Clinical characteristics and prognosis of primary hepatolithiasis in hospitalized children.

The purpose of this study is to evaluate the clinical characteristics and prognosis of primary hepatolithiasis in hospitalized children. This retrospective cohort study included 106 hospitalized patients with primary hepatolithiasis at Beijing Children's Hospital. Clinical data were derived from electronic inpatient (2010-2021) and outpatient (2016-2021) medical records. The prognosis was evaluated by outpatient ultrasounds after discharge and telephone interviews performed in December 2022. Intrahepatic bile duct stones in patients enrolled in the study were all found incidentally by abdominal ultrasound during hospitalization, with an incidence of 1.7 per 10,000 hospitalized children. The mean age at diagnosis was 9.3 ± 3.6 years, with male predominance (69/106, 65.1%). The right lobe of the liver (80/106, 75.5%) was preferentially affected. All patients underwent conservative observation. Seventy-eight patients (78/106, 73.6%) were followed up with a mean follow-up age of 17.1 ± 5.0 years, and 4 (4/78, 5.1%) had intermittent abdominal pain. From 2016 to 2021, 32 patients were diagnosed with primary hepatolithiasis, and follow-up abdominal ultrasounds were performed in 20 of them (20/32, 60.0%) with a median time of 2.1 (0.1, 3.5) years. The stones were present in 17 patients (17/20, 85.0%). CONCLUSION: Primary hepatolithiasis in hospitalized children is rare, almost found accidentally; mostly affects the right lobe of the liver; and can be conservatively observed without surgical treatment in childhood. WHAT IS KNOWN: • Primary hepatolithiasis in adults often presents with severe clinical symptoms and requires hepatectomy.. • There are few studies on primary hepatolithiasis in children. WHAT IS NEW: • Primary hepatolithiasis in children is mostly found accidentally by abdominal ultrasound without associated symptoms during hospitalization. • Children with accidental primary hepatolithiasis can be conservatively observed without surgical treatment in childhood.

2022 Recommendations of the AFU Lithiasis Committee: Management of symptomatic urinary stones.

The acute situation, caused by an obstructive stone, is defined by a renal colic that may be uncomplicated, complicated, or at risk in specific conditions. Its management may be medical or require interventional treatment by extracorporeal shockwave lithotripsy, endoscopic removal, or ureteroscopy. METHODOLOGY: These recommendations were developed using two methods, the Clinical Practice Recommendations (CPR) and the ADAPTE method, in function of whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU Guidelines on urolithiasis. 2022] and whether they could be adapted to the French context.

2022 recommendations of the AFU Lithiasis Committee: Objectives, results, residual stones and fragments.

The main objectives of interventional stone treatment are stone removal, symptom elimination, and kidney function preservation. After treatment of kidney stones (extracorporeal shock wave lithotripsy [ESWL], or endoscopy), fragments may remain in the kidney, either deliberately left in place or due to treatment failure (i.e. residual stone [RS], resistant to ESWL, left or inaccessible by endoscopy), or due to failure to eliminate the obtained fragments (i.e. residual fragments [RF]). Their management may differ. The most commonly used definition of RF in the literature is based on a size cut-off (≤4mm) and on three criteria: spontaneous clearance rate, secondary intervention rate, and disease progression rate. RF may be spontaneously eliminated (42%), persist and increase in size (32%), or become complicated and require a secondary urological procedure (36%). Like for the initial treatment, it is important to consider the stone composition for the treatment decision-making concerning RS/RF. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) (EAU, 2022) and their adaptability to the French context.

2022 Recommendations of the AFU Lithiasis Committee: Endoscopic description of renal papillae and stones.

Endoscopic observation is performed during treatments by flexible ureteroscopy to differentiate in situ between renal papillary abnormalities and stones based on their concordance with Daudon's morphological/composition descriptions adapted to endoscopy. These intraoperative visual analyses are now an integral part of the urinary stone disease diagnostic approach in addition to the morphological/structural and spectrophotometric analysis that remains the reference exam, but that loses information on the stone component representativeness due to the development of in situ laser lithotripsy. These are the first practical recommendations on the endoscopic description of renal papillae and stones. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendations (CPR) and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis [EAU Guidelines on urolithiasis. 2022]) and their adaptability to the French context.

Endourology (Lithiasis). Management, surgical considerations and follow-up of patients in the COVID-19 era.

PURPOSE: To provide recommendations on the endourological management of lithiasis in the scenario of the COVID-19 pandemic. MATERIALS AND METHODS: A non-systematic review in PubMed and the grey literature, as well as recommendations by a panel of stakeholders was made, regarding management, surgical considerations and follow-up of patients affected by lithiasis in the COVID-19 era. RESULTS: Under the current outbreak and COVID-19 pandemic scenario, patients affected by lithiasis should be prioritized into low, intermediate and high risk categories, to decide their delay and save resources, healthcare personnel, beds and ventilators. However, patients with potentially serious septic complications need emergency interventions. The possibility of performing or restarting elective activity depends on local conditions, the availability of beds and ventilators, and the implementation of screening protocols in the context of the COVID-19 pandemic. Delaying lithiasis surgery and increasing waiting lists will have consequences and will require considerable additional effort. Teleconsultation may be useful in guiding these patients, reducing visits and unnecessary exposure. CONCLUSIONS: categorization and prioritization of patients affected by lithiasis is crucial for management, surgical selection and follow-up. Protocols, measures and additional efforts should be carried out in the current situation of the COVID-19 pandemic.

Extracorporeal shock wave lithotripsy is safe and effective for pediatric patients with chronic pancreatitis.

Background and aims Pancreatic extracorporeal shock wave lithotripsy (P-ESWL) is recommended as the first-line treatment for pancreatic stones. However, how well P-ESWL performs in pediatric patients remains unclear. We aimed to evaluate the safety and efficacy of P-ESWL for pediatric patients with chronic pancreatitis. Methods This prospective observational study was conducted in patients with painful chronic pancreatitis who underwent P-ESWL. Patients aged under 18 years were included in the pediatric group; patients aged over 18 years who underwent P-ESWL in the same period were assigned to the control group. For investigation of long-term follow-up, the pediatric group were matched with patients from the control group in a 1:1 ratio. The primary outcomes were P-ESWL complications and pain relief. The secondary outcomes included: stone clearance, physical and mental health, quality of life score, and growth and developmental state. Results From March 2011 to March 2015, P-ESWL was performed in 1135 patients (72 in the pediatric group, 1063 in the control group). No significant differences were observed in the occurrence of P-ESWL complications between the two groups (11.1 % vs. 12.8 %; P = 0.68). Among the 67 pediatric patients (93.1 %) who underwent follow-up for 3.0 years (range 1.3 - 5.2), complete pain relief was achieved in 52 patients (52 /67; 77.6 %); this value was not significantly different from that of the matched controls (55 /69; 79.7 %; P = 0.94). Conclusions P-ESWL is safe and effective for pediatric patients with chronic pancreatitis. It can promote significant pain relief and stone clearance, and can benefit growth and development.

Dacryolithiasis: A Review.

PURPOSE: To review and summarize the clinical features, presentations, diagnostic modalities and management of dacryolithiasis. METHODS: A comprehensive PubMed search of all English articles on dacryolithiasis was reviewed. Although this review primarily relied on articles written in English, non-English-language articles that had abstracts translated into English were also reviewed. Data reviewed included epidemiology, pathogenesis, appearance and composition, clinical features, presentations, diagnostic modalities, management of dacryolithiasis and the implications of incidental dacryoliths found during lacrimal surgery. RESULTS: Although an unknown proportion of dacryolithiasis cases may remain asymptomatic; epiphora, acute and/or recurrent dacryocystitis, punctal discharge, and localized swelling are the most common presenting features of dacryolithiasis. It may also present as partial nasolacrimal duct obstruction. Dacryoliths exhibit a variety in external appearances. While some minimally invasive techniques for the removal of dacryoliths have been described, dacryocystorhinostomy with removal of the dacryoliths remain the most effective treatment in cases of symptomatic dacryolithiasis. The expression and production of certain proteins and peptides, namely those of the trifoil factor family play a significant role in the pathogenesis of dacryoliths. CONCLUSIONS: The management of dacryolithiasis is driven by the goal of resolution of secondary obstruction and/or inflammation. Although a large number of dacryoliths are incidentally found during dacryocystorhinostomy, certain clinical features such as unilateral sac distension, particularly those with a palpable firm medial canthal mass, might lead one to have a high index of suspicion. It remains unclear if the incidental finding of a dacryolith during a dacryocystorhinostomy has a favorable prognostic value.

[Percutaneous Nephrolithotripsy for Renal Transplant Lithiasis: A Case Report].

A 54-year-old man was introduced to our hospital for follow-up examinations after renal transplantation. At the initial visit, a 25 mm renal transplant stone was noted, which had enlarged to 32 mm at an examination 1 year later. We first attempted transurethral lithotripsy (TUL), but failed due to ureteral stricture. However, we could completely remove the stone in 2 sessions of percutaneous nephrolithotripsy (PNL). The incidence of urinary lithiasis after renal transplantation ranges from 0.17-1.8%, for which PNL and TUL are frequently used. Although considered to be accompanied with risks of bleeding, bowel injury, and renal dysfunction, PNL is effective for urinary lithiasis after renal transplantation. TUL is less invasive, but access may be difficult when the ureter has an unusual course or ureteral stricture exists, as in our patient.

Screening of different probiotic strains for their in vitro ability to metabolise oxalates: any prospective use in humans?

BACKGROUND: Oxalate is the salt-forming ion of oxalic acid and can generate oxalate salts combining with various cations, such as sodium, potassium, magnesium, and calcium. Approximately 75% of all kidney stones are composed primarily of calcium oxalate (CaOx) and hyperoxaluria, a condition involving high urinary oxalate concentration, is considered a primary risk factor for kidney stone formation, known as nephrolithiasis. Current therapeutic strategies often fail in their compliance or effectiveness, and CaOx stone recurrence is still common. After an initial stone, there is a 50% chance of forming a second stone within 7 years if the condition is left untreated. The potential therapeutic application of some probiotics, mainly lactobacilli and bifidobacteria, in reducing hyperoxaluria in vivo through intestinal oxalate degrading activity is compelling and initial reports are promising. This study was undertaken to screen different Lactobacillus and Bifidobacterium strains for their capacity to degrade oxalate in vitro using reverse-phase high-performance liquid chromatography (HPLC). METHODS: The oxalate-degrading activity of 13 lactobacilli and 5 bifidobacteria was tested using a novel HPLC method after growth in a broth culture added with 10 mM ammonium oxalate. Experiments were repeated 3 times. Oxalobacter formigenes (DSM 4420) was used as positive reference to validate HPLC oxalate-degrading capability assays. RESULTS: Lactobacillus strains were more efficient than bifidobacteria in degrading oxalates. L. paracasei LPC09 (DSM 24243) gave the best result, as 68.5% of ammonium oxalate was converted at the end of incubation, whereas the following best converters belong to the L. gasseri and L. acidophilus species. The relatively low conversion rate observed for most bifidobacteria can probably be attributed to intrinsic oxalate toxicity toward this genus. CONCLUSIONS: Humans lack the enzymes needed to directly metabolise oxalate, and this potentially toxic compound is, therefore, managed using alternative pathways. As oxalate-degrading bacteria are present in the endogenous microbiota of the human intestine, although with significant individual differences, it is possible to hypothesise that the administration of selected oxalate-degrading probiotics could be an alternative and innovative approach to reducing the intestinal absorption of oxalate and the resulting urinary excretion.

New treatment strategy for cupulolithiasis associated with benign paroxysmal positional vertigo of the lateral canal: the head-tilt hopping exercise.

This study was performed to determine whether a novel treatment was effective against cupulolithiasis associated with benign paroxysmal positional vertigo (BPPV) of the lateral semicircular canal, which is characterized by apogeotropic direction-changing nystagmus. We herein describe our head-tilt hopping (HtH) exercise, which is designed to release otoconial debris strongly adhered to the cupula. The subjects were trained to hop while tilting their heads laterally. They completed 3 to 5 exercise sessions per day over a 4-week period. Each session ended with a 20-hop trial. The HtH exercises were performed by 27 patients with intractable lateral canal BPPV who exhibited positional vertigo and persistent nystagmus beating toward the uppermost ear for more than 4 weeks, despite performing therapeutic head shaking in the horizontal plane maneuver. All the patients were subjected to the supine roll test before and immediately after the first trial as well as after 1 and 4 weeks of the program to evaluate the effect of the treatment on their apogeotropic nystagmus. Nystagmus of 9 (33.3 %) patients disappeared immediately after the first training session. After 1 and 4 weeks of the training, the number of patients that had experienced either of these improvements had increased to 15 (55.6 %) and 19 (70.4 %) subjects, respectively. These results suggest that HtH exercises aimed at releasing otoconial debris from the cupula are feasible as a new therapy for cupulolithiasis associated with intractable lateral canal BPPV. However, further studies for comparison with control are required to confirm these preliminary results.

Spontaneous expulsion of lacrimal gland ductule stones by eyelid squeezing: a rare event.

PURPOSE: To report a rare case of lacrimal gland ductule stones. METHODS: Case report. RESULTS: A 12-year-old female patient presented with pain, redness and swelling in the superotemporal fornix of the left eye of 1-week duration. She had experienced four similar episodes over a period of 2 years. Clinical evaluation revealed a mass adjacent to the lacrimal gland and some stone edges protruding through the lacrimal gland ductules. During preparation for their mechanical removal, a spontaneous expulsion of stones occurred. Microbiological examination of stones did not show any microorganism or nidus such as cilia. Fourier transform infrared spectroscopy revealed the stones to be composed of calcium carbonate 90% and magnesium hydrogen phosphates 10%. After spontaneous expulsion, the condition subsided without any complications. CONCLUSION: Lacrimal gland stones represent a very rare clinical entity and this should be considered in the differential diagnosis of recurrent nonspecific conjunctivitis and dacryoadenitis.

Is extracorporeal lithotripsy a first-line treatment for urinary stones today?

OBJECTIVE: To evaluate the efficacy and complications of extracorporeal lithotripsy (SWL) as a first-line treatment for renal and ureteral stones METHODS: Retrospective and observational study of all the patients treated with lithotripsy in a third level center between January 2014 and January 2021; characteristics of the patients, the stones, complications and results of SWL is recollected. Multivariate logistic regression of the factors associated with stone size reduction was performed. A statistical analysis of the factors associated with additional treatment after SWL and factors associated with complications is also executed. RESULTS: 1727 patients are included. Stone mean size was 9,5mm. 1540 (89.4%) patients presented reduction in stone size. In multivariate analysis, stone size (OR=1.13; p=0.00), ureteral location of the lithiasis (OR=1.15; p=0.052) and number of waves (p=0.002; OR=1.00) used in SWL are the factors associated with reduction of stone size. Additional treatment after lithotripsy was needed in 665 patients (38.5%). The factors associated with the need for retreatment were stone size (OR=1.131; p=0.000), number of waves (OR=1.000; p=0.000), energy (OR=1.005; p=0.000). 153 patients (8.8%) suffered complications after SWL. A statistically significant association was found between the size of the lithiasis (p=0.024, OR=1.054) and the previous urinary diversion (P=0.004, OR=0.571). CONCLUSION: Lithotripsy remains an effective treatment as the first line of therapy for reno-ureteral lithiasis with a low percentage of complications.

Three-dimensional visualization technology for guiding one-step percutaneous transhepatic cholangioscopic lithotripsy for the treatment of complex hepatolithiasis.

BACKGROUND: Biliary stone disease is a highly prevalent condition and a leading cause of hospitalization worldwide. Hepatolithiasis with associated strictures has high residual and recurrence rates after traditional multisession percutaneous transhepatic cholangioscopic lithotripsy (PTCSL). AIM: To study one-step PTCSL using the percutaneous transhepatic one-step biliary fistulation (PTOBF) technique guided by three-dimensional (3D) visualization. METHODS: This was a retrospective, single-center study analyzing, 140 patients who, between October 2016 and October 2023, underwent one-step PTCSL for hepatolithiasis. The patients were divided into two groups: The 3D-PTOBF group and the PTOBF group. Stone clearance on choledochoscopy, complications, and long-term clearance and recurrence rates were assessed. RESULTS: Age, total bilirubin, direct bilirubin, Child-Pugh class, and stone location were similar between the 2 groups, but there was a significant difference in bile duct strictures, with biliary strictures more common in the 3D-PTOBF group (P = 0.001). The median follow-up time was 55.0 (55.0, 512.0) days. The immediate stone clearance ratio (88.6% vs 27.1%, P = 0.000) and stricture resolution ratio (97.1% vs 78.6%, P = 0.001) in the 3D-PTOBF group were significantly greater than those in the PTOBF group. Postoperative complication (8.6% vs 41.4%, P = 0.000) and stone recurrence rates (7.1% vs 38.6%, P = 0.000) were significantly lower in the 3D-PTOBF group. CONCLUSION: Three-dimensional visualization helps make one-step PTCSL a safe, effective, and promising treatment for patients with complicated primary hepatolithiasis. The perioperative and long-term outcomes are satisfactory for patients with complicated primary hepatolithiasis. This minimally invasive method has the potential to be used as a substitute for hepatobiliary surgery.

Hepatolithiasis: Epidemiology, presentation, classification and management of a complex disease.

The term hepatolithiasis describes the presence of biliary stones within the intrahepatic bile ducts, above the hilar confluence of the hepatic ducts. The disease is more prevalent in Asia, mainly owing to socioeconomic and dietary factors, as well as the prevalence of biliary parasites. In the last century, owing to migration, its global incidence has increased. The main pathophysiological mechanisms involve cholangitis, bile infection and biliary strictures, creating a self-sustaining cycle that perpetuates the disease, frequently characterised by recurrent episodes of bacterial infection referred to as syndrome of "recurrent pyogenic cholangitis". Furthermore, long-standing hepatolithiasis is a known risk factor for development of intrahepatic cholangiocarcinoma. Various classifications have aimed at providing useful insight of clinically relevant aspects and guidance for treatment. The management of symptomatic patients and those with complications can be complex, and relies upon a multidisciplinary team of hepatologists, endoscopists, interventional radiologists and hepatobiliary surgeons, with the main goal being to offer relief from the clinical presentations and prevent the development of more serious complications. This comprehensive review provides insight on various aspects of hepatolithiasis, with a focus on epidemiology, new evidence on pathophysiology, most important clinical aspects, different classification systems and contemporary management.

Long-term clinical outcomes of extracorporeal shockwave lithotripsy in painful chronic calcific pancreatitis.

BACKGROUND: Long-term results of extracorporeal shockwave lithotripsy (ESWL) for large pancreatic duct (PD) stones in patients with idiopathic calcific pancreatitis (CP) are scanty. OBJECTIVE: To evaluate intermediate and long-term results of ESWL in a large cohort of patients with idiopathic CP. DESIGN: Cross-sectional study; retrospective chart review. SETTING: A high-volume, tertiary-care center for endoscopy and GI diseases. PATIENTS: A total of 636 patients with idiopathic CP who underwent ESWL and ERCP were followed-up. Patients were divided into intermediate (24-60 months) and long-term (>60 months) follow-up groups. INTERVENTION: ESWL and ERCP. MAIN OUTCOME MEASUREMENTS: Improvement in pain, analgesic use, hospitalization for pain, recurrence of calculi, need for additional intervention, and quality of life. RESULTS: A total of 636 of 1006 patients who underwent ESWL between 2004 and 2009 were followed for a maximum of 96 months. There were 364 patients in the intermediate follow-up group and 272 in the long-term follow-up group. After ESWL and ERCP, absence of pain was seen in 250 patients (68.7%), mild-to-moderate pain in 94 patients (25.4%), and severe pain in 20 patients (5.5%) of the intermediate group. In the long-term group, 164 patients (60.3%) had no pain, 97 patients (35.7%) had mild or moderate episodes of pain, whereas 11 patients (4.04%) had episodic severe pain. Recurrence of calculi was seen in 51 patients (14.01%) in the intermediate follow-up group and in 62 patients (22.8%) in the long-term group. Quality of life improved in a significant number of patients in both groups. LIMITATIONS: Retrospective study, single center, recall bias, and subjective pain and quality-of-life measurement scale. CONCLUSION: ESWL for large PD calculi offers good results in patients of idiopathic CP on intermediate and long-term follow-up.

New developments in diagnosis and non-surgical treatment of chronic pancreatitis.

Chronic pancreatitis is progressive and irreversible, leading to digestive and absorptive disorders by destruction of the exocrine pancreas and to diabetes mellitus by destruction of the endocrine pancreas. When complications such as pancreatolithiasis and pseudocyst occur, elevated pancreatic ductal pressure exacerbates pain and induces other complications, worsening the patient's general condition. Combined treatment with extracorporeal shock-wave lithotripsy and endoscopic lithotripsy is a useful, minimally invasive, first-line treatment approach that can preserve pancreatic exocrine function. Pancreatic duct stenosis elevates intraductal pressure and favor both pancreatolithiasis and pseudocyst formation, making effective treatment vitally important. Endoscopic treatment of benign pancreatic duct stenosis stenting frequently decreases pain in chronic pancreatitis. Importantly, stenosis of the main pancreatic duct increases risk of stone recurrence after treatment of pancreatolithiasis. Recently, good results were reported in treating pancreatic duct stricture with a fully covered self-expandable metallic stent, which shows promise for preventing stone recurrence after lithotripsy in patients with pancreatic stricture. Chronic pancreatitis has many complications including pancreatic carcinoma, pancreatic atrophy, and loss of exocrine and endocrine function, as well as frequent recurrence of stones after treatment of pancreatolithiasis. As early treatment of chronic pancreatitis is essential, the new concept of early chronic pancreatitis, including characteristics findings in endoscopic ultrasonograms, is presented.