Left Loin Research Articles

Surgery in the Treatment of Acute Pancreatitis Minimal Access Pancreatic Necrosectomy

Between 5% and 10% of patients with acute pancreatitis will develop infected pancreatic necrosis. Traditional open surgery for this condition carries a mortality rate of up to 50%, and therefore a number of less invasive techniques have been developed, including radiological drainage and a minimal access retroperitoneal approach. No randomised controlled trials have been published which compare these techniques. Indications for minimal access surgery are the same as for open surgery, i.e. infected pancreatic necrosis or failure to improve with extensive sterile necrosis. Access is obtained to the pancreatic necrosis via the left loin and necrosectomy performed using an operating nephroscope, and this often requires several procedures to remove all necrotic tissue. The cavity is continuously irrigated on the ward in between procedures. The results of this approach are encouraging, with less systemic upset to the patient, a lower incidence of post-operative organ failure when compared with open surgery, and a reduced requirement for ITU support. There is also a trend towards a lower mortality rate, although this does not reach statistical significance on the data published so far. Current evidence suggests that a minimal access approach to pancreatic necrosis is feasible, well tolerated and beneficial for the patient when compared with open surgery.

X-Ray Quiz: An Old Lady with Urinary Tract Symptoms

A 72-year-old lady suffering from a systemic disease presented with frequency, dysuria and haematuria for two days. She had no fever. She claimed to have pain over the lower abdominal and left loin regions. The r e wa s no r e c en t h i s t o r y o f su rg e r y o r instrumentation. Physical examination revealed left loin and supra-pubic tenderness but there was no guarding. A plain kidney, ureter and bladder (KUB) r a d i o g r a p h w a s t a k e n . U l t r a s o u n d s h ow e d unremarkable kidneys. The bladder was found collapsed during the examination.

Relationship between the Porcine Stress Syndrome gene and carcass and performance traits in F2 pigs resulting from divergent crosses

The PSS genotypes of 596 F2 pigs produced by initial mating of Brazilian native boars commercial sows and were characterized by PCR-RFLP and their carcass and performance traits were evaluated. Among the 596 animals analyzed, 493 (82.72%) were characterized as NN and 103 (17.28%) as Nn. With respect to carcass traits, Nn animals presented higher (p < 0.05) right half carcass weight, left half carcass weight, loin depth and loin eye area, and lower shoulder backfat thickness, backfat thickness between last and next to last but one lumbar vertebrae and backfat thickness after last rib at 6.5 cm from the midline compared to NN animals. Nn animals also showed (p < 0.05) higher values for most of the cut yields, indicating higher cutting yields for animals carrying the n allele and lower values for bacon depth, confirming lower fat deposition in carcass. In addition, Nn animals presented (p < 0.05) lower values for the performance trait weight at 105 days of age. These results indicate that animals carrying the PSS gene generate leaner carcasses, higher cut yields, and that the effects of the gene can be observed even in divergent crosses.

Painful attraction: a magnetic penile injury

noted. No gastrointestinal abnormalities were found. His abdominal pain was attributed to the muscular strain of vomiting and was treated with simple analgesics. Now he had a low-grade fever and a tender left loin and his urine contained blood and leukocytes. Serum creatinine was 150 mmol/L, lactate dehydrogenase 1694 U/L (reference range 270–620). CT revealed bilateral renal infarcts, more numerous in the left kidney (Figure 1) than the right; the left renal artery was also obstructed. At echocardiography the left ventricle was found to be dilated and severely impaired in function; its apex appeared aneurysmal and contained a mobile thrombus. He was anticoagulated and made a slow recovery.

Endometriosis Presenting as Hydronephrosis

The most serious urological complication of endometriosis is hydronephrotic renal atrophy secondary to ureteric involvement. As only half of these patients are symptomatic, it is commonly diagnosed late and more by the clinicians awareness and suspicion of this entity. We report a case of an unmarried young female who presented primarily with left loin pain of 2-year duration. She was found to have lower ureteric stricture by an IVU done by her referring doctor. Further workup at our center showed that she had pelvic endometriosis with hydronephrosis secondary to extrinsic ureteric endometriosis. She had a first-degree relative with the same disease. She had no menstrual problems. Diagnostic laparoscopy, biopsy of the lesion, ureteric dilatation with stenting, along with hormonal treatment was given to her as first line of treatment. There was no improvement of the ureteric obstruction even after 6 months of treatment. Finally, surgical excision of the endometrioma, left oophorectomy, along with resection of the ureteric stricture with uretero-ureterostomy was done. This case report includes details of her further management and outcome along with a brief review of literature.

Epiphrenic gastric diverticulum containing tablets simulating a left adrenal mass with calcification

An 83-year-old woman was admitted to hospital with left lowerlobe pneumonia and a urinary tract infection. The patient wasreferred to the Radiology Department for investigation ofunremitting pyrexia associated with left loin pain.Abdominal ultrasound demonstrated a small amount of leftperinephric fluid with mild bilateral renal cortical thinning. Thepatient subsequently underwent contrast-enhanced multisliceCT of the abdomen (70 ml Niopam 300 intravenous contrast with500 ml water oral contrast; Aquilion 16 CT machine, ToshibaMedical Systems Limited, The Netherlands, Europe BV). Multi-planar reformatting was performed on a Vitrea Workstation(Toshiba ReportDirect V500, Toshiba Medical Systems Limited)using 1 mm-thick reconstructed axial images.Axial images demonstrated an approximately 4

Radiation-Induced Rectal Cancer Originating from a Rectocutaneous Fistula: Report of a Case

This report describes a patient with radiation-induced rectal cancer with an unusual history. A 51-year-old man was admitted in 2000 because of ichorrhea of the skin on the left loin. The patient had received irradiation for a suspicious diagnosis of a malignant tumor in the pelvic cavity in 1975. A subcutaneous abscess in the right loin appeared in 1989, and rectocutaneous fistula was noted in 1992. Moreover, radiation-induced rectal cancer developed in 2000. Plain computed tomography and magnetic resonance imaging of the pelvis demonstrated a presacral mass and tumor in the rectum. Finally, we diagnosed the presacral mass to be an abscess attached to the center of the rectal cancer. The rectum was resected by Miles' operation and a colostomy of the sigmoid colon was also performed. Many cases of radiation-induced rectal cancer have been reported. However, this is a rare case of radiation-induced rectal cancer originating from a presacral abscess and rectocutaneous fistula.

Sensory and instrumental analysis of longitudinal and transverse textural variation in pork longissimus dorsi

In the present study sensory and instrumental analysis of the textural properties of pork longissimus dorsi were performed and analysed using multivariate data analytical methodologies. The aims were to determine how textural properties of musculus longissimus dorsi varied transversely, longitudinally, between left and right muscles, and as a function of ageing. By training the panel in the descriptive texture profile method the panellists were able to clearly detect, discriminate and describe the textural variation in the samples, except for the transverse variation. Sensory evaluation revealed a non-significant trend ( P>0.05) of decreasing tenderness from dorsal (nearest the spinal column) to medial sampling position. When analysed instrumentally, using a modified Warner–Bratzler shear force apparatus, the transverse muscle variation was found to increase in force (N) required for deformation from dorsal to lateral sampling position. Overall, these two methods agreed in that the dorsal position was the more tender of the three positions investigated. Lengthwise muscle variation was highly defined when assessed using sensory analysis, whereas instrumental analysis was unable to detect this variation. The sensory analysis revealed that tenderness decreased and hardness increased as the sample position approached the caudal end of the muscle. Additionally, sensory analysis revealed a major turnover point in textural properties at the end of the ribcage area in that tenderness showed a marked decrease in this area and hardness and juiciness increased correspondingly in the same area. Both sensory and instrumental analysis showed that muscles from left and right side of the carcass differed significantly ( P<0.05) in their textural properties. The right side muscle was clearly defined into stages more so than the left side muscle. In addition, the right loin was found to be harder per se than the left loin, which was postulated to be caused by a greater amount of work performed by right muscles compared to left muscles. Significant differences ( P<0.05) in sensory textural attributes were observed overall with increased ageing. The variation within muscles, which contributed to the overall change in texture with ageing, was found to be due to changes in the longitudinal variation, in that the individual chop variation observed at the cranial end became less pronounced when the meat was aged. Differences observed between the cranial and caudal end remained, regardless of ageing for 4 or 7 days. No changes could be seen in the transverse texture during ageing. In general, sensory and instrumental analyses were found largely to be predictive indexes of each other. However, these two methods could not be said to be causally predictive in that they did not measure the same physical properties of the meat. For instance sensory determined tenderness is a result of the type and rate of deformation and the heterogeneity of the sample assessed, whereas instrumental measurement is a result of resistance to shearing. The present study showed significant variation between longitudinal locations and this variation is critical when designing sensory texture profiling experiments of meat from loins. Moreover, the textural differences between left and right loin muscles must be considered when texture prediction is the objective if an applicable conclusion is to be drawn.

Upper Urinary Tract Complications in Pregnant Women with an Ileal ConduitLessons Learned from Two Cases

We describe the occurrence of severe upper urinary tract complications during pregnancy in two women with an ileal conduit. The first patient developed several episodes of left pyelonephritis throughout the duration of her pregnancy but never received proper antibiotic prophylaxis. Intravenous urography performed after delivery documented bilateral staghorn kidney stones and a non-functioning left kidney. The second patient developed severe left loin pain and a high temperature during the fourth month of pregnancy after discontinuing antibiotic prophylaxis. An MRI urogram demonstrated compression of the ureter by the foetus. Symptoms were relieved as soon as the antibiotic prophylaxis was resumed and the pain remained under control with the occasional use of paracetamol until delivery. Based on these observations it appears that the left upper urinary tract may be more prone to dilatation in pregnant patients with an ileal conduit and antibiotic prophylaxis is mandatory throughout the duration of the pregnancy in order to minimize the risk of severe upper urinary tract complications.

Unpredicted spontaneous extrusion of a renal calculus in an adult male with spina bifida and paraplegia: report of a misdiagnosis. Measures to be taken to reduce urological errors in spinal cord injury patients

BackgroundA delay in diagnosis or a misdiagnosis may occur in patients with spinal cord injury (SCI) or spinal bifida as typical symptoms of a clinical condition may be absent because of their neurological impairment.Case presentationA 29-year old male, who was born with spina bifida and hydrocephalus, became unwell and developed a swelling and large red mark in his left loin eighteen months ago. Pyonephrosis or perinephric abscess was suspected. X-ray of the abdomen showed left-sided staghorn calculus. Since ultrasound scan showed no features of pyonephrosis or perinephric abscess, he was prescribed a prolonged course of antibiotics for infection presumed to arise from the site of metal implant in spine. He developed a discharging sinus, following which the loin swelling and red mark subsided. About three months ago, he again developed a red mark and minimal swelling in the left loin. Ultrasound scan detected no abnormality in the renal or perinephric region. Therefore, the red mark and swelling were attributed to pressure from the backrest of his chair. Five weeks later, the swelling in the left loin burst open and a large stone was extruded spontaneously. An X-ray of the abdomen showed that he had extruded the central portion of the staghorn calculus from left kidney. With hindsight, the extruded renal calculus could be seen lying in the subcutaneous tissue of left loin lateral to the 10th rib in the X-ray of abdomen, which was taken when he presented with red mark and minimal swelling.ConclusionThis case illustrates how mistakes in diagnosis could occur in spinal cord injury patients, and highlights the need for corrective measures to reduce urological errors in these patients. Voluntary reporting of urological errors is recommended to facilitate learning from our mistakes. In the patients who have marked spinal curvature, ultrasonography of kidneys and perinephric region may not be entirely reliable. As clinical symptoms and signs may be non-specific in SCI patients, they require prompt, detailed and occasionally, repeated investigations. A joint team approach by health professionals belonging to various medical disciplines, which is strengthened by frequent, informal and honest discussions of a patient's clinical condition, is likely to reduce urological errors in SCI patients.

RETROPERITONEAL FIBROSIS IN 2 BROTHERS

Case 1. A 51-year-old man presented with a 3-month history of left loin pain. Excretory urography and ultrasound revealed moderate left hydronephrosis. Left retrograde ureterography revealed a tight stricture at the level of the 3rd and 4th lumbar vertebrae (fig. 1). Computerized tomography (CT) of the abdomen with contrast medium showed a dilated left renal pelvis. There was abnormal soft tissue surrounding the left ureter and extending along the proximal common iliac arteries. Isotope renography confirmed that the left kidney was nonfunctioning and left nephrectomy was performed. Histological examination revealed chronic interstitial nephritis with periureteral inflammation and fibrosis. Biopsies of the retroperitoneum were consistent with the clinical diagnosis of retroperitoneal fibrosis. Case 2. The 62-year-old brother of case 1 presented with a 1-month history of back pain. Ultrasound reveale da4c m. infrarenal fusiform aneurysm extending across the bifurcation to involve the right common iliac artery. Contrast enhanced CT confirmed these findings and showed excess soft tissue around the lower aorta consistent with an inflammatory response. Diagnosis was inflammatory aneurysm (fig. 2). At 10 months after presentation aortic lumbar graft repair was performed. Histological examination of the resected specimen showed collagenous tissue infiltrated by fat and inflammatory cells. The patient returned a month later with right loin pain. Ultrasound revealed right hydronephrosis and excretory urography showed a nonfunctioning right kidney. CT confirmed the presence of retroperitoneal fibrosis causing extrinsic ureteral obstruction. DISCUSSION

CHYLURIA AFTER RADICAL NEPHRECTOMY TREATED WITH N-BUTYL-2-CYANOACRYLATE

Chyluria is usually due to parasitic infection with Wuchereria bancrofti. Nonparasitic chyluria can be due to trauma, tuberculosis, surgery, for example aortoiliac bypass grafting, tumor or congenital lymphatic anomalies. We report a case of chyluria due to a lymphatic ureteral fistula after radical nephrectomy and lymphadenectomy. The fistula was treated successfully with ureteral occlusion using N-butyl-2-cyanoacrylate tissue adhesive. CASE REPORT A 42-year-old woman presented with severe left loin pain radiating to the iliac fossa. She had had 2 episodes of painless hematuria during the previous 4 months and was apyrexial with a large ballotable mass in the left loin. Erythrocyte sedimentation rate, serum albumin and creatinine were normal. Ultrasound and computerized tomography showed an 8 cm. heterogeneous solid lesion in the lower pole of the left kidney and suspiciously enlarged para-aortic nodes. Left radical nephrectomy was performed with the ureter ligated and transected at its mid third. The left para-aortic lymph nodes were 1 cm. in diameter and the entire lymphatic chain from the celiac axis to the pelvic brim was excised in continuity. Histology demonstrated Fuhrman grade II clear cell carcinoma without capsular invasion and reactive changes only in the lymph nodes. The patient noticed milky urine 3 weeks postoperatively. Urinalysis revealed 2.0 mmol./l. triglyceride concentration and 15.36 gm./l. proteinuria consistent with chyluria. There was post-prandial worsening of the chyluria and voiding was difficult due to obstruction from fibrin clots. Cystoscopy showed no chylous efflux. Retrograde assessment of the ureteral stump confirmed a fine communication with a lymphatic collection in the para-aortic space (fig. 1). There were multiple chyle clots in the bladder. Dilute povidone-iodine (0.2%, 15 ml.) was injected into the ureteral stump to sclerose the fistula.1 However, chyluria recurred 48 hours after the injection and persisted 2 months postoperatively, causing hypoproteinemia (albumin 27 gm./l.), ankle swelling, weight loss, lethargy and malaise. Under fluoroscopic guidance a catheter and long vascular sheath primed with 5% dextrose were advanced over a guide wire into the left ureteral stump. A mixture of 1 ml. N-butyl2-cyanoacrylate and 1 ml. iodized oil was injected into the upper half of the ureteral stump with immediate solidification (fig. 2). The chyluria resolved immediately and serial abdominal ultrasonography showed no evidence of intraabdominal lymphatic collection. At 1-year followup the patient was well with no recurrence of chyluria. DISCUSSION N-butyl-2-cyanoacrylate has been used to close minor superficial skin wounds as an alternative to sutures for many years. It has also been used by interventional radiologists for a wide variety of purposes, including embolization of intracranial arteriovenous malformations, spinal dural arteriovenous fistulas, uterine arteriovenous malformation, massive obstetric hemorrhage and high flow prapism due to blunt perineal trauma.2 In the urinary tract interventional radiologists have performed antegrade transrenal ureteral occlusion as palliative treatment of lower urinary tract fistulas, mainly in the presence of extensive pelvic malignancy or following radiotherapy. Gianturco coils with tissue adhesive and detachable balloons with or without tissue adhesive have also been used.3

Intestinal pseudo-obstruction following renal stone extracorporeal lithotripsy in a diabetic patient

A 61-year-old male patient was admitted because of fications are also detectable. chronic loin pain due to a kidney stone in the left renal pelvis. At 48 years of age type 2 diabetes mellitus was diagnosed and treated with oral anti-diabetic drugs for kidney without significant dilation of pelvis or caliceal 3 years and then by insulin. Peripheral vascular disease structures. Physical examination was unremarkable. was also reported. Two weeks before admission, the The patient’s body weight was 69 kg, body mass index patient experienced left loin pain with gross haemat- 26.0 kg/m2 and arterial blood pressure was uria. Sonography and plain radiography demonstrated 125/80 mmHg. Plasma biochemistry showed fasting a calcium stone in the left renal pelvis ( Figure 1). glucose levels of about 150 mg/dl, HbA 1c 8.2%, and Excretory urography confirmed the presence of a normal values for ALT, AST, pseudocholinesterase, 18 mm diameter calcium-containing stone in the left creatinine, electrolytes and coagulation tests.

FILARIAL CYSTITIS WITH URETERAL OBSTRUCTION

Filariasis is a common parasitic infection in the tropics. The epididymis, scrotum, penile skin and rarely the kidney are the sites of involvement in the genitourinary tract. To our knowledge we report the first case of filarial cystitis with ureteral obstruction with an excellent response to medical therapy. CASE REPORT A 58-year-old man presented with frequent dysuria and left loin pain 4 months in duration with 1 episode of hematuna. He was from northeastern India, which is endemic for filariasis. Physical examination was noncontributory. Urine was sterile and showed numerous red cells on microscopy. Biochemical parameters and renal function were normal. An excretory urogram showed delayed excretion on the left side and a small capacity bladder (fig. 1, A). Ultrasound demonstrated left hydronephrosis. The right kidney was normal. At cystoscopy the mucosa was red and edematous. The left ureteral orifice could not be located. Bladder capacity was 250 ml. Multiple bladder mucosal biopsies were taken. To salvage renal function ultrasound guided left percutaneous nephrostomy was performed. The nephrostogram revealed a 3 cm. narrowing at the lower end of the ureter (fig. 1, B). Bladder biopsy showed evidence of bladder mucosa inflammation with Wuchereria bancrofti microfilaria in the wall (fig. 2). Peripheral blood smear was negative for microfilaria and urine was negative for eosinophils. The patient was started on diethylcarbamazine and antiinflammatory drugs. Symptomatically, there was marked improvement. A nephrostogram 8 weeks later showed free drainage of contrast material into the bladder. Cystoscopy demonstrated improvement in the appearance of the bladder

Observations on the treatment of painful cancer of the rectum, without obstruction, by establishing an anus in the left loin: with cases. 1811-1888.

Observations on the treatment of painful cancer of the rectum, without obstruction, by establishing an anus in the left loin: with cases. 1811-1888.

Thomas Blizard Curling 1811-1888

Reprinted with permission from Curling TB. Observations on the treatment of painful cancer of the rectum, without obstruction, by establishing an anus in the left loin: with cases. Lancet 1865;1:3-5. Courtesy of The Lancet Ltd.

Delayed Presentation of Renal Artery Pseudoaneurysm Following Blunt Trauma

The authors describe a 50-year-old-man who developed renal artery pseudoaneurysm (RAP) 3 months after blunt trauma, which he sustained during a car accident. The patient presented with fever and left loin pain of 1 month's duration. Ultrasound examination of the abdomen revealed a large cystic lesion in the upper pole of the left kidney, which was separated from the nondilatated pelvis of the kidney. The patient underwent left nephrec tomy, and pathological examination confirmed the absence of infection, vasculitis, or malignancy.

Renal hydatid disease. A case report.

Renal hydatid disease is uncommon even in counties where it is endemic accounting for less than 3Vo of all cases. We report a case ofrenal hydatid disease, for its raity, presenting as dull ache in left loin and diagnosed on abdominal CT and hydatid serology. It was treated with 3 cycles of Albendazole 400 mg tvvice a day, each cycle of 28 days duration. Abdominal CT done 6 months later showed disappearance of the cyst.

Splenic Rupture After Extracorporeal Shock Wave Lithotripsy

A 60-year-old woman presented with recurrent left renal colic. Excretory urography confirmed a 20 x 11 mm. calculus in the left renal pelvis (fig. l). On the day of treatment she was well. With the patient under general anesthesia ureteral stent insertion and ESWL were performed without incident. The calculus was easily localized under fluoroscopic guidance and it fragmented well after 3,000 shocks at 24 kV. using the Dornier MFL 5000. Postoperatively signs were normal but the patient complained of pain and required analgesia. Seven hours after ESWL she was pale, sweaty, in pain, tachycardic (heart rate 100 beats per minute) and hypotensive (blood pressure 100/60 mm. Hg). On physical examination the abdomen was not distended, and there were bowel sounds and tenderness in the left loin with no rebound. Voiding demonstrated slight hematuria. Appropriate resuscitative measures were performed. Hemoglobin was 10.3 gm./dl. (13.8 before ESWL, normal 11.5 to 16.5). Blood was cross-matched and 2 units of packed cells were given. The working diagnosis was renal hematoma and conservative management was planned based on clinical parameters. No imaging studies were done at that time. Three hours later the condition seemed improved with better fluid and pain management. Abdominal findings were unchanged but the patient complained of left shoulder tip pain (which was not brought to the attention of the

Isolated renal mucormycosis

To report a case of isolated renal mucormycosis in a previously healthy man, and to briefly review the literature relating to this rare condition. An 18-year-old man presented with a two-month history of fevers followed by two weeks of severe left loin pain. Initial treatment with antibiotics failed and abdominal computed tomography and renal perfusion scans were requested, demonstrating a non-functioning left kidney. Nephrectomy was performed, the histology of which was consistent with mucormycosis. Amphotericin B was administered for one month. The patient made a complete recovery and no underlying disorder was found. This man is believed to be the first reported Australian with isolated renal mucormycosis, and only the second person worldwide in whom an identifiable underlying disorder was absent.