Laparoscopic liver resection: Wedge resections to living donor hepatectomy,are we heading in the right direction?

Despite inception over 15 years ago and over 3000 completed procedures, laparoscopic liver resection has remained mainly in the domain of selected centers and enthusiasts. Requirement of extensive open liver resection(OLR) experience, in-depth understanding of anatomy and considerable laparoscopic technical expertise may have delayed wide application. However healthy scepticism of its actual benefits and presence of a potential publication bias; concern about its safety and technical learning curve, are probably equally responsible. Given that a large proportion of our work, at least in transplantation is still OLR, we have attempted to provide an entirely unbiased, mature opinion of its pros and cons in the current invited review. We have dividedthis review into two sections as we believe they merit separate attention on technical and ethical grounds. The first part deals with laparoscopic liver resection(LLR) in patients who present with benign or malignant liver pathology, wherein we have discussed its overall outcomes; its feasibility based on type of pathology and type of resection and included a small section on application of LLR in special scenarios like cirrhosis. The second part deals with the laparoscopic living donor hepatectomy(LDH) experience to date, including its potential impact on transplantation in general. Donor safety, graft outcomes after LDH and criterion to select ideal donors for LLR are discussed. Within each section we have provided practical points to improve safety in LLR and attempted to reach reasonable recommendations on the utilization of LLR for units that wish to develop such a service.     

Cardiac abnormalities of Sudanese patients with Down’s syndrome and their short-term outcome

Background

Congential heart disease (CHD) is an important cause of morbidity and mortality in patients with Down’s syndrome (DS).

Methods

All patients with DS seen at the Sudan Heart Centre from July 2004 to November 2007 were included in the study. All patients were examined clinically and echocardiographically, and cardiac catheterisation was carried out in selected patients. All patients were prospectively followed up.

Results

In the study period, 1 566 patients were evaluated for heart disease. Of these, 80 patients with DS were identified (5%). Their ages ranged from 15 days to 18 years. Cardiac abnormalities included atrioventricular septal defect (AVSD) in 38 patients (48%), with the complete form in 25, a partial form in seven, AVSD with intact atrial septum in one, and complex AVSD in four patients. In one patient there was AVSD with right atrioventricular valve malformation with severe valve regurgitation and functional pulmonary atresia. The other main lesions were ventricular septal defect (VSD) in 19 patients (23%) and tetralogy of Fallot (TOF) in five (6%).Cardiac catheterisation was done in four patients with AVSD to measure pulmonary pressures and resistance, and in one patient with patent ductus arteriosus for device closure. Ten percent of the patients had Eisenmenger’s syndrome at the time of presentation. Only 15% of patients who were in need of surgery were operated on; all had an uneventful postoperative course and a good outcome at a mean follow-up period of one year

Conclusion

The pattern of CHD in Sudanese patients with DS was comparable with that in the literature, including the rare occurrence of AVSD with intact atrial septum. In addition, we described an unreported association with right atrioventricular valve malformation. Although there was a significant delay in diagnosis and surgery, surgical results and short-term follow up were good.     

THERAPEUTIC HYPERBARIC OXYGENATION AS AN ADJUNCT TO MULTIDRUG THERAPY IN HANSEN'S DISEASE

Hansen''s disease is a chronic infection caused by Mycobacterium leprae. Current therapy for this disease is with the WHO recommended Multi Drug Therapy (MDT) with DDS, rifampicin and clofazimine. Hyper Baric Oxygen Therapy (HBOT) has been used to treat many medical conditions including infections with a great deal of success. It''s efficacy on various species of mycobacteria and other bacteria have been studied in vitro and in vivo and it is found to be an effective antimicrobial agent under specified conditions. HBOT has been used to treat Hansen''s disease, including drug resistant lepromatous leprosy cases with good results. However there is a paucity of literature on this form of therapy. We have treated twenty cases of Hansen''s disease with HBOT prior to exhibiting MDT as per the WHO schedule. There has been a marked regression in skin signs especially decrease in erythema and flattening of raised lesions. This correlated well with the histopathological picture which showed a reduction in the inflammatory exudate.KEY WORDS: Hansen''s Disease, HBOT, Hyperbaric Oxygen, Leprosy, Therapy     

Molar furcation entrance and its relation to the width of curette blades used in periodontal mechanical therapy

Abstract: Aim:  The purpose of this research was to evaluate molar furcation entrances and the width of periodontal curette blades used in periodontal instrumentation.
Materials and methods:  One hundred extracted molars (50 upper and 50 lower) were analysed. The furcation entrances were measured using orthodontic wires of different predetermined diameters: 0.4, 0.5, 0.6, 0.7, 0.8 and 0.9 mm. McCall 17–18, Gracey 5–6 and Gracey 5–6 mini-five curette blades were measured at their anterior (AT), middle (MT) and posterior (PT) thirds by a single trained investigator, through the use of a digital caliper.
Results:  The results showed significant differences ( P  < 0.0001) in relation to furcation entrances. The buccal upper molar furcations showed the narrowest dimensions. In relation to the blade diameter, significant differences among the instruments were found for their MT and PT ( P  < 0.0001), but not for the AT ( P  = 0.183). Significant differences were found among curette manufacturers. Nineteen per cent of evaluated furcations presented entrances <0.60 mm and 75% of the blades at their AT presented width >0.60 mm.
Conclusions:  These findings demonstrated that some molar furcation entrances could not be adequately instrumented with the tested curettes. The use of other hand instruments, such as periodontal files, rotating instruments and ultrasonic devices should be taken into consideration during periodontal therapy.     

Interrater agreement in visual scoring of neonatal seizures based on majority voting on a web-based system: The Neoguard EEG database

Objective

To assess interrater agreement based on majority voting in visual scoring of neonatal seizures.

Management of Band Erosion with Omental Plugging: Case Series from a 5-Year Laparoscopic Gastric Banding Experience

Background  

Although reports on band erosion management after laparoscopic adjustable gastric banding (LAGB) agree that in most cases the affected band will need to be removed, there is no consensus on the technique of removal. We report a minimalistic, laparoscopic technique which is safe and avoids management delay.     

Recurrent renal cell cancer presenting as gastrointestinal bleed

We present an unusual case of renal cell cancer(RCC) which relapsed with duodenal metastasis and unveiled itself by gastrointestinal(GI) bleeding.An 80-year old Caucasian gentleman with history of renal cell cancer status post nephrectomy 11 mo previously,presented with syncope and melena.Computed tomography scan of the abdomen revealed heterogeneous soft tissue mass in the right nephrectomy bed invading the duodenum.Upper GI endoscopic biopsy confirmed the presence of recurrent renal cell cancer.However,due to extensive metastatic disease,the patient was placed on palliative chemotherapy as surgical options were ruled out.Our case report reiterates the fact that renal cell carcinoma can recur with gastrointestinal manifestations and,although a rarity,it should be considered in a patient with a history of malignancy who presents with these symptoms.     

The expanded programme on immunization: a lasting legacy of smallpox eradication

Since the mid-1970s, the widespread establishment and implementation of the Expanded Programme on Immunization (EPI) has led to remarkable achievements in controlling vaccine preventable diseases worldwide. Today, more children than ever are being reached with immunization; interruption of poliomyelitis transmission has occurred in most countries; mortality due to measles, tetanus, diphtheria and pertussis has been reduced to record low levels. In addition, increasing numbers of vaccines are being used for infants and older age persons, such as vaccines against hepatitis A and hepatitis B, Haemophilus influenzae type b, rotavirus, pneumococcus, meningococcus, human papilloma virus (HPV) and varicella. The design of EPI reflects in large part the experience accumulated during the implementation of the intensified campaign for smallpox eradication during the period 1966-1977. At that time, the existing health infrastructure and network was found inadequate to reach most individuals with community wide immunization programmes in most countries. Thus, efforts were made to train dedicated health personnel and allocate specific resources for programme coordination and implementation. With the establishment of EPI, there was a gradual shift in emphasis from vaccination campaign strategies using mobile teams to the delivery of immunization services as part of routine health services of health facilities. Both the campaign and the outreach strategies are nevertheless required to reach those segments of the population not reached by the routine health services and to accelerate the achievement of disease control initiatives such as polio eradication and measles elimination. Whilst the campaign for smallpox eradication was set up as special and time-limited effort, the EPI requires long-term sustainable approaches to protect new cohorts of susceptible persons with vaccination and monitor trends and progress towards disease control with high quality surveillance.