Articles: cations.
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Our goal was to evaluate the feasibility of transrectal rigid hybrid natural orifice translumenal endoscopic surgery (NOTES) sigmoidectomy (trNS) in a series of consecutive prospective patients with diverticular disease. The NOTES for left colectomy offers patients reduced pain and easier recovery. Limited data are available for trNS, which is considered safe for various indications. However, the technique is not standardized, and patients in the reported series are highly selected. ⋯ Transrectal rigid hybrid natural orifice translumenal endoscopic sigmoidectomy is feasible and safe in a high proportion of unselected consecutive patients with diverticular disease undergoing elective treatment. Intracorporeal side-to-end anastomosis is the preferred technique, and trNS should be offered for elective sigmoidectomy presupposing advanced laparoscopic experience.
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Comparative Study
Impact of "Do Not Resuscitate" Status on the Outcome of Major Vascular Surgical Procedures.
Patients with Do Not Resuscitate (DNR) orders may still be offered surgery that aims to prolong or improve quality of life. The widely accepted approach of "required reconsideration" mandates that patients and surgeons discuss perioperative risks and expected outcomes in the context of the patient's values and preferences. However, surgical outcomes in this patient population have not been well-defined. The objectives of this study are to assess outcomes in DNR patients undergoing major vascular procedures, and develop an evidence basis for informed, shared decision-making. ⋯ DNR patients are at high risk for major complications and mortality after vascular surgery procedures. Compared with a matched cohort of "high-risk" non-DNR patients, those with DNR orders suffered equivalent rates of postoperative morbidity, but markedly increased mortality. This suggests that DNR status, independent of comorbidities and perioperative complications, may increase the risk of "failure to rescue." These findings have implications not only for risk adjustment, but also provide an evidence basis for shared decision-making in challenging circumstances.
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Thoracoabdominal aortic aneurysm (TAAA) remains a challenging problem. We sought to examine our experience with thoracic and thoracoabdominal aortic repairs over a 24-year period. ⋯ Open DTAA and TAAA repair can be performed with acceptable early and late outcomes. This study provides important early- and long-term data on open repair, allowing for better risk stratification of patients with DTAA and TAAA. It is the high-risk subgroup that can now be targeted for endovascular techniques.
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Nitric oxide (NO) is a potent signaling molecule maintaining numerous physiological and pathophysiological processes. Because of its short lifespan, the detection of NO by electron paramagnetic resonance spectroscopy (EPR) in frozen tissues requires stabilization by specific exogenous NO-traps. Such NO-traps are unfeasible in clinical settings, and are restricted to experimental models only. ⋯ Our methodological approach enables quantification of NO production in vivo without introduction of NO-traps and allocates NO-generation either to extra- or intracellular compartments of the liver. This method can be effectively applied for analysis of human biopsies.
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Trauma patients (TP) often develop an imbalanced immune response, frequently leading to infectious post-injury complications. Monocytes, part of innate immune system, show diminished HLA-DR-expression and impaired pro-inflammatory cytokine-release upon stimulation after trauma. Monocytes recognize lipopolysaccharide (LPS) via TLR4 and CD14. Data on TLR4-expression in TP's monocytes are conflicting. Moreover, there are no studies describing TLR4-expression after secondary stimulation or TLR4- and HLA-DR-co-expression after trauma. ⋯ Next to reduced monocyte function, TP show diminished TLR4-expression after stimulation. Here, a possible mechanism for endotoxin tolerance in monocytes after major trauma is shown. Additionally, impaired TLR4-expression on naive HLA-DR- monocytes may contribute to functional suppression of monocytes after trauma.