Robotic Heller's myotomy using the new Hugo™ RAS system: first worldwide report

BACKGROUND

Achalasia is a rare disorder of the esophagus characterized by motor dysfunction in the esophagus and relaxation failure of the lower esophageal sphincter (LES). Currently, surgical myotomy procedures are considered the standard of care. Robotic Heller's myotomy (RHM) with fundoplication has been gaining popularity due to documented advantages in the precision of myotomy as well as avoiding the potential reflux following per-oral endoscopic myotomy (POEM). To the best of our knowledge, RHM has thus far has been performed exclusively by the da Vinci surgical system. The new Hugo RAS™ system offers a unique modular design and an open console which offers better maneuverability and docking options. In this study, we present the first worldwide series of patients undergoing RHM using the new Hugo RAS™ platform. Our objective is to propose optimal operating configuration and setup to fully harness the advantages of the unique modular design of this system.

METHODS

Ten consecutive achalasia patients underwent Robotic Heller's myotomy (RHM) with the Hugo RAS™ system. We prospectively collected patient data, including demographics, comorbidities, ASA class, Eckardt scores, pre-operative manometric data, and EndoFlip parameters. Additionally, we recorded the docking and total operative times.

RESULTS

Between December 2022 and August 2023, 10 patients underwent RHM with the Hugo™ RAS system. Patients had a median age of 42.5 years, 60% were female, and mean BMI was 23.2. Fifty percent had achalasia type 2 and 50% type 1. The median pre-operative integrated relaxation pressure (IRP) was 24.9. Median docking time was 10 min and overall operative time was 129.5 min. All patients, except one with acute coronary syndrome, had an uneventful peri-operative course and were discharged on post-operative day 2.

CONCLUSION

The Hugo™ RAS system is well designed for robotic Heller myotomy. The operative and clinical results are similar to the currently used robotic system; however, the modular design of the system has some differences. These translate to better docking angles and maneuverability as well as console surgeon's ergonomics. Further experience is needed to explore the advantages of the system's modular design and function.

The Angle of His as a Measurable Element of the Anti-reflux Mechanism

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common condition, resulting from the loss of the anti-reflux barrier. Laparoscopic fundoplication is the surgical procedure of choice for treatment of GERD; however, there remains a debate on the exact mechanism through which it prevents reflux.

OBJECTIVES

Our aim was to understand the relationship between reflux, fundoplication, and the angle of His on an experimental model.

METHODS

The study was conducted on four groups of fresh explanted swine stomachs: control group, myotomy, myotomy with Nissen fundoplication, and myotomy with Toupet fundoplication. The stomachs were placed in a specially designated container on an inclinable platform which would increase the hydrostatic pressure on the esophago-gastric junction. Measurements of the angle of His using fluoroscopy and the esophago-gastric orifice area using endoscopy were performed, and the occurrence of reflux was documented.

RESULTS

Each group of the study contained nine swine stomachs. In the control and myotomy groups, the angle became wider as the incline level increased the pressure and was significantly different between the groups (p < .001). Both groups demonstrated an increase in the orifice area as the incline level increased the pressure. There was a significant correlation between the angle of His and the area of the esophago-gastric orifice (p < .001). In the control group, the reflux began at the 0°. In the myotomy group, it began at the + 15° incline (less pressure). Reflux rarely occurred in the Nissen and Toupet groups, with the breaking point being mostly defined as "beyond - 30°". A significant difference was noted in the occurrence of reflux between fundoplication and the non-fundoplication groups (p < 0.001), while there was no significant difference between the Toupet and Nissen groups (p = 0.134). Analysis showed a significant independent correlation between both the angle of His and the orifice area with the presence of reflux (p = .002 and p = .024 respectively).

CONCLUSIONS

In this study, we developed an experimental model to enable careful evaluation of the elements of the anti-reflux mechanism, of which, the angle of His has a measurable element. We demonstrated that as the angle of His becomes wider the esophago-gastric orifice area becomes larger. Additionally, a wider angle of His and a larger esophago-gastric orifice area were correlated independently with more reflux. This suggests that the fundoplication creates an acute angle of His which is correlated with a smaller area of the esophago-gastric orifice and eventually with a lower incidence of reflux.

Immunohistochemical assessment of endothelin-1 axis in psoriasis, basal cell carcinoma and squamous cell carcinoma

AIM

Endothelin-1 is an autocrine growth factor for keratinocytes, an effect controlled by its A and B receptors, with no previous comparison of endothelin axis expression in inflammatory and neoplastic skin diseases showing keratinocyte proliferation. The aim of the study was to investigate endothelin-1 axis expression in skin lesions of psoriasis, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC).

METHODS

This study included 40 subjects (8 patients with SCC, 12 patients with BCC, 10 patients with psoriasis, and 10 healthy controls). Biopsies from lesional skin of patients and normal skin of controls were examined immunohistochemically for endothelin-1 and its receptors A and B frequency and grade of expression.

RESULTS

Endothelin-1 and receptor A were detected in all patients with SCC and psoriasis, with a higher frequency and grade of expression than controls and BCC. The frequency of receptor B expression was significantly lower while higher staining grade was found in BCC (8.3%) rather than other studied groups.

CONCLUSION

A comparable higher frequency and grade of expression of endothelin-1 and its receptor A are documented in psoriasis and SCC than in BCC and controls denoting their involvement in keratinocyte proliferation in both diseases. Receptor A is the predominately expressed receptor in psoriasis and SCC.

Can laparoscopic removal of Essure device before embryo transfer correct poor reproductive outcome pattern in IVF? A case report

OBJECTIVE

This report describes a successful surgical approach to multiple in vitro fertilization (IVF) failures in the setting of hydrosalpinges, which had been previously treated with Essure inserts.

MATERIALS AND METHODS

A non-smoking 33-year-old Caucasian G2 P0020 (body mass index: BMI = 22) attended for second opinion. Her history was significant for bilateral hydrosalpinges having been noted on hysterosalpingogram two years earlier. This was managed by hysteroscopic placement of Essure inserts bilaterally. One year later, and now with Essure in situ, the patient completed three IVF cycles elsewhere. Her first and third IVF attempts resulted in biochemical pregnancy, while human chorionic gonadotropin (hCG) was negative after the second cycle. Upon presentation at the authors' center and before beginning a fourth IVF cycle, further testing and surgical removal of the Essure devices was recommended.

RESULTS

Repeat hysteroscopy was unremarkable; laparoscopic bilateral salpingectomy and extirpation of Essure implants was accomplished without difficulty. Following menses, the patient initiated IVF with three embryos transferred. At day 60, a single intrauterine pregnancy was identified with positive cardiac activity (rate > 100/min). Her obstetrical course was uneventful; a healthy 4,195 gram male infant was delivered (breech) by Cesarean at 40 weeks' gestation.

CONCLUSION

Essure inserts comprise inner fibers of polyethylene terephthalate, a stainless steel coil, and a nickel-titanium coil. The product received FDA approval as a contraceptive in 2002 although its use for hydrosalpinx remains off-label. While successful outcomes with IVF following Essure placement have been reported, this is the first description of pregnancy and delivery from IVF after Essure removal. Essure may be considered for sterilization when laparoscopy is contraindicated, but experience with its use specifically for treating hydrosalpinges before IVF is limited. This observed association between prior poor IVF outcomes and Essure with subsequent delivery after surgical Essure removal is the first of its kind to be reported, and warrants further investigation.

Study on the possible role of heat shock proteins in host resistance to Trichinella spiralis infection in experimental animals

The expression of heat shock proteins (HSPs) and their immunogenic role in host parasite relationship has been studied in T. spiralis infection in mice. Two groups of infective stage larvae were incubated at 37 degrees C or at 43 degrees C for 3 hours in a nutrient medium. Crude somatic extracts and excretory/secretory (E/S) products were obtained. Quantitative estimation and in vitro translation of mRNA were carried out. Crude somatic extracts, E/S products and in vitro translated proteins were all subjected to SDS-PAGE and immunoelectrophoresis against a monoclonal antibody to HSP70. They were further used to immunize mice which were then infected with T. spiralis. The degree of immunization was assessed by counting adult worms, muscle larvae and estimating total gamma globulins of mice. SDS-PAGE revealed intense peaks of 71 KDa and 81 KDa in all proteins obtained from heat shocked larvae. These proteins have been proved to involve HSP70 as manifested by their strong reactivity with anti-HSP70. In vitro translated products of heat shocked larvae (at 43 degrees C) proved to be strongly immunogenic as evidenced by the lower adult worm, muscle larval counts and higher total gamma globulins in sera of mice in comparison with the control non immunized group as well as to other larval antigens incubated at 37 degrees C. So, exposure to heat, can induce the synthesis of heat shock proteins which can defend the organism against environmental stress. Meanwhile, these heat shock proteins can render the host more refractory to reinfection.

Physico-chemical and technological studies on sugar beet roots

The morphological and chemical characteristics of ten varieties of sugar beet roots were evaluated during the season of 1996-1997. The best morphological characteristics were found in Top, Ito and Pamela varieties. The highest expected technological yield of sugar was found in Pamela and Top. The chemical constituents of different varieties of sugar-beet roots showed significant differences. The suitability of sugar beet juice for preparing beet syrup as a new product was also evaluated and compared with sugar cane syrup. Purified beet-syrups concentrated under vacuum or under atmospheric pressure showed more stability during storage than sugar cane syrup. The effect of storage conditions (at cold storage and at room temperature) and packaging materials (glass and polyethylene high-density bottles) on properties of beet-syrup and sugar cane syrup were also studied.

Effect of some parasitic infection on neurotransmitters in the brain of experimentally infected mice before and after treatment

The effects of some parasitic infection (bilharziasis, toxocariasis and trichinosis) on the brain of experimentally infected mice were investigated. Eighty animals were classified into four groups, group I contained five non infected animals as a control group. The other groups each contained twenty-five mice infected with Schistosoma mansoni (group II), Toxocara canis (group III) and Trichinella spiralis (group IV). Each infected group was divided into two subgroups (a,b). Subgroup (a) left untreated and subgroups (b) treated by praziquantel (in group II) and mebendazole (in group III and IV). Histopathological and immunological examination using peroxidase antiperoxidase (PAP) technique and neurotransmitters estimation (nor-epinephrine, dopamine and serotonine) were carried. In the untreated animals, there were mild histopathological changes and mild antigenic deposition in subgroups (IIa and IIIa) and marked changes in subgroup (IVa). There were significant decrease in dopamine in subgroup (IIIa), not improved after treatment (subgroup IIIb) and significant decrease in nor-epinephrine and serotonine in subgroup (IVa) improved after treatment in subgroup (IVb). The neurotransmitters changes may explain the motor, behavioural and emotional changes that occurred with these parasites.

Evaluation of two cultural media (CPLM & TYM) for isolation and maintenance of Trichomonas vaginalis stocks in the laboratory

Five hundreds vaginal discharge specimens were inoculated simultaneously in 2 axenic culture media (CPLM & TYM), in order to compare their ability to isolate and to maintain the growth of T. vaginalis in the laboratory. While both media were found to be equally good in detecting the organisms in vaginal discharges, yet, T. vaginalis stocks were maintained for a longer time in TYM medium (one year), than in the CPLM medium (2 weeks). The yields of the parasites with different inocula subcultured and after different incubation periods were counted in the TYM medium.

Endoscopic diagnosis of gastric varices

In this retrospective study, the presence and appearance of gastric varices were analyzed among patients presenting at Kasr El Aini Hospital with variceal bleeding during the period from 1984 to 1989. Two groups of patients were studied. The first group included 970 patients with documented variceal bleeding with no history of sclerotherapy. Of these patients 6.7%, had concomitant gastric varices, and 27.1% had direct gastric extension of esophageal varices (mostly of grade 3). Gastric varices alone, without esophageal varices, were found in five cases (0.5%). The second group was a subgroup, and included 376 patients who underwent complete sclerotherapeutic eradication of varices restricted to the esophagus and were without gastric varices at the first presentation. Eleven of these patients (2.9%) developed secondary gastric varices. There was no correlation between the risk of bleeding from primary gastric varices (seen at the first presentation) and the grade of the esophageal varices. There were more bleeding episodes from large gastric varices (35.4% for the cauliflower and 16.9% for the cystic forms) than from the small varices, i.e. ruga-like and network-like gastric varices. The study also shows that the secondary development of gastric varices after endoscopic variceal sclerotherapy is a rare event, and that there was no risk of bleeding from the secondary gastric varices. Patients with esophageal varices with gastric extension had a small risk of bleeding from their gastric varices (5.2%).

Characterization of Egyptian isolates of Trichomonas vaginalis: I. Serotyping

Antitrichomonal hyperimmune sera against T. vaginalis stocks isolated from Egyptian female patients were employed for serological differentiation of somatic and soluble antigens in the Ouchterlony gel double immunodiffusion technique. It was concluded that soluble trichomonal antigens present in association with living flagellates are stock--specific reacting with some, but not all the antitrichomonal hyperimmune sera, while those present in association with dead parasites are common antigens reacting with all the sera. Three stocks, E1, E2 and E3 could be differentiated into two strains using their stock--specific antigens. The somatic antigens of six trichomonal stocks reacted with all the hyperimmune sera denoting common antigenic make up.

The immune defensive mechanism in parasitic infection with eosinophilia

This study was attempted to assess the extent of stimulation of the immune system in some patients suffering from parasitic infection with eosinophilia. Eighty-eight cases were selected, they included 10 apparently healthy, 10 suffering from different atopic disorders associated with eosinophilia and free from parasitic infections and 68 patients suffering from different parasitic infections associated with marked eosinophilia. The results showed a highly significant increase in the absolute eosinophil count in the atopic group while the parasitized group showed a moderate increase. The IgE serum level was increased in both atopic and parasitized groups. The cellular immunity expressed by phagocytic power of neutrophils was more depressed in parasitized than atopic group.

Parasitic infections associated with malignancy and leprosy

Results of parasitic infections, as revealed by urine and stool examination was significant (P less than 0.05) in 43.3% of patients suffering from different malignant diseases and non significant (P greater than 0.05) in 29.3% of leprosy patients compared to 22% in control subjects. The most prevalent parasites were E. histolytica and G. lamblia. Cryptosporidium occysts were not detected. By stool examination and culture, S. stercoralis larvae were detected only in the malignancy group. The most common parasites occurring concomitantly were A. duodenale and S. stercoralis. By the IFAT, strongyloidiasis gave significantly higher positive results in the malignancy group than in the leprosy and control groups. IFAT for toxocariasis, showed highly significant positivity in the leprosy group and significantly positivity in the malignancy group. For toxoplasmosis, it showed highly significant positive results in both leprosy and malignancy groups. Eosinophilia was significantly more prominent among malignancy patients and insignificant among those with leprosy. Parasitic infection detected by urine and stool examination among patients with eosinophilia was found in 76% of the malignancy patients and in 66.7% of the leprosy patients.

Experimental trichinosis: effect of immunosuppression on the host-parasite system

Experimental trichinosis in immunocompetent verus immunosuppressed albino rats was studied over a period of two months. The immunosuppressed ones showed significant delay in expulsion of adult worms, significant increase in the yield of muscle larvae, lower IFA titres and delayed encystation of muscle larvae with mild cellular infiltration. Specific antigen deposits detected in the muscles and different tissues of the immunosuppressed rats indicated augmentation of circulating antigens. In both groups, the liver, kidney, lung, brain and testes showed nonspecific pathological changes but larvae were never detected in examined sections. Incidentally, on the 14th post-infection day, two immunocompetent rats were found pregnant, and near-full-term embryos showed more deposition of Trichinella antigens in most of their tissues indicating placental passage of circulating antigens. This study indicates that in patients receiving immunosuppressive drugs, possible exposure to T. spiralis infection will result in severe manifestations or complications.

Parasitic infections associated with mental retardation in Egypt

Examination of 150 mentally retarded patients for parasitic infections by urine and stool analysis revealed that 115 (76.67%) were positive. The most prevalent parasites found were T. trichiura in 56%, A. lumbricoides in 40.6% and A. duodenale in 21.33%. Double infection was present in 30.67%, triple infection in 15.33% and quadriple infection in 6%. Eosinophilia was detected in 91 (64.08%) of 142 examined cases, all were suffering from intestinal parasites. S. stercoralis was present in 11.33% by stool examination and culture and in 24 (60%) out of 40 examined cases by the IFAT. Toxocara antibodies were present in 38 (56.72%) out of 67 examined cases by the IFAT. Toxoplasma antibodies were present in 106 (74.65%) out of 142 examined cases by the IFAT.

Effect of Hymenolepis nana on the mouse ileal mucosal cells: histochemical studies

Histochemical studies of the ileal mucosal cells of mice experimentally infected with H. nana revealed definite increase in mucous secretions indicating increased activity of the goblet cells in response to mucosal irritation. The activity of acid phosphatase was also increased representing a sort of defence mechanism against the attached worms. The activities of ATP-ase and NADH diaphorase enzymes were decreased indicating disturbance in the metabolic and transport processes and in the absorptive function of the intestinal epithelial cells.

A survey for enteroparasites in Menoufia governorate, Egypt with special reference to Strongyloides stercoralis

The prevalence of Strongyloides stercoralis and other enteroparasites was studied in Menoufia Governorate. 565 stool & 500 serum samples were examined by direct smear, zinc sulphate, stool culture & IFAT using ultrasonicated non digested non fixed filariform larva as antigen. IFAT proved superior than the direct methods since it detected 11.1% of cases while the latter detected only up to 3.4%. The prevalence of enteroparasites was found to be 62.3%. E. histolytica and A. lumbricoides showed the highest incidence while Taenia showed the lowest incidence.

A study of adhesive organelles of Giardia intestinalis

This study revealed that the adhesive disc of Giardia lamblia trophozoite has different forms. The anterior limitation of the ventrolateral flange to the adhesive disc and its flexibility suggests its participation in the mechanism of attachment of the trophozoite. Normal intestinal crypts promote attachment of Giardia trophozoite by providing a passive mechanical barrier against the main peristaltic flow. The mechanism of attachment is described in details.

Ultrastructure of penetrating Giardia trophozoite and the possible mechanism of invasion

The ultrastructure of penetrating Giardia lamblia trophozoites in immunosuppressed albino rats is described for the first time. Recorded changes in the general contour of the parasite; loss of flagellae, and suction disc, disappearance of the endoplasmic reticulum, appearance of abundant electron dense coarse granules as well as large sized vacuoles opening to outside, are probably modifications associated with penetration and accommodation to the new environment. Penetration appears to be due to activity of the trophozoite rather than passive transfer by tissue macrophages.

Experimental trichinosis in alloxan induced diabetes in mice

The course of Trichinella spiralis infection was studied in Alloxan induced diabetes in mice. The number of Trichinella larvae in muscles of infected animals was estimated by digestion of whole carcases and compared with control non diabetic group. Histopathological study of infected muscles was also done. It was found that diabetic mice developed very heavy muscle parasitism and their larval count was high compared with non diabetic animals. Besides, there was heavy inflammatory cellular reaction around poorly encapsulated larvae. Mortality rate was 100% by day 45 in diabetic mice while control animals survived during the period of observation which was 3 months. These data indicated that hyperglycaemia significantly increased parasitisaemia and mortality in mice infected with T. spiralis.

New Guaianolides and Farnesol Derivatives from Arctotis arctotoides1

The aerial parts of ARCTOTIS ARCTOTOIDES afforded eight known sesquiterpene lactones and three new ones, the 11beta,13-dihydroguaianolides 9 and 10 as well as the chlorohydrine 8. Furthermore two 2Z-farnesol derivatives 12 and 13 were isolated. The structures were elucidated by highfield (1)H-NMR. The stereochemistry of several compounds has been revised.

Effects of ranitidine on the disposition of metoprolol

The effects of ranitidine on the pharmacokinetics of metoprolol were examined in two studies. In the first study, pharmacokinetics of single doses of metoprolol were examined in six subjects before, during and after ranitidine administration for 1 week. Peak concentrations of metoprolol were increased on ranitidine but its half-life and clearance were unaltered. In the second study, 12 subjects received metoprolol twice daily for 1 week; once with ranitidine and once with placebo. Ranitidine had no effects on the chronic-dose pharmacokinetics or pharmacodynamics of metoprolol. The chronic dose study suggests no inhibition of the metabolism of metoprolol by ranitidine. The single dose study suggests, however, that some interaction of an as yet unknown nature, cannot be excluded.

Central effects of single oral doses of propranolol in man

The central effects of propranolol, a lipophilic beta-adrenoceptor antagonist, were investigated in six healthy male volunteers using two flash fusion threshold (2FFT), simple reaction time (SRT), digital copying test (DCT), symbol digit modalities test (SDMT), Gibson spiral maze test (GSMT) and mood rating scales for tension, alertness, depression, detachment and anxiety. Compared to placebo, 2FFT was prolonged by propranolol 40, 80 and 160 mg at one or more times tested but not by propranolol 320 mg: the largest effect was seen at 3 h after 40 mg, and the effects of 40, 80 and 160 mg were significantly greater than 320 mg at 2 h. SRTs were significantly prolonged by all doses of propranolol at 2 and 3 h and by 40 and 80 mg doses at 5 h. DCT was lowered by 40 and 80 mg at 2 and 3 h by 80 mg at 5 h, and by 320 mg at 2 h, but the 160 mg dose had no effect. Propranolol impaired the expected retest gain of the SDMT with all doses except 320 mg and at 2 h after 40, 80 and 160 mg, performance was actually worsened. Mood rating scales showed increased detachment with 40 mg and decreased alertness with 80 and 320 mg. The results show that propranolol has central effects in man: the effects appeared to be greater with lower doses, 40 and 80 mg, than with higher doses, 160 and 320 mg.

Central effects of beta-adrenoceptor antagonists

The central effects of atenolol, a cardioselective beta-adrenoceptor antagonist, were investigated in six healthy men. Two flash-fusion threshold (2FFT), simple reaction time (SRT), digital copying (DCT), symbol-digit modalities (SDMT), and Gibson's spiral maze tests (GSMT) and mood rating scales for tension, alertness, depression, detachment, and anxiety were used. Each subject took 50, 100, 200, and 400 mg atenolol and identical placebo orally in a randomized, double-blind, crossover study and the psychomotor tests were performed at 0, 2, 3, 5, and 8 hr. 2FFT was prolonged at 3 hr after all doses and at 2 and 5 hr with 100, 200, and 400 mg. The maximum effect was achieved with 200 mg and mean 2FFT correlated with mean plasma atenolol concentration. SRTs were prolonged after all doses at between 2 and 5 hr. The DCT and the retest gain of the SDMT were both lower than after placebo at 2 hr with 100, 200, and 400 mg. The time taken to perform the GSMT was not altered by active drug, but the number of errors was lower at 2 hr with 100 and 200 mg. The self-rating mood scales showed a subjective decrease in tension 2 hr after 400 mg. The results show that atenolol exerts central effects in man.

Induction of microsomal enzyme activity by flupenthixol in chronic schizophrenics

The effect of long-term treatment with flupenthixol on hepatic microsomal enzyme activity was studied in 12 chronic schizophrenic outpatients who had been receiving two weekly maintenance doses for at least 6 months. Antipyrine half-life was measured in the 12 patients while they continued to receive the drug. Flupenthixol was then discontinued for 6 weeks and antipyrine half-life was repeated in 7 of the 12 patients. In the 12 patients the plasma antipyrine elimination half-life was 4-24 h (mean 9.73 +/- 1.61 h) when receiving flupenthixol and there was a significant negative correlation between antipyrine half-life and the dose of flupenthixol (r = 0.582, P less than 0.05). In the seven patients to whom antipyrine was given on two occasions, antipyrine half-life was 7.33 +/- 1.07 h and 12.04 +/- 1.87 h on and off flupenthixol treatment respectively. The clearance significantly decreased when flupenthixol was discontinued, but there was no change in the apparent volume of distribution.

Reduced induction of drug metabolism in the elderly

Young and elderly subjects were given the hypnotic dichloralphenazone (Welldorm) in a dose of 20 mg/kg nightly for two weeks and the extent of induction of liver microsomal drug metabolism was assessed from alteration in the plasma elimination of quinine and antipyrine (phenazone). With both indices, there was a significant increase in plasma drug clearance in young subjects following dichloralphenazone treatment but no significant alterations occured in the elderly group. These results indicate that, in addition to being less able to metabolize some drugs, elderly patients show a reduced induction response. They may therefore be less likely to become tolerant to those drugs which are inactivated by metabolism.