New insight into the molecular pathways of metallothionein-mediated neuroprotection and regeneration

There is a large body of evidence demonstrating that metallothioneins (MTs) expressed in astrocytes following CNS injury, exhibit both neuroprotective and neuroregenerative properties and are critical for recovery outcomes. As these proteins lack signal peptides, and have well characterized free radical scavenging and heavy metal binding properties, the neuroprotective functions of MTs have been attributed to these intracellular roles. However, there is an increasing realization that the neuroprotective functions of MTs may also involve an extracellular component. In this issue of Journal of Neurochemistry, Ambjørn et al. reveal considerable insight into this novel function of MTs. In this review, we examine the seminal work of Ambjørn et al. in the context of our current understanding of the role of MT in astrocyte-neuron interactions in the injured brain, and also discuss the significant therapeutic potential of their work.

Excitotoxicity mediated by non-NMDA receptors causes distal axonopathy in long-term cultured spinal motor neurons

Excitotoxicity has been implicated as a potential cause of neuronal degeneration in amyotrophic lateral sclerosis (ALS). It has not been clear how excitotoxic injury leads to the hallmark pathological changes of ALS, such as the abnormal accumulation of filamentous proteins in axons. We have investigated the effects of overactivation of excitatory receptors in rodent neurons maintained in long-term culture. Excitotoxicity, mediated principally via non-N-methyl-D-aspartate (NMDA) receptors, caused axonal swelling and accumulation of cytoskeletal proteins in the distal segments of the axons of cultured spinal, but not cortical, neurons. Axonopathy only occurred in spinal neurons maintained for 3 weeks in vitro, indicating that susceptibility to axonal pathology may be related to relative maturity of the neuron. Excitotoxic axonopathy was associated with the aberrant colocalization of phosphorylated and dephosphorylated neurofilament proteins, indicating that disruption to the regulation of phosphorylation of neurofilaments may lead to their abnormal accumulation. These data provide a strong link between excitotoxicity and the selective pattern of axonopathy of lower motor neurons that underlies neuronal dysfunction in ALS.

Metallothionein expression by NG2 glial cells following CNS injury

Metallothionein (MT) expression is rapidly up-regulated following CNS injury, and there is a strong correlation between the presence or absence of MTand improved or impaired (respectively) recovery from such trauma.We now report that a distinct subset of NG2-positive, GFAP-negative glial cells bordering the injury tract express MT following focal injury to the adult rat neocortex. To confirm the ability of these NG2 glial cells to express MT, we have isolated and cultured them and identified that they can express MT following stimulation with zinc. To investigate the functional importance of MT expression by NG2 glial cells, we plated cortical neurons onto these cells and found that expression of MT enhanced the permissivity of NG2 glial cells to neurite outgrowth. Our data suggest that expression of MT by NG2 glial cells may contribute to the overall permissiveness of these cells to axon regeneration.

Cyclosporin-A treatment attenuates delayed cytoskeletal alterations and secondary axotomy following mild axonal stretch injury

Following central nervous system trauma, diffuse axonal injury and secondary axotomy result from a cascade of cellular alterations including cytoskeletal and mitochondrial disruption. We have examined the link between intracellular changes following mild/moderate axonal stretch injury and secondary axotomy in rat cortical neurons cultured to relative maturity (21 days in vitro). Axon bundles were transiently stretched to a strain level between 103% and 106% using controlled pressurized fluid. Double-immunohistochemical analysis of neurofilaments, neuronal spectrin, alpha-internexin, cytochrome-c, and ubiquitin was conducted at 24-, 48-, 72-, and 96-h postinjury. Stretch injury resulted in delayed cytoskeletal damage, maximal at 48-h postinjury. Accumulation of cytochrome-c and ubiquitin was also evident at 48 h following injury and colocalized to axonal regions of cytoskeletal disruption. Pretreatment of cultures with cyclosporin-A, an inhibitor of calcineurin and the mitochondrial membrane transitional pore, reduced the degree of cytoskeletal damage in stretch-injured axonal bundles. At 48-h postinjury, 20% of untreated cultures demonstrated secondary axotomy, whereas cyclosporin A-treated axon bundles remained intact. By 72-h postinjury, 50% of control preparations and 7% of cyclosporin A-treated axonal bundles had progressed to secondary axotomy, respectively. Statistical analyses demonstrated a significant (p < 0.05) reduction in secondary axotomy between treated and untreated cultures. In summary, these results suggest that cyclosporin-A reduces progressive cytoskeletal damage and secondary axotomy following transient axonal stretch injury in vitro.

Localization of glutamate receptors in developing cortical neurons in culture and relationship to susceptibility to excitotoxicity

Overactivation of glutamate receptors leading to excitotoxicity has been implicated in the neurodegenerative alterations of a range of central nervous system (CNS) disorders. We have investigated the cell-type-specific changes in glutamate receptor localization in developing cortical neurons in culture, as well as the relationship between glutamate receptor subunit distribution with synapse formation and susceptibility to excitotoxicity. Glutamate receptor subunit clustering was present prior to the formation of synapses. However, different receptor types showed distinctive temporal patterns of subunit clustering, localization to spines, and apposition to presynaptic terminals. N-methyl-D-aspartate (NMDA) receptor subunit immunolabelling was present in puncta along dendrites prior to the formation of synapses, with relatively little localization to spines. Vulnerability to NMDA receptor-mediated excitotoxicity occurred before receptor subunits became localized in apposition to presynaptic terminals. Clustering of alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA) receptors occurred concurrently with development of vulnerability to excitotoxicity and was related to localization of AMPA receptors at synapses and in spines. Different AMPA receptor subunits demonstrated cell-type-specific localization as well as distribution to spines, dendrites, and extrasynaptic subunit clusters. A subclass of neurons demonstrated substantial perineuronal synaptic innervation, and these neurons expressed relatively high levels of GluR1 and/or GluR4 at receptor puncta, indicating the presence of calcium-permeable AMPA receptors and suggesting alternative synaptic signalling mechanisms and vulnerability to excitotoxicity. These data demonstrate the relationship between glutamate receptor subunit expression and localization with synaptogenesis and development of neuronal susceptibility to excitotoxicity. These data also suggest that excitotoxicity can be mediated through extrasynaptic receptor subunit complexes along dendrites.

Metallothionein biology in the ageing and neurodegenerative brain

In recent years metallothionein (MT) biology has moved from investigation of its ability to protect against environmental heavy metals to a wider appreciation of its role in responding to cellular stress, whether as a consequence of normal function, or following injury and disease. This is exemplified by recent investigation of MT in the mammalian brain where plausible roles for MT action have been described, including zinc metabolism, free radical scavenging, and protection and regeneration following neurological injury. Along with other laboratories we have used several models of central nervous system (CNS) injury to investigate possible parallels between injury-dependent changes in MT expression and those observed in the ageing and/or degenerating brain. Therefore, this brief review aims to summarise existing information on MT expression during CNS ageing, and to examine the possible involvement of this protein in the course of human neurodegenerative disease, as exemplified by Alzheimer's disease.

Olfactory ensheathing cells promote neurite sprouting of injured axons in vitro by direct cellular contact and secretion of soluble factors

Olfactory ensheathing cells (OECs) represent an exciting possibility for promoting axonal regeneration within the injured spinal cord. A number of studies have indicated the ability of these cells to promote significant reactive sprouting of injured axons within the injured spinal cord, and in some cases restoration of functional abilities. However, the cellular and/or molecular mechanisms OECs use to achieve this are unclear. To investigate such mechanisms, we report for the first time the ability of OECs to promote post-injury neurite sprouting in an in vitro model of axonal injury. Using this model, we were able to differentiate between the direct and indirect mechanisms underlying the ability of OECs to promote neuronal recovery from injury. We noted that OECs appeared to act as a physical substrate for the growth of post-injury neurite sprouts. We also found that while post-injury sprouting was promoted most when OECs were allowed to directly contact injured neurons, physical separation using tissue culture inserts (1 mm pore size, permeable to diffusible factors but not cells) did not completely block the promoting properties of OECs, suggesting that they also secrete soluble factors which aid post-injury neurite sprouting. Furthermore, this in vitro model allowed direct observation of the cellular interactions between OECs and sprouting neurites using live-cell-imaging techniques. In summary, we found that OECs separately promote neurite sprouting by providing a physical substrate for growth and through the expression of soluble factors. Our findings provide new insight into the ability of OECs to promote axonal regeneration, and also indicate potential targets for manipulation of these cells to enhance their restorative ability.

A role for extracellular metallothioneins in CNS injury and repair

For many years, research focus on metallothioneins, small zinc binding proteins found predominantly within astrocytes in the brain, has centred on their ability to indirectly protect neurons from oxygen free radicals and heavy metal-induced neurotoxicity. However, in recent years it has been demonstrated that these proteins have previously unsuspected roles within the cellular response to brain injury. The aim of this commentary is to provide an overview of the exciting recent experimental evidence from several laboratories including our own suggesting a possible extracellular role for these proteins, and to present a hypothetical model explaining the newly identified function of extracellular metallothioneins in CNS injury and repair.

Olfactory ensheathing cells promote collateral axonal branching in the injured adult rat spinal cord

In recent years, injection of olfactory ensheathing cells (ECs) into the spinal cord has been used as an experimental strategy to promote regeneration of injured axons. In this study, we have compared the effects of transplanting encapsulated ECs with those injected directly into the spinal cord. The dorsal columns of adult rats were cut at T(8-9) and rats in experimental groups received either EC-filled porous polymer capsules or culture medium (CM)-filled capsules with ECs injected at the injury site. Control rats were in three groups: (1) uninjured, (2) lesion with transplantation of CM-filled capsules and (3) lesion with transplantation of CM-filled capsules and injections of CM. Three weeks after injury, Fluororuby was injected into the hindlimb motor and somatosensory cortex to label corticospinal neurons. Observations indicated that there were a few regenerating fibres, up to 10, in the EC-treated groups. In rats that received encapsulated ECs, regenerating fibres were present in close association with the capsule. Rats that received EC injections demonstrated a significant increase in the number of collateral branches from the intact ventral corticospinal tract (vCST) compared with the corresponding control, CM-injected group (P=0.003), while a trend for increased collateral branches was observed in rats that received encapsulated ECs (P=0.07).

The decline of training in open biliary surgery: effect on the residents' attitude toward bile duct surgery

BACKGROUND

After more than a decade of growth for laparoscopic cholecystectomy and decline in open cholecystectomy, the impact on the training of resident's in other open biliary operations can be analyzed quantitatively.

METHODS

The national operative statistics for residents' operations from 1988 to 2001 (data in the public domain) were analyzed by regression analysis to establish trends and to calculate the rate of change. For laparoscopic biliary operations, the changes in laparoscopic and open operations over time and the number of operations per trainee each year were used to measure the growth of a laparoscopic operation and to predict future trends. A survey of attitude, management algorithm, and self-confidence for coping with unexpected events in laparoscopic cholecystectomy also was conducted for senior residents and recent graduates.

RESULTS

In 2001, open cholecystectomy decreased to 28%, open common duct exploration to 27%, sphincteroplasty to 20%, of 1988 (baseline year) levels. Cholecystostomy and choledochoenteric bypass decreased to 70% and 75%, respectively. The decline began before the era of laparoscopic cholecystectomy, but accelerated after its introduction. Many of the recent graduates surveyed in one program indicated a preference for a nonsurgical, mainly endoscopic, approach for all bile duct conditions, but also for the assistance of senior surgeons in the operative management of unexpected events.

CONCLUSION

The popularity of noninvasive therapy in biliary surgery significantly reduced the resident's exposure to open biliary surgery, adversely affecting their confidence in the management of unexpected events encountered during laparoscopic operations. Supplemental and remedial education measures must be instituted in training programs.

Metallothionein-III inhibits initial neurite formation in developing neurons as well as postinjury, regenerative neurite sprouting

Human metallothionein-III (MT-III) is an inhibitory factor deficient in the Alzheimer's disease (AD) brain. MT-III has been identified as an inhibitor of neurite sprouting, and its deficiency has been proposed to be involved in the formation of neurofibrillary tangles (NFT) in the neuropathology of AD. However, there has been limited investigation of the proposed neurite growth inhibitory properties of MT-III. We have applied recombinant human MT-III to both single cell embryonic cortical neurons (to investigate initial neurite formation), as well as mature (21 days postplating) clusters of cortical neurons (to investigate the regenerative sprouting response following injury). We report that MT-III inhibited the initial formation of neurites by rat embryonic (E18) cortical neurons. This was based on both the percentage of neurite positive neurons and the number of neurites per neuron (45 and 30% inhibition, respectively). Neurite inhibition was only observed in the presence of adult rat brain extract, and was also reversible following replacement of MT-III-containing medium. MT-III inhibited the formation and growth of both axons and dendrites. Of more physiological significance, MT-III also inhibited the regenerative neurite sprouting response following axonal transection. The morphology of sprouting neurites was also altered, with the distal tip often ending in bulb-like structures. Based on these results, we propose that MT-III, in the presence of brain extract, is a potent inhibitor of neurite sprouting, and may be involved in abnormal sprouting potentially underlying both AD and epilepsy.

Influenza vaccination, hospitalizations, and costs among members of a Medicare managed care plan

OBJECTIVE

To evaluate the effectiveness and possible cost savings of influenza vaccination.

SUBJECTS

Members age 65 and older in a Medicare managed care plan during the 1994-1995, 1995-1996, and 1996-1997 influenza seasons.

RESEARCH DESIGN

The study examined administrative data on influenza vaccination and subsequent hospitalizations. Outcomes included hospitalization with pneumonia or influenza, with any respiratory condition, and with congestive heart failure (CHF).

RESULTS

Vaccinated subjects experienced fewer hospitalizations with respiratory conditions or CHF than had unvaccinated subjects (OR=0.8 (95% CI, 0.7, 0.9) in analyses adjusted for age, sex, pneumococcal vaccination, health utilization, and morbidity). Analyses adjusted in addition for ethnicity obtained similar results among the subgroup of members whose ethnicity was known. Subjects without major disease in the previous 12 months had lower odds ratios for vaccination than subjects with major disease (OR values of 0.5 [95% CI, 0.4, 0.7] and 0.9 [95% CI, 0.8, 1.1], respectively). Subjects ages 65 to 79 had lower odds ratios for vaccination than subjects ages 80 and older (OR values of 0.7 [95% CI, 0.6, 0.9] and 0.9 [95% CI, 0.8, 1.1], respectively). Estimated cost savings averaged about $80 per vaccinated subject.

CONCLUSIONS

Subjects ages 65 to 79 who had received influenza vaccination experienced fewer hospitalizations and had lower costs than had unvaccinated subjects. Associations were weaker for subjects age 80 and older. The results, consistent with recommendations for the use of influenza vaccine, suggest that people ages 65 to 79 should be heavily targeted for vaccination.

Carbon dioxide flux density in cultivated rice paddy field

The carbon dioxide flux density in a subtropical cultivated rice paddy field were determined over four crop seasons (two consecutive years) at five stages of rice plant development, transplanting, active tillering, booting, flowering and ripening, and an idle period between crops. During 24 h sampling periods at those stages, the CO2 flux densities were measured and found to be -2,000 to 55,000 mg CO2/m2/day in the first year and 600 to 29,000 mg CO2/m2/day in the second year in acrylic chambers covering rice plants. The CO2 flux densities in glass domes without plants but with soil were -700 to 6,000 mg CO2/m2/day in the first year and 147 to 4,500 mg CO2/m2/day in the second year. The data for the CO2 flux density over an entire year are extrapolated. Although our non-controlled environment experiments have inherent drawbacks, the collected data indicate that continuous rice cultivation has a tendency to result in increased CO2 emissions.

The clinical diagnosis of chronic acalculous cholecystitis

BACKGROUND

Chronic acalculous cholecystitis (CAC), a diagnosis of exclusion, appears to be more common than was previously thought. We correlated the pathology with test results and response to treatment in a prospective study to obtain data for evidence-based management.

METHODS

The study subjects were patients with chronic biliary symptoms but had normal sonogram results. They were further investigated with esophagogastroduodenoscopy, multidiscipline evaluations, and cholecystokinin-stimulated scintigraphy (CCK-HIDA). They were offered laparoscopic cholecystectomy (LC) when the symptoms were intransigent, and the main abnormality was a low ejection fraction (EF) as determined by CCK-HIDA. We analyzed the histologic findings of the gallbladder, CCK-HIDA EF, and clinical outcomes during the control period with a concurrent series of LC for calculus from the same surgeons.

RESULTS

Of 176 cholecystectomies for biliary pain without stones, 152 had pathologically verified CAC. EF by CCK-HIDA was low in patients with CAC (18%) and low in normal gallbladders (26%). In the same period, 497 patients had cholecystectomies for cholelithiasis. Lasting symptom relief for CAC after LC was not different from that for calculous disease (85% vs 90%).

CONCLUSIONS

The syndrome consisting of chronic biliary symptoms, stone-free sonograms, low EF in CCK-HIDA, and absence of other pain sources is highly predictive for CAC, which is well treated with LC, with results similar to those for calculous disease.

Correlating physical and mental health status with satisfaction in a health plan

Managed care organizations strive to prevent illness where possible and improve patient outcomes for enrollees. The objective of this study was to examine how data from the Medical Outcomes Study Short Form-12 from more than 45,000 health plan enrollees can be used to: compare enrollee health status with national norms, examine the relationship between health status and member characteristics, and determine the extent to which health status is related to member satisfaction. The member survey measured physical and mental health and the following aspects of satisfaction: access, communication, and medical services. The researchers found that physical and mental health status were significantly associated with age, education, and ethnicity, whereas satisfaction was positively correlated with mental health status. Monitoring the health status of enrollees through the administration of a short, well-validated questionnaire can provide useful information in comparison with national norms as well as important insights regarding potential areas to target for quality improvement initiatives.

Pretarsal fat compartment in the lower eyelid

It is generally accepted that there are three infraorbital fat regions in the lower eyelid; medial, central, and lateral compartments. However, removing only the fat in the lateral compartment does not remove the bulge just below the eyelashes, which is caused by another fat pad. The aim of this study was to describe the anatomy of the pretarsal fat compartment and to demonstrate its clinical implications in lower lid blepharoplasty. Ten cadavers (total 20 lower eyelids) were studied. A skin-muscle flap was reflected to expose the soft pretarsal structures. A small stab incision was made on the lateral portion of the sac containing fat on the tarsus. Methylene blue dye was injected into the sac. Specimens were fixed and sagittal sections in four different planes were prepared for histological analysis. The injected dye remained within the sac and demarcated it as a pear or cone shaped structure. This encapsulated fat compartment sits on the lateral half of the tarsal plate above the lateral compartment fat. Auxillary or submuscular fat is well known. This study, however, designates the pretarsal fat as "encapsulated" in a compartment instead of being unbound. We have named it the "pretarsal fat compartment." Histologically, orbital septal fibers separate "pretarsal fat" from lateral infraorbital fat. It is recommended that fat in the pretarsal fat compartment be removed during lower lid blepharoplasty in order to alleviate the bulge or knoll of the skin just below the lower eyelashes.

Histomorphometry of parietal bones versus age and race

Surgeons are used to obtaining bone grafts of calvaria, which are abundant and available. The outer table of the parietal bone can be split, usually at the level of the diploic interstice, with an osteotome. Inadvertently violating the inner table and the dura leads some surgeons to avoid using the outer table in the elderly. Sullivan and Smith measured the thickness of the outer tables, diploe, and inner table of 37 cadavers (average age, 59 years) and found each layer to be well preserved distinctly. However, they suggested that calvaria become brittle in patients older than 50 years of age. The current authors hypothesized that diploic composition is not changed, even in the elderly. The thickest part of the parietal bone of 49 Koreans and 30 whites were acquired, and undecalcified slides were made. Via light microscopy, using the National Institutes of Health image, the following measurements were made: the thickness of the parietal bone (PT), outer table (OT), diploe (DT), and inner table (IT); trabecular bone volume percent (TBV); trabecular thickness (TT); and trabecular separation (TS). There was no significant difference in the thickness of the OT, DT, and IT of the PT, TBV, TT, and TS among different ages. The PTs of women were thicker than men's. The PTs of whites were significantly thicker than Koreans'. This study disclosed that the DT is not different among varying age groups and is not sclerosed in the persons older than 80 years, and the OT of these individuals is not brittle. Thus, surgeons do not need to hesitate when taking the OT of the PT in older patients. However, the selection of the site is attentive to PT. The thickest posteromedial part of the PT is favorable and safe as a donor.

Meta-analyses of randomized controlled trials of laparoscopic vs conventional inguinal hernia repairs

BACKGROUND

Despite randomized controlled trials, the merits of laparoscopic hernia repair remain poorly defined. A meta-analysis may provide a timely overview.

METHODS

An electronic MEDLINE search, supplemented by a manual search, yielded 14 randomized controlled trials with usable statistical data, involving 2,471 patients. The trials were grouped for separate meta-analyses according to the control operation, either a tension-free or sutured repair, used for comparison. The effect sizes for operating time, postoperative pain, return to normal activity, and early recurrence were calculated, using a random-effects model when the effect sizes were heterogeneous and without subcategories.

RESULTS

In all meta-analyses, the laparoscopic operation was significantly longer. When compared with tension-free repairs, the laparoscopic operation showed no advantage in terms of postoperative pain, but resulted in a shorter recovery (marginal significance). As compared with sutured repair, both postoperative pain and recovery were in favor of the laparoscopic operation. When all 14 trials were analyzed together, laparoscopic repairs still had moderately reduced postoperative pain and recovery time.

CONCLUSIONS

Laparoscopic hernia repair has a modest advantage over conventional repairs. This advantage is more apparent when laparoscopic repairs are compared with sutured repairs rather than tension-free repairs.

Impact of a dedicated trauma service on the quality and cost of care provided to injured patients at an urban teaching hospital

BACKGROUND

To determine the impact of a dedicated trauma service on cost and quality of care in an urban teaching hospital, a before-and-after study was designed. The key elements of the trauma service were dedicated in-house trauma attending surgeons and residents, and continuity and integration of trauma care.

METHODS

Injury Severity Scores and probabilities of survival for each patient were calculated from the hospital International Classification of Diseases, Ninth Revision, codes, and individual patient costs were estimated from charges using the Medicare Cost Report.

RESULTS

The trauma service resulted in a significant increase in the severity of injuries. There was a highly significant (p<0.001) increase in the mean probability of death (from 0.16 to 0.21). There was no change in actual mortality. Although the mean cost of care increased by 16.6%, there were small reductions in the cost of care of the most severely injured patients.

CONCLUSION

A dedicated trauma service has a positive impact on the quality of care.

A meta-analysis of randomized controlled trials of laparoscopic versus conventional appendectomy

BACKGROUND

Despite many randomized controlled trials, the merits of laparoscopic appendectomy remain unclear. A meta-analysis may provide insights not evident from any individual studies.

DATA SOURCES

Systematic literature search yielded 17 trials (1,962 subjects) of true randomized design with usable statistical data comparing laparoscopic and conventional appendectomy in adults. The effect sizes for operating time, hospitalization, postoperative pain, return to normal activity, wound infection, and intra-abdominal abscess were calculated, using the random effects model to allow for heterogeneity. An estimate of the robustness of all positive findings was also calculated.

RESULTS

Modest but statistically significant effect sizes were found for four of the six outcome measures. Laparoscopic appendectomy takes 31% longer to perform, but results in less postoperative pain, faster recovery (by 35%), and lower wound infection rates (by 60%).

CONCLUSION

Laparoscopic appendectomy offers significant improvement in postoperative outcomes at the cost of a longer operation.

An anatomical study of the junction of the orbital septum and the levator aponeurosis in Orientals

The anatomical relationships of the orbital septum and levator aponeurosis has been studied in 40 eyelids subjected to blepharoplasty and corrective ptosis surgery by dissection in 10 cadavers and in histological sections. The orbital septum originates from the arcus marginalis of the frontal bone and consists of two layers. The whitish outer (superficial) layer, containing vertically running vessels, descends just inside the orbicularis oculi muscle to interdigitate with the levator aponeurosis with loose connective tissue, then disperses inferiorly. The inner (deep) layer follows the superficial one initially, then reflects at the levator aponeurosis and continues posteriorly with the levator sheath. We reconfirmed Whitnall's original description that the levator sheath thickens to form the superior transverse ligament runs continuously inferiorly anterior to the levator aponeurosis and forms the inner layer of the orbital septum. This detailed anatomical analysis should assist in performing upper eyelid surgery such as the Oriental double fold operation or levator resection.

Unsuspected choledocholithiasis first diagnosed at laparoscopic cholecystectomy: treatment by trans-cystic duct stenting and elective stent-guided sphincterotomy

BACKGROUND

Despite advances in laparoscopic surgery, management of unsuspected choledocholithiasis diagnosed at laparoscopic cholecystectomy is controversial. We propose a simple maneuver of laparoscopic trans-cystic duct stenting of the papilla during cholecystectomy, followed by elective stent-guided sphincterotomy, as an expedient option.

METHODS

We studied retrospectively 16 patients with choledocholithiasis first diagnosed in the course of laparoscopic cholecystectomy, treated with laparoscopic stenting of the papilla via the cystic duct using a short Cotton-Leung stent before completion of cholecystectomy. Elective stent-guided, needle-knife sphincterotomy and stone clearance was performed 2 to 3 weeks postoperatively.

RESULTS

Of 16 patients attempted, the procedure failed in one due to an impacted stone that prevented passage of the guidewire. Stenting time was 13 +/- 5 minutes (n = 15). Two stented patients had no stones at endoscopic retrograde cholangiography. Thirteen patients had successful elective stent-guided sphincterotomy with stone clearance without complications.

CONCLUSIONS

Laparoscopic biliary stenting combined with stent-guided sphincterotomy is a simple, safe, and cost-effective option for the management of uncomplicated choledocholithiasis.

Efficacy of routine laparoscopy for the acute abdomen

BACKGROUND

Laparoscopic surgery of selected acute abdominal conditions has been shown to be highly effective. Therefore, we investigated the diagnostic accuracy and therapeutic efficacy of routine laparoscopic surgery for the acute abdomen.

METHODS

After appropriate investigations, patients with acute abdomen, with or without a specific diagnosis, were offered the options of either laparoscopic or open surgery. Postoperatively, we analyzed the outcome measures of diagnostic accuracy, complications, and operating time of laparoscopy. The hospital stays for our patients were compared to case-matched controls.

RESULTS

The accuracy of laparoscopic diagnosis is the same as laparotomy. The 62% of our patients who were managed totally laparoscopically required shorter hospitalization than the case-matched controls treated by open operation. Morbidity was not increased by laparoscopy in patients who required conversion to open operation. The additional cost of laparoscopy appeared modest.

CONCLUSIONS

Routine laparoscopy for the acute abdomen is safe and accurate. Patients eligible for laparoscopic treatment also require less hospitalization time.

Laparoscopy-assisted jejunal resection for bleeding leiomyoma

We report a case of successful resection of a jejunal leiomyoma using a minimally invasive technique. By combining the procedures of push enteroscopy and laparoscopy, jejunal resection can be performed expeditiously without laparotomy.

In vitro effects of simulated gastric juice on swallowed metal objects: implications for practical management

BACKGROUND

Swallowed metal objects often pose a technical challenge for the endoscopist. We studied in vitro the effects of simulated gastric juice on metal objects commonly encountered in endoscopic practice and measured the physical-chemical changes.

METHOD

Razor blades, disc batteries, and pennies were incubated in simulated gastric juice at 37 degrees C. The weights of the objects were recorded hourly. When no change could be detected, the solution was subjected to mass spectrometry to verify absence of effect. The findings were correlated with clinical observation in one patient who swallowed razor blades repeatedly.

RESULTS

Dissolution of the razor blade was proportional to the duration of acid immersion. At 24 hours, the blades weighed 63% of the original weight. Double-edged razor blades could be broken with a snare at 15 hours. The thickened back of the single-edged blade totally dissolved in 2 hours. No leak of contents could be detected with disk batteries. Pennies were unaffected.

CONCLUSION

Corrosion of razor blades occurs rapidly in the normal stomach. Within 24 hours double-edged blades become fragile and can be broken with a snare. This observation may guide the timing of endoscopic removal. Modern disk batteries are acid resistant for 24 hours.

Client satisfaction data and quality improvement planning in managed mental health care organizations

Quality improvement (QI) planning is enhanced when TQM administrators ensure appropriate analysis of client satisfaction (CS) survey data. A cost-effective QI strategy is to shift "moderately satisfied" into "maximally satisfied" clients. Use of a categorical variable derived from CS data and development of a predictive model with Chi Square Automatic Interaction Detection (CHAID) produces recommendations for quality improvement.

Palliative gastrojejunostomy. A minimally invasive approach

Palliative bypass for neoplastic gastric outlet obstruction should be minimally invasive. We designed a laparoscopically assisted approach that appears to meet the need. The proximal jejunum is exteriorized by laparoscopy via an epigastric trocar-site incision. An EEA anvil is installed in the exteriorized jejunum, which is returned to the abdomen. Through this mini-incision, the anterior wall of the stomach is opened for insertion of the EEA stapler, which penetrates the posterior gastric wall. When snapped to the anvil and fired, an antecolic gastrojejunostomy is created. No mortality or anastomotic leak occurred in two cases. The operation and recovery appeared to be faster than historic controls. This operation is minimally invasive and expeditious, ideal for patients requiring palliative bypass.

One-on-one mentor-resident rotation for improving continuity of care in a surgical training program

The modern resident team, staffed by multiple attendings, often makes sacrifices on continuity of care due to scheduling conflicts. We investigated a one-on-one mentor-resident rotation where all clinical activities were synchronized to produce near-perfect continuity of care, and we compared the objective and subjective outcome measures to those of control rotations of the same resident during the same year. The results showed that continuity of care close to 100% was possible in such rotations, but work hours were increased by 25%. Also, the number of patients seen was decreased by over 50%. The rotation was well-received by both mentors and residents. Continuity of care per se can be improved by this rotation. However, theoretical disadvantages, mainly narrow training due to exposure to only one mentor and fewer patients, make it unsuitable for extended use.

Colectomy for sigmoid volvulus

PURPOSE

Volvulus of the sigmoid carries a high mortality. This minimally invasive technique is designed for poor-risk patients.

TECHNIQUE

Aided by laparoscopy, the mobile sigmoid is exteriorized through a mini-incision without preliminary dissection. The entire resection and anastomosis is performed on the surface of the abdomen. The options of end colostomy, primary anastomosis with or without fecal diversion, can all be used with this method.

RESULTS

No mortality or leakage occurred in four patients.

CONCLUSION

This rapid operation does not require advanced laparoscopic skills. Preliminary results should be confirmed by others.

Closure of trocar wounds using a suture carrier

We developed a hook suture carrier for closure of trocar wounds, making use of the vertical rather than the horizontal space, which is limited in small wounds. The technique is simpler than all the laparoscopically assisted devices currently available, and it has no learning curve. No complications developed in 6 months of use.

Laparoscopic resection of accessory spleen for recurrent immune thrombocytopenic purpura 19 years after splenectomy

Routine identification and resection of accessory splenic tissue, an integral part of splenectomy for immune thrombocytopenic purpura (ITP), is not necessarily a "blind spot" of the laparoscopic technique. This case report of laparoscopic resection of accessory spleen for recurrent ITP 19 yr after splenectomy supports this view.

Closure of trocar wounds in laparoscopic operations. The threading technique

A method of fascial closure utilizing a hypodermic needle as a conduit for threading the suture through the fascia is described. This technique is designed to make use of vertical space rather than horizontal space, which is lacking in the small trocar wounds. The technique is easy to master and teach and has resulted in secure closures in over 150 wounds.

Pancreas-sparing duodenectomy: indications, surgical technique, and results

BACKGROUND

Pancreatoduodenectomy, originally performed for malignancy of the pancreas and duodenum, is also commonly used for potentially malignant lesions. Because a normal pancreas should be spared, we investigated the concept of duodenectomy alone with the pancreas intact for diseases such as familial adenomatous polyposis syndrome.

METHODS

Five patients underwent pancreas-sparing duodenectomy for nonmalignant lesions performed by means of meticulous detachment of the duodenum from the pancreas, transecting the bile and pancreatic ducts outside the duodenum. Reconstruction was accomplished by advancing the jejunum to anastomose end-to-end with the juxtapyloric duodenal cuff, implanting the bile and pancreatic ducts in a location corresponding to the native papilla. The hospital course, complications, and long-term follow-up status of all patients are reviewed in detail.

RESULTS

No deaths occurred in this series. Delayed gastric emptying was seen in one patient and transient pancreatic fistula in another. Long-term endoscopic follow-up showed no stenosis of the ductal anastomoses. Endoscopic surveillance, including endoscopic retrograde cholangiopancreatography, was not hampered by this technique of reconstruction.

CONCLUSIONS

Pancreas-sparing duodenectomy is a practical operation for nonmalignant duodenal lesions where the pancreas is not involved by the disease process.

Incomplete excision of the gallbladder during laparoscopic cholecystectomy

Dissection and transection of the cystic duct close to the gallbladder has been advocated as a means of avoiding common bile injury during laparoscopic cholecystectomy (LC). We present three cases in which inadequate identification of the gallbladder-cystic duct junction resulted in incomplete cholecystectomy. In two patients an unsecured gallbladder infundibulum presented as cystic duct leaks and one patient developed recurrent symptomatic cholelithiasis. These cases emphasize the need for complete dissection and visualization of the cystic duct at the gallbladder prior its division and secure ligation during LC.

Endoscopic treatment of biliary leakage after laparoscopic cholecystectomy

Laparoscopic cholecystectomy is an effective and safe treatment for uncomplicated symptomatic cholelithiasis. However, biliary tract injury may be more common with this procedure than with open cholecystectomy. We have encountered 17 patients with a biliary leak among 465 patients undergoing laparoscopic cholecystectomy, the diagnosis being established by clinical and radiographic parameters. The most common site of leakage was the cystic duct stump. Patients underwent endoscopic sphincterotomy and biliary stent placement, with an overall success rate of 96%. No morbidity or mortality related to the endoscopic procedures was encountered. We conclude that biliary leakage after laparoscopic cholecystectomy is uncommon. When it occurs, it can be treated safely and efficaciously by endoscopic means.

Surgical decisions in the management of duodenal perforation complicating endoscopic sphincterotomy

The management of duodenal perforation associated with endoscopic sphincterotomy is controversial. Despite the fact that many patients recover without surgery, surgical opinion tends to favor immediate operation upon diagnosis since the mortality is high when sepsis is advanced. To refine the criteria for operative management, all duodenal perforations after endoscopic sphincterotomy over a 5-year period were studied. In a series of 464 consecutive endoscopic sphincterotomies, 8 duodenal perforations occurred; additionally, 4 patients with duodenal perforation were referred from elsewhere for management. Six patients were managed initially with nonoperative treatment (group I), and six underwent exploratory surgery upon diagnosis or hospital transfer (group II). One patient in group I was operated on 4 days after diagnosis. Of the seven surgically treated patients, three had repair of the duodenal perforation and drainage of the abscess or phlegmon, but four had no gross inflammation or visible duodenal perforation requiring repair at exploration. The clinical features of abdominal pain with physical signs significantly correlated with operative findings of pus or phlegmon (p < 0.05). Improvement in symptoms within 24 hours is correlated with spontaneous recovery (p < 0.01). Neither the presence of retroperitoneal air nor contrast leak is predictive of the need for surgery, and neither correlated with the size of the perforation. It is concluded that duodenal perforation may be treated successfully without surgery when the symptoms are mild and improve rapidly with medical treatment, but surgery should be undertaken if pain and abdominal signs are prominent, if suppuration is suspected, or if symptoms do not improve after a brief period of nonoperative management.

Thiamin and vitamin B6 intakes and erythrocyte transketolase and aminotransferase activities in morbidly obese females before and after gastroplasty

To assess the need for postoperative vitamin supplements, intakes and nutritional status of thiamin (B1) and vitamin B6 were studied in 18 female gastroplasty patients who received a placebo or different levels of supplemental vitamins. Postoperative erythrocyte transketolase basal (BA) and thiamin pyrophosphate-stimulated (SA) activities and activity coefficients (AC) correlated significantly with B1 intake. Despite a decrease in apotransketolase, low thiamin intakes were associated with increased AC values during the first 3 months. With return to low B1 intakes following repletion during month 4, the AC values remained normal with low total activities. Both alanine (EALT) and aspartate (EAST) aminotransferase apoenzyme levels declined and AC values increased significantly during the first 3 months. Although the EALT-indices were more sensitive to changes in B6 intake than the EAST-indices, the EASTBA and SA correlated most consistently with the intake. Postoperative dietary intakes of both vitamins were inadequate for maintenance of normal activities of these erythrocyte enzymes. Although B1 intake of greater than or equal to 1.0 mg/day was adequate for maintenance of normal thiamin status in most subjects of this study, supplementation with greater than or equal to 1.5 mg/day is prudent even though it may not prevent the early postoperative loss of apotransketolase. Vitamin B6 intake at the current recommended dietary allowance (1.6 mg) was not adequate to maintain coenzyme saturation of the erythrocyte aminotransferases. Marginal intake of other nutrients may have affected the utilization of both thiamin and vitamin B6.

The phenomenal growth of laparoscopic cholecystectomy: a review

The widespread use of laparoscopic cholecystectomy 2 years after its introduction suggests that the procedure is a viable therapeutic option for uncomplicated gallstone disease. Early results seem to support a shorter convalescence for this procedure compared to open cholecystectomy. However, the actual complication rate is unknown. The outcome appears to be highly dependent on the skill and experience of the surgeon. How this operation is ranked against the classical cholecystectomy remains to be assessed.

Gastric perforation after endoscopic treatment of a Dieulafoy's lesion

Dieulafoy's vascular malformation is an underdiagnosed cause of massive, often recurrent upper gastrointestinal hemorrhage. Attempted endoscopic treatment of Dieulafoy's lesion has been recommended prior to surgery in many instances, but may occasionally be employed as primary therapy in patients that are not considered good "operative risks." Although generally considered safe and effective therapy for nonvariceal hemorrhage, combination therapy by injection and thermocoagulation techniques may result in perforation. We present a patient with a Dieulafoy's lesion of the stomach that illustrates both the efficacy and risks of combination endoscopic therapy for nonvariceal gastrointestinal hemorrhage.

Retrograde dilation of esophageal strictures with balloon dilators

Balloon dilators may be safely applied for retrograde dilation of esophageal strictures without the use of fluoroscopy or a pressure-gauge attachment. The turgidity of the dilating balloon is preferred to that of other materials such as polyvinyl, rubber, or metal. The technique enables endoscopic monitoring and can be adapted for strictures elsewhere in the gastrointestinal tract.

Giant cerebral aneurysm repair. Incorporating cardiopulmonary bypass and neurosurgery

Since our initial experience on April 28, 1989, a total of nine patients have received treatment for giant cerebral aneurysm using cardiopulmonary bypass with deep hypothermia and circulatory arrest. The following data summarize our findings associated with these patients. The average patient's age was 46 years (range: 16 to 59 years of age). Seven patients were female, two were male. The procedure required approximately eight hours to complete with an average cardiopulmonary bypass time of 104 minutes (range: 60 to 140 minutes). Circulatory arrest time averaged 26 minutes (range, 12 to 45 minutes) with an average of 30 minutes (range: 10 to 62 minutes) required to cool the patient to below 18 degrees C (64 degrees F). An average of 54 minutes (range: 28 to 81 minutes) was required to warm the patient to a bladder temperature of 36 degrees C (96.8 degrees F). During the cooling period, five patients went into asystole spontaneously, four patients required bolus of 20 mEq of potassium chloride, and upon rewarming, spontaneous defibrillation occurred in six patients. Three patients were defibrillated without difficulty with external shock. The average number of blood products administered in each of the nine patients was 3.6 units of packed red blood cells, 3 units of fresh frozen plasma, and 6.5 units of platelets. Six patients recovered postoperatively without complication, and the recovery of three patients was affected by the complex anatomical location of the giant aneurysm. Cardiopulmonary bypass with deep hypothermia and circulatory arrest offers an alternative approach to the treatment of giant cerebral aneurysms considered inoperable by conventional techniques. The effectiveness of each procedure depends on the collaborative efforts of every member of the perioperative nursing team, the neurosurgical team, the cardiac surgical team, the neuroanesthesiology team, and the perfusionists. Careful planning and anticipation at every stage of the surgery can reduce surgical time, cardiopulmonary bypass time, and most importantly, circulatory arrest time.

Effect of Wound Closure Technique on Wound Infection in the Morbidly Obese: results of a randomized trial

The effect of suture obliteration of the subcutaneous dead space in morbidly obese abdominal wounds was studied in a randomized trial, comparing a pre-fascial retention suture technique (utilized for approximated of the thick panniculus) to controls where the skin was simply closed with staples. The wound infection rates were similar (11.8% for the sutured group versus 12.3% for controls, p 0.4), as were the total wound complication rates (26.5% for sutured group versus 21.9% for controls, p 0.4). Ultrasound study of the wounds closed without suturing the panniculus demonstrated no dead spaces. We conclude that no advantage is to be gained by suturing the subcataneous fat, however thick. The finding is of general application in wound closures involving thick layers of fat.