Endoscopic dacryocystorhinostomy without silicone stenting

Fifteen endoscopic dacryocystorhinostomies (DCRs) were performed without the use of silicone stents. These patients were followed up for an average of eight months. This procedure was successful in 87% of cases as measured by patients' relief of symptoms and endoscopic visualisation of a middle meatal ostium draining the lacrimal sac. Endoscopic DCR without silicone stenting compares favourably with other techniques described in the literature which use silicone stents. It does not have the disadvantage of complications associated with these stents.     

Long-term results of endonasal dacryocystorhinostomy with and without stenting

Introduction

This study aimed to evaluate the short and long-term results of endoscopic dacryocystorhinostomy (DCR) with and without silicone stenting in chronic dacrocystorhinitis due to postsaccal blockage.

Methods

The study involved a case series of consecutive 89 patients (128 eyes) who underwent endoscopic DCR. All patients were operated on by the senior author. The stent group comprised 63 eyes (44 patients), for which the DCR was performed between September 2002 and September 2005. The non-stent group with 65 eyes (45 patients) underwent the DCR between October 2005 and December 2006. The follow-up duration was up to 33 months after surgery. The statistical significance (p-value) was calculated using the chi-squared test.

Results

The short-term success rate at six months’ follow-up was 70% in the stent group and 97% in the non-stent group (p=0.0005) while the long-term success rate at 33 months was only 57% in stent group compared with 89% in the non-stent group (p=0.0003).

Conclusions

In this study, the non-stent group showed a higher success rate than the stent group on both short and longterm follow-up. Our study suggests that postoperative stents are not necessary for primary DCR and may be associated with a worse outcome.     

Balloon-expandable stenting with and without coiling for wide-neck and complex aneurysms

BACKGROUND: Wide-necked, saccular, dissecting, and fusiform intracranial aneurysms are poor coil retainers. Retention can be improved by parent-artery stenting across the aneurysm. METHODS: We used a balloon-expandable stent and delivery system, intending to treat 38 aneurysms in 36 patients. Stents could not be advanced across the neck of 2 aneurysms near the ophthalmic artery origin. These cases were managed by temporary balloon remodeling and coiling. Stenting alone was done for 15 aneurysms, including 7 in vertebral artery V4 segments. Stenting with immediate or delayed coiling was done in 21 aneurysms. RESULTS: Stenting alone caused immediate and complete obliteration of 1 treated aneurysm (7%), subtotal obliteration in 13 treated (86%) aneurysms, and was associated with 1 failure. Stenting and coiling yielded a significantly better 57% complete obliteration rate, 43% subtotal obliteration, and no failures. There were 5 complications: 1 wire perforation, 2 cavernous-carotid-sinus fistulae, and 2 partial in-stent thromboses. All were controlled or cleared with no long-term sequelae or deaths. Contrast imaging at 1 to 12 months was available for 30 patients (13 stent-only, 17 stent-plus-coiling), demonstrating complete obliteration in 25 (83%) and subtotal obliteration in 5. A total of 7 stent-only aneurysms (4 V4s) were completely obliterated, and 3 (all V4s) were > or = 90% obliterated. CONCLUSION: Stenting and coiling through the wall of the stent resulted in 88% (15/17) complete obliteration when imaged 1 to 12 months after treatment. Stenting alone effectively closed off V4-segment wide-necked aneurysms but was inferior to stenting and coiling in less mobile vessels.     

A randomized trial of carotid artery stenting with and without cerebral protection

BACKGROUND: The use of a distal filter cerebral protection device with carotid artery stenting is commonplace. There is little evidence, however, that filters are effective in preventing embolic lesions. This study examined the incidence of embolic phenomenon during carotid artery stenting with and without filter use. METHODS: This was a prospective, randomized, single-center study of carotid artery stenting with or without a distal cerebral protection filter. A 1:1 scheme was used to randomize 36 carotid artery stenting procedures in 35 patients. Diffusion-weighted magnetic resonance imaging (DW MRI) 24 hours after stenting was used to assess the occurrence of new embolic lesions. Blinded observers calculated lesion number and volume. RESULTS: The mean age was 78.6 +/- 7.0 in the cerebral protection group compared with 74.1 +/- 8.7 in the no cerebral protection group (P = .92). Despite similar average age, the percentage of octogenarians was higher in the cerebral protection group (61.1% vs 22.2%; P = .04). Two procedures in the cerebral protection group were not successful. One was completed without protection because of inability to track the filter, and the second was aborted because of severe tortuosity with a later carotid endarterectomy. New MRI lesions were noted in 72% of the cerebral protection group compared with 44% in the no cerebral protection group (P = .09). The average number of lesions in these patients was 6.1 and 6.2, respectively, with mean DW MRI lesion size of 16.63 mm(3) vs 15.61 mm(3) (P = .79 and .49, respectively). Four strokes occurred (11%), two in each group, in patients aged 75, 80, 82, and 84 years. The only major stroke occurred in the no cerebral protection group. CONCLUSIONS: The use of filters during carotid artery stenting provided no demonstrable reduction of microemboli, as expected. Routine use of cerebral protection filters should undergo a more critical assessment before mandatory universal adoption.     

A corner-saving ureteral reimplantation technique without stenting

In this study we present our new technique, which will simplify reconstruction of even a small-caliber ureter. Our transplantation team has performed 1523 renal transplantation since 1975. From 1975 to 1983, we performed 300 ureteroneocystostomies using the modified Politano-Leadbetter technique. Since 1983, the extravesical Lich-Gregoir technique was used in combination with temporary ureteral stenting in 1141 patients. After September 2003, we began a corner-saving technique. Eighty-two (62 living related, 20 cadaver) renal transplantations have been performed since September 2003. The mean recipient age was 32.2 +/- 10.9 years (range, 7 to 63). Mean donor age was 38.9 +/- 13.1 years. For ureteral reimplantation, a running suture is started from 3 mm ahead from the middle of the posterior wall and finished 3 mm afterward. After the last stitch, both ends of the suture material are pulled and the posterior wall of the ureter and bladder are approximated tightly. The anterior wall is sewn either with the same suture or another running suture. Since using this technique, we have not employed a double J or any other stent to prevent ureteral complications at the anastomosis side. We have seen only two (2.4%) ureteral complications. In conclusion, due to the low complication rate, we believe that our new technique is the safest way to perform a ureteroneocyctostomy.     

Steinstrasse: a comparison of incidence with and without J stenting and the effect of J stenting on subsequent management.

OBJECTIVE: To analyse the effect of ureteric stenting on the incidence of steinstrasse and its effects on the subsequent management of steinstrasse. PATIENTS AND METHODS: Four hundred adult patients with a unilateral stone burden (mean diameter 1.5-3.5 cm) were randomly allocated into two groups; in group 1, patients had a J stent inserted before extracorporeal shock wave lithotripsy (ESWL) and group 2 did not. Before randomization, the patients had normal renal function and no evidence of ureteric obstruction on intravenous urography. All patients underwent ESWL, with the shock waves delivered first to the most dependent part of the calculi. Patients who developed steinstrasse were identified and the effect of the size of the calculi and the presence of a J stent on the incidence and level of the steinstrasse, on the time of diagnosis, the size of the major stone fragment, associated presenting symptoms and effect on subsequent management were compared between the groups. RESULTS: Patients developed steinstrasse in both groups, with 12 (6%) and 26 (13%) in groups 1 and 2, respectively (significantly different, P<0.05). The incidence of steinstrasse depended on the size of the calculus, regardless of whether a J stent was present, being 2.6% and 56% for a burden of 1.5-2.0 cm and 3.1-3.5 cm, respectively (P<0.001). There was no difference in the presenting symptoms in the two groups. The steinstrasse was in the lower third of the ureter in eight of 12 patients in group 1 and in 16 of 26 (62%) in group 2. The steinstrasse resolved spontaneously in seven patients in group 1 and in 12 (46%) in group 2 (P<0.11). Similarly, J stenting had no effect on the subsequent treatment modalities to resolve steinstrasse. CONCLUSION: The use of J stenting before lithotripsy significantly lowers the incidence of steinstrasse in patients with a stone burden of 1.5-3.5 cm. The incidence of steinstrasse increases with the size of the calculi, whether or not a J stent is present; J stenting has no apparent effect on the mode of presentation or the subsequent management of steinstrasse.     

Pancreaticojejunostomy using duct-to-mucosa anastomosis without a stenting tube

Background Purpose There is a high risk of anastomotic leakage after pancreaticojejunostomy following pancreaticoduodenectomy in patients with a normal soft pancreas because of the high degree of exocrine function. Therefore, pancreaticojejunostomy is generally performed using a stenting tube (stented method). However, pancreaticojejunostomy with a certain duct-to-mucosa anastomosis does not always require a stenting tube, even in patients with a normal soft pancreas. Recently, we have performed pancreaticojejunostomy with duct-to-mucosa anastomosis without a stenting tube (nonstented method) and obtained good results. Methods The point of this technique is to maintain adequate patency of the anastomosis using a fine atraumatic needle and monofilament thread. The results of end-to-side pancreaticojejunostomy of the normal soft pancreas using the nonstented method (n = 123) were compared with those using the stented method (n = 45). Results There were no differences in background characteristics between the groups, including age, gender, and disease. The mean times to complete pancreaticojejunostomy were around 30 min in the two groups and the rates of morbidity and leakage of pancreaticojejunostomy were 26.8% and 5.7% in the nonstented group and 22.2% and 6.7% in the stented group, respectively. These differences were not statistically significant. One patient in the stented group died of sepsis following leakage of pancreaticojejunostomy. There were also no significant differences in the mean time to initiation of solid food intake or postoperative hospital stay. Conclusions In conclusion, complete pancreaticojejunostomy using duct-to-mucosa anastomosis for a normal soft pancreas does not require a stenting tube. This nonstented method can be considered one of the basic procedures for pancreaticojejunostomy because of its safety and certainty.     

Risk of target lesion revascularization after coronary stenting in patients with and without chronic kidney disease.

BACKGROUND: Rates of restenosis following percutaneous coronary intervention with stent placement are high in patients with advanced renal failure. Whether mild to moderate chronic kidney disease (CKD) is associated with a similarly increased need for short or long-term target lesion revascularization (TLR) following coronary stenting is uncertain. METHODS: We analysed results from 1228 patients enrolled in four separate, randomized, controlled clinical trials who underwent elective coronary angioplasty with stenting and were prospectively followed for 5 years after the index procedure. Cox proportional hazards regression was used to correct for confounding and to estimate the short and long-terms risks of target lesion revascularization in patients with vs without mild to moderate CKD. RESULTS: During a median follow-up of 5 years, 205 patients (16.7%) required TLR with 59 (4.8%) requiring TLR after the first year. Mild (HR 1.07, 95% CI 0.74-1.53) and moderate (HR 0.95, 95% CI 0.552-1.64) CKD were not associated with an increase in the adjusted, overall-risk of TLR. However, mild to moderate CKD was associated with a non-significantly increased risk of late TLR (HR 1.40, 95% CI 0.73-2.69). CONCLUSIONS: Coronary stenting appears to be similarly effective in patients with mild to moderate CKD and patients with normal renal function. While target lesion revascularization is rarely needed beyond the first year after revascularization, long-term results of coronary stenting may be less-favourable in patients with CKD.     

Orbital hemorrhage with proptosis following a dacryocystorhinostomy

A 65-year-old patient with chronic leukemia underwent an uncomplicated dacryocystorhinostomy. On the first postoperative day, the eye was proptotic and chemotic with restricted movements. A CT scan revealed a medial juxtabulbar hemorrhage that blocked the surgical osteotomy. A clot was locally suctioned through the nose, and the symptoms resolved over the following weeks.