Recurrent Stenosis Research Articles

Efficacy of endoscopic ultrasound and endoscopic resection for esophageal schwannoma

Background Esophageal schwannoma (ES) is a rare submucosal tumor, and its complete and safe resection is a topic that deserves special attention. Aim This study aimed to investigate the clinical value of endoscopic ultrasound (EUS) in the diagnosis of ES and the clinical efficacy of endoscopic resection for ES. Methods The clinical data, endoscopic characteristics, endoscopic treatment, postoperative complications, immunohistochemical results, and follow-up records of patients with ES admitted to the Tianjin Medical University General Hospital from January 2012 to January 2022 were retrospectively analyzed. Results Under white-light endoscopy, 81.8% (9/11) of lesions were submucosal elevations, covering the normal esophageal epithelium. Two of the lesions with redness and erosive surface. Eight lesions (72.7%) appear on EUS originating from the muscularis propria were homogeneous or inhomogeneous hypoechoic signals. Two lesions were inhomogeneous hyperechoic originating from the submucosa or muscularis propria, respectively. One lesion was homogeneous hypoechoic originating from the submucosa. All lesions had no blood flow signals, cystic changes, or calcification, and were completely removed by submucosal tunnel endoscopic resection (STER) or endoscopic submucosal dissection (ESD). All patients did not experience serious adverse events as well as recurrence, metastasis, or cicatricial esophageal stenosis during the follow-up period. Conclusion ES is a rare submucosal lesion, which endoscopic characteristics are difficult to distinguish from other esophageal submucosal tumors. Endoscopic resection can provide a minimally invasive and alternative treatment for ES.

Hospitalist Co-Management of Urethroplasty Patients in an Academic Center: Implementation of a Standardized Postoperative Care Model

Objectives: to evaluate whether hospitalist co-management would lead to improved outcomes and value in patients undergoing urethroplasty (UPL) with a single surgeon for urethral stricture disease (USD). Material: A co-management model with hospitalists was introduced in August 2019 for all patients undergoing UPL for USD with a single surgeon in a United States teaching center. The hospitalist worked closely with the urologic surgeon and the support staff. The hospitalist managed post-operative concerns, such as pain and comorbidities, as well as conducted rounds with the urological team for disposition planning and addressing interdisciplinary needs. Retrospective analysis compared a 42-month period before initiation of co-management (Jan 2016–July 2019) with a 32-month period after initiation (Aug 2019–March 2022). Outcomes assessed were recurrence of stricture, complications, length of stay, readmission, and emergency room visits. Results: A total of 135 patients (71 surgeon-managed, 64 co-managed) underwent urethroplasty from January 2016 to March 2022. Hospitalist co-management did not affect complications, length of stay, readmission, and emergency room visits. Accounting for confounding variables using multivariable analysis, no factors were independently associated with recurrence. There were no demographic, comorbidity, or American Society of Anesthesiologists (ASA) score differences between the two groups. Conclusions: This study suggests that hospitalist care for patients undergoing urethroplasty may be non-inferior to surgeon care, based on similar outcomes between the two groups. There were no significant differences in the total length of stay or blood pressure readings, and the complication rates and hospital readmission rates were also similar.

Female urethroplasty with dorsal onlay buccal mucosal graft: a single institution experience

PurposeFemale urethral stricture disease is frequently unrecognized or misdiagnosed, with controversy in the literature regarding the definition of strictures and approach to management. The purpose of this study is to report our institutional experience with female urethroplasty and add our experience to the growing body of research.MethodsWe performed a retrospective review of patients undergoing female urethroplasty with dorsal onlay BMG at the University of Colorado between March 2015 and December 2021 performed by two surgeons (BF and JO). The primary outcome measure was surgical success, defined as no stricture recurrence. The secondary outcome measure was the incidence of de novo urinary incontinence.Results23 patients were included in our data analysis. The median duration of lower urinary tract symptoms prior to urethroplasty was 16 years. 87% had undergone previous dilations. At a median follow-up of 12.2 months (range 1–81 months), four patients required a secondary procedure for obstruction with an overall success rate of 83%. One patient developed de novo stress urinary incontinence and one patient developed urge urinary incontinence. Subgroup analysis was performed comparing the patients that developed stricture recurrence (N = 4) to those that did not (N = 19). Those with stricture recurrence had a longer duration of symptoms and more dilations prior to urethroplasty.ConclusionFemale urethroplasty with BMG is effective at treating female urethral stricture disease, with excellent outcomes at over a year of follow-up and minimal risk of stress incontinence postoperatively.

Abstract Number ‐ 146: Re‐stenting Following Recurrence after Venous Sinus Stenosis Stenting for Idiopathic Intracranial Hypertension

Introduction Venous sinus stenosis (VSS) stenting in medically refractory Idiopathic Intracranial Hypertension (IIH) patients has emerged as an effective treatment with low rates of failure and recurrence. However, the best treatment strategy following recurrence of symptoms in previously stented patients with initial response is unclear and frequently leads to shunt placement. We investigated the role of re‐stenting in patients with recurrence after prior successful stenting. Methods This is a retrospective review of a prospectively maintained IIH registry. Inclusion criteria included patients with confirmed IIH and angiographically demonstrable VSS who underwent interventions from 2012–2022. Patients were divided into those who underwent a single stenting procedure (Group S) and those who underwent placement of an additional stent due to recurrence of clinical symptoms and angiographic stenosis (Group R). All re‐stenting was performed in adjacent or remote regions of stenosis. Bivariate analyses were utilized to compare clinical outcomes. Results 86 patients were included with a median age of 33 [IQR 26‐39] and 94% were females. Group S (79/86) and Group R (7/86) had similar baseline characteristics. There was similar improvement in post‐stenting opening pressure (22.4±6.7 vs. 25.2±4.6 cm H2O, p = 0.35, Group S vs. Group R), change in opening pressure (11.6±10.4 vs. 5.3±12.2 cm H2O, p = 0.20, Group S vs. Group R) and resolution of tinnitus (91.8 vs. 80%, p = 0.28, Group S vs. Group R). Headache improvement was higher in Group S at 6 weeks, but similar at 6 months (92.8 vs. 60%, p = 0.02 and 88.2 vs. 80%, p = 0.59, Group S vs. Group R). Group S also had higher improvement in visual disturbances at 6 months (93.8 vs. 60%, p = 0.01, Group S vs. Group R), but similar improvement in papilledema (92.2 vs 100%, p = 0.68, Group S vs. Group R). None of the re‐stented patients required VPS rescue. Conclusions VSS re‐stenting in IIH patients with recurrence after initial stenting is feasible with similar efficacy in reducing intracranial pressure and symptoms.

Surgical Referral for Hemodialysis Access Maintenance.

Hemodialysis access is the lifeline for end-stage renal disease patients. However, dialysis access is associated with a host of complications, including thrombosis, recurrent stenosis, infection, aneurysmal changes and bleeding. Although endovascular therapy remains the first-line treatment owing to its less invasive nature, there are certain situations where surgical referral is recommended or even necessary. Regardless, management of dialysis access complications requires a multidisciplinary approach. Interventional radiologists should be familiar with the appropriate timing for surgical referral to better serve the complex patient population.

Short and Intermediate-Term Outcome of Robot-Assisted Inverted YV-Plasty for Recurrent Bladder Neck Stenosis - a Single Centre Study

ObjectiveTo report the technique and preliminary results for extraperitoneal robot-assisted laparoscopic YV-plasty (RAYV) for refractory bladder neck stenosis (BNS) and vesicoureteral anastomosis stenosis (VUAS). Materials and methodsIncluded were patients with recurrent BNS and VUAS who underwent RAYV at our institution. Primary outcome was short and intermediate-term functional results measured with urinary peak flow (Qmax), post-void residual urine (PVR) as well as quality of life assessment with the international prostate symptom score (IPSS) and short form health survey (SF-8). Short- and intermediate-term follow-up periods were defined as 1-6 months and 6-24 months, respectively. Secondary, all patients were reviewed for etiology as well as perioperative data. Treatment success was defined by absence of further treatment and/or need for intermittent or permanent catheterization. ResultsBetween March 2016 and October 2020 a total of 30 patients with a median age of 70.8 (64-77) years underwent RAYV with a median follow-up of 27 months. Median operative time (skin-skin) was 131 (112-145) minutes. The transurethral indwelling catheter was removed after 10 (5 – 16) days. There were no intraoperative complications but 2 postoperative major complications Clavien-Dindo IIIa and IV, respectively. Short- and intermediate-term results revealed significant improvement of IPS score from 17 (11-24) points to 11 (6-13) points and 6 (3-9) points, respectively. Further PVR decreased from 90 (5-302) mL to 0 (0-30) mL and 0 (0-90) mL, respectively, and Qmax increased from 7.4 mL/s to 13 (8-16) mL/s and 17 (12-4) mL/s, respectively. Improvement of SF-8 did not reach significance. A total of 5/30 (16.7%) patients had a treatment failure after 24 months whereof 2 had a re-stricture. ConclusionRAVY-Plasty for recurrent bladder neck stenosis is a safe and effective procedure with good functional short- and intermediate-term outcome.

Combining Transurethral Resection of Fibrous Tissue and Temporary Urethral Stent Insertion Is an Optimal Strategy for Minimally Invasive Treatment of Recurrent and Long Urethral Strictures

This study investigated the optimal strategy for the treatment of chronic recurrent urethral strictures longer than 3 cm, using a temporary urethral stent. Between September 2011 and June 2021, 36 patients with chronic bulbomembranous urethral strictures underwent temporary urethral stent placement. Retrievable self-expandable polymer-coated bulbar urethral stents (BUSs) were placed in 21 patients (group A), and thermo-expandable nickel-titanium alloy urethral stents were placed in 15 patients (group M). Each group was subdivided into those with and without transurethral resection (TUR) of fibrotic scar tissue. The urethral patency rates at 1 year after stent removal were compared between the groups. The patients in group A showed a higher urethral patency maintenance rate at 1 year after stent removal than those in group M (81.0% vs. 40.0%, log rank test p = 0.012). Analysis of subgroups in which TUR was performed due to severe fibrotic scar, showed that the patients in group A showed a significantly higher patency rate than patients in group M (90.9% vs. 44.4%, log rank test p = 0.028). In the treatment of chronic urethral strictures with a long fibrotic scar, temporary BUS combined with TUR of fibrotic tissue seems to be the optimal minimally invasive treatment strategy.

Analysis of the Efficacy and Risk Factors for Failure of Balloon Dilation for Benign Ureteral Stricture

This study aimed to investigate the efficacy of balloon dilation in ureteral stricture and to analyze the risk factors for the failure of balloon dilation, which will hopefully provide some reference for clinicians to develop treatment plans. We retrospectively analyzed 196 patients who underwent balloon dilation between January 2012 and August 2022, 127 of whom had complete baseline and follow-up data. General clinical data, perioperative data, balloon parameters at the time of surgery, and follow-up results were collected from the patients. Univariate and multivariate logistic regression analyses were performed for the risk factors for surgical failure in patients undergoing balloon dilatation. The success rates of balloon dilatation (n = 30) and balloon dilatation combined with endoureterotomy (n = 37) for lower ureteral stricture at 3 months, 6 months, and 1 year were 81.08%, 78.38%, and 78.38% and 90%, 90%, and 86.67%, respectively. The success rates of balloon dilation at 3 months, 6 months, and 1 year in patients with recurrent upper ureteral stricture after pyeloplasty (n = 15) and primary treatment (n = 30) were 73.33%, 60%, and 53.33% and 80%, 80%, and 73.33%, respectively. The success rates of surgery at 3 months, 6 months, and 1 year for patients with recurrence of lower ureteral stricture after ureteral reimplantation or endoureterotomy (n = 4) and primary treatment with balloon dilatation (n = 34) were 75%, 75%, and 75% and 85.29%, 79.41%, and 79.41%, respectively. Multivariate analysis of the failure of balloon dilation showed that balloon circumference and multiple ureteral strictures were risk factors for balloon dilation failure (OR = 0.143, 95% CI: 0.023-0.895, p = 0.038; OR = 1.221, 95% CI: 1.002-1.491, p = 0.05). Balloon dilation combined with endoureterotomy in lower ureteral stricture had a higher success rate than balloon dilation alone. The success rate of balloon dilation in the primary treatment of the upper and lower ureter was higher than that of balloon dilation in the secondary treatment after failed repair surgery. Balloon circumference and multiple ureteral strictures are risk factors for balloon dilation failure.

Robotic ureteral reconstruction for recurrent strictures after prior failed management.

To describe our multi-institutional experience with robotic ureteral reconstruction (RUR) in patients who failed prior endoscopic and/or surgical management. We retrospectively reviewed our Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database for all consecutive patients who underwent RUR between 05/2012 and 01/2020 for a recurrent ureteral stricture after having undergone prior failed endoscopic and/or surgical repair. Post-operatively, patients were assessed for surgical success, defined as the absence of flank pain and obstruction on imaging. Overall, 105 patients met inclusion criteria. Median stricture length was 2 (IQR 1-3) centimetres. Strictures were located at the ureteropelvic junction (UPJ) (41.0%), proximal (14.3%), middle (9.5%) or distal (35.2%) ureter. There were nine (8.6%) radiation-induced strictures. Prior failed management included endoscopic intervention (49.5%), surgical repair (25.7%) or both (24.8%). For repair of UPJ and proximal strictures, ureteroureterostomy (3.4%), ureterocalicostomy (5.2%), pyeloplasty (53.5%) or buccal mucosa graft ureteroplasty (37.9%) was utilized; for repair of middle strictures, ureteroureterostomy (20.0%) or buccal mucosa graft ureteroplasty (80.0%) was utilized; for repair of distal strictures, ureteroureterostomy (8.1%), side-to-side reimplant (18.9%), end-to-end reimplant (70.3%) or appendiceal bypass (2.7%) was utilized. Major (Clavien >2) post-operative complications occurred in two (1.9%) patients. At a median follow-up of 15.1 (IQR 5.0-30.4) months, 94 (89.5%) cases were surgically successful. RUR may be performed with good intermediate-term outcomes for patients with recurrent strictures after prior failed endoscopic and/or surgical management.

Unexpected difficult airway in a patient with an asymptomatic recurrence of postintubation stenosis

Unexpected difficult airway in a patient with an asymptomatic recurrence of postintubation stenosis

Delineating Which Patient-reported Symptoms Are Associated with Satisfaction After Urethroplasty

To determine which patient-reported symptoms are associated with satisfaction after urethroplasty. From 2011 to 2018, patients were offered enrollment in a prospective study assessing patient-reported outcomes after urethroplasty. Outcomes were assessed preoperatively and 6-months postoperatively including patient satisfaction, voiding function (International Prostate Symptom Score), erectile function (International Index of Erectile Function 5) and ejaculatory function (ejaculatory component of brief sexual function inventory). Additionally, penile curvature/appearance, genitourinary pain, postvoid dribbling, and standing voiding function were also evaluated using either 3 or 5 point Likert scales. Stricture recurrence was defined as the inability to easily pass a 16Fr flexible videocystoscope. Multivariable binary logistic regression was used to examine the associations between outcomes and patient satisfaction. A total of 387 patients completed the study with a mean age of 49.5 years and a mean stricture length of 4.5 cm. Location was bulbar (59.4%), penile (19.6%), posterior (13.7%) and pan-urethral (7.2%). At 6-months, 96.1% of patients were stricture-free, 81.6% reported being satisfied with surgery and 8% were unsatisfied. On multivariable binary logistic regression, improvement in International Prostate Symptom Score (odds ratio [OR]: 1.1, 95% confidence interval [CI]: 1.1-1.2, P=.04), new erectile dysfunction (OR: 0.5, 95% CI: 0.2-0.9, P=.04), new penile curvature (OR: 0.4, 95% CI: 0.2-0.9, P=.03) and improved standing voiding function (OR: 1.3, 95% CI: 1.1-1.5, P=.004) were associated with patient satisfaction. Cystoscopic success (P=.60), change in pain score (P=.14), postvoid dribbling (P=.69), change in penile length (P=.44), and ejaculatory dysfunction (P=.51) were not. Improved voiding function, patient-reported penile curvature, new erectile dysfunction and improved standing voiding are independently associated with patient satisfaction after urethroplasty and should be incorporated into any patient-centered approach to urethral stricture management.

Smoking is an independent risk factor for stricture recurrence after the urethroplasty: a systematic review and meta-analysis.

To clarify the association between smoking and stricture recurrence after urethroplasty. Pubmed, Web of Science, Embase, and Cochrane databases were searched with keywords: "urethroplasty," "buccal mucosa graft urethroplasty," "oral mucosa graft urethroplasty," "excision and primary anastomosis urethroplasty," "urethral stricture recurrence" until July 1, 2022. Inclusion and exclusion criteria were based on PICOS principles. The quality of included studies was assessed by Newcastle-Ottawa Scale (N.O.S.) system. Hazard ratio (H.R.), odds ratio (OR), and relative risk (RR) with 95% confidence interval (CI) were extracted or re-calculated from included studies. Meta-analysis was performed with Stata 15.0 based on univariate and multivariate data separately. Sensitivity analysis was performed to test the stability of the meta-analysis. I2 was calculated to evaluate heterogeneity. Publication biases were assessed by Egger's and Begg's tests. Funnel plots of univariate analysis and multivariate analysis were also offered. Twenty one studies with 6791 patients were involved in this meta-analysis. The analysis results of the two stages were consistent. In the univariate meta-analysis stage, 18 studies with 5811 patients were pooled, and the result indicated that smoking might promote stricture recurrence (RR=1.32, P=0.001). Based on the adjusted estimate, 11 studies with 3176 patients were pooled in the multivariate meta-analysis stage, and the result indicated that smoking might promote stricture recurrence (RR=1.35, P=0.049). There was no significant heterogeneity in both the univariate and multivariate stages. Our study demonstrates that smoking may prompt stricture recurrence after the urethroplasty. Quitting smoking may be a good option for patients undergoing urethroplasty surgery.

Ureteroscopic and Robot-Assisted Ureteroplasty with Buccal Mucosa Graft

Introduction and Objective: In this video we present a case of a ureteroscopic and robot-assisted redo ureteroplasty with buccal mucosa graft for a proximal ureteral stricture. Methods: Here, we present a case of 72-year-old female patient with a history of a right-sided proximal ureteral stricture after ureteroscopic stone treatment. For this stricture she underwent robotic end-to-end ureteroplasty. Two years later, she presented with recurrence of the stricture for which she underwent balloon dilatation and tandem stenting. Unfortunately, the stricture recurred rapidly. A redo ureteroplasty with buccal mucosa graft was planned. Results: Surgery and postoperative course were uneventful. Six weeks after surgery, the Double-J stent was removed and 4 months postoperatively, the patient is doing fine without evidence for recurrence of the ureteral stricture. Conclusions: The video illustrates how retrograde ureteroscopy in combination with FireFly fluorescence imaging can be a valuable contribution to identifying the ureter, which in redo cases is often surrounded by a lot of fibrotic tissue. Moreover, localization of the stricture site is facilitated by retrograde ureteroscopy. After onlay of the buccal mucosa graft, patency and watertightness of the ureteroplasty can easily be controlled. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. All authors declare no conflict of interest in connection with this video. Runtime of video: 3 mins 16 secs

Paclitaxel drug coated balloon for the treatment of recurrent bulbar urethral stricture

Paclitaxel drug coated balloon for the treatment of recurrent bulbar urethral stricture

P669 Improving Crohn’s disease stricture dilation outcome: Effect of repeated dilation, needle knife stricturotomy, and ongoing active inflammation

Abstract Background Traditionally Crohn’s disease strictures have been treated by a single endoscopic balloon dilation (EBD), repeated only for obstructive symptom recurrence. We postulated that scheduled repeated EBD may result in greater dilation effect than a single EBD; and that needle-knife stricturotomy (NKSt) may be a valuable salvage intervention in patients with strictures. Methods In this prospective observational study, patients with endoscopically accessible and short (<5cm), symptomatic Crohn’s disease stricture were assessed clinically (using an Obstructive Symptom Score [OSS]) and by imaging (colonoscopy, MRI and IUS). All patients had drug treatment optimized to decrease inflammation. Patients were treated with 3 serial balloon dilatations each 3 weeks apart, single EBD, or needle-knife stricture incision. The primary endpoint was improved OSS at 6m. Secondary outcomes; ability to endoscopically pass the stricture, treatment failure / surgery, stricture morphology on imaging, and safety. Results Twenty-one consecutive patients were included in the analysis. Of these 17 (81%) were receiving treatment with a biologic therapy. Median stricture length at baseline was 20mm (IQR 20mm) and median estimated stricture diameter was 8mm (IQR 3mm). 18 (86%) had visible ulceration. Of the 21 patients 11 (52%) underwent more than one EBD, 5 (24%) had ≥1 NKSt and 5 (21%) underwent a single EBD. Four of the 21 patients (19%) strictures were passable before endoscopic treatment. All procedures were technically successful. 14/21 (67%) had improvement in OSS at 6m, including 8/11 (73%) with 3 serial EBD, 4/5 (80%) with NKSt and 2/5 (40%) patients undergoing a single EBD. Two patients required surgery. At 6m, 3/8 (38%) who had repeat dilations, 4/5 (80%) who had NKSt, and 2/5 (40%) having a single EBD had a passable stricture. All 4 patients with highly elevated stricture inflammation (stricture magnetic resonance index of activity [MaRIA] score ≥20) at the 6m MRI had a non-passable stricture at study endpoint, whilst 9/12 (75%) were passable when stricture MARIA was <20 (P=0.019). No major complications occurred. Conclusion Endoscopic stricture treatment was safe and technically successful in all patients with accessible Crohn’s disease strictures and was associated with symptom improvement in most. Progression to surgery in this symptomatic and advanced disease was low at 6m. The highest rates of symptom improvement were seen in patients who had NKSt. Lesser stricture inflammation on MRI was associated with a better outcome, suggesting that controlling inflammation is important in preventing stricture recurrence after dilation. NKSt should be considered when balloon dilation is not possible or has failed, as a salvage treatment alternative to surgery.

LONG RECTAL CUFF SYNDROME AFTER ILEOANAL POUCH FOR INFLAMMATORY BOWEL DISEASE

Abstract BACKGROUND Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) removes the entire rectum to the anal canal, but is technically challenging, especially with minimally invasive (MIS) approaches. Pouches are most commonly double-stapled, leaving a 1-2 cm “rectal cuff”. If the cuff is longer, patients may develop recurrent ulcerative proctitis (UP) or rectal stricture (RS) of the retained rectum. The aim of this study is to describe long rectal cuff syndrome (LRCS) and its outcomes after redo IPAA performed for long rectal cuffs. METHODS We defined LRCS as a constellation of UP or RS symptoms related to a long (≥ 4 cm) rectal cuff. We retrospectively reviewed our prospectively maintained Pouch Registry to identify patients whose indication for redo pouch was LRCS. We report their presentation and outcomes after redo IPAA for LRCS. Figures are frequency (percentage) and median (interquartile range). RESULTS LRCS was the primary indication for redo IPAA in 40 patients (7% of the redo IPAA cases at our Center); median age at redo surgery, 42.5 (29 – 49 years); 18 (42%) were females; 36 (90%) patients were referral cases. Diagnosis at index IPAA was ulcerative colitis in 39 (97.5%), and Crohn’s in 1 (2.5%) case. The index pouch was performed MIS in 14 (35%). The median rectal cuff length was 6 (5 – 8) cm, with 13 (32.5%) patients having a cuff ≥ 8 cm. After a median of 21 (16 – 68) months, patients most commonly presented (31, 77.5%) with UP-symptoms (urge-incontinence, frequency, abdominopelvic or rectal pain) or with obstructive (9, 22.5%) symptoms (crampy abdominopelvic pain, outlet obstruction). Preoperative pouchoscopy was available in 32 (80%) cases: pouchoscopy findings included proctitis (18, 56%), rectal stricture (16, 50%), and/or dilated pouch (7, 22%). The median interval between the index pouch and redo pouch was 31 months (16 – 67.5). The pouch was disconnected and re-anastomosed to anus in 16 (40%), while excised with neo-pouch construction in 24 (60%) of cases. The anastomosis was stapled vs. handsewn 25 (62.5%) vs. 15 (27.5%). Pathologic exam revealed chronic active proctitis in 38 (90%) cases; the remained showed other pathologic changes. In terms of long-term outcomes, two (5%) patients never had their stoma closed after redo due to Crohn’s-related pouch complication, and fistulae development, respectively. After a median follow up of 34.5 (12 – 109) months, pouch failure occurred in 9 (22.5%) cases. The median interval between redo IPAA and pouch failure was 10 (4 – 34) months. Pouch survival at 3-, 5- and 10-years was 78%, 72%, and 63%. CONCLUSION Long rectal cuff syndrome is a potentially avoidable complication which presents with symptoms from either ulcerative proctitis or stricture. Redo IPAA can be offered as treatment to maintain intestinal continuity and may allow long-term pouch salvage in many cases.

Multi-stage surgery for anterior urethral strictures: assessment of immediate and long-term surgical outcomes

BACKGROUND: The progress made in reconstructive urethral surgery over the past 20 years has shown the effectiveness of one-stage repair of anterior urethral strictures. Nevertheless, multi-stage urethroplasty retains its primary role in the treatment of patients with the most complex urethral narrowing and obliterations.
 AIM: To evaluate the immediate and long-term surgical results of multi-stage urethroplasty for penile and bulbar urethral strictures.
 MATERIALS AND METHODS: The study included 110 men aged 1884 years who underwent multi-stage urethroplasty for the anterior urethral structures in 20102019. The techniques of buccal and skin augmentation or urethral replacement plastics were applied. Before surgery, all patients underwent a standard urological examination. Early surgical complications were evaluated from medical records. Late surgical complications were determined according to examinations that included symptomatic assessment with specialized questionnaires, laboratory tests of serum and urine, physical examination, uroflowmetry, and retrograde urethrography and ureteroscopy (if urinary disorders were detected). The median follow-up was 5 years and 2 months.
 RESULTS: Early surgical complications were detected in 27 (24.5%) patients. Surgical interventions to resolve them were required in 7 (31.8%) cases: urethrocutaneous fistulas (5), acute urinary retention (1), scrotal hematoma (1). Late surgical complications were detected in 33 (30.0%) patients, including 29 (26.7%) cases of recurrent urethral strictures. All late complications cases were classified as Clavien-Dindo IIIb, and a total of 49 additional operations were performed to eliminate them. The primary success rate for multi-stage urethroplasty was 67.3 % with a median follow-up of 62 months. Only 73 (66.4%) completed all stages of the planned surgery. Urethral integrity throughout its entire length was restored in 67 (60.9%) cases, spontaneous urination in 106 (96.4%) cases.
 CONCLUSIONS: Multi-stage surgery for anterior urethral strictures is associated with relatively high risks of surgical complications at each stage of treatment. The probability of surgical revision of complications can reach 31.8%. Patients should be informed about the risks of developing surgical complications and the potential for more than two surgeries to achieve treatment goals when planning multi-stage urethroplasty.

High Tracheal Resection With Intralaryngeal Extension as an Alternative to Cricotracheal Resection for Treatment of Subglottic Stenosis.

Some patients with subglottic stenosis (SGS) require open airway reconstruction, which traditionally involves resection of the anterior cricoid cartilage. As an alternative, we present a novel technique: cricoid-sparing high tracheal resection with excision of subglottic stenotic tissue from below. A novel set of posterior circumferential cricoid sutures is used to reline the exposed cricoid plate. Retrospective chart review. Single tertiary care center. The surgical technique is described and illustrated. A chart review was performed for all patients who underwent surgery between January 1, 2016, and June 30, 2021. Fourteen patients (100% female) underwent this airway resection and reconstruction surgery during the study time period. After a mean follow-up of 12 months, no patients required tracheostomy. Twelve of 14 patients (86%) had durable airways. Two patients (14%) have required repeated endoscopic procedures for recurrent stenosis and are considered treatment failures. None exhibited postoperative dysfunction to suggest posterior cricoarytenoid muscle injury. Thirteen patients (93%) had a postoperative normal voice or only transient dysphonia. One patient had permanent unilateral vocal fold paralysis. Cricoid-sparing high tracheal resection is a safe and effective alternative to cricotracheal resection, especially for predominantly posterior SGS. The cricoid cartilage and cricothyroid muscles are left undisturbed, potentially decreasing the risk of postoperative dysphonia, namely lowered fundamental frequency. This is especially meaningful in the setting of a predominantly female patient population.

Surgical management of acute life-threatening events affecting esophageal atresia and/or tracheoesophageal fistula patients

BackgroundFollowing surgical correction, many patients with esophageal atresia with or without tracheoesophageal fistula (EA/TEF) present to the emergency department (ED) with acute airway complications. We sought to determine the incidence and risk factors for severe acute life-threatening events (ALTEs) in pediatric patients with repaired congenital EA/TEF and the outcomes of operative interventions. MethodsA retrospective cohort chart review was performed on patients with EA/TEF with surgical repair and follow-up at a single centre from 2000 to 2018. Primary outcomes included 5-year ED visits and/or hospitalizations for ALTEs. Demographic, operative, and outcome data were collected. Chi-square tests and univariate analyses were performed. ResultsIn total, 266 EA/TEF patients met inclusion criteria. Of these, 59 (22.2%) had experienced ALTEs. Patients with low birth weight, low gestational age, documented tracheomalacia, and clinically significant esophageal strictures were more likely to experience ALTEs (p < 0.05). ALTEs occurred prior to 1 year of age in 76.3% (45/59) of patients with a median age at presentation of 8 months (range 0–51 months). Recurrence of ALTEs after esophageal dilatation was 45.5% (10/22), mostly due to stricture recurrence. Patients experiencing ALTEs received anti-reflux procedures (8/59, 13.6%), airway pexy procedures (7/59, 11.9%), or both (5/59, 8.5%) within a median age of 6 months of life. The resolution and recurrence of ALTEs after operative interventions are described. ConclusionSignificant respiratory morbidity is common among patients with EA/TEF. Understanding the multifactorial etiology and operative management of ALTEs have an important role in their resolution. Type of StudyOriginal Research, Clinical Research. Level of EvidenceLevel III Retrospective Comparative Study.

Recurrent Lower Abdominal Pain, Altered Bowel Habits, and Malaise: Conservative or Surgical Approach to a Common Disorder

Recurrent Lower Abdominal Pain, Altered Bowel Habits, and Malaise: Conservative or Surgical Approach to a Common Disorder