The Modified Procedure of Totally Tubeless PNL

Mini percutaneous nephrolithotomy (mPNL) is a standard treatment for kidney stones larger than 1.5 cm, with the placement of a nephrostomy drainage at the end of it, which is considered the standard procedure, but tubeless/ totally tubeless mPNL techniques reduce postoperative discomfort in patients and shorten hospital stays. The aim of article was to compare the efficacy and safety of our proposed modified method of totally tubeless mPNL with control of the parenchymal canal, with existing methods of tubeless/totally tubeless mPNL. Novelty of the study presented by modified method of totally tubeless mPNL. During the period from 2018 to 2020 we performed 486 mPNL were performed in our clinic in total, among which 63 (12.9%) patients underwent tubeless PNL. Patients whose surgeries ended with using tubeless techniques were divided into three groups: Group I – 22 patients who had tubeless mPNL (with ureteral stent), Group II (20 patients) – totally tubeless mPNL with a safety thread (the proposed procedure), Group III (21 patients) – totally tubeless mPNL. In all three groups, the access point was most often made through the lower group of renal calyces: Group I – 12 (54.5%), Group II – 14 (70.0%), Group III – 13 (61.9%); then through the middle calyx: Group I – 8 (36.4%), Group II – 6 (30.0%), Group III – 7 (33.3%); and the upper calyx: Group І – 2 (9.1%), Group ІІ – 0%, Group ІІІ – 1 (4.8%), no differences in the distribution of access points between groups were found (p=0.67). There were no differences in the distribution of tract sizes between the groups (p=0.95) with tract dilatation to 16.5/17.5 Fr was performed most often: Group I – 12 (54.5%), in Group II – 11 (55.0%) and Group III – 11 (52.4%). The mean duration of surgery in Group I was 83.0±22.9 min, in Group II – 74.9±13.6 min, in Group III – 72.6±12.0 min (p=0.47). This study confirms the high effectiveness of totally tubeless mPNL. The proposed modification to perform totally tubeless mPNL allows you to have permanent postoperative control over the parenchymal channel and in case of postoperative bleeding it enables you to immediately insert nephrostomy drainage through the safety thread. Study contributes to practical methods as an intermediate step for surgeons who are considering transition to a totally tubeless PCNL technique.

Efficacy of Dexmedetomidine as an Adjunct to Ropivacaine in Bilateral Dual-Transversus Abdominis Plane Blocks in Patients with Ovarian Cancer Underwent Cytoreductive Surgery

Objective: To evaluate the postoperative control of pain and recovery in patients with ovarian cancer underwent cytoreductive surgery by adding dexmedetomidine to ropivacaine in bilateral dual-transversus abdominis plane (Bd-TAP) blocks.Methods: We enrolled ninety ASA I-III patients undergoing open abdominal cytoreductive surgery in this study. Patients were randomized assigned into three groups (TAP-R, TAP-DR, and CON, n=30 in each). All patients received standardized general anesthesia and postoperative Bd-TAP blocks were performed. The TAP-R, TAP-DR and CON group received Bd-TAP blocks with 0.3% ropivacaine, 0.3% ropivacaine and dexmedetomidine 0.5µg/kg, and 0.9% normal saline, respectively. All patients received patient-controlled intravenous analgesia (PCIA). The first request time for PCIA bolus, the VAS scores at 0, 6, 12, 24, and 48 hours after operation, the cumulative sufentanil consumption in 24 and 48 hours were compared. Pulmonary function was evaluated pre-operation and 24h after operation. The use of rescue drugs, early recovery quality was recorded.Results: Median values of the first request time for PCIA in the TAP-DR was 13.5 (11.0-16.0) hours, which was significantly longer than those in the TAP-R and CON groups [7.0 (6.0-9.0) and 3.0 (1.0-4.5)]. The VAS scores at rest and on coughing of TAP-DR group at all time points after operation were significantly lower than those of CON group (P <0.05). Cumulative sufentanil consumption in TAP-DR group were the least at 48h after surgery. Postoperative FEV1 and FEV1/FVC in TAP-DR group was significantly higher than group CON. Less rescue analgesics was needed by the patients in TAP-DR group (P <0.05). There was no significantly difference in the early recovery quality between TAP-DR and CON group (P >0.05).Conclusion: Dexmedetomidine combined with ropivacaine for Bd-TAP blocks prolonged the first bolus time of PCIA for ovarian cancer surgery and decreased sufentanil consumption. The procedure provided better postoperative analgesia and improved postoperative pulmonary function without excessive sedation.

Initial Results of Laser Ureteroscopy Treatment for Lithiasis of the Upper Urinary Tract at Aristide Le Dantec Hospital in Dakar (Senegal)

Background: In Africa, lithogenesis was initially considered rare and it was mostly caused by infections. Recent studies suggest that obesity, change in dietary habits (milk, dairy products) and hot climate can contribute to an increase of the condition in the region. Over the past decades, the management of upper urinary tract urolithiasis has evolved significantly with minimally invasive techniques. The challenge for sub-Saharan countries is related with the acquisition and the training for minimally invasive treatment. In fact, open surgery has less indications in the management of urolithiasis. The aim of this study is to evaluate the preliminary results of ureteroscopic laser treatment for upper urinary tract lithiasis in our hospital. Methods: This was a prospective, descriptive study realized between June 2016 and December 2018. The patients included were those who had ureteroscopic laser treatment for upper urinary tract lithiasis. The treatment was performed under general anesthesia by two surgeons. The studied parameters were: age, sex, patient medical history, comorbidities, renal function, cytobacteriological examination of urine, characteristics of lithiasis, intra and postoperative complications (using the Clavien–Dindo classification), ureteroscopic laser failures (frequency and causes). Success of treatment was defined by: the absence of a residual fragment at the renal and ureteral level or of a residual fragment <4 mm at the renal level on the control imaging. Data analysis was done with IBM SPSS Statistic 23 software. Statistical significance was considered when P < 0.05. Results: This study involved 43 patients. The mean age was 40.84 years ± 15.33 years. The age group between 30 and 39 years was predominant. The sex ratio was 1.26. Nephritic colic was the circumstance of discovery in 93.02%. The Uro-CT scan performed in all our patients, revealed kidney stones in 16.3% and ureteral stones in 83.7%. The right side was the most involved in 55.8%. The mean size of the stones was 12.2 mm ± 4.89 at the renal level and 12.05 mm ± 5.54 at the ureteral level. The semi-rigid ureteroscope was used in 88.37% and the flexible ureteroscope in 11.63%. The lithiasis was visualized in 74.4% of cases. Laser fragmentation was performed in 69.77% of cases. A J stent was placed after 72.1% of cases. Pelvic ureteral stripping and pelvic ureteral aspiration were realized in one case each. Acute pyelonephritis (ANP) was observed in 25.6% of patients. There were 75% fragment free at postoperative control. Any factors associated with treatment failure were not found.

Intraoperative anaesthesia, postoperative analgesia and postoperative prevention of nausea and vomiting in case of acute bowel obstruction (clinical lecture)

The main efforts during anaesthesia for acute bowel obstruction surgery should be aimed at stabilizing the patient’s haemodynamics and compensation of electrolyte disorders that often occur in the preoperative period. Modern devices for monitoring hemodynamics, temperature, respiratory mechanics and gas exchange function should be used extensively. Effective monitoring of these functions and early use of medium doses of vasopressors in arterial hypotension allow stabilizing hemodynamics and limi-ting the volume of intraoperative fluid infusion. The choice of infusion solutions should be goal-directed and selected according to the type of electrolyte disturbances, but balanced crystalloids solutions should be the choice for baseline infusion. The choice for the anaesthetic drugs should be based on the possibility to promptly awake the patient soon after anaesthesia and for early mobilisation. If possible, general anaesthetic techniques should be complemen-ted by regional anaesthesia. The issue of avoiding intraoperative intestinal intubation, as well as early removal of nasojejunal and/or nasogastric tubes in the postoperative period should be discussed together with surgeons. Such a tactic often helps reduce the seve-rity of nausea and accelerate postoperative patients’ rehabilitation. For effective postoperative control of nausea and vomiting in case of bowel obstruction, it is often necessary to use a combination of drugs that reduce gastrointestinal secretion with drugs that inhibit the central regulation of the vomiting reflex in the central nervous system, as well as with prokinetics that improve the evacuation of gastric contents.

Preservation of the Tenon’s capsule and Sub-Tenon’s space after the autologous limbal-conjunctival transplantation in pterygium surgery

Background No previous studies have evaluated the scarring of the conjunctiva and Tenon’s capsule (TC) separately when only the conjunctiva is removed, and TC is preserved in the upper part of the bulb: the site designated for trabeculectomy. Thus, this cohort interventional study aims to investigate the scarring of the donor area after autologous limbal-conjunctival transplantation (ALCT) using anterior segment optical coherence tomography (AS-OCT). Methods Twenty-three eyes with pterygium were submitted to resection and local reconstruction with ALCT. AS-OCT images obtained from each eye preoperatively served as postoperative control. ALCT was removed superiorly with preservation of TC. The cure of this donor area occurred by secondary intention. AS-OCT was performed preoperatively and 30 and 180 days postoperatively in the donor area, measuring the thickness of the conjunctiva (epithelium and stroma) and TC. The sub-Tenon’s space (STS) was clinically assessed. Results The mean thickness of the conjunctival epithelium was 48.04 ± 11.37µm in the preoperative period and 51.87±15.04µm 180 days after surgery, without statistically significant difference (P=0.282). A statistically significant increase (P=0.005) in the mean thickness of the conjunctival stroma, from 85.35±23.10µm in the preoperative period to 101.61±20.19µm 180 days after surgery was found. TC had no significant changes, slightly increasing from 117.13±24.26µm preoperatively to 118.09±19.24µm (P=0.808) 180 days after surgery. STS was found in 19 (82%) eyes 180 days after surgery. Conclusions Following ALCT with TC preservation, scarring took place in the conjunctiva, epithelium, and stroma. The TC and the STS were preserved not showing any significant changes.

The use of ultrasound during Anterolateral Ligament (ALL) reconstruction improves femoral positioning

Objectives: We developed a minimally invasive technique for ALL reconstruction with the gracilis tendon folded in two strands. This is done by palpating the bone contours or under ultrasound control. Our hypothesis is that ultrasound control improves the positioning of the graft. Methods: We conducted a prospective controlled before-after study. All the patients who had an anatomical ALL reconstruction surgery were included. Patients for whom the postoperative control radiographs of a strict cross-section of the knee did not meet the quality criteria were excluded. The first 60 patients included were palpated for lateral epicondyle location, and for the next 60 patients ultrasound was used. The primary endpoint was the distance measured along an antero-posterior and proximo-distal axis between the graft insertion point and the theoretical ALL insertion point. The comparative analysis was carried out by student’s t-test. We determined the number of subjects to be included at 60 per group by assuming a minimum of 90% of grafts ≤5 mm in the "US" group versus 50% in the "palpation" group. Results: 120 patients were included in 2 groups of 60 (US vs. palpation) with no statistical difference. The mean anteroposterior distance between the theoretical point and the point identified in the palpation group was 6.3 mm (+/- 2.4) and 1.2 mm (+/- 1.1) in the ultrasound group (p<0.001). Conclusion: Our hypothesis was confirmed. Ultrasound control improves the positioning of the ALL graft.

FEATURES OF APPLICATION OF EXTERNAL OSTEOSYNTHESIS IN CORRECTION OF VARUS DEFORMATION OF LOWER EXTREMITIES IN PATIENTS WITH GONARTHROSIS

Background: Arthrosis of the knee joint is one of the most common diseases in elderly patients with varus deformity. One of the treatment methods is corrective osteotomy. Aims: optimization of the diagnosis of deformities in patients with gonarthrosis, improvement of the technique of operation and postoperative control of the main reference lines and angles, assessment of correction results, analysis of complications. . Materials and methods: Under observation were 39 patients, who performed 78 operations on both legs simultaneously. In all cases, tibia bone osteotomies and osteosynthesis with Ilizarov apparatus were used. All patients underwent x-ray of the legs along the entire length with the definition of the main reference lines and angles. . Results: In all cases, it was possible to normalize the position of the mechanical axis and the angle of orientation of the knee joint. After surgery, the wounds were not sutured for the prevention of compartment syndrome. Correction was performed simultaneously in elderly patients, gradually in young patients. The fixation period by Ilizarov apparatus was 16.6 + 3.1 weeks. . Conclusions: The Ilizarov method has significant advantages: low invasiveness, stable fixation, absence of foreign bodies at the end of treatment. This allows us to recommend it for wider use in patients with gonarthrosis and varus deformity. Keywords: Knee Osteoarthritis, ilizarov method, Genu Varus, Osteoarthritis of the Knee .

Postoperative Regional Scalp Block versus Intravenous Fentanyl for Postsupratentorial Craniotomy Analgesia in Adult Patients under General Anesthesia

Majority of patients undergoing experienced moderate to severe pain in surgical site after the procedure, and there is a reluctance to manage this pain with systemic that is understandable as it may impair neurological assessment, that is crucial in the postoperative period. In addition to that, evidence concerning alternative analgesia techniques to manage post pain is deficient. This research aims at evaluating the effect of postoperative regional scalp block (RSB) versus intravenous for analgesia in adult patients under general . Patients were automatically divided into two groups with 15 patients in each, Group B: postoperative RSB was done after the end of skin closure and before emergence from general , Group C: control group: in which standard analgesia was given in the form of intravenous with no block. This study included patients with brain were admitted to Zagazig University Hospitals. We gathered the cases in the time between March 2018 and March 2020. Results: the results displayed highly significant differences between RSB group and control group. Postoperative RSB showed advantages over standard analgesia in the point of more significant reduction of response to pain in the form of heart rate and blood pressure , decrease consumption, lower Visual Analogue Score(VAS), Postoperative RSB can be performed easily in a short time with very high success rate allowing better postoperative control of , less postoperative pain. We recommend using postoperative RSB in as a gold standard in our hospital to get the advantages as mentioned above.