Demonstration in human cadavers of feasibility of ileoproctostomy performed entirely through a transanal route

Innovative surgical techniques are frequently developed in animal models before of trials in surgical patients. However, these experimental approaches do not permit a perfect evaluation of feasibility due to obvious anatomical differences between humans and animals. The Body Donation Program of the University of Padua has recently developed studies of feasibility on human cadavers of new surgical approaches. Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an innovative kinf of surgery which utilizes a flexible endoscope to enter the abdominal, pelvic or thoracic cavities through the body’s natural orifices and then through an internal incision. Skin incisions are thus unnecessary and, as a consequence, tissue trauma, postoperative pain, and incision-related complications are minimized and less anaesthesia is required. The aim of the present study was to verify in human cadavers the technical feasibility of a new NOTES technique, i.e., ileoproctostomy performed entirely through a transanal access. This surgical procedure was previously performed only in a porcine model. The procedure was carried out in three human cadavers (two males and a female). One cadaver was fresh. The other cadavers were fixed through infusion of Thiel’s solution through the larger arteries. A Transanal Endoscopic Microsurgery (TEM) device and endoscopic instruments were utilized. The study demonstrated that ileoproctostomy through a transanal access is technically feasible in humans. The principal steps of the procedure were: placement of the TEM device; rectal perforation above the peritoneal reflection; peritoneoscopy using a standard gastroscope; grasping the small bowel with retrieval forceps and pulling it through the rectal hole; suturing the ileum and the rectum together with two semi-circular continuous sutures utilizing the TEM device; opening the ileal loop from the rectal side followed by endoscopic exploration. Although still at an experimental stage, ileoproctostomy through a transanal access is technically feasible in humans. In planning new procedures, a fundamental step is represented by feasibility tests on donated corpse

Measurement of the Z/gamma* + b-jet cross section in pp collisions at 7 TeV

The production of b jets in association with a Z/gamma* boson is studied using proton-proton collisions delivered by the LHC at a centre-of-mass energy of 7 TeV and recorded by the CMS detector. The inclusive cross section for Z/gamma* + b-jet production is measured in a sample corresponding to an integrated luminosity of 2.2 inverse femtobarns. The Z/gamma* + b-jet cross section with Z/gamma* to ll (where ll = ee or mu mu) for events with the invariant mass 60 < M(ll) < 120 GeV, at least one b jet at the hadron level with pT > 25 GeV and abs(eta) < 2.1, and a separation between the leptons and the jets of Delta R > 0.5 is found to be 5.84 +/- 0.08 (stat.) +/- 0.72 (syst.) +(0.25)/-(0.55) (theory) pb. The kinematic properties of the events are also studied and found to be in agreement with the predictions made by the MadGraph event generator with the parton shower and the hadronisation performed by PYTHIA.Comment: Submitted to the Journal of High Energy Physic

Operative endoscopy for benign gastro-intestinal lesions

Operative endoscopy has proven to be a discipline that continually renews itself. Referrals for treatment using flexible endoscopes in the gastroenteric tract are in fact on the rise. Diagnoses made at earlier phases of the disease uncover pre cancerous lesions that can be treated locally. The technological development of endoscopic instruments, on the other, make it possible to enter into the abdominal cavity and to go beyond the intestinal lumen and to carry out mini-invasive surgical procedures. Operative endoscopy must, of course, confront and collaborate with other traditional disciplines such as pharmacological therapy, interventistic radiology, and, above all, traditional surgery. It must, in particular, join hands with the latter placing itself at its service in the treatment of anastomic complications and imitating it in the development of miniinvasive endoluminal surgery. Some fields of application of operative endoscopy used in the treatment of benign lesions of the gastroenteric tract have been considered here. These include: endoscopic therapy of telangiectasia which represents its principal therapy once the disease has been staged and controlled; prophylactic ligation of esophageal varices in trasplant candidates who, due to their limited follow up, present more disadvantages than advantages with regards to propranolol therapy, laser therapy of Barrett's esophagus which aims to reduce the risk of adenomacarcinoma of the esophagus by ablating metaplasic tissue - further studies are warranted here to quantify its effect; laser therapy of large colorectal adenomas found to be an efficacious alternative to surgery in inoperable patients or those who reject surgery, avoiding the risk of degeneration; treatment of anastomic complications in esophageal surgery and in liver transplant patients in whom endoscopic therapy is the first choice therapy, and finally drainage of abdominal abscesses and necrosectomy carried out endoscopically with the aid of ecoendoscopy, which has taken operative endoscopy beyond the intestinal lumen. The latter field of application is a first step, already in fact utilized in clinical practice, towards the development of NOTES, the new miniinvasvie surgical discipline, still in an experimental stage but already being watched with great interest by the endoscopic and surgical worlds

Adenomas at resection margins do not influence the long-term development of pouch polyps after restorative proctocolectomy for familial adenomatous polyposis

Background: The aim of this study was to consider whether adenomas in the resection margins could represent a risk factor for pouch polyps in familial adenomatous polyposis (FAP) patients. Methods: We reviewed 46 patients treated by restorative proctocolectomy (RPC) for FAP: 9 hand-sewn and 37 stapled ileal pouch\u2013anal anastomosis (IPAA). We analyzed the presence of polyps in the doughnuts from stapled anastomosis and in the resection margins from hand-sewn anastomosis. The presence of polyps in the IPAA was then assessed in 30 patients (6 hand-sewn and 24 stapled IPAA): 4 from the histology of the excised pouch and 26 by endoscopy (range 4 months to 12 years after operation, mean 6 years). Results: Surprisingly, pouch adenomas were found in only 2 of 30 (7%) of patients, 1 of 6 hand-sewn and 1 of 24 stapled anastomosis (P 0.1), 9 and 11 years, respectively, after operation. However, there were 6 patients with inflammatory (3), fibroepithelial (2), or lymphoid (1) polyps. The risk of pouch adenomas after 8 years was 20% (P 0.05). Pouch adenomas were found in 1 of 11 patients having adenomas in the margins or in the doughnuts (9%) and in 1 of 19 with no adenomas at the margins (5%; P 0.1). Conclusions: Incidence of pouch adenomas was low. There was no correlation between adenomas in the resection margins and the development of pouch adenomas. \ua9 2003 Excerpta Medica, Inc. All rights reserved

Reply: Prophylactic Variceal Ligation Is Not Recommended for Patients Awaiting Live Donor Liver Transplant.

We thank Wai and colleagues1 for their comment on our article.2 Their experience is consistent with ours and different from that reported by Jutabha et al.3 In all 3 studies, the patients were liver transplant candidates and thus constituted a particular subgroup of patients with cirrhosis, as underlined also by Boyer.4 In our opinion, this favors the use of beta-blockers instead of banding for primary prophylaxis for at least 2 reasons. The first, as underlined by Wai et al., is the short follow-up before liver transplantation. In fact, as shown in Fig. 2 of our study, patients treated by ligation can bleed during treatment but not after variceal eradication unless varices recur. In contrast, patients taking beta-blockers present the same risk of bleeding over the same time period. As a result, a possible advantage of banding can be seen only after a long follow-up, which is unlikely in patients awaiting liver transplant as usually this occurs within 1 year. The other reason is that this group of patients is followed up intensively, and this may increase compliance to therapy. The use of beta-blockers does require dose adjustment and trying to maximize the dose tolerated by the patient. The 2 bleeding episodes from postbanding ulcers reported by Wai et al.1 are added to several others that have taken place during prophylactic treatment, including 2 events described in our study. Globally, the reported cases number at least 15, some of which have been fatal. In contrast, beta-blockers for primary prophylaxis of variceal bleeding have not caused fatalities thus far.5 It is difficult to predict which patients are at risk for postbanding ulcer bleeding. Our patients bled 9 and 11 days after the first banding session, respectively. One was Child B7, and the other was Child C14. The patients treated by Wai et al.1 bled 8 and 9 days after the second prophylactic ligation. Shepke et al.6 reported 5 (7%) bleeding episodes from postbanding ulcers, 2 of them fatal. The latter happened 3 and 12 days after the first banding session, respectively. Triantos et al.,7 treating patients unable to take beta-blockers, reported 3 cases of variceal bleeding, all between the first and second prophylactic banding sessions. As most bleeding occurs after the first banding session, we think that longer intervals between sessions, advocated by some authors to overcome this problem,5 would not reduce this risk. In addition and not to be discounted, we found that the costs are reduced to a third when beta-blockers are used with respect to banding for primary prophylaxis in these patients. Thus, nonselective beta-blockers remain the therapy of first choice for primary prophylaxis in liver transplant candidates

Quality of life in patients with an ileostomy

AIM: Temporary or permanent ileostomy is a common procedure in colorectal surgery. Our aim was to assess the impact of ileostomy on quality of life and the relevant risk factors. METHODS: A 33-question questionnaire was sent, by mail, to 74 patients (over 70, between 70 and 50 and under 50 y old). The questionnaire explored 5 parameters of function: systemic symptoms, bowel symptoms, functional impairment, social impairment and emotional impairment. Further questions investigated the need for a nurse or relative to assist with management of the stoma, the frequency of changing the bag and the appliance, diet and the ability of patients to attend their normal daily activity. RESULTS: Thirty-four patients completed the questionnaire. The final quality of life score was similar for all the 3 age groups but elderly patients needed more assistance in the stoma management. The quality of life scores in males patients were significantly better than in females. No statistically significant difference was observed comparing loop ileostomy versus end ileostomy and Crohn's disease versus ulcerative colitis. CONCLUSIONS: Quality of life is not influenced by age, underlying inflammatory disease or type of ileostomy. Males report less impact on quality of life than women