An in vitro evaluation of endodontic sealers and an antibiotic to assess their antimicrobial effect against Enterococcus faecalis.

Objective: This study aimed to compare the antimicrobial effect of three endodontic sealers (AH Plus, Mineral trioxide aggregate [MTA] Fillapex, and BioRoot RCS) with and without amoxicillin against E. faecalis. Methodology: Amoxicillin, equivalent to 10% of the sealers' total weight, was mixed with the sealers. Another batch was prepared without amoxicillin. The direct contact test (DCT) and the agar diffusion test were used to assess the antibacterial effect. Results were analysed using one-way analysis of variance (ANOVA), the F-test, and the Kruskal-Wallis test. Results: AH Plus significantly suppressed E. faecalis without the addition of amoxicillin in the DCT (p = 0.011), while in the agar diffusion test, BioRoot RCS had a larger inhibition zone than the control (p < 0.001). When amoxicillin was added to the sealers, AH Plus (p = 0.003) and MTA Fillapex (p = 0.042) reduced E. faecalis growth. In contrast, all three sealers showed larger inhibition zones than the control (p = 0.001), with AH Plus displaying a larger inhibition zone than MTA Fillapex (p = 0.042) and BioRoot RCS (p = 0.032). Conclusions: It was thus concluded that the addition of amoxicillin to endodontic sealers enhances their antimicrobial activity against E. faecalis.

Shaping ability of BlueShaper, TruNatomy, DC Taper and HyFlex EDM in long oval canals: An ex vivo study.

AIM: This study evaluated and compared the shaping ability of four rotary instrument systems in long-oval root canals using microcomputed tomographic (micro-CT) evaluation. Currently, there is no data available on the canal shaping abilities of BlueShaper and DC Taper instruments. METHODOLOGY: Sixty-four single-rooted mandibular premolars were matched based on similar root canal morphologic features as determined by (micro-CT) and randomly assigned to 1 of 4 experimental groups (n = 16) according to the instrument system used: BlueShaper, TruNatomy, DC Taper and HyFlex EDM One File. Changes in the root canal surface and volume, remaining dentine thickness, and number of prepared areas were assessed. RESULTS: No significant differences were found amongst the four instrument systems for the parameters evaluated (p > .05). There was a significant reduction in the number of unprepared areas and the remaining dentine thickness after each increase in size of the instruments tested (p < .05). CONCLUSIONS: The four instrument systems perform similarly in long oval root canals. Although none could prepare all canal walls, larger preparations incorporated significantly more surfaces in the final shape.

Depressive symptoms exacerbate disability in older adults: A prospective cohort analysis of participants in the MemAID trial.

BACKGROUND: Maintaining independence in older age is an important aspect of quality of life. We investigated depressive symptoms as an important modifiable risk factor that may mediate the effects of physical and cognitive decline on disability. METHODS: We prospectively analyzed data from 223 adults (age 50-85; 117 controls and 106 with type-2 diabetes) over 48 weeks who were participating in a clinical trial "Memory Advancement by Intranasal Insulin in Type 2 Diabetes." Data from self-reported disability (World Health Organization Disability Assessment Schedule) and depressive symptoms (Geriatric Depression Scale) were obtained from baseline, week 25, and week 48 visits. Cognition (Mini-mental status examination) and medical comorbidities (Charlson Comorbidity Index) were assessed at baseline. Longitudinal analysis assessed the extent to which change in depressive symptoms predicted worsening disability. Mediation analyses were performed to determine the extent to which depressive symptoms accounted for disability associated with worse cognition, walking speed, and comorbidities. RESULTS: At baseline, depressive symptoms, cognition, and walking speed were within normal limits, but participants had a high 10-year risk of cardiovascular mortality. Depressive symptoms were related to disability at baseline (p<0.001), and longitudinally (p<0.001). Cognition, walking speed, and comorbidities were associated with disability at baseline (p-values = 0.027-0.001). Depressive symptoms had a large mediating effect on disability longitudinally: the indirect effect on disability via depression accounts for 51% of the effect of cognition, 34% of the effect of mobility, and 24% of the effect of comorbidities. CONCLUSIONS: Depressive symptoms substantially exacerbated the effects of worsening cognition, gait speed, and comorbidities on disability. In our sample, most individuals scored within the "normal" range of the Geriatric Depression Scale, suggesting that even subclinical symptoms can lead to disability. Treating subclinical depression, which may be under-recognized in older adults, should be a public health priority to help preserve independence with aging.

Antimicrobial effectiveness of root canal sealers against Enterococcus faecalis.

We evaluated four root canal sealers to determine their antimicrobial effectiveness against E. faecalis. The direct contact test was used to measure the effectiveness of the study materials and close contact between bacteria on the kinetics of bacterial growth. The agar diffusion test (ADT) was also performed for comparison. Using one-way ANOVA and the F-test, significant differences between the sealers were confirmed. Whereas BioRoot endodontic sealer had an antimicrobial effect statistically similar to the zinc oxide-eugenol control (p=.99), EndoSequence sealer and AH Plus sealer both had a significantly lower antimicrobial effect than the control (p=.0000266 and p=.0000068, respectively).

Antimicrobial potential of AH Plus supplemented with bismuth lipophilic nanoparticles on E. faecalis isolated from clinical isolates.

The objective of this study was to determine the antimicrobial potential of AH plus supplemented with bismuth lipophilic nanoparticles (BisBAL NPs) on the growth of Enterococcus faecalis isolated from patients with endodontic infections. BisBAL NPs, synthesized with the colloidal method, were characterized, in its pure form or AH Plus-absorbed, by energy-dispersive X-ray spectroscopy and scanning electron microscopy (EDS-SEM). Antimicrobial activity was evaluated with disc diffusion assays, and antibiofilm activity with fluorescence microscopy. BisBAL NP-supplemented AH Plus had a 4.9 times higher antimicrobial activity than AH Plus alone (p = 0.0001). In contrast to AH Plus alone, AH Plus supplemented with BisBAL NP inhibited E. faecalis biofilm formation. The sealing properties of AH plus were not modified by the incorporation of BisBAL NPs, which was demonstrated by a 12-day split-chamber leakage assay with daily inoculation, which was used to evaluate the possible filtration of E. faecalis. Finally, BisBAL NP-supplemented AH plus-BisBAL NPs was not cytotoxic for cultured human gingival fibroblasts. Their viability was 83.7% to 89.9% after a 24-h exposure to AH Plus containing 50 and 10 µM BisBAL NP, respectively. In conclusion, BisBAL NP-supplemented AH Plus constitutes an innovative nanomaterial to prevent re-infection in endodontic patients without cytotoxic effects.

Desplazamiento de Tercer Molar Superior a Fosa Infratemporal: Reporte de Casos y Revisión de Literatura

RESUMEN: Dentro de las complicaciones transoperatorias de una cirugía de tercer molar se encuentra el desplazamiento del diente a espacios anatómicos adyacentes. Dicho accidente representa un porcentaje muy bajo de las complicaciones y se atribuye a una planeación y manejo clínico inadecuado. En este reporte se abordará específicamente el desplazamiento accidental de terceros molares superiores a la fosa infratemporal. Se realizó una búsqueda de información en la plataforma PubMed con las palabras claves "third molar displacement", obteniendo un total de 22 artículos según los criterios de inclusión. Se presentan dos casos de desplazamiento de tercer molar superior a fosa infratemporal manejados en el Centro Académico de Atención Odontológica (CAAD) del Tecnológico de Monterrey. El propósito del presente escrito es proponer un protocolo de manejo para dicha complicación.

ABSTRACT: One of the intraoperative complications of third molar surgery is the displacement of the tooth to adjacent anatomical spaces. This accident represents a small percentage of complications and is attributed to inadequate clinical planning and management. This report will specifically address the accidental displacement of upper third molars to the infratemporal fossa. A search was conducted by using the PubMed database with the keywords "third molar displacement", a total of 22 articles were included according to the inclusion criteria. Two cases of displacement of the upper third molar to the infratemporal fossa managed at the Centro Academico de Atencion Odontologica (CAAD) of the Tecnologico de Monterrey will be reported. The aim of this paper is to present a management protocol for this complication.

Evaluación de calidad en los servicios de salud: un análisis desde la percepción del usuario / Evaluation of health care services quality: An analysis from the user's perception

Resumen Objetivo: Analizar los determinantes de la evaluación en la calidad de los servicios de salud públicos y privados usando como caso de estudio el Área Metropolitana de Monterrey (AMM). Material y métodos: A partir de un estudio cuantitativo-exploratorio que utiliza la información del estudio de percepción ciudadana "Así Vamos 2018" y cuyo diseño permite la representatividad a nivel estatal, municipal y por género en la población objetivo, se utilizan dos métodos estadísticos (análisis factorial y modelo de regresión Tobit) para identificar cuales características son valoradas en la percepción de calidad para cada servicio de salud, distinguiendo entre instituciones públicas y privadas. Posteriormente, se analiza como las variables de servicio que determinan esta evaluación de calidad. Resultados: Las estimaciones sugieren diferencias significativas de los determinantes de calidad entre distintos servicios de salud: mientras para los usuarios del IMSS lo más importante es la "características de las instalaciones", "horarios de servicio" y preponderantemente "acceso a medicinas", para usuarios del Seguro Popular y servicios privados es la "atención del personal administrativo". Conclusión: Los usuarios utilizan diferentes criterios para evaluar las alternativas de servicios de salud a las que tienen acceso, y por tanto esta discrepancia es fundamental al comparar la calidad ofrecida por diferentes oferentes.

Abstract Objective: This paper studies the determinants of the quality assessment of public and private health services using the Monterrey Metropolitan Area (AMM) as a case study Material and Methods: This is a quantitative-exploratory study that uses the information from the citizen perspective study "Asi Vamos 2018" and whose design allows representativeness at the state, municipal, and gender levels in the relevant population, two statistical methods are used (factor analysis and a Tobit regression model) to identify which characteristics are valued in the perception of quality for each health service, distinguishing between public and private institutions. Subsequently, it is analyzed how service variables determine this quality evaluation. Results: The estimations suggest significant differences in the determinants of quality between health services: while for IMSS users the most important characteristics evaluated are the quality of installations, "access to more dates for medical attention", and "access to medicines" for Seguro Popular and private services users it is the "hospital managerial personnel attitude". Conclusion: Users apply different criteria to evaluate the alternatives on health service to which they have access, and therefore this discrepancy is fundamental when comparing the quality offered by different suppliers.

TS-HDS and FGFR3 antibodies in small fiber neuropathy and Dysautonomia.

INTRODUCTION: The specificity of trisulfated heparin disaccharide/fibroblast growth factor receptor 3 (TS-HDS/FGFR3) antibodies in the diagnosis of autoimmune small fiber neuropathy (SFN) is unclear. METHODS: This was a retrospective study of patients evaluated for SFN and dysautonomia in the Brigham and Women's Faulkner Hospital Autonomic Laboratory in 2019-2020. Associations were assessed between TS-HDS/FGFR3 antibodies and SFN markers, including epidermal nerve fiber density (ENFD), sweat gland nerve fiber density (SGNFD), and autonomic dysfunction assessed by Valsalva maneuver, deep breathing, sudomotor, and tilt testing. RESULTS: Of 322 patients; 28% had elevated anti-TS-HDS, 17% had elevated anti-FGFR3, 96% had autonomic dysfunction, 71% had abnormal ENFD, and 49% had abnormal SGNFD. TS-HDS/FGFR3 antibodies were present in patients with autonomic dysfunction irrespective of whether they had normal or abnormal skin biopsies unless ENFD/SGNFD were combined for anti-FGFR3 seropositivity. DISCUSSION: TS-HDS/FGFR3 antibodies are present in patients with evidence of autonomic dysfunction. Further studies are needed to document the clinical value of these antibodies in assessment of immune mediated dysautonomia.

In Vivo Evaluation of 3 Electronic Apex Locators: Root ZX Mini, Apex ID, and Propex Pixi.

INTRODUCTION: The aim of this in vivo study was to compare the accuracy of 3 electronic apex locators (EALs) (Root ZX mini [J Morita Corp, Tokyo, Japan], Apex ID [SybronEndo, Glendora, CA], and Propex Pixi [Dentsply Maillefer, Ballaigues, Switzerland]) to determine the working length. METHODS: Thirty single-rooted human teeth that were scheduled for extraction were selected for the study. Electronic measurements were performed with the 3 EALs. After the teeth had been extracted, a #10 K-file was used to determine the actual working length, which was established at 0.5 mm short of the major foramen. The data were statistically analyzed with analysis of variance (α = 0.05). RESULTS: No significant differences were found among the experimental groups (P > .05). The mean distance from the actual working length to the file tip was 0.163 ± 0.032 mm when Root ZX mini was used, 0.343 ± 0.032 mm for Propex Pixi , and 0.012 ± 0.008 mm for Apex ID. CONCLUSIONS: Under the in vivo conditions of this study, no statistically significant differences were observed among the 3 EALs.

Apexification in a mandibular first molar with a middle mesial canal.

Apexification procedures have been widely used to treat teeth with incomplete root development and pulp necrosis. The middle mesial canal (MMC) is an anatomical variation and in most cases represents a challenge during endodontic treatments. In this article, a favorable outcome is reported after apexification in a molar with MMC.

3D Imaging Detection of HER2 Based in the Use of Novel Affibody-Quantum Dots Probes and Ratiometric Analysis.

Patients with breast cancer (BC) overexpressing HER2 (HER2+) are selected for Trastuzumab treatment, which blocks HER2 and improves cancer prognosis. However, HER2+ diagnosis, by the gold standard, immunohistochemistry, could lead to errors, associated to: a) variability in sample manipulation (thin 2D sections), b) use of subjective algorithms, and c) heterogeneity of HER2 expression within the tissue. Therefore, we explored HER2 3D detection by multiplexed imaging of Affibody-Quantum Dots conjugates (Aff-QD), ratiometric analysis (RMAFI) and thresholding, using BC multicellular tumor spheroids (BC-MTS) (~120 µm of diameter) as 3D model of BC. HER2+, HER2- and hybrid HER2+/- BC-MTS (mimicking heterogeneous tissue) were incubated simultaneously with two Aff-QD probes (anti-HER2 and negative control (NC), respectively, (1:1)). Confocal XY sections were recorded along the Z distance, and processed by automatized RMAFI (anti-HER2 Aff-QD/ NC). Quantifying the NC fluorescence allowed to predict the fraction of non-specific accumulation of the anti-HER2 probe within the thick sample, and resolve the specific HER2 level. HER2 was detected up to 30µm within intact BC-MTS, however, permeabilization improved detection up to 70µm. Specific HER2 signal was objectively quantified, and HER2 3D-density of 9.2, 48.3 and 30.8% were obtained in HER2-, HER2+ and hybrid HER2+/- permeabilized BC-MTS, respectively. Therefore, by combining the multiplexing capacity of Aff-QD probes and RMAFI, we overcame the challenge of non-specific probe accumulation in 3D samples with minimal processing, yielding a fast, specific spatial HER2 detection and objective quantification.

Quistectomía conservadora mediante trepanaciones múltiples: reporte de un caso / Conservative cystectomy by multiple trepanations: report of a case

En la actualidad los procedimientos quirúrgicos han evolucionado con la intención de ser lo más conservadores posible, dando pie a una regeneración fi siológica más rápida y completa. La extirpación de quistes de gran tamaño de los maxilares mediante descompresión y marsupialización ha demostrado obtener excelentes resultados, siendo éste un procedimiento que permite evitar un amplio abordaje quirúrgico, aunque generalmente requiere un segundo tiempo para reconstruir el defecto. La quistectomía conservadora mediante múltiples trepanaciones de acceso, permite la eliminación del cuerpo patológico por completo sin la necesidad de un segundo procedimiento quirúrgico. La excelente cicatrización ósea fi siológica y adecuado reposicionamiento y soporte de tejidos blandos sin necesidad de utilizar membranas, son logrados gracias a los puentes óseos que se mantienen entre las trepanaciones, los cuales brindan soporte además de mantener células osteoprogenitoras. Se presenta caso clínico de enucleación conservadora de quiste periapical de gran tamaño y extracción de canino retenido en paciente masculino de 12 años de edad mediante trepanaciones múltiples (AU)

Nowadays the surgical procedures have evolved aiming to be as conservative as possible, resulting in a faster physiological regeneration. The removal of large maxillary cysts using decompression and marsupialization has proved to have excellent results, is this a procedure that avoids the use of large surgical access, although a second procedure is generally needed to completely remove the lesion. Conservative cystectomy using multiple access trepanations allows the complete elimination of the cyst without the need for a second surgical intervention. Excellent physiological bone healing and adequate soft tissue reposition without the need of grafting material and membrane is achieved thanks to the osseous bridges between the multiple trepanations, which gives support for soft tissue and provides osteoprogenitor cells. A clinical case of conservative enucleation of a large radicular cyst is presented as well as the extraction of a retained canine in a 12-year-old male patient using multiple trepanations (AU)

Efectividad del uso de la bolsa adiposa de bichat para la reconstrucción de defectos en el paladar: reporte de un caso / Effectiveness of the use of the bichats fat pad for the reconstructionof defects in the palate. report a case

La bolsa adiposa de Bichat está constituida por un cuerpo y tres extensiones de tejido adiposo, se localiza dentro del espacio bucal y seextiende siguiendo el borde anterosuperior del músculo masetero. En la actualidad su uso como colgajo pediculado ha demostrado excelentesresultados en el tratamiento de reconstrucción de defectos postumorales de tejido blando en el paladar. Lo anterior se debe a su gran aporte vascular, composición histológica y a la presencia de células madre en tejido adiposo que fomentan una metaplasia del tejido, convirtiéndose en tejido fibroso y superfi cialmente con epitelio en tan sólo cinco semanas. La técnica de abordaje y reposicionamiento del colgajo pediculado en paladar fue modifi cada con la extirpación de la tuberosidad del maxilar para corregir el defecto ocasionado por un adenoma pleomorfo en el paladar. Se destacan las características y cualidades de la bolsa adiposa de Bichat para su uso en reconstrucción de defectos tumorales.

Bichat’s buccal fat pad is constituted by a body and three extensions ofadipose tissue within the buccal space and extending to the anteriorsuperiorborder of the masseter muscle. To this days, the use of thebuccal fat pad as a pedicled graft has shown excellent results onoral post tumoral reconstruction treatment. This is due to its greatvascularity, histological composition and perhaps to the presenceof stem cells that promotes a metaplasia, turning adipose tissue intofi brous and superfi cially epithelized tissue within fi ve week aftersurgery. Surgical approach and repositioning technique of the pedicledgraft was modifi ed, extirpating part of the maxillary tuberosity, topreserve vascularity and cover up a hard-soft tissue defect caused by apleomorphic adenoma on a patient’s palate. Buccal fat pad’s qualitiesand characteristics are taken into consideration to demonstrate theeff ectiveness on its surgical reconstructive uses.

A local representation of the head-related transfer function.

Spatial descriptions of the head-related transfer function (HRTF) using spherical harmonics, which is commonly used for the purpose, consider all directions simultaneously. However, in perceptual studies, it is necessary to model HRTFs with different angular resolutions at different directions. To this end, an alternative spatial representation of the HRTF, based on local analysis functions, is introduced. The proposal is shown to have the potential to describe the local features of the HRTF. This is verified by comparing the reconstruction error achieved by the proposal to that of the spherical harmonic decomposition when reconstructing the HRTF inside a spherical cap.

Osteomielitis causante de fractura patológica: reporte de un caso / Pathological fracture resulting from osteomyelitis: report of a case

Las fracturas patológicas mandibulares son poco comunes, representanel 1 a 2% de todas las fracturas. Pueden ser defi nidas como fracturasque ocurren en regiones donde el hueso ha sido debilitado bajo un procesopatológico. Los factores de causa más comunes incluyen procesosquirúrgicos tales como extracciones de terceros molares, colocación deimplantes, osteonecrosis relacionada con bifosfonatos, osteorradionecrosisde la mandíbula, osteomielitis, infecciones, tumores o lesionesquísticas. La osteomielitis es una condición infl amatoria del hueso; estapatología es uno de los factores que puede determinar el debilitamientodel hueso mandibular y causar una subsecuente fractura patológica. Laosteomielitis mandibular se puede desarrollar si una infección primaria noes manejada adecuadamente. El tratamiento de las fracturas patológicaspuede representar un reto para el profesional de la salud y difi ere segúnla etiología de la misma. Se presenta un caso de una paciente de 54 añosde edad, con una fractura mandibular patológica causada por osteomielitis,la cual fue tratada con antibioticoterapia e intervención quirúrgica.

Pathological mandibular fractures are rare, accounting for between1 and 2% of all fractures. They can be defi ned as fractures thatoccur in regions where the bone has become weakened as a result of a pathological process. Common causal factors include surgicalprocedures such as third molar removal, implant placement, bisphosphonate-related osteonecrosis, osteoradionecrosis of the jaw,osteomyelitis, infections, tumors, and cystic lesions. Osteomyelitisis an infl ammatory condition of the bone; this pathology is one ofthe factors that may prompt weakening of the mandibular boneand cause subsequent pathological fracture. Osteomyelitis of themandible may develop if a primary infection is not properly treated.Treatment of pathological mandibular fractures can be challengingand varies according to their etiology. This article looks at the caseof a 54-year-old woman with a pathological mandibular fracture caused by osteomyelitis, which was treated by means of antibioticotherapy and surgical intervention.

Changes in T-Tubules and Sarcoplasmic Reticulum in Ventricular Myocytes in Early Cardiac Hypertrophy in a Pressure Overload Rat Model.

BACKGROUND/AIMS: Pressure-overload (PO) causes cardiac hypertrophy (CH), and eventually leads to heart failure (HF). HF ventricular myocytes present transverse-tubules (TT) loss or disarrangement and decreased sarcoplasmic reticulum (SR) density, and both contribute to altered Ca2+ signaling and heart dysfunction. It has been shown that TT remodeling precedes HF, however, it is unknown whether SR structural and functional remodeling also starts early in CH. METHODS: Using confocal microscopy, we assessed TT (with Di-8-ANNEPS) and SR (with SR-trapped Mag-Fluo-4) densities, as well as SR fluorophore diffusion (fluorescence recovery after photobleach; FRAP), cytosolic Ca2+ signaling and ex vivo cardiac performance in a PO rat hypertrophy model induced by abdominal aortic constriction (at 6 weeks). RESULTS: Rats developed CH, while cardiac performance, basal and upon ß-adrenergic stimulation, remained unaltered. TT density decreased by ∼14%, without spatial disarrangement, while SR density decreased by ∼7%. More important, FRAP was ∼30% slower, but with similar maximum recovery, suggesting decreased SR interconnectivity. Systolic and diastolic Ca2+ signaling and SR Ca2+ content were unaltered. CONCLUSION: SR remodeling is an early CH event, similar to TT remodeling, appearing during compensated hypertrophy. Nevertheless, myocytes can withstand those moderate structural changes in SR and TT, preserving normal Ca2+ signaling and contractility.

The use of porcine small intestinal submucosa as a prosthetic material for laparoscopic hernia repair in infected and potentially contaminated fields: long-term follow-up.

INTRODUCTION: The treatment of hernias remains controversial, with multiple prosthetic meshes being exalted for a variety of their characteristics. In the event of incarcerated/strangulated hernias and other potentially contaminated fields the placement of prosthetic material remains controversial because of increased risk of recurrence and infection. Porcine small intestinal submucosa mesh (Surgisis, Cook Bloomington, IN) has been demonstrated safe and feasible in laparoscopic hernia repairs in this scenario. We present our 5-year experience, with placement of Surgisis mesh in potentially or grossly contaminated fields. METHODS: From May 2000 to October 2006, 116 patients (52 male, 64 female) with 133 procedures were performed. Placement of Surgisis mesh for either incisional, umbilical, inguinal, femoral or parastomal hernia repairs in an infected or potentially contaminated setting were achieved, and studied in a prospective fashion. RESULTS: All procedures were laparoscopically with two techniques [intraperitoneal onlay mesh (IPOM) and two-layered "sandwich" repair]. Mean follow-up was 52 +/- 20.9 months. Thirty-nine cases were in an infected field and the rest in a potentially contaminated field. Ninety-one procedures were performed concurrently with a contaminated procedure. Twenty-five presented as intestinal obstruction, 16 strangulated hernias, and 17 required small bowel resection; 29 were inguinal hernias, 57 incisional, and 38 umbilical. In 13 patients more than two different hernias were repaired. Eighty-five percent 5-year follow-up was achieved, during which we identified 7 recurrences, 11 seromas (all resolved), and 10 patients reporting mild pain. Six second looks were performed and in all cases except one the mesh was found to be totally integrated into the tissue with strong scar tissue corroborated macro- and microscopically. CONCLUSIONS: In our experience the use of small intestine submucosa mesh in contaminated or potentially contaminated fields is a safe and feasible alternative to hernia repair with minimal recurrence rate and satisfactory results in long-term follow-up.

Laparoscopic intraluminal surgery for gastrointestinal malignancies.

INTRODUCTION: Intraluminal surgery began with the advent of endoscopy. Endoscopic endoluminal surgery has limitations; and its failure results in conventional open or laparoscopic interventions with increased morbidity. Laparoscopy-assisted intraluminal surgery is a novel alternative to open or laparoscopic surgery for a failed endoscopic endoluminal technique, minimizing the associated complications. Endoscopic resection of early gastric and duodenal cancers is restricted by the limited view of the endoscope, insufficient number of instrument channels, and inability to have adequate margins of resection without risking perforation. These cancers potentially can be treated by laparoscopy-assisted intraluminal surgery without resorting to major gastric or duodenal resection. This procedure is relatively easy to perform and oncologically effective. We present the experience of the Texas Endosurgery Institute (TEI) in treating early gastric and duodenal cancers, including large malignant polyps and carcinoid tumors, with laparoscopy-assisted endoluminal surgery. MATERIALS AND METHODS: The data for all patients with early gastric and duodenal cancers who underwent laparoscopy-assisted endoluminal surgery at TEI between 1996 and 2007 were prospectively recorded. All of the patients had been referred by the endoscopist as noncandidates for endoscopic resection. We prospectively collected data on preoperative diagnosis, operating time, estimated blood loss, postoperative complications, histopathology, and recurrence rate. All patients underwent endoluminal port placement under direct visualization after a pneumoperitoneum was established. Operations were performed in conjunction with upper endoscopy for assistance with port placement under endoluminal visualization, insufflation, and specimen retrieval. After the intraluminal portion of the operation was completed, the endoluminal port sites were closed with laparoscopic intracorporeal suturing. RESULTS: From 1996 to 2007, a total of 12 patients underwent laparoscopic endoluminal surgery. All cases were completed successfully, including 5 resections of early gastric cancer (stage I), 3 wedge resections of carcinoid tumor, 2 resections of duodenal adenocarcinoma, and 2 resections of a malignant polyp at the gastroesophagic junction; all the cases were completed with disease-free margins. No recurrence of the original pathology have been reported, and the complications were minimal. CONCLUSION: Laparoscopic intraluminal surgery for early gastric and duodenal cancer is a feasible alternative to open conventional therapies; and it is associated with a lower incidence of incisional hernia formation and a lower infection rate.

Long-term experience with the laparoscopic approach to perforated diverticulitis plus generalized peritonitis.

BACKGROUND: The treatment of perforated diverticulitis is changing form the current standard of laparotomy with resection, Hartmann procedure, and colostomy to a minimally invasive technique. In patients with complicated acute diverticulitis and peritonitis without gross fecal contamination, laparoscopic peritoneal lavage, inspection of the colon, and intraoperative drain placement of the peritoneal cavity appears to alleviate morbidity and improve the outcome. In this article, we report our experience of a laparoscopic peritoneal lavage technique with delayed definitive resection when necessary. METHOD AND MATERIALS: Records of patients who underwent intraoperative peritoneal lavage for purulent diverticulitis at the Texas Endosurgery Institute from April 1991 to September 2006 were retrospectively reviewed. RESULTS: Forty patients were included in the study, with a male/female ratio of 26:14. The average age was 60 years. Many had associated co-morbidities. The average operating time was 62 minutes. There were no conversions to an open procedure. Apart from mild postoperative paralytic ileus in six patients and chest infections in two, there were no significant peroperative or postoperative complications. Just over 50% underwent elective interval laparoscopic sigmoid colectomy. During the mean follow-up of 96 months, none of the other patients required further surgical intervention. CONCLUSION: Laparoscopic lavage of the peritoneal cavity and drainage is a safe alternative to the current standard of treatment for the management of perforated diverticulitis with or without gross fecal contamination. It is associated with a decrease in the overall cost of treatment; the use of a colostomy is avoided; patient improvement is immediate; and there is a reduction in mortality and morbidity as definitive laparoscopic resection can be performed in a nonemergent fashion. Perhaps the most important benefit, other than avoiding a colostomy, is the association of fewer wound complications such as dehiscence, wound infection, and the high risk of hernia formation. Laparoscopic lavage and drainage should be considered in all patients in whom medical and/or percutaneous treatment is not feasible. It carries minimal morbidity and should be considered the standard of care.