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Early detection of liver transplantation (LT) vascular complications enables timely management. Our aim was to assess if routine Doppler ultrasound (rDUS) improves the detection of hepatic artery thrombosis (HAT), portal vein thrombosis (PVT) and hepatic venous outflow obstruction (HVOO). We retrospectively analysed timing and outcomes, number needed to diagnose one complication (NND) and positive predictive value (PPV) of rDUS on post-operative day (POD) 0,1 and 7 in 708 adult patients who underwent primary LT between 2010-2022. We showed that HAT developed in 7.1%, PVT in 8.2% and HVOO in 3.1% of patients. Most early complications were diagnosed on POD 0 (26.9%), 1 (17.3%) and 5 (17.3%). rDUS correctly detected 21 out of 26 vascular events during the protocol days. PPV of rDUS was 53.8%, detection rate 1.1% and NND was 90.5. Median time to diagnosis was 4 days for HAT and 47 days for PVT and 21 days for HVOO. After intervention, liver grafts were preserved in 57.1%. In conclusion, rDUS protocol helps to detect first week's vascular events, but with low PPV and a high number of ultrasounds needed. [ABSTRACT FROM AUTHOR]

Early detection of liver transplantation (LT) vascular complications enables timely management. Our aim was to assess if routine Doppler ultrasound (rDUS) improves the detection of hepatic artery thrombosis (HAT), portal vein thrombosis (PVT) and hepatic venous outflow obstruction (HVOO). We retrospectively analysed timing and outcomes, number needed to diagnose one complication (NND) and positive predictive value (PPV) of rDUS on post-operative day (POD) 0,1 and 7 in 708 adult patients who underwent primary LT between 2010–2022. We showed that HAT developed in 7.1%, PVT in 8.2% and HVOO in 3.1% of patients. Most early complications were diagnosed on POD 0 (26.9%), 1 (17.3%) and 5 (17.3%). rDUS correctly detected 21 out of 26 vascular events during the protocol days. PPV of rDUS was 53.8%, detection rate 1.1% and NND was 90.5. Median time to diagnosis was 4 days for HAT and 47 days for PVT and 21 days for HVOO. After intervention, liver grafts were preserved in 57.1%. In conclusion, rDUS protocol helps to detect first week’s vascular events, but with low PPV and a high number of ultrasounds needed.

Purpose: The liver function in outflow-obstructed regions is reportedly impaired; however, the functional decrease has not been quantitatively assessed. We therefore evaluated the uptake of indocyanine green (ICG) into hepatocytes and the mRNA expression associated with the liver function in outflow-obstructed regions using rat models. Methods: A total of 20 rats with the ligation of the right median hepatic vein to induce outflow obstruction were studied. Five rats each were grouped by the time of re-laparotomy, and the fluorescence intensity (FI) values of ICG. The mRNA expression, including that of Albumin, Cytochrome P450 (Cyp) 1a2, Cyp3a1, Cyp7a1, and Gamma-glutamylcysteine synthetase, in outflow-obstructed (mRNAOut-Ob) and non-outflow-obstructed (mRNANon) regions was assessed. Results: Microscopic fluorescence imaging showed that the FI values were significantly lower in outflow-obstructed regions than in non-outflow-obstructed regions at 12 h, 24 h, and 3 days after ligation of the hepatic vein. The mRNAOut-Ob/mRNANon ratios decreased to approximately 30% at 12 h after the outflow obstruction and increased to approximately 70–80% at 7 days. Conclusions: The liver function in outflow-obstructed regions was impaired in terms of the uptake of ICG and the mRNA expression. Our findings may help estimate the postoperative functional remnant liver volume by considering the decrease in the liver function in outflow-obstructed regions. [ABSTRACT FROM AUTHOR]

Up to date, there are no reports on animal survival rate and morphological changes in the liver caused by the impairment of blood outflow from the liver and its time dependence. Moreover, the impact of duration and degree of occlusion of inferior vena cava on pathological changes was not investigated yet. This study aimed at the assessment of the survival rate and morphological changes in the liver with varying degrees of occlusion of inferior vena cava. The exact timing of the reversibility of pathological processes was determined. Rats (n = 160) were randomly divided into five groups: I – control group (CG) (n = 20); II – sham group (SG) (n = 20); III – intervention group (IG-1) (narrowing of the lumen of the inferior vena cava by 25%) (n = 40); IV intervention group (IG-2) (narrowing by 50%) (n = 40); and intervention group V (IG-3) (narrowing by 75%) (n = 40). The level of postoperative pain, the body and liver weight of the animals, histological examination, morphometry, and macroscopic evaluation of abdominal organs were carried out on the 1, 3, 7, 14, and 30 days following the surgical intervention. The survival rate of animals was assessed using the Kaplan–Meier method. On the 30th day, the rat grimace scale indices in the IG-1 (P ≤ 0.05), IG-2, and IG-3 (P ≤ 0.001) groups were higher. By body weight, this indicator on the 30th day was lower in the IG-1 (P ≤ 0.05), IG-2, and IG-3 (P ≤ 0.001) groups compared to the CG and SG groups. In the IG1 and IG2 groups, the survival rates were 72.5% and 65.0%, respectively. The lowest survival rate was observed in the IG3 group (22.5%). Compression of the inferior vena cava by 75% led to an increase in animal mortality and the development of persistent morphological changes in the liver. At the same time, the survival rate of animals and the extent of changes in the liver with narrowing of the inferior vena cava by 25% and 50% had similar results. The results acquired possess scientific and practical importance. [ABSTRACT FROM AUTHOR]

Aim: To assess the efficacy of Intralesional injection of mitomycin C (MMC) following visual internal urethrotomy (VIU) in the management of recurrent urethral stricture., Materials: Fifty male patients diagnosed with recurrent single bulbar urethral stricture measuring less than 1.5 cm previously treated with VIU were randomly allocated into two equal groups, (Group A) planned for VIU only and (Group B) planned for VIU with intralesional MMC injection using Botox injection needle. All patients were objectively evaluated pre- and post-operatively at 3, 6, and 12 months using uroflowmetry, post-void residual urine volume, and retrograde urethrography., Results: Forty-five patients completed their follow-up in our study. Patients who underwent intralesional MMC injection showed significant improvement in uroflowmetry, post-voiding residual, and with a success rate (82.6% in Group B, compared to 50% in Group A with a highly statistically significant difference, p -value: <0.001). VIU with MMC was the only factor associated with a marked decrease in stricture recurrence ( p  = 0.02) as shown in the Multivariate Cox regression analysis., Conclusion: Intralesional injection of mitomycin C seems to be a safe and effective modality in reducing the recurrent stricture rate after VIU., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Our objective was to review our experience with isomerism associated with univentricular hearts and evaluate the prevalence of pulmonary versus systemic outflow obstruction. We identified those prenatally or postnatally diagnosed, between September 2004 and October 2021, with right and left isomerism and a functionally univentricular heart. We identified 62, 51 prenatally and 11 postnatally. Of the 62, 61 had prenatal care for an 84% (51/61) prenatal detection rate. Of the 62, 36 (58%) had right isomerism. Of the 51 prenatally diagnosed, 36 were live-born, 13 had fetal demise, and two underwent elective termination. Of the total 62, 43 had pulmonary outflow obstruction, 14 had systemic outflow obstruction, three had no outflow obstruction, and two had a common arterial trunk. However, between September 2004 and December 2019, 41 of 52 (79%) had pulmonary outflow obstruction, and between January 2000 and October 2021, 2 of 10 (20%) had pulmonary outflow obstruction (p = 001). We noted a statistically significant temporal change in the prevalence of pulmonary versus systemic outflow obstruction in those with isomeric situs and a functionally univentricular heart. Further, prenatal diagnosis exceeded 80% in the general population of Nevada. [ABSTRACT FROM AUTHOR]

This study was designed to investigate the techniques of hepatic venous outflow reconstruction and the management of its complications using ex vivo liver resection and autotransplantation (ELRA). Being a retrospective case series covering 84 patients who underwent hepatic venous outflow reconstruction during ELRA from January 2016 to October 2020, 11 cases of postoperative hepatic venous outflow obstruction (HVOO), whose surgery details were described and survival rates analyzed. A total of the 84 alveolar Echinococcosis (AE) series was no intraoperative death. The 30-day mortality was 5.95% (5 /84). The most common postoperative complication was pleural effusion in 21 cases (25%). HVOO occurred in 11 cases, one of them died of liver failure, and the other 10 patients underwent interventional revascularization with good results. There was no significant difference in survival between patients with successful interventional revascularization due to HVOO and patients without HVOO (P > 0.05). Individualized and well design reconstruction of hepatic vein can be considered as a key procedure to reduce the complications of HVOO in ELRA. Once HVOO occurs, emergent management must be performed immediately before liver dysfunction. Interventional revascularization showed an effective approach, though the more clinical cases need to be evaluated. [ABSTRACT FROM AUTHOR]

Background: With the development of high-resolution manometry (HRM) and peroral endoscopy, more patients with esophageal motility disorders (EMDs) including achalasia are diagnosed and treated. The characteristics of Japanese patients with EMDs are unknown and should be elucidated. Methods: A large-scale database analysis was performed at seven high-volume centers in Japan. EMDs between 2010 and 2019 were analyzed. Results: A total of 1900 patients were diagnosed with treatment naïve achalasia on esophagography. A long disease history was related to the sigmoid and dilated esophagus, and patients' symptom severity declined as achalasia progressed to the sigmoid type. Among 1700 patients received starlet HRM, 1476 (86.8%) completed the examination. Long disease history and sigmoid achalasia were identified as risk factors for the failure of HRM examination. Type I achalasia was the most common type found on starlet HRM, and 45.1% of patients with achalasia had lower esophageal sphincter (LES) pressure within the normal range. Type III had a high age of onset and mild symptom severity, compared to the other two subtypes. Type III achalasia, esophagogastric outflow obstruction (EGJ-OO), jackhammer esophagus (JE), and diffuse esophageal spasm (DES) were relatively rare compared to type I–II achalasia. The clinical characteristics of EGJ-OO, JE, and DES were generally close to those of achalasia. Conclusion: This first large-scale database analysis indicates that more Japanese patients with achalasia are type I and have a normal range of LES pressure on starlet HRM. Failure of HRM is not rare; therefore, esophagography continuously has a complementary role in achalasia diagnosis. [ABSTRACT FROM AUTHOR]

In the Chicago Classification version 4.0 (CCv4), esophagogastric junction outflow obstruction (EGJOO) is manometrically defined as an elevated median integrated relaxation pressure (IRP) and elevated intrabolus pressure (IBP) during supine wet swallows, and persistently elevated median IRP in the upright position. A clinically relevant conclusive diagnosis of EGJOO requires a manometric diagnosis of EGJOO and associated symptoms such as dysphagia and/or chest pain with at least one of the following supportive investigations (pharmacologic provocation, timed barium esophagogram, and/or endoflip). The Chicago Classification is intended for diagnosis of primary esophageal motor disorders, and thus history and endoscopic evaluation are important to exclude conditions (eg, previous surgery, strictures, or masses) that can secondarily generate the EGJOO pattern on HRM. While a manometric finding of EGJOO is often made and can be an early sign of achalasia, more often it is a manometric finding without clinical implications. The proposed changes in CC4.0 have attempted to make the diagnosis more specific, in order to reduce the number of clinically irrelevant diagnoses and avoid confusion by patients and physicians alike. [ABSTRACT FROM AUTHOR]

Background: The anatomic variation of hepatic vein in the left lateral segment (LLS) increases the risk of outflow complication in pediatric living liver transplantation (LDLT). Here, we share a modified method for dual hepatic vein reconstruction in pediatric LDLT using LLS with two wide orifices.Methods: From Sep 2018 to Dec 2019, 434 pediatric LDLTs using LLS were performed in our center. Hepatic veins of grafts were classified into three types with emphasis on the number, size, and location of orifices at the cut surface: a single opening (type I, n = 341, 78.57%); two adjacent orifices (type II, n = 66, 15.21%); two wide orifices with orifices distances 20 mm (type IIIb, n = 12, 2.76%). Rv was defined as the ratio of diameter of V2 and V3 (refer to hepatic vein drained segments II and III). We developed a modified dual hepatic vein anastomosis to reconstruct outflow for type IIIb grafts with Rv ≤1. Briefly, the hepatic vein of segment II was anastomosed to the common stump of middle hepatic vein (MHV) and left hepatic vein (LHV), followed by unification of V3 and the longitudinal incision orifice in inferior venous cave (IVC).Results: During median follow-up of 15.6 months (7.5–22.9 months), no hepatic vein complications occurred.Conclusion: This novel modified dual hepatic vein anastomosis could serve as a feasible surgical option for type IIIb LLS grafts with Rv ≤1 in pediatric LDLT.

Background: Esophageal hypercontractility (EHC) is considered a major esophageal motor disorder of unclear etiology. Different mechanisms have been proposed, including an imbalance in inhibitory and excitatory esophageal innervation. We hypothesized that patients with EHC suffer from cholinergic hyperactivity. Aim: To interrogate the excitatory and inhibitory neurotransmission in EHC by assessing the esophageal motor response to atropine (ATR) and cholecystokinin (CCK), respectively, in EHC patients. Method: We retrospectively reviewed patients who underwent high‐resolution manometry (HRM) with pharmacologic challenge in a tertiary referral center between 2007 and 2017. We identified 49 EHC patients who were categorized based on frequency of hypercontractile peristaltic sequence into "frequent" and "infrequent" and motility diagnosis groups. Deglutitive pressure metrics and esophageal motor responses to ATR (12 mcg/kg iv) and CCK (40 ng/kg iv) were analyzed across groups. Results: Atropine abolished hypercontractility across all groups studied, converting nearly half of patients to a motor pattern of ineffective esophageal motility. Abnormal CCK responses primarily occurred in the patient groups with concomitant outflow obstruction. Conclusions: Hypercontractility is cholinergically mediated in all esophageal motor disorders. Most patients with isolated EHC appear to have excessive cholinergic drive, rather than loss of inhibitory innervation, and might be candidates for treatment with anticholinergic agents. [ABSTRACT FROM AUTHOR]

Abstract Background Cardiac syncope can result from an atrial myxoma due to outflow obstruction. Myxoma is the most common primary cardiac tumor that may cause sudden death and the nonspecific symptoms may make early diagnosis difficult. Case presentation A 27-year-old man presented to our emergency department after two episodes of syncope and severe fatigue. He had no complaint of fever, weight loss, sweating, chest pain or dyspnea. Vital signs were within normal limits. A loud heart S1 was detected and normal neck veins. Other systemic examinations including neurological assessment were normal. Electrocardiography showed normal sinus rhythm. An obvious variability in heart rate was noticed on cardiac monitor changing by the patient’s position. Point-of-care ultrasonography (PoCUS) showed a large hyperechoic lesion with a well-defined stalk originating from the left atrium (LA). Thus, the patient was transferred to a cardiac surgery center for surgical intervention. Histopathology reported an LA mass compatible with myxoma. Conclusions Emergency physicians should be familiar with the vague presentations of cardiac tumors to improve patient outcomes. It is beneficial to take advantage of bedside ultrasound for prompt diagnosis and subsequent treatment.

Purpose: To establish the correlation between flow rate curve shape and video-urodynamic findings in women with lower urinary tract symptoms (LUTS). Methods: A retrospective review of consecutive women with LUTS who performed a free flow study immediately before undergoing video-urodynamic investigations over a 28-month period. Flow rate curve shape and video-urodynamic parameters were analysed. Free flow curves were defined into five categories: bell-shaped, prolonged, fluctuating, intermittent or plateau. Women who voided less than 150 ml on the free flow study were excluded from the analysis. Results: A total of 250 women with LUTS, with a mean age 48 years (range 18–83), were included. Bell-shaped tracings excluded obstruction in 89%. Prolonged flow rate curves diagnosed obstruction in 62% and detrusor underactivity in 8%. Fluctuating and intermittent flow rate curves were associated with urodynamic obstruction in 37 and 39%, respectively, and detrusor underactivity in 25 and 29%, respectively. A plateau flow rate curve was indicative of urodynamic obstruction in all three cases observed. Conclusion: Flow rate curve patterns can be suggestive of urodynamic diagnoses. Women without a prolonged void and bell-shaped traces had normal voiding urodynamics in 76% of cases, and the majority could be managed without invasive investigations. Patients with fluctuating and intermittent flow rate curves demonstrate a spectrum of urodynamic diagnoses with a third of cases having obstruction and a third of cases having detrusor underactivity. Plateau flow rate curve patterns are associated with urethral obstruction. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the effectiveness and safety of percutaneous transhepatic stent placement in management of hepatic venous outflow obstruction after living-donor liver transplantation (LDLT). Materials and methods: From September 2010 to May 2015 percutaneous transhepatic venography was performed in 30 patients of 489 patients who underwent LDLT with suspected hepatic venous outflow obstruction with stent placement performed in 25 patients. Patient follow-up included clinical and laboratory data collection, Doppler ultrasonography (US), hepatic venography, and computed tomography. Technical success, complications, clinical improvement, and recurrence were evaluated. Results: Technical success was achieved in all patients. The mean pressure gradients across the stenosis before and after the procedure were 17.8 mmHg ± 6.4 (range, 3–39 mmHg) and 2.4 mmHg ± 2.6 (range, 0–8 mmHg), respectively. Four patients developed recurrent stenosis, and these patients underwent balloon angioplasty and remained with no events until the end of the observation period. During the mean follow-up period of 21 months (range 10–40 months) clinical success was achieved in 24 of 25 patients (96%). Conclusion: In conclusion, percutaneous transhepatic stenting is safe and effective for venous outflow obstruction after LDLT.

Hydatid disease is a common health problem in sheep-farming countries such as Iran. The liver and lungs are the most common primary sites of hydatid cysts in humans. Cardiac involvement is an uncommon manifestation, and the right ventricle outflow tract (RVOT) is rarely involved. This is a case report of a 34-year-old man who presented to the Heart Clinic, Tehran, Iran, in 2019 with a history of dyspnoea and fatigue. Following an imaging study, the patient was diagnosed with an RVOT hydatid cyst. He underwent surgical resection of the cyst. The post-operative course was uneventful. [ABSTRACT FROM AUTHOR]

Takotsubo cardiomyopathy (TCM) is an unusual form of acute cardiomyopathy showing left ventricular apical ballooning. Patients with hypotension should undergo urgent echocardiography to determine if left ventricular outflow tract (LVOT) obstruction is present. This complication has been described in 10–25% of all TCM patients. That some patients do not survive an acute TCM event underscores the importance of prompt recognition and targeted management of dynamic LVOT obstruction. Described in the present report is the case of a TCM patient with cardiogenic shock, the hemodynamics of which worsened after inotropic agents were administered, alleviated after serum fluid and beta-blocker treatment.

Background: Cardiac syncope can result from an atrial myxoma due to outflow obstruction. Myxoma is the most common primary cardiac tumor that may cause sudden death and the nonspecific symptoms may make early diagnosis difficult. Case presentation: A 27-year-old man presented to our emergency department after two episodes of syncope and severe fatigue. He had no complaint of fever, weight loss, sweating, chest pain or dyspnea. Vital signs were within normal limits. A loud heart S1 was detected and normal neck veins. Other systemic examinations including neurological assessment were normal. Electrocardiography showed normal sinus rhythm. An obvious variability in heart rate was noticed on cardiac monitor changing by the patient's position. Point-of-care ultrasonography (PoCUS) showed a large hyperechoic lesion with a well-defined stalk originating from the left atrium (LA). Thus, the patient was transferred to a cardiac surgery center for surgical intervention. Histopathology reported an LA mass compatible with myxoma. Conclusions: Emergency physicians should be familiar with the vague presentations of cardiac tumors to improve patient outcomes. It is beneficial to take advantage of bedside ultrasound for prompt diagnosis and subsequent treatment. [ABSTRACT FROM AUTHOR]

Abstract: Background: Esophago‐gastric junction (EGJ) outflow obstruction is of unclear significance. Rapid drink challenge (RDC) test is easy to perform during esophageal high resolution manometry. We aimed to assess the yield of RDC test in patients with EGJ outflow obstruction. Methods: Manometry studies of patients with EGJ outflow obstruction according to the Chicago Classification v3.0 were retrospectively reviewed. Pan‐esophageal pressurization (PEP), esophageal shortening, and pressure gradient across the EGJ were analyzed during RDC test (200‐mL free drinking in sitting position) and compared according to the causes of EGJ outflow obstruction determined by charts review. Key Results: Seventy‐five patients (29 males, mean age 62 years) were included. Causes of EGJ outflow obstruction were previous esophago‐gastric surgery (40%), incomplete form of achalasia (7%), mediastinal neoplasia (7%), other associated conditions (21%), and undetermined (25%). Rapid drink challenge test was successfully performed in 70 patients and associated with PEP and shortening in 41% and 13%, respectively. The causes of EGJ outflow obstruction were similarly distributed in patients with and without PEP during RDC test. Esophageal shortening tended to be more likely in patients with definitive findings of obstruction (achalasia, previous surgery, neoplasia) than in the others. Dysphagia was more severe in patients with PEP and/or shortening during RDC test compared to those without. Conclusions & Inferences: Pan‐esophageal pressurization and esophageal shortening were associated with symptoms severity but did not predict the cause of this disorder. Further prospective studies are necessary to determine if RDC test could help to select patients who might benefit from treatment. [ABSTRACT FROM AUTHOR]

Abstract: Background: Advances in clinical measurement of esophageal motility and function have improved the assessment of swallowing disorders and reflux symptoms. Variation in data acquisition, analysis, and reporting exists and impacts on diagnosis and management. Aims and Methods: This study examined variation in esophageal manometry methodology between institutions to establish the status in current practice. A structured survey was distributed through international NGM societies using an Internet‐based platform. Questions explored infrastructure, technology, analysis, and reporting. Key Results: Responses were received from 91 centers from 29 countries. Eighteen (20%) centers used “conventional” manometry, 75 (82%) high‐resolution manometry, and 53 (58%) HR impedance manometry. All centers documented motility for single water swallows. The Chicago Classification was applied by 65 (71.4%) centers. In contrast, analysis of EGJ morphology varied widely. Adjunctive testing was often applied: multiple rapid swallows (77%), rapid drink challenge (77%), single solid swallows (63%), and a standard test meal (18%). Of 86 (94.5%) units that offered pH impedance (pH‐Z) studies, approximately half (53.5%) performed tests on acid‐suppressant medication in patients with a high pretest probability (eg, erosive esophagitis). Most (75.6%) centers manually reviewed every reflux event. Others examined pH‐Z data only prior to symptoms. To assess symptom association with reflux events, 73.6% centers analyzed each symptom separately, whereas 29.7% centers pooled symptoms. Conclusions and Inferences: There is marked variation in the data acquisition, analysis, and reporting of esophageal manometry studies. Further efforts to improve quality and uniformity in testing and reporting are required. This survey provides information upon which best‐practice guidelines can be developed. [ABSTRACT FROM AUTHOR]

Aim To evaluate the effectiveness and safety of percutaneous transhepatic stent placement in management of hepatic venous outflow obstruction after living-donor liver transplantation (LDLT). Materials and methods From September 2010 to May 2015 percutaneous transhepatic venography was performed in 30 patients of 489 patients who underwent LDLT with suspected hepatic venous outflow obstruction with stent placement performed in 25 patients. Patient follow-up included clinical and laboratory data collection, Doppler ultrasonography (US), hepatic venography, and computed tomography. Technical success, complications, clinical improvement, and recurrence were evaluated. Results Technical success was achieved in all patients. The mean pressure gradients across the stenosis before and after the procedure were 17.8 mmHg ± 6.4 (range, 3–39 mmHg) and 2.4 mmHg ± 2.6 (range, 0–8 mmHg), respectively. Four patients developed recurrent stenosis, and these patients underwent balloon angioplasty and remained with no events until the end of the observation period. During the mean follow-up period of 21 months (range 10–40 months) clinical success was achieved in 24 of 25 patients (96%). Conclusion In conclusion, percutaneous transhepatic stenting is safe and effective for venous outflow obstruction after LDLT. [ABSTRACT FROM AUTHOR]

Accessory mitral valve tissue is a rare congenital anomaly that is commonly incidentally diagnosed. When symptomatic, it tends to present with features of left ventricular outflow (LVOT) obstruction in about two thirds of cases. It is also commonly associated with other congenital anomalies, notably ventricular septal defects. Transthoracic echocardiography is a very useful diagnostic test to make a diagnosis and its widespread use will increase detection of this condition. We are presenting a case of a 29-year-old lady who presented with breathlessness in the third trimester of pregnancy and was subsequently found to have evidence of accessory mitral valve tissue on echocardiography. [ABSTRACT FROM AUTHOR]

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High-resolution manometry (HRM) with 36 pressure transducers spanning the esophagus has revolutionized the diagnosis and treatment of esophageal motility disorders, especially with respect to achalasia. The three major contributions of HRM are as follows: (a) Integrated relaxation pressure (IRP) at the esophagus gastric junction (EGJ) >15 mmHg has a sensitivity of 97 % for the diagnosis of achalasia; (b) there are three distinct subtypes of achalasia—type 1 (no distal pressurization), type II (panesophageal pressurization), and type III (spastic contractions); and (c) subtypes predict the success of treatment with type II patients doing the best and type III being the most difficult to treat. Recent studies also suggest that HRM is superior to conventional manometry for diagnosis of achalasia. Other useful observation from HRM is the recognition of EGJ outflow obstruction (type IV achalasia) with normal peristalsis which may be due to mechanical or functional impairment at the EGJ. Finally, after successful treatment of achalasia, the IRP falls to less than 15 mmHg and the achalasia pressurization pattern resolves sometimes with the return of weak peristalsis. This complements well with the information obtained by the timed barium esophagram. [ABSTRACT FROM AUTHOR]

Objective: Retroverted impacted adenomyosis may cause progressive lower urinary bladder compression, resulting in bladder outflow obstruction and lower urinary tract symptoms. We report a case of a huge impacted adenomyosis in which the pathogenesis of bladder outflow obstruction was explored using three-dimensional sonography and was clearly shown to be different from that of pelvic-organ prolapse. The pathogenesis of urinary retention is described and discussed. Case Report: A 43-year-old patient was admitted for acute urinary retention and a huge impacted retroverted uterus with adenomyosis. Sonographic study revealed that the lower urinary bladder was compressed by the cervix, which was upwardly and forwardly displaced. Three-dimensional sonography more clearly identified the bladder neck and adjacent tissue. Conclusion: Sonography is helpful in exploring the anatomic nature of bladder outflow obstruction resulting from retroverted impacted adenomyosis. In this case, the urethra was neither distorted nor compressed, quite different from cases with pelvic organ prolapse. These two types of bladder outflow obstruction are not distinguishable using traditional urodynamic study. Three-dimensional sonography is more helpful in identification of the compressed reshaped lower urinary bladder and its adjacent anatomic structures, even without urine in the low bladder cavity as contrast.

Objectives: This study examined the relationship between peak-to-peak (common invasive measurement), peak instantaneous (common Doppler measurement), and mean pressure gradients in patients with hypertrophic cardiomyopathy (HCM) and aortic stenosis (AS). Background: In patients with AS, the peak-to-peak gradient and peak instantaneous gradient are discrepant, and the mean gradient best represents obstruction severity. The pathophysiology of outflow obstruction differs in HCM, with the maximum gradient occurring in late systole, thus the optimal method for quantifying gradient severity in HCM remains undefined. Methods: Fifty patients with HCM and 50 patients with AS underwent gradient characterization at cardiac catheterization (age 55 ± 15 years vs. 72 ± 9 years; 48% vs. 42% male, respectively). All HCM patients were studied with high-fidelity, micromanometer-tip catheters and transseptal measurement of left ventricular inflow and central aortic pressures. In AS, simultaneous left ventricular and central aortic pressures were recorded. Results: The peak instantaneous gradient was linearly correlated with peak-to-peak gradient in HCM (R2 = 0.98, p < 0.0001), with the relationship close to the line of identity. In AS, more scatter and further deviation from the line of identity occurred when comparing the peak instantaneous gradient to the peak-to-peak gradient (R2 = 0.70, p < 0.0001). Both peak-to-peak and peak instantaneous gradients were consistently higher than the mean gradient in HCM, with wide 95% confidence limits of agreement (26.7 ± 46.5 mm Hg and 16.4 ± 47.2 mm Hg, respectively). Conclusions: In HCM, peak instantaneous and peak-to-peak gradient demonstrate excellent correlation. Consequently, both peak instantaneous and peak-to-peak gradients can be used to classify obstruction severity in HCM. By contrast, the mean gradient should direct clinical management in AS. [ABSTRACT FROM AUTHOR]

OBJECTIVE To study the effects of the phosphodiesterase-5 inhibitor, vardenafil, on contraction and cyclic nucleotide levels in isolated detrusor preparations with and without mucosa, from control rats and rats with partial urethral obstruction (PUO) and intact mucosa. MATERIALS AND METHODS Female Sprague-Dawley rats were divided into groups subjected to PUO for 14 days (six), and sham-operated control rats (12). Detrusor preparations were mounted in organ baths and effects of increasing concentrations of vardenafil (1 nm to 100 µm) assessed on carbachol-activated (1 µm) preparations, and on contractions induced by transmural activation of nerves (electrical field stimulation, EFS). Levels of cGMP and cAMP were determined using radioimmunoassays. RESULTS Vardenafil caused concentration-dependent relaxations of carbachol-contracted detrusor, the mean (sd) of which at 100 µm was 91 (4)% in control and 100% in PUO rats. The −log 50% inhibitory concentration (IC50) was 4.41 (0.08) and 4.73 (0.05) ( P < 0.01), respectively. Removing the mucosa increased the relaxant effect of vardenafil at 1–10 µm ( P < 0.05) although −log IC50 values were unaffected compared to the control. The cGMP levels ( pmol/mg protein) in control preparations increased from 2.5 (0.6) to 5.0 (0.8), and from 1.4 (0.2) to 7.2 (1.3) in obstructed bladders. In mucosa-denuded preparations the cGMP content increased from 0.6 (0.1) to 1.6 (0.4) in response to vardenafil. In control rats, the levels of cAMP increased from 12.8 (2.5) to 18.9 (0.9) ( P < 0.05) after vardenafil. In mucosa-denuded preparations the cAMP levels after vardenafil increased from 16.5 (2.11) to 37.8 (3.4) ( P < 0.01). In PUO bladders, the tissue content of cAMP increased from 12.6 (2.4) to 20.6 (3.4) ( P < 0.01). Vardenafil concentration-dependently inhibited nerve-induced contractions in all groups studied. At 100 µm 19 (3)% of the control contraction remained, vs 8 (1)% for preparations from obstructed rats, and 11 (4)% in mucosa-denuded preparations. CONCLUSION In normal rats, vardenafil relaxed carbachol- and inhibited EFS-induced contractions of detrusor preparations with and without urothelium, and in PUO rats with urothelium. Relaxations were accompanied by increases in both cAMP and cGMP content. It is proposed that vardenafil-induced relaxation of rat detrusor, also in obstructed and mucosa-denuded preparations, is mediated via cAMP. [ABSTRACT FROM AUTHOR]

Intermittent catheterization (IC) is a widely used technique for emptying the bladder, first recorded in 1000 BCE. This article describes the normal anatomy and physiology of bladder filling and emptying, and discusses the reasons why emptying may be incomplete. Incomplete emptying usually has a neurogenic or obstructive cause, leading to symptoms such as frequency, urge incontinence and urinary tract infection. IC may be carried out for several reasons: as an acute intervention for transitory problems with bladder emptying; to enable the instillation of drugs into the bladder; or as a long-term intervention where there is a regular post-void residual volume of more than 100 ml. Ideally, the patient intermittently catheterizes his/her own bladder, but a relative or healthcare professional may carry out this task. Some patients have specific requirements and problems, and case studies are presented to illustrate how these problems may be resolved. [ABSTRACT FROM AUTHOR]

Background: The incidence of the small-for-size syndrome (SFSS) is inversely correlated to the size of the remnant liver or the partial graft. The relevance of factors besides the absolute liver mass is discussed controversially. It is the aim of this study to test the effect of two different mass ligation techniques in comparison with our newly developed parenchyma-preserving vessel-oriented liver resection technique on the induction of a SFSS after extended 90% liver resection in the rat. Materials and methods: Ninety percent liver resections were performed using three surgical techniques, two mass ligation techniques, and a vessel oriented technique. Diagnosis of SFSS was based on the combination of biochemical and morphological criteria on the first postoperative day and was related to the outcome on postoperative day 7 and the regenerative capacity of the liver. Results: Only the use of mass ligation techniques was associated with a low 1-wk survival rate (<40%), more pronounced histomorphological signs of liver damage at 24 h postoperatively, and a delayed onset of hepatocyte proliferation. Histological analysis revealed an extended stump necrosis in the paracaval liver and signs of sinusoidal damage in the remaining caudate lobes as morphological correlates of a putative outflow obstruction as the possible underlying reason. The lesions added up to a high small-for-size score in rats operated according to mass ligation techniques. Conclusions: These results indicate that preservation of functional liver mass and prevention of an outflow obstruction by delicate surgery is essential to prevent a SFSS in a size-reduced liver. [Copyright &y& Elsevier]

Abstract: Background: Gastric bypass is an established bariatric procedure that has undergone multiple modifications to improve its effectiveness. The side-to-side stapled technique is well recognized, but closure of the gastrotomy/enterotomy by the stapler can potentially narrow the Roux limb. Because of this, many surgeons will hand suture the closure of the gastrotomy/enterotomy. To obviate this difficulty, we inserted the linear stapler from the stomach’s greater curvature, using a double-stapled anastomosis that minimized the need for hand suturing. Methods: We performed a retrospective analysis of 307 patients undergoing this technique for laparoscopic gastric bypass. The weight loss and 30-day morbidity and mortality were tabulated and compared with those in other published series. Results: Of the 307 patients, none died postoperatively. The overall 30-day morbidity rate was 15%. Two leaks from the gastrojejunostomy and 2 from the jejunojejunostomy (1.2%) developed. The mean percentage of excess weight loss was 34% at 3 months, 52% at 6 months, 73% at 1 year, 71% at 2 years, and 69% at 3 years. Conclusion: The greater curve approach avoids Roux limb obstruction, minimizes the need for hand suturing, and uses standard trocar incisions. Our short-term follow-up results are similar to those of series of other techniques. [Copyright &y& Elsevier]

Living-donor liver transplantation (LDLT) is now widely accepted as a therapeutic option for adult patients with acute and chronic end-stage liver disease. In the early period, the left lobe was the major liver graft used in adult LDLT to ensure donor safety, especially in Eastern countries. However, the frequent extremes of graft-size insufficiency in left-lobe LDLT represented a greater risk of small-for-size graft syndrome in the recipient, which has focused attention on transplantation of the right lobe from a living donor. The major concern of right-lobe LDLT has focused on its safety for the donor and the necessity for including the middle hepatic vein (MHV) in the graft to avoid congestion of the right anterior segment. The MHV carries out important venous drainage for the right anterior segment and is essential for perfect graft function. The decision of whether to take the MHV with the liver graft (extended right lobe graft) or whether to retain it in the donor, with reconstruction of the MHV tributaries in the liver graft (modified right lobe graft) has been extensively discussed in numerous studies. However, adequate right hepatic vein and major short hepatic vein (middle and inferior right hepatic vein [RHV]) drainage of the liver graft is perhaps equally important as MHV outflow drainage for the integrity of right-lobe graft function. Herein, the author describes various techniques of venoplasty of the right hepatic vein (RHV) and the major short hepatic veins to obviate venous outflow obstruction in these veins. [ABSTRACT FROM AUTHOR]

Aims Our aim was to clarify the location and structure of the outlet septum relative to the free-standing sub-pulmonary infundibulum in the setting of tetralogy of Fallot and to examine its relationship to the other components of the subpulmonary outflow tract, determining their potential influence on clinical outcome. Methods and Results We studied prospectively 41 patients with tetralogy of Fallot (mean age 14±10·9 months) prior to surgical repair, and compared them with 15 patients undergoing closure of a ventricular septal defect associated with malalignment of the outlet septum but no subpulmonary infundibular stenosis (Eisenmenger ventricular septal defect), and 20 healthy controls. We also examined available autopsied hearts from cases with uncorrected tetralogy of Fallot (8) and Eisenmenger ventricular septal defect (13). Data were indexed for body surface area, and diameter of the tricuspid valve, respectively. The overall length of the subpulmonary infundibulum, including the extent of the muscular outlet septum, was significantly greater for patients with tetralogy of Fallot compared to normals (2·34±0·6 vs 1·46±0·34cm/BSA0·5,P<0·001), whereas the difference between those with tetralogy of Fallot and an Eisenmenger ventricular septal defect was confined to the degree of narrowing of the subpulmonary outlet (0·43±0·22 vs 2·17±0·64cm/BSA0·5,P<0·001). Within the tetralogy of Fallot group, there were linear relationships between deviation of the outlet septum (r=−0·61,P<0·005) and the diameter of the pulmonary valvar orifice (r=0·75,P<0·001), suggesting that growth of the pulmonary arteries may be related to this feature. When patients requiring a transannular patch as part of their surgical repair were compared with those not needing this procedure, differences were found in the diameter of the pulmonary valvar orifice and the pulmonary trunk, but not in the dimensions of the outlet septum. Conclusion The position of the outlet septum in relationship to the remainder of the muscular subpulmonary infundibulum represents a hallmark of tetralogy of Fallot, permitting its differentiation from Eisenmenger ventricular septal defects and normal hearts. [ABSTRACT FROM PUBLISHER]

The effect of provocation on left ventricular (LV) outflow was studied by continuous-wave Doppler echocardiography in 103 nonselected, consecutively enrolled patients with LV hypertrophy (LVH), either due to pressure overload (97 patients) or hypertrophic cardiomyopathy (HCM, 6 patients). In 34 patients with LVH, outflow acceleration (gradients ranging from 18 to 122 mm Hg) was induced or accentuated by the Valsalva maneuver after 1.6 mg nitroglycerine sublingually independent of LVH etiology. Factors associated with LV outflow acceleration were female sex, small body surface area and LV cavity size, increased relative wall thickness, LV contractility, and resting LV outflow velocity, mitral anulus calcifications and systolic anterior movement of the mitral valve. It is concluded that dynamic, intracavity LV gradients are a nonspecific flow abnormality that merit consideration because they can be frequently found in LVH patients. [ABSTRACT FROM AUTHOR]

Objective To compare the effects of microwave hyperthermia in benign prostatic hypertrophy (BPH) to sham treatment. Patients and methods The trial included 96 patients with proven symptomatic bladder outflow obstruction (BOO) caused by BPH. Patients underwent a full subjective and objective assessment (including urodynamics) before inclusion and again 3 and 6 months later. They were randomly assigned to receive 1 h of microwave hyperthermia or a sham treatment. Of the 96 patients, 93 were assessed at 3 months and 62 at 6 months after treatment. Results There was no statistically significant difference in the objective measures of BOO between the treated and control groups of patients. There was an improvement of approximately 40% in all the subjective measures, but there was no significant difference between the treated and control groups. Conclusion Microwave hyperthermia, within the parameters defined in this trial, resulted in no significant difference from sham treatment in subjective or objective outcome. [ABSTRACT FROM AUTHOR]

We investigated the effects of ischemia induced by ligation of the bilateral internal iliac arteries following partial outlet obstruction on changes in detrusor function in rat. Rats were divided into three groups: sham-operated control rats, rats with partial outlet obstruction, and rats with obstruction + ischemia. Bladder function was studied by the in vitro organ bath technique 7 days after surgery. The weight of the bladder was significantly increased in both the obstruction and obstruction + ischemia groups. The obstruction + ischemia group exhibited a greater increase in weight. The passive length-tension relationship of detrusor muscle strips showed that tissue elasticity was decreased and the active length-tension relationship demonstrated that the peak response was observed at a shorter tissue length in the obstruction + ischemia group compared with the other two groups. There was no difference in the passive and active length-tension relationships between the control group and the obstruction group. The contractile response to various kinds of stimulation (field stimulation, bethanechol, ATP, and KCl) increased in the obstruction group and decreased in the obstruction + ischemia group. These findings suggest that partial outflow obstruction alone increased bladder contractility in response to stimuli. However, ischemia reduced the contractility and elasticity of the bladder wall. [ABSTRACT FROM AUTHOR]

Background: The anatomic variation of hepatic vein in the left lateral segment (LLS) increases the risk of outflow complication in pediatric living liver transplantation (LDLT). Here, we share a modified method for dual hepatic vein reconstruction in pediatric LDLT using LLS with two wide orifices. Methods: From Sep 2018 to Dec 2019, 434 pediatric LDLTs using LLS were performed in our center. Hepatic veins of grafts were classified into three types with emphasis on the number, size, and location of orifices at the cut surface: a single opening (type I, n = 341, 78.57%); two adjacent orifices (type II, n = 66, 15.21%); two wide orifices with orifices distances <20 mm (type IIIa, n = 15, 3.46%); and two wide orifices with orifices distances >20 mm (type IIIb, n = 12, 2.76%). Rv was defined as the ratio of diameter of V2 and V3 (refer to hepatic vein drained segments II and III). We developed a modified dual hepatic vein anastomosis to reconstruct outflow for type IIIb grafts with Rv ≤1. Briefly, the hepatic vein of segment II was anastomosed to the common stump of middle hepatic vein (MHV) and left hepatic vein (LHV), followed by unification of V3 and the longitudinal incision orifice in inferior venous cave (IVC). Results: During median follow-up of 15.6 months (7.5-22.9 months), no hepatic vein complications occurred. Conclusion: This novel modified dual hepatic vein anastomosis could serve as a feasible surgical option for type IIIb LLS grafts with Rv ≤1 in pediatric LDLT., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Hou, Wan, Feng, Qiu, Zhou, Zhu, Luo, Zhang and Xia.)

Introduction: our study aimed to assess the safety and efficacy of Holmium: YAG laser internal urethrotomy compared to the cold knife internal urethrotomy. Methods: Eighty adult male patients presented with a urethral stricture less than 1.5 cm were included in our study; they were randomly allocated into 2 groups representing Holmium and cold knife internal urethrotomy. A careful evaluation with ascending cystourethrogram and uroflowmetry were done on all patients, and they were followed up for 1 year with uroflowmetry. Results: Each group included 40 patients sharing the same demographic data. The most common cause of a urethral stricture in both groups was iatrogenic injury. The mean operative time of the cold knife urethrotomy procedure was 10.98 ± 2.40 minutes compared to 15.43 ± 2.48 minutes in the holmium laser urethrotomy group with a highly significant difference. The results showed success rates of 90% and 80% for the holmium laser and cold knife internal urethrotomy groups respectively. The perioperative complication according to the Clavien-Dindo classification, showed no statistically significant difference in grade 1 and 2 complications. A recurrence rate with the need for redo surgery representing grade 3B complication was seen in 4 cases in the Holmium group compared to 8 cases in the cold knife group with a statistically significant difference. Conclusion: Both Holmium Laser and cold knife internal urethrotomy are an effective surgical option for the treatment of a urethral stricture less than 1.5 cm with a promising outcome after 1-year follow-up with a better success rate using the Holmium laser., (Copyright © 2021 J Lasers Med Sci.)

Introduction: Outflow stenosis is a frequent complication of vascular access for hemodialysis. It may cause increased pressure within the angioaccess along with reduced blood flow. Elective treatment is percutaneous transluminal angioplasty; however, when a long occlusion (>2 cm) occurs, success and mid-term patency of endovascular treatment are uncertain. We describe a case series of patients with long occlusion of elbow outflow complicating an otherwise excellent forearm arteriovenous fistula, treated by a bypass across the elbow through cubital vein transposition., Patients and Methods: Six consecutive patients have been treated between 2015 and 2017; all were referred because of either low flow, increased venous pressure, excessive bleeding time, or recirculation and were examined by duplex ultrasound. A total of 83% of patients showed associated thrombosis within the access. All procedures were performed under loco-regional anesthesia and preventive hemostasis. Surgical thrombectomy was also performed when needed., Results: Immediate success was obtained in all but two patients converted in veno-venous polytetrafluoroethylene bypass. Post-operative blood flow increased from 316 to 878 mL/min. All patients were dialyzed through the forearm access immediately the day after surgery, without the need for central vein catheter. Overall, 75% of patients needed a percutaneous transluminal angioplasty of the veno-venous anastomosis within 6 months. Primary and secondary patency at 12 and 24 months were 25%-0% and 100%-100%, respectively., Conclusion: Outflow reconstruction through the elbow bypass by cubital vein transposition is a valuable resource to rescue radiocephalic arteriovenous fistula complicated by outflow obstruction, avoiding the use of an interim central vein catheter. Endovascular treatment is vital to maintain functional patency in the mid- and long term.

Purpose: Percutaneous endovenous iliac stenting has emerged as a new modality in the treatment of advanced chronic venous insufficiency with outflow obstruction. However, the effect of this intervention on the quality of life remains unclear. We examined the impact of iliac venous stenting for outflow obstruction as compared to conservative medical management on the quality of life in severe chronic venous insufficiency patients. Methods: Medical records of all patients with CEAP class 5 and 6 disease (N = 172) who underwent ilio-caval venography with intravascular ultrasonography (IVUS) at a single institution over a seven-year period, were reviewed for this case–control study. Quality of life evaluation was performed utilizing the Chronic Venous Insufficiency Quality of Life Questionnaire (CIVIQ-20) one year after the index procedure. Results: Of the 172 severe chronic venous insufficiency patients, 109 were stented and 63 patients were treated medically based on their venography and IVUS results. The indication for stenting was confirmation of IVUS determined surface area or diameter outflow stenosis of greater than 50% within the common or external iliac venous systems. Eighty patients (47%) responded with completed CIVIQ-20 questionnaires for analysis. Of these, 47 were from the stented group and 33 from the non-stented group. At least moderate persistent pain or discomfort post-procedure was reported by 20 (43%) stented group patients and 19 (58%) non-stented group patients. Scores for all the other criteria in the CIVIQ-20 were similar between the groups. The mean total CIVIQ-20 score was 45.23 and 47.13, respectively, in stented group and non-stented group patients. (p = 0.678). Conclusion: There was no significant difference in the quality of life reported by CEAP 5 and 6 patients who underwent iliac venous stenting versus those who were treated medically for presumed iliac outflow obstruction. Prospective studies are needed to determine the true value of iliac venous stenting based on IVUS criteria in the management advanced chronic venous insufficiency. [ABSTRACT FROM AUTHOR]

Background Septal haematomas causing left ventricular or biventricular outflow obstruction are rare but known complications of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) and can be life-threatening. Case summary In this case, we describe the formation of a septal haematoma during retrograde CTO PCI. The patient was initially managed conservatively but became progressively unstable, for which she underwent coiling of the inflow and outflow of the septal perforator. Despite coiling, she developed near complete right ventricular outflow obstruction (based on echocardiography). She was successfully managed with a percutaneous right ventricle assist device, with subsequent resolution of the outflow obstruction. Discussion Septal haematomas with resultant outflow obstruction have been uniformly fatal. In our case, the use of a percutaneous right ventricle assist device was life-saving. [ABSTRACT FROM AUTHOR]

Background: Advances in clinical measurement of esophageal motility and function have improved the assessment of swallowing disorders and reflux symptoms. Variation in data acquisition, analysis, and reporting exists and impacts on diagnosis and management., Aims and Methods: This study examined variation in esophageal manometry methodology between institutions to establish the status in current practice. A structured survey was distributed through international NGM societies using an Internet-based platform. Questions explored infrastructure, technology, analysis, and reporting., Key Results: Responses were received from 91 centers from 29 countries. Eighteen (20%) centers used "conventional" manometry, 75 (82%) high-resolution manometry, and 53 (58%) HR impedance manometry. All centers documented motility for single water swallows. The Chicago Classification was applied by 65 (71.4%) centers. In contrast, analysis of EGJ morphology varied widely. Adjunctive testing was often applied: multiple rapid swallows (77%), rapid drink challenge (77%), single solid swallows (63%), and a standard test meal (18%). Of 86 (94.5%) units that offered pH impedance (pH-Z) studies, approximately half (53.5%) performed tests on acid-suppressant medication in patients with a high pretest probability (eg, erosive esophagitis). Most (75.6%) centers manually reviewed every reflux event. Others examined pH-Z data only prior to symptoms. To assess symptom association with reflux events, 73.6% centers analyzed each symptom separately, whereas 29.7% centers pooled symptoms., Conclusions and Inferences: There is marked variation in the data acquisition, analysis, and reporting of esophageal manometry studies. Further efforts to improve quality and uniformity in testing and reporting are required. This survey provides information upon which best-practice guidelines can be developed., (© 2017 John Wiley & Sons Ltd.)

Presents a case study of an aged woman who developed left ventricular outflow tract (LVOT) obstruction following anomalous attachment of chordae tendineae. Medical history of the patient; Causes of LVOT obstruction; Use of echocardiography in diagnosing the patient.

♦ BACKGROUND: Outflow obstruction, a common complication in patients with peritoneal dialysis (PD), usually results in unnecessary catheter removal or replacement. This study describes a modified simple method of anchoring a PD catheter on the anterior peritoneal wall without using a laparoscopic system (peritoneal wall anchor technique, PWAT). ♦ METHODS: We performed a retrospective cohort study of consecutive PD catheter insertions, and compared the catheter survival rate between the traditional method and the modified simple PWAT. The traditional method was used in 54 cases and the modified simple PWAT was used in 17 cases. The primary endpoint was the occurrence of surgical catheter repair because of outflow obstruction by day 365. The secondary endpoint was the occurrence of catheter migration with obstruction requiring any interventions, including the alpha-replacement method by day 365. Catheter survival was analyzed by Kaplan-Meier survival curves. ♦ RESULTS: Migration-free catheter survival was significantly (p = 0.02) higher in the PWAT group (100%, 17/17) than in the traditional group (72.2%, 39/54). Catheter survival without surgical repair or cessation of PD was also significantly (p = 0.04) higher in the PWAT group (100%, 17/17) than in the traditional group (77.8%, 42/54). Similarly, migration-free and surgery-free catheter survival rates in cases with a straight-type catheter in the PWAT group were significantly higher than those in cases with a straight-type catheter in the traditional group. ♦ CONCLUSIONS: Our results suggest that the modified simple PWAT provides a better catheter survival rate than the traditional method by preventing catheter migration with obstruction in PD., (Copyright © 2017 International Society for Peritoneal Dialysis.)

Laparoscopic abdominal surgery has opened many previously unexploited diagnostic and therapeutic options. At our institution, we have used laparoscopic techniques in several patients to successfully salvage dysfunctional Tenckhoff catheters. Peritoneal dialysis has gained widespread approval as an acceptable alternative to hemodialysis. Unfortunately, following surgical placement of the catheter, mechanical complications are all too common and usually result in unnecessary removal or replacement. To illustrate the usefulness of laparoscopy in preventing this unnecessary patient morbidity, we present a case study of an easily correctable cause of Tenckhoff catheter outflow obstruction that would have avoided detection under normal circumstances. [ABSTRACT FROM AUTHOR]