Safety and efficacy of percutaneous nephrolithotomy for the treatment of paediatric urolithiasis

INTRODUCTION

Paediatric percutaneous nephrolithotomy (PCNL) has revolutionised the treatment of paediatric nephrolithiasis. Paediatric PCNL has been performed using both adult and paediatric instruments. Stone clearance rates and complications vary according to the technique used and surgeon experience. We present our experience with PCNL using adult instruments and a 28Fr access tract for large renal calculi in children under 18 years.

METHODS

All patients undergoing PCNL at our institution between 2000 and 2009 were reviewed. Demographics, surgical details and post-operative follow-up information were obtained to identify stone clearance rates and complications.

RESULTS

PCNL was performed in 32 renal units in 31 patients (mean age: 10.8 years). The mean stone diameter was 19mm (range: 5–40mm). Twenty-six cases required single puncture and six required multiple tracts. Overall, 11 staghorn stones, 10 multiple calyceal stones and 11 single stones were treated. Twenty-seven patients (84%) were completely stone free following initial PCNL. Two cases had extracorporeal shock wave lithotripsy for residual fragments, giving an overall stone free rate of 91% following treatment. There was no significant bleeding or sepsis encountered either during the operation or in the post-operative setting. No patient required or received a blood transfusion.

CONCLUSIONS

Paediatric PCNL can be performed safely with minimal morbidity using adult instruments for large stone burden, enabling rapid and complete stone clearance.     

Outpatient tubeless percutaneous nephrolithotomy: the initial case series

Introduction:

Percutaneous nephrolithotomy (PCNL) has traditionally been performed on an inpatient basis. To the best of our knowledge, this is the first report of tubeless PCNL on a completely outpatient basis. The purposes of this study were to assess the safety and efficacy of outpatient PCNL.

Methods:

We reviewed the initial consecutive outpatient tubeless PCNLs performed at our institution by a single surgeon. Patients were discharged home the day of surgery only after meeting strict discharge criteria. Preoperative, intraoperative and postoperative data were collected prospectively.

Results:

Outpatient tubeless PCNL was performed in 3 patients. The mean maximum stone diameter was 14 mm. The average hospital stay was 175 minutes. All 3 patients were discharged home in stable condition after meeting all of the inclusion criteria. There were no emergency room visits or hospital readmissions postoperatively. The mean follow-up period was 47 days. All stones were calcium oxalate and the stone free rate was 100%. There were no minor or major complications.

Conclusion:

In properly selected patients, outpatient tubeless PCNL is safe and effective. Our initial experience with outpatient PCNL has been favourable and warrants further investigation in a larger patient population.     

Contemporary practice of percutaneous nephrolithotomy: review of practice in a single region of the UK

INTRODUCTION

Most series of percutaneous nephrolithotomy (PCNL) from single specialised centres represent optimum results achievable and may not reflect outcomes of everyday practice. We analysed the practice in our region.

PATIENTS AND METHODS

Medical records of 178 patients undergoing PCNL in 2002 in 12 participating hospital trusts were retrospectively analysed.

RESULTS

Even outside the tertiary referral centres, there was a 6-fold difference between trusts in the frequency of PCNL. In 28% of cases, another stone-removing modality had been tried first. Failed renal puncture was a major cause of abandoning surgery (9%). An indication of the difficulty in obtaining complete stone clearance is that only 107 (60%) operation notes recorded complete clearance, while 75 (42%) patients required a subsequent procedure (13% a secondary PCNL). Use of supra 12th rib punctures was small (6%) as was the rate of ‘tube-less’ PCNL (4%). Some 22% had simultaneous ureteric stent insertion. Approximately 8% of cases required a blood transfusion. Thirty-eight patients (23%) had a proven infection (UTI) pre-operatively (> 10⁴ organisms; > 10 white blood cells) with almost all patients receiving antibiotics at anaesthesia induction. Postoperative sepsis rates (temperature > 38.5°C) were similar in those with and without a pre-operative UTI (18.4% versus 14.3%) and pre-operative antibiotics appeared to have little extra protective effect. Severe sepsis was rare with no patient requiring intensive care admission for this reason. Median length of stay postoperatively was 5 days.

CONCLUSIONS

These results present important figures to quote when counselling patients pre-operatively, albeit that the degree of difficulty (and hence the likelihood of problems) is identifiable from stone and anatomical configurations. In addition, the present data are a more accurate reflection of urinary stone surgery in non-tertiary, general urological practice.     

Role of Extracorporeal Shock Wave Lithotripsy in Management of Upper Ureteric Stones

Introduction

The treatment options for upper ureteric stones range from open surgeries to minimally invasive and non invasive techniques. Presently the two most frequently used options for upper ureteric calculi that require intervention are extracorporeal shock wave lithotripsy (ESWL) and ureterorenoscopy (URS) with contact lithotripsy applied by attaining endoscopic access to the calculi.

Ureteroscopy is more cost effective than shock wave lithotripsy for stone treatment: systematic review and meta-analysis

Introduction

A rising incidence of kidney stone disease has led to an increase in ureteroscopy (URS) and shock wave lithotripsy (SWL). Our aim was to compare the cost of URS and SWL for treatment of stones.

Methods

A systematic review and meta-analysis based on Cochrane and PRISMA standards was conducted for all studies reporting on comparative cost of treatment between URS and SWL. The cost calculation was based on factual data presented in the individual studies as reported by the authors. English language articles from January 2001 to December 2017 using Medline, PubMed, EMBASE, CINAHL, Cochrane library and Google Scholar were selected. Our study was registered with PROSPERO (International prospective register of systematic reviews)—registration number CRD 42017080350.

Results

A total of 12 studies involving 2012 patients (SWL-1243, URS-769) were included after initial identification and screening of 725 studies with further assessment of 27 papers. The mean stone size was 10 and 11 mm for SWL and URS, respectively, with stone location in the proximal ureter (n?=?8 studies), distal ureter (n?=?1), all locations in the ureter (n?=?1) and in the kidney (n?=?2). Stone free rates (84 vs. 60%) were favourable for URS compared to SWL (p?<?0.001). Complication rates (23 vs. 30%) were non-significantly in favor of SWL (p?=?0.11) whereas re-treatment rates (11 vs. 27%) were non-significantly in favor of URS (p?=?0.29). Mean overall cost was significantly lower for URS ($2801) compared to SWL ($3627) (p?=?0.03). The included studies had high risk of bias overall. On sub-analysis, URS was significantly cost-effective for both stones ?<?10 and ?≥?10 mm and for proximal ureteric stones.

Conclusion

There is limited evidence to suggest that URS is less expensive than SWL. However, due to lack of standardization, studies seem to be contradictory and further randomized studies are needed to address this issue.

     

Trends of ‘urolithiasis: interventions,simulation, and laser technology’ over the last 16 years (2000–2015) as published in the literature (PubMed): a systematic review from European section of Uro-technology (ESUT)

Purpose

To look at the bibliometric publication trends on ‘Urolithiasis’ and aspects of treatment and training associated with it over a period of 16 years from 2000 to 2015. To this end, we conducted this study to look at the publication trends associated with urolithiasis, including the use of simulation, laser technology, and all types of interventions for it.

Materials and methods

We performed a systematic review of the literature using PubMed over the last 16 years, from January 2000 to December 2015 for all published papers on ‘Urolithiasis’. While there were no language restrictions, English language articles and all non-English language papers with published English abstracts were also included. Case reports, animal and laboratory studies, and those studies that did not have a published abstract were excluded from our analysis. We also analyzed the data in two time periods, period-1 (2000–2007) and period-2 (2008–2015).

Results

During the last 16 years, a total of 5343 papers were published on ‘Urolithiasis’, including 4787 in English language and 556 in non-English language. This included papers on URS (n = 1200), PCNL (n = 1715), SWL (n = 887), open stone surgery (n = 87), laparoscopic stone surgery (n = 209), pyelolithotomy (n = 35), simulation in Endourology (n = 82), and use of laser for stone surgery (n = 406). When comparing the two time periods, during period 2, the change was +171% (p = 0.007), +279% (p < 0.001), and ?17% (p = 0.2) for URS, PCNL, and SWL, respectively. While there was a rise in laparoscopic surgery (+116%), it decreased for open stone surgery (?11%) and pyelolithotomy (?47%). A total of 82 papers have been published on simulation for stone surgery including 48 papers for URS (67% rise in period-2, p = 0.007), and 34 papers for PCNL (480% rise in period-2, p < 0.001). A rising trend for the use of laser was also seen in period 2 (increase of 126%, p < 0.02, from 124 papers to 281 papers).

Conclusions

Published papers on intervention for Urolithiasis have risen over the last 16 years. While there has been a steep rise of URS and minimally invasive PCNL techniques, SWL and open surgery have shown a slight decline over this period. A similar increase has also been seen for the use of simulation and lasers in Endourology.

     

Perceived Proficiency in Minimally Invasive Surgery Among Senior Ob/Gyn Residents

Background and Objectives:

To assess self-perceived proficiency in minimally invasive surgical procedures among fourth-year Ob/Gyn residents in the United States and to evaluate trends in self-perceived proficiencies by comparing the current survey to a similar survey distributed in 2001.

Methods:

A Web-based survey was sent out to all fourth-year residents in accredited obstetrics and gynecology programs in the United States. The residents completed the online survey regarding their perceived proficiency in performing minimally invasive procedures. These results were compared with the results from a similar survey performed in 2001. The residents were also asked about teaching methods and the importance of minimally invasive surgery training during residency.

Results:

We received responses from 248 senior residents. Of these, 65.1% thought emphasis on laparoscopic surgery training should be increased or greatly increased, and 97.1% thought laparoscopic skills were important for building a successful practice. Perceived proficiencies in advanced laparoscopic procedures, such as total laparoscopic hysterectomy and supracervical hysterectomy, were significantly higher compared with our results in 2001. Residents also seemed to feel more comfortable performing basic and advanced hysteroscopic procedures. Of respondents, 56.8% felt that a fellowship in minimally invasive surgery would be beneficial to them following graduation.

Conclusion:

Senior Ob/Gyn residents seem to feel more comfortable performing advanced laparoscopic procedures at graduation than they did 7 years ago. The majority feels that the emphasis on training in minimally invasive surgery should be increased.     

Combined endoscopic and laparoscopic approach to a gastroesophageal tumor

Background and Objectives:

Smooth muscle tumors of the stomach, especially when benign, are a common clinical entity and can represent a therapeutic challenge. Classically the removal of such a tumor requires open laparotomy. We sought to perform this surgery utilizing minimally invasive technology.

Methods:

We describe a minimally invasive technique combining laparoscopy with endoscopy to remove a submucosal leiomyoma at the gastroesophageal junction.

Results:

A 3.3-cm smooth muscle tumor of the gastroesophageal junction was removed completely and safely with the described procedure and thus saved the patient from requiring a laparotomy.

Conclusion:

Minimally invasive techniques can be used in combination to tackle difficult problems in general surgery leading to shorter hospital stays and improved patient satisfaction.     

Minimally Invasive Hysterectomy at a University Teaching Hospital

Background and Objectives:

To evaluate the feasibility of a minimally invasive approach for hysterectomy for benign disease at a university teaching hospital.

Methods:

Five hundred thirty-seven consecutive patients underwent hysterectomy for benign disease at Penn State Milton S. Hershey Medical Center in 2010. No cases were excluded. Minimally invasive approaches included total vaginal hysterectomy, laparoscopy-assisted vaginal hysterectomy, total laparoscopic hysterectomy, and laparoscopic supracervical hysterectomy. All surgeries were completed with the resident as the primary surgeon or first assistant.

Results:

The median age was 45 years, the median body mass index was 30 kg/m², the median estimated uterine size was 11 cm, and 22% of patients had a prior cesarean section. Of the 537 hysterectomies, 526 (98%) were started with a minimally invasive approach and 517 (96%) were completed in that fashion; thus only 9 conversions (2%) were required. Of the cases in which a minimally invasive approach was used, 16% were vaginal and 84% were laparoscopic. The median operative time was 86 minutes, the median blood loss was 95 mL, the median hospital stay was 1 day, and the median uterine weight was 199 g. For the minimally invasive hysterectomies, there was a 5% major complication rate.

Conclusion:

Our residency training institution completed 96% of 537 hysterectomies using a minimally invasive approach while maintaining an acceptable operative time, amount of blood loss, hospital stay, and complication rate. Thus our study supports that a minimally invasive approach for hysterectomy for benign disease at an academic resident teaching facility is feasible.     

Minimally invasive cardiac surgery for removal of the greater saphenous vein

Objective

To determine if saphenous vein required for coronary bypass could be quickly, easily and safely removed with a minimally invasive technique.

Design

A consecutive series.

Setting

A university centre.

Material and Methods

In cadavers, a standard mediastinoscope was used to remove segments of the greater saphenous vein. Thigh segments, superior leg segments and ankle segments were removed. Fifteen minutes were allowed for removal of a segment.

Results

Segments of vein 15 to 17 cm long could be removed. One segment could not be removed within 15 minutes. Thigh segments were easy to remove, calf segments were the most difficult. There were no avulsed side branches. All incisions were less than 5 cm long.

Conclusions

Saphenous vein can be harvested quickly and safely by a minimally invasive method. Lower extremity complications may be reduced and long-term patency improved with this in-situ technique of vein removal.     

What do Patients Think About Minimally Invasive Total Hip Arthroplasty?

INTRODUCTION

The introduction of minimally invasive techniques for hip replacement into clinical practice has been driven by the perceived benefits of smaller incisions, shorter in-patient stays and faster rehabilitation. This may be at the cost of higher complication rates. The purpose of this study was to explore the opinions and priorities of patients in relation to these techniques.

PATIENTS AND METHODS

A cross-sectional survey was performed in an elective out-patient setting.

RESULTS

Of 44 patients approached, 36 agreed to participate. From most important to least important, patients rated the following items in order: ‘rate of complications’; ‘implant survival’; ‘length of rehabilitation’; ‘time in hospital’ and ‘length of scar’. Despite this, 21 of 35 (60%) responders stated they would accept the offer of minimally invasive techniques if made.

CONCLUSIONS

Patients appear to prioritise long-term outcomes and low complication rates over the shorter scars, reduced in-patient stay and reduced rehabilitation times potentially offered by minimally invasive hip arthroplasty. Despite this, the technique remains popular among patients.     

Hand-Assist Laparoscopic Surgery for the Gynecologic Surgeon

Background:

Hand assist laparoscopy (HALS) is a minimally invasive technique which allows for the placement of the surgeon''s non-dominant hand through a hand-port device while maintaining pneumoperitoneum. There is no standardization of this procedure and it is rarely used in gynecology.

Methods:

The multidisciplinary team of authors, with experience in minimally invasive pelvic surgery, has developed a practical approach performing HALS over several years. Here we present our technique.

Conclusions:

There are several roles for HALS in the world of gynecology and pelvic surgery. Further experience will help improve upon a standard technique.     

Minimally Invasive Surgery in Gastrointestinal Cancer: Benefits,Challenges, and Solutions for Underutilization

Background and Objectives:

After the widespread application of minimally invasive surgery for benign diseases and given its proven safety and efficacy, minimally invasive surgery for gastrointestinal cancer has gained substantial attention in the past several years. Despite the large number of publications on the topic and level I evidence to support its use in colon cancer, minimally invasive surgery for most gastrointestinal malignancies is still underused.

Methods:

We explore some of the challenges that face the fusion of minimally invasive surgery technology in the management of gastrointestinal malignancies and propose solutions that may help increase the utilization in the future. These solutions are based on extensive literature review, observation of current trends and practices in this field, and discussion made with experts in the field.

Results:

We propose 4 different solutions to increase the use of minimally invasive surgery in the treatment of gastrointestinal malignancies: collaboration between surgical oncologists/hepatopancreatobiliary surgeons and minimally invasive surgeons at the same institution; a single surgeon performing 2 fellowships in surgical oncology/hepatopancreatobiliary surgery and minimally invasive surgery; establishing centers of excellence in minimally invasive gastrointestinal cancer management; and finally, using robotic technology to help with complex laparoscopic skills.

Conclusions:

Multiple studies have confirmed the utility of minimally invasive surgery techniques in dealing with patients with gastrointestinal malignancies. However, training continues to be the most important challenge that faces the use of minimally invasive surgery in the management of gastrointestinal malignancy; implementation of our proposed solutions may help increase the rate of adoption in the future.     

Impact of minimally invasive surgery in the treatment of esophageal cancer

Background

Surgical treatment of esophageal cancer is associated to a high morbidity and mortality rate. The open transthoracic or transhiatal esophagectomy are considerably invasive procedures and have been associated to high rates of complications and operative mortality. In this way, minimally invasive esophageal surgery has been suggested as an alternative to the classic procedures because would produce improvement in clinical longterm postoperative outcomes.

Aim

To assess survival, mortality and morbidity results of esophagectomy due to esophageal cancer submitted to minimally invasive techniques and compare them to results published in international literature.

Method

An observational, prospective study. Between 2003 and 2012, 69 patients were submitted to a minimally invasive esophagectomy due to cancer. It was recorded postoperative morbidity and mortality according to the Clavien-Dindo classification. The survival rate was analyzed with the Kaplan-Meier method. The number of lymph nodes obtained during the lymph node dissection, as an index of the quality of the surgical technique, was analysed.

Results

63.7% of patients had minor complications (type I-II Clavien Dindo), while nine (13%) required surgical re-exploration. The most common postoperative complication corresponded to leak of the cervical anastomosis seen in 44 (63.7%) patients but without clinical repercusion, only two of them required reoperation. The mortality rate was 4.34%, and reoperation was necessary in nine (13%) cases. The average survival time was 22.59±25.38 months, with the probability of a 3-year survival rate estimated at 30%. The number of resected lymph nodes was 17.17±9.62.

Conclusion

Minimally invasive techniques have lower morbidity and mortality rate, very satisfactory lymphnodes resection and similar long term outcomes in term of quality of life and survival compared to results observed after open surgery.     

‘Nephrostomy-Free’ Percutaneous Nephrolithotomy: Experience in a UK District General Hospital

INTRODUCTION

Percutaneous nephrolithotomy (PCNL) is the first-line treatment for large and complex renal calculi. Accepted UK practice is to insert a nephrostomy tube at the end of the procedure to drain the kidney and reduce potential complications. ‘Tubeless’ or ‘nephrostomy-free’ PCNL has been advocated in selected patients as it is thought to reduce length of hospital stay, analgesia requirements and pain experienced. We present our outcomes of a consecutive series (n = 101) of ‘nephrostomy-free’ PCNLs compared to standard PCNL over a 4-year period.

PATIENTS AND METHODS

Between January 2004 and October 2006, we performed 55 standard (with nephrostomy tube) PCNLs (Group 1). From October 2006 onwards, we changed our technique and have performed 46 consecutive ‘nephrostomy-free’ PCNLs (JJ stent inserted), independent of patient and stone factors (Group 2). We have compared the two groups in terms of length of hospital stay (LOS), analgesia requirements, transfusion rates, haemoglobin (Hb) decrease and immediate, early and late complications.

RESULTS

‘Nephrostomy-free’ PCNL significantly reduced the length of hospital stay (2.8 vs 5.1 days; P < 0.001), morphine-based analgesia requirements (23% no morphine required vs 2.8%; P < 0.001), transfusion rate (2.5% vs 7%; P < 0.01) and mean Hb decrease (1.89 g/dl vs 2.25 g/dl; P > 0.05). Overall, no patient experienced a serious complication. All attempted ‘nephrostomy-free’ PCNLs were completed (stone clearance 95%) and no patient needed an unplanned nephrostomy. Only 5% in Group 2 needed their ureteric JJ stent removing earlier than planned secondary to pain. Both groups were comparable in terms of immediate, early and late complications, though three patients in Group 1 developed chronic loin pain and one patient in the ‘nephrostomy-free’ group developed a delayed perirenal haematoma.

CONCLUSIONS

‘Nephrostomy-free’ percutaneous nephrolithotomy is a safe, effective and feasible procedure independent of patient and stone factors. It decreases the length of hospital stay, the pain experienced and the need for morphine-based analgesia; we feel it should be the standard of care for patients undergoing a PCNL.     

Laparoscopic Transhiatal Esophagectomy for Barrett's Esophagus with High Grade Dysplasia

Background:

A number of case reports have described the application of minimally invasive surgical techniques to accomplish esophagectomy. However, most reports have employed thoracoscopic or laparoscopic techniques to perform esophagectomy in addition to an “access” incision which often approaches a standard laparotomy or thoracotomy.

Case Report:

This report describes a total laparoscopic transhiatal esophagectomy in a 55 year old female with Barrett''s esophagus and high grade dysplasia.

Conclusions:

The patient had an uneventful recovery and was discharged home on the fourth day after a total laparoscopic esophagectomy. This report demonstrates the technical feasibility of this complex procedure by a minimally invasive approach.     

Robotic-Assisted Repair of Iatrogenic Ureteral Ligation Following Robotic-Assisted Hysterectomy

Background and Objectives:

Ureteral injuries, while rare, do occur during gynecologic procedures. The expansion of laparoscopic and robotic pelvic surgical procedures increases the risk of ureteral injury from these procedures and suggests a role for minimally invasive approaches to the delayed repair of ureteral injuries. We present, to our knowledge, the first case of delayed robotic-assisted ureteral deligation and ureterolysis following iatrogenic ureteral injury occurring during a robotic abdominal hysterectomy.

Methods:

We present a case report and review of the literature.

Results:

A 57-year-old female underwent a seemingly uncomplicated robotic-assisted laparoscopic total abdominal hysterectomy and bilateral oophorectomy for symptomatic fibroids. On postoperative day 8, she presented with persistent right flank pain. Imaging studies revealed high-grade ureteral obstruction consistent with suture ligation of the right ureter. She underwent successful robotic-assisted ureteral deligation and ureterolysis. Her postoperative course was unremarkable, and she was discharged home on postoperative day 1 from the deligation.

Conclusion:

Robotic-assisted management of complications from urologic or gynecologic surgery is technically feasible. This can potentially preserve the advantages to the patient that are being seen from the initial less-invasive surgery.     

Nephroureterectomy for transitional cell carcinoma - the value of pre-operative histology

INTRODUCTION

Nephroureterectomy with excision of a cuff of bladder remains the standard for managing upper tract transitional cell carcinoma (TCC). Increasing use of diagnostic upper tract endoscopy has underlined the importance of obtaining a pre-operative histological diagnosis in order to avoid under-treating high-grade or multifocal disease and over-treating low-grade disease, which could, in selected cases, be managed conservatively. We review nephroureterectomy at our institution over a 10-year period with particular reference to a pre-operative histological diagnosis.

PATIENTS AND METHODS

Nephroureterectomy was performed in 113 patients from February 1994 to February 2004. Of these cases, 58 were for upper tract TCC and 50 of these 58 had intravenous urography (IVU): 9 had only IVU, 28 had an additional CT scan, 5 had an additional ultrasonography and 8 had additional CT + ultrasonography for pre-operative work-up. Thirty-four of the 58 cases had retrograde pyelography. Nineteen (32.7%) of the 58 cases had a pre-operative ureteroscopy (URS) and biopsy; 14 of these had rigid URS for tumours in the lower (11) and middle (3) thirds of the ureter and 5 had flexible URS for pelvicalyceal tumours by an experienced endourologist. Thirty-one (53%) of the 58 tumours were within the pelvicalyceal system and 27 within the ureter (upper, 5; middle, 3; lower, 19). Forty-eight patients underwent a total nephroureterectomy: 40 had a two incision approach and 8 had an endoscopic resection of the lower ureter. Five of the 58 cases had a sub-total nephroureterectomy and 5 a laparoscopic nephroureterectomy with open excision of lower ureter.

RESULTS

Nineteen (32.7%) of the 58 patients had a pre-operative histological diagnosis – 17 G2pTa, 1 G1pTa, and 1 G2pT1. Fourteen (74%) biopsies matched the final postoperative histology, but 1 was down-staged, 3 up-staged and 1 up-graded compared to the original histology. Five (12.8%) of 39 patients without pre-operative histology had no TCC in the final surgical specimen: 4 (10.25%) had benign pathology such as capillary haemangioma, urothelial cysts and reactive urothelial changes while one had renal cell carcinoma (RCC).

CONCLUSIONS

This study underlines the importance of obtaining a pre-operative histological diagnosis in cases with presumed upper tract TCC. Failure to do so can result in unnecessary ablative surgery for benign disease. Such an approach can also help identify multifocality and grade of disease so that treatment of upper tract TCC can be tailored more appropriately with ablative surgery for high-grade or multifocal disease and conservative (endoscopic) therapy for low-grade disease in selected cases. Patients with suspected TCC of the upper tract should be managed at centres where facilities for the comprehensive evaluation of such tumours exist.     

Pulmonary Complications following Percutaneous Nephrolithotomy: A Prospective Study

Introduction

Pulmonary complications may occur in the post-operative period and are a significant cause of morbidity and mortality in patients undergoing anesthesia and surgery. Complication rates vary according to different procedures and different types of anesthesia and may be affected by the patient condition. The purpose of this study was to examine pulmonary complications following percutaneous nephrolithotomy (PCNL) and to search for associations between the pre- and intra-operative factors and the risk of post-operative pulmonary complications (PPC).

Patients and Methods

This was a prospective observational study of 100 consecutive adult patients who underwent PCNL surgery. We collected data of the patient, surgery and anesthesia and analyzed it to find correlations with PPC.

Results

Eight (8%) patients had PPC following PCNL, 7 patients had pneumothorax and 1 had atelectasis and pleural effusion. The latter patient died at post-operative day 24 due to respiratory failure. It was found that patients who had PCNL on the right kidney were at lower risk for PPC. In addition it was found that younger patients had a higher incidence of PPC.

Conclusions

Based on this study the most common type of post-operative complication following PCNL is pulmonary, with pneumothorax being the main complication. PPC may result in patient mortality. The side of the operation and the patient''s age might affect the risk of PPC.Key Words: Percutaneous nephrolithotomy, Anesthesia, Post-operative Pulmonary complications     

Outcomes of Minimally Invasive Myotomy for the Treatment of Achalasia in the Elderly

Background:

An increasing number of elderly patients diagnosed with achalasia are being referred for minimally invasive myotomy. Little data are available about the operative outcomes in this population. The objective of this study was to review our experience with this procedure in an elderly population.

Methods:

A retrospective review was performed of 51 consecutive patients, 65 years of age or older, diagnosed with achalasia who underwent a minimally invasive myotomy at our institution. Prior therapies, perioperative outcomes, and postoperative interventions were also analyzed.

Results:

Of the 51 patients, 28 (55%) had undergone prior endoscopic therapy, and 2 patients (7%) had a prior myotomy. Mean duration of symptoms was 10.9 years (range, 0.5 to 50). No perioperative mortality occurred, and the median hospital stay was 3 days. Two patients (3.8%) had complications, including a gastric mucosal injury and one atelectasia. Eleven patients (21%) required additional therapy postoperatively. Symptom improvement was described in all patients.

Conclusion:

Laparoscopic Heller myotomy can safely be performed in elderly patients, providing significant symptom relief. No evidence suggests that surgery should not be considered a first-line treatment. Advanced age does not appear to adversely affect outcomes of laparoscopic Heller myotomy.