Rapid exchange of a percutaneous gastrostomy tube during an early episode of COVID-19

We retrospectively report a case of rapid exchange of a percutaneous radiologic gastrostomy tube (balloon-occluded type catheter) via off-label use of a pigtail catheter for nutrition supply during a very early episode of coronavirus disease 2019 (COVID-19) in an outpatient clinic. This case demonstrates that minimally invasive percutaneous procedures might be provided safely and effectively under appropriate precautions for preventing COVID-19 transmission during the pandemic.Copyright © 2023, Society of Gastrointestinal Intervention.

Navigating the iodinated contrast media shortage: A review

The current COVID-19 climate has caused an unforeseen supply shortage of iodinated contrast media (ICM) worldwide, disrupting global distribution.1 In addition, the scarcity has resulted in a ripple effect in healthcare facilities such as radiology departments where ICM is required to perform contrast-enhanced examinations. ICM plays a significant part in contrast-enhanced CT, angiography and fluoroscopic procedures within the radiology department, holding a primary role in the differentiation and diagnosis of pathologies which range from pulmonary emboli to tumours.1 Its use extends beyond radiology, where ICM is heavily relied on in cardiology, urology and gastrointestinal studies, further highlighting the heavy dependence on the critical agent.2 With the global increase in the number of CT examinations requested, where approximately 60% of studies require ICM, optimal usage of ICM must be considered to meet heightened demand.3 The shortage has represented an opportunity for imaging providers to re-examine current imaging protocols and identify whether non-contrast imaging, alternative contrast agents and other imaging modalities could be viable options moving forward.1,2 Additionally, current literature has discussed volume-reduction strategies and dual-energy use in newer-generation CT scanners to conserve ICM.1,4 This review will explore currently proposed solutions that can be implemented in the radiology department to maximise ICM supply with minimal impact on patient care.

Use of novel oxygenated right ventricular assist device hybrid ECLS for adolescents with refractory hypoxemic respiratory dailure due to Covid-19 pneumonia

Objectives: To describe institutional experience using Oxygenated Right Ventricular Assist Device (OxyRVAD) Hybrid ECLS for adolescents with respiratory failure due to SARS-CoV-2 pneumonia. Method(s): Between September and December 2021, 44 Covid-19+ patients were admitted to our regional Pediatric Intensive Care Unit (PICU), including 4 adolescents who required Extracorporeal life support (ECLS) due to refractory hypoxemia. Two patients were initially cannulated onto Veno-Venous (VV) ECLS and converted to Oxy-RVAD ECLS due to refractory hypoxemia;the others were cannulated directly onto Oxy-RVAD ECLS. Two patients had observed right ventricular (RV) dysfunction or failure on echocardiography. Cannulations were performed in the cardiac catheterization suite by an interventional cardiologist using percutaneous technique under fluoroscopy. Circuit construction was varied and included the use of a dedicated RVAD cannula or standard cannula used for VA/VV ECLS. All patients were connected to Cardiohelp systems with built in centrifugal pumps and oxygenators. Result(s): Two patients were initially placed on VV-ECLS and converted to Oxy-RVAD ECLS days into their course due to severe, refractory hypoxemia with one having improvement in hypoxemia after the conversion. Two patients received renal replacement therapy (RRT) without complications, the others did not have indications for renal support. Two patients underwent tracheostomy on ECMO though none were able to separate from mechanical ventilation. Three patients survived to discharge. No incidents of circuit air or clotting were noted. The patient with the longest ECLS run required one circuit change and was the only patient to develop a superinfection: a successfully-treated fungal infection. All patients were mobilized on ECLS to sitting in a chair;one was able to ambulate. Conclusion(s): Oxy-RVAD hybrid ECLS can be used to effectively support adolescents with severe respiratory disease from conditions associated with RV dysfunction. Pediatric providers can collaborate with adult critical care colleagues to use novel methods to support these patients. RRT can also be used with this circuit. While more experience and data on this modality is needed, Oxy-RVAD ECLS should be considered in patients with severe RV dysfunction and associated refractory hypoxemia. (Figure Presented).

Dysphagia rehabilitation in post-COVID patients: Review of the literature

COVID-19 causes acute respiratory failure syndrome (SIRA), leading patients to require intubation in the intensive care unit (ICU). A common complication of this ventilatory support is dysphagia, which has a prevalence of up to 30%.This work aims to describe rehabilitation methods in patients with coronavirus infection based on levels of evidence according to the GRADE System, so a systematic review of the literature was carried out. The selected articles were divided into the following subtopics: diagnosis of dysphagia and rehabilitation in COVID patients. The gold standard for the diagnosis of dysphagia is the videofluoroscopic swallowing study (VFS). Fiberoptic Evaluation of Swallowing Assessment (FEES) has high sensitivity and specificity, although they have the disjunction of an aerosol-generating procedure (AGP);however, in a pandemic situation, the study of choice in the literature is VF. Once the diagnosis is made, it is necessary to initiate rehabilitation as soon as possible, even from hospitalization in patients who have hemodynamic stability to prevent long-term effects and promote normal swallowing even before discharge. In patients with COVID-19 infection dysphagia, the risk-benefit of assessment tools and therapy used for diagnosis should be decided to help to maintain social distancing. It becomes imperative to carry out clinical studies with high levels of evidence that allow us to generate Clinical Practice Guides for the benefit of our patients.Copyright © 2021 Sociedad Medica del Hospital General de Mexico. Published by Permanyer.

Use of Novel Oxygenated Right Ventricular Assist Device Hybrid ECLS for Adolescents with Refractory Hypoxemic Respiratory Failure due to Covid-19 Pneumonia

Objective: To describe institutional experience using Oxygenated Right Ventricular Assist Device Oxy-RVAD) Hybrid ECLS for adolescents with respiratory failure due to SARS-CoV-2 pneumonia. Method(s): Between September and December 2021, 44 Covid-19+ patients were admitted to our regional Pediatric Intensive Care Unit (PICU) including 4 adolescents who required Extracorporeal life support (ECLS) due to refractory hypoxemia. Two patients were initially cannulated onto Veno-Venous (VV) ECLS and converted to Oxy-RVAD ECLS due to refractory hypoxemia;the others were cannulated directly onto Oxy-RVAD ECLS. Two patients had observed right ventricular dysfunction (RV) or failure on echocardiography. Cannulations were performed in the cardiac catheterization suite by an interventional cardiologist using percutaneous technique under fluoroscopy. Circuit construction was varied and included the use of a dedicated RVAD cannula or standard cannula used for VA/VV ECLS. All patients were connected to CardiohelpTM systems with built-in centrifugal pumps and oxygenators. Result(s): Two patients were initially placed on VV-ECLS and converted to Oxy-RVAD ECLS days into their course due to severe, refractory hypoxemia with one having improvement in hypoxemia after the conversion. Two patients were cannulated directly to Oxy-RVAD ECLS support. Two patients received renal replacement therapy (RRT) without complications, the others did not have indications for renal support. Two patients underwent tracheostomy on ECMO though none were able to separate from mechanical ventilation. Three patients survived to discharge. No incidents of circuit air or clotting were noted. The patient with the longest ECLS run required one circuit change and was the only patient to develop a superinfection: a successfully-treated fungal infection. All patients were mobilized on ECLS to sitting in a chair;one was able to ambulate. Conclusion(s): Oxy-RVAD hybrid ECLS can be used to effectively support adolescents with severe respiratory disease from conditions associated with RV dysfunction. Pediatric providers can collaborate with adult-focused colleagues to use novel methods to support these patients. RRT can also be used with this circuit. While more experience and data on this modality is needed, Oxy-RVAD ECLS should be considered in patients with severe RV dysfunction and associated refractory hypoxemia.

Life-threatening Coagulation Disorders

The article discusses the task of radiologic technologists to know clotting disorders and image them best. Topics covered include the various symptoms and blood clots of patients with thrombotic disorders, and medical imaging's beneficial indication of the severity and blood clots' location in the patient's circulatory system, and support for accurate diagnosis and appropriate treatment. Also noted is the boost for positive patient outcomes when the health care team works together.

Right heart catherisation - a virtual reality

Introduction: Right heart catheterisation (RHC) is the gold standard for assessing patients with pulmonary hypertension. Doctors require training in this procedure in a safe and friendly environment with minimal risk to patients. Due to the Covid pandemic, formal RHC teaching workshops were cancelled in our country, so we sought to develop a Virtual Reality Right Heart Catheterisation (VRRHC) training program to fulfil this area of need without the need for face to face contact. The aim was to improve training, competency and confidence in this technique with improved diagnostic skills and reduction of procedural errors. Method(s): We approached a health technology company to design a VRRHC training module based on our current RHC simulation workshops. Phase 1 required virtual insertion of RHC via the right internal jugular vein using micro-puncture, double Seldinger technique under ultrasound guidance, followed by insertion of the RHC to the right atrium, right ventricle and pulmonary artery with pulmonary artery occlusion using real time pressure tracings and fluoroscopy. Thermodilution cardiac outputs and chamber saturations were also performed. The proprietary platform technology was delivered via a laptop and VR headset. Clinicians perform the VRRHC with imaging, monitoring and haptic feedback with the collection of real time performance tracking allowing user data (e.g. failed steps and proficiency scores) to be captured and subsequently visualised in the learning management system. We collected analytics and data on user engagement, experience and retention, targeted learning outcomes and learning curve, reduction in operating costs, reduction in procedure times due to higher proficiency, early diagnosis of pulmonary hypertension, reduced complications, improved interpretation and diagnosis. Result(s): The program was launched in October 2021. Preliminary data shows a learning curve is associated with both using VR (10-15 minutes) and the RHC procedure itself. Initial time to completion of the RHC was 30-40 mins, reducing to 20-30 minutes with experience and 15 minutes in experts. Completion rates increase with experience from 40-50% to 100% and error rates reduce with frequency of completion. Conclusion(s): A Virtual Reality Right Heart Catheter training program is safe, feasible and non-invasive. Increased experience results in increased completion rates, reduced procedure time and reduced errors. Using this program will potentially have beneficial effects on doctor training, outcomes, patient safety and health economics with no risk to a real patient. VRRHC images VRRHC hardware and utilisation.

Bilateral optic neuritis and myocarditis after the first dose of COVID-19 vaccine

Since the introduction of COVID-19 vaccine, various adverse events have been reported including injection site pain, fatigue, headaches, and myocarditis. Cranial neuropathies and optic neuritis, have been also rarely reported, however, the significance of these autoimmune manifestations after the administration of COVID-19 vaccine remain controversial. In this report we present a case of myocarditis and bilateral optic neuritis that occurred in a young healthy male patient after the administration of first dose of mRNA-1273 vaccine (Moderna).Copyright © 2022 The Author(s)

The Importance of Simulation in Vascular Training: A Literature Review

Funding: None. Synopsis: Once a subspecialty of general surgery, vascular surgery has transitioned to an entity with its own training paradigms and board certification. Part of this transition is due to many advances in technology, devices, and techniques. The management of vascular pathology that was at one time relegated to open procedures has now shifted to a field where endovascular options can be performed. These advances come with the concern of training competent vascular surgeons who are already under stringent duty hours restrictions, deal with heightened scrutiny associated with patient safety, and recently have had their operative volumes decreased due to COVID-19-related cancellations and shut downs. Simulation has been offered as a possible means to mitigate these limitations and shift the learning curve to competency. Despite this, little is known regarding the efficacy and best practices of incorporating simulation into vascular training. Method(s): A literature review was performed of English language articles on the EBSCO database without publication date restrictions on vascular surgery simulation. Search terms included vascular surgery simulation, endovascular surgery simulation and vascular education simulation. Additional studies were found by searching reference lists of relevant articles. All study designs were included if they pertained to simulation for open vascular or endovascular procedures. Simulator fidelity, educational efficacy, validity of the simulator, transfer of skill, and cost and time effectiveness were assessed. With endovascular simulation we assessed the amount of handling error, procedure time, fluoroscopy time, and the amount of contrast used. Result(s): Using these methods, twenty-two articles were identified. In regards to simulation used for open procedures in vascular surgery, the analysis showed that the most important factors in determining efficacy were the involvement of expert level (attending) proctors and the use of high fidelity (cadaver) simulators. Other important determinants were the use of trainee-specific models and the employment of specific learning objectives. The use of virtual endovascular simulators in enhancing trainee competence is supported by better quality data in the literature. Specifically measured and proven outcomes are a decrease in catheter handling errors, a reduction in both procedure and fluoroscopy time, and a diminished volume of contrast used. Endovascular simulators also allowed for reliable and consistent assessment of operator performance and showed a good transfer of skill to actual cases. Conclusion(s): Simulation is an important tool for both the assessment and training of vascular residents. The use of expert proctors, appropriate simulators, and well-designed curricula are the keys to success. Further studies connecting simulation training to patient-centered outcomes are still needed to define the true potential of these tools and methods. Institution: Lousiana State University HSC, New Orleans, LACopyright © 2022

Polytrauma patient with lateral thoracic spondyloptosis: case report and literature review

Background: Spondyloptosis is caused by high force trauma. The vast majority of cases occur in the sagittal plane and at transition points where ridged sections meet more flexible regions. Lateral thoracic spondyloptosis is extremely rare and there is no current consensus on the optimal treatment plan. Case Description: Here we present a case of a previously physically healthy 24-year-old polytrauma patient after he was struck as a pedestrian by a motor vehicle. Of note the patient was found to have lateral spondyloptosis between T9-10 with complete spinal cord transection. The patient also sustained multi-ligamentous left knee injury, pelvic fractures, open comminuted left tibia and fibular fracture, lacerated liver, bilateral renal lacerations, ischemic bowel, and an aortic arch pseudoaneurysm. Conclusion(s): Lateral thoracic spondyloptosis is a devastating injury with an extreme rate of persistent neurologic deficits. There is no unanimously accepted treatment because of the rarity if the injury and the poor outcomes that patients face. Additionally, patients who experience high level trauma often develop severe psychiatric illness, and the importance of identifying risk factors and implementing care early may improve patient outcomes.Copyright © AME Medical Journal.

Outcome of Tunneled Cuffed Catheter as Hemodialysis Access;a Single Centre Experience in a Tertiary Care Centre in Eastern India

Introduction: Although AVFs are preferred vascular access for hemodialysis, tunneled cuffed catheters(TCC) are increasingly being used as dialysis access in certain clinical situations such as in AVF failure or lack of suitable vessels for AVF creation or bridge to living donor transplant. Aim and objective of this study was to study the characteristics of the population having benefited from tunneled cuffed catheters, to identify the different indications as well as the complications secondary to tunneled cuffed catheters in hemodialysis patients and to determine the catheter and patient survival rate and the factors associated with complications and survival. Method(s): This was an retrospective Observational study done after institutional ethics committee approval. All data was captured using standard proforma. The data was tabulated using MS excel and all results projected in form of bar graphs, pie charts, histograms or tables. Kaplan- meier analysis was used for survival. All patients included in the study consented for the procedure as well as collection of data. 527 TCC placement were done in 498 patients by nephrologists without fluoroscopy in a percutaneous fashion between jan 2021 to march 2022. Minimum follow up was 12 months. 37 patients lost to follow up. Result(s): 316 (68.5%) were males and mean age was 48.3+/-12.6 years. Staggered tip MAHURKAR MaxidTM Covidien, was used in every patient. Most common native kidney disease was cresentic GN 176(38.1%). Most common Site of TCC was right internal jugular 88.9%(441/496), followed by left internal jugular 10.48%(52/496), femoral TCC done in 0.6%. Mean blood flow achieved was 311+/- 32ml/min. Most common indication of TCC placement was starting of HD after 1/2 temporary access- 162(32.66%), followed by awaiting Maturation of autogenous AVF 66 (13.3%) and awaiting living-related transplantation 54(10.88%). Total catheter related infective episodes (CRBSI) were 229 (1.07 episodes/1000catheter days),Exit site infection was in 57 cases (0.26 /1000 catheter days), Tunnel infection was in 51(0.19/1000 catheter days), Infective endocarditis was seen in 3 cases. Catheter loss due to CRBSI was 23 (12.16%). Most common organism was Enterococci (29.7%), followed by s.aureus (24.32%). Most common immediate complication was tunnel bleeding (5.9% ), followed by improper tip position 4.68%. Late complications due to TCC thrombosis/ fibrin sheath was 74(15.07%). Recanalisation with urokinase was successful in 36.84%. Central venous stenosis was in 26 cases. successful recanalisation after central venoplasty was 16/19 (84.21%). Mean catheter survival was 201.9 +/- 114.9 days (3day to 12 months). Catheter survival at the end of 3 months was 75.76%, at 6 months 63.4%, at 12months 32.17%. Patient survival at 6 months was 86.7%, at 12 months- 77.5%. Most common cause of death was unrelated to TCC - cardiovascular cause (77.6%). Direct TCC related death was in 5 cases. Most common cause of catheter drop out was patient death (33.03%), followed by maturation of AVF (22.82%), catheter thrombosis/fibrin sheath (22.2%). [Formula presented] Conclusion(s): Though AVF is the best access, for late unplanned HD initiation in many CKD patients, TCC insertion becomes next best option. In access crisis patients, TCC may remain one feasible option for bridge to available live donor transplant. With strict asepsis protocol and technical aptitude TCC placement is safe with few side effects. No conflict of interestCopyright © 2023

An audit of patient radiation doses in interventional radiology at a South African hospital.

Background: Interventional radiology (IR) is becoming more relevant in patient care and is associated with increased patient radiation exposure and radiation-induced adverse effects. Diagnostic reference levels (DRLs) are crucial for radiation control. There is a paucity of published DRLs for IR in South Africa and sub-Saharan Africa. Objectives: This study aimed to determine local DRLs for fluoroscopically-guided IR procedures and compare the achieved DRLs with published local and international DRLs. Method: Retrospective, descriptive, single-centre study. Kerma air product (KAP), reference point air kerma (Ka,r) and fluoroscopy time (FT) were collected for patients (12 years and older) who underwent IR procedures at a university hospital from 01 January 2019 to 31 December 2019. The 75th percentile of the distribution of each dose parameter (KAP, Ka,r and FT) per procedure was calculated and taken as the local diagnostic reference levels (LDRL). The established LDRLs were compared to published DRLs. Results: A total of 564 cases were evaluated. The 13 most frequent procedures (with 15 or more cases) represented 86.1% (487/564). Percutaneous transhepatic biliary drainage was the most common procedure (n = 146, 25.9%). Diagnostic cerebral angiogram DRLs exceeded the published DRL data ranges for all parameters (DRL 209.3), and interventional cerebral angiogram exceeded published ranges (DRL 275). Uterine artery embolisation (UAE) exceeded these ranges for KAP and Ka,r. (KAP-954.9 Gy/cm2, Ka,r-2640.8 mGy). Conclusion: The LDRLs for diagnostic cerebral angiogram, interventional cerebral angiogram and UAE exceeded published international DRL ranges. These procedures require radiation optimisation as recommended by the International Commission on Radiological Protection (ICRP). Contribution: In addition to informing radiation protection practices at the level of the institution, the established LDRLs contribute towards Regional and National DRLs.

Computed tomography fluoroscopy-guided percutaneous biopsy of pulmonary nodules ≤ 10 mm: retrospective analysis of procedures performed during the COVID-19 pandemic.

Objective: To evaluate the diagnostic performance of computed tomography (CT) fluoroscopy-guided percutaneous transthoracic needle biopsy (PTNB) in pulmonary nodules ≤ 10 mm during the coronavirus disease 2019 pandemic. Materials and Methods: Between January 1, 2020 and April 30, 2022, a total of 359 CT fluoroscopy-guided PTNBs were performed at an interventional radiology center. Lung lesions measured between 2 mm and 108 mm. Of the 359 PTNBs, 27 (7.5%) were performed with an 18G core needle on nodules ≤ 10 mm in diameter. Results: Among the 27 biopsies performed on nodules ≤ 10 mm, the lesions measured < 5 mm in four and 5-10 mm in 23. The sensitivity and overall diagnostic accuracy of PTNB were 100% and 92.3%, respectively. The mean dose of ionizing radiation during PTNB was 581.33 mGy*cm (range, 303-1,129 mGy*cm), and the mean biopsy procedure time was 6.6 min (range, 2-12 min). There were no major postprocedural complications. Conclusion: CT fluoroscopy-guided PTNB appears to provide a high diagnostic yield with low complication rates.

Potential Cardiac Tamponade Development Secondary to SARS-CoV-2 Infection

Upon initial discovery in late 2019, severe acute respiratory syndrome coronavirus 2, SARS-CoV-2, has managed to spread across the planet. A plethora of symptoms affecting multiple organ systems have been described, with the most common being nonspecific upper respiratory symptoms: cough, dyspnea, and wheezing. However, the cardiovascular system is also at risk following COVID-19 infection. Numerous cardiovascular complications have been reported by physicians globally, in particular cardiac tamponade Physicians must hold a high index of suspicion in identifying and treating patients with cardiac tamponade who may have contracted the novel coronavirus. This review will describe the current epidemiology and pathophysiology of SARS-CoV-2 and cardiac tamponade, highlighting their clinical course progression and the implications it may have for the severity of both illnesses. The paper will also review published case reports of cardiac tamponade, clinical presentation, and treatment of this complication, as well as the disease as a whole. © 2022 Elsevier Inc.

Outcome of emergency transvenous cardiac pacing placement by echocardiography guidance in non-cardiac centre

Background: Temporary transvenous cardiac pacing (TTVCP) is crucial and lifesaving procedure for hemodynamically unstable bradyarrhythmia. TTVCP placement under fluoroscopy guidance is considered the "gold-standard". However, its use is limited by equipment availability. During the COVID-19 pandemic, access to operation-theatre with fluoroscopy service is severely restricted due to delay in confirming patient COVID-19 status (COVID19 PCR 6 h, GeneXpert 2 h). With this limitation, physicians rely on echocardiography guided placement of TTVCP for unstable emergent cases. The aim of the study is to describe and determine outcome of temporary transvenous cardiac pacing placement by echocardiography guidance. Methodology: A retrospective analysis was carried out on all patients who underwent TTVCP in Hospital Sungai Buloh and Hospital Selayang from March 2020 until March 2022. All TTVCP were inserted by cardiology fellow. A bipolar electrode catheter was inserted in the jugular vein with vascular ultrasound guidance and placed in the right ventricular apex by means of echocardiography or fluoroscopy. Physicians chose the method of TTVCP taking into account their own experience and patient's clinical condition. All echocardiography guided TTVCP placement underwent formal readjustment under fluoroscopy once patient COVID-19 status was confirmed. Baseline characteristics and outcome were compared between two groups (echocardiography-guided and fluoroscopy-guided). Result(s): Total of 18 patients underwent TTVCP: 9 echo-guided and 9 fluoro-guided TTVCP placement. Patients with echo-guided placement were significantly more hypotensive and higher ionotropic support compared to fluoro-guided at baseline. The indication-to-pacing time (elapse of time from the cardiologist decision for TTVCP implantation to the time of transvenous pacing activation) was significantly shorter in the echo-guided group compared to fluoro-guided group [70 +/- 15 vs 210 +/- 120 min, p < 0.00001]. There was a slightly higher pacing threshold in the echo-guided group compared to fluoro-guided group [0.8 +/- 0.3 vs 0.5 +/- 0.2 p = 0.18]. There were no significant difference in complications such as TTVCP death, infection, sepsis, hematoma and ventricular arrhythmia. Conclusion(s): Temporary transvenous cardiac pacing implantation under echocardiography guidance is a feasible and safe alternative in hemodynamically unstable bradyarrhythmia particularly during COVID-19 pandemic. Copyright © 2022

Office-Based Ureteral Stent Insertion Without Fluoroscopy under Minimal Sedation is Safe and Effective

Introduction &Objective: Acute renal colic due to obstructing stones has been a challenge for urologists to manage during the COVID-19 pandemic. Due to overwhelmed hospital resources, operating room (OR) time and staff became scarce, resulting in prolonged pain and suffering for patients. Early during the pandemic, we instituted an office-based ureteral stent placement protocol to relieve immediate discomfort. Later with less constrained OR availability, we extended this protocol to patients undergoing chronic stent changes. Method(s): Patients who presented with severe renal colic due to obstructing stones were offered immediate office-based ureteral stent placement under minimal sedation. Patients filled a prescription of diazepam 10mg and were brought to the procedure suite 2 hours later. Intramuscular ketorolac 15mg was given and 2% lidocaine lubricant jelly was inserted per urethra. Flexible cystoscopy was performed with a standard 16Fr scope, and the stent was placed through the cystoscope. For the first two cases, a 0.038" hybrid wire and 4.8fr stent were used while subsequently, a 0.035" stiff hydrophilic nitinol wire and 4.5fr stent were used. No intraoperative fluoroscopy was used. After stent placement, KUB X-Ray was done to confirm stent placement. Result(s): Seven patients (4 females, 3 males) with a mean age of 62.5 years and a mean BMI of 31.3 underwent an office-based procedure. Five stent insertions were done for obstructing ureteral stone (unilateral = 4, Bilateral = 1) and 2 stent changes for ureteral stricture and ureteral obstruction due to fibroids. In most cases, it was clear when the wire had gone past the stone, as there was immediate efflux of urine into the bladder. The efficiency of the procedure was greatly increased by changing the wire and stent size. Stent placement failed in one case due to overfilling of the bladder causing acute angulation of the ureteral orifice. The stent was later inserted under general anesthesia. Conclusion(s): Office-based ureteral stent insertion and exchange are safe and effective even in the absence of fluoroscopy. Further studies are needed to investigate predictors of success of office-based stent insertion, along with cost analysis to expand its use routinely.

Transiting Ureteric Stent Change under General Anaesthesia in Major Operation Theatre to a Procedure under Local Anaesthesia in Ambulatory Endoscopy Suite

Introduction &Objective: Patients with long term ureteric stents for urinary diversion need regular changes, done at intervals appropriate for their condition, type of stent and adjusted to stent encrustation risks. This is usually done under General Anaesthesia in the operating room. We present our series of patients on ureteric stents with change of stents done under local anaesthesia in the endoscopy suite as an outpatient day procedure. Method(s): Since July 2021, we started a stent change service for our patients on long term ureteric stents done solely by Urologists in the outpatient day procedure setting under Local anaesthesia. This is done in the outpatient endoscopy suite away from the operating theatre, with flexible cystoscopy aided by fluoroscopy. We review our series of ureteric stent changes including indications and technical success rate of stent change. Result(s): 56 patients underwent stent change under local anaesthetic from 7th July 2021 to 16th Feb 2022, with mean age of 75 years old (range 55 to 97). 24(42%) were male and 32(57%) female. 9 patients had bilateral stents changed (16%), with the rest unilateral. Etiology wise, 34 (61%) had strictures, 13 (23%) had stones, and 9 (16%) had extraluminal compression. Mean duration from the last stent change was 4.6 months (SD = 1.38) based on clinical condition and stent type. 54 (96%) of patients had successful stent changes. The two patients with unsuccessful stent changes had failed retrograde wire access, one with tight extraluminal compression and the other with severe stent encrustation. Advantages of the new service for the patients include avoiding risks of sedation or general anaesthesia, and procedure performed as day surgery with decreased duration of hospital stay, particularly in this time of COVID-19 pandemic. From a resource point of view, this has freed up operating theatre space and anaesthetist manpower to focus on Urological procedures needing general anaesthesia, decreasing waiting time for higher acuity cases. Conclusion(s): Moving flexible cystoscopy guided ureteric stent change from major operation theatre under general anaesthesia to an ambulatory endoscopy center setting under local anaesthesia is a feasible and safe option for patients with long-term ureteric stents. It avoids risk of general anaesthesia, is potentially cost saving and conserves hospital resources.

Ambulatory Tubeless Supine Mini-PCNL under Spinal Anaesthesia for Stones Size 1.5-3 cm: A Novel Approach in the COVID-19 Era for Minimising Risk of Contagion

Introduction &Objective: In the ongoing Covid-19 era where physical distancing is utmost important, we assessed the feasibility of ambulatory tubeless supine mini-PCNL under spinal anaesthesia for stone size between 1.5 - 3 cm to minimise hospitalisation. Method(s): Between June 2020 to August 2021, total 284 patients underwent PCNL out of which 122 underwent ambulatory tubeless mini-PCNL. The inclusion criteria were those consented for study, size of the stone 1.5 - 3 cm, pre-operative Covid-19 negative test (CT-chest and RT-PCR). Those excluded were with solitary kidney, morbidly obese, active UTI, congenital abnormalities. Patient's demographics, peri-operative parameters, stone free rate, blood loss, pleural complications and requirements of auxiliary procedures were prospectively evaluated Results: All the patients underwent supine mini-PCNL in FOSML (Flank-Oblique Supine Modified Lithotomy) position through a single tract of size 14/16 Fr. In, 18 (15%) patients' additional tracts were made for inaccessible secondary stones. Holmium laser and pneumatic source of energy were used for fragmentation of stones. Supra 12th rib tracts were made in 23 (19%) patients while in remaining 99 (81%) had infra-costal tracts. Complete SFR (stone-free rate) was achieved in 112 (92%) under fluoroscopy and the remaining 10 (8%) needed auxiliary procedure to render stone free. Average total operative time was 44 +/- 15 minutes and no nephrostomies were placed. All patients were discharged within 24 hours of operation with only 7 (6%) patients required readmission within 48 hours of discharge with hematuria and were managed conservatively. No other major complications occurred except for mild fever in few. Conclusion(s): Ambulatory supine tubeless mini-PCNL under spinal anaesthesia is safe and effective in this uncertain rapidly spreading COVID-19 era to minimise hospitalisation. It should be recommended whenever feasible, and it is easy to adapt to this newer approach especially for urologist already performing supine PCNL.

Trends in Urologic Cancer Surgical Volumes and Post-Operative Length of Stay during the COVID-19 Pandemic

Introduction &Objective: Single step dilation technique has been reported to be safe and effective. In contrast, other reports have shown that single step dilation may cause more trauma to the renal parenchyma than sequential dilation. Data on the use of this technique during pediatric PCNL in the literature are sparse. In this study, we aimed to compare the safety, efficacy and perioperative complications of single step versus serial tract dilation, using Alken metal telescopic dilators during pediatric PCNL. Method(s): Between April 2017 and May 2020, all children who were candidates for PCNL were enrolled in this prospective randomized study. Patients were randomized between the two treatment groups according to the dilation technique used. In group A. Alken telescopic metal dilation was employed, and in group B, single step dilation technique was performed. The primary outcomes were access time and dilation fluoroscopy time. The secondary outcomes were tract dilation time, operative time, stone free rate, complications rate, postoperative hospital stay, haemoglobin deficit, and need for blood transfusion. Result(s): There were no differences in demographic characteristics, operative duration, total fluoroscopy time and postoperative hospital stay between the two groups. Access was successfully obtained in all procedures. We did not encounter any difficulties in tract dilation in either technique. All of the procedures were performed through a single tract. Access time and dilation fluoroscopy time was statistically significantly shorter in group B compared to group A (p = 0.034 and 0.042, respectively). The overall complication rate was 21.4% in all patients (25.7% in group A and 17.1% in group B). There were no major complications (modified Clavien IV or higher) in the study population. The mean haemoglobin deficit before and after surgery was not significantly different between the two groups (p = 0.517). There overall stone-free rates at one month was similar for the two groups (33/35, 94.3%). Conclusion(s): Compared with serial metal track dilation, single step dilation technique showed comparable safety and efficacy during pediatric PCNL, with significantly reduced access time and dilation fluoroscopy time.

"Tool-in-Lesion" Accuracy of Galaxy System: Robotic-Assisted, Electromagnetic Navigation Bronchoscopy with Integrated Tool-in-Lesion-Tomosynthesis Technology: The Match Study

SESSION TITLE: Late Breaking Procedures Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: The Galaxy SystemTM (Noah Medical, San Carlos, CA) is a novel robotic endoluminal platform using electromagnetic navigation combined with integrated tomosynthesis technology and augmented fluoroscopy. It provides intraprocedural imaging to correct CT-to-body divergence and novel confirmation of tool-in-lesion. The primary aim of this study was to assess the tool-in-lesion accuracy of the robotic bronchoscope with integrated digital tomosynthesis and augmented fluoroscopy. METHOD(S): Over four separate days, four operators (the authors) conducted the experiment using four pigs. Each physician performed between 4 and 6 nodule biopsies for 20 lung nodule biopsies. A porcine model (S. s. domesticus) was utilized. Each pig was anesthetized with volatile gas and underwent tracheostomy with an 8.5 endotracheal tube and bilateral chest tube thoracostomy. Anesthesia was monitored by a veterinarian with invasive hemodynamic monitoring. Under CT fluoroscopic guidance, simulated lung nodules were created by percutaneous injection of a gelatinous agar solution containing purple dye and radiopaque material into the lung periphery. A CT was then performed for pre-procedure planning. Using Galaxy's "Tool in Lesion TOMO+" with augmented fluoroscopy, the physician navigated to the lung nodules and a tool (needle) was placed into the lesion. Tool in lesion was defined by the needle in or tangential to the lesion determined by CBCT. Center strike was defined as the needle in the middle third in three orthogonal angles (axial, sagittal, and coronal) on CBCT. RESULT(S): Lung nodules' average size was 16.3+/-0.97 mm and were predominantly in the lower lobes (65%). Only 15% (3/20) had a bronchus sign and the average distance to the pleura was 6.88+/-5.5 mm. All four operators successfully navigated to all (100%) of the lesions in an average of 3 minutes and 39 seconds. The median number of tomosynthesis sweeps was 3 and augmented fluoroscopy was utilized in most cases (17/20 or 85%). Tool in lesion after final tomography sweep was 100% (20/20). Biopsy yielding purple pigmentation on microscopic or gross examination was also 100% (20/20). Center strike rate was 60%. CONCLUSION(S): The Galaxy SystemTM demonstrated successful digital tomography confirmed tool in lesion success in 100% (20/20) of lesions as confirmed by CBCT. Successful biopsy was achieved in 100% of lesions as confirmed by intralesional pigment acquisition. CLINICAL IMPLICATIONS: The combination of robotic navigation, catheter maneuverability and real-time correction for CT body divergence capitalizes on the strengths of all three technologies to improve diagnosis. Additional clinical trials are warranted to see if high success rates can be reproduced in patients. 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