Self-Mechanical Anal Dilatation: A Simple Trick to Minimize Postoperative Pain and Stenosis Following Hemorrhoidectomy With Radiofrequency

Aim: Hemorrhoidectomy is still the most effective surgical treatment for hemorrhoidal disease, but it is, however, associated with complications such as pain and stenosis. We proposed to break the “vicious circle” of “pain–sphincteric spasm–stenosis–pain” with the postoperative use of self-mechanical anal dilation.Methods: We retrospectively analyzed patients with hemorrhoidal disease presenting with a minimum of piles of three quadrants, treated with radiofrequency hemorrhoidectomy between January 2018 and December 2019. All the patients that at 3 weeks presented sphincteric spasms with painful defecation, were considered. Thirty-nine patients performed the cycle of self-mechanical anal dilation (Group A). This group was 1:1 matched with homogeneous patients from our historical cohort of patients (Group B). The primary endpoint was the pain evaluation, secondary endpoints: WCS, overall satisfaction of the patient, anal sphincter spasm, scarring, and the incidence of postoperative stenosis.Results: In Group A mean VAS was 3.25 after 14 days of application and 1.15 at the end of the application. In Group B mean VAS was persistently higher, with a mean VAS of 5 (p = 0.000002) and 3.38 (p = 0.0000000000009). In Group A we observed an improvement of symptoms at the end, with a good overall satisfaction (Group A 7.4 vs. Group B 5.9; p = 0.0000007) and a better mean WCS (Group A WCS 2.8 vs. Group B WCS 4.18; p = 0.0001). Stenosis was observed in 3/39 patients of Group B (7.7%).Conclusions: Self-mechanical anal dilation improves the pain in the late postoperative course, minimizing the risk of anal stenosis.

Radial incision and cutting for dilation before endoscopic submucosal dissection in patients with esophageal cancer on the distal side of severe benign esophageal strictures

ABSTRACT We investigated the efficacy and safety of radial incision and cutting as a novel dilation method for strictures just before endoscopic submucosal dissection in patients with metachronous esophageal cancer localized on the distal side of strictures and determined the optimal dilation method. Consecutive patients who underwent endoscopic submucosal dissection for superficial esophageal squamous cell carcinomas localized on the distal side of severe strictures were investigated retrospectively and assigned to a radial incision and cutting (19 patients; 23 lesions) or an endoscopic balloon dilation (20 patients; 20 lesions) group. We evaluated the passage success rates of cap-wearing endoscopes with diameters ≥8.9 mm, the procedural success, en bloc resection, complete resection, major adverse event rates, and total procedure times. Compared to the endoscopic balloon dilation group, the passage success rate of a conventional endoscope with a transparent cap (87% vs. 50%) and procedural success rate (96% vs. 63%) were significantly higher in the radial incision and cutting group. The mean procedure time of ‘dilation and ESD’ was significantly shorter in the radial incision and cutting group than in the endoscopic balloon dilation group. Neither group experienced any serious adverse events. Radial incision and cutting followed by endoscopic submucosal dissection was effective and safe in patients with superficial esophageal squamous cell carcinomas localized on the distal side of severe benign esophageal strictures. Endoscopic submucosal dissection using a cap-wearing endoscope was possible with radial incision and cutting, and the procedure time was shorter than that for endoscopic balloon dilation.

Proposal of a new scoring system for equalization problems during freediving

Objective: Scuba diving and freediving are popular activities around the world, and their growth has increased the frequency of related pathology. A good ability to equalize is of paramount importance for diving. This is especially true for freediving, during which dive time is limited to just one breath. Even though equalization disorders are quite common in divers, a scoring system does not exist to date. In this paper we propose a new scoring system for equalization problems of freedivers: the EP score – shorthand for “equalization problems.” Methods: We administered the EP score assessment to 40 Italian freediving spearfishermen who were divided in two groups: Group A comprised 20 freedivers complaining of equalization problems and multiple barotraumas but totally asymptomatic in their everyday lives. These individuals had already received medical treatment and nasal surgery without improvement and then had undergone Eustachian tube balloon dilation. Group B comprised 20 healthy freedivers without any history of equalization disorders. We performed a statistical analysis to evaluate the reliability of this scoring system and to evaluate its usefulness in diagnosis and follow-up. Results: Our data show substantial statistical differences between healthy freedivers and freedivers complaining of equalization disorders (Z-Score = -5.396 at p < 0.05); data do not show any statistical difference between healthy freedivers and patients successfully treated by Eustachian tube balloon dilation (U-value = 152.5 and Z-Score= -1.271 at p < 0.05). Conclusion: The EP score assessment seems to be a reliable tool to quantify equalization disorders during freediving and to evaluate how the difficulty varies over time and after treatment. Since equalization disorders could be present in different populations, the EP score assessment could be applicable to a wider group.

One-shot dilation versus serial dilation technique for access in percutaneous nephrolithotomy: a systematic review and meta-analysis

ObjectiveThe purpose of this study was to systematically review the outcomes of the use of one-shot dilation (OSD) and serial tract dilation for percutaneous nephrolithotomy (PCNL).MethodsA systematic review and meta-analysis was conducted. The randomised controlled trials (RCTs) included in the study were identified from EMBASE, MEDLINE and the Cochrane Central Register of Controlled Trials. The last search was performed on 30 April 2018. Summary effects were calculated as risk ratios (RRs) with 95% CIs or mean differences (MDs) with 95% CIs. The endpoints included access time, fluoroscopy time, successful dilation rate, stone-free rate, postoperative decrease in haemoglobin levels, transfusion rate, complication rate and length of postoperative hospital stay.ResultsA total of seven RCTs were included in the study, with clinical data reported for 697 patients. The overall access time was approximately 110 s shorter in the OSD group than in the serial dilation group (MD, −110.14; 95% CI −161.99 to −58.30; p<0.0001). The fluoroscopy time was shorter with OSD in all RCTs. In addition, the decrease in postoperative haemoglobin levels was approximately 2.3g/L less in patients in the OSD group than in those in the serial dilation group (MD, −0.23; 95% CI−0.39 to −0.07; p=0.004). No relationship was found between the successful dilation rate, stone-free rate, transfusion rate, or complication rate and the method of tract dilation.ConclusionOSD is a safe and efficacious tract dilation technique that can reduce the access time, fluoroscopy time and postoperative decrease in haemoglobin level. No difference was found in the successful dilation rate, stone-free rate, transfusion rate or rate of complications between the OSD and serial dilation groups. The difference in the length of postoperative hospital stay was uncertain. OSD may be a better method of tract creation for PCNL.

Endoscopic Management of Postradiation Dysphagia in Head and Neck Cancer Patients: A Systematic Review

Objectives: To systematically review the success rate and safety profile of the available endoscopic surgical options for radiation-induced dysphagia in head and neck cancer patients following organ preservation treatment, including upper esophageal sphincter (UES) dilation, cricopharyngeus (CP) myotomy (CPM), and CP intramuscular botulinum toxin (Botox) injection. Methods: A search of MEDLINE, Scopus, Google Scholar, and Cochrane databases was done to identify articles published between January 1980 and December 2017. Pediatric series, foreign language articles, series with Zenker’s diverticulum or following primary surgical treatment including laryngectomy, open UES/CP surgery, or samples with fewer than 5 patients were excluded. Results: An initial search identified 539 articles. All titles and abstracts were reviewed. One hundred and sixteen potentially relevant articles were inspected in more detail, and 14 retrospective studies met eligibility criteria. Dilation group included 10 studies on anterograde and/or retrograde dilation, with an overall 208 patients. Success rate ranged from 42% to 100%. The endoscopic CPM group included 3 studies with a total of 36 patients, and the success rate ranged from 27% to 90%. In the Botox group, 1 one study with 20 patients met our inclusion criteria, with an overall 65% success rate (13/20). Major complications were only reported in the dilation group, which included esophageal perforation and death. Conclusions: The lack of consistency across trials indicates insufficient evidence for guiding clinical practice. This systematic review suggests the need for greater standardization of outcomes and instruments. Future prospective evaluation should use validated patient-rated and clinician-rated assessment tools to optimally measure postoperative swallowing outcomes of head and neck cancer dysphagic patients following organ preservation therapy.

PS01.043: FACTORS EFFECT THE RESULT OF ESOPHAGEAL DILATION WITH INTRALESIONAL STEROID INJECTION IN SEVERE CORROSIVE STRICTURE PATIENTS

Background Endoscopic esophageal dilation has been the primary therapy in severe corrosive stricture. There is a few study on effectiveness of intralesional steroid injection combined with esophageal dilation. The author studied factors that may give positive or negative effect results of dilation, and may extend the indication of dilation before definite surgery. Methods The authors reviewed the complete medical records as the retrospective study of patients those underwent intralesional steroid injection combined with esophageal dilation due to severe corrosive stricture. Primary outcome is the success rate of treatment by intralesion steroid injection combined with endoscopic esophageal stricture dilation. Secondary outcome is the risk that effect result of treatment. Statistical analysis was performed using STATA version 12 for Fisher's exact, students t-test, and relative risk regression, p-value of < 0.05 isconsidered as statistical significant. Results There are 55 patients was enrolled and presented with at least grade 4 of dysphagia, Marchand's grade III and IV from imaging stress review, and received intralesional steroid injection combined with endoscopic esophageal dilation. We divided patients into two groups, (1) a success esophageal dilation group (76.36%; mean number of dilation is 6 sessions/year), and (2) a failure esophageal dilation group whounderwent reconstruction surgery (23.64%). Patient characteristics including gender, age, time from transfer to the first dilation, type of corrosive agent, grading of dysphagia, number, length of lesion(s), and site of lesion(s). This study showed that gender, age, type of substance, number or length of stricture(s) had no significant difference about the result of treatment. Significant success factors are timing from first swallowing to first dilation (within 8 weeks, 78.57% success), no gastric deformity combined with esophageal stricture (90.48% success), and failure factor is the occurrence of complication during the period of treatment (69.23%) that mainly related to long segment of stricture more than 5 centimeters. Conclusion We gained high success rate in Marchand's grade III and IV by steroid injection combined with esophageal dilation. Predictors indicate that specific factor caused failure of treatment. The author extends the indication for endoscopic intervention in severe esophageal stricture before decision to do reconstructive surgery. Disclosure All authors have declared no conflicts of interest.

Revision of biliary sphincterotomy by re-cut, balloon dilation or temporary stenting: comparison of clinical outcome and complication rate (with video)

Background and study aims Revision of endoscopic retrograde cholangiopancreatography (ERCP) may be necessary following previous biliary endoscopic sphincterotomy for recurrent biliary symptoms related to biliary stone recurrence, cholangitis or post-biliary endoscopic sphincterotomy (bEST) papillary stenosis and cholestasis. The aim of this retrospective study was to evaluate the clinical outcome and complication rate associated with re-cut, balloon dilation and biliary metal stenting in revision ERCP. Patients and methods From January 2010 to January 2015, 139 subjects with stigma of a previous sphincterotomy required a revision ERCP (64 Men/75 Women; mean age 71 years; range 32 – 101 years). The most appropriate technique (re-cut, balloon dilation or fully covered self-expandable metal stent [FCSEMS] placement) was tailored according to underlying pathologies and anatomical features. Results Technical success was achieved in all cases (100 %).Clinical success (definitive clearance of common bile duct stones and liver test normalization) was achieved in 127 out of 139 patients (91.4 %) with a mean follow up of 12 months.12 clinical failures occurred: 11 patients required a new ERCP after an average of 9 months meanwhile 1 patient required surgery for definite treatment. The overall complication rate was 9 % (13 /139) with 5 acute complications (intra-procedural) and 8 short-term complications (before 1 month). Group specific overall complication rates were as follow: re-cut 11.5 % (8 bleeds and 3 perforations), balloon dilation 25 % (4 mild PEP [post-ERCP pancreatitis]), FCSEMS 14.3 % (1 moderate PEP), re-cut + balloon dilation and re-cut + FCSEMS 0 %. A statistically significant higher risk of post-ERCP pancreatitis was highlighted in the balloon dilation group meanwhile re-cut was burdened by a higher risk of bleeding and perforation. Conclusions Revision ERCP following previous bEST is a feasible procedure enabling clinical success in most cases. Different approaches are available and must be considered according to underlying pathologies. Re-cut is burdened by a higher risk of perforation and bleeding compared to balloon dilation and SEMS meanwhile balloon dilation is associated to increased risk of PEP.

A scale-covariant quantum spacetime

A noncommutative spacetime admitting dilation symmetry was briefly mentioned in the seminal work [8] of Doplicher, Fredenhagen and Roberts. In this paper, we explicitly construct the model in detail and carry out an indepth analysis. The C*-algebra that describes this quantum spacetime is determined, and it is shown that it admits an action by *-automorphisms of the dilation group, along with the expected Poincaré covariance. In order to study the main physical properties of this scale-covariant model, a free scalar neutral field is introduced as an investigation tool. Our key results are then the loss of locality and the irreducibility, or triviality, of special field algebras associated with regions of the ordinary Minkowski spacetime. It turns out, in the conclusions, that this analysis allows also to argue on viable ways of constructing a full conformally covariant model for quantum spacetime.

EFFECT OF URETHRAL DILATION ON ANTERIOR URETHRAL STRICTURE RECURRENCE AFTER INTERNAL URETHROTOMY IN MALES

Objective: The aim is to evaluate the effect of urethral dilation on anterior urethral stricture recurrences after direct vision internal urethrotomy (DVIU). Material & Method: Patients were classified into 2 groups after internal urethrotomy for urethral dilation or observation. All strictures included were anterior, single, and causing partial obstruction. Urethral dilation was performed using a metal sound. This procedure was performed every 1 or 2 weeks in the first and second month after operation and then once a month for 1 year or in case of voiding complaints or low flow rate (< 10 mL/s). Follow up at least until 1 year after DVIU. Results: A total of 32 cases could be reviewed, of which are 21 had urethral dilation and 11 observation only. In the urethral dilation group, we found 4 recurrences (19%) with mean time to recurrence 10,52 months. In the observation group, we found 7 recurrent cases (63,63%) with a mean time to recurrence of 8,09 months. P value is 0,02 which means urethral dilation significantly decreased the chance of stricture recurrence. By Kaplan Meier survival analysis, urethral dilation had a better and longer time to recurrence. Conclusion: In this study, regular meatal dilation is proven to prolong the time to recurrence of an anterior urethral stricture after DVIU. Keywords: Urethral dilation, anterior urethral stricture, stricture recurrence.