Long-term results of endoscopic treatment of vesicoureteral reflux with the sub-ureteric injection of calcium hydroxyapatite

Aim To review our long-term results of the sub-ureteric injection of calcium hydroxyapatite in the endoscopic management of vesicoureteral reflux (VUR) in children. Materials and methods A sub-ureteric injection of calcium hydroxyapatite was given to 14 children (23 ureteral units) affected by VUR grades I–V. All children were followed-up with monthly urine cultures, and a renal ultrasound was done on the postoperative 4th week, while the first voiding cysto-urethrogram (VCUG) control was performed on postoperative week 12. The children were followed-up with yearly renal ultrasound and monthly urine cultures, thereafter. Data from the patients’ charts were retrospectively analyzed regarding the outcome of the procedures. Results Mean follow-up time was 52 months (47–60 months). VUR was cured in 47.4% of cases after a single injection. After the second injection the global success rate was 52.1%. Ureteroneocystostomy was performed on seven refluxing ureters of five children unresponsive to sub-ureteric injection therapy. One patient underwent nephroureterectomy because of a non-functioning kidney secondary to ureteral obstruction due to migration of material at the 23rd month postoperatively. Conclusion Although favorable short-term success rates have been reported with the sub-ureteric injection of calcium hydroxyapatite without any side effects, our long-term results showed a low success rate, with the only reported serious morbidity.     

Pseudoachalasia occurring after laparoscopic Nissen fundoplication and crural mesh repair

Background Benign esophageal pseudoachalasia is a rare condition. Discussion We report the case of a 70-year-old man who complained of severe dysphagia after laparoscopic Nissen fundoplication and crural mesh repair performed for long-standing gastroesophageal reflux disease. Severe dysphagia and nocturnal aspiration developed soon after the operation. A marked dilatation of the esophageal body and a manometric pattern resembling achalasia was documented. Results Endoscopic balloon dilatation was ineffective. Five months after the initial operation, the patient underwent revisional laparoscopic surgery that consisted of Nissen’s wrap takedown, enlargement of the hiatus with partial resection of the mesh, Heller myotomy, and Dor fundoplication. After a 2-year follow-up, the patient is doing well and is free of symptoms.     

Evolution of endoscopic management of ectopic ureterocele: a new approach

PURPOSE: We report the evolution of endoscopic treatment of ectopic ureteroceles from the unroofing technique to a novel approach using concomitant ureterocele double puncture and intraureterocele fulguration. We also compare the results of different endoscopic modalities at a single center. MATERIALS AND METHODS: We reviewed the records of 46 children with ectopic ureteroceles who were treated endoscopically between 1995 and 2005. The patients were divided into 2 main groups. Group 1 included 17 patients who underwent common endoscopic treatments, including ureterocele incision (4 patients), single ureterocele puncture (4), and single puncture with insertion of a Double-J stent (9). Group 2 included 29 children who underwent ureterocele double puncture and fulguration of the anterior and posterior walls of the collapsed ureterocele after insertion of a Double-J stent into both punctured sites. We also managed concomitant vesicoureteral reflux by endoscopic injection of tricalcium phosphate ceramic into the subureteral region. RESULTS: Total success rates in group 1 were 0%, 25% and 33% in patients who underwent ureterocele incision, single ureterocele puncture and single puncture with insertion of a stent, respectively. Total success rate in group 2 was 90% (p<0.05). New onset vesicoureteral reflux developed in 8 patients (47%) in group 1, of which 6 were in ureterocele moieties, and in 8 patients (28%) in group 2, with none in a ureterocele moiety (p<0.01). A total of 13 patients (76%) in group 1 required open surgical intervention, compared to 3 (10%) in group 2 (p<0.05). CONCLUSIONS: This new endoscopic approach is highly effective in the treatment of children with ectopic ureteroceles.     

Legg-Perthes病动物模型设计与评价

目的：设计制作静脉回受阻Legg-Perthes病动物模型，并对其进行观察评价。方法：选择健康杂种幼犬20只，雌雄不拘。采用自身对照方法，一侧髋用来实验，一侧髋作为对照，应用套针经皮大于转子下方穿入股骨颈中央达股骨头颈部骺板远侧，注入1ml医用TH胶，于实验不同时期行骨骺后内压、X线、CT检查，组织标本行常规病理检查，结果：实验制作了影像及组织病理变化类似于人类Legg-Perthes病的动物模型。结论：此模型设计合理，制作方法简单，重复性较强。     

食管胃黏膜延长分层吻合的实验研究

目的　探讨食管胃吻合抗胃食管反流、预防吻合口瘘及狭窄的术式。　方法　选杂种犬 5 8条 ,随机分为实验组和对照组。实验组 :31条犬 ,自贲门横断 ,食管黏膜延长 1.5～ 2 cm;切除部分胃小弯 ,剥除大弯侧保留部分浆肌层 ,成形为宽 3～ 3.5 cm、长 4～ 5 cm黏膜管 ,行食管胃黏膜、肌层分层吻合。对照组 :2 7条犬 ,用“深套叠”术式。于术后 3～ 180天检测对比分析。　结果　两组突入胃内结构长度、肌层吻合口直径差别无显著性意义 (P>0 .0 5 ) ,黏膜游离缘直径差别有显著性意义 (P<0 .0 1) ;实验组能耐受较高胃内压 ,胃与食管压力差两组差别有显著性意义 (P<0 .0 1) ;突向胃腔内结构厚度两组相差 1倍以上 ;实验组成形黏膜血供良好 ,吻合口愈合及缝线脱落早于对照组。　结论　适当剥除肌层不引起黏膜缺血坏死 ;成形黏膜瓣薄软 ,具有良好的抗反流效果 ;黏膜层密缝对合严密、愈合快 ,能有效预防吻合口瘘的发生 ,不同平面吻合狭窄发生率低。     

Physiologic mechanism and preoperative prediction of new-onset dysphagia after laparoscopic Nissen fundoplication

The aim of this study was to determine whether preoperative physiologic factors can account for and be used to predict the development of postoperative dysphagia after laparoscopic Nissen fundoplication. One hundred sixty-three patients with gastroesophageal reflux disease underwent laparoscopic Nissen fundoplication with a median follow-up of 14 months (range 6 to 81 months). Preoperative dysphagia was present in 37% (60 of 163) and was relieved in all but five patients (92%). Female sex (P = 0.01) and the presence of a stricture (P = 0.02) were the only preoperative variables associated with the presence of preoperative dysphagia. Eight percent (8 of 103) of patients without preoperative dysphagia developed new-onset dysphagia, and of these 63% (5 of 8) had a normal lower esophageal sphincter (LES) (pressure >6 mm Hg; length >2 cm; abdominal length >1 cm). New-onset dysphagia was significantly more common in patients with a normal LES (22% [5 of 23] vs. 4% [3 of 80], P = 001). Patients with a normal LES had almost a sixfold increase in the risk of developing dysphagia as those with an abnormal LES (relative risk = 5.8). Only a preoperative normal LES (P = 0.02) or mean LES pressures (P = 0.04) were positively associated with the development of postoperative dysphagia. The severity of this dysphagia also showed a strong positive trend of increasing with mean preoperative LES pressures (P = 0.07). Finally, preoperative LES pressure significantly correlated with postoperative LES pressure (r = 0.48, P = 0.01) and with mean residual LES (nadir) pressure (r = 0.33, P = 0.05) offering insight into the mechanism of this dysphagia. In conclusion, preoperative LES parameters play a role in the development of dysphagia after laparoscopic Nissen fundoplication. Patients with a normal LES or high mean LES pressures are at increased risk for developing this complication and should be informed of this before laparoscopic Nissen fundoplication. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Ga., May 20–23, 2001.     

Extravesical diverticuloplasty for repair of a paraureteral diverticulum and the associated refluxing ureter

PURPOSE: Extravesical diverticuloplasty for repairing a paraureteral (Hutch) diverticulum and the related refluxing ureter is presented. MATERIALS AND METHODS: Of the 16 children in this study 10 had bilateral paraureteral diverticula with associated bilateral vesicoureteral reflux, 2 had bilateral paraureteral diverticula with a bilateral duplicated ureter, unilateral duplex refluxing ureters and contralateral lower moiety vesicoureteral reflux, and 4 had a unilateral paraureteral diverticulum with an ipsilateral refluxing ureter. The anatomical relationship of the ureteral orifice and diverticulum was identified by cystourethroscopy preoperatively and confirmed during the extravesical operation. The surgical technique differed depending on the size of the diverticulum and the position of the ureteral opening when the bladder was completely distended. The larger prolapsed diverticular mucosa served as a backing for the detrusor muscle, which was closed over the ureter, and the smaller diverticulum was repaired as a dilated ureter. Overall 30 renal units with grades II to IV vesicoureteral reflux were corrected by this method. RESULTS: All patients were followed with ultrasound and voiding cystourethrography 3 and 9 months postoperatively. The diverticula with associated refluxing ureters were successfully cured. Neither postoperative recurrence nor ureteral obstruction were noted. CONCLUSIONS: Extravesical diverticuloplasty can be performed for many sizes of paraureteral diverticula and concomitantly for the associated refluxing ureter, including refluxing duplex ureters.     

下肢静脉曲张患者静脉溃疡形成危险因素的病例对照研究

目的探讨下肢静脉曲张患者静脉溃疡形成的潜在危险因素,为静脉溃疡预防策略提供依据。方法纳入下肢静脉曲张伴静脉溃疡患者92例作为病例组,同期住院的下肢静脉曲张但不伴静脉溃疡患者92例作为对照组,收集两组患者一般资料、近两年生活及工作方式、既往史及家族史等资料,分析下肢静脉曲张患者静脉溃疡形成的危险因素。结果年龄≥45岁、下肢深静脉反流、高血压病、大量吸烟、重体力工作、下肢静脉血栓及外伤史是下肢静脉曲张患者静脉溃疡形成的独立危险因素(P<0.05,P<0.01)。结论对于下肢静脉曲张患者积极治疗下肢深静脉反流、控制血压、戒烟及减少重体力工作对预防静脉溃疡形成具有重要的临床意义。     

Differential molecular changes in patients with asymptomatic long-segment Barrett's esophagus treated by antireflux surgery or medical therapy

Background

The Barrett's to adenocarcinoma sequence is characterized by molecular changes including activation of nuclear factor-κB (NF-κB) and related cytokines. In this observational nonrandomized study this molecular environment was compared in matched asymptomatic cohorts who had undergone either fundoplication or therapy with proton pump inhibitors (PPIs).

Methods

Asymptomatic patients with long-segment Barrett's esophagus had endoscopic biopsy specimens taken from 2 cm below the squamocolumnar junction for measurement of activated NF-κB and a panel of cytokines and growth factors.

Results

Thirty-seven patients were recruited (surgical: n = 18, medical: n = 19). The mean patient age was 51 years, and the mean follow-up period was 5.6 years. There were no differences in the length of Barrett's segment and endoscopic and histopathologic features in both groups. Mean activated NF-κB p50 and p65 subunits, interleukin (IL)-1α, IL-1β, and interleukin-8 levels, were significantly (P < .05) lower in the surgically treated group.

Conclusions

This study provides proxy support to the thesis that antireflux surgery may provide an environment that is less inflammatory and tumorigenic than that observed in medically treated patients.     

Laparoscopic transgastric esophageal mucosal resection: 4-year minimum follow-up

Background

The management of high-grade esophageal dysplasia has included surveillance, endoscopic ablative techniques, and esophagectomy. Herein we describe an alternative treatment, laparoscopic transgastric esophageal mucosal resection.

Methods

Laparoscopic transgastric esophageal mucosal resection was accomplished through an anterior gastrotomy. The mucosa was stripped from the Z-line to the proximal extent of the abnormal epithelium. The gastrotomy then was closed with a linear stapler, and a Nissen fundoplication was performed.

Results

Six patients with high-grade dysplasia of the distal esophagus underwent mucosal resection. After 4 to 7 years of endoscopic surveillance, all patients have regenerated squamous epithelium. One patient developed nondysplastic Barrett's esophagus after 2 years and was treated medically. Two strictures were treated successfully with dilatation.

Conclusions

Laparoscopic transgastric esophageal mucosal resection was a reasonable treatment for high-grade dysplasia in this small sample of patients. This technique is a potential alternative treatment for high-grade dysplasia of the esophagus.