A “bridge” technique to replace the obstructed single-J stent in the patient with ileal conduit urinary diversion: a case report

The ureteroileal anastomotic stricture is a complication of ileal conduit urinary diversion. To prevent the hydronephrosis and protect the renal function, a single-J ureteral stent may be needed. However, the most common complication of these patients is single-J stent obstruction. To solve this problem, we describe an easy, useful and low-cost technique to replace the obstructed ureteral stent under radiographic guidance without intervention by flexible cystoscopy or percutaneous nephrostomy. The key steps of our procedure are to identify the location of the stricture, to place the super smooth guide wire into pinhole of the obstructed single-J stent and to get the super smooth guide wire and 5-Fr ureteral catheter across the stricture. Our case was a 40-year-old male patient who was diagnosed as pelvic lipomatosis and received ileal conduit urinary diversion 3 years ago. The left-side ureteroileal anastomotic stricture occurred 1 year after surgery. He refused to repair the stricture by open or other minimal invasive surgery. He regularly changed his ureteral stent with intervals of three months. As the stent was obstructed by the stone, the guide wire couldn’t be inserted through the primary ureteral stent. We used our “bridge” technique to solve his problem successfully. No bleeding and no urinary tract infection were observed after intervention. The urine from the ureteral stent was fluent. We think that this “bridge” technique may be a good choice for the replacement of the obstructed single-J stent in the patients of ileal conduit urinary diversion.     

An unusual and life-threatening cause of epigastric pain presenting to the general surgical team: a case report

As general surgeons, we are regularly referred patients with epigastric pain. There are a huge number of common pathologies which cause this complaint, most of which are gastrointestinal in origin. Although the old adage goes ’common things are common’, we must always keep our minds open to the possibility of the uncommon and not miss warning signs which are present in the history or examination. We present the case of a 59-year-old woman with a ruptured sinus of Valsalva aneurysm presenting to the accident and emergency department as epigastric pain.     

An unusual case of congenital scoliosis associated with rib agenesis in the upper part of the concavity treated by VEPTR vertebra to vertebra

Background contextRib agenesis in congenital scoliosis is rarely encountered, and its disposal in the application area of the proximal vertical expandable prosthetic titanium rib (VEPTR) module is a challenge to the orthopedic surgeon.PurposeTo present a case in which known treatment methods in early-onset scoliosis were not possible to apply.Study designCase report.MethodsA patient aged 1 year and 10 months, presenting a congenital scoliosis with the following characteristics: left T3 hemisegmented hemivertebra, T5–T6–T7 hemivertebral segment, T9, T10 trapezoidal vertebrae, right side I–IV rib agenesis with T1–T2–T4 hemivertebral hypoplasia (T3 agenesis) and bilateral XIIth rib agenesis, and V–VI and VII–VIII–IX fused ribs on the right side. We applied a standard VEPTR in a new construct, vertebra to vertebra.ResultsThe VEPTR vertebra to vertebra proved to be an efficient and stabile construct after 1.5 years of follow-up and three device distractions in a row. The curve corrected from 100 to 58 Cobb degrees.ConclusionsWe believe that the vertebra-to-vertebra construct with eventual modifications may be a solution in the treatment of early-onset scoliosis needing surgery, which associate rib agenesis in the area where the proximal module has to be applied.     

Positioning the instillation of contrast at the ureteral orifice cystography can be useful to predict postoperative contralateral reflux in children with unilateral vesicoureteral reflux

The aim of the present study was to evaluate the usefulness of positioning the instillation of contrast at the ureteral orifice (PIC) cystography in prediction of postoperative contralateral reflux in patients with unilateral vesicoureteral reflux (VUR) undergoing ureteral reimplantation. Between January 2007 and March 2009, 34 children (20 boys and 14 girls) had antireflux surgery for unilateral primary VUR. This was diagnosed by conventional fluoroscopic voiding cystourethrography (VCUG) in all patients. After induction of general anesthesia, PIC cystography was carried out immediately before ureteral reimplantation by instilling contrast material at the ureteral orifice. Patients with positive PIC cystogram on the contralateral side underwent bilateral ureteral reimplantation via the Cohen technique. VCUG was repeated at 6–12 months postoperatively. Of the 34 patients, 16 (47%) showed VUR on the contralateral side on PIC cystography and underwent bilateral reimplantation. The remaining 18 patients (53%) with negative PIC cystogram underwent unilateral reimplantation, and no VUR was detected by postoperative VCUG in all ureters. None of the 34 patients had surgical complications or recurrent urinary tract infections. In conclusion, PIC cystography represents a useful tool to predict new onset contralateral VUR in patients with unilateral VUR on conventional VCUG.     

Ponseti technique for the correction of idiopathic clubfeet presenting up to 1 year of age. A preliminary study in children with untreated or complex deformities

Introduction: The aim of this study is to evaluate the effectiveness of the Ponseti method in children presenting before 1 year of age with either untreated or complex (initially treated unsuccessfully by other conservative methods) idiopathic clubfeet. Patients and methods: The authors report 134 feet of 92 patients with Dimeglio grade 2, 3, or 4 deformities treated with the Ponseti method. Twenty-four percent of feet were of complex deformities at initial presentation to the authors’ clinics. Results: At a mean follow-up of 46 months (range 24–89) we avoided joint release surgery in 97% of feet. Sixty-seven percent required a percutaneous tenotomy of the Achilles tendon. Relapse rate was 31% (41 feet). We treated 2 relapses by restarting the use of orthosis, 17 with re-casting, 18 with anterior tibial tendon transfer following a second relapse, and 4 feet with extensive joint surgery. Compliance with the use of orthosis was identified as the most important risk factor (P<0.0001) for relapses. Previous unsuccessful treatment attempts by other conservative methods did not adversely affect the results unless the cases had iatrogenic deformities. Cases with iatrogenic deformities from previous treatment had a significantly increased risk of non-compliance and relapse. Experience of the treating surgeon and cast complications were also related to relapses. Conclusion: Our results show that the Ponseti technique is reproducible and effective in children at least up to 12 months of age. It can also produce good correction in children presenting with complex idiopathic deformities. Therefore, extensive joint releases should not be considered immediately in such cases. The treating surgeon should be meticulous in using the technique and ensure compliance to foot abduction brace in order to avoid recurrences.     

Gsα activity is reduced in erythrocyte membranes of patients with psedohypoparathyroidism due to epigenetic alterations at the GNAS locus

In pseudohypoparathyroidism (PHP), PTH resistance results from impairment of signal transduction of G protein–coupled receptors caused by a deficiency of the Gsα‐cAMP signaling cascade due to diminished Gsα activity in maternally imprinted tissues. In PHP‐Ia, inactivating mutations of the GNAS gene lead to haploinsufficiency in some tissues with biallelic expression, so in addition to PHP, Albright's hereditary osteodystrophy (AHO) is also present. In PHP‐Ib, caused by methylation defects at the GNAS locus, diminished Gsα activity was thought to be limited to maternally imprinted tissues, such as the renal proximal tubule and the thyroid, leading to a lack of AHO. Recently, we demonstrated methylation defects in patients with AHO signs, indicating a connection between epigenetic changes and AHO. Our objective was to determine Gsα activity in erythrocyte membranes in patients with epigenetic defects at the GNAS locus compared to normal controls and patients with inactivating GNAS mutations. Gsα activity and expression, mutation of the GNAS locus, and methylation status were studied in patients with PHP and mild signs of AHO (PHP‐Ia: 12; PHP‐Ib: 17, of which 8 had some features of AHO). Then, we statistically compared the Gsα activity of the different PHP subtypes. Patients with methylation defects at the GNAS locus show a significant decrease in erythrocyte Gsα activity compared to normal controls (PHP‐Ib versus controls, p < .001). This was significantly lower in patients with AHO signs (PHP‐Ib + mild‐AHO versus PHP‐Ib, p < .05). Our research shows that PHP‐Ia and PHP‐Ib classification is not only overlapped genetically, as reported, but also in terms of Gsα activity. Reduced expression of GNAS due to methylation defects could downregulate Gsα activity in other tissues beyond those described and could also be causative of AHO. © 2011 American Society for Bone and Mineral Research     

An audit of the effect of case selection on compliance with a 30-minute audit standard for decision-to-delivery interval at category 1 caesarean section

BackgroundOur hospital has an audit standard that ≥90% of women having category 1 (emergency) caesarean section should have a decision-to-delivery interval (DDI) ≤30 min. This audit aimed to identify potential influences of case selection on compliance.MethodsA prospective audit of category 1 caesarean section recorded urgency at time of decision for surgery and any urgency changes, as well as whether caesarean section followed failed operative vaginal delivery in the operating theatre.ResultsAmong 405 women, 158 women had failed operative vaginal delivery in the operating theatre followed by caesarean section, 247 had the delivery decision made in the labour room, 43 had a change in urgency. Depending on case inclusion, the proportion of women with DDI room, and 43 >30 min ranged between 8.3% (30/362; no urgency change, failed operative vaginal delivery included) and 21.9% (54/247; change in urgency, failed operative vaginal delivery excluded). The proportion of women with a DDI >30 min was 18.5% (42/227) if the decision for category 1 caesarean section was made in the labour delivery room (excluding cases of failed operative vaginal delivery).ConclusionsCompliance with an audit standard for (DDI) at category 1 caesarean section is markedly influenced by the inclusion criteria. For comparability with other publications, it is suggested urgency should be reported as that applied at the point of decision for caesarean section, however, category 1 caesarean section cases following failed operative vaginal delivery in the operating theatre should be identified and reported separately.