Consensus conference statement on fluorescence-guided surgery (FGS) ESSO course on fluorescence-guided surgery

BACKGROUND

Fluorescence-guided surgery (FGS) has emerged as an innovative technique with promising applications in various surgical specialties. However, clinical implementation is hampered by limited availability of evidence-based reference work supporting the translation towards standard-of-care use in surgical practice. Therefore, we developed a consensus statement on current applications of FGS.

METHODS

During an international FGS course, participants anonymously voted on 36 statements. Consensus was defined as agreement ≥70% with participation grade of ≥80%. All participants of the questionnaire were stratified for user and handling experience within five domains of applicability (lymphatics & lymph node imaging; tissue perfusion; biliary anatomy and urinary tracts; tumor imaging in colorectal, HPB, and endocrine surgery, and quantification and (tumor-) targeted imaging). Results were pooled to determine consensus for each statement within the respective sections based on the degree of agreement.

RESULTS

In total 43/52 (81%) course participants were eligible as voting members for consensus, comprising the expert panel (n = 12) and trained users (n = 31). Consensus was achieved in 17 out of 36 (45%) statements with highest level of agreement for application of FGS in tissue perfusion and biliary/urinary tract visualization (71% and 67%, respectively) and lowest within the tumor imaging section (0%).

CONCLUSIONS

FGS is currently established for tissue perfusion and vital structure imaging. Lymphatics & lymph node imaging in breast cancer and melanoma are evolving, and tumor tissue imaging holds promise in early-phase trials. Quantification and (tumor-)targeted imaging are advancing toward clinical validation. Additional research is needed for tumor imaging due to a lack of consensus.

The first international Delphi consensus statement on Laparoscopic Gastrointestinal surgery

BACKGROUND

Laparoscopic surgery has almost replaced open surgery in many areas of Gastro-Intestinal (GI) surgery. There is currently no published expert consensus statement on the principles of laparoscopic GI surgery. This may have affected the training of new surgeons. This exercise aimed to achieve an expert consensus on important principles of laparoscopic GI surgery.

METHODS

A committee of 38 international experts in laparoscopic GI surgery proposed and voted on 149 statements in two rounds following a strict modified Delphi protocol.

RESULTS

A consensus was achieved on 133 statements after two rounds of voting. All experts agreed on tailoring the first port site to the patient, whereas 84.2% advised avoiding the umbilical area for pneumoperitoneum in patients who had a prior midline laparotomy. Moreover, 86.8% agreed on closing all 15 mm ports irrespective of the patient's body mass index. There was a 100% consensus on using cartridges of appropriate height for stapling, checking the doughnuts after using circular staplers, and keeping the vibrating blade of the ultrasonic energy device in view and away from vascular structures. An 84.2% advised avoiding drain insertion through a ≥10 mm port site as it increases the risk of port-site hernia. There was 94.7% consensus on adding laparoscopic retrieval bags to the operating count and ensuring any surgical specimen left inside for later removal is added to the operating count.

CONCLUSION

Thirty-eight experts achieved a consensus on 133 statements concerning various aspects of laparoscopic GI Surgery. Increased awareness of these could facilitate training and improve patient outcomes.

Prevalence, diagnosis, and surgical management of complex ileocolic-duodenal fistulas in Crohn's disease

BACKGROUND

The aim of the present study was to review the prevalence and surgical management of patients with Crohn's disease (CD) complicated by ileocolic-duodenal fistulas (ICDF).

METHODS

We performed a retrospective chart review of CD patients who underwent surgical takedown and repair of ICDF during January 2011-December 2021 at two inflammatory bowel disease referral centers.

RESULTS

We identified 17 patients with ICDF (1.3%) out of 1283 CD patients who underwent abdominal surgery. Median age was 42 (20-71) years, 13 patients were male (76%) and median body mass index was 22.7 (18.4-30.3) kg/m². Four patients (24%) were diagnosed preoperatively and only 2 (12%) were operated on for ICDF-related symptoms. The most common procedure was ileocolic resection (13 patients, 76%) including 4 repeat ileocolic resections (24%). The duodenal defect was primarily repaired in all patients with no re-fistulization or duodenal stenosis, regardless of the repair technique. A laparoscopic approach was attempted in the majority of patients (14 patients, 82%); however, only 5 (30%) were laparoscopically completed. The overall postoperative complication rate was 65% including major complications in 3 patients (18%) and 2 patients (12%) who required surgical re-intervention for abdominal wall dehiscence and postoperative bleeding. Preoperative nutritional optimization was performed in 9 patients (53%) due to malnutrition. These patients had significantly less intra-operative blood loss (485 vs 183 ml, p = 0.05), and a significantly reduced length of stay (18 vs 8 days, p = 0.05).

CONCLUSION

ICDF is a rare manifestation of CD which may go unrecognized despite the implementation of a comprehensive preoperative evaluation. Although laparoscopic management of ICDF may be technically feasible, it is associated with a high conversion rate. Preoperative nutritional optimization may be beneficial in improving surgical outcomes in this select group of patients.

Changing trends in bariatric surgery

BACKGROUND AND AIMS

Bariatric surgery is considered the only long-lasting treatment for morbid obesity. Techniques and procedures have changed dramatically. We report on some of the major changes in the field.

MATERIALS AND METHODS

We reviewed some of the major changes in trends in bariatric surgery based on some landmark paper published in the literature.

RESULTS

We identified three major phases in the evolution of bariatric surgery. The pioneer phase was mostly characterized by discovery of weight loss procedures serendipitously from procedures done for other purposes. The second phase can be identified with the advent of laparoscopic techniques. This is considered the phase of greatest expansion of bariatric surgery. The metabolic phase derives from the improved understanding of the mechanisms of actions of the bariatric operations at the hormonal and molecular level.

CONCLUSIONS

Bariatric surgery has changed significantly over the years. The safety of the laparoscopic approach, along with the better understanding of the metabolic changes obtained postoperatively, has led to a more individualized approach and also an attempt to expand the indications for these procedures.

Varieties of Pathological Self-mutilation

Pathological self-mutilation appears as a non-specific symptom as well as a specific syndrome. Since psychotic persons may commit horrifying acts, such as enucleation of an eye or amputation of a body part, identification of high risk patients is crucial. Stereotypical self-mutilation, such as head banging and biting off of fingertips, is associated with mental retardation and with the syndromes of Lesch-Nyhan, deLange, and Tourette. This type of self-mutilation is the focus of biological research or endorphins and on dopamine receptors. Skin cutting and burning, the most common type of self-mutilation, is often associated with personality disorders, post-traumatic stress disorder, and multiple personality disorder. When cutting and burning become established as responses to disturbing psychological symptoms on environmental events, a specific Axis I impulse disorder known as Repetitive Self Mutilation may be diagnosed. Patients with this newly identified syndrome may alternate their direct acts of self-mutilation with eating disorders and episodic alcoholism.

Pathological gambling: A review of the literature (prepared for the American Psychiatric Association task force on DSM-IV committee on disorders of impulse control not elsewhere classified)

This is a review of the literature on pathological gambling prepared for the work group on disorders of impulse control, not elsewhere classified of the American Psychiatric Association. It introduces the new DSM-IV criteria as well as outlines the phases of the career of the pathological gambler. Research discussed includes that on pathological gambling and psychiatric disorders, substance abuse, family issues, children, finances, and crime. Psychoanalytic, personality, behavioral, sociological, psychologically based addiction theories, and physiological research are also summarized. Finally, treatment outcome studies are outlined.

Malnutrition in morbidly obese patients: fact or fiction?

Reports of nutritional deficiencies after Bariatric surgery have lead investigators to inquire about the preoperative nutritional status of morbidly obese patients. Interestingly, numerous reports demonstrated a pattern of low levels of various micronutrients among overweight and obese patients, even in comparison with normal weight population. In this article we reviewed the literature for micronutrient deficiencies in obese patients prior to weight reduction surgery.

Indications for sleeve gastrectomy as a primary procedure for weight loss in the morbidly obese

BACKGROUND

Single-stage laparoscopic sleeve gastrectomy (LSG) may represent an additional surgical option for morbid obesity.

METHODS

We performed a retrospective review of a prospectively maintained database of LSG performed from November 2004 to April 2007 as a one-stage primary restrictive procedure.

RESULTS

One hundred forty-eight LSGs were performed as primary procedures for weight loss. The mean patient age was 42 years (range, 13-79), mean body mass index of 43.4 kg/m(2) (range, 35-75), mean operative time of 60 min (range, 58-190), and mean blood loss of 60 ml (range, 0-300). One hundred forty-seven procedures (99.3%) were completed laparoscopically, with a mean hospital stay of 2.7 days (range, 2-25). A 2.7% major complication rate was observed with four events in three patients and no deaths. Four patients required readmission; mild dehydration in two, choledocholithiasis in one, and a gastric sleeve stricture in one.

CONCLUSION

Laparoscopic SG is a safe one-stage restrictive technique as a primary procedure for weight loss in the morbidly obese with an acceptable operative time, intraoperative blood loss, and perioperative complication rate.

Compression anastomosis for Roux-en-Y gastric bypass: observations in a large animal model

BACKGROUND

In the morbidly obese, laparoscopic Roux-en-Y gastric bypass (RYGB) effectively achieves weight loss with the resolution of co-morbidities. The goal is to create a small-volume gastric pouch with a narrow gastrojejunal anastomosis (GJA). The procedure is associated with a GJA stricture rate of approximately 3%. The use of a compression anastomotic device to create a sutureless gastrointestinal anastomosis, replacing sutures or staples, might reduce tissue trauma and improve the GJA patency rate. A temperature-dependent, memory-shape, Nitinol Compression Anastomosis Clip (CAC) has been successfully used in intestinal anastomoses. Compression of the entrapped bowel leads to necrosis, with device expulsion after 7-10 days.

METHODS

We designed a pilot animal model study of open RYGB to examine the clip's safety in the performance of upper gastrointestinal anastomoses. Six 40-kg female pigs underwent RYGB. Group 1 (n = 3) underwent GJA with the CAC and a stapled jejunojejunal anastomosis (JJA). Group 2 (n = 3) underwent GJA and JJA with the CAC. One pig from each group was euthanized at 1, 4, and 8 weeks postoperatively.

RESULTS

Two pigs, one from each group, developed gastroparesis. At autopsy, all anastomoses were patent; the mean GJA diameter with the CAC was 1.6 cm (range 0.6-3), the mean JJA diameter with the stapler was 3.8 cm (range 35-40), and the mean JJA diameter with the CAC was 3 cm (range 3-3.2). Anastomotic burst pressures were similar between the stapled and CAC anastomoses. The device was passed per rectum by postoperative day 9 (range 8-12). Histologic examination of the CAC anastomoses demonstrated a complete mucosal lining with no evidence of stricture formation at 2 months.

CONCLUSION

The results of this small animal study have demonstrated the safety of sutureless compression anastomoses in an animal model of open RYGB.

Surgical management of gastro-gastric fistula after divided laparoscopic Roux-en-Y gastric bypass for morbid obesity

BACKGROUND

Gastro-gastric fistula (GGF) formation is uncommon after divided laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity. Optimal surgical management remains controversial.

METHODS

A retrospective review was performed of a prospectively maintained database of patients undergoing LRYGB from January 2001 to October 2006.

RESULTS

Of 1,763 primary procedures, 27 patients (1.5%) developed a GGF and 10 (37%) resolved with medical management, whereas 17 (63%) required surgical intervention. An additional seven patients requiring surgical intervention for GGF after RYGB were referred from another institution. Indications for surgery included weight regain, recurrent, or non-healing gastrojejunal anastomotic (GJA) ulceration with persistent abdominal pain and/or hemorrhage, and/or recurrent GJA stricture. Remnant gastrectomy with GGF excision or exclusion was performed in 23 patients (96%) with an average in-hospital stay of 7.5 days (range, 3-27). Morbidity in six patients (25%) was caused by pneumonia, n=2; wound infection, n=2; staple-line bleed, n=1; and subcapsular splenic hematoma, n=1. There were no mortalities. Complete resolution of symptoms and associated ulceration was seen in the majority of patients.

CONCLUSION

Although uncommon, GGF formation can complicate divided LRYGB. Laparoscopic remnant gastrectomy with fistula excision or exclusion can be used to effectively manage symptomatic patients who fail to respond to conservative measures.

Direct visual insertion of primary trocar and avoidance of fascial closure with laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (RYGBP) has been used increasingly more often in the past 10 years. The authors summarize their experience and safety/complications data based on 849 laparoscopic RYGBP procedures. They also evaluate the use of the Endopath trocar in terms of trocar-site hernias, bowel obstruction, and elimination of time-consuming fascial closure.

METHODS

From July 2000 to December 2003, 849 laparoscopic RYGBP procedures were performed using a bladeless, 12-mm, visual entry trocar. The patients' average body mass index (BMI) was 53.2 kg/m2. The trocar ports (n = 3,744) were not closed. Perioperative and postoperative assessments were performed.

RESULTS

In this study, 74% of the patients were retained for follow-up evaluation (mean, 10 months). Among these patients, no intraoperative bowel or vascular injuries, no mortality, and two trocar-site hernias (0.2%) were found. At 1 year, the mean excess weight loss was 73.4%.

CONCLUSIONS

The Endopath trocar system shows a trend toward reducing trocar-site hernias, decreasing bowel obstruction, and eliminating the need for time-consuming fascial closure, although further studies are needed to confirm these findings.

Is gastroscopy still a valid diagnostic tool in detecting gastric MALT lymphomas? A dilemma beyond the eye. Mucosa-associated lymphoid tissue

BACKGROUND

Primary gastric lymphomas are distinct entities with an indolent clinical course and biologic behavior. They account for 2-8% of all gastric malignancies. We conducted this study to evaluate the role of gastroscopy as the principal diagnostic method in detecting gastric MALT lymphomas.

METHODS

Sixty-three consecutive patients with gastric MALT lymphomas, who were evaluated and treated at our institution between January 1978 and December 1997, are retrospectively reviewed. There were 36 males and 27 females, with a mean age of 53 years (range 20-80 years). All patients underwent the standard diagnostic evaluation, including gastroscopy and biopsy. Patients were staged according to revised Musshof modification of the Ann Arbor classification system, whereas histological evaluation was made according to the Isaacson classification system for gastric MALT lymphomas.

RESULTS

According to endoscopic findings, the antrum harbored the neoplasm in 31 patients (49%), the body in 38% (24 patients), and the fundus in 4% (3 patients), whereas in 5 patients (8%) the neoplasm occupied the entire stomach. The macroscopic appearance was not in most cases pathognomonic of the disease. Three macroscopic patterns were recognized at endoscopy: (a) the ulcerative in 51% (32 patients), (b) the polypoid in 33% (21 patients) and (c) the diffuse infiltrative in 16% (10 patients). The neoplasm was characterized as a benign disease in 24 patients (38%), with malignancy being suspected in 62% (39 patients). Endoscopy displayed a sensitivity of 61% in detecting malignancy; however, the sensitivity dropped to 27% when endoscopic diagnosis of non-Hodgkin's lymphoma was hypothesized.

CONCLUSIONS

Although the impact of gastroscopy as a diagnostic tool in the patients of our study was of limited value, due to the nonspecific gross pattern of gastric MALT lymphomas, it should be maintained in the diagnostic intervention of the upper GI tract pathologies.

A simple technique for decompression of distended gallbladder during laparoscopic cholecystectomy

During laparoscopic cholecystectomy, distended gallbladder can create exposure difficulties, that precludes adequate visualization, thus rendering laparoscopic dissection impossible and even unsafe. To overcome this problems, we devised a simple technique for the decompression of distended gallbladders.

Laparoscopic resection of ectopic pancreas in the gastric antrum: case report and literature review

We report a case of ectopic pancreas tissue in the gastric wall that was removed using a minimally invasive approach. The patient was a 46-year-old obese woman who presented with fatigue, weakness, abdominal discomfort, and guaiac-positive stools. Laboratory analysis showed iron deficiency anemia. Preoperative endoscopy revealed a submucosal lesion in the gastric antrum. Intraoperative upper endoscopy clearly located the lesion at the antrum. The lesion was marked with India ink, allowing it to be identified easily at laparoscopy. A laparoscopic wedge resection of the gastric antrum was performed. The patient had an uneventful recovery. We believe that this is a valid treatment option for this benign condition.

Laparoscopic surgery of the liver and biliary tract

Laparoscopic treatment of liver and biliary tract disease is growing in popularity but requires extensive experience. Among the lesions now managed with minimally invasive methods are simple cysts, polycystic liver disease, hydatid cysts, biliary stones, and benign solid tumors. Patient selection, surgical techniques, and outcomes are described.

Laparoscopic cholecystectomy performed under regional anesthesia in patients with chronic obstructive pulmonary disease

BACKGROUND

Laparoscopic cholecystectomy has been successfully performed using epidural anesthesia. We evaluated our experience with this surgical approach in high-risk patients.

METHODS

We present the results of 29 patients with gallstones who, between 1998 and 1999, underwent laparoscopic cholecystectomy with epidural anesthesia. All but 1 patient had chronic obstructive pulmonary disease.

RESULTS

All 29 surgeries were successfully completed via laparoscopy and with the patients under epidural anesthesia. No patient required endotracheal intubation during surgery or pain medication afterward. Postoperatively, 1 patient developed a wound infection and 3 patients developed urinary retention. At last follow-up (12 months postop), all patients were in good health.

CONCLUSION

In this series, laparoscopic cholecystectomy was feasible under epidural anesthesia and it eliminated the need for postoperative analgesia. We believe that this approach should be considered for patients who require biliary surgery but who are not good candidates for general anesthesia due to cardiorespiratory problems.

Bedside laparoscopy in the ICU: report of four cases

BACKGROUND

Patients in the intensive care unit (ICU) may suffer from life-threatening abdominal pathologies, which may necessitate a surgical intervention. Diagnosis may be difficult, as deep sedation and analgesia often mask symptoms, and physical examination is unreliable. Imaging studies are not accurate enough, and exploratory laparotomy carries significant morbidity and mortality rates in this patient population. The unstable patient is difficult to mobilize to the imaging department or to the operating room. Bedside laparoscopy may overcome these difficulties.

PATIENTS AND METHODS

We describe our initial experience with the use of bedside laparoscopy in critical patients with suspected abdominal pathology. The procedure was performed in four patients over a 4-month period and completed in all four.

RESULTS

The findings were: turbid fluid consistent with viscus perforation in a patient with unexplained sepsis after cardiac surgery, sterile hemorrhagic fluid in a patient with malignancy and thrombotic thrombocytopenia purpura, a retroperitoneal mass from which biopsies were taken in a patient with sudden respiratory failure, and abdominal abscess in a patient after bowel resection for mesenteric embolism. None of these patients had a laparotomy after the laparoscopy. Patients 1 and 4 died a few hours after the procedure from sepsis, and patients 2 and 3 died several days later.

CONCLUSION

Bedside laparoscopy in the ICU is feasible, informative, and accurate. It has a role in diagnosing abdominal pathologies and planning further treatment. It may avert a nontherapeutic laparotomy. Unfortunately, the prognosis in these patients is poor. Earlier use of this diagnostic modality may improve patient outcome.

The additive effect of neurotransmitter genes in pathological gambling

As access to gambling increases there is a corresponding increase in the frequency of addiction to gambling, known as pathological gambling. Studies have shown that a number of different neurotransmitters are affected in pathological gamblers and that genetic factors play a role. Polymorphisms at 31 different genes involved in dopamine, serotonin, norepinephrine, GABA and neurotransmitters were genotyped in 139 pathological gamblers and 139 age, race, and sex-matched controls. Multivariate regression analysis was used with the presence or absence of pathological gambling as the dependent variable, and the 31 coded genes as the independent variables. Fifteen genes were included in the regression equation. The most significant were the DRD2, DRD4, DAT1, TPH, ADRA2C, NMDA1, and PS1 genes. The r(2) or fraction of the variance was less than 0.02 for most genes. Dopamine, serotonin, and norepinephrine genes contributed approximately equally to the risk for pathological gambling. These results indicate that genes influencing a range of brain functions play an additive role as risk factors for pathological gambling. Multi-gene profiles in specific individuals may be of assistance in choosing the appropriate treatment.

[Laparoscopic splenectomy: new techniques and indications]

Over the recent years laparoscopic splenectomy has become the preferred approach for the treatment of many conditions requiring splenic removal. At first limited to small spleens and to benign hematologic disorders, this procedure is now used for a variety of indications. Enlarged spleens are possible to be removed laparoscopically, although this is still a demanding procedure. Two factors facilitated the technique and contributed to its wide acceptance: 1) Change in the technique originally used, by positioning the patient in right lateral decubitus, and approaching the spleen from a postero-lateral direction. 2) The development of new technologies to dissect and divide tissues and vessels, including the ultrasonic shears and the laparoscopic linear stapler. In this article we review the current indications for laparoscopic splenectomy, as well as the techniques to accomplish this procedure.

Laparoscopic transabdominal suspension sutures

A limited number of access ports used in laparoscopic surgery may impair the ability of the surgeon to achieve adequate retraction and exposure, or to stabilize "moving targets" while operating on nonfixed organs. Solutions such as adding more ports or using a hand-assisted technique have the disadvantages of being more invasive, possibly creating a cumbersome situation of multiple instruments in a limited working space. We describe a useful technique for retraction and stabilization with the use of temporary sutures that pass through the abdominal wall. Although not new, this technique is not widely known or used, and laparoscopic surgeons may find it useful for a variety of applications.

Laparoscopy for gastric tumors

A decade after the introduction of therapeutic laparoscopy, the use of laparoscopic gastric surgery is becoming accepted. While still evolving, currently available techniques and equipment are already sufficient for performing most ablative and reconstructive procedures. Despite feasibility, problems such as procedural complexity, long operative time, and high cost may negate the advantages of earlier and easier recovery. At present, these procedures are limited to highly trained laparoscopic surgeons, but they may become more prevalent among the next generations of surgeons, due to constant changes in surgical training and education. The question of laparoscopic curative treatment of malignant gastric tumors has not been answered. Diagnostic laparoscopy for staging is effective and widely practiced, but gastric resections are mostly limited to benign lesions. Currently, early malignant lesions are laparoscopically treated mainly in Japan, whereas more advanced lesions are laparoscopically resected in only a few centers around the world. Full endorsement of these procedures, by randomized controlled trials, although desirable, is unlikely soon, due to the technical complexity and low prevalence of these pathologies in western countries.

Closure of laparoscopic trocar site wounds with cyanoacrylate tissue glue: a simple technical solution

Cyanoacrylate-based tissue glue has been widely used for many years around the world, and was recently approved for use in the United States, mainly for skin cuts and lacerations. Other applications were described, in different surgical situations. Although ideal for small, clean incisions, its use in laparoscopic surgery is currently limited. Over a year period, 100 patients with more 250 trocar site wounds had their wounds glued using histoacryl. Infection rate was extremely low (one case), and partial dehiscence of the wound happened in two patients, where wound edge approximation was not optimal. Cosmetic results were excellent and patient satisfaction was high, as no sutures had to be removed. Glue application is easy and quick, with no risk of needle sticks, and it is a viable option for laparoscopic wound closure.

[Laparoscopic surgical of the liver and bile ducts]

The liver, gallbladder, bile ducts, and spleen are the least mobile organs in the upper abdomen. Thus, the laparoscopic approach is commonly used to manage a variety of pathologies related to these organs [5, 10, 60, 78]. Compared with conventional "open" surgery, minimally invasive surgery reduces postoperative pain and discomfort, lowers morbidity rates, promotes early mobilization, decreases recovery time and length of stay, and improves cosmetic results. In addition, the surgical results of laparoscopic surgery are as good as or better than those of conventional surgery [5]. This paper reviews the advances in laparoscopic surgery, and describes current patient selection practices and laparoscopic surgical techniques for benign liver cysts and tumors and biliary tract diseases.

Adverse hemodynamic effects of intraabdominal pressure- is it all in the head?

BACKGROUND

Elevated intraabdominal pressure (IAP) is observed in various clinical situations, the most common of which are severe abdominal trauma and laparoscopic surgery. Extreme pressures may lead to Abdominal Compartment Syndrome (ACS), but even with lower pressures adverse effects are apparent. The cardiovascular system, the respiratory system, the kidneys and the visceral circulation are all affected, but the exact physiological mechanism is not well defined.

AIMS

To discuss possible mechanisms which explain the observed hemodynamic effects of increased IAP.

METHODS

Large animal model observations and review of current literature regarding the correlation between IAP and intracranial pressure (ICP).

RESULTS

It was shown that the elevation of abdominal pressure leads to elevation of ICP. Transfer of pressure through the central venous system or by the cerebrospinal fluid (CSF) has been proposed as an explanation. In response to elevated ICP, various stress hormones are secreted by the central nervous system, including vasoconstricting agents such as vasopressin and catecholamines. It is hypothesized that the central nervous system is the link between the increased abdominal pressure and its adverse hemodynamic effects. This may be a protective mechanism of the brain, aimed to increase the mean arterial pressure when the ICP is elevated, in order to preserve the cerebral perfusion pressure.

CONCLUSION

ICP is elevated in response to IAP elevation, and may be responsible for its adverse hemodynamic effects. Antagonists to vasopressin may have a role in the treatment of this condition.

A review of technical and clinical aspects of biliary laser lithotripsy

OBJECTIVE

This paper reviews the current use of laser techniques for the treatment of biliary stones.

BACKGROUND DATA

Biliary stones may pose a special problem when access to them is limited, when previous attempts of removal have failed, or when a less invasive option than surgery is needed. The availability of various laser sources and the adaptation of the technology for safe use in the biliary system make the use of laser energy for stone fragmentation possible.

METHODS

Current literature is reviewed concerning the use of laser for biliary lithotripsy, including experimental data and experience with human series. Technology, indications, alternatives, and cumulative world experience are discussed.

CONCLUSIONS

Recent technical advances have made the use of laser energy for fragmentation of biliary calculi possible. It is a valid option for treatment of "difficult" stones, when other methods have failed or as a primary treatment in certain situations. The technical complexity and the high cost limit its use for specialized centers.

Mechanisms of systemic hypertension during acute elevation of intraabdominal pressure

INTRODUCTION

In previous studies we described mechanisms by which acute elevation of the intraabdominal pressure (IAP) induces intracranial hypertension (ICHTN). Here we sought to define the role of ICHTN in mediating systemic hypertension (HTN) during CO(2) pneumoperitoneum (PNP).

METHODS

Six large animals (swine) were hyperventilated to buffer hypercarbia. Intracranial pressure (ICP) was monitored with a Camino intraparenchymal ICP monitoring system. A Foley catheter was introduced intracranially via a separate burr hole. At phase 1, changes in ICP, central venous pressure (CVP), and mean arterial pressure (MAP) were recorded during periods of CO(2) PNP at IAP levels of 15, 20, 25, and 30 mm Hg. At phase 2, ICHTN was produced directly by inflating the intracranial balloon to the same ICP levels that had been measured in phase 1 for each degree of IAP. CVP and MAP were recorded. Repeated measures analysis of variance was applied.

RESULTS

At phase 1, the mean DeltaCVP, DeltaICP, and DeltaMAP increased relative to the degree of IAP (P = 0.0001, 0.0004, and 0.024, respectively). At phase 2, the increments in DeltaMAP were significant (P = 0.024) and in the same direction and amplitude as at phase 1.

CONCLUSIONS

In this study, increasing the IAP with CO(2) PNP with a consequent increase of ICP and direct manipulation of the ICP produced a comparable systemic HTN. We believe that this further supports our hypothesis: Elevated IAP produces an immediate increase in the CVP, which impairs venous drainage from the central nervous system (CNS), increases the ICP, and initiates a CNS-mediated response and systemic HTN.

Causes of arterial hypertension and splachnic ischemia during acute elevations in intra-abdominal pressure with CO2 pneumoperitoneum: a complex central nervous system mediated response

The application of laparoscopic technique has gained popularity in the past decade. Numerous studies have qualified and quantified the systemic impact of acutely elevated intra-abdominal pressure during pneumoperitoneum at time of laparoscopy. The major hemodynamic effects are increased central venous pressure, increased systemic vascular resistance and systemic hypertension. Reductions in splanchnic and renal blood flow have also been documented, but the clinical significance of these observations is not clear and required further investigation. In our previous work we demonstrated intracranial hypertension secondary to acute elevation in intra-abdominal pressure and described the pathophysiology. Elevated intra-abdominal pressure during induced pneumoperitomeum can serve as a basic model for other disease processes which are characterized by acute or chronic abdominal hypertension. Here we review the current literature and describe our own experience to suggest a unifying model, with emphasis on the key role of the central nervous system in mediating the systemic response to increased intra-abdominal pressure.

Studies of the 48 bp repeat polymorphism of the DRD4 gene in impulsive, compulsive, addictive behaviors: Tourette syndrome, ADHD, pathological gambling, and substance abuse

Prior studies have reported an association between the presence of the 7 repeat allele of the 48 bp repeat polymorphism of the third cytoplasmic loop of the dopamine D4 receptor gene (DRD4) and novelty seeking behaviors, attention deficit hyperactivity disorder (ADHD), Tourette syndrome (TS), pathological gambling, and substance abuse. However, other studies have failed to replicate some of these observations. To determine whether we could replicate these associations we genotyped 737 individuals from four different groups of control subjects, and 707 index subjects from four different groups of impulsive, compulsive addictive behaviors including substance abuse, pathological gambling, TS, and ADHD. Chi-square analysis of those carrying the 7 allele versus non-7 allele carriers was not significant for any of the groups using a Bonferroni corrected alpha of.0125. However, chi-square analysis of those carrying any 5 to 8 allele versus noncarriers was significant for pathological gambling (p <.0001), ADHD (p </=.01) and the total index group (p </=.0004). When the comparison included all 7 alleles the results were significant for gamblers (p <.0001), TS (p </=.003), ADHD (p </=.003), and the total group (p </=.0002). There was a significant increase in the frequency of heterozygosity versus homozygosity for all alleles for pathological gamblers (p </=.0031) and the total index group (p </=.0015), suggesting that heterosis played a role. In the substance abuse subjects a quantitative summary variable for the severity of drug dependence, based on the Addiction Severity Index, showed that the scores varied by increasing severity across the following genotypes: 44 </= heterozygotes </= 77 </= 22. Studies of other quantitative traits indicated an important role for the 2 allele and the 22, 24, and 27 genotypes. All studies indicated that the role of the DRD4 gene in impulsive, compulsive, addictive behaviors is more complex than a sole focus on the 7 versus non-7 alleles.

Options and strategies for the management of choledocholithiasis

The introduction of laparoscopic techniques for the management of biliary stone disease has expanded the therapeutic choices for surgeons confronted with choledocholithiasis. As new strategies emerge, the treatment of cholelithiasis and choledocholithiasis remains controversial. This paper discusses the options available for the treatment of common bile duct stones. Diagnostic and therapeutic algorithms are proposed. The treatment of these patients must be individualized, taking into consideration the condition of the patient, associated diseases, secondary complications of the gallstones, and the surgical expertise and resources of the institution.

Reasons for intracranial hypertension and hemodynamic instability during acute elevations of intra-abdominal pressure: observations in a large animal model

In previous studies we reported that an acute elevation in intra-abdominal pressure (IAP) is responsible for the elevation in intracranial pressure (ICP) and mean blood pressure (MBP). Thus far, the reasons for the increased ICP during an acute elevation in IAP and the combined effects of increased IAP and ICP on hemodynamics have not been reported. Five large animals (swine) were studied. Each animal served as its own control. A subarachnoid screw was placed for ICP monitoring. The jugular vein, femoral vein, and femoral artery were cannulated. ICP, MBP, central venous pressure above (CVPA) and below (CVPB) the diaphragm, and PaC02 were monitored after a pneumoperitoneum with C02 was established at 5, 15, and 30 mm Hg of IAP. Cavography was performed to evaluate the morphology of the inferior vena cava at different increments of IAP. Measurements were obtained in reverse Trendelenburg (group 1), supine (group 2), and Trendelenburg (group 3) positions. Multiple regression analysis was used to examine the effects of IAP and positioning in separate models with different blood pressures as dependent variables. Increased IAP significantly increased CVPA, CVPB, ICP, and MBP. There were no changes in cerebral perfusion pressure. The change in position (from group 1 to group 3) significantly increased CVPA and decreased the CVPB. Cavograms performed on animals in the supine position with increased IAP showed a narrowing of the IVC at the level of the diaphragm. Increases in IAP will increase ICP and MBP without altering the cerebral perfusion pressure. A mechanical effect mediated by compression of the inferior vena cava at the level of the diaphragm with increased central venous pressure and decreased drainage from the lumbar plexus and central nervous system is responsible for this effect.

Effects of hyperventilation and hypoventilation on PaCO2 and intracranial pressure during acute elevations of intraabdominal pressure with CO2 pneumoperitoneum: large animal observations

BACKGROUND

The side effects of acute elevations in intraabdominal pressure (IAP) are related to a multifactorial etiology. Previous studies have reported that acute elevations in IAP produce an immediate increase in intracranial pressure (ICP). This study was designed to analyze the reasons for increased ICP during acute elevations of IAP and to determine the combined effects of IAP and changes in ventilation indices on ICP and hemodynamic indices.

STUDY DESIGN

Five pigs were studied. A subarachnoid screw was placed for ICP monitoring. The jugular vein, femoral vein, and femoral artery were cannulated. Mean arterial pressure (MAP), central venous pressure (CVP), ICP, and arterial pressure of carbon dioxide (PaCO2) were monitored before and after carbon dioxide pneumoperitoneum was established at 0, 10, and 20 mmHg of IAP Effects of hyperventilation and hypoventilation were recorded and compared with baseline ventilation. Cavography was performed to evaluate the morphology of the inferior vena cava (IVC) at different levels of IAP. Multiple regression and Student's t-test were used to examine the effects of IAP and ventilation on dependent variables.

RESULTS

The IVC showed a progressive narrowing at the level of the diaphragm as IAP was increased. There was a simultaneous increase in CVP, MAP, and ICP. The mean changes in ICP with hypoventilation were significantly larger than with hyperventilation.

CONCLUSIONS

Acutely increased IAP displaces the diaphragm cranially, narrowing the IVC and increasing intrathoracic pressure. This increases CVP and increases ICP by venous stasis and increased pressure in the sagittal sinus with decreased resorption of cerebrospinal fluid. Hemodynamic changes are directly related to the rise in ICP. Hypoventilation and hypercarbia significantly increase ICP when compared with hyperventilation and hypocarbia. Hyperventilation does not significantly decrease ICP during acute elevations of IAP.

Intracranial pressure. Effects of pneumoperitoneum in a large-animal model

BACKGROUND

The effects of pneumoperitoneum on intracranial pressure (ICP) have received relatively little attention. This study was undertaken to investigate the changes in ICP occurring as a result of increased intraabdominal pressure (IAP) and positioning in animals with normal and elevated ICP.

METHOD

Five pigs (average weight 60 lb) were studied. A subarachnoid screw was placed for ICP monitoring. End tidal CO2 was monitored. Ventilation was performed to keep PCO2 between 30 and 50 mmHg. Measurements of arterial blood gases, mean arterial blood pressure, and ICP were recorded at four different levels of intraabdominal pressure (IAP 0, 8, 16, and 24 mmHg), both in the supine and Trendelenburg positions. A Foley catheter was introduced into the subarachnoid space to elevate the intracranial pressure, and the same measurements were performed.

RESULTS

There was a significant and linear increase in ICP with increased IAP and Trendelenburg position. The combination of increased IAP of 16 mmHg and Trendelenburg position increased ICP 150% over control levels.

CONCLUSIONS

Patient positioning and level of IAP should be taken into consideration when performing laparoscopy on patients with head trauma, cerebral aneurysms, and other conditions associated with increased ICP.

Studies of the potential role of the dopamine D1 receptor gene in addictive behaviors

Abnormalities in the dopaminergic reward pathways have frequently been implicated in substance abuse and addictive behaviors. Recent studies by Self and coworkers have suggested an important interaction between the dopamine D1 and D2 receptors in cocaine abuse. To test the hypothesis that the DRD1 gene might play a role in addictive behaviors we examined the alleles of the Dde I polymorphism in three independent groups of subjects with varying types of compulsive, addictive behaviors-Tourette syndrome probands, smokers and pathological gamblers. In all three groups there was a significant in the frequency of homozygosity for the DRD1 Dde I 1 or 2 alleles in subjects with addictive behaviors. The DRD1 11 or 22 genotype was present in 41.3% of 63 controls and 57.3% of 227 TS probands (P = 0.024). When 23 quantitative traits were examined by ANOVA those carrying the 11 genotype consistently had the highest scores. Based on these results, we examined the prevalence of the 11 genotype in controls, TS probands without a specific behavior, and TS probands with a specific behavior. There was a progressive, linear increase, significant at alpha < or = 0.005 for scores for gambling, alcohol use and compulsive shopping. Problems with three additional behaviors, drug use, compulsive eating and smoking were significant at alpha < or = 0.05. All six variables were related to addictive behaviors. In a totally separate group of controls and individuals attending a smoking cessation clinic, and smoking at least one pack per day, 39.3% of the controls versus 66.1% of the smokers carried the 11 or 22 genotype (P = 0.0002). In a third independent group of pathological gamblers, 55.8% carried the 11 or 22 genotype (P = 0.009 vs the combined controls). In the TS group and smokers there was a significant additive effect of the DRD1 and DRD2 genes. The results for both the DRD1 and DRD2 genes, which have opposing effects on cyclic AMP, were consistent with negative and positive heterosis, respectively. These results support a role for genetic variants of the DRD1 gene in some addictive behaviors, and an interaction of genetic variants at the DRD1 and DRD2 genes.

Techniques for intrasplenic hepatocyte transplantation in the large animal model

BACKGROUND

The preferred therapy for acute and chronic liver insufficiency and severe heritable disorders of liver metabolism is whole-organ transplantation. However, due to the shortage of organ donors and high cost, alternative therapeutic approaches have been proposed, including transplantation of normal allogeneic hepatocytes. Recently, it has been reported that many hepatocytes transplanted into the spleen migrated to the liver. We therefore carried out a series of large-animal experiments to reexamine the intrasplenic route and to develop a method for large-scale hepatocellular transplantation in pigs.

METHODS

Allogeneic porcine hepatocytes were transplanted using the following routes: (1) retrograde injection of cells via the splenic vein, (2) intraarterial injection of cells, (3) direct intrasplenic injection of cells after laparotomy, (4) percutaneous intrasplenic injection of cells under laparoscopic control, (5) laparoscopic intrasplenic injection of cells. The number of cells injected varied from 2 x 10(9) to 10 x 10(9) cells.

RESULTS

Of all the methods tested, only direct intrasplenic injection of 2 bln of cells was found to be compatible with survival. However, even with this "small" number of cells (2% original liver mass), there was a significant risk of spleen infarction, perisplenic adhesion formation, and portal vein thrombosis. The laparoscopic approach was found to be reliable, simple, and safe.

CONCLUSION

Even though the spleen is considered by many authors the optimal site for hepatocellular transplantation, transplantation of cells in a number needed to support the failing liver may be associated with significant complications, morbidity, and mortality.

Exon and intron variants in the human tryptophan 2,3-dioxygenase gene: potential association with Tourette syndrome, substance abuse and other disorders

Defects in serotonin metabolism, and abnormalities in both blood serotonin and tryptophan levels, have been reported in many psychiatric disorders. Tryptophan 2,3-dioxygenase (TDO2) is the rate limiting enzyme for the breakdown of tryptophan to N-formyl kenurenine. Functional variants of this gene could account for the observed simultaneous increases or decreases of both serotonin and tryptophan in various disorders. We have identified four different polymorphisms of the human TDO2 gene. Association studies show a significant association of one or more of these polymorphisms and Tourette syndrome (TS), attention deficit hyperactivity disorder (ADHD) and drug dependence. The intron 6G-->T variant was significantly associated with platelet serotonin levels. Only the association with TS was significant with a Bonferroni correction (p = 0.005). Our purpose here is not to claim these associations are proven, but rather to report preliminary results and show that easily testable polymorphisms are available. We hope to encourage additional research into the potential role the TDO2 gene in these and other psychiatric disorders.

A study of the dopamine D2 receptor gene in pathological gambling

Pathological gambling has been termed both the 'pure' and the 'hidden' addiction. 'Pure' because it is not associated with the intake of any addicting substance, and 'hidden' because it is an extension of a common, socially accepted behaviour. The Taq A1 variant of the human DRD2 gene has been associated with drug addiction, some forms of severe alcoholism, and other impulsive, addictive behaviours. We have sought to determine if there is a similar association with pathological gambling. A total of 222 non-Hispanic Caucasian pathological gamblers from multiple sites across the US participated in the study. Of these 171 donated a sample of blood, 127 filled out several questionnaires, and 102 did both. Of the 171 pathological gamblers 50.9% carried the D2A1 allele versus 25.9% of the 714 known non-Hispanic Caucasian controls screened to exclude drug and alcohol abuse, p < 0.00000001, odds ratio (OR) = 2.96. For the 102 gamblers who filled out the questionnaires, 63.8% of those in the upper half of the Pathological Gambling Score (more severe) carried the D2A1 allele (OR versus controls = 5.03), compared to 40.9% in the lower half (less severe). Of those who had no comorbid substance abuse, 44.1% carried the D2A1 allele, compared to 60.5% of those who had comorbid substance abuse. Forty-eight controls and 102 gamblers completed a shorter version of the Pathological Gambling Score. Of the 45 controls with a score of zero, 17.8% carried the D2A1 allele. Of the 99 gamblers with a score of 5 or more, 52.5% carried the D2A1 allele (chi 2 = 15.36, p = 0.00009). These results suggest that genetic variants at the DRD2 gene play a role in pathological gambling, and support the concept that variants of this gene are a risk factor for impulsive and addictive behaviours.

Complications of laparoscopic cholecystectomy in HIV and AIDS patients

We retrospectively evaluated the results of laparoscopic cholecystectomy in patients infected with the human immunodeficiency virus (HIV) with and without acquired immunodeficiency syndrome (AIDS). One thousand one hundred twenty-seven consecutive patients underwent laparoscopic cholecystectomy by our surgical group. Eighteen of these patients were known to be infected with the HIV virus; 6 were asymptomatic and 12 had AIDS. We reviewed the medical records of all HIV-positive individuals with regard to morbidity, mortality, and postoperative outcome following laparoscopic cholecystectomy. In the six HIV-patients without AIDS, five (83%) had improvement of symptoms postoperatively. There was one minor complication (17%). In contrast, only one of the 12 patients with AIDS had postoperative improvement of symptoms and eight (66%) had complications after surgery. There were four deaths (33%) within 30 days of surgery in this group. Only a small percentage of AIDS patients benefit from laparoscopic cholecystectomy. There is a significantly morbidity and mortality following this procedure in this group. Strategies to improve outcome are presented.

Bile duct stones in the laparoscopic era. Is preoperative sphincterotomy necessary?

OBJECTIVE

To evaluate treatments for common bile duct stones (CBDS).

DESIGN

Retrospective review of authors' case series.

SETTING

Large private metropolitan teaching hospital.

PATIENTS

All patients with CBDS (N = 145) from a series of 1231 patients who underwent laparoscopic cholecystectomy, 99% with intraoperative fluorocholangiography.

INTERVENTIONS

Treatments for CBDS included one or more of the following: laparoscopic transcystic duct exploration (n = 123), laparoscopic choledochotomy (n = 10), open choledochotomy (n = 7), preoperative endoscopic sphincterotomy (ES) (n = 9), intraoperative ES (n = 2), post-operative ES (n = 11), or observation (n = 10).

MAIN OUTCOME MEASURES

Success of various interventions for CBDS, morbidity and mortality, frequency of retained stones, operative time, and length of postoperative hospitalization.

RESULTS

Laparoscopic transcystic duct exploration was successful in 91% of attempts and resulted in the shortest postoperative stay (3.4 days), least morbidity (5%), and fewest retained stones (5%). Endoscopic sphincterotomy was successful in 56% of preoperative attempts, 50% of intraoperative attempts, and 91% of postoperative attempts. There were no reoperations and one death.

CONCLUSIONS

For patients requiring cholecystectomy, laparoscopic transcystic duct exploration is safe and effective, treats CBDS in one session, and if unsuccessful still allows for open choledochotomy or postoperative ES. Preoperative endoscopic retrograde cholangiography and ES should be reserved for patients with serious illness or possible malignant disease.

Laparoscopic trans-cystic-duct common-bile-duct exploration

One thousand seventy-one consecutive laparoscopic cholecystectomies were performed. Routine cholangiography was employed with a 99% success rate. One hundred thirty patients were found to have common duct stones (CBDS). In 48 (37%) patients they were unsuspected. One hundred eleven patients underwent attempted trans-cystic-duct extraction techniques (TCD-CBDE). One hundred three (93%) were successful. The following techniques were employed: 101--biliary endoscopy, 23--ampullary balloon dilation, 2--fluoroscopic basket retrieval. The average operative time was 136 min. The average postsurgical stay was 3.7 days. There were 19 (17%) complications--6 (5%) major. There were 4 retained stones (2 intentional) and 1 death. Patients over 65 years of age had more complications and patients with unsuspected CBDS under 65 years of age had the fewest. TCD-CBDE is a safe, effective way to extract common duct calculi. Endoscopy and basket stone retrieval was the primary technique employed.

Role of intraoperative cholangiography during endoscopic cholecystectomy

Six hundred sixty-nine German hospitals participated in a survey on the use of intraoperative cholangiography (IOC) in its relationship to common bile duct injuries. Of these, 174 surgical departments are presently practicing IOC, 30 routinely. Only 16 injuries to the bile duct occurred in the 6,328 patients who underwent surgery in those 30 units. Approximately 80% of these injuries were discovered during surgery because of IOC and were treated immediately. A significant difference was found between these rates and those reported by units that performed IOC selectively. Only 58% of bile duct injuries were discovered at the time of surgery in units performing selective cholangiography. In addition, it appears that IOC helps to avoid bile duct injuries; the 30 units that performed routine IOC were defined as "learners," as they had performed fewer LCs, and yet they had a significant lower bile duct injury rate than "experienced" centers that did not perform IOC routinely.

Diagnostic issues in self-mutilation

OBJECTIVE

Pathological self-mutilation--the deliberate alteration or destruction of body tissue without conscious suicidal intent--was examined both as a symptom of mental disorders and as a distinct syndrome.

METHODS

Data from more than 250 articles and books were reviewed, as well as data obtained by the authors from their extensive clinical experience in treating self-mutilating patients.

RESULTS AND CONCLUSIONS

The diverse behaviors that constitute pathological self-mutilation can be categorized into three basic types: major--infrequent acts that result in significant tissue damage, usually associated with psychoses and acute intoxications; stereotypic--fixed, rhythmic behavior seemingly devoid of symbolism, commonly associated with mental retardation; and superficial or moderate--behavior such as skin cutting, burning, and scratching associated with a variety of mental disorders. The authors propose that a syndrome of repetitive superficial or moderate self-mutilation should be regarded as an axis I impulse disorder. In most cases, the syndrome coexists with character pathology.

[Bile composition and antibiotic excretion. Observations with T-drainage]

Patients comparable in disease, therapy and serum bilirubin concentration were either treated with mezlocillin intravenously or not at all. The bile of each patient was collected either from a T-drainage or from a percutaneously placed drainage into the bile ducts. The concentrations of GGT and AP, which were liberated by destroyed liver cells, and of bilirubin and mezlocillin, which were secreted actively, were analysed. Those patients who had normal serum bilirubin concentrations had a significantly higher biliary bilirubin excretion than those with high serum bilirubin level. The maximum excretion was after 4 hours. While the biliary concentration of bilirubin decreased, the concentration of secreted mezlocillin increased. Due to destroyed liver cells those patients with pathologically elevated blood bilirubin levels had a 50-fold lower mezlocillin excretion than those with normal blood values.

The pathological gambler as criminal offender. Comments on evaluation and treatment

Over the past three decades, gambling has been the nation's fastest growing industry. Although there is now some leveling off, states are still turning to legalized gambling to address financial problems without having to raise taxes. In addition, there is new technology that produces more rapidly addicting games. States are accepting some responsibility and, as of this writing, 12 of them have funded some programs in public education, research, training, and treatment. Although there are only a half dozen inpatient programs and very few qualified counselors and therapists, we can anticipate the development of clinics, residential programs, halfway houses, and alternative sentencing programs. The National Council on Problem Gambling has developed guidelines for the certification of gambling counselors. In addition to the training of mental health professionals, workshops are needed for attorneys, judges, probation and parole officers, and prison administrators. Initially, the task of assessing and diagnosing the pathological gambler was left to a small number of experts. Starting with DSM-IV, there will be clear and reliable criteria available to the professional community. These criteria, which are the product of thorough testing, should easily discriminate the pathological gambler from other types of gamblers. Most of what we have learned about pathological gambling has come in the last 5 years. A major impetus for research has been the Journal of Gambling Studies, which began publication in 1985. A review of the nature and course of the disorder, including the studies of criminal behavior, leads one to conclude that the majority of pathological gamblers (at least 70% to 80%) commit offenses late in the disorder and that these offenses are strictly gambling related. This is a population which is essentially nonviolent and which turns to property crimes out of desperation over gambling losses and their sequelae. The minority (in one study 14%) of gamblers with antisocial personality disorder--the group for whom treatment would be least likely to be effective--can be recognized easily both by the pattern of offenses and by diagnostic criteria for antisocial personality. Once this group is excluded, treatment for the others, in combination with restitution, community service, and some form of monitoring, would seem beneficial both for the individual and for society. Once they have stopped gambling, pathological gamblers are frequently hard-working people, whose mathematical skills and intelligence, high energy, and need to excel make them extremely valuable at their jobs. The alternative, imprisonment, may very well reinforce the disorder.(ABSTRACT TRUNCATED AT 400 WORDS)

Transparent screens

There is a kind of transitional phenomenon found among certain borderline patients which is quite distinct from Winnicott's transitional object. These are patients who are preoccupied with maintaining proper physical distance from their objects, in order to regulate anxieties about isolation on the one hand, and identity-annihilating closeness on the other. Since they believe the activity of looking to be intrusive and devouring, hence dangerous, transparent screens are interposed between self and other, and serve as protective barriers. These screens function intrapsychically as well, to split off or hide those aspects of the self felt to be unacceptable. The analyst may witness the failure of the screen in several ways: it may create too great a distance, isolating the individual and keeping him from life; it may become contaminated by projections and turn into a persecutor, or trap the individual, a state of intolerable claustrophobia; most dramatically, it may suddenly shatter. The latter is associated with psychosis and death, and its appearance may be a harbinger of suicide.