Natural orifice surgery: initial clinical experience

Natural orifice translumenal endoscopic surgery (NOTES) has moved quickly from preclinical investigation to clinical implementation. However, several major technical problems limit clinical NOTES including safe access, retraction and dissection of the gallbladder, and clipping of key structures. This study aimed to identify challenges and develop solutions for NOTES during the initial clinical experience. Under an Institutional Review Board (IRB)-approved protocol, patients consented to a natural orifice operation for removal of either the gallbladder or the appendix via either the vagina or the stomach using a single umbilical trocar for safety and assistance. Nine transvaginal cholecystectomies, one transgastric appendectomy, and one transvaginal appendectomy have been completed to date. All but one patient were discharged on postoperative day 1 as per protocol. No complications occurred. The limited initial evidence from this study demonstrates that NOTES is feasible and safe. The addition of an umbilical trocar is a bridge allowing safe performance of NOTES procedures until better instruments become available. The addition of a flexible long grasper through the vagina and a flexible operating platform through the stomach has enabled the performance of NOTES in a safe and easily reproducible manner. The use of a uterine manipulator has facilitated visualization of the cul de sac in women with a uterus to allow for safe transvaginal access

Cooperative learning in a Cree community : a small experiment, 1996-1998

"Cooperative Learning in a Cree Community" is a study of the implementation of innovative teaching methods in a cooperative learning environment at Sabtuan Cree Adult Education. The implementation was a response to the historical context of education in Mistissini Lake. I was the English Language Arts teacher for the adult sector in Mistissini Lake between 1996--1998. My students ranged between the ages of 16 and 50. In addition to Language Arts I taught optional courses like Economics, History, Word Processing and Personal and Social Development.I determined to investigate the potential of cooperative, and student self-evaluation as a valid instructional model for Cree adult learners. My primary objective was to increase critical thinking, learner confidence, and self-directed activity in the classroom. My aim was to study the correlation between interactive pedagogy and student engagement. One indicator of student involvement is student absenteeism. Thus one component of this study examines the correlation between cooperative learning and student attendance.In the introduction I discuss the problems indigenous people have encountered and my understanding and assessment of the present situation in Cree schools. The second section gives a summary of the Cree context, their culture and history, particularly as it pertains to education, and largely from the Cree perspective. The third section contains my classroom activities, the goals I set for the students and the indicators with which I gauged and measured the effectiveness of the project.In conclusion, the implementation of cooperative learning methods yielded positive results both in student achievement and in decreasing truancy for Cree adult learners. The study confirms that cooperative learning can address students' needs to increase language proficiency and to be active participants in classroom activity. This model is congruent with Cree learners' collaborative and egalitarian values that are inherent in the traditional Cree culture

Use of a large-diameter 30-French venting gastrostomy tube is effective and safe for symptom palliation in patients with malignant bowel obstruction.

BackgroundTreatment options for malignant bowel obstruction are limited, particularly in poor surgical candidates. Standard percutaneous endoscopic gastrostomy (PEG) tubes used for venting are of small caliber, limiting success. This study examines outcomes in patients who received larger-caliber 30-Fr PEGs for treatment of malignant bowel obstruction.MethodRetrospective chart review for all patients who received a large-caliber venting PEGs for malignant bowel obstruction in a series of patients at a single institution.ResultsThirty-six patients were included. The most common primary cancer diagnoses were ovarian (22%), mucinous appendiceal (19%), and colorectal (17%). Symptom relief was achieved in all patients (100%). Four patients (11%) sought medical care for recurrent symptoms due to an incorrect venting technique. Large-caliber venting PEGs were placed on the first admission for obstruction in 17 patients (47%), and were used to replace standard caliber PEGs in 8 patients because of persistent symptoms (22%). Significant ascites was observed in 12 patients (33%), but paracenteses were performed in only 3 of these patients prior to PEG placement. Most large-caliber venting PEGs were placed during hospital admission (34/36, 94%), and facilitated hospital discharge (33/34, 97%). Two significant (6%) and 2 minor adverse events (6%) occurred.ConclusionsThis study demonstrates the efficacy and safety of large-caliber venting PEGs for malignant bowel obstruction. This facilitated hospital discharge in almost all patients and prevented readmissions when a correct venting technique was utilized; these PEGs were also effective in patients who had failed standard PEG tube venting

Enteral stenting for gastric outlet obstruction and afferent limb syndrome following pancreaticoduodenectomy.

BackgroundObstruction of the afferent or efferent limbs of a gastrojejunal anastomosis is a potential complication after pancreaticoduodenectomy (PD) resulting in either gastric outlet obstruction or afferent limb syndrome. The use of self-expanding metal stents for the management of anastomotic strictures after resection of pancreatic cancer has not been well studied. We present four such cases and review published data regarding this population.MethodsRetrospective chart review and literature search. Outcomes were summarized with descriptive statistics.ResultsAt our institution, 4 patients underwent metal stent placement for gastrojejunal obstruction after PD for pancreatic cancer. Enteral stents were placed in two patients across the afferent limb, in one patient across the efferent limb, and in another patient across both limbs. Similar cases in the literature revealed that the anastomotic stricture was malignant in 26 of 27 cases. Clinical improvement occurred in 88%. Afferent limb syndrome was successfully treated in 5 of 6 cases. Median survival was 3.5 months after stent placement.ConclusionsEffective palliation of both gastric outlet obstruction and afferent limb syndrome after PD can be provided with enteral stenting. Gastrojejunal strictures after PD for pancreatic cancer are usually malignant with median survival of 3.5 months after stent placement