Sharp Angulation Research Articles

Advantages of robotic surgery for rectal cancer compared to laparoscopic surgery: pelvic anatomy and its impact on urinary dysfunction.

The anatomical dimensions and the shape of the pelvis influence surgical difficulty for rectal cancer. Compared to conventional laparoscopic surgery, robot-assisted surgery is expected to improve surgical outcomes due to the multi-joint movement of its surgical instruments. The aim of this study was to investigate the impact of pelvic anatomical indicators on short-term outcomes of patients with rectal cancer. A retrospective analysis was conducted using data from 129 patients with rectal cancer who underwent conventional laparoscopic low anterior resection (L-LAR) or robot-assisted low anterior resection (R-LAR) with total mesorectal excision or tumor-specific mesorectal excision between January 2014 and December 2022. The transverse diameter of the lesser pelvis and the sacral promontory angle were used as indicators of pelvic anatomy. The sacral promontory angle was not associated with age and sex while the pelvic width was smaller in male than in female. The pelvic width did not affect postoperative complications in both L-LAR and R-LAR. In contrast, postoperative urinary dysfunction occurred more frequently in patients with a small sacral promontory angle (p = 0.005) in L-LAR although there was no impact on short-term outcomes in R-LAR. Multivariate analysis demonstrated that a small sacral promontory angle was an independent predictive factor for urinary dysfunction (p = 0.032). Sharp angulation of the sacral promontory was a risk factor for UD after L-LAR. Robot-assisted surgery could overcome anatomical difficulties and reduce the incidence of UD.

Radiological Vascular Anatomy of the Caudate Lobe of the Liver Required for Transarterial Chemoembolization of Hepatocellular Carcinoma.

The caudate lobe is located between the bilateral hepatic lobes and is divided into three subsegments: the Spiegel lobe, paracaval portion, and caudate process. The caudate artery arises from various sites of the bilateral hepatic arteries as an independent branch, common trunk, or arcade. Extrahepatic arteries can enter the caudate lobe mainly by the right inferior phrenic artery. The caudate artery also supplies the main bile duct and posterior aspect of segment IV. Although catheterization into the caudate artery is occasionally difficult because of its small size and sharp angulation, selective embolization of a tumor feeder is a significant prognostic factor in patients with hepatocellular carcinoma originating there. Therefore, we should recognize the peculiarity of its vascular anatomy and should be familiar with catheterization and embolization techniques.

V02-04 MINI-PCNL FOR TRANSPLANT NEPHROLITHIASIS

You have accessJournal of UrologyCME1 Apr 2023V02-04 MINI-PCNL FOR TRANSPLANT NEPHROLITHIASIS Kavita Gupta, Kevin Liu Kot, Dima Raskolnikov, Charbel Chalouhy, and Alexander Small Kavita GuptaKavita Gupta More articles by this author , Kevin Liu KotKevin Liu Kot More articles by this author , Dima RaskolnikovDima Raskolnikov More articles by this author , Charbel ChalouhyCharbel Chalouhy More articles by this author , and Alexander SmallAlexander Small More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003232.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Surgical management of transplant nephrolithiasis has many challenges. Technically, access to the kidney is limited by the neoureteral orifice, tortuous ureteral path and variable orientation of the kidney. We present a case of a 72-year old man with history of liver and kidney transplant 6 years prior who was found to have 1.9 cm and 0.9 cm stones in the transplant kidney. We demonstrate how endoscopic combined intrarenal surgery (ECIRS) and mini-percutaneous nephrolithotomy (mPCNL) can help improve stone clearance in transplant kidneys. METHODS: Percutaneous access to the kidney was previously obtained and a nephrostomy tube had been placed. In the operating room, the patient was positioned into lithotomy position. During cystoscopy, the transplant ureteral orifice in the right dome was accessed with an angled 0.038" hybrid wire. Retrograde pyelogram and nephrostogram showed an upside down lie of the kidney and a sharp angle at the ureteropelvic junction (UPJ). A 22 cm 12/14 Fr ureteral access sheath was placed up to the mid ureter and a flexible ureteroscope was passed into the kidney. There was sharp angulation at the UPJ which limited mobility of the scope. An impacted stone was visualized within the renal pelvis. Percutaneous access to the lower pole was established using the nephrostomy tube. Dilation was performed with an 18 Fr balloon and a sheath was placed. The Storz MIPS 12 Fr rigid nephroscope was placed into the field and the stones were visualized. Using the 200 um Holmium laser fiber, we fragmented the stones at a setting 1 J×20 Hz. The fragments were vortexed out and extracted with the nitinol basket. Simultaneously, retrograde ureteroscopy was used to ensure complete clearance of the stones. Additional stone fragments were encountered in the extreme lower pole below the sheath and further fragmented and extracted until stone-free. The scope was removed and a nephrostomy tube was placed. A 6 Fr×22 cm ureteral stent was advanced retrograde. A foley catheter was placed. RESULTS: Estimated blood loss was minimal. A CT abdomen and pelvis without contrast on post-operative day 1 showed no residual stone burden. The nephrostomy tube and foley catheter were removed, and the patient was discharged home. His ureteral stent was removed in the office one month later. The patient remained symptom free. CONCLUSIONS: Our video demonstrates the utility of ECIRS and mPCNL during transplant PCNL due to the complexity of the anatomy. In addition, ECIRS can improve stone clearance and overcome some of the challenges of transplant endoscopic surgery. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e169 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kavita Gupta More articles by this author Kevin Liu Kot More articles by this author Dima Raskolnikov More articles by this author Charbel Chalouhy More articles by this author Alexander Small More articles by this author Expand All Advertisement PDF downloadLoading ...

Structured versus non-structured reporting of pelvic MRI for ileal pouch evaluation: clarity and effectiveness.

Given that ileal pouch-anal anastomosis (IPAA) surgery is a technically challenging and high-morbidity procedure, there are numerous pertinent imaging findings that need to be clearly and efficiently communicated to the IBD surgeons for essential patient management and surgical planning. Structured reporting has been increasingly used over the past decade throughout various radiology subspecialties to improve reporting clarity and completeness. We compare structured versus non-structured reporting of pelvic MRI for ileal pouch to evaluate for clarity and effectiveness. 164 consecutive pelvic MRI's for ileal pouch evaluation, excluding subsequent exams for the same patient, acquired between 1/1/2019 and 7/31/2021 at one institution were included, before and after implementation (11/15/2020) of a structured reporting template, which was created with institutional IBD surgeons. Reports were assessed for the presence of 18 key features required for complete ileal pouch assessment: anastomosis (IPAA, tip of J, pouch body), cuff (length, cuffitis), pouch body (size, pouchitis, stricture), pouch inlet/pre-pouch ileum (stricture, inflammation, sharp angulation), pouch outlet (stricture), peripouch mesentery (position, mesentery twist), pelvic abscess, peri-anal fistula, pelvic lymph nodes, and skeletal abnormalities. Subgroup analysis was performed based on reader experience and divided into three categories: experienced (n = 2), other intra-institutional (n = 20), or affiliate site (n = 6). 57 (35%) structured and 107 (65%) non-structured pelvic MRI reports were reviewed. Structured reports contained 16.6 [SD:4.0] key features whereas non-structured reports contained 6.3 [SD:2.5] key features (p < .001). The largest improvement following template implementation was for reporting sharp angulation of the pouch inlet (91.2% vs. 0.9%, p < .001), tip of J suture line and pouch body anastomosis (both improved to 91.2% from 3.7%). Structured versus non-structured reports contained mean 17.7 versus 9.1 key features for experienced readers, 17.0 versus 5.9 for other intra-institutional readers, and 8.7 versus 5.3 for affiliate site readers. Structured reporting of pelvic MRI guides a systematic search pattern and comprehensive evaluation of ileal pouches, and therefore facilitates surgical planning and clinical management. This standardized reporting template can serve as baseline at other institutions for adaptation based on specific radiology and surgery preferences, fostering a collaborative environment between radiology and surgery, and ultimately improving patient care.

S2885 Endoscopic Ultrasound-Guided Drainage of a Remnant Gallbladder

Introduction: Endoscopic Ultrasound (EUS) guided drainage of a remnant gallbladder (RGB) with lumen-apposing metal stents (LAMS) can be safely performed for suppurative cholecystitis and choledocholithiasis following subtotal cholecystectomy (STC). Case Description/Methods: A 68-year-old man presented with recurrent bacteremia secondary to symptomatic RGB after undergoing STC for severe necrotizing gallstone pancreatitis. His preceding course was complicated by infected walled-off pancreatic necrosis, recurrent choledocholithiasis with ascending cholangitis, liver abscess, and bacteremia. His treatments included EUS-guided necrosectomy, multiple endoscopic retrograde cholangiopancreatopgraphies (ERCPs) with unsuccessful attempts at transpapillary gallbladder drainage, and percutaneous cholecystostomy followed by laparoscopic STC. Given his life-threatening complications and poor surgical candidacy EUS-guided drainage of the RGB was pursued. Linear EUS identified the RGB measuring 19.4mm in diameter. Using a 19-gauge FNA needle, the RGB was instilled with 80cc of sterile saline to a diameter of 28.5mm (Figure a). EUS-guided cholecystogastrostomy was then performed using a 10 x 15 mm electrocautery-enabled access catheter-enhanced LAMS. The LAMS was dilated to 12mm sequentially using a controlled radial expansion balloon. Multiple large, pigmented stones passed with several remaining in the gallbladder (Figure b). A 10Fr by 5cm double pigtail stent was passed over a wire into the gallbladder to complete the procedure (Figure c). At one month follow-up ERCP, the LAMS was removed leaving a mature gastrocholecystic fistula. No recurrence of symptoms noted at 12-month follow-up. Discussion: Laparoscopic cholecystectomy after recovery of gallstone pancreatitis is recommended to reduce risk of recurrent pancreatitis. In some patients, difficult anatomy and inflammation necessitates STC to avoid injury to the extrahepatic bile ducts and surrounding blood vessels. STC is associated with significant morbidity. Completion cholecystectomy for symptomatic complications from RBG is recommended if possible. However, our patient was deemed a poor surgical candidate. Transpapillary drainage of the RBG was also precluded by difficult anatomy with sharp angulation at the confluence of the common hepatic and cystic ducts. This case describes the novel application of EUS-guided drainage of an RBG as a safe and effective alternative to completion cholecystectomy for patients who are poor operative candidates.Figure 1.: EUS used to measure dimensions of remnant gallbladder after injecting 80mL of sterile saline (A). Cholecystogastrostomy was performed using a 10 mm X 15 mm LAMS with cautery tip over a wire and dilated using a controlled radial expansion balloon (B). A double pigtail stent was placed through the lumen of the LAMS (C).

S2468 Stop, Drop, and Roll: One Woman’s Pelvic Floor Disease Journey

Introduction: Pelvic floor disease includes symptoms of the anterior (urinary, vaginal) and posterior (anorectal) pelvic floor. This case describes a woman who developed dyssynergic defecation after surgical management of urinary incontinence. The diagnostic route taken to reveal the unusual cause of her symptoms is a lesson in how to evaluate ambiguous gastrointestinal(GI)/genitourinary symptoms. Case Description/Methods: A 69-year-old woman presents with bloating and difficulty defecating for 2 years. She senses incomplete evacuation, passing 1-2 thin stools per day despite an extensive bowel regimen (e.g. posturing, straining). Two years ago, she underwent sacrocolpopexy and mesh placement to treat pelvic organ prolapse. Her urinary incontinence improved but constipation worsened. She was thus evaluated by GI- many CTs showed nonspecific sigmoid (SC) thickening. A colonoscopy noted SC narrowing; mucosa pathology was normal. She came to our clinic to investigate further. Digital rectal exam had a normal tone with widening of the vault with strain. Anorectal manometry (ARM) showed dyssynergic defecation and unsuccessful balloon expulsion, consistent with mechanical obstruction. A flexible sigmoidoscopy showed benign-appearing extrinsic compression at the rectosigmoid junction. The SC also had a large stool burden despite 2 pre-procedure enemas. Given a concern for mass effect of the mesh into the colon, an exploratory laparoscopy was performed, showing a redundant SC with scarred, edematous mesentery. A partial sigmoidectomy was performed and adhesions at the anterior rectal wall (near the sacrocolpopexy mesh) were lysed. In just 3 months, the patient’s symptoms resolved. Repeat ARM had a normal defecation pattern and balloon expulsion (Figure). Discussion: Postoperative adhesions are present after 63-97% of open abdominal surgeries. The most common complication of such adhesions is bowel obstruction, occurring in 15% of patients within 1 month of surgery. Our patient had an even more unique complication- constipation and dyssynergic defecation. Literature on post-op adhesions and defecation dysfunction mainly describes surgery of the rectal sphincter. In contrast, the sacrocolpopexy did not involve the rectum or surrounding peritoneum, but caused adhesions with a mass effect on the rectum. Given the morbidity associated with lower abdominal adhesions, suspicion must remain high in populations with a history of complicated abdominal surgery- especially for treatment of anterior pelvic floor disease.Figure 1.: A. Flexible sigmoidoscopy: Very narrowed lumen in the sigmoid colon. B. CT abdomen and pelvis: Coronal view showing sharp angulation in the sigmoid colon (due to the mass effect of the mesh and adhesions) C.Anorectal manometry: The Y-axis notes length (cm) from anal sphincter (0cm) into sigmoid. The X-axis shows time (in seconds). The color of the data points denotes pressure exerted. Here, the top horizontal line in green shows rectal pressure. The same amount of pressure is shows in the bottom “green” areas, indicating that anal tone faily to appropriately relax. This increase in anal pressure with a good push, indicating dyssynergic defecation pattern.

Hunchback with “S” Shape Spine: Cadaveric Case series

Introduction: Kyphosis is a sharp posterior angulation due to localized collapse or wedging of one or more vertebrae and scoliosis is the lateral curvature of the spine. These may occur due to a congenital defect, fracture, and sometimes pathological or spinal tuberculosis. Materials and Methods: During routine cadaver dissection, four cases of kyphoscoliosis were identified. In the first case, a protrusion on the posterior surface of the trunk of the cadaver at L1 level was observed in a 60-year-old male. The lungs were collapsed and adherent with the pleura and thoracic wall. The posterior wall of the stomach was adherent to the pancreas and a depression was noted on the anterior surface of abdominal aorta. The T12 and L1 vertebrae were fused, and the spine was deviated to the left side. The anterior aspect of the body of L1 vertebrae was marginally eroded. The second case of kyphoscoliosis was from 80-year-old female cadaver. The descending and abdominal aorta had an abnormal course along the vertebral column, third and fourth cases were observed with slight protrusion and scoliosis but not much changes in the vertebral column. Results: The cause of the deformity was confirmed by pathological examination of the tissues showed inter vertebral disc degeneration with calcification and ossification and osteopenia. The underlying etiology can be tuberculosis, injuries, or infections. Conclusion: Severe kyphoscoliosis can affect wide range of systems in the body. It will affect not only the respiratory system also pressure on great vessels as a consequence of bony deformity. KEY WORDS: Kyphosis, Cadaver Dissection, Kyphoscoliosis, Deformity, Calcification, Ossification.

Study of coronary sinus anatomy during levophase of coronary angiography.

BACKGROUNDCoronary sinus (CS) imaging has recently gained importance due to increasing need for mapping and ablation of electrophysiological arrhythmias and left ventricular (LV) pacing during cardiac resynchronization therapy (CRT). Retrograde venogram is the current standard for imaging CS and its tributaries. AIMTo evaluate CS anatomy during levophase of routine coronary angiography to aid LV lead implantation during CRT.METHODSIn this prospective observational study, 164 patients undergoing routine coronary angiography for various indications (Chronic stable angina-44.5%, acute coronary syndrome- 39.5%, Dilated cardiomyopathy-11%, atypical chest pain-5%) were included. Venous phase (levophase) of left coronary injection was recorded in left anterior oblique - cranial and right anterior oblique -cranial views. Visibility of coronary veins, width and shape of CS ostium, angulations of proximal CS with body of CS were noted. Presence, size, take-off angle and tortuosity of posterolateral vein (PLV), anterior interventricular veins (AIV) and middle cardiac vein (MCV) were also noted.RESULTSDuring levophase, visibility grade (Muhlenbruch grade) for coronary veins was 3 in 74% and 2 in 26% of cases. Visibility of CS did not correlate with body mass index. The diameter of CS ostium was < 10 mm, 10-15 mm and > 15 mm in 48%, 42% and 10% of patients respectively. Proximal CS was tubular in 136 (83%) patients and funnel-shaped in 28 (17%) patients. Sharp take-off angulation between ostium and body of CS was seen in 16 (10%) patients. Two or more PLV were present in 8 patients while PLV was absent in 52 (32%) patients. Angle of take-off of PLV with body of CS was favourable (0°-45°) in 65 (40%) patients. The angle was 45°-90° in 36 patients and difficult take-off angle (> 90°) was seen in 8 patients. Length of PLV reached distal third of myocardium in 84 cases and middle third in 11 cases. There was no tortuosity in 79 cases, a single bend in 29 cases and more than 2 bends in 4 cases. Thirty nine (24%) patients had other veins supplying posterior/Lateral wall of LV. There was a single vein supplying lateral/posterior wall in 31 (19%) patients. Diameter of MCV and AIV was significantly larger in patients with absent PLV as compared to patients with a PLV. CONCLUSIONLevophase study of left coronary injection is effective in visualization of the CS in almost all patients undergoing coronary angiography and may be an effective alternative to retrograde venogram in patients with LV dysfunction or LBBB.

De novo heterozygous variants in KIF5B cause kyphomelic dysplasia.

Kyphomelic dysplasia is a heterogeneous group of skeletal dysplasias characterized by severe bowing of the limbs associated with other variable findings, such as narrow thorax and abnormal facies. We searched for the genetic etiology of this disorder. Four individuals diagnosed with kyphomelic dysplasia were enrolled. We performed whole-exome sequencing and evaluated the pathogenicity of the identified variants. All individuals had de novo heterozygous variants in KIF5B encoding kinesin-1 heavy chain: two with c.272A>G:p.(Lys91Arg), one with c.584C>A:p.(Thr195Lys), and the other with c.701G>T:p.(Gly234Val). All variants involved conserved amino acids in or close to the ATPase activity-related motifs in the catalytic motor domain of the KIF5B protein. All individuals had sharp angulation of the femora and humeri, distinctive facial features, and neonatal respiratory distress. Short stature was observed in three individuals. Three developed postnatal osteoporosis with subsequent fractures, two showed brachycephaly, and two were diagnosed with optic atrophy. Our findings suggest that heterozygous KIF5B deleterious variants cause a specific form of kyphomelic dysplasia. Furthermore, alterations in kinesins cause various symptoms known as kinesinopathies, and our findings also extend the phenotypic spectrum of kinesinopathies.

A125 A NOVEL TECHNIQUE COMBINING EUS AND SPYGLASS DS SYSTEM GUIDANCE FOR BOTH THE DIAGNOSIS AND MANAGEMENT OF AFFERENT LIMB SYNDROME

BackgroundAfferent limb syndrome is obstruction of a biliary-enteric limb following pancreaticoduodenectomy. In the past, treatment was limited to surgery or insertion of a percutaneous transhepatic biliary drainage tube. A more recent approach to treatment is Endoscopic Ultrasound (EUS)-guided gastrojejunostomy using a lumen apposing metal stent (LAMS). It was first described in two single case reports in 2015 and has been growing in its application. We present a case series of 2 patients where afferent limb syndrome was successfully managed with EUS guided gastrojejunostomy using LAMS.Aims1-To demonstrate a novel technique for diagnosis and management of afferent limb syndrome.MethodsCase # 1- 79 year old female post Whipple’s surgery for ampullary carcinoma, presented two years after surgery with significant nausea and vomiting. CT scan showed obstruction of the afferent loop suspicious for local tumor recurrence. Patient underwent EUS-guided gastrojejunostomy with successful insertion of 20 x 10 mm (AXIOS EC, Boston Scientific) stent.Case # 2-. A 51 year old male with pancreatic CA status post Whipple surgery presented with worsening abdominal pain and nausea. CT scan confirmed afferent limb syndrome. He underwent EUS- guided gastrojejunostomy with successful placement of 10 x 10 mm (AXIOS EC, Boston Scientific).ResultsCase #1: Patient improved dramatically within days and resumed oral diet. Fourteen days later, an upper endoscopy was performed in order to assess the stricture via an anterograde approach. The adult Olympus HQ gastroscope was advanced through the AXIOS stent into the afferent limb to the level of the stenosis where a tight stricture was seen. Multiple biopsies taken and were negative for malignancy. Four weeks later, she continued to tolerate oral diet well with no abdominal pain or discomfort.Case # 2: Patient continued to do well clinically 12 weeks post operation. Follow-up upper endoscopy was performed to determine the etiology of the obstruction but due to a sharp angulation, the gastroscope could not be advanced through the AXIOS stent. As such, we advanced an adult Olympus 1T gastroscope down to the site of the AXIOS stent and then utilized the Spyglass DS system to advanced deep into the afferent limb to the level of the stricture and took multiple biopsies for diagnostic purposes.ConclusionsInterventional endoscopic management of afferent limb syndrome has been evolving in the past few years with EUS guided LAMS gastrojejunostomy becoming a well stablished modality. We have demonstrated this technique with subsequent endoscopic anterograde assessment. In one of these cases, this anterograde assessment was performed using the cholangioscope in conjunction with the gastroscope to overcome unfavorable angulated anatomy which to our knowledge has not been described in the literature previously. Funding AgenciesNone

New Technique of Posterior Fixation of Tube With Fibrin Sealant Prevents Dysphagia in Patients Undergoing Sleeve Gastrectomy.

This study compared the effects of posterior fixation (PF) of the remnant tube with fibrin tissue glue to prevent sharp angulation and gastric twist and traditional techniques on postoperative dysphagia and vomiting. In total, 200 patients scheduled to undergo laparoscopic sleeve gastrectomy (LSG) as a bariatric surgical intervention were randomly classified into 2 groups (LSG + PF and LSG alone). We compared postoperative dysphagia symptoms among patients who underwent PF and those who did not. The Dysphagia Handicap Index (DHI) results were compared statistically among these groups. The study included a total of 191 patients (85.9% (n = 164) women and 14.1% (n = 27) men) who underwent LSG for obesity. The groups were similar in terms of the patient demographics. The DHI scores of the LSG + PF group were statistically significantly lower than those of the LSG alone group. Adoption of a standardized method of PF with a standardized surgical procedure after LSG considerably reduced the rate of surgical complications.

Novel risk factors for recurrent biliary obstruction and pancreatitis after metallic stent placement in pancreatic cancer.

Background and study aims Self-expandable metallic stents (SEMS) are now widely used even for patients with borderline resectable (BR) pancreatic cancer (PC), as neoadjuvant therapy has become common. Therefore, we conducted this study to evaluate safety of SEMS placement in the population including BR PC and to explore risk factors for recurrent biliary obstruction (RBO), pancreatitis, and cholecystitis. Patients and methods We retrospectively investigated consecutive patients with PC who received initial SEMS between January 2015 and March 2019. We compared time to RBO (TRBO), causes of RBO, and stent-related adverse events (AEs) according to resectability status. Univariate and multivariate analyses were performed to explore risk factors for TRBO, pancreatitis, and cholecystitis. Results A total of 135 patients were included (BR 31 and unresectable [UR] 104). Stent-related AEs occurred in 39 patients: pancreatitis 14 (mild/moderate/severe 1/6/7), cholecystitis 12, and non-occluding cholangitis 13. TRBO, causes of RBO, and stent-related AEs were not significantly different according to resectability status. Overall rate of RBO was higher in UR PC due to the longer follow-up period. Sharp common bile duct (CBD) angulation was an independent risk factor for short duration of TRBO. High pancreatic volume index and SEMS of high axial force were independent risk factors for pancreatitis, whereas tumor involvement to orifice of cystic duct was the only risk factor for cholecystitis. Conclusions We demonstrated that SEMS can be safely deployed even in patients with BR PC. Sharp CBD angulation and high pancreatic volume index were identified as novel risk factors for RBO and pancreatitis, respectively, after SEMS placement.

Risk factors and management of primary choledocholithiasis: a systematic review.

Primary choledocholithiasis (PC) is a common disease in biliary surgery. The treatment is always challenging due to its high recurrence. A systemic review is undertaken to determine the risk factors for recurrence and provide with the individualized management strategy. Electronic databases PubMed (Medline), Embase and Cochrane Central Register of Controlled Studies were searched for relevant articles on risk factors for PC recurrence. Its therapeutic intervention was also collected and analysed. A total of 36 articles were eligible for inclusion. The recurrent risk factors include abnormalities of biliary anatomy (peripapillary diverticulum), dynamics (choledochal dilation, sharp angulation and stone number), metabolism (advanced age and hypothyroidism) and bacterial infection (Enterobacter and Helicobacter pylori). These factors eventually induce cholestasis and stone formation. At present, there is no guideline and expertise consensus for PC management. The treatment mainly consists of stone retrieval approaches and internal drainage surgeries. The former are minimally invasive methods: endoscopic sphincterotomy (EST), papillary balloon dilation (EPBD) and laparoscopic common bile duct exploration (LCBDE). The latter include choledochoduodenostomy (CDS) and choledochojejunostomy (CJS) with Roux-en-Y reconstruction. By far, the internal drainage surgeries have significantly lower recurrence than stone retrieval approaches. Abnormal biliary anatomy, dynamics, metabolism and bacterial infection are the risk factors for PC. Both EST/EPBD and LCBDE can be performed as initial treatment. For recurrent PC, CDS is more suitable to the elderly, while Roux-en-Y CJS reserves for young patients or those in good conditions.

Afferent limb syndrome after total proctocolectomy and ileal pouch-anal canal anastomosis

BackgroundSmall bowel obstruction (SBO) is a common postoperative complication of ulcerative colitis (UC). There have been a few recent reports of afferent limb syndrome (ALS) as a rare occurrence in cases of SBO. We present a case of ALS with recurrent SBO that was successfully managed surgically.Case presentationWhen this male patient was 55 years old, he underwent laparoscopy-assisted anus-preserving total proctocolectomy, the creation of a J-type ileal pouch, ileal pouch-anal canal anastomosis (IPAA), and creation of ileostomy for intractable UC. Three months later, ileostomy closure was performed. The first onset of SBO was observed 5 months after ileostomy closure. SBO occurred repeatedly, and the patient was hospitalized nine times in approximately 2 years. Each SBO was improved by non-surgical treatment. A computed tomography (CT) scan revealed that the afferent limb was narrowing and twisted, and gastrografin enema confirmed narrowing at the proximal portion of the pouch inlet. Endoscopy showed a sharp angulation at the pouch inlet. We suspected ALS and decided on a surgical policy and performed pouchopexy and ileopexy to the retroperitoneum by suturing with excision of the remaining blind end of the ileum. Endoscopy 3 days after surgery showed neither twist nor stricture in the fixed ileal pouch or the afferent limb. At the time of writing, the patient remains free of SBO symptoms.ConclusionClinicians should consider ALS when examining a patient with recurrent intermittent SBO after IPAA surgery. When ALS is suspected, the patient is indicated for surgery such as surgical pexy.

Endoscopic submucosal dissection of a large duodenal neuroendocrine tumor adjacent to the pyloric ring.

Endoscopic submucosal dissection (ESD) in the duodenum is technically difficult because of the thinner duodenal wall and poor maneuverability of the endoscope resulting from the sharp angulation of the duodenum.1 Although well-differentiated nonfunctional duodenal neuroendocrine tumors (NETs) that are limited to the mucosa/submucosa, ≤10 mm, can be endoscopically removed, the optimal management of duodenal NETs 10 to 19 mm is still controversial. Published studies have reported the utility of ESD for removal of duodenal NETs measuring ≤10 mm in diameter.

Right posteroinferior bile duct angulation correlates with bile duct stone occurrence in patients with hepatolithiasis.

This study aimed to examine the correlation between right posteroinferior bile duct (RPBD) angulation and the occurrence of bile duct stones in patients with hepatolithiasis. Patients presenting with hepatolithiasis in our hospital from January 2011 to July 2016 were divided into two groups according to whether their RPBD was affected by stones. A statistical analysis for the relevant factors associated with bile duct stone formation in the RPBD was performed. The binary logistic regression results showed that stenosis of the right hepatic duct [odds ratio (OR): 7.313; 95% confidence interval (CI) 4.131-12.945)] and the angle of the RPBD (OR 0.896; 95%CI 0.877-0.916) were risk factors associated with the formation of RPBD stones. Further, the receiver operating characteristic curve indicated that, when the angle of the RPBD was less than 44.58°, stones were able to form more easily in the RPBD. The occurrence of bile duct stones is well correlated with sharp bile duct angulation.

Initial Experience of a Community Gastroenterology Practice with Ultraslim Colonoscopy

Colonoscopies are performed for cancer screening as well as for other diagnostic and therapeutic reasons. It is considered successful if cecal intubation is achieved and adequate mucosa is visualized. It is not always possible to achieve cecal intubation due to multiple reasons such as sharp angulation or fixed segments of the colon and stricture. A pediatric colonoscope (PDC) and an ultrathin colonoscope (UTC) are used as a tool to negotiate sharp angulation and the fixed segments of the colon because their small diameter allows easy movement. An ultrathin colonoscope is used at many practices as a rescue in situations where standard colonoscopes have failed. Our study highlights the use of an ultraslim scope in both rescue situations and as the initial colonoscope of choice in an ambulatory endoscopy center.

High-Drade Small Bowel Obstruction Caused by a Migrated Lumen-Apposing Metal Stent (LAMS)

Brief Introduction: Cautery-enhanced lumen-apposing metal Stent (LAMS) allow easy access and drainage of pancreatic fluid collections under endoscopic and endoscopic ultrasound (EUS) guidance. Here we describe a rare complication of a migrated LAMS causing high-grade small bowel obstruction. Case Description: An 88-year-old woman presented with severe worsening crampy abdominal pain and distension for 2 days. She also endorsed nausea and 1 episode of non-bloody bilious vomiting. Her past medical history was significant for a recent episode of acute gallstone pancreatitis complicated by a large (9 cm by 8 cm) perigastric pancreatic pseudocyst for which she underwent an EUS-guided cystgastrostomy with placement of a transgastric 15 mm x 10 mm LAMS 3 weeks ago. Physical exam was significant for distended abdomen which was tympanic on percussion and increased high-pitched bowel sounds. Computed tomography (CT) of the abdomen showed markedly distended stomach and multiple dilated small bowel loops with a transition point in the distal ileum where a migrated LAMS was noted causing high-grade small bowel obstruction (Figures 1 & 2). Patient was made NPO and a NG tube was placed for decompression. However, conservative management was unsuccessful with worsening abdominal pain, distension and repeat abdominal x-ray showing worsening bowel dilation and no change in stent position. Single balloon retrograde enteroscopy was attempted for retrieval of the migrated stent. However, it was unsuccessful due to due to significant colonic looping and sharp angulation of the terminal ileum. Patient underwent exploratory laparotomy with small bowel enterotomy and removal of LAMS (Figure. 3), with subsequent resolution of the bowel obstruction and uneventful post-operative course Discussion:Although LAMS migration has been reported in the past; migration occurs to the stomach, proximal duodenum, or off the gastrointestinal lumen into a pancreatic cavity or to the retroperitoneal space. Mahmood et al reported a case of stent migration down to the rectum, without any obstruction, and it was successfully retrieved via flexible sigmoidoscopy. Mechanical small bowel obstruction is rare and has been only been reported once by Razzak et al in which, like our case, resulted in surgical extraction of the stent although retrograde enteroscopy was not attempted.2143_A Figure 1 No Caption available.2143_B Figure 2 No Caption available.2143_C Figure 3 No Caption available.

Evaluation of risk factors for recurrent primary common bile duct stone in patients with cholecystectomy

Objectives: Recurrence of primary common bile duct (CBD) stone commonly occurs after complete removal of CBD stones in patients with cholecystectomy. This study aimed to investigate potential risk factors for the recurrence of primary CBD stones after endoscopic treatment.Materials and methods: Between January 2005 and December 2015, the endoscopic retrograde cholangiopancreatography (ERCP) database of our medical center was retrospectively reviewed; information regarding eligible patients who had recurrent CBD stones with a history of previous cholecystectomy was collected. The characteristics of the patients, CBD stone, CBD and ERCP-related factors were analyzed.Results: The recurrence rate of CBD stone was 18.5% (115/622) after endoscopic treatment in patients with cholecystectomy. In univariate analysis, the number of CBD stones (≥2), CBD stone diameter (≥10 mm), stone composition, stone consistency, CBD diameter (≥15 mm), bile duct dilatation pattern, sharp bile duct angulation (<145°), balloon dilatation, large balloon (>12 mm) dilatation, endoscopic mechanical lithotripsy, endoscopic sphincterotomy, and endoscopic papillary balloon dilatation alone method were significant between the non-recurrence and recurrence groups. However, in multivariate analysis (based on the binary logistic regression method), the number of CBD stones (≥2) (adjusted odds ratio [AOR] 3.232; 95% confidence interval [CI] 1.344–7.773; p = .009), cholesterol stone (AOR 2.824; 95% CI 1.175–6.786; p =.02) and sharp bile duct angulation (<145°) (AOR 2.462; 95% CI 1.062–5.711; p = .036) were independent risk factors of CBD stone recurrence after cholecystectomy.Conclusions: CBD stone number (≥2), cholesterol stone and sharp bile duct angulation (<145°) are associated with recurrent common bile duct stones after cholecystectomy.

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.