Impact of intestinal dysbiosis-related drugs on the efficacy of immune checkpoint inhibitors in clinical practice.

PURPOSE: Intestinal dysbiosis has emerged as a biomarker of response to immune checkpoint inhibitors (ICIs). It can be caused by antibiotics, although it may also result from the use of other drugs that have been studied to a lesser extent. The objective of our study was to analyze the association between the use of potentially dysbiosis-related drugs and survival in patients treated with ICIs in the clinical practice. MATERIALS AND METHODS: A retrospective, multicenter, cohort study was conducted. Clinicopathological variables were collected and the concomitant use of drugs was analyzed. A descriptive analysis of variables and overall survival, estimated by the Kaplan-Meier method, was performed, and association with various independent variables was assessed using Cox regression. RESULTS: We included 253 patients, mainly with non-small cell lung cancer and melanoma. The most commonly used drugs were acid reducers, prescribed to 55.3% of patients, followed by corticosteroids (37.9%), anxiolytic drugs (35.6%), and antibiotics (20.5%). The use of acid reducers (9 vs. 18 months, P < .0001), antibiotics (7 vs. 15 months, P < .017), anxiolytic drugs (8 vs. 16 months, P < .015), and corticosteroids (6 vs. 19 months, P < .00001) was associated with poorer overall survival. Furthermore, the greater the number of drugs used concomitantly with ICIs, the higher the risk of death (1 drug: hazard ratio, 1.88; CI 95%, 1.07-3.30; 4 drugs: hazard ratio, 4.19; CI9 5%, 1.77-9.92; P < .001). CONCLUSION: Response to ICIs may be influenced by the use of drugs that lead to intestinal dysbiosis. Although a confirmatory prospective controlled study is required, our findings should be taken into account when analyzing ICI efficacy.

Modelling approach to obtain regional respiratory mechanics using electrical impedance tomography and volume-dependent elastance model.

OBJECTIVE: This paper presents a method for breath-by-breath estimation of regional respiratory mechanics without the need for special manoeuvres (such as inspiratory pause or low-flow inflation) using electrical impedance tomography (EIT) associated with pressure/airflow waveforms. APPROACH: We developed a method to estimate regional parameters using the regional impedance fraction, by multiplying it by global flow and volume waveforms. A volume-dependent elastance model was used to obtain compliance, resistance, volume-independent (E 1), and volume-dependent (E 2) components. Three swine under invasive mechanical ventilation were used to assess internal consistency and illustrate potential applications of our method. One animal (case 1) was ventilated with a broad range of tidal volumes to compare the consistency between regional and global resistances and compliances. Two other animals (cases 2 and 3) had respiratory compliance decreased, respectively, by overdistension and collapse as quantified by x-ray computed tomography. MAIN RESULTS: In case 1, derived global estimates obtained from the independent regional estimates were strongly associated with direct measurements of global mechanics (correlation coefficients of 0.9976 and 0.9981 for compliances and resistances, respectively), suggesting consistency of our modelling. In cases 2 and 3, the development of lung overdistension and collapse over time was captured by regional estimates. CONCLUSIONS: Using EIT and pressure/airflow waveforms, regional respiratory parameters can be obtained cycle-by-cycle, refining lung function monitoring. SIGNIFICANCE: The method allows real-time monitoring of regional parameters and their trends over time, which might be helpful to differentiate deterioration in lung compliance due to overdistension or collapse.

High frequency of Taenia pisiformis metacestodes and high sex-associated susceptibility to cysticercosis in naturally infected wild rabbits.

Sexual dimorphism is a well-documented phenomenon observed at all levels of the animal kingdom, with the inclusion of both sexes in clinical trials and basic research becoming mandatory. Regarding parasitosis, in several animal species, the signs and virulence of the disease may change depending on the sex of the affected animal. In the cestodiasis caused by Taenia solium and Taenia crassiceps, females are more susceptible to experimental infection than males. Cysticercosis by Taenia pisiformis in rabbits has acquired relevance due to its economic impact, namely affecting welfare and production. In America, specifically in Mexico, there are no formal reports on the infection with T. pisiformis metacestodes in populations of wild rabbits, despite being the country with more endemic species (about 15 species), among them, the volcanoes rabbits or the endangered teporingo (Romerolagus diazi). In this study, 31 wild rabbits were obtained by hunters of some regions of Morelos state during several hunting seasons, and sex, physiological stage, and number of metacestodes were recorded. A high frequency of infection by T. pisiformis metacestodes (67.7%) was found. Also, a higher susceptibility to this infection was observed in does (80% infected) compared to bucks (40%), finding 84.2% of metacestodes (235 metacestodes) in does and 15.8% of metacestodes (44 metacestodes) in bucks. The percentage of infection was higher in lactating compared with pregnant and non-pregnant does, with metacestodes lodging mainly in the uterus. Increasing our knowledge regarding parasitic infections can help us better understand transmission circles as well as the parasite-host interaction of these increasingly at risk rabbit species.

Conducta de los profesionales sanitarios ante las recomendaciones de profilaxis de endocarditis infecciosa en nuestro medio: ¿se siguen las guías? / Behaviour of health professionals concerning the recommendations for prophylaxis for infectious endocarditis in our setting: Are the guidelines followed?

Objetivos. Las pautas de profilaxis de endocarditis infecciosa recomendadas por las guías de práctica clínica han cambiado recientemente. Se desconoce en nuestro medio si se siguen correctamente las pautas actuales. Nuestro objetivo es describir las actitudes de diferentes profesionales sanitarios ante ellas. Material y métodos. Hemos realizado una encuesta en Córdoba, mediante un cuestionario online con 16 ítems sobre este tema. Se seleccionó aleatoriamente una muestra de 180 profesionales (20 cardiólogos, 80 dentistas, 80 médicos de atención primaria), de la cual contestaron 173. Resultados. La mitad eran varones, teniendo más de 20 años de ejercicio profesional el 52%. El 88,3% consideró que la profilaxis de endocarditis es efectiva (cardiólogos, 77,8%, dentistas, 93,7%, p=0,086). En general, se realiza profilaxis en las situaciones de riesgo claramente establecidas (>90% de los encuestados), pero también en una alta proporción de casos sin riesgo de endocarditis, que oscila entre el 30 y el 60% según los procedimientos (más los dentistas, entre el 36 y 67%, seguidos de los médicos de atención primaria, entre el 28 y 59%). Las pautas antibióticas usadas son muy variadas, siendo los médicos de primaria los que se alejan más de lo recomendado (solo un 25,8% usaban la pauta recomendada, frente a un 54,4% de dentistas y un 72,2% de cardiólogos, p=0,002). Conclusiones. El seguimiento de las recomendaciones sobre profilaxis de endocarditis debe mejorarse en nuestro medio, observándose una tendencia, sobre todo en no cardiólogos, a una «sobreindicación» de la misma (AU)

Objectives. The prophylaxis regimens for infectious endocarditis recommended by the clinical practice guidelines have recently changed. We do not know whether the current regimens are correctly followed in our setting. Our objective was to describe the approaches of various health professionals concerning these guidelines. Material and methods. We conducted a survey in Cordoba, using a 16-item online questionnaire on this topic. We randomly selected a sample of 180 practitioners (20 cardiologists, 80 dentists and 80 primary care physicians), of whom 173 responded. Results. Half of the participants were men; 52% had more than 20 years of professional experience. Some 88.3% of the participants considered that prophylaxis of endocarditis is effective (77.8% of the cardiologists, 93.7% of the dentist; p=.086). In general, prophylaxis is performed in conditions of clearly established risk (>90% of those surveyed). However, prophylaxis is also performed in a high proportion of cases with no risk of endocarditis, varying between 30 and 60% according to the procedure (mostly the dentists, between 36 and 67%, followed by the primary care physicians, between 28 and 59%). The antibiotic regimens employed varied significantly. The primary care physicians were furthest from the recommended regimen (only 25.8% used the recommended regimen vs. 54.4% of dentists and 72.2% of cardiologists; p=.002). Conclusions. Compliance with the recommendations on prophylaxis for endocarditis should be improved in our setting. We observed a tendency, especially among noncardiologists, to 'overindicate' the prophylaxis (AU)

Behaviour of health professionals concerning the recommendations for prophylaxis for infectious endocarditis in our setting: Are the guidelines followed? / Conducta de los profesionales sanitarios ante las recomendaciones de profilaxis de endocarditis infecciosa en nuestro medio: ¿se siguen las guías?

OBJECTIVES: The prophylaxis regimens for infectious endocarditis recommended by the clinical practice guidelines have recently changed. We do not know whether the current regimens are correctly followed in our setting. Our objective was to describe the approaches of various health professionals concerning these guidelines. MATERIAL AND METHODS: We conducted a survey in Cordoba, using a 16-item online questionnaire on this topic. We randomly selected a sample of 180 practitioners (20 cardiologists, 80 dentists and 80 primary care physicians), of whom 173 responded. RESULTS: Half of the participants were men; 52% had more than 20 years of professional experience. Some 88.3% of the participants considered that prophylaxis of endocarditis is effective (77.8% of the cardiologists, 93.7% of the dentist; p=.086). In general, prophylaxis is performed in conditions of clearly established risk (>90% of those surveyed). However, prophylaxis is also performed in a high proportion of cases with no risk of endocarditis, varying between 30 and 60% according to the procedure (mostly the dentists, between 36 and 67%, followed by the primary care physicians, between 28 and 59%). The antibiotic regimens employed varied significantly. The primary care physicians were furthest from the recommended regimen (only 25.8% used the recommended regimen vs. 54.4% of dentists and 72.2% of cardiologists; p=.002). CONCLUSIONS: Compliance with the recommendations on prophylaxis for endocarditis should be improved in our setting. We observed a tendency, especially among noncardiologists, to "overindicate" the prophylaxis.

Vasculopatía periférica asociada al tratamiento con metilfenidato en niños con Trastorno por déficit de atención e hiperactividad / Peripheral vasculopathy associated with methylphenidate treatment in children with Attention Deficit Hyperactivity Disorder

Presentamos el Caso Clínico de una niña diagnosticada de un Trastorno por Déficit de Atención e Hiperactividad que desarrolló una vasculopatía periférica (Síndrome de Raynaud) secundaria al tratamiento con metilfenidato. Se analizan las relaciones entre el tratamiento con metilfenidato y la aparición de fenómenos vasculares periféricos, su relevancia e implicaciones diagnósticas y terapéuticas

We report the case of a girl who is diagnosed of Attention Deficit Hyperactivity Disorder who developed a secondary peripheral vascular disease (Raynaud's Syndrome) after starting treatment with methylphenidate. The relationship between treatment with methylphenidate and the occurrence of peripheral vascular phenomena, its relevance and diagnostic and therapeutic implications are discussed

La violencia en la palabra: narraciones de madres atrapadas en sus redes sociales* / Violence in the Word: Narratives of Mothers Trapped in Their Social Networks

Objetivo: Realizar un estudio descriptivo y analítico sobre los imaginarios de mujeres embarazadas en condiciones de precariedad y violencia, acerca de su percepción del embarazo y de sus redes intrafamiliares y extrafamiliares, por medio de sus narrativas. Método: Se aplicó una encuesta a 350 mujeres gestantes del programa Familia Gestante-Bebé Sano, del Departamento Administrativo de Bienestar Social de la Localidad de Usaquén, con seguimiento de un año (seis meses de gestación y seis meses de crianza del niño), realizando un análisis a profundidad de la narrativa en 50 madres entrevistadas. Resultados: Las mujeres entrevistadas pertenecen, en su mayoría, a familias extensas, jerarquizadas, rígidas en su dinámica, con prácticas monótonas, cuyos valores son impuestos por el grupo familiar (padres o pareja) y relaciones ambiguas con las instituciones. De ellas, 44% no venían planifi cando y 52% no lo hacen luego del parto; 92% no son propietarias y la mayoría manejan relaciones de dependencia. Más de la mitad suspendieron su escolaridad al quedar embarazadas y tres cuartas partes no trabajan. Conclusiones: La población evaluada requiere mayor apoyo para el fomento de su autonomía en la toma de decisiones en temas como sexualidad, escolaridad, tenencia de propiedad, planifi cación y, en general, un mayor conocimiento y ejercicio de sus derechos ciudadanos.

Objective: To carry out a descriptive and analytical study on the imaginaries of pregnant women in precarious and violent conditions, concerning their perception on pregnancy, and their intra and extrafamily networks, basing this study on their usual speech. Methodology: Survey applied to 350 pregnant women from the “Gestating familyhealthy baby” Program of the Administrative Department of Social Welfare at Usaquén (Bogotá), with a one-year monitoring period (six month during pregnancy and six month during the nursing stage), based on the detailed speech analysis of the interviews with 50 women. Results: Most of the interviewed women belong to extensive, hierarchical families, with rigid dynamics and monotonous practices; their values are imposed by the family group (parents or couple) and they have ambiguous relationship with institutions. 44% of them did not use any birth control method, and 52% would not use it after the labor. 92% of the women are not house owners, and the majority of them manage relationships of dependence. More than 50% suspended their studies due to pregnancy and 75% do not work. Conclusions: The evaluated population requires greater support in order to promote its autonomy in making decisions about topics like sexuality, education, house ownership, birth control, and, in general, exercising their civil rights.

Primary glioblastoma with EGFR amplification and a ring chromosome 7 in a young patient.

Glioblastoma is the most common primary tumor of the central nervous system, but the underlying genetic changes that give rise to these tumors are still poorly understood. We report a primary glioblastoma with an unusual age of presentation. The patient was a 22-year-old man with a survival of 16 months. Morphological findings showed an increase of cellularity with positive GFAP and EGFR expression, increase of proliferate index, vascular hyperplasia with glomeruloid structures and necrosis. Molecular analysis showed EGFR amplification. No mutations of the TP53 or amplification of MDM2 and CDK4 were detected. Neither homozygous deletion of the 9p21 locus genes nor aberrant methylation were found. The cytogenetic study showed a clonal karyotype. The metaphases presented, among other anomalies, a small ring chromosome and double-minutes chromosomes. Using FISH and CGH techniques, it was found that the ring chromosome was a partial trisomy of chromosome 7, and the region implicated corresponded to 7p13-q21. Partial trisomies in glioblastoma could play an important role in defining those regions where genes implicated in this tumor process may be found. We studied the possible correlation of these findings with the tumoral phenotype.

Gastric actinomycosis: a rare complication after gastric bypass for morbid obesity.

A 41-year-old woman in November 2002 underwent a gastric bypass by the Capella technique for morbid obesity. Almost 1 year after the surgery, she developed severe vomiting. Radiological studies confirmed a severe stenosis of the gastrojejunal anastomosis. Two pneumatic dilatations of the stenosis failed. In February 2004, she underwent resection of the stenotic anastomosis. Histology showed an intact mucosa and beneath it an abscess filled with numerous filamentous microorganisms, with typical features of Actinomyces. With the diagnosis of gastric actinomycosis, she received a postoperative course of antibiotherapy with imipenem and was discharged after an uneventful recovery. Gastric actinomycosis is a rare infection, of which only 19 additional cases have been reported in the literature. To our knowledge, this is the first case to affect a patient following batriatric surgery. The reported cases of this entity are reviewed, and the diagnostic criteria that could avoid surgery in these cases are discussed.

A simple and species-independent coding measure.

We present a coding measure which is based on the statistical properties of the stop codons, and that is able to estimate accurately the variation of coding content along an anonymous sequence. As the stop codons play the same role in all the genomes (with very few exceptions) the measure turns out to be species-independent. We show results both for prokaryotic and for eukaryotic genomes, indicating, first, the accuracy of the measure, and, second, that better prediction is achieved if the measure is applied on homogeneous, isochore-like sequences than if it is applied following the standard moving window approach. Finally, we discuss on some of the possible applications of the measure.

Study of statistical correlations in DNA sequences.

Here we present a study of statistical correlations among different positions in DNA sequences and their implications by directly using the autocorrelation function. Such an analysis is possible now because of the availability of large sequences or even complete genomes of many organisms. After describing the way in which the autocorrelation function can be applied to DNA-sequence analysis, we show that long-range correlations, implying scale independence, appear in several bacterial genomes as well as in long human chromosome contigs. The source for such correlations in bacteria, which may extend up to 60 kb in Bacillus subtilis, may be related to massive lateral transfer of compositionally biased genes from other genomes. In the human genome, correlations extend for more than five decades and may be related to the evolution of the 'neogenome', a modern evolutionary acquisition composed by GC-rich isochores displaying long-range correlations and scale invariance.

Lista integrada para el diagnóstico de los trastornos de personalidad (LIDTP) / Integrated list for the personality disorders diagnostic (ILPDD)

Se ha pretendido confeccionar un instrumento de fácil manejo y aplicabilidad para alcanzar el diagnóstico de los diferentes tipos de trastornos de personalidad, integrando los criterios que para ello establecen las clasificaciones internacionales al uso, tanto la CIE 10 como la DSM IV y su edición de texto revisado. El resultado es la Lista Integrada para el Diagnóstico de los Trastornos de Personalidad (LIDTP) que presentamos. Teniendo presente que la etiología de los trastornos de personalidad abarca a todas y cada una de las áreas que conforman la personalidad en realimentación continua, la LIDTP se ha confeccionado siguiendo una agrupación por las esferas cognitivas, exploratoria, anímica, impulsiva y ansiosa (AU)

Isochore chromosome maps of eukaryotic genomes.

Analytical DNA ultracentrifugation revealed that eukaryotic genomes are mosaics of isochores: long DNA segments (>>300 kb on average) relatively homogeneous in G+C. Important genome features are dependent on this isochore structure, e.g. genes are found predominantly in the GC-richest isochore classes. However, no reliable method is available to rigorously partition the genome sequence into relatively homogeneous regions of different composition, thereby revealing the isochore structure of chromosomes at the sequence level. Homogeneous regions are currently ascertained by plain statistics on moving windows of arbitrary length, or simply by eye on G+C plots. On the contrary, the entropic segmentation method is able to divide a DNA sequence into relatively homogeneous, statistically significant domains. An early version of this algorithm only produced domains having an average length far below the typical isochore size. Here we show that an improved segmentation method, specifically intended to determine the most statistically significant partition of the sequence at each scale, is able to identify the boundaries between long homogeneous genome regions displaying the typical features of isochores. The algorithm precisely locates classes II and III of the human major histocompatibility complex region, two well-characterized isochores at the sequence level, the boundary between them being the first isochore boundary experimentally characterized at the sequence level. The analysis is then extended to a collection of human large contigs. The relatively homogeneous regions we find show many of the features (G+C range, relative proportion of isochore classes, size distribution, and relationship with gene density) of the isochores identified through DNA centrifugation. Isochore chromosome maps, with many potential applications in genomics, are then drawn for all the completely sequenced eukaryotic genomes available.

Surgical site infections in ambulatory surgery: a 5-year experience.

OBJECTIVES: To evaluate the ambulatory surgical site infection rate and risk factors associated with surgical site infection. METHODS: We conducted a case-control analysis of all ambulatory surgeries between January 1, 1993, and December 31, 1997. The frequency of surgical site infection per 100 surgeries was calculated. The odds ratio (OR) was estimated by using logistic regression analysis. SETTING: A 140-bed tertiary-care teaching hospital for adult patients with cancer. RESULTS: The study followed 1350 outpatient surgeries. Thirty-eight patients had a surgical site infection (rate per 100 surgeries: 2.8). The risk factors statistically associated with surgical site infection were postoperative antibiotics (OR = 7.5; 95% CI, 2.5-23.0), and surgical time >35 minutes (OR = 2.4; 95% CI, 1.1-5.5). CONCLUSIONS: The surgical site infection rate for same-day surgery at our hospital is within the limits reported in the literature and below the rates reported previously for inpatient surgeries at our hospital. Full review of medical records and microbiology reports at day 30 allowed us to identify infections that otherwise would have been missed. Postoperative antibiotics may increase the risk of infection.

El remordimiento y los trastornos de la personalidad / Remorse and personality disorders

En la observación diacrónica de los trastornos de personalidad, da la impresión fenoménica de una estructura funcional de comportamiento basada en la no-renuncia pulsional. Partiendo de la hipótesis de trabajo de que los trastornos de personalidad son el resultado fenomena de un "ser inacabado", se muestra la ausencia de remordimiento y de culpa como uno de los ingredientes fundamentales en la forma de establece y mantener relaciones interpersonales. Analizamos la psicología de la ausencia de remordimiento en conjunción con las distorsiones cognitivas que se aprecian en los comportamientos de los trastornos de personalidad, para poder establecer los elementos fisiopatológicos que procuran la represión y la negación subsiguientes, en conjunción con el tipo de Súper-Yo, que es idiosincrásico en este tipo de pacientes. Por fin, proponemos las líneas patogénicas individuales y sociales, en conjunción interactiva, responsables tanto del incremento epidemiológico actual de los trastornos de personalidad como de que la "alarma social" ante ellos sea mayor que en otras épocas históricas (AU)

Finding borders between coding and noncoding DNA regions by an entropic segmentation method.

We present a new computational approach to finding borders between coding and noncoding DNA. This approach has two features: (i) DNA sequences are described by a 12-letter alphabet that captures the differential base composition at each codon position, and (ii) the search for the borders is carried out by means of an entropic segmentation method which uses only the general statistical properties of coding DNA. We find that this method is highly accurate in finding borders between coding and noncoding regions and requires no "prior training" on known data sets. Our results appear to be more accurate than those obtained with moving windows in the discrimination of coding from noncoding DNA.

Tunicamycin inhibits capillary endothelial cell proliferation by inducing apoptosis. Targeting dolichol-pathway for generation of new anti-angiogenic therapeutics.

Bovine adrenal medulla microvascular endothelial cells used in this study undergo cellular proliferation and differentiation upon culturing in vitro as observed both by light and scanning electron microscopy. Cells also respond to the growth promoting activity of serum and basic fibroblast growth factor (FGF2). Flow cytometric analysis of a synchronized culture established that cells take 68 hours to complete one cell cycle spending 36 hours in the G1 phase, 8 hours in the S phase, and 24 hours in the G2 + M phase when cultured in EMEM containing 2% heat-inactivated fetal bovine serum (FBS). At 10% serum, or in the presence of FGF2 (10 ng/ml-100 ng/ml) length of the cell cycle is reduced to 56 hours due to shortening of the G1 phase by 12 hours. Tunicamycin (a glucosamine-containing pyrimidine nucleotide), and an inhibitor of glucosaminyl-1-phosphate (GlcNAc 1-P) transferase, the first step of Glc3Man9GlcNAc2-PP-Dol (OSL) biosynthesis is found to inhibit the endothelial cells proliferation by inducing apoptosis as observed by flow cytometry and DNA laddering. Cell shrinkage, compaction of nuclei, membrane fragmentation, etc., typical of apoptotic response are frequently seen by light microscopy in the presence of tunicamycin. Scanning electron microscopy also exhibited a considerable amount of cell surface blebbing. Accumulation of an immunopositive cell specific asparagine-linked (N-linked) glycoprotein, Factor VIII:C in the absence of Glc3Man9GlcNAc2-PP-Dol in tunicamycin treated cells has been proposed as an apoptotic triggering mechanism under the current experimental conditions.

[Cervical curvature. A cephalometric study in position of clinical rest]. / Curvatura cervical. Estudio cefalométrico en posición de reposo clínico postural.

BACKGROUND: Alterations in the head position and in cervical curvature are associated with mandibular dysfunction, an increased vertical occlusal dimension, upper airways obstruction and bad postural behaviors at work among other conditions. AIM: To perform a cephalometric analysis in young adults. SUBJECTS AND METHODS: Lateral cervical X-ray examinations were performed in 46 university students (26 female) aged 19 years old as a mean, Cephalometric landmarks and planes reported by Sollow & Tallgren, determined by investigators, were used for radiographic analysis. RESULTS: The combined error of the method did not exceed 0.9 degree for any studied variable. Mean craniocervical angulations were 102 degrees for OPT-SNL, 109 degrees for CVT-SNL, 94.8 degrees for cranium-C2 and 105 for SN-vertical. There were significant sex differences in craniocervical angulations and these were abnormal in two thirds of subjects studies. The Forward Head Position is characterized by a cervical compensation with head inclination. This abnormal postural position showed a dolichofacial growth and an alteration of hyoid angle. CONCLUSIONS: The craniocervical position appeared to be related to a vertical craniofacial growth pattern.

Surgical technique for inferior mesenteric vein to renal vein shunt in portal hypertension.

An important role still exists for the creation of surgical portasystemic shunts. Multiple techniques have been described. However, no particular one is satisfactory for all clinical situations. The objective of the present paper is to describe an alternative surgical technique for the creation of a decompressive portasystemic shunt. This technique consists of an end-to-side anastomosis between the inferior mesenteric vein and the left renal vein. In our experience, the inferior mesenteric vein to left renal vein anastomosis may be a useful portal decompressive shunt for patients with otherwise difficult peri-portal or peri-pancreatic anatomic exposures. This technique should be a useful tool in the armamentarium of surgeons dealing with patients who need portal decompressive surgical shunts.