Common bile duct size in malignant distal obstruction and lumen-apposing metal stents: a multicenter prospective study

Background and study aims Feasibility of EUS-guided choledochoduodenostomy (EUS-CDS) using available lumen-apposing stents (LAMS) is limited by the size of the common bile duct (CBD) (≤ 12 mm, cut-off for experts; 15 mm, cut-off for non-experts). We aimed to assess the prevalence and predictive factors associated with CBD size ≥ 12 and 15 mm in naïve patients with malignant distal biliary obstruction (MDBO). Patients and methods This was a prospective cohort study involving 22 centers with assessment of CBD diameter and subjective feasibility of the EUS-CDS performance in naïve jaundiced patients undergoing EUS evaluation for MDBO. Results A total of 491 patients (mean age 69 ± 12 years) with mean serum bilirubin of 12.7 ± 6.6 mg/dL entered the final analysis. Dilation of the CBD ≥ 12 and 15 mm was detected in 78.8 % and 51.9 % of cases, respectively. Subjective feasibility of EUS-CDS was expressed by endosonographers in 91.2 % for a CBD ≥ 12 mm and in 96.5 % for a CBD ≥ 15 mm. On multivariate analysis, age (P < 0.01) and bilirubin level (P ≤ 0.001) were the only factors associated with both CBD dilation ≥ 12 and ≥ 15 mm. These variables were poorly associated with the extent of duct dilation; however, based on them a prediction model could be constructed that satisfactorily predicted CBD size ≥ 12 mm in patients at least 70 years and a bilirubin level ≥ 7 mg/dL. Conclusions Our study showed that at presentation in a large cohort of patients with MDBO, EUS-CDS can be potentially performed in three quarters to half of cases by expert and less experienced endosonographers, respectively. Dedicated stents or devices with different designs able to overcome the limitations of existing electrocautery-enhanced LAMS for EUS-CDS are needed.

Endoscopic Ultrasound versus Conventional Ultrasonography as A Diagnostic Tool for Patients with Obstructive Jaundice

Background Patient presented with jaundice, initial evaluation should be ultrasonography for evaluation of liver parenchymal changes, cirrhosis and assessment of hepatic vascularity and evaluation of intrahepatic, extrahepatic biliary system. Aim of the Work to compare between the Conventional US and Endoscopic Ultrasound in diagnosis of obstructive jaundice and other diagnostic modality including CT/MRI, ERCP for diagnosis and evaluation of the cause of OJ. Patients and Methods This study was conducted on 60 patients with obstructed jaundice as evident by ultrasonography in the form of dilated CBD with IHBRDs, with visualization of Gall bladder content and pancreas if can be well visualized, all patients had clinically apparent jaundice with disturbance of liver biochemical profile, all patient underwent EUS and compare finding with US including CBD diameter and IHBRDs degree. Results EUS provide better visualization of CBD and IHBRDs with diagnosis of pathological lesion including stones, malignancy. EUS also has better visualization of pancreatic pathology including inflammation and malignancy and extent of the tumor including local extent, lymphatic spread with vascular invasion. Conclusion EUS is better than US and other modality CT&MRI and ERCP in diagnosis of distal CBD stricture including malignant obstruction especially in cases of early malignancy and small tumors, and calculary distal obstruction. CT is insensitive in diagnosis of periampullary cancer, EUS provide early diagnosis of Pancreaticobiliary malignancy and give better advandage for early resectability .

Мinimally invasive stent technologies in hepatopancreatobiliary surgery

Aim. To compare the aspects of the use of various stents in hepatopancreatobiliary zone diseases.Materials and methods. We analyzed the experience of using biliary plastic and metal self-expanding stents placed by the antegrade percutaneous (n = 45) or retrograde endoscopic method (n = 160). Pancreatic stenting with 5 Fr plastic stents was performed in 35 patients.Results. Our experience shows the high efficiency of stenting performed by antegrade and endoscopic retrograde access for bile and pancreatic ducts obstruction. Pancreatic stenting is justified in the prevention of acute pancreatitis (in the presence of a risk factor) and in treatment of post-ERCP pancreatitis, as well as in the treatment of acute biliary pancreatitis with impacted stone in papilla Vater.Conclusion. Minimally invasive technologies has a leading role in the treatment of patients with ductal failure of the hepatopancreatobiliary zone. Stenting should be used to prepare for radical surgery or as a final palliative treatment method. A differentiated approach is important in selecting a stent, depending on the specific clinical task. For biliary drainage in patients with obstructive jaundice of various etiologies, it is permissible to use both the retrograde and antegrade stenting. The choice of the decompression method depends on the level of the biliary obstruction, the cause of obstructive jaundice, the technical equipment of the department and the training of specialists in retrograde and (or) antegrade endobiliary technologies. Antegrade access is preferred for proximal obstruction of the bile ducts, retrograde endoscopic access is preferred for distal obstruction.

Surgical management of spontaneously ruptured kidney with peritonitis due to neglected renal and ureteric calculi

A 30-year-old woman presented with right-sided abdominal pain associated with fever. Her ultrasound showed right renal calculus with no hydronephrosis along with collection in peritoneal cavity and pouch of Douglas. CT showed ruptured right kidney with multiple renal and ureteric calculi as well as displaced renal calculi in perinephric space and pararenal space. Exploratory laparotomy and right nephroureterectomy were done. Nephrolithiasis with secondary infection makes the kidney fragile due to pathological changes, which may cause rupture of the renal calyces with trivial trauma or may be spontaneous. Distal obstruction by the stone and increased back pressure in the calyces may have added to the spontaneous rupture of the calyx and subsequently renal parenchyma. Management includes early exploration with nephrectomy and it is often life saving.

Flaps in adult urethrocutaneous fistula repair: a report of two cases with the review of literature

Urethrocutaneous fistula (UCF) poses a challenge to the reconstructive urologist in terms of its location, patient’s expectations, availability of tissues for interposition, wound infection and chances of recurrence. Also, patient-related factors, such as uncontrolled diabetes, local surgery with extensive tissue loss, prior history of radiation, poor nutritional status and presence of any distal obstruction in the urethra severely affect the outcomes of a good repair with vascularised flap. We report two cases of UCF repair in adults using scrotal and gracilis muscle flaps (GMFs), their anatomic basis, technicality and advantages. The scrotal flap was used in the first case where it was freely available and GMF in second case where the patient had already undergone extensive local tissue debridement for Fournier’s gangrene and hence, we had to look for a distant flap for protection of the UCF repair. Both patients had an uneventful recovery, there were no early or late treatment-related complications and follow-up after the third and sixth month of surgery revealed no recurrence and the patients are voiding well.

Feasibility and patency of echoendoscopic anastomoses with lumen apposing metal stents depending on the gastrointestinal segment involved

EUS-guided anastomoses with LAMS have emerged as a therapeutic option for patients with obstruction of the digestive tract. However, the long-term permeability of these anastomoses remains unknown. Most of the published cases involve the gastric wall and experience in distal obstruction is limited to few case reports. We review our series of patients treated with LAMS for gastrointestinal obstruction and describe the technical success according to the anastomotic site and the long-term follow-up in those cases in which the stent migrated spontaneously or was removed. Out of 30 cases treated with LAMS, EUS-guided anastomosis did not involve the gastric wall in 6 patients. These procedures were technically more challenging as two failures were recorded (2/6, 33%) while technical success was achieved in 100% of the cases in which the stent was placed through the gastric wall. In two of the patients, one with entero-enteric and another with recto-colic anastomosis, stent removal after spontaneous displacement was followed by long term permeability of the EUS-guided anastomosis (172 and 234 days respectively). In a EUS-guided gastroenterostomy the stent was removed at 118 days, but closure of the fistula was confirmed 26 days later. Our experience suggests that LAMS placement between bowel loops is feasible and might allow the creation of an anastomosis with long-term patency. As compared to LAMS placement between bowel loops, when LAMS are placed through the gastric wall, removal of the LAMS seems to lead to closure of the fistula.

OUTCOME OF TUNICA VAGINALIS FLAP FOR REPAIR OF URETHROCUTANEOUS FISTULA AFTER HYPOSPADIAS REPAIR

The commonest complication following hypospadias repair is occurrence of urethro-cutaneous stula(UCF) with a reported incidence of 4-25% 1. The expected stula rate is between 10% to 15% for onestage hypospadias surgery. UCF after hypospadias repair remains a signicant challenge for paediatric surgeons despite the advances in surgical techniques. Our aim is to assess the outcome of tunica vaginalis ap repair in cases of urethro-cutaneous stula. Our study included 23 patients who underwent UCF repair using TVF. Successful repair of these UCF depends on several basic principles, which are the avoidance of procedures on inamed tissue, correction of distal obstruction, a tension-free urethral closure with absorbable suture material, and covering of the urethral repair with well-vascularized tissue. From our study we feel that many complications mainly recurrent stula can be avoided using the above principles.

Novel measurement tool and model for aberrant urinary stream in 3D printed urethras derived from human tissue

Background An estimated 10% of male adults have split or dribbled stream leading to poor hygiene, embarrassment, and inconvenience. There is no current metric that measures male stream deviation. Objective To develop a novel method to measure spray in normal and abnormal anatomical conformations. Design, setting, and participants We developed a novel platform to reliably describe spray. We used cadaveric tissues and 3D Printed models to study the impact of meatal shape on the urinary stream. Cadaveric penile tissue and 3D printed models were affixed to a fluid pump and used to simulate micturition. Dye captured on fabric allowed for spray detection. Outcome measurements and statistical analysis Spray pattern area, deviation from normal location, and flowrates were recorded. Computational fluid dynamic models were created to study fluid vorticity. Results and limitations Obstructions at the penile tip worsened spray dynamics and reduced flow. Ventral meatotomy improved flowrate (p<0.05) and reduced spray (p<0.05) compared to tips obstructed ventrally, dorsally or in the fossa navicularis. 3D models do not fully reproduce parameters of their parent cadaver material. The average flowrate from 3D model was 10ml/sec less than that of the penis from which it was derived (p = 0.03). Nonetheless, as in cadavers, increasing obstruction in 3D models leads to the same pattern of reduced flowrate and worse spray. Dynamic modeling revealed increasing distal obstruction was correlated to higher relative vorticity observed at the urethral tip. Conclusions We developed a robust method to measure urine spray in a research setting. Dynamic 3D printed models hold promise as a methodology to study common pathologies in the urethra and corrective surgeries on the urine stream that would not be feasible in patients. These novel methods require further validation, but offer promise as a research and clinical tool.

Factitious Disorder Presenting with Refractory Enterocutaneous Fistula that Underwent 7 Surgeries

The formation of a post-appendicectomy fistula is rare but devastating. Major etiological factors include leakage from the appendiceal stump, neoplasm of the appendix and/or cecum, infection, inflammatory bowel disease, and distal obstruction. The management of enterocutaneous fistula involves enteral nutrition, drainage, antibiotic coverage, as well as surgical excision and segmental resection of the involved bowel. Here we present a case where a young female suffered from refractory enterocutaneous fistula after appendicectomy. Despite extensive treatments, her symptoms persisted and contradicted with objective test results. Therefore, a diagnosis of factitious disorder was suspected. After questioning, she finally admitted to having applied feces to her wound to fake fistula. It was estimated that the lifetime prevalence of factitious disorder in the general population was 0.1%, which warrants the awareness of clinicians.