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Islet transplantation is superior to extrinsic insulin supplementation in the treating severe Type 1 diabetes. However, its efficiency and longevity are limited by substantial islet loss post-transplantation due to lack of engraftment and vascular supply. To overcome these limitations, we developed a novel approach to bio-fabricate functional, vascularized islet organs (VIOs) ex vivo. We endothelialized acellular lung matrixes to provide a biocompatible multicompartment scaffold with an intact hierarchical vascular tree as a backbone for islet engraftment. Over seven days of culture, islets anatomically and functionally integrated into the surrounding bio-engineered vasculature, generating a functional perfusable endocrine organ. When exposed to supra-physiologic arterial glucose levels in vivo and ex vivo, mature VIOs responded with a physiologic insulin release from the vein and provided more efficient reduction of hyperglycemia compared to intraportally transplanted fresh islets. In long-term transplants in diabetic mice, subcutaneously implanted VIOs achieved normoglycemia significantly faster and more efficiently compared to islets that were transplanted in deviceless fashion. We conclude that ex vivo bio-fabrication of VIOs enables islet engraftment and vascularization before transplantation, and thereby helps to overcome limited islet survival and function observed in conventional islet transplantation. Given recent progress in stem cells, this technology may enable assembly of functional personalized endocrine organs., (Copyright © 2019. Published by Elsevier Ltd.)

Decellularized native extracellular matrix (ECM) biomaterials are widely used in tissue engineering and have reached clinical application as biomesh implants. To enhance their regenerative properties and postimplantation performance, ECM biomaterials could be functionalized via immobilization of bioactive molecules. To facilitate ECM functionalization, we developed a metabolic glycan labeling approach using physiologic pathways to covalently incorporate click-reactive azide ligands into the native ECM of a wide variety of rodent tissues and organs in vivo, and into the ECM of isolated rodent and porcine lungs cultured ex vivo. The incorporated azides within the ECM were preserved after decellularization and served as chemoselective ligands for subsequent bioconjugation via click chemistry. As proof of principle, we generated alkyne-modified heparin, immobilized it onto azide-incorporated acellular lungs, and demonstrated its bioactivity by Antithrombin III immobilization and Factor Xa inhibition. The herein reported metabolic glycan labeling approach represents a novel platform technology for manufacturing click-reactive native ECM biomaterials, thereby enabling efficient and chemoselective functionalization of these materials to facilitate tissue regeneration and repair., (Copyright © 2018. Published by Elsevier Ltd.)

The first lung transplantation in the rat was achieved by Asimacopoulos et al using sutured anastomoses in 1971. Subsequent development of a cuffed technique to construct the anastomoses by Mizuta and colleagues in 1989 represented a breakthrough that resulted in simplification of the procedure and shorter warm ischemic times. Since then, a number of further variations on the technique of rat lung transplantation have been described. In spite of this, the procedure remains technically demanding and involves a long learning curve. This minireview describes the following new technical safeguards to further evolve the technique for cuffed anastomoses in rat lung transplantation: the use of anatomical landmarks to avoid twisting of the everted donor pulmonary vein and bronchus in the cuff, the use of the cuff tie as a landmark to avoid twisting of the anastomotic cuffs relative to the recipient vessels, distal ties on the recipient vessels to achieve a bloodless field and triangulation of the venotomy to avoid pulmonary vein tearing., Competing Interests: Conflict-of-interest statement: No potential conflicts of interest relevant to this article were reported.

Aortic aneurysms are usually asymptomatic until catastrophic rupture occurs. Ruptured abdominal aortic aneurysms classically present with acute back pain, shock, and a pulsatile abdominal mass. The natural history of some aortic aneurysms also includes a stage of contained rupture. This occurs when extravasation of blood from the ruptured aneurysm is contained by surrounding tissues. Here, the authors report the case of a chronic contained abdominal aortic aneurysm rupture that resulted in erosion of the spine., Competing Interests: The authors declare no conflict of interest related to this article., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

The emergence of multi-drug resistant bacteria threatens to end the era of antibiotics. Drug resistant bacteria have evolved mechanisms to overcome antibiotics at therapeutic doses and further dose increases are not possible due to systemic toxicity. Here we present a pilot study of ex vivo lung perfusion (EVLP) with high dose antibiotic therapy followed by autotransplantation as a new therapy of last resort for otherwise incurable multidrug resistant lung infections. Severe Pseudomonas aeruginosa pneumonia was induced in the lower left lungs (LLL) of 18 Mini-Lewe pigs. Animals in the control group (n = 6) did not receive colistin. Animals in the conventional treatment group (n = 6) received intravenous application of 2 mg/kg body weight colistin daily. Animals in the EVLP group (n = 6) had their LLL explanted and perfused ex vivo with a perfusion solution containing 200 μg/ml colistin. After two hours of ex vivo treatment, autotransplantation of the LLL was performed. All animals were followed for 4 days following the initiation of treatment. In the control and conventional treatment groups, the infection-related mortality rate after five days was 66.7%. In the EVLP group, there was one infection-related mortality and one procedure-related mortality, for an overall mortality rate of 33.3%. Moreover, the clinical symptoms of infection were less severe in the EVLP group than the other groups. Ex vivo lung perfusion with very high dose antibiotics presents a new therapeutic option of last resort for otherwise incurable multidrug resistant pneumonia without toxic side effects on other organs.

Introduction: Cardiovascular complications represent the leading cause of morbidity and mortality in patients with Marfan syndrome. Here, we describe a unique case where a total artificial heart was implanted in a young Marfan syndrome woman., Methods: A 22-year-old postpartum African American female with Marfan syndrome developed multiple severe valve dysfunction and biventricular failure that was refractory to medical management. She previously had a Bentall procedure for Type A aortic dissection and repair of a Type B dissection., Results: We implanted a total artificial heart with a good outcome., Conclusion: Total artificial heart is a durable option for severe biventricular failure and multiple valvular dysfunction as a bridge to transplant in a young patient with Marfan syndrome.

Objective: Bioengineering of viable, functional, and implantable human lung grafts on porcine matrix., Summary Background Data: Implantable bioartificial organ grafts could revolutionize transplant surgery. To date, several milestones toward that goal have been achieved in rodent models. To make bioengineered organ grafts clinically relevant, scaling to human cells and graft size are the next steps., Methods: We seeded porcine decellularized lung scaffolds with human airway epithelial progenitor cells derived from rejected donor lungs, and banked human umbilical vein endothelial cells. We subsequently enabled tissue formation in whole organ culture. The resulting grafts were then either analyzed in vitro (n = 15) or transplanted into porcine recipients in vivo (n = 3)., Results: By repopulating porcine extracellular matrix scaffolds with human endothelial cells, we generated pulmonary vasculature with mature endothelial lining and sufficient anti-thrombotic function to enable blood perfusion. By repopulating the epithelial surface with human epithelial progenitor cells, we created a living, functioning gas exchange graft. After surgical implantation, the bioengineered lung grafts were able to withstand physiological blood flow from the recipient's pulmonary circulation, and exchanged gases upon ventilation during the 1-hour observation., Conclusions: Engineering and transplantation of viable lung grafts based on decellularized porcine lung scaffolds and human endothelial and epithelial cells is technically feasible. Further graft maturation will be necessary to enable higher-level functions such as mucociliary clearance, and ventilation-perfusion matching.

Separating wounded serosa by physical barriers is the only clinically approved adjunct for postoperative adhesion prevention. Since the optimal adhesion barrier has not been found, it is essential to improve our pathogenic understanding of adhesion formation and to compare the effects of different barrier materials on tissue and cells. Wistar rats underwent standardized peritoneal damage and were treated either with Seprafilm, Adept, Intercoat, Spraygel, SupraSeal or remained untreated as a control. 14 days postoperatively, the lesions were explanted and histomorphologically analyzed using the European ISO score to evaluate material implants. Striking differences between the material groups were present regarding the inflammation, fibrosis, and foreign body reaction. According to the ISO score, Intercoat and Spraygel were considered as nonirritating to tissue. Adept, Seprafilm, and SupraSeal were assessed as mild-irritating materials. Interestingly, the most effective material in adhesion prevention revealed moderate inflammation accompanied by minor fibrosis. The degree of inflammation to barrier materials does not predict the efficacy in the prevention of adhesions. Histopathological investigations are crucial to improve our understanding of the cellular mechanisms during adhesion formation and elucidate the tissue response to material approaches used in adhesion prevention. This will lead to improved antiadhesive strategies and the development of functional barrier biomaterials. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 598-609, 2018., (© 2017 Wiley Periodicals, Inc.)

We describe the intraoperative non-invasive use of an infrared (IR) camera to monitor Del Nido cardioplegia delivery in patients undergoing cardiac surgery. Thermal pictures were taken pre- and post-cardioplegia and at timed points after arrest, and compared to readings from a transseptal temperature probe. There was good concordance between the transseptal probe and the IR camera temperature readings. This non-invasive technique, which assesses cardioplegic distribution, may help to determine when additional doses of Del Nido cardioplegia are required during periods of cardioplegic arrest., (© 2017 Wiley Periodicals, Inc.)

Introduction: Indications and surgical techniques for pulmonary metastasectomy (PME) are controversially discussed issues. Laser-assisted surgery (LAS) is a recent innovation that has been advocated especially in patients with multiple pulmonary metastases (PM). However, there are hardly any studies comparing surgical outcomes after laser-assisted and conventional resection. The aim of the current study was to evaluate the value of LAS in a larger study population., Materials & Methods: A retrospective analysis was completed on 178 consecutive patients undergoing 236 PMEs at a single center between 2010 and 2015. The main endpoint was survival. Statistical analysis was performed using the Kaplan-Meier method and survival rates were compared with the log rank test. Follow-up was done with special attention to the development of recurrent PM. Local relapse was defined as a recurrent metastasis in direct relation to the previously resected area according to CT scan comparisons., Results: LAS was performed on 256 metastases in 99 patients, non-laser-assisted surgery (NLAS) on 127 metastases in 79 patients. 5-year-survival rates were 69.3% in all patients, 65.7% after LAS and 73.6% after NLAS. There was no statistically significant survival difference after LAS or NLAS (p = 0.41). The rate of local relapse was 0.8% after LAS vs 3.1% after NLAS (p = 0.073)., Conclusion: Despite a larger number of negative predictors for survival in LAS patients, overall survival (OS) was similar in the compared groups. There was also a trend for a lower risk of local relapses after LAS. Therefore, LAS should be considered a promising method for PME., (Copyright © 2016 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

A 64-year-old man experienced a driveline infection that was treated with serial debridements and antibiotics. When the wound clinically appeared ready for closure, a handheld fluorescence imaging device still revealed a margin of red fluorescence around the wound edges consistent with a subclinical infection. Therefore, a wider margin was made and additional specimens for wound culture were taken, which demonstrated a vancomycin-resistant enterococcal infection. The autofluorescence signals of common bacteria can be detected with a fluorescence camera in subclinical wound infections without clinical signs. Here we describe the first use of this technology to diagnose ventricular assist device driveline infections after left ventricular assist device implantation., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Functional tricuspid regurgitation (TR) is primarily caused by enlargement of the tricuspid annulus due to right ventricular dilation, frequently secondary to left sided valvular disease. Early techniques for the treatment of functional TR were introduced by Jerome Kay in 1965 and Norberto DeVega in 1972. Modified suture annuloplasty is a modification of DeVega's semicircular purse string technique, however, it is based on Kay's principle of obliteration of the posterior segment of the annulus only. While ring annuloplasty is the procedure of choice for severe functional TR, posterior suture annuloplasty is a technically simpler option for patients with moderate functional TR., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

In preventing postoperative adhesion formation the optimal barrier material has still not been found. It is therefore imperative to assess the biocompatibility of potential barrier devices. Macrophages play a decisive role in the regulation of wound healing, tissue regeneration and foreign body reaction. Since the number of CD68-positive macrophages represents an important parameter within biomaterial testing, in the present study it was analysed whether a correlation exists between the total number of CD68-positive macrophages and the extent of fibrosis or inflammation in peritoneal adhesion prevention using biomaterials. After standardized peritoneal wounding, Wistar rats were treated with five adhesion barriers or remained untreated as a control. After 14 days, animals were sacrificed and the treated areas were evaluated histomorphologically and immunohistologically. A heterogeneous pattern of macrophage count in relation to fibrosis or inflammation was found. While some groups described a moderate macrophage infiltration without fibrosis, others showed similar numbers of macrophages, but accompanied by moderate fibrosis. Moreover, a minimal number of macrophages was associated with minimal fibrosis. Mild inflammation was seen both with minimal and moderate macrophage infiltration. Altogether, no correlation could be established between the tissue response and the count of CD68-positive macrophages. With a view to macrophage heterogeneity further studies are required to determine the different macrophage subpopulations and clarify the role of these in the tissue responses to barrier materials., Competing Interests: The authors declare that they have no competing interests. Ethical statements The authors complied with all of the legal requirements pertaining to the location in which the animal experiments were done. The animal study was approved by the Ethics Committee of the Eberhard-Karls-University of Tuebingen, Germany.

Background: There is a scarcity of externally valid data that investigate the utility of operative time, a common clinical parameter, as a predictor of free flap failures. Our aim was to assess whether prolonged operative time correlates with early flap failure following free tissue transfer in the acute care setting using the American College of Surgeons National Surgical Quality Improvement Program database., Methods: The 2005-2011 American College of Surgeons National Surgical Quality Improvement Program databases were reviewed for encounters that entailed a free tissue transfer via a CPT algorithm. Patients identified as having a flap loss were compared with people who did not with regards to operative time and patient comorbidities. Patients were subdivided into the following cohort groups with regards to operative time: <6 hours, 6-12 hours, and >12 hours. Secondary outcome was association between increasing operative time and postoperative complications., Results: Of the 2,008 patients identified, 62 (3.1%) had early flap failure. After multivariable analysis, it was found that progressive operative time was associated with an increased risk of flap failure; 6-12 hours odds ratio was 4.64 and >12 hours odds ratio was 5.65 (P = 0.0140). Higher American Society of Anesthesiologists class (P = 0.0042) was also shown to be significantly associated with flap failure. On secondary analysis, increasing operative time was correlated with the following complications: pneumonia, blood transfusions, prolonged ventilation, wound dehiscence, and wound complications., Conclusion: Our results, one of the largest series in the literature, revealed that prolonged operative time was associated with a stepwise increase in the likelihood of early flap failure as well certain postoperative complications. © 2014 Wiley Periodicals, Inc. Microsurgery 37:12-20, 2017., (© 2015 Wiley Periodicals, Inc.)

Objective: A nondesignated preliminary surgery (NDPS) position encompasses 1 year of training provided by many general surgery residencies. Our aim was to assess factors predicting success and provide evidence for program directors to support career guidance to preliminary residents., Methods: Retrospective cohort study of 221 NDPS residents who entered 5 university-based institutions were identified from 2009 to 2013. Records for trainees were reviewed. We defined primary success as obtaining a categorical position in the specialty of choice and secondary success as obtaining a categorical position in any specialty immediately after finishing their NDPS training. Statistical evaluation was performed using chi-square analysis, independent t-test and logistic regression using α <0.05., Results: Of the 221 NDPS residents, 217 (98%) completed postgraduate year (PGY)-1 and 65 (29%) completed PGY-2. Totally, 90 (41%) obtained categorical general surgery positions, 89 (40%) obtained categorical positions in other specialties, and 42 (19%) failed to obtain a categorical position immediately after their NDPS years. Ultimately, 139 (63%) of residents achieved primary success and 40 (18%) additional residents obtained categorical positions in specialties other than their first choice, resulting in a total of 179 (81%) of residents obtaining categorical positions. Mean United States Medical Licensing Examination step 1 and step 2 scores for those who obtained secondary success were 227 and 234 vs. 214 and 219, respectively, for those who failed to secure a categorical position (p < 0.01). United States Medical Licensing Examination step 2 score was a significant predictor of primary (p < 0.03) and secondary success (p < 0.02). Of 65 PGY-2 NDPS residents, 32 (49%) achieved primary success, and 11 (17%) others achieved secondary success for a total of 43 (66%). For PGY-2 NDPS, American Board of Surgery In-Training Examination was the only significant predictor of primary and secondary success (p < 0.02 and p < 0.05)., Conclusions: NDPS training provides a viable and successful opportunity for at least 81% of young physicians to pursue their career goals even after an unsuccessful first match., (Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

A 24-year-old man with systemic lupus erythematosus and antiphospholipid syndrome complicated by lupus nephritis presented with acute limb ischaemia secondary to an embolus. Following embolectomy, the patient underwent a transthoracic echocardiogram which revealed a large vegetation on all three cusps of the aortic valve. The patient was taken for an urgent aortic valve replacement with a mechanical valve. Cultures of one cusp remained sterile. Histopathological examination of the remaining two cusps revealed sterile fibrin-rich thrombotic vegetations characteristic of non-bacterial thrombotic endocarditis., Competing Interests: Conflicts of Interest: None declared., (2016 BMJ Publishing Group Ltd.)

Objectives: Lung auto-transplantation is the surgical key step in experiments involving ex vivo therapy of severe or end-stage lung diseases. Ex vivo therapy has become a clinical reality because of systems such as the Organ Care System (OCS) Lung, which is the only commercially available portable lung perfusion system. However, survival experiments involving porcine lung auto-transplantation pose special surgical and anaesthesiological challenges. This current study was designed to describe the development of surgical techniques and aneasthesiological management strategies that facilitate lung auto-transplantation survival surgery including a follow-up period of 4 days., Methods: Left pneumonectomy was performed in 12 Mini-Lewe miniature pigs. After ex vivo treatment of the harvested lungs within the OCS Lung for 2 h, the lungs were retransplanted into the same animal (auto-transplantation). Four animals were used to develop the optimal techniques and establish an experimental protocol. According to the final protocol, eight additional animals were operated. The follow-up period was 4 days., Results: There were four severe intraoperative surgical complications [anatomical variant of the superior vena cava (two times), a complication related to the bronchial anastomosis and a complication related to the pulmonary arterial anastomosis]. The major postoperative problems were hyperkalaemia, prolonged recovery from anaesthesia and pulmonary oedema after reperfusion. Establishment of the surgical technique showed that using a pericardial tube to facilitate the anastomosis of the thin left superior pulmonary vein should be considered to prevent thrombosis. However, routine use of the patch technique to construct venous and arterial anastomoses is not necessary. Furthermore, traction on the venous anastomoses can be avoided by performing the bronchial anastomosis first., Conclusions: Lung auto-transplantation is a feasible experimental model for ex vivo therapy of lung diseases and is applicable for experimental questions concerning human lung transplantation., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

With the development of the transcatheter aortic valve replacement, innovative approaches can be geared to atypical and challenging cases. We describe a case of transcatheter aortic valve replacement via a left anterior thoracotomy in a patient with pectus excavatum and unusual intrathoracic anatomy where surgical and traditional transcatheter aortic valve replacement approaches were deemed inapplicable., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Del Nido cardioplegia, a crystalloid-based solution with lidocaine as a key element, is given as a single dose and has been used successfully in congenital cardiac surgery., Hypothesis: We retrospectively compared a lidocaine containing "modified del Nido" solution with our standard whole blood cardioplegia to investigate its safety and efficacy in adult cardiac surgery., Methods: From June 1, 2013 to December 30, 2013, we used a single dose of lidocaine containing cardioplegia (LC group) in 92 consecutive operations. Propensity matching analysis was undertaken to compare the outcomes of such patients with those who underwent their surgery by the same surgeon using standard whole blood cardioplegia (WB group), n = 396. Propensity score matching yielded 79 pairs of patients., Results: After propensity matching, LC and WB groups were similar in baseline operative characteristics including cross-clamp time (LC: 65 minutes [range 54 to 89] vs. WB: 70 minutes [54 to 86], p = 0.993). Postoperative outcomes were similar including inotropic requirements (30.4% [24/72] vs. 25.3% [20/72], p < 0.60), median ventilation time (4.7 hours vs. 5.3, p < 0.74) and median length of stay was seven days for both groups (p < 0.82). Despite higher median postoperative, 24-hour CK-MB levels LC group (LC:22.3 ng/ml, range [15.6 to 40.3] vs. WB:18.4 ng/ml [13.9 to 28.2], p = 0.040), operative and one-year mortality were comparable among study groups (both p > 0.798)., Conclusions: Lidocaine containing cardioplegia appears to be safe in adults undergoing cardiac procedure when administered for the first 60 minutes of aortic cross clamping. Higher CK-MB levels did not translate into adverse clinical outcomes., (© 2015 Wiley Periodicals, Inc.)

The first successful mitral valve repair was performed by Elliot Cutler at Brigham and Women's Hospital in 1923. Subsequent evolution in the surgical techniques as well as multi-disciplinary cooperation between cardiac surgeons, cardiologists and cardiac anesthesiologists has resulted in excellent outcomes. In spite of this, the etiology of mitral valve pathology ultimately determines the outcome of mitral valve repair.

Introduction: Pulmonary metastasectomy represents an established approach in the treatment of lung metastases related to several solid malignant tumors, promising the chance of long term survival. Regarding the proper timing of metastasectomy both operation promptly after diagnosis and delayed operation after an interval of 3 months are common practice., Materials and Methods: A systematic Medline search addressing the optimal timing of metastasectomy was performed. Since the search query "timing of metastasectomy" yields only a limited number of articles, the Medline search was expanded to include the main arguments for prompt metastasectomy ("metastases of metastasis", "growth rate of pulmonary metastases") and for delayed metastasectomy., Results: Based on the data available to date, there is no necessity to expedite the timing of the operation. On the other hand, there is no evidence that a delayed operation, for example after re-staging following an interval of 3 months, provides a benefit., Conclusion: Therefore the timing of metastasectomy should only depend on the patient's requirements, such as general state of health and oncologic considerations, such as promising multimodal therapy concepts, extrathoracal tumor manifestations or oncologic type of the primary tumor. A delayed operation seems justified if the indication for resection is questionable due to a high risk of early multilocal recurrence., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Intraoperative hypotension is associated with adverse outcomes. The preferred treatment for intraoperative hypotension is to address its cause. In the interim the blood pressure can be supported by the anesthesia team with volume resuscitation and vasopressors. Additionally, preferential perfusion of vital organs, such as the myocardium and cerebrum, at the expense of non-vital vascular beds, such as the extremities, is desirable. In the state of shock, the flight or fight response will ensure perfusion of the extremities in order to prepare the organism for a physical confrontation. However, in the context of intraoperative hypotension this response is counter-productive. Therefore we propose bilateral femoral artery compression as a new technique to increase vital organ perfusion during intraoperative hypotension. This results in shunting of blood flow from the legs and towards the vital organs. Bilateral femoral artery compression can be employed by the surgical team to immediately improve blood pressure until other counter-measures against intraoperative hypotension take effect., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Respiratory failure after Ivor-Lewis esophagectomy results in poor outcomes. Limited treatment strategies are available to manage this severe complication. One possibility is extracorporeal support. We report the successful use of extracorporeal support as a successful strategy for refractory respiratory failure., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Animal models for adhesion induction are heterogeneous and often poorly described. We compare and discuss different models to induce peritoneal adhesions in a randomized, experimental in vivo animal study with 72 female Wistar rats. Six different standardized techniques for peritoneal trauma were used: brushing of peritoneal sidewall and uterine horns (group 1), brushing of parietal peritoneum only (group 2), sharp excision of parietal peritoneum closed with interrupted sutures (group 3), ischemic buttons by grasping the parietal peritoneum and ligating the base with Vicryl suture (group 4), bipolar electrocoagulation of the peritoneum (group 5), and traumatisation by electrocoagulation followed by closure of the resulting peritoneal defect using Vicryl sutures (group 6). Upon second look, there were significant differences in the adhesion incidence between the groups (P < 0.01). Analysis of the fraction of adhesions showed that groups 2 (0%) and 5 (4%) were significantly less than the other groups (P < 0.01). Furthermore, group 6 (69%) was significantly higher than group 1 (48%) (P < 0.05) and group 4 (47%) (P < 0.05). There was no difference between group 3 (60%) and group 6 (P = 0.2). From a clinical viewpoint, comparison of different electrocoagulation modes and pharmaceutical adhesion barriers is possible with standardised models.

Laparoscopic instruments that are newly inserted into trocars are initially outside the surgeon's endoscopic field of view. This can make it difficult to accurately position the instrument at the operative site and presents a potential risk to patients since the tip of the instrument could potentially perforate organs and blood vessels while it is advanced blindly. To solve this problem, I have designed a trocar that incorporates a laser pointer to guide laparoscopic instruments while they are outside the endoscopic field of view. The laser dot is projected along the long axis of the trocar. This allows the surgeon to instantly determine the direction and target of the introduced instrument. Furthermore, the projected laser dot serves as evidence of an unobstructed path from the trocar to the target. This modification improves safety in laparoscopic surgery.

Background: We investigated the hypothesis that local tissue ischemia is responsible for suture-induced adhesion formation., Methods: A total of 160 interrupted sutures were placed in the parietal peritoneum of 20 Wistar rats. The animals were randomized into an ischemia group, where the sutures were pulled tight and a non-ischemia group, where the sutures were tied as loose loops with air knots to avoid any local ischemia. The midline laparotomy was closed with a running suture. On postoperative day 10, adhesions to the sutures were counted., Results: There was no statistically significant difference in the number of adhesions forming to sutures with local ischemia (n = 66/80) versus sutures without local ischemia (n = 69/80)., Conclusion: We conclude that local tissue ischemia is not necessary for suture-induced adhesion formation and propose an additional mechanical mechanism to explain how suture knots can predispose to adhesiogenesis.

Background: On the one hand, barrier materials remain the only licensed adjuncts for postoperative adhesion reduction in the United States. On the other hand, pharmacotherapy for adhesion reduction has been a focus of intensive research. Therefore, the next step in the evolution of adhesion prophylaxis will consist of pharmacological functionalization of barrier materials to locally elute drugs. However, conventionally available animal models for postoperative adhesions are not optimized to screen candidate pharmaceutical agents for their local adhesion suppressing properties. Therefore, we have developed an animal model specifically for this purpose., Methods: Ischemic peritoneal lesions are created by ligating buttons of transversus abdominis muscle with sutures. These ischemic lesions are then directly injected with the candidate pharmaceutical agent. Injection of ischemic tissue ensures that the tested agent can only exert a local effect. Lesions injected with normal saline serve as internal controls., Results: In a pilot experiment n = 40 lesions were created in 10 Wistar rats and injected with normal saline. When analyzed by interval laparotomy on postoperative day 10, 58% (n = 23/40) of these lesions were affected by adhesions (95% confidence interval 42-71%). None of the adhesions were avascular. Ten adhesions were filmy and vascular. Twelve adhesions were dense and vascular. One adhesion involved organ inclusion with the liver attached to the experimental lesions., Conclusion: The described model is suitable for screening pharmaceutical agents for their local adhesion suppressing properties. It will help with the development of novel adhesion barriers that simultaneously function as drug-eluting vehicles.

Adhesions complicate most intra-peritoneal operations. Once adhesions have formed, patients are at life-long risk for complications that include small bowel obstruction, increased risks during subsequent operations and female infertility. This has two implications for the daily work of surgeons. On the one hand, surgeons need to include the risks from adhesions during pre-operative consent. On the other hand, surgeons need to use operative techniques that minimize adhesions. Therefore this review focuses on the practical implications of adhesions for preoperative consent and operative technique., (Copyright © 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Purpose: Intraabdominal adhesions represent a major cause of postoperative morbidity potentially causing pain, small bowl obstruction and infertility. The process of adhesion formation might be regarded as an ischemic disease. Under hypoxic conditions, metabolic enzymes are regulated via hypoxic responsive elements by the hypoxia-inducible factor 1 (HIF-1). We therefore investigated the gene expression of HIF-1 and two pivotal metabolic genes, pyruvate-dehydrogenaseβ (PDHb) and succinate-dehydrogenase-complex-subunit-A (SDHa) in a validated ischemia model of adhesion formation., Methods: Peritoneal adhesions were created using an ischemic button model in female Wistar rats. Expression levels of HIF-1α/β, PDHb and SDHa in adhesiogenic versus native peritoneum were analyzed using quantitative PCR on the third post-operative day., Results: Gene expression of HIF-1α was up-regulated by 10 % (p = 0.003), PDHb was up-regulated by 23 % (p = 0.0004) and SDHa (p = 0.0005) was up-regulated by 24 % in the adhesiogenic peritoneum compared to native peritoneum. The expression level of HIF-1β was not significantly influenced by adhesion formation., Conclusion: The increased expression level of HIF-1α in the peritoneal tissue of ischemic buttons associated with postsurgical adhesions supports the major role for hypoxia in influencing peritoneal expression patterns of genes involved in the process of adhesion formation. As pivotal metabolic genes are upregulated, this seems to be an anabolic process associated with increased cellular metabolism.

Separation of traumatized tissue represents the only promising strategy in postoperative adhesion prevention, a relevant clinical problem after surgical intervention. In the present study scanning electron microscopy (SEM) and subsequent morphometry were used to analyse the tissue response to five commercial adhesion barriers. Standardised peritoneal lesions in Wistar rats were covered with solid and viscous barrier materials and semiquantitatively analysed 14 days postoperatively. Striking morphological differences in lesion surface organisation between the barrier groups became apparent with colonisation of the barrier by mesothelial cells to different degrees. Furthermore, the mesothelial cells showed either a normal or activated phenotype depending on the underlying biomaterial. These experiments demonstrate that the examination by SEM gives useful insights into the performance of barrier materials and the cellular processes of adhesion prevention, since mesothelial cells play an active role in the pathogenesis of adhesion formation.

Introduction: The formation of peritoneal adhesions still is a relevant clinical problem after abdominal surgery. Until today, the most important clinical strategies for adhesion prevention are accurate surgical technique and the physical separation of traumatized serosal areas. Despite a variety of barriers which are available in clinical use, the optimal material has not yet been found., Discussion: Mesothelial cells play a crucial physiological role in friction less gliding of the serosa and the maintenance of anantiadhesive surface. The formation of postoperative adhesions results from a cascade of events and is regulated by various cellular and humoral factors. Therefore, optimization or functionalization of barrier materials by developments interacting with this cascade on a structural or pharmacological level could give an innovative input for future strategies in peritoneal adhesion prevention. For this purpose, the proper understanding of the formal pathogenesis of adhesion formation is essential. Based on the physiology of the serosa and the pathophysiology of adhesion formation, the available barriers in current clinical practice as well as new innovations are discussed in the present review.

Case Report: An asymptomatic 70-year-old man was found to have elevated liver function tests on a routine screening evaluation. Abdominal ultrasound revealed a pancreatic head mass. Magnetic resonance cholangiopancreatography confirmed a heterogeneously enhancing pancreatic mass that was suspicious for malignancy due to obstruction of the common bile duct and pancreatic duct. Consequently a pylorus-sparing pancreaticoduodenectomy was performed. Histology revealed a serous cystadenoma with scattered foci of PanIN III., Discussion: Serous cystadenomas are benign tumors without significant malignant potential. Unlike pancreatic adenocarcinomas, these tumors tend to be slow growing, well-demarcated, and rarely, as in this case, produce a mass effect.

Background: Pharmacotherapy for peritoneal adhesion prophylaxis has been a focus for intensive research. Previous strategies included intravenous and intraperitoneal application of suitable pharmaceutical agents. However, success of these strategies in humans has been limited. Here we describe intra-operative local injection of pharmaceuticals as a novel strategy for adhesion prophylaxis., Methods: N=208 peritoneal lesions were created in 26 adult Wistar rats. In each animal, lesions on one flank were randomly chosen for treatment with locally injected prednisolone whereas the contralateral side was injected with normal saline. Half of the animals were randomly selected for early adhesion scoring after 3 days. Adhesions were scored after 10 days in the other animals., Results: One animal randomized into the late group died peri-operatively. In the early analysis group, 27% (14/52) of treated lesions were affected by adhesions, whereas 50% (26/52) of control lesions were affected by adhesions. This difference was statistically significant (p=0.02). In the late analysis group, 52% (25/48) of treated lesions were affected by adhesions, whereas 60% (29/48) of control lesions were affected by adhesions. This difference did not reach statistical significance., Conclusions: These experiments provide proof of principle that intra-operative local injection of pharmaceutical agents is a promising strategy for adhesion prophylaxis. Once sutiable agents become available this could become as common as local anesthesia for pain reduction. However, the effect of injected prednisolone diminishes before the vulnerable time-frame for adhesion formation closes. Therefore slow-release formulations and other agents with longer effect will need to be investigated in the future., (Copyright © 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Chest compressions have saved the lives of countless patients in cardiac arrest as they generate a small but critical amount of blood flow to the heart and brain. This is achieved by direct cardiac massage as well as a thoracic pump mechanism. In order to optimize blood flow excellent chest compression technique is critical. Thus, the quality of the delivered chest compressions is a pivotal determinant of successful resuscitation. If a patient is found unresponsive without a definite pulse or normal breathing then the responder should assume that this patient is in cardiac arrest, activate the emergency response system and immediately start chest compressions. Contra-indications to starting chest compressions include a valid Do Not Attempt Resuscitation Order. Optimal technique for adult chest compressions includes positioning the patient supine, and pushing hard and fast over the center of the chest with the outstretched arms perpendicular to the patient's chest. The rate should be at least 100 compressions per minute and any interruptions should be minimized to achieve a minimum of 60 actually delivered compressions per minute. Aggressive rotation of compressors prevents decline of chest compression quality due to fatigue. Chest compressions are terminated following return of spontaneous circulation. Unconscious patients with normal breathing are placed in the recovery position. If there is no return of spontaneous circulation, then the decision to terminate chest compressions is based on the clinical judgment that the patient's cardiac arrest is unresponsive to treatment. Finally, it is important that family and patients' loved ones who witness chest compressions be treated with consideration and sensitivity.

A 26-year-old Rwandan male presented with constrictive pericarditis, massive ascites and a giant umbilical hernia that had been asymptomatic for over a decade. Successful pericardiectomy was complicated by prompt incarceration of the abdominal hernia. This unexpected complication was caused by rapid resolution of the ascites due to autodiuresis and subsequent collapse of the hernial orifice. Patients with constrictive pericarditis and massive ascites who are evaluated for pericardiectomy should be carefully examined for the presence of abdominal hernias. If any such hernias are found, perioperative hernia repair should be considered and postoperative diuresis should be undertaken under close observation.