The active guidewire technique versus standard technique as different way to approach ureteral endoscopic stone treatment

Background: One of the greatest challenges in semi-rigid ureteroscopies, for both stones and tumors, is the control of endoscopic vision and the maintenance of low intracavitary liquid pressure. We present a comparison between two operative techniques: in the first method an ordinary guide wire (diameter 0.032'') is used for the procedure; in the second one a 5 Fr ureteral catheter replaces the guidewire (we called it “Active guidewire”) Methods We compared 50 semirigid ureteroscopies (sURS) performed using the active guidewire with another 50 procedures conducted with a classic guidewire. We evaluated the difference in operating times, quality of endoscopic vision, periprocedural infections rate and stone-free rate. Results: The use of active guidewire has considerably reduced the standardized operating times per unit stone-volume by about 39%. Vision quality has improved considerably thanks to the continuous flow in-and-out. Consequently, periprocedural infections decreased (3% vs 30%) and the stone-free rate rose from 86% to 92%. Discussion and conclusions: Employing an “active guidewire” instead of the standard guidewire, the risk of complications related to high pressures and operating time is considerably lower, as well as better treatment quality thanks to the cleaner vision. This technique has proven to be safe as well as easy to apply, and in our belief is to be preferred whenever the ureter accepts without forcing, both the presence of the catheter and the semi-rigid 7 F ureteroscope.

Routine Chest Radiography Following Tunneled Hemodialysis Catheter: Use and Clinical Outcomes

Highlights Abstract Background: A postoperative chest x-ray (CXR) remains part of some hospital protocols following tunneled hemodialysis catheter placement despite the use of operative imaging-guided techniques. The aim is to assess the usefulness of this practice and its impact on clinical outcomes and resource use. Methods: A review of medical records and postoperative CXR was done for 78 adult patients who had tunneled hemodialysis catheters placed in the operating room under fluoroscopy guidance. Catheters were inserted by ultrasound-guided puncture (51.3%) or exchanged from an existing catheter over a guide wire (48.7%). The postoperative CXRs were also examined by an independent reviewer to assess the catheter tip position and the need for repositioning to mimic a real-life postoperative setting. Procedural, nursing, and billing records were also reviewed. Results: No patients had a pneumothorax or major complications. On postoperative CXRs, 29 (37.2%) patients had the catheter tips in the right atrium, 23 (29.5%) in the cavoatrial junction, 25 (23.1%) in the superior vena cava, and 1 (1.3%) in the brachiocephalic vein. The independent reviewer found the catheter tips in acceptable anatomical positions in 75 of 78 patients. Only 3 (3.9%) patients had catheter malfunctions during dialysis and exchanged their catheters (2 had high catheters in the superior vena cava and brachiocephalic vein, 1 had a kinked catheter). Postoperative CXRs also caused delays in patient discharge from postanesthesia care units and significant increases in medical expenses (around $199 per patient). Conclusion: Routine CXR after tunneled hemodialysis central venous catheter insertion is unnecessary and does not add to the procedure's safety or to the patient's outcome.

Surgical Technique of Supine Percutaneous Nephrolithotomy in Children

Percutaneous nephrolithotomy (PCNL) in children has become more widely used due to its high efficacy and safety and to the development of miniaturized instruments. A supine approach is promising due to advantages such as better ventilation, reproducibility, and ergonomics. The purpose of the present study is to describe our surgical technique with special considerations in the pediatric population. We used an oblique supine position supported by one silicone gel positioning pad under the hip and another under the ipsilateral flank. The anatomical landmarks used to guide the puncture were the 11th and 12th ribs, the posterior axillary line, and the iliac crest. Initially, a ureteral catheter was introduced endoscopically. A retrograde pyelography was performed to guide the puncture, which was performed using a biplanar technique. A hydrophilic guide wire was then advanced through the needle. Dilation was performed with Alken telescopic dilators until 14 Ch. Fragmentation was performed either with a 13 Ch semirigid cystoscope or a flexible ureteroscope using a holmium: yttrium aluminum garnet (Ho:Yag) laser. We left a double J catheter. Supine PCNL in the pediatric population has comparable efficacy in terms of stone free rate to that of the prone approach as well as less complications. Certain considerations in children are careful padding and placement of the patient close to the edge of the table. Puncture should be guided by ultrasound to reduce radiation exposure. Miniaturized equipment is not widely available, so adaptation of adult equipment for the pediatric population is sometimes necessary.

Modified Seldinger technique for internal jugular open central venous line insertion in neonates: merging two different manoeuvers

Background Central venous line insertion in neonates is an important and lifesaving procedure. It can carry significant risks and complications, including death, at the time of insertion or later. We aimed to retrospectively assess the modified Seldinger technique for open placement of a central venous catheter in neonates, regarding its safety, feasibility, operative time, and preservation of the patency of the internal jugular vein. This study was conducted on 120 neonates from March 2018 to March 2020. We closely monitored the pulse for the detection of arrhythmia or bradycardia, which might be caused during the insertion of the guide wire or the tip of the catheter. Post-operative X-ray was done immediately after the end of the procedure for all cases, to determine the site of the central venous catheter and to detect the presence of pneumothorax. Results Arrhythmia was observed in 9 cases (7.5%), and blood oozing in 5 cases (4.1%). There were 3 cases of pneumothorax (2.5%), 2 cases of neck hematoma in two cases (1.6%), 6 cases of internal jugular vein thrombosis (5%), and dislodging of the catheter in 3 cases (2.5%). There were no cases of arterial puncture, failure of cannulation, or haemothorax in our study. Conclusions The modified Seldinger technique insertion for open central venous line in neonates is a safe, accessible, and feasible method, especially in centers that lack the experience of ultrasound-guided insertion in neonates.

Comparison of stone clearance rate in patients with distal ureteric stones, undergoing URS with and without a safety guide wire.

Objective: To compare stone clearance rate in patients with distal ureteric stones, undergoing URS with safety guide wire and without safety guide wire. Study Design: Randomized Clinical Trial study. Setting: Department of Urology, Pir Abdul Qadir Shah Institute of Medical sciences. Period: January, 2020 to December 2020. Material & Methods: The study patients fulfilling the inclusion criteria were divided into two groups using the lottery method. Group A: Patients underwent URS with insertion of safety guidewire (SGW). Group B: These patients underwent URS without safety guidewire (SGW). Patients in both groups were compared for stone clearance. Results: Mean age in Group A was 37.79±12.44 years and in Group B were 33.31±11.48 years. Group wise distribution of gender showed 79 (73.83%) male and 28 (26.17%) females in Group A and 70(65.42%) male and 37 female (34.57%) in Group B. In comparison of both groups, 65.42% stone clearance was noted in Group A while 78.50% stone clearance was found in Group B and p-value found to be significant (P=0.033). Conclusion: Our study concluded that stone clearance in patients with distal ureteral stones undergoing URS without SGW is higher in comparison to URS with SGW, without any added advantage.

High-Definition Intravascular Ultrasound Versus Optical Frequency Domain Imaging for the Detection of Calcium Modification and Fracture in Heavily Calcified Coronary Lesion

Purpose While optical frequency domain imaging (OFDI) can delineate calcium modification and fracture, the capability of high-definition intravascular ultrasound (HD-IVUS) for detecting these remains unclear. This study evaluated the diagnostic accuracy of HD-IVUS for assessing calcium modification and fracture as compared to OFDI. Methods HD-IVUS and OFDI were used during orbital or rotational atherectomy procedures conducted for 21 heavily calcified coronary lesions in 19 patients. With OFDI assessment used as the gold standard, diagnostic accuracies of HD-IVUS for calcium modification and fracture were compared every 1 mm to the matched pre-stenting images (n=1,129). Calcium modification, as assessed by OFDI, was defined as polished and concave-shaped calcium. For HD-IVUS, calcium modification was defined as the presence of reverberation with concave-shaped calcium. In both assessments, the definition of calcium fracture was defined as a slit or complete break in the calcium plate. Results Calcified plaque was found in 86.4% of analyzed OFDI images. Calcium modification and fracture were detected in 20.6% and 11.0% of detected calcified plaques. Sensitivity, specificity, positive and negative predictive values of HD-IVUS detection for calcium modification and fracture were 54.4%, 97.8%, 86.7%, 89.1% and 86.0%, 94.5%, 58.2%, 96.8%, respectively. Discordance cases between both assessments demonstrated that heterogeneous calcium visualized by OFDI, separated calcium and guide wire artifact can be misdiagnosed. Conclusion Diagnostic accuracies of HD-IVUS for assessing calcium modification and fracture were modest as compared to OFDI. These results suggest that OFDI guidance is more feasible during treatment of heavily calcified coronary lesions versus HD-IVUS guidance.

Double plastic stent implantation for recurrent acute pancreatitis with incomplete pancreas divisum: a case report and literature review

Pancreas divisum (PD) is a common pancreatic malformation caused by the failure of fusion between ventral and dorsal pancreatic ducts. There is a small branch of communication between the two systems in incomplete PD, and this variation has an incidence of 15%. A 43-year-old female patient presented to our department with recurrent abdominal pain. Magnetic resonance cholangiopancreatography (MRCP) showed that the ventral pancreatic duct was curved, with a local pouchlike dilatation. Endoscopic ultrasonography supported the diagnosis of incomplete PD and showed a thin branch of communication between ventral and dorsal pancreatic ducts. Endoscopic retrograde cholangiopancreatography (ERCP) and papillotomy of the minor papilla with double plastic stent implantation were performed. One pancreatic plastic stent was inserted across the minor and major papilla over the guide wire, creating a U-shape. The other wire-guided plastic stent was inserted through the minor papilla into the dorsal pancreatic duct. The pancreatic fluid drained smoothly after stent placement. During the 6-month follow-up, the patient remained well, without recurrence of pancreatitis.

Two Different Minimally Invasive Approaches for Management of Thoracolumbar Fractures

Objective To compare the clinical effect and safety of pedicle screw fixation via percutaneous approach and Wiltse paraspinal approach for thoracolumbar fractures without neurological deficit.Methods 98 cases who suffered from single level thoracolumbar fracture without nerve injury were treated by pedicle screws fixation via either percutaneous approach (percutaneous group) and Wiltse paraspinal approach(paraspinal group). Perioperative indexes, imaging parameters and functional and symptom results of the two groups were recorded and compared. Results All patients were followed for more than 12 months, and the incision length and postoperative hospital stay in the percutaneous group were significantly shorter than those in the paraspinal group (P<0.05), intraoperative blood loss was less than that of the paraspinal group (P<0.05), operative and postoperative costs and the number of fluoroscopy were significantly higher than those of the paraspinal group (P<0.05). There was no significant difference in operative time between the two groups (P > 0.05). The anterior edge height percentage of the injured vertebrae and kyphosis Cobb Angle were significantly improved 1 week and 1 year postoperatively in each group (P<0.05), there was no statistical difference between the two groups (P<0.05). As for Visual Analog Scale (VAS) scores, in each group there were continuous decreases 3 days, 6 months, and 1 year postoperatively (P<0.05); There were no statistically significant differences between the two groups before operation, 6 months and 1 year postoperatively (P<0.05), but a significant difference 3 days postoperatively (P<0.05). In terms of Oswestry disability index (ODI), in each group there was continuous decreases 6 months and 1 year postoperatively (P<0.05); and there was no significant difference between the two groups (P<0.05).There was no significant difference in the accuracy of implant between the two groups (P<0.05). In the percutaneous group, there were 2 cases of incision fat liquefaction, 1 case of guidewire fracture and 1 case of the anterior wall of the vertebra penetrated by guide wire rupture. 1 diabetic case of superficial incision infection and 2 cases of skin edge necrosis were found in the paraspinal group.Conclusion In the treatment of thoracolumbar fractures without neurological defect, pedicle screw fixations via Wiltse paraspinal and percutaneous approach both can obtain minimally invasive and reliable effect, but the percutaneous approach bring smaller trauma, less blood loss, longer operation time, more fluroscopy, higher surgery and postoperative costs, with its own unique complications especially in early learning curve.

Outcome and Complications of Percutaneous Transhepatic Biliary Drainage: Influence of Liver Entry Site

Objective: To determine the outcome and complications of percutaneous transhepatic biliary drainage (PTBD) performed via right lobe and left lobe duct puncture. Study Design: Cross-sectional study. Place and Duration of Study: Department of Interventional Radiology, Dow Institute of Radiology, Dow University of Health Sciences from July 2020 to March 2021. Methodology: Both adult male and female patients with obstructive jaundice having dilated intrahepatic biliary ducts on ultrasound were included. PTBD was performed under ultrasound guidance. Following intrahepatic biliary duct puncture, a guide wire was inserted followed by placement of 8 Fr or 10 Fr pigtail drainage catheter. Total bilirubin level was measured before and one day after the procedure. Cholangiogram was performed 48 hours after the procedure to check the drain placement and residual dilatation. Results: 130 patients were included with mean age of 55.3 ± 12.3 years. Success rate was same in patients with right and left lobe puncture i.e. 96.9%. The frequency of complication in right lobe puncture was higher (37.5%). Mean procedure time was significantly higher in patients who developed complications (75.92 ± 19.20 minutes) as well as mean exposure time was also significantly higher in patients who developed complications (12.00 ± 6.87 minutes) as compared to patients who did not develop any complication (8.08 ± 3.43 minutes) (p <0.05). Conclusion: It was concluded that the success rate in right and left lobe puncture was equal and complication rate in right lobe puncture was observed to be high as compared to left lobe puncture. Keywords: Biliary drainage, Complications, Effect, Liver

Complications of Standard Percutaneous Nephrolithotomy versus Tubeless Percutaneous Nephrolithotomy

Objective: To compare grade I complication as per Clavien-Dindo classification in patients undergoing standard (with tube) verses tubeless percutaneous nephrolithotomy. Study design: Hospital based randomized control study. Place and Duration of Study: Urology Clinic, Sindh Institute of Urology & Transplantation Karachi from 3rd June 2016 to 2nd December 2016. Methodology: Seventy four patients (37patients) in each group were enrolled. In group 1 patients, a 20 F nephrostomy tube were placed in the kidney over the guide wire, which was removed later. Group II patients had antegrade placement of a Double-J stent without nephrostomy and the wound compressed for 5min. The demographic like age, gender and complications grade I complications according to Clavian-Dindo classification were noted. Results: The mean age was 49.42±7.06 years. There were 46 (62.16%) males and 28 (37.84%) females. There was no significant difference in stone clearance rate between the groups; 91.9% in standard percutaneous nephrolithotomyg roup and 94.6% in tubeless percutaneous nephrolithotomy group. Need for analgesics for pain control was high in standard percutaneous nephrolithotomy group 86.5% versus 64.9% in tubeless percutaneous nephrolithotomy group (p=0.03). Frequency of urine leakage was 18.9% in standard percutaneous nephrolithotomy group and only 2.7% in tubeless percutaneous nephrolithotomy group (p=0.02). Conclusion: Tubeless percutaneous nephrolithotomy procedure has fewer complications as per Clavien-Dindo classification regarding need for analgesics and urine leakage. In suitable cases, the tubeless procedure can be safely used as the standard for percutaneous nephrolithotomy. Keywords: Percutaneous nephrolithotomy (PCNL), Clavien-Dindo classification, Complication