Mini-invasive Procedure Research Articles

Clinical application of thoracoscopic surgery for esophageal neoplasms in lateral prone position

Thirty-three patients with esophageal carcinoma (T3N1M0 or less) underwent thoracoscopic surgery in lateral prone position for esophagectomy from February 2010 to November 2012. Their postoperative outcomes and survivals were retrospectively analyzed. The results confirmed the feasibility and safety of this mini-invasive thoracoscopic procedure in lateral prone position for patients with esophageal carcinoma. A possible advantage of lateral prone technique is that in case of an emergency switch to open surgery, precious time may be saved in changing body position. Key words: Esophageal neoplasms; Posture

Laparoscopic Treatment of Urinary Stones After Failure of Previous Mini-Invasive Approaches

Introduction: Urolithiasis in the general population has been estimated at about 5%–12%, with an annual incidence of just over 1% and recurrence rates close to 50% involving patients of all races, ages, and gender.1 There are several methods for the management of patients with urinary stone disease.1 Within the therapeutic options, we have minimally invasive procedures, such as percutaneous nephrolithotomy (PNL), shockwave lithotripsy (SWL), and endoscopic ureterolithotripsy (EUL). Laparoscopic pyelolithotomy, laparoscopic ureterolithotomy, and laparoscopic cystolithotomy are now considered second-line therapeutic procedures, whereas open surgery still represents an effective more invasive treatment.2 We present our case series on laparoscopic management of renal, ureteral, and bladder stones previously unsuccessfully treated with mini-invasive procedures. Materials and Methods: From September 2010 to April 2012, 18 patients, previously treated with minimally invasive techniques (PNL, SWL, and EUL), underwent laparoscopic surgery for urinary tract stones. Epidemiological, clinical, and surgical variables were reviewed. Clinical variables, such as the presence of unilateral or bilateral stones and their position (renal pelvis, proximal, middle, or distal ureter and bladder), were taken into account. The mean operative time, use of indwelling ureteral stent, postoperative hospitalization, stone clearance rate, and perioperative complications were analyzed. No patient had associated morbidities that required any other additional procedure (pyeloureteral junction obstruction, urinary diversions, etc.). Results and Conclusions: Eighteen laparoscopic procedures were performed: nine ureterolithotomies, six cystolithotomies, and three pyelolithotomies. The mean age of the patients was 48 years (27–66 years), all were Caucasian subjects: 14 males and 4 females. No patient had acute renal failure. The mean serum creatinine value was 1.01 mg/dL (range: 0.8–2.5 mg/dL). Two patients presented a bilateral location of the stones. Stone position was as follows: nine ureteral (three proximal, two middle, and four distal), six in the bladder, and three in the renal pelvis. The mean operative time was ureteral stone, 82 ± 23 minutes; bladder stone, 47 ± 10 minutes; and kidney stone, 99 ± 26 minutes. Transfusion was not required in any patient, and the open conversion did not happen. The mean hospital stay was 3 days (2–4 days). The overall stone clearance rate was 88.9% (16/18), and two patients had residual kidney stones that were managed with extracorporeal SWL. At a mean follow-up of 6 months, no serious complications (bleeding, sepsis, bowel injury, ureteral strictures, or urinary leakage) occurred. Laparoscopic surgery is an effective and safe technique for the management of urinary tract stone disease, with a high stone clearance rate. Considering our case series and the literature,2,3 it might be considered an alternative second-line procedure in selected cases where other less invasive procedures (SWL, PNL, etc.) had failed. The authors declare that no competing financial interests exist. Runtime of video: 6 mins 47 secs

Percutaneous vertebroplasty in the treatment of osteoporotic compression fracture and vertebral tumor

Objective To assess the clinical and radiographic outcome of patients who underwent percutaneous vertebroplasty (PVP) in osteoporotic compression fractures and vertebral tumor.Methods Between January 2007 and June 2012,45 patients were treated with PVP at neurosurgery department of Xuanwu hospital; it were analyzed that the clinical and radiologic outcome including cement feature.The patient's clinic outcome was assessed before operation and 24 hours,3,6,12,24,36 months after the operation using visual analogue scale (VAS) and Oswestry disability index (ODI).The anterior vertebral body height and local sagittal Cobb's angle were also measured.Results The mean follow-up period was 13.917.8 months.Postoperative VAS,ODI,the local sagittal Cobb angle decreased from 7.3 ± 1.9,32.0±3.4 and 15.0° ±2.3° to4.8 ±1.6,22.1 t2.1 and 14.0° ±1.9° respectively before and after surgery (P ＜0.05).The anterior vertebral height increased from(16.0 ± 1.8) mm to(19.0 ± 2.1) mm before and after surgery (P ＜ 0.05).There are no significant changes in VAS,ODI,anterior vertebral body height and the local sagittal Cobb's angle during 3-36 months follow-up.54％ patients maintained with decreased VAS within 5 during follow-up.Conclusion PVP is an efficient miniinvasive procedure,which can provide durable pain relief in patients with osteoporotic compression fractures and vertebral tumor. Key words: Percutaneous vertebroplasty ; Osteoporotic vertebral compression fracture ; Vertebral tumor

A new mini-invasive technique in treating pediatric diaphyseal forearm fractures by bioabsorbable elastic stable intramedullary nailing: a preliminary technical report

Operative treatment is often indicated in unstable pediatric diaphyseal forearm fractures. Recently minimally invasive reduction and elastic stable intramedullary nailing have been of increasing interest, instead of open reduction and internal fixation with plates. There are several disadvantages of metallic intramedullary implants, such as soft-tissue irritation and a risk of disturbing later imaging. Thus, they are generally removed in later operations. We aimed to develop a new technique to stabilize pediatric forearm fractures by the bioabsorbable intramedullary nailing. We developed a new, two-stage mini-invasive surgical technique to stabilize the unstable diaphyseal fractures in children. The procedure is bioabsorbable elastic stable intramedullary nailing. Ultra-high-strength bioabsorbable intramedullary nails of poly(lactide-co-glycolide) were manufactured for our purpose. The material has been widely proven to be biocompatible and stable enough for fracture treatment as screws and pins. We have used the new technique in the unstable both-bone diaphyseal forearm fractures in children between the ages of 5 and 15 years. We report the technique and our clinical experience in the series of those three cases that have been followed up for at least 12 months. The present series has been randomized for the procedure instead for titanium elastic stable intramedullary nailing, and the series represents a part of ongoing randomized trial. The reported cases operated by the new technique referred good union in the fractured bones and acceptable alignment in the follow-up. Removal of the implants was not required. No troubles with the procedure or implant per se were noticed, indicating good feasibility. One high-energy refracture occurred half year after the primary trauma. Traditional titanium implants were used to control the refracture. We report our preliminary experience of a new surgical mini-invasive procedure to stabilize the unstable pediatric forearm shaft fractures by bioabsorbable elastic stable intramedullary nailing. Our clinical experience suggests that the procedure combined with long-arm casting is feasible in treating the pediatric forearm fractures. The technique may bring benefits to handling these challenging fractures. The disadvantages of metallic implants may be avoided. In addition, removal of the implant will not be required. There was one refracture in the series, but it was due to new high-energy trauma. According to our understanding, it was not related to the type of former osteosynthesis. However, ignoring the good preliminary experience, still we do not have results of the superiority of the procedure over traditional elastic stable intramedullary nailing. Our ongoing randomized multicenter study is aimed to determine its long-term outcome against the present golden standard. Nevertheless, due to encouraging preliminary results, we see it necessary to report the technique.

The case of an acute thoracic aorta dissection in the patient with Marphan syndrome

Acute thoracic aorta dissection is one the most dangerous pathology of aorta. If left untreated, is associated with high mortality. Early diagnosis and proper treatment improves outcomes. Miniinvasive procedures give the opportunity to plan the hybrid approach. In this way, all the advantages and opportunities of chosen methods can be used, minimising their complications. Multidisciplinary cooperation during the whole process of treatment, including out-patient care is crutial. Doing so creates the optimal conditions for the treatment by reducing operative trauma and improving the quality of life.

Mo1675 Learning Curve of Direct PerOral Cholangioscopy Using Ultra Slim Gastroscopes

Mo1675 Learning Curve of Direct PerOral Cholangioscopy Using Ultra Slim Gastroscopes Jochen Weigt*, Arne Kandulski, Peter Malfertheiner Gastroenterology, Hepatology and Infectious Diseases, University Magdeburg, Magdeburg, Germany Direct peroral cholangioscopy (POCS) is an emerging technique complementing ERCP. Unless several data show the feasibility and clinical relevance of POCS, only few data about the learning process of this technique are available. Aim: To investigate the technical success rate and learning process of POCS in a tertiary center. Methods: All patients were investigated with standard ERCP and biliary sphincterotomy directly prior to cholangioscopy. After removal of the duodenoscope, an ultra slim gastroscope was directly advanced to the duodenum. The common bile duct was intubated using the balloon anchor technique. All POCS procedures were performed with water irrigation. Histology was taken from suspicious lesions. The investigation times and the success rates were calculated. Special caution was given to the time from oral intubation until visualization of the bile ducts, that served as a key technical parameter. Results: A total of 28 POCS were performed. Intubation was successful in 24/28 (86%). Reasons for failed intubation were small caliber bile ducts, duodenal diverticulum and papillary adenoma. The mean intubation time was 9.5 min (3-23 min). The average intubation time did not change significantly over time (R*2 -0.05). The variance of intubation times changed over time and was 35,7 min in the first half of investigations and 13,5 min in the second half. Complications did not occur. Conclusions: The technique of direct peroral cholangioscopy using the balloon anchor technique in combination with ultra-slim gastroscopes is technically demanding but learning does not show a long learning period at last in a tertiary center. However the technical measures present signs of adaptation and learning of the technique.Nevertheless, as POCS is not yet a standard technique, we suggest that POCS may only be performed by experienced endoscopists. Mo1676 Evaluated Experimental Model of Gallstone Cholecystitis Available for Miniinvasive Surgical Procedures Ondrej Ryska*, Zuzana Serclova, Jan Martinek, Radek Dolezel, Stefan Juhas, Jana Juhasova, Bohus Bunganic, Miroslav Ryska Department of Surgery and 2nd Medical Faculty, Central Military Hospital, Prague 6, Czech Republic; Hepatogastroenterology Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Department of Internal Medicine, Central Military Hospital, Prague, Czech Republic; Institute of Animal Physiology and Genetics, Academy of Sciences, Libechov, Czech Republic Background: Natural orifice transluminal endoscopic surgery (NOTES), single port laparoscopy (SILS) and other miniinvasive surgical techniques are recently under the experimental investigation. Cholecystectomy as a most frequent laparoscopic procedure is usually the subject of evaluation where the clear benefits of new approaches should be proved. Experimental studies using healthy animals with physiological finding on gallbladder are lacking for the clinical relevance. The aim of the experimental study was to create and evaluate surgical model of gallstone cholecystitis in large animal. Material And Method: Model creation: 14 pigs weighing 40.3 10.0 kg were included. Laparoscopy (3 ports) was performed under general anesthesia. Bile from the gallbladder was aspirated and cholecystotomy was done. Three to five gallstones obtained by human cholecystectomy were inserted and incision was closed. Evaluation: 11 pigs with artificial cholelithiasis the laparoscopic cholecystectomy (3-port access) was performed. This group was compared to 10 cholecystemies in pigs without lithiasis. All pigs were euthanized 30th postoperative day (POD) and the autopsy performed. The protocol was approved by committee for the protection of the animals. Results: All animals survived without severe complications. Model procedure took 42 (35-150) minutes. White blood cells (WBC) count increased 1.POD and 2.POD markedly; 18.7 (10.4-23.7)x109/l and 16.7 (8.3-27.8)x109/l); and remained slightly higher till 7.POD 15.4 (9.2-22.8)x109/l. CRP levels were higher on 1st, 2nd and 3rd POD 12.4 (6.9-21.4, 13.3 (1.4-35.7) and 13.0 (8.117.8)mg/l) and decreased to normal levels till 7.POD. Levels of interleukin 6 were the highest 2 hours after surgery 472.7 (50.9-1286) and decreased the 1.POD 80.8 (36.4-153) and the 2.POD 35.6 (8.257.2) pg/ml. The ultrasound signs of chronic gallstone cholecystitis were observed 4 weeks after intervention, which was also confirmed by histology. Laparoscopic cholecystectomy in gallstone model took longer time compare to healthy animals: 63 (42-91) minutes vs. 46 (31-62) minutes (p 0,0182). The perioperative gallbladder perforation was significantly less more frequent in healthy pigs 1/10 vs. 8/11 (RR: 7,27; CI95%: 1,09-48,3; p 0,04) as well as postoperative complications rate nonsignificantly lower 0/10 vs. 2/11 (2 abscesses in gallbladder bed) at autopsy (RR: 4,58; Cl95%: 0,25-85,3; p 0,307). Conclusion: Simple surgical model of gallstone cholecystitis was created as a reliable tool for accurate evaluation of NOTES and other miniinvasive procedures. Sonographic and histological signs of inflammation with no elevation of inflammatory markers were observed 4 weeks after intervention. The laparoscopic cholecystectomy was technically more difficult in cholecystitis model than in healthy animals. Supported by a grant from IGA NT12250-4

Chirurgie de l’incontinence anale : évolution depuis vingt ans et perspectives

Studies showing the frequency of anal incontinence and its social and economic impact have driven progress in surgical treatment, from muscle repair by myorraphy (mainly posterior myorraphy) or sphincteroplasty by direct suture of the external anal sphincter some 20 years ago, to invasive surgery with implantation of an artificial anal sphincter in 1993, mini-invasive surgery based on sacral nerve stimulation in 1998, failure of mini-invasive procedures with injection of a bulking agent or radiofrequency in 2000-2010, and development in 2012 of cellular therapy based on injection of autologous myoblasts. Progress in functional gut exploration (anorectal manometry, electrophysiological tests, endoanal ultrasonography, MRI, colonic transit time) and better knowledge of colonic and ano-rectal physiology will lead to further surgical advances.

Percutaneous computed tomography-guided resection of non-spinal osteoid osteomas in 54 patients and review of the literature

Osteoid osteoma is a benign osteoblastic tumor with a nidus of <20mm in maximum diameter. There are several treatment options, all of them aiming either to resect or to eliminate the nidus. To report and to describe the benefits of treating non-spinal osteoid osteoma by percutaneous computed tomography-guided resection, according to our experience. Retrospective case series Between 1992 and 2008, 54 patients with non-spinal osteoid osteoma underwent primary treatment with percutaneous CT-guided resection. In all cases, the materials obtained were processed for pathology and microbiology. Fifty-four patients with a mean age of 22.7years (range 10-47), of whom 46 were males (85.2%) and 8 were females (14.8%). The lesion size ranged between 5 and 15mm with an average size of 6.9mm. The resection was considered complete by the CT study in all 54 cases. Of all the specimens sent to pathology, the histological diagnosis was achieved in 41 (75.9%). Cure was obtained in 50 patients (92.6%) and the other four patients required a second surgery using the same technique, after which all of them achieved clinical and radiological improvement (100%). Percutaneous computed tomography-guided resection of non-spinal osteoid osteomas provides good results, similar to other surgical techniques, with the advantages of being a simple, mini invasive, safe and economic procedure without the need for specific materials. Level of evidence, IV.

Robotic Assisted Surgery in Pediatric Gynecology: Promising Innovation in Mini Invasive Surgical Procedures

Study ObjectiveRobotic assisted surgery is not yet widely applied in the pediatric field. We report our initial experience regarding the feasibility, safety, benefits, and limitations of robot-assisted surgery in pediatric gynecological patients. DesignDescriptive, retrospective report of experience with pediatric gynecological patients over a period of 12 months. SettingDepartment of Pediatric Surgery, IRCCS Policlinico San Matteo Foundation. ParticipantsChildren and adolescents, with a surgical diagnosis of ovarian and/or tubal lesions. Main Outcome MeasuresRobot assembly time and operative time, days of hospitalization, time to cessation of pain medication, complication rate, conversion rate to laparoscopic procedure and trocar insertion strategy. ResultsSix children and adolescents (2.4-15 yrs), weighing 12-55 kg, underwent robotic assisted surgery for adnexal pathologies: 2 for ovarian cystectomy, 2 for oophorectomy, 1 for right oophorectomy and left salpingo-oophorectomy for gonadal disgenesis, 1 for exploration for suspected pelvic malformation. Mean operative time was 117.5 ± 34.9 minutes. Conversion to laparatomy was not necessary in any of the cases. No intra- or postoperative complications occurred. ConclusionInitial results indicate that robotic assisted surgery is safely applicable in the pediatric gynecological population, although it is still premature to conclude that it provides better clinical outcomes than traditional laparoscopic surgery. Randomized, prospective, comparative studies will help characterize the advantages and disadvantages of this new technology in pediatric patients.

Percutaneous Ultrasound-Guided Laser Ablation Is Effective for Treating Selected Nodal Metastases in Papillary Thyroid Cancer

Mini-invasive procedures may be useful for control of local neck nodal metastases of papillary thyroid cancer (PTC) in high-risk patients. Our objective was to assess the effectiveness and safety of ultrasound (US)-guided laser ablation (LA) for nonsurgical treatment of small-size neck metastases of PTC. We conducted a pilot study on a surgically controlled metastasis, followed by a prospective trial with a 12-month follow-up. Participants included five patients with previous total thyroidectomy and neck dissection for PTC, with eight new lymph node metastases in an area already treated with surgical dissection and lymph node volume less than 2 ml and absent radioiodine uptake. We evaluated thyroglobulin (Tg) and US changes of the lymph nodes 6 and 12 months after LA as well as tolerability and side effects of the procedure. A single LA treatment induced progressive volume reduction of the eight metastatic lymph nodes. Mean baseline volume decreased from 0.64 ± 0.58 to 0.07 ± 0.06 ml at 12-month control. Mean volume reduction was 64.4 ± 0.19% at 6 months (P < 0.02 vs. baseline) and 87.7 ± 0.11% at 12 months (P < 0.01 vs. baseline). No regrowth was registered. Mean serum Tg on LT4 decreased from 8.0 ± 3.2 ng/ml to 2.0 ± 2.5 ng/ml at 12-month control (P < 0.02 vs baseline). In three patients (60%) Tg levels were undetectable at 12-month control. Pain was tolerable in two cases and mild in three cases. Transient dysphonia in one patient was the only complication. After 1 yr, no cancer seeding was present. LA is a well-tolerated outpatient procedure that results in a rapid cytoreduction of cervical nodal metastases of PTC. Mini-invasive procedures may be used in lieu of surgery as an adjunctive therapy for small-burden local/regional disease recurrence. They are occasionally associated with an anatomical or biochemical cure, but long-term follow-up or controlled trials are needed.

Thermal ablation in the treatment of lung cancer: present and future

Surgery is considered the best choice for stage I non-small cell lung cancer and also in treatment of selected patients with lung metastasis. However, surgery is often a high-risk procedure because of severe medical comorbidities affecting this cohort of patients. Thermal ablation (TA) has recently been proposed to achieve destruction of lung tumours whilst avoiding the use of general anaesthesia, thereby limiting the invasiveness of the procedure. For pulmonary malignancies, there are two methods of TA based on tissue heating: radio frequency ablation (RFA) and microwave ablation (MWA). Both are mini-invasive procedures, delivering energy to the tumour through single or multiple percutaneous needles introduced under guidance of computed tomography. The procedure may be performed under conscious sedation or general anaesthesia to avoid pain caused by needle insertion and tissue heating. Local efficacy is directly correlated to tumour target size: for RFA, tumours smaller than 2 cm can be completed ablated in 78-96% of cases; for MWA-according to the largest available study-95% of initial ablations are reported to be successful for tumours smaller than 5 cm. Very few series provide survival data beyond 3 years. For nodules smaller than 3 cm, the registered survival rate is higher: 50% at five years. The data collected in the last 10 years allow us to conclude that TA is an established alternative treatment for patients who cannot undergo surgery because of their compromised general condition. In the case of pulmonary metastasis, most authors agree to offer TA only if lesions are smaller than 5 cm.

Serdev Suture for Buttock's Lift - Ambulatory Scarless Procedure

Background: This article presents the author's technique and experience in the treatment of the flaccid unhappy form with his surgical procedure of buttock lift by suture, without incision The author first presented this new operation technique on a national level at the 2nd Annual Meeting of the National Bulgarian Society for Aesthetic Surgery and Aesthetic Medicine in Sofia on March 18, 1994 (1) and internationally at many scientific meetings over the world (2, 3, 4…). The result is a visual change in the buttock position to a higher one, which elongates the lower limbs and changes the proportions between lower and upper half of the body. Objective: The aim of this study is to describe a mini-invasive procedure of beautification of the buttock form without scars by creating a lifting effect on the buttock's subcutaneous tissue, using a suture that takes the inferiorly positioned deep fibrose tissue and fixes it upwards to the sacro-cutaneous fascia, discovered by the author. Aesthetic and technical considerations required properly sculpting the buttocks into a higher position, demonstrating nicely rounded form. Methods: 1032 female patients, and 26 male patients aged 18-62 years, with ptosis and cellulite on the buttocks were treated since 1993 on an outpatient basis by the Serdev suture technique without visible scars. Important instrumentarium is a long, curved, elastic needle and Polycon semi-elastic Bulgarian antimicrobial polycaproamide long term (in 2 years) absorbable surgical threads Polycon, produced in Bulgaria. This operation has been performed either alone or after ultrasonic assisted liposculpture (UAL) that reduces the amount of fat and heaviness. Results: All patients reported a high degree of satisfaction. A stable improvement in the buttock position and form was observed for the period described. In the postoperative period the complication rate was minimal and resolved in the first 4-5 days post operative period. The skin puncture in the perianal zone makes antibiotic prophylaxis obligatory as well as a strict follow up for the first 7 days. Some pain in the sitting position was observed for at least 5 to 10 days, but all other social and professional duties and activities were possible. Conclusions: This outpatient procedure is effective in the correction of buttock laxity and ptosis and creates a new form, universally accepted as happy buttocks.

Transcutaneous Serdev Suture For Buttock’s Lift

This article presents the author's technique and experience in the treatment of the flaccid "unhappy buttock" form with his surgical procedure of buttock lift by suture, without incision scars. The author first presented this new operation technique on a national level at the 2nd Annual Meeting of the National Bulgarian Society for Aesthetic Surgery and Aesthetic Medicine in Sofia on March 18, 1994 [1] and internationally at many scientific meetings over the world [2, 3, 4…]. The result is a visual change in the buttock position to a higher one, which elongates the lower limbs and changes the proportions between lower and upper half of the body. The aim of this study is to describe a mini-invasive procedure of beautification of the buttock form without scars by creating a lifting effect on the buttock's subcutaneous tissue, using a suture that takes the inferiorly positioned deep fibrose tissue and fixes it upwards to the sacro-cutaneous fascia, discovered by the author. Aesthetic and technical considerations required properly sculpting the buttocks into a higher position, demonstrating nicely rounded form. Preoperative shape is discussed and patient evaluations, operative techniques, postoperative management and results after 4 years of experience are emphasized. 1032 female patients, and 26 male patients aged 18-62 years, with ptosis and cellulite on the buttocks were treated since 1993 on an outpatient basis by the "Serdev suture technique without visible scars". Important instrumentarium is a long, curved, elastic needle and Polycon semi-elastic Bulgarian antimicrobial polycaproamide long term (in 2 years) absorbable surgical threads Polycon, produced in Bulgaria. This operation has been performed either alone or after ultrasonic assisted liposculpture (UAL) that reduces the amount of fat and heaviness. All patients reported a high degree of satisfaction. A stable improvement in the buttock position and form was observed for the period described. In the postoperative period the complication rate was minimal and resolved in the first 4-5 days post operative period. The skin puncture in the perianal zone makes antibiotic prophylaxis obligatory as well as a strict follow up for the first 7 days. Some pain in the sitting position was observed for at least 5 to 10 days, but all other social and professional duties and activities were possible. This outpatient procedure is effective in the correction of buttock laxity and ptosis and creates a new form, universally accepted as "happy buttocks".

Decrease in and Management of Urolithiasis After Kidney Transplantation

Urolithiasis after kidney transplantation can involve several contributing factors and the treatment strategy is open to question. We determined the incidence and management of urolithiasis in kidney recipients. We retrospectively reviewed a single center series of 3,000 kidney graft recipients during 32 years to identify those with urolithiasis. We analyzed data by the prevalence per decade, including perioperative procedures (preoperative assessment, anastomosis type and urinary drainage) and long-term followup (urinary stenosis, time to presentation, size, site, treatment type, renal function and survival). We identified 31 cases and noted a significant decrease in incidence from 2.1% to 0.6% during the 3 decades. Excluding 4 cases of donor in situ stones the mean time to diagnosis was 8.5 years. Surgical risk factors were ureteral obstruction in 41% of cases, infravesical obstruction in 14% and urinary-digestive anastomosis in 14%. A total of 12 cases (38%) were observed exclusively with 2 of spontaneous passage. With minor adaptations all mini-invasive procedures, including extracorporeal shock wave lithotripsy, endoscopy and percutaneous nephrolithotomy, were feasible in graft recipients. Antegrade procedures were facilitated by the ventral position of the graft. Eight patients (25%) were treated with open surgical ureteroureteral anastomosis. Prevention with a perioperative Double-J® stent and early treatment of ureteral obstruction have decreased and stabilized the urolithiasis rate at around 0.6%. Careful surveillance or any currently available instrumental treatments of urinary stones can be valid options.

Kyste neuroépithélial thalamo-mésencéphalique

Thalamo-mesencephalic neuroepithelial cysts are rare lesions of the central nervous system. They are thought to arise from neuroectoderm and are also referred to as ependymal cysts due to their origin. It can remain asymptomatic throughout life or rarely can cause symptoms. We describe a 42-year-old woman who presented with thalamic syndrome due to a neuroepithelial cyst of the thalamo-midbrain. Differential diagnosis is made with other cystic lesions in the brain. However a good analysis of imaging feature led to diagnosis. When the lesion is symptomatic, mini-invasive procedure is indicated.

Retroperitoneoscopic dismembered pyeloplasty for pediatric ureteropelvic junction obstruction: a report of 85 cases

To investigate the clinical application of retroperitoneoscopic dismembered pyeloplasty for pediatric ureteropelvic junction obstruction (UPJO). Of the 85 pediatric patients with UPJO, 56 were boys and 29 were girls. The age of the patients ranged from 2.5 to 11 years (mean = 4.6 years).B-ultrasonography showed hydronephrosis <15 mm (mild) in 15 patients,15-30 mm (moderate) in 59, <30 mm (severe) in the other 6. Intravenous urography (IVU) showed good imaging in 55 patients within 30 min, light imaging in 27 at 30-120 min, and no imaging in 3 after 120 min. The 85 patients underwent retroperitoneoscopic dismembered pyeloplasty. Conventional antegrade or modified antegrade double-J stenting was inserted in the 85 patients intraoperatively. The operation was successful in all, with no conversion to open surgery during the operation. The mean operation time was 146 min (125-240 min).The mean blood loss was 68 mL (55-112 mL).The mean postoperative hospitalization was 7 d (6-8 d ).Urine leakage occurred in 1 patient and with a good drainage, urine leakage disappeared in 1 week. Follow-up ranged 3-24 months (mean = 11 months).IVU showed on UPJ stricture, and good imaging in 75 patients within 30 min, light imaging in 10 at 30-120 min. Hydronephrosis was remitted:hydronephrosis resolution in 51 patients, mild in 6 and moderate in 3. Retroperitoneoscopic dismembered pyeloplasty is a safe, effective and mini-invasive procedure for pediatric ureteropelvic junction obstruction, with a rapid postoperative recovery. It will be the ideal treatment for UPJO in pediatric patients.

Anesthesiologist Assistance in Endoscopic Retrograde Cholangiopancreatography Procedures in the Elderly: Is it Worthwhile?

Anesthesiologists provide sedation of the patients for mini-invasive procedures such as endoscopic retrograde cholangiopancreatography (ERCP) at many institutions at present, particularly for the elderly. The purpose of the present study was to define the safety of sedation and the tolerance of ERCP procedures in the extremely elderly patients at our institution, in which sedation is provided and controlled by endo team only. Forty-one ERCP procedures were performed in patients aged 90 years or older. All patients had chronic concomitant diseases, and 88% of the patients belonged to American Society of Anesthesiologists group IV. The patients were sedated with midazolam, and 7 out of 41 patients received fentanyl. All ERCP procedures except one could be successfully completed, indicating good tolerance in 98% of the patients. There were neither sedation-related complications nor procedural mortality. In none of the cases, anesthesiologist assistance was needed. Routine anesthesiological assistance in ERCP procedures in the elderly seems unnecessary.

Indications and clinical benefits of mini-invasive parenchymal-sparing bronchoplastic procedures

Indications and clinical benefits of mini-invasive parenchymal-sparing bronchoplastic procedures

Percutaneous Vertebroplasty as a Treatment for Painful Osteoblastic Metastatic Spinal Lesions

Percutaneous vertebroplasty (PVP) has been used widely to treat pain caused by osteolytic spinal lesions, whereas vertebroplasty for osteoblastic spinal lesions is less known. The purpose of this study is to describe PVP as a highly effective miniinvasive procedure to treat painful osteoblastic metastatic spinal lesions. Four patients with painful osteoblastic metastatic spinal lesions were treated by PVP in the authors' department, and immediately relief of pain was achieved in all of them. The findings from this study may encourage more studies of PVP in palliative treatment of patients with osteoblastic lesions.

Manual hemorrhoidopexy in the treatment of hemorrhoidal disease

Over the last 10years a number of mini-invasive procedures have been introduced which have revolutionized the surgical treatment of hemorrhoidal disease. I would like to present a very effective method of approaching this disease with reduced postoperative pain. I have been using this technique since the year 2000 with excellent results. From 1999 to 2006 we used a proctoscope, especially, designed and patented by me to perform Doppler-guided ligation of the branches of the superior hemorrhoidal artery in the treatment of prevalently grade III hemorrhoids (THD method). Since 2006, we have performed the hemorrhoidopexy procedure alone, without Doppler-guided ligation of the arteries, and achieved excellent results (67 cases), with greater simplicity (easy-learning curve) and reduced surgery times. We use the "beak" proctoscope to this end, as it provides good illumination of the surgical field and enables the excision of areas of grade IV prolapse which are irreducible with this conservative technique.