Tratamiento laparoscópico de la ureterolitiasis: nuestra experiencia

ObjectiveAnalyze technical details and results of laparoscopic treatment of ureterolithiasis.Materials and methodsBetween January 2005 and August 2008 it was performed laparoscopic ureterolithotomy in 22 patients in our service. Two (9%) by retroperitoneal access and 20 (91%) by transperitoneal access. Mean size of the calculi was 15 mm. with a variation from 8 mm to 23 mm. The calculus were in the upper tract in 18 patients (81,8%) and in mid ureter in 4 patients (18,2), any of the calculus were in lower ureter. Most of calculi were obstructive stones for more than 2 months. Eight patients were submited a previous section of extracorporeal shockwave lithotripsy and 2 by extracorporeal shockwave lithotripsy plus ureterolithotripsy as a calculi treatment attempt. Twelve patients had a laparoscopic ureterolithotomy as a primary indication for treatment.ResultsLaparoscopic ureterolithotomy was successful for 20 patients (90,9%), and the fails occurred in the beginning of our experiment. Mean operative time was 145 minutes with range from 70 to 240 minutes. The indwelling ureteral stent was used in 03 cases; 02 preoperative, and 01 postoperative. The ureteral suture was performed with absorbable 4.0 separated stitches in all patients. The global average of permanence in hospital was 3,3 days and the drain permanence was 7,2 days. The global complication rate was 13,6%. The global rate of stone free was 91%, and there were residual stone in 2 patients.ConclusionsThe laparoscopic treatment of ureterolithiasis besides minimally invasive, it is viable, secure and very effective. It should have taken into consideration as a procedure to extracorporeal shockwave lithotripsy and ureteroscopy. But, in cases where there are obstructive stones for a long time, in selected patients and, in special, in patients with just one kidney, it can be considered as a first line treatment. About the access, if retroperitoneal or transperitoneal; it is not still possible to affirm which would be the best one, the option must take into account the surgeon preference and experience.     

Aortoiliac surgery concomitant with kidney transplantation: a single center experience

Abstract: Introduction: Aortoiliac pathology in kidney allograft recipients is not rare but treatment timing is controversial. As most publications on this topic are case reports it’s difficult to evaluate long‐term outcomes of those clinical challenges. Herein we report long‐term results of these procedures. Methods: From 1970 to 2006, 1544 kidney transplants were performed in our center. Thirty patients underwent aortoiliac surgery simultaneously with kidney transplantation. We analyzed their clinical records to come up with outcomes of these complex clinical challenges. Results: Vascular pathology was distributed as following: 19 stenoses treated with endarterectomy (15), aortoiliac bypass (two), aorto‐bi‐iliac bypass (one) and aorto‐bifemoral bypass (one); and 11 aneurysms treated with arterioplasty (four), aorto‐bi‐iliac bypass (four) and iliac‐iliac bypass (three). In 24 cases (80%) the necessity of vascular surgery was established intraoperatively as vessels’ conditions did not permit safe anastomoses and jeopardized graft survival. Mean follow‐up was 59 months (12–125). Five (16.7%) grafts were lost and three (10%) patients died in the first post‐operative month: acute myocardial infarction (two) and non‐viable kidney (one). Three patients died six, seven and 10 yr after the procedure. Nineteen patients are currently well with functioning grafts. Conclusions: Surgical correction of aortoiliac pathology may be performed simultaneously with kidney transplantation with acceptable outcome. This complex surgery can be performed in centers with experienced vascular surgeons. Specific vascular imaging should be performed regularly on patient at risk of aortoiliac disease before insertion and while on waiting list.     

Diagnostic assessment and long-term follow-up of 13 patients with Very Long-Chain Acyl-Coenzyme A dehydrogenase (VLCAD) deficiency

Very Long-Chain Acyl-CoA dehydrogenase (VLCAD) deficiency is an inborn error of mitochondrial long-chain fatty acid oxidation (FAO) most often occurring in childhood with cardiac or liver involvement, but rhabdomyolysis attacks have also been reported in adults. We report in this study the clinical, biochemical and molecular studies in 13 adult patients from 10 different families with VLCAD deficiency. The enzyme defect was demonstrated in cultured skin fibroblasts or lymphocytes. All patients exhibited exercise intolerance and recurrent rhabdomyolysis episodes, which were generally triggered by strenuous exercise, fasting, cold or fever (mean age at onset: 10 years). Inaugural life-threatening general manifestations also occurred before the age of 3 years in four patients. Increased levels of long-chain acylcarnitines with tetradecenoylcarnitine (C14:1) as the most prominent species were observed in all patients. Muscle biopsies showed a mild lipidosis in four patients. For all patients but two, molecular analysis showed homozygous (4 patients) or compound heterozygous genotype (7 patients). For the two remaining patients, only one mutation in a heterozygous state was detected. This study confirms that VLCAD deficiency, although being less frequent than CPT II deficiency, should be systematically considered in the differential diagnosis of exercise-induced rhabdomyolysis. Measurement of fasting blood acylcarnitines by tandem mass spectrometry allows accurate biochemical diagnosis and should therefore be performed in all patients presenting with unexplained muscle exercise intolerance or rhabdomyolysis.     

A critical appraisal of lithium's efficacy and effectiveness: the last 60 years

The history that depicts the evaluation of lithium's efficacy presents an interesting contrast: on the one hand, conviction that, of all psychotropic drugs, lithium has the best demonstrated efficacy; on the other hand, repeated attempts to question it. Those contesting lithium's stabilizing abilities have argued from several angles, for example that the proof was methodologically incorrect or insufficient, that the number of responders is small, or that the response is poor in practice and does not last. But there is a good explanation for this paradox. While the early challenges to lithium's value in recurrent mood disorders reflected mainly that psychiatry had not yet developed a methodology suitable for testing long-term efficacy, more recent questioning has resulted mostly from retesting its efficacy and effectiveness in a substantially broadened bipolar spectrum, outside the classical diagnosis. Lithium, however, continues to stabilize very well the patients suffering from typical bipolar disorder—the condition for which its efficacy was originally demonstrated. More recently, lithium has also proven to dramatically reduce suicidal behavior and mortality and to augment markedly the efficacy of antidepressants in unresponsive patients.     

Technical aspects of an impact acceleration traumatic brain injury rat model with potential suitability for both microdialysis and PtiO2 monitoring

This report describes technical adaptations of a traumatic brain injury (TBI) model—largely inspired by Marmarou—in order to monitor microdialysis data and P_tiO₂ (brain tissue oxygen) before, during and after injury. We particularly focalize on our model requirements which allows us to re-create some drastic pathological characteristics experienced by severely head-injured patients: impact on a closed skull, no ventilation immediately after impact, presence of diffuse axonal injuries and secondary brain insults from systemic origin… We notably give priority to minimize anaesthesia duration in order to tend to banish any neuroprotection.Our new model will henceforth allow a better understanding of neurochemical and biochemical alterations resulting from traumatic brain injury, using microdialysis and P_tiO₂ techniques already monitored in our Intensive Care Unit. Studies on efficiency and therapeutic window of neuroprotective pharmacological molecules are now conceivable to ameliorate severe head-injury treatment.