Transanal Endoscopic Video-Assisted Excision: Application of Single-Port Access

Transanal endoscopic video-assisted excision of benign and malignant rectal lesions with pneumorectal distension appears to optimize the visual field and avert several of the pitfalls commonly associated with transanal endoscopic microsurgery

Mode-sum regularization of the scalar self-force: Formulation in terms of a tetrad decomposition of the singular field

We examine the motion in Schwarzschild spacetime of a point particle endowed with a scalar charge. The particle produces a retarded scalar field which interacts with the particle and influences its motion via the action of a self-force. We exploit the spherical symmetry of the Schwarzschild spacetime and decompose the scalar field in spherical-harmonic modes. Although each mode is bounded at the position of the particle, a mode-sum evaluation of the self-force requires regularization because the sum does not converge: the retarded field is infinite at the position of the particle. The regularization procedure involves the computation of regularization parameters, which are obtained from a mode decomposition of the Detweiler-Whiting singular field; these are subtracted from the modes of the retarded field, and the result is a mode-sum that converges to the actual self-force. We present such a computation in this paper. There are two main aspects of our work that are new. First, we define the regularization parameters as scalar quantities by referring them to a tetrad decomposition of the singular field. Second, we calculate four sets of regularization parameters (denoted schematically by A, B, C, and D) instead of the usual three (A, B, and C). As proof of principle that our methods are reliable, we calculate the self-force acting on a scalar charge in circular motion around a Schwarzschild black hole, and compare our answers with those recorded in the literature.Comment: 38 pages, 2 figure

Robotic-Assisted Laparoscopic “Salvage” Rectopexy for Recurrent Ileoanal J-Pouch Prolapse

Total restorative proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA) has become the standard of care for the surgical treatment of ulcerative colitis. Despite its correlation with an excellent quality of life and favorable long-term outcomes, RP/IPAA has been associated with several complications. Prolapse of the ileoanal pouch is a rare and debilitating complication that should be considered in the differential diagnosis of pouch failure. Limited data exist regarding the prevalence and treatment of pouch prolapse. We present the case of a recurrent J-pouch prolapse treated with a novel minimally invasive “salvage” approach involving a robotic-assisted laparoscopic rectopexy with mesh

Measuring Quality: The Impact of Minimally Invasive Surgery and Operative Time on Surgical Site Infections

Objective: To evaluate the relationship between operative approach, operative time, and SSI rate.Methods: Inpatient database review identified patients undergoing 5 common procedures from 1/2010-12/2011. Patients were stratified into laparoscopic or open approaches. The main outcome measure was the relationship between operative time and SSI by approach.Results: 226,006 patients were evaluated- 28.2% open and 71.8% laparoscopic. Mean overall operative time was significantly shorter laparoscopically (p<0.001). Laparoscopy was associated with significantly lower costs and shorter length of stay (LOS) overall and for each procedure(p<0.0001). Multivariate analysis found SSI increased directly with operative time: for every 30-minute increase, SSI risk increased by 12%. Operative approach was an independent risk factor for SSI: open surgery increased SSI risk by 78%. A direct relationship between open procedures, operative time, and SSI risk was found.Conclusions: Laparoscopy has overall shorter operative time and improved outcomes in SSI rate, LOS, and total costs for common surgical procedures. As operative time and approach were independent risk factors for SSI, the use of laparoscopy and operative time are valuable quality measures

Learning curve for robotic-assisted laparoscopic colorectal surgery.

BACKGROUND: Robotic-assisted laparoscopic surgery (RALS) is evolving as an important surgical approach in the field of colorectal surgery. We aimed to evaluate the learning curve for RALS procedures involving resections of the rectum and rectosigmoid. METHODS: A series of 50 consecutive RALS procedures were performed between August 2008 and September 2009. Data were entered into a retrospective database and later abstracted for analysis. The surgical procedures included abdominoperineal resection (APR), anterior rectosigmoidectomy (AR), low anterior resection (LAR), and rectopexy (RP). Demographic data and intraoperative parameters including docking time (DT), surgeon console time (SCT), and total operative time (OT) were analyzed. The learning curve was evaluated using the cumulative sum (CUSUM) method. RESULTS: The procedures performed for 50 patients (54% male) included 25 AR (50%), 15 LAR (30%), 6 APR (12%), and 4 RP (8%). The mean age of the patients was 54.4 years, the mean BMI was 27.8 kg/m(2), and the median American Society of Anesthesiologists (ASA) classification was 2. The series had a mean DT of 14 min, a mean SCT of 115.1 min, and a mean OT of 246.1 min. The DT and SCT accounted for 6.3% and 46.8% of the OT, respectively. The SCT learning curve was analyzed. The CUSUM(SCT) learning curve was best modeled as a parabola, with equation CUSUM(SCT) in minutes equal to 0.73 × case number(2) - 31.54 × case number - 107.72 (R = 0.93). The learning curve consisted of three unique phases: phase 1 (the initial 15 cases), phase 2 (the middle 10 cases), and phase 3 (the subsequent cases). Phase 1 represented the initial learning curve, which spanned 15 cases. The phase 2 plateau represented increased competence with the robotic technology. Phase 3 was achieved after 25 cases and represented the mastery phase in which more challenging cases were managed. CONCLUSIONS: The three phases identified with CUSUM analysis of surgeon console time represented characteristic stages of the learning curve for robotic colorectal procedures. The data suggest that the learning phase was achieved after 15 to 25 cases

Minimally Invasive Approaches for the Management of “Difficult” Colonic Polyps

Traditionally, patients with colonic polyps not amenable to endoscopic removal require open colectomy for management. We evaluated our experience with minimally invasive approaches including endoscopic mucosal resection (EMR), laparoscopic-assisted endoscopic polypectomy (LAEP), and laparoscopic-assisted colectomy (LAC). Patients referred for surgery for colonic polyps were selected for one of three minimally invasive modalities. A total of 123 patients were referred for resection of “difficult” polyps. Thirty underwent EMR, 25 underwent LAEP, and 68 underwent LAC. Of those selected to undergo EMR or LAEP, 76.4% were successfully managed without colon resection. The remaining 23.6% underwent LAC. Nine complications were encountered, including two requiring reoperative intervention. Of the 123 patients, three were found to have malignant disease on final pathology. Surgical resection can be avoided in a significant number of patients with “difficult” polyps referred for surgery by performing EMR and LAEP. In those who require surgery, minimally invasive resection can be achieved

Pelvic Muscle Rehabilitation: A Standardized Protocol for Pelvic Floor Dysfunction

Introduction. Pelvic floor dysfunction syndromes present with voiding, sexual, and anorectal disturbances, which may be associated with one another, resulting in complex presentation. Thus, an integrated diagnosis and management approach may be required. Pelvic muscle rehabilitation (PMR) is a noninvasive modality involving cognitive reeducation, modification, and retraining of the pelvic floor and associated musculature. We describe our standardized PMR protocol for the management of pelvic floor dysfunction syndromes. Pelvic Muscle Rehabilitation Program. The diagnostic assessment includes electromyography and manometry analyzed in 4 phases: (1) initial baseline phase; (2) rapid contraction phase; (3) tonic contraction and endurance phase; and (4) late baseline phase. This evaluation is performed at the onset of every session. PMR management consists of 6 possible therapeutic modalities, employed depending on the diagnostic evaluation: (1) down-training; (2) accessory muscle isolation; (3) discrimination training; (4) muscle strengthening; (5) endurance training; and (6) electrical stimulation. Eight to ten sessions are performed at one-week intervals with integration of home exercises and lifestyle modifications. Conclusions. The PMR protocol offers a standardized approach to diagnose and manage pelvic floor dysfunction syndromes with potential advantages over traditional biofeedback, involving additional interventions and a continuous pelvic floor assessment with management modifications over the clinical course

Apolipoprotein A–I binding to anionic vesicles and lipopolysaccharides: Role for lysine residues in antimicrobial properties

AbstractHuman apolipoprotein A–I (apoA–I) is a 28kDa protein and a major component of high-density lipoproteins, mediating several essential metabolic functions related to heart disease. In the present study the potential protective role against bacterial pathogens was explored. ApoA–I suppressed bacterial growth of Escherichia coli and Klebsiella pneumoniae. The protein was able to bind lipopolysaccharides and showed a strong preference for bilayer vesicles made of phosphatidylglycerol over phosphatidylcholine. Lysine side chains of apoA–I were acetylated to evaluate the importance of electrostatic forces in the binding interaction with both membrane components. Electrophoresis properties, dot blot analysis, circular dichroism, and fluorescence spectroscopy to probe for changes in protein structure indicated that the acetylated protein displayed a strongly reduced lipopolysaccharide and phosphatidylglycerol binding. A mutant containing only the N-terminal domain of apoA–I also showed a reduced ability to interact with the membrane components, although to a lesser extent. These results indicate the potential for apoA–I to function as an antimicrobial protein and exerts this function through lysine residues

Land Use Influences the Composition and Antimicrobial Effects of Propolis

Honey bee propolis is a complex, resinous mixture created by bees using plant sources such as leaves, flowers, and bud exudates. This study characterized how cropland surrounding apiaries affects the chemical composition and antimicrobial effects of propolis. The chemical composition and compound abundance of the propolis samples were analyzed using Gas Chromatography- Mass Spectrometry (GC-MS) and the antimicrobial effects were analyzed using the 50% minimum inhibitory concentration (MIC50) assay against four relevant bee pathogens, Serratia marcescens, Paenibacillus larvae, Lysinibacillus sphaericus, and Klebsiella pneumoniae. Propolis composition varied significantly with apiary, and cropland coverage predicted mean sum abundance of compounds. The apiary with the highest cropland coverage exhibited significantly higher MIC50 values for S. marcescens and K. pneumoniae compared to other apiaries. These results demonstrate that agricultural land use surrounding honey bee apiaries decreases the chemical quality and antimicrobial effects of propolis, which may have implications for the impacts of land use on hive immunity to potential pathogens