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.

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.

Resolution of occult anastomotic stricture with anal dilator: challenges with the conventional diagnostic criteria in low anterior rectal resection patient-a case report.

Background: Anastomotic stricture (AS) is a common complication following rectal cancer surgery with anastomosis, but its diagnosis and management pose significant challenges due to the lack of standardized diagnostic criteria. We present a case highlighting the complexities encountered in diagnosing and managing occult AS post-rectal cancer surgery. Case presentation: A 51-year-old male patient presented with symptoms suggestive of AS following robot-assisted laparoscopic low anterior resection for rectal adenocarcinoma. Despite conventional evaluations, including colonoscopy, digital rectal examination, and radiography, AS was not identified. Following prolonged and ineffective treatment for suspected conditions such as low anterior resection syndrome (LARS), the patient underwent anal dilatation, resulting in significant symptom improvement. Conclusions: This case underscores the challenges associated with diagnosing and managing occult AS following rectal cancer surgery. The absence of standardized diagnostic criteria and reliance on conventional modalities may lead to underdiagnosis and inadequate treatment. A comprehensive diagnostic approach considering intestinal diameter, elasticity, and symptoms related to difficult defecation may enhance diagnostic accuracy. Further research is needed to refine the diagnostic and therapeutic strategies for occult AS.

Efficacy of Different Steroid Therapy in Preventing Esophageal Stricture after Endoscopic Submucosal Dissection: A Comparative Meta-analysis.

BACKGROUND AND AIMS: Endoscopic submucosal dissection (ESD) is the standard therapy for superficial esophageal cancer (SEC) presently. However, postoperative mucosal defects often lead to esophageal stricture. Although steroid application is effective prophylaxis, the efficacy and safety of various steroid administration modes remain unclear. Thus, this study aimed to evaluate the efficacy and safety of different steroid administrations for SEC patients post-ESD. METHODS: A search for relevant studies was conducted on China National Knowledge Infrastructure, Wanfang Database, PubMed, Embase, and Web of Science up to March 25, 2024. Treatment strategies were categorized into four groups: no prevention as control (CON), steroid injection (SI), oral steroids (OS), and SI combined with OS (SI+OS). Comparative meta-analysis was conducted to assess outcomes, including postoperative esophageal stricture rate and the number of endoscopic balloon dilatation (EBD) sessions required after stricture. RESULTS: A total of 25 studies, involving 1555 patients, were included. The SUCRA rankings were as follows: SI+OS (98.9%) > OS (59.9%) > SI (41.2%) > CON (0.0%) in preventing postoperative esophageal stricture rate, and OS (76.9%) > SI+OS (62.1%) > SI (61.0%) > CON (0.0%) in the number of EBD sessions required. Forest plot results indicated that compared with the non-steroid group, steroid interventions were associated with lower rates of postoperative stricture and fewer EBD sessions. Additionally, SI+OS was superior to SI or OS alone in preventing stricture, with no significant differences observed between different steroid administrations in terms of EBD sessions. The incidence of adverse reactions was less than 10% for all interventions, mostly mild and resolvable upon discontinuation. CONCLUSION: This study suggests that combined administration appears preferable for preventing esophageal stricture in patients post-ESD, and steroids could enhance stricture prognosis. However, due to the lack of large-sample RCT studies comparing different steroid administrations, more high-quality research is necessary to confirm these findings in the future.

Safety of long-term esophageal stent use for multiple indications.

Background: Long-term (>30 days) esophageal stenting is controversial. Previous studies have documented complications associated with long-term esophageal stent use. This study's objective was to investigate complications associated with long-term esophageal stent use. Methods: A retrospective review of stenting done by thoracic surgery for any reason between 2010-2020 was completed. Patients were included if they had at least 30 days of follow-up after their initial stent placement. Outcomes included stent dwell time, patient outcomes, procedural and stent-related complications. Results: Fifty-six patients, with 25 having ≥2 stents placed were included; overall, 90 stents were placed. The median length of initial esophageal stent dwell time was 59 [interquartile range (IQR), 21-119] days. Stent migration was the most common complication and occurred more with benign indications (P=0.12). As the length of dwell time increased, prevalence of any complication decreased. Complication rates between short-term (<30 days) and long-term stents were not significantly different (P=0.39). No instances of esophageal perforation or aortoesophageal fistulas related to stents were identified. There was one instance of post-esophagectomy tracheoesophageal fistula which was managed successfully with prolonged stenting. Conclusions: Over a 10-year period, there were no instances of stent erosion into the aorta or esophageal perforation, and the most frequent stent-related complication was stent migration. Long-term esophageal stenting did not result in increased rates of stent related complications in our cohort. This case series demonstrates that long-term stents may be safely used for many different indications. Randomized controlled studies may be needed to validate these findings.

Verapamil inhibits inflammation and promotes autophagy to alleviate ureteral scar by regulation of CaMK IIδ/STAT3 axis.

BACKGROUND: Ureteral stricture (US) is a pathological stenosis in the urinary tract characterized by increased collagen synthesis and inflammation. Autophagy activation has been shown to ameliorate tissue fibrosis and protect against fibrotic diseases. Verapamil has beneficial therapeutic benefits on fibrotic disorders. The pharmacological effects of verapamil on fibroblast autophagy in US and the underlying mechanism need to be investigated further. METHODS: US patients were recruited to isolate scar tissues, hematoxylin-eosin (HE) and Masson trichrome staining were performed to analyze histopathological changes. The US animal model was established and administered with verapamil (0.05 mg/kg) in the drinking water. Transforming growth factor (TGF)-ß1 was adopted to facilitate collagen synthesis in fibroblasts. The mRNA and protein expressions were examined by qRT-PCR, western blot, immunofluorescence and immunohistochemistry. ELISA was adopted to measure interleukin (IL)-1ß and IL-6 levels. Molecular interaction experiments like dual luciferase reporter and chromatin immunoprecipitation (ChIP) assays were performed to analyze the interaction between signal transducers and activators of transcription 3 (STAT3) and RNA polymerase II associated factor 1 (PAF1). RESULTS: Herein, our results revealed that verapamil activated TGF-ß1-treated fibroblast autophagy and inhibited inflammation and fibrosis by repressing Ca2+/calmodulin-dependent protein kinase II (CaMK II) δ-mediated STAT3 activation. Our following tests revealed that STAT3 activated PAF1 transcription. PAF1 upregulation abrogated the regulatory effect of verapamil on fibroblast autophagy and fibrosis during US progression. Finally, verapamil mitigated US in vivo by activating fibroblast autophagy. CONCLUSION: Taken together, verapamil activated TGF-ß1-treated fibroblast autophagy and inhibited fibrosis by repressing the CaMK IIδ/STAT3/PAF1 axis.

Laparoscopic-Assisted Removal of Two Video Capsule Endoscopy Cameras Retained for More Than Two Years.

Video capsule endoscopy (VCE) is used to evaluate the gastrointestinal tract, particularly the small bowel for obscure bleeding, Crohn's disease, and tumors. A rare complication of VCE is the retention of the pill camera. With the expanding use of VCE, it's important to consider the pathology that may lead to retention and approach to treatment. VCE for subacute or intermittent bowel obstruction is considered a contraindication due to the increased risk of retention, however, it may also identify significant pathology. Capsule retention should be treated promptly to prevent complications such as acute small bowel obstruction (SBO) and perforation. This case describes a 51-year-old female who presented with retention of two VCE cameras in the bowel for multiple years. She had intermittent abdominal pain and partial SBOs before the retention. She underwent a successful laparoscopic-assisted surgery removing the two endoscopy cameras and resection of the stenosed small bowel. This case sheds light on the challenges and opportunities in the management of VCE and capsule retention.

Single-Cell RNA Sequencing Reveals a Unique Fibroblastic Subset and Immune Disorder in Lichen Sclerosus Urethral Stricture.

Purpose: Lichen sclerosus urethral stricture disease (LS USD) is a refractory and progressive disease primarily affecting the anterior urethra in males. Various potential etiological factors, such as genetics, autoimmunity, infection, and exposure to infectious urine, have been suggested. However, the accurate etiology of LS in the male urethra remains unclear. Patients and Methods: In this study, we conducted single-cell RNA sequencing to identify the transcriptional profiles of three patients with LS USD and three patients with non-LS USD. Immunofluorescence was used to confirm the single-cell sequence results. Results: Our study revealed distinct subsets of vein endothelial cells (ECs), smooth muscle cells (SMCs), and fibroblasts (FBs) with high proportions in LS USD, contributing to the tissue microenvironment primarily involved in proinflammatory and immune responses. In particular, FBs displayed a unique subset, Fib7, which is exclusively present in LS USD, and exhibited high expression levels of SAA1 and SAA2. The accumulation of macrophages, along with the dysregulated ratios of M1/M2-like phenotype macrophages, may be engaged in the pathogenesis of LS USD. Through cell-cell communication analysis, we identified significant interactions involving CXCL8/ACKR1 and CCR7/CCL19 in LS USD. Remarkably, Fib7 exhibited exclusive communication with IL-1B macrophages through the SAA1/FPR2 receptor-ligand pair. Conclusion: Our study provides a profound understanding of the tissue microenvironment in LS USD, which may be valuable for understanding the pathogenesis of LS USD.

Perineal Urethrostomy for Complex Urethral Strictures: Long-Term Patient-Reported Outcomes from a Reconstructive Referral Center and a Scoping Literature Review.

PURPOSE: There is a paucity of long-term objective and patient-reported outcomes after definitive perineal urethrostomy for complex urethral strictures. Our objective is to determine comprehensive long-term success of perineal urethrostomy with our 15-year experience at a reconstructive referral center. MATERIALS AND METHODS: Patients who underwent perineal urethrostomy between 2009 and 2023 were identified. A comprehensive long-term follow-up was conducted, evaluating both objective outcomes (retreatment-free survival) and subjective outcomes through the use of validated questionnaires. Additionally, to provide further context for our findings, we conducted a scoping review of all studies reporting outcomes following perineal urethrostomy. RESULTS: Among 76 patients, 55% had iatrogenic strictures, with 82% previously undergoing urethral interventions. At a median follow-up of 55 months, retreatment-free survival was 84%, with 16% of patients experiencing perineal urethrostomy recurrent stenosis. Patient-reported outcomes revealed a generally satisfactory voiding function (Urethral Stricture Surgery patient-reported outcome measure Lower Urinary Tract Symptoms score) and continence (International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form), with median scores of 4 (range 0-24) and 0 (range 0-21), but with bimodal distributions of sexual function scores (median International Index of Erectile Function-Erectile Function domain: 3.5; median Male Sexual Health Questionnaire-Ejaculation Scale: 21). Treatment satisfaction was very high with a median International Consultation on Incontinence Questionnaire-Satisfaction outcome score of 21 (range 0-24). The scoping review revealed varying success rates ranging from 51% to 95%, highlighting difficulties in comparison due to variable success definitions and patient case mix. CONCLUSIONS: Perineal urethrostomy provides effective treatment for complex anterior urethral strictures, with high patient satisfaction, preserved continence function, and favorable voiding outcomes. It presents a viable option for older and comorbid patients, especially after thorough counseling on expected outcomes and potential risks.

Impact of SPY Fluorescence Angiography on Incidence of Ureteroenteric Stricture After Urinary Diversion.

PURPOSE: Ureteroenteric strictures (UESs) are a common and morbid complication of radical cystectomy and urinary diversions. UES occurs in 4% to 25% of all patients undergoing urinary diversion, and anastomotic ischemia is implicated in stricture formation. SPY fluorescence angiography is a technology that can be employed during open surgery that allows for evaluation of ureteral perfusion. MATERIALS AND METHODS: We performed a prospective single-institution study of intraoperative use of SPY for ureteral assessment with a primary outcome of UES incidence compared with a cohort of historic controls prior to the use of SPY during urinary diversion at our institution. Chart abstraction was conducted to determine the presence of confirmed stricture in these patients, defined as endoscopic diagnosis or definitive imaging findings. Statistical analysis was performed using χ2 test for UES incidence. Demographics characteristics were analyzed with Wilcoxon rank sum test and χ2 test. RESULTS: A total of 332 patients underwent urinary diversion during the study period. UES occurred in 31 of 277 patients (11.1%) in the control group compared with 1 of 55 patients (1.8%) enrolled in the SPY arm (P = .03). The per-ureter UES rate was 6.7% (33/582) in the control group compared with 0.9% (1/107) in the SPY group. Median follow-up in the SPY group was 17.5 months and 58.6 months in the control group. Median Charlson Comorbidity Index was 5 in the SPY group and 4 in the control group. There were no other significant demographic differences between the study groups. CONCLUSIONS: SPY fluorescent angiography can be used during open urinary diversion to ensure perfusion to ureteroenteric anastomosis. Our single-institution study demonstrates a decreased incidence of UES when ureteral perfusion assessment is performed. CLINICAL TRIAL REGISTRATION NO.: NCT05022199.

Risk factors for and treatment of anastomotic strictures after Ivor Lewis esophagectomy.

INTRODUCTION: Anastomotic strictures following esophagectomy occur frequently and impact on nutrition and quality of life. Although strictures are often attributed to ischemia and anastomotic leaks, the role of anastomosis size and pyloroplasty is not well evaluated. Our study aims to assess the rate of and risk factors for anastomotic stricture following esophagectomy, and the impact of treatment with regular endoscopic balloon dilatations. METHODS: Consecutive patients (n = 207) undergoing Ivor Lewis esophagectomy performed by two surgeons at our institution were included. Data on patient demographics, surgical outcomes and anastomotic strictures were recorded. Relationship of anastomotic strictures with circular stapler size, pyloroplasty and anastomotic leak was analyzed. Treatment of strictures with endoscopic balloon dilatation was reviewed and percentage weight loss at 1 year was evaluated. RESULTS: Anastomotic strictures occurred in 17.4% of patients. Patient demographics between those with and without stricture were similar. Stricture rate was similar in patients with or without pyloroplasty (13.9% vs 21.7%, respectively, p = 0.14) and in those with or without an anastomotic leak (25.0% vs 16.6%, respectively, p = 0.345). Stricture risk increased with smaller sized stapler (25 mm = 33.3%, 28 mm = 15.3%, 31 mm = 4.8%; p = 0.027). The median number of dilatations required to fully treat strictures was 2 (IQR: 1-3). The median length of time from surgery to first dilatation was 2.9 months (IQR: 2.0-4.7) and to last dilatation was 6.1 months (IQR: 4.8-10.0). Median maximum dilatation diameter was 20 mm (IQR: 18.0-20.0). There were no complications from dilatations. Percentage weight loss at 1 year in patients with strictures was similar to those without strictures (8.7% vs 11.1%, respectively, p = 0.090). CONCLUSIONS: Post-esophagectomy anastomotic strictures are common and not necessarily related to anastomotic leaks or absence of pyloroplasty. Smaller anastomosis size was strongly linked with stricture formation. A driven approach with regular endoscopic balloon dilation is safe and effective in treating these strictures with no excess weight loss at 1 year once treated.

Upper Gastrointestinal Involvement in Crohn's Disease as an Independent Predictor of New-Onset Strictures: Insights from an Extensive Retrospective Cohort Analysis.

BACKGROUND/AIMS: Crohn's Disease (CD) can affect the entire gastrointestinal tract, including the upper sections (UGI), which is often overlooked, especially in Asian populations. There's a notable gap in research regarding the impact of UGI involvement on the intricate landscape of ensuing complications. This study aims to address this gap. METHODS: Conducting a retrospective study at Chang Gung Memorial Hospital from January 2001 to September 2023, we compared CD patients with UGI (Montreal L4) involvement against non-L4 counterparts, focusing on baseline characteristics, post-diagnosis complications, and overall outcomes. Routine UGI endoscopy was performed around the time of diagnosis in all patients followed in our inflammatory bowel disease (IBD) center, and all CD patients with adequate follow-up were included in this study. RESULTS: The study included 212 CD patients, 111 in the L4 group and 101 in the non-L4 group, with an average follow-up of 40.8 ± 15.1 months. At baseline, individuals in the L4 category demonstrated elevated smoking rates, increased Crohn's Disease Activity Index scores, a higher prevalence of strictures, and a more prevalent usage of biologics and proton pump inhibitors. Moreover, this group was characterized by reduced albumin levels. Upon concluding the follow-up, those with L4 involvement continued to show escalated CDAI scores and hospitalization frequencies, alongside heightened C-reactive protein levels and diminished albumin concentrations. Additionally, the occurrence of UGI involvement, stricturing disease at the time of diagnosis, and a younger age at the onset of CD were pinpointed as independent predictors for the development of new-onset strictures. CONCLUSIONS: CD patients with UGI involvement exhibit elevated disease activity and serve as independent predictors for the development of intestinal strictures. Thorough UGI evaluations at the time of diagnosis, coupled with assertive treatment strategies, are essential for managing these patients effectively.

A Rare Afferent Loop Syndrome Case in Adulthood Following Liver Transplantation in Neonatal Hemochromatosis.

Afferent loop syndrome, sometimes referred to as afferent limb syndrome, is an infrequent mechanical complication frequently observed following foregut surgeries involving the connection of the stomach or esophagus to the jejunum. This condition is commonly found in individuals who have undergone Billroth II reconstruction following a partial gastrectomy. Here, we present the first documented case of afferent loop syndrome in a patient with a medical history involving a liver transplant due to neonatal hemochromatosis.

Long-Term Outcomes Following Surgical Repair for Post-cholecystectomy Biliary Strictures.

INTRODUCTION: Bile duct injuries (BDIs) are a serious complication of cholecystectomy. Strictures that form after major injuries ultimately require surgical repair. This study aimed to analyse our experience with the surgical repair of post-cholecystectomy biliary strictures (PCBS). METHODS: Patients who underwent surgical repair for PCBS between January 2013 and March 2020 were retrospectively reviewed. The strictures were classified using the Bismuth system. Delayed repair with Roux-en-Y hepaticojejunostomy was performed using the Hepp-Couinaud technique. Outcomes were graded according to McDonald's criteria. Statistical analysis was performed to identify factors influencing the outcomes. RESULTS: Sixty-eight patients underwent repair for PCBS. Forty-five patients presented within one month and eight patients presented late after six months. Presenting symptoms were jaundice, external biliary fistula, biliomas, cholangitis and peritonitis. Portal hypertension was present in two patients. The median interval for definitive repair was 22 weeks. The median hospital stay was 9.5 days. Eighteen patients had postoperative complications. One patient had postoperative mortality due to uncorrectable coagulopathy. With a median follow-up of 54 months, successful outcomes were achieved in 61 (90%) patients. Four patients had anastomotic strictures evident at two, four, five and eight years after repair. Portal hypertension and postoperative complications were the variables associated with poor outcomes. CONCLUSION: BDIs following cholecystectomy are a devastating complication. Surgical repair for biliary strictures yields durable long-term outcomes with early identification and timely referral to a tertiary care centre where standardized techniques for biliary reconstruction are followed.

Course of Esophageal Strictures in Eosinophilic Esophagitis Using Structured Esophagram Protocol.

Background and Aims: A key unknown in eosinophilic esophagitis (EoE) is the long-term course of esophageal stenosis. Our aim was to evaluate the course of esophageal strictures using structured serial esophagrams and determine predictors of diameter improvement in patients with EoE. Methods: This was a retrospective study of 78 EoE patients who completed 2 structured esophagrams at an academic tertiary referral center between 2003 and 2021. Maximum and minimum esophageal diameters were measured during esophagram using a standardized protocol to reduce measurement errors. Results: The median age at first esophagram was 36.2 (12.9-64.3) years; 60.3% of patients were male; 41 patients had active EoE; and 9 were inactive. Of the patients, 39.7% had allergic rhinitis, asthma (32.1%), and atopic dermatitis (7.7%). Medical therapies at second esophagram and esophagogastroduodenoscopy included proton pump inhibitors (39.5%), swallowed topical steroids (31.6%), diet elimination (13.2%), biologic therapies (1.3%), and clinical trial medications (1.3%). Median maximum diameter significantly increased by 1.0 mm (Q1: -1.0 mm, Q3: 3.0 mm) (P = .034), independent of dilation (P = .744). Increase was most profound in patients starting in the lowest maximum diameter group (9-15 mm) with median increase of 3.0 mm. For patients in disease remission at the second esophagram, there was a significant increase in maximum diameter per year compared to active disease at 0.8 mm (Q1: 0.0 mm, Q3: 5.3 mm) and 0.0 mm (Q1: -0.4 mm, Q3: 0.6 mm) respectively (P = .019). Conclusion: Long-term improvement in esophageal strictures in patients with EoE may occur but is modest and likely occurs over years. Progression also appears to be minimal. Continuous medical treatment may reduce the rate of stricture recurrence and may improve stricture diameter over time.

Endoscopic Colorectal Stenting: Lessons Learned from a Two-Decade Journey.

Endoscopic colorectal stenting has gained momentum over the last two decades as a viable alternative to surgical intervention in a subgroup of patients with colorectal disease. Stenting can be used as a temporizing bridge to surgical intervention or as a definitive treatment measure. Patient selection and the technical expertise of the endoscopist are of paramount importance to optimize the clinical outcome. Technical skills in therapeutic endoscopy and the choice of proper equipment including the consumables are required for the conduct of a safe and successful procedure. In this article, we share the lessons learned from a two-decade journey of the senior author with therapeutic endoscopy.

Robot-assisted uretero-enteric reimplantation for uretero-enteric anastomotic strictures following robot-assisted radical cystectomy: Surgical approach and outcomes over two decades.

Objective: We described the technique and outcomes of robot-assisted repair of uretero-enteric strictures (UES) following robot-assisted radical cystectomy (RARC) and urinary diversion. Methods: Retrospective review of our RARC database from November 2005 to August 2023 at Roswell Park Comprehensive Cancer center was performed. Patients who developed UES and ultimately underwent robot-assisted uretero-enteric reimplantation (RUER) were identified. Kaplan-Meier method was used to compute the cumulative incidence recurrence rate of UES after RUER. A multivariable regression model was used to identify variables associated with UES recurrence. Results: A total of 123 (15%) out of 808 RARC patients developed UES, of whom 52 underwent reimplantation (45 patients underwent RUER [n=55 cases] and seven patients underwent open uretero-enteric reimplantation). The median time from RARC to UES was 4.4 (interquartile range 3.0-7.0) months, and the median time between UES and RUER was 5.2 (interquartile range 3.2-8.9) months. The 3-year recurrence rate after RUER is about 29%. On multivariable analysis, longer hospital stay (hazard ratio 1.37, 95% confidence interval 1.16-1.61, p<0.01) was associated with recurrent UES after RUER. Conclusion: RUER for UES after RARC is feasible with durable outcomes although a notable subset of patients experienced postoperative complications and UES recurrence.

Role of buccal mucosa graft ureteroplasty in the surgical management of pyeloplasty failure.

Objective: Secondary pyeloplasty for recurrent ureteropelvic junction obstructions may be a safe and feasible surgical option for patients. This study aimed to demonstrate outcomes of utilizing a non-transecting buccal mucosa graft ureteroplasty for management of recurrent ureteropelvic junction obstruction after prior failed pyeloplasty. Methods: We performed a retrospective review of our Collaborative of Reconstructive Robotic Ureteral Surgery database for all consecutive patients who underwent buccal mucosa graft ureteroplasty between April 2012 and June 2022 for management of recurrent ureteropelvic junction obstructions after prior failed pyeloplasty. The primary outcome included surgical success which was defined as the absence of flank pain and no obstruction on imaging. Results: Overall, ten patients were included in our analysis. The median stricture length was 2.5 (interquartile range [IQR] 1.8-4.0) cm. The median operative time was 230.5 (IQR 199.5-287.0) min and median estimated blood loss was 50.0 (IQR 28.8-102.5) mL. At a median follow-up of 10.3 (IQR 6.2-14.8) months, 80% of patients were surgically successful and there were no major (Clavien-Dindo Grade>2) complications. Conclusion: Buccal mucosa graft ureteroplasty is a valuable non-transecting surgical option for patients with recurrent ureteropelvic junction obstructions who failed prior pyeloplasty and has comparable outcomes to the literature regarding standard transecting techniques.

Analysis of the urethral stricture score and patient-related factors as predictors of outcomes following oral mucosal graft urethroplasty.

Objective: The complexity of urethral strictures can predict outcomes following urethroplasty. The previously described urethral stricture score (U score) considered only stricture-related factors to grade the complexity of urethral strictures and to predict recurrence post urethroplasty, but not considered patient-related factors for the same. We aimed to study the correlation of both of these factors to the outcomes of oral mucosal graft urethroplasty. Methods: We retrospectively reviewed data of 101 patients who underwent oral mucosal graft urethroplasty in our institute with a minimum follow-up of 6 months. Baseline patient characteristics and stricture-related parameters were noted. The U score was calculated for all patients which consisted of the length, location, number, and etiology of stricture. Univariate and multivariate Cox proportional hazard regression models were used to determine significant risk factors of recurrence. Results: The mean follow-up of patients was 15 months. Recurrence was seen in 28 patients and the mean time for detection of recurrence was 8 months of follow-up. The Charlson Comorbidity Index, history of previous intervention, length of strictures, location of strictures, number of strictures, history of smoking, and etiology were independent predictors of recurrence following urethroplasty. Based on these parameters, we formulated the modified U score (MU score). The scores ranged from 0 to 6 and a score of >2 was found to be predictive of recurrence. On comparing receiver operating characteristic curves for both scores by the DeLong test, the MU score had larger area under the curve than the U score. Conclusion: The MU scoring system is the first of its kind attempt taking into consideration both patient- and stricture-related factors to predict recurrence following oral mucosal graft urethroplasty.