Search Results (73)

Hydronephrosis caused by malignant ureteral obstruction or radiotherapy-induced ureteral stenosis is a frequent complication in patients with cervical cancer. Effective management requires continuous urinary drainage, which can be achieved either internally through ureteral stent placement or externally via percutaneous nephrostomy. Among available devices, the Allium^TM fully covered nitinol mesh ureteral stent is designed to treat ureteral or urethral strictures while allowing safe and easy removal. However, serious complications have been reported, including uretero-enteric, uretero-arterial, and uretero-vaginal fistulas, pseudoaneurysm, ureteral perforation and sepsis. We report the case of a 44-year-old woman diagnosed in 2020 with stage IIIC1 cervical cancer (FIGO classification) who underwent surgery followed by adjuvant radiotherapy. In 2021, a right metallic ureteral stent was placed to treat ureteral obstruction. Two years later, she presented with right lumbar pain, and abdominal ultrasonography revealed grade III right hydronephrosis. CT scan demonstrated migration of the metallic ureteral stent into the rectal wall. Endoscopic extraction of the migrated stent was successfully performed via colonoscopy. Retrograde pyelography and CT imaging confirmed the presence of a recto-ureteral fistula. A 6 Ch/26 cm double-J ureteral stent was subsequently placed with good positioning and drainage. At the six-month follow-up, replacement of the double-J stent was performed. Imaging studies showed only minor residual hydronephrosis. Although metallic ureteral stents are effective for managing malignant ureteral obstruction, particularly in complex oncologic cases, they are not free of severe complications. The risk appears increased in patients who have undergone radiotherapy, emphasizing the need for careful monitoring and long term follow-up. Full article

Background and Clinical Significance: Bilateral carotid-cavernous fistulas are rare clinical entities characterized by heterogeneous clinical presentations and variable outcomes. Case presentation: We report the case of a 69-year-old woman with a three-month history of progressive bilateral conjunctival hyperemia, proptosis, intermittent diplopia, and a left eye abduction deficit. Her systemic history included long-standing arterial hypertension and previous thyroidectomy with stable substitutive therapy. Comprehensive ophthalmologic, neurologic, and endocrine evaluations excluded more common causes of orbital congestion, including thyroid eye disease, orbital cellulitis, cavernous sinus thrombosis, and idiopathic orbital inflammation. The patient denied any history of recent trauma. Digital subtraction angiography (DSA) confirmed a bilateral, low-flow, indirect Barrow type D carotid–cavernous fistula (CCF) supplied by dural branches of both the internal and external carotid arteries, with marked reflux into dilated superior ophthalmic veins. DSA was essential, as prior CT and MRI studies did not identify any vascular abnormalities. The patient was scheduled for transvenous embolization; however, during the follow-up she noted gradual improvement in her condition. Repeat pre-procedural angiography performed approximately two months later demonstrated complete spontaneous closure of all shunts, accompanied by full clinical resolution. Conclusions: Owing to the exceptional rarity of bilateral indirect CCFs and the added occurrence of spontaneous closure, this case expands the limited existing literature and emphasizes the diagnostic challenges and the need for individualized treatment timing supported by multidisciplinary evaluation in low-flow dural carotid–cavernous fistulas. Full article

Background: Anterior cranial fossa dural arteriovenous fistulas (ACF DAVFs) usually receive ethmoidal dural supply. Pial arterial supply has been described in intracranial DAVFs, including ACF DAVFs, but a dominant orbitofrontal pial feeder can create diagnostic overlap with mixed pial-dural arteriovenous malformation and make endovascular treatment hazardous. Case Presentation: A 75-year-old man with atrial fibrillation presented with right middle cerebral artery occlusion and underwent intravenous thrombolysis followed by mechanical thrombectomy. During right internal carotid angiography, transient arterial-phase opacification of a contralateral frontal draining vein through the anterior communicating artery prompted post-recanalization angiography. A high-grade left ACF DAVF was diagnosed, with dominant supply from the left orbitofrontal artery, minor anterior ethmoidal supply, two venous drainage routes, cortical venous reflux, and a varix. Although the DAVF was incidental to the ischemic presentation, it was considered to require treatment because of high-risk angioarchitecture, including Borden type III/Cognard type IV drainage, cortical venous reflux, and venous ectasia. No intraparenchymal nidus or normal venous-phase use of the refluxing veins was identified. Because pial transarterial access and complete transvenous closure were considered unsafe or uncertain, microsurgical draining-vein disconnection was performed. Postoperative angiography confirmed complete obliteration. Conclusions: In this case, microsurgical disconnection achieved angiographic cure, and the patient was transferred for rehabilitation with a modified Rankin Scale score of 1. The central diagnostic and therapeutic issue in pial-feeder-dominant ACF DAVF is not rarity alone, but angiographic differentiation from mixed pial-dural arteriovenous malformation and assessment of whether the shunt can be closed without compromising normal pial arteries or venous outflow. The thrombectomy angiogram provided the route to diagnosis, whereas pial arterial dominance and divided venous drainage determined the curative strategy. Full article

Background and Objectives: After the publication by Haylen et al. introducing the MUSPACC (midline uterosacral plication anterior colporrhaphy combination) procedure, we implemented this technique in our clinical practice for the treatment of cystocele and vaginal vault prolapse (VVP). The aims of this study were to evaluate peri- and postoperative complications, as well as vaginal and urinary symptoms, including patient satisfaction 3 months postoperatively. Materials and Methods: A retrospective analysis was conducted on 58 women who underwent MUSPACC over a five-year period. Patient-reported outcomes were assessed using three prolapse-related items from the International Consultation on Incontinence–Vaginal Symptoms (ICIQ-VS) and the International Consultation on Incontinence Questionnaire–Urinary Incontinence Short Form (ICIQ-UI SF), administered preoperatively and at three months following surgery. Demographic characteristics, as well as perioperative and postoperative complications, were obtained through review of medical records. Results: At follow-up, patients demonstrated improvement in vaginal symptoms, with the mean preoperative ICIQ-VS score decreasing from 15.2 to 1.16. Among those with preoperative urinary incontinence (UI), 42.1% became completely dry after MUSPACC procedure alone. Three patients (15%) developed de novo UI. Perioperative complications occurred in one patient. The postoperative complication rate was 20.7% (12/58), including one patient who experienced a postoperative fistula between the right ureter and vagina. No further surgeries were required. Overall, 96.4% of patients were satisfied postoperatively. Conclusions: MUSPACC procedure appears to be an effective treatment for VVP and cystocele, with improvement in vaginal and urinary symptoms, high patient satisfaction, and a low rate of serious complications. Routine perioperative cystoscopy is now performed for immediate detection and management of urinary tract injuries. Full article

Background/Objectives: Hemodialysis (HD) is a life-sustaining treatment for an increasing number of patients around the globe. The options for vascular access (VA) in HD are arteriovenous fistulas (AVFs), arteriovenous grafts (AVGs), and central venous catheters (CVCs). AVFs are historically associated with better long-term outcomes. Recently, international guidelines have shifted to a more individualized approach driven by evidence that patient-specific factors influence the success of AVF creation. The initial “Vienna ACTS NOW” study revealed significant inter-center variability in CVC prevalence in Vienna. This two-year follow-up aimed to document the continuing variability in CVC-based HD management and to monitor the clinical outcomes and cost associated with an attempted conversion to AVF/G. Methods: This multi-center cohort study collected data (March 2023 to March 2025) on 153 CVC-based HD patients from six Viennese institutions. Primary endpoints included VA-related events and patency; the secondary endpoint was overall mortality. Costs were calculated using the Austrian Catalogue for Medical Services (MEL). Results: Overall, 28 (18.3%) out of 153 patients underwent AVF/G surgery, and 20 (71.4%) achieved successful cannulation. A total of 12 surgical and 14 endovascular interventions were performed to either support VA maturation or maintain patency. The median hospital admission was 3 days for VA creation and 4 days for later interventions. VA creation in patients that did not require later interventions cost 3130.44 € per patient, and it cost 11,893.02 € in patients that did. The proportion of AVF/G creation attempts varied from 0% to 40.9% between centers. Patients who underwent VA-creating surgery had a better rate of survival after two years compared to patients who did not undergo VA-creating surgery. (86.2% vs. 63.3% p < 0.02). Overall, 6.3% of deaths were related to VA management. Conclusions: Patient-specific characteristics and the capability of the healthcare system to timely detect and treat CKD might influence the outcome of patients. The proportion of CVC- and AVF/G-based HD might therefore be associated with the level of access patients have to the healthcare system and the efficiency of the care network. Our own data point towards a difference in CVC use between different centers in Vienna, not solely driven by patient characteristics, but by locally available resources and differences in policies. Full article

Background/Objectives: Leaks and fistulas are serious surgical complications associated with substantial morbidity and mortality. Traditional management has relied on surgical reintervention or percutaneous drainage, both of which carry significant risks. In recent decades, interventional endoscopy has emerged as a minimally invasive alternative, offering a growing range of therapeutic options. This scoping review aimed to systematically map the available evidence on endoscopic management of post-surgical leaks and fistulas, with a focus on techniques used, indications, outcomes, and gaps in the literature. Methods: This scoping review was conducted according to PRISMA-ScR guidelines. PubMed/MEDLINE, Embase, and Scopus were searched from inception to 5 December 2025. Eligible studies included original studies, systematic reviews, and narrative reviews reporting therapeutic endoscopic interventions for post-surgical leaks or fistulas in any patient population. Case reports and case series with fewer than 20 patients were excluded. Data were charted on study design, surgical context, endoscopic techniques, and reported outcomes. Results: A total of 69 studies were included, comprising 46 original studies involving 2550 patients, along with 11 systematic reviews and 12 narrative reviews. Endoscopic techniques identified included through-the-scope and over-the-scope clipping, stenting, endoscopic vacuum therapy, internal drainage, tissue sealants, endoscopic suturing, and hybrid devices such as VAC-Stent^®. Reported technical and clinical success rates varied widely across techniques and clinical settings, influenced by defect characteristics, timing of intervention, anatomical location, and operator experience. Endoscopic vacuum therapy was supported by the most consistent evidence, particularly for esophageal and colorectal leaks. Conclusions: Interventional endoscopy represents an increasingly central component in the management of post-surgical leaks and fistulas, enabling individualized, less invasive treatment strategies. However, the current evidence base remains heterogeneous and largely retrospective, underscoring the need for well-designed, multicenter prospective studies. Full article

Background: Pancreaticopleural fistula is a rare complication of chronic pancreatitis resulting from pancreatic duct disruption, typically presenting with pleural effusion and predominant respiratory symptoms. Bilateral pleural involvement is exceptionally uncommon and poses significant diagnostic and therapeutic challenges. Case Presentation: A 56-year-old man with a history of chronic alcohol abuse presented with progressive dyspnea and mild epigastric pain. Imaging revealed bilateral pleural effusions, an atrophic pancreas with a markedly dilated main pancreatic duct containing calculi, and a fistulous tract extending from the pancreatic body through the esophageal hiatus into the mediastinum. Magnetic resonance cholangiopancreatography confirmed the diagnosis of chronic calculous pancreatitis complicated by a pancreaticopleural fistula. After unsuccessful conservative management, the patient underwent distal pancreatectomy, resection of the fistulous tract, and Roux-en-Y pancreatojejunostomy. The postoperative course was uneventful, with complete resolution of pleural effusions and sustained clinical improvement. Conclusions: This case highlights the importance of considering pancreaticopleural fistula in patients with unexplained pleural effusions and minimal abdominal symptoms, particularly in the context of chronic pancreatitis. Bilateral involvement, although rare, should not preclude timely diagnosis. Appropriate diagnostic studies by computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography are crucial for establishing the diagnosis. Surgical management offers definitive treatment in patients with ductal obstruction and calculous disease, resulting in excellent long- term outcomes. Full article

Background/Objectives: The International Study Group for Pancreatic Surgery has recently defined post-pancreatectomy acute pancreatitis (PPAP), stating that sustained postoperative hyperamylasemia (POH) for at least 48 h is a pivotal criterion. However, the clinical relevance of POH and PPAP following distal pancreatectomy remains uncertain. This study compares two PPAP definitions differing in POH criteria. Methods: We retrospectively analyzed all patients who consecutively underwent distal pancreatectomy at our institution (2010–2023). PPAP diagnosis required clinical symptoms, characteristic CT findings, and either sustained POH ≥ 48 h (standard group) or transient POH less than 48 h (modified group). Outcomes were compared between definitions. Results: Among 207 patients included, in the standard group, PPAP was diagnosed in 12 (5.8%), and in the modified group in 27 (13.0%) patients. Independent of the applied POH criteria, PPAP was associated with the occurrence of clinically relevant postoperative pancreatic fistulas (standard: 66.7% vs. 23.7%; p < 0.001; modified: 44.4% vs. 23.7%; p = 0.027). Post-pancreatectomy hemorrhage and major complications (Clavien–Dindo grade ≥ III) were also significantly more frequent in patients with PPAP. This was mirrored by a significantly longer length of stay and higher costs. However, in the standard group, PPAP more often resulted in pancreas-specific and major complications compared to the modified group. Of note, in the standard group, only 50% of patients with POH progressed to PPAP, and one-third of patients suffering from PPAP did not develop harmful sequelae. Conclusions: PPAP is an uncommon, however clinically relevant complication following distal pancreatectomy that is better captured using the standard POH definition. Still, further stratification is needed to aid in the prediction of the clinical course. Full article

Bariatric surgery is an effective treatment for morbid obesity but is frequently complicated by anastomotic leaks, fistulas, and strictures, which can significantly impair patient outcomes. Optimal management of these complications relies on a timely and accurate diagnostic assessment; however, effective treatment strategies are central to improving clinical recovery. This review primarily focuses on the endoscopic management of post-bariatric surgery complications, while providing a concise overview of the diagnostic imaging modalities that guide therapeutic decision-making. Contrast-enhanced imaging techniques, including computed tomography (CT) and fluoroscopy, as well as endoscopic ultrasound (EUS), are briefly discussed in relation to their role in identifying complications, defining their extent, and selecting the most appropriate endoscopic intervention. The core of this review is dedicated to current endoscopic treatment approaches, including endoscopic internal drainage with double pigtail plastic stents, self-expanding metal stents (SEMSs), endoscopic vacuum therapy (EVT), and EUS-guided drainage of fluid collections. Particular emphasis is placed on indications, technical considerations, and outcomes of these therapies. Finally, this review highlights emerging endoscopic technologies that may further optimize the management of post-bariatric surgery complications and improve patient outcomes, underscoring the evolving role of minimally invasive endoscopic treatment within a multidisciplinary framework. Full article

Background and Objectives: Pancreatoduodenectomy (PD) is the primary treatment for patients with resectable, non-metastatic pancreatic adenocarcinoma and periampullary tumors. Although surgical methods and perioperative management have improved, the procedure still carries a high risk of complications, with postoperative pancreatic fistula (POPF) being the most significant. This study focuses on identifying current risk factors for POPF after PD in a single HPB center. Materials and Methods: We retrospectively analyzed prospectively collected data from patients undergoing PD in our department between October 2018 and April 2024. Data included demographics, comorbidities, lifestyle factors, preoperative tests (bilirubin, CA19-9, HbA1c), intraoperative variables (pancreatic texture, duct diameter), and postoperative outcomes. POPF was classified using the International Study Group of Pancreatic Surgery (ISGPS) criteria. Univariate and multivariate logistic regression analyses were performed. Results: A total of 118 patients underwent PD (82 males, 36 females; mean age 67 (45–85) years; mean body mass index (BMI) 26.6 kg/m²). POPF occurred in 37 patients (31%), with 27 Grade B (23%) and 10 Grade C (9%). The 30- and 90-day mortality rates were 5% and 12.7%, respectively. Univariate analysis showed associations between POPF and soft pancreas (p = 0.018), c-reactive protein (CRP) on postoperative day (POD) 5 (p = 0.004), and serum amylase on POD 0 (p = 0.008). Diabetes mellitus was associated with a lower incidence of POPF (p = 0.014). Multivariate analysis confirmed CRP on POD 5 (OR 1.007, p = 0.025) and DM (OR 0.254, p = 0.015), as independent factors. ROC analysis identified POD 0 amylase >113.5 U/L (AUC 0.717) and POD 5 CRP >125.3 mg/dL (AUC 0.669) as predictive values. Conclusions: POPF remains an important complication after PD. CRP > 126 mg/dL on POD 5 was associated with POPF and may serve as an adjunctive signal to guide further assessment, including imaging. The observed inverse association with diabetes mellitus is hypothesis-generating and should be interpreted cautiously, considering potential confounding and the influence of center volume, surgeon heterogeneity, and institutional protocols. Full article

Background/Objectives: Obesity imposes a significant and growing burden on healthcare systems worldwide. Bariatric surgery remains the most effective long-term treatment for morbid obesity, but its success depends heavily on the quality of perioperative management and institutional expertise. This study presents a comprehensive analysis of 14 years of bariatric surgical activity in a university-based Center of Excellence, emphasizing complication rates and safety outcomes. Methods: A cohort analysis was performed on a prospectively collected database including all bariatric procedures conducted between June 2012 and June 2025 in an Obesity Center, located in ‘Saint Spiridon’ Hospital’ in Iasi, Romania. Eligibility was determined according to the American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) guidelines. All patients underwent standardized preoperative evaluation by a multidisciplinary team. Results: Over a 14-year period, 1010 patients underwent surgery and had a mean age of 39 years and 72% of them were females. A total of 68 patients (6.73%) experienced complications, including 28 (2.77%) within 30 days and 40 (3.96%) after first month. No postoperative fistulas or deaths were recorded during the entire study period. Conclusions: The long-term data from over one thousand consecutive bariatric cases confirm the high safety and effectiveness of a multidisciplinary, protocol-driven approach. The absence of postoperative fistulas and mortality underscores the value of institutional experience and standardized perioperative care. Full article

Background/Objectives: We aimed to construct a nomogram model for predicting arteriovenous fistula dysfunction risk and to conduct internal validation. Methods: The clinical data of 335 patients from the 8th Affiliated Hospital of Sun Yat-Sen University, collected from January 2019 to January 2024, were retrospectively analyzed. Among these patients, 103 were assigned to the arteriovenous fistula (AVF) dysfunction group, while 232 were in the non-dysfunction group. In this study, we first identified risk factors for AVF dysfunction using univariate and logistic regression analyses, and then constructed a prediction model by resampling the data. The model’s performance was evaluated using the C-index, ROC curve, calibration plot, and decision curve analysis, confirming its strong predictive ability and clinical value. Results: The results indicated that post-dialysis hypotension, abnormal fibrinogen levels, platelet abnormalities, total cholesterol levels, and diabetes mellitus emerged as independent risk factors for AVF dysfunction in MHD patients; however, total protein levels were a protective factor for AVF dysfunction. The model’s performance was assessed using the receiver operating characteristic (ROC) curve, the Hosmer–Lemeshow test, and the calibration curve. The ROC curve results demonstrated that the area under the curve (AUC) for the training set was 0.852 (0.799–0.904), while that for the validation set was 0.810 (0.715–0.906), indicating good calibration. The decision curve analysis revealed that the predictive nomogram was clinically useful when the threshold for intervention was set between a 15% and 78% probability of dysfunction. Conclusions: The nomogram prediction model constructed in this study can be used to predict the risk of autogenous arteriovenous fistula dysfunction in hemodialysis patients. Full article

Objective. Limited evidence is available concerning the surgical outcomes of patients with congenital gastrointestinal malformations and perioperative SARS-CoV-2 infection. This study examines the scientific evidence on SARS-CoV-2 infection and congenital gastrointestinal malformations requiring surgery in children. Material and Methods. We performed a systematic review of studies reporting data on children with congenital gastrointestinal malformations and SARS-CoV-2 infection, published in international databases (PubMed and Embase) from pandemic inception up to August 2024. Studies not reporting data on the SARS-CoV-2 infection status on patients with congenital digestive malformation were excluded. We assessed the quality of the included studies according to the Joanna Institute (JBI) appraisal checklist, adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, and registered the protocol with the PROSPERO database (CRD42024550744). Results. From the 902 titles retrieved, eight observational studies met the inclusion criteria comprising 29 patients from countries with different socioeconomic statuses. Most patients were neonates (75%) with a median age of 3 days at diagnosis and male to female ratio of 2:1. In total, 18 (62%) presented upper gastrointestinal tract anomalies, including esophageal atresia ± tracheoesophageal fistula (n = 10, 34.48%), duodenal atresia (n = 3, 10.3%), and congenital hypertrophic pyloric stenosis (n = 5, 17.2%). Lower digestive tract malformations (11, 38%) included anorectal malformations (n = 6, 20.6%), intestinal atresia (n = 3, 10.3%), Hirschsprung disease (n = 1, 3.44%), and Meckel’s diverticulum (n = 1, 3.44%). Surgeries were primarily emergency or urgent procedures and only pyloromyotomy (5/5) was consistently operated minimally invasively. SARS-CoV-2 infection was identified mainly on routine screening (>95%). Of 29 patients, 85% were discharged home, and no postoperative surgical mortality and significant complications directly associated with COVID-19 were identified, although routine postoperative morbidity not linked to SARS-CoV-2 was observed. Conclusions. Pediatric patients with congenital gastrointestinal malformationsand perioperative SARS-CoV-2 infection typically have mild illness and favorable surgical outcomes. SARS-CoV-2 positivity alone should not delay essential surgery when infection control measures are ensured. Standardized, multicenter studies are needed to clarify perioperative risks to and inform management of this high-risk group. Full article

Introduction: Pancreatico-duodenectomy (PD) remains one of the most complex abdominal surgeries, and pancreatico-jejunostomy (PJ) fistula is its most critical postoperative complication. In efforts to reduce the incidence of postoperative pancreatic fistula (POPF), several PJ techniques and adjuncts, including stents, have been recommended. This article presents data from an international survey regarding PJ methods, the use of pancreatic stents, and their correlation with POPF rates from surgical centers worldwide. Methods: A nine-item online questionnaire was sent globally through social networks, individual mailing lists, and the ASHBPS mailing list. Data were analyzed through the Student’s t-test (two-tailed, unequal variance). A p-value < 0.05 was considered to be statistically significant. Results: A total of 122 units of pancreatic surgery from 26 countries distributed across five continents responded to the survey. Most centers performed less than 50 PDs a year, preferred a duct-to-mucosa PJ, and employed a stent routinely. Mean POPF grade B and C incidences were lower in high-volume (15.24% ± 7.29 and 3.95% ± 2.39) and in PJ stent-using centers (16.25% ± 8.7 and 5.37% ± 7.49). Conclusions: Institutional case volume and stent usage are more crucial determinants of POPF incidence than the PJ technique itself. Centralization and standardization of PD procedures are related to reductions in major fistula rates. Full article

This paper presents comprehensive studies of pitting corrosion, which precedes the appearance of fistulas in galvanized steel pipelines of hot and cold water supply systems. Corroded galvanized pipes taken out from water supply systems within their operation and scale samples were the subject of this research. The current work continues the research on one of the four structural elements of tubercles—the dense layer. The corrosion of the zinc coating and the steel base of pipes inside the tubercles led to a gradual increase in the concentration of a solution containing components of the corroding metal (zinc and iron cations) and anions in water (mainly chlorides and sulfates). To explain the corrosion under the tubercles, their dense layer was compared with an anion exchange membrane with selective properties, which provided the primary concentration of the salt solution in the structure of the tubercles with a significant increase in the concentration of aggressive anions compared to the source water. The formation of fistulas in the cavity leads to a secondary concentration of solution inside the tubercle, mainly consisting of iron chloride. At the same time, due to the hydrolysis of the formed iron salts and a decrease in pH, the corrosion rate increases and becomes independent of external conditions. This article summarizes ten years of experience in examining corrosion of steel pipes from external and internal water supply systems. Full article