A single centre experience on the formation of double barrelled uro-colostomy in pelvic exenteration surgery: a cohort study.

BACKGROUND: Double barrelled uro-colostomy (DBUC) is an alternative to traditional ileal conduit (IC) and separate colostomy in patients requiring simultaneous urinary and faecal diversion for reconstruction in pelvic exenteration surgery (PES). METHODS: This cohort study evaluated short- and long-term morbidity and mortality associated with DBUC formation in 20 consecutive adult patients undergoing PES in an Australian Complex Pelvic Surgical Unit. Data were obtained from a prospective database. RESULTS: Mean age 59 years (range 27-76 years). PES was performed for malignant disease in 18 patients (curative intent in 17). Mean operative duration 11.8 h (range 7-17 h). Mean follow-up duration 29.1 months (range 2.6-90.1 months). Early DBUC-related complications occurred in four patients (20.0%): urinary tract infection (UTI)/urosepsis (n = 4) and early ureteric stenosis requiring intervention (n = 1). Late DBUC-related complications occurred in five patients (25.0%): recurrent UTI/urosepsis (n = 4), chronic kidney disease (n = 4), ureteric stenosis (n = 2) and parastomal hernia (n = 4). No mortality occurred secondary to a DBUC complication. CONCLUSION: DBUC is a safe reconstructive option with acceptable morbidity profile in patients requiring simultaneous urinary and faecal diversion.

Laparoscopic right hemicolectomy with intracorporeal anastomosis and natural orifice surgery extraction/minimal extraction site surgery in the obese.

BACKGROUND: Despite advantages associated with laparoscopic colorectal surgery, there is significant morbidity associated with incisions required for specimen extraction and restoration of bowel continuity. In laparoscopic colorectal surgery, the length of the longest incision depends upon that required to facilitate extra-corporeal steps. The purpose of this study was to analyse obese patients (body mass index >30 kg/m2 ) who have undergone laparoscopic small bowel or right-sided colonic resection with intracorporeal anastomosis (ICA) and natural orifice surgery extraction (NOSE)/minimal extraction site (MES) surgery. METHODS: A retrospective review of 11 obese patients who have undergone laparoscopic small bowel and right-sided colonic resection with ICA and NOSE/MES was conducted. RESULTS: Mean body mass index was 40.4 kg/m2 (range 32.7-56 kg/m2 ) in 11 patients. Procedures performed were laparoscopic right hemicolectomy (7) - one with high anterior resection, pelvic peritonectomy, bilateral salpingo-oophorectomy and greater omentectomy, small bowel resection (2), transverse colotomy (1) and segmental transverse colectomy (1). All colonic specimens were extracted via NOSE (vaginal colpotomy or transcolonic), except two requiring a miniaturized extraction wound. Small bowel specimens were extracted via a 12-mm port hole, without extension. Mean operating time was 240 min (range 100-510 min). Mean time to discharge was 4 days (range 4-6 days). Complications included a superficial wound infection in a patient presenting with an obstructed tumour and a second patient developed a seroma following small bowel resection for an incarcerated hernia. CONCLUSION: Obese patients can undergo laparoscopic small bowel and right-sided colonic resection with ICA and NOSE/MES surgery and benefit from short length of stay and low morbidity.

Concomitant Abdominoplasty and Laparoscopic Umbilical Hernia Repair.

BACKGROUND: Umbilical hernia is a common finding in patients undergoing abdominoplasty, especially those who are postpartum with rectus divarication. Concurrent surgical treatment of the umbilical hernia at abdominoplasty presents a "vascular challenge" due to the disruption of dermal blood supply to the umbilicus, leaving the stalk as the sole axis of perfusion. To date, there have been no surgical techniques described to adequately address large umbilical herniae during abdominoplasty. OBJECTIVES: To present an effective and safe technique that can address large umbilical herniae during abdominoplasty. METHODS: A prospective series of 10 consecutive patients, undergoing concurrent abdominoplasty and laparoscopic umbilical hernia repair between 2014 and 2017 were included in the study. All procedures were performed by the same general surgeon and plastic surgeon at the Macquarie University Hospital in North Ryde, NSW, Australia. Data were collected with approval of our ethics committee. RESULTS: At 12-month follow up there were no instances of umbilical necrosis, wound complications, seroma, or recurrent hernia. The mean body mass index was 23.8 kg/m2 (range, 16.1-30.1 kg/m2). Rectus divarication ranged from 35 to 80 mm (mean, 53.5 mm). Umbilical hernia repair took a mean of 25.9 minutes to complete (range, 18-35 minutes). CONCLUSIONS: We present a technique that avoids incision of the rectus fascia minimizes dissection of the umbilical stalk and is able to provide a gold standard hernia repair with mesh. This procedure is particularly suited to postpartum patients with large herniae (>3-4 cm diameter) and wide rectus divarication, where mesh repair with adequate overlap is the recommended treatment.

Inhibition of human recombinant T-type calcium channels by N-arachidonoyl 5-HT.

BACKGROUND AND PURPOSE: N-arachidonoyl 5-HT (NA-5HT) has anti-nociceptive effects reported to be mediated by inhibitory actions at the transient receptor potential vanilloid receptor 1 (TRPV1) and fatty acid amide hydrolase (FAAH). Anandamide and N-arachidonoyl dopamine (NA-DA), endocannabinoids that activate TRPV1 or are metabolized by FAAH, also inhibit T-type calcium channels (I(Ca) ). T-type I(Ca) are expressed by many excitable cells, including neurons involved in pain detection and processing. We sought to determine whether NA-5HT also modulates T-type I(Ca) . EXPERIMENTAL APPROACH: Human recombinant T-type I(Ca) (Ca(V) 3 channels) expressed in HEK 293 cells were examined using standard whole-cell voltage-clamp electrophysiology techniques. KEY RESULTS: NA-5HT completely inhibited Ca(V) 3 channels with a rank order of potency (pEC(50) ) of Ca(V) 3.1 (7.4) > Ca(V) 3.3 (6.8) ≥ Ca(V) 3.2 (6.6). The effects of NA-5HT were voltage-dependent, and it produced significant hyperpolarizing shifts in Ca(V) 3 steady-state inactivation relationships. NA-5HT selectively affected Ca(V) 3.3 channel kinetics. CONCLUSIONS AND IMPLICATIONS: NA-5HT increases the steady-state inactivation of Ca(V) 3 channels, reducing the number of channels available to open during depolarization. These effects occur at NA-5HT concentrations at or below those at which NA-5HT affects TRPV1 receptors and FAAH. NA-5HT is one of the most potent inhibitors of T-type I(Ca) described to date, and it is likely to exert some of its biological effects, including anti-nociception, via inhibition of these channels.

Inhibition of human recombinant T-type calcium channels by the endocannabinoid N-arachidonoyl dopamine.

BACKGROUND AND PURPOSE: N-arachidonoyl dopamine (NADA) has complex effects on nociception mediated via cannabinoid CB(1) receptors and the transient receptor potential vanilloid receptor 1 (TRPV1). Anandamide, the prototypic CB(1)/TRPV1 agonist, also inhibits T-type voltage-gated calcium channel currents (I(Ca)). These channels are expressed by many excitable cells, including neurons involved in pain detection and processing. We sought to determine whether NADA and the prototypic arachidonoyl amino acid, N-arachidonoyl glycine (NAGly) modulate T-type I(Ca) EXPERIMENTAL APPROACH: Human recombinant T-type I(Ca) (Ca(V)3 channels) expressed in HEK 293 cells and native mouse T-type I(Ca) were examined using standard whole-cell voltage clamp electrophysiology techniques. KEY RESULTS: N-arachidonoyl dopamine completely inhibited Ca(V)3 channels with a rank order of potency (pEC(50)) of Ca(V)3.3 (6.45) > or = Ca(V)3.1 (6.29) > Ca(V)3.2 (5.95). NAGly (10 micromol.L(-1)) inhibited Ca(V)3 I(Ca) by approximately 50% or less. The effects of NADA and NAGly were voltage- but not use-dependent, and both compounds produced significant hyperpolarizing shifts in Ca(V)3 channel steady-state inactivation relationships. By contrast with anandamide, NADA and NAGly had modest effects on Ca(V)3 channel kinetics. Both NAGly and NADA inhibited native T-type I(Ca) in mouse sensory neurons. CONCLUSIONS AND IMPLICATIONS: N-arachidonoyl dopamine and NAGly increase the steady-state inactivation of Ca(V)3 channels, reducing the number of channels available to open during depolarization. These effects occur at NADA concentrations at or below to those affecting CB(1) and TRPV1 receptors. Together with anandamide, the arachidonoyl neurotransmitter amides, NADA and NAGly, represent a new family of endogenous T-type I(Ca) modulators.