Risks, advantages, and complications of intercostal vs subcostal approach for percutaneous nephrolithotripsy.

OBJECTIVES: To establish the efficacy of nephrolithotripsy via intercostal access route vs subcostal access route with respect to attained stone-free status, operating time, and complications. METHODS: Percutaneous nephrolithotripsies via the upper pole were performed in 142 patients (93 male, 49 female, age 24-78 years) from 1998 to 2005 at our 4 academic medical centers. Selection criteria for nephrolithotripsy via upper pole access were staghorn calculi > or = 5.5 cm(3), upper pole calyx calculi > or = 2.5 cm, and abnormal or high lying kidney, often in combination with obesity. Of 68 staghorn calculi, 49 were accessed via intercostal and 19 via subcostal route. Of 57 upper calyx calculi 38 were accessed via intercostal and 19 via subcostal route; all calculi in the upper ureter considered easily accessible via the intercostal route. RESULTS: Of 103 patients with intercostal access, 91 attained a stone-free status. There were 4 major and 6 minor complications. Depending on stone location, mean operating times varied from 42 to 152 minutes. Of 39 patients in whom a subcostal access route was chosen, 29 were made stone-free. There were 3 major and 8 minor complications. The mean operating time varied from 108 to 145 minutes. CONCLUSIONS: The significantly higher rate of achieving stone-free status, lower rate of complications, and markedly reduced operating time when using intercostal access make this the route of choice for upper pole nephrolithotripsy.

Identifying patients with gastroesophageal reflux disease: validation of a practical screening tool.

A reliable, accurate noninvasive method for identifying patients with gastroesophageal reflux disease (GERD) in the primary care setting is needed. A population-based case-finding instrument may assist managed care organizations in identifying candidates for disease management or quality improvement programs. Our aim was to develop and validate a GERD case-finding instrument. A 12-item "GERD Screener" was developed based on literature review and expert opinion with questions about heartburn and regurgitation frequency and severity and medication use, as well demographics and exclusion criteria. Categorical and continuous scoring methods with and without medication use were developed a priori. Using a telephone interview in a medical group, we identified and enrolled 100 subjects with a history of GERD-like symptoms and 103 controls. Each subject completed the GERD Screener, a validated gastrointestinal symptom questionnaire, the Digestive Health Symptom Index (DHSI), and was evaluated independently by two gastroenterologists using a structured format. Agreement by the two physicians that symptoms were consistent with GERD and required an intervention was considered the gold standard. In all, 70 subjects were classified as having GERD and 106 as controls using the gold standard (K = 0.73; 95% CI, 0.63-0.82). The scoring method for the screening instrument using a continuous measure of GERD symptoms (frequency and severity) and weighted medication use resulted in an area under ROC of 0.89 (95% CI, 0.84-0.94). Using a cutoff of >9 points, this measure was 83% sensitive and 83% specific. Compared to the gold standard, the DHSI GERD subscale has an area under ROC of 0.89 (95% CI, 0.84-0.94). The GERD Screener was highly correlated with the DHSI GERD subscale, r = 0.78 (95% CI 0.72-0.83; P < 0.0001). In conclusion, the GERD Screener has demonstrated construct, convergent, and predictive validity. It is shorter than existing validated instruments, practical, and easily administered, which may reduce the response and administrative burden. This may serve as a valuable case-finding instrument in primary-care and managed-care organizations wishing to implement programs to improve the quality and efficiency of care.