Assessing the invasiveness of NOTES perforated viscus repair: a comparative study of NOTES and laparoscopy.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) repair of perforated peptic ulcers may decrease surgical invasiveness and improve patient outcomes. METHODS: Full thickness gastrotomy was created laparoscopically in swine followed by soilage time. Repair proceeded with a laparoscopic (n = 14) or the NOTES (n = 14) approach. For NOTES repair, the omentum was endoscopically pulled into the gastric lumen and clipped. Intraoperative and postoperative parameters were recorded, including arterial blood gas (ABG) analysis and serum samples for white blood cell (WBC), TNF-α, IL-1, and IL-6 analysis. RESULTS: Twenty-four of 28 animals thrived to study completion. NOTES repair could not be accomplished in one animal. At necropsy, all repairs were intact. Blood pressure was equivalent between groups. Pulse examined during the last 30 min of each procedure revealed a slightly higher mean pulse in the animals undergoing NOTES procedures (NOTES, 102 ± 28; laparoscopy, 83 ± 24). ABG obtained at the conclusion of the procedure revealed a pH of 7.47 in NOTES animals and 7.43 in the laparoscopy animals (p = 0.06), a change from baseline in both groups. The final pCO(2) was lower in the NOTES group (NOTES, 40.62; laparoscopy, 47.49, p = 0.03). WBC counts were comparable on postoperative day (POD) 1 (NOTES, 21.1; laparoscopy, 19.0; p = 0.49). Mean TNF-α serum levels were equivalent at all time points between groups; however, TNF-α varied significantly from baseline to POD 7 (p = 0.002). CONCLUSION: NOTES omental repair appears comparable to that of laparoscopy. The lower arterial pCO(2) at the conclusion of the NOTES procedure may be advantageous in critically ill patients.

The challenges with NOTES retroperitoneal access in humans.

BACKGROUND: Animal studies have supported natural orifice transluminal endoscopic surgery (NOTES) retroperitoneal access. NOTES also may offer unique retroperitoneal access in humans. OBJECTIVES: This study was designed to assess the feasibility of endoscopic transgastric and transrectal retroperitoneal access in a cadaver model using prone and supine positioning, and to compare NOTES retroperitoneal examination with endoscopic ultrasound. METHODS: Using a multidisciplinary team, this institutional review board-approved study evaluated transgastric and transrectal retroperitoneal examination in six cadavers (3 male, 3 female; body mass index range, 25-37 kg/m(2)). Endoscopic ultrasound retroperitoneal examination preceded NOTES access. Transgastric Access: Using a prototype dual channel endoscope, a needle knife gastrotomy was created on the preantral posterior gastric wall. Retroperitoneal examination specifically targeted the pancreas and surrounding structures with the cadaver supine and prone. Transrectal Access: Using the same endoscope, a posterior needle knife rectotomy distal to the upper valve of Houston provided extraluminal access. Retroperitoneal examination proceeded with the cadaver prone and supine. Open dissection followed procedure completion. RESULTS: Access into the retroperitoneum succeeded at all sites. Significant challenges locating identifiable landmarks were faced-mostly transrectal and improved transgastric prone. All cadavers, despite body mass index or sex, had significant retroperitoneal adipose tissue limiting the endoscopic view. CONCLUSIONS: Although porcine studies have highlighted successful NOTES retroperitoneal procedures, the abundant human retroperitoneal adipose tissue challenged the translation of porcine research to humans. Additionally, although access to the retroperitoneal space and dissection within this space were accomplished easily, the appearance of cadaveric tissue and lack of blood flow made confident landmark identification impossible. Further study should continue in this area and focus on confident landmark identification for directed dissection. In a cadaveric model, this would best be improved by pre-NOTES anatomic marking or active perfusion of vasculature along with consideration of direct entry into the retroperitoneum from a targeted intraperitoneal site in clinical patients.

Functional and comparative evaluation of flexible monopolar endoscopic scissors.

BACKGROUND: The continued success of natural orifice translumenal endoscopic procedures requires reliable, accurate tissue dissection and suture cutting. This study aimed to evaluate a flexible endoscopic scissors prototype. METHODS: An acute study of two domestic swine was conducted. Laparoscopic access provided an overview and allowed comparison of the flexible endoscopic scissors with laparoscopic shears. The endoscopic cautery-compatible scissors consists of cutting blades with a flexible wire catheter assembly (outer diameter, 3.1 mm) for use within a therapeutic endoscopic channel. A dual-channel colonoscope was advanced through a gastrotomy created for peritoneal access. With the aide of a grasping forceps, multiple peritoneal biopsies were obtained using the endoscopic scissors. Cautery (Monopolar 18-30 W) then was attached to the scissors, and gallbladder dissection proceeded. The device then was used to perform a small bowel enterotomy. A timed comparison of this function with laparoscopic enterotomy was made. Finally, 3-0 Polyglactin 910 suture was cut using the endoscopic scissors. RESULTS: Peritoneal biopsies 2 cm(2) in size were obtained from multiple abdominal locations and endoscopic positions, including the retroflexed position. The scissors cut effectively and accurately. Cutting performance was enhanced with parallel countertraction provided by grasping forceps passed through the second endoscopic channel. The use of cautery with the scissors controlled small vessels (2-3 mm) and permitted partial dissection of the gallbladder from the hepatic bed. Small bowel enterotomy sufficiently large for stapler passage was created in 4 min and 54 s. Laparoscopically, this was completed in 1 min and 22 s. Suture was successfully cut at the first attempt in a controlled, reproducible fashion. CONCLUSIONS: Controlled tissue biopsy, dissection, enterotomy creation, and suture cutting can be performed with this endoscopic scissors. Endoscopic tissue dissection and enterotomy creation was completed effectively but less efficiently than with laparoscopy primarily due to parallel device use imposed by the dual-channel endoscope.

Axillary nerve injury: diagnosis and treatment.

Axillary nerve injury is infrequently diagnosed but is not a rare occurrence. Injury to the nerve may result from a traction force or blunt trauma applied to the shoulder. The most common zone of injury is just proximal to the quadrilateral space. Atraumatic causes of neuropathy include brachial neuritis and quadrilateral space syndrome. The vast majority of patients recover with non-operative treatment. Baseline electromyographic and nerve conduction studies should be obtained within 4 weeks after injury, with a follow-up evaluation at 12 weeks. If no clinical or electromyographic improvement is noted, surgery may be appropriate. The results of operative repair are best if surgery is performed within 3 to 6 months from the injury. Surgical options include neurolysis, nerve grafting, and neurotization. The results of repair of axillary nerve injuries have been good compared with treatment of other peripheral nerve lesions, due to the monofascicular composition of the nerve and the relatively short distance between the zone of injury and the motor end-plate.

Hyperbaric oxygen therapy in the treatment of soft tissue necrosis resulting from a stingray puncture.

Necrotizing soft tissue processes of the foot secondary to an acute stingray envenomation can be a challenge to manage. Very little is reported in the orthopaedic literature to aid the practicing surgeon faced with this problem. In this case report, we describe the wound management and team approach employed in this patient's care, including the indications for hyperbaric oxygen therapy, which, in this case, was ultimately successful.

[Programs for supervised professional practice and for rural oral health promoters in Guatemala]. / Programas de ejercicio profesional supervisado y de promotores rurales de salud oral en Guatemala.

The experiences of the programs of Supervised Professional Practice and for Rural Oral Health Promoters conducted by the School of Dentistry of San Carlos University in Guatemala are described. The first of these programs was designed to have students practice the profession during an eight-month academic period in hinterland towns under periodical supervision by their professors, and the second resulted as an unexpected offshoot during the initial stages of the program of Supervised Professional Practice in a northwestern district of Guatemala. The history and progress of both programs are described, some results are presented, and the salient features of university-community interaction, as exemplified by these programs, are discussed in terms of a theoretical model designed by one of the authors.