Living donor hepatectomy (LDH) is a technically demanding procedure that is an alternative for providing livers for transplantation. Unlike liver resections for other pathology, LDH requires ...preservation of the major vessels and biliary tree. This study was performed to determine if current technology can be integrated to perform laparoscopic LDH.
Six adult sheep underwent laparoscopic LDH of the left lateral segment under general anesthesia. Instruments utilized included standard dissecting instruments, ultrasound, ultrasonic dissectors, CUSA, the TissueLink Floating Ball, and endoscopic staplers.
LDH-harvested liver grafts were 44% of whole liver weight. Estimated blood loss was 300 cc. Warm ischemia time was 5-7 min. Grafts were delivered through 18-cm abdominal wounds. Major vessels and biliary anatomy were positively identified in the grafts.
Laparoscopic LDH can be performed with available technology. Theoretical advantages include reduced liver manipulation and smaller wound size.
There is mounting concern that internal hernia formation after laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity remains unrecognized until complications develop. In this report we ...present our experience with this complication. Out of 100 patients who underwent LRYGB we identified five patients who were diagnosed with postoperative internal hernia formation. The medical records and operative details of these patients were reviewed. Of the five patients four were female and the average age was 36 years (range 30–43). All Roux limbs were placed in a retrocolic position. The average time interval to presentation was 104 days (range 4–305). All patients had abdominal pain and four patients experienced vomiting. One patient had obstipation. Only one patient had fever (38.1° C) and the highest white cell count was 14,500. The average loss in body-mass index was 5.21 kg/m2 (range 2.5–14.8). Plain abdominal films revealed dilated bowel in the upper abdomen in three patients. Contrast bowel series was diagnostic in only one patient. One patient had a CT scan, which was diagnostic of small bowel obstruction. All patients underwent operative reduction of the internal hernia; two of these were completed laparoscopically. All hernias had occurred at the mesocolic window and were caused by sutures that had pulled through tissue at the dorsal and lateral aspect of the initial repair. One patient had a nonviable segment of small bowel. There were no deaths. Patients who undergo LRYGB are at a 5 per cent risk for developing small bowel obstruction secondary to internal hernia formation at the mesocolic window. Clinical evaluation and traditional study modalities may not be effective diagnostic tools. A high index of suspicion and low threshold to explore these patients may be the best way to avoid serious sequelae. Modification of operative techniques may reduce the occurrence of internal hernia formation.
QSARs based upon the logarithm of the octanol-water partition coefficient, logP, and energy of the lowest unoccupied molecular orbital, E
LUMO
were developed to model the toxicity of aliphatic ...compounds to the marine bacterium Vibrio fischeri. Statistically robust, hydrophobic-dependent QSARs were found for chloroalcohols and haloacetonitriles. Modelling of the toxicity of the haloesters and the diones required the use of terms to describe both hydrophobicity and electrophilicity. The differences in intercepts, slopes, and fit of these models suggest different electrophilic mechanisms occur between classes, as well as within the diones and haloesters. In order to model globally the toxicity of aliphatic compounds to V. fischeri, all the data determined in this study were combined with those determined previously for alkanones, alkanals, and alkenals. A highly predictive two-parameter QSAR pT
15
= 0.760(log P) −0.625(E
LUMO
) −0.466; n = 63, s = 0.462, r
2
= 0.846, F = 171, Pr > F = 0.0001 was developed for the combined data that models across classes and is independent of mechanisms of action. The toxicity of these compounds to V. fischeri compares well to the toxicity (50% population growth inhibition) to the ciliate Tetrahymena pyriformis (r
2
= 0.850).
One criticism of laparoscopic ventral hernia repair (LVH) is that the rectus muscles are not re-approximated to the midline, and the effect of LVH repair on the fascial edges is unclear. Progressive ...migration of the fascial edges toward the midline has been observed anecdotally, but objective evidence remains limited. The purpose of this study is to observe the effect of LVH repair on the rectus abdominus fascia.
Patients undergoing LVH repair with defects > 10 cm in horizontal diameter were identified prospectively and enrolled. All were repaired laparoscopically with intraperitoneal placement of mesh (DualMesh, W.L. Gore and Associates) using a standard approach. Radio-opaque clips were placed at the fascial edges intraoperatively to mark the defect, and plain abdominal films were taken postoperatively (Time 1) to establish the initial distance between clips (measured in cm). A subsequent follow-up film was taken (Time 2), and the difference in clip distance per patient was recorded. Results were analyzed using a chi-squared test.
Twelve patients qualified for analysis and their results were compared. Mean fascial defect size was 15.1 cm (range 8.3-22.0). With respect to change in clip distance from Times 1 to 2, three events were observed: (1) Diminished (i.e. medialized), (2) Enlarged, or (3) No Change. Ten patients (83%) medialized, one patient enlarged, and one patient showed no change (chi2 (d.f. = 2) 9.17, p < 0.0023).
Medialization of the rectus abdominus fascia occurs in the majority of patients undergoing LVH repair. Causes for this phenomenon are unclear: however eliminating intrabdominal pressure with intraperitoneal mesh placement likely plays a role.
There are few prospective studies that document the histologic follow-up after antireflux surgery in patients with Barrett's esophagus, as defined by the recently standardized criteria. We report the ...clinical, endoscopic, and histologic results of patients with Barrett's esophagus followed postoperatively for at least 2 years. Diagnosis of Barrett's esophagus required preoperative endoscopic evidence of columnar-lined epithelium in the esophagus and a biopsy demonstrating specialized intestinal metaplasia, which stains positively with Alcian blue stain. Between April 1993 and November 1998, a total of 104 patients meeting these criteria underwent fundoplication (laparoscopic n = 84 or open n = 6 nissen, laparoscopic Toupet n = 11, laparoscopic Collis-Nissen n = 1, Collins-Toupet n = 1 or open Dor n = 1). Short-segment Barrett's esophagus (length of intestinal metaplasia <3 cm) was found preoperatively in 34% and low-grade dysplasia in 4% of patients. All patients were contacted yearly by mail, phone, or clinic visit. At a mean follow-up of 4.6 years (range 2 to 7.5 years), 81% of patients had stopped taking antisecretory medications and 97% were satisfied with the results of their operations. Eight patients have undergone reoperation for recurrence of symptoms. Two patients have died and two were excluded from endoscopic biopsy because of portal hypertension. Sixty-six patients complied with the surveillance protocol, and their histologic results were returned to our center. Symptomatic follow-up of the 34 patients who refused surveillance esophagogastro and duodenoscopy revealed two patients who were taking medication for reflux symptoms. None of the patients have developed high-grade dysplasia or esophageal carcinoma during surveillance endoscopy (337 total patient-years of follow-up). The incidence of regression of intestinal metaplasia to cardiac-fundic–type metaplasia after successful antireflux surgery is greater than previously reported. We suspect that this is a result of longer follow-up and the inclusion of patients with short-segment Barrett's esophagus. A substantial number of patients with Barrett's esophagus who are asymptomatic after antireflux surgery refuse surveillance endoscopy. (
J Gastrointest Surg 2002;6:532–539)
In 2003, The John A. Hartford Foundation Institute for Geriatric Nursing, New York University Division of Nursing, convened an expert panel to explore the potential for developing recommendations for ...the caseloads of advanced practice nurses (APNs) in nursing homes and to provide substantive and detailed strategies to strengthen the use of APNs in nursing homes. The panel, consisting of nationally recognized experts in geriatric practice, education, research, public policy, and long‐term care, developed six recommendations related to caseloads for APNs in nursing homes. The recommendations address educational preparation of APNs; average reimbursable APN visits per day; factors affecting APNs caseload parameters, including provider characteristics, practice models, resident acuity, and facility factors; changes in Medicare reimbursement to acknowledge nonbillable time spent in resident care; and technical assistance to promote a climate conducive to APN practice in nursing homes. Detailed research findings and clinical expertise underpin each recommendation. These recommendations provide practitioners, payers, regulators, and consumers with a rationale and details of current advanced practice nursing models and caseload parameters, preferred geriatric education, reimbursement strategies, and a range of technical assistance necessary to strengthen, enhance, and increase APNs' participation in the care of nursing home residents.
We compare two observations of gamma-rays before, during, and after lightning flashes initiated by upward leaders from a tower during low-altitude winter thunderstorms on the western coast of Honshu, ...Japan. While the two leaders appear similar, one produced a terrestrial gamma-ray flash (TGF) so bright that it paralyzed the gamma-ray detectors while it was occurring, and could be observed only via the weaker flux of neutrons created in its wake, while the other produced no detectable TGF gamma-rays at all. The ratio between the indirectly derived gamma-ray fluence for the TGF and the 95% confidence gamma-ray upper limit for the gamma-ray quiet flash is a factor of \(1\times10^7\). With the only two observations of this type providing such dramatically different results -- a TGF probably as bright as those seen from space and a powerful upper limit -- we recognize that weak, sub-luminous TGFs in this situation are probably not common, and we quantify this conclusion. While the gamma-ray quiet flash appeared to have a faster leader and more powerful initial continuous current pulse than the flash that produced a TGF, the TGF-producing flash occurred during a weak gamma-ray "glow", while the gamma-ray quiet flash did not, implying a higher electric field aloft when the TGF was produced. We suggest that the field in the high-field region approached by a leader may be more important for whether a TGF is produced than the characteristics of the leader itself.
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