. The exact pathophysiology is not clear and most of the times, these patients present with non-specific symptoms. We encountered a 51-year-old male with symptoms of bilateral recurrent nasal obstruction and nasal discharge of 10 years' duration. Anterior rhinoscopy and diagnostic nasal endoscopy revealed a greyish white hard gritty mass covered with mucopurulent discharge in the floor of left nasal cavity and a mucosal covered bulge was noted in the floor of right nasal cavity. CT showed 2 hyperintense lesions in the maxilla reaching the floor of both nasal cavities. Diagnosis of supernumerary teeth was made and treated accordingly. Although the presence of tooth has been reported in ovaries, maxilla, maxillary sinus, mandibular condyle, mediastinum, this is the rare case reported with supernumerary teeth in both nasal cavities.

Unusual occurrence of acquired hypoganglionosis following surgery for Hirschsprung's disease

Acquired hypoganglionosis or aganglionosis after surgery for Hirschsprung's disease is a littler described situation. To investigate and describe the mechanism of acquired aganglionosis or hypoganglionosis following sugery in the pulled-through bowel which had been previously confirmed as ganglionated. A full-term boy initially presented with polymalformatif syndrome and dwarfism. The symptoms started at birth with abdominal distension and failure to pass meconium in the first 48 hours of life which was relieved by the use of a rectal tube. At the age of 4 months he developed abdominal distention and acute bowel obstruction. He was operated on and during surgery a narrow distal recto-sigmoid transition zone was found. A diverting right transverse colostomy was done. A barium enema was done and showed a recto-sigmoid transition zone. A rectal biopsy suction was performed and showed aganglionic segment. At the age of 8 months, a Soave pull-through procedure was performed . Ganglion cells were documented in the pull-through segment. The recurrent symptom patterns of abdominal distention constipation, and failure to thrive developed. Another contrast enema was performed two years later and shows massive colonic dilation with a rectosigmoid zone of transition. A redo Soave pull-through was done. Histology concluded to a hypoganglionosis. The CD56 staining was positive confirming aganglionosis. After surgery and during follow-up the boy was in a good condition, without abdominal distention. The cause of acquired aganglionosis or hypoganglionosis could be secondary to destruction of neuroganglionic cells due to secondary hypoxemia. That's why this diagnosis should be considered when recurrent obstructive symptoms appear several months following pull-through for HD.

Effectiveness of Double-J Metallic Mesh Ureteral Stents for Malignant Ureteral Obstruction: A Retrospective Study.

Malignant ureteral obstruction is associated with high rates of failure with traditional ureteral stents. Double-J metallic mesh ureteral stent is one of the latest options for treating malignant ureteral obstruction. However, data regarding the efficacy of using this stent in this context are limited. Thus, we retrospectively investigated the efficacy of this stent. We retrospectively analyzed the records of all patients who required double-J metallic mesh ureteral stent placement for malignant ureteral obstruction at Ishikawa Prefectural Central Hospital (Kanazawa, Japan) between October 2018 and April 2022. Primary stent patency was defined as complete or partial resolution of hydronephrosis as shown by imaging studies or successful removal of a preexisting nephrostomy tube. Stent failure was defined as unplanned stent exchange or nephrostomy tube placement for signs or symptoms of recurrent ureteral obstruction. A competing risk model was used to estimate the cumulative incidence of stent failure. Double-J metallic mesh ureteral stents were placed in 63 ureters of 44 patients (13 males, 31 females). The median age of patients was 67 years (range=37-92 years). There was no grade 3 or higher complications. The overall primary patency rate was 95% (60 ureters). Stent failure occurred in seven patients (11%) during follow-up. The cumulative incidence of stent failure at 12 months after placement was 17.3%. Double-J metallic mesh ureteral stent is a safe, simple, and promising treatment option for malignant ureteral obstruction.

Single-Port, Robot-Assisted Transanal Harvest of Rectal Mucosa Grafts for Substitution Urethroplasty

ObjectiveTo describe a novel single-port, endorobotic technique for harvesting rectal mucosa grafts (RMGs) for urethral reconstruction. MethodsA 57-year-old man with prior transurethral procedures developed recurrent obstructive voiding symptoms. Urethrography revealed a panurethral stricture, meatus to the bulbomembranous junction. It was decided to proceed with surgical repair. Owing to the stricture's length, available oral mucosa would require additional material, and repair with a single rectal mucosa graft was offered instead. Single-port (SP) endorobotic approach offered ideal access for transanal harvest. With the patient placed in a modified lithotomy position, a GELPOINT Path transanal access platform was inserted through the anal canal. Pneumorectum was established at 12 mmHg with an AirSeal CO2 insufflator. A Da Vinci SP surgical system was docked, equipped with Maryland bipolar forceps and a monopolar spatula. After injection of ORISE gel, endorobotic submucosal dissection began posteriorly proximal to the dentate line. ResultsProceeding cranially through the rectal submucosa, a 21 ✕ 3 cm strip of mucosa was obtained with appropriate hemostasis. The resulting graft was thoroughly thinned. The robot was undocked, and the patient repositioned to high lithotomy. The patient underwent a penis-inverting, dorsolateral approach augmentation urethroplasty. With an indwelling catheter placed, the patient was discharged on postoperative day 2 with no postoperative complications. ConclusionTransanal rectal mucosal dissection with a single-port endorobotic approach can be an enticing and minimally invasive harvesting technique to provide substitution grafts for long-segment urethral reconstruction.

Small intestine motility disorders: Chronic intestinal pseudo-obstruction.

Chronic intestinal pseudo-obstruction (CIPO) is a syndrome associating chronic or recurrent obstructive symptoms with intestinal dilation on imaging but without organic obstruction in the digestive tract. It is a rare disease with varying severity whose diagnosis is very complex. The diagnosis is based on clinical and paraclinical arguments in the context of repetitive occlusive syndromes when no mechanical obstruction of the digestive lumen is observed. Abdomino-pelvic computerized tomography (CT) must be performed to rule out a mechanical obstruction. An additional reference examination is trans-duodenal manometry of the small intestine, which is almost never normal in CIPO, but the test is rarely systematically performed. CIPO can be primary (acquired or congenital) or secondary to a systemic pathology (neurological, metabolic, etc.) resulting in neuromuscular damage to the intestinal tract. There are familial forms associated with genetic mutations. The majority of CIPO cases are idiopathic. Symptoms of the CIPO syndrome should be investigated with a complete assessment, guided by questioning and clinical examination that should also focus on urinary, neurological and cardiac involvement. Pathological tissue analysis is interesting for the etiological classification but is difficult to obtain. CIPO must be distinguished from non-CIPO intestinal dysmotility. Management must be carried out in an expert center with multidisciplinary care involving gastroenterologists, nutritionists, psychologists, radiologists, pathologists and digestive surgeons. It is essentially based on symptomatic management (especially with pro-kinetic agents and analgesics), nutritional support, as well as psychological support in view of its impact on quality of life. Surgical management is sometimes necessary.

Clinical Presentations, Diagnosis, and Management for Pediatric Antral Web-A 20-Year Experience of a Referral Center.

Background: Antral web is a rare cause of gastric outlet obstruction in children. The presentation is diverse, depending on the degree of obstruction. Unfortunately, the guidance of management is still lacking.Methods: This study retrospectively evaluated the presentations, management, and outcomes of the pediatric antral web based on a 20-year experience in a referral center.Results: A total of 23 cases were included. The median age of diagnosis was 10 months (interquartile range, IQR, 0.8–23 months). Main presentations comprised vomiting (83%) and upper gastrointestinal (UGI) bleeding (48%). Concurrent gastric ulcers were common (68%). A total of 13 cases (57%) underwent interventional treatment. The median duration from diagnosis to intervention (DtI) was 10 days, but five with longer DtI, ranged from 30 to 755 days. Among the 15 cases with concurrent gastric ulcers, 10 patients received intervention, immediately in six but delayed in four. Surgical treatments (N = 12) achieved a cure in 11, with one rescued by endoscopic treatment.Conclusions: Children who suffer from early gastric ulcers with outlet obstruction shall raise the suspicion of the antral web. Complete obstruction madates early intervention. Around half of the cases with adequate feeding and growth need no intervention. Recurrent obstructive symptoms or adjacent ulcers justify a switch from observation to intervention to avoid complications or growth faltering.

Determining the etiology of small bowel obstruction in patients without intraabdominal operative history: a retrospective study.

Most of the causes of small bowel obstruction (SBO) in patients without a history of abdominal surgery are unclear at initial assessment. This study was conducted to identify the etiology and clinical characteristics of SBO in virgin abdomens and discuss the proper management. A retrospective review involving operative cases of SBO from a single institute, which had no history of abdominal surgery, was conducted between January 2010 and December 2020. Clinical information, including radiological, operative, and pathologic findings, was investigated to determine the etiology of SBO. A total of 55 patients were included in this study, with a median age of 57 years and male sex (63.6%) constituting the majority. The most frequently reported symptoms were abdominal pain and nausea or vomiting. Neoplasm as an underlying cause accounted for 34.5% of the cases, of which 25.5% were malignant cases. In patients aged ≥60 years (n=23), small bowel neoplasms were the underlying cause in 12 (52.2%), of whom 9 (39.1%) were malignant cases. Adhesions and Crohn disease were more frequent in patients aged <60 years. Coherence between preoperative computed tomography scans and intraoperative findings was found in 63.6% of the cases. There were various causes of surgical cases of SBO in virgin abdomens. In older patients, hidden malignancy should be considered as a possible cause of SBO in a virgin abdomen. Patients with symptoms of recurrent bowel obstruction who have no history of prior abdominal surgery require thorough medical history and close follow-up.

Coblation intracapsular tonsillectomy in children: A prospective study of 1257 consecutive cases with long-term follow-up.

Intracapsular tonsillectomy (ICT) is increasingly adopted by paediatric centres worldwide due to its association with reduced pain, fast recovery and low risks of post-operative complications. Questions still surround its role in patients with recurrent tonsillitis, as well as tonsillar regrowth requiring revision surgery. Prospective consecutive case series from March 2013 to April 2020. Tertiary paediatric ENT referral centre. Paediatric patients undergoing Coblation ICT, with or without adenoidectomy, for obstructive and/or infective indications. Health-Related Quality of Life (HRQL), analgesia requirement, post-operative haemorrhage rates, time to return to normal diet and activity or school/nursery, and parental satisfaction. We report revision surgery rates and identify predictive factors for revision surgery. A total of 1257 patients (median age 4.2years) underwent Coblation ICT, with a median direct and implied follow-up of 101.5 and 1419days, respectively. We noted significantly improved HRQL scores across all domains. Median analgesia requirement was six days, and no patients required a return to theatre for post-operative haemorrhage. The majority of patients were eating a normal diet within 24hours and returned to normal activity/school within a week post-operatively. Revision surgery was required in 2.6% of cases, mainly due to recurrent obstructive symptoms from tonsillar regrowth. Being under two years old at initial surgery (OR 5.10), having severe OSA (OR 4.43) or severe comorbidities (OR 2.98) increased the risk of needing revision surgery. Long-term data demonstrate the efficacy and safety of Coblation ICT in paediatric patients across a range of indications.

Clinical Outcomes of Pediatric Chronic Intestinal Pseudo-Obstruction.

Chronic intestinal pseudo-obstruction (CIPO) is an extremely rare condition with symptoms of recurrent intestinal obstruction without any lesions. The outcomes of pediatric CIPO and predictors for the outcomes have not yet been well established. We analyzed the clinical outcomes and associated factors for the outcomes of pediatric CIPO. We retrospectively reviewed 66 primary CIPO patients diagnosed between January 1985 and December 2017. We evaluated parenteral nutrition (PN) factors such as PN duration, PN use over 6 months, home PN, and mortality as outcomes. We selected onset age, presence of urologic symptoms, pathologic type, and involvement extent as predictors. The early-onset CIPO was found in 63.6%, and 21.2% of the patients presenting with urologic symptoms. Of the 66 patients, 47 and 11 had neuropathy and myopathy, respectively. The generalized involvement type accounted for 83.3% of the cases. At the last follow-up, 24.2% of the patients required home PN management. The mean duration of PN was 11.8 ± 21.0 months. The overall mortality rate of primary CIPO was 18.2%. PN factors were predicted by the urologic symptoms and extent of involvement. However, mortality was predicted by pathologic type. The onset age was not significantly associated with the outcomes. CIPO with urologic symptoms and generalized CIPO had poor PN outcomes. Myopathy is suggested as a predictor of mortality in children with primary CIPO.

Redo pull-through in total colonic aganglionosis due to residual aganglionosis: a single center's experience.

BackgroundReoperation for total colonic aganglionosis (TCA) may be required for residual aganglionosis after an initial radical operation. We aimed to investigate the symptoms, management, and outcomes of patients who required a redo pull-through (Redo PT).MethodsNine TCA patients underwent Redo PT at our center between 2007 and 2017. Their medical records were reviewed. Parental telephone interviews that included disease-specific clinical outcomes were conducted, and post-operative complications and long-term outcomes (including height-for-age/weight-for-age and bowel-function score) were compared to those of single-pull-through (Single PT) patients (n = 21).ResultsAll the nine Redo PT patients suffered obstruction within 1 month after the initial operation that could not be alleviated by conservative treatment. All abdominal X-ray/contrast barium enemas showed proximal bowel dilatation, indicating residual aganglionosis. The median ages at the initial operation and Redo PT were 200 and 509 days, respectively. Reoperation consisted of an intraoperative frozen biopsy and a modified laparotomic Soave procedure in all patients. Post-operative complications included perianal excoriation (n = 3), intestinal obstruction (n = 2), enterocolitis (n = 2), and rectovestibular fistula (n = 1). Seven Redo PT patients were followed up for a mean time of 7.1 ± 2.3 years; six (85.7%) had good growth and four (57.1%) had good bowel-function recovery. Post-operative complications and long-term outcomes were almost equal between the Redo PT and Single PT groups (all P > 0.05).ConclusionTCA patients with recurrent obstructive symptoms and dilated proximal bowel may have residual aganglionosis after an initial operation. Redo PT is effective and provides good long-term outcomes comparable to those of patients who benefited from Single PT.

Prevention and management of recurrent postoperative Hirschsprung's disease obstructive symptoms and enterocolitis: Systematic review and meta-analysis

Background/PurposeThe purpose of this study was to review the management of obstructive symptoms and enterocolitis (HAEC) following pull-through for Hirschsprung's disease. MethodsA systematic review and meta-analysis (1992–2017) was performed. Included studies were: randomized controlled trials (RCT), retrospective/prospective case–control (C-C), case-series (C-S). Random-effect model was used to produce risk ratio (RR) [95% CI]. P < 0.05 was considered significant. ResultsTwenty-nine studies were identified. Routine postoperative dilatations (5 C-S, 2 C-C; 405 patients): no effect on stricture incidence (RR 0.3 [0.02–5.7]; p = 0.4). Routine postoperative rectal irrigations (2 C-C; 172 patients): reduced HAEC incidence (RR 0.2 [0.1–0.5]; p = 0.001). Posterior myotomy/myectomy (4 C-S; 53 patients): resolved obstructive symptoms in 79% [60.6–93.5] and HAEC in 80% [64.1–92.1]. Botulinum toxin injection (9 C-S; 166 patients): short-term response in 77.3% [68.2–85.2], long-term response in 43.0% [26.9–59.9]. Topical nitric oxide (3 C-S; 13 patients): improvement in 100% of patients. Probiotic prophylaxis (3 RCT; 160 patients): no reduction in HAEC (RR 0.6 [0.2–1.7]; p = 0.3). Anti-inflammatory drugs (1 C-S, sodium cromoglycate; 8 patients): improvement of HAEC in 75% of patients. ConclusionsSeveral strategies with variable results are available in patients with obstructive symptoms and HAEC. Routine postoperative dilatations and prophylactic probiotics have no role in reducing the incidence of postoperative obstructive symptoms and HAEC. Type of studySystematic review and meta-analysis. Level of evidenceLevel II.

Long-Term Outcomes of Endoscopic Balloon Dilation for Benign Strictures in Patients with Inflammatory Bowel Disease.

Background/AimsBenign intestinal strictures are common complications in patients with inflammatory bowel disease (IBD). This study aimed to assess the long-term prognosis of endoscopic balloon dilation (EBD) to treat benign strictures in IBD patients.MethodsPatients with IBD who had benign strictures and who underwent EBD in four tertiary referral university hospitals between January 2004 and February 2014 were retrospectively reviewed. Technical success was defined as the ability to pass the scope through the stricture after balloon dilation, and clinical success was defined as improved obstructive symptoms.ResultsForty-two benign strictures were identified in 30 patients (15 males and 15 females). Technical success was achieved in 26 patients (86.7%) at the first EBD attempt and in all 30 patients (100%) at the second EBD attempt. Clinical success was seen in 28 patients (93.3%). The median follow-up duration was 134.8 months (range, 10.2 to 252.0 months), and recurrence occurred in eight patients (26.7%), who required repeat EBD. The median duration to relapse was 1.7 months (range, 0.2 to 6.3 months). During repeat EBD, perforation occurred in two cases (6.7%), which were both clipped successfully. Finally, only one patient (3.3%) underwent surgery for the relief of recurrent obstructive symptoms during the follow-up period.ConclusionsThe experience of 10 years shows that EBD is safe and effective for the treatment of benign strictures in IBD patients. Importantly, EBD may allow long-term effective palliation of the symptoms associated with benign intestinal strictures in IBD patients.

Afferent Loop Syndrome

Introduction: Distal small bowel obstruction following ileal pouch anal anastomosis (IPAA) can occur secondary to acute angulation or prolapse of the afferent limb at the pouch inlet, namely, afferent loop syndrome (ALS). It is characterized by clinical presentation of partial small bowel obstruction, which can be diagnosed by careful pouchoscopy and/or abdominal imaging. Endoscopic or surgical intervention is often needed and surgical therapy appears to be more definitive. Case Presentation: A 33-year-old female with original diagnosis of ulcerative colitis (UC) underwent a 3 stage total proctocolectomy (TPC) and IPAA in 2014 for medically refractory UC. She had chronic complaints of abdominal bloating, intermittent nausea, vomiting and diarrhea starting one year after closure of stoma. She was treated with nasogastric tube placement and antibiotics intermittently without significant relief of symptoms. In the current encounter, patient presented to the hospital with nausea, vomiting, abdominal pain and cramping. A pouchoscopy was performed, which showed a normal pouch body and cuff. However there was a sharp luminal angulation 20 cm above pouch inlet, where attempted passage of flexible sigmoidscope failed, for which an afferent loop syndrome (ALS) was considered. Defecography showed a 180-degree kink in the afferent limb of the pouch approximately 18 cm above the anal verge correlating with the findings of pouchoscopy. Exploratory laparotomy was performed with extensive lysis of adhesions and plication of afferent loop of the small intestine to the anterior abdominal wall to prevent rotation into the pelvis. Patient experienced a significant improvement in her symptoms after the surgical correction of ALS. Discussion: Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical procedure of choice for patients with UC who require surgery. Small bowel obstruction is one of the common complications after IPAA. When a patient presents with recurrent intermittent obstructive symptoms after IPAA, then we recommend considering ALS and conducting both endoscopy and abdominal imaging for the diagnosis. Bypass of the obstructed segment from the distal ileum to the pouch has been attempted. Due to risk of recurrent afferent limb angulation, pouchopexy may also be considered.

Delayed Reconstruction of Bulbar Urethral Strictures is Associated with Multiple Interventions, Longer Strictures and More Complex Repairs

Prior to urethral reconstruction many patients with stricture undergo a variable period during which endoscopic treatments are performed for recurrent obstructive symptoms. We evaluated the association among urethroplasty delay, endoscopic treatments and subsequent reconstructive outcomes. We reviewed the records of men who underwent primary bulbar urethroplasty from 2007 to 2014. Those with prior urethroplasty, penile and/or membranous strictures and incomplete data were excluded from analysis. Men were stratified by a urethroplasty delay of less than 5, 5 to 10 or greater than 10 years from diagnosis. A total of 278 primary bulbar urethroplasty cases with complete data were evaluated. Median time between stricture diagnosis and reconstruction was 5 years (IQR 2-10). Patients underwent an average ± SD of 0.9 ± 2.4 endoscopic procedures per year of delay. Relative to less than 5 and 5 to 10 years a delay of greater than 10 years was associated with more endoscopic treatments (median 1vs 2 vs 5), repeat self-dilations (13% vs 14% vs 34%), strictures longer than 2 cm (40% vs 39% vs 56%) and complex reconstructive techniques (17% vs 17% vs 34%). An increasing number of endoscopic treatments was independently associated with strictures longer than 2 cm (OR 1.06, p = 0.003), which had worse 24-month stricture-free survival than shorter strictures (83% vs 96%, p = 0.0003). Each consecutive direct vision internal urethrotomy was independently associated with the risk of urethroplasty failure (HR 1.19, p = 0.02). Urethroplasty delay is common and often associated with symptomatic events managed by repeat urethral manipulations. Endoscopic treatments appear to lengthen strictures and increase the complexity of repair.

Sialendoscope-assisted transoral removal of hilo-parenchymal sub-mandibular stones: surgical results and subjective scores.

SUMMARYIt has been suggested that a conservative trans-oral approach to proximal and hilo-parenchymal submandibular stones (HPSMS) is a valid alternative to the more frequently used sialadenectomy. The aim of this study was to evaluate the surgical, ultrasonographic and patients' subjective outcomes of results of the trans-oral removal of HPSMS. Between January 2003 and September 2015, sialendoscope-assisted trans-oral surgery was used to remove symptomatic, large (> 7 mm), fixed and palpable HPSMS from 479 patients under general anaesthesia. All patients were followed clinically and ultrasonographically to investigate symptom relief and recurrence of stones, and were telephonically interviewed to assess saliva-related subjective outcomes with a questionnaire. Stones were successfully removed from 472 patients (98.5%); the seven failures (1.5%) concerned pure parenchymal stones. One year after the procedure, 408 patients (85.1%) were symptom free, 59 (12.3%) had recurrent obstructive symptoms and 12 (2.6%) had recurrent infections. Of the 54 patients who developed a recurrent stone (11.2%), 52 underwent a second procedure: 29 interventional sialendoscopies, two sialendoscope-assisted intra-corporeal pneumatic lithotripsy, eight secondary transoral surgery to remove residual stones, six a cycle of extra-corporeal lithotripsy and seven submandibular sialadenectomy. Most patients (75.2%) reported mild surgery-related pain. The symptoms of 454 patients (94.8%) improved after adjunctive treatment and, at the end of follow-up, the affected gland was preserved in 98.5% of patients. A sialendoscope-assisted trans-oral removal of large HPSMS is a safe, effective, conservative surgical procedure, and functional preservation of the main duct and parenchyma of the obstructed gland allows sialendoscopic access through the natural ostium in case of recurrence. Combining a trans-oral approach with other minimally invasive, conservative procedures ensures symptomatic relief and salivary duct system clearance in the majority of patients.

Pediatric Robot-Assisted Laparoscopic Excision of Multifocal Ureteral Polyps

Introduction: Fibroepithelial polyps are a rare cause of upper urinary tract obstruction in children. Although endoscopic management is preferred in many cases,1,2 large or multifocal polyps may preclude endoscopic management. Presented here is a case of a 9-year-old boy with large, multifocal obstructive ureteral and renal pelvis polyps managed with robot-assisted excision. Patient and Methods: Previous evaluation with a retrograde pyelogram confirmed the presence of obstructive polyps that precluded ureteroscopy. Given the numerous large polyps seen on fluoroscopy, a robot-assisted approach was chosen over an attempt at endoscopic management. A standard robotic setup for upper urinary tract surgery was planned, utilizing two robotic surgeon arms and a working port for the bedside assistant. A ureterotomy was made in the proximal ureter, exposing the ureteral polyps. Counter-incisions were made distally on the ureter to identify additional polyps and the anterior portion of the ureter was opened to expose all involved urothelium. More than 20 polyps were identified spanning the ureteropelvic junction to the pelvic brim. Polyps were excised with electrocautery. Intracorporeal ureteroscopy confirmed the excision of all significant disease. The ureterotomy was closed in a water-tight, running anastomosis over a ureteral stent. The operative time was 5 hours 28 minutes and the estimated blood loss was 25 mL. Results: Final pathology analysis confirmed the presence of fibroepithelial polyps of the urinary tract. The patient is currently without signs or symptoms of recurrent obstruction. An ultrasonography 7 months postoperatively shows near complete resolution of his hydronephrosis. Conclusions: Robot-assisted laparoscopy is a safe and feasible alternative to endoscopic treatment of fibroepithelial ureteral polyps. The robotic platform may be especially applicable for large or multifocal polyps of the ureter or renal pelvis. No competing financial interests exist. Runtime of video: 4 mins 58 secs A version of this video abstract was presented at the 2015 Western Section AUA Meeting in Indian Wells, CA, on October 25, 2015.

Factors affecting long-term outcome of transoral surgery for submandibular stones: a follow-up study of 125 patients.

To investigate the long-term results of transoral surgery for submandibular stones and assess factors that may affect the long-term outcomes. A follow-up study including retrospective review of medical records and prospective telephone survey. Tertiary Hospital. A total of 125 patients who had undergone transoral surgery for submandibular stones and responded to telephone survey. Recurrent obstructive symptoms, tongue paraesthesia. The period between transoral surgery and telephone survey was mean 54.8months. Eighteen (14.4%) of 125 patients had recurrent obstructive symptoms, and 7 (5.6%) patients showed tongue paraesthesia. Proximal stones (P=0.041) and partially removed stones (P=0.003) had significant impact on the development of recurrent obstructive symptoms via multivariate analysis. No significant factors for increased risk of tongue paraesthesia were identified. Recurred symptoms could be managed by subsequent transoral surgeries or conservative management. Complete removal of proximal stones and gland-preserving management of recurred symptoms are the essential elements to achieve good long-term outcome of transoral surgery for the submandibular stones.

Clinical features and management of afferent limb syndrome after ileal pouch-anal anastomosis for ulcerative colitis.

Afferent limb syndrome (ALS) is a type of small bowel obstruction (SBO) caused by obstruction of the afferent intestinal limb after ileal pouch-anal anastomosis (IPAA). The aim of this study was to reveal the clinical features and management of ALS. Of 320 patients undergoing IPAA for ulcerative colitis, we analyzed data from patients presenting with SBO. Six of 19 patients with SBO were diagnosed with ALS. All patients with ALS presented with recurrent intermittent obstructive symptoms before admission, whereas 15% of patients without ALS presented with these symptoms (P<0.0005). Among the six patients with ALS, four patients required surgery, although they underwent transanal decompression for each episode of obstruction. The proportion of surgery was higher in the ALS group (P<0.01). Acute angulation of the afferent limb was recognized in four cases and followed by fixation of the afferent limb. No further surgery was required in any patient following the last fixation. SBO after IPAA may be caused by acute angulation of the afferent limb of the ileal J-pouch. Most patients with ALS may eventually require fixation of the afferent limb due to acute angulation of the afferent limb.