Double Barrel Research Articles

Abstract No. 452: Single session management of SVC syndrome and complex central vein occlusion

1) The reader will learn an algorithmic approach to single session treatment of extensive central vein occlusions in SVC Syndrome: i.e. techniques, tools, results and evidence. 2) To learn an approach to vein stenting: i.e. double barrel, end-to-side, bare vs. covered, single side and best sizing. Central vein occlusions (CVO) are common in end stage renal disease (ESRD) patients, due to chronic catheter use, and patients with thoracic malignancies. Symptoms include: facial, laryngeal, neck and/or upper extremity edema, and syncope. The exhibit will review existing literature of techniques and results to treating CVOs and provide case examples from review of 23 consecutive patients, who were diversely treated for SVC syndrome at a single academic institution. The proposed algorithm to single session treatment of CVO's will include description of patient procedural positioning, access site entry, procedural equipment and complex image guidance (i.e. sharp recanulization and echocardiography). Specific procedural techniques to treat single brachiocephalic, internal jugular, SVC occlusion and complex multi-vein occlusion of the SVC, brachiocephalic and internal jugular veins will be discussed and case examples presented. Diverse management strategies including a guide to catheter selection to maximize transversal of occlusions, balloon angioplasty, stenting (i.e. sizing, configuration, bare metal vs. covered), thrombolytic treatment with or without mechanical thrombolysis to achieve durable vessel patency in a single session will be presented. To present an algorithmic approach to endovascular management of SVC Syndrome, including a range of endovascular tools to allow a reliable single session treatment of a broad range of anatomic central vein occlusions.

Vascularized fibular graft for bone defects after wide resection of musculoskeletal tumors

BackgroundIn reconstruction by vascularized fibular graft (VFG) after wide resection of musculoskeletal tumors, there are problems such as the method of fixing the fibular graft, the period of achieving bone union, and the avoidance of postoperative fractures. We have performed VFG on 19 cases over a 30-year period. We have investigated these problems and now report the results. MethodsFrom 1980 to 2009, we performed VFG on 19 cases to reconstruct the bone defect after resection of a musculoskeletal tumor. The mean age was 19.5years. Reconstructed bone defects were located in the femur in 10 cases (1 of inlay graft, 1 of individual intercalary graft, 7 of intercalary graft into treated bone, 1 of curettaged bone marrow), the tibia in 3 cases (1 of individual intercalary graft, 2 of intercalary graft into treated bone), the humerus in 3 cases (2 of sling procedure, 1 of individual intercalary graft), the foot in 2 cases individual intercalary graft, and the sacroiliac joint in 1 case of individual intercalary graft. The mean follow-up period after surgery was 7.25years. We evaluated the success of primary bone union, the period required to achieve bone union, complications, clinical outcome, and the Musculoskeletal Tumor Society (MSTS) score. ResultsSuccessful bone union was achieved for 79% of cases (15/19 patients). The average period required to achieve bone union was 7.8months. There were 4 cases of non-union and 2 other complications. Clinical outcome status was continuous disease-free in 12 cases and died of disease in 7. The mean MSTS score was 98% (93–100%). ConclusionVascularized fibular graft is a useful reconstructive procedure for long-bone defects after wide excision of musculoskeletal tumors. The method of fixation can be selected according to the situation; although times required for bone union are long, it is possible to prevent postoperative fractures by a combined approach with treated bone and/or double barrel fibular grafts.

Incomplete transverse vesical septum: An unusual congenital anomaly

A rare case of incomplete transverse vesical septum with urinary tract tuberculosis is being reported. A 52-year-old male presented with lower urinary tract and systemic symptoms. On investigation he had anemia, leucocytosis, and high serum creatinine. On cystopanendoscopy, there was a transverse ledge of tissue connecting the two lateral walls of the bladder approximately 4 cm proximal to the bladder neck dividing the caudal vesical cavity into anterior and posterior parts. Also, the left ureteric orifice had double barrel look. To our knowledge this is the first ever reported case of incomplete transverse vesical septum.

Lambeau libre de péroné en « double barre » et risque vasculaire. Enquête nationale

The free fibula flap is the most commonly used flap for mandibular reconstruction thanks to its multiple advantages. Its main drawback is the thin width of the bone section. The "double barrel" fibula flap is a solution to this problem allowing reconstruction of both basilar and alveolar ridges for a stable prosthetic dental rehabilitation. The authors wanted to assess its use, in France, to evaluate its reliability, and to determine its indications. The authors sent a questionnaire to the 25 French Maxillo-Facial University Hospital Departments. Questions concerned the surgical technique, its indications, and the operative results, between January 2002 and December 2007. Out of the 18 teams who answered, 16 used a free fibula flap for mandibular reconstruction but only seven used the double barrel technique, for a total of 24 double barrel reconstructions. Only one total necrosis was reported. The indications for double barrel fibula flap were nearly all for corpus reconstruction and the operating overtime was less than one hour. The international literature review analysis gives results which compare to French ones, with a weak rate of necrosis despite the intermediate rectangular ostectomy. This technique may be recommended especially since it does not increase the operative time much and it improves dental restoration.

One and a Half Barrel Vascularized Free Fibular Flap for the Reconstruction of Segmental Mandibular Defect

Ulkur, Ersin MD; Karagoz, Huseyin MD; Kocyigit, Ismail D. DDS, PhD; Oksuz, Sinan MD; Acikel, Cengiz MD; Urhan, Muammer MD

Ostomy complicatıons in patients with anorectal malformations

Ostomy is an important step in the treatment of patients with anorectal malformation (ARM). Sometimes this basic surgical procedure may cause a devastating complication. The medical reports of the patients with ARM who had ostomy in the past were inspected. How many of them were operated in this center or sent from others, the type of ARM, what type of ostomy performed and which place of the bowel used and the complication type and rate related to ostomy and ostomy closure were evaluated. Nearly, 157 of 230 patients with ARM had ostomy during twenty-two years were evaluated. The prevelent type of ostomy was loop (50.3%) and then separated (36.9%), end (7%), double barrel (4.4%) and window (1.2%). The ostomies were located in the tranverse colon (53.5%), descending colon (24.2%), sigmoid colon (17.8), pouch colon (2.5%) and ileum (1.9). Total complication rate was found to be 15.2% (24/157) (window 100%, double barrel 42.8%, separated 15.5%, loop 11.3%, end 9%). The main complication of loop ostomies was prolapse whereas wound problems, stenosis, intestinal obstruction or perforation were serious problems of separated ostomies. Complication rate in the descending colon and tranverse colon was found to be 7.1 and 28%, respectively (p=0.001). Any difference for complication rate between loop and separated ostomies was not found. Eighteen of separated ostomies had mucous fistula and six of them (33%) were complicated, this rate was higher than those without mucous fistula (p=0.012). Two babies with separated ostomy were lost due to surgical complications (1.2%). Complication rate after ostomy closure was 10.7% [wound infection (4.4%), intestinal obstruction (1.7%)]. According to this study, ostomy performed in the descending colon carries greater risks for complication regardless of its type. Nevertheless, separated ostomy with mucous fistula should be performed by experienced hands.

AN EXPERIENCE OF SIGMOID COLON VOLVULUS AT EMMERGENCY WARD LRH

BACKGROUND: Sigmoid volvulus is a serious condition due to rotation of sigmoid colon. Volvulusoften presents with abdominal colic and distention. It can be managed conservatively by colonoscopicdecompression, followed by optimization of patient and finally surgical procedure. The present studywas based on the comparison of resection of sigmoid colon and double barrel colostomy or resection andprimary anastomosisOBJECTIVE: Objective of the study was to compare the results of primary anastomosis and colostomyin patients presenting with sigmoid volvulus.METHODOLOGY: In this study a total of 48 patients with sigmoid volvulus coming to Accident &Emergency Department were included. All the patients were examined and investigated. After diagnosisbased on x-ray erect abdomen all the patients were admitted in Accident and Emergency ward. Afteradmission Full Blood count, urea, sugar, S. Electrolysis and ECG were also performed. Patients werecatheterized and a nasogastric tube passed for gastric decompression. All the patients were givenintravenous fluids antibiotics and prepared for surgery as facilities for colonoscopic sigmoidscopicdecompression were not available and decompressions by rectal tube was unsuccessfulRESULTS: Among the cases with sigmoid volvulus there were 36 males and 12 were females. Majority28 cases were in age range of 61-70 years. Eight patients had gangrene of sigmoid colon, 23 patients hadresection and colostomy while 20 had resection and primary anastomosis. Among the postoperativecomplications, 05 patients had wound infection and 01 wound dehiscence. Two patients died because ofsepsis and cardiopulmonary complications.CONCLUSION: Patients presenting as acute abdomen should have urgent laparotomy as soon aspossible. Decompression by colonoscope is the gold standard procedure for stable patients with sigmoidvolvulus. Sigmoidectomy and primary anastomosis is the procedure of choice as it not only avoidssecond admission and operation, but it also avoids the side effects and care of stoma, which is majorcause of morbidity and mortality.

443: Double barrel placental cord insertions (DBPCI): marker for high risk placental vascular configuration impacting survival with selective fetoscopic laser photocoagulation (SFLP) in twin-to-twin transfusion syndrome

SFLP has become the standard treatment for TTTS with survival of one or both twins in >90% and of both twins in >70% of pregnancies, respectively. Recently, we recognized the presence of “double barrel” PCIs (< 2 cm apart) as a marker of poor outcome following selective fetoscopic laser photocoagulation (SFLP) due to complex vascular anatomy. In order to better understand the effect on survival we reviewed our experience with this unusual vascular configuration, “double barrel” PCIs (DBPCI).

The group II chaperonin Mm‐Cpn binds and refolds human γD crystallin

Chaperonins assist in the folding of nascent and misfolded proteins, though the mechanism of folding within the lumen of the chaperonin remains poorly understood. The archeal chaperonin from Methanococcus marapaludis, Mm-Cpn, shares the eightfold double barrel structure with other group II chaperonins, including the eukaryotic TRiC/CCT, required for actin and tubulin folding. However, Mm-Cpn is composed of a single species subunit, similar to group I chaperonin GroEL, rather than the eight subunit species needed for TRiC/CCT. Features of the β-sheet fold have been identified as sites of recognition by group II chaperonins. The crystallins, the major components of the vertebrate eye lens, are β-sheet proteins with two homologous Greek key domains. During refolding in vitro a partially folded intermediate is populated, and partitions between productive folding and off-pathway aggregation. We report here that in the presence of physiological concentrations of ATP, Mm-Cpn suppressed the aggregation of HγD-Crys by binding the partially folded intermediate. The complex was sufficiently stable to permit recovery by size exclusion chromatography. In the presence of ATP, Mm-Cpn promoted the refolding of the HγD-Crys intermediates to the native state. The ability of Mm-Cpn to bind and refold a human β-sheet protein suggests that Mm-Cpn may be useful as a simplified model for the substrate recognition mechanism of TRiC/CCT.

In vivo simultaneous intra- and extracellular potassium recordings using a micro-optrode

This technique proposes a new approach to correlate intra- and extracellular variations of the ionic concentrations in vivo by means of tapered optical waveguides coupled to standard electrophysiological electrodes to monitor in vivo simultaneously the intracellular and extracellular K+ concentration as well as the neighboring field potential. The optical fibers were tapered to a final diameter of approximately 10μm and were used to guide the excitation light deep into the tissue and to collect the fluorescence emanating from the intracellular milieu. This fiber was coupled to a double barrel ion-sensitive electrode forming a micro-optrode with a final diameter around 15μm. The method was successfully used to record the intracellular K+ evolution with the fluorescent indicator PBFI during three states: normal sleep-like patterns, paroxysmal seizures, and coma. While we could not disclose any phasic fluctuations of the intracellular K+ during normal sleep patterns, they were clearly present during seizures and coma. In the majority of cases (58%), paroxysmal discharges were associated with positive variations of the intracellular fluorescence of 62±5% corresponding to extracellular K+ increases of 2.04±0.4mM. In the remaining cases (42%) intracellular K+ dropped by 44.4±12% for an extracellular K+ increase of 2.62±0.47mM. We suggest that this differential behavior might reflect different cellular populations (glia vs. neurons, respectively). Comatose states were accompanied by an extracellular drop of K+ of 1.31±0.13mM, which was reflected, in all cases, by an intracellular K+ increase of 39±4%.

Structural classification of proteins and structural genomics: new insights into protein folding and evolution.

During the past decade, the Protein Structure Initiative (PSI) centres have become major contributors of new families, superfamilies and folds to the Structural Classification of Proteins (SCOP) database. The PSI results have increased the diversity of protein structural space and accelerated our understanding of it. This review article surveys a selection of protein structures determined by the Joint Center for Structural Genomics (JCSG). It presents previously undescribed β-sheet architectures such as the double barrel and spiral β-roll and discusses new examples of unusual topologies and peculiar structural features observed in proteins characterized by the JCSG and other Structural Genomics centres.

P-017 ‘Double barrel’ stent reconstruction of a symptomatic fusiform basilar artery aneurysm

Objective and importanceGiant fusiform aneurysms of the basilar artery are associated with a high rate of morbidity and mortality. Treatment of these lesions can be difficult especially when there are...

Staged Surgery for Severe Soft Tissue and Bone Loss of the Knee

A 20- year-old female student was involved in a motor vehicle accident. She sustained a severe friction injury to the left knee that resulted in considerable soft tissue and bone loss. There was also damage to the knee extensor mechanism, tibialis anterior muscle, femoral trochlea, the anterior half of the tibial plateau extending distally to the proximal tibia and skin. However, there was no crushing of the limb or resultant neurovascular deficit but cancellous bone and the remainder of the joint were exposed. Repeated surgical debridement was performed and was followed by covering of the soft tissue using a latissimus dorsi free flap and skin grafts. The bony defect was reconstituted with antibiotic bone cement to prevent flap adherence and shrinkage, enhance stability and prevent fracture. The cement was later removed at the time of arthrodesis at which time an ipsilateral double barrel vascularised fibular graft supplemented with autogenously cancellous bone and a ring fixator was used. Computer tomography confirmed union at three months post procedure. The fixator was then removed and a tibialis posterior transfer was performed.

An Unprotected Distal Left Main Disease Treated with Stenting- A Maiden Experience at a Tertiary Care Center

Unprotected left main disease which till recently was considered a class III indication for PCI has been accepted as a IIb indication in the last updated AHA/ACC guidelines. Now world over , UPLM stenting is being increasingly taken up , especially after the entry of drug eluting stents in the coronary interventional arena. The distal left main disease is considered the technically most challenging. We present here a case of distal left main disease with critical ostial LAD and LCX disease, successfully managed with stenting via the double barrel technique. J Med Sci 2010;13(1):25-27

Combined microsurgical and endovascular treatment of a giant left middle cerebral artery aneurysm

Giant fusiform aneurysms of the middle cerebral artery (MCA) bifurcation pose significant treatment challenges. A giant fusiform aneurysm of the left MCA in a pediatric patient, which persisted despite Hunterian...

Structural Insights on the Mycobacterium tuberculosis Proteasomal ATPase Mpa

Proteasome-mediated protein turnover in all domains of life is an energy-dependent process that requires ATPase activity. Mycobacterium tuberculosis (Mtb) was recently shown to possess a ubiquitin-like proteasome pathway that plays an essential role in Mtb resistance to killing by products of host macrophages. Here we report our structural and biochemical investigation of Mpa, the presumptive Mtb proteasomal ATPase. We demonstrate that Mpa binds to the Mtb proteasome in the presence of ATPgammaS, providing the physical evidence that Mpa is the proteasomal ATPase. X-ray crystallographic determination of the conserved interdomain showed a five stranded double beta barrel structure containing a Greek key motif. Structure and mutational analysis indicate a major role of the interdomain for Mpa hexamerization. Our mutational and functional studies further suggest that the central channel in the Mpa hexamer is involved in protein substrate translocation and degradation. These studies provide insights into how a bacterial proteasomal ATPase interacts with and facilitates protein degradation by the proteasome.

Osteocutaneous Free Flap Including Medial and Lateral Scapular Crests: Technical Aspects, Viability, and Donor Site Morbidity

The aims of the present study were to check for metabolism of the bony segments of osteocutaneous free flaps that included lateral as well as medial scapular crests by 18F-fluoride positron emission tomography (PET)/computed tomography (CT) examinations and to assess donor site morbidity. Twenty patients were included in the study. In 10 patients, osteocutaneous free flaps were harvested that included lateral as well as medial scapular crests. Seven days after surgery, an 18F-fluoride PET/CT examination was performed to assess the metabolism and viability of the bony segments. In the additional 10 patients, flaps were harvested that only included the lateral scapular crest. All patients were asked to fill in the disabilities of the arm, shoulder, and hand (DASH) questionnaire 1 and 6 months after surgery. In the 10 free flaps that included lateral as well as medial scapular crests, 18F-fluoride PET/CT examinations revealed metabolism and viability of both bony segments. The DASH scores for the two patient groups did not differ significantly at 1 and 6 months after surgery (p(1 month) = 0.520, p(6 months) = 0.545). It seems that scapular osteocutaneous free flaps adopting lateral as well as medial scapular crests are a viable option for mandibular reconstruction and may be an alternative to the fibular double barrel.

Synthesis and Biophysical Studies on 35‐Deoxy Amphotericin B Methyl Ester

The use of molecular editing in the elucidation of the mechanism of action of amphotericin B is presented. A modular strategy for the synthesis of amphotericin B and its designed analogues is developed, which relies on an efficient gram-scale synthesis of various subunits of amphotericin B. A novel method for the coupling of the mycosamine to the aglycone was identified. The implementation of the approach has enabled the preparation of 35-deoxy amphotericin B methyl ester. Investigation of the antifungal activity and efflux-inducing ability of this amphotericin B congener provided new clues to the role of the 35-hydroxy group and is consistent with the involvement of double barrel ion channels in causing electrolyte efflux.

Novel Transaortic Double Barrel Ventricular Cannula

A novel transaortic ventricular cannula, known as the ‘double barrel’ cannula (DBC), is designed to minimize the invasiveness of Ventricular Assist Device (VAD) implantation by combining the inlet and outlet cannulae into a single dual lumen cannula. Both flows will pass through a single opening in the apex of the Left Ventricle with the outflow then continuing past the aortic valve, into the aortic arch. This design offers several potential advantages over the current state-of-the-art. These include less invasive surgery and providing mechanical support to the septum. By routing the outflow through the aortic valve, the need to access the external structure of the ascending aorta is eliminated thereby eliminating the need for open heart surgery. In determining the DBC's design, close attention has been paid to the outflow portion of the cannula, which passes through the aortic valve. It was anticipated that this portion of the DBC could have the largest impact on the device's usability in practice. The object of this study was to test the performance of the valve with the cannula passing through it. Three different geometries are circular, equilateral triangular, and one-third semicircular. Experiments measuring aortic insufficiency during the diastolic phase were conducted. The experiment was designed to analyze several geometries passing through an aortic valve under diastolic flow conditions. All experiments used a simple flow loop which allows a natural porcine aortic valve to be viewed from downstream. The loop was driven with a pneumatic ventricular simulator in order to produce a cyclic flow. Three cannulae cross-sections were molded from RTV11 Silicone. During this test, High Speed Cinematography and flow rate measurement were used to quantify valve sealing and leakage. All data was collected and analyzed for the three cross-sectional geometries during diastole. The performances of the three geometries were compared using American Heart Association guidelines of aortic insufficiency (Al) diagnosis. The flow rate data was integrated in order to determine the volume of ventricle ejection and valve regurgitation. All three geometries exhibit low and acceptable levels of Al (⩽15%Al), with the circular geometry causing the least amount of Al at 7.1%. The experimental control (Porcine aortic valve with no cannulae) exhibited an Al or 2.4%, validating both the harvested aortic valve and experimental flow loop for further testing. Using the high speed cinematography, several phenomena were observed during the sealing of the porcine valve; including leaflet folding leaflet bunching, and cannula displacement due to valve closure.

Rupture of urinary bladder: a case report and review of literature

IntroductionSpontaneous rupture of the urinary bladder is a rare event. Patients usually present with features of peritonitis and diagnosis is usually made at operation. The morbidity and mortality rate is very high in these groups of patients.Case presentationWe present a case of a 47-year-old caucasian woman who was known to have transitional cell carcinoma of the urinary bladder who presented with features of peritonitis. An exploratory laparotomy revealed free perforation of the urinary bladder. The perforation was closed. However, on the second post-operative day she started draining urine from the abdominal drain and was taken back to the operating theatre. The stitches in the urinary bladder had given off and she underwent radical cystectomy along with double barrel cutaneous ureterostomies. Peritoneal biopsies revealed disseminated transitional cell carcinoma in the peritoneum. She made a slow postoperative recovery.ConclusionPerforation of the urinary bladder should be considered in patients presenting with peritonitis particularly with a previous history of urinary bladder cancer.