Multiple Stones Research Articles

HPB SO79 - Dropped Gallstones After Laparoscopic Cholecystectomy: An Umbrella Review

Abstract Background The enduring presence of gallstones after laparoscopic cholecystectomy (LC) presents a substantial clinical obstacle, potentially resulting in morbidity and diagnostic intricacies, frequently leading to delayed identification. This umbrella systematic review aims to investigate the available body of literature regarding the symptoms, signs, etiology, management strategies, and associated complications of retained gallstones. Method We performed an extensive search of the academic literature spanning several databases, namely PubMed, Embase, Scopus, Web of Science, and Google Scholar. Inclusion criteria for this research encompassed systematic reviews, with or without meta-analysis, focusing on the examination of spilled gallstones in terms of signs, symptoms, diagnosis, imaging, and management. The assessment of potential bias in the final study selection was undertaken utilizing the R-AMSTAR and Risk of Bias in Systematic Reviews (ROBIS) assessment tools. Results The most sites for lost gallstones were the subhepatic, perihepatic, retroperitoneal, right flank and pelvic regions. A higher proportion of patients underwent emergency laparoscopic cholecystectomy compared to those who underwent elective procedures. complications included intra-abdominal abscesses, foreign body granulomas, parietal wall abscesses or pelvic abscesses. Multiple stones more common than single stones. Various clinical presentations have been documented, including the presence of abdominal masses simulating malignancy, intestinal obstruction, pelvic pain or fistula formation. Surgical intervention emerged as the primary treatment approach. Computed tomography was the most frequently employed diagnostic modality for stone identification (70.2%), ultrasonography (US) (63.2%) and X-ray (42.9%). Conclusion Our study highlights the overlooked issue of spilled gallstones post-laparoscopic cholecystectomy, posing diagnostic challenges and potential complications. Surgeons and patient education regarding this is lacking, stressing the need for increased awareness. Comprehensive studies with larger cohorts are essential for understanding risk factors and developing effective interventions.

HPB SO11 - Dropped Gallstones After Laparoscopic Cholecystectomy: An Umbrella Review

Abstract Background Gallstones (cholelithiasis) are solid formations in the gallbladder or biliary tract due to high cholesterol or bilirubin levels, affecting 10-20% of adults. Over 20% of those affected show symptoms like biliary colic. Gallstones can be cholesterol, black pigment, or brown pigment, with cholesterol stones being the most common. The persistence of gallstones following laparoscopic cholecystectomy (LC) poses a significant clinical challenge, potentially leading to morbidity and diagnostic complexities, often with delayed recognition. These complications can present as various intraabdominal conditions such as abscesses (intraabdominal or abdominal wall), fistula formation, peritonitis, bowel perforation, or ileus. Method We performed an extensive search of the academic literature spanning several databases, namely PubMed, Embase, Scopus, Web of Science, and Google Scholar. Inclusion criteria for this research encompassed systematic reviews, with or without meta-analysis, focusing on the examination of spilled gallstones in terms of signs, symptoms, diagnosis, imaging, and management. The assessment of potential bias in the final study selection was undertaken utilizing the R-AMSTAR and Risk of Bias in Systematic Reviews (ROBIS) assessment tools. Results The most prevalent sites for lost gallstones were identified as the right subhepatic, perihepatic, retroperitoneal, right flank, and pelvic regions. Multiple stones were found to be more common than single stones. Clinical presentations included the presence of abdominal masses simulating malignancy, intestinal obstruction, and pelvic pain or fistula formation. Surgical intervention emerged as the primary treatment approach. Pain localized to the right upper quadrant was reported by 24% of participants. Computed tomography (CT) was the most frequently employed diagnostic modality for stone identification (70.2%), followed by ultrasonography (US) (63.2%) and X-ray (42.9%). Conclusion Our research underscores a significant area that has received limited attention in existing literature. The occurrence of spilled gallstones presents challenges in diagnosis and carries the potential for severe post-laparoscopic cholecystectomy complications. A notable gap exists in the education of both surgeons and patients regarding this complication, emphasizing the need for heightened awareness among surgeons. Given the considerable variability observed between laparoscopic cholecystectomy procedures and the onset of associated symptoms, comprehensive studies with larger cohorts are imperative for elucidating pertinent risk factors and devising effective interventions.

Pancreatic Heterotopia in the Biliary Cyst Wall of a Pregnant Patient and Literature Review.

Pancreatic heterotopia is the presence of pancreatic tissue in a different anatomical location with no connection to the main pancreas. The most common locations in the gastrointestinal system are duodenum, stomach, and Meckel diverticulum. However, it is quite rare in the hepatobiliary system. Here we present a patient with pancreatic heterotopia who we treated with left hemihepatectomy and extrahepatic bile duct resection for Todani type 4a bile duct cyst. Heterotopic pancreatic tissue was present in dilated cystic bile ducts on pathological examination. A 22-year-old 26-week pregnant patient presented to the emergency department with right upper quadrant pain. There was massive dilatation of the left lobe bile ducts and common bile duct, and multiple stones were observed distal to the common bile duct. The patient was hospitalized for definitive surgical treatment 4 months after giving birth. The patient underwent left hemihepatectomy, extrahepatic bile duct resection, and hepaticojejunostomy. The postoperative course was uneventful. Pathological examination of the specimen showed heterotopic pancreatic tissues in the wall of the dilated cystic intrahepatic and extrahepatic bile ducts. One of the most accepted hypotheses in the etiology of biliary tract cysts involves the abnormal union of the pancreatic duct and common bile duct. This lesion is unique in the absence of pancreaticobiliary junction anomaly. We think that cystic dilation of intrahepatic and extrahepatic bile ducts is likely secondary to recurrent inflammation due to the release of digestive enzymes by heterotopic pancreatic tissue in the biliary tract. It is also the first example in the literature diagnosed during pregnancy.

Predicting urinary stone recurrence: a joint model analysis of repeated 24-hour urine collections from the MSTONE database

To address the limitations in existing urinary stone recurrence (USR) models, including failure to account for changes in 24-hour urine (24U) parameters over time and ignoring multiplicity of stone recurrences, we presented a novel statistical method to jointly model temporal trends in 24U parameters and multiple recurrent stone events. The MSTONE database spanning May 2001 to April 2015 was analyzed. A joint recurrent model was employed, combining a linear mixed-effects model for longitudinal 24U parameters and a recurrent event model with a dynamic first-order Autoregressive (AR(1)) structure. A mixture cure component was included to handle patient heterogeneity. Comparisons were made with existing methods, multivariable Cox regression and conditional Prentice-Williams-Peterson regression, both applied to established nomograms. Among 396 patients (median follow-up of 2.93 years; IQR, 1.53–4.36 years), 34.6% remained free of stone recurrence throughout the study period, 30.0% experienced a single recurrence, and 35.4% had multiple recurrences. The joint recurrent model with a mixture cure component identified significant associations between 24U parameters - including urine pH (adjusted HR = 1.991; 95% CI 1.490–2.660; p < 0.001), total volume (adjusted HR = 0.700; 95% CI 0.501–0.977; p = 0.036), potassium (adjusted HR = 0.983; 95% CI 0.974–0.991; p < 0.001), uric acid (adjusted HR = 1.528; 95% CI 1.105–2.113, p = 0.010), calcium (adjusted HR = 1.164; 95% CI 1.052–1.289; p = 0.003), and citrate (adjusted HR = 0.796; 95% CI 0.706–0.897; p < 0.001), and USR, achieving better predictive performance compared to existing methods. 24U parameters play an important role in prevention of USR, and therefore, patients with a history of stones are recommended to closely monitor for future recurrence by regularly conducting 24U tests.

A Case of a Young Adult with Multiple Intrahepatic Stones Diagnosed as Low Phospholipid-Associated Cholelithiasis Showing &lt;i&gt;ABCB4&lt;/i&gt; Gene Mutation

A Case of a Young Adult with Multiple Intrahepatic Stones Diagnosed as Low Phospholipid-Associated Cholelithiasis Showing &lt;i&gt;ABCB4&lt;/i&gt; Gene Mutation

Bilateral duplex kidney and ureter with multiple stones: a case report

BackgroundBilateral duplicated kidney and ureter is a rare condition in urology, and it is even rarer for patients to have multiple stones simultaneously. We delineate the diagnostic and therapeutic trajectory of a patient presenting with bilateral duplex kidneys and ureters, characterized by the presence of multiple stones. Notably, the left kidney is a complete duplication, whereas the right kidney exhibits an incomplete duplication.Case presentationA 47-year-old male patient was diagnosed with bilateral duplex kidney and ureter combined with multiple stones. Ureteral flexible lithotripsy and percutaneous nephrolithotomy were performed successively in our hospital. On the postoperative five day, he was discharged from the hospital without apparent discomfort.The double J tube was pulled out one month later, and no stone recurrence was found after 3 months of follow-up.ConclusionsBilateral duplicated renal ureteral malformations combined with multiple stones are very rare. Stones can be removed by ureteroscopic lithotripsy or percutaneous nephrolithotripsy and sometimes multiple procedures are required, which should be chosen according to the patient’s relevant condition.

Efficacy of flexible ureterorenoscopy in treating multiple renal stones: a cohort study.

While the efficacy of flexibleureterorenoscopy (URS) in managing solitary kidney stones (KSs) is widely acknowledged, its effectiveness intreating multiple stones has scarcely been investigated. This study aims to assess the effectiveness and safety of retrogradeintrarenal surgery (RIRS) utilizing flexible URS and laser lithotripsy in the management of multiple KSs. Methods: This study was a single-group cohort study conducted on patients with multiple KSs who underwent treatment withRIRS using flexible URS and laser lithotripsy. Stone-free status was considered as the lack of residual stone fragments or anyresidual stone of any size. The first follow-up appointment was arranged 3-4 weeks following the procedure. If significant residualstones were present, patients underwent reintervention within 2-4 weeks. A total of 110 patients with multiple KSs were included. The mean stone burden was 27.5 ± 7.9 mm, and the mean duration of the operation was 54.9 ± 19.7 minutes. Seven cases(6.3%) experienced intraoperative complications, while postoperative complications were found in eight cases (7.3%). Afterfour weeks, a stone-free rate (SFR) was documented in 80.9% of the cases, and this rate increased to 93.6% after three months.The SFR after three months was significant with Guy's stone score (p < 0.001); however, it did not reach a significant level with any other parameters. Conclusions: The RIRS with flexible URS may be an effective and potentially safe procedure for treating multiple KSs. It mayyield a favorable SFR with an acceptable complication rate.

A Machine Learning Predictive Model for Ureteroscopy Lasertripsy Outcomes in a Pediatric Population-Results from a Large Endourology Tertiary Center.

Introduction: We aimed to develop machine learning (ML) algorithms for the automated prediction of postoperative ureteroscopy outcomes for pediatric kidney stones based on preoperative characteristics. Materials and Methods: Data from pediatric patients who underwent ureteroscopy for stone treatment by a single experienced surgeon, between 2010 and 2023 in Southampton General Hospital, were retrospectively collected. Fifteen ML classification algorithms were used to investigate correlations between preoperative characteristics and postoperative outcomes: primary stone-free status (SFS, defined as stone fragments <2 mm at the end of the procedure confirmed endoscopically and no evidence of stone fragments >2 mm at Xray kidney-ureters-bladder (XR KUB) or ultrasound kidney-ureters-bladder (US KUB) at 3 months follow-up) and complications. For the task of complication and stone status, an ensemble model was made out of Bagging classifier, Extra Trees classifier, and linear discriminant analysis. Also, a multitask neural network was constructed for the simultaneous prediction of all postoperative characteristics. Finally, explainable artificial intelligence techniques were used to explain the prediction made by the best models. Results: The ensemble model produced the highest accuracy (90%) in predicting SFS, finding correlation with overall stone size (-0.205), presence of multiple stones (-0.127), and preoperative stenting (-0.102). Complications were predicted by Synthetic Minority Oversampling Technique (SMOTE) oversampled dataset (93.3% accuracy) with relation to preoperative positive urine culture (-0.060) a1nd SFS (0.003). Training ML for the multitask model, accuracies of 83.3% and 80% were respectively reached. Conclusion: ML has a great potential of assisting health care research, with possibilities to investigate dataset at a higher level. With the aid of this intelligent tool, urologists can implement their practice and develop new strategies for outcome prediction and patient counseling and informed shared decision-making. Our model reached an excellent accuracy in predicting SFS and complications in the pediatric population, leading the way to the validation of patient-specific predictive tools.

SPECTRUM OF BACTERIAL CULTURE AND ANTIBIOGRAM IN PCNL PUNCTURE URINE SAMPLE

Percutaneous nephrolithotripsy (PCNL) is the standard treatment for high-volume renal stones, stones resistant to extracorporeal shockwave lithotripsy (ESWL), and multiple and inferior calyx renal stones. Objective: The study's main objective is to find bacterial culture and antibiogram spectrum in PCNL puncture urine samples. Methods: This retrospective observational study was conducted at CMH, Lahore, from April 2024 to July 2024. Data were collected from 185 patients. Urine samples were collected directly from the renal pelvis through the PCNL puncture site during the surgical procedure. This method ensures that the samples accurately represent the microbial environment of the kidney. Results: Data were collected from 185 patients according to the study's criteria. The gender distribution comprised 110 males (59.5%) and 75 females (40.5%). The age of the patients ranged from 25 to 70 years, with a mean age of 48.23±3.54 years. Among the positive cultures, Escherichia coli was the most prevalent species, found in 46.2% of cases, followed by Klebsiella pneumoniae (23.1%), Pseudomonas aeruginosa (15.4%), Enterococcus faecalis (7.7%), and Proteus mirabilis (3.8%). Additionally, 3.8% of the samples included other bacteria, including mixed infections. Conclusion: It is concluded that the bacterial spectrum in PCNL urine samples is diverse, with significant antibiotic resistance patterns observed among isolated pathogens.

Sheathless RIRS in the era of slim and single use flexible ureteroscopy (ssFURS): Prospective analysis of clinical outcome.

the purpose is to assess the feasibility of sheathless and time-limited retrograde intrarenal surgery (RIRS) using slim and single use flexible ureteroscopy (ssFURS) in view of the stone-free rate (SFR), complication rate and upfront ureteral stenting. A prospective, cross-sectional study of patients who underwent RIRS for kidney stones between December 2021 and December 2023 at our tertiary urology center was performed. Patient demographics, clinical presentations and stone characteristics were calculated. The SFR and complication rate were included. Hundred and eighteen patients were included. The median age was 48 (35.7-60.0) years. Diabetes mellitus (DM) was present in 32 patients (27.1%). The median length of the kidney stones was 1.15 (range [0.4-3.0]), and the median width was 1 (range [0.05-3.7]). The pelvi-ureteric junction (PUJ) represented 75 (63.6%) patients. The lower pole stone (LP) consisted of 27 (22.9%) patients. Thirty-seven (31.4%) of the patients had multiple kidney stones. An overall complete SFR after the first session was observed for 94 (79.7%) patients. The second session of complete SFR was observed in 15 patients (12.7%). A median stone length of 1 (0.8-1.5) cm and a median stone width of 0.95 (0.7-1.3) cm were both significantly associated with a complete SFR after the first session (p < 0.001). A single kidney stone in 69 (73.4%) patients was significantly more strongly associated with a complete SFR after the first session than was multiple kidney stones in 25 (26.6%) patients (p = 0.027). Upfront stenting was performed in 74 patients (62.7%). The complete SFR after the first session was significantly greater in patients who underwent upfront stenting (65; 69.1%) than in those who underwent primary ssFURS (29; 30.9%, p = 0.004). Sheathless and time-limited RIRS using ssFURS is a feasible and successful procedure with low complication rate.

Efficacy of Upper Gastrointestinal Endoscopy In Cholelithiasis Before Laparoscopic Cholecystectomy

Background: The most prevalent condition affecting the gallbladder and biliary tree is cholelithiasis. Presence of gall stones is discovered commonly during imaging tests for other pathologies. Laparoscopic cholecystectomy is a preferred modality for the treatment of gallstone disease. Objective: The primary aim of the study is to determine the efficacy of upper gastrointestinal endoscopy as a routine investigative modality in symptomatic presentation of cholelithiasis prior to laparoscopic cholecystectomy. Methods: A total 50 participants having single or multiple stones in the gall bladder found on ultrasound were included in the study. Enrolled patients underwent routine investigations. The baseline demographic details like patient name, age, gender, clinical presentation, and upper endoscopy findings were documented. The intensity of the pain was measured by visual analogue scale. Results: A total of 36% patients were in the age-group of &lt; 30 years. The highest incidence of cholelithiasis was observed in female gender. Abdominal pain was the most common symptom. The most common upper gastrointestinal endoscopy findings were gastritis followed by gastritis erosion. A significant reduction of pain was noted in group I as compared to group II at first- and fourth-week time durations. Conclusion: Cholelithiasis has common clinical presentations in similarity to other upper gastrointestinal diseases. Upper gastrointestinal endoscopy can be recommended for patients with atypical presentation to prevent post-surgical adverse outcomes.

Pre-Operative Evaluation of Risk Factors for Difficult Laparoscopic Cholecystectomy

Cholelithiasis or the gallstone disease is the most common biliary pathology. 10-15% population of western world is estimated to be affected by gallstone disease, of which majority remains asymptomatic (&gt;80%) and 1-2 % of these asymptomatic patients will develop symptoms needing surgery per year. In this prospective study, 77 patients years undergoing elective Laparoscopic Cholecystectomy (LC) and meeting all inclusion criteria in Department of General Surgery, Nepal Medical College and Teaching Hospital over period of 1 year. History, detailed clinical examination and laboratory investigations were performed as per the working proforma. Operative time and conversion to open cholecystectomy were recorded. The association between clinical, laboratory and sonographic factors with difficult laparoscopy were obtained. Data analysis was done using SPSS-17 version. Out of 77 patients, 63 were females. Body mass index (BMI) above 30 representing obese population were 33.2% with p value 0.0004. Also, 41.5% patients had history of acute cholecystitis while 12.9% patients had previous history of abdominal surgery and 70.1% patients had history of recurrent abdominal pain. Total of 19.4% patients had increased leucocyte count. On ultrasonography thickened GB wall of &gt;3 mm was seen in 42.8%, distended GB was seen in 41.5%, stone size of &gt;1 cm was seen in 70.1% patients and multiple stones were seen in 84.4%. Similarly, duration of surgery was &gt;90 mins in 31.1% and 7.04% patients underwent conversion to open cholecystectomy both of which were considered difficult laparoscopy. Our study reveled that clinical factors like age, BMI, history of acute cholecystitis, previous history of recurrent abdominal pain and past history of abdominal surgery had significant association in prediction of difficult LC.

Multiple giant bladder stones in spinal cord injury patient from rural Indonesia: a rare case report

Multiple giant bladder stones in spinal cord injury patient from rural Indonesia: a rare case report

WP3.3 - Surgical Management of multiple mega large stones of a congenitally low inserted Cystic Duct – A Case Report

Abstract Introduction Low cystic duct insertion is uncommon, and the presence of multiple large stones in the cystic duct with normal laboratory investigation is rare. The infrequency with which it is encountered and the management done makes this an interesting presentation. Case presentation A 61-year-old female with incidental gall stones and possible CBD/cystic duct stones on a CTAP during a workup for management of an incisional hernia of the abdomen. The patient initially presented with abdominal pain that was thought to be due to the incisional hernia. On examination, the patient had a soft abdomen with no jaundice and normal laboratory investigations. MRCP scan demonstrated multiple gall stones and cystic duct stones suggestive of Mirizzi syndrome. The patient underwent laparoscopic repair of the incisional hernia and cholecystectomy with an on-table cholangiogram. Cholangiogram showed a low inserting cystic duct joining the common hepatic duct at the sphincter of Oddi with an almost nonexistent common bile duct and a cystic duct containing multiple mega-large stones. The cystic duct was explored and stones were milked out except the most inferior stone which was impacted at the sphincter of Oddi. This was dislodged with a Fogarty catheter and all stones were retrieved. Completion cholangiogram demonstrated complete clearance of the biliary tree with dye entering the duodenum. The patient recovered well postoperatively with no complications at 1 month post-operative. Conclusion This case illustrates a rare presentation of large cystic duct stones in the presence of abnormal anatomy and provides an option for surgical management.

Operative outcomes 24 hours after retrograde intrarenal surgery for solitary renal calculi using a flexible and navigable suction ureteral access sheath. A prospective global multicenter study by the European Association of Urology Section on Urolithiasis.

Suction techniques showed potential to improve outcomes of retrograde intra-renal surgery (RIRS). We assessed the 24-hour stone-free rate (SFR) and complications after RIRS using flexible and navigable suction ureteral access sheaths (FANS-UAS). Sixteen centers prospectively contributed to data (August 2023-October 2023). Inclusion criteria: age ≥18 years, single renal stone, pre and 24-hour post-RIRS CT scan. Exclusion criteria were: ureteral stone, anomalous kidney, multiple stones. SFR was divided into: 1) grade A - no fragments; 2) grade B - fragments ≤2 mm; 3) grade C - fragments 2.1-4 mm; and 4) grade D - fragments >4 mm. A multivariable logistic regression analysis model was performed to assess factors associated with the odds of having grade A stone-free status. Data are expressed as median (interquartile range), absolute numbers and frequencies, odds ratio (OR), and 95% confidence interval (CI). One hundred forty-two patients with a median age of 52 years (40-61) were enrolled. 61.3% were males. Median stone volume was 1165 mm3 (656-1936). Median operative time was 48.5 (36.25-71.75) min. Transient fever (37°C-37.5°C) occurred in 10 (7%) patients. No sepsis case occurred. 96.5% of patients were stone-free (Grade A+B). Grade A SFR was 52.8%. All patients were discharged within 48 hours. Bone window (OR 3.156 95% CI 1.177-9.130, P=0.027) was the only factor significantly associated with higher odds of 100% SFR, while stone volume (OR 0.999, 95% CI 0.999-1.000, P=0.007) was significantly associated with lower odds. Imaging and clinical evidence demonstrate excellent perioperative outcomes just 24 hours post RIRS with FANS-UAS. The technique demonstrates a good safety profile, ability for immediate high SFR, and a low rate of infective complications.

Conventional ultrasonography enabled with augmented reality needle guidance for percutaneous kidney access: An innovative methodologies randomized controlled trial.

Successful needle puncture of the renal collecting system is a critical but difficult procedure in percutaneous nephrolithotomy (PCNL). Although fluoroscopy and ultrasound are the standard imaging techniques to guide puncture during PCNL, both have known limitations. To assess the feasibility and safety of a new navigation system for needle puncture in ultrasound-guided PCNL. This study employed a single-center randomized controlled trial (RCT) design to assess the feasibility and safety of a new navigation system for needle puncture in ultrasound-guided PCNL. Conducted between May 2021 and November 2021, the trial utilized computer-generated random numbers for participant allocation to control for selection bias. The trial was executed at the *********, which serves as an academic medical center. All patients who met the inclusion criteria were randomly divided into two groups, with 29 patients in each group. One group underwent PCNL procedures using the new navigation system, while the control group underwent standard ultrasound-guided PCNL procedures. Included patients had renal pelvis or caliceal calculi larger than 2.0cm in diameter or had multiple or staghorn stones. The puncture procedure was performed with the support of real-time ultrasound imaging and visual guidance displayed on the screen. The primary outcome was system feasibility and puncture success rate. Secondary outcomes included puncture time, total surgical time, number of attempts, post-procedure complications, and one-year and three-year stone recurrence rates. Stone clearance was defined by postoperative CT. Descriptive statistics summarized patient demographics, stone size, and location. Independent samples t-tests analyzed puncture time and total surgical time. Chi-square or Fisher's exact tests compared stone clearance, complications, socioeconomic status, renal hydronephrosis, stone location, race, and medical history. Linear regression examined the correlation between BMI and puncture time. Significance was set at P<0.05. For all 58 patients undergoing PCNL, needle punctures of the renal collecting system were completed with a success rate of 100%. The average time from planning the puncture protocol to successful puncture was significantly shorter in the AcuSee guidance system group (3.12min, range 0.2-6.88min) compared to the standard ultrasound-guided group (7.58min, range 5.41-10.68min), representing a reduction of approximately 59%. The total surgical time was also shorter in the AcuSee group for patients with no and mild hydronephrosis (P<0.05). Complication rates were lower in the AcuSee group, with no major complications observed. However, 3 patients in the standard ultrasound-guided group have adverse effects after the PCNL procedure. The one-year stone recurrence rate was significantly lower in the AcuSee group (3.4%) compared to the standard group (24.1%), and the three-year recurrence rate was also lower (6.9% vs. 41.4%). Patient-specific factors such as BMI, renal morphology, and prior surgical history did not significantly affect the performance of the AcuSee system. We report the first clinical application of a new navigation system for needle puncture in ultrasound-guided PCNL. It has been demonstrated that it is feasible and safe compared to the standard ultrasound-guided group in percutaneous renal puncture. This technology provides intuitive and easy-to-use visual guidance, which may facilitate safe, accurate and fast needle puncture of the kidney.

Validation of stone-kidney size score to predict outcome and complications of pediatric percutaneous nephrolithotomy

The prevelance of urinary system stone disease in children is emphasizing the need for minimally invasive treatments to decrease morbidity and recurrence risk. Percutaneous nephrolithotomy (PCNL) has emerged as a preferred approach for pediatric patients with complex stones due to its minimally invasive nature, including miniaturized and vacuum-assisted access sheaths, advanced laser technology and tubeless and outpatient procedures. However, adult scoring systems have proven ineffective in predicting success and complications in pediatric PCNL. This highlights the need for specialized scoring systems, such as the Stone-Kidney Size (SKS) scoring system, tailored to pediatric patients and will be evaluated in our study for its association with the stone-free rate (SFR) and complications. The data of 144 patients aged <17 years who had undergone PCNL between January 2008 and December 2019 were evaluated retrospectively. Demographics, stone characteristics, perioperative/postoperative outcomes were recorded for each patient. The SKS scoring system comprises the stone kidney index (SKI) and the number of stones, assigns one or two points based on single or multiple stones and an SKI value of <0.3 or ≥0.3, respectively. The SKI is computed by dividing the stone's longest axis by the kidney's longest axis. Residual stones less than 4mm on non-contrast computed tomography are considered clinically insignificant residual fragments (CIRFs). Stone-free and CIRF patients were considered successful results. The relationship between the SKS scoring system and SFR, success, and complication rates after surgery was investigated. Statistical analyses were conducted using SPSS 22.0 software. The SFR was 67.36% and 74.31% when CIRF patients were included, respectively, with a complication rate of 27%. In multivariate analysis, stone treatment history, stone burden, and SKS score were statistically significantly associated with SFR (p<0.001, p=0.032, p<0.001, respectively). Furthermore, the SKS score was the only variable that showed a statistically significant relationship with success. No significant association was found between SKS score and complications (p=0.342). Our study demonstrates a relationship between the SKS scoring system and SFR in pediatric PCNL patients. However, shortcomings have been observed in its capacity to accurately predict post-PCNL complications. Despite being a retrospective analysis and having a single-center design, our study externally validates the relationship between the SKS scoring system and SFR after pediatric PCNL. The SKS scoring system is associated with SFR in pediatric patients undergoing PCNL; however, this relationship has not been established for complications.

Effectiveness of pre-operative routine MRCP in patients scheduled for laparoscopic cholecystectomy

Background: Cholelithiasis is one of the most common surgical diseases worldwide. Laparoscopic cholecystectomy is the gold standard treatment for cholelithiasis, and has become the most common performed gastro intestinal operation. The prevalence is higher in women (7.7%) than in men (3.3%). We aimed to investigate the effectiveness of pre-routine magnetic resonance cholangiopancreatography (MRCP) before performing scheduled Laparoscopic cholecystectomy. Methods: This was a prospective observational study conducted in the Department of General Surgery, Dhaka Central International Medical College, and selected single private Hospital from Dhaka, Bangladesh during the period from January 2021 to January 2023. In our study, we included 90 female patients presented with acute or chronic calculus cholecystitis. All patients were diagnosed with multiple gall stones diseases on USG abdomen after initial clinical evaluation were included in this study. Result: In our study, we found the mean age was 34.97±8.48 years. Among 90 patients USG showed multiple stones in 85(94.44%) patients whereas, MRCP showed stones only in 24 (26.67%) patients. Among patients with normal CBD, MRCP found 25.33 % and USG found 93.33% with stones. There were 3 patients with more than 5 mg/dl. bilirubin who was diagnosed with stones in both findings. Among the patients with 148-220 ALP levels, both USG and MRCP found 90.48% of patients with stones. We found 1 true negative case and 20 true positive cases of multiple stones (with a p value of 0.017). Conclusion: We found that MRCP helps increase the safety of perioperative management in some cases. Preoperative ultrasonography has a low diagnostic accuracy rate when it comes to patients who also have gallstones and CBD stones. So, individuals with gallstones are advised to undergo a normal preoperative MRCP examination.

The predictive ability of Mayo adhesive probability score for evaluating intraoperative bleeding in standard percutaneous nephrolithotomy in adult patients.

Mayo adhesive probability (MAP) score is one of the commonest tool to predict the adherence status of perirenal fat. The association between MAP score and intraoperative hemorrhage in patients undergoing micropercutaneous nephrolithotomy was comfirmed in a recent well designed study. We aimed to investigate if MAP score may predict the possibility for significant intraoperative bleeding in supine percutaneous nephrolithotomy (PCNL) performed with a 26 Fr rigid nephroscope. In this observational retrospective study, demographic, clinical, laboratory, radiological, perioperative (operation duration, hospitalization, intraoperative bleeding, success) and MAP score (perinephric fat stranding, posterior perinephric fat thickness and total MAP score) data of all patients who underwent supine PCNL between June 2021 and July 2023 were evaluated. The patients were divided into 2 groups according to their MAP scores (79 [54.1%] patients with MAP score < 3 [low MAP score] and 67 [54.1%] patients with MAP score ≥ 3 [high MAP score]). The rate of patients with intraoperative bleeding was 47.8% in the patient group with a high MAP score, while it was 22.8% in the patient group with a low MAP score (p = 0.002). In multivariate logistic regression analysis, anticoagulant drug use history (OR = 2.525; 95% CI = 1.025-6.224; p = 0.044), presence of multiple stones (OR = 3.015; 95% CI = 1.205-7.543; p = 0.018), calyx localization of the stone (OR = 2.871;95% CI = 1.166-7.068; p = 0.022), higher renal parenchymal thickness (OR = 1.119; 95% CI = 1.049-1.193; p = 0.001) and MAP score > 3 (OR = 3.486; 95% CI = 1.579-7.696; p = 0.002) were defined as independent risk factors for significant intraoperative bleeding. In clinical practice, the MAP score can be used to predict bleeding before PCNL.

Cholecystocutaneous Fistula.

This image article presents an 88-year-old indigenous woman with a history of several episodes of abdominal pain, for which she went to numerous different hospitals in the countryside, was always treated with analgesics, and then discharged. After a long time, the patient eventually was evaluated with magnetic resonance imaging. The test revealed a displaced gallbladder with thickened walls, multiple stones, and a fistulous tract extending to the skin. This case underscores the significant challenges faced by patients in regions with limited healthcare access, highlighting the impact of delayed diagnosis and inadequate management on patient outcomes.