Sphincter Incompetence Research Articles

EndoFLIP Use in De Novo and Revisional Foregut Surgery

AbstractEndoFLIP technology, utilizing impedance planimetry, has revolutionized the assessment of gastrointestinal sphincters by providing real-time measurements of cross-sectional area and pressure to calculate distensibility. This review explores its application in de novo and revisional foregut surgeries. Preoperatively, EndoFLIP has demonstrated efficacy in evaluating gastroesophageal reflux disease, hiatal hernia, and esophageal motility disorders, including achalasia, by distinguishing motility patterns and identifying sphincter incompetence. In gastroparesis, EndoFLIP's measurement of pyloric distensibility correlates with gastric emptying and symptom severity, guiding therapeutic decisions for pyloric interventions. Intraoperatively, EndoFLIP optimizes surgical outcomes in antireflux procedures, such as fundoplication and hiatal hernia repairs, by balancing effective reflux control with minimizing postoperative complications like dysphagia and gas bloat. For esophageal myotomy, including Heller myotomy and per oral endoscopic myotomy, EndoFLIP ensures adequate sphincter relaxation, reducing reflux risks. Additionally, during endoscopic pyloromyotomy for gastroparesis, EndoFLIP predicts clinical success by assessing postprocedural distensibility. While promising, further research is essential to establish standardized intraoperative protocols and ideal measurement targets, enhancing the reproducibility and accuracy of EndoFLIP applications. Overall, EndoFLIP offers a significant advancement in foregut surgery, improving diagnostic precision and therapeutic outcomes.

GI Manifestation in Scleroderma

The gastrointestinal (GI) system frequently experiences complications in systemic sclerosis. Pathological changes in the GI system can be revealed from the early onset of the disease, such as esophageal hypomotility, to the late stage of the disease, where severe complications like intestinal pseudo-obstruction may occur. Systemic sclerosis can cause pathological changes throughout the entire gastrointestinal tract. Common symptoms include dysphagia, choking, heartburn, hoarseness, abdominal distension, diarrhea, constipation, and fecal incontinence. Oropharyngeal involvement in systemic sclerosis presents as weakened pharyngeal muscles, leading to oropharyngeal dysphagia, choking, food leakage, and aspiration, attributed to the dysfunction between the pharyngeal muscles and the upper esophageal sphincter due to muscle weakness. However, weak pharyngeal muscles may also be a clinical feature of the systemic sclerosis-polymyositis overlap syndrome. Esophageal involvement is frequently observed, with conditions such as esophageal hypomotility and lower esophageal sphincter incompetence, leading to early symptoms of dysphagia, gastroesophageal reflux, and potential complications such as esophagitis, esophageal stricture, Barrett’s esophagus, and aspiration pneumonia. Furthermore, gastric involvement includes gastric antral vascular ectasia, commonly known as “watermelon stomach,” which leads to gastrointestinal bleeding and chronic anemia. Intestinal manifestations comprise malabsorption, intestinal pseudo-obstruction, and bacterial overgrowth. Additionally, wide-mouthed diverticulosis and fecal incontinence are frequently found. Liver involvement includes primary biliary cirrhosis, most prevalent in limited cutaneous systemic sclerosis or certain overlap syndromes rather than diffuse cutaneous systemic sclerosis. The severity of these changes varies among patients, ranging from asymptomatic to severe conditions, which may result in malnutrition. Severe and chronic GI involvement significantly impacts daily life, making normal eating difficult, diminishing the quality of life, and potentially causing depression. Managing patients with systemic sclerosis who have GI involvement requires a multidisciplinary approach, involving collaboration among rheumatologists, gastroenterologists, nutritionists, surgeons, and possibly psychiatrists. This teamwork is essential to achieve successful patient care outcomes.

(403) Artificial Urinary Sphincter Implantation for Severe Post-Prostatectomy Incontinence in Setting of Salvage Radiotherapy and Prior Inflatable Penile Prosthesis

Abstract Introduction Artificial urinary sphincter (AUS) implantation is one of the most common treatment options for individuals with severe stress urinary incontinence (SUI), which is a common complication after radical prostatectomy (RP). The modern AUS consists of a urethral cuff, pump, and reservoir, which serves as a replacement for the native incompetent sphincter. There are various surgical approaches for AUS insertion, including transperineal, transscrotal, and abdominal approaches. Objective This video covers the surgical technique for the implantation of an AUS for management of SUI. Notably, this patient underwent RP followed by salvage radiotherapy (XRT) for biochemical recurrence of prostate cancer and had prior inflatable penile prosthesis (IPP) placement. Methods A standard step-by-step surgical technique for placement of an AUS through a perineal incision and additional counter incision to allow for high submuscular placement of the pressure-regulating balloon is demonstrated in this unique case of a patient with prior IPP placement and salvage XRT. Results We highlight a meticulous dissection around the urethra in a case that had a challenging urethral dissection secondary to prior radiotherapy and a prior IPP in the proximal corpora. The AUS pump was successfully placed in the subdartos pouch of the scrotum on the contralateral side to avoid the patient’s prior IPP pump. At the conclusion, a flexible cystourethroscopy showed adequate AUS cuff coaptation and cycling. Conclusions This video covers the step-by-step technique for insertion of an AUS with a transperineal approach in the unique context of a patient with prior IPP placement and XRT. Preoperative counseling, evaluation, and careful intraoperative dissection of key parts of the procedure are critical for successful placement of the AUS, especially in patients who are at high-risk for complications, such as in this case. Disclosure No

Idiopathic lumbar epidermoid: review of literature and case report

BackgroundSpinal epidermoid tumors are rare, comprising of less than 1% of tumors involving the spine. These tumors arise from pathological displacement of epidermal cells into the spinal canal. Therefore, these tumors can be congenital, when there is improper closure of the neural tube; or acquired, in patients who have had prior lumbar punctures, trauma, or surgery. Spinal epidermoids are typically found in the lumbosacral region but can be found in other locations as well.Case presentationWe report an original case of a 50 year old. He presented with 1 year with back pain and bilateral sciatica. The patient was neurological intact with no sphincter incompetence. The magnetic resonance image of the lumbosacral spine showed a 12 × 3 cm well-circumscribed intradural mass at the L3–S1 level. The patient was operated on with posterior lumbar laminectomy for tumor removal. Postoperation, the patient had improved pain and numbness. The motor power was intact as preoperative.ConclusionsMRI with DWI is especially useful to confirm the diagnosis with the lesions appearing hyperintense. The most conventional approach to resection involved laminectomies and intradural tumor resection. GTR provided better outcomes in most cases even when the tumor was adherent to the nearby spinal cord or nerve roots.

Impact of endoscopic laser cricopharyngeal myotomy on lower oesophageal sphincter physiology.

Dysphagia is a watershed symptom that localises poorly. Dividing causes of dysphagia into oropharyngeal and oesophageal does not always best serve the patient. We report the case of a patient whose diagnosis and treatment required three separate specialist referrals to two specialties, with 18 months passing between initial referral and definitive treatment. The predominant pathology was isolated upper oesophageal sphincter dysfunction that responded well to laser cricopharyngeal myotomy. Following surgery, patient symptoms resolved and lost weight was regained. High-resolution manometry showed that the upper sphincter resting pressure had fallen from 117±45 to 21±11mmHg, but the lower sphincter resting pressure had risen, albeit without symptoms, from 16±8 to 44±17mmHg (p<0.001 in both cases). Surgery on upper oesophageal sphincter in the presence of lower oesophageal sphincter incompetence is known to lead to intractable regurgitation and pneumonia, and this novel physiological observation further emphasises the need to holistically consider the patient and to systematically evaluate the entire swallowing system before undertaking invasive interventions.

Effect of early pelvic floor muscle exercises (Kegel's) after Robotic Prostatectomy in Prostate cancer patients.

Post-prostatectomy Urinary incontinence (PPUI) due to open or robotic surgery has a negative impact on patients' psycho-social well-being and leads to altered quality of life (Kielb and Dunn in J Urol 166:958-61, 2001). Sphincteric incompetence overall remains the primary cause of PPUI, and it is believed that direct damage and manipulation intraoperatively could be the probable causes [1] (Bayoud et al. in Int J Urol 22:283-7-10, 2015). Pelvic floor muscle (PFM) rehabilitation appears to be beneficial in hastening the return of continence (Kampen and Poppel in Lancet 355:98-102, 2000). Hence, there is a need to re-educate or strengthen the pelvic floor muscles. To study the return of continence, and time duration required for the pelvic floor muscles to regain strength and endurance, thereby, leading to urinary continence and its effect on the quality of life of patients who have undergone robotic prostatectomy. Pelvic floor muscle grading, a 24h pad test, and an International Prostate symptom scoring (IPSS) were the outcome measures used to assess the effect on incontinence status post-operatively. 69 patients were screened between a duration of 3years, i.e., 2017-2020. Four patients remained incontinent 3months post-surgery. On the contrary, 65 patients regained continence. There is a definitive effect of early Kegel's exercise, the patient gains good pelvic floor muscle strength, portraying a reduction in dribbling or leakage of urine. Also, there is an improvement in the quality of life after Robotic Prostatectomy in Prostate cancer patients after 6weeks of surgery. 94.20% of the patients have shown a have gained continence by 3months post-robotic prostatectomy following a regular exercise regime of Kegel's exercise.

Correlation of urodynamic studies and somatosensory evoked potential and their prognostic value in children with closed spinal dysraphism

Somatosensory evoked potential (SSEP) and urodynamic studies (UD) are valuable tools for assessing patients with closed spinal dysraphism (CSD) before neurosurgical intervention. No studies have correlated their findings in this cohort and our aim is to study their correlation and prognostic value in pediatric patients with closed spinal dysraphism. Retrospective review of all patients referred to a multidisciplinary clinic in a tertiary pediatric surgical center over a 17 years period between April 2004 to September 2021 was performed. Inclusion criteria were <18 years old, diagnosed with CSD, with SSEP and UD done within 1 year of each other. Demographics data collected include age at presentation/at referral/at neurosurgical operation, gender, symptoms at presentation and intra-operative diagnoses. Pre-operative SSEP and UD findings were documented. Primary outcome was UD results in the group with normal and abnormal SSEP. Secondary outcome was urological and bowel function outcome in 4 groups of patients (Group A-both normal SSEP and UD, Group B- abnormal SSEP only, Group C - abnormal UD only and Group D-both abnormal SSEP and UD). A total of 45 patients were included for analysis. Mean follow up time was 118.9 months (24-216 months, SD 55.8 months). SSEP was normal in 20 patients and abnormal in 25 patients. Baseline demographics, preoperative symptoms and imaging were similar between 2 groups. Primary outcome Patients with abnormal SSEP were more likely to have abnormal UD results with a statistically significant difference (84% vs 40%, p<0.05). They have a significantly higher end-fill detrusor pressure (12% vs 0%, p<0.05), abnormal bladder compliance (20% vs 0%, p<0.05), abnormal cystometric capacity (48% vs 10%, p<0.05), poor emptying efficiency (24% vs 5%, p<0.05) and sphincter incompetence (8% vs 0%, p<0.05). Secondary outcome When compared to Groups A to C, patients in group D were more likely to be on anti-cholinergic (33.3% vs 4.3%, p<0.05), required clean intermittent catheterization (42.9% vs 4.3%, p<0.05) and had intravesical botulinum injection (19% vs 0%, p<0.05). All the patients who had augmentation cystoplasty were in this group as well. Bowel function in terms of regular enema use was also statistically significantly higher in this group (33.4% p<0.05). Pre-operative SSEP and UD results correlate well in patients with closed spinal dysraphism. Patients with abnormal SSEP and UD preoperatively have higher risk of urological deterioration over time. Close monitoring in this group is warranted.

Arecae pericarpium extract induces porcine lower-esophageal-sphincter contraction via muscarinic receptors

BackgroundGastroesophageal reflux disease (GERD) is associated with lower esophageal sphincter (LES) incompetence. In some patients, GERD is refractory to acid reduction therapy which is the main treatment for GERD. So far, medications that can increase LES tone are few. Arecae pericarpium (A. pericarpium) is a medication in Traditional Chinese Medicine known to promote intestinal motility.MethodsWe investigated the effect of A. pericarpium extracts on porcine LES motility. In addition, we used tetrodotoxin (TTX) and atropine to study the underlying mechanism of A. pericarpium extracts-induced contractions of LES.ResultsThe results of this study showed that A. pericarpium extracts and their main active ingredient, arecoline, can induce the contractions of porcine LES sling and clasp muscles in a dose-response manner. TTX did not have an inhibitory effect on the contractions induced by A. pericarpium extracts and arecoline in LES. However, atropine significantly inhibited A. pericarpium extracts- and arecoline-induced contractions of LES.ConclusionA. pericarpium extracts can induce the contractions of porcine LES in a dose dependent manner, possibly through muscarinic receptors, and hence, may be worth developing as an alternative therapy for GERD.

GERD and Barrett’s esophagus as indications for revisional surgery after sleeve gastrectomy: experience of a bariatric center of excellence IFSO-EC and narrative review

ABSTRACT Introduction Laparoscopic sleeve gastrectomy is the most commonly performed bariatric procedure worldwide; due to its extensive impact and analysis, multiple procedure-related early and late complications have been described. Gastroesophageal reflux and Barrett’s esophagus are highly debated issues related to sleeve gastrectomy in long-term follow-up. This review aims to explore the association between sleeve gastrectomy and gastroesophageal reflux in terms of their occurrence, and to analyze the protective or affecting factors. Areas covered Gastroesophageal reflux and Barrett’s esophagus after laparoscopic sleeve gastrectomy. Expert opinion Gastroesophageal reflux is the Achilles’ heel of sleeve gastrectomy and is affected by multiple procedure-related functional or mechanical factors (intrathoracic migration, stenosis, lower esophageal sphincter incompetence). Its postoperative incidence is about 30% with significant variability among groups, especially in terms of preoperative workup (lack of routine upper gastro-intestinal endoscopy and symptom assessment). Strict patient selection and mandatory pre-operative endoscopy are the primary steps taken to prevent and reduce the incidence of post-operative severe gastroesophageal reflux. However, patients should also be informed of the possibility of the ‘de novo gastroesophageal reflux disease’ (incidence – 22–50%) and the need for surgical revision in selected cases (0.5–7%).

Urinary tract imaging in infants with spina bifida: a selective approach to a baseline DMSA

There is no general agreement among paediatric urologists on how infants with spina bifida (SB) should be investigated after birth. Recently the EUA/ESPU guidelines have been published recommending a baseline DMSA scan in the first year of life and a Voiding Cystourethrogram (VCUG) or Videourodynamic (VUD) between the second and third month of life. The aim of this study was to evaluate the outcome of renal investigations in the first year of life in infants with SB to verify if an early DMSA scan is indicated in the management of this group of patients. All renal imaging, Renal and Bladder Ultrasound (RBUS), VCUGs, VUDs and DMSA were reviewed by two independent assessors to evaluate outcome. Seventy patients with spina bifida (40 girls) were enrolled between June 2015 and February 2020. An early VUD detected vesico-ureteral reflux (VUR) in 8/49 (16%) of patients. An early VUD also gave additional information on detrusor under or over activity, bladder trabeculation, end filling detrusor pressure (EFDP) and sphincteric incompetence. DMSA scan detected renal scarring in 4/68 (6%) patients. Three of these 4 patients had significant history of febrile UTIs while the fourth patient had grade 2 left sided VUR. The initial assessment of a newborn with myelodysplasia includes a Renal and Bladder Ultrasound during birth hospitalization. This study confirms the recently published EUA/ESPU guidelines on the management of neurogenic bladder in children and adolescents, which recommend a VUD or VCUG & Cystomanometry with Electromyogram (CMG) (if VUD not available) in the first 6-12 weeks of life. A selective approach to DMSA scan only in infants with SB who either had a febrile UTI or vesico-ureteric reflux would not have missed any scarring or dysplasia and would have saved 58 unnecessary nuclear scans.

Advanced Approaches to Rubber Band Ligation in Treatment of Hemorrhoidal Disease in the Elderly and Senile Outpatients

Introduction. Currently, rubber band ligation of internal hemorrhoids is performed during surgical treatment of hemorrhoids in 26,8844,0 % of cases. However, this technique can lead to the need for repeated interventions. Moreover, at stage IV hemorrhoids a relapse occurs in almost 40% of cases.The aim of the study was to improve clinical outcomes of the senile and elderly outpatients with stage II-III internal hemorrhoids by optimizing a rubber band ligation technique and indications for its use.Materials and methods. The authors analyzed clinical outcomes of 60 senile and elderly outpatients with stage II-III internal hemorrhoids. Patients were divided into 2 study groups. Patients of the control group received standard treatment including ligation of hemorrhoidal nodes with latex ligatures using a KARL STORZ suction ligature instrument with an integrated vacuum pump at a pressure equal 0.8 atm. Patients of the case group were exposed to ligation of hemorrhoidal nodes with latex ligatures using a KARL STORZ suction ligature instrument with an integrated vacuum pump at a pressure equal to 0,60,7 atm. Ligation in the case group was performed on the following conditions: high and medium degree of compliance in patients, hemorrhoids size less than 1,5 cm, absence of anemia, no antiplatelet drug intake a possibility to discontinue an antiplatelet drug in case it is takenResults. The study results demonstrated that 60 % of patients of the case group required pain relief on Day 1 after the intervention, 13,3% of patients of the case group required pain relief on Day 3 after the intervention. The correspondence to these parameters in the control group was 66,6% and 16,6% of patients respectively. The first defecation in patients of the case group occurred in 1,73 0,48 days on average; in patients of the control group in 1,74 0,47 days. Acute swelling of the external hemorrhoids was reported in 13,3% of patients of the case group and in 16,7% patients of the control group. Thrombosed external hemorrhoids, rectal bleeding, acute urinary retention were reported in 6,7% of patients of the case group and in 10,0% of patients of the control group. Vaso-vagal syndrome and local wound complications were reported in 6,7% of patients of the case group and in 3,3% of patients of the control group. Stricture of the anal canal was noted in 3,3% of patients of the case group and in 3,3% of patients of the control group. Anal sphincter incompetence was not detected in patients of the case group, while it was reported in 3,3% of patients of the control group. The average time of temporary disability was 2,3 0,4 days in patients of the control group and 1,9 0,4 days in patients of the case group. In 6 months after ligation, 60,0% of patients of the control group and 63,3% of patients of the case group manifested good results; 30,0% and 33,3% manifested satisfactory results; and 10,0% and 3,3% manifested unsatisfactory results respectively. After rubber band ligation, the relapse rate of the disease was 13,3% in patients of the control group and 10,0% in patients of the case group.Conclusion. Rubber band ligation is well tolerated by the senile and elderly patients. To reduce pain, tenesmus, vaso-vagal conditions, and urinary retention, the negative pressure created in the device sleeve degressed, which resulted in an improvement of patients general state and decrease in the number of complications.

Is pre-operative urodynamic bladder function the true predictor of outcome of male sling for post prostatectomy incontinence?

PurposeTo investigate pre-operative urodynamic parameters in male sling patients to ascertain whether this might better predict surgical outcomes and facilitate patient selection.MethodsWe performed a retrospective, case notes and video-urodynamics, review of men who underwent AdVanceXP male sling in three London hospitals between 2012 and 2019. Urodynamics were performed in all centres, while retrograde leak point pressure (RLPP) was performed in one centre.ResultsSuccessful outcome was seen in 99/130 (76%) of men who required one pad or less per day. The dry rate was 51%. Pad usage was linked to worse surgical outcomes, mean 2.6 (range 1–6.5) for success vs 3.6 (range 1–10) although the ranges were wide (p = 0.002). 24 h pad weight also reached statistical significance (p = 0.05), with a mean of 181 g for success group versus 475 g for the non-successful group. The incidence of DO in the non-successful group was significantly higher than in successful group (55% versus 29%, p = 0.0009). Bladder capacity less than 250 ml was also associated with worse outcomes (p = 0.003). Reduced compliance was not correlated with outcomes (31% for success groups vs 45% for non-successful group, p = 0.15). Preoperative RLPP was performed in 60/130 patients but did not independently reach statistical significance (p = 0.25).ConclusionUrodynamic parameters related to bladder function—detrusor overactivity and reduced maximum cystometric capacity predict male sling outcomes and may help in patient selection for male sling (or sphincter) surgery; whereas urodynamic parameters of sphincter incompetency (RLPP) were not predictive. Further larger scale studies are required to confirm these findings.

MP04-18 IN VITRO BENCH TESTING OF A TELEMETRIC DEVICE USING BLUE TOOTH TECHNOLOGY : ADVANCING THE SCIENCE OF PRECISE URETHRAL COMPRESSION

INTRODUCTION AND OBJECTIVE:Sphincteric incompetence is a common problem in Urology. Precision Medical Devices (PMD) has developed a new telemetric compressive device. The Politano-Sayet-Sutherland ...

FIRST EXPERIENCE IN VIDEOURODYNAMIC STUDY AT CIPTO MANGUNKUSUMO HOSPITAL IN 2012-2014

Objective: Accuracy of diagnosis is a fundamental thing in terms of plan of treatment. Nowadays, symptoms from lower urinary tract can be diagnosed accurately with videourodynamic study (VUDS). Videourodynamic combines a fluoroscopic voiding cystourethrogram with multichannel urodynamics, allowing anatomic and functional assessment of the bladder and outlet. Material &amp; Methods: This research is a descriptive retrospective. Data was taken from the patients who underwent VUDS at Department of Urology Cipto Mangunkusumo Hospital from 2012 to 2014. Patient’s characteristics were gender, age, chief complaint, working diagnosis pre investigation, and diagnosis after VUDS was performed. Then, data was analyzed in a descriptive fashion and presented using tables and narative form. Results: There were 8 male patients (67%) and 4 female (33%) who underwent VUDS. Most of the patients were children (75%). Five patients (42%) complained about incontinence with or without other LUTS, only 1 patient (8%) had LUTS and disuria. Overall, working diagnosis pre investigation was neurogenic bladder with various causes. We found a variable diagnoses after VUDS. At filling phase, we found 7 patients (58%) with small bladder capacity, 5 patients (42%) with low bladder compliance then followed respectively by overflow incontinence (33%), detrusor overactivity (17%) and urethral sphincter incompetence (8%). At voiding phase, the most common abnormality detected were detrusor underactivity (42%), followed by infravesical obstruction (8%). VUR was found both at filling phase (42%) and voiding phase (33%). Conclusion: VUDS could be the first choice of modality for diagnosing dysfunction of lower and upper urinary tract especially in neurogenic cases.

Surgical Management of Neurogenic Sphincter Incompetence in Children.

We report on the results of a literature review regarding the indications and results of operations to increase bladder outlet resistance to achieve dryness in children with neurogenic sphincter incompetence (NSBD). The relative advantages and disadvantages of injection of bulking agents, periurethral slings, bladder neck reconfiguration, artificial sphincters, and bladder neck closure based on a literature review and our combined clinical experience are discussed. Based on this review and our experience, we propose that periurethral injection of bulking agents is not justified as a primary treatment. Likewise, operations that reconfigure the bladder neck are not very useful since most patients also require bladder augmentation and an abdominal catheterizable channel. Bladder neck slings with autologous tissues are effective, mostly in females bur in the majority of patients a bladder augmentation is necessary. There is a role also for implantation of artificial urinary sphincters but when done as an isolated procedure, close monitoring to detect possible detrusor changes is needed. Bladder neck closure is an effective measure when other methods have failed.

СОВРЕМЕННАЯ ДИАГНОСТИЧЕСКАЯ И ЛЕЧЕБНАЯ ТАКТИКА ПРИ ПИЩЕВОДЕ БАРРЕТТА

The article represents the first experience of endoscopic mucosal cap resection of Barrett’s epithelium in Belarus. The implementation of endoscopic treatment of intestinal metaplasia into clinical practice is suggested on the basis of a case report and literature data. The comparison has been drawn between the updated clinical guidelines on the diagnosis and management of Barrett’s esophagus of different gastroenterological societies. It should be noted however that this article covers the aspect of endoscopic surveillance and treatment of esophageal columnar epithelium only. It doesn’t focus on a combination therapy that should include drug therapy of gastroesophageal reflux disease (GERD) and surgery of the lower esophageal sphincter incompetence if need be.

PS01.065: MAGNETIC SPHINCTER AUGMENTATION AS AN EFFECTIVE ALTERNATIVE TO ROUX-EN-Y CONVERSION AFTER BILLROTH II GASTRECTOMY

Abstract Background Background and hypothesis Conversion into a 60 cm Roux-en-Y jejunal loop is the most common remedial procedure in patients with gastroesophageal reflux after Billroth II gastrectomy. While this allows diversion of bilio-pancreatic secretions, symptomatic acid reflux may persist in the presence of a mechanically incompetent lower esophageal sphincter. We hypothesized that magnetic sphincter augmentation (MSA) may relieve symptoms and control esophagitis by reducing both acid and biliary reflux. Methods Methods A 70 year-old male patient presented with intractable reflux symptoms and grade B esophagitis 46 years after partial gastrectomy and Billroth II reconstruction for perforated gastric ulcer. The patient underwent extensive diagnostic evaluation. There was a 3 cm hiatus hernia, grade B esophagitis, and hyperemia of the gastrojejunal anastomosis. Biopsies were negative for malignancy and Helicobacter Pylori. pH-impedance testing showed combined acid and non-acid reflux; esophageal peristalsis was normal on high-resolution manometry. After informed consent, the patient preferred the option of laparoscopic MSA versus open laparotomy and Roux-en-Y conversion. Pneumoperitoneum was established with a Hasson trocar. After adhesiolysis, a hiatus hernia with retroesophageal lipoma was identified. The gastroesophageal junction was completely reduced in the abdominal cavity and a posterior crural repair was performed. A tunnel was made between the esophageal wall and the posterior vagus nerve and a no. 16 MSA (Linx®) device was applied. Results Results The postoperative course was uneventful and the patient was discharged home on postoperative day one. At 1- and 6-month follow-up visit the patient was off-medication, tolerated a free diet, and did not complain of any reflux symptom. The mean GERD-HRQL score decreased from 26 to 2 compared to baseline. A barium swallow confirmed the complete reduction of the hiatal hernia and the absence of reflux in the Trendelenburg position. Esophagitis was completely healed. Conclusion Conclusions To the best of our knowledge, this is the first case of MSA implant for refractory gastroesophageal reflux disease after Billroth II gastrectomy. This simple laparoscopic procedure allowed correction of both acid and biliary reflux. Disclosure All authors have declared no conflicts of interest.

Long-term follow-up of bladder outlet procedures in children with neurogenic urinary incontinence

Achieving continence in children with neurogenic sphincteric incompetence is a challenge. Awareness of the long-term outcome in this young patient population is important. In the past 25 years, the study institution has built experience in bladder outlet procedures such as bladder neck sling and bladder neck reconstructions. The objective of this study was to evaluate the long-term outcome on continence and re-intervention rate of bladder outlet procedures in children with neurogenic urinary incontinence at the study institution. All children who underwent a bladder neck procedure between 1992 and 2017 at the study institution were retrospectively reviewed. Continence at the end of follow-up was the primary endpoint, defined as 'dry' when there was an interval of a minimum of 4h without urinary leakage. Non-parametric tests were used for statistical analysis. During this 25-year period, a total of 60 children underwent a bladder outlet procedure, either a bladder neck sling (n=43) or a bladder neck reconstruction (n=17). The median age at surgery was 11.6 years (interquartile range [IQR] 7.8-13.9). Concomitant surgery consisted of bladder augmentation in 80% and continent catheterizable urinary channel in 97% of children. Dry rate within 1 year was 38%. After a median follow-up of 10.4 years (IQR 6.5-15.5), 77% of all children were dry. Twenty-five children (42%) needed one or more re-interventions, including redo of the bladder outlet procedure, other type of outlet procedure, bulking agents, bladder augmentation, and bladder neck closure. This study confirms that achieving continence is a challenge. The inconsistent use of the definition of urinary continence creates confusion in the literature and makes comparison of outcome with other studies difficult. Openness of (long-term) results in achieving urinary continence is important and helpful for future patients. On the long term, the majority of children with neurogenic urinary incontinence were dry after a bladder outlet procedure, but a considerable number of patients had a re-intervention. The initial outcome on continence was slightly disappointing. Reporting long-term results is essential and helpful for patient counseling.

L’incontinence coïtale

Urinary incontinence may seriously impact quality of life, self-image and subsequently the sexual life. Beside this fact, urinary leakage can specifically occur during sexual intercourse, formally named coital incontinence, and thus lead to specific alteration of the sexual life. To analyse the prevalence, pathophysiological mechanisms and possible therapeutic options for coital urinary incontinence. Related terms to urinary incontinence and sexual dysfunction were search on PubMed database. Whereas at least a quarter of incontinent women have a coital incontinence, this symptom was rarely spontaneously reported. Some women had only coital incontinence (7.6 to 20% of cases). In men, urinary incontinence during sexual intercourse was mainly observed after prostatectomy in 20 to 64% of cases. Coital incontinence requires precise assessment. Indeed, it can occur whatever the phase of coitus: local stimulation (20-30%), excitement (13-18%), penetration (62.9-68%), movements back and forth, orgasm (27-37.1%). Cervico-urethral hypermobility, sphincter incompetence, urethral instability, detrusor overactivity could be the principal physiopathological mechanisms. In men, the main cause was a stress incontinence secondary to sphincter deficiency. Specific therapeutic strategies have proved their effectiveness. The rehabilitative approach (RR=0.25, CI [0.06-1.01]), medicinal (anticholinergic were effective in 59% of cases) or surgical therapeutic (slings with an efficiency of 87%) was proposed to patients. Coital incontinence is a common and troublesome symptom. Its precise assessment may suggest a specific mechanism and thus a specific treatment.

Minimal Risk of Biliary Tract Complications, Including Hepatic Abscess, After Transarterial Embolization for Hepatocellular Carcinoma Using Concentrated Antibiotics Mixed with Particles.

To assess the incidence of biliary complications, cholecystitis, and abscess formation in HCC patients following transarterial embolization (TAE) using particles mixed with concentrated antibiotics. Retrospective review of HCC patients treated with embolization over a 10-year period revealed 499 procedures in 257 patients. TAE was performed with particles mixed with concentrated antibiotics in addition to IV antibiotics. All follow-up imaging after treatment was retrospectively reviewed for the development of bilomas, biliary strictures, acute cholecystitis, and hepatic abscess. Clinical notes and laboratory tests were also reviewed. Mean follow-up duration was 18.2months. In total, there was one biliary complication consisting of biloma formation. This patient had subsegmental hepatic infarction identified on imaging 8days post-embolization in the setting of subsegmental portal vein thrombus, with subsequent biloma development. There were no cases of new biliary strictures in the embolized portion of the liver at any point after treatment. One patient developed acute gangrenous cholecystitis 10days post-procedure. No patients developed a hepatic abscess, although 10 patients had bilioenteric anastomoses or incompetent sphincters of Oddi. Biliary complications and cholecystitis occurred extremely rarely after TAE, at a markedly lower rate than historical data on TACE. Despite significant risk factors for abscess formation in 10 patients, TAE with particles mixed with concentrated antibiotics resulted in zero abscesses, in contrast to a very high rate after TACE in the literature.