Multiple Stones Research Articles

Type 2 Diabetes Mellitus with Diabetic Gastroparesis and Occasional Liver Dysfunction Treated by Low Carbohydrate Diet

Diabetes mellitus (DM) has wider neurological complications. They include upper gastrointestinal (GI) symptoms, impaired motility, impaired gastric emptying (GE) and diabetic gastroparesis (DG), which are usually found. The patient was a 64-year-old man with type 2 diabetes (T2D) for 22-years. The patient weighed 74 kg with body mass index (BMI) 23.6 kg/m2, hemoglobin A1C (HbA1c) 9.2%, ankle brachial index (ABI) 1.19/1.23, AST 25 U/L(7-38), ALT 23 U/L(4-44), GGT 48 U/L(<86), Chest X-P normal, and electrocardiogram (ECG) negative. When the patient was treated with low carbohydrate diet (LCD), a significant reduction in body weight and HbA1c was observed. Abdominal computerized tomography (CT) revealed multiple gall stone, dilated common bile duct and impaired GE, indicating DG. For endoscopic examination, much food residue was found in the stomach due to DG after 13 hours fasting. Treatment for DG was initiated by mosapride citrate hydrate. During clinical progress, occasional liver dysfunction was observed twice associated with elevation of AST 196 U/L, GGT 373 U/L and without symptoms, indicating cholestasis-type dysfunction. Some possible triggers may be involved in these episodes, such as gall stone, enlarged volume of stomach due to DG, overeating, overdrinking, and other factors. This impressive report will hopefully become a reference for developing diabetic practice and research.

Unusual Case of Foreign Body Ingestion in a Child: A Case Report

Foreign body ingestion is a common problem in pediatric age group patients throughout the world. Radiographic findings revealed multiple foreign bodies throughout abdomen. Foreign objects attach frequently at the esophageal anatomic narrowing. They must be taken out immediately because they can cause an obstruction, mucosal erosion or perforation. Endoscopy is the criterion standard for removal of foreign bodies from the esophagus. Here, we report an interesting case of a multiple stones ingested by a female child. The child presented with complaints of distension of abdomen, vomiting and pain all over abdomen. The foreign bodies were found as hard black stones after removing them through anal route.

Complications of Percutaneous Nephrolithotripsy (Literature Review)

Percutaneous nephrolithotripsy is a standard treatment option for upper urinary tract stones ≥1.5 cm in size, multiple and staghorn stones. The efficiency and reliability of this procedure have improved, because of advances in technology and increased experience. This operation is considered a safe technique, which have the highest level of stone-free rate in comparison with shock-wave lithotripsy and retrograde nephrolithotripsy. The percutaneous nephrolithotripsy does not rule out the risk of complications. To analyze the complications of percutaneous nephrolithotripsy, their risk factors and treatment methods based on overview of scientific literature. It was identified the following complications such as bleeding during surgery and postoperatively, perforation of the renal collecting system, chest injuries, spleen injuries, liver and gallbladder injuries, injuries of the small and large intestine, and also infectious complications. The risk factors such as stone size and stone location, renal syntopia and skeletotopia, urinary system abnormalities, and overweight affect were established. Preoperative leukocytosis, positive urinary nitrite, and positive bacteriological culture of bladder urine are independent risk factors for infectious complications after percutaneous nephrolithotripsy, especially in patients with diabetes mellitus. Percutaneous nephrolithotripsy is the most difficult technique for treating urolithiasis. Therefore, the training of this operation is long and difficult. It is established that competence and perfection are achieved after 45 and 105 operations, respectively. Adequate preoperative preparation, especially elimination of urinary tract infection before surgery, accurate puncture under the guidance of fluoroscopy and / or ultrasound, maintenance of low intrarenal pressure and reduction of surgery time are important technical requirements for safety and efficacy of percutaneous nephrolithotripsy. According to the literature, percutaneous nephrolithotripsy is an effective and safe method of treating nephrolithiasis with a low level of complications. Knowledge of risk factors, treatment methods is important for every endourologist. Most complications, with timely diagnosis, can be eliminated conservatively, or with minimal invasive techniques, which has a positive effect on the treatment time and the psycho-emotional state of the surgeon.

An insight into predominance of pulmonary complications on right side in supracostal percutaneous nephrolithotomy.

To analyse pulmonary complications following supracostal percutaneous nephrolithotomy especially after right sided supracostal punctures, both in initial and relook PCNL. From February 2016 till date, 90 patients underwent PCNL in Government Medical College, Jammu through supracostal puncture - 53 on right side and 37 on left side. All supracostal punctures were made about 7-8.5 cm from midline. Tract dilatation was done using metal dilators and calculi were fragmented using pneumatic lithotripsy. Patients with supracostal superior calyceal punctures were evaluated for chest complications intraoperatively by fluoroscopy, X-ray chest on evening of postoperative day 0 and repeated thereafter on third and seventh postoperative days. Stone configuration included complete staghorn in 16, partial staghorn in 23, multiple stones in 16 and pelvic stone in 35 cases. Age range of patients was 07-76 years. There was 14.4% (13 out of 90) incidence of early or delayed chest complications - 20.8% (11 out of 53) on right side and 5.4% (2 out of 37) on left side. Pulmonary complications in supracostal punctures; especially on right side should not be underestimated. There are always chances of delayed hydrothorax after supracostal puncture. A chest X-ray should be repeated after 1 week in patients with supracostal PCNL punctures.

Open stone surgery in the treatment of bilateral complex renal stones with left infected hydronephrosis: A case report

Introduction and importanceWith the strong development of percutaneous nephrolithotomy as well as other less invasive procedures, the indication of open surgery for the treatment of nephrolithiasis has been significantly reduced and is only applied in selective cases.Case presentationA 55-year-old male was admitted to the Department of Urology due to fever and left flank pain. Clinical examination and imaged studies reveal staghorn calculi in the right kidney and infected hydronephrosis with multiple stones on the left side. The stone removal surgery was performed in 2 sessions, left first - right after. The two operations came out with no peri- or post-operative complication, no blood transfusion.Clinical discussionThe two reasons for the indication of open surgery instead of percutaneous nephrolithotomy were i/ the stone's sizes were very large and very hard, and ii/ the multi-tract nephrolithotomy increased the risks of blood transfusion and parenchymal's damage. Also, a long-time and difficult nephroscopy was not the good choice for the left-infected hydronephrosis.ConclusionOpen stone surgery is still a good alternative approach for kidney complex stone burden, especially infected hydronephrosis.

Outcomes of fluoroscopy-free retrograde intrarenal surgery and predictive factors of stone-free.

To evaluate the outcomes of flouroscopy-free retrograde intrarenal surgery (ffRIRS) and to investigate the factors that may affect stone-free rate. The charts of patients who underwent ffRIRS between January 2017 and August 2019 were reviewed retrospectively. Patients with missing preoperative imaging and patients with kidney anomalies were excluded from the study. Age, gender, stone size, stone localization, stone density, laterality, operation time, stone-free rate, complications and auxiliary procedures were recorded and analyzed. Study group involved 44 (43.1%) female and 58 (56.8%) male patients. Stone-free rate in a single-session ffRIRS were found to be correlated with stone localization (p = 0.003), stone volume (p = 0.004), and stone density (p = 0.009) but not with age (p = 0.950). Patients with multiple calyceal stones and a stone burden over 520 mm3 were found to be less stone-free. The complication rate in female gender (n = 7) was significantly higher compared to male (n = 1) (p = 0.011). No major complications such as ureteral injury or avulsion were observed. Overall, 13 patients (12.7%) needed auxiliary procedures. The operation time seemed to be affected by stone size and gender (p = 0.005; p = 0.044, respectively). Stone-free rate in ffRIRS were found to be affected by stone density, size, and localization. Patients with multiple caliceal stones and high stone burden (< 520 mm3) have been found to have low stone-free rate, so one can speculate that having fluoroscopy assistance in RIRS might help us to improve surgical success.

Transperitoneal Laparoscopic Pyelolithotomy versus Percutaneous Nephrolithotomy for Treating the Patients with Staghorn Kidney Stones: A Randomized Clinical Trial.

To compare the performance and outcomes of laparoscopic pyelolithotomy (LPL) versus percutaneous nephrolithotomy (PCNL) in the management of staghorn kidney stones. This study was a parallel-group randomized clinical trial study carried out on 68 patients with staghorn stones (one single piece or maximally two-piece stones with large extra renal part) over 18 years referred to Labbafinejhad Hospital. Patients were randomly divided on a ratio of 1:1 into two groups of LPL and PCNL using random allocation software. The primary outcome was the stone free rate, which was evaluated with KUB, and ultrasonography. Secondary outcomes were duration of surgery, bleeding, fever, post-operative pain, length of hospital stay, and postoperative complications. The mean±SD age of patients in PCNL and LPL groups were 48.50 ± 13.33 years and 52.17 ± 15.74 years, respectively (P=.303). LPL was associated with a higher duration of surgery (196.55 ± 26.58 minutes versus 110.88 ± 34.82; P=.001). Hemoglobin drop in the PCNL group was higher than the LPL group (2.67 ± 2.61 g/dL versus -0.7912 ± 1.06 g/dL; P=.001). Stone free status was observed in 29 (85.3%) patients in the LPL group, which was significantly higher than the PCNL group (22 patients, 64.7%; P =.050). The results of this study indicate that LPL offers a higher stone free rate with less bleeding in patients with single particle or limited particles staghorn stones with extrarenal pelvis but is associated with a higher duration of operation. The application of LPL in patients with multiple stones carries a lower achievement and is not encouraged.

Abound Hepatic Mitosis: Unusual Morphology in the Intrahepatic Cholelithiasis Patient

To explore the clinicopathological features of abound mitosis of the hepatocytes in intrahepatic cholelithiasis. The clinicopathological data of one case diagnosed as intrahepatic cholelithiasis was collected from Yantai Yuhuangding Hospital and the clinicopathological characters were discussed. A 68-year-old man suffered from the pain in the right upper quadrant and radiology showed multiple stones in the gallbladder and left liver. The images suggested intrahepatic cholelithiasis. The patient received gallbladder and partial hepatectomy. A large number of mitosis was observed and twelve nuclear fissions were found under high magnification, even in some area pathological nuclear fission could be observed in morphology. On the basis of detection in laboratory, the diagnosis of intrahepatic cholelithiasis was made. The patient did not receive any therapy after surgery. The patient was in a good condition after 18 months follow-up. Increased number of hepatic mitosis might be due to the stimulation from stones, hepatic biliary or secondary inflammatory. High index of proliferation should be prevented from the potential misdiagnosis of hepatic tumor.

Laser lithotripsy using dusting technique (low energy, high frequency) for symptomatic upper urinary tract stones

BackgroundA prospective study to assess the feasibility of stone dusting technique (low energy and high frequency) during laser lithotripsy in symptomatic upper urinary tract |(UUT) stones.MethodsSixty patients with symptomatic single or multiple UUT stones less than 3 cm in diameter were included. Patients with coagulation disorders and active UTIs were excluded. All patients were clinically evaluated and underwent non-contrast spiral CT (NCSCT) to detect stone site, size, number, Hounsfield unit. A rigid or flexible ureteroscope was used with stone dusting using the Ho: YAG laser at low-energy and high-frequency (0.5 J & 20 Hz) set. Operative and fluoroscopy time, total energy delivered, type of stent, hospitalization time, complications and its grade, and stone-free rate using NCSCT after 4 weeks were recorded.ResultsThe mean stone size ± SD (range) was 1.55 ± 0.55 (0.5–3) cm; out of sixty patients (50 with single stone and 10 with multiple stones), fifty-five patients were stone-free at 4 weeks. Complications had occurred in 11 patients (eight with grade I, one with grade II, and two with grade IIIa) according to Clavien–Dindo grading of surgical complications. Stone size was the only parameter which correlated significantly with stone-free rate. No significant correlation was found between incidence of complications and other parameters (stone size, site, BMI, age and operative time).ConclusionsStone dusting technique is feasible, safe and effective in management of UUT stones.

Assess the safety and effectiveness of a novel approach during transurethral pneumatic cystolithotripsy in large urinary bladder stone: quasi-clinical trial

To assess the safety and efficacy of using continuous irrigation-modified hysteroscopy during transurethral pneumatic cystolithotripsy for large bladder calculi. A prospective study was carried out from May 2016 until March 2020. All patients with solitary or multiple bladder stones > 2.5cm were subjected to Transurethral pneumatic cystolithotripsy using a modified continuous irrigation hysteroscopy, the stone fragments were removed by Ellik Evacuator, the safety and effectiveness of the procedures were evaluated, stone-free rate (SFR), stone recurrence and stricture urethra disease during follow-up. 55 patients with a mean age of 57.36 (22-82) years were included, the male: female ratio was 4:1, single stone in 74.5% and the mean stone size was 52mm. Lithotripsy time and an operative time were (20.39 ± 3.06 and 32.00 ± 3.57) minutes, respectively. Mean hospital stay was 10 ± 3.6h. This endoscopic technique succeeded with a 100% SFR. During the 22months of follow-up, no urethral stricture or stone recurrence was documented. The mean visual analog pain score (VAS) was 4.2 ± 2.1 and 1.4 ± 0.6, respectively, during and after the operation. The use of the modified hysteroscopy sheath during transurethral pneumatic cystolithotripsy is safe and effective for the management of large urinary bladder stones, an alternative to holmium laser in developing countries when laser equipment is unavailable. Comparable to other transurethral maneuvers, with a decrease in the risk of urethral stricture disease due to the small caliber of the device, as there is no urethral dilatation is required.

Ambulatory percutaneous nephrolithotomy is safe and effective in patients with extended selection criteria.

Ambulatory percutaneous nephrolithotomy (PCNL) has been limited to highly selected patients. The objective of our study was to compare complication and stone-free rates after ambulatory PCNL in standard selection criteria vs. extended criteria patients. We conducted a retrospective review of prospective data on all patients who underwent ambulatory PCNL at one academic center from 2007-2018. Extended criteria patients were defined as one or more of: age >75 years, body mass index (BMI) >30 kg/m2, American Society of Anesthesiologists (ASA) score >2, bilateral stones, solitary kidney, transplant kidney, complete staghorn calculi, stone burden >40 mm, multiple tracts, or prior nephrostomy tubes/stents. Primary outcomes were complication rates (Clavien-Dindo classification) and stone-free rates. We identified 118 patients, of which 92 (78%) met extended criteria. Mean BMI was 31 kg/m2 and 45% were ASA 3 or higher. Mean sum maximum stone diameter was 24 mm. Multiple stones were present in 25%, bilateral stones in 7%, and complete staghorn stones in 4% of patients. There was no difference in complication (12% vs. 18%, p=0.56), emergency department visit (12% vs. 18%, p=0.56), or re-admission (4% vs. 5%, p=1) rates between standard and extended criteria patients, respectively. Of the complications, 85% were Clavien-Dindo grade 1. Stone-free rates were not different between standard (84%) and extended (83%) criteria patients (p=1). No extended criteria variables were associated with complications in multivariable analysis. Complication and stone-free rates were not different between standard and extended selection criteria patients undergoing ambulatory PCNL. This data indicates that many of the preoperative patient and stone factors that have previously been used as exclusion criteria for ambulatory PCNL are not strictly necessary.

EP.TH.594Is Laparoscopic Common bile duct exploration feasible after failed ERCP?

Abstract Aims Concomitant gallstones and common bile duct stones are a common problem with no consensus on the best management approach. Our aim is to review the outcomes of laparoscopic clearance of common bile duct stones after failed ERCP. Methods We retrospectively studied all cases that had a failed ERCP prior to surgery in 200 cases of laparoscopic cholecystectomy with common bile duct exploration performed between 2006 and 2019. Results Twenty-two patients underwent a laparoscopic common bile duct exploration after failed ERCP. Seventeen of these were before 2013. Eleven (50%) of these were after at least one failed attempt at clearance. In 8 patients (32%) the duct was not accessible (failed cannulation) due to a variety of reasons. Nine patients had large and impacted stones, two patients had Mirrizi syndrome with concomitant CBD stones, 2 had multiple stones and one a missed stone discovered intraoperatively. CBD clearance was successful in 19 patients (88%), 8 were completed by a transcystic approach and 14 by a transcholedochal approach. Post-operative length of stay was 12 (±10) days. 1 patient had an unplanned re-admission within 30 days. 1 patient required re-operation for bleeding. 3 patients developed recurrent stones and 1 developed a subsequent stricture. No mortalities were recorded. Conclusions Laparoscopic common bile duct exploration is feasible and safe as a secondary procedure after failed ERCP. New technologies and advancements in surgical techniques will continue to improve success and morbidity.

Prediction models of low-power holmium laser effectiveness in renal stone lithotripsy during retrograde intrarenal surgery.

The objectives of this study are to develop prediction models for total laser energy (TLE) in order to infer surgical time and assist operative planning of intrarenal low-power Ho:YAG laser lithotripsy, and to predict the fragmented volume as well as the stone-free status (SFS). A retrospective review was performed, comprising all single surgeon standardized retrograde intrarenal surgery and low-power Ho:YAG laser lithotripsy at a tertiary care centre between October 2014 and September 2019. Automated measurement of stone volume and stone density (MSD), measured in Hounsfield units (HU), was employed in both pre- and post-operative non-contrast-enhanced computed tomography (NCCT), using a standardized technique on Osirix Lite® software. SFS was defined as complete absence of stone fragments, or fragments < 0.1cm on meticulous inspection at the end of the procedure, and residual stone burden < 0.0005 cm3 on postoperative NCCT at 3months. Statistical analysis was performed using the STATA® version 13.1 software for regression models. A p value < .05 was considered statistically significant. A total of 100 patients met the inclusion criteria, requiring a median of 22.3kJ/cm3 (13.4-36.0) and resulting in a SFS of 41% at 3months. In a multivariate analysis, according to stone composition, predicted TLE is equal: for uric acid (UA), 11.17 × volume(cm3) + 0.17 × MSD(HU) + 7.48kJ; for mixed stones, 11.17 × volume(cm3) + 0.17 × MSD(HU) + 6.26kJ; for calcium oxalate monohydrate (CaOM) stones, 11.17 × volume(cm3) + 0.17 × MSD(HU) + 1.14kJ; and for calcium phosphate (CaPh) stones 11.17 × volume(cm3) + 0.17 × MSD(HU) - 1.94kJ. Predicted fragmented volume is equal to 0.93 × volume(cm3) cm3. The significant predictors for SFS were UA stones, the presence of multiple stones, and lower TLE. In clinical practice, our models for intrarenal low-power Ho:YAG laser lithotripsy indicate that larger, denser, and UA stones are associated to higher TLE, and that single and UA stones are more commonly associated to SFS. Since higher TLE means longer operative time, when adjusting for laser parameters, our prediction models may help urologists plan surgeries more precisely based on stone characteristics, ultimately optimizing patients' treatment.

Comparison of Body Mass Index and Cholelithiasis Diagnosed on Ultrasound in the Population of Pindi Bhattian

Obesity is one of the emerging conditions in our population. Gallstones are composed of cholesterol. It is postulated that gallstones are associated with the deposition of cholesterol. Ultrasound is the first line imaging modality for the diagnosis of cholelithiasis. If gallstones are correlated with BMI, it will open up a new vista for further research. In Yaqoob Ultrasound Clinic, PindiBhattian, Pakistan, a cross sectional analytical study was conducted. All included patients were inquired regarding variables like Age, Height, Weight, Presences of stones, Wall thickness of gall bladder, and location of gall stones on grey scale ultrasound findings. Patients were asked to lie down and expose their abdomen; grey scale abdominal ultrasound was performed of these patients. All variables mentioned above for each patient was recorded and maintain in their individual case record form (CFR). Data was collected during allocated period. Statically package SPSS version 2.4 was used to check the collected data and to organize and compile results. According to results out of total 160 patients, 105 were females and 55 were male. Out of 160 patients 150 (93.8%) were present with gall stones and 10 (6.3%) were having no gall stone. In total 61 patients (38.1%) were having single gall stone whereas 89 (55.6%) were diagnosed with multiple gall stones. According to the results, minimum age was 18 years and maximum was 80 years. Our study concluded that obesity is one of the major risk factors for gall stones. Obesity is usually more common in females, so they are more likely to have gall stones and overweight patients were more prone to GB stones.

Management of complex renal stones by a novel ureterorenoscope with vacuum suctioning system combined with flexible ureteroscope

Objective: To evaluate the feasibility and safety of Sotn ureterorenoscope combined with flexible ureteroscope on managing complex renal stones. Methods: Patients treated with the Sotn ureterorenoscope combined with flexible ureteroscope between January 2010 and December 2019 were employed from the Sun Yat-sen Memorial Hospital of Sun Yat-sen University and Jiangmen Wuyi Traditional Chinese Medicine Hospital. The patients' information of age, gender, comorbidities, stone characteristics (stone size, hounsfield units, stone composition, stone location, etc.), operative time and console time, stone-free rate (SFR), and perioperative complication rate were collected. The primary outcome was defined as primary SFR in 1 month of operation, and the secondary outcome was the perioperative complication rate. The differences in preoperative and postoperative data between patients with different kinds of stones were compared. Results: A total of 347 patients were included in the study, with 220 males and 127 females. The age [M(Q1,Q3)] was 51 (42, 58) years. There were 94 patients suffered from multiple renal stones and 253 patients with staghorn renal stones. The operative time and console time age [M(Q1,Q3)] for all patients were 87 (55, 115) min and 59 (27, 75) min, respectively. The primary SFR was 81.3% [83.8% for multiple renal stones and 74.5% for staghorn renal stones (P=0.048)]. Complications occurred in 80 patients (23.1%), of which 79 cases were classified as Clavien-Dindo grade 1-2, and 1 case (0.3%) was grade 3-4. For patients with multiple renal stone, compared with the residual stone group, the complete stone-free group had smaller stone size [15.5 (12.0, 21.0) vs 22.0 (17.5, 28.1) mm, P<0.001], and lower hounsfield units [920.0 (658.0, 1 172.5) vs 1 125.0 (944.9, 1 247.5), P=0.022]. Patients with complications had longer operative time than those without complications [60.0 (38.5, 90.0) vs 75.0 (51.3, 110.0) min, P=0.022]. The SFR was higher in patients with stones size ≤ 20 mm compared to those with stones size > 20 mm (91.8% vs 67.5%, P<0.001), while the difference in complication rate was not statistically significant (P>0.05). In the staghorn renal stones group, compared with the residual stone group, the complete stone-free group had smaller stone size [35.0 (25.8, 45.3) vs 53.5 (39.3, 67.5) mm, P<0.001]. Patients with complications had larger stone size than those without complications [43.5 (34.8, 56.5) vs 36.0 (27.0, 50.0) mm, P=0.007]. Patients with stone size ≤ 40 mm had higher SFR (87.5% vs 55.3%, P<0.001) and lower complication rate(10.7% vs 31.6%, P=0.012) compared to those with stone size >40 mm. Conclusion: Sotn ureterorenoscope combined with flexible ureteroscope is an effective and safe choice for the treatment of complex renal calculi.

Investigation of factors affecting spontaneous ureteral stone excretion

Introduction: Various factors such as structure of stone, size, location of stone and metabolic diseases affect stone excretion. Objectives: The aim of this study was to investigate factors related to spontaneous ureteral stone excretion. Patients and Methods: This descriptive-analytical observational study was conducted in the university urology centers of Yazd, Iran, during a 16-month period. All patients presenting with unilateral ureteral stone whose ureteral stone was confirmed by CT scan or ultrasound were included in the study. Pregnant patients, patients with uncontrolled hypertension, patients with multiple urinary stones, patients with more than four weeks of history of urinary stones, patients with severe hydronephrosis, and patients with malformations of ureter and kidney were excluded from the study. Computed tomography and ultrasound of the patients evaluated the size of the stone, the location of the stone and the degree of hydronephrosis and also perinephric stranding. Results: In this study, 146 patients with mean age of 45.3±15.1 years (ranging from 11 to 84 years) were enrolled. CT scan and ultrasound were diagnostic in 121 (82.9%) and 25 patients (17.1%) respectively. In logistic regression model analysis, size less than 5mm, stone location and male gender and diabetes were significant predictors of spontaneous stone excretion, while size less than 5 mm was the strongest predictor. Conclusion: The strongest predictor of spontaneous excretion is the size of the stone and the next step is the location of the stone. Male gender and diabetes are also contributing factors to the spontaneous excretion of ureteral stones.

A Clinical Study on Laparoscopic Cholecystectomy in a Tertiary Care Teaching Hospital

Background: Laparoscopic cholecystectomy is gaining popularity for the surgical treatment of gallbladder diseases. The technique has advantages of safe surgery, minimal complications, lower duration of hospital stay, and early return to normal activities. We in the current study tried to evaluate the outcomes of laparoscopic cholecystectomies done in our tertiary care teaching hospital. Methods: Based on the inclusion and exclusion criteria n=40 cases were identified and treated with laparoscopic cholecystectomy. A complete history which included the pasthistory, family history, socioeconomic status, nature of symptoms, diet history was obtained. All the patients underwent a complete clinical examination. The investigations carried out were complete blood picture, bleeding time, clotting time, ECG, LFT, KFT, FBS, blood groups, chest x-ray, and Ultrasound scan of the abdomen. All cases were operated as per the standard procedures. Results: The most common sign recorded in the cases was pain in right hypochondrium. Out of n=40 cases, 95% were present with pain 5% was without pain. Clinical jaundice was found in 10% of cases and tenderness was found on examination in 95% of cases. USG showed the presence of multiple stones was in 76% of cases, thickening of the gall bladder was in 80% cases and presence of mass was detected in 8% of cases. The follow-up period was 3 months in which no complications were reported. Conclusion: The study found that most of the cases of cholelithiasis now occurring across the spectrum of different ages. The diagnosis has now become easy with the presence of ultrasonography which has sensitivity and specificity. The motto of safe surgery, low morbidity, and early back to work is best done with laparoscopic cholecystectomy.

Ureteral wall thickness at the stone site: A critical predictor of success and complications in children undergoing semi-rigid ureteroscopy

We retrospectively assessed the role of ureteral wall thickness (UWT) at the ureteral stone site in predicting the stone-free status and the complication rates in children undergoing semi-rigid ureterorenoscopy (URS). The children who underwent URS and had undergone non-contrast abdominal computerized tomography before the URS were included in the study. The following protocol was used to determine the outcome. Immediately before removing the stent, all children were evaluated by ultrasound (US) and plain film (KUB) for residual stones in the upper urinary tract and after removing the double J stent, the presence of stone fragments in the ureter was checked with URS. The children were considered stone-free if no residual fragments were identified in radiologic imaging and the evaluation of the ureter by URS. The case was accepted as a failure if any fragments were seen on immediate US, KUB, and/or during URS just after the stent removal. The patients who could not complete the standard primary URS procedure due to stone-related reasons (patients for whom we could not pass the safety guidewire behind the stone and/or the procedure was terminated due to pyuria during the procedure) were also accepted as a failure. The possible factors related to the patient, stone, ureter, and the operation that could affect the outcome and the complications following the URS were evaluated. The children's median age was six years (1-17 years). Among the 89 children included in the study, 69 (78%) were stone-free, and 20 (22%) presented residual stone after the first URS session. The ROC analysis revealed that a UWT value of 4.5mm (sensitivity 60%, specificity 92%) was the optimal cut-off value predictive of the URS outcome. The regression analysis revealed UWT >4.5mm (p=0.006) and multiple stone presentation (p=0.005) as independent risk factors for residual stone. Complications were detected in 15 (17%) children. Thick ureteral wall (p=0.012) and longer operative time (p=0.016) were defined as the independent risk factors for complications. Increased UWT is associated with the adverse outcomes of URS due to tissue hypertrophy, edema, and mucosal bleeding may cause difficulty in removing the stone. The thick ureteral wall might increase the risk of complications due to the necessity of manipulating the instruments or the involuntary forceful use of instruments while removing the stone. UWT was the only independent variable affecting both increased failure and complication rates in children undergoing URS.

Intraductal Fragmentation in Sialolithiasis Using Pneumatic Lithotripsy: Initial Experience and Results.

ObjectiveTo report initial experience in using a pneumatic lithotripter to treat salivary stones.Study DesignLevel IV retrospective study.SettingUniversity hospital and tertiary referral center.MethodsA pneumatic lithotripter was used to treat salivary stones after these were diagnosed. Probes with diameters of 0.7 mm were used. Total fragmentation was intended in all stones. Stone fragments were removed using several instruments in serial sialendoscopies to achieve complete stone clearance.ResultsA total of 62 patients with 77 stones were treated. Forty-three submandibular stones were treated in 34 patients, and 34 parotid stones were treated in 28 patients. An operating pressure of 2.5 bar and a single frequency mode were used. Complete fragmentation was achieved in all but one of the treated stones in both glands (98.7%). Among the patients, 90.32% became stone free and 100% symptom free. Multiple stones were treated in 24.19% of the patients, and multimodal therapy was also carried out in 24.19%. All of the glands were preserved.ConclusionsThe pneumatic lithotripter proved to be effective in the treatment of sialolithiasis. Stone size, location, and the gland involved were important clinical factors. The device was sufficient to achieve success without any increased risk for complications in the patients or damage to the sialendoscopes.

971 A Rare Case of a Reno-colic Fistula Presenting as a Retroperitoneal and Psoas Abscess

Abstract Background Fistulous connections arising between the kidney and colon are rare and develop due to multiple aetiologies. We present a rare case of a reno-colic fistula presenting unusually as a retroperitoneal and psoas abscess managed surgically with a good outcome. Case Report A 49-year-old lady presented with 5-day history of left flank pain and swelling with no significant surgical or medical history. Physical examination revealed a tender left renal angle with raised inflammatory markers (CRP and WCC). Computed tomography (CT) revealed an extensive collection extending from an atrophic left kidney through the retroperitoneum and psoas into the subcutaneous tissues with possible fistulation into the descending colon. This was initially treated with antibiotics and percutaneous drainage of the collection. A reno-colic fistula was confirmed via left retrograde pyelogram. Under the multidisciplinary care of the urology and colorectal general surgical teams she underwent a left nephrectomy, large bowel resection and defunctioning colostomy successfully and was discharged eight days later. Histology later confirmed an extensively scarred atrophic left kidney with multiple renal stones with no preserved glomeruli, focal inflammatory infiltrate and stromal calcification consistent with end stage nephropathy. With the resected 5 cm descending colon showing mucosal and serosal inflammation consistent with site of fistula. Conclusions Reno-colic fistula is rare and presentation with a retroperitoneal and psoas abscess uncommon. We report a rare case of a reno-colic fistula secondary to a chronically infected and obstructed left kidney managed surgically with a good outcome.