Feasibility of full-thickness gastric resection using master and slave transluminal endoscopic robot and closure by overstitch: a preclinical study

Background

Gastric submucosal tumors are often treated by laparoscopic wedge resection. This study aimed to examine the feasibility of gastric full-thickness resection through a totally endoscopic approach using the master and slave transluminal endoscopic robot (MASTER), and closure of the luminal defect with an endoscopic suturing device.

Methods

The operation was performed in two live porcine models under general anesthesia. First, the anterior wall of the stomach was slung to the abdominal wall using a percutaneous suturing device. An imaginary 5-cm lesion was marked using a needle knife. After the initial mucosal incision was made using an IT knife, the MASTER was introduced through a long overtube. A circumferential mucosal incision was completed with the MASTER to expose the muscularis propria which was grasped and incised to the serosal layer by electrocautery applied through the hook of the MASTER. The full-thickness resection of the gastric wall was completed with retraction using the grasper and dissection using the hook. While the defect was being created, the luminal space was maintained with traction of the percutaneous sutures. The defect was closed with suture plication using an Apollo Overstitch device.

Results

Two full-thickness gastric resections were performed in two nonsurvival porcine models (body weight = 30 and 35 kg, respectively) using the MASTER. The total procedure time was 56 min for the first model and 70 min for the second model. The luminal view was maintained during the whole procedure, and there was no damage to surrounding organs throughout the whole procedure. The gastric defects were closed successfully using Overstitch, with satisfactory gastric distension and no gas leakage afterward.

Conclusion

The current experiment demonstrated the feasibility and safety of a totally endoscopic approach for the treatment of gastric submucosal tumors: full-thickness resection with the MASTER and successful closure of the defect using Overstitch.     

The actual state of the effects, treatment and incidence of disabling pain in a gender perspective-- a Swedish study

Purpose: The purpose of the study was to elicit the actual state of self-perceived experience of long-term and/or recurrent pain and its effects as reported by women and men with disabilities due to pain, in order to determine criteria for assessing the need for measures in rehabilitation/occupational therapy. Methods: The study used a comparative design with a sample randomized from the Swedish population aged 18-58 years (n = 10000). The inclusion criterion was that the respondents had or had had pain causing activity limitation or restricting participation in daily life. A special questionnaire including items concerning demography, pain, coping, occupations in daily life, work, treatments, care institutions and hospital/care staff visited, was posted to 1849 persons and was answered by 1448 respondents (study group n = 1305, control group n = 117). Results: Gender differences were found in the overall prevalence of pain, women reporting more frequent episodes of pain than men did. Differences were also found in pain variables, in daily occupations, days of sick-leave and work variables. Women completed more varied treatment than men. The incidence rate of long-term/recurrent pain in the population studied was 0.07. Conclusions: As a conclusion from this study, three essential components are suggested for use when assessing the need for rehabilitation/occupational therapy: (1) shoulder/arm or lower back pain of aching, tensed and/or searing character, particularly among women; (2) emotional/affective pain effects causing restlessness and depression, particularly among women; and (3) limitations in daily occupations assessed by FSQ and the demand/control/support model with results falling within the warning zones plus long sick-leave periods.     

Randomized comparative trial of three antivenoms in the treatment of envenoming by lance-headed vipers (Bothrops jararaca) in Sao Paulo, Brazil

In São Paulo City, Brazil, 121 patients with moderatelysevere envenoming by Bothrops snakes (principally B. jararaca)were randomized for treatment with Brazilian polyspecific Bothropsantivenoms: Instituto Butantan (39 patients), Instituto VitalBrazil (41), Fundação Ezequiel Dias (FUNED) (41).The initial dose was four ampoules (40 ml) in 89 patients withless severe envenoming and eight ampoules (80 ml) in 32 patientswith more severe envenoming. A second dose of four ampouleswas required in 20 patients. Patients receiving the three antivenoms were comparable in allrespects before treatment There were no deaths. The majorityshowed rapid clinical improvement, resolution of local envenoming,cessation of bleeding and restoration of blood coagulability.No differences in the efficacy of the three antivenoms wererevealed by clinical or laboratory observations, including measuresof haematological, haemostatic and biochemical ab normalities.Twelve patients developed abscesses (Butantan 1, Vital Brazil6, FUNED 5) and seven developed local necrosis (3,1,3). Of 88patients followed up 20–30 days after the bite 33 (37.5%)still had symptoms or signs of local envenoming, especiallyswelling. Early (anaphylactic) reactions were unexpectedly frequent afterall three antivenoms but were significantly more frequent withButantan (87%) than with Vital Brazil (37%) or FUNED (56%) antivenoms(p < 0.001). A possible explanation was the higher totalprotein content and percentage immunoglobulin of Butantan antivenom. The doses of antivenom recommended in Brazil and used in thisstudy may be unnecessarily high, resulting in an unacceptablyhigh incidence of reactions. Results of the study should prompta critical re-evaluation of antivenom production techniquesand dosage recommendations in Brazil.     

Balloon Cinch Deformity during Angioplasty Procedures: An Indication for Impending Rupture

Percutaneous transluminal balloon angioplasty (PTA) is a commonly performed procedure for hemodialysis vascular access dysfunction including thrombosis. While PTA is generally safe, balloon rupture during the procedure is a potential complication. Because such a rupture can cause damage to the blood vessel, indication of an imminent balloon rupture might help avoid such a complication. This analysis reports on six PTA procedures that were complicated by balloon rupture. All cases demonstrated terminal (caudal/cranial) cinch deformation. There was a loss of sharp terminal tapering and its replacement with banana silhouette before the balloon rupture. Importantly, the contour deformation and balloon rupture occurred at a pressure that was lower than the rated burst pressure. The cinch deformity can be used as an indication for impending balloon rupture. We suggest deflation of balloons that demonstrate shape deformations to avoid vascular injury.     

Computerunterstütztes „ring sizing“ für die Anuloplastie

Background

Current methods to determine the size of an annuloplasty ring for mitral valve reconstruction are semi-quantitative and dependent on the subjective assessment by the surgeon which requires a high degree of professional experience.

Aim

Computer-assisted ring sizing supports the surgeon with a quantitative measurement tool for an objective ring selection.

Material and methods

A fast modeling method for the annulus of the mitral valve was developed, which is easy to integrate into the clinical workflow. It enables precise measurement and preoperative deformation analysis of annuloplasty rings. Additionally, ring implants can be created based on the patient’s individual anatomy.

Results

Computer-assisted modeling and measurement tools enable an objective and reproducible ring selection. The possibility of manufacturing patient-specific designed rings can lead to a novel patient-centered treatment.     

Transplantation tolerance

Although transplantation has been a standard medical practice for decades, marked morbidity from the use of immunosuppressive drugs and poor long-term graft survival remain important limitations in the field. Since the first solid organ transplant between the Herrick twins in 1954, transplantation immunology has sought to move away from harmful, broad-spectrum immunosuppressive regimens that carry with them the long-term risk of potentially life-threatening opportunistic infections, cardiovascular disease, and malignancy, as well as graft toxicity and loss, towards tolerogenic strategies that promote long-term graft survival. Reports of “transplant tolerance” in kidney and liver allograft recipients whose immunosuppressive drugs were discontinued for medical or non-compliant reasons, together with results from experimental models of transplantation, provide the proof-of-principle that achieving tolerance in organ transplantation is fundamentally possible. However, translating the reconstitution of immune tolerance into the clinical setting is a daunting challenge fraught with the complexities of multiple interacting mechanisms overlaid on a background of variation in disease. In this article, we explore the basic science underlying mechanisms of tolerance and review the latest clinical advances in the quest for transplantation tolerance.