Robotically assisted biliary pancreatic diversion with a duodenal switch: a new technique

BACKGROUND

Minimally invasive surgical techniques decrease the length of hospitalization and the morbidity for general surgery procedures. Application of minimally invasive techniques to obesity surgery had previously been limited to stapled techniques used primarily for the Roux-en-Y gastric bypass and laparoscopic band placement. The authors present the technique for totally intracorporeal robotically assisted biliary pancreatic diversion with a duodenal switch (BPD/DS) using five ports.

METHODS

After development of the technique in animal and human cadaver models, the da Vinci robot was first used in October 2000 to perform BPD/DS using five ports and a totally intracorporeal technique. Patient selection was based on standard surgery guidelines for the morbidly obese.

RESULTS

This technique was applied for 47 patients with a mean body mass index (BMI) of 45 kg/m2 and a mean age of 38 +/- 10 years. The median operating time was 514 min (range, 370-931 min). The median operative time for the last 10 patients was 379 min (range, 370-582 min). Three patients underwent conversion to open surgery, and four patients experienced postoperative leaks with no mortality.

CONCLUSION

The safety, feasibility, and reproducibility of a minimally invasive robotic surgical approach to complex abdominal operations such as BPD/DS is demonstrated. The BPD/DS allows for a sutured bowel anastomosis similar to the open technique using a minimal number of small access ports.

Phacoemulsification combined with silicone oil removal through a posterior capsulorhexis

PURPOSE

To evaluate the technique of silicone oil removal through a posterior capsulorhexis combined with phacoemulsification and intraocular lens (IOL) implantation.

SETTING

Dr. Rajendra Prasad Center for Ophthalmic Sciences, New Delhi, India.

METHODS

Fifteen eyes of 15 patients had phacoemulsification with removal of silicone oil, which had been used for intraocular tamponade after a previous pars plana vitrectomy. Eyes with a stable retina were included in the series. In all eyes, the silicone oil was removed through a planned posterior capsulorhexis after phacoemulsification. The parameters evaluated were the primary diagnosis, duration between silicone oil instillation and phacoemulsification, type of cataract, preoperative and postoperative best corrected visual acuities (BCVAs), and complications such as frequency of retinal redetachment and secondary cataract.

RESULTS

Vitreoretinal surgery with silicone oil instillation was performed for rhegmatogenous-tractional detachment resulting from Eales' disease in 6 eyes and from proliferative diabetic retinopathy in 2 eyes, for primary rhegmatogenous retinal detachment in 6 eyes, and for traumatic rhegmatogenous detachment in 1 eye. The mean duration between the silicone oil instillation and phacoemulsification was 7.5 months +/- 3.8 (SD). Fourteen eyes had posterior subcapsular cataract, and 10 had nuclear sclerosis. Preoperative BCVA was worse than 6/60 in all eyes. The BCVA was 6/60 or better in 9 eyes after a minimum follow-up of 6 months. Two eyes had choroidal detachment in the early postoperative period. No eye had vitreous hemorrhage, retinal redetachment, secondary cataract, clinically significant endothelial decompensation or macular edema, or a dislocated IOL.

CONCLUSION

The results indicate that silicone oil removal through a posterior capsulorhexis during phacoemulsification is a viable option and can be performed in selected cases of cataract with previous silicone oil instillation and a stable retina.

Long-term outcome of simultaneous kidney-pancreas transplantation: analysis of 61 patients with more than 5 years follow-up

BACKGROUND

The long-term outcome of simultaneous kidney pancreas transplant recipients is not well established.

METHODS

We retrospectively reviewed all patients who underwent simultaneous kidney-pancreas transplantation with bladder drainage at our center between January 1989 and December 1991. A total of 57 patients (93%) were alive with functioning grafts 1 year after transplantation and were followed for a minimum of 5 years. These patients formed the study group.

RESULTS

Five-year actual patient, kidney and pancreas survival rates were 95%, 85%, and 88%, respectively. Fasting serum glucose fell from 198 mg/dL preoperatively to 94 mg/dL and remained stable thereafter. Glycohemoglobin levels decreased from 9.8% preoperatively to 4.8% 1 year after transplantation and remained normal thereafter. Kidney function remained good, with mean serum creatinine of 2.0 and creatinine clearance of 56 ml/min throughout the follow-up period. Hospital admissions decreased significantly with increasing time after transplantation from a mean of 1.2 admissions per patient in the 1st year to a mean of 0.2 admissions per patient 6 years after transplantation. Of the readmissions, 42% were for <48 hr and the most common reasons for readmission were infection, surgery, and dehydration. Mean systolic blood pressure decreased from 166 mm Hg before the transplant to 142 mm Hg 1 year after the transplant.

CONCLUSIONS

Simultaneous kidney pancreas transplantation is a safe and effective method to treat advanced diabetic nephropathy and is associated with stable metabolic function, decreased cholesterol, improved hypertension control, improved rehabilitation over time, and little morbidity or mortality after the 1st year.

An emerging schizophrenic syndrome

This case history describes a 16-year-old adolescent male who developed schizophrenia with prominent negative symptoms. For the previous 6 years his diagnosis had been oppositional defiant disorder or conduct disorder. The clinical presentation, differential diagnosis, and management are discussed. The case exemplifies issues addressed in DSM IV.

Long-term stability of electroenzymatic glucose sensors implanted in mice. An update

Protection of the enzyme layer of glutaraldehyde vapor-stabilized glucose oxidase-based glucose sensors from attack by proteolytic enzymes and peritoneal macrophages can be accomplished by covering with a regenerated cellulose (viscose) membrane, as commonly used for laboratory dialysis. These implanted sensors are not externally polarized, but continuously consume oxygen and glucose and generate gluconic acid and hydrogen peroxide. On the average (sensors in 45 mice) the activity declines with time, almost vanishing by 600 days. However, the fact that some sensors retain nearly all of their activity for over 500 days indicates that glucose sensors can be made with a life span compatible with the requirements for an artificial pancreas (glucose sensor/insulin pump). Limited observation with similar implanted lactate sensors indicates their life span to be shorter.

Polarographic cerebral oxygen availability, fluorocarbon blood levels and efficacy of oxygen transport by emulsions

In order to relate blood perfluorocarbon (PFC) level to brain tissue oxygen availability (aO2) and respiratory oxygen (FIO2), twelve conscious rabbits with chronically implanted platinum cathodes were infused with six types of emulsions in 14 infusions and their response to oxygen and carbogen breathing recorded. Blood was removed for sampling and to avoid a volume overload. Blood lactate was measured as an indicator of adequacy of perfusion. Glucose, osmotic pressure, packed cell volume, PFC by combustion and volatilization were also measured in blood samples. Methyl prednisolone was administered to 5 rabbits. Blood PFC levels measured by the commonly used centrifugation method (Fluorocrit) were subject to considerable variation, depending mainly upon centrifugation time. Fluorocrit values after Oxypherol infusion decreased from an average of 43% for 5 minutes to 15% for 30 minutes centrifugation. Fluorocrit tended to slightly increase with time of centrifugation when phospholipid was used as the emulsifier, early in PFC infusion and on the next day. Blood fluorocarbon was always lower, about half that of 30 minutes of centrifugation, when determined by combustion or by volatilization, than by centrifugation. The increase in brain a O# response to oxygen and carbogen was observed at a lower PFC blood level than expected and in some animals appeared in either the right or left hemisphere, but not in both, suggesting that oxygen transport, at least near the electrode, was by other than oxygen solubility in blood PFC. Blood lactate proved to be an excellent monitor of whole body perfusion. Animals with a blood lactate above 5 mM/L at 1 hour post infusion died the following day. The fluorocrit after 5, 10, 20, and 30 minutes of centrifugation, which we have named the "fluoro-gram," can have a sharp downward, a slight upward curve, or stay level, depending upon the type of emulsifier, the amount of PFC circulating and the time it has circulated. The fluorocarbon-induced increases in aO2 persist through the third day. This enhanced cerebrocortical aO2 current can be very roughly calculated as: aO2 current equals the air aO2 current plus (the 30 minute fluorocrit times K) where K for oxygen is 0.05 and for carbogen is 0.07. Some enhancement of the aO2 current in oxygen lingers to the fifth day after the blood PFC level is vanishingly small. Methyl prednisolone has a transient effect in suppressing the PFC enhanced oxygen and carbogen aO2 responses and no effect on the Oxypherol fluorogram.(ABSTRACT TRUNCATED AT 400 WORDS)

Long-term implantation of voltammetric oxidase/peroxide glucose sensors in the rat peritoneum

Methods for designing, fabricating, testing in vitro and in vivo, and improving chronically implantable oxidase/peroxide-type polarographic glucose sensors are described. Voltammetric means to evaluate oxygen supply to the sensor and to measure the nearby microcirculation with hydrogen washout techniques using the implanted glucose sensor are outlined. Because some peritoneally implanted sensors have, perhaps surprisingly, remained functional for months, such devices may prove with further development to be useful as the sensing components in artificial pancreatic beta cells for the control of diabetes.