Bypass Technique Research Articles

IBC-Oxford University2023_BJSOral_2Gut Microbiota and Metabolic Status shift 1 year after Laparoscopic Roux-en-Y vs One Anastomosis Gastric Bypass. Results of a Multi-centre Randomised Controlled Trial

Abstract Introduction The comparison of effectiveness between R-en-Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB/MGB) remains unclear, as well as the changes in gut microbiota (GM). Materials: prospective, cohort, multi-centre study enrolling 96 patients with severe obesity, applying inclusion criteria, randomised between OAGB/MGB or RYGB. Faecal and blood samples were collected, pre- (T0) and 12 months postoperatively (T1). GM was determined by V3-V4 16S rRNA regions sequencing and home-made bioinformatic pipeline based on Qiime2 plugin and R packages. A standardised meal test was performed at T0 and T1 with 250 ml of liquid meal Oxepa (Abbott, Japan). Aim To evaluate and compare OAGB/MGB vs RYGB microbiota profile shift postoperatively and its impact on metabolic and nutritional status. Results 54 patients completed the study, 27 for each procedure (females 61%). No significant differences were found at T0 for anthropometric and nutritional parameters, while a statistically significant anthropometrics’ reduction was registered at T1, with a significant improvement of glucose and lipid profile, and significant reduction in vitamins and iron. Postoperatively fasting glucose, lipid profile, vitamins and minerals were not significantly different between the 2 procedures. Fasting GLP-1 was higher at T1, but postprandial values showed a lower peak both 60' and 120' after ingestion of the mixed meal., with no significant difference between the 2 groups. Examining the GM’s alpha and beta diversity, Firmicutes/Bacteroides ratio increased postoperatively, mainly dependent on Bacteroidetes decreasing. Relative abundances evaluation highlighted those main differences between the identified clusters (group A 29 subjects, group B 14 subjects and group C 10 subjects) were dependent on variation in Bacteroidetes and Firmicutes. A different trend was detected at Phylum level between T0 and T1 of each cluster. Bacteroides and Streptococcus genera appeared mainly changed between the three groups (both showing p< 0.001). Conclusions The emergence of slightly different GM profile postoperatively may be related to clinical condition or may play a key role in the long-term outcome and may represent a biomarker to follow bariatric surgery’s outcomes. No difference between the two bypass techniques were found in GM profile or other examined metabolic parameters one year postoperatively.

United States insurance coverage of immediate lymphatic reconstruction.

Immediate Lymphatic Reconstruction (ILR) is a prophylactic microsurgical lymphovenous bypass technique developed to prevent breast cancer related lymphedema (BCRL). We investigated current coverage policies for ILR among the top insurance providers in the United States and compared it to our institutional experience with obtaining coverage for ILR. The study analyzed the publicly available ILR coverage statements for American insurers with the largest market share and enrollment per state to assess coverage status. Institutional ILR coverage was retrospectively analyzed using deidentified claims data and categorizing denials based on payer reason codes. Of the 63 insurance companies queried, 42.9% did not have any publicly available policies regarding ILR coverage. Of the companies with a public policy, 75.0% deny coverage for ILR. In our institutional experience, $170,071.80 was charged for ILR and $166 118.99 (97.7%) was denied by insurance. Over half of America's major insurance providers currently deny coverage for ILR, which is consistent with our institutional experience. Randomized trials to evaluate the efficacy of ILR are underway and focus should be shifted towards sharing high level evidence to increase insurance coverage for BCRL prevention.

Surgical bypass to the left subclavian artery: an extra-anatomical transpleural approach

A distal anastomosis in zone 3 is technically demanding during the frozen elephant trunk procedure. Proximalization of the distal anastomosis to zone 2 with subsequent revascularization of the left subclavian artery is an attractive alternative. This video tutorial describes the technique of an extra-anatomical bypass from the aortic prosthesis to the infraclavicular left subclavian (axillary) artery in arch replacement with the distal aortic graft anastomosis in zone 2.

Outcomes of Castor Single-Branched Stent Graft for Reconstruction of Multiple Supra-Aortic Branches in Aortic Arch Disease.

To report the outcomes of a combination of Castor single-branched stent grafts with other techniques for the reconstruction of multiple supra-aortic branches in aortic arch disease. Between December 2019 and December 2021, 20 patients with aortic arch disease underwent thoracic endovascular aortic repair (TEVAR) at our institution using a Castor single-branched stent graft combined with the fenestration, chimney, or bypass techniques. Thoracic endovascular aortic repair is indicated for complicated or acute type B aortic dissection (TBAD), nonruptured aneurysms with a maximum aneurysm diameter >5.5 cm or showing rapidly expanded, ruptured, or threatened aneurysms, and penetrating aortic ulcers (PAUs) with a maximal aortic diameter >5.5 cm or with PAUs >10 mm deep or >20 mm in diameter. Preoperative, intraoperative, and postoperative clinical data were recorded. The median age of the patients was 56 (range=52-69 years) years, and 19 patients were men. Seven patients underwent the Castor single-branched stent graft and left common carotid artery (LCCA) chimney technique, 8 patients underwent the Castor single-branched stent graft and fenestration technique, and 5 patients underwent the Castor single-branched stent graft and bypass technique. The technical success rate was 100%. Major adverse events included 2 endoleaks, 1 spinal cord ischemia, and 1 early-stage retrograde type A aortic dissection. No cerebral stroke-related complications were observed. The mortality rate was 10% (2/20 patients). One patient with thoracic aortic aneurysm (TAA) died because of a sudden decrease in oxygen saturation and blood pressure after surgery. Relatives declined autopsy, and the cause of death was not determined. Another patient died of a retrograde type A dissection after surgery. The median follow-up period was 6 months (range=3.5-12 months). During follow-up, 1 patient with type I endoleak underwent thoracotomy again after a year. The remaining patients recovered well. The combination of a Castor single-branched stent graft with fenestration, chimney, or bypass techniques may be an effective treatment for preserving multiple supra-aortic branches in aortic arch disease. This study introduced three methods of reconstruction of multiple supra-aortic branches using a Castor single-branched stent graft (Castor single-branched stent graft combined with fenestration, chimney, or bypass technique) and analysed their advantages and shortcomings to provide experience for the future treatment of aortic arch diseases.

Clinical effect of a modified superficial temporal artery-middle cerebral artery bypass surgery in Moyamoya disease treatment

BackgroundCerebral extracranial-intracranial (EC-IC) revascularization technique (superficial temporal artery-middle cerebral artery (STA-MCA) bypass grafting) has become the preferred surgical method for the treatment of Moyamoya disease (MMD). We attempted to completely free the two branches of the superficial temporal artery without disconnection. Extracranial and intracranial blood flow reconstruction were then modified by selectively performing a direct bypass technique on one branch and a patch fusion technique on the other of the STA based on the blood flow and the vascular diameter of the intracranial surface blood vessels.MethodsA series of modified STA-MCA bypass surgeries performed consecutively between March 2022 and March 2023 were reviewed and compared to conventional combined bypass surgeries performed during the same period. The following information was collected from all enrolled patients: demographic characteristics, clinical symptoms, and preoperative and postoperative imaging, including Suzuki stage and Matsushima grade. The modified Rankin scale (mRS) was used to assess the changes in neurological status before and after surgery.ResultsA total of 41 patients with Moyamoya disease (MMD) who underwent cerebral revascularization were included in this study, of which 30 were conventional revascularization and 11 were modified revascularization. The mean age was 49.91 years, and 18 (43.9%) of the patients were women. The modified group had a lower incidence of cerebral hyperperfusion syndrome (18.2%) than the conventional group (23.3%). After at least 3 months of follow-up, the bypass patency rate remained 100% in the modified group and 93.3% in the conventional group. All patients in the modified group achieved a better Matsushima grade (A + B), with six (54.5%) having an A and five (45.5%) having a B. In contrast, four patients (13.3%) in the conventional group had a Matsushima grade of C. In all, 72.8% of the modified group had postoperative mRS scores of 0 and 1, which was higher than that of the traditional group (63.3%).ConclusionThe improved STA-MCA bypass could provide blood flow to multiple cerebral ischemic areas, reduce excessive blood perfusion, and ensure blood supply to the scalp, with lower complications and better clinical benefits than the traditional combined bypass.

Vascular Repair for Iatrogenic Injury during Microsurgical Procedures: Clinical Investigation and Review of 18 Cases at a Single Institution.

Intracranial vascular injury (VI) due to surgery is a critical complication that can lead to serious neurologic deficits. To our knowledge, only a few review articles on VI during an operation have been published so far. We retrospectively investigated the type, cause, and measurement of VI during surgery at our institution. Unexpected VI cases occurred in 18 of 2,228 craniotomy procedures, including 794 aneurysm clippings and 357 tumor resections. We investigated the causes and coping techniques of the VI cases, as well as their full details. There were six cases of aneurysm neck tear, one case of sylvian vein injury, and one case of superior trunk perforation during direct clipping. Regarding tumor resection procedures, nine cases of arterial injury and one case of cortical vein injury were extracted. Almost all VIs were caused by carelessness or basic manipulation mistakes. We repaired all these cases with simple placement of suture threads with or without pinch clips, flow alteration using bypass techniques, and in 16 cases no neurologic deficit or deterioration on imaging occurred; however, 3 patients were verified to have ischemic changes on postoperative imaging. Most VIs were directly caused by a simple error and carelessness of an operator or an assistant. Many of these injuries can be avoided if a basic set of rules are followed and remembered during the surgical procedure. However, the surgical procedure involves human work, and errors cannot be eradicated even upon maximum concentration levels. Neurosurgeons should be prepared for an eventual quick repair of an unexpected cerebral VI.

Alternative Bypass Technique Using Radial Artery Graft between V3 Segment of Vertebral Artery and Middle Cerebral Artery: Technical Note.

There are some cases where a radial artery (RA) graft is needed for a high-flow extracranial to intracranial (EC-IC) bypass as the external carotid artery (ECA) cannot be utilized as a donor artery. In this report, we describe two cases of extracranial vertebral artery (VA) to middle cerebral artery (MCA) high-flow bypass using an RA graft with an artificial vessel as an alternative bypass technique. The patient was placed supine with a head rotation of 80 degrees. After frontotemporal craniotomy, another C: -shaped skin incision was made at the retroauricular region and the V3 portion of the VA was exposed at the suboccipital triangle. Prior to attempting the high-flow bypass, the superficial temporal artery (STA) was anastomosed to the M4 portion of the MCA as an insurance bypass. The RA graft was anastomosed to the V3 portion of the VA that traveled under the periosteum at the supra-auricular region through an artificial vessel. After RA-M2 anastomosis, an alternative EC-IC bypass, the V3-RA-M2 bypass, was achieved. Postoperative angiography demonstrated successful graft patency and no perioperative complications were observed in both cases. In the cases where a high-flow bypass is required, the V3 portion of the VA is a suitable alternative proximal anastomosis site when the ECA is not a candidate donor. Furthermore, an artificial vessel shows satisfactory protection against graft complications.

Design of CapEx and OpEx aware IP-over-WDM network using different types of traffic bypass and grooming techniques

To improve efficiency in setting up and operation of IP-over-WDM (IPoWDM) network, the network can be designed by minimizing either the capital expenditure (CapEx) or the operational expenditure (OpEx) in the planning phase. However, the CapEx-aware designed network may differ from the OpEx-aware designed network. Thus, Capex and OpEx need to be considered together to develop an expenditure-efficient network for a given planning period. Lightpath bypass and traffic grooming techniques help to minimize the required line card number in the core IP router. We design an expenditure (i.e., CapEx and OpEx put together for a given planning period) efficient IPoWDM network. We also review the effect of lightpath bypass and traffic grooming in the design. To design IPoWDM networks, we develop an optimization model and auxiliary-matrix-based heuristics to reduce the network’s total expenditure. The proposed methods judiciously deploy the network equipment at different places to reduce the total expenses and provide solutions for traffic grooming and placement of regenerators. We assume a realistic network framework where the bidirectional WDM equipment has finite transparent reach limit. The performance analysis shows that the multi-hop bypass approach provides more expenditure-efficient networks compared with the direct bypass and the non-bypass methods.

Microsurgical treatment of distal middle cerebral artery aneurysm: A single-center review.

To review the characteristics of distal middle cerebral artery (MCA) aneurysm treated by microsurgery, the detailed surgical options, and the clinical result. We retrospectively reviewed cerebral aneurysm in the M2 and M3 segments of the MCA surgically treated between January 2015 and December 2022. The demographic data, aneurysm-related findings, type of surgical approach, surgical technique, and clinical outcomes of the enrolled patients were analyzed. Sixteen distal MCA aneurysms were treated with microneurosurgery (incidence, 1.0%; female, 12; mean age, 58.1 years; ruptured, three). Twelve aneurysms were in the M2 segment (insular segment), two aneurysms at the M2-M3 junction, and two aneurysms in the M3 segment (opercular segment). Twelve aneurysms were saccular (average size, 4.9 mm; multiplicity, 50%; average aneurysms, 3.0; partially thrombosed, 1; sidewall aneurysm, 2). Three aneurysms were fusiform, of which two were ruptured. Of the ruptured aneurysms, one was a ruptured dissecting aneurysm. The trans-sylvian and trans-sulcal approaches were used in fourteen and two patients, respectively. Neck clipping, wrap clipping, and surgical trapping were performed in twelve, one, and one patient, respectively. Proximal occlusion was performed in one patient. Bypass technique was required in two patients (neck clipping and proximal occlusion). The modified Rankin Score was 6 in the two patients with ruptured aneurysms. The remaining patients did not show further neurological deterioration after microneurosurgery. Distal MCA aneurysms had a high incidence of being diagnosed with multiple other aneurysms and were relatively non-saccular.

Analysis of medium and long term efficacy of ossicle chain bypass technique in treatment of tympanosclerosis

Objective:For tympanosclerosis patients with ossicular chain fixation, we use ossicular chain bypass technique and evaluate its long-term effects. Methods:From June 2017 to June 2019, 147 patients with tympanosclerosis who underwent middle ear surgery with otoscopy in Yinchuan First People's Hospital were reviewed. The subjects were divided into three groups according to the implemented operation plan, 51 cases in the ossicular chain mobilization group（OCM）, 56 cases in the ossicular chain bypass reconstruction group（OCB）, and 40 cases in the malleus-incus complex resection reconstruction group（MICR）. Through a three-year follow-up, the medium and long-term effects of different operation plans were compared and analyzed. Results:There was no significant difference among the three groups in the incidence of tympanic membrane perforation, delayed facial nerve palsy, and the dispatch and displacement of PORP. The incidence of tympanic membrane retraction pocket or cholesteatoma after operation in OCB group（0） was significantly lower than that in OCM group（11.76%） and MICR group（7.5%）（P<0.05）. At 12 months after operation, ΔABG of OCB group and MICR group were better than that in the OCM group（P<0.05）. At 36 months after operation, ΔABG of OCB group was better than that in the OCM group（P<0.05）, and there was no significant difference between OCB group and MICR group. The audiological performance of patients with epitympanic sclerosis（ETS） at 12, 24 and 36 months after operation was better than that of patients with posterior tympanosclerosis（PTS） and total tympanosclerosis（TTS）（P<0.05）. Conclusion:Compared with patients undergoing ossicular chain mobilization and malleus-incus complex resection for ossicular chain reconstruction, patients with tympanosclerosis undergoing bypass technique have better and stable hearing prognosis in medium and long term. This technique can effectively prevent the formation of retracted pocket and cholesteatoma in patients with tympanosclerosis after operation.

Laparoscopic retrovesical lower uterine segment bypass for hysterectomy with previous caesarean section: Hung Up the Bladder Bypass (HUBB) technique.

Patients with a history of cesarean section and a highly adherent bladder may have difficulty in bladder dissection and may suffer damage. It may also be difficult to orient the patient for repair in the event of damage. In such cases, dissection from the side between the bladder and cervix is a good way to avoid complication. This video reviews the steps of the HUBB technique procedure, provides tips and tricks for performing a successful adhesiolysis, and illustrates the procedure's adaptability. The first is the identification of the uterine artery and its position. Step2, a Laparoscopic retrovesical lower uterine segment bypass is created. Step3 a Hung Up the Bladder Bypass is created, the bladder is completely dissected. Step4, an adhesiolysis and leak test is performed. In this report, we would like to introduce a technique for creating a retrovesical lower uterine segment bypass using a laparoscope and traction on the bypass to dissect the bladder.

IronNetInjector: Weaponizing .NET Dynamic Language Runtime Engines

As adversaries evolve their Tactics, Techniques, and Procedures (TTPs) to stay ahead of defenders, Microsoft’s .NET Framework emerges as a common component found in the tradecraft of many contemporary Advanced Persistent Threats (APTs), whether through PowerShell or C#. Because of .NET’s ease of use and availability on every recent Windows system, it is at the forefront of modern TTPs and is a primary means of exploitation. This article considers the .NET Dynamic Language Runtime as an attack vector, and how APTs have utilized it for offensive purposes. The technique under scrutiny is Bring Your Own Interpreter (BYOI), which is the ability of developers to embed dynamic languages into .NET using an engine. The focus of this analysis is an adversarial use case in which APT Turla utilized BYOI as an evasion technique, using an IronPython .NET Injector named IronNetInjector. This research analyzes IronNetInjector and how it was used to reflectively load .NET assemblies. It also evaluates the role of Antimalware Scan Interface (AMSI) in defending Windows. Due to AMSI being at the core of Windows malware mitigation, this article further evaluates the memory patching bypass technique by demonstrating a novel AMSI bypass method in IronPython using Platform Invoke (P/Invoke).

Evaluating outcomes among surgeons who changed their technique for gastric bypass: a state-wide analysis from 2011 to 2021.

Technical variation exists when performing the gastrojejunostomy during Roux-en-Y gastric bypass (RYGB). However, it is unclear whether changing technique results in improved outcomes or patient harm. Surgeons participating in a state-wide bariatric surgery quality collaborative who completed a survey on how they perform a typical RYGB in 2011 and again in 2021 were included in the analysis (n = 31). Risk-adjusted 30-day complication rates and case characteristics for cases in 2011 were compared to those in 2021 among surgeons who changed their gastrojejunostomy technique from end-to-end anastomosis (EEA) to either a linear staple or handsewn anastomosis (LSA/HSA). In addition, case characteristics and outcomes among surgeons who maintained an EEA technique throughout the study period were assessed. A total of 15 surgeons (48.3%) changed their technique from EEA to LSA/HSA while 7 surgeons (22.3%) did not. Nine surgeons did LSA or HSA the entire period and therefore were not included. Surgeons who changed their technique had significantly lower rates of surgical complications in 2021 when compared to 2011 (1.9% vs 5.1%, p = 0.0015), including lower rates of wound complications (0.5% vs 2.1%, p = 0.0030) and stricture (0.1% vs 0.5%, p = 0.0533). Likewise, surgeons who did not change their EEA technique, also experienced a decrease in surgical complications (1.8% vs 5.8%, p < 0.0001), wound complications (0.7% vs 2.1%, p < 0.0001) and strictures (0.2% vs 1.2%, p = 0.0006). Surgeons who changed their technique had a significantly higher mean annual robotic bariatric volume in 2021 (30.0 cases vs 4.9 cases, p < 0.0001) when compared to those who did not. Surgeons who changed their gastrojejunostomy technique from circular stapled to handsewn demonstrated greater utilization of the robotic platform than those who did not and experienced a similar decrease in adverse events during the study period, despite altering their technique. Surgeons who chose to modify their operative technique may be more likely to adopt newer technologies.

Modern synergetic neural network for imbalanced small data classification

Deep learning’s performance on the imbalanced small data is substantially degraded by overfitting. Recurrent neural networks retain better performance in such tasks by constructing dynamical systems for robustness. Synergetic neural network (SNN), a synergetic-based recurrent neural network, has superiorities in eliminating recall errors and pseudo memories, but is subject to frequent association errors. Since the cause remains unclear, most subsequent studies use genetic algorithms to adjust parameters for better accuracy, which occupies the parameter optimization space and hinders task-oriented tuning. To solve the problem and promote SNN’s application capability, we propose the modern synergetic neural network (MSNN) model. MSNN solves the association error by correcting the state initialization method in the working process, liberating the parameter optimization space. In addition, MSNN optimizes the attention parameter of the network with the error backpropagation algorithm and the gradient bypass technique to allow the network to be trained jointly with other network layers. The self-learning of the attention parameter empowers the adaptation to the imbalanced sample size, further improving the classification performance. In 75 classification tasks of small UC Irvine Machine Learning Datasets, the average rank of the MSNN achieves the best result compared to 187 neural and non-neural network machine learning methods.

Assessing the Learning Curve of the Minimally Invasive Direct Coronary Artery By-pass Technique

Assessing the Learning Curve of the Minimally Invasive Direct Coronary Artery By-pass Technique

Technique and early results of percutaneous femoropopliteal bypass with stent graft

ObjectiveWe describe the technique and early results of lower extremity revascularization with total percutaneous bypass using extravascular placement of a stent graft (percutaneous prosthetic bypass). MethodsPatients with severe chronic limb threatening ischemia for whom open or endoluminal repair was either not feasible and or had failed were selected for a pilot study using percutaneous prosthetic bypass. The procedure requires placement of three introducer sheaths in the contralateral common femoral artery, and the ipsilateral proximal and distal superficial femoral arteries (SFAs). A guidewire is placed from the contralateral sheath to the ipsilateral popliteal artery via the two ipsilateral sheaths. Two self-expanding polytetrafluoroethylene-covered stents are then placed from the proximal SFA to the distal SFA. ResultsA total of 30 bypasses were performed in 28 patients aged 71 ± 3 years. Of the 28 patients, 16 had severe claudication (Rutherford class 3; 53%) and 14 had critical ischemia (Rutherford class 4-6; 47%). The early results were excellent, with no deaths and one occlusion successfully treated with thrombolysis. No other complications requiring reintervention occurred. The mean follow-up was 25.4 months (range, 3-36 months). The 12- and 36-month Kaplan-Meier survival curve was 100% and 81%, respectively. The primary patency, secondary patency, and freedom from amputation rates were 75% and 75%, 78% and 75%, and 100% and 91%, respectively. ConclusionsFor patients with long lesions and/or failed endovascular treatment, the described technique offers the advantage of a total percutaneous procedure with acceptable early results. If these favorable outcomes are confirmed in larger series with longer follow-up, percutaneous extravascular bypass of the SFA will represent a complementary tool for infrainguinal arterial repair.

Influence of condenser bypass port area on maximum thermal load of heat pipe

Experimental works have been conducted to enhance the performance of heat pipes by focusing on the maximum thermal load, which is a very important performance indicator. Ordinal operation on the heat pipe occurs when the capillary force is sufficient to overcome the flow resistance of the working fluid. Therefore, one method of increasing the maximum thermal load is to reduce the flow resistance of the liquid and vapor with counter flow in the system. Moreover, the flow resistance of the working fluid is immediately dependent on the mass flow rate, and reducing the flow rate can effectively increase the maximum thermal load. The liquid bypass technique is one method of alleviating the flow resistance of the working fluid inner side a heat pipe container. In this work, a modified heat pipe system with one liquid bypass tube was manufactured and investigated, with the bypass tube being constructed so that some of the working fluid inside the condenser could be bypassed to an evaporator not going through a heat pipe interspace with vapor and liquid counterflow. Three bypass ports were located in the condenser; hence, the influence of bypass port area on thermal of heat pipe performance was investigated experimentally. Mass flow rate control valves were attached to these three bypass ports, and the maximum thermal loads according to the activation of each port were experimentally measured. The maximum thermal load in a horizontal position increased by up to 45.8% with an increase in the area of the bypass port. With the increase of the activated bypass port area, the condenser wall temperature increased by up to 15.9 °C.

Effect of laparoscopic mini-gastric bypass versus laparoscopic sleeve gastrectomy on hypertension and dyslipidemia in obese type 2 diabetes mellitus patients.

The aim of the research was to compare the effect of the laparoscopic mini-gastric bypass (LMGB) technique with the laparoscopic sleeve gastrectomy (LSG) technique in bariatric surgery on type 2 diabetes mellitus (T2DM), hypertension (HTN), and dyslipidemia in obese T2DM patients. A prospective, cross-sectional study, conducted in Surgery Department at Al-Mouwasat and Al-Assad University Hospitals in Damascus, and included T2DM obese patients who would undergo bariatric surgery using the LMGB or LSG technique. The research included two groups: the LSG group (92 patients, 60.9% female, age 44.6 year, BMI 41.85kg/m2) and the LMGB group (137 patients, 59.1% female, age 47.1 year, BMI 43kg/m2). Before surgery, the prevalence of HTN and dyslipidemia were similar in the two groups. After one year: T2DM improvement and remission rate in the LMGB group (13.9, 80.3%) were greater than in the LSG group (13, 62%), the difference was statistically significant. The HTN improvement and remission rate in the LMGB group (52.9, 41.4%) were greater than in the LSG group (47.5, 39%), the difference was not statistically significant. The dyslipidemia improvement rate was greater in LSG group (47.2 vs. 32.7%), while the dyslipidemia remission rate was greater in LMGB group (67.3 vs. 52.8%), the difference was statistically significant. The authors found that the LMGB technique was more effective than the LSG technique in controlling cardiovascular risk factors of obesity, T2DM, HTN, and dyslipidemia.

The Feasibility and Early Results of Multivessel Minimally Invasive Coronary Artery Bypass Grafting for All Comers.

Cardiovascular surgery advancements have emerged with various minimally invasive approaches for treating multivessel coronary disease to improve outcomes and minimize the burden associated with conventional cardiac surgery. We present our clinical experience and minimally invasive coronary bypass techniques through minithoracotomy, which we apply without selection to patients who have decided to have elective surgery for multivessel isolated coronary artery disease. It consists of 230 consecutive patients operated by the same team with this method between July 2020 and September 2022. The patients were assigned to one of the two methods preoperatively to their accompanying comorbidities and operated on either with blood cardioplegia via 5 to 7 cm left anterior minithoracotomy, with on-pump clamped technique or without pump via left anterolateral minithoracotomy. Mortality was observed in two of our patients (0.9%), but myocardial infarction was not observed in our patients in the early postoperative period. None of our patients required conversion to sternotomy (0%). Five patients' needed reoperation from the same incision due to postoperative bleeding (2.2%), and atrial fibrillation developed in 17 patients in the postoperative period (7.4%). The mean number of bypasses was found to be 3.0 ± 0.9. Minimally invasive coronary artery bypass surgery via minithoracotomy can be routinely reproduced safely. More long-term results and more multicenter studies are needed for more widespread acceptance of the technique.

Cost-effective QKD protocol upgrading for metropolitan quantum optical networks

Quantum key distribution (QKD) is a promising technology that can provide future-proof security. With the emergence of multiple advanced QKD protocols, the QKD protocol upgrading for a metropolitan quantum optical network (MQON) is critical for fulfilling the requirements of users for secret keys with a high security level. Conventionally, due to the lack of effective QKD protocol upgrading strategies for MQONs, massive amounts of resources have to be consumed during QKD protocol upgrading, resulting in high costs. In order to reduce the costs for practical implementation of QKD protocol upgrading, in this work, a new policy of QKD protocol upgrading is proposed, where the bypass technique is adopted to decouple multiple protocols from the linking patterns for efficient resource utilization. Moreover, we illustrate a multi-role QKD node structure for enabling the harmonious operation of multiple QKD protocols. A mixed integer linear programming (MILP) model and a novel divided-packet-based QKD protocol upgrading algorithm are designed to save costs by relying on flexible traffic management. We also propose a fixed-chain-based QKD protocol upgrading algorithm with fixed traffic management for achieving low costs. Simulation results indicate that the proposed heuristic algorithms are significantly more cost effective than the associated benchmark algorithms, while the MILP model can reduce the cost of protocol upgrading by 41% compared with the benchmark.