Transvesicoscopic Cohen ureteric reimplantation for vesicoureteral reflux in children: A single-centre 5-year experience

PurposeTo evaluate our results with a new method of intravesical ureteric reimplantation using laparoscopic pneumovesicum in children.Materials and methodsSeventy-two patients (mean age 4.2 years, range 0.5–20 years) with primary vesicoureteral reflux (VUR) underwent a laparoscopic transtrigonal ureteric reimplantation with CO₂ pneumovesicum. Ports were inserted suprapubically – 5 mm for the camera and two 3–5-mm working ports. Having mobilized the ureter(s) intravesically, a submucosal tunnel is created and ureteric reimplantation performed with 5/0 and 6/0 absorbable sutures. Bladder drainage was maintained for 2–3 days postoperatively. Patients were followed up with clinical assessment and renal ultrasonography ± voiding cystourethrogram.ResultsNinety percent had VUR grade ≥3. A total of 113 ureters were reimplanted. The mean operative time was 82 min for unilateral and 130 min for bilateral reimplantation. Four cases (6%) were converted. Three patients presented with temporary ureteric dilatation without symptoms on follow-up renal ultrasound. Seven patients had postoperative urinary tract infection without persistent reflux on cystography. Follow-up cystogram was performed in 50 patients (81 ureters). Reflux persisted in four patients (8%).ConclusionsLaparoscopic ureteric reimplantation with CO₂ pneumovesicum is technically feasible with a high success rate (92%). The role of this new technique in the treatment of VUR remains to be determined.     

Interleukin‐6 and chemokines in the neuropsychiatric manifestations of systemic lupus erythematosus

Objective

To define the cytokine and chemokine profile in cerebrospinal fluid (CSF) from patients with neuropsychiatric systemic lupus erythematosus (NPSLE).

Methods

Forty‐two SLE patients who had been hospitalized because of NP manifestations were studied. Patients were evaluated at hospitalization and 6 months later; a CSF sample was obtained at each evaluation. As controls, CSF from 6 SLE patients with septic meningitis, 16 SLE patients with no history of NP manifestations (non‐NPSLE), and 25 patients with nonautoimmune diseases were also studied. Soluble molecules, including cytokines (interleukin‐2 [IL‐2], IL‐4, IL‐6, IL‐10, tumor necrosis factor α [TNFα], and interferon‐γ [IFNγ]) and chemokines (monocyte chemotactic protein 1 [MCP‐1], RANTES, IL‐8, monokine induced by IFNγ [MIG], and interferon‐γ–inducible 10‐kd protein [IP‐10]), were measured with the use of cytometric bead array kits.

Results

CSF levels of the following molecules were significantly increased in NPSLE patients as compared with non‐NPSLE and nonautoimmune diseases control patients, respectively: IL‐6 (32.7 versus 3.0 and 2.96 pg/ml), IL‐8 (102.8 versus 29.97 and 19.7 pg/ml), IP‐10 (888.2 versus 329.7 [P not significant] and 133.6 pg/ml), RANTES (3.8 versus 2.5 and 2.2 pg/ml), MCP‐1 (401.7 versus 257.9 [P not significant] and 136.9 pg/ml), and MIG (35.4 versus 11.4 and 3.5 pg/ml). Low levels of IL‐2, IL‐4, IL‐10, TNFα, and IFNγ were found in all groups. All cytokines and chemokines, except TNFα, were significantly higher among the SLE patients with septic meningitis than among the NPSLE patients. Six months later and in the absence of NP manifestations, all elevated molecule levels, except RANTES, in patients with NPSLE had decreased significantly, and no differences were noted between the NPSLE and non‐NPSLE groups.

Conclusion

A central nervous system response composed of IL‐6 and chemokines, but not Th1/Th2 cytokines, is associated with NP manifestations in SLE patients.

     

The natural history of intimal flaps caused by angioscopy

This study tried to determine the natural history of angioscopy-induced arterial intimal flaps as assessed by video angioscopy, light and transmission electron microscopy. Eight mongrel dogs were anesthetized and bilateral femoral and carotid arteries surgically exposed. A 3.0 mm American Edwards angioscope was inserted into each artery and passed vigorously until an intimal flap was visualized by angioscopy. The location of intimal flaps was externally marked with 6–0 polypropylene adventitial sutures. Animals were then recovered and follow-up angioscopy performed at one, two, three, and four week intervals. Following repeat angioscopy, all animals were sacrificed and vessels perfusion-fixed in situ with 2.5% glutaraldehyde in 0.1 M sodium cacodylate. A total of 37 intimal injuries were created (immediate, n=10; one week, n=8; two weeks, n=4; three weeks, n=8; four weeks, n=7). No arterial thrombosis occurred following intimal flap formation. Only one of 37 (2.7%) lesions progressed to a hemodynamically significant stenosis. Histology of immediate lesions demonstrated deep intimal fractures extending into the tunica media. Complete healing of intimal flaps was observed by follow-up angioscopy in zero of eight lesions by one week, zero of four lesions by two weeks, one of eight lesions by three weeks, and four of seven lesions by four weeks (p=0.02). Light and electron microscopy confirmed the angioscopic intimal fractures and regrowth of denuded endothelium. Conclusion: follow-up angioscopy and microscopy one month after angioscopy-induced arterial intimal trauma demonstrated a significant trend towards complete endothelial healing.Presented at the 16th Annual Meeting of the Peripheral Vascular Surgery Society, June 2, 1991, Boston, Massachusetts.     

Influenza vaccine: Development of a novel intranasal and subcutaneous recombinant adjuvant

The synthetic peptide GK-1, derived from Taenia crassiceps, enhances the protection induced by human influenza vaccine in both young and aged mice. Herein, the adjuvant properties of GK-1 fused to the pVIII protein of a heat-inactivated phagemid vector (FGK1) when co-administered with the influenza vaccine were assessed, to evaluate its feasibility as a low-cost adjuvant. In mice, FGK1 significantly increased the expected IgG and IgA anti-influenza antibody levels both in sera and in bronchoalveolar fluids when intranasally or subcutaneously co-administered with influenza vaccine. Single-dose pig co-immunization with FGK1 and influenza vaccine induced serum levels of IgG anti-influenza antibodies similar to those elicited by a two-dose immunization with the influenza vaccine alone. Preclinical evaluation of FGK1 with the influenza vaccine is currently in progress, in order to recommend its use for veterinary purposes.     

Anti‐reflux surgery for patients with esophageal atresia

Gastroesophageal reflux (GER) is almost constant in esophageal atresia and tracheoesophageal fistula (EA/TEF). These patients resist medical treatment and require antireflux surgery quite often. The present review examines why this happens, the long‐term consequences of GER and the main indications and results of fundoplication in this particular group of patients. The esophagus of EA/TEF patients is malformed and has abnormal extrinsic and intrinsic innervation and, consequently, deficient sphincter function and dysmotility. These anomalies are permanent. Fifty percent of patients overall have GER, and one‐fifth have Barrett's metaplasia. Close to 100%, GER of pure and long‐gap cases require fundoplication. In the long run, these patients have 50‐fold higher risk of carcinoma than the control population. GER in EA/TEF does not respond well to dietary, antacid, or prokinetic medication. Surgery is necessary in protracted anastomotic stenoses, in pure and long‐gap cases, and when there is an associated duodenal atresia. It should be indicated as well in other symptomatic cases when conservative treatment fails. However, confection of a suitable wrap is anatomically difficult in this condition as shown by a failure rate of 30% that is also explained by the persistence for life of the conditions facilitating GER.