Technical review of endoscopic ultrasound-guided drainage/anastomosis and trans-endosonographically created route procedures for the treatment of pancreatic diseases.

Endoscopic ultrasound (EUS)-guided pancreatic duct drainage includes two procedures: EUS-guided drainage/anastomosis (EUS-D/A) and trans-papillary drainage with EUS-assisted pancreatic rendezvous. EUS-guided pancreatogastrostomy is the most common EUS-D/A procedure and is recommended as a salvage procedure in cases in which endoscopic retrograde cholangiopancreatography fails or is difficult. However, initial EUS-D/A is performed in patients with surgically altered anatomy at our institution. It is one of the most difficult interventional EUS procedures and has a high incidence of adverse events. The technical difficulties differ according to etiology, and the incidence of adverse events varies between initial EUS-D/A and subsequent trans-endosonographically/EUS-guided created route procedures. Hence, it is important to meticulously prepare a procedure based on the patient's condition and the available devices. The technical difficulties in EUS-D/A include: (1) determination of the puncture point, (2) selection of a puncture needle and guidewire, (3) guidewire manipulation, and (4) dilation of the puncture route and stenting. Proper technical procedures are important to increase the success rate and reduce the incidence and severity of adverse events. The complexity of EUS-D/A is also contingent on the severity of pancreatic fibrosis and stricture. In post-pancreatectomy cases, determination of the puncture site is important for success because of the remnant pancreas. Trans-endosonographically/EUS-guided created route procedures following initial EUS-D/A are also important for achieving the treatment goal. This article focuses on effective strategies for initial EUS-D/A, based on the etiology and condition of the pancreas. We mainly discuss EUS-D/A, including its indications, techniques, and success-enhancing strategies.

Steroid lifting method during endoscopic submucosal dissection: A novel strategy for stricture prevention.

A 73-year-old male patient was referred to us with a long Barrett's esophagus (BE). He had a history of pulmonary embolism under anticoagulant therapy. Esophagogastroduodenoscopy showed a C8M9 BE with no macroscopic lesions. Random biopsies from the BE revealed multifocal high-grade dysplasia. The case was discussed in a multidisciplinary team conference and the decision for full resection of BE with endoscopic submucosal dissection (ESD) was made. Considering the large ESD resection and the high risk of stricture, we developed a novel preventive technique: the "steroid lifting method" for submucosal injection during ESD. Complete circumferential ESD with en bloc resection was performed using the "steroid lifting method", without adverse events. Oral liquids were initiated on day 1 and the patient was discharged on day 4. Oral prednisolone (30 mg per day) was started and tapered for a total of 6 weeks. The pathological examination confirmed multifocal high-grade dysplasia, with radical and curative resection. The patient had neither stricture, dysphagia nor recurrence of Barrett's mucosa at the 2, 6, 12, and 24-month follow-up. International guidelines recommend oral prednisolone and triamcinolone injection to prevent stricture formation in large ESD of esophageal squamous cell carcinoma. However, there is no solid data on BE ESD. The risk factors for stricture formation and the optimal preventive management after large BE ESD is not known. The "steroid lifting method" might be an option in this context. Large prospective studies addressing stricture formation and preventive measures on BE ESD are necessary.

Prospective assessment of probe-based confocal laser endomicroscopy under direct cholangioscopic visualization for biliary strictures that could not be definitively diagnosed using endoscopic retrograde cholangiopancreatography (with video).

The definitive diagnosis of patients with indeterminate biliary strictures remains challenging. Probe-based confocal laser endomicroscopy (pCLE) provides real-time histological assessment of bile duct tissues. Since no previous studies have evaluated the efficacy of pCLE under direct cholangioscopic visualization for biliary strictures that cannot be definitively diagnosed through endoscopic retrograde cholangiopancreatography using fluoroscopy, we prospectively assessed the feasibility and safety of this procedure in three cases. pCLE findings were obtained in three cases, providing accurate diagnoses. Additionally, no adverse event was reported. pCLE under direct cholangioscopic visualization for indeterminate biliary strictures might be feasible and safe, even though these strictures were not previously diagnosed using endoscopic retrograde cholangiopancreatography. Further studies with more cases are warranted to clarify the effectiveness of pCLE under direct cholangioscopic visualization.

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.

Multilayered hydrogel scaffold construct with native tissue matched elastic modulus: A regenerative microenvironment for urethral scar-free healing.

The unsuitable deformation stimulus, harsh urine environment, and lack of a regenerative microenvironment (RME) prevent scaffold-based urethral repair and ultimately lead to irreversible urethral scarring. The researchers clarify the optimal elastic modulus of the urethral scaffolds for urethral repair and design a multilayered PVA hydrogel scaffold for urethral scar-free healing. The inner layer of the scaffold has self-healing properties, which ensures that the wound effectively resists harsh urine erosion, even when subjected to sutures. In addition, the scaffold's outer layer has an extracellular matrix-like structure that synergizes with adipose-derived stem cells to create a favorable RME. In vivo experiments confirm successful urethral scar-free healing using the PVA multilayered hydrogel scaffold. Further mechanistic study shows that the PVA multilayer hydrogel effectively resists the urine-induced inflammatory response and accelerates the transition of urethral wound healing to the proliferative phase by regulating macrophage polarization, thus providing favorable conditions for urethral scar-free healing. This study provides mechanical criteria for the fabrication of urethral tissue-engineered scaffolds, as well as important insights into their design.

Safety and effectiveness of additional triamcinolone acetonide with endoscopic radial incision and cutting for benign stenosis of the lower gastrointestinal tract: A pilot study.

Objectives: Radial incision and cutting (RIC) is being investigated as an alternative endoscopic dilation method for lower intestinal tract stenosis, providing a high technical success rate and improving subjective symptoms. However, several patients develop re-stenosis following RIC. In this pilot study, we aimed to evaluate the safety and efficacy of triamcinolone acetonide (TA) addition after RIC. Methods: RIC with TA was performed in 20 patients with lower gastrointestinal tract stenosis. We evaluated the rate of adverse events 2 months after RIC with TA. We investigated the short- and long-term prognoses, as well as the improvement in subjective symptoms, using a visual analog scale. Results: The delayed bleeding rate after RIC was 23.8%. Endoscopic hemostasis was achieved in all patients with delayed bleeding. No perforations were observed. The cumulative re-stenosis-free, re-intervention-free, and surgery-free rates 1 year after RIC were 52.9%, 63.7%, and 85.2%, respectively. Subjective symptoms, including abdominal pain, abdominal bloating, nausea, and dyschezia, significantly improved after RIC with TA. Conclusion: Although additional TA administration after RIC could be safe, additional TA may not be effective on luminal patency after dilation. Further investigation is warranted.

Tubeless ureteroenteric anastomosis in robot-assisted radical cystectomy with intracorporeal urinary diversion does not increase the risk of anastomotic stenosis or postoperative complications.

The objective is to demonstrate that omitting ureteral stent placement in robotic intracorporeal urinary diversion does not lead to increased risk of perioperative complications, namely ureteral strictures or anastomotic leaks. We retrospectively reviewed the records of 68 consecutive patients who underwent robotic radical cystectomy with ileal conduit creation or orthotopic neobladder by a single surgeon between January 2020 and September 2023. Chronologically, the first cohort of patients had ureteral stents placed to bridge the ureteroenteric anastomosis, and in the second cohort, stenting was omitted. Cohort 1 consisted of 28 patients with surgeries performed between January 2020 and April 2021, while cohort 2 had 40 patients who underwent surgery from April 2021 to September 2023. The cohorts were well matched with regard to patient age, gender, ASA score and rate of neoadjuvant chemotherapy. The choice of urinary diversion was left to surgeon and patient preference, and there was no significant difference in the proportion of ileal conduits versus orthotopic neobladders within each cohort. Estimated blood loss, total operative time, inpatient length of stay and pathologic T and N staging did not statistically differ between the cohorts. Overall, there was no difference in the rates of postoperative ileus, ureteral stricture, anastomotic leak, infectious complications, and 30-day readmission rates between the groups. Tubeless ureteroenteric anastomosis in patients undergoing robotic radical cystectomy with intracorporeal diversion does not appear to increase the risk of anastomotic strictures or postoperative complications. Further prospective evaluation is warranted.

Prediction of post-ESD esophageal stricture by a nomogram and risk factor analysis of ineffective oral steroids prophylaxis.

BACKGROUND AND AIMS: Several risk models for esophageal stricture after endoscopic submucosal dissection have been developed. However, some of them did not include the use of steroids in the risk analysis. Glucocorticoid sensitivity mediated by glucocorticoid receptor expression has not been discussed in this condition. METHODS: Clinical and endoscopic characteristics were included in the logistic regression model to establish a nomogram for stenosis prediction. The score for each risk factor was estimated. Risk factors of ineffective oral steroid prophylaxis were analyzed and glucocorticoid receptor expressions were detected by immunohistochemistry. RESULTS: Three hundred fourteen patients of endoscopic submucosal dissection for esophageal superficial neoplasms were included to develop the nomogram. The circumferential range(≤ 3/4, 3/4-1 or the whole circumference), longitudinal diameter reached 4 cm (yes or not) and lesion location (the cervical and upper thoracic part, the middle thoracic part or the lower thoracic part) consisted of the nomogram. Patients have a high risk of esophageal stricture if they have a total point greater than 36. In the simplified risk score model, the corresponding cutoff score was 1. 92 patients with oral steroid prophylaxis were separately analyzed and the circumferential mucosal defect involving 7/8 or more was an independent risk factor of ineffective prevention (OR 12.2, 95%CI 5.27-28.11). The expression of glucocorticoid receptor ß was higher in the stricture group (p = 0.042 for AOD; p = 0.016 for the scoring system). CONCLUSIONS: We established a nomogram for esophageal stricture prediction. Depending on the characteristics of lesions, it is possible to estimate the risk of stricture under routine post-ESD treatments (no steroids or oral steroids). Alternative treatments should be considered if the risk is extremely high, especially for patients with mucosal defects involving 7/8 or more of circumference in which oral steroid treatment tends to be ineffective. The higher glucocorticoid receptor ß may indicate potential glucocorticoid resistance.

Predictors of stricture after endoscopic submucosal dissection of the esophagus and steroids application.

BACKGROUND: Endoscopic submucosal dissection (ESD) is a reliable method to resect early esophageal cancer. Esophageal stricture is one of the major complications after ESD of the esophagus. Steroid prophylaxis for esophageal strictures, particularly local injection of triamcinolone acetonide (TA), is a relatively effective method to prevent esophageal strictures. However, even with steroid prophylaxis, stenosis still occurs in up to 45% of patients. Predicting the risk of stenosis formation after local TA injection would enable additional interventions in risky patients. AIM: To identify the predictors of esophageal strictures after steroids application. METHODS: Patients who underwent esophageal ESD and steroid prophylaxis and who were comprehensively assessed for lesion- and ESD-related factors at Southeast University Affiliated Zhongda Hospital between February 2018 and March 2023 were included in the study. The univariate and multivariate regression analyses were conducted to identify the predictors of stricture among patients undergoing steroid prophylaxis. RESULTS: A total of 120 patients were included in the analysis. In the oral prednisone and oral prednisone combined with local tretinoin injection groups, the stenosis rates were 44/53 (83.0%) and 56/67 (83.6%), respectively. Among them, univariate analysis showed that the lesion circumference (P = 0.01) and submucosal injection solution (P = 0.04) showed significant correlation with the risk of stenosis formation. Logistic regression analyses were then performed using predictors that were significant in the univariate analyses and combined with known predictors from previous reports, such as additional chemoradiotherapy and tumor location. We identified a lesion circumference < 5/6 (OR = 0.19; P = 0.02) and submucosal injection of sodium hyaluronate (OR = 0.15; P = 0.03) as independent predictors of on esophageal stricture formation. CONCLUSION: Steroid prophylaxis effectively prevents stenosis. Moreover, the lesion circumference and submucosal injection of sodium hyaluronate were independent predictors of esophageal strictures. Additional interventions should be considered in high-risk patients.

Comparison of Biliary Complications Between Living and Deceased Donor Liver Transplantations: A Systematic Review and Meta-analysis.

To understand if the risk of biliary complications is higher with living donor liver transplantation (LDLT) compared to deceased donor liver transplantation (DDLT), the present meta-analysis was conducted to analyze the differences between these two types of liver transplantations. Three databases were searched from inception to September 2023 for comparative studies reporting biliary complications with LDLT and DDLT. Odds ratios (OR) with 95% confidence intervals were calculated for all the dichotomous outcomes. Twenty-eight studies were included in the final analysis. LDLT was associated with a significantly higher incidence of biliary complications than DDLT (OR 1.96, 95% CI: 1.56-2.47). However, on subgroup analysis, only studies published in or before 2014 reported a higher incidence of biliary complications with LDLT, but not with studies published after 2014. An analysis of individual adverse events showed that LDLT was associated with a higher incidence of both bile leak (OR 3.38, 95% CI: 2.52-4.53) and biliary stricture (OR 1.75, 95% CI: 1.20-2.55). LDLT was associated with a higher incidence of overall biliary complications, including bile leak and biliary stricture. With advances in surgical techniques, there has been a reduction in the risk of biliary complications.

An alternative method in the diagnosis of intrabiliary lesions: Percutaneous endobiliary brush biopsy.

Background and Aim: Biliary strictures can occur as a result of various benign or malignant processes. The aim of this study is to evaluate the effectiveness and reliability of percutaneous endobiliary brush biopsy in the diagnosis of intrabiliary lesions. Materials and Methods: This retrospective, single-center study was conducted between January 2022 and April 2023, involving a total of 16 patients. Of the patients, 10 were male (62.5%), and 6 were female (37.5%). The average age of the patients was 68.1±8. All patients underwent the procedure using an endobiliary biopsy brush under ultrasound and fluoroscopic guidance. Results: Technical success was achieved in all patients (100%). Cell detection was not observed in biopsy samples from 2 patients (12.5%), resulting in a diagnostic success rate of 87.5%. Access was made to the right biliary system in 14 patients (87.5%) and to the left biliary system in 2 patients (12.5%). Biopsy locations included the common bile duct in 12 patients (75%), hepatic hilum in 2 patients (12.5%), and bilioenteric anastomosis line in 2 patients (12.5%). The mean fluoroscopy time was 16.2±7.1 minutes. The average radiation dose was 660±370 mSv. Pathological diagnosis revealed malignancy in 8 patients (50%) and benign findings in 6 patients (37.5%). Liver abscess requiring drainage developed in 2 patients (12.5%). Conclusion: Percutaneous endobiliary brush biopsy performed under imaging guidance is an effective and reliable method for the diagnosis of biliary lesions.

Evaluating the yield of digital single operator cholangioscopy in posttransplant biliary strictures after unsuccessful guidewire placement with ERCP.

Background and Aims: Strictures are the most common biliary complication after liver transplantation, and endoscopic retrograde cholangiopancreatography (ERCP) is considered the gold standard in its management. Failure to cross the biliary anastomosis requires a repeated attempt with ERCP, referral for percutaneous transhepatic cholangiography (PTC) or surgery. We present our experience with the digital single operator cholangioscope (D-SOC) in achieving guidewire access in a liver transplant cohort with difficult biliary strictures who have failed conventional ERCP methods. Methods: This was a retrospective study involving two adult liver transplant centers servicing the two most populated states in Australia. Deceased-donor liver transplant recipients undergoing D-SOC for biliary strictures who have failed conventional methods to achieve biliary access were included. Results: Between July 2017 to April 2022, eighteen patients underwent D-SOC after failing to achieve guidewire placement through standard ERCP techniques. Thirteen out of eighteen (72%) had successful guidewire placement with index D-SOC. Five of eighteen patients (28%) had unsuccessful guidewire placement with D-SOC. In two of these patients, use of D-SOC informed further endoscopic management, with one avoiding PTC and the other avoiding surgery. Two of the five patients required PTC and one patient was left unstented. Three patients developed post D-SOC cholangitis. Conclusions: D-SOC is effective at achieving guidewire access in post-liver transplant patients who fail conventional ERCP techniques and should be considered in the treatment algorithm as a step before PTC and surgery.

Safety and efficacy of thermo-expandable metallic stent in ureteral stricture following gynecological malignancy surgery and radiotherapy: a single center experience with 33 cases.

BACKGROUND: The effectiveness of metallic stents in treating ureteral strictures following surgery and radiotherapy for gynecological tumors is currently uncertain. We aimed to investigate the efficacy and safety of thermo-expandable metallic stent (Memokath) in the treatment of ureteral stricture after radiotherapy for gynecological tumors. METHODS: In this descriptive cross-sectional study, 27 patients with ureteral stricture were treated with Memokath stent after gynecological tumor radiotherapy with or without chemotherapy that was admitted to our hospital from August 2021 to August 2023. Clinical data on efficacy, safety, and complications during stent insertion and indwelling were analyzed. RESULTS: The successful insertion of thirty-three stents in twenty-seven patients studied. The stenosis length was 10.14 ± 6.76 cm, and the hospitalization was 4.43 ± 1.83 days. One patient has died from the primary disease carrying a patency stent. The Kaplan-Meier graph showed that the cumilative patency rate of patients with thermo-expandable metallic stent were 92.4% (SD = 5.2%) in eight months, 77.4% (9.1%) in 12 months and 67.7% (SD = 12%) in 29 months, while the cumilative survival rate was 87.5% (SD = 11.5%) in 29 months. The stent patency was 81.48% and later complications of stent indwelling were 5/27, including refractory urinary tract infection (UTI) in three cases, stent migration, and stent intolerance respectively. The creatinine levels, hydronephrosis degree, and glomerular filtration rate improved after the operation, and the first two indicators were statistically significant. CONCLUSION: Memokath stent is a safe and effective treatment for ureteral stricture after surgery and radiotherapy with or without chemotherapy for gynecological tumors.

Outcomes of Percutaneous Endobiliary Radiofrequency Ablation in Managing Resistant Benign Biliary Strictures: A Retrospective Analysis.

OBJECTIVES: To assess the safety and effectiveness of percutaneous endobiliary radiofrequency ablation (EB-RFA) in the management of refractory benign biliary strictures. MATERIALS AND METHODS: Percutaneous EB-RFA was performed in 15 individuals (M/F = 8/7; median age: 57 [33-84]) for benign biliary strictures resistant to traditional methods (transhepatic cholangioplasty and biliary drains). All patients underwent ≥1 unsuccessful cholangioplasty session and upsizing of their transhepatic biliary drains pre-procedure. Technical and clinical success were defined as luminal gain with enhanced flow and a lack of clinically evident recurrent stricture on follow-up after drain/stent removal, respectively. RESULTS: A total of 16 EB-RFA procedures were performed. Technical success rate was 100% (16/16). Procedure-related complications occurred in 1/16 cases (drain leakage with subsequent cellulitis). Clinical success rate was 87% (13/15) with a median follow-up of 17 (2-24) months. Drain/stent was not removed in one case (1/16) as the patient was lost to follow-up immediately post-procedure. The 1-year patency rate was 100%. A significant reduction was observed in the median number of IR visits (8 [1-51] to 1 [0-9]; p = 0.003) and drain insertion/exchange procedures (5 [1-45] to 0 [0-6]; p = 0.003) pre- and post-EB-RFA with a median follow-up of 18 (0-26) months. CONCLUSION: Percutaneous EB-RFA can safely and effectively treat refractory benign biliary strictures. However, larger prospective studies with extended follow-ups are needed to gather more robust data. ADVANCES IN KNOWLEDGE: This study contributes to the limited evidence on the role of EB-RFA in addressing refractory benign biliary strictures, enhancing the understanding of its clinical utility.

Intravenous indocyanine green to evaluate distal ureteral vascularity during robot-assisted radical cystectomy with intracorporeal urinary diversion.

PURPOSE: The aim of the present study is to assess the role of indocyanine green (ICG) to evaluate distal ureteral vascularity during robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion and its impact on the incidence of benign ureteroenteric strictures (UES). METHODS: The study included patients who underwent RARC for bladder cancer between 2018 and 2023. All patients included underwent intracorporeal urinary diversion with ileal conduit or neobladder. Bricker technique was performed in all ureteroenteric anastomosis. ICG was employed during the study period to evaluate ureteral vascularity. We divided patients into 2 groups depending on the utilization of ICG during surgery and compared demographic, clinicopathological and perioperative outcomes, including benign UES rates. RESULTS: We identified 221 patients that underwent RARC with intracorporeal urinary diversion. Ileal conduit was performed in 173 (78.3%) patients and neobladder in 48 (21.7%) cases. A total of 142 (64.3%) and 79 (35.7%) patients were in the non-ICG and ICG group, respectively. With a median follow-up of the entire cohort of 21.1 months, there were no differences in the rate of benign UES after RARC between the non-ICG and the ICG group (p = 0.901). In the non-ICG group, 26 (18.3%) patients developed benign UES and in the ICG group 15 (19.0%) patients. Most of the strictures appeared in the left ureter in both groups (80.8% non-ICG vs. 66.7% ICG, p = 0.599). Median time to stricture diagnosis was 4 months (IQR 3-7.25) for the non-ICG and 3 months (IQR 2-5) for the ICG group (p = 0.091). The ICG group had a slightly greater length of ureter resected compared with the non-ICG group (1.5 vs. 1.3 cm, p = 0.007). CONCLUSION: In our experience, choosing to use ICG intraoperatively to evaluate distal ureteral vascularity may not reduce the rate of benign UES after robot-assisted radical cystectomy with intracorporeal urinary diversion and Bricker ureteroileal anastomosis.

Self-expanding metal stent for relieving the stricture after endoscopic injection for esophageal varices.

BACKGROUND: Esophageal stricture is one of the complications after esophageal varices sclerotherapy injection (ESI), and the incidence rate is between 2%-10%. AIM: To explore the efficacy of self-expanding metal stent (SEMS) for the stricture after endoscopic injection with cyanoacrylate (CYA) and sclerotherapy for esophageal varices. METHODS: We retrospectively analyzed the efficacy of SEMS to improve the stricture after endoscopic injection with CYA and sclerotherapy for esophageal varices in 4 patients from February 2023 to June 2023. RESULTS: The strictures were improved in four patients after stenting. The stent was removed after two weeks because of chest pain with embedding into esophageal mucosa in one patient. The stent was removed after one month, however, the stent was reinserted because of the strictures happening again in two patients. The stent was removed after three months, however, the stent was reinserted because of the strictures happening again in one patient. The stent embedded into esophageal mucosa in three patients. There were 3 patients suffered reflux esophagitis, and the acid reflux was relieved by taking hydrotalcite. There was no other complication of esophageal perforation, bleeding from varices or infection. CONCLUSION: SEMS may relieve the stricture which happened after endoscopic injection with CYA and sclerotherapy for esophageal varices. However, when we should remove the stent still needs to be explored.

Tuberculosis Peritonitis Resulting in Small Bowel Obstruction.

Tuberculosis (TB) peritonitis resulting in a small bowel obstruction is uncommon and can be a challenging infectious disease to diagnose. It often has an insidious onset with non-specific symptoms. Today we report a rare case of a 30-year-old woman who recently traveled to Vietnam and presented with worsening upper and lower gastrointestinal symptoms. CT scan revealed an ill-defined mass in the terminal ileum with prominent mucosal enhancement and wall thickening, which ultimately led to subsequent colonoscopy and Quantiferon Gold testing, revealing a positive result. Biopsy of the mass demonstrated noncaseating granulomatous colitis with rare acid-fast positive bacillus consistent with mycobacterial infection. As a result, the patient was ultimately initiated on antituberculosis therapy. Shortly thereafter, she was readmitted with clinical features suggestive of a bowel obstruction. The patient was managed with supportive care and did not require surgical intervention. However, approximately two months following the readmission, she presented to the emergency department once again with a mechanical bowel obstruction that ultimately required surgery. This case underscores the importance of TB testing in patients with insidious, worsening gastrointestinal symptoms and highlights the potential complications of TB peritonitis, even in those undergoing antituberculosis treatment.

Does the suturing technique (barbed continuous versus conventional interrupted) impact the outcome of anastomotic urethroplasty?

PURPOSE: To evaluate and compare continuous suture (CS) and interrupted suture (IS) techniques applied in excision and primary anastomosis (EPA) urethroplasty in terms of surgical success and complication rates. METHODS: A retrospective evaluation was conducted on patients with bulbar urethral strictures measuring ≤ 2.5 cm who underwent EPA between April 2020 and December 2022. Patients with a history of urethral reconstruction, multiple strictures, a history of pelvic radiotherapy, a diagnosis of Lichen sclerosis, a history of surgery due to congenital penile curvature or Peyronie's disease, and a follow-up period of less than 12 months were excluded. The patients were divided into two groups according to the suture technique used (CS or IS), and the groups were compared for demographic and perioperative data. RESULTS: A total of 97 patients (CS n = 52, IS n = 55) were included in the sample. The mean age of the entire patient group was calculated to be 56.2 years and the mean stricture length was 19.3 mm. Operation time and postoperative catheter time were shorter in the CS group (94.7 ± 7.3 vs. 117.2 ± 5.7 min and 9.9 ± 1.6 vs. 15.8 ± 1.9 min, p < 0.001, respectively). The groups were similar regarding anatomical success, stress urinary incontinence, penile numbness, curvature, and postoperative infection (p > 0.05). CONCLUSION: No significant difference was observed in terms of success or complications between the CS and IS techniques employed during EPA urethroplasty. However, in addition to reducing the operation time, the CS technique offers the advantage of safely removing the urethral catheter earlier.

Repair of Type C Tracheo-esophageal Fistula/Esophageal Atresia With or Without Trans Anastomotic Tube: A Pilot Randomized Controlled Trial.

BACKGROUND: The use of trans anastomotic feeding tube (TAFT) during the repair of Esophageal atresia/Tracheo-esophageal fistula (EA/TEF) aims to enhance outcomes by enabling early feeding, reducing the requirement for parenteral nutrition, and reducing complications such as anastomotic leak by stenting the anastomosis. However, TAFT's benefits and drawbacks are debated due to conflicting reports. Thus, we conducted a prospective pilot randomized control trial to elucidate the impact of TAFT on postoperative outcomes and the potential benefits of avoidance of TAFT. METHODS: We performed a single-center randomized controlled trial in 53 neonates diagnosed with Type C EA/TEF who were operated on from January 2022 to June 2023. The patients were randomized into TAFT (n = 30) and non-TAFT (n = 23) groups. The patients were followed up for a minimum of 6 months following discharge. The primary objective of the study was to compare the rate of anastomotic leaks following primary repair of EA/TEF in both groups. Secondary objectives included early postoperative outcomes such as the occurrence of anastomotic stricture, time taken to initiate feeding, the time required to reach full feeding, the incidence of brief resolved unexplained events (BRUE) or acute life-threatening events (ALTE), the incidence of gastroesophageal reflux (GER), somatic growth, and all-cause mortality within 30 days post-surgery. RESULT: The study demonstrated that TAFT placement was associated with a higher incidence of anastomotic leaks (20 % vs 0, p = 0.03). However, there was no difference in the 30-day mortality between both groups. Although the rate of anastomotic strictures and GER was higher in the TAFT group (54.5 % vs 27.8 %, p = 0.08 and 25 % vs 57.1 %, p = 0.076), it did not reach statistical significance. Avoiding TAFT resulted in earlier initiation of enteral feeding (18 vs 22 days, p = 0.002), shorter time to achieve full feeds (15 vs 21 days, p = 0.03), reduced duration of TPN (3 vs 10 days; p = 0.001), improved weight gain at the 2-week follow-up (27.5 vs. 24.4 g/kg/day, p-value = 0.037) and lesser incidence of ALTE/BRUE (11.1 % vs 48 %, p = 0.01) at 6 months. CONCLUSION: While previous research has covered TAFT's impact on complications such as anastomotic leak, stricture, use of TPN and enteral feed, prospective randomized studies remain limited, and the impact on GER, somatic growth, and occurrence of ALTE/BRUE is still unexplored. This study evaluated the short-term outcomes of EA/TEF in a resource-challenged setting, shedding light on the potential benefits of repair without TAFT such as reduction in the rate of anastomotic leak, earlier feeding, reduced GER, better somatic growth and reduced incidence of ALTE/BRUE. LEVEL OF EVIDENCE: Level II (Treatment study/Randomized controlled trial).

Utilizing computed tomography-based renal parenchymal volumes to calculate split renal function in patients with ureteral stricture disease.

PURPOSE: Evaluation of split renal function (SRF) is critical for guiding surgical treatment decisions for patients with ureteral stricture disease (USD). We aimed to determine whether computed tomography (CT)-based renal parenchymal volumes may be used to predict SRF in patients with USD. METHODS: We retrospectively reviewed all patients undergoing surgical management for USD at a single institution from October 2021 to January 2024. Patients who had preoperative nuclear medicine scan (NMS) and CT scan with intravenous contrast that were obtained within six weeks of each other were included. Interval between NMS and CT could be longer if the affected renal unit was drained with ureteral stent and/or percutaneous nephrostomy. Volume measurements were obtained using the 3D Region of Interest (ROI) Tool on Visage®7 Enterprise Imaging Platform (Visage Inc., San Diego, USA) by two investigators that were blinded to NMS derived SRF. Intraclass correlation coefficient (ICC) was used to assess consistency between investigators. Predictive accuracy was assessed using Pearson correlation coefficient (r) and linear regression. RESULTS: 40 of 160 patients met inclusion criteria. There was excellent reliability in calculating renal parenchymal volume between raters (ICC = 0.990). There was a strong linear correlation between estimated CT SRF and NMS SRF (r = 0.912, p < 0.00001). A linear regression model found RObservedSRF = -0.013 + 1.015(REstimatedSRF), with r2 = 0.832. CONCLUSION: CT-derived parenchymal volume analysis may be used to estimate SRF in patients with USD. This may obviate the need to obtain preoperative renal scans for SRF measurement in selected patients when assessing surgical management options.