Mini-invasive Procedure Research Articles

Чрескожная эндоскопическая гастростомия: показания, техника, осложнения и результаты

Цель. Обобщение данных литературы и собственного опыта выполнения чрескожной эндоскопической гастростомии (ЧЭГ).
 Материалы и методы. За период с 2011 по 2018 г. 105 пациентам клиники «Обериг» выполнена ЧЭГ. Проанализированы результаты, показания, противопоказания, методика установки гастростомы, особенности лечения пациентов, осложнения.
 Результаты. Выполнение ЧЭГ было технически успешным во всех наблюдениях. Всего отмечено 5 (4,8%) осложнений (95% доверительный интервал (ДИ) 1,6 - 10,8): несостоятельность гастростомы с перитонитом (1), пневмоперитонеум (1), кровотечение из брюшной стенки (1), инфильтрат мягких тканей передней брюшной стенки (1), миграция бампера гастростомы в стенку желудка (1). В сроки наблюдения 30 дней летальности не было.
 Выводы. ЧЭГ – безопасный, доступный миниинвазивный метод, который является выбором у пациентов, требующих длительного энтерального питания или длительной декомпрессии желудка. Необходимы строгое соблюдение всех технических этапов ЧЭГ, показаний и противопоказаний, правильный послеоперационный уход за стомой.

Two-photon optical imaging, spectral and fluorescence lifetime analysis to discriminate urothelial carcinoma grades.

In the framework of urologic oncology, mini-invasive procedures have increased in the last few decades particularly for urothelial carcinoma. One of the essential elements in the management of this disease is still the diagnosis, which strongly influences the choice of treatment. The histopathologic evaluation of the tumor grade is a keystone of diagnosis, and tumor characterization is not possible with just a macroscopic evaluation. Even today intraoperative evaluation remains difficult despite the emergence of new technologies which use exogenous fluorophore. This study assessed an optical multimodal technique based on endogenous fluorescence, combining qualitative and quantitative analysis, for the diagnostic of urothelial carcinoma. It was found that the combination of two-photon fluorescence, second harmonic generation microscopy, spectral analysis and fluorescence lifetime imaging were all able to discriminate tumor from healthy tissue, and to determine the grade of tumors. Spectral analysis of fluorescence intensity and the redox ratio used as quantitative evaluations showed statistical differences between low-grade and high-grade tumors. These results showed that multimodal optical analysis is a promising technology for the development of an optical fiber setup designed for an intraoperative diagnosis of urothelial carcinoma in the area of endo-urology.

Mini-Invasive Intramedullary Fixation of Displaced Midshaft Clavicle Fractures with an Elastic Titanium Nail.

The treatment of completely displaced midshaft clavicle fractures is still controversial, but surgical treatment provides a shorter recovery period and higher union rates than nonoperative treatment with a sling1-5. Even though the literature does not clearly support surgery for these fractures, surgery is becoming more frequent6. Elastic stable intramedullary nailing (ESIN) with a titanium nail is a well-documented mini-invasive procedure with functional outcomes comparable with those of plate fixation after 1 year but a high rate of implant removal of up to 80%6-8. The ideal injury for ESIN is a fracture without comminution that is available for surgery within a couple of days. ESIN is also a good option for fractures with comminution, but a somewhat slower functional recovery during the first 6 months should be expected. The patient is placed in beach-chair position with the fluoroscope placed on the injured side or cranially in relation to the fracture. The surgeon pushes the skin gently with his/her index finger at the jugular fossa before incising it. This places the skin incision inferior to the implant. A 1 to 2-cm incision down to the bone is then placed about 1 to 2 cm lateral to the sternoclavicular joint. A unicortical entry hole is made at the medial end with a 2.5-mm drill bit and then widened and directed laterally with an awl. Two reduction forceps are placed percutaneously and used by the assistant to align the main fragments. The nail is passed with oscillating movements until it is secured into the lateral fragment. If it is not possible to obtain a closed reduction, an open reduction is performed. The nail is cut short down to the bone, and the myocutaneous layer and skin are closed with sutures. Five to 10 mL of bupivacaine is injected into the fracture area for postoperative pain management. The arm is placed in a simple sling for comfort. A non-weight-bearing active range of motion of <90° is encouraged. Closed completely displaced midshaft clavicle fractures can be treated operatively or nonoperatively with a sling. Superior plate fixation is well documented, but use of anterior or several mini-fragment plates is also an option. There are several intramedullary implant techniques, but most require an open reduction. Most intramedullary implant methods are open procedures, whereas closed reduction and internal fixation is possible with ESIN. This ensures preservation of the fracture hematoma and no periosteal stripping, in contrast with the open intramedullary techniques. The nail enters the fracture medially, which decreases the chance of perioperative pulmonary or neurovascular injury. The procedure is less time-consuming than plate fixation, the result is cosmetically superior, and the functional outcomes after 1 year are equal. When ESIN is used for fractures without intermediary fragments, the functional recovery time is equal to that after plate fixation, although it is longer when used for fractures with intermediary fragments8.

Effectiveness of Oral Sucrose Sucking for Procedural Pain Management in Preterm and Term Neonates

Aim: The aim of the study is to assess the effectiveness of oral sucrose sucking prior to minor invasive procedures in pain reduction among term and preterm neonates. Materials and Methods: The research design was true experimental posttest only control group design with convenient sampling technique. The total study sample consisted of 60 term and preterm neonates for minor invasive procedure in NICU of CAIMS hospital were selected (30 experimental, 30 control group). Unpaired t-test was used to test the statistical significance and Fisher exact test was used to test the relationship between the demographic variables and pain scores. The tool used to assess the pain score was Lawrence’s neonatal pain scale (NIPS). Results: With available recent research evidences the results were compared in the nursing practice on safe administration of sucrose sucking prior to minor invasive (heel lance/venepuncture) procedure in term and preterm neonates. There is significant difference in the control and experimental group of neonates in pain reduction with t-test value of 7.73197 and the P value of <0.05. Conclusion: Use of nonpharmacological methods (sucrose sucking) is usually practical and easily implemented in daily care and can provide neonatal nurses with a range of methods for preventing procedural pain and protecting neonates.

Patient-specific simulation of guidewire deformation during transcatheter aortic valve implantation.

Transcatheter aortic valve implantation is a recent mini-invasive procedure to implant an aortic valve prosthesis. Prosthesis positioning in transcatheter aortic valve implantation appears as an important aspect for the success of the intervention. Accordingly, we developed a patient-specific finite element framework to predict the insertion of the stiff guidewire, used to position the aortic valve. We simulated the guidewire insertion for 2 patients based on their pre-operative CT scans. The model was designed to primarily predict the position and the angle of the guidewires in the aortic valve, and the results were successfully compared with intraoperative images. The present paper describes extensively the numerical model, which was solved by using the ANSYS software with an implicit resolution scheme, as well as the stabilization techniques which were used to overcome numerical instabilities. We performed sensitivity analysis on the properties of the guidewire (curvature angle, curvature radius, and stiffness) and the conditions of insertion (insertion force and orientation). We also explored the influence of the model parameters. The accuracy of the model was quantitatively evaluated as the distance and the angle difference between the simulated guidewires and the intraoperative ones. A good agreement was obtained between the model predictions and intraoperative views available for 2 patient cases. In conclusion, we showed that the shape of the guidewire in the aortic valve was mainly determined by the geometry of the patient's aorta and by the conditions of insertion (insertion force and orientation).

Interventional radiology of the thyroid gland: critical review and state of the art.

Thyroid nodules are a common incidental finding during a routinely ultrasound (US) exam unrelated to the thyroid gland in the healthy adult population with a prevalence of 20-76%. As treated before with surgery, in the last years new minimally invasive techniques have been developed as an alternative to surgery. The aim of this review, based on newly revised guidelines, is to provide some information regarding the basic principles, indications, materials, techniques, and results of mini-invasive procedures or treatments for thyroid nodules. We performed a narrative review including both newest and representative papers and guidelines based on the different procedures of ablation techniques developed in the last years for the diagnosis and the treatment of thyroid nodules. All examined papers referred very good results in term of volume nodule reduction, improvement in related symptoms and cosmetic problems, with a very low rate of complications and side effects for all the minimally invasive technique analyzed. Obviously, some differents between technique based on different kind of thyroid nodules and different indication were found. In conclusion, many thyroid nodules nowadays could be treated thanks to the advent of new mini-invasive technique that are less expensive and present a lower risk of major complications and side effects compared to surgery.

Dexmedetomidine Infusion Perioperative to Control Agitation in Non-intubated Young Patient with Cystic Fibrosis Undergoing Upper Arm Ultrasound Guided Totally Implantable Port-A-Cath Placement: A Case Report

Untreated anxiety can lead to difficult induction, increased postoperative pain, greater analgesic requirements, emergence agitation and even postoperative psychological effects and behavioral issue. The Dexmedetomidine [DMET] could be an effective sedative analgesic agent for analgesia peri-operative management in young patients anxious and agitated, with “difficult of ventilation and intubation”, undergoing brief and minimally invasive surgical procedures without the need of tracheal intubation. We described a case of successfully used the Dexmedetomidine for sedation and analgesia during ultrasound guided percutaneous right arm Port-A-Cath device implantation in agitation young patient affected by cystic fibrosis with respiratory failure. The aim of this case report was evaluate the effectiveness and efficiency of the use of dexmedetomidine on the peri-operative and postoperative period. We observed that the DMET improved the effects of local anesthetics and its determined sedation, anxiolysis and analgesia with a more comfortable and effective management during mini-invasive procedure and excellent patient satisfaction. In the postoperative period the patient showed better oxygenation, excellent anxious control and good pain management.

Characteristics and outcomes of laparoscopic surgery in patients with large hiatal hernia. A single center study

IntroductionGiant hiatal hernia is characterized by the presence of more than 1/3 of the stomach in the chest, through the diaphragmatic hiatus, with or without other intra-abdominal organs. It is a rare pathology, representing the 5–10% of all hiatal hernias. The advent of laparoscopic surgery led to new surgical techniques, which include the simple reduction with the excision of the hernial sac and the execution of a posterior hiatoplasty, with or without mesh, and the execution of a Collis-Nissen gatroplasty in case of short esophagus. Presentation of casesWe followed 24 cases of giant hiatal hernia with more than 1/3 stomach located in the chest, analyzing the results reached by the miniinvasive procedure, and the long-term pathophysiologic results of the disease. DiscussionLaparoscopic hiatal hernia repair results in less postoperative pain compared with the open approach. The smaller incisions of minimally-invasive surgery are less likely to be complicated by incisional hernias and wound infection. Postoperative respiratory complications are reduced. ConclusionResults from multiple studies are similar, with shorter hospital stay and less morbidity resulting from the minimally invasive approach.

RETRO-DUODENAL PERFORATES - SURGICAL TREATMENT

Retro-duodenal perforations / iatrogenic and ulcerative / fortunately, are a relatively rare surgical problem, but unfortunately, in therapeutic aspect, they are associated with severe complications,and still high lethality. On the other hand, in the last quarter of the century, we have witnessed increasing of possibilities of mini-invasive procedures. In addition to diagnostic value, much of them have a therapeutic character, the latter often have either definitive effect. However, we also encounter new iatrogenic complications that are unknown until this moment. Much of these complications are managed conservatively and do not require aggressive surgical interventions. One of the most difficult for diagnosis and treatment complications are retroduodenal perforations. According to the literature, this complication occurs in a frequency of 2-4% of papilla Vatery's manipulations. With the intensive work at Gastroenterology diagnostic departments at university and district hospitals, the surgeons need to be familiar and ready to diagnose and treat this kind of complication. Surgical treatment in both types of perforations is prevented by the presence of many vital vessels, a nervous network and, on the other hand, retro-duodenal adipose tissue highly susceptible to infection spreading. According to publications in the world literature, a number of methods of treatment are proposed: conservative, less and more invasive, yet still with variable success and considerably extended hospital staying and expensive cost of treatment.

Surgical Stress Response and Enhanced Recovery after Laparoscopic Surgery - A systematic review

Background: Enhanced Recovery Program (ERP) is a multimodal perioperative protocol. Its feasibility and benefits on short term outcomes have been widely reported. These well described improvements, like shorter length of stay and early resumption of body's functions, represent the consequence of an attenuated surgical stress response (SSR). When this response is uncontrolled, it leads to postoperative complications and poor long-term outcomes. SSR can be easily monitored through the analyses of mediators in the bloodstream. Available evidences do not achieve to tell if ERP allows a measurable surgical stress reduction. In this review, we searched for papers investigating the surgical stress response and ERP applied to elective mini-invasive procedures, in order to better understand the level of evidence regarding the effectiveness of ERP in minimizing the surgical stress response. Materials and Methods: A systematic review of published literature was performed using PubMed, Cochrane, EMBASE and Google Scholar database, following the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Included studies concerned SSR analysis in ERP patients undergoing laparoscopic surgery through different surgical specialties. Eight studies with a total of 632 patients were included. Results: The three steps of SSR, endocrine, inflammatory and nutritional were all reported in the papers included in this review. Results showed no powerful evidence of difference in endocrine phase while an attenuated inflammatory response was reported for ERP patients when Interleukin-6 (IL-6) and C Reactive Protein (CRP) were dosed. Nutritional status was also preserved as albumin, pre-albumin and transferrin had better values in these patients. Conclusions: ERP applied to different types of laparoscopic surgery has a role in reducing SSR. This can be shown by the analysis of mediators such as IL-6, CRP and nutritional markers.

54. Primary cutis verticis gyrata associated to chronic migraine treated with ultrasound guided onabotulinum injections. A case report

Cutis verticis gyrata (CVG), also known as “bulldog” scalp syndrome was originally described in 1837 by Jean-Louis-Marc Alibert. CVG is a descriptive term for a condition of the scalp manifesting as convoluted folds and furrows formed from thickened skin of the scalp resembling cerebriform pattern. In 1953 Polan and Butterworth classified CVG into two forms: primary and secondary. The primary form can be divided in essential and non-essential, where the essential form do not present other abnormality (while primary nonessential can be associated with other pathologies or a combination of this. In the primary essential form, the etiology is not known, and, though most of the cases seem sporadic, autosomal recessive and autosomal dominant inheritance with variable expression have been described. In the primary nonessential form, the pathogenesis (beside the genetic determination) may have an endocrinologic basis. In the secondary form, the etiology depends on the underlying process (eg,inflammatory, neoplastic). Our patient was a 25 year old caucasian male who presented for three years scalp skin redundancy, with deep cerebriform folds and wrinkles, located in frontoparietal regions He denied comorbidities. He referred fronto temporal headache often unilateral with casual trigeminal diffusion, described as chronic and burning pain with allodinia. For those he performed a 3T MRI of head with a 3D reconstraction of scalp that excluded abnormality of the brain lobes and essentially revealed thickened dermis and a slight increase in the volume of subcutaneous fat and irregularly distributed cutaneous folds characteristic of CVG. Because neurologist considered patient with CM and inadequate response or intolerance to previous two prophylactic treatments he was treated with pericranial injections of about 150 UI of BoNT-A with the proposal to repeat treatment every 3–4 months and the purpose to increase dose up to 200 U in case of no response. After 3 months unfortunately patient achieved minimal reduction of pain of about 20–30% in headache frequency and intensity and during the 3 months follow-up period. The first weeks after BonT-A treatment he reduced NSAIDs and analgesics consumption but unfortunately after first stage he preferred to avoid further botulinum injections due to mini invasive procedure on scalp. Primary essential cutis verticis gyrata firstly because is a cosmetic problem, but also because eventual pain symptoms and psychological repercussions are very important issues. In this case both pain relief and reduction of folds width could be beneficials and therefore we encouraged the patient to treat both CM and CVG with BonT-A Injections.

Skeletal Anchorage for the Correction of Bimaxillary Protrusion and Gummy Smile

Many methods of achieving maximum anchorage have been experimented by various clinicians through the years. Usage of mini implants has its own limitations, inconsistent results being the most common. However, anchorage using mini plates produced consistent results even though it requires a minor invasive surgical procedure. The aim was to retract and correct a gummy smile of 5 mm, diagnosed to be due to a vertical maxillary excess, with mini plates used bilaterally in the zygomatic buttress region. A modified “L” shaped surgical stainless steel mini plate was inserted and stabilized with 3 screws in the anterior region of the zygomatic buttress and sutured with the tip of the surgical plate exposed in the oral cavity for the attachment of an elastomeric chain to the arch wire. The gummy smile was fully corrected with minimal intrusion of maxillary anteriors. Cephalometrically, there was intrusion and retraction of maxillary incisors with absolutely no anchor loss. The modified surgical mini plate is an excellent tool for the successful correction of the gummy smile and also has proved to be a very efficient absolute anchorage system for en masse retraction.

Management of proximal humeral fractures by the Ilizarov external fixator.

External fixation can be performed in poor bone and soft tissue conditions, and can be used in patients with poor general conditions or multiple injuries as a rapid, mini-invasive procedure. The purpose of the current study was to evaluate the effectiveness and safety of the Ilizarov external fixator in the management of proximal humeral fractures. Between May 2011 and December 2013, 14 patients with displaced proximal humeral fractures were enrolled in the current study. Nine patients were males and five were females, with mean age 42.9years (range 21-55). All fractures were acute. The mode of injury was road traffic accident in eight patients and fall in six patients. There were six patients with two-part fracture, one of them with fracture dislocation, and eight patients presented with three-part fracture, two of them with fracture dislocation. All fractures were fixed using the Ilizarov external fixation. The average operative time was about 67min (range 50-90). The mean follow-up period was (18) months (range 12-28). Healing was obtained in all 14 patients in a mean of 10.4weeks (range 8-14). At the final follow-up, the mean constant score was 73.1 points (range 60-97 points), the mean visual analog score (VAS) for pain 3.2 (range 1-5), the mean DASH score 31.8 points (range 10-55 points), and the mean satisfaction VAS 7.6 (range 4-10). The Ilizarov external fixation is an effective technique in managing proximal humeral fractures with good outcome and low complication rates. Level IV, case series.

Cirugía de supresión ácida y derivación duodenal laparoscópica vs abierta en esófago de Barrett extenso: resultados y complicaciones a corto y largo plazo

IntroductionIn patients with long Barrett esophagus we have suggested to perform fundoplication with antrectomy, vagotomy and Roux-en-Y duodenal diversion however it could be associated with complications and side effects. ObjectiveThe objective of this study is to compare open versus laparoscopic surgery for early and early postoperative complications, mortality and distant outcomes. Material and methodWe compare 2 cohorts of patients, 73 patients with open surgery and 53 patients, who underwent laparoscopic surgery using the same technique. Only patients with Long Barrett were included. They are clinically monitored in the early and late postoperative period, with endoscopy and histology at long term follow-up (3-5 years). The results were evaluated in terms of early and late complications, the quality of life and patient satisfaction were analyzed. For the analysis we used t-student considering a P<.05 as significant. ResultsAs for early complications, there were no significant differences in both groups. There was no postoperative mortality. In the late complications, the total complications are not significantly different between the two groups (only their causes and characteristics changed) neither in terms of Visick's classification and the quality of life score ConclusionThe fundoplication, with laparoscopic acid suppression and duodenal diversion, presents similar short-term and long-term results than open surgery, with the benefits of a mini-invasive procedure.

Pulmonary-pleural complications of pancreatitis

OBJECTIVE. The authors investigated pulmonary-pleural complications of pancreatitis and evaluated results of CT examination in diagnostics and possibility of low invasive surgery in treatment of pancreaticogenic pleurisy. MATERIAL AND METHODS. A retrospective analysis was made of 156 medical histories of patients with acute pancreatitis and their results. An ultrasound examinations of the chest and CT scan were applied in order to determine lung tissue condition and presence of fluid in pleural cavities. RESULTS. The application of CT in diagnostics of pulmonary-pleural complications allowed doctors to identify an effusion in pleural cavities in 3,5-50 % patients with acute pancreatitis. The number and localization of effusions were defined more precisely. CONCLUSIONS. Mini-invasive procedures (puncture, videothoracoscopy) with examination of exudate on amylase activity and biopsy of pleura determined the causes of pleuritis. This was effective in pleritis elimination against a background of different methods of treatment of pancreatitis.

Surgical treatment of intraforaminal/extraforaminal lumbar disc herniations: Many approaches for few surgical routes.

Several disc disease nomenclatures and approaches for LDH exist. The traditional midline bone-destructive procedures together with approaches requiring extreme muscular retraction are being replaced by muscle sparing, targeted, stability-preserving surgical routes. The increasing speculation on LDHs and the innovative corridors described to treat them have lead to an extensive production of papers frequently treating the same topic but adopting different terminologies and reporting contradictory results. The review of such literature somehow confounding gave us the chance to regroup by surgical corridors the vast amount of approaches for LDH differently renamed over time. Likewise, LDHs were simplified in intra-foraminal (ILDH), extra-foraminal (ELDH), and intra-/extra-foraminal (IELDH) in relation to precise anatomical boundaries and extent of bulging disc. Through the analysis of the papers, it was possible to identify ideal surgical corridors for ILDHs, ELDHs, and IELDHs, distinguishing for each approach the exposure provided and the technical advantages/disadvantages in terms of muscle trauma, biomechanical stability, and nerve root preservation. A significant disproportion was noted between studies discussing traditional midline approaches or variants of the posterolateral route and those investigating pros and cons of simple or combined alternative corridors. Although rarely discussed, these latter represent valuable strategies particularly for the challenging IELDHs, thanks to the optimal compromise between herniation exposure and bone-muscle preservation. The integration of adequate mastery of traditional approaches together with a greater confidence through unfamiliar surgical corridors can improve the development of combined mini-invasive procedures, which seem promising for future targeted LDH excisions.

Randomized Comparison of Power Doppler Ultrasonography-Guided Core-Needle Biopsy with Open Surgical Biopsy for the Characterization of Lymphadenopathies in Patients with Suspected Lymphoma

BackgroundIn case of clinical suspicion of lymphoma, the histological examination of lymphadenopathy is essential for defining a correct diagnosis and for developing a proper treatment plan. An open surgical biopsy (OSB) is still the "gold standard", owing to the large amount of tissue obtained. The sensitivity of lymph node core-needle biopsy under imaging guidance requires validation.AimsThis randomized study compared the ultrasound-guided core-needle cutting biopsy (CNCB) approach with OSB approach.Patient and methodsInstitutional review board approval and informed consent were obtained. In a single center between 1 January 2009 and 31 December 2015, patients with lymph node enlargement suspected for lymphoma were randomly assigned (1:1) to biopsy with either OSB (standard group) or ultrasound-guided 16 gauge modified Menghini needle (core-needle group). In the core-needle group, the lymph node to undergone biopsy was determined by power Doppler US, in particular, the main criterion to select the node to be biopsied was the hypervascularization. The primary endpoint was to test the superiority of sensitivity for diagnosis of malignancy for ultrasound-guided CNCB compared with OSB. Secondary endpoints were negative predictive values, likelihood ratio of negative test, biopsy related complications, costs and times to biopsy.ResultsA total of 372 patients were randomized either to standard group (N= 187) or core-needle group (N= 185). Sensitivity for detection of malignancy was significantly better for US-guided CNCB [98.8%; 95% confidence interval (CI), 95.9-99.9] than standard biopsy [88.7%; 95% CI, 82.9-93] (P<0.001). Therefore, the study objective to show superiority of US-guided CNCB versus OSB was achieved, being the sensitivity rate of experimental approach significantly higher than standard approach. For all secondary endpoints, the comparison was significantly disadvantageous for standard approach. The negative predictive value was 50% (19 of 38; 95% CI, 33.4-66.6) for OSB and 84.6% (11 of 13; 95% CI, 54.5-98.1) for US-guided CNCB (P= 0.014). The negative likelihood ratio was 0.11 (95% CI: 0.07-0.17) for OSB and 0.01 (95% CI: 0.00-0.05) for US-guided CNCB, confirming the value of the US-guided CNCB for detecting malignancy. Patients who received standard biopsy had significantly more procedure-related complications (P<0.001). Furthermore, estimated cost per biopsy performed with standard surgery was 24-fold higher compared with that performed with US-guided CNCB (P<0.0001). The median waiting time for performance of biopsy (from procedure indication to perform itself), was 4 days with a range of 1 to 10 days in the core-needle group. By contrast, it was 16 days, with a range of 5 to 34 days in the standard group (P<0.0001).ConclusionsThis study is the first to compare in a randomized fashion the sensitivity of US-guided CNCB and OSB in detecting lymphoma. Power Doppler US and CNCB are diagnostic tools that enable effective, safe, fast and low-cost routine biopsy for patients with suspected lymphoma, avoiding psychological and physical pain of an unnecessary surgical intervention. We suggest this approach as first-line mini-invasive procedure for patients with a suspected lymphoma and not merely when surgical intervention is not possible, or to document relapse. DisclosuresNo relevant conflicts of interest to declare.

Retrograde intrarenal surgery (RIRS), regular and small sized percutaneous nephrolithotomy (PCNL) in daily practice: European Association of Urology Section of Urolithiasis (EULIS) Survey.

A wide selection of both anterograde and retrograde mini-invasive procedures exist for stones' treatment. The 2016 European Association of Urology (EAU) guidelines still don't univocally define a best option. Our purpose is to give an overview on some European Stone Centers' customs and to compare real life clinical practice with statements of opinion leaders and Guidelines. In 2015 we performed a survey in 3 step about the spread of retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) techniques among EAU Section of Urolithiasis (EULIS) members. The 1st and 2nd steps dealt with the definition of EULIS urologist and department by collecting personal opinions about the endoscopic techniques. The third step was about clinical results. This paper presents data from the first two steps. Ninety-one people answered. Out of them, 80% are European and 42% work in Centres fully dedicated to stone treatment. In particular, 50% of responders perform more than 80 RIRS/year, 25% more than 80 PCNL/year, 48% more than 100 extracorporeal shock wave lithotripsy (SWL)/year. RIRS is mainly used to treat stones &lt; 2 cm both as primary treatment and after SWL failure. 73% don't perform routine pre-stenting and 66% ordinarily use a ureteral sheath. Hospital stay for RIRS is 24h for 70% of responders. Regular PCNL is performed by 87% of the responders, MiniPCNL by 58%, Ultra-MiniPCNL by 23% and MicroPCNL by 28%. Pneumatic balloon dilation is the favourite dilation technique (49%). 37% of responders perform PCNL always in the supine position, 21% always in the prone one. Almost all the responders agree about using Mini, Ultra-Mini and MicroPCNL for 1-2 cm stones. Approximately 50% also use MiniPCNL for stones &gt; 2 cm. our survey confirms the great heterogeneity existing in stones' treatment techniques in daily practice.

Scoliosis and Pectus Excavatum in Adolescents: Does the Nuss Procedure Affect the Scoliotic Curvature?

Pectus excavatum (PE) is known to be associated with adolescent idiopathic scoliosis (AIS). The correction of severe PE requires a mini-invasive procedure (MIRPE), with a metal bar positioned and left in the chest for 3 years. Adolescence seems to be the more appropriate time not only for MIRPE but also for AIS peak progression. This study was designed to answer the question whether, in adolescents, MIRPE could affect mild/moderate AIS. We carried out a meta-analysis focused on defining the natural progression of untreated AIS. Inclusion criteria were as follows: AIS patients -age 10-18 years old -Cobb angle <40°-none treated as orthotics/electrostimulation/surgery. The expected outcome was the percentage of patients who improved, worsened, or hold steady of their condition at follow-up. Between 2008 and 2014, we followed up a cohort of 67 adolescents with severe PE treated with MIRPE, assessing whether AIS underwent a modification in the period between bar insertion and removal. Meta-analysis included 9 studies with 1641 AIS patients. Although heterogeneous (I(2) = 99.5%, P < .0001), the overall percentage of progression for untreated AIS was 42.5% (CI 18.2%-72.2%). In our follow-up group who underwent MIRPE, 34 out of 67 patients had concurrent AIS with a Cobb angle >10° (range 10°-45°). We demonstrated that MIRPE had a favorable effect on AIS, with a mean improvement of 1.5° (CI 0.64-2.44; P = .0011). In our PE patients with AIS, MIRPE had a beneficial effect also on the spine. From our preliminary results, it seems that MIRPE should be offered during puberty as a timely option for treating PE and stabilizing mild/moderate scoliosis progression, when concurrent.

A mini-invasive procedure for treating arthrofibrosis of the knee

ObjectiveThe aim of this study was to introduce the results of a novel mini-invasive operative technique comprising mini-incision release, “pie-crusting” lengthening of the quadriceps extensor, and arthroscopic lysis in severe arthrofibrotic knees. MethodsFrom 2010 to 2014, 17 patients (12 males and 5 females with a mean age of 44 years (range, 19–62 years)) with severely arthrofibrotic knees were treated with this operative technique. The mean follow-up duration was 23 months. The knee range of motion (ROM) was assessed with a goniometer. The functional outcomes were evaluated according to the Hospital for Special Surgery (HSS) score and Judet's criteria. ResultsThe ROM significantly improved from 29.7° (range, 7°–56°) preoperatively to 127° (range, 120°–136°) at the final follow-up in all patients (p < 0.001). According to Judet's criteria, all patients achieved excellent results (ROM>100°). The HSS score was improved from 70 points (range, 60–85 points) preoperatively to 91 points (range, 84–98 points) (p < 0.001) at the final follow-up. No extension lag, skin necrosis, quadriceps weakness, wound dehiscence or quadriceps tendon rupture occurred. ConclusionsMini-invasive quadricepsplasty-associated arthroscopic lysis and manipulation of the knee in flexion is simple and easy and should be considered as a legitimate treatment for arthrofibrosis of the knee.