And don't forget your anti in-stent stenosis pill! Commentary on 'Factors associated with in-stent stenosis after cerebral aneurysm embolization using a Pipeline embolization device' by Flores-Milan et al.

In their INR study, Flores-Milan et al. present a retrospective single-centre study that aimed to investigate and determine some of the factors associated with in-stent stenosis (ISS) after intracranial aneurysm (IA) embolization using a commercially available flow diverter stent (FD). The retrospective analyses included ruptured and unruptured intracranial aneurysms treated with standalone flow diverter stent implantation or initial coil obliteration with the FD device placed subsequently two weeks after initial treatment. The article's methodology was carefully tailored to demystify the unknown pathophysiological mechanism behind the entity of interest called in-stent stenosis. Study outcomes also included angiographic evaluation of aneurysm occlusion thrombotic and hemorrhagic events. The authors reported excellent technical and clinical results altogether. The achieved angiographic occlusion rates resonate with the current obliteration results reported in the literature. Mortality and morbidity are congruent with previously published results and were 5.3% and 1.1%, respectively.

Management of Isolated Anal Strictures in Crohn's Disease.

BACKGROUND: Anorectal stricturing is a particularly morbid manifestation of Crohn's disease resulting in a diminished quality of life related to pain, incontinence, and recurrent operative interventions. OBJECTIVE: To determine the role of medical therapy, endoscopic dilation, and surgical intervention for the treatment of isolated anorectal stricturing. DATA SOURCES: An organized search of MEDLINE, PubMed, EMBASE, Scopus, and the Cochrane Database of Collected Reviews was performed from January 1, 1990 through May 1, 2020. STUDY SELECTION: Full text papers which included management of isolated anorectal strictures in the setting of Crohn's disease. INTERVENTION(S): Medical and surgical management. MAIN OUTCOME MEASURES: Symptomatic relief, need for proctocolectomy. RESULTS: Our search identified a total of 553 papers; after exclusion based on title (n = 430) and abstract (n = 47), 76 underwent full text review with 65 relevant to the management of anorectal strictures. A summary of the retrospective reports suggests that medical therapy can help control luminal inflammation, but fibrosis may ultimately set in resulting in a need for endoscopic or surgical intervention. Surgical options are limited in the anal canal due to inflammation and ulceration and concomitant perianal fistulizing disease. While fecal diversion can provide symptomatic relief, successful restoration of intestinal continuity remains uncommon and most patients ultimately undergo a total proctocolectomy with end ileostomy. LIMITATIONS: Limited literature published, all retrospective in nature. CONCLUSIONS: Despite significant advances in medical and surgical therapy in Crohn's disease over the last decades, there is clearly an unmet need in the management of anorectal strictures in Crohn's disease.

Clinical and imaging evaluation of Congenital Midnasal Stenosis.

OBJECTIVES: To illustrate the clinical and radiological presentation of a rare etiology of nasal obstruction in neonates, midnasal stenosis (MNS), including a comparison of nasal dimensions with those of normal infants. METHODS: We retrospectively reviewed medical charts and computerized tomography (CT) imaging of neonates with nasal obstruction diagnosed as stenosis in the midnasal area in a tertiary pediatric medical center. MNS was defined clinically by inability to visualize the middle turbinate with an endoscope despite the absence of stenosis of the anterior aperture or any gross septal deviation. CT measurements of the midnasal width were taken by an experienced neuroradiologist. We compared widths between the bony inferior turbinate to the bony septum in the narrowest area of symptomatic patients, to widths in a control group of asymptomatic children. RESULTS: Nine neonates from birth to three months old presenting with nasal obstruction, severe stertor, and blocked nasal passage at the midnasal level in endoscopic examination, were diagnosed with MNS. 6/9 had CT scans. Four had isolated unilateral stenosis, two unilateral MNS and contralateral choanal atresia, and three bilateral MNS. All patients were managed conservatively, initially with nasal saline irrigation and local steroids and topical antibiotics; Median time to resolution of symptoms was 14 days. When comparing the dimensions at the midnasal narrowest area of the stenotic group with a control group of 139 healthy children, the median bony width was 1.7 mm vs. 3.2 mm, respectively (p < 0.00001). Average dimensions according to age groups until the age of 12 months are given. CONCLUSION: In neonates with nasal obstruction, when choanal atresia and pyriform aperture stenosis are excluded, stenosis of the midnasal area should be considered. Most of these neonates can be managed conservatively. LEVEL OF EVIDENCE: 4.

Non-vascular interventional radiology in the paediatric alimentary tract.

Paediatric interventional radiology is an evolving speciality which is able to offer numerous minimally invasive treatments for gastrointestinal tract pathologies. Here we describe interventions performed by paediatric interventional radiologists on the alimentary tract from the mouth to the rectum. The interventions include sclerotherapy, stricture management by dilation, stenting and adjunctive therapies such as Mitomycin C administration and enteral access for feeding, motility assessment and administration of enemas.

Analysis of the long-term efficacy of core decompression with synthetic calcium-sulfate bone grafting on non-traumatic osteonecrosis of the femoral head.

OBJECTIVE: to investigate the safety and long-term efficacy of core decompression with synthetic calcium-sulfate bone grafting on non-traumatic osteonecrosis of the femoral head. METHOD: a total of 76 patients with non-traumatic osteonecrosis of the femoral head were admitted to our hospital from February 2012 to November 2014 and included in the study. All the patients were treated by core decompression with synthetic calcium-sulfate bone grafting. After treatment, the patients were followed-up for 12 months. The operation time, intraoperative blood loss, and perioperative complications were also recorded intraoperatively to evaluate the clinical efficacy and safety. The preoperative and postoperative pain scores measured by visual analogy score (VAS) were also recorded and compared. RESULTS: all of the 76 patients were successfully operated and included in the study. The mean operation time was 34.6±14.2 min, and the intraoperative blood loss was 23.6±8.9 mL. The patients hip functions were assessed on the basis of the Harris hip score, 3 and 12 months after operation. The excellent rates 3 and 12 months after operation were significantly higher than those before operation (P<0.05). The imaging stabilities of the hip joints 3 and 12 months after operation were significantly higher than those before operation (P<0.05). The patient postoperative pain scores (VAS score) gradually decreased. The VAS scores 12 months after operation were significantly lower than those before operation (P<0.05). CONCLUSION: the long-term efficacy of core decompression with synthetic calcium-sulfate bone grafting on non-traumatic osteonecrosis of the femoral head is good and accompanied with significantly improved postoperative joint functions.

Endoscopic management of Crohn's strictures.

Symptomatic intestinal strictures develop in more than one third of patients with Crohn's disease (CD) within 10 years of disease onset. Strictures can be inflammatory, fibrotic or mixed and result in a significant decline in quality of life, frequently requiring surgery for palliation of symptoms. Patients under the age of 40 with perianal disease are more likely to suffer from disabling ileocolonic disease thus may have a greater risk for fibrostenotic strictures. Treatment options for fibrostenotic strictures are limited to endoscopic and surgical therapy. Endoscopic balloon dilatation (EBD) appears to be a safe, less invasive and effective alternative modality to replace or defer surgery. Serious complications are rare and occur in less than 3% of procedures. For non-complex strictures without adjacent fistulizaation or perforation that are less than 5 cm in length, EBD should be considered as first-line therapy. The aim of this review is to present the current literature on the endoscopic management of small bowel and colonic strictures in CD, which includes balloon dilatation, adjuvant techniques of intralesional injection of steroids and anti-tumor necrosis factor, and metal stent insertion. Short and long-term outcomes, complications and safety of EBD will be discussed.

Ischemic or toxic injury: A challenging diagnosis and treatment of drug-induced stenosis of the sigmoid colon.

A 48-year-old woman was admitted with 15-mo history of abdominal pain, diarrhea and hematochezia, and 5-mo history of defecation difficulty. She had been successively admitted to nine hospitals, with an initial diagnosis of inflammatory bowel disease with stenotic sigmoid colon. Findings from computed tomography virtual colonoscopy, radiography with meglumine diatrizoate, endoscopic balloon dilatation, metallic stent implantation and later overall colonoscopy, coupled with the newfound knowledge of compound Qingdai pill-taking, led to a subsequent diagnosis of ischemic or toxic bowel disease with sigmoid colon stenosis. The patient was successfully treated by laparoscopic sigmoid colectomy, and postoperative pathological examination revealed ischemic or toxic injury of the sigmoid colon, providing a final diagnosis of drug-induced sigmoid colon stenosis. This case highlights that adequate awareness of drug-induced colon stenosis has a decisive role in avoiding misdiagnosis and mistreatment. The diagnostic and therapeutic experiences learnt from this case suggest that endoscopic balloon expansion and colonic metallic stent implantation as bridge treatments were demonstrated as crucial for the differential diagnosis of benign colonic stenosis. Skillful surgical technique and appropriate perioperative management helped to ensure the safety of our patient in subsequent surgery after long-term use of glucocorticoids.

[Treatment of complications after laparoscopic intersphincteric resection for low rectal cancer].

OBJECTIVE: To summarize the perioperative and postoperative complications follow laparoscopic intersphincteric resection (LapISR) in the treatment of low rectal cancer and their management. METHODS: An observational study was conducted in 73 consecutive patients who underwent LapISR for low rectal cancer between June 2011 and February 2016 in our hospital. The clinicopathological parameters, perioperative and postoperative complications, and clinical outcomes were collected from a prospectively maintained database. Perioperative and postoperative complications were defined as any complication occurring within or more than 3 months after the primary operation, respectively. RESULTS: Forty-nine(67.1%) cases were male and 24(32.9%) were female with a median age of 61(25 to 79) years. The median distance from distal tumor margin to anal verge was 4.0(1.0 to 5.5) cm. The median operative time was 195 (120 to 360) min, median intra operative blood loss was 100 (20 to 300) ml, median number of harvested lymph nodes was 14(3 to 31) per case. All the patients underwent preventive terminal ileum loop stoma. No conversion or hospital mortality was presented. The R0 resection rate was 98.6% with totally negative distal resection margin. A total of 34 complication episodes were recorded in 21(28.8%) patients during perioperative period, and among which 20.6%(7/34) was grade III(-IIII( according to Dindo system. Anastomosis-associated morbidity (16.4%,12/73) was the most common after LapISR, including mucosa ischemia in 9 cases(12.3%), stricture in 7 cases (9.6%, 4 cases secondary to mucosa necrosis receiving anal dilation), grade A fistula in 3 cases (4.1%) receiving conservative treatment and necrosis in 1 case (1.4%) receiving permanent stoma. After a median follow up of 21(3 to 60) months, postoperative complications were recorded in 12 patients (16.4%) with 16 episodes, including anastomotic stenosis (8.2%), rectum segmental stricture (5.5%), ileus (2.7%), partial anastomotic dehiscence (1.4%), anastomotic fistula (1.4%), rectovaginal fistula (1.4%) and mucosal prolapse (1.4%). These patients received corresponding treatments, such as endoscopic transanal resection, anal dilation, enema, purgative, permanent stoma, etc. according to the lesions. Six patients (8.2%) required re-operation intervention due to postoperative complications. CONCLUSION: Anastomosis-associated morbidity is the most common after LapISR in the treatment of low rectal cancer in perioperative and postoperative periods, which must be strictly managed with suitable methods.

[Moxibustion at Geshu (BL 17) for diabetic limb arterial obliteration at early stage].

OBJECTIVE: To compare the efficacy differences between moxibustion at Geshu (BL 17) and oral administration of cilostazol on diabetic limb arterial obliteration (DLAO) at early stage as well as the impacts on hemorheology and arterial inner dimension of lower extremity. METHODS: Seventy patients of DLAO at early stage were randomly divided into an observation group and a control group, 35 cases in each one. The two groups were treated with regular treatment of blood glucose and blood lipid. The patients in the control group was treated with oral administration of cilostazol, 50 mg, twice a day; the patients in the observation group were treated with moxibustion at Geshu (BL 17), once a day. The consecution treatment of two weeks constituted one session, and totally 4 sessions were given. The total syndrome score, hemorheology index (including low and high shear viscosity of blood, plasma viscosity, hematocrit and erythrocyte aggregation index) and arterial inner dimension of lower extremity (including popliteal artery, posterior tibial artery and dorsalis pedis artery) were compared before and after treatment. RESULTS: Compared with those before treatment, the total syndrome score, hemorheology index and arterial inner dimension of lower extremity were significantly improved after treatment in the two groups (all P<0.05). The total syndrome score, hemorheology index in the observation group were superior to those in the control group (all P<0.05), but the improvement of arterial inner dimension of lower extremity was not significantly different between the two groups (P>0.05). After treatment, the total effective rate was 91.4% (32/35) in the observation group, which was significantly superior to 85.7% (30/35) in the control group (P<0.05). CONCLUSION: Moxibustion at Geshu (BL 17) is superior to oral administration of cilostazol for DLAO at early stage, which could effectively improve the clinical symptoms, blood flow and blood vessel and increase the blood flow of lower limb.

Ventilation catheter-assisted airway stenting under local anaesthesia for patients with airway stenosis: initial clinical experience.

PURPOSE: This report details our preliminary results of ventilation catheter-assisted airway stenting under local anaesthesia for airway stenosis. MATERIALS AND METHODS: Fifteen consecutive patients with airway stenosis underwent ventilation catheter-assisted airway stenting under local anaesthesia. A 4F angiographic catheter was used as the ventilation catheter. During the treatment, the distal tip of the ventilation catheter was placed across the stenosis into one of the main bronchi and the proximal tip of the catheter was linked to the oxygen tube for oxygen supplementation. Airway stenting was performed under ventilation support. Patients maintained autonomous respiration throughout the procedures. Data on technical success, clinical outcome and follow-up were collected and analysed. RESULTS: Ventilation catheter-assisted airway stenting under local anaesthesia was technically successful and well tolerated in all patients. Respiratory difficulty was improved in all patients after treatment. The average Hugh-Jones classification grade, arterial oxygen saturation value, and respiratory rate improved from 4.20 ± 0.68, 80.60 ± 3.83%, and 30.33 ± 2.02 times/min, respectively, before stenting to 1.47 ± 0.52 (P < 0.001), 94.93 ± 1.33% (P < 0.001), and 18.07 ± 1.33 times/min (P < 0.001), respectively, after stenting. After 2-11 months (average 5.73 ± 2.40 months) of follow-up, one patient experienced re-stenosis of the stent. The mean survival time of the 15 patients was 162.00 ± 71.60 days (range 55-320 days). CONCLUSIONS: Ventilation catheter-assisted airway stenting under local anaesthesia can be an effective, simple and safe method for airway stenosis.

Vaginal dilator therapy for women receiving pelvic radiotherapy.

BACKGROUND: Vaginal dilation therapy is advocated after pelvic radiotherapy to prevent stenosis (abnormal narrowing of the vagina), but can be uncomfortable and psychologically distressing. OBJECTIVES: To assess the benefits and harms of different types of vaginal dilation methods offered to women treated by pelvic radiotherapy for cancer. SEARCH METHODS: Searches included the Cochrane Central Register of Controlled Trials (CENTRAL 2013, Issue 5), MEDLINE (1950 to June week 2, 2013), EMBASE (1980 to 2013 week 24) and CINAHL (1982 to 2013). SELECTION CRITERIA: Comparative data of any type, which evaluated dilation or penetration of the vagina after pelvic radiotherapy treatment for cancer. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. We found no trials and therefore analysed no data. MAIN RESULTS: We identified no studies for inclusion in the original review or for this update. However, we felt that some studies that were excluded warranted discussion. These included one randomised trial (RCT), which showed no improvement in sexual scores associated with encouraging women to practise dilation therapy; a recent small RCT that did not show any advantage to dilation over vibration therapy during radiotherapy; two non-randomised comparative studies; and five correlation studies. One of these showed that objective measurements of vaginal elasticity and length were not linked to dilation during radiotherapy, but the study lacked power. One study showed that women who dilated tolerated a larger dilator, but the risk of objectivity and bias with historical controls was high. Another study showed that the vaginal measurements increased in length by a mean of 3 cm after dilation was introduced 6 to 10 weeks after radiotherapy, but there was no control group; another case series showed the opposite. Three recent studies showed less stenosis associated with prophylactic dilation after radiotherapy. One small case series suggested that dilation years after radiotherapy might restore the vagina to a functional length. AUTHORS' CONCLUSIONS: There is no reliable evidence to show that routine, regular vaginal dilation during radiotherapy treatment prevents stenosis or improves quality of life. Several observational studies have examined the effect of dilation therapy after radiotherapy. They suggest that frequent dilation practice is associated with lower rates of self reported stenosis. This could be because dilation is effective or because women with a healthy vagina are more likely to comply with dilation therapy instructions compared to women with strictures. We would normally suggest that a RCT is needed to distinguish between a casual and causative link, but pilot studies highlight many reasons why RCT methodology is challenging in this area.

Spa adjuvant therapy improves diabetic lower extremity arterial disease.

OBJECTIVE: To investigate the effect of spa adjuvant therapy on diabetic lower extremity arterial disease (LEAD). METHODS: 128 patients with type II diabetes were separated into three groups according to the degree of lower extremity vascular stenosis. Patients within each group were then randomly divided to receive no treatment (control) or spa adjuvant therapy (treatment). Clinical symptoms, blood pressure and hemodynamic analyses were compared between control and treatment groups by Chi square or t-test. RESULTS: After adjuvant therapy with spa, patients' pain, numbness, and cold sensation were significantly improved compared with control groups (P<0.05). Spa adjuvant therapy also significantly increased the dorsalis pedis pulse and systolic peak velocity ratio of patients with mild lower extremity vascular stenosis compared with control groups (P<0.05), while there were no significant differences between the two groups for patients with moderate and severe stenosis (P>0.05). Both in the spa and control groups, there were no significant differences before and after medication for fasting, 2-h postprandial blood glucose and glycosylated hemoglobin (HbA1C) analyses (P>0.05). CONCLUSIONS: Spa adjuvant therapy can significantly alleviate lower extremity pain, numbness, and cold sensory symptoms in diabetic LEAD patients with stenosis. Moreover, in LEAD patients with mild stenosis, spa adjuvant therapy also improves the dorsalis pedis pulse and systolic peak velocity ratio, suggesting a potential role for spa therapy as an early intervention strategy to treat the initial stages of disease.

Atherosclerotic intracranial arterial stenosis: risk factors, diagnosis, and treatment.

Intracranial atherosclerosis is one of the most common causes of stroke worldwide and is associated with a high risk of recurrent stroke. New therapeutic approaches to treat this high-risk disease include dual antiplatelet treatment, intensive management of risk factors, and endovascular therapy. Early data from randomised trials indicate that aggressive medical therapy is better than stenting for prevention of recurrent stroke in high-risk patients with atherosclerotic stenosis of a major intracranial artery. Nevertheless, there are subgroups of patients who remain at high risk of stroke despite aggressive medical therapy. Further research is needed to identify these high-risk subgroups and to develop more effective treatments. Non-invasive vascular imaging methods that could be used to identify high-risk patients include fractional flow on magnetic resonance angiography (MRA), quantitative MRA, and high-resolution MRI of the atherosclerotic plaque. Alternative therapies to consider for future clinical trials include angioplasty alone, indirect surgical bypass procedures, ischaemic preconditioning, and new anticoagulants (direct thrombin or Xa inhibitors).

Endoscopic therapy in inflammatory bowel diseases (with videos).

Endoscopic therapies are important modalities in the treatment of IBD, adjunct to medical and surgical approaches. These therapeutic techniques are particularly useful in the management of IBD-associated or IBD surgery­associated strictures, fistulas, and sinuses and colitis-associated neoplasia. Although the main focus of endoscopic therapies in IBD has been on balloon stricture dilation and ablation of adenoma-like lesions, new endoscopic approaches are emerging, including needle-knife stricturotomy, needle-knife sinusotomy, endoscopic stent placement, and fistula tract injection. Risk management of endoscopy-associated adverse events is also evolving. The application of endoscopic techniques in novel ways in the treatment of IBD is just beginning and will likely expand rapidly in the near future.

Antiplatelet and anticoagulant drugs for prevention of restenosis/reocclusion following peripheral endovascular treatment.

BACKGROUND: Peripheral arterial disease (PAD) is frequently treated by balloon angioplasty. Restenosis/reocclusion of the dilated segments occurs often, depending on length of occlusion, lower leg outflow, stage of disease and presence of cardiovascular risk factors. To prevent reocclusion, patients are treated with antithrombotic agents. This is an update of a review first published in 2005. OBJECTIVES: To determine whether any antithrombotic drug is more effective in preventing restenosis or reocclusion after peripheral endovascular treatment, compared to another antithrombotic drug, no treatment, placebo or other vasoactive drugs. SEARCH METHODS: For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched 14 February 2012) and CENTRAL (2012, Issue 1). SELECTION CRITERIA: We selected randomised controlled trials (RCTs). Participants were patients with symptomatic PAD treated by endovascular revascularisation of the pelvic or femoropopliteal arteries. Interventions were anticoagulant, antiplatelet or other vasoactive drug therapy compared with no treatment, placebo or any other vasoactive drug. Clinical endpoints were reocclusion, restenosis, amputation, death, myocardial infarction, stroke, major bleeding and other side effects, such as minor bleeding, puncture site bleeding, gastrointestinal side effects and haematoma. DATA COLLECTION AND ANALYSIS: We independently extracted and assessed details of the number of randomised patients, treatment, study design, patient characteristics and risk of bias. Analysis was based on intention-to-treat data. To examine the effects of outcomes such as reocclusion, restenosis, amputation and major bleeding, we computed odds ratios (OR) with 95% confidence intervals (CI) using a fixed-effect model. MAIN RESULTS: Twenty-two trials with a total of 3529 patients are included (14 in the original review and a further eight in this update). For the majority of comparisons, only one trial was available so results were rarely combined in meta-analyses. Individual trials were generally small and risk of bias was often unclear due to limitations in reporting. Three trials reported on drug versus placebo/control; results were consistently available for a maximum follow-up of only six months. At six months post intervention, a statistically significant reduction in reocclusion was found for high-dose acetylsalicylic acid (ASA) combined with dipyridamole (DIP) (OR 0.40, 95% CI 0.19 to 0.84), but not for low-dose ASA combined with DIP (OR 0.69, 95% CI 0.44 to 1.10; P = 0.12) nor in major amputations for lipo-ecraprost (OR 0.89, 95% CI 0.44 to 1.80). The remaining trials compared different drugs; results were more consistently available for a longer period of 12 months. At 12 months post intervention, no statistically significant difference in reocclusion/restenosis was detected for any of the following comparisons: high-dose ASA versus low-dose ASA (OR 0.98, 95% CI 0.64 to 1.48; P = 0.91), ASA/DIP versus vitamin K antagonists (VKA) (OR 0.65, 95% CI 0.40 to 1.06; P = 0.08), clopidogrel and aspirin versus low molecular weight heparin (LMWH) plus warfarin (OR 0.31, 95% CI 0.06 to 1.68; P = 0.18), suloctidil versus VKA: reocclusion (OR 0.59, 95% CI 0.20 to 1.76; P = 0.34), restenosis (OR 1.87, 95% CI 0.66 to 5.31; P = 0.24) and ticlopidine versus VKA (OR 0.71, 95% CI 0.37 to 1.36; P = 0.30). Treatment with cilostazol resulted in statistically significantly fewer reocclusions than ticlopidine (OR 0.32, 95% CI 0.13 to 0.76; P = 0.01). Compared with aspirin alone, LMWH plus aspirin significantly decreased occlusion/restenosis (by up to 85%) in patients with critical limb ischaemia (OR 0.15, 95% CI 0.06 to 0.42; P = 0.0003) but not in patients with intermittent claudication (OR 1.73, 95% CI 0.97 to 3.08; P = 0.06) and batroxobin plus aspirin reduced restenosis in diabetic patients (OR 0.28, 95% CI 0.13 to 0.60). Data on bleeding and other potential gastrointestinal side effects were not consistently reported, although there was some evidence that high-dose ASA increased gastrointestinal side effects compared with low-dose ASA, that clopidogrel and aspirin resulted in fewer major bleeding episodes compared with LMWH plus warfarin, and that abciximab resulted in more severe bleeding episodes. AUTHORS' CONCLUSIONS: There is limited evidence suggesting that restenosis/reocclusion at six months following peripheral endovascular treatment is reduced by use of antiplatelet drugs compared with placebo/control, but associated information on bleeding and gastrointestinal side effects is lacking. There is also some evidence of variation in effect according to different drugs with cilostazol reducing reocclusion/restenosis at 12 months compared with ticlopidine and both LMWH and batroxobin combined with aspirin appearing beneficial compared with aspirin alone. However, available trials are generally small and of variable quality and side effects of drugs are not consistently addressed. Further good quality, large-scale RCTs, stratified by severity of disease, are required.

Tumescent anesthesia reduces pain associated with balloon angioplasty of hemodialysis fistulas.

We describe the use of tumescent local anesthesia during endovascular treatment of arteriovenous fistula stenosis. Using ultrasound guidance, 11 patients were hand-injected with tumescent lidocaine anesthesia around the fistula stenosis prior to endovascular therapy. All patients rated the pain experienced during angioplasty on a numeric scale (0-10). The mean balloon inflation pressure was 12 ± 3.01 atm. During angioplasty, eight patients reported pain between 0 and 2; three patients reported 4, 5, and 7 out of 10 on the pain scale. In this small series, tumescent anesthesia provided adequate pain control to perform angioplasty of arteriovenous fistulas.

Urogenital manifestations in Wegener granulomatosis: a study of 11 cases and review of the literature.

We describe the main characteristics and treatment of urogenital manifestations in patients with Wegener granulomatosis (WG). We conducted a retrospective review of the charts of 11 patients with WG. All patients were men, and their median age at WG diagnosis was 53 years (range, 21-70 yr). Urogenital involvement was present at onset of WG in 9 cases (81%), it was the first clinical evidence of WG in 2 cases (18%), and was a symptom of WG relapse in 6 cases (54%). Symptomatic urogenital involvement included prostatitis (n = 4) (with suspicion of an abscess in 1 case), orchitis (n = 4), epididymitis (n = 1), a renal pseudotumor (n = 2), ureteral stenosis (n = 1), and penile ulceration (n = 1). Urogenital symptoms rapidly resolved after therapy with glucocorticoids and immunosuppressive agents. Several patients underwent a surgical procedure, either at the time of diagnosis (n = 3) (consisting of an open nephrectomy and radical prostatectomy for suspicion of carcinoma, suprapubic cystostomy for acute urinary retention), or during follow-up (n = 3) (consisting of ureteral double J stents for ureteral stenosis, and prostate transurethral resection because of dysuria). After a mean follow-up of 56 months, urogenital relapse occurred in 4 patients (36%). Urogenital involvement can be the first clinical evidence of WG. Some presentations, such as a renal or prostate mass that mimics cancer or an abscess, should be assessed to avoid unnecessary radical surgery. Urogenital symptoms can be promptly resolved with glucocorticoids and immunosuppressive agents. However, surgical procedures, such as prostatic transurethral resection, may be mandatory in patients with persistent symptoms.

Botanical drugs and stem cells.

The potential to generate virtually any differentiated cell type from stem cells offers the possibility of creating new sources of cells for regenerative medicine. To realize this potential, it will be essential to control stem cell differentiation. Chinese herbal medicine is a major aspect of traditional Chinese medicine and is a rich source of unique chemicals. As such, individual herbs or extracts may play a role in the proliferation and differentiation of stem cells. In this review, we discuss some of the Chinese herbal medicines that are used to treat human diseases such as neuronal degenerative diseases, cardiovascular diseases, and osteoporosis. We also describe the relationship between Chinese herbal medicines and stem cell regulation.

Dual interventional approach of endoscopic reboring in completely stenosed rectal anastomosis using radiology guidance: a novel technique.

OBJECTIVE: Rectal stricture/stenosis is a well-recognized complication following anterior resection. Completely stenosed rectal anastomoses have been conventionally treated conservatively with permanent stoma. The surgical alternatives are either a redo low resection with its accompanying hazards or formation of a permanent colostomy. We describe a simple method of treating anastomotic stenoses using a novel technique in patients with a defunctioned bowel. METHOD: Three patients with complete stenosis of a rectal anastomosis following anterior resection underwent this novel technique with informed consent. A stenosis with no identifiable lumen was diagnosed at the time of examination under anaesthetic (EUA) or by contrast enema. Using a novel technique of combined endoscopic and radiology guidance, the anastomotic stenosis was rebored and subsequently dilated to restore bowel continuity. RESULTS: There were no complications observed following this procedure. Two of the three patients needed repeat endoscopic dilatation. All patients had restoration of the lumen in the anastomosis and subsequently underwent closure of ileostomy and made an uneventful recovery. CONCLUSION: Combined endoscopic dilatation under radiological guidance is a novel technique and appears to be a simple, safe, effective and inexpensive method for treating rectal anastomotic stenoses.

Use of customized MIC-KEY gastrostomy button for management of MACE stomal complications.

OBJECTIVES: Severe bowel dysfunction often accompanies neurogenic bladder, and Malone antegrade continence enema procedures can lead to improvement in the quality of life for these patients. The most commonly reported complication has been stomal stenosis of the conduit. We report our experience with the use of the MIC-KEY gastrostomy button for the management of this complication. METHODS: A retrospective cohort study of 53 consecutive children who had undergone the Malone antegrade continence enema (ACE) procedure from 2000 to 2006 was performed. The records of patients with stomal complications were assessed for presentation, management, and outcomes. RESULTS: We identified 20 patients (38%) with stomal stenosis. Stomal dilation and stenting alone was successful in 4 patients, and stomal revision was necessary in 16 (30%). Six children required placement of the MIC-KEY gastrostomy button into the ACE stoma for recurrent stomal stenosis (n = 5) or a buried stoma (n = 1). All patients were successfully treated with placement of a MIC-KEY button to continue their bowel irrigation. The size of the button was determined by the endoscopic assessment of the length and width of the ACE stoma and was custom made by the manufacturer. The average time that the button was in place was 26 months, and it was generally changed every 3 months. CONCLUSIONS: In the rare subset of patients with recurrent stomal stenosis or a buried stoma, the MIC-KEY gastrostomy button was found to be a practical and easy method for the management of these conditions and to preserve the ACE conduit.