Simple preoperative risk scale accurately predicts perioperative mortality following esophagectomy for malignancy.

Surgery remains one of the major treatment options available to patients with esophageal cancer, with high mortality in certain cohorts. The aim of this study was to develop a simple preoperative risk scale based on patient factors, hospital factors, and tumor pathology to predict the risk of perioperative mortality following esophagectomy for malignancy. The Nationwide Inpatient Sample database was used to create the risk scale. Patients who underwent open or laparoscopic transhiatal and transthoracic esophageal resection were identified using International Classification of Diseases, 9th edition codes. Patients <18 years and those with peritoneal disease were excluded. Multivariate logistic regressions were used to define a predictive model of perioperative mortality and to create a simple risk scale. From 1998 to 2011, a total of 23 751 patients underwent esophagectomy. The observed overall perioperative mortality rate for this cohort was 7.7%. Minimally invasive techniques, and operations performed in higher volume centers were protective, whereas increasing age, comorbidities and diagnosis of squamous cell carcinoma were independent predictors of mortality. Based on this population, a risk scale from 0-16 was created. The calibration revealed a good agreement between the observed and risk scale-predicted probabilities. A set of sensitivity/specificity analyses was then performed to define normal (score 0-7) and high risk (score 8-16) patients for clinical practice. Mortality in patients with a score of 0-7 ranged from 1.3-7.6%, compared with 10.5-34.5% in patients with a score of 8-16. This simple preoperative risk scale may accurately predict the risk of perioperative mortality following esophagectomy for malignancy and can be used as a clinical tool for preoperative counseling.

Alcohol metabolism is not affected by sleeve gastrectomy.

INTRODUCTION: It has been published that patients who underwent gastric bypass surgery have impaired alcohol metabolism, predisposing them to higher rates of intoxication and DUI arrests. Yet the impact of laparoscopic sleeve gastrectomy (LSG) on alcohol metabolism and in particular the long-term effects are still unclear. We hypothesized that LSG does not alter alcohol metabolism. METHODS: A prospective cohort study of patients undergoing LSG was evaluated. Blood alcohol concentration (BAC) was extrapolated using a Breathalyzer(®). Alcohol metabolism was evaluated by determining BAC every 5 min after a single dose of alcohol (5 oz. glass of 14% v/v Malbec wine), until BAC was equal to zero. Subjects were queried about alcohol intoxication symptoms. All parameters were obtained and analyzed preoperatively and at 3 and 12 months postoperatively. RESULTS: Our study consisted of 10 patients (9 female) with a mean age of 46.6 ± 2.2 years and BMI of 43.5 ± 2.2 kg/m(2). The mean percentage excess weight loss was 39.5 ± 3.3 at 3 months and 55.6 ± 4.4 at 12 months. Peak BAC at 20 min was not different at 3 months (0.068 ± 0.007, p = 0.77) or at 12 months (0.047 ± 0.008, p = 0.19) when compared to the preoperative assessment (0.059 ± 0.014). In addition, the time to BAC equal to zero was not significantly different between baseline and the follow-up values (preoperative: 70 ± 9 min, 3 months: 95 ± 18 min, and 12 months: 57 ± 8 min, (p > 0.05). Symptoms of intoxication were not significantly different in patients before and after surgery. CONCLUSIONS: Our study suggests that LSG does not alter alcohol metabolism. Patients who undergo LSG do not have higher levels of intoxication following alcohol consumption and are therefore not prone to higher rates of DUI charges than the general public, in contrast to that previously reported following in patients who undergo gastric bypass surgery.

Murine models of diastolic dysfunction and heart failure with preserved ejection fraction.

Left ventricular diastolic dysfunction leads to heart failure with preserved ejection fraction, an increasingly prevalent condition largely driven by modern day lifestyle risk factors. As heart failure with preserved ejection fraction accounts for almost one-half of all patients with heart failure, appropriate nonhuman animal models are required to improve our understanding of the pathophysiology of this syndrome and to provide a platform for preclinical investigation of potential therapies. Hypertension, obesity, and diabetes are major risk factors for diastolic dysfunction and heart failure with preserved ejection fraction. This review focuses on murine models reflecting this disease continuum driven by the aforementioned common risk factors. We describe various models of diastolic dysfunction and highlight models of heart failure with preserved ejection fraction reported in the literature. Strengths and weaknesses of the different models are discussed to provide an aid to translational scientists when selecting an appropriate model. We also bring attention to the fact that heart failure with preserved ejection fraction is difficult to diagnose in animal models and that, therefore, there is a paucity of well described animal models of this increasingly important condition.

Maximizing mesh mileage: evaluating the long-term performance of a novel hybrid mesh for ventral hernia repair.

PURPOSE: The objective of this study is to evaluate the safety and long-term outcomes of GORE Synecor™ in ventral hernia repair (VHR). METHODS: This retrospective, single-center case review analyzed outcomes in patients who underwent VHR with Synecor from May 2016 to December 2022. Primary outcomes were hernia recurrence and mesh infection rates. Secondary outcomes were 30-day morbidity, 30-day mortality, 30-day readmission, re-operation, surgical-site infection (SSI) and occurrence (SSO) rates, and occurrences requiring intervention (SSOI). RESULTS: 278 patients were identified. Mean follow-up was 24.1 (0.2-87.1) months. Mean hernia defect size was 63.4 (± 77.2) cm2. Overall hernia recurrence and mesh infection rates were 5.0% and 1.4% respectively. No mesh infections required full explantation. We report the following overall rates: 13.3% 30-day morbidity, 4.7% 30-day readmission, 2.9% re-operation, 7.2% SSI, 6.1% SSO, and 2.9% SSOI. 30-day morbidity was significantly higher in non-clean (42.1% vs 11.2%, p < 0.01), onlay (OL) mesh (37.0% vs preperitoneal (PP) 16.4%, p = 0.05 vs retrorectus (RR) 15.0%, p < 0.05 vs intraperitoneal (IP) 5.2%, p < 0.001), and open cases (23.5% vs 3.1% laparoscopic vs 4.4% robotic, p < 0.01). SSI rates were significantly higher in non-clean (31.6% vs 5.4%, p < 0.001), OL mesh (29.6% vs RR 11.3%, p < 0.05 vs PP 5.5%, p < 0.01 vs IP 0.0%, p < 0.001), and open cases (15.2% vs 0% laparoscopic vs 0% robotic, p < 0.05). CONCLUSION: Long-term performance of a novel hybrid mesh in VHR demonstrates a low recurrence rate and favorable safety profile in various defect sizes and mesh placement locations.

Three-dimensional vision enhances task performance independently of the surgical method.

BACKGROUND: Within the next few years, the medical industry will launch increasingly affordable three-dimensional (3D) vision systems for the operating room (OR). This study aimed to evaluate the effect of two-dimensional (2D) and 3D visualization on surgical skills and task performance. METHODS: In this study, 34 individuals with varying laparoscopic experience (18 inexperienced individuals) performed three tasks to test spatial relationships, grasping and positioning, dexterity, precision, and hand-eye and hand-hand coordination. Each task was performed in 3D using binocular vision for open performance, the Viking 3Di Vision System for laparoscopic performance, and the DaVinci robotic system. The same tasks were repeated in 2D using an eye patch for monocular vision, conventional laparoscopy, and the DaVinci robotic system. RESULTS: Loss of 3D vision significantly increased the perceived difficulty of a task and the time required to perform it, independently of the approach (P < 0.0001-0.02). Simple tasks took 25 % to 30 % longer to complete and more complex tasks took 75 % longer with 2D than with 3D vision. Only the difficult task was performed faster with the robot than with laparoscopy (P = 0.005). In every case, 3D robotic performance was superior to conventional laparoscopy (2D) (P < 0.001-0.015). CONCLUSIONS: The more complex the task, the more 3D vision accelerates task completion compared with 2D vision. The gain in task performance is independent of the surgical method.

Video. Single-incision laparoscopic cholecystectomy.

BACKGROUND: Single-incision laparoscopic surgery (SILS) has been proposed as a minimally invasive technique with the advantages of smaller external scars and reduced pain. Furthermore, usage of the flexible endoscope for SILS in lieu of the standard laparoscope provides distinct visualization advantages. This video shows a single-incision cholecystectomy performed using a single incision placed through the umbilicus. METHODS: A 39-year-old woman with chronic symptomatic cholelithiasis was enrolled under institutional review board protocol to undergo SILS. She had previously undergone a laparoscopic tubal ligation. A single incision was made using the previous umbilical incision, and the abdomen was entered in an open fashion. The flexible endoscope was placed directly through the fascial incision, with two 5-mm ports on either side. Adhesions to the gallbladder were taken down with the harmonic scalpel. Dissection proceeded using an articulating grasper and retraction to identify the cystic duct and artery. The duct and artery were serially clipped and divided. The cystic duct was additionally secured with a loop ligature. The gallbladder was cauterized from the liver bed using the articulating hook cautery and extracted through the wound. RESULTS: The final incision placed at the base of the umbilicus was 7 mm long. The operative time was 58 min, with minimal blood loss recorded. The patient was discharged home on the day of the procedure and did not experience any postoperative complications. CONCLUSIONS: Single-incision cholecystectomy can be performed safely through one incision in the umbilicus, optimizing cosmesis. Substitution of the flexible endoscope for the standard laparoscope allows many greater degrees of visualization in SILS. This allows clear identification of the biliary ductal anatomy, allowing cholecystectomy to proceed safely. Placement of the endoscope directly through the incision decreases the profile of ports through the incision and increases maneuverability.

Performance measures of surgeon-performed colonoscopy in a Veterans Affairs medical center.

BACKGROUND: Quality indicators are increasingly emphasized in the performance of colonoscopy. This study aimed to determine the standard of care rendered by surgeon-endoscopists in a Veterans Affairs (VA) medical center by evaluating the indications for colonoscopy and outcome performance measures according to established quality indicators for colonoscopy. METHODS: A prospective standardized computer endoscopic reporting database (ProVation MD) was retrospectively reviewed. All colonoscopies performed by attending surgeons at the San Diego VA medical center between 1 January 2004 and 31 July 2007 were included in the study. Patients with charts that had incomplete reporting were excluded. The quality indicators used included the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) criteria for colorectal cancer screening, the American Cancer Society (ACS) guidelines for postcancer resection surveillance, and the American Society of Gastrointestinal Endoscopists (ASGE) quality indicators for colonoscopy. RESULTS: The data for 558 patients (96% men) were analyzed. The average patient age was 63 years (range, 25-93 years). Almost all the colonoscopies (99%) were performed in accordance with established criteria. The most common indications for colonoscopy were screening (n = 143, 26%), non-acute gastrointestinal bleeding (n = 127, 23%), polyp surveillance (n = 100, 18%), postcancer resection surveillance (n = 91, 17%), abdominal pain (n = 19, 4%), and anemia (n = 14, 3%). Postcancer resection surveillance colonoscopies were performed according to recommended criteria in 98% of the cases. The cecal intubation rate was 97%, and the overall adenoma detection rate was 26%. Two patients (<1%) experienced complications requiring intervention. CONCLUSION: The study data indicate that surgeon-performed colonoscopies meet standard quality criteria for indications and performance measures. The authors therefore conclude that surgeon-endoscopists demonstrate proficiency in the standard of care for colonoscopy examinations.

Dual-lumen natural orifice translumenal endoscopic surgery (NOTES): a new method for performing a safe anastomosis.

BACKGROUND: Bowel anastomosis is one of the most challenging and difficult tasks to perform during natural orifice translumenal endoscopic surgery (NOTES). The difficulty is mainly due to the technical limitations of the endoscopic instruments available. Currently, endoscopic clips, T-bar sutures, or cumbersome suturing devices are used. A dual-lumen NOTES approach can facilitate bowel resection in a pig model by allowing the use of laparoscopic staplers through the rectum. METHODS: Acute studies were performed on four 40-kg pig models. The dual-lumen NOTES approach was used to perform small bowel resection and anastomosis. An endoscope was passed into the stomach and pushed through the stomach wall into the peritoneal cavity (first lumen), and a 12-mm trocar was placed through the anterior rectal wall, allowing access to the peritoneum (second lumen). Handling of the bowel, resection, and anastomosis were performed using endoscopic instruments through the gastric lumen and laparoscopic instruments through the rectal lumen. The resected small bowel then was removed through the rectum. RESULTS: Small bowel resection and anastomosis was successfully completed in all four animals using the dual-lumen NOTES approach. The laparoscopic stapler was used one more time to close the gastrotomy through the rectal port. At autopsy, intact suture lines were noted at the bowel anastomosis and at the stomach, with no evidence of leak from either site. CONCLUSIONS: Performing a sutured anastomosis in NOTES is complex and time consuming. The use of stapling devices designed for laparoscopic procedures greatly facilitates gastrointestinal tract operations in NOTES. Using both the upper and lower gastrointestinal tract as entry sites for NOTES eliminates some of the current technical limitations of these procedures.

Robotically assisted laparoscopic transhiatal esophagectomy.

BACKGROUND: Esophagectomy is a technically demanding operation with high procedure-related morbidity and mortality rates. Minimally invasive techniques were introduced in the late 1980s in an effort to decrease the invasiveness of the procedure. Data concerning the use of robotic systems for esophageal cancer are scarce in the literature. The goal of this report is to describe the authors' early experience using robotically assisted technology to perform transhiatal esophagectomy (RATE). METHODS: Between September 2001 and May 2004, 18 patients underwent RATE at the authors' institution. A retrospective review of prospectively collected data was performed. Gender, age, postoperative diagnosis, operative time, conversion rate, blood loss, hospital stay, length of the follow-up period, and complications were assessed. RESULTS: At the authors' institution, 18 patients underwent RATE, including 16 men (89%), with a mean age of 54 years (range, 41-73 years). The RATE procedure was completed for all 18 patients (100%). The mean operative time was 267 +/- 71 min, and estimated blood loss was 54 ml (range, 10-150 ml). The mean intensive care unit stay was 1.8 days (range, 1-5 days), and the mean hospital stay was 10 days (range, 4-38 days). A total of 12 perioperative complications occurred for 9 patients, including 6 anastomotic leaks, 1 thoracic duct injury, 1 vocal cord paralysis, 1 pleural effusion, and 2 atrial fibrillations. Anastomotic stricture was observed in six patients. There were no perioperative deaths. Pathologic examination of the surgical specimen yielded an average of 14 lymph nodes per patient (range, 7-27). During the mean follow-up period of 22 +/- 8 months, 2 patients died, 2 were lost to follow-up evaluation, 3 had recurrence, and 11 were disease free. CONCLUSION: The current study shows that RATE, with its decreased blood loss, minimal cardiopulmonary complications, and no hospital mortality, represents a safe and effective alternative for the treatment of esophageal adenocarcinoma.

Incidence of intra-operative floppy iris syndrome in a U.K. district general hospital and implications for future workload.

AIM: IFIS is a recently described condition observed during cataract surgery. However, its true incidence in the U.K. population is unknown. Our aim was to assess the incidence of IFIS associated with tamsulosin in patients undergoing cataract surgery in a U.K. district general hospital. METHOD: A prospective observational study of patients on tamsulosin undergoing cataract surgery was carried out over a six month period to determine the incidence of IFIS and to document outcomes of those cases. The patients were identified during routine pre-operative assessment. RESULTS: 1462 cataract cases were performed over six months. From these cases, 23 eyes of 16 patients who were taking Tamsulosin were recruited into the study. All the patients were men and the mean age was 76 years. A small pupil was demonstrated intra-operatively in 69% (16/23) of the eyes. A floppy iris or iris prolapse during surgery was noted in 57% (13/23) of the eyes. Complications reported included posterior capsule rupture in one case (4%) and iris trauma in five cases (22%). A best corrected visual acuity of 6/9 or better was achieved in 21/23 cases. The incidence of IFIS in patients undergoing cataract surgery over six months is 0.9%. CONCLUSION: IFIS appears to be strongly associated with tamsulosin use. The increasing use ofthis drug in the elderly male population is likely to increase the workload on our cataract service. Prospective risk stratification for such patients to be operated by senior surgeons is therefore recommended.

Effect of robotic assistance on the "learning curve" for laparoscopic hand-assisted donor nephrectomy.

BACKGROUND: The number of living-related donor kidney transplantations have increased since the advent of minimally invasive surgery. Robotic technology has emerged as a promising alternative to laparoscopic techniques. The authors reviewed their institution experience with robotic hand-assisted donor nephrectomies (RHADNs). METHODS: Between August 2000 and April 2006, 273 robotically assisted left donor nephrectomies were performed using a hand-assisted technique. Prospectively collected information for 214 patients regarding complications, hospital stay, blood loss, warm ischemia time, operative time, and outcomes is presented. RESULTS: The cohort of donors included 110 men and 104 women with a mean age of 36 years (range, 18-61 years). These donors included 86 African Americans, 46 Caucasians, 74 Hispanics, and 8 of other races. Left renal artery anomalies were found in 61 patients (29%). Four patients underwent conversion to open surgery. The hospital stay was 2.3 days (range, 1-8 days), the blood loss 82 ml (range, 10-1,500 ml), and the mean warm ischemia time 98 s (range, 50-200 s). The operative time was 201 min (range, 100-320 min) for the first 74 cases, 129 min (range, 65-240 min) for the second 70 cases, and 103 min for the last 70 cases (p < 0.001), for an overall average of 150 min. Complications decreased significantly after the first 74 cases. The 1-year patient survival rate was 100%, and the 1-year graft survival rate was 98%. The average recipient creatinine at 6 months was 1.4 mg/dl. CONCLUSIONS: Specific changes in operative technique over time have improved patient safety and diminished complications with RHADN. Currently, RHADN can be performed expeditiously with a minimal rate of complications and conversion to open procedure by a surgical team with appropriate training and experience.

Pouch enlargement and band slippage: two different entities.

BACKGROUND: Pouch enlargement and band slippage are the most common late complications of laparoscopic adjustable gastric banding (LAGB). Often, confusion exists among surgeons regarding the denomination or even the treatment of these two different entities. This study aimed to establish the differences in clinical presentation, radiologic features, and management between pouch enlargement and band slippage. The authors hypothesized that pouch enlargement can be managed nonoperatively (via band deflation), that band slippage is an acute complication requiring surgical treatment, and that tailored adjustment allows earlier diagnosis of pouch enlargement in asymptomatic patients. METHODS: From March 2001 to December 2004, 516 patients underwent LAGB placement. Barium swallow was performed preoperatively, postoperatively, and during band adjustments ("tailored adjustment"). Pouch enlargement was defined as dilation of the pouch, and band slippage was considered when band and stomach were prolapsed. Four radiologic types of pouch enlargement were considered: band 45 degrees, band 45 degrees with covering of the band, band 0 degrees, and band smaller than 0 degrees. RESULTS: A total of 1,600 barium swallows were performed with 516 patients. As a result, pouch enlargement was diagnosed for 61 patients (12%) and band slippage for 12 patients (2%). CONCLUSION: In this study, pouch enlargement was found to be a chronic complication that can be managed conservatively with a 77% success rate. Tailored adjustment allows early diagnosis of pouch enlargement, thus preventing adjustments in patients with undiagnosed pouch enlargement. Surgical treatment should be considered when medical treatment fails. By comparison, band slippage is an acute complication that requires surgical treatment in every case (100%).

Laparoscopic Heller myotomy for achalasia facilitated by robotic assistance.

BACKGROUND: Laparoscopic Heller myotomy is the standard operation for achalasia. The incidence of esophageal perforation is approximately 5% to 10%. Data about the safety and utility of robotically assisted Heller myotomy (RAHM) are scarce. The aim of this study was to assess the efficacy and safety of RAHM for the treatment of esophageal achalasia. METHODS: From a prospectively maintained database, demographic data, symptoms, esophagograms, manometries, and perioperative data from all the RAHMs performed between September 2002 and February 2004 were analyzed. RESULTS: A total of 54 patients underwent RAHM, including 26 men. The mean age of these patients was 43 years (range, 14-75 years). Dysphagia was present in 100% of the patients. Of the 54 patients, 26 (48%) had undergone previous treatment including pneumatic dilation (17 patients), Botox injections (4 patients), or both of these treatments (5 patients). The dissection was performed laparoscopically, and the myotomy was performed with robotic assistance. The operative time, including the robot setup time, averaged 162 min (range, 62-210 min). Blood loss averaged 24 ml. No mucosal perforations were observed. The hospital length of stay was 1.5 days. There were no deaths. At 17 months, 93% of the patients had relief of their dysphagia. CONCLUSIONS: The findings showed RAHM to be safe and effective, with a 0% incidence of perforation and relief of symptoms for 91% of the patients.

Laparoscopic adjustable gastric band versus laparoscopic Roux-en-Y gastric bypass: ends justify the means?

BACKGROUND: In the United States, the most frequently performed bariatric procedure is the Roux-en-Y gastric bypass (RYGB). Worldwide, the most common operation performed is the laparoscopic adjustable gastric band (LAGB). The expanding use of LAGB is probably driven by the encouraging data on its safety and effectiveness, in contrast to the disappointing morbidity and mortality rates reported for RYGB. The aim of this study was to evaluate the results of LAGB versus RYGB at a single institution. METHODS: Between November 2000 and July 2004, 590 bariatric procedures were performed. Of these, 120 patients (20%) had laparoscopic RYGB and 470 patients (80%) had LAGB. A retrospective review was performed. RESULTS: In the LAGB group, 376 patients (80%) were female, and the mean age was 41 years (range, 17-65). In the RYGB group, 110 patients (91%) were female, and the mean age was 41 years (range, 20-61). Preoperative body mass index was 47 +/- 8 and 46 +/- 5, respectively (p = not significant). Operative time and hospitalization were significantly shorter in LAGB patients (p < 0.001). Complications and the need for reoperation were comparable in both groups. Weight loss at 12, 18, 24, and 36 months for LAGB and RYGB was 39 +/- 21 versus 65 +/- 13, 39 +/- 20 versus 62 +/- 17, 45 +/- 25 versus 67 +/- 8, and 55 +/- 20 versus 63 +/- 9, respectively. CONCLUSIONS: The current study demonstrates that LAGB is a simpler, less invasive, and safer procedure than RYGB. Although mean percentage excess body weight loss (%EBWL) in RYGB patients increased rapidly during the first postoperative year, it remained nearly unchanged at 3 years. In contrast, in LAGB patients weight loss was slower but steady, achieving satisfactory %EBWL at 3 years. Therefore, we believe that LAGB should be considered the initial approach since it is safer than RYGB and is very effective at achieving weight loss.

Combined orbital floor betamethasone and depot methylprednisolone in uveitis.

PURPOSE: To evaluate the outcome of orbital floor injection of betamethasone and methylprednisolone in the management of uveitis, with particular reference to its efficacy in avoiding increase in systemic immunosuppressive drugs. METHODS: A sample of all patients attending the Uveitis Service at Moorfields Eye Hospital was carried out over a three-month period. All patients who had received one or more orbital floor injections of betamethasone (4 mg) and methylprednisolone (Depo-Medrone; 40 mg) in the management of their uveitis were identified and the case notes reviewed. RESULTS: A total of 48 patients who had received 75 orbital floor injections were identified during the sample period. Most patients had either panuveitis (n = 24) or pars planitis (n = 14). One-month post-injection visual acuity (VA) had improved by at least one Snellen line after 33/75 injections (44%) and at least two lines after 11/75 (15%), was unchanged after 25 (33%), but had deteriorated in 14 (19%). VA was not recorded after 3/75 injections. The only complications recorded were periorbital haemorrhage (n = 1) and complaints of persistent pain after an injection (n = 1). Symptoms (pain and subjective vision) improved after 36/75 injections (47%), were unchanged after 24 (32%), and were reported as worse after five (7%). Additionally, three patients reported an improvement in symptoms which lasted less than one month. Signs other than VA were improved after 28/75 (37%), were unchanged after 38 (51%), and deteriorated after only one injection. Of the 31 patients given orbital floor injections to avoid systemic therapy, seven (23%) subsequently went on to require it, and the clinical course then improved in 45%. CONCLUSIONS: Combined orbital floor injection of betamethasone and methylprednisolone can result in improved visual acuity, symptoms, and signs of inflammation in uveitis, and may therefore avoid the necessity for increased systemic medication.

Bis-basic-substituted polycyclic aromatic compounds. A new class of antiviral agents. 8. Bis-basic derivatives of carbazole, dibenzofuran, and dibenzothiophene.

A series of bisalkamine esters, bis-basic ethers, and bis-basic ketones of carbazole, N-ethylcarbazole, dibenzofuran, and dibenzothiophene was synthesized and evaluated for antiviral activity. The series also included two bis-basic alkanes of N-ethylcarbazole and one bis-basic carboxamide of dibenzofuran. Structure-activity relationships indicated that within the carbazole and N-ethylcarbazole series the bisalkamine esters gave the most active derivatives while the bis-basic ketone derivatives of dibenzofuran and dibenzothiophene afforded the more potent compounds within the respective series. The [6,5,6]heterocyclic nuclei were compared with the [6,5,6] aromatic nuclei (fluroene and fluoren-9-one) including tilorone with respect to antiviral activity against encephalomyocarditis (EMC) virus. Maximum activity was associated with the bis-basic ketone side chain and fluoren-9-one nucleus.

Combined pars plana vitrectomy and sutured posterior chamber implant.

OBJECTIVE: To describe the surgical technique, visual acuity results, and complications of sutured posterior chamber intraocular lenses with complete pars plana vitrectomy. METHOD: A retrospective review of 63 eyes was combined with a telephone survey of the patients and their ophthalmologists. RESULTS: The preoperative diagnoses were trauma, 25 eyes; ectopia lentis, 24 eyes; aphakia following retinal detachment surgery, 7 eyes; cataract surgery, 6 eyes; and endophthalmitis, 1 eye. Mean follow-up was 20 months. Preoperative best-corrected visual acuity was 20/40 or better in 36% (23 of 63 eyes), 20/60 to 20/120 in 33% (21 of 63 eyes), and 20/200 or worse in 31% (19 of 63 eyes) improving to 20/40 or better in 76% (48 of 63 eyes), 20/60 to 20/120 in 18% (11 of 63 eyes), and 20/200 or worse in 6% (4 of 63 eyes) at final follow-up. Preoperative complications included iatrogenic retinal breaks in 3 cases, difficulty with a fixation suture in 1 case, and mild vitreous hemorrhage in 1 case. Postoperative complications included retinal detachment in 2 cases, choroidal hemorrhage in 1 case, intermittent pupil capture in 9 cases, self-limiting vitreous hemorrhage in 3 cases, and late intraocular lenses dislocation in 1 case. CONCLUSIONS: Suturing a posterior chamber implant concurrently, or following, a complete pars plana vitrectomy is a safe procedure. Complete vitrectomy may reduce the rate of long-term complications. Optimal visual rehabilitation can be achieved without the need for contact lens wear with an acceptable additional risk of surgical complications. Arch Ophthalmol. 2000;118:905-910

Failed antireflux surgery: what have we learned from reoperations?

HYPOTHESIS: Factors that lead to failures in antireflux procedures can be identified, and dealing with them at the initial operation may decrease the number of such failures. DESIGN: Analysis of symptoms, 24-hour esophageal pH monitoring, manometry, upper gastrointestinal tract radiographs, and correlation with operative anatomic findings. SETTING: University referral center. PATIENTS: Forty-eight patients who previously underwent antireflux surgery (Nissen fundoplication, 29; Hill fundoplication, 7; Angelchik prosthesis, 1; multiple, 5; unknown, 6) and had symptoms of foregut disease. MAIN OUTCOME MEASURES: Determination of the cause of failure of previous operations and identification of factors that may prevent recurrence. RESULTS: Fourteen patients (29%) presented with symptoms of an incompetent cardia (heartburn and regurgitation), 15 patients (31%) presented with symptoms of defective esophageal emptying (dysphagia), 13 (27%) had symptoms of both, and 6 (13%) had other symptoms. All patients were initially treated medically and/or with dilation. A reoperation was performed in 31 patients (65%) whose symptoms persisted. Reoperation was completed laparoscopically in 28 patients (90%). At reoperation we identified 3 main types of failure: type 1, patients in whom the gastroesophageal junction was herniated through the hiatus, either with the wrap (IA) or without it (IB). There were 13 patients (43%) classified as having type IA, and 5 patients (16%) classified as having type IB. Type II failure involved a paraesophageal component resulting from a redundant wrap in 5 patients (16%), and type III involved a malformation (defective position or construction) of the wrap in 2 patients (6%). The remainder had a failed Hill fundoplication (3 patients), a herniated Angelchik prosthesis (1 patient), and normal postoperative anatomy (2 patients). CONCLUSIONS: Failure of the crural closure and malformation of the wrap are the main reasons for failure of antireflux procedures. Use of proper surgical techniques including meticulous closure of the crura and appropriate construction and fixation of the wrap at the first operation will help prevent recurrence.

An objective scoring system for laparoscopic cholecystectomy.

BACKGROUND: Direct observation with structured criteria for performance is the most reliable and valid method of assessing technical skill during operative procedures. We developed such a system to evaluate technical performance during a laparoscopic cholecystectomy. The reliability and validity of the system were tested by analyzing the correlation among three observers in a multicenter study and comparing performance with years of surgical experience. STUDY DESIGN: Thirty consecutive cases of laparoscopic cholecystectomy were recorded on videotape, 10 from each of 3 institutions. Independent scores were generated by three observers examining each of the videotapes, providing a total of 90 scores. Points were awarded for successful completion of each of 23 different steps required to perform a laparoscopic cholecystectomy. Error points were tabulated based on the frequency and relative severity of each of 21 potential technical mistakes during the operation. The final score was assumed to be a relative measure of technical skill and was derived by subtracting error points from points awarded for completion of each step of the procedure. Pearson correlation coefficients were used to assess agreement among examiners and correlation with year of surgical experience. RESULTS: Agreement in final scores among the three observers was excellent (r = 0.74-0.96) despite the fact that one observer assigned significantly fewer error points. Correlation between year of experience and two-handed technique scoring was good (r = 0.5, p = 0.057), but the correlation between experience and one-handed technique scores was poor (r = 0.02). CONCLUSIONS: The technical skills required to perform laparoscopic cholecystectomy can reliably be measured using this tool. This method can be used to track the learning curve of surgeons in training, evaluate the efficacy of alternative training tools, and provide a means of self-assessment for the trainee.