Novel technique for inline orientation of disarticulated limbs to seal type III endoleaks

In this report, we present a novel maneuver used to align disarticulated limbs to resolve a type III endoleak. The patient, a 77-year-old man, initially underwent endovascular abdominal aortic repair for infrarenal abdominal aortic aneurysm in 2017. During routine annual duplex ultrasound in 2022, a late type III endoleak was identified. A novel method of using current techniques was applied, allowing for successful limb graft repair. Managing the longitudinal care of endovascular grafts is an evolving aspect of endovascular repairs. This case report demonstrates the ability to preserve the original endograft repair and ensure the safety of the aneurysm sac.

Comparison of CT and Catheter Arteriography for Evaluation of Peripheral Arterial Disease

Computed tomographic arteriography (CTA) has emerged as a promising technique for less invasive imaging of the lower extremity arteries. The aim of this study was to determine the concordance between CTA and catheter arteriography (CA) in patients with peripheral arterial disease (PAD). Twenty-five patients underwent both CTA and CA, and each set of images was interpreted independently by 3 readers. The infrarenal arteries were divided into 16 segments, and each segment was scored as: 1 = stenosis <50%; 2 = 50–99% stenosis; 3 = occlusion. Modal scores from 3 readers were used to compare results for each segment, with CA assumed to represent true arterial anatomy. Agreement between CTA and CA readings was defined as: concordance (modal scores were identical); moderate discrepancy (MD) (modal scores differed by 1); or severe discrepancy (SD) (modal scores differed by 2). In total, 718 segments were assessed by both CTA and CA. For all segments, the sensitivity and specificity of CTA for <50% stenosis was 86% and 90%; for 50–99% stenosis, sensitivity and specificity were 79% and 89%; and for occlusion, 85% and 98%. Above-knee (AK) CTA scores had slightly better concordance of 86.1% than below-knee (BK) readings (82.3%) (p = 0.104). Severe discrepancies between AK CTA and CA scores were observed in 1.8% of segments compared to 5.4% of BK segments (p = 0.038). Poor CTA image quality was the cause in 20% of AK segments and 28% of BK segments. Poor CA image quality was the cause in 8% of AK and 7% of BK discrepancies. Registration disagreement (stenosis observed in a level in 1 study attributed to a different level in the other) accounted for 18% of AK and 17% of BK discrepancies. In 54% of AK and 48% of BK discrepancies, neither image quality nor registration errors were identified, indicating that inherent differences in the depiction of stenosis by CA and CTA were responsible. When discrepancies caused by registration error were excluded, SD observed in BK segments (4.0%) remained significantly higher than in AK segments (1.25%) (p = 0.029), and poor CTA quality image was the most common cause (76%) of severe BK discrepancies. In AK discrepancies without an identifiable technical cause, CTA uniformly showed more stenosis, suggesting greater CTA diagnostic precision in larger vessels. In general, agreement between CTA and CA was moderately good. Compared to CA, CTA may be better at depicting stenosis in large, proximal vessels owing to the superior accuracy of cross-sectional images in the measurement of stenosis. There appeared to be poorer CT resolution and higher frequency of severe discrepancies between CTA and CA in BK arteries.

Comparison of the Results of Percutaneous Transluminal Angioplasty and Stenting with Medical Treatment for Claudicants Who Have Superficial Femoral Artery Occlusive Disease

The outcomes of medical management of peripheral vascular disease localized to the superficial femoral artery (SFA) were compared with those obtained by percutaneous transluminal angioplasty (PTA) with or without stenting in a review of selected studies.

The natural history of localized SFA disease is favorable, with major amputation rates less than 10% and revascularization in only 18% of patients over a 10-year interval.

Conservative treatment of claudicants shows increases (150%) in walking distance if the ankle brachial index (ABI) is over 0.6 and patients stop smoking. Analysis of 10 trials (882 patients) of PTA with or without stenting found that the overall primary patency rates at 12 months were 71.1% for PTA plus stenting and 58.3% for PTA alone. Technical success with PTA with or without stenting is over 90%, and early results at 6 months are superior to those with exercise. In three randomized controlled trials, however, the difference between PTA and medical treatment at 2 years, whether measured by walking distance or ABI, was not significant, nor was the quality of life. For long-term improvement in walking distance (> 1 year) in the claudicant, intervention is not superior to medical treatment and a monitored exercise program. Consideration should be given to including a nonintervention control group and 2-year outcomes in the evaluation of new SFA stents.

Real-time dynamics of string breaking

We study the real-time dynamics of string breaking in quantum electrodynamics in one spatial dimension. A two-stage process with a clear separation of time and energy scales for the fermion-antifermion pair creation and subsequent charge separation leading to the screening of external charges is found. Going away from the traditional setup of external static charges, we establish the phenomenon of multiple string breaking by considering dynamical charges flying apart.

Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula: lessons learned

OBJECTIVE

Repair of esophageal atresia and tracheoesophageal fistula has traditionally been performed via thoracotomy. This study aims to evaluate the feasibility and pitfalls of the thoracoscopic approach.

MATERIALS AND METHODS

Six consecutive patients with type C tracheoesophageal fistulae underwent thoracoscopic repair. The operation was approached through the right chest using a three-trocar technique (two 5-mm and one 3-mm) with the patient placed in a three-quarter prone position. Patient characteristics, operative time, duration of narcotic usage, conversion factors, postoperative complications, and long-term follow-up were recorded.

RESULTS

Five of six patients were successfully operated on thoracoscopically. The average operative time was 143 minutes (range, 75-215 minutes) with repair of long-gap defects requiring significantly longer times than short-gap defects (200 vs. 129 minutes, P < 0.05). There were no intraoperative complications. Mean duration of narcotic use was 52 hours (range, 24-72 hours). There were no anastomotic leaks. One patient developed an anastomotic stricture at the third postoperative week, which resolved with two dilations. One patient died on the first postoperative day from respiratory failure.

CONCLUSION

Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula is feasible, but is technically challenging. Long-gap defects require more extensive dissection and difficult anastomosis, and are therefore associated with longer operative times. More data are needed for further evaluation of this approach.

Laparoscopic esophagectomy

Minimally invasive esophagectomy is emerging as an alternative option to open esophagectomy for benign and malignant esophageal diseases. This article provides a detailed review of the history of minimally invasive esophagectomy and an update on the currently accepted techniques for minimally invasive esophagectomy and its outcomes.

Current status of minimally invasive esophagectomy

Minimally invasive esophagectomy is emerging as an option in the management of benign and malignant esophageal diseases. With minimally invasive esophagectomy, the conventional laparotomy is substituted with laparoscopy and the open thoracotomy with thoracoscopy. This article discusses the surgical techniques and outcomes for a variety of minimally invasive esophagectomy options.

Bowel Obstruction after Laparoscopic Roux-en-Y Gastric Bypass

BACKGROUND

Bowel obstruction has been frequently reported after laparoscopic Roux-en-Y gastric bypass (LRYGBP). The aim of this study was to review our experience with bowel obstruction following LRYGBP, specifically examining its etiology and management and to strategize maneuvers to minimize this complication.

METHODS

We retrospectively reviewed the charts of 9 patients who developed postoperative bowel obstruction after LRYGBP. Each chart was reviewed for demographics, timing of bowel obstruction from the primary operation, etiology of obstruction, and management.

RESULTS

9 of our initial 225 patients (4%) who underwent LRYGBP developed postoperative bowel obstruction. The mean age was 46 +/- 12 years, with mean BMI 47 +/- 9 kg/m(2). 6 patients developed early bowel obstruction, and 3 patients developed late bowel obstruction. The mean time interval for development of early bowel obstruction was 16 +/-16 days. The causes for early bowel obstruction included narrowing of the jejunojenunostomy anastomosis (n=3), angulation of the Roux limb (n=2), and obstruction of the Roux limb at the level of the transverse mesocolon (n=1). The mean time interval for development of late bowel obstruction was 7.4 +/- 0.5 months. The causes for late bowel obstruction included internal herniation (n=2) and adhesions (n=1). 6 of 9 bowel obstructions (66%) were considered technically related to the learning curve of the laparoscopic approach. Eight of the 9 patients required operative intervention, and 6 of the 8 reoperations were managed laparoscopically. Management included laparoscopic bypass of the jejunojejunostomy obstruction site (n=5), open reduction of internal hernia (n=2), and laparoscopic lysis of adhesion (n=1).

CONCLUSIONS

Bowel obstruction is a frequent complication after LRYGBP, particularly during the learn ing curve of the laparoscopic approach. Specific measures should be instituted to minimize bowel obstruction after LRYGBP as most of these complications are considered technically preventable.

Three cdg operons control cellular turnover of cyclic di-GMP in Acetobacter xylinum: genetic organization and occurrence of conserved domains in isoenzymes

Cyclic di-GMP (c-di-GMP) is the specific nucleotide regulator of beta-1,4-glucan (cellulose) synthase in Acetobacter xylinum. The enzymes controlling turnover of c-di-GMP are diguanylate cyclase (DGC), which catalyzes its formation, and phosphodiesterase A (PDEA), which catalyzes its degradation. Following biochemical purification of DGC and PDEA, genes encoding isoforms of these enzymes have been isolated and found to be located on three distinct yet highly homologous operons for cyclic diguanylate, cdg1, cdg2, and cdg3. Within each cdg operon, a pdeA gene lies upstream of a dgc gene. cdg1 contains two additional flanking genes, cdg1a and cdg1d. cdg1a encodes a putative transcriptional activator, similar to AadR of Rhodopseudomonas palustris and FixK proteins of rhizobia. The deduced DGC and PDEA proteins have an identical motif structure of two lengthy domains in their C-terminal regions. These domains are also present in numerous bacterial proteins of undefined function. The N termini of the DGC and PDEA deduced proteins contain putative oxygen-sensing domains, based on similarity to domains on bacterial NifL and FixL proteins, respectively. Genetic disruption analyses demonstrated a physiological hierarchy among the cdg operons, such that cdg1 contributes 80% of cellular DGC and PDEA activities and cdg2 and cdg3 contribute 15 and 5%, respectively. Disruption of dgc genes markedly reduced in vivo cellulose production, demonstrating that c-di-GMP controls this process.

Outcome of African American men screened for prostate cancer: the Detroit Education and Early Detection Study

PURPOSE

Will early detection impact on stage of disease and recurrence of prostate cancer in a high risk population? We initiated a community based study to educate and recruit African American men for early diagnosis of prostate cancer, that is the Detroit Education and Early Detection (DEED) study. Our objective was to evaluate our recruitment process for this target population, examine the percentage of organ confined prostate cancer in men undergoing radical prostatectomy and measure recurrence biochemically.

MATERIALS AND METHODS

A community based study from February 1993 to February 1995 through the African American churches in metropolitan Detroit was initiated. We compared the early detection group treated with radical prostatectomy to the population presenting to our urological clinic during the same period. We tested and followed 1,105 African American men using the prostate specific antigen blood test.

RESULTS

Pathologically organ confined prostate cancer was diagnosed in 11 of 17 men (65%) who underwent radical prostatectomy in the DEED project. Within the clinic population 35% of the African American men were diagnosed with pathologically organ confined prostate cancer. The difference between the 2 populations was statistically significant (p = 0.033). Disease recurred in 1 of 15 (7%) and 39 of 157 (25%) men in the DEED and clinic populations, respectively (p = 0.97).

CONCLUSIONS

We demonstrated our ability to recruit African American men into a prostate cancer early detection program. We diagnosed early but clinically significant prostate cancers among African American men with characteristics similar to prostate cancers diagnosed in other early detection studies in which the overwhelming majority of men were white.

Recent advances in the polymerase chain reaction

The polymerase chain reaction (PCR) has dramatically altered how molecular studies are conducted as well as what questions can be asked. In addition to simplifying molecular tasks typically carried out with the use of recombinant DNA technology, PCR has allowed a spectrum of advances ranging from the identification of novel genes and pathogens to the quantitation of characterized nucleotide sequences. PCR can provide insights into the intricacies of single cells as well as the evolution of species. Some recent developments in instrumentation, methodology, and applications of the PCR are presented in this review.

Pneumothorax complicating enteral feeding tube placement

Two cases are presented of pneumothorax complicating enteral feeding tube insertion. A previous report describing three similar cases is noted. Neurologically impaired patients appear to be particularly at risk for this complication, which may be encouraged by use of a guidewire during tube insertion. It is suggested that enteral feeding tubes in neurologically impaired patients be inserted under fluoroscopic guidance using a tube specifically designed for this purpose.

Binding of glucocorticoid receptors to DNA

DNA has been implicated as the nuclear acceptor for receptor-glucocorticoid complexes. The present study concerns the interaction of these complexes, isolated from cultured rat hepatoma cells, with purified DNA. This association is rapid, reaching a maximum within a few minutes at 0 degrees, whereas dissociation requires several hours. DNA binds neither free glucocorticoids nor those complexed with transcortin or cytosol proteins different from the receptor. Receptors which are not complexed by steroid have little or no affinity for DNA. "Activation," necessary for the binding of receptor-steroid complexes to isolated nuclei, also enhances DNA binding. The capacity of DNA for binding receptor-steroid complexes is large; saturation was not observed at the complex concentrations studied, using either crude or partially purified receptor preparations. The association of complexes with DNA is inhibited by divalent cations, at increasing ionic strengths, and by mercurial reagents. Complexes bind equally well to bacterial, bacteriophage, or rat DNA; however, there was either no or substantially reduced binding by bacterial 23 S rRNA. The binding of complexes to native DNA is roughly 3-fold greater than to denatured DNA. These characteristics are consistent with the possibility that DNA is the nuclear acceptor for receptor-glucocorticoid complexes; however, the actual composition of the acceptor sites remains unknown.