Poly(I:C) source, molecular weight and endotoxin contamination affect dam and prenatal outcomes, implications for models of maternal immune activation.

The viral mimetic polyinosinic:polycytidylic acid (poly(I:C)) is increasingly used to induce maternal immune activation (mIA) to model neurodevelopmental disorders (NDDs). Robust and reproducible phenotypes across studies are essential for the generation of models that will enhance our understanding of NDDs and enable the development of improved therapeutic strategies. However, differences in mIA-induced phenotypes using poly(I:C) have been widely observed, and this has prompted the reporting of useful and much needed methodological guidelines. Here, we perform a detailed investigation of molecular weight and endotoxin variations in poly(I:C) procured from two of the most commonly used suppliers, Sigma and InvivoGen. We demonstrate that endotoxin contamination and molecular weight differences in poly(I:C) composition lead to considerable variability in maternal IL-6 response in rats treated on gestational day (GD)15 and impact on fetal outcomes. Specifically, both endotoxin contamination and molecular weight predicted reductions in litter size on GD21. Further, molecular weight predicted a reduction in placental weight at GD21. While fetal body weight at GD21 was not affected by poly(I:C) treatment, male fetal brain weight was significantly reduced by poly(I:C), dependent on supplier. Our data are in agreement with recent reports of the importance of poly(I:C) molecular weight, and extend this work to demonstrate a key role of endotoxin on relevant phenotypic outcomes. We recommend that the source and batch numbers of poly(I:C) used should always be stated and that molecular weight variability and endotoxin contamination should be minimised for more robust mIA modelling.

Dietary gap assessment: an approach for evaluating whether a country's food supply can support healthy diets at the population level.

OBJECTIVE: Dietary diversity, and in particular consumption of nutrient-rich foods including fruits, vegetables, nuts, beans and animal-source foods, is linked to greater nutrient adequacy. We developed a 'dietary gap assessment' to evaluate the degree to which a nation's food supply could support healthy diets at the population level. Design/Setting In the absence of global food-based dietary guidelines, we selected the Dietary Approaches to Stop Hypertension (DASH) diet as an example because there is evidence it prevents diet-related chronic disease and supports adequate micronutrient intakes. We used the DASH guidelines to shape a hypothetical 'healthy' diet for the test country of Cameroon. Food availability was estimated using FAO Food Balance Sheet data on country-level food supply. For each of the seven food groups in the 'healthy' diet, we calculated the difference between the estimated national supply (in kcal, edible portion only) and the target amounts. RESULTS: In Cameroon, dairy and other animal-source foods were not adequately available to meet healthy diet recommendations: the deficit was -365 kcal (-1527 kJ)/capita per d for dairy products and -185 kcal (-774 kJ)/capita per d for meat, poultry, fish and eggs. Adequacy of fruits and vegetables depended on food group categorization. When tubers and plantains were categorized as vegetables and fruits, respectively, supply nearly met recommendations. Categorizing tubers and plantains as starchy staples resulted in pronounced supply shortfalls: -109 kcal (-457 kJ)/capita per d for fruits and -94 kcal (-393 kJ)/capita per d for vegetables. CONCLUSIONS: The dietary gap assessment illustrates an approach for better understanding how food supply patterns need to change to achieve healthier dietary patterns.

Urologic complications in renal transplant recipients by donor type.

BACKGROUND AND PURPOSE: Reduced donor morbidity has been established after laparoscopic donor nephrectomy compared with open harvest, but differences in recipient outcomes remain less obvious. We compared the urologic complications in patients receiving kidneys procured by cadaveric, open, and laparoscopic harvest. PATIENTS AND METHODS: A retrospective study of all the kidney transplantations performed between January 1998 and December 2003 was undertaken to extract 100 consecutive patients in each group. All urologic complications were obtained and grouped by the type of donor procurement. RESULTS: Overall, 48 of the 276 transplant patients (17%) had urologic complications: 14% of the cadaveric-donor recipients, 20% of the open-donor recipients, and 18% of the laparoscopic-donor recipients. There were no ureteral complications in the laparoscopic group. CONCLUSIONS: Laparoscopically procured donor kidneys were associated with significantly fewer recipient ureteral complications than open cadaver or live-donor procurement.

Laparoscopic repair of complex ventral hernia facilitated by pre-operative chemical component relaxation using Botulinum Toxin A.

PURPOSE: The operative management of complex ventral hernia poses a formidable challenge, despite recent advances in surgical techniques. Recurrence rates after complex ventral hernia repair remain high, and increase with each failed attempt. This study examines the effect of pre-operative abdominal wall chemical component relaxation using Botulinum Toxin A (BTA) to induce temporary flaccid paralysis in order to facilitate laparoscopic repair of large complex ventral hernia. METHODS: This is a prospective evaluation of 27 patients from January 2013 to August 2015 who underwent ultrasound guided BTA injections to the lateral abdominal wall muscles prior to elective complex ventral hernia repair. Non-contrast serial CT imaging was obtained pre- and post-BTA injection to measure change in fascial defect size and abdominal wall muscle thickness and length. Fascial defects were closed and hernias repaired using laparoscopic or laparoscopic-assisted intra-peritoneal onlay mesh (IPOM) techniques. RESULTS: 27 patients received pre-operative BTA injections which were well tolerated with no complications. Comparison of pre-BTA and post-BTA CT imaging demonstrated a significant increase in mean length of the lateral abdominal wall from 15.7 cm pre-BTA to 19.9 cm post-BTA (p < 0.0001), with mean unstretched length gain of 4.2 cm/side (range 0-11.7 cm/side). All hernias were surgically reduced and repaired with mesh, with no early recurrences. CONCLUSION: Pre-operative administration of BTA is a safe and effective technique in the pre-operative preparation of patients undergoing elective complex ventral hernia repair. This technique lengthens and relaxes the laterally retracted abdominal muscles and enables laparoscopic closure of large complex ventral hernia.

Laparoscopic pancreatic resection: single-institution experience of 19 patients.

BACKGROUND: The number of laparoscopic pancreatic resections reported in the surgical literature has been remarkably low. Few substantive data are available concerning current indications and outcomes after laparoscopic pancreatectomy. The purpose of this article is to review the recent indications, complications, and outcomes after laparoscopic pancreatic resection. STUDY DESIGN: A retrospective analysis of the Mount Sinai hospital records was performed for all patients who underwent laparoscopic distal pancreatectomy or enucleation between the time of the first resection in November 1993 until the time of this study in March 2000. RESULTS: In the 19 patients (6 men) the mean age was 53 years (range 22 to 83 years). In 16 patients (84%) the entire procedure was done by laparoscopy; one operation was converted to a hand-assisted technique; and two cases were converted to open. Median operating time was 4.4 hours (range 1.6 to 6.6 hours), and median intraoperative blood loss was 200 mL. Postoperative complications included three pancreatic leaks (16%), one case of superficial phlebitis, and one prolonged ileus for 7 days (total morbidity of 26%). There were no deaths. The median length of postoperative hospital stay was 6 days (range 1 to 26 days). CONCLUSIONS: This represents the largest single-institution experience with laparoscopic pancreatic resection. The considerable morbidity rate is comparable to recently published open series, and is likely inherent in pancreatic surgery, rather than the technical approach. Laparoscopic pancreatic surgery resulted in shorter hospital stays and appears to be safe for benign diseases.

Laparoscopic surgery in the management of inflammatory bowel disease.

BACKGROUND: The role of laparoscopic surgery in the treatment of various upper and lower gastrointestinal disorders is still under investigation. However, a variety of laparoscopic procedures may be applied in the treatment of inflammatory bowel disease (IBD). PATIENTS AND METHODS: We present our initial results of laparoscopic and laparoscopic-assisted management of IBD in 72 consecutive patients (37 women and 35 men; mean age 36 years, range 20 to 79). The indications for surgery included: terminal ileitis in 29 patients, mucosal ulcerative colitis in 23 patients, Crohn's colitis in 11 patients, severe perianal Crohn's disease in 4 patients, duodenal Crohn's disease in 3 patients, Crohn's rectovaginal fistula in 1 patient, and rectourethral fistula in 1 patient. The procedures performed included: total abdominal colectomy (TAC) in 30 patients (22 with total proctocolectomy with ileoanal reservoir, 6 with TAC with ileorectal anastomosis, and 2 with TAC with end ileostomy), ileocolic resection in 30 patients, diverting loop ileostomy in 6 patients, closure of an end ileostomy as an ileorectal anastomosis in 3 patients who already underwent a TAC with end ileostomy, and duodenal bypass gastrojejunostomy in 3 patients. RESULTS: There were 16 complications in 13 (18%) patients: 3 enterotomies, 4 episodes of bleeding, 3 pelvic abscesses, 2 intestinal obstructions, 2 prolonged ileus, 1 anastomotic leak, and 1 efferent loop obstruction after gastrojejunostomy. However, only 3 patients required laparotomy for morbidity, and there was no mortality. In 7 (10%) patients, the laparoscopic procedure was converted to a laparotomy due to a large inflammatory mass with fistula in 4 patients, bleeding in 2 patients, and an enterotomy in 1 patient. The mean operating time was 2.9 hours (range 0.7 to 6) and the mean length of hospital stay was 6.5 days (range 3 to 19). When compared with ileocolic resection, total colectomy was associated with higher morbidity (30% versus 10%, P < 0.05) and longer hospitalization (8.7 days [range 4 to 19] versus 5.2 days [range 3 to 7], respectively; P < 0.05). CONCLUSIONS: According to this initial experience, laparoscopic surgery is a versatile and effective modality in the surgical management of inflammatory bowel disease in selected patients. However, laparoscopic total colectomy is associated with higher morbidity when compared with ileocolic resection.

Current laparoscopic approaches to pancreatico-biliary disease.

Biliary-enteric anastomoses to duodenum or jejunum are a laparoscopic reality and will find a place in the management of complicated choledocholithiasis or malignant strictures of the bile duct. Staging by laparoscopy in pancreatic malignancy is an ideal strategy, with some operators able to complete a definitive laparoscopic palliative bypass in the same sitting. Intraoperative laparoscopic sonography is an advancing technique and has great potential in the evaluation of choledocholithiasis, hepatic metastases and staging of pancreatic cancer. Innovative options exist to deal with bile duct calculi, including antegrade sphincterotomy and intraoperative stent placement.

Diagnostic and interventional laparoscopy and intraoperative ultrasonography in the management of pancreatic disease.

The laparoscopic management of pancreatic disorders has evolved dramatically from its inception in 1911 and its rediscovery in the 1970s. Although investigators once proclaimed that "it seems unlikely that laparoscopy will have any more than an extremely limited use in the investigation of pancreatic disorders," laparoscopy and LUS now have a well-recognized role in the staging of pancreatic cancer and an increasing part in the management of benign pancreatic disease at many institutions. Although the appropriate role of LS and LUS is debatable, the development and refinement of laparoscopic techniques and instrumentation and the improvement of noninvasive diagnostic modalities will provide new data, increase the rate of resection at laparotomy, and allow surgeons to treat a broader range of pancreatic disease by minimally invasive methods. The value of LS and LUS for benign and malignant pancreatic disorders has been clearly demonstrated, but the inevitable issues of hospital resource, operative expertise, and surgical philosophy will ultimately determine the role of laparoscopy and LUS in clinical practice.

Laparoscopic pancreatectomy.

Laparoscopic access to the retroperitoneum is safe and feasible. Pancreatic resection requires complete familiarity with two-handed technique and knowledge of pancreatic anatomy. At present, only benign diseases should be approached laparoscopically, unless institutional review board approval exists for malignant disease.

Hand-assisted laparoscopic surgery: an emerging technique.

BACKGROUND: Some surgeons are finding that the placement of one hand in the abdomen during laparoscopic procedures returns tactile feedback lost during purely laparoscopic surgery and facilitates dissection, retraction, and control of bleeding. Studies comparing patient postoperative discomfort after laparoscopic and hand-assisted laparoscopic procedures have not found a significant difference. METHODS: This article is a review of the current literature on hand-assisted laparoscopic surgery and of the different hand-assisted devices on the market. Included in the review are opinions of expert laparoscopic surgeons who have used hand-assisted devices. RESULTS: More than 100 hand-assisted laparoscopic procedures have been described in the literature. At least four different companies are involved in hand-assisted laparoscopic devices. Three of these companies currently are Food and Drug Administration (FDA) approved in the United States. CONCLUSIONS: Hand-assisted laparoscopic surgery is not necessary for all laparoscopic procedures. Hand-assisted laparoscopic technique is advantageous for certain procedures and clinical situations such as en bloc resections and removal of solid organ tumors, large colon tumors, and the kidney after donor nephrectomy. This technique offers benefits when a large incision is necessary to complete surgery such an open colon anastomosis.

Intraoperative cholangiography is still indicated after preoperative endoscopic cholangiography for gallstone disease.

BACKGROUND: Intraoperative cholangiography (IOC) is frequently omitted in patients undergoing laparoscopic cholecystectomy (LC) if they have had successful preoperative endoscopic retrograde cholangiography (ERC). METHODS: A prospectively maintained divisional laparoscopic cholecystectomy database was searched from 1991 to 1997 for patients who had IOC after preoperative ERC. The presence of recurrent or residual common duct stones seen on IOC and their impact on subsequent management were evaluated. RESULTS: We identified a group of 127 patients who underwent preoperative ERC. Thirty-one patients (31/127, or 24%) went on to receive an IOC during cholecystectomy. In 15 patients whose preoperative ERC was reported normal, five (33%) had an abnormal IOC. In 16 patients whose ERC was reported as having cleared the duct, eight (50%) had an IOC abnormality. Eight of these 31 patients required a further procedure to clear the duct. CONCLUSION: Retained or recurrent common duct stones at cholecystectomy following diagnostic or therapeutic ERC were more common than expected. Therefore, IOC is recommended during LC regardless of the findings yielded by the preoperative ERC.

[Laparoscopic nephrectomy in the liver donor: introduction of the method and preliminary results]. / Néphrectomie par laparoscopie chez le donneur vivant: introduction de la méthode et résultats préliminaires.

INTRODUCTION: The shortage of organs available for renal transplantation has focussed attention on the use of live donors. Techniques for laparoscopic nephrectomy have recently been described, which have limited morbidity, duration of hospitalization and the period off work. However, these surgical procedures are difficult, and may be risky for the organ to be transplanted. METHOD: The laparoscopic live donor nephrectomy was introduced in stages, including the use of a videoconference from a reference center. In this article, the prospective analysis of the present authors' preliminary results has been presented. RESULTS: Ten kidneys were removed by laparoscopy, i.e., three from the left and seven from the right side. No conversion of this technique to laparotomy was necessary. The mean warm ischemic time was five minutes, and in the last six operations it did not exceed three minutes. The patients were able to leave hospital between four and eight days following surgery. After a mean follow-up of 10.5 months, organ survival was 100%, and in all grafts excellent function was observed. CONCLUSION: The quality of these preliminary results which may act as a reference and the careful introduction of a live donor laparoscopic program could provide an incentive to potential donors, and thereby increase the pool of organs available for transplantation.

Conversions and complications of laparoscopic cholecystectomy. Results of a survey conducted by the French Society of Endoscopic Surgery and Interventional Radiology.

During 1991, 41 surgeons of the French Society of Endoscopic Surgery and Operative Radiology (SFCERO) performed 3,673 cholecystectome of which 2,955 were laparoscopic. Data for those patients in whom a conversion to laparotomy was necessary or a complication occurred were collected by a retrospective multicenter survey. Conversion was performed in 142 patients (4.8%): in 106 this was due to pathology in the subhepatic space; in 36 it was because of a complication related to the laparoscopy. There were 101 postoperative complications (morbidity 3.4%): 59 biliary and 42 non biliary complications and six deaths (mortality 0.2%). There were 18 bile duct injuries, one of which led to the death of the patient. Excluding conversions to laparotomy, these figures are comparable to those for open cholecystectomy. These results define the limits and advantages of laparoscopic cholecystectomy. Conversion to laparotomy remains a wise option in cases of technical difficulty or doubtful biliary anatomy.

Laparoscopic assisted colectomy.

BACKGROUND: The role and feasibility of laparoscopic assisted colectomy (LAC) in both benign and malignant disease of the colon are not clear. We have reviewed our series in an effort to further delineate whether or not LAC is appropriate in the treatment of colonic disease. METHODS: This is a retrospective view of a personal series focusing on feasibility, cure of malignant disease, and length of stay (LOS). RESULTS: One hundred and two LACs were completed out of 104 attempts (98%). There were no wound or trocar implants in the Dukes A, B and C patients. Lymph node retrieval was similar in the laparoscopic and open historical controls. The LOS was 5.9 days in the LAC group as compared with 11 days in the open group. There was a 4.8% major morbidity rate and a 1% mortality rate in this series. CONCLUSIONS: LAC is technically feasible in a high percentage of patients. While a definite statement regarding its use in malignant disease can not be ascertained from this review, the preliminary results are encouraging. A randomized trial comparing open and LAC is warranted.

The difficult cholecystectomy: problems related to concomitant diseases.

The difficult gallbladder is the most common "difficult" laparoscopic surgery performed by general surgeons. It is also "potentially" the one that places the patient at significant risk. This article reports on our first 1,900 laparoscopic cholecystectomies. With this report, it is the desire of the authors to share our experiences and lessons learned from more than 300 difficult gallbladder cases. We surgeons must strive for no bile duct injuries. If certain principles are followed, the surgeon will be able to improve his or her completion rate and decrease (if not eliminate) bile duct injuries. First and foremost is to know when to convert to open. Performance of fluorocholangiography to define anatomy is also very helpful in avoidance of bile duct injury. The laparoscopic surgeon should start with simple cases before "graduating" to more complex cases. Lastly, the ability to suture and knot tie is key in performing advanced procedures. This skill will allow completion of cases that otherwise would have to be converted to traditional surgery.

The role of laparoscopy in the diagnosis and treatment of abdominal pain syndromes.

BACKGROUND: Diagnostic laparoscopy plays a significant role in the evaluation of acute and chronic abdominal pain in the era of therapeutic laparoscopic surgery. METHODS: We referred to our personal series of laparoscopy for both acute and chronic abdominal pain. This is a retrospective review of data accumulated prospectively between 1979 and the present. RESULTS: In our series, 387 consecutive patients underwent laparoscopy because of abdominal pain. In a group of 121 patients with acute abdominal pain, a definitive diagnosis was made in 119 cases (98%). Two patients needed laparotomy to confirm the diagnosis; both had a disease process that did not require laparotomy to treat. A definitive therapeutic laparoscopic procedure was performed in 53 cases 944%). In 45 patients (38%), a diagnosis was made that did not require therapeutic laparoscopy or laparotomy to treat. In the remaining 21 patients (17.5%), exploratory laparotomy was needed to treat the condition. In a chronic abdominal pain group of 265 patients, the etiology was established laparoscopically in 201 cases (76%). A definitive therapeutic laparoscopic procedure was performed in 128 patients (48%). There was a normal laparoscopic examination in 64 patients (24%). There was one false negative laparoscopy that required laparotomy to treat 1 month later. CONCLUSIONS: Laparoscopy is an accurate modality for the diagnosis of both acute and chronic abdominal pain syndromes. These data support the use of laparoscopy as the primary invasive intervention in patients with acute and chronic abdominal pain.

Laparoscopic cholecystectomy in the obese patient.

Between September 1990 and September 1991 laparoscopic cholecystectomy (LC) was performed in 310 patients with symptomatic cholelithiasis by using a four-cannula technique. Of this group, 282 were normal or overweight (group A) and 28 were obese (group B) according to classification using the Body Mass Index. Forty-one patients had cholecystitis of varying degree. There were no deaths in this series. The conversion rate to laparotomy was 2.9% and the morbidity was 5.4%. There was no statistical difference between groups A and B in relation to the length of procedure, conversion rate, or morbidity. This small series suggests that laparoscopic access is still feasible, if at times difficult, in obese patients. Specific surgical techniques concerning instrument length and cannula placement that may be useful in obese patients are described.

Sac excision is essential to adequate laparoscopic repair of paraesophageal hernia.

BACKGROUND: We compared the incidence of early hernia recurrence in nonrandomized but consecutive patients undergoing laparoscopic repair of paraesophageal hernia (LRPH) without and with excision of the hernia sac. METHODS: LRPH was completed in 55 of 58 patients. In the first 25 patients, the sac was not excised. Total sac excision was performed in the subsequent 30 patients. All patients had crural repair with or without fundoplication, or gastropexy. RESULTS: Mean age of patients was 68 years (range, 34-95). There were three conversions; one patient died postoperatively. Mean operative time was 225 min in the first group and 190 min in the sac excision group. Median length of stay was 2 days (range, 1-15) for both groups. CONCLUSIONS: A precise method of total sac excision simplified dissection. It also ensured complete reduction of the hernia and availability of adequate esophageal length. Operative time was not increased, and no subsequent early recurrences were observed (p < 0.05).