Laparoscopic management of paratubal and paraovarian cysts.

OBJECTIVES: To define the proportion, methods of diagnosis, and a simplified laparoscopic technique for treating paratubal and paraovarian cysts. METHODS: We conducted a prospective cross-sectional study in the Gynecologic Endoscopy Unit of Assiut University Hospital in Assiut, Egypt in 1853 patients undergoing video-assisted laparoscopy. Transvaginal ultrasonography (TVS) was performed to detect paratubal or paraovarian cysts. Tubal shape and patency were evaluated with hysterosalpingography (HSG) in the infertile group. Diagnostic laparoscopy was performed to confirm the diagnosis of paratubal or paraovarian cysts. Small cysts were punctured and coagulated, and larger cysts required cystectomy and extraction of the cysts by using bipolar electrosurgery. Cystectomy was preceded by endocystic visualization in all cases. The primary outcomes measured included (1) correlation of the preoperative TVS, HSG, or both of these, with the laparoscopic diagnosis; (2) estimation of the success of the laparoscopic management of paratubal cysts; (3) assessment of the value of endocystic visualization prior to cystectomy; and (4) evaluation of tubal patency after laparoscopic management. RESULTS: Laparoscopically, only 118 patients (15.7%) were proved to have paratubal or paraovarian cysts. Preoperatively, TVS confirmed paratubal or paraovarian cysts in 52 (44%) patients. Cysts less than 3 cm in size (34 cases) were treated with simple puncture and bipolar coagulation of the cyst wall, whereas larger cysts (84 cases) were treated by cystectomy. Endocystic visualization using the 4-mm rigid hysteroscope was performed in 84 (71%) patients with large cysts. Statistically significant improvement occurred in tubal patency after laparoscopic management. CONCLUSIONS: Sonographic diagnosis of not uncommon paratubal and paraovarian cysts is not always feasible and requires greater awareness and accuracy. The characteristic laparoscopic differentiation of ovarian cysts is the crossing of vessels over them. Endocystic-endoscopic visualization is a simple, valuable step prior to cystectomy. Bipolar coagulation or extraction of these cysts diagnosed at laparoscopy is easy, not time-consuming, and should be routinely performed in all cases following microsurgical laparoscopic principles.     

Paratubal cysts, obesity, and hyperandrogenism

Objective

The aim of this study was to determine if an association exists between adolescents with polycystic ovarian syndrome (PCOS) or hyperandrogenism (HA), obesity, and paratubal cysts (PTCs).

Design

An institutional review board-approved retrospective chart review was performed between the years of 1998 and 2008 at a single children's hospital. Inclusion criteria were met if pathology reports demonstrated diagnosis of PTC. Age of menarche, body mass index, surgical procedure, and findings were correlated with the presence of HA.

Results

The incidence of PTCs was 7.3% among 1524 females presenting with adnexal masses. One hundred three patients had a confirmed pathology diagnosis of PTC and underwent surgery for suspected torsion or persistent adnexal mass on imaging studies. Forty-five percent of surgical cases had ovarian or adnexal torsion. Mean age of PTC diagnosis for the entire cohort was 13.7 ± 2.82 years. Mean age of menarche was 11.7 ± 1.34 years among pubertal females. Four patients were premenarchal at the time of PTC diagnosis. Forty percent of pubertal females had a diagnosis of PCOS. Pubertal adolescents with features of HA had a higher body mass index (31.3 vs 26.2 kg/m², P = .003) and had a trend toward larger cysts (7.6 vs 6 cm, P = .235). Overall, a significant association existed between obesity and PTC (P = .007), although no definite association could be made about HA or PCOS.

Conclusion

This study demonstrated an association between PTCs and obesity. In addition, HA appears to be associated with a trend toward large PTCs, although results were not significant.     

骶神经根周围囊肿的诊断及外科治疗

目的 探讨骶神经根周围囊肿的临床表现、影像学特点及外科治疗效果。方法 诊断22例骶管内神经根周围囊肿患者。对有明显症状的16例进行手术治疗。行病变部位后路椎板减压，13例囊肿切除，3例囊肿大部分切除，9例硬膜破裂神经根裸露采用胶原蛋白海绵覆盖。结果 MRI检查显示出椎管内神经根囊肿的形态，CT显示骶骨压迫性改变。16例切口均一期愈合，术后随访6个月～7年，平均2年9个月，患者术后腰骶疼痛、间歇跛行、骶神经症状均得到明显缓解，无感染病例，2例脑脊液漏1周内愈合。结论 骶管内神经周围囊肿临床上少见，容易误诊。MRI是最好的诊断方法，采用手术摘除囊肿和胶原蛋白海绵覆盖治疗，其治疗效果满意。     

The increasing incidence of adolescent bariatric surgery

Background

Morbid obesity continues to be a significant problem within the United States, as overweight/obesity rates are nearing 33%. Bariatric surgery has had success in treating obesity in adults and is becoming a viable treatment option for obese adolescents.

Methods

We studied 1615 inpatient admissions for children ≤ 20 years of age undergoing a bariatric procedure for morbid obesity in 2009 using the Kids' Inpatient Database (KID). Patients had a principal diagnosis of obesity and a bariatric procedure listed as one of their first 5 procedures. Procedures (open gastric bypass, laparoscopic gastric bypass, sleeve gastrectomy, laparoscopic gastroplasty, and laparoscopic gastric band) and complications were defined by ICD-9 codes.

Results

There were 90 open gastric bypasses, 906 laparoscopic gastric bypasses, 150 sleeve gastrectomies, 18 laparoscopic gastroplasties, and 445 laparoscopic gastric bandings. The length of stay for each procedure was 2.44, 2.20, 2.33, 1.10, and 1.02 days, respectively (P < 0.001). The complication rates were 3.3%, 3.5%, 0.7%, 0.0%, 0.2%, respectively (P = 0.004).

Conclusions

Bariatric surgery is an increasingly utilized option for the treatment of morbid obesity among adolescents. The procedures can be performed safely as evidenced by low complication rates. Additional long-term follow-up is necessary.     

Laparoscopic management of symptomatic simple renal cysts

Objective: To evaluate the efficacy of retroperitoneoscopy for the treatment of symptomatic renal cyst disease. Patients and methods: We evaluated the efficacy and morbidity of aspiration versus open and laparoscopic surgical techniques in a paired institution over a 20-year period. Prospectively recorded parameters for the 11 cases dealt with by primary retroperitoneoscopic techniques were compared with historical controls dealt with by open surgery. Results: Small volume cysts were satisfactorily dealt with by aspiration alone. All patients undergoing laparoscopic cyst decortication for the larger volume cysts had a satisfactory outcome with improvement in their symptoms and objective cure on follow up imaging studies. Conclusion: Laparoscopic management for all cysts is a safe, effective and minimally invasive alternative to open surgery for symptomatic renal cysts. Simple drainage under radiological guidance is also highly effective and should probably be first line treatment for cysts up to 6 cms in diameter whereas primary laparoscopic treatment should be suggested for larger cysts. This revised version was published online in August 2006 with corrections to the Cover Date.     

Transsphenoidal management of Rathke's cleft cysts a clinicopathological review of 10 cases

We report detailed data on 10 patients who underwent transsphenoidal microsurgical management of histopathologically confirmed Rathke's cleft cysts. Preoperatively, pituitary dysfunction was present in 90%, headaches in 80%, hyperprolactinemia in 70%, and visual interference in 40%. Computed tomography and magnetic resonance imaging had 90% and 100% sensitivity, respectively, in disclosing the lesion. The mean follow-up duration was 22 months. There was no mortality. The only morbidity was sustained diabetes insipidus in one case. Resolution or improvement in preoperative dysfunction occurred in the majority of patients: headaches in 100%, visual deficits in 75%, normalization of hyperprolactinemia in 83%, and reversal of panhypopituitarism in 33%. We conclude that Rathke's cleft cysts can be managed safely and effectively with transsphenoidal drainage and partial excision of the wall.     

Long-term outcome after surgical treatment of nonparasitic splenic cysts

Background The optimal treatment for patients with nonparasitic splenic cysts is controversial. This study aimed to evalulate the clinical outcome of patients treated for a symptomatic splenic cyst, and to define a surgical strategy. Methods Spleen-preserving surgery (9 laparotomies and 6 laparoscopies) was performed for a primary cyst in six patients and a secondary cyst in nine patients. The median follow-up time was 37.5 months. Partial splenic resection was performed for eight patients and cyst decapsulation for seven patients. Results Cyst recurrence was observed in four patients after decapsulation of a primary splenic cyst, as compared with none after resection. Postoperative complications were encountered only after laparotomy (5/9). The median hospital stay was 3.5 days (range, 2–5 days) after laparoscopy, as compared with 9 days (range, 5–14 days) after laparotomy. Conclusions Symptomatic splenic cysts should be treated laparoscopically. For patients with recurrent or suspected primary splenic cysts, laparoscopic partial splenectomy is preferable. For other cases, a laparoscopic decapsulation is advocated.     

儿童先天性胆管囊状扩张症的诊治

目的探讨儿童先天性胆管囊状扩张症的诊断及治疗。方法回顾性分析本院2000年3月至2011年8月治疗的28例儿童先天性胆管囊状扩张症患者临床资料。结果 28例年龄1岁8月至14岁,其中27例行囊肿完整切除、肝总管空肠Roux-en-Y吻合术,1例行囊肿大部分切除、肝总管空肠Roux-en-Y吻合术。获随访25例,随访时间为1～3年,患者情况良好,无结石、癌变、黄疸等。放置胆道金属支架固定好,引流通畅。结论影像学检查在儿童先天性胆管囊状扩张症的诊断中具有重要价值,儿童先天性胆管囊状扩张症的手术方式与其临床分型相关。     

Suprasellar arachnoid cysts: Options in operative management

Summary Suprasellar arachnoid cysts are uncommon lesions the optimal management of which is still subject for debate. Various authors have presented differing treatment preferences which include: 1) Subfrontal fenestration of the cyst to the basal cisterns; 2) Transcallosal fenestration of the cyst into the lateral ventricles with optional shunting; 3) Cystoperitoneal shunt; 4) Percutaneous ventriculocystostomy. There is a significant incidence of re-operation whatever the initial approach.Based on recent experience with 5 operative cases of suprasellar arachnoid cyst and a selective review of 6 major operative series covering 42 cases, the available surgical options are critically analyzed. Percutaneous ventriculostomy may offer the best chance for a definitive treatment. However the technique is demanding and is not readily available. Cystoperitoneal shunting entails shunt dependency and has a significant incidence of failure, as does cyst marsupialization to the subarachnoid cisterns. The establishment of a single CSF space by surgically communicating the cyst with the ventricular system appears to offer the best chance of success in the treatment of suprasellar arachnoid cysts, though a concomittant shunt may still be required in the occasional hydrocephalic patient.     

重度青少年特发性颈椎后凸畸形的手术治疗

目的 探讨重度青少年特发性颈椎后凸畸形的临床特征和手术策略.方法 回顾性分析2003年7月至2007年1月收治的12例重度青少年特发性颈椎后凸畸形患者的临床资料,术前后凸Cobb角55°～73°(平均61°).先以在过伸侧位X线片上测量的椎体后缘切线夹角为依据,决定颈椎后部的椎板及小关节等的截骨角度及范围,行颈后路截骨及前路松解术.术后行颅骨牵引使松解后颈椎后凸达到最大可能的矫正,7～10 d后二期行颈前路矫形、植骨内固定术.分别于术后第3天、3及6个月、1及2年摄颈椎正侧位X线片、MRI,观察矫形效果,植骨融合情况及内固定位置并对比手术前后临床症状的变化.结果 患者畸形外观明显改善,颈部疼痛症状全部消失,神经功能明显恢复.术后MRI显示:颈椎生理曲度重建,后凸畸形区域脑脊液线清晰,脊髓未见压迫.术后第3天X线片显示:后凸Cobb角为-12.3°～11.2°(平均-2.0°).除1例AISA神经功能评分为D级外其他11例AISA神经功能评分均为E级.结论 重度青少年特发性颈椎后凸畸形有其特有的临床特征,对该类患者进行全面评估,分期手术及手术间期持续牵引是较为理想的外科治疗方法.     

青少年特发性脊柱侧凸远端融合椎的选择

目的 论证一种新的青少年特发性脊柱侧凸(AIS)患者远端融合椎的选择方法,评估其临床疗效.方法 运用新的远端融合椎选择标准,前瞻性研究2005年7月至2008年9月接受诊治且符合人组条件的AIS患者31例,平均年龄15.6岁(12～19岁),平均随访27.5个月(12～49个月).观察术前、术后以及末次随访时冠状面的侧凸Cobb角、远端融合椎倾斜角、远端融合椎椎间角、C_7椎体中心至骶骨中垂线的距离(C_7-CSVL)、胸后凸、腰前凸等变化,并进行统计学分析.结果 术前、术后即刻冠状面胸弯Cobb角分别为(42±17)°和(12±7)°,侧凸矫形率平均70.6%;冠状面腰弯Cobb角分别为(44±7)°和(9±4)°,侧凸矫形率平均80.2%;C_7-CSVL分别为(13±8)和(9±7)mm,差异有统计学意义(P<0.05);远端融合椎倾斜角分别为(20.8±5.7)°和(1.5±3.1)°,术后较术前明显改善(P=0.000).末次随访时患者胸弯Cobb角为(14±8)°,腰弯cobb角为(9±5)°,C_7-CSVL为(6±5)mm,与术前比较差异均有统计学意义(P<0.05).末次随访远端融合椎倾斜角为(0.8±3.7)°,与术后即刻相比差异无统计学意义(P>0.05).结论 运用远端椎旋转度数和远端椎柔韧性选择远端融合椎的方法手术治疗AIS是安全、有效的.     

The surgical management of congenital liver cysts

BACKGROUND: Most series that report the results of surgical treatment for congenital liver cysts focus more on the technical aspects of the operation than on the late outcome of these patients. In this paper, we emphasize the importance of appropriate patient selection and adequate surgical technique for successful long-term outcome. METHODS: Twenty-four consecutive patients with congenital liver cysts were selected for surgical treatment. According to our own classification, 13 patients had simple liver cysts, nine had multicystic liver disease, and two had type I polycystic liver disease. All of these patients were treated by the fenestration technique. An open approach was used for five patients (group 1) treated between 1984 and 1990. In 19 patients (group 2) treated since 1991, a laparoscopic approach was used. The incidence of complicated liver cysts was 40% in group 1 and 68% in group 2. RESULTS: There were no treatment-related deaths in this series. The mean postoperative hospital stay was significantly shorter for patients who underwent successful laparoscopic fenestration (p < 0.05). In the open group (group 1), there were no postoperative complications, and all patients were alive and free of symptoms during a mean follow-up of 130 months, without any sign of cyst recurrence. In the laparoscopic group (group 2), four patients were converted to open surgery. One of these patients had an inaccessible posterior cyst; another had bile within the cystic cavity. A further two cases had complicated liver cysts with an uncertain diagnosis between congenital and neoplastic cysts. Four patients (21%) developed peri- or postoperative complications. During a mean follow-up time of 38.5 months, none of the patients with simple liver cysts incurred late symptoms or signs of cyst recurrence. In the six patients with multicystic liver disease, one developed disease-related cyst progression (17%) and required reoperation. One of the two patients with type I polycystic liver disease (50%) developed asymptomatic disease-related cyst progression. CONCLUSIONS: When patients are carefully selected and a proper surgical technique is employed, excellent long-term results with a low morbidity rate can be achieved in patients with congenital liver cysts. Patients with multicystic liver disease or type I polycystic liver disease are more prone to late cyst recurrence. A tailored approach is thus indicated for patients with congenital liver cystic disease. However, the laparoscopic approach appears to be the gold standard for the treatment of highly symptomatic or complicated simple liver cysts.     

甘肃兰州地区青春期舞蹈女生骨量减少发病及其危险因素分析

目的探讨甘肃兰州地区青春期舞蹈女生骨量减少发病原因,并分析其危险因素,以便于有针对性地进行干预。方法采用横断面整群分层随机抽取舞蹈专业16到20岁女生462名为研究对象,使用超声骨密度测定仪测定骨密度,并进行骨质T-score综合评价,发现骨量减少的68例,为病例组;骨量检测正常的394例为对照组,未检测到OP患者。对2组的年龄、身高、体重等12项因素予以比较分析。所得资料在单因素分析的基础上,又做多元线性回归和多因素logistic回归。结果骨量减少的检测率为14.72%;骨量减少发生的相关因素分析,排除进入模型的其他作用因素后,体重指数、初潮年龄与跟骨骨强度指数(SI)呈线性相关(P0.05),其中体重指数对SI影响最大(r=0.121-0.112),初潮年龄与骨强度指数负相关(r=-0.112);月经紊乱患病率为39.18%,患病率较高,月经紊乱者和吸烟者发生骨量减少的危险性分别是月经正常者和不吸烟者的1.88倍和1.92倍,进食奶制品少、进食豆制品少和节食促使发生骨量减少的危险性分别是进食奶制品多、进食豆制品多和不节食的1.84倍、2.20倍和2.65倍(OR值分别是1.88、1.92、1.84、2.20和2.65,其95%可信区间内均不包含1,P均0.05),促进发病。结论初潮年龄延迟、低体重指数、月经紊乱、吸烟、进食奶制品和豆制品过少及节食是甘肃兰州地区青春期舞蹈女生骨量减少的主要危险因素。     

腹腔镜下肝肾囊肿开窗去顶术的临床应用

目的:探讨腹腔镜治疗肝肾囊肿的方法和效果。方法: 1994至2004年于腹腔镜下为68例肝肾囊肿患者行开窗去顶术,其中肝囊肿56例,肾囊肿12例,并注入无水酒精灌洗残留粘膜。结果: 68例手术全部成功,无中转开腹。手术时间30~70min,随访时间6个月~10年, 1例复发。结论:腹腔镜治疗肝肾囊肿安全可行,在严格掌握适应证的条件下值得推广应用。     

Laparoscopic management of ovarian cysts in newborns

Background: Cysts are the most common ovarian masses found in newborn girls. Spontaneous regression, which occurs in ∼25–50% of cases, is more frequent with smaller cysts. Pre- or postnatal complications are common; these complications may consist of intracystic bleeding, torsion of the cyst or corresponding annex, or self-amputation of the cyst. When the cyst is <4 cm it is possible to perform a simple echographic monitoring to check for the possibility of spontaneous involution; all other cases require surgery. Methods: Between February 1985 and June 1997, we treated 22 neonatal ovarian cysts laparoscopically. In 14 cases, the right side was involved; in eight cases, it was the left. The patients' ages ranged between 7 days and 5 months (median, 45 days). In all cases, we used three trocars. An intraperitoneal cystectomy was done in eight cases, a transparietal cystectomy in four cases, an ovariectomy in seven cases, and the simple removal of the cyst in one case where self-amputation had occurred. In two cases of bilateral pathology, the cysts, which were <1 cm, were left untreated. Results: Average operating time was 40 min (range, 25–60 min). Intraabdominal pressure never exceeded 6–8 mmHg during the intervention. The postoperative course was always under 3 days. No intra- or postsurgical complications were recorded, and long-term ultrasonographic follow-ups were all normal. Conclusion: Our experience indicates that the laparoscopic approach is a reliable and safe technique in the treatment of neonatal ovarian cysts. Received: 30 July 1997/Accepted: 24 October 1997     

The surgical management of pediatric hydrocephalus

The surgical management of hydrocephalus has undergone incredible changes over the past generation of neurosurgeons, including dramatic improvements in imaging, especially computed tomographic scanning and magnetic resonance imaging, and remarkably innovative advances in cerebrospinal fluid valve technology, complex computer models, and endoscopic equipment and techniques. In terms of overall patient outcomes, however, one could conclude that things are a little better, but "not much." This frustrating yet fascinating dichotomy between technological advancements and clinical outcomes makes hydrocephalus, first described by the ancients, as one of the most understated and complex disorders that neurosurgeons treat. The challenge to the next generation of neurosurgeons is to solve this vexing problem through better understanding of the basic science, improved computer models, additional technological advances, and, most importantly, a broad-based, concerted multidisciplinary attack on this disorder. This review focuses on the evolution of surgery for hydrocephalus over the last 30 years, the current state of the art of hydrocephalus treatment, and what appear to be the most promising future directions.     

Minimally invasive management of dysontogenetic hepatic cysts

Background Liver cysts occur with a prevalence of 4%–7% in the general population. Laparoscopic surgery is effective for solitary cysts and in selected patients with polycystic liver disease (PLD). We present our experience in the laparoscopic management of dysontogenetic cysts.Patients and methods Between 1994 and 2002, 36 patients were referred to our centre for the management of dysontogenetic cystic liver disease. Management was laparoscopic in 16 cases. Indications were solitary giant cysts (n=9) and PLD (n=7).Results Laparoscopic procedures were completed in 15 patients. Mean operating time was 90 min. There were no deaths. In one case there was an intraoperative complication: bleeding from a superficial hepatic vein necessitated conversion to an open procedure. There were two postoperative complications: one patient with biliary leakage, which was managed conservatively, and one patient with a pneumothorax caused by the cava catheter installed for anaesthesia. Median follow-up was 36 months. There was no symptomatic recurrence.Conclusion Laparoscopy can be recommended as the procedure of choice for symptomatic solitary giant cysts and PLD Gigot type I.     

功能性甲状旁腺囊肿的诊断及外科处理

目的了解功能性甲状旁腺囊肿（ＦＰＴＣ）的特点,总结其诊治经验。方法回顾性研究了我院１９８４～１９９６年收治功能性甲状旁腺囊肿６例的临床表现及血钙、甲状旁腺素、Ｂ型超声和ＣＴ等辅助检查的特点;并结合文献讨论了功能性甲状旁腺囊肿诊治的有关问题。结果本组６例患者均经手术切除、病理检查证实为ＦＰＴＣ;其中囊实性２例,合并甲状旁腺腺瘤１例,位于纵隔１例;术后均恢复正常。结论功能性甲状旁腺囊肿应手术切除,避免囊肿穿刺活检。     

仰卧支点加压位X线片预测青少年特发性脊柱侧凸患者矫形效果的价值

目的研究运用仰卧支点加压位X片评价青少年特发性脊柱侧凸（adolescent idiopathic scoliosis,AIS）脊柱柔韧性和预测矫形效果的价值。方法AIS患者65例,根据站立位X线片Cobb角角度分为中度侧凸组和重度侧凸组。术前均拍摄脊柱全长站立位正位X线片、仰卧位左右侧屈位X线片、悬吊正位X线片、支点弯曲位X线片、仰卧位支点加压位X线片及术后站立位正位X线片。所有病例均采用TSRH内固定系统。测量每位患者各种体位X线片Cobb角角度。结果在两组中支点加压位X线片Cobb角大小与术前其他体位X线片Cobb角大小差异均有统计学意义（P〈0．05）,在中度侧凸组中支点加压位X线片与术后站立位X线片Cobb角大小相比差异无统计学意义,（P〉0．05）,并呈正相关（r=0．799）,预测的矫正率与术后矫正率比较差异也无统计学意义,（P〉0．05）。柔软性侧凸组中支点加压位发X线片与术后站立位X线片Cobb角大小相比较差异无统计学意义,（P〉0．05）,并呈正相关（r=0．682）。结论仰卧位支点加压位X线片能较为准确的评价AIS患者脊柱的柔韧性,预测柔软性侧凸患者术后的矫正率,并为手术方案的选择提供重要的参考依据。