A new method of intestinal salvage for severe small bowel ischemia

The morbidity and mortality in short bowel syndrome are directly related to the length of the remaining small bowel and to the duration of total parenteral nutrition. We describe the successful salvage of an infant with extensive small bowel infarction for whom a new technique was used to preserve all viable mucosal surfaces. The infant, with gastroschisis, was found to have a tight volvulus of the extruded bowel and extensive small bowel ischemia at the time of delivery. Forty-eight hours after reduction of the volvulus and abdominal decompression, a second-look laparotomy was performed. Although only the terminal 13 cm of ileum was completely viable, 25% of the circumference of a further 23 cm of proximal jejunum/ileum was considered salvageable. After debridement of the dead tissue, the remaining gutter of jejunum was divided at its midpoint, and the two halves were anastomosed longitudinally to provide a "neojejunum" of 12 cm in length, which was anastomosed between the duodenum and terminal ileum. Full enteral feeding was tolerated from day 47. Although the neojejunum was excised on day 149, after becoming dilated and atonic, by that time the remaining small bowel had elongated to 30 cm. Because of the early institution of full enteral feeding, there were no long-term complications related to total parenteral nutrition.     

Modelling of air damping effect on the performance of encapsulated MEMS resonators

Microsystem Technologies - The dynamic performance of a micro-resonator depends on its energy loss mechanism which is quantified by Q-factor (Quality factor). This paper presents numerical...     

Gains and losses of the XII-VII component of the "baby-sitter" procedure: a morphometric analysis

The classic hypoglossal transfer to the facial nerve is invariably followed by complications caused by tongue atrophy. In 1984, Terzis introduced the "baby-sitter" procedure which involved a formal cross-facial procedure, in addition to partial neurectomy of the hypoglossal nerve, and an end-to-side coaptation with the ipsilateral facial nerve. This reported study provides, for the first time, quantification of the number of hypoglossal motor fibers needed to successfully restore eye sphincter function, using an end-to-side coaptation with preservation of the tongue. Thirty adult Sprague-Dawley rats were divided into six groups: control, denervated, perineurial window, 20 percent partial neurectomy (PN), 40 percent PN, and 80 percent PN. The procedure involves interposing a nerve graft (saphenous) between the partially severed XII nerve and the upper zygomatic branch of the facial nerve. Evaluation of the behavioral data (blink reflex) revealed good-to-superb return of the blinking mechanism in the 40 percent group, without significant tongue atrophy. Electrophysiologic data in the 40 percent neurectomy group demonstrated superiority to the other groups. Quantitative axonal morphometry of the coaptation sites and graft, as well as motor end-plates of the orbicularis oculi muscle and tongue showed the 40 percent partial neurectomy group to be the optimal group.     

Creutzfeldt-Jakob disease in a husband and wife

A 53-year-old man died of sporadic Creutzfeldt-Jakob disease (CJD) after a 1.5-year clinical course. Four and a half years later, his then 55-year-old widow died from CJD after a 1-month illness. Both patients had typical clinical and neuropathologic features of the disease, and pathognomonic proteinase-resistant amyloid protein ("prion" protein, or PrP) was present in both brains. Neither patient had a family history of neurologic disease, and molecular genetic analysis of their PrP genes was normal. No medical, surgical, or dietary antecedent of CJD was identified; therefore, we are left with the unanswerable alternatives of human-to-human transmission or the chance occurrence of sporadic CJD in a husband and wife.     

Correction of congenital diaphragmatic hernia in utero IX: fetuses with poor prognosis (liver herniation and low lung-to-head ratio) can be saved by fetoscopic temporary tracheal occlusion

BACKGROUND/PURPOSE: Fetuses with congenital diaphragmatic hernia (CDH) who have a "poor prognosis" with postnatal treatment now can be identified on the basis of liver herniation, early diagnosis (before 25 weeks' gestation) and a low lung-to-head ratio (LHR). Because complete in utero repair proved unsuccessful for this group, the strategy of temporary tracheal occlusion was developed to gradually enlarge the hypoplastic fetal lung. The purpose of this study is to compare the outcome of patients in the poor-prognosis group treated by one of three methods: (1) standard postnatal care, (2) fetal tracheal occlusion via open hysterotomy, and (3) the recently developed video-fetoscopic (Fetendo) technique of tracheal occlusion without hysterotomy. METHODS: In the past 3 years, 34 of 86 fetuses with an isolated left CDH met criteria for the poor-prognosis group. Thirteen families chose postnatal treatment at an extracorporeal membrane oxygenation (ECMO) center, 13 underwent open fetal tracheal occlusion, and eight underwent fetoscopic tracheal occlusion. RESULTS: The survival rate was 38% in the group treated by standard postnatal therapy, 15% in the open tracheal occlusion group, and 75% in the Fetendo group. There were less postoperative pulmonary complications noted in mothers who underwent the Fetendo procedure versus the open tracheal occlusion. All but one Fetendo clip patient had a striking physiological response demonstrated by sonographic enlargement of the small left lung that was documented postnatally by plain radiographs and its subjective appearance during repair of the CDH. In contrast, only 5 of the 13 open tracheal occlusion patients demonstrated lung growth. CONCLUSION: Fetuses with a left CDH who have liver herniation and a low LHR are at high risk of neonatal demise and appear to benefit from temporary tracheal occlusion when performed fetoscopically, but not when performed by open fetal surgery.     

The "first generation" of endovascular stent-grafts for patients with aneurysms of the descending thoracic aorta

OBJECTIVE: Our goal was to determine whether endovascular stent-grafting is feasible and effective for patients with aneurysms of the descending thoracic aorta. METHODS: Starting in July 1992, we conducted a prospective, uncontrolled clinical trial in 103 patients (mean age 69 years [range 34-89 years]) who underwent endovascular treatment of aneurysms of the descending thoracic aorta using a custom-fabricated, self-expanding stent-graft device. Follow-up was 100% complete and averaged 22 months. Sixty-two patients (60%) were judged not to be reasonable candidates for a conventional "open" surgical procedure. RESULTS: Complete thrombosis of the aneurysm was ultimately achieved in 86 (83%) patients. The early mortality rate was 9% +/- 3% (+/- 70% CL). Multivariable analysis revealed that myocardial infarction or stroke was linked with a higher likelihood of early death (P = .001). Early serious complications included paraplegia in 3% +/- 2% and stroke in 7% +/- 3%. Actuarial survival estimates at 1 year and 2 years were 81% +/- 4% and 73% +/- 5% (+/- 1 SE), respectively; being judged not to be a surgical candidate portended a higher probability of death (P = .003). According to the intent-to-treat principle, "treatment failure" (including all late sudden unexplained deaths) occurred in 38 patients; 53% +/- 10% of patients were free from treatment failure at 3.7 years. Stent-graft related complications occurred commonly and were linked with several anatomic, technical, and patient-related risk factors. CONCLUSIONS: This 5-year clinical trial involving use of a "first generation" device indicates that endovascular stent-grafting of descending thoracic aortic aneurysms is feasible with acceptable medium-term results. More refined, commercially developed devices available today offer less traumatic and more precise stent-graft deployment; these major technical advantages, coupled with important lessons we have learned over time and better patient selection, should be associated with more salutary clinical results in the future.     

A decision support tool for the diagnosis of breast cancer based upon Fuzzy ARTMAP

This paper presents research into the application of the fuzzy ARTMAP neural network model to the diagnosis of cancer from fine-needle aspirates of the breast. Trained fuzzy ARTMAP networks are differently pruned so as to maximise accuracy, sensitivity and specificity. The differently pruned networks are then employed in a cascade of networks intended to separate cases into certain and suspicious classes. This mimics the predictive behaviour of a human pathologist. The fuzzy ARTMAP model also provides symbolic rule extraction facilities and the validity of the derived rules for this domain is discussed. Additionally, results are provided showing the effects upon network performance of different input features and different observers. The implications of the findings are discussed.     

Arachidonic acid potentiates the duration of the metabotropic, protein kinase C-mediated, suppression of the inhibitory adenosine A1 receptor pathway in glutamatergic nerve terminals from rat cerebral cortex

Percutaneous US guided nephrostomy is the simplest and most direct technique to drain an obstructed kidney. The indications are included in two groups: temporary drainage and permanent drainage; the former is indicated in the non endoscopically superable ureteral obstruction, in pyonephrosis, in pregnant women and in transplanted kidneys (due to the easier access), the latter is exclusively reserved to neoplastic obstructions. The only real contraindication to the method, besides a documented allergy to local anaesthetics, is represented by a severe coagulopathy. Positioning techniques are the "one shot" technique, in which dilation and positioning are synchronous (it can avoid fluoroscopy but it is more traumatic) and angiographic derived Seldinger's technique, that utilizes fluoroscopy and an instrumentation including a guidewire and a set of Amplatz dilators. Complications are due to the access route; the choice of an intercostal access is always inadvisable, due to the risk of pneumothorax or pulmonary injury; the most frequent complications are vascular (hemorrhage, retroperitoneal hematoma) and usually well controlled; more severe lesions (renal artery laceration and arteriovenous fistula) may require intervention or embolization, but the incidence of nephrectomies due to vascular injury accounts for one per thousand.     

Hepatectomy with hypothermic perfusion of the liver

Whereas most liver resections can be performed within 60 min, the period of vascular clamping and resulting ischemia may prove too short to allow complex major liver resections (MLR) especially on diseased livers. To overcome this problem, cooling of the liver with 4 degrees C preservations solution routinely used in liver transplantation may be used in three different approaches to MLR: I "In situ": the liver remains in the abdomen and integrity of afferent and efferent vessels is conserved. II "Ex situ-in vivo": the liver exteriorized from the abdomen by transecting all hepatic veins, remains connected to the porta hepatis. III "Ex vivo": the liver being removed from the abdomen, the MLR is performed extracorporeally. Of 15 MLR reported here, 11 were performed "in situ" and 4 "ex situ-in vivo"/Nowadays, the liver surgeon's "toolbox" must contain hypothermic liver perfusion. In carefully selected cases, these techniques allow MLR on diseases livers or mandating complex vascular procedures.