Biomechanical effects of posterior lumbar interbody fusion with vertical placement of pedicle screws compared to traditional placement

BACKGROUND The pedicle screw technique is widely employed for vertebral body fixation in the treatment of spinal disorders.However,traditional screw placement methods require the dissection of paraspinal muscles and the insertion of pedicle screws at specific transverse section angles(TSA).Larger TSA angles require more force to pull the muscle tissue,which can increase the risk of surgical trauma and ischemic injury to the lumbar muscles.AIM To study the feasibility of zero-degree TSA vertical pedicle screw technique in the lumbosacral segment.METHODS Finite element models of vertebral bodies and pedicle screw-rod systems were established for the L4-S1 spinal segments.A standard axial load of 500 N and a rotational torque of 10 N/m were applied.Simulated screw pull-out experiment was conducted to observe pedicle screw resistance to pull-out,maximum stress,load-displacement ratio,maximum stress in vertebral bodies,load-displacement ratio in vertebral bodies,and the stress distribution in pedicle screws and vertebral bodies.Differences between the 0-degree and 17-degree TSA were compared.RESULTS At 0-degree TSA,the screw pull-out force decreased by 11.35%compared to that at 17-degree TSA(P<0.05).At 0-degree and 17-degree TSA,the stress range in the screw-rod system was 335.1-657.5 MPa and 242.8-648.5 MPa,separately,which were below the fracture threshold for the screw-rod system(924 MPa).At 0-degree and 17-degree TSA,the stress range in the vertebral bodies was 68.45-78.91 MPa and 39.08-72.73 MPa,separately,which were below the typical bone yield stress range for vertebral bodies(110-125 MPa).At 0-degree TSA,the load-displacement ratio for the vertebral bodies and pedicle screws was slightly lower compared to that at 17-degree TSA,indicating slightly lower stability(P<0.05).CONCLUSION The safety and stability of 0-degree TSA are slightly lower,but the risks of screw-rod system fracture,vertebral body fracture,and rupture are within acceptable limits.

Preliminary study on the efficacy of lacrimal duct reconstruction with pedicled conjunctival flap in the treatment of severe lacrimal canalicular obstruction with conjunctivochalasis

AIM:To determine the efficacy and safety of pedicled conjunctival lacrimal duct reconstruction in the treatment of severe obstruction of superior and inferior lacrimal canaliculi with conjunctivochalasis.METHODS:This study was per formed as a retrospective analysis of patients who received conjunctival dacryocystorhinostomy with pedicled conjunctival flap reconstruction combined with tube intubation due to severe superior and inferior lacrimal canalicular obstruction with conjunctivochalasis from January 2019 to October 2019.The clinical data included the degree of preoperative epiphora and postoperative relief,preoperative examination of lacrimal duct computed tomography and ultrasound biomicroscopy,postoperative evaluation of lacrimal duct function by chloramphenicol taste and fluorescein dye disappearance test,etc.Syringing was carried out to determine the reconstruction and patency of the lacrimal duct.RESULTS:All 9 patients(9 eyes)had severe canalicular obstruction with conjunctivochalasis.The patients included 4 males and 5 females aged between 47–65y with an average age of 52.2±6.7y.At 3mo follow-up,the tube was removed and the patients were followed for a further 3mo.After tube removal,6 patients showed no epiphora.These patients also had positive chloramphenicol tastes and normal fluorescein dye disappearance test results.Two patientshad epiphora.Also,syringing showed partial patency of the reconstructed lacrimal duct.One patient had no improvement in epiphora with negative chloramphenicol taste and fluorescein dye disappearance test results and obstruction of the reconstructed lacrimal duct.The total effective rate of the operation was 8/9,with no serious complications.CONCLUSION:Pedicled conjunctival lacrimal duct reconstruction conjunctival dacryocystorhinostomy is safe and effective for superior and inferior canalicular obstruction with conjunctivochalasis.

Comparison of Sternal Wound Complication after Off-Pump CABG between Skeletonized and Pedicled LIMA Harvesting: A Single Centre Experience in Bangladesh

Background: Off-pump coronary artery bypass grafting (OPCAB) is a surgical procedure that has gained popularity due to its potential benefits over traditional coronary artery bypass grafting, including reduced morbidity and mortality. However, sternal wound complication (SWC) remains challenging following the procedure. The technique of left internal mammary artery (LIMA) harvesting has been shown to impact the incidence of SWC. This study aimed to compare the incidence of SWC between two techniques of LIMA harvesting, i.e., skeletonized and pedicled. Methods: The study was conducted at the Department of Cardiac Surgery, Bangabandhu Sheikh Mujib Medical University, and included 60 patients who underwent OPCAB. The patients were divided into two groups of 30 each based on the technique of LIMA harvesting used, i.e., skeletonized (group A) or pedicled (group B). The postoperative ICU care was given to each patient as per the protocol. The statistical analysis was conducted using the SPSS version 26.0 for Windows software. Results: The results showed that 5 (8.33%) patients developed SWC, with 1 (1.67%) patient in group A and 4 (6.66%) patients in group B. However, the occurrence of SWC was not statistically significant between the two groups (p = 0.35). The mean age, gender distribution, and comorbidities such as hypertension, diabetes, dyslipidemia, and anemia were also not statistically significant between the two groups. The number of smokers was statistically significant between the two groups (p = 0.03), and the occurrence of SWC was found to be higher in smoker patients in group B (p = 0.04). Preoperative and postoperative parameters such as duration of operation, duration of mechanical ventilation, duration of chest drains, duration of the central venous line, and amount of postoperative mediastinal bleeding were also not statistically significant between the two groups. The distribution of wound complications, duration of ICU stays, and hospital stay between the two groups was also not statistically significant. Conclusion: In conclusion, this study found that the incidence of SWC was less in skeletonized LIMA harvesting than in pedicled LIMA harvesting after OPCAB. However, this finding was not statistically significant. Further studies with larger sample sizes may be needed to confirm these results and determine the appropriate technique of LIMA harvesting to decrease the incidence of SWC after OPCAB.

Position and complications of pedicle screw insertion with or without image-navigation techniques in the thoracolumbar spine:a meta-analysis of comparative studies

Computer-navigated pedicle screw insertion is applied to the thoracic and lumbar spine to attain high insertion accuracy and a low rate of screw-related complications.However,some in vivo and in vitro studies have shown that no advantages are gained with the use of navigation techniques compared to conventional techniques.Additionally,inconsistent conclusions have been drawn in various studies due to different population characteristics and methods used to assess the accuracy of screw placement.Moreover,it is not clear whether pedicle screw insertion with navigation techniques decreases the incidence of screw-related complications.Therefore,this study was sought to perform a meta-analysis of all available prospective evidence regarding pedicle screw insertion with or without navigation techniques in human thoracic and lumbar spine.We considered in vivo comparative studies that assessed the results of pedicle screw placement with or without navigation techniques.PubMed,Ovid MEDLINE and EMBASE databases were searched.Three published randomized controlled trials（RCTs） and nine retrospective comparative studies met the inclusion criteria.These studies included a total of 732 patients in whom 4,953 screws were inserted.In conclusion,accuracy of the position of grade I,II,III and IV screws and complication rate related to pedicle screw placement were significantly increased when navigation techniques were used in comparison to conventional techniques.Future research in this area should include RCTs with well-planned methodology to limit bias and report on validated,patient-based outcome measures.

Treatment of Thoracolumbar Vertebrate Fracture by Transpedicular Morselized Bone Grafting in Vertebrae for Spinal Fusion and Pedicle Screw Fixation

To enhance the fusion of graft bone in thoracolumbar vertebrae and minimize the postoperative loss of correction, short-segment pedicle screw fixation was reinforced with posterior moselizee bone grafting in vertebrae for spinal fusion in patients with thoracrolumbar vertebrate fractures. Seventy patients with thoracrolumbar vertebrate fractures were treated by short-segment pedicle screw fixation and were randomly divided into two groups. Fractures in group A （n=20） were rein-forced with posterior morselized bone grafting in vertebrae for spinal fusion, while patients group B （n=50） did not receive the morselized bone grafting for bone fusion. The two groups were compared in terms of kyphotic deformity, anterior vertebral height, instrument failure and neurological functions after the treatment. Frankel grading system was used for the evaluation of neurological evaluation and Denis scoring scale was employed for pain assessment. The results showed that the kyphosis correction was achieved in both group A and group B （group A： 6.4 degree; group B： 5.4 degree）/At the end of follow-up, kyphosis correction was maintained in group A but lost in group B （P=0.0001）. Postoperatively, greater anterior height was achieved in group A than in group B （P〈0.01）. During follow-up study, anterior vertebral height was maintained only in Group A （P〈0.001）. Both group A and group B showed good Denis pain scores （P1 and P2） but group A outdid group B in terms of control of severe and constant pain （P4 and P5）. By Frankel criteria, the changes in neurological functions in group A was better than those of group B （P〈0.001）. It is concluded that reinforcement of short-segment pedicle fixation with morselized bone grafting for the treatment of patients with thoracolumbar vertebrae fracture could achieve and maintain kyphosis correction, and it may also increase and maintain anterior vertebral height. Morselized bone grafting in vertebrae offers immediate spinal stability in patients with thoracolumbar vertebrate fractures, decreases the instrument failure and provides better postoperative pain control than without the morselized bone grafting.

Techniques and accuracy of thoracolumbar pedicle screw placement

Pedicle screw instrumentation has been used to stabilize the thoracolumbar spine for several decades. Although pedicle screws were originally placed via a freehand technique, there has been a movement in favor of pedicle screw placement with the aid of imaging. Such assistive techniques include fluoroscopy guidance and stereotactic navigation. Imaging has the benefit of increased visualization of a pedicle's trajectory, but can result in increased morbidity associated with radiation exposure, increased time expenditure, and possible workflow interruption. Many institutions have reported high accuracies with each of these three core techniques. However, due to differing definitions of accuracy and varying radiographic analyses, it is extremely difficult to compare studies side-by-side to determine which techniques are superior. From the literature, it can be concluded that pedicles of vertebrae within the mid-thoracic spine and vertebrae that have altered morphology due to scoliosis or other deformities are the most difficult to cannulate. Thus, spine surgeons would benefit the most from using assistive technologies in these circumstances. All other pedicles in thethoracolumbar spine should theoretically be cannulated with ease via a free-hand technique, given appropriate training and experience. Despite these global recommendations, appropriate techniques must be chosen at the surgeon's discretion. Such determinations should be based on the surgeon's experience and the specific pathology that will be treated.

A new free-hand pedicle screw placement technique with reference to the supraspinal ligament

We sought to compare the safety and accuracy of a new free-hand pedicle screw placement technique to that of the conventional technique. One hundred fifty-three consecutive adult patients with simple fracture in the tho- racic or/and lumbar spine were alternately assigned to either the new free-hand or the conventional group. In the new free-hand technique group, preoperative computerized tomography （CT） images were used to calculate the targeted medial-lateral angle of each pedicle trajectory and the pedicle screw was inserted perpendicular to the corresponding supraspinal ligament. In the conventional technique group, the medial-lateral and cranial-caudal angle of each pedicle trajectory was determined by intraoperatively under fluoroscopic guidance. The accuracy rate of pedicle screw placement, the time of intraoperative fluoroscopy, the operating time and the amount of blood loss during operation were respectively compared. All screws were analyzed by using intraoperative ra- diographs, intraoperative triggered electromyography （EMG） monitoring data, postoperative CT data and clinical outcomes. The accuracy rate of pedicle screw placement in the new free-hand technique group and the conven- tional technique group was 96.3% and 94.2% （P 〈 0.05）, respectively. The intraoperative fluoroscopy time of the new technique group was less than that of the conventional technique group （5.37 seconds vs. 8.79 seconds, P 〈 0.05）. However, there was no statistical difference in the operating time and the amount of blood loss during op- eration （P 〉 0.05）. Pedicle screw placement with the free-hand technique which keeps the screw perpendicular to the supraspinal ligament is an accurate, reliable and safe technique to treat simple fracture in the thoracic or lum- bar spine.

Clinical outcomes with large macular holes using the tiled transplantation internal limiting membrane pedicle flap technique

AIM: To report the surgical technique and efficacy of the tiled transplantation internal limiting membrane(ILM) pedicle flap technique after vitrectomy for 33 patients with large macular hole(MH). METHODS: This study was a prospective noncontrolled interventional study. All patients were treated by vitrectomy, the tiled transplantation ILM pedicle flap and gas tamponade. All patients underwent visual acuity measurements and optical coherence tomography(OCT), during preoperative and the follow-up visits postoperative. RESULTS: Two high-myopic patient had flap dislocation during surgery. The thorough closure of MH following the tiled transplantation ILM pedicle flap technique was ultimately achieved in 31 patients observed by OCT imaging(93.94%) 1 wk after surgery. Visual acuity improved from 1.51±0.31(logMAR) preoperative to 0.92±0.30 6 mo after surgery(P=0.000). There were no significant changes in OCT finding during the follow-up period from 1 mo to 6 mo after surgery. CONCLUSION: The tiled transplantation ILM pedicle flap technique provides bridge for retinal gliosis to achieve successful closures of the large MHs, and the microenvironment of this technique is more similar to the normal physiological conditions.

Role of adipose-derived stromal cells in pedicle skin flap survival in experimental animal models

The use of skin flaps in reconstructive surgery is the first-line surgical treatment for the reconstruction of skin defects and is essentially considered the starting point of plastic surgery. Despite their excellent usability, their application includes general surgical risks or possible complications, the primary and most common is necrosis of the flap. To improve flap survival, researchers have used different methods, including the use of adiposederived stem cells, with significant positive results. In our research we will report the use of adipose-derived stem cells in pedicle skin flap survival based on current literature on various experimental models in animals.

Pedicle Screw Fixation with Kyphoplasty Decreases the Fracture Risk of the Treated and Adjacent Non-treated Vertebral Bodies:a Finite Element Analysis

Adjacent vertebral fractures are common in patients with osteoporotic vertebral compression fractures（OVCFs） after kyphoplasty.This finite element study was to examine whether short segment pedicle screw fixation（PSF） with kyphoplasty may decrease the fracture risk of the treated and adjacent non-treated vertebrae after kyphoplasty for OVCFs.By simulating cement augmentation with or without short segment pedicle screw fixation（PSF）,two tridimensional,anatomically detailed finite element models of the T10–L2 functional spinal junction were developed.The insertion of pedicle screws into the intact vertebra apparently decreased the stress distribution of the treated vertebra in vertical compression and other load situations.The stress distribution in the bone structures of the intact vertebra adjacent to the intact-screwed vertebra was much less than that in the one adjacent to the treated vertebra.The insertion of pedicle screws into the intact vertebra greatly decreased the maximum displacement of the cortical bones and cancellous bones of the vertebrae.Our results indicated that short segment PSF with kyphoplasty may decrease the fracture risk of the treated and adjacent non-treated vertebrae in the management of OVCFs.

Posterior Selective Thoracic Fusion in Adolescent Idiopathic Scoliosis Patients:a Comparison of All Pedicle Screws versus Hybrid Instrumentation

Objective To analyze the influence of segmental pedicle screws versus hybrid instrumentation on the correction results in adolescent idiopathic scoliosis patients undergoing posterior selective thoracic fusion. Methods By reviewing the medical records and roentgenograms of adolescent idiopathic scoliosis patients who underwent selective thoracic fusion from February 2000 to January 2007 in our hospital, the patients were divided into 2 groups according to different instrumentation fashions： Group A was hook-screw-rod （hybrid） internal fixation type, Group B was screw-rod （all pedicle screws） internal fixation type, and the screws were used in every segment on the concave side of the thoracic curve. The parameters of the scoliosis were measured and the correction results were analyzed. Results Totally, 48 patients （7 males, 41 females） were included, with an average age of 14.4 years old and a mean follow-up time of 12.3 months. Thirty and 18 patients were assigned to group A and group B, respectively. The mean preoperative coronal Cobb angles of the thoracic curve were 48.8° and 47.4°, respectively. After surgery, they were corrected to 13.7° and 6.8°, respectively. At final follow-up, they were 17.0° and 9.5°, with an average correction rate of 64.6% and 79.0%, respectively, and the correction rate of group B was significantly higher than that of group A （P=0.003）. The mean preoperative coronal Cobb angles of the lumbar curve were 32.6° and 35.2°, respectively. After surgery, they were corrected to 8.6° and 8.3°, respectively. At final follow-up, they were 10.3° and 11.1°, with an average correction rate of 66.8% and 69.9%, respectively, and the correction rate of group B was significantly higher than that of group A （P=0.003）. The correction loss of the thoracic curve and lumbar curve in the 2 groups were 3.1° and 1.8°, 2.4° and 2.4°, respectively. No significant difference was noted （both P〉0.05）. The decompensation rate at final follow-up in these 2 groups were 4% （1/25） and 7.1% （1/14） respectively, with no significant difference （P〉0.05）.

Comparison of Clinical Outcomes of Cortical Bone Trajectory and Traditional Pedicle Screw Fixation in Posterior Lumbar Interbody Fusion

Posterior lumbar interbody fusion (PLIF) is a common surgical procedure and widely used in the treatment of lumbar degenerative disc disorders. Traditionally, posterior lumbar interbody fusion is done by using the traditional pedicle screw (PS) which offers great advantages, but at the same time it has some disadvantages which include the risk of superior facet joint violation and muscle damage. Recently, an alternative method of screw insertion via cortical bone trajectory (CBT) has been invented which has less invasive process and can be placed without the drawbacks associated with the traditional pedicle screw. However, it has to remain an interest whether CBT will provide similar or greater clinical outcomes compared to PS in PLIF. So the main aim of this review is to compare the clinical outcomes of cortical bone trajectory and traditional pedicle screw fixation in posterior lumbar interbody fusion based on the articles published on this topic. Compared to the traditional pedicle screw fixation, PLIF with CBT has similar clinical outcome based on pain intensity, ODI status and JOA score, as well as similar fusion rate and radiological evaluated complication such as loosening of screw. In addition PLIF with CBT has advantages of less facet joint violation, less blood loss, less intraoperative muscle damage and perioperative pain. On the basis of this study, we can suggest that PLIF with CBT can be considered as a reasonable alternative to PS in PLIF.

Spinal pedicle subtraction osteotomy for fixed sagittal imbalance patients

In addressing spinal sagittal imbalance through a posterior approach, the surgeon now may choose from among a variety of osteotomy techniques. Posterior column osteotomies such as the facetectomy or Ponte or Smith-Petersen osteotomy provide the least correction, but can be used at multiple levels with minimal blood loss and a lower operative risk. Pedicle subtraction osteotomies provide nearly 3 times the per-level correction of Ponte/Smith-Petersen osteotomies; however, they carry increased technical demands, longer operative time, and greater blood loss and associated significant morbidity, including neurological injury. The literature focusing on pedicle subtraction osteotomy for fixed sagittal imbalance patients is reviewed. The longterm overall outcomes, surgical tips to reduce the complications and suggestions for their proper application are also provided.

Treatment of Anderson Type II Odontoid Fracture in Elderly Patients by Posterior Pedicle Screw Fixation Combined with Iliac Bone Grafting

Objectives: To explore the treatment and related prognosis of elderly patients with Anderson II odontoid fracture with posterior pedicle screw fixation combined with iliac bone grafting. Methods: Retrospective analysis of 17 cases of elderly patients with Anderson II odontoid fracture who underwent posterior pedicle screw fixation combined with iliac bone grafting from January 2013 to December 2016. 17 patients had a history of trauma before surgery, and they all have varying degrees of atlantoaxial instability or subluxation and varying degrees of neck occipital pain and limited mobility. Result: No spinal cord or vertebral artery injury occurred during surgery. Follow-up information is complete. The follow-up period was 6 to 48 months (mean 27.4 ± 12.4 months). Postoperative imaging review prompted a good reduction of cervical spine, stable sequence;no pedicle screw loosening, fracture, iliac bone graft at the location of the situation, odontoid fracture and bone healing at the good, the patient after cervical rotation are limited to varying degrees. Conclusion: Posterior pedicle screw fixation combined with iliac bone grafting in elderly patients with Anderson II odontoid fracture can achieve good stability, and the prognosis is good, but long-term cervical rotation function may be affected to varying degrees.

Preventing and localizing esophagogastric anastomosis leakage by sleeve-wrapping of the pedicled omentum

AIM: To develop a technique of sleeve-wrapping the pedicled omentum around the esophagogastric anastomosis for preventing and localizing leakage.

Successful outcomes of unilateral vs bilateral pedicle screw fixation for lumbar interbody fusion:A meta-analysis with evidence grading

BACKGROUND Whether it’s better to adopt unilateral pedicle screw(UPS)fixation or to use bilateral pedicle screw(BPS)one for lumbar degenerative diseases is still controversially undetermined.AIM To make a comparison between UPS and BPS fixation as to how they work efficaciously and safely in patients suffering from lumbar degenerative diseases.METHODS We have searched a lot in the databases through 2020 with index terms such as“unilateral pedicle screw fixation”and“bilateral pedicle screw fixation.”Only randomized controlled trials and some prospective cohort studies could be found,yielding 15 studies.The intervention was unilateral pedicle screw fixation;Primarily We’ve got outcomes of complications and fusion rates.Secondarily,we’ve achieved outcomes regarding total blood loss,operative time,as well as length of stay.Softwares were installed and utilized for subgroup analysis,analyzing forest plots,sensitivity,heterogeneity,forest plots,publication bias,and risk of bias.RESULTS Fifteen previous cases of study including 992 participants have been involved in our meta-analysis.UPS had slightly lower effects on fusion rate[relative risk(RR)=0.949,95%CI:0.910 to 0.990,P=0.015],which contributed mostly to this metaanalysis,and similar complication rates(RR=1.140,95%CI:0.792 to 1.640,P=0.481),Δvisual analog scale[standard mean difference(SMD)=0.178,95%CI:-0.021 to 0.378,P=0.080],andΔOswestry disability index(SMD=-0.254,95%CI:-0.820 to 0.329,P=0.402).In contrast,an obvious difference has been observed inΔJapanese Orthopedic Association(JOA)score(SMD=0.305,95%CI:0.046 to 0.563,P=0.021),total blood loss(SMD=-1.586,95%CI:-2.182 to-0.990,P=0.000),operation time(SMD=-2.831,95%CI:-3.753 to-1.909,P=0.000),and length of hospital stay(SMD=-0.614,95%CI:-1.050 to-0.179,P=0.006).CONCLUSION Bilateral fixation is more effective than unilateral fixation regarding fusion rate after lumbar interbody fusion.However,JOA,operation time,total blood loss,as well as length of stay were improved for unilateral fixation.

Potential contribution of pedicle screw design to loosening rate in patients with degenerative diseases of the lumbar spine:An observational study

BACKGROUND The majority of published data report the results of biomechanical tests of various design pedicle screw performance.The clinical relevance and relative contribution of screw design to instrumentation stability have been insufficiently studied.AIM To estimate the contribution of screw design to rate of pedicle screw loosening in patients with degenerative diseases of the lumbar spine.METHODS This study is a prospective evaluation of 175 patients with degenerative diseases and instability of the lumbar spine segments.Participants underwent spinal instrumentation employing pedicle screws with posterior only or transforaminal interbody fusion.Follow-up was for 18 mo.Patients with signs of pedicle screw loosening on computed tomography were registered;logistic regression analysis was used to identify the factors that influenced the rate of loosening.RESULTS Parameters included in the analysis were screw geometry,type of thread,external and internal screw diameter and helical pitch,bone density in Hounsfield units,number of levels fused,instrumentation without anterior support,laminectomy,and unilateral and bilateral total facet joint resection.The rate of screw loosening decreased with the increment in outer diameter,decrease in core diameter and helical pitch.The rate of screw loosening correlated positively with the number of fused levels and decreasing bone density.Bilateral facet joint removal significantly favored pedicle screw loosening.The influence of other factors was insignificant.CONCLUSION Screw parameters had a significant impact on the loosening rate along with bone quality characteristics,the number of levels fused and the extensiveness of decompression.The significance of the influence of screw parameters was comparable to those of patient-and surgery-related factors.Pedicle screw loosening was influenced by helical pitch,inner and outer diameter,but screw geometry and thread type were insignificant factors.

Evaluation of Percutaneous Pedicle Screw Fixation in Patients with Pyogenic Spondylitis of the Thoracolumbar Spine

Background: Basic principle for the treatment of pyogenic spondylitis (PS) is conservative care, but surgical intervention is often required when conservative treatment may fail. We have experienced many conservative cases of various complications due to long-term bed rest and poor pain control. Recently we have adopted percutaneous pedicle screw (PPS) fixation for the treatment of PS as a minimally invasive spine stabilization (MISt) fusion to reduce such morbidity of the conservative care. Objective: To evaluate the impact of PPS fixation in patients with PS. Study Design: A retrospective analysis of the medical records. Subjects, Methods: We reviewed 54 consecutive patients who underwent treatment in our hospital for PS during 2005-2018 and observed for more than 12 months. Of those we excluded cases showing effectiveness to initial treatment (it was defined fever relief or C-reactive protein (CRP) inversion in 3 weeks of antibiotics) so that this study is a retrospective study in cases showing initial treatment resistance. Finally, this study included 29 cases. Medical records of these 29 cases were reviewed for baseline, organism isolated and its detection rate, the clinical outcome in 12 months (Discharge, Transfer, Death), the period from the first visit to our hospital to fever relief, CRP inversion, ambulation, and Discharge or Transfer. Results: These cases were divided into two groups, the conservative group (C-group): 17 cases, and the PPS group (P-group): 12 cases. There is no statistically significant difference in fever relief (p = 0.051) and CRP inversion (p = 0.208). The period to ambulation and discharge or transfer was significantly shorter in group P (p = 0.020, p = 0.031). 1-Year survival rate was 92% in the P-group, and 71% in the C-group. There is no statistically significant difference (p = 0.354) between the two groups. The rate of Discharge to home and care facility is 58% in P-group, and 47% in C-group. And the rate of Transfer is 34% in P-group, and 35% in C-group. Conclusion: PPS fixation was effective to achieve shortening the period to ambulation and discharge or transfer. But it was not effective in infection control. This suggests that PPS fixation should be aggressively administered to patients who can expect pain relief and early ambulation by PPS fixation in the patient of PS showing resistance to initial treatment.

Endoscopic pedicle flap grafting in the treatment of esophageal fistulas:A case report

BACKGROUND Fistulization is a rare complication of esophageal diverticula.Patients with this condition often require surgery,which unfortunately can be invasive and traumatic.Endoscopic therapy is an alternative method for treating esophageal fistula.Hereby we introduce a new endoscopic technique that uses an esophageal pedicle flap to close esophageal fistulas.CASE SUMMARY A 49-year-old male patient,complaining of backache and choking,was formerly diagnosed with chronic bronchopneumonia.Chest computed tomography and esophagram confirmed the presence of esophageal diverticulum and mediastinal esophageal fistula.The patient was then treated by covering the fistulas using a pedicled flap that was acquired through endoscopic submucosal dissection of a patch from the proximal esophageal mucosa.Then the pedicle flap was reversed 180°to cover the fistula.Titanium clips were used to fix the flap.The procedure ended with percutaneous endoscopic gastrostomy for enteral nutrition.The patient was followed up to evaluate the size reduction of the fistula.Cough,backache,and fever were alleviated within a week.Forty-five days after the surgery,endoscopic examination showed that the fistulas were reduced in size.The larger one reduced from 0.5 cm to 0.2 cm,while the smaller one was fully closed.CONCLUSION Transplantation of a pedicle flap obtained from the esophageal mucosa endoscopically is minimally invasive for the treatment of fistula.