[Complications of mid-urethral sling - A review from the Committee for Female Urology and Pelviperineology for the French Association of Urology]. / Complications des bandelettes sous urétrales : une revue de la littérature par le Comité d'urologie et pelvipérinéologie de la femme de l'Association française d'urologie.

INTRODUCTION: Placement of a mid-urethral sling is the gold standard in the surgical management of stress urinary incontinence in women in France. The cure rate of this material is no longer to be demonstrated, but the per- and post-operative complications are currently the subject of a growing controversy not only in Europe but also across the Channel and across the Atlantic, having led to the modification of operative indications. In France, recommendations are also evolving with a stricter framework for indications for surgery by multidisciplinary consultation meeting and an obligation for postoperative follow-up in the short and long term. OBJECTIVES: In this context, CUROPF realized a review of the literature bringing together the available scientific evidence concerning the occurrence of per- and post-operative complications relating to the installation of mid urethral sling. The bibliographic search was carried out using the Medline database and 123 articles were selected. RESULTS: Analysis of the data highlights various complications, depending on the implanted material, the patient and the indication for surgery. The retro-pubic mid urethral sling provides more bladder erosion during surgery (up to 14%), more suprapubic pain (up to 4%) and more acute urinary retention (up to 19,7%) and postoperative dysuria (up to 26%). The trans obturator mid-urethral sling is responsible for more vaginal erosion during the operation (up to 10,9%), more lower limb pain of neurological origin (up to 26,7%). The risk of developing over active bladder is similar in both procedures (up to 33%). But these risks of complications must be balanced by the strong impact of urinary incontinence surgery on the overall quality of life of these women. CONCLUSION: Thus, surgical failure and long term complications exist but should not limit the surgical management of stress urinary incontinence with mid urethral tape. Women should be treated with individualized decision-making process and long-term follow -up is necessary.

[Percutaneous nephrolithotomy for kidney stones in elderly patients: Meta-analysis of results and complications]. / Néphrolithotomie percutanée des calculs rénaux des personnes âgées : méta-analyse des résultats et complications.

INTRODUCTION AND OBJECTIVE: Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for kidney stones regardless of age. Elderly patients (EP)≥65years old, in growing numbers, have more comorbidities than the general population, may alter results of PCNL. The aim of this meta-analysis was to compare efficacy and complications of this procedure between EP and young patients (YP). METHODS: Original studies of prospective and historical cohorts, in English or French, presenting PCNL series published on PubMed until 2015 were identified using the keywords percutaneous nephrolithotomy, elderly patients, kidney stones and staghorn calculi. Our analysis focused on therapeutic efficacy, defined by absence of residual fragment or the presence of residual fragments<4mm at 3 postoperative months, and postoperative complications according to patient age: YP<65 years old and EP≥65 years old. Binary qualitative data were analyzed using odds ratio (OR) and quantitative data by estimating the difference of means. RESULTS: In total 397 studies were identified among which 23 were checked and 8 included in the meta-analysis for methodological quality corresponding to 4995 YP and 820 EP. No efficacy difference (OR=0.96; [IC95 %: 0.80; 1.17]; P=0.71), operating time (+1.15min in EP [IC95 %: -2.83; 5.12]; P=0.57) and average length of stay (+0.29 days in EP [IC95 %: -0.14; 0.72]; P=0.19) has been reported. It was a trend to more urinary infections (OR=2.24; [IC95 %: 0.74-6.80]; P=0.16) and a significantly increase of postoperative blood transfusions in EP (OR=1.41; [IC95 %: 1.00-1.97]; P=0.04). CONCLUSIONS: PCNL for kidney stones n EP is effective with a significantly increase the risk of postoperative blood transfusions compared to YP.

Randomized clinical trial of laparoscopic versus open fundoplication for gastro-oesophageal reflux disease.

BACKGROUND: The aim of this study was to compare laparoscopic and open Nissen fundoplication for gastro-oesophageal reflux disease in a randomized clinical trial. METHODS: Ninety-nine patients were randomized to either laparoscopic (52) or open (47) Nissen fundoplication. Patients with oesophageal dysmotility, those requiring a concurrent abdominal procedure and those who had undergone previous antireflux surgery were excluded. Independent assessment of dysphagia, heartburn and patients' satisfaction 1, 3, 6 and 12 months after surgery was performed using multiple standardized clinical grading systems. Objective measurement of oesophageal acid exposure and lower oesophageal sphincter pressure before and after surgery, and endoscopic assessment of postoperative anatomy, were performed. RESULTS: Operating time was longer in the laparoscopic group (median 82 versus 46 min). Postoperative pain, analgesic requirement, time to solid food intake, hospital stay and recovery time were reduced in the laparoscopic group. Perioperative outcomes, postoperative dysphagia, relief of heartburn and overall satisfaction were equally good at all follow-up intervals. Reduction in oesophageal acid exposure, increase in lower oesophageal sphincter tone and improvement in endoscopic appearances were the same for the two groups. CONCLUSION: The laparoscopic approach to Nissen fundoplication improved early postoperative recovery, with an equally good outcome up to 12 months.

Pancreatic stents in the management of chronic pancreatitis.

BACKGROUND: Elevated pancreatic duct pressure is a potential source of pain in patients with chronic pancreatitis. Endoscopic pancreatic duct stenting is a minimally invasive way of reducing this pressure and may be a useful adjunct to surgery in these patients. METHODS: We prospectively reviewed a series of nine symptomatic patients with obstructive chronic pancreatitis and relative contraindications to open surgery, who were managed by attempted endoscopic placement of a pancreatic stent. RESULTS: Stents were successfully inserted endoscopically into the main or accessory duct in six patients and into a pseudocyst, transduodenally, in one patient. Of the two unsuccessful insertions, one proceeded to longitudinal pancreato-jejunostomy and in the other a stent was inserted at distal pancreatic cyst-jejunostomy. Median follow up was 21 months (range 14-43). In all eight cases with stent insertion there was rapid pain resolution, pain scores falling from 9/10 (8-10) to 2 (1-5) after 2 days (1-7). Associated symptoms of weight loss, nausea and vomiting settled in all eight cases. In one patient with a persistent pancreatic fistula, the fistula resolved. In the three with pseudocysts, the cysts resolved on computed tomography (CT) (one recurred). Five patients subsequently proceeded to stent removal after 6 months (5-23). In three of these, the stent was removed endoscopically, and replaced endoscopically in two cases, with pain resolution. Two patients underwent transduodenal pancreatic duct septectomy (one had stent change prior) and one proceeded to pseudocyst-gastrostomy, with pain resolution. the remaining three patients with stents in situ remain symptom-free. No patient suffered acute pancreatitis. CONCLUSIONS: In selected patients with obstructive chronic pancreatitis, insertion of a pancreatic stent is a safe procedure, which can lead to rapid symptomatic control over the intermediate period. A significant proportion will need further intervention.

The effect of duodenal distension upon antro-pyloric motility and liquid gastric emptying in pigs.

BACKGROUND: This study has investigated first the role of the antrum and pylorus in the retardation of gastric emptying during distension of the duodenum, and second whether ascending duodenal intramural nerves contribute to control of both antro-pyloric motility and liquid gastric emptying in response to distension of the duodenum. METHODS: Studies were performed on 18 pigs. In six the duodenum was transected 1-2 cm distal to the pylorus, to interrupt intramural nerves, in six the pylorus was excised and a further six pigs without any transection or resection acted as controls. Motility of the antrum, pylorus and duodenum was recorded by a sleeve/side hole manometric catheter. Gastric emptying was measured by drainage of the duodenum through a cannula. RESULTS: In control animals distension of the duodenum inhibited antro-pyloric pressure waves (APPW), from 1.52 waves/min at minimum distension to 0.25/min at maximum distension (P=0.0007), stimulated isolated pyloric pressure waves (IPPW), from 0.56/min to 1.80/min (P=0.034) and slowed emptying of a 1000 mL load of 5% dextrose over 30 min from 788 mL to 251 mL (P=0.0001). Duodenum transected animals did not show the duodenal distension-induced stimulations of IPPW (maximum distension: 0.93/min), but both the distension-induced inhibition of APPW (maximum distension: 0.85/min) and slowing of emptying (maximum distension: 52 mL emptied) were unaltered. Similarly in pylorus-excised animals, duodenal distension inhibited APPW (maximum distension: 0.47/min) and slowed liquid emptying (maximum distension: 267 mL), effects which did not differ from control animals. Retardation of gastric emptying by duodenal distension may be due in part to inhibition of antral contractions. CONCLUSIONS: Under the conditions of this experiment, increased pyloric resistance to flow does not play a major role in the slowing of emptying by duodenal distension, but the stimulation of the pylorus by duodenal distension depends on duodenal intramural neural pathways. Duodenal distension-induced feedback control of emptying is mediated primarily via pathways other than ascending intraduodenal nerves.

The importance of the pylorus as a regulator of solid and liquid emptying from the stomach.

The role of the pylorus in the control of gastric emptying of liquids and digestible solids was investigated in the present study by pylorus excision in six pigs. The pylorus was left intact in another six pigs. Antro-pyloro-duodenal motility was recorded by a sleeve sensor and side holes. Liquid emptying was significantly more rapid in pylorus excised than in pylorus intact animals, during intraduodenal infusion of isosmolar dextrose (712 mL vs 107 mL), fatty acid (402 mL vs 46 mL), amino acids (752 mL vs 112 mL), 25% dextrose (392 mL vs 51 mL) and 3 normal saline (705 mL vs 157 mL). In pylorus excised animals, in contrast to pylorus intact animals, the manometric pattern of isolated pyloric pressure waves at the distal stomach was rarely seen (P < 0.05). In a second series of experiments, pylorus excised animals emptied significantly more (P < 0.04) meat over 120 min (181 g) than pylorus intact animals (80 g), but the proportion of particle sizes emptied was unaltered. In the pig, localized pyloric contractions are important for retardation of gastric emptying when nutrient or hyperosmolar solutions enter the duodenum. By contrast, the pylorus is unimportant in determining the size of solid particles emptied from the stomach.

Developing a training model for laparoscopic common bile duct surgery.

Because of the paucity of adequate training models for laparoscopic common bile duct exploration, a live porcine training model was developed and evaluated. This model requires preliminary laparoscopic ligation of the distal bile duct 7-14 days prior to utilization. It aids the development of skills for laparoscopic common bile duct exploration and should enhance the subsequent performance of these procedures.

Primary duct closure versus T-tube drainage following exploration of the common bile duct.

T-tube drainage of the common bile duct (CBD) following duct exploration has become standard surgical practice. This randomized prospective study has compared primary closure versus T-tube drainage of the CBD following exploration for calculous disease. Thirty-seven patients underwent primary closure and 26 underwent closure over T-tube. Both groups were comparable in terms of age, indications for surgery, associated illnesses, pre-operative bilirubin, amylase and white cell count. Forty-three per cent of operations were performed by a consultant in the primary closure group and 65% in the T-tube group. There was no significant difference in the duration of operation, incidence of wound infection, surgical or other complications following operation between the two groups. However, the postoperative stay was significantly prolonged in the T-tube group, to a median of 11 days, compared to 8 days in the primary closure group (P = 0.0001). This prolongation in stay was unrelated to whether admission was as an emergency or elective. T-tube drainage of the bile continued for a median of 7 days postoperative, whereas the bile drained via a wound drain in only 13 (35%) of the primary closure group, for a median of 5 days in these 13 patients. Long-term follow up was achieved in 48 patients, by a questionnaire sent at a median of 2.8 years following operation. Abdominal pains following recovery from the operation were experienced by 18% of the primary closure group and 20% of the T-tube group. No patient developed jaundice or pancreatitis, nor needed further biliary surgery following operation.(ABSTRACT TRUNCATED AT 250 WORDS)

Pyloric motility and liquid gastric emptying during barostatic control of gastric pressure in pigs.

1. In conscious pigs, intragastric pressure was controlled by a water barostat such that the gastroduodenal pressure gradient was always positive with the barostat set above 15 cm. In six pigs pyloric motor function was removed by prior pylorectomy. 2. In pylorus-intact animals, isolated pyloric pressure waves (IPPWs) occurred at a median of 2.9 min-1 during duodenal dextrose infusion with the barostat set at or above a threshold of 15 cm. Increases of intragastric pressure above this threshold had no additional effect upon rates of IPPWs. Below this threshold, with identical duodenal dextrose infusion, IPPWs occurred infrequently (0.5 min-1). In pylorus-excised animals virtually no IPPWs were seen. 3. In both pylorus-intact and -excised animals, the rate of antral pressure waves (APWs) was dependent upon intragastric pressure during duodenal infusion of both saline and dextrose. No threshold for stimulation was seen. Duodenal dextrose infusion inhibited APWs in pylorus-intact animals only. 4. With a positive gastroduodenal pressure gradient, gastric emptying was more rapid in pylorus-excised animals than pylorus-intact animals during duodenal dextrose infusion. In contrast, gastric emptying rates were not different between pylorus-intact and -excised animals during saline infusion. 5. These findings suggest an all-or-none-type stimulation of localized pyloric contractions by distension of the stomach beyond a threshold, in synergism with stimulation by nutrients within the upper small bowel. In contrast, stimulation of antral motility is in proportion to distension of the stomach. The pylorus, by way of localized pyloric contractions, is an effective resistor to transpyloric flow in the face of a positive gastroduodenal pressure gradient.

Duodenal intramural nerves in control of pyloric motility and gastric emptying.

We have investigated the role of ascending duodenal intramural nerves in the control of isolated pyloric pressure waves (IPPW) and liquid gastric emptying. In six pigs, the proximal duodenum was transected to interrupt intramural nerves. A further six pigs had a sham operation. Four weeks after operation, motility of the antrum, pylorus, and duodenum was recorded by side holes and a sleeve sensor. Gastric emptying of a 1,000-ml test meal was significantly more rapid in duodenum-transected animals (P less than 0.0001) during intraduodenal infusion of each of isosmolar dextrose (424 ml emptied), fatty acid (335 ml), and amino acids (396 ml) than in duodenum-intact animals (dextrose: 128 ml; fatty acid: 57 ml; amino acids: 192 ml). Associated with this, in duodenum-transected animals infusion of each of isosmolar dextrose, fatty acid, amino acids, and hyperosmolar saline failed to produce the stimulation of IPPW seen in duodenum-intact animals. In both duodenum-intact and -transected animals, supramaximal stimulation by intraduodenal infusion of 25% dextrose slowed gastric emptying and stimulated IPPW. Ascending duodenal intramural nerves are a major physiological pathway for nutrient- and osmolar-stimulated feedback control of pyloric motility and gastric emptying.

Cutaneous malignant melanoma in Rochester, Minnesota: trends in incidence and survivorship, 1950 through 1985.

In Rochester, Minnesota, 107 incidence cases of cutaneous malignant melanoma (in 46 male and 61 female patients) were diagnosed during the years 1950 through 1985. Overall crude incidence rates were 6.0 and 6.6 per 100,000 males and females, respectively. Evaluation of trends in 9-year periods showed that the rates increased from 3.2 to 8.9 for males (P = 0.015) and from 4.4 to 11.7 for females (P less than 0.001). Age-specific rates suggested that the highest incidence occurs in the age-groups 50 to 59 years and 70 years or older for males and 40 to 49 years and 70 years or older for females. Lesions were most common in the head and neck area among males (P = 0.044) and on the lower extremities among females (P = 0.018). The most frequent histologic type was superficial spreading melanoma (61%). Five-year survival was diminished overall for patients with cutaneous malignant melanoma--0.72 in comparison with 0.88 expected for the general population. Statistically significant risk factors for survival were depth of invasion of the lesion (Clark level), thickness of the lesion, histologic type, and age of the patient.

Pyloric motor function during emptying of a liquid meal from the stomach in the conscious pig.

1. In six conscious pigs antral, pyloric and duodenal pressures were recorded with a 5.5 cm sleeve sensor and multiple perfused side holes. The manometric assembly was positioned by dual point transmucosal potential difference measurement. Gastric emptying was measured by drainage of the proximal duodenum through a Thomas cannula. Pressures were correlated with emptying of ingested radiolabelled 5% dextrose. Alteration of emptying was produced by infusion into the more distal duodenum of nutrient and non-nutrient solutions of differing osmolalities. 2. Motor activity of the pylorus and antrum was stimulated by ingestion and modulated by intraduodenal infusion. Duodenal infusion of normal saline was associated with antro-pyloric pressure waves and rapid emptying of the ingested liquid. Duodenal infusion of dextrose, fatty acid, amino acids and hyperosmolar saline was associated with stimulation of isolated pyloric pressure waves, suppression of antral pressure waves and slowing of gastric emptying. 3. The dose-response relationship of these effects was investigated using varying rates of intraduodenal dextrose infusions. The emptying rate of the ingested liquid was inversely related to the rates of delivery of dextrose to the duodenum, directly related to the rate of antro-pyloric pressure waves and inversely related to the rate of isolated pyloric pressure waves. 4. Clearly defined episodes of pulsatile flow produced slightly more than half of the total emptying that occurred. This pulsatile flow was intimately associated in time with antro-pyloric pressure waves. Sequences of isolated pyloric pressure waves were associated with near cessation of emptying. When there were periods of absent pyloric antral pressure waves, flow rates intermediate between the rapid emptying of pulsatile flow during antro-pyloric pressure waves and the near cessation of flow during isolated pyloric pressure waves occurred. 5. The findings suggest a major role for the pylorus in the control of emptying of liquids from the stomach, both as a component of an antro-pyloric peristaltic pump and as a resistor to transpyloric flow during nutrient and hyperosmolar stimulation of duodenal receptors.

An approach to the management of para-oesophageal hiatus hernias.

A variety of conservative and surgical options are available in the management of para-oesophageal hiatus hernia. However opinion is divided in regard to the best form of treatment. A series of 71 patients with para-oesophageal hiatus hernia has been studied, to assess hospital management and outcome after treatment. Case notes of all patients were reviewed, and a questionnaire sent to surviving patients. Of those patients treated surgically with an anatomical repair plus a fundoplication, 19% had recurrence of significant symptoms. In contrast, 55% of patients managed by an anatomical repair alone had recurrence of significant symptoms. Conservative management was undertaken in 29 of the 71 patients and 66% had recurrence of significant symptoms, with 13 proceeding to elective surgery. Nevertheless, there is a place for the conservative management of para-oesophageal hernias are usually combined type hernias with associated reflux symptoms and repair of the hernia should include an antireflux procedure.