Considerations in Minimally Invasive Surgery for Renal and Ureteric Calculi: A Bicenter Quality Control Study

Background

The use of minimally invasive surgery is increasing. Evaluating the quality of care brings new sights in the optimization of operating techniques.

Methods

We included all procedures performed in two hospitals during 2010 and 2011. A total of 264 patients were included in the ureterorenoscopy (URS) group and 77 patients in the percutaneous nephrolitholapaxy (PCNL) group. Data were gathered by retrospectively reviewing medical records.

Results

Mean stone diameter in the URS group was 9 mm. Patients suffered from a single stone in 79% of the cases. Calculi in the distal ureter, defined as the part of the ureter below the lower border of the sacroiliac joint, were most likely to be removed. A stone-free status was reached in 69% of the cases using URS. Mean stone diameter in the PCNL group was 23 mm. PCNL was successful in 70% of the cases in Haga Hospital versus 53% in Medisch Centrum Haaglanden. Incidence of complications was comparable between the hospitals (p = 0.5). Outcome and quality of both PCNL and URS was not influenced by sex, age or body mass index.

Conclusion

The clinical results were comparable with results in the literature. Further improvement can be made by optimization of technical aspects and centralization of treatment by urologists experienced in minimally invasive techniques.Key Words: Urolithiasis, Percutaneous nephrolithotomy, Ureterorenoscopy, Minimally invasive surgery     

The prevalence of depressive symptoms before and after surgery and its association with disability in patients undergoing lumbar spinal fusion

Purpose

The aim of this study was to evaluate the prevalence of depressive symptoms and disability pre-operatively, at 3 months and at 1 year after lumbar spine fusion surgery.

Methods

Data was extracted from a dedicated lumbar spine fusion register, giving 232 patients (mean age 62 years, 158 females) who had undergone instrumented lumbar spine fusion. The frequency of depressive symptoms and disability was evaluated using the Depression Scale (DEPS) and Oswestry Disability Index (ODI).

Results

Depressive symptoms were found in 34, 13, and 15 % of the patients pre-operatively, at 3 months and at 1 year after surgery, respectively. The mean DEPS score decreased from 16.2 to 8.6 (p < 0.001) in patients who had depressive symptoms pre-operatively, and from 6.1 to 3.8 (p < 0.001) in those patients without pre-operative depressive symptoms. The mean ODI values pre-operatively, at 3 months and at 1 year after surgery were 53, 30, and 23, respectively, in patients with pre-operative depressive symptoms and 41, 23, and 20 in those patients without pre-operative depressive symptoms. The differences between the groups were statistically significant at all time points (p < 0.001).

Conclusions

One-third of our patients with chronic back pain undergoing spinal fusion had depressive symptoms pre-operatively. The prevalence of depressive symptoms decreased after surgery. Although disability remained higher in those patients who had reported depressive symptoms pre-operatively, disability did decrease significantly in both groups post-operatively. Thus, there is no need to exclude depressive patients from operation, but screening measures and appropriate treatment practises throughout both pre-operative and post-operative periods are encouraged.     

Standard endovascular aneurysm repair in patients with wide infrarenal aneurysm necks is associated with increased risk of adverse events

Objective

Endovascular aneurysm repair (EVAR) has progressively expanded to treat more challenging anatomies. Although EVAR in patients with wide infrarenal necks has been reported with acceptable results, there is still controversy regarding the longer-term outcomes. Our aim is to determine the impact of infrarenal neck diameter on midterm outcome following EVAR with a single endograft with suprarenal fixation.

False lumen enhancement characteristics on computed tomography angiography predict risk of aneurysm formation in acute type B aortic dissection

 Open in a separate windowOBJECTIVESDifferential luminal enhancement [between true lumen (TL) and false lumen (FL)] results from differential flow patterns, most likely due to outflow restriction in the FL. We aimed to assess the impact of differential luminal enhancement at baseline computed tomography angiography on the risk of adverse events in patients with acute type B aortic dissection (TBAD).METHODSBaseline computed tomography angiographies of patients with acute TBAD between 2007 and 2016 (n = 48) were analysed using three-dimensional software at multiple sites along the descending thoraco-abdominal aorta. At each location, we measured contrast density in TL and FL [Houndsfield unit (HU)], maximal diameter (cm) and circumferential FL extent (°). Outcome data were collected via retrospective chart review. Multivariable logistic regression models were employed to determine the independent risk of TL–FL differential luminal enhancement on aneurysm formation (maximal diameter ≥55 mm) and medical treatment failure.RESULTSPatients were predominately male (75%) and 52.8±12.9 years at diagnosis. The mean follow-up was 5.9±2.6 years, and 42% (n = 20/48) patients were diagnosed with thoraco-abdominal aortic aneurysm. The baseline absolute difference between FL and TL contrast density measured at 2 cm distal to primary entry tear (TL–FL_abs-Tear) was significantly higher among patients who developed aneurysm (26 HU, IQR: 15–53 vs 13 HU, IQR: 4–24, P = 0.001). Aneurysm development during follow-up was predicted by TL–FL_abs-Tear (odds ratio 1.07, P = 0.012) and baseline maximal aortic diameter (odds ratio 1.90, P < 0.001). High (≥18 HU) differential luminal enhancement was associated with lower rates of aneurysm-free survival and higher rates of medical treatment failure.CONCLUSIONSDifferential luminal enhancement may be a novel predictor of aneurysm formation among patients with acute TBAD.     

Conventional and Laparoscopic Reversal of the Hartmann Procedure: a Review of Literature

Purpose

The aim of this study was to provide a systematic overview on both laparoscopic and conventional Hartmann reversal. Furthermore, the Hartmann procedure is reevaluated in the light of new emerging alternatives.

Methods

Medline, Ovid, EMBASE, and Cochrane database were searched for studies reporting on outcomes after Hartmann reversal.

Results

Thirty-five studies were included in this review of which 30 were retrospective. A total of 6,249 patients with a mean age of 60 years underwent Hartmann reversal. Two thirds of patients were classified as American Society of Anesthesiologists (ASA) I–II. The mean reversal rate after a Hartmann procedure was 44%, and mean time interval between Hartmann procedure and Hartmann reversal was 7.5 months. The most frequent reported reasons for renouncing Hartmann reversal were high ASA classification and patients’ refusal. The overall morbidity rate ranged from 3% to 50% (mean 16.3%) and mortality rate from 0% to 7.1% (mean 1%). Patients treated laparoscopically had a shorter hospital stay (6.9 vs. 10.7 days) and appeared to have lower mean morbidity rates compared to conventional surgery (12.2% vs. 20.3%).

Conclusion

Hartmann reversal carries a high risk on perioperative morbidity and mortality. The mean reversal rate is considerably low (44%). Laparoscopic reversal compares favorably to conventional; however, high level evidence is needed to determine whether it is superior.     

Near-infrared fluorescence imaging of a solitary fibrous tumor of the pancreas using methylene blue

A 67-year-old female presented with unexplained abdominal pain. A contrast-enhanced computed tomography scan of the abdomen incidentally revealed a mass in the uncinate process of the pancreas. This mass was resected and based on histopathological findings, diagnosed as a solitary fibrous tumor (SFT) of the pancreas. A SFT is an extremely rare benign mesenchymal tumor that in 65% of cases affects the visceral pleura but can also affect extra-pleural sites. The intraoperative demarcation of pancreatic tumors, such as SFTs, can bechallenging. In this report, the first clear intraoperative identification of a SFT of the pancreas in a human was shown using near-infrared fluorescence and methylene blue.     

Detection,visualization and evaluation of anomalous coronary anatomy on 16-slice multidetector-row CT

Early identification and evaluation of relatively frequent anomalous coronary anatomy is quite relevant because of the occurrence of sudden cardiac death or related symptoms of myocardial ischemia. Selective coronary angiography (CAG) is invasive, expensive and cannot always provide the required information adequately. Recently, non-invasive imaging techniques such as magnetic resonance imaging and multidetector-row computed tomography (MDCT) have been shown to provide a good anatomical view of the coronary artery tree. This study aims to demonstrate the value of 16-MDCT for evaluation of anomalous coronary anatomy. In 13 patients scanned using 16-MDCT, six different coronary anomalies were diagnosed [two absent left main, one single vessel left coronary artery (LCA), three LCA originating from the right (two with interarterial course), six right coronary artery originating from the left, one double left anterior descending (LAD)]. Mean diagnostic quality, recorded by two observers using a 5-point scale (1= non-diagnostic to 5= excellent diagnostic quality), resulted in a mean score of 3.73 (SD 1.19) without any non-diagnostic result. MDCT offers an accurate diagnostic modality to visualize the origin and course of anomalous coronary arteries by a three-dimensional display of anatomy. Shortcomings in CAG can be overcome by the use of contrast-enhanced MDCT.     

Study on motion artifacts in coronary arteries with an anthropomorphic moving heart phantom on an ECG-gated multidetector computed tomography unit

Acquisition time plays a key role in the quality of cardiac multidetector computed tomography (MDCT) and is directly related to the rotation time of the scanner. The purpose of this study is to examine the influence of heart rate and a multisector reconstruction algorithm on the image quality of coronary arteries of an anthropomorphic adjustable moving heart phantom on an ECG-gated MDCT unit. The heart phantom and a coronary artery phantom were used on a MDCT unit with a rotation time of 500 ms. The movement of the heart was determined by analysis of the images taken at different phases. The results indicate that the movement of the coronary arteries on the heart phantom is comparable to that in a clinical setting. The influence of the heart rate on image quality and artifacts was determined by analysis of several heart rates between 40 and 80 bpm where the movement of the heart was synchronized using a retrospective ECG-gated acquisition protocol. The resulting reformatted volume rendering images of the moving heart and the coronary arteries were qualitatively compared as a result of the heart rate. The evaluation was performed on three independent series by two independent radiologists for the image quality of the coronary arteries and the presence of artifacts. The evaluation shows that at heart rates above 50 bpm the influence of motion artifacts in the coronary arteries becomes apparent. In addition the influence of a dedicated multisector reconstruction technique on image quality was determined. The results show that the image quality of the coronary arteries is not only related to the heart rate and that the influence of the multisector reconstruction technique becomes significant above 70 bpm. Therefore, this study proves that from the actual acquisition time per heart cycle one cannot determine an actual acquisition time, but only a mathematical acquisition time.     

Meta-analysis urges the development of new strategies to treat depression in order to improve cardiac prognosis.

With interest, we read the meta-analysis by Nicholson et al.¹on depression as an aetiological and prognostic factor in coronaryheart disease (CHD). Focusing on the prognostic risk associatedwith depression,     

How to Avoid Underdiagnosed Asthma/Chronic Obstructive Pulmonary Disease?

The prevalence of asthma and chronic obstructive pulmonary disease (COPD) is rising in most countries, including the Netherlands. It has been suggested that a majority of these cases of (self-reported) symptoms related to asthma/COPD are not diagnosed in general practice. We compared a population screening for underdiagnosed asthma/COPD with a high-risk approach by a questionnaire form with specified questions about asthma/COPD-related symptoms. A case-controlled study including a record review was performed of cases and controls. The results of a population screening were used to classify patients as (a) asthma/COPD, (b) at risk for asthma/COPD, or (c) no asthma/COPD. Eleven hundred fifty-five patients were screened. One hundred fifty-five patients reported previous asthma/COPD-related care (cases). The difference between number of cases and controls in asthma/COPD diagnosis was chosen as main outcome measure. The population screening revealed 85 subjects with a diagnosis of asthma/COPD and 154 subjects with an increased risk. Nineteen diagnoses could be made in cases, and eight diagnoses in controls. The chart review showed that only seven cases and two controls were known to the general practitioner. From this study it can be concluded that in order to reduce the number of un- and underdiagnosed patients, all listed patients in general practice should be screened. However, if screening of all patients is not feasible, active case finding by asking a few questions about shortness of breath or wheezing to all patients in the group of listed individuals is recommended.