Unilateral drainage and chemotherapy prolong the patency of a plastic stent placed above the sphincter of Oddi in patients with malignant hilar biliary obstruction.

Objectives: To evaluate the results of inside stent therapy for unresectable malignant hilar biliary obstruction and identify factors related to stent patency duration. Methods: Of 44 patients who underwent initial inside-stent placement above the sphincter of Oddi from April 2017 to December 2022, 42 with the resolution of jaundice (clinical success rate, 95.5%) were retrospectively analyzed. Univariate and multivariate logistic regression analysis identified factors associated with stent patency duration. Results: Univariate analysis revealed significant differences in the drainage method (406 days for unilateral drainage vs. 305 days for bilateral drainage of the right and left liver lobes, p = 0.022) with or without chemotherapy (406 days with vs. 154 days without, p = 0.038). Multivariate analysis (Cox proportional hazards analysis) revealed similar results, with unilateral drainage (p = 0.031) and chemotherapy (p = 0.048) identified as independent factors associated with prolonged stent patency. Early adverse events were observed in two patients (4.8%; one cholangitis, one pancreatitis). Conclusions: Inside-stent therapy was safely performed in patients with malignant hilar biliary obstruction. Simple unilateral drainage and chemotherapy may prolong stent patency.

Effectiveness of direct needle puncture for complete hepaticojejunostomy anastomotic stricture after pancreaticoduodenectomy (with video).

A 79-year-old Japanese woman, who had undergone pancreaticoduodenectomy 6 months prior to presentation owing to pancreatic cancer, complained of jaundice with high fever. Computed tomography revealed proximal bile duct dilatation with complete hepaticojejunostomy anastomotic stricture (HJAS). We performed a single-balloon endoscopy for biliary drainage. The presence of a scar-like feature surrounding the anastomosis was identified as the HJAS. White-light imaging during single-balloon endoscopy revealed that the HJAS contained a milky whitish area (MWA), suggesting that a membranous and fibrosis layer affected continuous inflammation around the center of the anastomosis (within a scar-like feature). Endoscopic dilatation was performed using an endoscopic injection needle, with the MWA used as an indicator. A 23-gauge endoscopic injection needle was used to penetrate the center of the blind lumen within the MWA, and a pinhole was created in the stricture. After confirming the position of the proximal bile duct using a contrast medium with the needle, an endoscopic guidewire with a cannula was inserted into the pinhole. A through-the-scope sequential balloon dilator was used to dilate the stricture, and a plastic stent was inserted into the proximal bile duct. This endoscopic intervention led to positive outcomes. In cases of complete HJAS occlusion, an endoscopic approach to the bile duct is difficult because the anastomotic opening of the HJAS is not visible. Thus, puncturing within the MWA, which can be used as a scar-like landmark within a complete membranous HJAS, is considered a useful endoscopic strategy.

Analysis of Different Lymphedema Assessment Tools in Women with Breast Cancer After Mastectomy.

Background: Lymphedema is a common complication after mastectomy in women with breast cancer. Several methods have been described to assess and diagnose lymphedema, one of the most studied being the perimeter and ultrasonography. However, the reliability of these methods and the correlation between them are still controversial. The aim of this study was to analyze the reliability of cytometry and ultrasound imaging in the assessment of lymphedema after mastectomy in women with breast cancer and to study the correlation between them. Methods and Results: A cross-sectional study was conducted in 29 women with mastectomy after breast cancer. Lymphedema in the arm was measured both with cytometry and ultrasonography. Reliability was calculated with intraclass correlation coefficient. The correlation between the two methods was carried out with the Pearson correlation coefficient. Both cytometry (M1: α = 0.999, ICC = 0.996; M2=: α = 0.998, ICC = 0.994) and ultrasonography (M1: α = 0.992, ICC = 0.976; M2=: α = 0.991, ICC = 0.973) are reliable methods to assess lymphedema in the arm. No significant correlation was found between them (p > 0.05). Conclusions: Cytometry and ultrasonography appear to be adequate for the measurement of edema in women with breast cancer after mastectomy. However, for an accurate measurement of lymphedema, these measurements should not be used interchangeably.

Sustainable flood control strategies under extreme rainfall: Allocation of flood drainage rights in the middle and lower reaches of the yellow river based on a new decision-making framework.

Climate change has exacerbated the frequency and magnitude of extreme rainfall, which has led to the perpetuation of flooding as a hazard to humans and society. China has begun to consider introducing Flood drainage rights (FDR), a sustainable flood control measure, into non-engineering measures as a complement to engineering measures for flood control. FDR represent the right of regions to discharge regional floodwaters caused by extreme rainfall into the river, and are the primary means of controlling the amount of floodwaters from regions when regional flood capacity is exceeded. However, existing studies on quantitative FDR allocation still have limitations, and some previous methods have resulted in allocation schemes that are not entirely reasonable and fair because they do not comprehensively consider the influencing factors of FDR or the allocation method is unreasonable. This paper explores the impact of flooding on rural and agricultural areas. We incorporate the factors of agricultural economy and security and construct a system of the allocation indicators of FDR composed of five principles: Natural Environmental Endowment, General Economic and Social Development, Agricultural Economy and Security, Macro policy regulation, and Respect for Historical Background. Second, considering the influence of expert judgment and data of different time nodes on the allocation of FDR, we introduce the concepts of expert weight and time weight into the allocation model of FDR, and construct a new set of framework for the allocation of FDR, i.e., "[(expert weight + subjective weight)+(time weight + objective weight)]+decision making model ". To reduce the loss of information during the transformation of subjective judgments, we also introduced triangular fuzzy numbers for the transformation between expert judgments and numbers. Finally, we take the five provinces in the middle and lower reaches of the Yellow River as an example. Using the data from 2010 to 2021, we obtain the final allocation scheme (proportion) of FDR as Henan (33.26%) > Shaanxi (23.08%) > Inner Mongolia (21.31%) > Shanxi (14.44%) > Shandong (7.91%). On this basis, this paper utilizes sensitivity analysis and comparative validation to demonstrate the rationality and effectiveness of the method, and identifies several indicators that have a greater impact on the results of the allocation of FDR. FDR can form part of a set of integrated flood management system together with flood control projects, which greatly alleviates the drainage conflicts arising from flooding caused by extreme precipitation. Under extreme rainfall conditions, FDR improves drainage efficiency and minimizes the overall damage caused by flooding in the watershed. This study can contribute to the sustainable development of the watershed and provide a reference for the promotion and utilization of sustainable flood control measures.

ARE DRAIN ESSENTIALS IN KIDNEY TRANSPLANTATION? ANALYSIS OF RISK FACTORS AFFECTING THE POSTOPERATIVE DRAINAGE.

OBJECTIVE: The routine drain placement following renal transplantation is currently under debate. Its benefit is uncertain and may cause complications, particularly infectious ones. Some renal transplant patients have low-productive drains, that might be unnecessary. The objective of this study is to bring to light factors influencing drain volume in kidney transplantation. MATERIALS AND METHODS: All kidney transplant patients in Tours between 2019 and 2020 were included. The characteristics of the two groups were analyzed: patients with low-productive redons (quantification less than 100 mL/24h,) and patients with productive redons (≥100 mL/24h). Univariate and multivariate analyses by logistic regression were performed to look for risk factors associated with productive drainage. RESULTS: One hundred and eighty-nine patients were included (67 in the low-productive group and 122 in the productive group). The results in the productive group showed a significantly higher proportion of retransplantation (p=0.015), overweight (p=0.012), low residual diuresis (p=0.041), and a significantly lower proportion of preemptive transplantation (p=0.008) and peritoneal dialysis (p=0,037). After an adjustment, the following variables remained significantly associated with greater drainage: overweight (OR= 2.42. p = 0.014 ; CI95% [1.2-4.94]) ; retransplantation (OR = 3.98. p = 0.027 ; IC95% [1.27-15.45]), and preemptive transplant (OR= 0.22. p = 0.013 ; CI95% [0.06-0.7]). CONCLUSION: The non-implementation of a redon in renal transplantation could be considered, in a selected population of non-overweight patients, with significant residual diuresis for a first transplantation which should be preemptive. This could lead to a randomized controlled trial to determine the real benefits of a routine drain replacement in kidney transplantation.

ESR Essentials: image guided drainage of fluid collections-practice recommendations by the Cardiovascular and Interventional Radiological Society of Europe.

This ESR Essentials article intends to provide detailed, step-by-step, information on the role of imaging in the diagnosis, procedural management, and follow-up of patients with fluid collections. Evidence-based medicine recommendations for the positioning of percutaneous drainages and/or for diagnostic/therapeutic aspiration of fluid collections are provided. Although medical history, clinical symptoms, physical examination, and laboratory tests can raise suspicions regarding a collection, an imaging assessment is usually necessary for the diagnosis. Radiologists can easily identify fluid collections that are clinically suspected by using a wide range of imaging modalities, such as ultrasound, CT, MRI, and cone-beam CT. Consequently, these imaging methods (either alone or combined), can be used to aspirate the collection or for the placement of a drainage catheter. The choice of imaging technique to be used is influenced by the location of the collection, operator preference, size, and content of the collection. In addition, it is of utmost importance to underline the role of the interventional radiologist in the management and follow-up of patients with percutaneous drains, in collaboration with surgeons, clinicians, and diagnostic radiologists. KEY POINTS: Indications for percutaneous imaging-guided drainage are supported by clinical findings, laboratory tests, and pre-procedural imaging. Deciding between aspiration or drain insertion should follow patient assessment and fluid collection characterization. The interventional radiologist should be part of the entire patient care process including follow-up.

Revolutionizing palliative care: Electrocautery-enhanced lumen-apposing metal stents in endoscopic-ultrasound-guided biliary drainage for malignant obstructions.

Patients with malignant biliary obstruction, following endoscopic retrograde cholangiopancreatography (ERCP) failure could be referred for endoscopic-ultrasound-guided biliary drainage through electrocautery-enhanced (ECE) lumen-apposing metal stent (LAMS) placement. However, the efficacy and safety of ECE-LAMS in this scenario have remained debatable due to minimal scientific evidence. The current confirmed 91.0% clinical success, 96.7% technical success, 7.3% reintervention rate, and 17.5% adverse events, following the treatment of malignant biliary obstruction with ECE-LAMS delivery. Finally, ECE-LAMS proved to be a generalizable strategy for managing biliary obstruction for patients who were excluded from ERCP.

Unveiling the potential of electrocautery-enhanced lumen-apposing metal stents in endoscopic ultrasound-guided biliary drainage.

This editorial delves into Peng et al's article, published in the World Journal of Gastrointestinal Surgery. Peng et al's meta-analysis investigates the effectiveness of electrocautery-enhanced lumen-apposing metal stents (ECE-LAMS) in ultrasound-guided biliary drainage for alleviating malignant biliary obstruction. Examining 14 studies encompassing 620 participants, the research underscores a robust technical success rate of 96.7%, highlighting the efficacy of ECE-LAMS, particularly in challenging cases which have failed endoscopic retrograde cholangio pancreatography. A clinical success rate of 91.0% underscores its impact on symptom alleviation, while a reasonably tolerable adverse event rate of 17.5% is observed. However, the 7.3% re-intervention rate stresses the need for post-procedural monitoring. Subgroup analyses validate consistent outcomes, bolstering the applicability of ECE-LAMS. These findings advocate for the adoption of ECE-LAMS as an appropriate approach for biliary palliation, urging further exploration in real-world clinical contexts. They offer valuable insights for optimizing interventions targeting malignant biliary obstruction management.

Case Report: The effect of automated manual lymphatic drainage therapy on lymphatic contractility in 4 distinct cases.

Introduction: Automated manual lymphatic drainage therapy (AMLDT) is available for home use in the form of a pneumatic mat of 16 pressurized air channels that inflate and deflate to mimic the stretch and release action of manual lymphatic drainage therapy. Four cases (a patient with complex regional pain syndrome and lymphedema, a healthy patient, a breast cancer survivor with chronic pain, and a patient with a history of abdominal surgery) underwent near-infrared fluorescence lymphatic imaging (NIRFLI) with AMLDT to evaluate the effect of AMLDT on lymphatic pumping and pain. Methods: Each patient received 32-36 injections of 25 µg indocyanine green (ICG) on the anterior and posterior sides of their body and underwent 1 h of NIRFLI to assess the drainage of ICG laden lymph toward regional nodal basins at baseline. Each patient lay supine on the mat for 1 h of AMLDT with NIRFLI to assess lymphatic flow during treatment. A final NIFRFLI assessment was done 30-60 min posttreatment with the patient in the supine and prone position. Patients reported baseline and posttreatment pain using the Visual Analogue Scale. An imager analyzed NIRFLI images using ImageJ (US National Institutes of Health). Using time stamps of the first and last images to determine time lapsed and the number of pulses observed in a timeframe, pulsing frequency (pulses/min) was obtained to assess lymphatic function. Results: All 4 cases completed the NIRFLI and AMLDT without complications; all 3 patients with baseline pain reported reduced pain posttreatment. AMLDT appeared to alter lymphatic contractility, with both increased and decreased pulsing frequencies observed, including in nonaffected limbs. Pulsing frequencies were very heterogeneous among patients and varied within anatomic regions of the same patient. Discussion: This proof-of-concept study suggests that AMLDT may impact lymphatic contractility. Further research on its effect on lymphatic function is warranted.

Ruptured giant omphalocele with congenital short small intestine: a case report.

We herein present a case of a ruptured giant omphalocele with congenital short small intestine. Vacuum-sealing drainage and carboxymethylcellulose silver dressing promoted wound healing after repair, avoided abdominal compartment syndrome, and reduced the risks of multiple procedures. We review the perioperative management of omphaloceles in congenital short small intestines.

Graph neural network-based surrogate modelling for real-time hydraulic prediction of urban drainage networks.

Physics-based models are computationally time-consuming and infeasible for real-time scenarios of urban drainage networks, and a surrogate model is needed to accelerate the online predictive modelling. Fully-connected neural networks (NNs) are potential surrogate models, but may suffer from low interpretability and efficiency in fitting complex targets. Owing to the state-of-the-art modelling power of graph neural networks (GNNs) and their match with urban drainage networks in the graph structure, this work proposes a GNN-based surrogate of the flow routing model for the hydraulic prediction problem of drainage networks, which regards recent hydraulic states as initial conditions, and future runoff and control policy as boundary conditions. To incorporate hydraulic constraints and physical relationships into drainage modelling, physics-guided mechanisms are designed on top of the surrogate model to restrict the prediction variables with flow balance and flooding occurrence constraints. According to case results in a stormwater network, the GNN-based model is more cost-effective with better hydraulic prediction accuracy than the NN-based model after equal training epochs, and the designed mechanisms further limit prediction errors with interpretable domain knowledge. As the model structure adheres to the flow routing mechanisms and hydraulic constraints in urban drainage networks, it provides an interpretable and effective solution for data-driven surrogate modelling. Simultaneously, the surrogate model accelerates the predictive modelling of urban drainage networks for real-time use compared with the physics-based model.

Remediation of AMD based on hydrogeochemical zonation: A typical metal mine in China.

Mining activities disrupt the natural oxidative balance underground, increasing the oxidation of metal sulfides like pyrite. This process leads to the formation of highly acidic mine drainage (AMD) with elevated concentrations of iron (Fe) and sulfate (SO42-). However, generic plugging and backfilling methods, when applied without considering the specific post-mining oxidative environments of different metal mines, often yields minimal results. To clarify the distribution of the underground redox environment after mining of a metal mine in Dexing, China, fifteen water samples from flood and dry periods, as well as fifteen borehole samples, were collected for hydrogeological and chemical analysis. For the first time, the study proposed that the redox zone could be identified and delineated through vertical analysis of water storage media, mineral composition, and hydrochemical characteristics. A hydrogeochemical cause model was constructed, revealing that AMD formation primarily occurs in oxidative and transition zones. Based on the redox zone characteristics of the study area, actual engineering sealing was performed on the oxidation and transition zones of cavity No. 23. As a result, the pH increased from 2.5 before remediation to 4.5, indicating a reduction in acidity. The concentrations of SO42- and Fe significantly decreased, reducing from 1360.0 mg/L and 147.0 mg/L before treatment to 726.0 mg/L and 23.6 mg/L after treatment; the total decrease amounting to 46.6 % and 84.0 %, respectively. The concentrations of Mn and Cu similarly, decreased by 10.7 % and 15.6 %, respectively. This study provides a novel approach and valuable reference for the refined identification and classification of redox zones after metal mine exploitation, as well as for the targeted plugging and treatment of cavities that produce AMD.

Comparison of antimicrobial therapy termination in febrile and afebrile patients with acute cholangitis after drainage.

The standard treatment duration for acute cholangitis (AC) involves a 4-7-day antimicrobial treatment post-biliary drainage; however, recent studies have suggested that a ≤ 2-3 days is sufficient. However, clinical practice frequently depends on body temperature as a criterion for discontinuing antimicrobial treatment. Therefore, in this study, we assessed whether patients with AC can achieve successful outcomes with a ≤ 7-day antimicrobial treatment, even with a fever, assuming the infection source is effectively controlled. We conducted a single-center retrospective study involving patients with AC, defined following the Tokyo Guidelines 2018 for any cause, who underwent successful biliary drainage and completed a ≤ 7-day antimicrobial treatment. Patients were categorized into the febrile and afebrile groups based on their body temperature within 24 h before completing antimicrobial treatment. The primary outcome was the clinical cure rate, defined as no initial presenting symptoms by day 14 post-biliary drainage without recurrence or death by day 30. The secondary outcome was a 3-month recurrence rate. Logistic regression with inverse probability of treatment weighting was used. Overall, 408 patients were selected, among whom 40 (9.8%) were febrile. The two groups showed no significant differences in the clinical cure and 3-month recurrence rates. Notably, the subgroups limited to patients with a ≤ 3-day antibiotic treatment duration also showed no differences in these outcomes. Therefore, our results suggest that discontinuing antibiotics within the initially planned treatment period was sufficient for successful drainage cases of AC, regardless of the patient's fever status during the 24 h leading up to termination.

Harnessing phosphate limestone waste as a cost-effective solution for acid mine drainage treatment.

Mining mineral ores like pyrrhotite often generates positive and negative outcomes for the community. On the one hand these valuable minerals are explored to provide economic opportunities. On the other, mining pyrrhotite presents adverse environmental and health effects that relates to acid mine drainage (AMD) formation in abandoned mines. This suggest that the sustainable mining of valuable minerals in Pyrrhotite requires cost and environmentally friendly approaches. In this research, we simulate in-situ neutralisation effect of phosphate limestone waste (PLW) on AMD from two mining sites in Morocco under continuous oxic conditions. To this end, we conducted batch tests to assess the effectiveness of PLW in mitigating AMD and releasing contaminants. These tests involved reacting limestone particles (at two sizes: <2 cm and < 4 cm) with AMD leachates over a five-day period The results indicated that the AMD is characterised by a pH of 2.5 and an electrical conductivity of 11.8 mS/cm. The inductively coupled plasma optical emission spectroscopy (ICP-OES) analyses showed a high sulfate concentration of 3668.83 mg/L and the presence of some metals, notably copper, aluminium, and iron. The neutralisation process of the AMD using PLW under oxic conditions was highlighted by the variation in pH while the water was in contact with the PLW. The pH rose from 2.5 to 5.25 while the electrical conductivity decreased from 11.8 to 7.03 mS/cm. During the treatment of the AMD with PLW, the percentage of sulfate removal from the effluent was 35 %. In addition, iron and aluminium were significantly removed from the AMD with a percentage of 99 % in the leachate. Therefore, these results indicate that neutralising AMD using this passive treatment approach is effective and may serve as a cost-effective mitigation for AMD, since no excessive grinding is required for the PLW.

Patent conversion of a novel closed chest drainage device.

Closed chest drainage is typically necessary following Lobar and Sublobar resections to evacuate gases and fluids from the thoracic cavity, eliminate residual pleural space for lung expansion, and maintain negative pressure. Currently, three conventional closed chest drainage systems are commonly employed: single-chamber, double-chamber, and triple-chamber systems; each system has its own advantages and disadvantages. Despite the emergence of digital drainage systems in recent years, their high cost hinders their widespread adoption. Based on this premise, our research team has achieved a patent for a micro air pump-integrated chest closed drainage bottle, which has been further developed into a novel device integrating a three-chamber system with negative pressure control and power supply capabilities. This device enables patients undergoing perioperative lung procedures to ambulate freely while simultaneously receiving chest suction therapy-a concept that theoretically promotes rapid postoperative recovery. Moreover, this device offers economic benefits and holds potential for clinical implementation (particularly in economically underdeveloped regions). In this article, we modified the thoracic closed drainage device based on our patent and presented this novel thoracic closed drainage device after 3D printing and assembly.

Impact of Drain Placement on Postoperative Complications after Thyroidectomy for Substernal Goiter.

Introduction Despite the evidence against drain placement after thyroidectomy, there is a lack of consensus on drain use in patients with substernal goiter. Objective To assess the factors that increase the likelihood of drain placement and its impact on postoperative hematoma and other 30-day complications among adult patients undergoing thyroidectomy for substernal goiter. Methods A retrospective cohort study that used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Adult patients (aged ≥ 18 years) who underwent elective thyroidectomy for substernal goiter from 2016 to 2020 were included. Cases with closed suction neck drains placed upon completion of surgery were included in the drain group, and the remaining cases formed the nondrain group. Results A total of 1,229 patients were included (46.5% with drain placement). The factors that increased the likelihood of drain placement included body mass index (BMI) ≥ 30 kg/m 2 , score between 3 and 5 on the American Society of Anesthesiologists (ASA) physical status classification, sternal split/transthoracic surgical approach, operative time ≥ 90 minutes, and surgery conducted by otolaryngologists. Patients with clean-contaminated or contaminated wound classifications were less likely to be submitted to drain placement. In addition, drain use had no impact on postoperative hematoma formation but was found to independently increase the risk of prolonged length of hospital stay. Conclusion Thyroidectomy without drain placement might be safe for substernal goiter. However, this decision should be individualized for each patient. Level Of Evidence: 3.

Risk factors for recurrent biliary obstruction following suprapapillary placement of a plastic stent as preoperative biliary drainage for perihilar biliary malignancy.

BACKGROUND/PURPOSE: The usefulness of endoscopic biliary stenting by deploying a plastic stent suprapapillary, called inside-stent (IS) placement, as preoperative biliary drainage (PBD) for perihilar biliary malignancy (PHBM) has been demonstrated. This study investigated risk factors for recurrent biliary obstruction (RBO) after IS placement. METHODS: Consecutive patients with potentially resectable PHBM treated with IS placement as PBD between 2017 and 2023 at Nagoya University Hospital were retrospectively reviewed. RESULTS: A total of 157 patients were included, with RBO occurring in 34 (22%) patients. The non-RBO rates were 83% at 30 days, 77% at 60 days, and 57% at 90 days. The most common cause of RBO was stent occlusion (n = 14), followed by segmental cholangitis (n = 12) and stent migration (n = 8). Stent migration and occlusion occurred more frequently within and after 1 week post-stenting, respectively. In multivariate analysis, biliary infection before IS was the sole risk factor for RBO, with a hazard ratio of 2.404 (95% confidence interval 1.163-4.972; p = .018). This risk was reduced by temporary endoscopic nasobiliary drainage prior to definitive IS placement. CONCLUSIONS: Biliary infection before IS was identified as an independent risk factor for RBO in patients with PHBM with IS as PBD. CLINICAL TRIAL REGISTER: Clinical trial registration number: UMIN000025631.

Protean Drainage Patterns of the Left Renal Vein: A Cadaveric and Retrospective Clinical Study on the Surgical Implications and Technical Feasibility.

BACKGROUND: The diverse drainage patterns of the left renal vein (LRV), often with asymptomatic congenital anomalies, present considerable challenges in renal and retroperitoneal surgical contexts. The potential for significant bleeding and subsequent renal compromise upon vascular injury highlights the need for increased surgical awareness. OBJECTIVE: This study investigates the LRV's variable anatomical drainage patterns and morphometry. It also evaluates the embryological factors contributing to these variations and discusses their surgical implications and technical considerations. METHODS: Anatomical dissections were conducted on 21 adult human cadavers within the Department of Anatomy. Concurrently, a retrospective analysis was conducted on 15 patients who underwent various retroperitoneal surgical interventions in the Urology Department. Demographic variables and intraoperative findings were recorded and analyzed. RESULTS: Dissection analysis predominantly identified preaortic LRVs in 18 cadavers. Notable anatomical variations included a circumaortic left renal vein (CLRV), a delayed preaortic confluence of extrahilar duo LRVs, and an extrahilar tetramerous confluence with a retroiliac topography. The majority of LRVs usually end in the inferior vena cava. However, an extrahilar tetramerous variant had an unusual drainage pathway. Out of 15 cases, three (20%) had a retroaortic left renal vein (RLRV). One patient with a nonfunctioning kidney had type 1 RLRV, and another patient with pelvic ureteric junction obstruction had type 4 retroiliac left renal vein (RILRV). In both of these patients, symptoms were relieved after surgery. In a young patient with left varicocele and microscopic hematuria who had type 2 RLRV, symptoms resolved spontaneously after a few months. CONCLUSION: A thorough understanding of the variable anatomical drainage patterns of the LRV is crucial for surgeons. Accurate preoperative identification can provide valuable insights, potentially leading to improved surgical outcomes in renal procedures.

Splenic abscesses in the new millenium - a systematic review.

BACKGROUND: Isolated splenic abscesses are rare, but increasingly reported with newer organisms and changes in mechanisms involved. We conducted a comparative review of publications from 1900-1977, 1977-1986, 1987-1995, and 1996-2022. METHODS: A systematic search in Embase and PubMed resulted in 522 publications (1111 cases). Data was tabulated, analysed, and compared. RESULTS: Patient demographics and symptoms remain unchanged although more Asian patients were reported. Metastatic infections remain the main cause, but COVID-19-linked and iatrogenic causes post bariatric surgery and splenic artery embolization are increasingly reported. Aerobic organisms remain the commonest (68%), with a variety of exotic organisms reported. Splenectomy remains the definitive treatment, although antibiotics only and percutaneous aspiration/catheter-drainage are increasingly used with reasonable outcomes, with salvage splenectomy for therapeutic failures not having significantly higher mortality than upfront splenectomy. CONCLUSIONS: Isolated splenic abscesses continue to be uncommon, with diagnosis requiring a high degree of suspicion. Non-surgical options for treatment can sometimes be definitive.

Management of iatrogenic perforations during endoscopic interventions in the hepato-pancreatico-biliary tract.

Endoscopic retrograde cholangiopancreaticography (ERCP) and endoscopic ultrasound (EUS) guided interventions are among the most challenging procedures performed by interventional endoscopists and are associated with a significant risk of complications. Early recognition and classification of perforations allows immediate therapy which improves clinical outcomes. In this article we review the different aspects of iatrogenic perforations associated with pancreatico-biliary interventions, elucidating risk factors, diagnostic challenges and the latest therapeutic interventions.