Urologic complications of laparoscopic radical hysterectomy and lymphadenectomy

Introduction and hypothesis

The purpose of this study was to evaluate the intra- and postoperative urologic complications and management in patients with cervical or endometrial cancer treated with laparoscopic radical hysterectomy and lymphadenectomy.

Methods

We retrospectively reviewed the medical records of 146 patients with cervical or endometrial cancer who underwent total laparoscopic radical hysterectomy with lymphadenectomy between August 2002 and April 2011. The intra- and postoperative urologic complications were analyzed.

Results

Double ureteral stents were inserted prophylactically in 13 patients (8.9?%), 2 of whom had postoperative urologic complications. Nine patients (6.2?%) had postoperative urologic complications. Of four patients with ureterovaginal fistulas, two were treated conservatively with cystoscopic placement of ureteral stents and two underwent ureteroneocystostomies. Vesicovaginal fistulas occurred in two patients, both of whom underwent vesicovaginal fistula repairs. One patient noted to have a bladder injury intraoperatively had a laparoscopic repair, and one patient noted to have a ureteral injury postoperatively was treated conservatively with cystoscopic placement of ureteral stents.

Conclusions

Iatrogenic lower urinary tract injuries during laparoscopic radical hysterectomy are relatively common complications. Intraoperative prophylactic ureteral stent insertion and the early detection of urologic complications postoperatively is advised for patients who undergo laparoscopic radical hysterectomies.     

Management of ureterovaginal fistulae: an audit

Introduction and hypothesis

A retrospective study was done from January 2008 to January 2011 to analyze the outcome of ureterovaginal fistula management in relation to intervention mode.

Patients and methods

Eighteen patients who developed ureterovaginal fistulae following gynecological and obstetric procedures were studied. Ureteroscopic stenting was attempted in 17 cases, and one patient electively underwent ureteral reimplantation.

Results

Ureteroscopic stenting was successfully accomplished in 13 of 17 patients; four patients underwent ureteral reimplantation, as stenting was not feasible. The success rate was 100 % at a mean follow-up of 24.6 months, irrespective of modality.

Conclusion

The majority of iatrogenic ureterovaginal fistulae can be successfully managed by ureteroscopic stenting. Our study also suggests that ureteroscopic stenting should be considered as the primary mode of intervention in all cases. Ureteral reimplantation is required and remains practicable when stenting turns out to be impossible.     

Metallic ureteral stents in malignant ureteral obstruction: short-term results and radiological features predicting stent failure in patients with non-urological malignancies

Purpose

To provide short-term result of the metallic ureteral stent in patients with malignant ureteral obstruction and identify radiological findings predicting stent failure.

Materials and methods

The records of all patients with non-urological malignant diseases who have received metallic ureteral stents from July 2009 to March 2012 for ureteral obstruction were reviewed. Stent failure was detected by clinical symptoms and imaging studies. Survival analysis was used to estimate patency rates and factors predicting stent failure.

Results

A total of 74 patients with 130 attempts of stent insertion were included. A total of 113 (86.9 %) stents were inserted successfully and 103 (91.2 %) achieved primary patency. After excluding cases without sufficient imaging data, 94 stents were included in the survival analysis. The median functional duration of the 94 stents was 6.2 months (range 3–476 days). Obstruction in abdominal ureter (p = 0.0279) and lymphatic metastasis around ureter (p = 0.0398) were risk factors for stent failure. The median functional durations of the stents for abdominal and pelvic obstructions were 4.5 months (range 3–263 days) and 6.5 months (range 4–476 days), respectively. The median durations of the stents with and without lymphatic metastasis were 5.3 months (range 4–398 days) and 7.8 months (range 31–476 days), respectively.

Conclusion

Metallic ureteral stents are effective and safe in relieving ureteral obstructions resulting from non-urological malignancies, and abdominal ureteral obstruction and lymphatic metastasis around ureter were associated with shorter functional duration.     

Gastric Leak After Laparoscopic Sleeve Gastrectomy: Early Covered Self-Expandable Stent Reduces Healing Time

Background

Laparoscopic sleeve gastrectomy has become a very frequent procedure in bariatric surgery due to its efficacy and simplicity compared to gastric bypass. Gastric staple line leak (1 to 7 % of cases) is a severe complication with a long nonstandardized treatment. The aim of this retrospective study was to examine the success and tolerance of covered stents in its management.

Methods

From January 2009 to December 2011, nine patients with gastric staple line leaks after sleeve gastrectomy were treated with covered stents in our department (seven referred from other institutions). The leaks were diagnosed by CT scan and visualized during the endoscopy. Among the studied variables were operative technique, post-operative fistula diagnosis delay, stent treatment delay, and stent tolerance. In our institution, Hanarostent® (length 17 cm, diameter 18 mm; M.I. Tech, Seoul, Korea) was used and inserted under direct endoscopic control.

Results

Stent treatment was successful in seven cases (78 %). Two other cases had total gastrectomy (405 and 185 days after leak diagnosis). Early stent removal (due to migration or poor tolerance) was necessary in three cases. The average stent treatment duration was of 6.4 weeks, and the average healing time was 141 days. The five patients with an early stent treatment (≤3 weeks after leak diagnosis) had an average healing time of 99 days versus 224 for the four others.

Conclusions

Covered self-expandable stent is an effective treatment of gastric leaks after sleeve gastrectomy. Early stent treatment seems to be associated with shorter healing time.     

Extravesical robotic ureteral reimplantation for ureterovaginal fistula

Introduction

We present a video describing the technical considerations for performing an extravesical robotic ureteral reimplantation.

Methods

A 55-year old woman presented with urinary incontinence secondary to a ureterovaginal fistula after robotic-assisted hysterectomy. After failure of more conservative measures, she proceeded to a robotic ureteral reimplantation. Following port placement, the ureter is identified at the level of the iliac vessels and dissected circumferentially. The ureter is dissected free to the level of the ureterovaginal fistula, transected, and the distal remnant ligated. The ureter is spatulated, a cystotomy created, and a running anastomosis with mucosa-to-mucosa apposition performed over a stent. Care is taken to ensure it is tension free. The integrity of the anastomosis is tested with retrograde filling of the bladder. Postoperatively, a drainage catheter is left to allow for adequate healing. Follow-up imaging is performed to ensure a patent anastomosis.

Results

The patient had an uncomplicated postoperative course. A cystogram showed adequate healing at 10 days, and the stent was removed at 6 weeks. A follow-up renal ultrasound 6 weeks later showed no hydronephrosis.

Conclusions

Extravesical robotic ureteral reimplantation is a useful technique for managing ureterovaginal fistula; here we highlight pertinent technical considerations.

     

Plasmadeponierte Kohlenstoffbeschichtung auf urologischen Verweilkathetern

Background

Any material placed in the urinary tract is susceptible to the formation of encrustations of crystalline bacterial biofilms. These biofilms cause severe complications in some cases. The strategies used so far for reduction of these complications by surface modifications of the implant material failed to show the expected results.

Patients and methods

In this study, we investigated amorphous carbon coatings (a-C:H) for their ability to effectively reduce or to repress the progressive formation of infection-enhancing crystalline biofilms as new functional surface coatings. In nine patients suffering for several years from stenting, a-C:H-coated ureteral stents were tested in treatment attempts. The current replacement intervals amounted to a mean of 77 days; the principle cause for early replacement was massive stent encrustations associated with symptomatic urinary tract infections.

Results

In total, 20 coated ureteral stents were tested spanning indwelling times between 3 and 4 months. No stent-related complications occurred. In all cases extraordinarily facile handling, less pain during replacement, and markedly increased tolerance were observed. Symptomatic urinary tract infections were reduced by more than 50%. The stents remained virtually free of encrustations.

Conclusion

a-C:H coatings are a novel strategy leading to an enhancement of long-term applicability of ureteral stents and catheters and to improved patient comfort.     

Evaluation of a novel gel-based ureteral stent with biofilm-resistant characteristics

Purpose

Current ureteral stents, while effective at maintaining a ureteral lumen, provide a substrate for bacterial growth. This propensity for biofilm formation may be a nidus for bacterial growth leading to infection and a reason for early removal of a stent before it is clinically indicated. A newly devised stent, composed of a highly hydrated, partially hydrolyzed polyacrylonitrile polymer, is believed to have bacterial resistant properties. The objective of this study is to evaluate the biofilm growth and bacterial resistant properties of this novel stent.

Materials and methods

Multiple 1 cm sections of the pAguaMedicina? Pediatric Ureteral Stent (pAMS) (Q Urological, Natick, MA) and the conventional polymer stent (SS) (Boston Scientific, Natick, MA) were incubated for 3 days in the 3 different growth media. Afterward, J96 human pathogenic Escherichia coli was added. At 3, 6, 9, 12, and 15 days following bacterial inoculation, the stent segments were washed, sonicated, and analyzed for bacterial growth. Scanning electron microscopy (SEM) imaging was performed to assess biofilm formation.

Results

pAMS demonstrated significant reductions (43–71 %) in bacterial counts when compared to standard stents in all conditions tested. SEM imaging demonstrated biofilm formation on both types of stents in all media, with a relative reduction in apparent cell debris and bacteria on the pAMS.

Conclusions

In this study, the gel-based stent shows a demonstrable reduction in bacterial counts and biofilm formation. The use of the pAMS may reduce the risk of infection associated with stent usage.     

La colocación de catéteres doble J con anestesia local en régimen ambulatorio es un procedimiento seguro y eficiente para el manejo de distintas patologías ureterales

Objective

To assess the outcomes of ureteral stent placement under local anesthesia for the management of multiple ureteral disorders.

Clinical role of a modified seton technique for the treatment of trans-sphincteric and supra-sphincteric anal fistulas

Purposes

We have devised a modified seton technique that resects the external fistula tract while preserving the anal sphincter muscle. This study assessed the technique when used for the management of complex anal fistulas.

Methods

Between January 2006 and December 2007, 239 patients (208 males and 31 females, median age: 41 years) underwent surgery for complex anal fistulas using the technique. Of the 239 patients, 198 patients had trans-sphincteric fistula and 41 patients had supra-sphincteric fistula.

Results

The durations of the surgeries were 17 min (47, 13) [median (range, interquartile range)] for trans-sphincteric fistulas and 38 (44, 16) for supra-sphincteric fistulas. The durations of the surgeries were significantly (P < 0.05) longer for supra-sphincteric fistula than trans-sphincteric fistula. The hospital stays were 4 (13, 2) days and 5 (14, 3) days, respectively, for trans- and supra-sphincteric fistulas. The durations of seton placement until the spontaneous dropping of the seton were 42 (121, 48) and 141 (171, 55) days respectively. The recurrence rate was 0 % in patients with trans-sphincteric fistulas and 4.9 % (2 of 41) in patients with supra-sphincteric fistulas (P < 0.01). Serious incontinence was not observed.

Conclusions

The technique provided favorable results for the treatment of complex anal fistulas and could be safely applied while preserving the sphincter function and conserving fecal continence.     

Endoscopic stenting for benign upper gastrointestinal strictures and leaks

Background

Self-expandable metal stents (SEMS) and self-expandable plastic stents (SEPS) maybe used for the treatment of benign upper gastrointestinal (GI) leaks and strictures. This study reviewed our experience with stent insertions in patients with benign upper GI conditions.

Methods

Patients who underwent stent placement for benign upper GI strictures and leaks between March 2007 and April 2011 at a tertiary referral academic center were studied using an endoscopic database and electronic patient records. The technical success, complications, and clinical improvement after stent removal were compared according to type of stent. The outcomes measured were clinical response, adverse events, and predictors of stent migration.

Results

Thirty-eight patients (50 % male, mean age = 54 years, range = 12–82) underwent 121 endoscopic procedures. Twenty patients had stents placed for strictures, and 18 had stents placed for leaks. Stent placement was technically successful in all patients. The average duration of stent placement was 54 days (range = 18–118). Clinical improvement immediately after stent placement was seen in 29 of the 38 patients (76.3 %). Immediate post-procedure adverse events occurred in 8 patients. Late adverse events were seen in 18 patients. Evidence of stent migration occurred in 16 patients and was seen in 42 of the 118 successfully placed stents (35.5 %). Migration was more frequent with fully covered SEMS (p = 0.002). After stent removal, 27 patients were evaluable for long-term success (median follow-up time of 283 days, IQR 38–762). Resolution of strictures or leaks was seen in 11 patients (40.7 %). Predictors for long-term success included increasing age and if the stent did not cross the GE junction.

Conclusions

Placement of SEPS and SEMS for benign refractory strictures and fistulas has modest long-term clinical efficacy and is limited by a significant migration rate. Stent migration is common and frequent with fully covered SEMS compared to other types of stents, regardless of indication or location.     

Stent treatment for fistula after obesity surgery: results in 47 consecutive patients

Background

Leaks occurring after weight loss operations constitute a therapeutic challenge. There is no consensus as to what comprises state-of-the-art management of leaks after bariatric surgery. We sought to determine the efficacy and possible adverse effects of endoluminal stenting for leaks after bariatric surgery.

Methods

We report our experience with the stent treatment of consecutive bariatric patients with a leak (retrospective cohort study). Between October 2005 and July 2010, 47 patients presented an acute leak after a bariatric procedure (61 % primary procedures, 39 % revisions). Fifteen patients were initially approached laparoscopically, and 32 were treated by nonoperative techniques. After adequate drainage and resuscitation, all 47 patients were treated by the endoscopic placement of a partially covered metallic stent, and later of a plastic stent inside the metallic prosthesis to facilitate removal. Both stents were then ablated 1 week later. Primary outcome measurement concerned healing of the fistula, as evidenced by radiographic imaging. Secondary outcomes were length of hospital stay and occurrence of peri- and postprocedural complications.

Results

There was no mortality. 41 patients (87.23 %) healed with stent treatment alone; 5 of the 6 persisting leaks healed with laparoscopic intervention (intention-to-treat success rate 96 %). Complication rate was 28.7 %. Length of hospital stay was mean ± standard deviation 22.4 ± 19.38 days for the patients treated by stent alone, and 23.4 ± 18.4 days for the patients requiring additional surgery (P = NS). One patient developed a stricture and required endoscopic dilation, and one is still awaiting surgical treatment.

Conclusions

Leaks after bariatric surgery can be treated safely and effectively by endoscopic stents. In cases of persisting leaks, laparoscopic intervention is successful in a majority of cases. Late strictures seldom occur.     

Is the enteral replacement of externally drained pancreatic juice valuable after pancreatoduodenectomy?

Purposes

External drainage of pancreatic juice using a pancreatic duct stent following pancreatoduodenectomy is widely performed. We hypothesized that the replacement of externally drained pancreatic juice would help to prevent postoperative complications, including pancreatic fistulas.

Methods

Sixty-four patients who underwent pancreatoduodenectomy between 2006 and 2008 were randomly assigned to either a pancreatic juice non-replacement (NR) or replacement (R) group. Eighteen patients were excluded from the analysis because they had unresectable tumors (n = 4), low pancreatic juice output (<100 ml) (n = 11) or for other reasons (n = 3). A total of 46 patients (NR = 24, R = 22) were included in the final analysis. The volume and amylase levels of externally drained pancreatic juice were analyzed on postoperative days 7 and 14. The incidence of postoperative complications, including pancreatic fistulas and delayed gastric emptying, was also assessed.

Results

The total amylase secretion from the pancreatic tube on postoperative day 7 was significantly higher in the NR group compared with the R group (P = 0.044). The incidence of pancreatic fistulas (>Grade B) was also significantly higher in the NR group (33.3 vs. 9.1 %, P = 0.046).

Conclusions

In cases for whom external pancreatic juice drainage from a stent is applied following pancreaticojejunostomy, enteral replacement of externally drained pancreatic juice may reduce the incidence of postoperative pancreatic fistula formation.     

Die Duplex-Doppel-J-Schiene bei intrinsischen und extrinsischen Harnleiterengen

Background

Duplex or twin ureteral stenting has previously been described as a viable option for patients where single double-J ureteral stenting has failed in order to avoid nephrostomies or further surgical intervention. We assessed a series of 20 patients at our institution after unsuccessful primary single ureteral stenting where parallel ureteral stents were inserted.

Methods

Between 2003 and 2009, 20 patients underwent double-J ureteral stenting for ureteral compression or ureteral strictures. After failure of single stenting two ureteral stents were consecutively inserted into the ureter in a parallel fashion after dilating the ureter up to 14 F. The second stent was passed over a hydrophilic guidewire while holding the first stent secure to prevent dislocation.

Results

In all patients the insertion of two parallel stents was technically possible. In 8 of 12 patients with extrinsic tumor compression the stents provided sufficient drainage (67%). When the stricture was due to surgery or radiation two of three patients were successfully diverted with twin stents. In five patients with a ureteral stricture due to malignant disease the stenting did not provide sufficient drainage and a nephrostomy had to be placed after a mean duration of 19 days. Two of those patients were later managed with a pyelovesical bypass. Three patients were later managed with a ureterocystoneostomy (psoas hitch). In four of five patients with benign disease a long-term management was feasible. The patient with retroperitoneal fibrosis developed immediate hydronephrosis and severe flank pain and ultimately underwent an ileal ureter replacement. In three patients with a benign ureteral stenosis after stone therapy, hysterectomy, or colon ureter replacement, a temporary duplex stenting sufficiently resolved the hydronephrosis for spontaneous urine passage. In one patient the duplex stenting prevented a kidney stone from dislocating into the ureter during lithotripsy.

Conclusions

Duplex or twin (double) ureteral stenting is a valid option in selected patients to avoid the placement of a nephrostomy. Severe stenosis may however demand a nephrostomy insertion or more invasive procedures in the later course. For certain benign ureteral strictures a therapeutic dilating effect of the two ureteral stents that makes further intervention unnecessary can be discussed.     

Is stone diameter a variable in the decision process of employing a ureteral stent in patients undergoing uncomplicated ureterorenoscopy and associated intracorporeal lithotripsy?

Introduction

A number of randomized trials and meta-analysis in patients who underwent ureteroscopic stone removal investigated the effects of placing a ureteral stent at the end of the procedure on complication rates. However, none of these investigates the stone diameter and its possible influence on complication rates and, as such, if it should be considered a possible variable in the decision process of placing or not a ureteral stent.

Materials and methods

A bibliographic search covering the period from January 1990 to March 2012 was conducted in PubMed, MEDLINE and EMBASE. This analysis is based on the fifteen remaining studies which fulfilled the predefined inclusion criteria. All statistical evaluations were performed using SAS version 9.2. and by RevMan 5.0.

Results

A total of 1,416 patients were included. All the studies were published after 2000. Mean stone diameter ranged between 5.3 and 13.3 mm in the non-stented group and between 6.26 and 13.28 mm in the stented group. Meta-analysis showed that stone diameter was not statistically different for stented or non-stented subgroups, whereas surgical operative time was shorter for the non-stented subgroup. The effect of stone diameter, irrespectively if patients were operated with or without stents were grouped or considered separately, did not influence complications of fever, haematuria, unplanned medical visits after surgery and urinary tract infections.

Conclusions

Stone diameter is not a variable in the pre- or intraoperative decision process of placing or not placing a ureteral stent in patients undergoing uncomplicated ureterorenoscopy with intracorporeal lithotripsy.     

Comparison of the roll-plate and sonication techniques in the diagnosis of microbial ureteral stent colonisation: results of the first prospective randomised study

Background

Microbial ureteral stent colonisation (MUSC) is one leading risk factor for complications associated with ureteral stent placement. As MUSC remains frequently undetected by standard urine cultures, its definitive diagnosis depends on microbiological investigation of the stent. However, a standard reference laboratory technique for studying MUSC is still lacking.

Materials and methods

A total of 271 ureteral stents removed from 199 consecutive patients were investigated. Urine samples were obtained prior to device removal. Stents were divided into four parts. Each part was separately processed by the microbiology laboratory within 6 h. Ureteral stents were randomly allocated to roll-plate or sonication, respectively, and analysed using standard microbiological techniques. Demographic and clinical data were prospectively collected using a standard case-report form.

Results

Overall, roll-plate showed a higher detection rate of MUSC compared with sonication (35 vs. 28 %, p < 0.05) and urine culture (35 vs. 8 %, p < 0.05). No inferiority of Maki’s technique was observed even when stents were stratified according to indwelling time below or above 30 days. Compared with roll-plate, sonication commonly failed to detect Enterococcus spp., coagulase-negative staphylococci (CoNS) and Enterobacteriaceae. In addition, sonication required more hands-on time, more equipment and higher training than roll-plate in the laboratory.

Conclusions

This prospective randomised study demonstrates the superiority of Maki’s roll-plate technique over sonication in the diagnosis of MUSC and that urine culture is less sensitive than both methods. The higher detection rate, simplicity and cost-effectiveness render roll-plate the methodology of choice for routine clinical investigation as well as basic laboratory research.     

Assessment of readability,quality and popularity of online information on ureteral stents

Objective

To evaluate the quality and readability of online information on ureteral stents.

Methods

Google.com was queried using the search terms “ureteric stent”, “ureteral stent”, “double J stent” and, “Kidney stent” derived from Google AdWords. Website popularity was determined using Google Rank and the Alexa tool. Website quality assessment was performed using the following criteria: Journal of the American Medical Association (JAMA) benchmarks, Health on the Net (HON) criteria, and a customized DISCERN questionnaire. The customized DISCERN questionnaire was developed by combining the short validated DISCERN questionnaire with additional stent-specific items including definition, placement, complications, limitations, removal and “when to seek help”. Scores related to stent items were considered as the “stent score” (SS). Readability was evaluated using five readability tests.

Results

Thirty-two websites were included. The mean customized DISCERN score and “stent score” were 27.1 ± 7.1 (maximum possible score = 59) and 14.6 ± 3.8 (maximum possible score = 24), respectively. A minority of websites adequately addressed “stent removal” and “when to seek medical attention”. Only two websites (6.3%) had HON certification (drugs.com, radiologyinfo.org) and only one website (3.3%) met all JAMA criteria (bradyurology.blogspot.com). Readability level was higher than the American Medical Association recommendation of sixth-grade level for more than 75% of the websites. There was no correlation between Google rank, Alexa rank, and the quality scores (P > 0.05).

Discussion

Among the 32 most popular websites on the topic of ureteral stents, online information was highly variable. The readability of many of the websites was far higher than standard recommendations and the online information was questionable in many cases. These findings suggest a need for improved online resources in order to better educate patients about ureteral stents and also should inform physicians that popular websites may have incomplete information.

     

How to manage total avulsion of the ureter from both ends: our experience and literature review

Objectives

To evaluate the treatment alternatives of total avulsion of the ureter from both ends including ureteropelvic junction (UPJ) and ureterovesical junction (UVJ).

Methods

Total ureteral avulsion on both ends of the ureter was examined in 4 cases performing ureteroscopy. In two male patients of the four cases, avulsion was noticed intraoperatively and ureteral re-anastomosis at UPJ and re-implantation at UVJ were performed immediately. Boari flap was performed for one female patient immediately and for the other female patient who was referred from another hospital after the ureteroscopy, 4 days later.

Results

One patient who had ureteral re-implantation was followed with 3-month intervals by ultrasonography and abdominal X-ray. At the end of 1 year, it was determined that kidney parenchyma was normal and the patient had kidney and upper ureteral stones. Percutaneous nephrolithotomy was performed, and the patient was stone-free at the end of the operation. Two years after the surgery, both kidneys were normal. This is the only case who had a successful ureteral re-implantation in literature. The other patient turned up a year later for routine checks after the ureteral stent was removed. Then, hydronephrosis and renal atrophy were detected. The patient did not accept nephrectomy or any other intervention and he was lost to follow-up. Boari flap procedure was performed after UPJ repair for the other two female patients. Their kidneys were both normal 3 months after the operation.

Conclusions

In case of ureteral avulsion from both ends of the ureter in the male patients, as bladder capacity is not enough for a Boari flap, proximal anastomosis and distal re-implantation could be a good choice for the management of this untoward event. This new approach also saves time for reconstructive treatments if necessary. If bladder capacity is enough to reach UPJ, Boari flap could be a good choice in female patients.     

Feasibility of insertion of a microcatheter through a Y-stent in coil embolization of cerebral aneurysms and its detailed geometry by micro-computed tomography

Background

In Y-stent-assisted coil embolization for cerebral aneurysms, open or closed cell stents are used. Different microcatheters for coil insertion are available. We investigated which microcatheter could be navigated into an aneurysm through a Y-stent with different stents.

Methods

Double Neuroform open-cell stents or double Enterprise closed-cell stents were deployed in Y-configuration in a silicon model of a bifurcation aneurysm. Two endovascular neurosurgeons independently tried to navigate an SL-10 microcatheter for 0.010” coils or a PX Slim microcatheter for 0.020” Penumbra coils into the aneurysm through the Y-stent. In addition, we measured lengths of stent pores of the Y-stents with double Enterprise stents deployed in the model by micro-computed tomography.

Results

It was feasible to navigate an SL-10 microcatheter into the aneurysm through the Y-stent with Enterprise or Neuroform stents. Navigation of a PX Slim microcatheter was feasible in the Y-stents only with Neuroform stents. In the Y-stent with double Enterprise stents, the lengths of the second stent pores were significantly smaller than those of the first stent (0.41?±?0.18 mm vs 0.69?±?0.20 mm; P?=?0.008). The SL-10 microcatheter was smaller than approximately 80 % of the stent pores of the first stent and 30 % of those of the second stent. The PX Slim microcatheter was smaller than 20 % of the stent pores of the first stent and 0 % of those of the second stent.

Conclusions

It was feasible to insert an SL-10 microcatheter into the aneurysm through Y-stents with Enterprise or Neuroform stents. Navigation of a PX Slim microcatheter for 0.020” Penumbra coils was feasible in Y-stents with Neuroform stents, but not with double Enterprise stents. The measurements of stent pores by micro-computed tomography supported this feasibility study. These results may be helpful to select appropriate stents and microcatheters in Y-stent-assisted coil embolization, especially in case of retreatments.     

Endoscopic realignment in the management of complete transected ureter

Purpose

To present experience and feasibility of endoscopic realignment for treatment of delayed recognized iatrogenic complete transected ureteral injuries.

Patients and methods

Patients suffering from iatrogenic complete transected ureteral injuries were treated by two surgeons. Five women and 3 men with a mean age of 50.8 years (range 22–69) received diagnosis during the immediate postoperative period (2–6 days after surgery). Ureteral continuity was re-established using a technique combining antegrade flexible ureteroscopy and retrograde rigid ureteroscopy. Then, three ipsilateral 5F double J stents were inserted to assure ureteral patency.

Results

All eight realignment procedures were successful, and no major complications occurred. Average injury length was 1.9 cm (range 1.5–3.0). Average hospitalization time was 8 days (range 3–14). Nephrostomy tubes and stents were removed after a mean period of 3.9 weeks (range 2–6) and 6.8 months (range 5.9–7.1), respectively. At a mean follow-up of 21.5 months (range 10–56), 6 patients were stent-free without image evidence of obstruction, a patient developed strictures was treated with balloon dilation and another exchanged double J stents periodically. No patient has developed significant renal impairment.

Conclusion

Endoscopic realignment is a safe and efficient method as an initial procedure to manage iatrogenic complete transected ureteral injuries in properly selected cases.     

Roux-En-Y Fistulo-Jejunostomy as a salvage procedure in patients with post–sleeve gastrectomy fistula

Background

Sleeve gastrectomy (SG) is currently the most common bariatric procedure in France. It achieves both adequate excess weight loss and significant reduction of comorbidities. However, leak is still the most common complication after SG. Nevertheless, its risk of occurrence is <3 % in specialized centers. Its management is difficult, long, and challenging. Although the procedure is commonly endoscopic and nonoperative, the management of post-SG fistulas could sometimes be surgical, including peritoneal lavage, abscess drainage, disrupted staple line suturing, resleeve, gastric bypass, or total gastrectomy. Roux-en-Y fistulojejunostomy (RYFJ) has been described as a salvage option. In this study, we report the early results of RYFJ for post-SG fistula, emphasizing indications, operative technique, and short-term outcome.

Methods

Between January 2007 and December 2012, we treated 62 patients with post-SG fistula. Before surgery, intra-abdominal or thoracic abscesses or collections were either excluded or treated by computed tomographic scan–guided drainage or even surgery. Endoscopic stenting was then attempted. After optimization of the nutritional status in case of failure of endoscopic measures, some of the patients underwent RYFJ.

Results

Between January 2007 and December 2012, a total of 21 patients (16 women and 5 men) had RYFJ for post-SG fistula. Mean age was 47 years (range, 22–59 years). Procedures were performed laparoscopically in all but 3 cases. The rate of secondary conversion to laparotomy was 11.1 %. The was no mortality. The postoperative morbidity rate was less than 5 %. The rate of fistula control was eventually 100 %.

Conclusions

RYFJ is a safe and feasible salvage procedure for the treatment of patients with post-SG fistula. Longer outcome analysis is, however, needed especially regarding the physiological and metabolic behavior of the procedure.