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International audience; BACKGROUND:Liver hypertrophy induced by partial portal vein occlusion (PVL) is accelerated by adding simultaneous parenchymal transection ("ALPPS procedure"). This preclinical experimental study in pigs tests the hypothesis that simultaneous ligation of portal and hepatic veins of the liver also accelerates regeneration by abrogation of porto-portal collaterals without need for operative transection.METHODS:A pig model of portal vein occlusion was compared with the novel model of simultaneous portal and hepatic vein occlusion, where major hepatic veins draining the portal vein-deprived lobe were identified with intraoperative ultrasonography and ligated using pledgeted transparenchymal sutures. Kinetic growth was compared, and the portal vein system was then studied after 7 days using epoxy casts of the portal circulation. Portal vein flow and portal pressure were measured, and Ki-67 staining was used to evaluate the proliferative response.RESULTS:Pigs were randomly assigned to portal vein occlusion (n = 8) or simultaneous portal and hepatic vein occlusion (n = 6). Simultaneous portal and hepatic vein occlusion was well tolerated and led to mild cytolysis, with no necrosis in the outflow vein-deprived liver sectors. The portal vein-supplied sector increased by 90 ± 22% (mean ± standard deviation) after simultaneous portal and hepatic vein occlusion compared with 29 ± 18% after PVL (P < .001). Collaterals to the deportalized liver developed after 7 days in both procedures but were markedly reduced in simultaneous portal and hepatic vein occlusion. Ki-67 staining at 7 days was comparable.CONCLUSION:This study in pigs found that simultaneous portal and hepatic vein occlusion led to rapid hypertrophy without necrosis of the deportalized liver. The findings suggest that the use of simultaneous portal and hepatic vein occlusion accelerates liver hypertrophy for extended liver resections and should be evaluated further.

Objective Mycotic aneurysms of the infrapopliteal vessels are rare, with few cases reported in the literature. Management strategies are diverse and should be tailored to the patient’s presentation. Methods We describe the case of a 40-year-old male who presented with a painful left leg mass in the setting of bacteremia and infective endocarditis. Imaging revealed an aneurysm of the anterior tibial artery. Results The patient was treated with antibiotics and open surgical repair with excision of the aneurysmal sac, ligation of the anterior tibial artery, and primary repair of the popliteal artery and tibioperoneal trunk. Conclusion The epidemiology, pathophysiology, and clinical management of infrapopliteal aneurysms are briefly reviewed in this case study.

Laparoscopic sleeve gastrectomy is the most commonly performed bariatric procedure in the USA. Identifying preoperative risk factors for prolonged postoperative hospital stay will help appropriately select patients for fast-track protocols and avoid costly readmissions. To date, there has been no large national database analysis of risk factors for prolonged length of stay following laparoscopic sleeve gastrectomy. Laparoscopic sleeve gastrectomy procedures reported to the American College of Surgeons National Surgical Quality Improvement Program between 2009 and 2012 were reviewed. Open procedures and revisional procedures were excluded. Baseline patient characteristics and preoperative lab values were reviewed. Univariate analysis was conducted to identify patient factors that predicted prolonged hospitalization (defined as ≥ 3 days). Multivariate logistic regression was used to identify factor associated with prolonged length of stay. We identified 11,430 patients who underwent laparoscopic sleeve gastrectomy. The median length of stay was 2 days and 18.4% required hospitalization ≥ 3 days. Multivariate analysis revealed that female sex, age greater than 65, body mass index greater than 50, chronic obstructive pulmonary disease, hypertension, renal insufficiency, anemia, and prolonged operative time were significantly associated with prolonged hospital stay. Preoperative patient characteristics as well as operative details predict prolonged length of stay following laparoscopic sleeve gastrectomy. As the utilization of fast-track protocols in bariatric surgery programs expands, these data may be used to assist in the selection of patients who may be inappropriate for rapid discharge from the hospital after sleeve gastrectomy as well as guide medical optimization strategies preoperatively.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) induces more rapid liver growth than portal vein ligation (PVL). Transection of parenchyma in ALPPS may prevent the formation of collaterals between lobes. The aim of this study was to determine if abrogating the formation of collaterals through parenchymal transection impacted growth rate. Twelve Yorkshire Landrace pigs were randomized to undergo ALPPS, PVL, or “partial ALPPS” by varying degrees of parenchymal transection. Hepatic volume was measured after 7 days. Portal blood flow and pressure were measured. Portal vein collaterals were examined from epoxy casts. PVL, ALPPS, and partial ALPPS led to volume increases of the RLL by 15.5% (range 3–22), 64% (range 45–76), and 32% (range 18–77), respectively, with significant differences between PVL and ALPPS/partial ALPPS (p

An Institutional Quality and Safety Initiative to reduce postoperative urinary retention (POUR) and improve patient safety indicators (PSIs) was undertaken after a nurse driven protocol for catheter removal lead to an increase in POUR. The aim of this study was to identify the number of risk factors present in patients with POUR while examining the prevalence of those risk factors individually.A retrospective review of our institution's surgical database was performed to identify 500 consecutive cases of POUR between July 1, 2013 and July 1, 2014. POUR was defined as the inability to void postoperatively with bladder scan volumes greater than 450 mL and subsequent need for catheterization with an output greater than 450 mL. These records were individually reviewed for 15 known independent risk factors for urinary retention. Patients with incomplete records or preoperative baseline urinary retention requiring catheterization were excluded.Of the 500 consecutive patients with POUR, 288 (57.6%) were male and 212 (42.4%) were female. At the time of voiding trial, all 500 patients with POUR (100%) had at least one perioperative risk factor identified and over 75% had six or more (mean 6.88, median 7, range 1-12).Multiple perioperative risk factors are present in the vast majority of patients with POUR. Many of the risk factors are modifiable and represent an opportunity for intervention. This could ultimately lead to a risk profile which could be used to optimize timing of postoperative voiding trials, thus improving patient care (improve PSIs and patient comfort, reduce trauma) while maintaining low rates of CAUTI.

The impact of Roux-en-Y gastric bypass (RYGB) on weight loss and co-morbid disease resolution is well established. However, the mechanisms underlying the procedure remain incompletely understood. Intestinal remodeling involving glucose transporters (GLUTs) may play a crucial role. Rat studies have demonstrated morphological adaptation of GLUTs within adipose and intestinal cells in association with the reprogramming of glucose metabolism. There is a limited understanding of the variations in expression amongst GLUT family receptors in the human intestine. The aim of this study was to evaluate and describe jejunal GLUT expression patterns in the obese versus non-obese. Tissue samples were collected from 19 adults (age ≥18) patients with morbid obesity undergoing elective RYGB. Specimens were obtained from excess jejunum removed during the stapled jejuno-jejunal anastomosis. All subjects met National Institutes of Health criteria for bariatric surgery (body mass index or BMI ≥40 or ≥35 with obesity-related comorbidities). Exclusion criteria included age less than 18, age greater than 65, patients undergoing a revision procedure, and the presence of a seizure disorder (possible association with GLUT-1 deficiency syndrome). Five samples were obtained from non-obese subjects (average BMI 26.7) without diabetes who were consenting organ donors after brain death. Samples of jejunum from non-obese individuals were obtained at the time of organ procurement. Institutional Review Board and Gift of Hope approval was obtained. Specimens underwent quantitative real-time PCR and Western blotting. Western blot densitometry was performed using Image J software. Student T test was performed using SPSS statistics software. GLUT-1 and GLUT-7 expression were not detected in the jejunum of either group. No difference in expression pattern was observed for GLUT-2, GLUT-4, and GLUT-9 between the groups. Western blot band density of GLUT-5 to loading control (GADPH) mean ratio was 0.21 (SD = 0.20) in obese specimens compared to 0.56 (SD = 0.17) in non-obese. Densitometry revealed GLUT-5 levels in the jejunum of the obese were significantly lower than non-obese specimens (P

Background The purpose of our study was to determine the predictive impact of individual academic measures for the matriculation of senior medical students into a general surgery residency. Methods Academic records were evaluated for third-year medical students (n = 781) at a single institution between 2004 and 2011. Cohorts were defined by student matriculation into either a general surgery residency program (n = 58) or a non–general surgery residency program (n = 723). Multivariate logistic regression was performed to evaluate independently significant academic measures. Results Clinical evaluation raw scores were predictive of general surgery matriculation ( P = .014). In addition, multivariate modeling showed lower United States Medical Licensing Examination Step 1 scores to be independently associated with matriculation into general surgery ( P = .007). Conclusions Superior clinical aptitude is independently associated with general surgical matriculation. This is in contrast to the negative correlation United States Medical Licensing Examination Step 1 scores have on general surgery matriculation. Recognizing this, surgical clerkship directors can offer opportunities for continued surgical education to students showing high clinical aptitude, increasing their likelihood of surgical matriculation.

Background Laparoscopic cholecystectomy is the treatment of choice for biliary dyskinesia; however, long-term outcomes remain unclear. Methods A retrospective review of patients diagnosed with biliary dyskinesia and treated with laparoscopic cholecystectomy at a single institution between 2001 and 2012 was conducted. Long-term outcome data were obtained by telephonic interview using a modified Likert scale. Results Sixty-seven patients met inclusion criteria, of which 34 patients (51%) had long-term follow-up data. Mean time of follow-up was 65 (range: 6 to 134) months. Long-term follow-up demonstrated symptom response in 88% ( n = 30) of patients (responders), compared to no response in 12% ( n = 4) of patients (nonresponders). Responders underwent a mean of 1.56 preoperative diagnostic procedures, compared to 2.5 for nonresponders ( P = .01). Conclusion This represents the longest mean time of follow-up study demonstrating the success of laparoscopic cholecystectomy to improve symptoms in patients with biliary dyskinesia.

Background Determine the utility of mock oral examinations in preparation for the American Board of Surgery certifying examination (ABS CE). Methods Between 2002 and 2012, blinded data were collected on 63 general surgery residents: 4th and 5th-year mock oral examination scores, first-time pass rates on ABS CE, and an online survey. Results Fifty-seven residents took the 4th-year mock oral examination: 30 (52.6%) passed and 27 (47.4%) failed, with first-time ABS CE pass rates 93.3% and 81.5% ( P = .238). Fifty-nine residents took the 5th-year mock oral examination: 28 (47.5%) passed and 31 (52.5%) failed, with first-time ABS CE pass rates 82.1% and 93.5% ( P = .240). Thirty-eight responded to the online survey, 77.1% ranked mock oral examinations as very or extremely helpful with ABS CE preparation. Conclusions Although mock oral examinations and ABS CE passing rates do not directly correlate, residents perceive the mock oral examinations to be helpful.

This paper reports the outcomes of an inter- and intra-laboratory microcalorimetric investigation of the triacetin hydrolysis reaction in an imidazole/acetic acid buffer system. The purpose was to establish whether this reaction would be an appropriate test reaction system for validation of isothermal heat conduction microcalorimeters used to determine both thermodynamic and kinetic data. To be acceptable for this purpose a reaction should be simple to perform, robust in operation, undemanding with respect to sources of chemicals, operators, calorimeters and their operating procedures (within defined limits). The reaction system studied is shown to fulfil these criteria. For this second-order reaction, performed at 298 K the recommended values for the reaction rate constant, k, and the enthalpy change, ΔRH, are: k=2.80±0.10×10−6 dm3 mol−1 s−1; Δ R H=−91.7±3.0 kJ mol −1 .

The successful use of operant procedures to alter behaviors associated with various medical conditions suggests that such behaviors may be learned and that the principles of learning may be applied not only to treatment but also to the study of the pathogenesis of illness behavior. The present study, conducted within an ongoing neuromuscular research project, assessed the covariation of behaviors associated with chronic pain within and across behavioral and drug approaches to treatment. Problems of screaming and five other behaviors (including self-reports of pain) were measured across conditions of varying behavioral contingencies (noncontingent reinforcement vs the removal of reinforcement contingent upon screaming) and varying administration (time since medication and dosage) of Parsidol during attempts to treat the muscle pain of a 24-year-old male with a severe, chronic neuromuscular disorder diagnosed as dystonia musculorum deformans (DMD). Results indicated that: (a) pain behaviors covaried during behavioral and drug conditions even though the behavioral intervention only targeted screaming; (b) effects were greater on nontargeted behaviors during periods that followed rather than preceded drug administration; (c) in contrast to behavioral observation data, physiological measures of neuromuscular activity (EMG) did not differ across conditions. These results suggest that functional response-response relationships exist in patients as the result of their illness experience.

Behavioral interventions have had limited success in managing the chronic hyperphagia and obesity that are of presumed organic etiology in Prader-Willi syndrome. Thus, frequent foraging for food and covert consumption continue to be health-threatening problems for many Prader-Willi individuals. This case study was designed to replicate methods for assessment and treatment of food theft. A token program based on differential-reinforcement-of-other-behavior and response-cost eliminated theft in three hospital settings. Prior to discharge, the program was expanded to include contingencies on exercise behavior and weight loss, and staff from the subject's group home residence were trained to implement a modified program in the natural environment. Reduced food theft and continued weight loss were maintained in the group home and an apartment-living arrangement. A total of 81 lb (37 kg) was lost during a 2-yr period.