RESUMO
BACKGROUND: Robotic surgery offers three-dimensional visualization and precision of movement that could be of great value to hepatobiliary surgeons. Previous reports of robotic choledochocele resections in adults have detailed extracorporeal jejunojejunostomies. We describe a total robotic excision of a choledochal cyst with hepaticojejunostomy and intracorporeal Roux-en-Y anastomosis. METHODS: A 58-year-old woman underwent a robotic excision of a small choledochocele with hepaticojejunostomy and intracorporeal Roux-en-Y. RESULT: Port placement was determined via collaborative surgical discussion and previously reported robotic right hepatectomies. Total operative time was 386 min and total robot working time was 330 min. The hepaticojejunostomy was performed using 5-0 PDS suture with parachute-style back wall and running front wall sutures. The jejunojejunostomy was a stapled anastomosis. Estimated blood loss was less than 100 mL. The patient was ambulating and tolerating oral intake on post-operative day 1, and was discharged home on post-operative day 2. CONCLUSIONS: Robotic resection of choledochal cyst with intracorporeal Roux-en-Y anastomosis is feasible, with advantages over open surgery such as superior visualization, precision, and post-operative patient recovery.
RESUMO
The relationship between antibacterial effect, resistance, and concentration/MIC parameters with S. pneumoniae was studied. Thirty duplicate bacterial concentration-time-kill curve (TKC) experiments were performed with an in vitro model. TKC with levofloxacin (LVX), Ofloxacin (OFX), and ciprofloxacin (CIP) were studied against six S. pneumoniae isolates. Experiments simulated variable peak serum concentrations, but clinically relevant half-lives and dosing intervals. TKC were performed in Mueller-Hinton Broth supplemented with horse blood (SMHB) at 10(7) CFU/ml. Susceptibility was assessed on colonies recovered post TKC. Multiple regression tested association of pharmacodynamic variables with antimicrobial effect, and logistic regression with resistance post TKC. Only drug (r(2) = 0.27; p < 0.0001) and AUC/MIC(24) (r(2) = 0.15; p < 0.001) were significant variables predictive of antibacterial effect. LVX AUC/MIC(24) of =20 CFU/ml. Hr were significantly related to a loss of antimicrobial effect, and CIP was significantly more likely to select for resistant pneumococci than OFX, or LVX (p = 0.03). Selection of fluoroquinolone resistance only occurred at C(max)/MIC < 5.0 (p = 0.03). No independent association between pharmacokinetic or microbiological variables and resistance could be identified. The relationship between AUC/MIC(24) and antibacterial effect may be organism and fluoroquinolone specific. Clinically relevant CIP dosages that result in low C(max)/MIC against S. pneumoniae may foster fluoroquinolone resistance.
Assuntos
Anti-Infecciosos/farmacocinética , Ciprofloxacina/farmacocinética , Levofloxacino , Ofloxacino/farmacocinética , Streptococcus pneumoniae/efeitos dos fármacos , Anti-Infecciosos/farmacologia , Ciprofloxacina/farmacologia , Contagem de Colônia Microbiana , Resistência Microbiana a Medicamentos , Modelos Logísticos , Testes de Sensibilidade Microbiana , Modelos Biológicos , Ofloxacino/farmacologia , Streptococcus pneumoniae/isolamento & purificação , Streptococcus pneumoniae/metabolismoRESUMO
Mycobacterium fortuitum is a rapidly growing organism that has rarely been associated with meningitis. A patient developed M. fortuitum meningitis as the result of a permanent indwelling, contaminated, epidural catheter. Diagnosis and treatment of the disease are difficult in that clinical features may be indolent, and many antimicrobials with activity against M. fortuitum have minimal cerebrospinal fluid penetration. This patient was cured with an antibiotic regimen that consisted of doxycycline, ciprofloxacin, imipenem, and clarithromycin, and removal of the epidural catheter.