Early endoscopic treatment of symptomatic pancreatic necrotic collections

EUS-guided transmural endoscopic drainage is commonly used in the treatment of WOPN in the late phase of ANP. The role of endoscopic intervention remains unclear in the early phase of ANP. This study aimed to prospectively evaluate early endoscopic treatment of ANCs compared with endoscopic drainage of WOPN. Overall, 71 patients with ANP who underwent transmural endoscopic drainage for necrotic collections were included. Endoscopic intervention was performed within the first four weeks of ANP in 25 (35.21%) patients with ANC (Group 1) and in 46 (64.79%) patients after four weeks since the onset of ANP with WOPN (Group 2). The overall mean age of patients was 49.9 (22–79) years and 59 of them were males. The mean time of active drainage and duration of total endoscopic treatment was 26.8 and 16.9 days (P = 0.0001) and 270.8 and 164.2 days (P = 0.0001) in Groups 1 and 2, respectively. The average total number of endoscopic interventions was 9.5 and 4.5 in Groups 1 and 2, respectively (P = 0.0001). The clinical success rate, frequency of complications of endoscopic interventions, long-term success rate, and recurrence rate were not significantly different between the groups (P > 0.05 for each). Transmural endoscopic drainage is effective method of treatment of early ANCs within the first four weeks of ANP. However, compared with endoscopic intervention in WOPN, more interventions and longer duration of drainage are required.

Surgical Treatment of Iatrogenic Low Variety Anal Stenosis with Diamond Flap Anoplasty – A Prospective Study

Background: Anal stenosis results from loss of anoderm with subsequent fibrosis and scarring of underlying tissue. The condition represents a technical challenge in terms of surgical management. It is a serious complication of anorectal surgery, most commonly seen after surgical haemorrhoidectomy. However, stenosis can also occur after perianal circumferential burn due to application of herbal medicine by village doctors. Objective: This study was conducted to see the outcome of diamond-flap anoplasty for the treatment of moderate to severe anal stenosis. Patients and interventions: Unilateral diamond flaps anoplasty was performed for moderate to severe anal stenosis. Final anal calibre of 25 to 26 mm was targeted. The demographic characteristics, causes of anal stenosis, number of previous surgeries, anal stenosis severity, postoperative complications and the time of return to work were recorded. Results: From July 2012 to January 2017, 18 patients (12 males, 67% and 6 female patients, 33%) with a mean age of 34 years (range, 25-52) were treated. 15 of the patients had a history of previous haemorrhoidectomy and 3 had circumferential perianal chemical burn due to application of herbal medicine by village doctors. Five patients (28%) had moderate anal stenosis and 13 (72%) had severe anal stenosis. Preoperative, intraoperative, and 12-month postoperative anal calibration values were 9 ± 3 mm (range, 5-15), 25 ± 0.75 mm (range, 24- 26), and 25 ± 1 mm (range, 23-27). The clinical success rate was 98.9%. No severe postoperative complications were observed. Conclusion: Diamond-flap anoplasty is a highly successful method for the treatment of anal stenosis caused by previous haemorrhoidectomy and perianal circumferential chemical burn by herbal medicine. J Shaheed Suhrawardy Med Coll 2020; 12(2): 67-71

Is a small-caliber or large-caliber endoscope more suitable for colonic self-expandable metallic stent placement? A randomized controlled study

Objectives: The colonic self-expandable metallic stent (C-SEMS) with a 9-French (Fr) delivery system allows for a small-caliber endoscope (SCE) to be used to treat malignant colonic obstruction. Despite the lack of evidence, the SCE has become popular because it is considered easier to insert than the large-caliber endoscope (LCE). We aimed to determine whether the SCE is more suitable than the LCE for C-SEMS placement. Methods: Between July 2018 and November 2019, 50 consecutive patients who were scheduled to undergo C-SEMS for colon obstruction were recruited in this study. Patients were randomized to the SCE or LCE group. The SCE and LCE were used with 9-Fr and 10-Fr delivery systems, respectively. The primary outcome was the total procedure time. Secondary outcomes were the technical success rate, complication rate, clinical success rate, insertion time, guidewire-passage time, stent-deployment time, and colonic obstruction-scoring-system score. Results: Forty-five patients (SCE group, n = 22; LCE group, n = 23) were analyzed. The procedure time in the LCE group (median, 20.5 min) was significantly ( p = 0.024) shorter than that in the SCE group (median, 25.1 min). The insertion time in the LCE group (median, 2.0 min) was significantly ( p = 0.0049) shorter than that in the SCE group (median, 6.0 min). A sub-analysis of the procedure difficulties showed that the insertion time in the LCE group (median, 5.0 min) was significantly shorter than that in the SCE group (median, 8.5 min). Conclusion: Both LCE and SCE can be used for C-SEMS; however, LCE is more suitable than SCE as it achieved a faster and equally efficacious C-SEMS placement as that of SCE. Clinical trial registration number: University Hospital Medical Information Network Clinical Trials Registry (UMIN 32748)

Endoscopic diverticulotomy for Killian-Jamieson diverticulum: mid-term outcome and description of an ultra-short tunnel technique

Background and study aims Killian-Jamieson Diverticulum (KJD) is a rarer and more recently described upper pharyngeal diverticulum than Zenker’s diverticulum (ZD). KJD is more difficult to manage than ZD because it tends to extend lower into the upper mediastinum and the diverticulum neck is in close proximity to the recurrent laryngeal nerve. There is limited literature on KJD management and transcervical surgical diverticulectomy is the mainstay of therapy. Patients and methods Here we describe two methods of endoscopic diverticulotomy to treat KJD – direct and tunneling diverticulotomy (with hypopharyngeal tunnel or ultra-short tunnel – the latter being our preferred technique). Results This was a retrospective study including 13 consecutive patients between March 2015 and April 2018. Three patients received direct and 10 received tunneling diverticulotomy (7 with the hypopharyngeal tunnel and 3 with the ultra-short tunnel). All procedures were completed in 16 to 52 minutes. There was no incidence of bleeding, mediastinitis, or sign of recurrent laryngeal nerve injury. At follow up of 9 to 79 months (median 33), the clinical success rate was 92 % (12/13); 11 patients had complete symptom resolution (post-operative symptom score = 0) and one patient had near-complete symptom resolution (occasional residual dysphagia). One patient receiving direct myotomy had limited symptom relief (frequent residual dysphagia and occasional residual regurgitation), possibly related to incomplete myotomy. Conclusions Endoscopic tunneling diverticulotomy is a feasible, safe, and effective method to treat KJD.

Comparison of facemask therapy effects using skeletal and tooth-borne anchorage:

ABSTRACT Objectives To investigate long-term outcomes of dentoskeletal changes induced by facemask therapy using skeletal anchorage in Class III patients and compare them to those of conventional tooth-borne anchorage. Materials and Methods This retrospective study included 20 patients who received facemask (FM) therapy with miniplates as anchorage for maxillary protraction (Miniplate/FM group, 10.6 ± 1.1 years old [mean ± SD]) and 23 patients who were treated with facemask with rapid maxillary expander (RME/FM group, 10.0 ± 1.5 years old [mean ± SD]). Dentoskeletal changes were evaluated using lateral cephalograms at pretreatment (T1), after facemask therapy (T2), and at the post-pubertal stage (T3). Cephalometric changes were compared between groups and clinical success rates at T3 were evaluated. Results SNA and A to N perpendicular to FH increased significantly more in the Miniplate/FM group than in the RME/FM group when comparing short-term effects of facemask therapy (T1–T2). ANB, Wits appraisal, Angle of convexity, mandibular plane angle, and overjet decreased significantly more in the RME/FM group than in the Miniplate/FM group after facemask therapy (T2–T3). A more favorable intermaxillary relationship was observed in the Miniplate/FM group than in the RME/FM group in long-term observations (T1–T3). Clinical success rate at T3 was 95% in the Miniplate/FM group and 85% in the RME/FM group. Conclusions Facemask therapy with skeletal anchorage showed a greater advancement of the maxilla and more favorable stability for correction of Class III malocclusion in the long-term than conventional facemask therapy with tooth-borne anchorage.

CT-Guided Transhepatic Catheter Drainage of Deep Postoperative Collections: Initial Experience

Introduction This article assesses the safety and utility of transhepatic drainage of deep seated postoperative intra-abdominal collections under computed tomography (CT) guidance in a short series. Materials and Methods This retrospective study included five patients (mean age: 45.8 years; 3 males, 2 females) who underwent CT-guided transhepatic drainage of postoperative abdominal abscess in our department between April 2019 and December 2020. The clinical and surgical details and the details of the transhepatic drainage procedure were evaluated along with success rates and complications. Results The surgical procedures were Whipple's pancreaticoduodenectomy in four patients and gastrectomy in one patient. Four out of five abscesses were drained through the right lobe of liver, while one was through the left lobe with a technical success rate of 100%. The mean total time for catheter drainage procedure including patient positioning and preparation was 29.2 minutes. None of the patients had procedure-related complications. Mean duration of catheter drainage was 12 days. All patients had complete resolution of symptoms after drainage and the clinical success rate was 100%. Conclusion Transhepatic approach is safe and effective for the drainage of inaccessible postoperative abdominal collections or abscesses where a standard percutaneous approach is not possible.

Comparative Evaluation of the Success Rate of Pulpotomy in Primary Molars Using Ferric Sulphate (FS) and Mineral Trioxide Aggregate (MTA): A Clinical and Radiographic Study

Purpose: The aim of this present study was to observe clinical, radiographic response of pulp to Ferric Sulphate and Mineral Trioxide Aggregate when used as pulpotomy agent in primary molars. Materials and Methods: Sixty restorable primary molars were selected for the study. The children were chosen who require minimum two pulpotomies in either arch preferably each on the opposite side (i.e. right and left). Primary molars on the right side of the patient were assigned to Ferric Sulphate (FS) (Group A) and left side was assigned for the Mineral Trioxide Aggregate (MTA) (Group B). Statistical analysis was done for pain, swelling, sinus, and fistula and for internal resorption, furcation radiolucency and periapical pathology using the chi-square test. Results: outcome of the present study was observed at 3 month interval and after 6 months. The clinical success rate for MTA (AQUA) and ferric sulphate during 3 and 6 month follow up was 100%. The radiographic follow up of MTA was 100% during 3 and 6 month, whereas it was 96.6% for 3 and 6 month follow up with respect to ferric sulphate. There were no significant differences in the clinical (p>0.1) and radiographic (p>0.98) success rates among both the groups. Conclusion: ferric sulphate was found to be equally effective when compared with MTA. Radiographic success rate was lower for Ferric sulphate (Group A) than that of MTA (Group B) with occurrence of one internal resorption seen with first primary molar.

655 The valuable interaction among cardiac surgeon and electrophysiologist for transvenous rotational mechanical lead extraction

Aims Recent studies have shown that evolution RL bidirectional rotational mechanical sheath (Cook Medical, USA) is an effective and safe technique for transvenous lead extraction (TLE). We reported our experience with the bidirectional rotational mechanical tools using a multidisciplinary approach highlighting the value of a joint cardiac surgeon and electrophysiologist collaboration. Methods and results The study population comprised 84 patients (77% male; mean age 65 ± 18 years) undergoing TLE. After multidisciplinary evaluation, a combined procedure was considered. The main indication for TLE was infection in 54 cases (64%).Overall, 152 leads were extracted with a mean implant duration of 94 ± 63 months (range: 6–421). Complete procedural success rate, clinical success rate, and lead removal with clinical success rate were 91.6% (77/84), 97.6% (82/84), and 98.6% (150/152), respectively. Eighteen combined procedures were performed in 12 patients (14%), such as ‘hybrid approach’ (n = 2) or TLE concomitant to: (i) transcatheter aspiration procedure for large vegetation (n = 8); (ii) left ventricular assistance device implantation as bridge to cardiac transplantation (n = 1); (iii) permanent pacing with epicardial leads (n = 6); and (iv) tricuspid valve replacement (n = 1).One major complication (1.2%) and 11 (13%) minor complications were encountered. No injury to the superior vena cava occurred and no procedure-related deaths were reported. During a mean time follow-up of 21 ± 18 months, 17 patients (20%) died. They were more often diabetics (P = 0.02), and they underwent TLE more often for infection (P = 0.004). Conclusions Our results support the finding that excellent outcomes can be achieved in performing TLE of chronically implanted leads by using the evolution RL bidirectional rotational mechanical sheath and a multidisciplinary team approach involving both electrophysiologist and cardiac surgeon as first line operators.

Single-centre experience with endovascular rotational thrombectomy for single session salvage of thrombosed arteriovenous fistulas and grafts

Objectives: This paper documents our experience and outcomes of using a relatively new endovascular rotational thrombectomy device for salvage of thrombosed vascular access. Methodology: A retrospective study reviewing patients with thrombosed native AVF or AVG who underwent endovascular declotting using a rotational thrombectomy device between November 2018 and May 2020 at a tertiary university hospital in Southeast Asia. We evaluated demographics, procedural data, technical and procedural success, patency rates and complications. Results: A total of 40 patients underwent single session endovascular declotting of thrombosed vascular access. The mean follow-up period was 21.6 months (range 13.4–31 months). The technical success was 92.5% and clinical success was 80%. About 50% of patients had concomitant thrombolysis for pharmacomechanical thrombectomy. One patient had a myocardial infarction during the post-operative period. There were no other major complications within 30 days. The primary patency was 45.5% at 6 months and 22.7% at 12 months. Assisted primary patency was 68.1% at 6 months and 61.6% at 12 months, which was maintained up to 2 years. The secondary patency was 84.1% at 6 and 12 months. Conclusion: Our study shows that rotational thrombectomy device for single session thrombectomy of thrombosed arteriovenous fistulas and grafts is safe and effective. A high technical and clinical success rate was achieved, with low complication rates and specific advantages compared to other techniques, including reduced length of hospital stay. Our reported mid-term outcomes are reasonable with an assisted primary patency of 62% at 12 and 24 months. The use of newer techniques and novel dedicated thrombectomy devices show promise.

Trans-radial percutaneous intervention for thrombosed hemodialysis access: A single-center experience

Background: Traditionally, percutaneous transluminal angioplasty (PTA) is a first-line approach for stenosed dialysis accesses and has been performed through the non-thrombosed vein segment. For thrombosed accesses, thrombectomy (whether open or percutaneous) is a standard approach. The primary objective of our study is to determine the clinical and technical outcomes of the trans-radial approach of PTA among thrombosed dialysis accesses, in terms of safety and feasibility, technical and clinical aspects and factors influencing them, as well as assisted primary patency, secondary patency at 6 and 12 months. Methods: This is a single-center retrospective study that included 150 patients over 3 years. About 123 patients underwent successful percutaneous balloon angioplasty through the radial access. Results: We report an overall technical and clinical success rate of 82%, assisted primary patency rate of about 90.25% at 3 months, 82.93% at 6 months, 73.18% at 1 year, and secondary patency rate of 94% at 1 year. Twenty-seven patients were referred for surgical revisions/creation of a new fistula for reasons like inability to pass wire (6 patients), unfavorable anatomical variations like aneurysms at the proximal segments (5 patients), inability to cross the fistula (5 patients), and persistent fistula dysfunction with no flow after initial balloon dilatation (11 patients). Three patients had hematoma at the radial access site (2.5%) while two patients had the AV fistula segment rupture and were successfully treated conservatively. Conclusion: We conclude that PTA through the trans-radial approach to completely thrombosed hemodialysis accesses is a good alternative to transvenous access and has a very good assisted primary patency and secondary patency at 1 year without major complications.