Choledochojejunostomy revision performed by using the laparoscopic linear cutter

Choledochojejunostomy is commonly performed for biliary bypass for benign and malignant disease. Anastomotic stricture is a known complication of enteric surgery. We report the use of the laparoscopic linear cutter at laparotomy to revise a choledochojejunostomy created 12 years previously for benign disease.     

Factors influencing survival after bypass procedures in patients with advanced pancreatic adenocarcinomas

BACKGROUND: Patients with occult metastasis or locally nonresectable pancreatic cancer found during surgical exploration have a limited life expectancy. We sought to define markers in these patients that could predict survival and thus aid decision making for selection of the most appropriate therapeutic palliative option. METHODS: In a prospective 4-year single-center study, 136 consecutive patients with obstructive pancreatic cancer and intraoperative diagnosis of nonresectable or disseminated pancreatic cancer underwent a palliative surgical bypass procedure. Potential factors predicting survival were evaluated. RESULTS: Ninety-eight patients had metastatic disease and 38 locally advanced disease. Surgical morbidity rate was 16 %, re-operation rate 1%, and overall in-hospital mortality 4%. Univariate analysis showed American Society of Anesthesiologists (ASA) score, pain, operation time, presence of metastasis, and levels of leukocytes, albumin, C-reactive protein (CRP), carcinoembryonic antigen (CEA), and carbohydrate antigen (CA) 19-9 were associated significantly with survival. The multivariate analysis identified ASA score, presence of liver metastasis, pain, CA 19-9, and CEA levels as independent indicators for poor survival. Patients with none or 1 of these risk factors had a median survival of 13.5 months, whereas patients with 4 or 5 risk factors had a median survival of 3.5 months. CONCLUSIONS: The clinical markers identified predict poor outcome for patients with palliative bypass surgery and therefore aid the appropriate selection of either surgical bypass or endoscopic stenting in these patients.     

Ethnic differences in relative risk of idiopathic calcium nephrolithiasis in North America

PURPOSE: Data on susceptibility to kidney stone disease are sparse in individuals of nonEuropean ancestry residing in North America. We determined the relative risk of calcium nephrolithiasis among people of different ethnic backgrounds living in the same geographic region. MATERIALS AND METHODS: Using a cross-sectional design 1,128 consecutive patients with idiopathic calcium nephrolithiasis 18 to 50 years old were recruited from a population based Kidney Stone Center in Toronto. Age and gender adjusted odds ratios and 95% confidence intervals were calculated by logistic regression using the 2001 Canada Census population data. RESULTS: Compared to Europeans the relative risk of calcium nephrolithiasis was significantly higher in individuals of Arabic (OR 3.8, 2.7-5.2), West Indian (OR 2.5, 1.8-3.4), West Asian (OR 2.4, 1.7-3.4) and Latin American (OR 1.7, 1.2-2.4) origin, and significantly lower in those of East Asian (OR 0.4, 0.3-0.5) and African (OR 0.7, 0.5-0.9) background. Several ethnic groups had kidney stone risk factors that were significantly different from those of the European group including higher urinary uric acid, urea excretion and estimated protein intake, and lower urinary citrate, potassium, magnesium and phosphate excretion. However, none was consistent with the variation in relative risk of stone disease overall. CONCLUSIONS: The propensity for the development of calcium nephrolithiasis differed markedly among ethnic groups in North America. While environmental factors could not be completely ruled out, this variability may reflect the influence of genetic susceptibility because there was no dominant environmental factor to account for the differences in relative risk of stone disease.     

Urolithiasis in pediatric patients: a single center study of incidence, clinical presentation and outcome

PURPOSE: The incidence of kidney stones in adults has increased in the last 30 years. This retrospective, single site review was done to test the hypotheses that the incidence of urolithiasis in pediatric patients increased from 1994 to 2005, and that metabolic abnormalities were more common in patients with renal stones in the final 3 years of the study period. MATERIALS AND METHODS: Charts from 2 time periods were reviewed, 1994 to 1996 (period 1) and 2003 to 2005 (period 2). Clinical and laboratory data, including demographics, presenting complaints, laboratory assessment, treatment and outcome, were tabulated in patients with confirmed urolithiasis. RESULTS: The number of patients with urolithiasis increased from 7 in period 1 to 61 in period 2. When expressed as cases per 100 new patients the incidence increased 4.6 times (p = 0.014). Focusing on period 2, 28% of patients were younger than 10 years. While blood tests were generally normal, 76% of patients had at least 1 abnormality in the 24-hour urine collection. Hypocitraturia, which was the most common metabolic abnormality, was noted in 52% of patients. The small number of patients in period 1 precluded determination as to whether metabolic abnormalities were more common in period 2. Surgery and/or lithotripsy was required in 12 children. Stone disease recurred in 39% of the patients. CONCLUSIONS: The incidence of urolithiasis in the pediatric population increased nearly 5-fold at our institution during the last decade. We recommend that the primary diagnostic test be a 24-hour urine collection. The most common metabolic abnormality was hypocitraturia, followed by hypercalciuria. Recurrence of stones is common (approximately 40% rate) and followup is advised.     

Combined electrohydraulic and holmium:YAG laser ureteroscopic nephrolithotripsy of large (greater than 4 cm) renal calculi

PURPOSE: Percutaneous nephrolithotripsy is standard treatment for renal calculi larger than 2 cm. Modern flexible ureteroscopes and accessories using the complimentary effects of electrohydraulic lithotripsy and holmium:YAG laser lithotrites can treat large (greater than 4 cm) branched renal calculi in a minimally invasive fashion with similar or superior results. This report is an assessment of the safety and efficacy of ureteroscopic nephrolithotripsy monotherapy for the management of large (greater than 4 cm) branched renal calculi in the community setting. MATERIALS AND METHODS: A total of 16 patients with 17 branched renal calculi ranging from 41 to 97 mm (mean 65) in length and 560 to 2,425 mm2 (mean 1,169) in area underwent staged ureteroscopic nephrolithotripsy monotherapy. Obesity (body mass index greater than 30) was present in 81% and 38% were morbidly obese (body mass index greater than 40). An infectious etiology was present in 81% and hard stone components were present in 94%. All patients presented with hematuria, pain and/or recurrent urinary tract infection. Lithotripsy was performed with a single deflection flexible ureteroscope and predominantly electrohydraulic lithotripsy. Laser drilling was used (in 4) to weaken hard stones before electrohydraulic lithotripsy. Low intrarenal pressure was maintained by continuous bladder drainage and placement of a stiff safety wire. Visibility was maintained using manual pulsatile irrigation. RESULTS: All patients were rendered pain and infection-free. No patient required a blood transfusion and there was no change in serum creatinine. Mobile stone-free status was achieved in 15 of 17 renal units (88%) with a mean of 2.4 stages and 36 of 40 (90%) procedures performed on an outpatient basis. Operative time averaged 49 minutes per stage and 115 minutes per calculus. There were 3 patients admitted for fever and 1 patient (90 years old) admitted for pneumonia 3 days postoperatively. There were also 3 patients with calculi larger than 75 mm who required ureteroscopic management of steinstrasse. CONCLUSIONS: Staged ureteroscopic nephrolithotripsy of large renal calculi is feasible with low morbidity and stone clearance rates that compare favorably with percutaneous nephrolithotripsy.     

Is ureteroscopy first line treatment for pediatric stone disease?

PURPOSE: We report our current outcomes for ureteroscopic management of pediatric stone disease. MATERIALS AND METHODS: We carried out a retrospective review of all ureteroscopic procedures for kidney or ureteral calculi performed between 2001 and 2005. Stone location and size, preoperative and postoperative stenting, intraoperative dilation, use of ureteral access sheath, stone-free rates and complications were noted. RESULTS: A total of 100 patients (58% female, mean age 13.2 years) underwent 115 procedures. Stones were located in the renal pelvis in 6% of patients, upper pole in 10%, mid ureter in 11%, lower pole in 17%, proximal ureter in 19% and distal ureter in 37%. Mean stone size was 8.3 mm (median 7.0), with a mean of 1.5 stones per patient. Preoperative stenting was used in 54% of patients, and a stent was placed postoperatively in 76%. Ureteral coaxial dilators and ureteral access sheaths were used in 70% and 24% of patients, respectively. There were no major intraoperative complications, although 5 patients required stent placement for ureteral perforation or extravasation. One patient had a ureteral stricture requiring ureteral reimplantation. Mean followup was 10.1 months (median 2.6). Stone-free rate was 91% on followup ultrasound, abdominal radiography or computerized tomography. Seven patients required staged ureteroscopic procedures to achieve stone-free status. While the number of percutaneous nephrolithotomy and shock wave lithotripsy cases remained stable, the number of ureteroscopic cases increased 7-fold during this period. CONCLUSIONS: Improved ureteroscopic access to stones throughout the pediatric urinary tract and stone-free rates that are comparable to the adult population have led to the adoption of ureteroscopy as first line therapy in children at our institution.     

Biliary complications after liver transplantation: A computed tomography and magnetic resonance imaging pictorial review

Biliary complications are the most common complications after liver transplantation. Computed tomography (CT) and magnetic resonance imaging (MRI) are cornerstones for timely diagnosis of biliary complications after liver transplantation. The diagnosis of these complications by CT and MRI requires expertise, mainly with respect to identifying subtle early signs to avoid missed or incorrect diagnoses. For example, biliary strictures may be misdiagnosed on MRI due to size mismatch of the common ducts of the donor and recipient, postoperative edema, pneumobilia, or susceptibility artifacts caused by surgical clips. Proper and prompt diagnosis of biliary complications after transplantation allows the timely initiation of appropriate management. The aim of this pictorial review is to illustrate various CT and MRI findings related to biliary complications after liver transplantation, based on time of presentation after surgery and frequency of occurrence.     

EMT与输尿管结石钬激光碎石后输尿管狭窄的关系研究

目的　探讨分析上皮间质转化（EMT）与输尿管结石钬激光碎石后输尿管狭窄的关系。方法　选取2019年6月至2021年6月河南科技大学第一附属医院行输尿管结石钬激光碎石术后34例出现输尿管狭窄患者作为狭窄组,其中男19例、女15例,年龄（44.54±10.35）岁,按1∶1比例选取同期收治行输尿管钬激光碎石术后未出现输尿管狭窄的34例作为非狭窄组,男20例、女14例,年龄（45.56±9.57）岁。采用χ²检验或独立样本t检验比较两组患者一般资料及血清高迁移率族蛋白B1（HMGB1）、白细胞介素-1β（IL-1β）、转化生长因子-β1（TGF-β1）水平差异,并使用受试者工作特征曲线（ROC）分析血清HMGB1、IL-1β、TGF-β1水平对钬激光碎石术后输尿管狭窄的预测效能。结果　术前,两组患者血清HMGB1、IL-1β、TGF-β1水平比较,差异均无统计学意义（均P>0.05）;术后第7天,狭窄组患者血清HMGB1、IL-1β、TGF-β1水平分别为（15.98±1.11）μg/L、（24.23±1.54）μg/L、（381.58±38.52）ng/L,均高于非狭窄组的（14.21±1.02）μg/L、（23.11±1.08）μg/L、（318.23±27.54）ng/L,差异均有统计学意义（均P<0.05）。ROC分析显示,患者术后第7天血清HMGB1、IL-1β、TGF-β1水平均可作为钬激光碎石术后输尿管狭窄的预测指标（Z=7.421、2.759、10.740,均P<0.05）,其曲线下面积（AUC）分别为0.848、0.679、0.898,其中血清TGF-β1的预测效能最高。结论　钬激光碎石术引起输尿管损伤可导致血清HMGB1、IL-1β、TGF-β1水平升高,患者血清HMGB1、IL-1β、TGF-β1水平可作为钬激光碎石术后输尿管狭窄的预测指标。     

Supracostal access for percutaneous nephrolithotomy: less morbid,more effective

Objectives The aim of this research was to study the success and morbidity of supracostal access for percutaneous nephrolithotomy (PCNL), as it is often avoided for fear of complications. Materials and methods Between July 2000 and May 2007, 565 patients underwent PCNL, of whom 110 had a supracostal access. All procedures were performed in a single sitting under general anesthesia. Data were analyzed prospectively for indications, stone clearance rates, and preoperative and postoperative complications. Results Indications for supracostal access included large pelvic stones in 39 patients, partial or complete staghorn stones in 32, calyceal stones with major stone bulk above the level of 12th rib in 35, and upper ureteric stones in four. Patients’ ages ranged between 13 and 71 years (mean 44.2 years). Fifty-six cases were left sided and 54 right sided, whereas 103 (93.6%) were radiopaque stones. All tracts were in the 11th intercostal space, though one had an additional tract in the tenth space. Single-tract access was used in 101 cases (91.8%), but nine (8.2%) required a second tract. Overall stone clearance rate with PCNL monotherapy was 86.4%, and this increased to 97.3% with secondary procedures. Overall complication rate was 11.8% and included hydrothorax/hemothorax in ten, perinephric collection in one, infection/sepsis in two, and excessive bleeding in two. Postoperative hospital stay ranged from 2 to 15 days. Conclusions The supracostal approach gives high stone clearance rates with acceptable morbidity rates and should be attempted in selected cases. Complications when present may be managed easily with conservative measures.     

Ureteroscopic holmium laser lithotripsy in patients with renal impairment

Objectives In this study, we try to evaluate the efficacy and safety of holmium lasers for treatment of ureteric stones in patients with renal impairment or obstructive anuria. Patients and methods Twenty-six patients were included in this study, of which 20 patients presented with elevated blood urea and serum creatinine (2.1–7.6 mg%), and six patients presented with calcular anuria (mean serum creatinine 22 mg%). None of the patients had a ureteric stent or nephrostomy tube before the ureteroscopy. All patients were treated with holmium laser. A stone basket or grasper was used to remove significant stone fragments at the end of the procedure in seven patients. In these seven patients, ureteric stents were placed at the end of the procedure. Results All patients were free of any stone fragments at 1 week and at 3 months postoperatively. In all patients, including the six with obstructive anuria, the renal impairment resolved or improved as evidenced by normalization or fall in blood urea and creatinine. Thus, in this small group of uremic patients, the success rate for treatment of ureteral stone was 100%. Conclusions A holmium laser is a safe and effective modality of ureteroscopic lithotripsy in patients with significant renal impairment or even obstructive anuria. The use of holmium laser with ureteroscopy may be considered in this group of patients as long as the general condition of the patient permits the safe administration of anesthesia.