Percutaneous antegrade management of large proximal ureteral stones using non-papillary puncture

Objective:To evaluate the feasibility and the safety of medial non-papillary percutaneous nephrolithotomy(npPCNL)for the management of large proximal ureteral stones.Methods:We evaluated prospectively collected data of 37 patients with large proximal ureteral stones more than 1.5 cm in diameter treated by prone npPCNL.Depending on stone size,in-toto stone removal or lithotripsy using the Lithoclast®Trilogy(EMS Medical,Nyon,Switzerland)was performed.Perioperative parameters including operative time(from start of puncture to the skin suturing),stone extraction time(from the first insertion of the nephroscope to the extraction of all stone fragments),and the stone-free rate were evaluated.Results:Twenty-one males and 16 females underwent npPCNL for the management of large upper ureteral calculi.The median age and stone size of treated patients were 58(interquartile range[IQR]:51-69)years and 19.3(IQR:18.0-22.0)mm,respectively.The median operative time and stone extraction time were 25(IQR:21-29)min and 8(IQR:7-10)min,respectively.One case(2.7%)of postoperative bleeding and two cases(5.4%)of prolonged fever were managed conservatively.The stone-free rate at a 1-month follow-up was 94.6%.Conclusion:The npPCNL provides a straight route to the ureteropelvic junction and proximal ureter.Approaching from a dilated portion of the ureter under low irrigation pressure with larger diameter instruments results in effective and safe stone extraction within a few minutes.

Antegrade scrotal sclerotherapy and varicocele

Antegrade scrotal sclerotherapy is a simple and easy technique for the treatment of varicocele. The success rate varies between 87% and 95%. The initial reflux grade and the number of collateral vessels of the spermatic vein are the most important factors to predict the outcome of the technique. The postoperative complication rate is about 7% and the common ones are scrotal hematoma and epididymo-orchitis of slight severity. Testicular athrophy is a rare event (0.6%). This technique offers a considerable cost reduction compared to other therapeutic options currently available for varicocele.

A new buddy stingray and stick technique for antegrade dissection and re-entry during chronic total occlusion recanalization: a case report

Although the retrograde approach was a promising strategy for chronic total occlusions(CTO)-percutaneous coronary interventions(PCI),[1]with the development of coronary interventional therapy technology and interventional instruments,antegrade dissection and re-entry(ADR)are commonly employed in PCI to open CTO of coronary arteries.

Intravascular ultrasound-guided “extended” reverse controlled antegrade and retrograde subintimal tracking technique using a cutting balloon for recanalizing chronic coronary total occlusion with a side branch

Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) represents the most technically challenging procedure in contemporary interventional cardiology.[1] Blunt lesions and presence of proximal side branch are considered to be strong predictors of reduced technical success.[ 2,3] For such lesions, the antegrade approach may not be feasible or desirable, and the retrograde approach can be used as the initial crossing strategy. However, when treating the blunt CTO with a large side branch proximal to the occlusion, the side branch might be occluded after stent implantation if the retrograde guidewire passed the occluded segment through the subintimal space and re-entered into the true lumen at the opposite side of the side branch.[4] We reported a useful method to solve the above issue which utilizes intravascular ultrasound (IVUS) to guide “extended” reverse controlled antegrade and retrograde subintimal tracking (CART) technique with a cutting balloon.

Antegrade in situ laser fenestration of aortic stent graft during endovascular aortic repair:A case report

BACKGROUND The endovascular repair of juxtarenal abdominal aortic aneurysms(JAAA)usually requires combination treatment with various stent graft modifications to preserve side branch patency.As a feasible technique,according to the situation,antegrade in situ laser fenestration still needs to be improved.CASE SUMMARY This report describes a case that was successfully treated with endovascular repair facilitated by antegrade in situ laser fenestration while maintaining renal arterial flow.Laser fenestration was performed using a steerable sheath positioned in the stent graft lumen in front of the renal artery ostium.With the bare stent region unreleased,renal artery perfusion could be maintained and accurate positioning could be achieved by angiography in real time.CONCLUSION This study suggests the feasibility and short-term safety of this novel antegrade in situ laser fenestration technique for select JAAA patients.

A New Rotator Interval Approach for Antegrade Humeral Nailing: A Technical Note

The lateral and anterior lateral approaches are the most commonly used for antegrade nailing of humerus fractures. However, the surgical exposure is restricted by the bony acromion. The iatrogenic injury to the rotator cuff can also cause post-operative pain and compromise shoulder function. This article describes a new rotator interval approach that we used for central entry point nailing. In this approach, the skin incision starts from the midpoint between the acromion and coracoid process. A trans-rotator interval split in front of the anterior border of the supraspinatus (SSP) tendon is then made to open the glenohumeral joint. With the SSP retracted laterally and the long head of the biceps (LHB) retracted medially, the humeral head is directly visualized. The entry point can thus be determined and confirmed by intra-operative fluoroscopy in both axial and AP planes. We recommend this rotator interval approach as an alternative nailing technique for 2-part humeral neck fractures and humeral shaft fractures.

Optimal entry point for antegrade and retrograde femoral intramedullary nails

Surgical management of femoral shaft fractures with intramedullary nails has become the standard ofcare,with multiple options for entry point described,including piriformis entry,trochanter entry andretrograde femoral nails.Our present review describes the surgical anatomy of the proximal and distalfemur and its relation to different entry points for intramedullary femoral nails.In addition,we reviewedrelative indications for each technique,difficulties associated and possible complications.

Antegrade scrotal sclerotherapy of internal spermatic veins for varicocele treatment： technique, complications, and results

Varicocele repair is mainly indicated in young adult patients with clinical palpable varicocele and abnormal semen parameters. Varicocele treatment is associated with a significant improvement in sperm concentration, motility, morphology, and pregnancy rate. Antegrade scrotal sclerotherapy （ASS） represented one of the main alternatives to the traditional inguinal or suprainguinal surgical ligation. This article reviews the use of ASS for varicocele treatment. We provide a brief overview of the history of the procedure and present our methods used in ASS. In addition, we review complication and success of ASS, including our own retrospective data of treating 674 patients over the last 17 years. Herein, we analyzed step by step the ASS technique and described our results with an original modified technique with a long follow-up. Between December 1997 and December 2014, we performed 674 ASS. Mean operative time was 14 min （range 9 to 50 min）. No significant intraoperative complications were reported. Within 90 days from the procedure, postoperative complications were recorded in overall 49 （7.2%） patients. No major complications were recorded. A persistent/recurrent varicocele was detected in 40 （5.9%） cases. In 32/40 （80%） cases, patients showed preoperative grade III varicoceles. In patients with a low sperm number before surgery, sperm count improved from 13 x 106 to 21 x 106 m1-1 （P〈 0.001）. The median value of the percentage of progressive motile forms at 1 h improved from 25% to 45% （P 〈 0.001）. Percentage of normal forms increased from 17% before surgery to 35% 1 year after the procedure （P 〈 0.001）. In the subgroup of the 168 infertile patients, 52 （31%） fathered offspring at a 12-month-minimum follow-up. Therefore, ASS is an effective minimal invasive treatment for varicocele with low recurrence/persistence rate.

Cerebral Metabolic Profiling of Hypothermic Circulatory Arrest with and Without Antegrade Selective Cerebral Perfusion： Evidence from Nontargeted Tissue Metabolomics in a Rabbit Model

Background： Antegrade selective cerebral perfusion （ASCP） is regarded to perform cerebral protection during the thoracic aorta surgery as an adjunctive technique to deep hypothermic circulatory arrest （DHCA）. However, brain metabolism profile after ASCP has not been systematically investigated by metabolomics technology. Methods： To clarify the metabolomics profiling of ASCP, 12 New Zealand white rabbits were randomly assigned into 60 min DHCA with （DHCA＋ASCP [DA] group, n = 6） and without （ DHCA [D] group, n = 6） ASCP according to the random number table. ASCP was conducted by cannulation on the right subclavian artery and cross-clamping of the innominate artery. Rabbits were sacrificed 60 min after weaning off cardiopulmonary bypass. The metabolic features of the cerebral cortex were analyzed by a nontargeted metabolic profiling strategy based on gas chromatography-mass spectrometry. Variable importance projection values exceeding 1.0 were selected as potentially changed metabolites, and then Student＇s t-test was applied to test for statistical significance between the two groups. Results： Metabolic profiling of brain was distinctive significantly between the two groups （Q2y = 0.88 for partial least squares-DA model）. In comparing to group D, 62 definable metabolites were varied significantly after ASCP, which were mainly related to amino acid metabolism, carbohydrate metabolism, and lipid metabolism. Kyoto Encyclopedia of Genes and Genomes analysis revealed that metabolic pathways after DHCA with ASCP were mainly involved in the activated glycolytic pathway, subdued anaerobic metabolism, and oxidative stress. In addition, L-kynurenine （P = 0.0019）, 5-methoxyindole-3-acetic acid （P = 0.0499）, and 5-hydroxyindole-3-acetic acid （P = 0.0495） in tryptophan metabolism pathways were decreased, and citrulline （P - 0.0158） in urea cycle was increased in group DA comparing to group D. Conclusions： The present study applied metabolomics analysis to identify the cerebral metabolic profiling in rabbits with ASCP, and the results may shed new lights that cerebral metabolism is better preserved by ASCP compared with DHCA alone.

The antegrade continence enema procedure and total anorectal reconstruction

Patients may present with anal incontinence(AI)following repair of a congenital anorectal anomaly years previously,or require total anorectal reconstruction(TAR)following radical rectal extirpation,most commonly for rectal cancer.Others may require removal of their colostomy following sphincter excision for Fournier’s gangrene,or in cases of severe perineal trauma.Most of the data pertaining to antegrade continence enema(the ACE or Malone procedure)comes from the pediatric literature in the management of children with AI,but also with supervening chronic constipation,where the quality of life and compliance with this technique appears superior to retrograde colonic washouts.Total anorectal reconstruction requires an anatomical or physical supplement to the performance of a perineal colostomy,which may include an extrinsic muscle interposition(which may or may not be‘dynamized’),construction of a neorectal reservoir,implantation of an incremental artificial bowel sphincter or creation of a terminal,smooth-muscle neosphincter.The advantages and disadvantages of these techniques and their outcome are presented here.

Comprehensive review on EUS-guided biliary drainage

Feasibility of endoscopic retrograde cholangiopancreatography(ERCP) for biliary drainage is not always applicable due to anatomical alterations or to inability to access the papilla. Percutaneous transhepatic biliary drainage has always been considered the only alternative for this indication. However,endoscopic ultrasonography-guided biliary drainage represents a valid option to replace percutaneous transhepatic biliary drainage when ERCP fails. According to the access site to the biliary tree,two kinds of approaches may be described: the intrahepatic and the extrahepatic. Endoscopic ultrasonography-guided rendezvous transpapillary drainage is performed where the second portion of the duodenum is easily reached but conventional ERCP fails. The recent introduction of self-expandable metal stents and lumen-apposing metal stents has improved this field. However,the role of the latter is still controversial. Echoendoscopic transmural biliary drainage can be challenging with potential severe adverse events. Therefore,trained endoscopists,in both ERCP and endoscopic ultrasonography are needed with surgical and radiological backup.

Balloon-occluded retrograde transvenous obliteration for treatment of gastric varices

Rupture of gastric varices(GVs)can be fatal.Balloon-occluded retrograde transvenous obliteration(BRTO),as known as retrograde sclerotherapy,has been widely adopted for treatment of GVs because of its effectiveness,ability to cure,and utility in emergency and prophylactic treatment.Simplifying the route of blood flow from GVs to the gastrorenal shunt is important for the successful BRTO.This review outlines BRTO indications and contraindications,describes basic BRTO procedures and modifications,compares BRTO with other GVs treatments,and discusses various combination therapies.Combined BRTO and partial splenic embolization may prevent exacerbation of esophageal varices and shows promise as a treatment option.

Endoscopic ultrasound-guided biliary drainage-current status and future perspectives

Endoscopic retrograde cholangiopancreatography(ERCP)with stenting is the treatment modality of choice for patients with benign and malignant bile duct obstruction.ERCP could fail in cases of duodenal obstruction,duodenal diverticulum,ampullary neoplastic infiltration or surgically altered anatomy.In these cases percutaneous biliary drainage(PTBD)is traditionally used as a rescue procedure but is related to high morbidity and mortality and lower quality of life.Endoscopic ultrasound-guided biliary drainage(EUS-BD)is a relatively new interventional procedure that arose due to the development of curvilinear echoendoscope and the various endoscopic devices.A large amount of data is already collected that proves its efficacy,safety and ability to replace PTBD in cases of ERCP failure.It is also possible that EUS-BD could be chosen as a first-line treatment option in some clinical scenarios in the near future.Several EUS-BD techniques are developed EUS-guided transmural stenting,antegrade stenting and rendezvous technique and can be personalized depending on the individual anatomy.EUS-BD is normally performed in the same session from the same endoscopist in case of ERCP failure.The lack of training,absence of enough dedicated devices and lack of standardization still makes EUS-BD a difficult and not very popular procedure,which is related to life-threatening adverse events.Developing training models,dedicated devices and guidelines hopefully will make EUS-BD easier,safer and well accepted in the future.This paper focuses on the technical aspects of the different EUS-BD procedures,available literature data,advantages,negative aspects and the future perspectives of these modalities.

Efficacy and safety of laparoscopic radical resection following neoadjuvant therapy for pancreatic ductal adenocarcinoma:A retrospective study

BACKGROUND Multiple studies have demonstrated that neoadjuvant chemotherapy(NACT) can prolong the overall survival of pancreatic ductal adenocarcinoma(PDAC) patients. However, most studies have focused on open surgery following NACT.AIM To investigate the efficacy and safety of laparoscopic radical resection following NACT for PDAC.METHODS We retrospectively analyzed the clinical data of 15 patients with pathologically confirmed PDAC who received NACT followed by laparoscopic radical surgery in our hospital from December 2019 to April 2022. All patients underwent abdominal contrast-enhanced computed tomography(CT) and positron emission tomography-CT before surgery to accurately assess tumor stage and exclude distant metastasis.RESULTS All 15 patients with pancreatic cancer were successfully converted to surgical resection after NACT, including 8 patients with pancreatic head cancer and 7 patients with pancreatic body and tail cancer. Among them, 13 patients received the nab-paclitaxel plus gemcitabine regimen(gemcitabine 1000 mg/m^(2) plus nabpaclitaxel 125 mg/m^(2) on days 1, 8, and 15 every 4 wk) and 2 patients received the modified FOLFIRINOX regimen(intravenous oxaliplatin 68 mg/m^(2), irinotecan 135 mg/m^(2), and leucovorin 400 mg/m^(2) on day 1 and fluorouracil 400 mg/m^(2) on day 1, followed by 46-h continuous infusion of fluorouracil 2400 mg/m^(2)). After each treatment cycle, abdominal CT, tumor markers, and circulating tumor cell counts were reviewed to evaluate the treatment efficacy. All 15 patients achieved partial remission. The surgical procedures included laparoscopic pancreaticoduodenectomy(LPD, n = 8) and laparoscopic radical antegrade modular pancreatosplenectomy(L-RAMPS, n = 7). None of them were converted to a laparotomy. One patient with pancreatic head carcinoma was found to have portal vein involvement during the operation, and LPD combined with vascular resection and reconstruction was performed. The amount of blood loss and operation times of L-RAMPS vs LPD were 435.71 ± 32.37 m L vs 343.75 ± 145.01 m L and 272.52 ± 49.14 min vs 444.38 ± 68.63 min, respectively. The number of dissected lymph nodes was 16.87 ± 4.10, and 3 patients had positive lymph nodes. One patient developed grade B postoperative pancreatic fistula(POPF) after LRAMPS, and one patient experienced jaundice after LPD. None of the patients died after surgery. As of April 2022, progressive disease was noted in 4 patients, 2 patients had liver metastasis, and one had both liver metastasis and lymph node metastasis and died during the follow-up period.CONCLUSION Laparoscopic radical resection of PDAC after NACT is safe and effective if it is performed by a surgeon with rich experience in LPD and in a large center of pancreatic surgery.

Effect of partial hepatectomy on the memory ability in rats

BACKGROUND： Patients suffer from changes of cognitive function postoperatively, which has attracted extensive attentions in clinic. It is still to be investigated whether operation damages both antegrade memory and retrograde memory, or either of them. OBJECTIVE： To observe the effects of operation on the anterograde and retrograde memory with Y maze test. DESIGN： A randomly controlled animal trial. SETTING： Department of Anesthesiology, Pudong New Area Gongli Hospital of Shanghai City. MATERIALS： Sixty-three male healthy Sprague-Dawley （SD） rats of clean degree, weighing 200 - 250 g, 10 weeks old, were provided by the animal center of Chinese Academy of Sciences. The rats were tested by antegrade and retrograde respectively. The rats were randomly divided into normal control group （n =7）, anesthesia group （n =14）, sham-operated group （n =14）; partial hepatectomy group （n =14）, short-term retrograde memory group （n =7） and long-term retrograde memory group （n =7）. According to the time of Y maze training started, rats in the anesthesia group, sham-operated group and partial hepatectomy group were observed at 1 and 7 days after anesthesia. METHODS： The experiments were carried out in the central laboratory of Pudong New Area Gongli Hospital of Shanghai City from February to June in 2006. ① Test for antegrade memory： Rats in the normal control group were only treated with intraperitoneal injection of saline without aesthesia and operation; Those in the anesthesia group were anesthetized with intraperitoneal injection of 10 g/L pentobarbital sodium （40 mg/kg）; Those in the sham-operated group were anesthetized, then intraperitoneal exploration was performed without hepatectomy; Those in the partial hepatectomy group were anesthetized, then fixed in a supine position after righting reflex disappeared, and an incision of 1.5 - 2.0 cm was made along the midline of xiphoid lower abdomen, then left lateral lobe of liver （about 1/3 of total liver） was freed, and ligated at distal pedicel with 1^# filament. The abdomen was closed layer by layer after complete hemostasis. The learning and memory abilities were tested after operation. The rats were exposed to Y maze exercise from the 1st or 7th day after surgery, the error numbers, the time to complete whole trials per day and active avoidance numbers were recorded to evaluate the antegrade memory ability. ② Test for short-term retrograde memory Rats in the short-term retrograde memory group were trained in Y maze as the above methods for 1 day, then partial hepatectomy was performed immediately, and the effects on short-term memory were evaluated at 24 hours postoperatively.③ Test for long-term retrograde memory： Rats in the long-term retrograde memory group were trained in Y maze till reached the standard for grasping, then partial hepatectomy was performed in those reached the standard for grasping within 3 days, and the effects on long-term memory were evaluated at 48 hours postoperatively. MAIN OUTCOME MEASURES： The error times, the time to complete whole trials per day and active avoidance times were observed every day. RESULTS： Totally 63 SD rats were used, including 6 failed in the partial hepatectomy in the partial hepatectomy group, 3 died due to over-anesthesia, and 5 in the long-term retrograde memory group grasped the tasks in Y maze till the 4^th day, which were supplemented by other rats. ① Impairment of anterograde memory after partial hepatectomy： The results of Y maze test in the partial hepatectomy group were not obviously different from those in the other groups on the 1st day. The error times on the 2^nd and 3^rd days of training in the partial hepatectomy group at l and 7 days after anesthesia were obviously more than those in the normal control group （F =6.08, P 〈 0.01）, and the active avoidance numbers were obviously fewer than those in the normal control group （F =10.85, P 〈 0.05）; For the rats at 1 day after anesthesia, the error times on the 3^rd day of training in the partial hepatectomy group were obviously more than those in the normal control group （F = 12.34, P 〈 0.01）, and the active avoidance numbers were obviously fewer than those in the normal control group （F =3.91, P 〈 0.05）. There were no obvious differences in the anesthesia group and sham-operated group as compared with those in the normal control group. ② hnpairment of retrograde memory after partial hepatectomy： The results of Y maze test in the normal control group and retrograde short-term memory group at 24 hours after operation were better than those in each group on the 1^st day of training （F=35.22, 22.56, P 〈 0.01）, and the results on the 2nd day had no obvious differences between the two groups. For the rats reached the standards for grasping in the retrograde long-term memory group, the results of Y maze test on the 3rd day of training were obviously better than those on the 1^st day （F-52.38, 43.86, P 〈 0.01）. At 48 hours after operation （the 5^th day of training）, the results of Y maze test in the normal control group and retrograde short-term memory group were still obviously better than those in each group on the 1^st day of training （F=52.38, 43.86, P 〈 0.01）, but there were no obvious differences between the two groups on the 5^th day, CONCLUSION： Partial hepatectomy mainly impaires the anterograde memory abilities of rats, and it has no effect on the retrograde short-term memory and long-term memory.

A modified Rendezvous ERCP technique in duodena diverticulum

AIM: To postoperative endoscopic retrograde cholangiopancreatography(ERCP) failure, we describe a modified Rendezvous technique for an ERCP in patients operated on for common bile duct stone(CBDS) having a T-tube with retained CBDSs. METHODS: Five cases operated on for CBDSs and having retained stones with a T-tube were referred from other hospitals located in or around Istanbul city to the ERCP unit at the Haydarpasa Numune Education and Research Hospital. Under sedation anesthesia, a sterile guide-wire was inserted via the T-tube into the common bile duct(CBD) then to the papilla. A guide-wire was held by a loop snare and removed through the mouth. The guide-wire was inserted into the sphincterotome via the duodenoscope from the tip to the handle. The duodenoscope was inserted down to the duodenum with a sphincterotome and a guidewire in the working channel. With the guidance of a guide-wire, the ERCP and sphincterotomy were suc-cessfully performed, the guide-wire was removed from the T-tube, the stones were removed and the CBD was reexamined for retained stones by contrast. RESULTS: An ERCP can be used either preoperatively or postoperatively. Although the success rate in an isolated ERCP treatment ranges from up to 87%-97%, 5%-10% of the patients require two or more ERCP treatments. If a secondary ERCP fails, the clinicians must be ready for a laparoscopic or open exploration. A duodenal diverticulum is one of the most common failures in an ERCP, especially in patients with an intradiverticular papilla. For this small group of patients, an antegrade cannulation via a T-tube can improve the success rate up to nearly 100%. CONCLUSION: The modified Rendezvous technique is a very easy method and increases the success of postoperative ERCP, especially in patients with large duodenal diverticula and with intradiverticular papilla.

Subtrochanteric fractures after retrograde femoral nailing

Secondary fractures around femoral nails placed for the management of hip fractures are well known. We report, two cases of a fracture of the femur at the interlocking screw site in the subtrochanteric area after retrograde femoral nailing of a femoral shaft fracture. Only a few reports in the existing literature have described these fractures. Two young men after sustaining a fall presented to us with pain, swelling and deformity in the upper thigh region. On enquiring, examining and radiographing them, peri-implant fractures of subtrochanteric nature through the distal interlocking screws were revealed in both patients who also had histories of previous falls for which retrograde intramedullary nailing was performed for their respective femora. Both patients were managed with similar surgical routines including removal of the existing hardware, open reduction and ace cephallomedullary antegrade nailing. The second case did show evidence of delayed healing and was additionally stabilized with cerclage wires. Both patients had uneventful postoperative outcomes and union was evident at the end of 6 mo postoperatively with a good range of motion at the hip and knee. Our report suggests that though seldom reported, peri-implant fractures around the subtrochanteric region can occur and pose a challenge to the treating orthopaedic surgeon. We suggest these be managed, after initial stabilization and resuscitation, by implant removal, open reduction and interlocking intramedullary antegrade nailing. Good results and progression to union can be expected in these patients by adhering to basic principles of osteosynthesis.

Natural History of Kawashima Palliation in Single-Ventricle and Interrupted Inferior Vena Cava Heart Disease in China 11 Years Result

Background:The long-term outcomes of patients treated with a Kawashima procedure and keeping the antegrade pulmonary blood flow(AnPBF)in single-ventricle(SV)and interrupted inferior vena cava(IVC)heart disease is still uncertain as yet.Methods:We investigated 18 patients who underwent the Kawashima procedure with SV physiology and an interrupted IVC between January 2009 and June 2018,perioperative,operative and postoperative characteristics were recorded.Results:A total of 18 patients underwent the Kawashima procedure at a median age of 2.7 years(range 0.5–24.7 years),of which 12(66.7%)were male and 6(33.3%)were female.The mean saturation was 76.2±8.5%in preoperative period and 94.2±2.2%in postoperative period.All patients had kept AnPBF.The median duration of mechanical ventilation was 12 h(range 2.5–22.5 h)and the median duration of pleural drainage was 5 days(range 2–27 days).The median hospital stay was 9 days(range 6–70 days).There was no operative death and no mortality was seen in early postoperative period.Follow-up was 100%completed,with an average follow-up period of 6.1±2.7 years(range 1–11 years).4 patients died during the follow-up.The overall 5 and 10 years’survival rates estimated by Kaplan-Meier method were 88%and 68%,respectively.Although there were no significant differences in the duration of postoperative follow-up between the death group and the survival group(p>0.05),the major systemic ventricular end-diastolic diameter(SVEDD)(p=0.018)and the degree of AVVR(p=0.001)showed significant difference between the two groups.The diameters of main pulmonary artery showed significant growth in both the death group(p=0.015)and the survival group(p=0.012)over time.SVEDD had no significant increase in the survival group(p=0.665)but was significantly larger in the death group(p=0.014).Multivariable risk factors of late mortality in patients treated with Kawashima procedure were follow-up AVVR(p=0.044;HR:3.124;95%CI:1.030–9.473)and SVEDD(p=0.031;HR:9.766;95%CI:1.226–77.8).14 patients(100%)were all in New York Heart Association(NYHA)functional class I and the mean saturation was 93±2%at last follow-up.Only one patient finished Fontan completion.Conclusions:The Kawashima procedure with AnPBF can be safely performed with acceptable early and long outcomes.Although some previous studies have shown the risk of pulmonary arteriovenous malformations(PAVMS)after Kawashima procedure in the mid-and long-term,our findings are in contradiction with it.No PAVMs occurred in all the survivors.Kawashima procedure with open AnPBF may be a good option for unsuitable Fontan candidates.

Intramedullary bone pedestal formation contributing to femoral shaft fracture nonunion:A case report and review of the literature

BACKGROUND Femoral shaft fracture is a commonly encountered orthopedic injury that can be treated operatively with a low overall delayed/nonunion rate.In the case of delayed union after antegrade or retrograde intramedullary nail fixation,fracture dynamization is often attempted first.Nonunion after dynamization has been shown to occur due to infection and other aseptic etiologies.We present a unique case of diaphyseal femoral shaft fracture nonunion after dynamization due to intramedullary cortical bone pedestal formation at the distal tip of the nail.CASE SUMMARY A 37-year-old male experienced a high-energy trauma to his left thigh after coming down hard during a motocross jump.Evaluation was consistent with an isolated,closed,left mid-shaft femur fracture.He was initially managed with reamed antegrade intramedullary nail fixation but had continued thigh pain.Radiographs at four months demonstrated no evidence of fracture union and failure of the distal locking screw,and dynamization by distal locking screw removal was performed.The patient continued to have pain eight months after the initial procedure and 4 mo after dynamization with serial radiographs continuing to demonstrate no evidence of fracture healing.The decision was made to proceed with exchange nailing for aseptic fracture nonunion.During the exchange procedure,an obstruction was encountered at the distal tip of the failed nail and was confirmed on magnified fluoroscopy to be a pedestal of cortical bone in the canal.The obstruction required further distal reaming.A longer and larger diameter exchange nail was placed without difficulty and without a distal locking screw to allow for dynamization at the fracture site.Post-operative radiographs showed proper fracture and hardware alignment.There was subsequently radiographic evidence of callus formation at one year with subsequent fracture consolidation and resolution of thigh pain at eighteen months.CONCLUSION The risk of fracture nonunion caused by intramedullary bone pedestal formation can be mitigated with the use of maximum length and diameter nails and close follow up.

Humerus Nailing in Lateral Position (Operative Technique)

With the advent of good designs of nails, straight and angled in the arena of treatment for fractures from surgical neck of humerus to approximately 5 cm above the olecranon fossa, nailing is gaining popularity in recent literature. Many different nails are available in market with different proximal and distal locking configurations. Beach chair and supine are the main principle positions for antegrade humerus nailing. Beach chair or supine is the preferred position by many, but there is always difficulty in distal locking by free hand technique as it is difficult to locate the distal locking hole due to rounded smooth anatomy of anterior distal humerus and fear of neurovascular complications in both anteroposterior and latero-medial locking. The aim of this article is to demonstrate the utility of lateral position in ease of nailing all types of humerus fractures. The technique and illustrations below describe the positioning of patient, image intensifier and free hand postero-anterior distal locking without injury to neurovascular structures.