Single incision laparoscopic adjustable gastric band: technique,feasibility, safety and learning curve

Introduction

Single incision laparoscopic surgery (SILS) is established in many procedures but not in bariatric surgery. One explanation may be that SILS is technically demanding in morbidly obese patients. This report describes our technique and experience with single incision laparoscopic adjustable gastric banding (SILAGB).

Methods

Prospective data collection was performed on consecutive obese patients who underwent SILAGB between November 2009 and February 2011. A single 3cm transverse incision in the right upper quadrant was used for a Covidien SILS^™ multichannel access port. The technique is described with a standard pars flaccida approach and the ‘tips and tricks’ needed for a wide range of candidates using standard laparoscopic equipment.

Results

A total of 29 patients (27 female) with a median body mass index of 41kg/m² (range: 35–52kg/m²) and median age of 44 years (range: 22–57 years) underwent SILAGB. There were no ‘conversions’ to a standard laparoscopic technique. Two cases required the addition of one single 5mm port. The only complications were two postoperative wound infections (one with a port site infection requiring replacement of the port) and one faulty band requiring replacement. There were therefore two returns to theatre and no 30-day deaths. All patients were discharged on the first postoperative day. In this series, operative times reduced significantly to be comparable with the conventional laparoscopic approach.

Conclusions

SILAGB is safe and feasible in the morbidly obese. Proficiency in this technique using conventional laparoscopic equipment can be achieved with a short learning curve.     

Anti-Thymocyte Gamma-Globulin May Prevent Antibody Production After Heart Transplantation

BackgroundRabbit anti-thymocyte globulin (RATG) has been used as induction therapy in heart transplantation. RATG is polyclonal and has been postulated to have anti-humoral properties by preventing the production of circulating antibodies after heart transplant. Thus, we reviewed our patients who received RATG induction therapy and compared them with those who did not receive therapy for post-transplant de novo antibody production.MethodsBetween January 1, 2006, and January 1, 2013, we assessed 196 non-sensitized heart transplant recipients and divided them into those who received 3 to 5 days of RATG induction therapy mostly due to renal insufficiency (n = 35) versus patients who did not receive therapy (n = 161). All patients were given tacrolimus, mycophenolate mofetil, and corticosteroids. Post-transplant circulating antibodies were routinely monitored at 1, 3, 6, and 12 months after heart transplantation; 1-year and 3-year end points were assessed.ResultsThe RATG-treated group had a significantly higher 12-month freedom from de novo antibody production compared with the patients who did not receive RATG induction (89% vs 71%, log-rank P = .043); however there was no significant difference for 12-month freedom from de novo donor-specific antibody production (91% vs 88%, log-rank P = .541). Treated rejection rates in the first-year were comparable in both groups; 3-year actuarial survival, freedom from cardiac allograft vasculopathy, and freedom from non-fatal major adverse cardiac events were also similar between both groups.ConclusionsRATG induction therapy appears to reduce the production of de novo circulating antibodies in non-sensitized patients during the first year after heart transplantation. Although there were no short-term clinical differences between groups, there were imbalances in group characteristics and relatively short follow-up, which are limitations to this study. A randomized, clinical trial with longer follow-up in a larger cohort of patients is warranted.     

Oscillatory potentials and the b-Wave: Partial masking and interdependence in dark adaptation and diabetes in the rat

Background Diabetes inhibits dark adaptation and both processes alter the electroretinogram (ERG) in similar ways. This study aimed to investigate the relationship between oscillatory potentials (OPs) and the b-wave during dark adaptation and to determine if this relationship changes during the development of diabetes. Methods Twenty-one rats were assigned to adaptation, control and diabetic groups. Rats were dark adapted for periods between 20 minutes and 4 hours, and ERGs recorded. Diabetes was induced with streptozotocin, and ERGs measured after 3, 6, 9 and 12 weeks after injection. Results Increasing periods of dark adaptation led to a logarithmic increase in the amplitude of the b-wave and the OPs. This was accompanied by a decrease in the peak times of the OPs and b-wave. Total OP amplitude and b-wave amplitude were linearly related, allowing an empirical OP constant to be developed to describe the relationship between the two parameters. Diabetes led to a progressive decrease in the amplitude and increase in the peak time of all waves. The OP constant decreased in a linear fashion with increasing duration of diabetes. Conclusions It is argued that OP masking of the b-wave could explain previous inconsistencies in reported ERG changes in diabetes and that a slowing of dark adaptation does not account for these ERG changes. The report concludes that the OPs and b-wave amplitudes and latencies are intimately related in the normal retina and that this correlation is lost predictably during the development of diabetes.     

Rotavirus-induced changes in the microcirculation of intestinal villi of neonatal mice in relation to the induction and persistence of diarrhea

Using a histochemical peroxidase technique, under conditions that preferentially stain erythrocytes, we have shown changes in the microcirculation of villi of neonatal mice infected with murine rotavirus. Between 18 and 48 h postinfection (PI), throughout all areas of the small intestine there occurred, sequentially, a marked ischemia and atrophy of villi. By 72 h PI, villi had recovered their normal height and showed incipient hyperemic microcirculation. At 96 h PI, hyperemic microcirculation was most marked. Between 120 and 144 h PI, a second phase of villus atrophy occurred, which was more attenuated and confined to the upper and middle regions of the intestine. This phase was not accompanied by a wide-spread ischemia of villi: a minority of villi were short and ischemic but many appeared hyperemic. Recovery of villus microcirculation occurred at 168 h PI, which coincided with recovery from diarrhea. These changes in villus microcirculation are discussed in relation to the pathology and pathophysiology of rotavirus infection. We make two novel suggestions. First, the reduction in red cells flowing through villi in the early stages of the infection instigates hypoxia and hence atrophy of villi. The ensuing but ephemeral increase in rate of cell division, necessary for the reconstitution of villi, induces hypersecretion. Second, the increase in numbers of erythrocytes found in villi during their regrowth phase and throughout the remaining time course of the infection perturbs the countercurrent system, lowering the osmolality of the hyperosmotic zone located at villus tips, thereby impairing water absorption and prolonging diarrhea.     

Post-mortem changes in hair bundles of the guinea pig and human cochlea studied by high-resolution scanning microscopy

High-resolution scanning electron microscopic studies have been made on the guinea pig cochlea on material fixed from 15 min to 4 h post-mortem. Changes in the surface texture and cross-links of stereocilia were detected after only 15 min. Such changes included an increase in granularity of the surface membrane, thickening, stretching and fracturing of all types of cross-links accompanied by splaying apart and loss of rigidity of stereocilia. These changes were more pronounced in the basal turns of the cochlea and in general increased in severity and spread more apically with increasing times post-mortem. By 4 h, many hair bundles consisted of a fused amorphous mass in which individual stereocilia were not discernible. Remarkably at this time, some hair bundles appeared to have suffered little damage. These results will facilitate better discrimination between effects solely due to post-mortem necrotic changes and those due to specific actions of ototoxic drugs and other insults.     

A spectrum of skeletal anomalies associated with pulmonary agenesis: possible neural crest injuries

Six cases of unilateral pulmonary agenesis with skeletal and other deformities have been diagnosed in our hospitals. The various pulmonary, spinal, rib and limb anomalies with their possible inter-relationships were examined and described in detail and comparison with previously reported cases was made. It became apparent that the limb abnormalities which most constantly involved hypoplasia of the phalanges of a thumb with varying metacarpal and radial anomalies, were ipsilateral to the pulmonary agenesis in all cases. The spinal deformities involved degrees of failure of segementation of T1-T3 with other vertebrae randomly involved. Rib abnormalities also varied and did not necessarily correspond to the same side as the pulmonary agenesis. The concept of the anomalies all being part of a group of neural crest injuries was then explored.     

Laser vaporization of genital condylomata in pregnancy

Sixteen pregnant women with genital condylomata acuminata were treated with laser vaporization to assess effectiveness, complication rate, and impact on recurrence. Patients were treated at a gestational age of 13-35 weeks. No recurrences occurred before delivery. Five patients experienced uterine contractions before 37 weeks. Only one delivery before 37 weeks may have been attributed to the laser therapy. Four recurrences were detected during postpartum follow-up. Laser vaporization is a safe and effective treatment for condyloma during pregnancy. It is effective in maintaining a lesion-free state during pregnancy, but postpartum recurrences are not rare.     

An in vitro model to study aspects of the pathophysiology of murine rotavirus-induced diarrhoea

An in vitro system is described and validated for studying transport of solutes and water in both uninfected and rotavirus-infected neonatal mouse intestine. Control intestine exhibited stable water absorption for periods of up to 40 min. Water absorption was temperature-dependent. Na-dependent, and enhanced by glucose-containing perfusion solutions. Theophylline induced net secretion of water by control intestinal tissue. Water transport by rotavirus-infected lower small intestine was significantly depressed as compared to control levels, and rotavirus-infected middle small intestine exhibited net secretion of water. Upper small intestine and colon from infected animals did not differ significantly from control tissues in their ability to transport water. Water secretion by infected middle small intestine was reversed to absorption by glucose-containing solutions.