Ultrasound-guided paravertebral nerve block anesthesia for percutaneous endoscopic laser unroofing treatment of symptomatic simple renal cysts—An innovative ambulatory surgery mode

Objective:This study was designed to evaluate the feasibility,efficacy,and safety of percutaneous ureteroscopy laser unroofing as an ambulatory surgery for symptomatic simple renal cysts under multilevel paravertebral nerve block anesthesia.Methods:From December 2015 to September 2017,33 simple renal cyst patients who had surgical indications were enrolled.Under ultrasound guidance,the T10/T11,T11/T12,and T12/L1 paravertebral spaces were identified,and 7-10 mL 0.5%ropivacaine was injected at each segment.Then a puncture needle was placed inside the cyst cavity under ultrasonic monitoring.A guidewire was introduced followed by sequential dilation up to 28/30 Fr.The extra parenchymal portion of the cyst wall was dissociated and incised using a thulium laser,and a pathological examination was performed.Results:Sensory loss to pinprick from T8 to L1 and sensory loss to ice from T6 to L2 were observed in all patients.None of the patients complained of pain during surgery.No serious complications occurred perioperatively.After the surgery,all patients recovered their lower limb muscle strength quickly,got out of bed,resumed oral feeding,and left the hospital within 24 h of admission.The pathologic diagnosis of all cyst walls was a simple renal cyst.The mean follow-up was 35.8 months.At the end of follow-up,the cyst units were reduced in size by more than 50%compared to the preoperative size,and no patient experienced a recurrence.Conclusion:Multi-level paravertebral nerve block for percutaneous ureteroscopy laser unroofing as an ambulatory surgery mode is feasible,safe,and effective for the treatment of simple renal cysts in selected patients.

Unroofing Technique for Anomalous Origin of the Left Coronary Artery from the Right Sinus of Valsalva: Report of a Case

Anomalous origin of the left coronary artery (AOLCA) from the right sinus of Valsalva constitutes a rare congenital coronary artery anomaly. Patients with an anomalous left main coronary artery face a significantly higher risk of sudden cardiac death compared to those with an anomalous right coronary artery. The anomalous coronary artery traversing between the ascending aorta and the pulmonary artery markedly heightens the risk of myocardial ischemia, arrhythmia, and sudden death. Symptomatic patients often exhibit a longer intramural course of the coronary artery, which may necessitate earlier intervention or influence the choice of surgical repair method. Surgical intervention is advocated for patients with this anomaly, even in the absence of symptoms. For anomalous aortic origin of a coronary artery from the opposite sinus of Valsalva with an intramural course, coronary unroofing is the preferred revascularization procedure. This report presents a case of AOLCA originating from the right sinus of Valsalva, treated surgically using the unroofing technique for the aortic intramural segment of the anomalous coronary artery traversing between the great vessels. The unroofing technique is recommended for treating AOLCA with an extensive intramural course that does not involve the commissure.

Peeling a giant ileal lipoma with endoscopic unroofing and submucosal dissection

Lipoma is relatively common in the colon but is less often in the small intestine. Most lipomas are incidentally detected at endoscopy and are usually small and asymptomatic. However, some of them can present with obstruction and/or intussusceptions. Surgical resection is commonly recommended to remove such significant lipomas with a limited pedicle and larger than 2 cm in size, as endoscopic resection may result in unfavorable complications such as intestinal perforations. We report a case of 62-year-old man presenting with hematochezia. Colonoscopy showed a submucosal tumor, about 50 mm in size, in the terminal ileum. A clinical diagnosis of lipoma was established based on the findings of colonoscopy and abdominal computed tomography (CT). As the patient complained of hematochezia and mild iron deficiency anemia associated with repeated tumor prolapse, we decided to remove his lipoma. Consequently, the lesion was completely removed en bloc . Although abdominal CT immediately after removal of the lesion showed a small amount of free air, conservative treatment was successfully carried out for the perforation. Histologically, the removed lesion was a lipoma.

Clinical outcomes of transperitoneal laparoscopic unroofing and fenestration under seminal vesiculoscopy for seminal vesicle cysts

Symptomatic seminal vesicle cysts （SVCs）, especially those of a large size, can be removed by surgical treatments. Currently, open surgeries for SVC are rarely performed due to their extensive surgical trauma, and minimally invasive surgical therapies for treating seminal vesicle cysts are still in the early stages. In addition, relevant studies are mostly confined to case reports. In this study, we retrospectively reviewed 53 patients who had received transperitoneal laparoscopic unroofing or fenestration under seminal vesiculoscopy for SVC in our institution. Both surgeries decreased the cyst volume to a significant extent; however, according to the remnant lesion size after rechecking images, seminal vesiculoscopic fenestration tended to have a higher recurrence than laparoscopic unroofing. Regarding complications, two individuals in the laparoscopic unroofing group experienced ureteral injury and rectal injury, while patients in the fenestration group only had temporary hemospermia, which indicates that fenestration surgery tends to have less severe complications than laparoscopic unroofing. There was no solid evidence confirming semen improvement after these surgical therapies in our study. Future studies with a prospective design, larger sample size, and longer follow-up period are required to verify and further explore our findings.

Unroofing around Qaidam Basin of northern Tibet at 30 Ma: constraints from ^(40)Ar/^(39)Ar and FT thermochronology on granitoids

An 40Ar/39Ar and fission track thermochronological study has been carried out on three suites of granitoids collected along the northern and southern edges of the Qaidam Basin to better constrain the mechanisms accommodating the India-Asia collision around the Qaidam Basin (northern Tibet), in order to understand the evolution of the entire deformation area. Mica and K-feldspar have been analyzed and the cooling histories of the latter have been modeled. The cooling histories based upon K-feldspar modeling and fission track ages show that samples simultaneously recorded an important cooling event (7.5-10.7℃/Ma) around 30 Ma, which is thought to reflect an increase of denudation rate related to the tectonic activity in this area associated with uplift suggesting significant crustal thickening starting around 30 Ma in this area. The estimated sedimentation rate in the Qaidam Basin, the propagation rate along the Altyn Tagh fault and field observations support this deduction.

Provenance of upper Permian-lowermost Triassic sandstones, Wutonggou low-order cycle, Bogda Mountains, NW China:implications on the unroofing history of the Eastern North Tianshan Suture

This study investigates the provenance of sedimentary rocks in Bogda Mountains, NW China, and reconstructs the lithology and unroofing history of the Eastern North Tianshan Suture. Petrographic point counting data of sandstones and compositions of conglomerates of upper Permian-lowermost Triassic Wutonggou low-order cycle from Zhaobishan, North Tarlong, Taodonggou, and Dalongkou sections in the southern and northern foothills of Bogda Mountains were used to interpret the temporal and spatial variations of lithology of the Eastern North Tianshan Suture, which is the sediment source area. Three compositional trends were identified. A trend of upwardincreasing quartz content and granitic pebbles in Zhaobishan section suggests a change from the undissected volcanic arc, accretionary wedge and trench setting to predominantly transitional volcanic arc and subordinate accretionary wedge and trench, in the eastern part of the Eastern North Tianshan Suture. In North Tarlong and Taodonggou sections, however, the lithic content decreases and the contents of quartz and granitic pebbles increase up sections. These trends indicate that the western part of the Eastern North Tianshan Suture changed from an undissected volcanic arc to the transitional volcanic arc, accretionary wedge and trench. No clear trend in the lithic-rich sandstones of the Dalongkou section indicates that sediments were derived from the undissected volcanic arc in the Eastern North Tianshan Suture and local rift shoulders. Compositional variations of studied rocks suggest that the Eastern North Tianshan Suture was an amalgamated complex with great spatial and temporal heterogeneities in lithology and experienced persistent unroofing during late Permian-earliest Triassic. This study reconstructs a key element of the Chinese Tianshan Suture and serves as an example to understand the unroofing processes of ancient sutures.

Clinical course of suspected small gastrointestinal stromal tumors in the stomach

BACKGROUND Gastric subepithelial lesions are frequently encountered during endoscopic examinations,and the majority of them are small and asymptomatic.Among these lesions,gastrointestinal stromal tumors(GISTs)are the major concern for patients and clinicians owing to their malignant potentials.Although previous guidelines suggested periodic surveillance for such small(≤20 mm)lesions,several patients and clinicians have still requested or prescribed repeated examinations or radical resection,posing extra medical burdens and risks.AIM To describe the clinical course of suspected small gastric GISTs and provide further evidence for surveillance strategy for tumor therapy.METHODS This single-center,retrospective study was conducted at West China Hospital,Sichuan University.Consecutive patients with suspected small gastric GISTs were reviewed from November 2004 to November 2018.GIST was suspected according to endoscopic ultrasonography features:hypoechoic lesions from muscularis propria or muscularis mucosa.Eligible patients with suspected small(≤20 mm)GISTs were included for analysis.Patients’demographic data,lesions’characteristics,and follow-up medical records were collected.RESULTS A total of 383 patients(male/female,121/262;mean age,54 years)with 410 suspected small gastric GISTs(1 lesion in 362 patients,2 lesions in 16,3 lesions in4,and 4 lesions in 1)were included for analysis.The most common location was gastric fundus(56.6%),followed by body(29.0%),cardia(12.2%),and antrum(2.2%).After a median follow-up of 28 mo(interquartile range,16-48;range,3-156),402 lesions(98.0%)showed no changes in size,and size of 8 lesions(2.0%)was increased(mean increment,10 mm).Of the 8 lesions with size increment,endoscopic or surgical resection was performed in 6 patients(5 GISTs and 1 leiomyoma).For other 2 remaining patients,unroofing biopsy or endoscopic ultrasound-guided fine-needle aspiration was carried out(2 GISTs),while no further change in size was noted over a period of 62-64 mo.CONCLUSION The majority of suspected small(≤20 mm)gastric GISTs had no size increment during follow-up.Regular endoscopic follow-up without pathological diagnosis may be highly helpful for such small gastric subepithelial lesions.

Midline Prostatic Cysts Presenting with Chronic Prostatitis or Secondary Infertility and Minimally Invasive Treatment: Endoscopic or Laparoscopic Approach?

Backgrounds: Surgical interventions especially minimally invasive treatments are recommended for symptomatic midline prostatic cysts. The endoscopic unroofing of cysts close to urethra is easy and simple, but it has little effect on the large cysts and cysts lying deeply, in contrast with the laparoscopic approach. Therefore, the selection of minimally invasive therapeutic approaches is important. The aim of this study is to describe our experience in the diagnosis and selection of minimally invasive treatment for midline prostatic cyst. Methods: 15 cases of midline prostatic cyst were studied.10 cases presented with prostatitis-like symptoms, 1 with dysuria and acute urinary retention, 3 with secondary infertility and the rest 1 with hemospermia. 6 patients presented with small cysts (≤2 cm × 2 cm) close to urethra and underwent transurethral unroofing. The other 9 patients with large cysts (>2 cm × 2 cm) or cysts lying closely behind the prostate received the laparoscopic excision. Results: The average duration of transurethral unroofing and laparoscopic excision was 39 mins and 118 mins respectively, whereas the average time of hospitalization was 2.7 days and 4.5 days respectively. After a follow-up of 21 months, all cases were treated successfully without complications and recurrence. Their prostatitis-like symptoms disappeared, and the three patients presented with secondary infertility achieved conception within one year after the operation. Conclusions: A midline prostatic cyst can present with chronic prostatitis-like symptoms and secondary infertility. It can be cured by minimally invasive treatments, but these procedures should be carefully selected according to the size and location of the cyst.

SURGICAL TREATMENT OF UNROOFED CORONARY SINUS SYNDROME

Unroofed coronary sinus syndrome (UCSS) is uncommon. In more than 3170 congenital heart defect patients undergoing open-heart surgery at Xinhua Hospital between 1973 and 1988 there were 6 cases with an incidence rate of approximately 0.18%. Two patients belonged to the complete type while 4 patients to the partial type. The pericardial patch treated by 0.5% glutaraldehyde was sewn into the right atrium so as to receive the left superior vena cava (LSVC) drainage. Neither residural shunt nor obstruction was detected by two-dimensional echocardiography in the follow-up.

Mesozoic basin evolution and tectonic mechanism in Yanshan, China

The Mesozoic basins in Yanshan, China underwent several important tectonic transformations, including changes from a pre-Late Triassic marginal cratonic basin to a Late Triassic-Late Jurassic flexural basin and then to a late Late Jurassic-Early Cretaceous rift basin. In response to two violent intraplate deformation at Late Triassic and Late Jurassic, coarse fluvial depositional systems in Xingshikou and Tuchengzi Formations were deposited in front of thrust belts. Controlled by transform and extension faulting, fan deltas and lacustrine systems were deposited in Early Cretaceous basins. The composition of clastic debris in Late Triassic and Late Jurassic flexural basins respectively represents unroofing processes from Proterozoic to Archean and from early deposited, overlying pyroclastic rocks to basement rocks in provenance areas. Restored protobasins were gradually migrated toward nearly NEE to EW-trending from Early Jurassic to early Late Jurassic. The Early Cretaceous basins with a NNE-trending crossed over early-formed basins. The Early-Late Jurassic and Early Cretaceous basins were respectively controlled by different tectonic mechanisms.