[NK@Hyd]

Originally Posted by abhishek_bmw

@ NK@Hyd :Welcome.
HAVE YOUR T.T AS SOON AS POSSIBLE.YOU ARE IN DANGER.GET THE T.T. BEFORE CONSULTING SURGEON (to save time).

YIKES! I rushed off to get the TT done as soon as reading your post.
Later went to a general surgeon who suggested a few tablets and recommended getting the dressing redone every alternate day.

Thanks again, Abhishek.

[abhishek_bmw]

@NK@Hyd : you are welcome again.

We surgeons really love " like you minded " patients
Obviously,you will get well soon

[CaliAtenza]

Originally Posted by abhishek_bmw

Please say me the full form of Physio-Physiotherapy or Physical medicine or Physiology?

Its nice idea to start,but as a Departmental Head,Department of General Surgery of a Govt. Medical college,I will say,it is just a luxary to spend money for such project.If some person/NGO has to spend money,please contribute to any Medical college for the poor Thallasemic childs or those with cancers.
Yes,I also get irritated,when I see a poor mother is crying for that reason they could not bear the cost of desferrioxamine for a thallasemic child any more,simply,because(many will not beleive) she has only Rs.10 for that day as their total savings upto that date,at the same time,some patient party (better economic condition) is demanding to get good treatment by purchasing costly drugs (it is very difficult to nail in to ones brain that costly medicine does not mean the best available medicine-it is not like engine oil or something like that).
I really love my poor hospital patients,because,they do what I advice,dont hesitate about it-because,they beleive,I or others from my unit is doing the level best for their treatment,also the return of love I get them from just speaking softly with them is much much precious to me than doing the surgery for a megalomaniac rich's remonaration outside who thinks that health is a product,and he can get good product by paying much more and from the best showroom.
But,beating or physical abuse is other things-it is not prevalent in the medical colleges of West Bengal,at least,I have not seen.
And unfortunately,this patient doctor relationship gap will be more and more and finally,the health will cost you so much that you have to go for expensive health insurances like US.

oops, sorry im used to shortening everything. It was the physiology dept . You have a great attitude, seriously. From your post i can see that your patients really trust you and are intent on following your instructions and not stopping treatment midway, etc. I think at least in my college, many of the docs think that poor people are dumb, dont understand whats going on, etc, etc. They obviously do, but it has to be explained to them in a simple way. Thats what i try to do with every patient i interact with in the wards (during an exam, or simply during daily classes, etc). The patient-doctor relationship is the foundation of treatment...if its not there, then whats the point of giving treatment. Yes, more expensive drugs do not neccesarily equal better results but this tends to be more valid in countries such as india. This wouldnt fly back in the states due to HMOs, patient perception, insurance, etc.

[condor]

All doctors here : Need your advice regarding the PCNL procedure for removal of a large staghorn calculi.

Friend's got a large staghorn (phospate) calculi. He's been suggested the PCNL procedure to remove this. He has been under treatment to control his BP / sugar (which started over the last few months), and is now getting ready for his operation. Can he go for this ? Where can we find more information regarding this procedure ?

He's also been suggested to get this done in Fortis (hospital) in Seshadripuram. Need feedback on this hospital, esp for this procedure.

TIA !

[KITE RUNNER]

Originally Posted by condor

All doctors here : Need your advice regarding the PCNL procedure for removal of a large staghorn calculi.

Friend's got a large staghorn (phospate) calculi. He's been suggested the PCNL procedure to remove this. He has been under treatment to control his BP / sugar (which started over the last few months), and is now getting ready for his operation. Can he go for this ? Where can we find more information regarding this procedure ?

He's also been suggested to get this done in Fortis (hospital) in Seshadripuram. Need feedback on this hospital, esp for this procedure.

TIA !

If it is a large calcus, your friend definitely needs to go for PCNL as a semi emergency procedure. I think he an undergo it after optimising his BP & Blood sugar levels. Better to have a cardiological evaluation prior to undergoing anaesthesia and surgery as he is a hypertensive & diabetic.

I dont have much idea about the hospital you have mentioned, some one else will enlighten you.

BTW, I am an anaesthesiologist presently working in Muscat.

[abhishek_bmw]

First of all thanks CaliAtenza for understanding me.You know,ethically I/we cant say anything about my fellow docs.But,I will always suggest you,go for the doctor who is not too busy and listens your words carefully.It is a patient's homework to find the right doctor for him/her.

condor
KITE RUNNER has already given his opinion rightly.

Yes,I completely agree with him.
And I know nothing about the hospital you told.
For " Can he go for this ? Where can we find more information regarding this procedure ?"

My answer is, always ask your Surgeon,because you have the right to ask,right to know.If he denies in the ground that "you will not understand",it is better to look for he/she who can quench your thirst.Better to avoid "package" (its applicable not only to you but for all),instead,its good to consult a Surgeon in chamber directly and let him to arrange (I say this remembering of West-Bengal,but,is applicable almost nation wide)-he knows better than a general people which hospital has the best intruments,O.T. setup,post operative care for that particular case.Also,you(and the patient) are having a direct relation with the surgeon.This is called pre operative councelling.

I am writing today about your question, What is PCNL?

Just wait for few minutes,you will get the information right here.

[abhishek_bmw]

Percutaneous Nephrolithotomy (PCNL)

Indications for Percutaneous Nephrolithotomy:

• Calculi >2–3cm
• Staghorn calculi
• Complex calculi

(I am writting is very simply,there are many indications actually)

Although significantly less morbid than open surgery, percutaneous nephrolithotomy
(PCNL) is still the most invasive approach to urinary lithiasis when compared to ureteroscopy or extracorporeal shockwave lithotripsy (SWL). Consequently, this technique is generally reserved for specific needs. Bulky stones greater than 2 cm are frequently best treated with a percutaneous approach to minimize repeat treatments and trauma to the kidney. Complete stone clearance can also avoid the risk of steinstrasse if the ureter is unable to accommodate a large bolus of stone debris. These concerns are especially true of staghorn calculi or complex stones that occupy multiple calyces. Some stones are simply too dense or organic in nature to respond well to SWL and may be best served with an initial percutaneous approach. Calcium oxalate monohydrate calculi are noted to be the densest stones and often experience incomplete fragmentation.Cystine stones are also resistant to shockwave energy, likely owing to their organic origin and their tight crystalline formation. Additionally, residual cystine fragments can
easily act as “seed calculi” leaving the patient with multiple smaller stones rather than their initial large calculus. In light of these difficulties, many authors advocate a percutaneous approach for cystine stones even less than 2 cm in order to achieve complete stone clearance .
Some stones smaller than 2 cm may be best treated with a percutaneous approach if they reside within difficult anatomic locations. Calyceal divertula have a tight neck that will not allow the easy passage of stone debris. If the diverticulum is inaccessible from a retrograde ureteroscopic approach, then percutaneous access can clear any stone material and allow either destruction of the urothelial lining or creation of a wider infundibular orifice (or both). Owing to obvious anatomic constraints, this technique is best reserved for posterior calyces.
Stones within a lower pole calyx may have a difficult time clearing out of this region into the pelvis and down the ureter following SWL. A well-controlled large randomized trial has demonstrated that percutaneous nephrolithotomy is superior to SWL for lower
pole calculi. The difference was particularly dramatic for stones larger than 1 cm.

Contraindications for Percutaneous Nephrolithotomy

• Uncontrolled coagulopathy
• Ectopic kidney
• Active urinary tract infection
• Fusion anomalies
• Severe dysmorphism
• Morbid obesity

Special note for Staghorn Calculi

Staghorn calculi (either partial or complete) represent a unique challenge for the endourologist . The sheer bulk of the stone burden and the complex branched anatomy of the collecting system require careful planning regarding access and plurality
of access tracts. Additionally, these calculi are typically associated with an infectious etiology. Antibiotics are never able to completely penetrate the interstices of a complex stone, running the risk of a release of bacteria and endotoxin during stone ablation.
Despite these warnings, however, PCNL remains the standard of care for staghorn calculi,replacing anatrophic nephrolithotomy and other open approaches.
Results from many authors have demonstrated the superiority of PCNL over SWL alone. In 1994, the evidence was compelling enough to prompt the AUA Guidelines Committee to recommend PCNL as first line therapy, often combined with SWL to ablate calculi in difficult to reach calyces.Second-look PCNL may also be added to the end of this regimen to “clean-up” any residual fragments left after the shockwave lithotripsy. This technique has been dubbed “sandwich therapy.” Stone-free rates tend to range from 70 to 100% with this approach, with acceptable complication rates. Randomized trials have been performed comparing a combination of PCNL with SWL vs SWL alone. One particularly noteworthy analysis from Meretyk et al. demonstrated a stone-free rate of 74% with combination therapy vs 22% with SWL alone . Nearly half of all shockwave lithotripsy patients had septic episodes whereas the combination patients had an 8% rate. Finally, 26% of the monotherapy patients required ancillary procedures over 6 mo vs 4% of the combination patients over one additional month.
More recently, some centers have moved away from a sandwich technique, relying on aggressive PCNL at the first sitting. This may require the use of a supracostal access or a multi-tract access at the first procedure . These same approaches may remove so much stone burden that there is no longer a need for the “meat” portion of the sandwich (SWL) or the second-look PCNL. Others have moved away from the removal of all residual fragments, electing to treat small remnants with aggressive medical therapy. This therapy should be directed by the information gained from a complete metabolic evaluation and/or stone analysis.Anatomic abnormalities (UPJ obstruction, caliceal diverticulum) or genetic predisposition (cystinuria) that played a role in the formation of the original calculus should be addressed if possible. Residual fragments should be small and expected to have a reasonable chance of spontaneous passage. The presence of infected fragments is generally frowned on as these can easily act as “seed” calculi and reinfect the patient’s urinary tract.


Complications

The list of potential complications from PCNL is long and varied. The percutaneous access must traverse multiple tissue layers and planes, including skin, subcutaneous fat,muscle, fascia, perirenal fat, and parenchyma. In addition, difficulties can arise from the location of the access tract, trauma to the renal parenchyma, injury to the collecting system, hemorrhage, fluid shifts or even the physiologic stress of surgery. Rarely, other structures may be abnormally displaced and are at risk of inadvertent damage. An incomplete list includes: colon, small bowel, spleen, liver, gallbladder, and the great vessels.Transfusion rates generally run in the low single digits, but have been reported as high as 50% in some older series. Hemorrhage can arise from the parenchyma of the kidney,from branches of the renal vasculature or from the torn edges of the urothelium. As mentioned in previous sections, increasing the number of access tracts will increase the need for transfusion. A rare but impressive source of postoperative hemorrhage is from the formation of an arteriovenous fistula along the percutaneous tract. These patients can present with massive hematuria and usually require embolization or even nephrectomy.
Urinary tract infection and sepsis are always a risk during this procedure owing to colonization of the urine and sequestration of bacteria within the calculi. Careful attention to preoperative urine cultures and the liberal use of perioperative antibiotics can minimize the risk of overwhelming infections. Patients with known or suspected struvite calculi should be treated with extra care. Rubenstein et al. have demonstrated that even patients with neurogenic bladders and known urine colonization can be safely treated with this technique. These authors have advocated the placement of the nephrostomy access one day before the scheduled procedure to allow time for observation and the early treatment of signs of systemic infection.
Colonic perforation has been reported from multiple authors and sites . This particular complication is thought to be caused by the presence of a retrorenal colon or caused by the placement of the access tract in too lateral a location. Very thin patients may be at higher risk, as are females and left-sided procedures. Surgeons may not notice the problem until after the case has been completed, because the nephrostomy access sheath will likely tamponade the defect and “bypass” the injury. Patients may develop significant fevers or abdominal pain in the postoperative period. Feculent material may be visible in the urine, the urine leak may cause watery diarrhea or stool may exude from the nephrostomy tract. Most authors recommend the placement of a ureteral catheter or stent to attempt to divert the urine down towards the bladder and away from the nephrocolonic fistula. In addition, the nephrostomy should be pulled back into the colonto allow the fistula to heal spontaneously. Colon resection is always a distinct possibility but is usually avoided. Intrathoracic complications can arise from upper pole or supracostal access tracts when the pleura are violated. Pneumothorax, hydrothorax, or hemothorax have been reported. Intraoperative manifestations may include difficulty with mechanical ventilation, poor oxygenation, hypotension or cardiovascular collapse. The fact that the patient is usually in a prone position for this procedure can make recognition and management of a severe intrathoracic complication quite challenging for the anesthesiologist. Most of these patients can be managed with the placement of a draining chest tube, which may be placed intraoperatively if the complication is recognized during the procedure.Intraoperative fluoroscopy can be used to diagnose the condition with poor penetration of the ipsilateral lung field or for the correct interpretation of a collapsed lobe.

Your friend has Both Hypertension and Diabetes,definitely there is additional risk for having associated nephropathty.He is also at risk for infection.

[jassi]

docs - i've been having pain when swallowing for the last 3 days. No other symptoms of cold, cough, fever, etc, just pain when swallowing anything.
This has been there for 3 days now and after lots of hot fluids, my throat is now better, there is less pain when swallowing, but now it continuously feels like something is stuck up my throat.
I sneeze once or twice a day and boy is that painful (10times worse than the swallowing pain). No continuous pain though it goes after a few seconds.

I am not sure but 3 days back I was staying up few nights for meetings with US folks, and had cold milk with muesli at 3am, maybe that caused it.

Should i be bothered, is this some infection or did i swallow a staple or something in that muesli

Thanks for any advice!

[abhishek_bmw]

Jassi,its impossible for me to diagnose without clinical examinations (=seeing you in real) and two xray plates,because there are atleast eight disease condition which can cause you this.Also I dont know your age,sex,habbits of drinking,smoking etc.
Its better if you consult an ENT specialist,or an Esophagologist (If you reside in US or UK).
If there were infection,it could cause rise in temperature,so its ruled out.
I think you have developed a neurological condition of Esophagus,but nothing should be said without an examination.

[james]

Docs, I have been suffering from Gout ever since i was 14. Medications started at 18 i.e 5yrs ago. I keep off the red meat and anything high in proteins. I had a bad attack last week. I as wondering if there some kind of a spray/gcream that i could put on my toe joint to reduce the swelling/pain? I had been taking Zyric-100 3 times a day and havent had an attack for over a year.
The pain at night is just horrible and all i can do is put my foot in hot water.
Advice would be greatly appreciated.
Thank you.

[jassi]

Originally Posted by abhishek_bmw

Jassi,its impossible for me to diagnose without clinical examinations (=seeing you in real) and two xray plates,because there are atleast eight disease condition which can cause you this.Also I dont know your age,sex,habbits of drinking,smoking etc.
Its better if you consult an ENT specialist,or an Esophagologist (If you reside in US or UK).
If there were infection,it could cause rise in temperature,so its ruled out.
I think you have developed a neurological condition of Esophagus,but nothing should be said without an examination.

Hey Abhishek - I understand, such things need a thorough diagnosis to conclude on anything. I did read this Swallowing Disorders - Red River ENT, Alexandria, LA - Patient Education and get the fact that is complicated to diagnose swallowing problems, but after 5 days I have almost 0 pain when swallowing. A very little pain when I sneeze or yawn, and yeah some phlegm in the throat. Maybe it was swelling of the lymph glands or something, but I am going to watch out and if the pain returns will go to an ENT and get it checked. Thanks for the advice.

[Thad E Ginathom]

abhishek_bmw; we call it ENT in UK too!

James... I too was diagnosed as sufferring from gout as a teenager. They said that it was so rare in one so young that it took them ages to think of looking for it as the explanation for my stiff finger joints. Interesting to hear of another young sufferer.

I've been luckier though, in that it largely cleared up during my twenties. It is very occasional now, giving stiffness (the feeling is like the spring motion of a light switch instead of smooth motion of the fingers) but not really pain.

The last time I talked to a doc about this, she told me that there wasn't a cure, and the only thing was to take daily medication, and if it didn't bother me much, what was the point?

Sorry to hear about your pain. I have been lucky.

[srishiva]

Originally Posted by jassi

Hey Abhishek - I understand, such things need a thorough diagnosis to conclude on anything. I did read this Swallowing Disorders - Red River ENT, Alexandria, LA - Patient Education and get the fact that is complicated to diagnose swallowing problems, but after 5 days I have almost 0 pain when swallowing. A very little pain when I sneeze or yawn, and yeah some phlegm in the throat. Maybe it was swelling of the lymph glands or something, but I am going to watch out and if the pain returns will go to an ENT and get it checked. Thanks for the advice.

I get throat infections now and then and it matches some of your symptoms. Swallowing is not really a problem though. Unless its severe cold along with it, I dont get fever. So could it be some minor infection?

[james]

Thad, Its quite rare to get Gout as a teenager. The Docs here just couldnt wrap their heads around the fact that a 14yr old has severe gout.
In a way im quite happy i found someone who has been through what im going through now and is living a happy life. The stories ive heard from the docs are quite frighting to say the least! Your reply surely brought some peace to my mind!

[jassi]

Originally Posted by srishiva

I get throat infections now and then and it matches some of your symptoms. Swallowing is not really a problem though. Unless its severe cold along with it, I dont get fever. So could it be some minor infection?

maybe a minor infection - cos today its almost gone - no pain when i had my once a day bout of sneeze or when yawning. Little feeling of phlegm but i guess that is seasonal here in bangy, I was scared thinking I swallowed something like a stapler pin in my muesli or cornflakes, you never know these days