Nest temperature fluctuations in a cavity nester, the southern ground-hornbill.

Southern ground-hornbills Bucorvus leadbeateri inhabit savanna and bushveld regions of South Africa. They nest in the austral summer, which coincides with the wet season and hottest daytime temperatures in the region. They are secondary cavity nesters and typically nest in large cavities in trees, cliffs and earth banks, but readily use artificial nest boxes. Southern ground-hornbills are listed as Endangered in South Africa, with reintroductions into suitable areas highlighted as a viable conservation intervention for the species. Nest microclimate, and the possible implications this may have for the breeding biology of southern ground-hornbills, have never been investigated. We used temperature dataloggers to record nest cavity temperature and ambient temperature for one artificial and 11 natural southern ground-hornbill tree cavity nests combined, spanning two breeding seasons. Mean hourly nest temperature, as well as mean minimum and mean maximum nest temperature, differed significantly between southern ground-hornbill nests in both breeding seasons. Mean nest temperature also differed significantly from mean ambient temperature for both seasons. Natural nest cavities provided a buffer against the ambient temperature fluctuations. The artificial nest provided little insulation against temperature extremes, being warmer and cooler than the maximum and minimum local ambient temperatures, respectively. Nest cavity temperature was not found to have an influence on the breeding success of the southern ground-hornbill groups investigated in this study. These results have potentially important implications for southern ground-hornbill conservation and artificial nest design, as they suggest that the birds can tolerate greater nest cavity temperature extremes than previously thought.

Feasibility of esophagogastric junction distensibility measurement during Nissen fundoplication.

Increased esophagogastric junction distensibility has been implicated in the development of gastroesophageal reflux disease (GERD). Previous authors have demonstrated a reduction in distensibility following anti-reflux surgery, but the changes during the operation are not clear. Our study aimed to ascertain the feasibility of measuring intraoperative distensibility changes and to assess if this would have potential to modify the operation. Seventeen patients with GERD were managed in a standardized manner consisting of preoperative assessment with symptom scoring, endoscopy, 24 hours pH studies, and manometry. Patients then underwent laparoscopic Nissen fundoplication with intraoperative distensibility measurement using an EndoFLIP EF-325 functional luminal imaging probe (Crospon Ltd, Galway, Ireland). This device utilizes impedance planimetry technology to measure cross-sectional area and distensibility within a balloon-tipped catheter. This is inflated at the esophagogastric junction to fixed distension volumes. Thirty-second median cross-sectional area and intraballoon pressure measurements were recorded at 30 and 40 mL balloon distensions. Measurement time points were initially after induction of anesthesia, after pneumoperitoneum, after hiatal mobilization, after hiatal repair, after fundoplication, and finally pre-extubation. Postoperatively, patients continued on protocol and were discharged after a two-night stay tolerating a sloppy diet. Patients with a hiatus hernia on high-resolution manometry had a significantly higher initial esophagogastric junction distensibility index (DI) than those without. Hiatus repair and fundoplication resulted in a significant overall reduction in the median DI from the initial to final recordings (30 mL balloon distension reduction of 3.26 mm(2) /mmHg (P = 0.0087), 40 mL balloon distension reduction of 2.39 mm(2) /mmHg [P = 0.0039]). There was also a significant reduction in the DI after pneumoperitoneum, hiatus repair, and fundoplication at 40 mL balloon distension. Two individual cases in the series highlight the utility of the system in potentially changing the operation. After fundoplication, patient 7 recorded a DI of 0.47 mm(2) /mmHg, the lowest in our series, and subsequently required reoperation because of significant symptoms of dysphagia. Patient 12 had a fundoplication that appeared visually too tight and was converted intraoperatively to a Lind 270° wrap resulting in a change in the DI from 0.65 to 0.89 mm(2) /mmHg. Laparoscopic Nissen fundoplication results in a significant reduction in the distensibility of the esophagogastric junction. The EndoFLIP system is able to demonstrate significant changes during the operation and may help guide intraoperative modification. Larger multicenter studies with long-term follow up would be beneficial to develop a target range of distensibility associated with good outcome.

Anastomotic strictures and delayed gastric emptying after esophagectomy: incidence, risk factors and management.

The aim of this study was to report the incidence, risk factors, and management of gastric conduit dysfunction after esophagectomy in 177 patients over a 3-year period in a single center. Patients with anastomotic strictures or delayed gastric emptying (DGE) were identified from a prospective database. Anastomotic strictures occurred in 48 patients (27%). Eighty-three percent of early anastomotic strictures (<1 year) were benign, and all late strictures (>1 year) were malignant. Dilatation was effective in 98% of benign and 64% of malignant strictures. DGE occurred in 21 patients (12%), and was associated with both anastomotic leak (P = 0.001) and anastomotic stricture (P = 0.001). 4/8 patients with late DGE (>3 months postesophagectomy) were tumor-related. Pyloric dilatation was effective in 92% of early and 63% of late DGE. Pyloric stents were inserted in 3 patients with tumor-related DGE. After esophagectomy, early anastomotic strictures (within 1 year) and early delayed gastric emptying (within 3 months) are usually benign and respond to dilatation. However, patients presenting later with tumor-related obstruction are unlikely to respond to anastomotic or pyloric dilatation and should be stented.

Substernal long segment left colon interposition for oesophageal replacement.

Long segments of colon, transposed on a vascular pedicle, have been used for oesophageal substitution for a long time. However the techniques employed for colonic reconstruction remain debated. We describe our substernal long segment replacement technique and emphasise several key aspects which are important in management of these patients. Optimising nutritional status and pulmonary function remain important aspects. Thymectomy allows room for the colonic segment preventing venous congestion. These patients are best managed in specialist units incorporating a multidisciplinary approach with good intensive care and radiological support.

Postinjury neutrophil priming and activation states: therapeutic challenges.

Both hyperactivity and hypoactivity of neutrophils (PMNs) have been implicated in the pathogenesis of postinjury multiple organ failure. In this paper, the cellular and molecular mechanisms involved in the regulation of PMN O2- production are reviewed. In addition, relevant research laboratory techniques for measuring both intracellular and extracellular O2- release are outlined. In a pilot study PMN O2- release in response to a battery of PMN agonists was determined, and four functional states of the NADPH were defined: resting, primed, activated, and unresponsive. PMNs from normal adult volunteers are in the resting state. In contrast, PMNs from patients with severe torso trauma are primed and activated in the first 24 h postinjury, but, after 48 h, become unresponsive to both receptor-dependent (platelet activating factor and N-formyl-methyl-leucyl-phenylalanine) and receptor-independent (phorbol 12-myristate 13-acetate) activation. The ability to identify at-risk patients and provide a rationale for ameliorating PMN-mediated tissue injury in patients with hyperinflammation syndromes are discussed. In addition, the importance of identifying patients with PMNs that are unresponsive, and the necessity for increasing PMN function in these patients in order to reduce the risk of sepsis, are also discussed.

Base deficit after major trauma directly relates to neutrophil CD11b expression: a proposed mechanism of shock-induced organ injury.

OBJECTIVE: To determine whether expression of neutrophil integrin receptors is related to the degree of post-traumatic shock. DESIGN: Data were collected prospectively on patients with major trauma admitted to the surgical intensive care unit. SETTING: Denver General Hospital, Colorado. PATIENTS AND PARTICIPANTS: 17 severely injured adults. MEASUREMENTS AND RESULTS: The mean fluorescence intensity and per cent positive of neutrophil integrin receptors CD11 b, CD18 and CD11 a, and systolic blood pressure, blood transfusion, lactate and base deficit as indices of shock. CD11 b expression on circulating neutrophils was increased 6 and 12 h after trauma. After correcting for the other shock indices, base deficit predicted CD11 b expression at 12 h. CD11 b expression was negatively correlated with the circulating neutrophil count. CONCLUSIONS: The degree of metabolic acidosis after trauma correlates directly with CD11 b receptor expression on circulating neutrophils. This relation may be the mechanism whereby post-traumatic shock results in neutrophil sequestration and neutrophil-mediated organ injury and failure.

Postinjury neutrophil priming and activation: an early vulnerable window.

BACKGROUND: Generation of extracellular, cytotoxic superoxide anion (O2-) by polymorphonuclear neutrophils (PMNs) contributes to an unbridled inflammatory response that can precipitate multiple organ failure (MOF). Release of O2- is markedly enhanced when activated PMNs have been previously "primed" by inflammatory mediators, such as those expressed after trauma. We therefore hypothesized that PMN priming occurs as an integral part of the early inflammatory response to trauma. METHODS: PMNs were obtained from 17 high-risk patients with torso trauma at 3, 6, 12, 24, 48, and 72 hours after injury, as well as from 10 healthy donors, and the in vitro release of O2- was quantitated with a kinetic, superoxide dismutase (SOD)-inhibitable cytochrome c reduction assay. PMN O2- release was measured in the presence and absence of 1 mumol/L N-formyl-methionyl-leucyl-phenylalanine (fMLP) and after priming and activation with 20 nmol/L platelet-activating factor (PAF) and 1 mumol/L fMLP, respectively. RESULTS: In vitro PMN O2- release was used to determine whether postinjury PMNs were (1) activated in vivo, (2) primed in vivo, or (3) primable in vitro. Unstimulated PMNs from trauma patients spontaneously expressed modest amounts of O2- in vitro from 6 to 48 hours after injury, suggesting endogenous activation. Also, fMLP-activated PMNs collected between 3 and 24 hours after injury expressed more O2- than controls (p < or = 0.02), indicating in vivo, trauma-related priming. Furthermore, postinjury PMNs were maximally primed in vivo (i.e., in vitro exposure to PAF before fMLP activation failed to significantly enhance O2- release) as compared to PMNs treated with fMLP. CONCLUSIONS: These data indicate that major torso trauma (first hit) primes and activates PMNs within 3 to 6 hours after injury. Consequently, we postulate that postinjury priming of PMNs may create an early vulnerable window during which a second hit (e.g., a secondary operation or delayed hemorrhage) activates exuberant PMN O2- release, rendering the injured patient at high risk for MOF.

Ultrastructure of buffalo, Syncerus caffer, platelets: comparison with bovine and human platelets.

Platelets are found in the blood of all mammals and serve the same basic hemostatic functions in all. Species differences in the morphology and activities of platelets in human and domesticated animals have been observed, but there is little published information regarding the blood pictures of wild animals. In this study, the ultrastructure of buffalo platelets was compared with that of bovine and human platelets. Buffalo platelets were found to be smaller than human platelets and intracellularly had larger alpha-granules, possessed distinctive dense granules and a more distinct microtubuli system, but they lacked the open canalicular system observed in the human type. This morphology is similar to that of cattle platelets.

Morphology of rhinoceros platelets.

Basic hematological information about rhinoceros species is limited. In this study, we have determined the platelet counts and described the platelet morphology of free-living white (Ceratotherium simum) and black (Diceros bicornis) rhinoceros using light and electron microscopy. The platelet counts of the two species were similar, but there were significant differences in platelet size as well as morphology between the species. The presence of large, nondiscoid platelet forms, resembling proplatelet or stress platelet forms, were observed in both, although not as often in the white rhinoceros as in the black rhinoceros.

Impala, Aepyceros melampus, platelets: count, morphology, and morphometric observations.

There is little published information regarding the platelets of impala (Aepyceros melampus). In this study we determined the platelet counts of 12 healthy adult male impalas and describe the morphology of the platelets. The platelet counts of the animals are high. Although the platelets appear to be extremely small, they have the characteristic ultrastructure of the platelets of the family Bovidae. They have few but prominent alpha-granules. Other cytoplasmic inclusions are the dense bodies, microtubules, mitochondria, and glycogen. There is no surface-connecting canalicular system present.

Laparoscopic appendicectomy: a trainee's perspective.

Minimally invasive surgery is rapidly becoming an integral part of general surgery. Many general surgeons have been trained to undertake laparoscopic cholecystectomy. It has been recommended that laparoscopic appendicectomy should be the training operation for junior surgeons. The aim of our study was to assess whether laparoscopic appendicectomy training can safely be introduced to junior surgeons in a district general hospital. During the 11 month study period, 27 laparoscopic and 38 open appendicectomies were performed. The median anaesthetic time was 80 min for laparoscopic and 52.5 min for open appendicectomies. Laparoscopic appendicectomies cost, on average, 618 pounds and open appendicectomies 770 pounds per case. The complication rate between the two procedures was equal. We therefore showed that laparoscopic appendicectomy by junior surgeons is both safe and cost-effective. Although the registrar did most of the laparoscopic appendicectomies, with resultant less operating for the SHO, laparoscopic appendicectomy provided the SHO with training in diagnostic laparoscopy and laparoscopic dissection. We conclude that basic laparoscopic training should be introduced early in surgical training, after which laparoscopic appendicectomy is a safe procedure for surgical trainees.

The Royal London Hospital Helicopter Emergency Medical Service: first phase 1990.

A Helicopter Emergency Medical Service (HEMS) has been introduced to improve trauma care in the Southeast of England. The majority of the workload comes from the area bounded by the M25 ring road. In 1989 a Dauphin 365N helicopter equipped for pre-hospital primary rescue and emergency inter-hospital secondary transfer was certified by the Civil Aviation Authority. The helicopter commenced carrying patients with a paramedic and a doctor on board early in 1990. In September 1990 this service was further improved by the opening of a helipad at the Royal London Hospital and a designated HEMS desk at London Ambulance Service central control. Eighty-four patients were transported in primary rescue missions and 107 as emergency transfers in 1990.

Gastric tube necrosis following minimally invasive oesophagectomy is a learning curve issue.

INTRODUCTION: Gastric tube necrosis following oesophagectomy is thought to have an increased association with a minimally invasive technique. Some suggest gastric ischaemic preconditioning may reduce ischaemic complications. We discuss our series of 155 consecutive minimally invasive oesophagectomies (MIOs), including a number of cases of gastric tube ischaemia, of which 4 (2.6%) developed conduit necrosis. METHODS: Data were collected prospectively of MIOs carried out by a single surgeon between 2005 and 2011. Cases of gastric tube necrosis were identified. RESULTS: Overall, 155 patients were identified. The inpatient mortality rate was 2.6%. Gastric tube necrosis occurred in four patients (2.6%). An ultrasonic dissector injury to the gastroepiploic arcade had occurred in two cases. In another case, the gastric tube was strangulated in the hiatus. In the remaining case, no clear mechanical cause was identified. All 4 cases occurred within the first 73 cases. The gastric tube necrosis rate of the first 50 cases versus cases 51-155 was 4% and 2% respectively (p=0.5948). The anastomotic leak rate in these two cohorts was 18% and 7% respectively (p=0.0457). There was a significant reduction in overall gastric tube complications from 22% to 10% following the learning curve of the initial 50 cases (p=0.0447). CONCLUSIONS: In our series, gastric tube necrosis appears to be a learning curve issue. Prophylactic measures such as ischaemic preconditioning become less relevant as the operating surgeon's experience increases. Instead, meticulous attention to preserving the gastroepiploic arcade, avoidance of tension in the tube and careful positioning of the gastric conduit through an adequately sized hiatus are key factors.

Total adventitial resection of the cardia: 'optimal local resection' for tumours of the oesophagogastric junction.

INTRODUCTION: Little is published about the local resection of oesophageal cancers. We adopted the principles of rectal cancer surgery, ie standard surgical dissection techniques as well as standard pathological processing and reporting, and assessed the feasibility of applying them to oesophagogastric junction (OGJ) cancer. METHODS: Over a two-year period consecutive patients with invasive cancers of the OGJ were studied. Following staging and neoadjuvant chemotherapy (NAC), a standard dissection defined as a total adventitial resection of the cardia (TARC) was performed. Standard histopathological processing involved external inking, photographing, transverse slicing and mounting of cut samples on megablocks. Hospital morbidity and mortality as well as survival at five years' follow-up were assessed. RESULTS: Forty consecutive patients had a TARC for OGJ carcinoma. Of these, 32 were offered NAC. Introducing TARC did not result in increased morbidity or mortality. Twenty-seven patients (68%) had an R0 resection that was directly related to the tumour stage and significantly related to a response to chemotherapy. Sixteen patients (42%) were alive five years after their TARC operation. CONCLUSIONS: Although the adventitia of the OGJ is not as well developed as that of the rectum, TARC can be performed safely as a standardised resection for OGJ cancers. Whereas the R0 rate for early stage tumours is very high, it remains disappointingly low for T3N1 tumours despite NAC. Improved long-term survival for these advanced tumours will only be achieved with better neoadjuvant and adjuvant therapies.

Surgical tip--a novel method of applying fibrin sealant during repair of divarication of the recti via an abdominoplasty incision.

The use of fibrin sealant to secure the mesh after a hernia repair, and to reduce seroma formation after abdominoplasty, is well recognised. However, delivery of the fibrin sealant post-abdominoplasty has proved technically difficult due to the competing demands of: (1) applying instant pressure to the fibrin sealant-containing cavity and (2) accurate suturing of the skin flaps. A new technique is proposed for the application of the fibrin sealant during abdominoplasty.

Centralisation of oesophagogastric cancer services: can specialist units deliver?

INTRODUCTION: Oesophagogastric cancer surgery is increasingly being performed in only centralised units. The aim of the study was to examine surgical outcomes and service delivery within a specialist unit. PATIENTS AND METHODS: The case notes of all patients undergoing attempted oesophagogastrectomy between January 2000 and May 2003 were identified from a prospective consultant database. RESULTS: A total of 187 patients (median age, 63 years; range, 29-83 years; M:F ratio, 3.9:1) underwent attempted oesophago-gastrectomy. Of these, 91% were seen within 2 weeks of referral and treatment was instituted after a mean of 31 days (range, 1-109 days). More patients underwent surgery (63%) than neoadjuvant therapy (56%) within 1 month of referral. The main indication for surgery was invasive malignancy in 166 patients (89%). The 30-day mortality was 0.5% (1 death) and in-hospital mortality was 1.1% (2 deaths). The median length of hospital stay was 14 days (range, 7-69 days). Significant postoperative morbidity included: pulmonary complications (36%), cardiovascular complications (16%), wound infection (13%) and clinically significant anastomotic leaks (7%). Of the study group, 28 patients (15%) were admitted to ICU with a median stay of 10 days (range, 1-44 days); this accounted for 0.9% of ICU bed availability. Twelve patients (6.4%) were returned to theatre, most commonly for bleeding. The 1-year survival rates were 78%. During 2002-2003, national waiting list targets for both hernia repair and cholecystectomy were achieved. CONCLUSIONS: Despite recent increases in workload, high volume specialist units can deliver an efficient and timely service with both good treatment outcomes and minimal impact upon elective surgical waiting lists and ICU provision.

Endometriosis in gluteus muscle with surgical implantation. A case report.

Intrapelvic endometriosis is a fairly common condition affecting women during their reproductive years. Extrapelvic disease is, however, very rare. We report a case where an endometrioma was found in the body of the gluteus minimus muscle, and endometrial tissue was implanted in the wound at the time of excision.