The Evolution of Minimally Invasive Techniques in Restoration of Colonic Continuity

Restoration of bowel continuity after Hartmann’s procedure is considered technically challenging and is associated with high morbidity and mortality. This is the main reason why restoration of intestinal continuity is often not attempted. Over the past decade, considerable international experience has gained on this topic with new minimally invasive techniques being developed. This review details the evolution of minimally invasive techniques in restoration of colonic continuity after Hartmann’s procedure. A comprehensive search of PubMed and Embase was done. Different restoration modalities were included. Eight studies, from six different countries, in which multiport laparoscopic restoration of continuity was compared to conventional open restoration of bowel continuity, were included. In the total of 254 patients, continuity was restored laparoscopically compared with 255 patients in which continuity was performed in open fashion. Restoration of bowel continuity via trephine access was also reported; three studies including 37 patients were included in this review. Single-port restoration of bowel continuity after Hartmann’s procedure is a natural evolution of multiport laparoscopy and trephine access. Six studies reporting on single-port reversal of Hartmann’s procedure were included with a total of 75 patients. Single-port access in combination with a transanal approach has also been reported; however, data are extremely limited as there is only one study in the published literature. Success of restoration of bowel continuity with less morbidity and mortality has been demonstrated throughout the evolution of the different surgical techniques. In this review advantages of different approaches for restoration of bowel continuity after Hartmann’s procedure are discussed. Furthermore, surgical techniques are described, pictorial guides are added for some techniques, and flowcharts are given for easy use during clinical decision-making

Poortwachters van de Nederlandse arbeidsmarkt. Arbeidsvoorziening en de verlening van tewerkstellingsvergunningen . Reeks Recht en Samenleving 12

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Obstructive putty-like cast of the biliary tree

A 62-year-old woman was presented at the emergency department with cholangiosepsis. She had a history of liver metastases for which she had a left hemihepatectomy and loco regional recurrence at the liver hilum for which she received chemoradiation therapy MR-imaging of the liver showed multiple intrahepatic fluid collections/abscesses, together with significantly dilated intrahepatic bile ducts. For her significant hepatic function impairment she received antibiotic treatment and percutaneous drainage. The differential diagnosis was local tumor recurrence or post radiation fibrosis causing outflow obstruction centrally in the liver hilum. During the admission the serum bilirubin values kept rising. During surgery surgeons decided to perform a hepatotomy and connect a loop of the jejunum directly on the liver parenchyma, in order to allow better drainage. Intra operatively, after the hepatotomy, we encountered green-brownisch putty-like material. By traction a 'cast' of a large part of the biliary tree was removed

A framework for improving reliability of truck turn times in FMCG transport networks

Truck turn times in FMCG supply chain are unreliable. The Dutch ‘Speed Docking’ project in 2011 and 2012 gave clear evidence to this. This leads to additional trucks and drivers in transport networks. Improving reliability of truck turn time will lead to less trucks and drivers in the transport network and improved productivity at distribution centres. The research is focused on Fast Moving Consumer Goods (FMCG) transport networks. A reduction of transport is high on the agenda’s of FMCG companies. The objectives in the FMCG industry are: less CO2, increased reliability, secure transport capacity and ultimately a better service to consumers. The FMCG industry, together with logistics service providers, can realise improvements with the use of mobile communication, on board computers, connected navigation and intelligent transport systems, process mining based on big data to benefit better tactical and operational planning, geo-fencing, agent based dynamic planning and time slot allocation and the use of community platforms were data is shared with all chain partners in FMCG

Verblijfsrecht en gebruik van collectieve voorzieningen door immigranten

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Aan de grenzen van de verzorgingsstaat: Verblijfsrecht en het gebruik van collectieve voorzieningen

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Off-line balanced forward-flyback converter

Due to the flybacks' indirect characteristic of energy transfer, the transformer size increases for high power levels. Providing an additional direct energy transfer path can decrease its size. Parallel forward-flyback converters offer such functionality and outperform forward converters with regard to PFC functionality. A balanced forward-flyback converter is a variation on this kind of parallel converter. The forward and flyback sub-converters share a transformer winding and an additional balancing capacitor enables even better AC line voltage utilization. This paper starts with an in-depth analysis of the balanced forward-flyback converter, and introduces ten operating modes in which this converter can operate. A boundary-conduction mode (BCM) controller for the magnetization current is developed and presented, and through simulations the PFC performance of the converter is tested with a constant switch on-time controller. Moreover, a prototype is designed and built with both a dissipative R-C-D snubber and two-switch clamp configuration. Experimental results from the 100W/120–373V AC/DC prototype were obtained to prove the converter operation and BCM controller concept. The balanced forward-flyback converter in BCM offers good PFC performance and manages a THD of input current between 1.69% and 4.38%