Single leaflet reconstruction of pulmonic valve with decellurized bovine pericardium.

A patient presented with a complex mass seen extending from the lumen of the aorta to the lumen of the pulmonary artery. Papillary fibroelastoma was identified at resection, however the left pulmonary valve leaflet required resection to fully remove the mass. The leaflet was reconstructed using the bovine pericardial extracellular matrix. Valve function and flow characteristics were excellent following repair.

Quality of life comparing dor and toupet after heller myotomy for achalasia.

BACKGROUND: Laparoscopic Heller cardiomyotomy (LHC) is standard therapy for achalasia. Traditionally, an antireflux procedure has accompanied the myotomy. This study was undertaken to compare quality-of-life outcomes between patients undergoing myotomy with Toupet versus Dor fundoplication. In addition, we investigated overall patient satisfaction after LHC in the treatment of achalasia. METHODS: One hundred thirty-five patients who underwent LHC over a 13-year period were identified for inclusion. Symptoms queried included dysphagia, heartburn, and bloating using the Gastroesophageal Reflux Disease-Health-Related Quality of Life Scale and a second published scale for the assessment of gastroesophageal reflux disease and dysphagia symptoms. The patients' overall satisfaction after surgery was also rated. Data were compared on the basis of type of fundoplication. Symptom scores were analyzed using chi-square tests and Fisher's exact tests. RESULTS: Sixty-three patients completed the survey (47%). There were no perioperative deaths or reoperations. The mean length of stay was 2.8 days. The mean operative time for LHC with Toupet fundoplication was 137.3±30.91 minutes and for LHC with Dor fundoplication was 111.5±32.44 minutes (P=.006). There was no difference with respect to the incidence or severity of postoperative heartburn, dysphagia, or bloating. Overall satisfaction with Toupet fundoplication was 87.5% and with Dor fundoplication was 93.8% (P>.999). CONCLUSIONS: LHC with either Toupet or Dor fundoplication gave excellent patient satisfaction. Postoperative symptoms of heartburn and dysphagia were equivalent when comparing LHC with either antireflux procedure. Dor and Toupet fundoplication were found to have equivalent outcomes in the short term. We prefer Dor to Toupet fundoplication because of its decreased need for extensive dissection and better mucosal protection.

Collaborating to increase access to clinical and educational resources for surgery: a case study.

A case study is described in which collaborations between a Department of Surgery, a Department of Information Technology, and an academic health sciences library resulted in the development of an electronic surgical library available at the bedside, the deployment of tablet devices for surgery residents, and implementation of a tablet-friendly user interface for the institution's electronic medical record.

An intestinal occlusion device for prevention of small bowel distention during transgastric natural orifice transluminal endoscopic surgery.

BACKGROUND AND OBJECTIVES: Bowel distention from luminal gas insufflation reduces the peritoneal operative domain during natural orifice transluminal endoscopic surgery (NOTES) procedures, increases the risk for iatrogenic injury, and leads to postoperative patient discomfort. METHODS: A prototype duodenal occlusion device was placed in the duodenum before NOTES in 28 female pigs. The occlusion balloon was inflated and left in place during the procedure, and small bowel distension was subjectively graded. One animal had no balloon occlusion, and 4 animals had a noncompliant balloon placed. RESULTS: The balloon maintained its position and duodenal occlusion in 22 animals (79%) in which the bowel distention was rated as none (15), minor (4), moderate (3), or severe (0). The intestinal occlusion catheter failed in 6 animals (21%) because of balloon leak (5) or back-migration into the stomach (1), with distention rated as severe in 5 of these 6 cases. CONCLUSION: The intestinal occlusion catheter that maintains duodenal occlusion significantly improves the intraabdominal working domain with enhanced visualization of the viscera during the NOTES procedure while requiring minimal time and expense.

Roux-en-Y gastric bypass increases intravenous ethanol self-administration in dietary obese rats.

Roux-en-Y gastric bypass surgery (RYGB) is an effective treatment for severe obesity. Clinical studies however have reported susceptibility to increased alcohol use after RYGB, and preclinical studies have shown increased alcohol intake in obese rats after RYGB. This could reflect a direct enhancement of alcohol's rewarding effects in the brain or an indirect effect due to increased alcohol absorption after RGYB. To rule out the contribution that changes in alcohol absorption have on its rewarding effects, here we assessed the effects of RYGB on intravenously (IV) administered ethanol (1%). For this purpose, high fat (60% kcal from fat) diet-induced obese male Sprague Dawley rats were tested ~2 months after RYGB or sham surgery (SHAM) using both fixed and progressive ratio schedules of reinforcement to evaluate if RGYB modified the reinforcing effects of IV ethanol. Compared to SHAM, RYGB rats made significantly more active spout responses to earn IV ethanol during the fixed ratio schedule, and achieved higher breakpoints during the progressive ratio schedule. Although additional studies are needed, our results provide preliminary evidence that RYGB increases the rewarding effects of alcohol independent of its effects on alcohol absorption.

Sleep deprivation increases cognitive workload during simulated surgical tasks.

BACKGROUND: There have been conflicting reports of the effects of modest sleep deprivation on surgical skills. The aim of this study was to assess the effects of a 24-hour call shift on technical and cognitive function, as well as the ability to learning a new skill. METHODS: Thirty-one students trained to expert proficiency on a virtual reality part-task trainer. They then were randomized to either a control or sleep-deprived group. On the second testing day they were given a novel task. Fatigue was assessed using the Epworth Sleepiness Scale. The National Aeronautics and Space Administration-Task Load Index was used to assess cognitive capabilities. RESULTS: There was no difference between the control and sleep-deprived groups for performance or learning of surgical tasks. Subjectively, the Epworth Sleepiness Scale showed an increase in sleepiness. The National Aeronautics and Space Administration-Task Load Index showed an increase in total subjective mental workload for the sleep-deprived group. CONCLUSIONS: Sleep-deprived subjects were able to complete the tasks despite the increased workload, and were able to learn a new task proficiently, despite an increase in sleepiness.

Reliability of gastric access closure with the self-approximating transluminal access technique (STAT) for NOTES.

BACKGROUND: STAT, or the self-approximating transluminal access technique, has been previously described and involves the dissection of a submucosal tunnel for peritoneal or mediastinal access from the esophagus and stomach. The objective of this study was to assess the safety and reliability of gastric access and closure in a porcine experience using STAT for natural orifice transluminal endoscopic surgery (NOTES). METHODS: A review of the experience using STAT access tunnels for intraperitoneal access was performed in 39 female pigs at a university animal lab. All animals underwent a predetermined NOTES surgical procedure using a STAT transgastric access tunnel based on a specific protocol. Details of the procedure, complications, and clinical course were documented. Necropsy was performed at 2 weeks. The main outcome measurements were clinical or necropsy evidence of gastrostomy site leak or inadequate access site closure. RESULTS: STAT was successful in providing safe peritoneal access in all animals. The width of the tunnel ranged from 1.5 to 5.5 cm and the length was up to 27 cm. There was no evidence of gastrostomy site leak in any animals. One animal required a single laparoscopic suture to help with tunnel closure. CONCLUSION: STAT provides safe transgastric access and allows secure closure of the gastrotomy site.

Multiply recurrent episodes of gastric emphysema.

Introduction. Gastric emphysema can present both a diagnostic challenge and a life-threatening condition for patients and has only once been reported as being recurrent. Background. A 64-year-old male presented with chronic abdominal pain and was found to have gastric pneumatosis on CT scan. The patient was successfully managed conservatively. The cause was attributed to aberrant arterial anatomy and atherosclerosis along with hypotension. The patient has since had 3 episodes of recurrent gastric emphysema, all managed nonoperatively. Discussion. To our knowledge, this is the first case of both serial episodes of gastric pneumatosis and gastric mucosal ischemia as a precipitating factor for the development of gastric emphysema.