Laparoscopic choledochojejunostomy and gastrojejunostomy in a porcine model

BACKGROUND

Surgical extirpation remains the only known curative treatment for cancer of the pancreas. Because of locally advanced or metastatic tumor, up to 80% of patients are unresectable at the time of initial diagnosis [13]. Other investigators previously have suggested that laparoscopy before laparotomy aids in the diagnosis of unresectable pancreatic cancer in a fair number of patients even after negative computed tomography scans [3, 17]. Many surgeons are reluctant to incorporate laparoscopy into the workup of patients with cancer of the pancreas because of the frequent need for surgical bypass in the management of either biliary tract obstruction or gastric outlet obstruction [9, 13]. Previous studies have demonstrated the feasibility of laparoscopic cholecystojejunostomy combined with gastrojejunostomy in a porcine model, as well as the individual accomplishment of laparoscopic choledochojejunostomy. The purpose of this study was to document the feasibility of performing laparoscopic choledochojejunostomy with gastrojejunostomy.

METHODS

Under general anesthesia, seven pigs underwent laparoscopic choledochojejunostomy and gastrojejunostomy using an intracorporeal hand-sutured technique.

RESULTS

The mean operating time ranged from 150 to 450 min. All the animals recovered completely from the operation and had patent anastomoses at the time of necropsy. One pig died of gastric bleeding on postoperative day 13, and two animals had intraabdominal fluid collections discovered at the time of necropsy.

CONCLUSIONS

These results suggest that synchronous laparoscopic bypass of biliary and gastric outlet obstruction is feasible, and can be performed in a manner similar to that used in open operations. We believe this lends support to the argument promoting laparoscopy in the evaluation of pancreatic cancer.

Impact of stepped verbal and written reinforcement of fluid balance advice within an outpatient haemodialysis unit: a pilot study

BACKGROUND

The present pilot study assesses a programme of verbal and written fluid balance advice within an out-patient haemodialysis unit.

METHODS

Twenty-one haemodialysis patients were followed over three separate 6-week periods. Each 6-week period assessed dietetic and nursing educational input using a stepped approach with interdialytic weight gain (IDWG) as a barometer of patient compliance. Weight gain was statistically examined using the non-parametric Friedman test.

RESULTS

Forty-eight per cent of the sample group demonstrated an overall improvement in mean weight gain; however, this was not statistically significant (P=0.504).

CONCLUSION

The pilot study suggests that further studies with greater numbers and a control group would have a useful contribution to make in this field.

The relationship between interdialytic weight gain and patient compliance. A single centred cohort study (n=21)

Haemodialysis patients are subject to many restrictions and face a lifetime attempting to adhere to various regimes. This small study was designed to explore the relationship between fluid gain, compliance and staff reinforcement. This was achieved by measuring dietetic and nursing educational input using interdialytic weight gain as a barometer of patient compliance. This study suggests renal nurses, dietitians and other members of the multi-disciplinary team may have less influence than previously assumed.

Issues of consent in renal transplantation

BACKGROUND

Renal transplantation is a semi-elective procedure. The specific risks of surgery are well-known. Obtaining informed consent is a complex process made more complicated in transplantation by the long-term nature of some of the risks involved.

METHODS

A questionnaire survey was conducted of consultant transplant surgeons to establish current practice regarding the levels of information and risks discussed as part of the consent process.

RESULTS

Responses were received from 47 (76%) of consultants. Risks were discussed by a range of individuals. Pre-assessment clinics were used by 70% of units to start the process. Only 74% routinely discussed malignancy and only 75% the risks of cytomegalovirus infection. Risks with individual organs were discussed by 32 (68%)--particularly HLA match, cold ischaemia, sensitisation, donor age and caused of donor death.

CONCLUSIONS

The current practice identified by this study falls broadly within General Medical Council guidelines on informed consent. There is wide variation in current practice which is highlighted and discussed in relation to case law and the levels of risk that a patient should expect to be informed of.

Hyperactivity and altered mRNA isoform expression of the Cl(-)/HCO(3)(-) anion-exchanger in the hypertrophied myocardium

OBJECTIVE

The aim was to examine the regulation of the cardiac Na(+)-independent Cl(-)/HCO(3)(-) exchanger (AE) mRNA isoform expression in association to the enhanced AE activity in the hypertrophied myocardium of spontaneously hypertensive rats (SHR).

METHODS

AE activity was determined by the initial rates of the pH(i) recovery from imposed intracellular alkalinization (forward mode of exchange) and the pH(i) rise induced by Cl(-) removal (reverse mode). Net HCO(3)(-) (J(HCO(3)(-))) efflux and influx were respectively determined. AE mRNA isoforms were analyzed by Northern blot with specific probes to detect AE1, AE2 and AE3 mRNAs.

RESULTS

Initial J(HCO(3)(-)) efflux after imposed alkaline load (pH(i) congruent with 7.5) was higher in SHR than in normotensive WKY rats (3.01+/-0.33, n=7, vs. 0.64+/-0.29 mM/min, n=5, P<0.05). J(HCO(3)(-)) influx induced by Cl(-) deprivation was also increased in SHR, 4.24+/-0.56 mM/min (n=10) versus 2.31+/-0.26 (n=10, P<0.05) in WKY. In arbitrary units, the 4.1-kb AE1 mRNA decreased in SHR (0.15+/-0.01, n=7) compared to WKY (0.29+/-0.06, n=7, P<0.05), whereas the 3.6-kb mRNA did not change. AE2 mRNAs were similarly expressed in WKY and SHR. Cardiac specific AE3 (cAE3) mRNA decreased in SHR, 1.10+/-0.16 arbitrary units (n=8) versus 1.79+/-0.24, (n=8, P<0.05) in WKY. Full length AE3 (flAE3) mRNA increased from 0.69+/-0.06 (WKY, n=8) to 1.25+/-0.19 arbitrary units in SHR (n=8, P<0.05).

CONCLUSIONS

The increase in flAE3 mRNA expression in cardiac tissue from the SHR is an adaptive change of the hypertrophied myocardium that might be in connection with the increased activity of the AE.

Advanced nursing practice in renal medicine

Renal Nursing presents many challenges for nurses seeking to work at advanced level. The ever-changing political climate and increasing service demands make it vital for nurses to grasp the opportunities that advanced practice offers. Theorists have suggested that the over-specialisation of nursing could lead to a fragmented nursing service and an undervaluing of the registered nurse. September 1999 saw the appointment of two such Advanced Nurse Practitioners within the renal unit. This article takes a personal look at the implementation of an Advanced Nurse Practitioner service over the first 12 months and suggests that such a role does have a lot to offer particularly in a renal setting.

Effect of femoral component designs on the contact and tracking characteristics of the unresurfaced patella in total knee arthroplasty

OBJECTIVES

To determine the effect of 5 different femoral components used in total knee arthroplasty (TKA) on the contact area and tracking characteristics of the nonresurfaced patella and to identify any design features that might adversely affect these characteristics.

DESIGN

An in-vitro study.

SETTING

The biomechanics laboratory, Department of Mechanical Engineering, McGill University, Montreal.

SPECIMENS

Six fresh-frozen cadaveric knee-joint specimens.

INTERVENTIONS

An unconstrained quadriceps simulator was used to apply the conditions of static lifting to the specimens first in their normal state and then sequentially implanted with femoral and tibial components of various designs (Miller/Galante II, Anatomic Modular Knee [AMK] System, Whiteside Ortholoc Modular, press-fit condylar and Insall-Burstein II).

OUTCOME MEASURES

Patellar 3-dimensional tracking characteristics, determined by using a 6 degrees-of-freedom electromechanical goniometer attached directly to the patella, and patellar contact pressure measurements, obtained using low-range Fuji Prescale film.

RESULTS

Articulation of the normal patella on a prosthetic femoral component resulted in alterations in the normal patellofemoral contact and tracking characteristics. The exact departure depended on the design of the prosthetic trochlea. Although all of the selected prostheses demonstrated satisfactory contact characteristics near extension, marked alterations occurred at higher flexion angles. With 90 degrees or more of flexion, there was incompatibility between the geometries of the prosthetic notch of 2 femoral designs (AMK and PFC) and the normal knee.

CONCLUSION

The design of the prosthetic femoral component must be taken into account when determining whether or not to resurface the patella at the time of TKA.

Virtual hepatic resection using three-dimensional reconstruction of helical computed tomography angioportograms

OBJECTIVE

To establish the accuracy of virtual hepatic resection using three-dimensional (3D) models constructed from computed tomography angioportography (CTAP) images in determining the liver volume (LV) resected during resectional liver surgery.

SUMMARY BACKGROUND DATA

The ability to measure LV before surgery could be useful in determining the extent and nature of hepatic resection. Accurate assessment of LV and an estimate of liver function may also allow prediction of postoperative liver failure in patients undergoing resection, assist in volume-enhancing embolization procedures, help with the planning of staged hepatic resection for bilobar disease, and aid in selection of living-related liver donors.

METHODS

A retrospective study was conducted involving 27 patients scheduled for liver resection. Using mapping technology, 3D models were constructed from helical CTAP images. From these 3D models, tumor volume, total LV, and functional LV were calculated and were compared with body weight. The 3D liver models were subjected to a virtual hepatectomy along established anatomical planes, and the resected LV was calculated. The resected volume predicted by radiologists (unaware of the actual weight) was compared with the specimen weight measured after actual surgical resection.

RESULTS

A significant correlation was found between body weight and functional LV but not total LV. The computer prediction of resected LV after virtual hepatectomy of 3D models compared well with resected liver weight.

CONCLUSION

Virtual hepatectomy of 3D CTAP reconstructed images provides an accurate prediction of liver mass removed during subsequent hepatic resection. The authors intend to combine this technology with an assessment of liver function to attempt to predict patients at risk for liver failure after hepatic resection.

A consensus sequence for long-chain fatty-acid alcohol oxidases from Candida identifies a family of genes involved in lipid omega-oxidation in yeast with homologues in plants and bacteria

The yeast Candida cloacae is capable of growing on alkanes and fatty acids as sole carbon sources. Transfer of cultures from a glucose medium to one containing oleic acid induced seven proteins of M(r) 102,000, 73,000, 61,000, 54,000, and 46,000 and two in the region of M(r) 45,000 and repressed a protein of M(r) 64,000. The induction of the M(r) 73,000 protein reached a 7-fold maximum 24 h after induction. The protein was confirmed by its enzyme activity to be a long-chain fatty-acid alcohol oxidase (LC-FAO) and purified to homogeneity from microsomes by a rapid procedure involving hydrophobic chromatography. An internal peptide of 30 amino acids was sequenced. A 1100-base pair cDNA fragment containing the LC-FAO peptide coding sequence was used to isolate a single exon genomic clone containing the full-length coding sequence of an LC-FAO (fao1). The fao1 gene product was expressed in Escherichia coli and was translated as a functional long-chain alcohol oxidase, which was present in the membrane fraction. In addition, full-length coding sequences for a Candida tropicalis LC-FAO (faoT) and a second C. cloacae LC-FAO (fao2) were isolated. The DNA sequences obtained had open reading frames of 2094 (fao1), 2091 (fao2), and 2112 (faoT) base pairs. The derived amino acid sequences of fao2 and faoT showed 89.4 and 76.2% similarities to fao1. The fao1 gene is much more highly induced on alkane than is fao2. Although this study describes the first known DNA sequences encoding LC-FAOs from any source, there are unassigned Arabidopsis sequences and an unassigned Mycobacterium sequence in the GenBank(TM) Data Bank that show strong homology to the described LC-FAO sequences. The conservation of sequence between yeast, plants, and bacteria suggests that an as yet undescribed family of long-chain fatty-acid oxidases exists in both eukaryotes and prokaryotes.

Motivational versus confrontational interviewing: a comparison of substance abuse assessment practices at employee assistance programs

The aim of this study was to conduct a quasi-experimental comparison of two employee assistance program (EAP) assessment approaches with substance abusers: confrontational interviewing (CI) and motivational interviewing (MI). A total of 176 EAP clients from 14 study sites met the study criteria, and 89 (51%) agreed to participate in the study. At three and nine months postassessment, both the MI and CI groups showed similar changes in readiness for change, completion of initial treatment plans, and subsequent treatment. Most important, both the MI and CI participants showed significant and comparable improvement on all of the substance abuse baseline measures as well as measures of family-social well-being and effects of drinking/drugging on work performance. The results open the door for EAP counselors to use an empirically supported assessment style that is at least as effective as the traditional confrontational approach.

One haemodialysis unit's experience of hepatitis B

Haemodialysis patients are at high risk of contracting Hepatitis B Virus (HBV). This blood borne virus has been responsible for many critical incidents within haemodialysis units around the world. This paper seeks to explore one such outbreak and at the same time look more closely at HBV and connected issues. The incident discussed occurred within a haemodialysis unit situated in the Northwest of England. This paper is presented as a case study. When HBV was detected in a previously HBV negative patient a crisis management team moved quickly to contain any possible outbreak and sought to discover the origin of the infection. An outline of the personal and financial cost to the organisation, what lessons have been learnt and why recommendations have been made to immunise the local dialysis population again HBV will be presented.

Delayed diagnosis of an enteric duplication cyst

Enteric duplication cysts are rare and often prove extremely difficult to diagnose. We report a case in which the definitive diagnosis was made 40 years after first presentation and following five exploratory laparotomies. A review of the literature is presented, with discussion regarding the presenting features, potential complications, radiological investigations and surgical treatment of this uncommon clinical entity.

Transplant surgeons in training: is anybody out there?

There is a long-standing recognition that there is an organ donor shortage in the United Kingdom and Ireland (UK&E) that limits transplant activity. However, the fact that, at present, there are several unfilled consultant vacancies would suggest that a shortage of trained surgeons may soon be an equally important limiting factor. The aim of this current study was to identify all transplant trainees in the UK&E and to determine their career aspirations. A list of all trainees intending to practice as transplant surgeons was compiled. A combination of postal questionnaire and telephone interview was used to construct a database on past and present training in transplantation, and preferred type of consultancy was assessed both by direct questioning and by using a visual analogue scale to grade desirability of various posts. Of 110 potential trainees identified, 50 (45%) replied and indicated a desire to pursue a career in transplant surgery. Thirty-one intended practising in the UK&E (19 UK&E graduates and 12 overseas). The preferred consultancy (27/31) was transplantation (Tx) together with a second specialty while only four wanted a multivisceral practice. The mean score (0-10) for desirability of a multivisceral transplant post was 4.7, for renal transplant and vascular access it was 3.6 and for transplantation and a second specialty it was 8.4. We conclude that the majority of trainees do not wish to apply for pure transplant posts, either single organ or multivisceral, and that the majority wish to practice transplantation with a second specialty. In addition, there is still a major shortage of trainees and further studies are required to identify reasons why trainees fail to pursue a career in transplantation.

Treatment of patients with pineoblastoma with high dose cyclophosphamide

The outcome for patients with pineoblastoma has historically been very poor, with most patients dying of disseminated disease despite irradiation. Furthermore, the low incidence of this tumor has hindered progress toward defining better treatment strategies. Here we report the activity and toxicity of cyclophosphamide administered as a single agent at a dose schedule of 2 g/m2/day for 2 successive days at monthly intervals for a maximum of four courses. Eight patients were evaluated, six newly diagnosed and two recurrent. Amongst the six newly diagnosed patients, there were three patients demonstrating partial responses, and three had stable disease throughout the cyclophosphamide treatment period. All six patients are alive and disease free after further therapy. One patient with recurrent disease demonstrated tumor progression on cyclophosphamide, and the other had stable disease throughout the cyclophosphamide treatment period. Both patients subsequently died of progressive disease. The major toxicity of high dose cyclophosphamide was hematopoietic, with one patient requiring a dose reduction after three courses due to prolonged thrombocytopenia. One patient was also withdrawn from treatment with cyclophosphamide due to impaired pulmonary function. This study demonstrates the activity of high dose cyclophosphamide in the treatment of pineoblastoma and may serve as basis for the design of future studies of this tumor.

Opposite in vitro and in vivo regulation of hepatic apolipoprotein A-I gene expression by retinoic acid. Absence of effects on apolipoprotein A-II gene expression

We studied the pharmacological potential of retinoids to modulate apolipoprotein (apo) A-I and apoA-II gene expression and production in vitro in the human cell line HepG2 as well as in primary cultures of adult rat hepatocytes and in vivo in the rat. In HepG2 cells, addition of all-trans retinoic acid (RA) doubled apoA-I mRNA within 24 hours and protein secreted in the culture medium after 48 hours. The induction of apoA-I mRNA by RA was completely blocked by actinomycin D, suggesting that RA acts at the transcriptional level in HepG2 cells. In primary cultures of rat hepatocytes, addition of RA increased apoA-I mRNA in a dose- and time-dependent manner as well as the secretion of apoA-I protein. Similar changes in apoA-I mRNA were observed with 9-cis RA. However, in vivo, hepatic apoA-I mRNA levels decreased after a single administration of RA at 10 mg/kg and remained low after prolonged treatment or at a higher dose, and serum apoA-I concentrations did not change. Furthermore, RA treatment did not substantially affect apoA-II mRNA levels or protein secretion either in vitro or in vivo. As a control, RA receptor-beta mRNA levels increased after RA both in vitro and in vivo. In conclusion, RA treatment selectively induces apoA-I and not apoA-II expression in vitro but not in vivo. These results therefore show additional regulatory effects of RA on apoA-I gene expression in vivo and raise questions about the usefulness of RA in the treatment of atherosclerosis.

Into battle with total quality management

Total quality management is the systematic way of improving quality while containing costs. In the elderly care unit at a hospital, a framework for TQM was installed using the patient trail to understand processes of care delivery, and basing its foundations on the principles of putting patients first, getting the service right first time, meeting and exceeding needs, reducing the costs of poor quality and empowering staff. Identifies operational problems following staff interview, analysed into quality indicators; quality costs in terms of time and materials; and likely locally grown solutions. Using the tools of patient information, improving the environment, communication, training, standard setting, monitoring and auditing, quality improvement teams, patient feedback and quality costing, a clinical management group is ideally poised to enjoy the benefits of total quality management.

Multipractice analysis of laparoscopic cholecystectomy in 1,983 patients

We analyzed the results of laparoscopic cholecystectomy in 1,983 patients from a variety of practice settings in order to evaluate a large, cross-sectional experience for this new procedure. Twenty general surgeons from 9 clinics in 4 states examined the records and outcome of their laparoscopic cholecystectomy patients through March 1991. In 88 patients (4.5%), the operation was converted to an open procedure, usually because of marked inflammation and unclear anatomy. A total of 644 cases were performed with laser dissection and 1,339 with cautery, and the results of these 2 methods were similar. There were 41 complications. Reoperation for repair was necessary in 18 patients, including 5 with common duct injuries, and, to date, the outcome has been good in each patient. Seventy-six patients (3.8%) have had recognized common duct stones; these were removed preoperatively by endoscopic sphincterotomy (ERS) in 20 patients, during cholecystectomy in 46 patients, and postoperatively by ERS in 4 patients. In six patients, common duct stones became apparent 1 to 4 months after cholecystectomy. We conclude that trained general surgeons can perform laparoscopic cholecystectomy safely with risks comparable to those for conventional open cholecystectomy.