Covered cloacal exstrophy – a poorly recognized condition: Hints for a correct diagnosis

Introduction

Covered cloacal exstrophy requires a high index of suspicion for its diagnosis. Low implantation of the umbilical cord, separated pubic bones, and anorectal malformation are the most common signs.

Methods

Thirty-one patients with this defect were retrospectively analyzed.

Results

Besides the anorectal malformation, the patients had important unique anatomic findings, including a colon shorter than 20 cm (17 patients) and absent bladderneck (27 patients). Twenty-four patients underwent a colonic pullthrough; of those, only 5 of them have voluntary bowel movements. Twelve patients underwent a urinary reconstruction. Eleven of them are dry with catheterization, and one leaks in between catheterization. Two patients are urinary continent.

Conclusions

Covered exstrophy is a serious condition. Externally, the patients may look like having a rather simple malformation. However, the intra-abdominal findings are similar to those seen in cloacal exstrophy. An early correct diagnosis is important to plan a reconstructive strategy and to adjust the parent’s expectations concerning bowel and urinary function. In addition to the traditional prognostic factors for bowel and urinary control (sacral ratio, tethered cord, and level of the rectum) these patients have other anatomic defects (absent bladderneck and short colon) that negatively affect the functional prognosis.     

内镜下覆膜食管支架治疗食管癌性狭窄及食管气管瘘的临床应用价值

目的探讨内镜下覆膜食管支架治疗食管癌性狭窄及食管气管瘘的临床价值及食管支架置入术并发症的防治。方法回顾性分析163例晚期食管癌患者内镜下覆膜食管支架治疗食管癌性狭窄及食管气管瘘的临床资料,其中7例患者为食管癌性狭窄并食管-支气管瘘伴双下肺感染,19例患者为食管癌术后复发吻合口狭窄置入镍钛记忆合金覆膜支架。102例患者由于食管过于狭窄先行食管扩张,再进行内镜下放置食管支架,35例患者直接内镜下置入食管支架。结果 163例患者先后放置174个支架,均一次性置入成功,成功率为100%。163例患者均有不同程度胸痛不适,有32例支架再狭窄,其中19例单纯行支架内球囊扩张,11例于原支架上端内部分重叠再放置一支架,有26例行氩气刀再通治疗。7例患者出现支架移位,有2例支架进入食管瘘管内于次日在内镜下取出支架重新放置。所有病例均未出现食管破裂、食管血肿或出血等严重并发症,术后患者进食能力提高,食管气管瘘闭合。结论内镜下覆膜食管支架置入术是中晚期食管癌性狭窄简单、安全、有效的姑息治疗方法,能提高患者的生活质量,延长患者的生存期。     

Polytetrafluoroethylene-covered stents in the venous and arterial system: angiographic and pathologic findings in a swine model

BACKGROUND: Although polytetrafluoroethylene (PTFE) is now used as a covering in a wide variety of vascular stents, little is known about the resultant pathologic and angiographic changes in the arterial and venous system after stent deployment. METHODS: Atrium PTFE-covered stents were deployed in the abdominal aorta and the inferior vena cava (IVC) of two Yorkshire pigs. Angiograms were performed after deployment and at recatheterization. A complete histopathological exam was performed after sacrifice, and angiographic and histology findings were then compared between the two types of blood vessels. RESULTS: The arterial stents demonstrated no stenosis on angiography and minimal in-stent intimal proliferation by histopathology. A uniform layer of neointima coated the inside of the stent by 1 month with no obvious thrombus formation. In contrast, the venous stents demonstrated angiographic evidence of significant in-stent stenosis of variable degrees and the histology showed increased intimal hyperplasia with fibrin deposition. PTFE from both the arterial and venous stents had variable amounts of tissue ingrowth with cells observed to be growing into and through the PTFE fibers. CONCLUSIONS: Atrium PTFE-covered stents have excellent short-term angiography and histopathology in the arterial system, while stents in the venous system developed rapid in-stent intimal hyperplasia. PTFE fibers from both types of vasculature permitted cells to grow through and within them.     

Clinical Experience with Covered Wallstents for Biliary Malignancies: 23-Month Follow-Up

Purpose: To evaluate the effectiveness of partially covered metallic Wallstents to prevent tumoral ingrowth in patients with neoplastic obstruction of the biliary tract. Methods: Twenty-one patients with malignant obstructive jaundice have been treated with Wallstents partially covered with a polyurethane polymer. In total, 36 covered stents (8 and 10 mm in diameter, 70 and 90 mm long) were deployed. All the stents were free from covering at both ends. Results: Jaundice was successfully treated in 100% of cases. There were no problems related to the releasing system during stent positioning, no major complications, and no incompatibility reactions to the materials composing the endoprostheses. At 23-month follow-up, 6 patients are still alive and 15 are dead; of these 15 patients, 11 died in the first 6 months and the last 4 died between 6 and 23 months. Seven patients had an obstructed stent; in four of these, cholangioscopy showed the presence of tumoral ingrowth and in one it showed necrotic tissue with biliary pigments and inflammatory cells. No biopsy specimen was obtained in the remaining two patients with stent obstruction. The follow-up, ranging from 7 to 23 months, showed a primary patency of 46.8% and 24.6% and an assisted patency of 66.3% and 59% at 6 months and 23 months, respectively. Conclusions: Covered metallic stents are effective and may produce improved survival in patients with malignant biliary obstruction (27.8% at 23 months). Stent patency, however, is similar to that of uncovered stents. Modifications in the design of the covering membrane may reduce stent obstruction resulting from disruption of the plastic covering. Received: 0/00/00/Accepted: 0/00/00     

无盖杰雪的消毒效果观察

目的验证无盖杰雪消毒效果的可靠性,为临床使用提供客观实验依据。方法①浓度测定(实验组:无盖洁雪12瓶放置60d后检测浓度;对照组:有盖洁雪12瓶放置60d后检测浓度)。②皮肤实验(自身对照,实验组30例:无盖杰雪消毒患者右手背皮肤,消毒区采样细菌培养72h;对照组30例:有盖杰雪消毒患者左手背皮肤,消毒区采样细菌培养72h)。结果①浓度测定;有盖洁雪、无盖杰雪浓度均在标准范围内(醋酸氯已定5.0~5.5g/L、乙醇70%~75%),两者比较差异无统计学意义(醋酸氯已定t=-0.196,P=0.847、乙醇t=-0.355,P=0.726);②皮肤实验:有盖洁雪、无盖杰雪消毒皮肤后均无细菌生长。结论无盖杰雪消毒效果可靠。     

Application of the Willis Covered Stent in the treatment of intracranial unruptured aneurysms in internal carotid artery: A retrospective single-center experience

The purpose of this study was to retrospectively analyse the clinical and angiographic outcomes of Willis covered stent placement for unruptured aneurysms in internal carotid artery. Forty-six consecutive patients with internal carotid artery aneurysms (49 cases) were included to evaluate clinical and angiographic outcomes. Covered stent placement was successful in 47 cases, whereas stent navigation failed in 2 cases. Of the 49 aneurysms (mean aneurysm size, 7.9 mm), 5, 6, and 38 were located in the petrous, cavernous, and ophthalmic segments, respectively. Immediate angiography revealed complete aneurysm exclusion in 36 (76.6%) cases, whereas minimal endoleak was observed in 11 cases. Four patients had procedure-related complications, including 1 patient with acute in-stent thrombosis, 2 with a post-operative subarachnoid haemorrhage, and 1 with artery rupture. Angiographic and clinical follow-up was available for 36 patients (38 aneurysms). Complete aneurysm occlusion was achieved in 34 (89.5%) cases, endoleak was present in 2 cases, and aneurysm recurrence occurred in 2 cases. Asymptomatic in-stent stenosis was observed in 3 patients. No hemorrhagic or ischemic events occurred during the follow-up period. At follow-up, the modified Rankin scores were 0–2 for 35 patients and >2 for 1 patient. Satisfactory angiographic outcomes were achieved in our study. However, the risks of stent navigation failure, endoleak after balloon re-inflation, procedure-related complications and coverage of side branches should be considered when choosing the best therapeutic option for internal carotid artery aneurysms.     

Transjugular intrahepatic portosystemic shunt with covered stents for hepatocellular carcinoma with portal vein tumor thrombosis

AIM: To evaluate transjugular intrahepatic portosystemic shunt(TIPS) with covered stents for hepatocellular carcinoma(HCC) with main portal vein tumor thrombus(PVTT). METHODS: Eleven advanced HCC patients(all male, aged 37-78 years, mean: 54.3 ± 12.7 years) presented with acute massive upper gastrointestinal bleeding(n = 9) or refractory ascites(n = 2) due to tumor thrombus in the main portal vein. The diagnosis of PVTT was based on contrast-enhanced computed tomography and color Doppler sonography. The patients underwent TIPS with covered stents. Clinical characteristics and average survival time of 11 patients were analyzed. Portal vein pressure was assessed before and after TIPS. The follow-up period was 2-18 mo. RESULTS: TIPS with covered stents was successfully completed in all 11 patients. The mean portal vein pressure was reduced from 32.0 to 11.8 mmHg(t = 10.756, P = 0.000). Gastrointestinal bleeding was stopped in nine patients. Refractory ascites completely disappeared in one patient and was alleviated in another. Hepatic encephalopathy was observed in six patients and was resolved with drug therapy. During the follow-up, ultrasound indicated the patency of the shunt and there was no recurrence of symptoms. Death occurred 2-14 mo(mean: 5.67 mo) after TIPS in nine cases, which were all due to multiple organ failure. In the remaining two cases, the patients were still alive at the 16- and 18-mo follow-up, respectively. CONCLUSION: TIPS with covered stents for HCC patients with tumor thrombus in the main portal vein is technically feasible, and short-term efficacy is favorable.     

Development of novel covered stents using salmon collagen

In this study, we newly developed self-expandable or balloon-expandable covered stents with a biodegradable salmon collagen (SC) film. The SC-covered stents were fabricated by placing a bare stent in a mixture of acidic SC solution and a fibrillogenesis-inducing buffer (pH 6.8) including a cross-linking agent (water-soluble carbodiimide), and subsequent incubation at 4°C for 24 h and lyophilization. The stents obtained were completely covered with an SC film having a nanofibrous structure (fibril diameter, about 70 nm). On immersion in water, the film is converted to a gel with slight swelling. There was no rupture of the SC cover after mounting on a balloon catheter or after expansion. Preliminary implantation was conducted by placing the balloon-expandable covered stents in the common carotid arteries of beagles. One month after implantation, angiography showed that all stented arteries were patent with no significant neointimal thickening. In conclusion, SC is potentially useful as a cover material of endovascular stents to enhance patency.