VersaStep trocar hernia rate in unclosed fascial defects in bariatric patients.

OBJECTIVE: Use of the VersaStep trocar system (US Surgical, Norwalk, CT) has the perceived advantage of minimal trocar-related hernias in patients undergoing Roux-en-Y gastric bypass surgery (RYGB). We performed a retrospective review of our last 747 consecutive operative procedures using these trocars. METHODS AND PROCEDURES: The patient population was 747 consecutive patients who underwent laparoscopic RYGB at Duke University Health System Weight Loss Surgery Center from January 2002 through April 2005. A total of 3735 radially expanded trocar sites were used. VersaStep trocars were used in all cases. The port configuration included one supraumbilical Hasson port, two 12-mm ports, and three 5-mm ports. The Hasson port was closed with a figure-of-eight number 1 Polysorb suture. All other trocar sites had no fascial closure. Intestinal anastomoses were created with a linear stapler in all of the laparoscopic cases, with hand suturing of the residual enterotomy. The fascial incisions were therefore not extended to accommodate an EEA stapler. The charts were reviewed for occurrence of subsequent trocar site hernias. RESULTS: There were no hernias at any of the VersaStep trocar sites-an incidence of 0%. There were nine incisional hernias at the Hasson port site which later required surgical repair-an incidence of 1.20%. CONCLUSIONS: There were no hernias detected at any of the 1494 12-mm or 2241 5-mm VersaStep trocar sites, despite lack of suture closure. At the Hasson port site, there was a hernia incidence of 1.20%. In the bariatric RYGB population, routine suture closure of the fascia or muscle is not necessary when using radially expanding VersaStep trocars.

Analysis of deep vein thrombosis in burn patients.

OBJECTIVE: Deep vein thrombosis (DVT) represents a major cause of morbidity in surgical patients. Controversial reports exist on the incidence of DVT in burn patients. We report our experience over a 10-year period. METHODS: Patients admitted to our Burn Unit over the period 1991-2001 and diagnosed with DVT were identified. Their records were retrospectively reviewed for demographic factors, extent and severity of burn injury and outcome. RESULTS: A total of 4102 patients were admitted to the WPH Burn unit during the study period. All patients received routine subcutaneous heparin prophylaxis. Ten patients were diagnosed with DVT (0.25%). Compared to our total burn population, these patients were older (mean age 47 +/- 22.7 years versus 35 +/- 22 years P = 0.14) and had more extensive burns (mean total body surface area (TBSA) 34.7 +/- 25.3% versus 12 +/- 15.7% P = 0.02). Two patients developed non-fatal pulmonary embolism (PE). There were three deaths, none due to thromboembolic disease. There were no complications from the routine administration of subcutaneous heparin. CONCLUSION: The incidence of DVT in our study is much less than the incidence reported in other critically ill patients and less than that of most reports on burn patients. In our experience, routine heparin prophylaxis is effective for the prevention of DVT in burn patients.

Highly selective glycosylated prodrugs of cytostatic CC-1065 analogues for antibody-directed enzyme tumor therapy.

Novel prodrugs of the cytotoxic antibiotic CC-1065 for an antibody-directed enzyme prodrug therapy (ADEPT) were prepared that show an excellent selectivity with a high toxicity of the corresponding drug. In particular, the seco-CBI analogue of CC-1065, 1-chloromethyl-5-hydroxy-1,2-dihydro-3H-benz[e]indole, as well as the novel methyl-seco-CBI analogue 1-(1'-chloroethyl)-5-hydroxy-1,2-dihydro-3H-benz[e]indole, were synthesized and transformed into their galactosides 10 a and 10 b, respectively. These galactosides can be cleaved with beta-D-galactosidase to give the free cytotoxic compounds. They were tested in in vitro cytotoxicity assays by using human bronchial carcinoma cells of line A549 in the presence and in the absence of beta-D-galactosidase. While the seco-CBI prodrugs revealed only modest selectivity, prodrugs of the methyl-seco-CBI analogue bearing an anti orientation of the substituents at the two stereogenic centers of the N-heterocycle displayed an excellent selectivity with an ED(50) quotient of about 750. The cytotoxicity of the corresponding phenol was rather high, with an ED(50) of 1.3 nM. The diastereomer with a syn orientation at the stereogenic centers was much less toxic.

A novel approach in drug discovery: synthesis of estrone--talaromycin natural product hybrids.

Hetero-Diels-Alder reaction of the steroidal exocyclic enol ethers 14 and 15, obtained from the secoestrones 8 and 9 by reduction, iodoetherification, and elimination, with ethyl O-benzoyldiformylacetate (16) leads to the spiroacetals 17 and 18 as a mixture of four diastereomers. Reduction of the major diastereomers 17a and 18a with DIBAH and subsequent hydrogenation yields the novel natural product hybrids 21, 23, 24, and 25, which possess the structural features of the steroid estrone (7) and the mycotoxin talaromycin 6.

What influences medical students' choice of surgical careers.

BACKGROUND: Recent emphasis in medical education has been to encourage students to pursue primary care careers. This could have a negative impact on applications to surgical residencies. METHODS: To determine what factors are most influential for a student to pursue a surgical career in spite of this environment, third- and fourth-year medical students were surveyed with a 40-item questionnaire. RESULTS: The response rate was 37% (76/205). Those students considering a career in surgery were more likely than their counterparts to be motivated by role models (P <.006), career opportunities (P <.006), and academic opportunities (P <.013) in surgery. They were less likely than their counterparts to be discouraged from surgery on the basis of lifestyle (P <.001), time commitment (P <.001), call schedules (P <.001), or residency length (P <.028). No differences regarding financial rewards, research opportunities, or intellectual challenges were seen between the groups. Neither race nor sex had a significant role in the selection of surgery as a career. CONCLUSIONS: The data suggests that students are more likely to be influenced to pursue surgical careers by offering early exposure to positive role models and career and academic opportunities in surgery. Knowledge of these influences on student career choices should help surgical educators attract and maintain student interest in surgical careers.