A Critical Comparison of Robotic Versus Conventional Laparoscopic Splenectomies

The benefit of robotic systems for general surgery is a matter of debate. We compare our initial series of robotic splenectomies with our first series of conventional laparoscopic ones. A retrospective analysis of the first six robotic versus the first six conventional laparoscopic splenectomies is presented. Patients were matched with regard to age, bodymass index, ASA score, and preoperative platelet levels. All procedures were performed by a single surgeon. Size and weight of the resected specimens were comparable in both groups. Median overall operating time was 154 (range, 115–292) min for the robotic and 127 (range, 95–174) min for the laparoscopic group. No complications occurred. There were no open conversions. The median postoperative hospital stay was 7 (robotic group) and 6 (laparoscopic group) days. Median average costs were $6927 for the robotic procedure versus $4084 for the conventional laparoscopic procedure (p < 0.05). Minimally invasive splenectomies are feasible using either conventional laparoscopic techniques or the da Vinci™ robotic system. In this analysis, procedures performed with the da Vinci™ robotic system resulted in prolonged overall operative time and significantly higher procedural costs. The use of a robotic system for laparoscopic splenectomy offers, at this stage, no relevant benefit and thus is not justified.     

Inhibition of Desmoteplase-Induced Fibrinolytic Activity In Vitro

Introduction. Laboratory monitoring of the hemostatic system during thrombolytic therapy requires that the fibrinolytic activity generated in vivo be immediately inhibited at blood collection in order to prevent artificial results as a consequence of degradation of clotting proteins. For most thrombolytic drugs efficient inhibitors have been described, but not yet for the new thrombolytic agent, desmoteplase, which is vampire bat salivary plasminogen activator. Therefore, we investigated the effect of aprotinin and D-Phe-Pro-Arg-chloromethylketone (PPACK) on desmoteplase-induced fibrinolysis.Materials and methods. We added desmoteplase in pharmacological concentrations to blood samples supplemented with aprotinin, PPACK or both. Fibrinolytic activity was assessed by measuring degradation products of fibrin and fibrinogen, plasmin-antiplasmin complex, thrombin-antithrombin complex, fibrinogen and some overall clotting assays.Results. Desmoteplase caused in vitro activation of plasminogen with concomitant degradation of fibrin and fibrinogen. Aprotinin completely inhibited these effects, whereas PPACK gave only partial inhibition. Neither inhibitor prevented plasminogen activation and thus significant generation of plasmin-antiplasmin complex was observed.Conclusion. Blood collection for hemostatic analyses in clinical studies with desmoteplase requires addition of aprotinin (final concentration 250 KIU/mL) in order to prevent in vitro artifacts.     

Clinical performance of a ventricular automatic capture verification algorithm

BACKGROUND: This study was conducted to evaluate the clinical performance of the ventricular automatic capture feature as implemented in the Insignia I Ultra pacemaker system (Guidant) utilizing a variety of ventricular leads. Currently, the optimal programming of the pacemaker output considers both pacemaker efficiency (prolonging battery longevity) and patient safety (adequate safety margin). The ability of a pacemaker to automatically adjust the ventricular output above the pacing threshold while maintaining the appropriate safety margin has been explored since the early 1970s and is only available today in conjunction with a specific low polarization lead system. METHODS: One hundred and five patients were enrolled from 17 European centers utilizing 31 different types of ventricular leads were followed through their 3-month follow-up visit. There were no restrictions on the type of ventricular leads used. RESULTS: The average mean difference between the commanded autothreshold test (0.652 + 0.335 V) and the manual threshold test (0.651 + 0.335 V) was 0.001 + 0.49 (P < 0.0001). The average mean difference between the ambulatory autothreshold test (0.696 + 0.322 V) and the commanded autothreshold test (0.682 + 0.315 V) was 0.002 + 0.74 (P < 0.0001). Holter recordings confirmed that there were no loss of capture incidences without a backup pulse being delivered. In addition, the mean number of backup pulses delivered in a 24-hour period was less than 0.1% of the total number of paced beats. CONCLUSIONS: This study provided that the automatic capture feature while using a variety of leads accurately determines the ventricular stimulation threshold and safely delivers a backup pulse when required.     

Back to basics in diagnosing diabetic polyneuropathy with the tuning fork!

OBJECTIVE: Several national and international scoring systems are used to diagnose diabetic polyneuropathy (PNP). The variety in these scores and the lack of data on validity and predictive value has led to a comparison and validation of the scores with clinical standards for PNP to determine the most powerful measurement for screening. RESEARCH DESIGN AND METHODS: Three matched groups were selected: 24 diabetic patients with neuropathic foot ulcers, 24 diabetic patients without PNP or ulcers, and 21 control subjects without diabetes. In all participants the scores from the International Consensus on the Diabetic Foot (ICDF) and the Dutch Nederlandse Diabetes Federatie-Centraal Beleids Orgaan (NDF/CBO) were tested. The Diabetic Neuropathy Symptom score, the Diabetic Neuropathy Examination score, Heart Rate Variability, the Nerve Conduction Sum score, and a San Antonio Consensus sum score were obtained as clinical standards. Reproducibility was tested in a separate study (13 patients). RESULTS: The construct validity and discriminative power of the ICDF and NDF/CBO scores were comparable, although monofilaments (NDF/CBO) scored lower. The predictive value was good for all scores, with the best results being obtained for the tuning fork (NDF/CBO). Reproducibility of the NDF/CBO scores (monofilaments and tuning fork) was high. CONCLUSIONS: The characteristics of the scores of tests recommended by ICDF and NDF/CBO are comparable. The single use of the 128-Hz tuning fork produces results similar to the extended scores of the ICDF and much better than those of monofilaments on validation and for predictive value. For screening we therefore advise the use of the tuning fork alone.     

Dynamic protein expression patterns during intraoral wound healing in the rat

Wound healing after cleft palate surgery is often associated with impairment of maxillary growth and dento-alveolar development. Wound contraction and scar tissue formation contribute strongly to these effects. In vitro studies have revealed that fibroblasts isolated during different phases of palatal wound healing show phenotypical differences. They change from a quiescent to an activated state and then partly back to a quiescent state. In this study, we evaluated the existence of fibroblast phenotypes at several time-points during palatal wound healing in the rat. Based on cytoskeletal changes (alpha-sma, vimentin, vinculin), integrin expression (alpha1, alpha2, alpha(v) and beta1) and changes in cellularity, we conclude that phenotypically different fibroblast populations are also present during in vivo wound healing. Alpha-sma and the integrin subunits alpha1 and alpha(v) were significantly up-regulated, and vinculin was significantly down-regulated, at early time-points compared to late time-points in wound healing. These changes point to an activated fibroblast state early in wound healing. Later in wound healing, these activated fibroblasts return only partially to the unwounded situation. These results strongly support the idea that different fibroblast populations with specific phenotypes occur in the course of palatal wound healing.