Analysis of long-term effect of ureteral balloon dilatation combined with internal and external drainage tube in the treatment of benign ureteral stricture

Purpose There are few reports about balloon dilatation combined with internal and external drainage tube in the treatment of ureteral stricture under interventional therapy. The aim of the study is to explore the safety, effectiveness and long-term efficacy of this treatment strategy. Materials and methods It is a retrospective and observational study. From October 2013 to October 2016, 42 patients with benign lower ureteral stricture received interventional treatment. Balloon dilatation combined with internal and external drainage tube implantation were used. There were 25 male patients and 17 female patients. There were 7 cases (16.7%) with congenital ureteral stricture, 12 cases (28.6%) with inflammation, 15 cases (35.7%) with ureteral stricture after lithotomy or lithotripsy, and 8 cases (19.0%) with ureteral stricture after pelvic or abdominal surgery. After the drainage tube was removed, B ultrasound, enhanced CTU or IVP of urinary system were reexamined every six months. The follow-up time was 12–60 months. Results The age was 52.9 ± 11.6 years. The length of ureteral stricture was 1.1 ± 0.5 cm. 42 patients completed interventional treatment, the technical success rate was 100%, no ureteral perforation, rupture or other complications were identified. Preoperative urea nitrogen 9.2 ± 2.3 mmol/L and creatinine 175.8 ± 82.8umol/L. Urea nitrogen and creatinine were 3.8–9.1 mmol/L and 45.2–189.6 umol/L when removing the drainage tube. There were significant differences in the levels of urea nitrogen and creatinine before and after tube removal (P < 0.05). The ureteral patency rate was 100% at 6 months, 93% at 12 months, 83% at 18 months, 79% at 24 months, 76% at 30 months and 73% at 36–60 months. The overall success rate was 73%. Multivariate Cox regression analysis showed that stenosis length was a risk factor for postoperative patency (P < 0.05). Conclusion Balloon dilatation combined with internal and external drainage tube implantation in the treatment of benign lower ureteral stricture is safe and effective.

Endoscopic vacuum therapy in salvage and standalone treatment of gastric leaks after bariatric surgery

Introduction Gastric leaks constitute some of the most severe complications after obesity surgery. Resulting peritonitis can lead to inflammatory changes of the stomach wall and might necessitate drainage. The inflammatory changes make gastric leak treatment difficult. A common endoscopic approach of using stents causes the problem of inadequate leak sealing and the need for an external drainage. Based on promising results using endoscopic vacuum therapy (EVT) for esophageal leaks, we implemented this concept for gastric leak treatment after bariatric surgery (Ahrens et al., Endoscopy 42(9):693–698, 2010; Schniewind et al., Surg Endosc 27(10):3883–3890, 2013). Methods We retrospectively analyzed data of 31 gastric leaks after bariatric surgery. For leak therapy management, we used revisional laparoscopy with suturing and drainage. EVT was added for persistent leaks in sixteen cases and was used in four cases as standalone therapy. Results Twenty-one gastric leaks occurred in 521 sleeve gastrectomies (leakage rate 4.0%), 9 in 441 Roux-en-Y gastric bypasses (leakage rate 2.3%), and 1 in 12 mini-bypasses. Eleven of these gastric leaks were detected within 2 days after bariatric surgery and successfully treated by revision surgery. Sixteen gastric leaks, re-operated later than 2 days, remained after revision surgery, and EVT was added. Without revision surgery, we performed EVT as standalone therapy in 4 patients with late gastric leaks. The EVT healing rate was 90% (18 of 20). In 2 patients with a late gastric leak in sleeve gastrectomy, neither revisional surgery, EVT, nor stent therapy was successful. EVT patients showed no complications related to EVT during follow-up. Conclusion EVT is highly beneficial in cases of gastric leaks in obesity surgery where local peritonitis is present. Revisional surgery was unsuccessful later than 2 days after primary surgery (16 of 16 cases). EVT shows a similar healing rate to stent therapy (80–100%) but a shorter duration of treatment. The advantages of EVT are endoscopic access, internal drainage, rapid granulation, and direct therapy control. In compartmentalized gastric leaks, EVT was successful as a standalone therapy without external drainage.

Vitrectomy and external drainage of subretinal fluid containing high concentration of vascular endothelial growth factor for advanced coats disease

This study investigated the surgical outcomes of Coats disease and the role of external drainage (XD) of subretinal fluid (SRF). The study is a multicenter retrospective interventional case series of 26 consecutive eyes of 26 patients who underwent surgeries for advanced Coats disease with retinal detachment. Main outcomes measured were: 1) comparison of complete SRF resolution with or without XD, and 2) variables that were associated with functional postoperative best-corrected visual acuity (BCVA) defined as BCVA of 0.1 or better, 3) intraocular vascular endothelial growth factor (VEGF) levels. Complete SRF resolution was achieved in all 14 eyes in which XD had been performed and in 75% of 12 eyes in which XD had not been performed (P = .03). Multivariable logistic regression analysis revealed that initial BCVA was the only variable associated with functional postoperative BCVA (odds ratio 3.24, 95% CI 0.93–11.33; P = .04). Markedly elevated VEGF levels were noted in the SRF compared with those in the vitreous humor (49,760 ± 52,990 vs. 707 ± 611 pg/mL, P = .03). XD seems to provide better anatomical success than without XD in the treatment of advanced Coats disease as XD could effectively eliminate substantial amount of VEGF in the SRF.

Choledochal cyst perforation: experience from a centre with limited emergency resources

Spontaneous perforation in Choledochal cyst (CDC) is a very rare initial manifestation and more commonly seen beyond infantile age. The management is challenging due to acute presentation, poor general condition of the patient and inflamed tissue that may jeopardize the appropriateness of any surgical intervention. The aim of the study was to analyse this rarity depending on clinical findings, diagnostic difficulty and optimum management plan in a limited resource set-up. It was a retrospective observational study where five patients presenting to the casualty department with biliary peritonitis between January 2015 and December 2020 were included. They were analysed with respect to symptomatology, laboratory parameters, radiology, emergency intervention with findings and definitive management plan. A female preponderance (60%) was found. Mean age was 5.4 years. One was a known case of CDC. Abdominal pain was the most common symptom. Inflammatory markers like Total leucocyte count (TLC) and Erythrocyte sedimentation rate (ESR) were raised in all (100%). Lipase was raised in 40% (2/5). Anaemia and low serum albumin were non-specific findings. A dilated Common bile duct (CBD) on Ultrasound (US) was seen in 80% (4/5). Magnetic resonance cholangio pancreaticography (MRCP) demonstrated type I CDC in all. All underwent laparotomy with lavage and external drainage followed by interval definitive surgery. Pre-operative diagnosis of a perforated CDC may not be possible. Strong clinical suspicion and bilious peritoneal fluid may point to this rare complication. Minimum exploratory manoeuvre with good lavage and external drainage should be the optimum emergency intervention. Definitive bilio-pancreatic reconstruction should be performed when tissue oedema subsides and general condition is improved. This approach usually achieves a rewarding outcome.

Pott’s Puffy Tumor - Overview of case series

Pott’s puffy tumor (PPT) is rare and usually seen as a complication of frontal sinusitis that has been neglected or partially treated, resulting in subperiosteal abscess of the frontal bone with underlying osteomyelitis, which can lead to life-threatening intracranial complications, such as epidural/subdural empyema, cerebral abscess and meningitis. Given this, the purpose of the present study was to gather the most diverse cases reported together to highlight the main treatment methods. Methods: It is a narrative review, starting from the search in the database PubMed, Lilacs and Scielo from 2010 to 2020, which resulted in 34 scientific articles. The search focused on obtaining data on new approaches and treatments established for Pott’s puffy tumor. Results: 34 articles were included which described 58 patients with a swollen Pott tumor, occurring predominantly in male adolescents, with streptococci (26,1%) as the main etiologic agent. Approximately 84% of all patients were male subjects. The most prevalent intracranial complication was an epidural or extradural abscess (84,2%). Regarding PTT therapy, all patients received antibiotic therapy (ATB), and the main empirical antimicrobial scheme used was cephalosporin third generation, with vancomycin and metronidazole. In most cases, surgery was performed using several techniques, mainly an external surgical approach, external drainage (ED) of the subperiosteal abscess associated with endoscopic sinus surgery (ESS). In general, the prognosis is favorable, even if neurological symptoms are present at admission. Conclusion: Based on available literature, PPT is a profoundly serious complication, which can be easily avoided if treated with the ATB, ED and ESS triad immediately, and, if necessary, craniotomy.

Acute Sub temporal and Infratemporal Dumbbell Abscess Secondary to Tooth Extraction: Case Report

To present a case of acute temporal and infratemporal dumbbell abscess following tooth extraction and discuss the possible anatomic pathways of spread of odontogenic infections. This is a case of right maxillary tooth extraction following which he developed local infection that spread to the temporal and sub temporal space. The history and examination revealed the infection spreading to the buccal and sub temporal space with trismus and feeding problems. Intraoral and external drainage along with antibiotics led to the resolution of the abscess. Of the many complications of tooth extraction infection spreading along the temporalis with formation of a dumbbell abscess can lead to severe discomfort and septicemia if not detected and treated early. A case with successful management and result are discussed.

Vitrectomy and External Drainage of Subretinal Fluid Containing High Concentration of Vascular Endothelial Growth Factor for Advanced Coats Disease

This study investigated the surgical outcomes of Coats disease and the role of external drainage (XD) of subretinal fluid (SRF). The study is a multicenter retrospective interventional case series of 26 consecutive eyes of 26 patients who underwent surgeries for advanced Coats disease with retinal detachment. Main outcomes measured were: 1) comparison of complete SRF resolution with or without XD, and 2) variables that were associated with functional postoperative best-corrected visual acuity (BCVA) defined as BCVA of 0.1 or better, 3) intraocular vascular endothelial growth factor (VEGF) levels. Complete SRF resolution was achieved in all 14 eyes in which XD had been performed and in 75% of 12 eyes in which XD had not been performed (P =.03). Multivariable logistic regression analysis revealed that initial BCVA was the only variable associated with functional postoperative BCVA (odds ratio 3.24, 95% CI 0.93–11.33; P =.04). Markedly elevated VEGF levels were noted in the SRF compared with those in the vitreous humor (49,760 ± 52,990 vs. 707 ± 611 pg/mL, P =.03). XD seems to provide better anatomical success than without XD in the treatment of advanced Coats disease as XD could effectively eliminate substantial amount of VEGF in the SRF.