OC-021 HYBRID ROBOTIC SURGERY - USING LAPAROSCOPY TO BETTER ROBOTIC OUTCOMES

Aim

To show that Hybrid Robotic Surgery is essential for a successful and a cost effective General Surgery Robotic Surgery Program

Material & Methods

38 Consecutive cases of General Surgery done from October 2021 to June 2022 were studied with respect to usage of Robotic Instruments & Laparoscopic Instruments, the utility of each instrument, Surgical time, costs & patient outcomes.

Results

A Hybrid approach by using Laparoscopic Instruments (Ports and/or Instruments) was necessary in 38/38 patients (100%) for atleast some step & in 32/38 patients for atleast one important surgical step. Robotic Platform was used to perform Hernia Surgery like TAPP (Trans Abdominal Pre-Peritoneal) & IPOM (Intra-peritoneal Onlay Meshplasty) (n=23). Laparoscopic Instruments were used in all the cases 23/23 (100%).

Conclusions

Usage of Laparoscopic Instruments helped reduce the Surgery duration, decrease use of Robotic instruments, help negate the Haptic blind spots proving to be a cost effective & a tool for optimal Robotic utilization. Laparoscopic instrumentation and steps remain an integral part of Robotic Surgery. The findings highlight the need for dual instrument set, both Robotic & Laparoscopic Instruments, in each Robotic Surgery and underscores the importance of adequate Laparoscopy knowledge and skills for a Robotic Surgery Program.

P-059 ROBOT ASSISTED TRANS ABDOMINAL PRE-PERITONEAL (RTAPP) MESHPLASTY FOR GIANT GROIN HERNIAS - OUR HYBRID ROBOTIC SURGERY CHOREOGRAPHY FOR OPTIMIZING OUTCOMES

Aim

To demonstrate our successful, cost effective & time saving choreography for managing Large Groin Hernia with Robot assisted Trans Abdominal Pre-Peritoneal (rTAPP) Meshplasty Surgery

Materials & Methods

7 patients with Groin Hernia EHS Classification P/R M/L 3 were operated using Da Vinci Xi Robotic platform and underwent TAPP Meshplasty between October 2021 & June 2022. We noted the instruments used(Robotic and Laparoscopic), the Surgery duration & Console Time, the ease of the surgery & the Choreography, Intra-operative challenges, intra-operative change in surgical steps, post-op pain scores, analgesia usage & outcomes.

Results

Laparoscopic instruments were used in 7/7 (100%) patients for accomplishing various steps. Both flat & 3D Anatomically contoured meshs were used. Usage of Laparoscopic Instruments at various steps & in tandem with Robotic instruments optimizes the cost of the surgery, helps in decreasing surgical duration & utilization of resources. The trends evolve as one negotiates the learning curve.

Conclusions

Our study demonstrated that for Large Groin Hernia it is recommended to include Laparoscopic instruments during Robot assisted surgery along with specific surgical steps for successful completion of rTAPP in a cost-effective manner.

Perceptions of students on a stand-alone dental materials course in a revised dental curriculum

BACKGROUND

The Dental Materials (DM) course was introduced as a stand-alone course in 2013, at the University. Prior to that, DM was integrated into clinical courses.

OBJECTIVE

To determine the perceptions of the Bachelor of Dental Science (BDS2 to BDS5) students on a stand-alone DM course following curricular amendment.

METHODS

This was a cross-sectional study, in which a simple random sampling strategy was used, with forty-six students participating. The study was conducted in 2017. A self-administered, structured, validated questionnaire was used to collect data. The obtained data were summarised and analysed using descriptive and inferential statistics (one-way ANOVA).

RESULTS

The study was conducted on Bachelor of Dental Science (BDS2 to BDS5) students. A response rate of 49% from the administered questionnaires was achieved. The overall perception, total mean percentage score of 71.4% was obtained showing a generally positive view on the relevance of the course by students. A total mean percentage score of 74.1% showed the students' view that the DM course was well managed whilst a total mean score of 56.7% expressed the overall view on the reintegration of DM into clinical courses.

CONCLUSION

The students felt that DM was relevant and it could continue as a stand-alone course. They perceived that the course was run effectively and managed well, but they had conflicting views on reintegration of the course into clinical modules. Studies with larger sample sizes at other Dental Schools are recommended to determine similarity of results.

Abrogation of red blood cell G6PD enzyme activity through Heat treatment: development of survey material for the UK NEQAS G6PD scheme

INTRODUCTION

Participation in external quality assessment (EQA) is central to the maintenance of high-quality laboratory results in patient diagnosis and clinical trials. Laboratories in the TAF112582 DETECTIVE study (ClinicalTrials.gov identifier: NCT01376167) are enrolled in the United Kingdom National Quality Assessment Scheme (UK NEQAS) for glucose-6-phosphate dehydrogenase (G6PD) quantitative assay, which utilizes ovine (sheep) blood as a readily available source of apparently G6PD-deficient survey material. A substitute for sheep blood was sought because some non-UK sites in the study encountered participation difficulties due to the strict regulations on the import of sheep blood into their countries.

METHODS

G6PD activity in normal human donor blood was abrogated by the action of heat under controlled conditions. Residual G6PD activity in the heated samples was measured by UK NEQAS using the Trinity Biotech 345 kit (Trinity Biotech) and a Jenway 6715 UV/Vis spectrophotometer with external temperature control to monitor enzyme kinetics and linearity over a set time. Heat-treated material was also assayed for G6PD activity and assessed for its acceptability as EQA survey material by selected UK laboratories.

RESULTS

Blood heated at 45 °C for 15 h showed a reduction in G6PD activity of 76.3 ± 4.6% (n = 6) and was considered acceptable as EQA material in terms of appearance and behaviour by the majority of UK sites in the trial.

CONCLUSIONS

We have developed a simple heat-treatment procedure to produce EQA survey material with low/intermediate G6PD activity, similar to that found in females heterozygous for G6PD deficiency.

Cuckoo search algorithm based satellite image contrast and brightness enhancement using DWT-SVD

This paper presents a new contrast enhancement approach which is based on Cuckoo Search (CS) algorithm and DWT-SVD for quality improvement of the low contrast satellite images. The input image is decomposed into the four frequency subbands through Discrete Wavelet Transform (DWT), and CS algorithm used to optimize each subband of DWT and then obtains the singular value matrix of the low-low thresholded subband image and finally, it reconstructs the enhanced image by applying IDWT. The singular value matrix employed intensity information of the particular image, and any modification in the singular values changes the intensity of the given image. The experimental results show superiority of the proposed method performance in terms of PSNR, MSE, Mean and Standard Deviation over conventional and state-of-the-art techniques.

Minimally Invasive Anal Fistula Treatment (MAFT)-An Appraisal of Early Results in 416 Patients

Minimally invasive anal fistula treatment (MAFT) was introduced to minimize early postoperative morbidity, preserve sphincter continence, and reduce recurrence. We report our early experience with MAFT in 416 patients. Preoperative MRI was performed in 150 patients initially and subsequently thereafter. The technique involves fistuloscope-aided localization of internal fistula opening, examination and fulguration of all fistula tracks, and secure stapled closure of internal fistula opening within anal canal/rectum. MAFT was performed as day-care procedure in 391 patients (93.9 %). During surgery, internal fistula opening could not be located in 100 patients (24 %). Seven patients required readmission to hospital. Mean visual analog scale scores for pain on discharge and at 1 week were 3.1 (1-6) and 1.6 (0-3), respectively. Mean duration for return to normal activity was 3.2 days (2-11 days). Fistula recurrence was observed in 35/134 patients (26.1 %) at 1 year follow-up. MAFT may be performed as day-care procedure with benefits of less pain, absence of perianal wounds, faster recovery, and preservation of sphincter continence. However, long-term results from more centers are needed especially for recurrence.

[Not Available]

Spigelian hernia occurs through slit like defect in the anterior abdominal wall adjacent to the semilunar line. Most of spigelian hernias occur in the lower abdomen where the posterior sheath is deficient. The hernia ring is a well-defined defect in the transverses aponeurosis. The hernial sac, surrounded by extraperitoneal fatty tissue, is often interparietal passing through the transversus and the internal oblique aponeuroses and then spreading out beneath the intact aponeurosis of the external oblique. Spigelian hernia is in itself very rare and more over it is difficult to diagnose clinically. It has been estimated that it constitutes 0.12% of abdominal wall hernias. The spigelian hernia has been repaired by both conventional and laparoscopic approach. Laparoscopic management of spigelian hernia is well established. Most of the authors have managed it by transperitoneal approach either by placing the mesh in intraperitoneal position or by raising the peritoneal flap and placing the mesh in extraperitoneal space. There have also been case reports of management of spigelian hernia by total extraperitoneal approach. We retrospectively reviewed our experience of ten patients between 1997 and 2007. Eight patients (8/10) presented with abdominal pain and two patients (2/10) were asymptomatic. In six patients (6/10) we performed an intraperitoneal onlay IPOM repair, in two patients (2/10) transabdominal preperitoneal repair (TAPP), and in two (2/10) total extraperitoneal repair (TEP). There were no recurrences, or other morbidity at mean follow up period of 3.2 years (range 6 months to 10 years).

Iatrogenic enterotomy in laparoscopic ventral/incisional hernia repair: a single center experience of 2,346 patients over 17 years

PURPOSE

Iatrogenic enterotomy (IE) during laparoscopic ventral/incisional hernia repair (LIVHR) is reported to be associated with poorer surgical outcomes. We report our experience with diagnosis, management and complications in patients who had IE during LIVHR at our tertiary referral institute between 1994 and 2011.

METHODS

We retrospectively reviewed prospectively collected data of 2,346 patients who underwent LIVHR from 1994 to 2011. We identified 33 patients who had IE during LIVHR. All surgical procedures were performed by five consultants and fellows under supervision who followed a standardized operative protocol. Patients were followed up for 6 months to evaluate morbidity, mortality, additional surgical procedures, unplanned readmissions and hospital stay.

RESULTS

Mortality occurred in 2 patients (6 %). Complications occurred in 16 patients (48.5 %). Median hospital stay was 3 days (2-36). Unplanned readmission was required in 6 patients (18 %). In 18 patients, (55 %) additional surgical procedures were required within 6 months of LIVHR. In 5 patients, the enterotomy was recognized postoperatively. These patients had worst outcomes [mortality 40 %, additional surgical procedures were required in all patients (100 %) and median hospital stay was 12 days (range 7-36)].

CONCLUSION

Iatrogenic enterotomy is a serious complication during LIVHR. IE is associated with mortality, morbidity, additional surgical procedures, unplanned readmissions and prolonged hospital stay. In patients where IE was recognized postoperatively, the prognosis was worst.

Induction of resistance to daunorubicin in drug-sensitive leukemia p388 cells - a role of pkc-Beta-I isozyme

A role of protein kinase C (PKC) has been suggested in multidrug resistance (MDR). Because of the molecular and biochemical heterogeneity of PKC, we examined a role of PKC beta isozyme in drug sensitive murine leukemia P388 cell line. Drug sensitive P388 and MDR P388/ADR cells were treated with various concentrations of 12-deoxyphorbol-13-O-phenylacetate 20 acetate (DPPA, an agonist of PKC beta I isozyme) and examined for its effect on daunorubicin (DNR) accumulation and sensitivity to DNR. dPPA increased DNR resistance and decreased DNR accumulation in P388 cells but had no effect in P388/ADR cells. The reduced dPPA-induced DNR accumulation was due to decreased uptake without any effect on DNR efflux. Furthermore, treatment of P388 cells with dPPA was associated with translocation of PKC beta isozyme from cytosol to plasma membrane. These data suggest that PKC beta I isozyme plays a role in acquired drug resistance.

Single port versus multiple port laparoscopic cholecystectomy-a comparative study

Single port laparoscopic cholecystectomy (SPLC) was introduced to minimize postoperative morbidity and improve cosmesis. We performed a comparative study to assess feasibility, safety and perceived benefits of SPLC. Two groups of patients (104 each) with comparable demographic characteristics were selected for SPLC and multiport laparoscopic cholecystectomy (MPLC) between May 2010 to March 2011. SPLC was performed using X cone® with 5 mm extra long telescope and 3 ports for hand instruments. MPLC was performed with traditional 4 port technique. A large window was always created during dissection to obtain the critical view of safety. Data collection was prospective. The primary end points were post-operative pain and surgical complications. Secondary end points were patient assessed cosmesis and satisfaction scores and operating time. The mean VAS scores for pain in SPLC group were higher on day 0 (SPLC 3.37 versus MPLC 2.72, p = 0.03) and equivalent to MPLC group on day 1(SPLC 1.90 versus MPLC 1.79, p = 0.06). Number of patients requiring analgesia for breakthrough pain (SPLC 21.1 % versus MPLC 26.9 %, p = 0.31) was similar. Number and nature of surgical complications was similar (SPLC 17.3 % versus MPLC 21.2 %, p =0.59). Mean patient assessed cosmesis scores (SPLC 7.96 versus MPLC 7.16, p = 0.003) and mean patient satisfaction scores (SPLC 8.66 versus MPLC 8.16, p = 0.004) were higher in SPLC group indicating better cosmesis and greater patient satisfaction. SPLC took longer to perform (61 min versus 26 min, p = 0.00). Conversion was required in 5 patients in SPLC group. SPLC appears to be feasible and safe with cosmetic benefits in selected patients. However, challenges remain to improve operative ergonomics. SPLC needs to be proven efficacious with a high safety profile to be accepted as standard laparoscopic technique.

Laparoscopic transabdominal extraperitoneal repair of lumbar hernia

Lumbar hernias need to be repaired due to the risk of incarceration and strangulation. A laparoscopic intraperitoneal approach in the modified flank position causes the intraperitoneal viscera to be displaced medially away from the hernia. The creation of a wide peritoneal flap around the hernial defect helps in mobilization of the colon, increased length of margin is available for coverage of mesh and more importantly for secure fixation of the mesh under vision to the underlying fascia. Laparoscopic lumbar hernia repair by this technique is a tensionless repair that diffuses total intra-abdominal pressure on each square inch of implanted mesh. The technique follows current principles of hernia repair and appears to confer all benefits of a minimal access approach.

Laparoscopic ventral/incisional hernia repair: a single centre experience of 1,242 patients over a period of 13 years

BACKGROUND AND PURPOSE

Laparoscopic technique is now well established for ventral/incisional hernia repair. However several issues such as optimal fixation technique, occult hernias, management of inadvertent enterotomies, postoperative seromas and recurrence require appraisal.

METHODS

A single centre retrospective review of 1,242 patients between January 1992 and June 2005 is described. All patients had laparoscopic ventral/incisional hernia repair (LVIHR) following a standardised protocol by five consultants and fellows in a dedicated minimal access surgery unit of a tertiary care hospital.

RESULTS

LVIHR was completed in 1,223 patients (98.5%). The average BMI was 32, mean defect size was 26.2 cm(2), mean operating time was 81 min and mean hospital stay was 1.9 days. The mean mesh to hernia ratio was 37.5. Occult hernias were observed in 203 (16.3%) patients and inadvertent enterotomies occurred in 21 (1.7%) patients. Mortality occurred in two patients, pulmonary embolism and cardiac dysrhythmia being the respective reasons. The most common sequel was early seroma formation (25%). Chronic pain occurred in 14.7% patients. Recurrence rate was 4.4%, which was associated with a higher BMI, use of staplers as fixation device, multiple defects and recurrent hernias. The mean follow up was 5.4 years; (range 2.4-10 years). The follow up rate was 78%.

CONCLUSION

LVIHR leads to low recurrence rates and low rates of wound and mesh infection. Occult hernias are diagnosed and optimally treated laparoscopically. However, chronic pain remains an unresolved issue.

Prospective randomized clinical trial comparing lightweight mesh and heavyweight polypropylene mesh in endoscopic totally extraperitoneal groin hernia repair

BACKGROUND

The purported advantage of lightweight large-pore meshes is improved biocompatibility that translates into lesser postoperative pain and earlier rehabilitation. However, there are concerns of increased hernia recurrence rate. We undertook a prospective randomized clinical trial to compare early and late outcome measures with the use of a lightweight (Ultrapro) mesh and heavyweight (Prolene) mesh in endoscopic totally extraperitoneal (TEP) groin hernia repair.

METHODS

A prospective study was performed on 402 patients (191 in Ultrapro and 211 in Prolene group) with bilateral groin hernias who underwent endoscopic TEP groin hernia repair from March 2006 to June 2007. All operations were performed by five consultants following a standardized operative protocol. Chronic groin pain and hernia recurrence were evaluated as primary outcome measures. Secondary outcome measure were early postoperative pain, operative time, number of fixation devices required to fix the mesh, return to normal daily activities of work, seroma, and testicular pain.

RESULTS

At 1-year follow-up, incidence in Ultrapro versus Prolene group for chronic groin pain was 1.6% vs. 4.7% (p = 0.178) and recurrence was 1.3% vs. 0.2% (p = 0.078). In Ultrapro versus Prolene group, mean visual analogue score for postoperative pain at day 7 was 1.07 vs. 1.31 (p = 0.00), mean return to normal activities was 1.82 vs. 2.09 days (p = 0.00), and mean number of fixation devices per patient required to fix the mesh was 4.22 vs. 4.08 (p = 0.043).

CONCLUSION

Lightweight meshes appear to have advantages in terms of lesser pain and early return to normal activity. However, more patients had hernia recurrence with lightweight meshes, especially for larger hernias. We surmise that the lightweight meshes have greater tendency to get displaced from their intended position during desufflation at the conclusion of endoscopic TEP repair.

Laparoscopic sleeve gastrectomy: an Indian experience-surgical technique and early results

BACKGROUND

Obesity has been observed to be on the rise in the Indian subcontinent. We report our early experience with the laparoscopic sleeve gastrectomy (LSG) for treating morbid obesity in the Indian population along with description of the surgical technique.

METHODS

The data of 75 patients who underwent LSG for the treatment of morbid obesity at the Minimal Access, Metabolic and Bariatric Surgery Centre, Sir Ganga Ram Hospital, Delhi, from November 2006 to February 2009, were retrospectively reviewed from prospective database. The gastric sleeve is created laparoscopically using sequential firings of a linear stapling device applied alongside a 36-Fr calibrating bougie. The data collected included age, gender, initial body mass index (BMI) and excess weight, the co-morbidity status, and preoperative investigations. Perioperative parameters and follow-up details [weight, BMI, excess weight loss (%EWL), resolution of co-morbidities, and postoperative investigations] were noted.

RESULTS

All procedures were completed laparoscopically. There was no major procedure-related morbidity. Hemorrhage requiring blood transfusion was observed in four patients. One patient died at 2 weeks postoperatively due to pulmonary embolism. There was a steady rise in %EWL from 31.2% at 3 months to 52.3% at 6 months, 59.13% at 1 year, and 65% at 2 years. Type II diabetes was resolved in 81.2%, hypertension in 93.75%, and dyslipidemia in 85% at 1 year.

CONCLUSION

Although long-term results are necessary to determine the benefits of the procedure, early results indicate that LSG may be a safe and feasible option for treating the morbidly obese patients.

Methotrexate bearing calcium pectinate microspheres: a platform to achieve colon-specific drug release

In the present work calcium pectinate (Ca-pectinate) microspheres were prepared to deliver methotrexate in the environment of colon. Calcium pectinate microspheres were prepared by modified emulsification method using calcium chloride as cross linker. All the formulations were evaluated for various physicochemical parameters. Particle size of the microspheres was determined using laser diffraction particle size analyzer. Encapsulation efficiency was determined by digesting with enzyme pectinase for 24 hours and swellability by equilibrium swelling in simulated gastrointestinal fluid. The in vitro drug release studies were performed in simulated gastric fluid for 2 hours and simulated intestinal fluid for 3 hours. In vitro release rate studies were also carried out in simulated colonic fluid in presence of rat caecal contents. Moreover, release rate studies were also carried out after enzyme induction by treating the rats with 1 ml of 1% w/v aqueous dispersion of pectin for 7 days. Mean particle size of the microspheres was found to be in the range of 20.82+/-1.34 to 32.26+/-1.59 microm whereas the entrapment efficiency varied from 52.28+/-0.32 to 74.01+/-3.32%. The in vitro drug release studies in simulated gastric fluid and simulated intestinal fluid showed that only 8.15+/-0.49% drug was released in 5 hours whereas most of the loaded drug was released in simulated colonic fluid containing pectinase. In vitro release rate study showed release of 69.94+/-3.46% of drug in presence of 3% rat caecal contents, which was further increased to 94.43+/-4.48% when enzyme induction was carried out for 7 days. Thus, it is concluded that calcium pectinate microspheres can be used to effectively localize the release of drug in the physiological environment of colon.

Design and development of multivesicular liposomal depot delivery system for controlled systemic delivery of acyclovir sodium

The aim of the present study was to design a depot delivery system of acyclovir sodium using multivesicular liposomes (MVLs) to overcome the limitations of conventional therapies and to investigate its in vivo effectiveness for sustained delivery. MVLs of acyclovir were prepared by the reverse phase evaporation method. The loading efficiency of the MVLs (45%-82%) was found to be 3 to 6 times higher than conventional multilamellar vesicles (MLVs). The in vitro release of acyclovir from MVL formulations was found to be in a sustained manner and only 70% of drug was released in 96 hours, whereas conventional MLVs released 80% of drug in 16 hours. Following intradermal administration to Wistar rats, the MVL formulations showed effective plasma concentration for 48 hours compared with MLVs and free drug solution (12-16 hours). C(max) values of MVL formulations were significantly less (8.6-11.4 microg/mL) than MLV and free drug solution (12.5 microg/mL). The AUC(0-48) of the MVL formulations was 1.5- and 3-fold higher compared with conventional liposomes and free drug solution, respectively. Overall, formulations containing phosphatidyl glycerol as negatively charged lipid showed better results. The MVL delivery system as an intradermal depot offers the advantage of a very high loading and controlled release of acyclovir for an extended period of time. The increase in AUC and decrease in C(max) reflects that the MVL formulations could reduce the toxic complications and limitations of conventional iv and oral therapies.

Videoendoscopically assisted combined retroperitoneal and pelvic extraperitoneal approach for aortoiliac occlusive disease

BACKGROUND

Laparoendoscopic surgery has emerged as a new method for the management of iliac and aortoiliac occlusive disease. This article describes a combined retroperitoneal and pelvic extraperitoneal approach to aorta and iliac arteries.

METHODS

A review was performed for 15 patients who underwent videoendoscopically assisted vascular bypass procedures between January 1999 and June 2003. A minimal access approach was used for access to the proximal anastomotic site (proximal common iliac or distal aorta) and creation of a tunnel for the prosthetic graft placement up to the distal anastomotic site. Altogether, 11 iliofemoral bypasses, 2 iliobifemoral bypasses and 2 aortobifemoral bypasses were performed. Patients with diffuse stenosis/long-segment occlusion and multiple lesions for whom percutaneous transluminal angioplasty with stenting proved to be unsuitable were included. The outcome parameters measured were intraoperative time, intraoperative blood loss, skin incision length, length of hospital stay, postoperative pain and analgesia requirement, and patency of graft.

RESULTS

Videoendoscopy was used to complete 14 procedures. The mean operating time was 258 +/- 49 min (range, 180-300 min) and the mean blood loss was 124 +/- 28.23 ml (range, 80-150 ml). The mean hospital stay was 6.7 +/- 4.46 days (range, 4-9 days). After a mean follow-up period of 14.4 +/- 3.55 months (range, 6-20 months), all grafts were patent.

CONCLUSION

Videoendoscopically assisted vascular surgery for iliac and aortoiliac occlusive disease by a combined retroperitoneal and pelvic extraperitoneal approach is feasible and appears to confer many advantages of minimal access surgery. However, prospective randomized trials are needed to define clearly any advantages of this approach over conventional surgery.

Solid lipid nanoparticles bearing flurbiprofen for transdermal delivery

Topical application of the drugs at the pathological sites offer potential advantages of delivering the drug directly to the site of action and thus producing high tissue concentrations of the drug. The solid lipid nanoparticles (SLN) bearing flurbiprofen were prepared by microemulsion method by dispersing o/w microemulsion in a cold aqueous surfactant medium under mechanical stirring. The SLN gel was prepared by adding SLN dispersion to polyacrylamide gel prepared by using polyacrylamide (0.5%), glycerol (10%), and water (69.5%). Shape and surface morphology was determined by scanning electron microscopy that revealed fairly spherical shape of the formulation. Percent drug entrapment was higher in SLN dispersion in comparison to SLN gel formulations. In vitro drug release, determined using cellophane membrane, showed that SLN dispersion exhibited higher drug release compared with SLN gel formulations. Both the SLN dispersion and SLN-gel formulation possessed a sustained drug release over a 24-hr period, but this sustained effect was more pronounced with SLN-gel formulations. The percent inhibition of edema after 8 hr was 55.51 +/- 0.26% in case of SLN-T4-gel, whereas flurbiprofen and SLN-T4 dispersion exhibited 28.81 +/- 0.46 and 31.89 +/- 0.82 inhibition of edema. The SLN-T4-gel not only decreased the inflammation to larger magnitude, but also sustained its effect.

Laparoscopic hepaticojejunostomy for biliary strictures: the experience of 10 patients

Hepaticojejunostomy is performed to reestablish bilioenteric continuity. During a 5-year period between July 1998 and July 2003, the authors attempted hepaticojejunostomy by a total laparoscopic approach in 10 patients with benign stricture disorders of the extrahepatic biliary tree. Six of these patients had type 1 (extrahepatic, fusiform) choledochal cyst and presented with pain, fever, and jaundice. Four of the patients had iatrogenic biliary strictures after cholecystectomy (2 patients after laparoscopic cholecystectomy and 2 patients after open cholecystectomy). These patients had a variable presentation 1 to 3 weeks after the primary procedure, with peritonitis and/or cholangitis or only progressive jaundice. For nine of the patients (90%), the procedure was completed entirely laparoscopically. The mean operative time was 326.6 min for the patients with choledochal cysts and 268 min for the patients with iatrogenic strictures. One patient with stricture after open cholecystectomy underwent conversion to an open repair because of severe anatomic distortion and fibrosis. Four patients drained bile postoperatively for 5 to 7 days. One patient with iatrogenic biliary stricture after open cholecystectomy required open revision of the anastomosis 18 months after laparoscopic hepaticojejunostomy because of recurrent cholangitis. The remaining eight patients (80%) were doing well a mean follow-up period of 3.1 years (range, 3 months to 5 years). Total laparoscopic hepaticojejunostomy is feasible for a select group of patients, but requires advanced laparoscopic skills, including intracorporeal suturing. It must be attempted only in centers well versed in advanced laparoscopic surgery.

Minimal access surgery for hydatid cyst disease: laparoscopic, thoracoscopic, and retroperitoneoscopic approach

Surgery has remained the mainstay for the treatment of hydatid cyst. The rapid development of laparoscopic techniques has encouraged surgeons to replicate principles of conventional hydatid surgery using a minimally invasive approach. Several reports have confirmed the feasibility of laparoscopic hepatic hydatid surgery. We report the use of a laparoscopic approach for cysts located in the liver, lung, and retroperitoneum. Fifteen patients with hydatid cysts, including one patient with a recurrent cyst, of various organs, including the liver, lung, and retroperitoneum, were operated on laparoscopically. Sixteen hydatid cysts were drained in a total of 15 patients. The mean operative time was 84 +/- 6 minutes (60-125 minutes). The mean duration of the hospital stay was 2.3 days (1-6 days). The mean cyst diameter was 9.2 cm (6.4-13.5 cm). No conversions to open surgery were required. One complication, a trocar-induced bowel perforation, occurred, and there was no mortality. During 3 to 44 months (mean, 27 months) of follow-up, no recurrences developed. Minimal access surgery is a safe, effective, and viable option for the management of selected patients with hydatid cysts in various locations, such as the liver, lung, and retroperitoneum.

Extraperitoneal endoscopic groin hernia repair under epidural anesthesia

We performed a prospective study to evaluate the feasibility of performing endoscopic total extraperitoneal repair of groin hernia (TEP) under epidural anesthesia in selected patients considered to be at high risk or unfit for general anesthesia. Fifty-eight endoscopic total extraperitoneal hernia repairs were performed in 36 patients between January 1997 and December 1999 under epidural anesthesia since they were considered a high risk or unfit for general anesthesia. All patients received intramuscular diclofenac sodium for preemptive analgesia. Intraoperatively, all were sedated with intravenous midazolam and fentanyl. Endoscopic TEP repair was successful under epidural anesthesia in 33 of 36 patients. In the remaining three patients, the procedure had to be converted to Lichtenstein's repair due to shoulder discomfort experienced by the patients as a result of pneumoperitoneum, which was produced by incidental peritoneal tears during extraperitoneal dissection. Intraoperatively, one patient had bleeding from the inferior epigastric artery, which was controlled with clipping of the artery. The mean operative time was 48 minutes (range, 28-72 minutes) in the TEP group and 94 minutes (range, 84-102 minutes) in the converted group. All the patients received an epidural top-up dose at the end of surgery for postoperative analgesia. All patients were ambulatory the same day. Postoperative pain was assessed by a visual analogue scale (VAS). The mean pain score was 1.2 (+/- 0.8) on discharge in the TEP group. During follow-up, seven patients developed scrotal swelling with cord induration, which was treated conservatively with scrotal support and analgesics. In all patients, resolution was observed within 6 weeks. One patient was detected to have a recurrence 4 months after surgery. Endoscopic TEP repair under epidural anesthesia appears to be safe, technically feasible, and an acceptable alternative in patients who are at high risk or unfit for general anesthesia.

Laparoscopic intragastric stapled cystogastrostomy for pancreatic pseudocyst

BACKGROUND

Mature symptomatic pancreatic pseudocysts require surgical intervention for their management. In this era of minimal access surgery, several reports are now available of laparoscopic management of pancreatic pseudocysts.

PATIENTS AND METHODS

We have performed this procedure in five patients over the past 2 years. Four patients developed the pseudocyst after acute alcoholic pancreatitis and one following acute biliary pancreatitis. The diameter of the pseudocyst ranged from 8 to 12 cm. The procedure was performed using five ports. The Harmonic Scalpel was used to create two ports in the anterior stomach wall through which two balloon trocars were placed into the gastric lumen. Following balloon inflation, the trocars were used to lift up the anterior gastric wall. This created the space for the cystogastrostomy to be fashioned laparoscopically through the balloon trocar. The ball probe of the Harmonic Scalpel was used to puncture the cyst through the posterior gastric wall. The cystogastrostomy was completed by firing an Endo-GIA30 stapler across the fused posterior gastric wall and anterior wall of the cyst.

RESULTS

The mean operative time was 90 minutes (range 80-125 minutes). The mean postoperative stay was 3.0 days. One patient had intraoperative bleeding at the anastomotic site, which was easily controlled.

CONCLUSION

Laparoscopic cystogastrostomy offers a feasible and safe therapeutic option for selected patients with large symptomatic pancreatic pseudocysts.

Fingerprinting method for phylogenetic classification and identification of microorganisms based on variation in 16S rRNA gene sequences

The paper describes a method for the classification and identification of microorganisms based on variations in 16S rRNA sequences. The 16S rRNA is one of the most conserved molecules within a cell. The nature of the variable and spacer regions has been found to be specific to a given organism. Thus, the method presented here can be very useful for the classification and identification of microorganisms for which very little information is available. To automate the method, a comprehensive computer program called FPMAP has been developed for the analysis of restriction fragment pattern data. The method involves the restriction digestion of genomic DNA, preferably using four-cutters that may recognize 6-9 sites within the 16S rDNA. The fragments are separated on a polyacrylamide gel along with a suitable marker, then transferred into a nylon membrane and hybridized with a radiolabeled 16S rDNA probe. After autoradiography, the fragment sizes are calculated, and the data are analyzed using the FPMAP software. We demonstrate that the method can be used for identification of strains of Streptomyces and mycobacteria. The software is available from our ftp site ftp:¿imtech.chd.nic.in/pub/com/fpmap/unix/.

Enhancement of obliterative airway disease in rat tracheal allografts infected with recombinant rat cytomegalovirus

BACKGROUND

Cytomegalovirus infection has been identified as a significant risk factor for the development of obliterative bronchiolitis in human lung transplant recipients. This study was designed to assess the influence of rat cytomegalovirus (RCMV) on the pathogenesis and development of obliterative bronchiolitis in an experimental model of obliterative airway disease, which occurs after allogenic heterotopic tracheal transplantation in rodents.

METHODS

Sixty Lewis rats were infected intraperitoneally with 10(7) plaque-forming units of recombinant lac-Z-tagged RCMV expressing the gene for beta-galactosidase. Rats were either infected at the time of surgery (acute infection, n = 30) or 56 days before surgery (chronic infection, n = 30). Tracheae from Brown Norway (allograft) or Lewis (isograft) rats were implanted and wrapped in the greater omentum of infected Lewis rats. RCMV infection was verified in different recipient tissues by in vitro plaque-assays and by direct in situ staining for beta-galactosidase activity. The tracheal grafts were harvested on days 7, 14, and 21 after transplantation and stained with hematoxylin-eosin and Masson's trichrome. The peritracheal cellular inflammation was scored visually. The cellular density of the infiltrating cells and the extent of airway obliteration were analyzed by use of computer-digitized morphometry and compared with uninfected allografts as control.

RESULTS

Both acute and chronic cytomegalovirus infection produced significantly higher mononuclear cell density values on days 7 and 14 compared with noninfected controls, indicating a more intense immune response in the infected allografts. Tracheal allograft obliteration was also more extensive after acute and, in particular, after chronic cytomegalovirus infection (64% narrowing after 21 days compared with 36% in grafts from noninfected control animals).

CONCLUSIONS

Our experimental results provide direct evidence that the tracheal grafts were infected with RCMV and that the development of obliterative airway disease was enhanced in the acutely and chronically infected allografts compared with grafts from noninfected control animals.

Obliterative airway disease after heterotopic tracheal xenotransplantation: pathogenesis and prevention using new immunosuppressive agents

BACKGROUND

The purpose of this study was to investigate whether obliterative bronchiolitis might occur after xenogenic pulmonary transplantation. A model for obliterative airway disease (OAD) after tracheal allograft transplantation in the rat undergoes tracheal obliteration with histologic features characteristic of obliterative bronchiolitis in human lung transplant recipients. Using this model, the pathogenesis of OAD and its prevention with immunosuppressive drugs was studied in rat recipients of hamster tracheal grafts.

METHODS

Tracheae from 30 hamsters (xenografts) or 23 Brown-Norway rats (allografts) were implanted and wrapped in the greater omentum of untreated Lewis rats. The grafts were removed on day 1, 3, 7, 14, 21, or 28 after transplantation and stained with hematoxylin and eosin and Masson's trichrome and by immunohistochemistry and immunofluorescence (IFL) techniques. In addition, 25 recipients were treated with cyclosporine (CsA, 10 mg/kg p.o.), leflunomide (LFM, 20 mg/kg p.o.), or rapamycin (RPM, 6 mg/kg i.p.) for 14 or 21 days (5 animals per treatment group). Visual and morphometric analyses were used to evaluate the extent of airway obliteration, luminal coverage by respiratory or flattened cuboidal epithelium, and extent and density of peritracheal cellular inflammation.

RESULTS

In all xenografts, a neutrophilic infiltration of the mucosa and submucosa was observed from day 1 until day 14 and was associated with complete loss of tracheal epithelium by day 14. A marked peritracheal mononuclear cellular infiltrate mixed with plasma cells and eosinophils was seen on days 7 and 14. Both the extent of peritracheal inflammation and the density of the mononuclear cell infiltrate were significantly increased in xenograft tracheae when compared with the allografts. Tracheal obliteration began on day 14 and reached a maximum of 43% on day 21 with evidence of intraluminal fibrosis. In contrast to IFL of allografts, IFL of xenografts demonstrated marked deposition of rat immunoglobulin in the peritracheal tissue on days 7 and 14. The effects of treatment with immunosuppressive drugs on tracheal graft narrowing and protection of respiratory epithelium were as follows: After 14 days of treatment, the percentage of tracheal graft narrowing was 12%, 23%, and 19% in the no treatment, CsA, and LFM groups, respectively; the percentage of respiratory epithelium at 14 days was 0%, 21%, and 95%. After 21 days of treatment, the percentage of tracheal graft narrowing was 43%, 49%, 12%, and 5% for the no treatment, CsA, LFM, and RPM groups, respectively; the percentage of respiratory epithelium at 21 days was 0%, 39%, 86%, and 0%. Using computerized morphometry, the extent and densities of the peritracheal cellular infiltrates were significantly reduced in LFM- and CsA-treated groups when compared with untreated xenograft controls. LFM and RPM, but not CsA, significantly reduced the degree of luminal obliteration compared with no treatment (P<0.05). LFM and, to a lesser extent, CsA were able to prevent the loss of normal respiratory epithelium. Analysis by IFL revealed a marked decrease in rat immunoglobulin deposition in xenografts from LFM- and RPM-treated groups compared with xenografts from CsA-treated or untreated rats.

CONCLUSIONS

(1) OAD occurs not only after tracheal allotransplantation but also after xenotransplantation. (2) Subepithelial infiltration of neutrophils and the appearance of plasma cells and eosinophils in the peritracheal infiltrates distinguished the histology of rejected xenografts from allografts. (3) Antibody deposition was detected by IFL only in xenografts. (4) Treatment with LFM or RPM significantly decreased the severity of luminal obliteration. Importantly, LFM also prevented the loss of respiratory epithelium.

Role of protein kinase beta isozyme in multidrug resistance in murine leukemia P388/ADR cells

To define a role of protein kinase C (PKC) in multidrug resistance (MDR), we examined the influence of PKC isozyme specific antibodies delivered intracellularly, on drug sensitivity and drug accumulation in P388/ADR cells. Drug sensitive (P388) and drug resistant (P388/ADR) cells were permeabilized at 4 degrees C with L-lysolecithin and were incubated with rabbit anti-PKC, alpha, beta antibodies, or normal rabbit serum for 10 minutes at 37 degrees C. Daunorubicin (DNR) accumulation and drug sensitivity were studied by flow cytometry and MTT assay, respectively. Anti-PKC beta antibody partially corrected drug accumulation defect and completely reversed resistance to DNR. Anti-PKC alpha antibody had no effect on either parameter of MDR. These results suggest that PKC beta plays an important role in MDR in P388/ADR cells. Furthermore, the technique of intracellular delivery of antibodies provides a new approach to discern the role of PKC isoforms in multidrug resistance in various tumor cells.

Schöpf-Schulz-Passarge syndrome

Three siblings, the children of a marriage between first cousins, are reported with the characteristic ophthalmological and cutaneous changes of the Schöpf-Schulz-Passarge syndrome. There have been only eight reported cases of this disorder, and it has not previously been described in Great Britain.