EUS-guided coil injection therapy in the management of gastric varices: the first U.S. multicenter experience (with video).

BACKGROUND AND AIMS: Despite the significant morbidity associated with gastric variceal bleeding, there is a paucity of high-quality data regarding optimal management. EUS-guided coil injection therapy (EUS-COIL) has recently emerged as a promising endoscopic modality for the treatment of gastric varices (GV), particularly compared with traditional direct endoscopic glue injection. Although there are data on the feasibility and safety of EUS-COIL in the management of GV, these have been limited to select centers with particular expertise. The aim of this study was to report the first U.S. multicenter experience of EUS-COIL for the management of GV. METHODS: This retrospective analysis included patients with bleeding GV or GV at risk of bleeding who underwent EUS-COIL at 10 U.S. tertiary care centers between 2018 and 2022. Baseline patient and procedure-related information was obtained. EUS-COIL entailed the injection of .018 inch or .035 inch hemostatic coils using a 22-gauge or 19-gauge FNA needle. Primary outcomes were technical success (defined as successful deployment of coil into varix under EUS guidance with diminution of Doppler flow), clinical success (defined as cessation of bleeding if present and/or absence of bleeding at 30 days' postintervention), and intraprocedural and postprocedural adverse events. RESULTS: A total of 106 patients were included (mean age 60.4 ± 12.8 years; 41.5% female). The most common etiology of GV was cirrhosis (71.7%), with alcohol being the most common cause (43.4%). Overall, 71.7% presented with acute GV bleeding requiring intensive care unit stay and/or blood transfusion. The most common GV encountered were isolated GV type 1 (60.4%). A mean of 3.8 ± 3 coils were injected with a total mean length of 44.7 ± 46.1 cm. Adjunctive glue or absorbable gelatin sponge was injected in 82% of patients. Technical success and clinical success were 100% and 88.7%, respectively. Intraprocedural adverse events (pulmonary embolism and GV bleeding from FNA needle access) occurred in 2 patients (1.8%), and postprocedural adverse events occurred in 5 (4.7%), of which 3 were mild. Recurrent bleeding was observed in 15 patients (14.1%) at a mean of 32 days. Eighty percent of patients with recurrent bleeding were successfully re-treated with repeat EUS-COIL. No significant differences were observed in outcomes between high-volume (>15 cases) and low-volume (<7 cases) centers. CONCLUSIONS: This U.S. multicenter experience on EUS-COIL for GV confirms high technical and clinical success with low adverse events. No significant differences were seen between high- and low-volume centers. Repeat EUS-COIL seems to be an effective rescue option for patients with recurrent bleeding GV. Further prospective studies should compare this modality versus other interventions commonly used for GV.

Endoscopic resection of GI stromal tumor using full-thickness resection device: tips and tricks.

Video 1R0 endoscopic resection of gastric GI stromal tumor using a dedicated gastroduodenal full-thickness resection device.

Factors predictive of persistent fistulas in EUS-directed transgastric ERCP: a multicenter matched case-control study.

BACKGROUND AND AIMS: EUS-directed transgastric ERCP (EDGE) is an established method for managing pancreaticobiliary pathology in Roux-en-Y gastric bypass patients, with high rates of technical success and low rates of serious adverse events (AEs). However, widespread adoption of the technique has been limited because of concerns about the development of persistent gastrogastric or jejunogastric fistulas. Gastrogastric and jejunogastric fistulas have been reported in up to 20% of cases in some series, but predictive risk factors and long-term management and outcomes are lacking. Therefore, our aims were to assess factors associated with the development of persistent fistulas and the technical success of endoscopic fistula closure. METHODS: This is a case-control study involving 9 centers (8 USA, 1 Europe) from February 2015 to September 2021. Cases of persistent fistulas were defined as endoscopic or imaging evidence of fistula more than 8 weeks after lumen-apposing metal stent (LAMS) removal. Control subjects were defined as endoscopic or imaging confirmation of no fistula more than 8 weeks after LAMS removal. AEs were defined and graded according to the American Society for Gastrointestinal Endoscopy lexicon. RESULTS: Twenty-five patients identified to have evidence of a persistent fistula on follow-up surveillance (cases) were matched with 50 patients with no evidence of a persistent fistula on follow-up surveillance (control subjects) based on age and sex. Mean LAMS dwell time was 74.7 ± 106.2 days. After LAMS removal, argon plasma coagulation (APC) ablation of the fistula was performed in 46 patients (61.3%). Primary closure of the fistula was performed in 26.7% of patients (20: endoscopic suturing in 17, endoscopic tacking in 2, and over-the-scope clips + endoscopic suturing in 1). When comparing cases with control subjects, there was no difference in baseline demographics, fistula site, LAMS size, or primary closure frequency between the 2 groups (P > .05). However, in the persistent fistula group, the mean LAMS dwell time was significantly longer (127 vs 48 days, P = .02) and more patients had ≥5% total body weight gain (33.3% vs 10.3%, P = .03). LAMS dwell time was a significant predictor of persistent fistula (odds ratio, 4.5 after >40 days in situ, P = .01). The odds of developing a persistent fistula increased by 9.5% for every 7 days the LAMS was left in situ. In patients with a persistent fistula, endoscopic closure was attempted in 19 (76%) with successful resolution in 14 (73.7%). CONCLUSIONS: Longer LAMS dwell time was found to be associated with a higher risk of persistent fistulas in EDGE patients. APC or primary closure of the fistula on LAMS removal was not found to be protective against developing a persistent fistula, which, if present, can be effectively managed through endoscopic closure in most cases.

EUS-directed transgastric interventions in Roux-en-Y gastric bypass anatomy: a multicenter experience.

BACKGROUND AND AIMS: Placement of a lumen-apposing metal stent (LAMS) between the gastric pouch and the excluded stomach allows for EUS-guided transgastric interventions (EDGIs) in patients with Roux-en-Y gastric bypass (RYGB). Although EUS-guided transgastric ERCP (EDGE) outcomes have been reported, data are scant on other endoscopic interventions. We aimed to evaluate the outcomes and safety of EDGIs. METHODS: This retrospective study involved 9 centers (United States, 8; Europe, 1) and included patients with RYGB who underwent EDGIs between June 2015 and September 2021. The primary outcome was the technical success of EDGIs. Secondary outcomes were adverse events (AEs), length of hospital stay, and fistula follow-up and management. RESULTS: Fifty-four EDGI procedures were performed in 47 patients (mean age, 61 years; 72% women), most commonly for the evaluation of a pancreatic mass (n = 16) and management of pancreatic fluid collections (n = 10). A 20-mm LAMS was used in 26 patients and a 15-mm LAMS in 21, creating a gastrogastrostomy in 37 patients and jejunogastrostomy in 10. Most patients (n = 30, 64%) underwent a dual-session EDGI, with a median interval of 17 days between the 2 procedures. Single-session EDGI was performed in 17 patients, of whom 10 (59%) had anchoring of the LAMS. The most common interventions were diagnostic EUS (with or without FNA or fine-needle biopsy sampling; n = 28) and EUS-guided cystgastrostomy (n = 8). The mean procedural time was 97.6 ± 78.9 minutes. Technical success was achieved in 52 patients (96%). AEs occurred in 5 patients (10.6%), of which only 1 AE (2.1%) was graded as severe. Intraprocedural LAMS migration was the most common AE, occurring in 3 patients (6.4%), whereas delayed spontaneous LAMS migration occurred in 2 (4.3%). Four of the 5 LAMS migration events were managed endoscopically, and 1 required surgical repair. LAMS anchoring was found to be protective against LAMS migration (P = .001). The median duration of hospital stay was 2.1 ± 3.7 days. Of the 17 patients who underwent objective fistula assessment endoscopically or radiologically after LAMS removal, 2 (11.7%) were found to have persistent fistulas. In 1 case the fistula was intentionally left open to assist with weight gain. The other fistula was successfully closed endoscopically. CONCLUSIONS: EDGI is effective and safe for the diagnosis and management of pancreaticobiliary and foregut disorders in RYGB patients. It is associated with high rates of technical success and low rates of severe AEs. LAMS migration is the most common AE with evidence that anchoring can be protective against its occurrence. Persistent fistulas may occur, but endoscopic closure seems to be effective.

Hepaticogastrostomy versus choledochoduodenostomy: An international multicenter study on their long-term patency.

BACKGROUND AND OBJECTIVES: EUS-guided biliary drainage (EUS-BD) offers minimally invasive decompression when conventional endoscopic retrograde cholangiopancreatography fails. Stents can be placed from the intrahepatic ducts into the stomach (hepaticogastrostomy [HG]) or from the extrahepatic bile duct into the small intestine (choledochoduodenostomy [CCD]). Long-term patency of these stents is unknown. In this study, we aim to compare long-term patency of CCD versus HG. METHODS: Consecutive patients from 12 centers were included in a registry over 14 years. Demographics, procedure info, adverse events, and follow-up data were collected. Student's t-test, Chi-square, and logistic regression analyses were conducted. Only patients with at least 6-month follow-up or who died within 6-month postprocedure were included. RESULTS: One-hundred and eighty-two patients were included (93% male; mean age: 70; HG n = 95, CCD n = 87). No significant difference in indication, diagnosis, dissection instrument, or stent type was seen between the two groups. Technical success was 92% in both groups. Clinical success was achieved in 75/87 (86%) in the HG group and 80/80 (100%) in the CCD group. A trend toward higher adverse events was seen in the CCD group. A total of 25 patients out of 87 needed stent revision in the HG group (success rate 71%), while eight out of 80 were revised in the CCD group (success rate 90%). Chi square shows CCD success higher than HG (90% vs. 71%, P = 0.010). After adjusting for diagnosis, jaundice or cholangitis presentation, instrument used for dissection, and gender, CCD was 4.5 times more likely than HG to achieve longer stent patency or manage obstruction (odds ratio 4.5; 95% 1.1548-17.6500, P = 0.0302). CONCLUSION: CCD is associated with superior long-term patency than HG but with a trend toward higher adverse events. This is particularly important in patients with increased survival. Additional studies are required before recommending a change in practice.

Safety and efficacy of the use of lumen-apposing metal stents in the management of postoperative fluid collections: a large, international, multicenter study.

BACKGROUND: Multiple studies have examined the use of lumen-apposing metal stents (LAMSs) for the drainage of peripancreatic fluid collections. Data on the use of LAMSs for postoperative fluid collections (POFCs) are scarce. POFCs may lead to severe complications without appropriate treatment. We aimed to study the outcomes (technical success, clinical success, rate/severity of adverse events, length of stay, recurrence) of the use of LAMSs for the drainage of POFCs. METHODS: This international, multicenter, retrospective study involved 19 centers between January 2012 and October 2017. The primary outcome was clinical success. Secondary outcomes included technical success and rate/severity of adverse events using the ASGE lexicon. RESULTS: A total of 62 patients were included during the study period. The most common etiology of the POFCs was distal pancreatectomy (46.8 %). The mean (standard deviation) diameter was 84.5 mm (30.7 mm). The most common indication for drainage was infection (48.4 %) and transgastric drainage was the most common approach (82.3 %). Technical success was achieved in 60/62 patients (96.8 %) and clinical success in 57/62 patients (91.9 %) during a median (interquartile range) follow-up of 231 days (90 - 300 days). Percutaneous drainage was needed in 8.1 % of patients. Adverse events occurred intraoperatively in 1/62 patients (1.6 %) and postoperatively in 7/62 (11.3 %). There was no procedure-related mortality. CONCLUSION: This is the largest study on the use of LAMSs for POFCs. It suggests good clinical efficacy and safety of this approach. The use of LAMSs in the management of POFCs is a feasible alternative to percutaneous and surgical drainage.

Setting minimum standards for training in EUS and ERCP: results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees.

BACKGROUND AND AIMS: Minimum EUS and ERCP volumes that should be offered per trainee in "high quality" advanced endoscopy training programs (AETPs) are not established. We aimed to define the number of procedures required by an "average" advanced endoscopy trainee (AET) to achieve competence in technical and cognitive EUS and ERCP tasks to help structure AETPs. METHODS: American Society for Gastrointestinal Endoscopy (ASGE)-recognized AETPs were invited to participate; AETs were graded on every fifth EUS and ERCP examination using a validated tool. Grading for each skill was done using a 4-point scoring system, and learning curves using cumulative sum analysis for overall, technical, and cognitive components of EUS and ERCP were shared with AETs and trainers quarterly. Generalized linear mixed-effects models with a random intercept for each AET were used to generate aggregate learning curves, allowing us to use data from all AETs to estimate the average learning experience for trainees. RESULTS: Among 62 invited AETPs, 37 AETs from 32 AETPs participated. Most AETs reported hands-on EUS (52%, median 20 cases) and ERCP (68%, median 50 cases) experience before starting an AETP. The median number of EUS and ERCPs performed per AET was 400 (range, 200-750) and 361 (range, 250-650), respectively. Overall, 2616 examinations were graded (EUS, 1277; ERCP-biliary, 1143; pancreatic, 196). Most graded EUS examinations were performed for pancreatobiliary indications (69.9%) and ERCP examinations for ASGE biliary grade of difficulty 1 (72.1%). The average AET achieved competence in core EUS and ERCP skills at approximately 225 and 250 cases, respectively. However, overall technical competence was achieved for grade 2 ERCP at about 300 cases. CONCLUSION: The thresholds provided for an average AET to achieve competence in EUS and ERCP may be used by the ASGE and AETPs in establishing the minimal standards for case volume exposure for AETs during their training. (Clinical trial registration number: NCT02509416.).

Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography, From Training Through Independent Practice.

BACKGROUND & AIMS: It is unclear whether participation in competency-based fellowship programs for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) results in high-quality care in independent practice. We measured quality indicator (QI) adherence during the first year of independent practice among physicians who completed endoscopic training with a systematic assessment of competence. METHODS: We performed a prospective multicenter cohort study of invited participants from 62 training programs. In phase 1, 24 advanced endoscopy trainees (AETs), from 20 programs, were assessed using a validated competence assessment tool. We used a comprehensive data collection and reporting system to create learning curves using cumulative sum analysis that were shared with AETs and trainers quarterly. In phase 2, participating AETs entered data into a database pertaining to every EUS and ERCP examination during their first year of independent practice, anchored by key QIs. RESULTS: By the end of training, most AETs had achieved overall technical competence (EUS 91.7%, ERCP 73.9%) and cognitive competence (EUS 91.7%, ERCP 94.1%). In phase 2 of the study, 22 AETs (91.6%) participated and completed a median of 136 EUS examinations per AET and 116 ERCP examinations per AET. Most AETs met the performance thresholds for QIs in EUS (including 94.4% diagnostic rate of adequate samples and 83.8% diagnostic yield of malignancy in pancreatic masses) and ERCP (94.9% overall cannulation rate). CONCLUSIONS: In this prospective multicenter study, we found that although competence cannot be confirmed for all AETs at the end of training, most meet QI thresholds for EUS and ERCP at the end of their first year of independent practice. This finding affirms the effectiveness of training programs. Clinicaltrials.gov ID NCT02509416.

Comparison of FNA and fine-needle biopsy for EUS-guided sampling of suspected GI stromal tumors.

BACKGROUND AND AIMS: Subepithelial lesions are found in about 1% of all EGD procedures, and GI stromal tumors are a type of subepithelial lesion commonly encountered. Although the majority of subepithelial lesions are benign, GI stromal tumors have malignant potential, making a definitive diagnosis important. Currently, the criterion standard for the diagnosis of GI stromal tumors is EUS-directed FNA (EUS-FNA). The definitive diagnosis of GI stromal tumors relies on immunohistochemical staining, which depends on enough tissue being submitted to the pathologist. Achieving adequate tissue acquisition from suspected GI stromal tumors by EUS-FNA remains a limitation. Advancements in needle design, however, have improved tissue acquisition and therefore may improve the definitive diagnosis of GI stromal tumors by EUS-FNA. The goal of this study is to compare a fine-needle biopsy (FNB) needle (SharkCore, Medtronics) with FNA needles in definitively diagnosing suspected GI stromal tumors. METHODS: This is a retrospective, single-center study of consecutive patients with suspected GI stromal tumors by EUS characterization who underwent EUS-FNA or EUS-FNB. RESULTS: A total of 106 patients (53 men, mean [± standard deviation {SD}] age 62.19 ± 16.33 years) were included in the study undergoing EUS-FNA or EUS-FNB of suspected GI stromal tumors. The needle size that was used most often was 22 gauge in both groups. The average size of the lesions was 27.68 ± 15.70 mm; 71.7% of lesions were located in stomach, 19.8% in the esophagus, 5.7% in the duodenum, and 2.8% in the rectosigmoid colon. Ninety-one patients underwent EUS-FNA and 15 patients underwent EUS-FNB. Adequate tissue was procured, allowing immunohistochemical staining in 59 (64.8%) patients in the FNA group and 15 (100%) patients in the FNB group; P = .006. A diagnosis was reached by immunohistochemical staining in 48 (52.7%) patients in the FNA group and 13 (86.7%) patients in the FNB group; P = .01. Tissue was insufficient to make a cytologic diagnosis in 22 (24.2%) patients in the FNA group compared with none in the FNB group; P = .03. Adequate tissue was procured on the first pass of the FNB needle in the majority of patients (83.3%), whereas only 23.5% of patients had adequate tissue on the first pass by the FNA needle, with a median of 3 passes; P = .00. Tissue was insufficient to perform immunohistochemical staining, and thus a diagnosis could not be confirmed before surgery in 8 of the 34 surgical patients in the FNA group. Ten of 15 patients in the EUS-FNB group underwent surgery, all of whom were correctly diagnosed by FNB. There were no reported immediate adverse events or technical difficulties in either group. CONCLUSIONS: EUS-FNB by using a SharkCore needle for suspected GI stromal tumors is technically similar and equally safe as FNA, with better tissue acquisition, which was achieved with fewer needle passes and an improved diagnostic yield by immunohistochemical staining.

Performance characteristics of molecular (DNA) analysis for the diagnosis of mucinous pancreatic cysts.

BACKGROUND: Diagnosis of mucinous pancreatic cysts (MPCs) is challenging due to the poor sensitivity of cytology provided by EUS-guided-FNA (EUS-FNA). OBJECTIVE: To quantify the test characteristics of molecular (DNA) analysis in suspected low-risk MPCs. DESIGN: A prospective cohort study performed in between 2008 and 2011. SETTING: Academic referral center. PATIENTS: Consecutive patients who underwent EUS-FNA of suspected MPCs. INTERVENTION: EUS-FNA and molecular (DNA) analysis of cyst fluid. MAIN OUTCOME MEASUREMENTS: The sensitivity and specificity of molecular analysis in the diagnosis of MPCs using the criterion standard of surgical pathology in resected cysts. RESULTS: Patients with suspected MPCs underwent EUS-FNA and cyst fluid DNA analysis. Surgical resection was performed in 48 patients (17%), confirming a mucinous pathology in 38 (79%). In this group, molecular analysis had a sensitivity of 50% and a specificity of 80% in identifying MPCs (accuracy of 56.3%). The combination of molecular analysis with cyst fluid carcinoembryonic antigen (CEA) and cytology resulted in higher MPC diagnostic performance than either one of its individual components, with a sensitivity, specificity, and accuracy of 73.7%, 70%, and 72.9%, respectively. There was no significant difference in accuracy between molecular analysis and CEA/cytology in this group. LIMITATIONS: Single-center experience. CONCLUSION: Molecular analysis aids in the diagnosis of MPCs when cytology is nondiagnostic or cyst fluid is insufficient for CEA or its level is indeterminate. Our results do not support the routine use of molecular analysis, which should be used selectively after review of imaging findings and cyst fluid studies. Further studies are needed to assess DNA's performance in malignant cysts.

Impact of preoperative endoscopic ultrasound-guided fine needle aspiration on postoperative recurrence and survival in cholangiocarcinoma patients.

BACKGROUND AND STUDY AIM: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is frequently performed for suspected biliary tumors for diagnosis and staging but carries a theoretical risk of needle-track seeding. We aimed to evaluate the impact of preoperative EUS-FNA on long-term outcomes for patients with cholangiocarcinoma (CCA). PATIENTS AND METHODS: In a retrospective single-center study of consecutive patients with CCA with preoperative EUS-FNA, main outcome measures were overall survival and progression-free survival. RESULTS: In 150 patients with confirmed CCA, 61 underwent preoperative FNA. Median overall survival was 18.5 months (95% confidence limits [CL] 15.4, 25.7): 111 patients died and 39 survived. Of the 150 patients, 119 underwent curative-intent surgical resection, with median progression-free survival of 17.8 months (95% CL 14.5, 22.8); 89/119 patients had tumor recurrence or died, and 30/119 remained alive and disease-free. On multivariable analysis, overall survival was associated with: undergoing curative-intent surgery (hazard ratio [HR] 5.79, P = 0.001), lack of lymph node involvement (HR 1.89, P = 0.011), younger age (HR 1.51 for every 10 years, P < 0.0015), and small tumor size (HR 1.11 for every 1 cm, P = 0.029). For patients undergoing curative-intent surgery, on multivariable analysis, improved progression-free survival was associated with: lack of lymph node involvement (HR 1.88, P = 0.010), smaller tumor size (HR 1.16 for every 1 cm smaller, P = 0.003), and younger age (HR 1.53 for every 10 years, P < 0.001). Number of needle passes showed no statistically significant impact on overall survival. CONCLUSION: Preoperative EUS-FNA in patients with CCA does not appear to adversely affect overall or progression-free survival.

Prospective description of coughing, hemodynamic changes, and oxygen desaturation during endoscopic sedation.

BACKGROUND: Deep sedation is increasingly used for endoscopy. The impact of sedation level on hemodynamic status, oxygenation, and aspiration risk is incompletely described. AIMS: To describe the incidence of intraprocedural cough, hemodynamic changes, oxygen desaturation, and their relationship to clinical factors and sedation level. METHODS: Detailed prospective recordings of hemodynamic changes, oxygen desaturation, and cough during 757 nonemergent endoscopic procedures done under sedation using propofol, midazolam, and/or fentanyl. RESULTS: Thirteen percent of patients had at least one cough and 3% had prolonged cough. Cough was more common in nonsmokers (P = 0.05), upper endoscopy (P < 0.0001), with propofol (P = 0.0008), longer procedures (P = 0.0001), and hiccups (P = 0.01). The association between supine positioning during colonoscopy and cough approached significance (P = 0.06). Oxygen desaturation was rare (4%) and associated only with deep sedation (P = 0.02). Mean systolic and diastolic blood pressure (BP) dropped by 7.3 and 5.6% respectively. Decreases in systolic BP were more common in whites (P = 0.03), males (P = 0.004), nonsmokers (P = 0.04), during colonoscopy (P < 0.0001), and in patients receiving midazolam and fentanyl (P = 0.01). Heart rate (HR) dropped >20% from baseline in 15% of patients and was more common during colonoscopy (P = 0.002). HR increased >20% in 20% of patients and was more common with coughing (P < 0.0001) and in younger patients (P = 0.0002). No patient required pharmacologic treatment of BP or HR. CONCLUSIONS: We have described procedural predictors of cough that may help clinicians reduce the risk of aspiration during endoscopy. Hemodynamic changes during endoscopy are common but largely clinically insignificant.

Overview on practices in thalassemia intermedia management aiming for lowering complication rates across a region of endemicity: the OPTIMAL CARE study.

Despite recent advances in understanding the pathophysiologic mechanisms behind the thalassemia intermedia (TI) phenotype, data on the effects of treatment are deficient. To provide such data, we evaluated 584 TI patients for the associations between patient and disease characteristics, treatment received, and the rate of complications. The most common disease-related complications were osteoporosis, extramedullary hematopoeisis (EMH), hypogonadism, and cholelithiasis, followed by thrombosis, pulmonary hypertension (PHT), abnormal liver function, and leg ulcers. Hypothyroidism, heart failure, and diabetes mellitus were less frequently observed. On multivariate analysis, older age and splenectomy were independently associated with an increased risk of most disease-related complications. Transfusion therapy was protective for thrombosis, EMH, PHT, heart failure, cholelithiasis, and leg ulcers. However, transfusion therapy was associated with an increased risk of endocrinopathy. Iron chelation therapy was in turn protective for endocrinopathy and PHT. Hydroxyurea treatment was associated with an increased risk of hypogonadism yet was protective for EMH, PHT, leg ulcers, hypothyroidism, and osteoporosis. Attention should be paid to the impact of age on complications in TI, and the beneficial role of splenectomy deserves revisiting. This study provides evidence that calls for prospective evaluation of the roles of transfusion, iron chelation, and hydroxyurea therapy in TI patients.

Vertical and horizontal coordinates of the nipple-areola complex position in males.

After massive weight loss, male breasts in particular are one of the most disturbing body regions and can be a difficult area to treat often requiring nipple-areola repositioning. The need for bilateral repositioning of the nipple-areola complex is also increasing in other surgical fields such as in female-to-male transsexual patients with large breasts and in patients with severe forms of gynecomastia. Proper configuration and localization of the nipple-areola complex requires both meticulous planning and a thorough understanding of the male anatomy and is essential in determining final aesthetic outcome. Currently available guidelines create areolas that are too large, place the nipple-areola complex too high and too far medially, and/or require complex abstract mathematical calculations. Relying on the recently appreciated aesthetic value of the golden number Phi (phi) we propose an easy and reliable method to determine the horizontal and vertical coordinates of the male nipples. With only 2 easily measurable distances, umbilicus-anterior axillary fold apex and umbilicus-suprasternal notch, the internipple distance and the position of the horizontal nipple plane relative to the suprasternal notch can be calculated. The internipple distance can be determined with 95% accuracy and the distance from the suprasternal notch can be determined in 80% of cases within a range of 3.33 +/- 1.25 cm.