Timing Of Resumption Research Articles

Abstract 14190: Optimal Peri-endoscopic Management of Anti-thrombotic Therapy in Chinese Elderly Patients: A Retrospective Study

Introduction: To investigate optimal timing of cessation and resumption of anti-thrombotic therapy (ATT) during gastrointestinal endoscopy in Chinese elderly patients. Methods: Between January 1st 2008 and December 31st 2014,at Chinese PLA General Hospital, 3747 patients (76.03±10.3 years) hospitalized for elective gastrointestinal endoscopy were retrospectively analyzed. The study population were predominately male(96.1%) and senile(age ≥60, 92.3%).Patients‘ peri-endoscopic management of ATT and adverse events (thromboembolism and bleeding) were recorded. RхC tables were used to compare the differences of peri-endoscopic adverse events among patients with different peri-endoscopic management of ATT. Results: the peri-endoscopic thromboembolic incidence in those with discontinuing ATT ≥7 days before procedure was significantly higher (8.12%). No difference of bleeding incidence was found among different cessation time before procedure. The peri-endoscopic thromboembolic incidence increased as the delaying of resuming ATT after procedure. However, the incidence of peri-endoscopic bleeding in patients with resuming ATT 2-7 days after procedure was lowest (0.63%). The reason why bleeding incidences in patients with resuming ATT >7 days, and those without resuming ATT were much higher than those with resuming ATT 2-7 days was that occurrence of bleeding urged physician to postpone or cancel resumption of ATT. When discontinuing ATT, the differences of peri-endoscopic thromboembolic or bleeding events between patients receiving low-molecular-weight heparin bridging therapy and those without bridging therapy were not significant. Conclusions: Cessation of ATT <7 days before endoscopic procedure and resumption of ATT in 2-7days after procedure were optimal peri-endoscopic ATT management strategy for Chinese elderly patients.Bridging therapy couldn’t protect elderly patients from peri-endoscopic thromboembolic events.

Timing of the resumption of antithrombotic agents following surgical evacuation of chronic subdural hematomas: a retrospective cohort study.

Antithrombosis (AT), defined here as either antiplatelets or anticoagulants, is a significant risk factor for the development of chronic subdural hematomas (cSDHs). Resuming AT following the evacuation of cSDH is a highly variable practice, with scant evidence in the literature for guidance. Here, a retrospective analysis of a cohort of patients from a single institution undergoing surgical drainage of cSDH was performed to evaluate postoperative complications and determine the optimal timing of the resumption of common antithrombotic agents. This retrospective analysis was performed on 479 patients undergoing surgical evacuation of cSDH at St. Michael's Hospital over a 5-year period (2007-2012). The collected variables included the type of AT agent, indications for AT, timing and type of postoperative complications, and the restart intervals for the AT agents, when available. Postoperative complications were classified as major hemorrhages, minor hemorrhages, or thromboembolic events. Among all 479 study patients, 71 experienced major hemorrhage (14.8%), 110 experienced minor hemorrhage (23.0%), and 8 experienced thromboembolism (1.67%) postoperatively. Patients on any type of preoperative AT regimen were at a higher risk of major hemorrhage (19.0% vs 10.9%; OR 1.93; 95% CI 1.15-2.71; p = 0.014). The type of AT agent did not affect the frequency of any postoperative complications. Patients on any preoperative AT regimen experienced earlier postoperative major hemorrhages (mean 16.2 vs 26.5 days; p = 0.052) and thromboembolic events (mean 2.7 vs 51.5 days; p = 0.036) than those patients without a history of AT; the type of AT agent did not affect timing of complications. Patients who were restarted on any AT therapy postoperatively were at decreased risk of major rebleeding following resumption than those patients who were not restarted (OR 0.06; 95% CI 0.02-0.2; p < 0.01). Patients with a history of preoperative AT experienced thromboembolic complications significantly earlier than those patients without AT, which peaked at 3 days postoperatively with no increase in hemorrhage risk when AT was restarted. Cursory evidence is presented that shows resuming AT early following the surgical evacuation of cSDH at 3 days postoperatively may be safe. However, much larger prospective studies are required prior to providing any definitive recommendations regarding the optimal timing and method of resumption of individual agents.

Does Early Resumption of Low-Dose Aspirin after Evacuation of Chronic Subdural Hematoma with Burr-Hole Trepanation Lead to Higher Recurrence Rates?

Aim: Chronic subdural hematoma (cSDH) is one of the most common neurosurgical diseases typically affecting elderly people. Many of these patients present with other comorbidities like coronary artery disease (CAD) and receive antiplatelet therapy with acetylsalicylic acid (ASA). Despite growing clinical relevance, there is still a lack of data focusing on the perioperative management of such patients. The aim of this study was to investigate the association between timing of postoperative antiplatelet resumption and the recurrence rates of cSDH. Methods: A total of 140 (18.7%) out of 750 consecutive patients undergoing surgical evacuation of cSDH under antiplatelet therapy with low-dose ASA were included in this study. In addition to the baseline characteristics, patients' files were retrospectively reviewed for recurrence rate, clinical outcome, morbidity, and mortality. Using a multivariate logistic regression model, the correlation between timing of postoperative ASA resumption and recurrence rate was analyzed. The primary end point was postoperative recurrence rate of subdural hematomas requiring revision surgery. The secondary end points were major cardiovascular events, morbidity, and mortality. Results: Multivariate logistic regression analysis showed no statistical significant association between early postoperative resumption of ASA treatment and recurrence of cSDH (OR 0.99; CI: 0.978–0.999; p > 0.5). The corresponding OR of experiencing a recurrence when resuming ASA therapy one day earlier was 1.01. High postoperative mRS (OR 1.59; CI 1.14–2.23; p = 0.006) and low postoperative GCS score (OR 0.78; CI: 0.6–1.01; p = 0.041) were statistically significant risk factors for recurrence of cSDH. Postoperative myocardial infarction (3 cases vs. 1 case), other thrombotic events (6 vs. 0 cases), surgical morbidity (19 cases vs. 1 case), and mortality (4 cases vs. 1 case) showed no significant difference between patients with discontinued ASA therapy and those under continuous ASA treatment. Conclusion: Our data suggest that in patients undergoing burr-hole trepanation for cSDH, the early resumption of low-dose ASA therapy is not associated with higher recurrence rates. We therefore recommend early resumption of ASA therapy, especially in patients treated for secondary prevention of CAD.

Do changes in spring phenology affect earlywood vessels? Perspective from the xylogenesis monitoring of two sympatric ring‐porous oaks

This study addresses relationships between leaf phenology, xylogenesis, and functional xylem anatomy in two ring-porous oak species, the temperate Quercus robur and the sub-Mediterranean Q.pyrenaica. Earlywood vessel (EV) formation and leaf phenology were monitored in 2012 and 2013. Ten individuals per species were sampled at each of three sites located in NW Iberian Peninsula. EV areas measured on microcore sections were used to calculate the hydraulic tree diameter (Dh ), in order to model relationships to phenology. Thermal requirements were evaluated using growing degree days (GDD). A species-specific timing of growth resumption was found. The onset of EV formation and budburst were associated to a particular GDD in each species. The onset and duration of EV enlargement affected Dh (and EV size) in Q.robur, but hardly in Q.pyrenaica. The relationship between the timings of EV formation and xylem structure appears to be stronger for the temperate oak, whose larger vessels may result from thermal-induced earlier resumption. In contrast, the sub-Mediterranean oak would maintain a more conservative hydraulic architecture under warming conditions.

Institutional transformation model of timing of the labor potential of the population in the Republic of Karelia

The article presents a transformation model of timing for resumption and fulfillment of the labor potential of the population over the working age in the Republic of Karelia as a northern region. Based on the sociological methods of gathering information and mathematical methods of data processing, as well as the proposed institutional transformation model of timing for the labor potential fulfillment, the main socio-economic factors of the labor potential realization of the population over the working age are identified. Some mechanisms to improve the institutional environment for resumption and fulfillment of the labor potential of the third age population are proposed. It is proved that under the conditions of aging of the population, reduction in the share of the working-age population, migration outflow of the most active groups the institutional innovations, enabling to stimulate economic activity of the third age population through creation of the institutional environment for the fulfillment of their labor potential, come into effect.

Técnica Pelosi de operación cesárea. Estudio clínico comparativo con la técnica convencional

OBJETIVO: Comparar las características y morbilidad asociadas a la técnica convencional de cesárea y la técnica Pelosi de cesárea. DISEÑO: Estudio retrospectivo, comparativo, descriptivo. LUGAR: Servicio de Obstetricia del Hospital I "Uldarico Rocca Fernández" (EsSalud). MATERIAL Y MÉTODOS: Se revisó 162 historias clínicas de pacientes que fueron sometidas a cesárea entre los años 2001 y 2002; de las cuales 81 fueron realizadas con la técnica convencional y otras 81 con la técnica Pelosi. Se determinó el tiempo operatorio, presencia y tipo de complicaciones, pérdida sanguínea, tiempo de reinicio de ingesta oral y estancia hospitalaria postoperatoria, mediante una ficha estadística especial. RESULTADOS: Las indicaciones principales en ambos grupos fueron sufrimiento fetal agudo (SFA) y antecedente de cesárea anterior. El tiempo operatorio fue de 34,8 minutos en la técnica Pelosi vs. 51,7 minutos en la técnica convencional. En cuanto al tiempo de reinicio de ingesta oral, en la técnica Pelosi fue 8,2 horas vs. 14,2 horas de la técnica convencional. La hemoglobina disminuyó 1,21 g% con la técnica Pelosi vs. 2,22 g% con la técnica convencional. La complicación principal en ambos grupos fue la infección de herida operatoria (6,2% en la convencional vs. 4,9% en la Pelosi). CONCLUSIONES: La técnica cesárea tipo Pelosi es una alternativa segura de elección de parto operatorio, inclusive en cesáreadas anteriores. Se sugiere realizar estudios similares en otros centros hospitalarios del Minsa y EsSalud, para corroborar las ventajas de esta técnica quirúrgica.

Timing of resumption of antithrombotic agents following surgical evacuation of chronic subdural hematomas: a retrospective cohort study

Background: Antithrombosis (AT), with antiplatelets or anticoagulants, is a significant risk factor for the development of chronic subdural hematomas (cSDH). Resumption of AT following hematoma evacuation is variable, with scant evidence for guidance. Methods: We retrospectively analyzed 479 patients with surgically-evacuated cSDH at St. Michael’s Hospital from 2007-2012. Collected variables included type of AT, indication for AT, timing and type of postoperative complications, and restart intervals for AT agents. Postoperative complications were classified as major or minor hemorrhages, or thromboembolism. Results: Among all patients, 14.8% experienced major hemorrhage, 23.0% minor hemorrhage, and 1.67% thromboembolism. Patients on any preoperative AT were at higher risk of major hemorrhage (OR=1.93, p=0.014), experienced earlier major hemorrhage (mean 16.2 versus 26.5d, p=0.052) and earlier thromboembolism (mean 2.7 versus 51.5d, p=0.036). The type of agent did not affect complication frequency or timing. Patients restarted on any AT postoperatively were at decreased risk of major rebleed following resumption, than those not restarted (OR=0.06, p&lt;0.01). Conclusions: Patients on preoperative AT experienced thromboembolism significantly earlier, at 3d postoperatively, with no increase in rebleed risk following AT resumption. We provide cursory evidence that resuming AT early, at 3d postoperatively, may be safe. Larger prospective studies are required for definitive recommendations.

To compare the safety, benefits, and incidence of postoperative complications among patients having early oral feeding versus traditional feeding in postoperative period following elective intestinal anastomosis

Objective: To compare the safety, benefits and incidence of postoperative complications among patients having early oral feeding versus traditional delayed feeding in postoperative period following elective intestinal anastomosis. Methods: This prospective study was conducted in the department of surgery IGMC Shimla. A total of 40 patients undergoing elective routine intestinal anastomosis were included in this studyIn study group patients were fed early within 8 hrs after surgery starting with liquids, semisolids. In control groups patients were started oral feeding after appearance of bowel sounds, passage of flatus and stool. Patients were matched according to age, sex, indication of surgery, nutritional status. Analysis was done using student t-test regarding timing of appearance of bowel sounds, nausea and vomiting, passage of flatus and stool, postoperative complications, duration of stay. Results: Five patients in study and four patients in control group developed postoperative nausea and vomiting (P>0.05). Average time for appearance of bowel sounds was 0.95 ± 0.39 day in study group and 1.85 ± 0.67 days in control group (P 0.05). In our study mean time for resumption of normal feeds was 6.05 ± 2.31 days in study group and 8.25 ± 2.75 days in control group (P 0.05). Conclusions: Early oral feeding after elective intestinal anastomosis is well tolerated. It helps in resolution of ileus, decreased wound infection and improved wound and anastomotic healing leading to shorter hospital stay.

Reducing the Disruptive Effects of Interruptions With Noninvasive Brain Stimulation.

The authors determine whether transcranial direct current stimulation (tDCS) can reduce resumption time when an ongoing task is interrupted. Interruptions are common and disruptive. Working memory capacity has been shown to predict resumption lag (i.e., time to successfully resume a task after interruption). Given that tDCS applied to brain areas associated with working memory can enhance performance, tDCS has the potential to improve resumption lag when a task is interrupted. Participants were randomly assigned to one of four groups that received anodal (active) stimulation of 2 mA tDCS to one of two target brain regions, left and right dorsolateral prefrontal cortex (DLPFC), or to one of two control areas, active stimulation of the left primary motor cortex or sham stimulation of the right DLPFC, while completing a financial management task that was intermittently interrupted with math problem solving. Anodal stimulation to the right and left DLPFC significantly reduced resumption lags compared to the control conditions (sham and left motor cortex stimulation). Additionally, there was no speed-accuracy tradeoff (i.e., the improvement in resumption time was not accompanied by an increased error rate). Noninvasive brain stimulation can significantly decrease resumption lag (improve performance) after a task is interrupted. Noninvasive brain stimulation offers an easy-to-apply tool that can significantly improve interrupted task performance.

Quality indicators common to all GI endoscopic procedures.

Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (1). The American Society for Gastrointestinal Endoscopy (ASGE), the American College of Gastroenterology (ACG), and the American Gastroenterological Association (AGA) have continually promoted the ideal that all patients have access to high-quality GI endoscopy services. A high-quality endoscopy is an examination in which patients receive an indicated procedure, correct and relevant diagnoses are recognized or excluded, any therapy provided is appropriate, and all steps that minimize risk have been taken.

The postpartum period in dromedary camels: Uterine involution, ovarian activity, hormonal changes, and response to GnRH treatment

The aim of the present study was to investigate the time for complete uterine involution and resumption of ovarian activity in postpartum dromedary camels, relative to hormonal changes. A total of six females were examined by ultrasonography twice weekly starting 3d after parturition. GnRH was administered when the follicles reached ≥0.9cm diameter. Blood samples were collected for hormonal analysis. Results revealed that the mean intervals for complete involution of the previously gravid horn, non-gravid horn, and cervix were 34.33±3.9, 29.01±0.81, and 28.71±1.51d, respectively. After GnRH treatment (Days 17–34), five of the six camels had ovulated. The corpus luteum was detected by Day 4.1±1.6 after GnRH treatment and lasted for 6±1.1d. Serum progesterone (P4) was basal and increased only after GnRH treatment. Serum estradiol 17-β (E2) peaked twice: when a large follicle was detected and 8.5±2.8d post-GnRH treatment. The serum FSH pattern was biphasic, with two peaks just before the recruitment of small follicles and 4.67±4.1d after GnRH treatment. The five ovulating females were mated; two conceived after the first service and three after the second service. The interval from calving to conception was 78.16±3.71d. It was concluded that in dromedary camels, involution of the uterus is completed by the 5th week postpartum, these camels are highly responsive to early GnRH treatment, and they can be mated between the 5th and 6th week after parturition with encouraging conception rates.

Fatigue and recovery during and after static loading

Subjectively assessed endurance time (ET), resumption time (RT) and perceived discomfort, pain or fatigue (PD), and objectively measured maximum force-exerting capacity were investigated for varying loads and durations of a pushing task with two repeated trials. Beyond the main results quantifying how the load scenario affected ET, RT and PD, three additional results are of note: (1) although the maximum pushing force did not change between trials, shorter ET, longer RT and higher PD indicated accumulation of fatigue in Trial 2; (2) the PD ratings showed a trend with a linear increase during loading and a curvilinear decrease during recovery; and (3) the RT and the load level for different relative loading times were found to have an unexpected U-shaped relationship, indicating lowest fatigue at the intermediate load level. These results can be used to model a more sustainable and productive work-recovery ratio.

Resumption of chest compressions after successful defibrillation and risk for recurrence of ventricular fibrillation in out-of-hospital cardiac arrest.

Prior investigation of out-of-hospital cardiac arrest has raised the concern that ventricular fibrillation (VF) recurrence may be triggered by chest compression (CC) resumption. We investigated predictors of VF recurrence after defibrillation, including timing of CC resumption. Patients with witnessed out-of-hospital cardiac arrest and initial rhythm of VF from an Utstein-style database were analyzed. For each shock that defibrillated VF, CC resumption and VF recurrence times were determined. Shocks were classified according to postshock rhythm. Factors (age, sex, time from dispatch to monitor/defibrillator application, and CC resumption) that could predict VF recurrence were analyzed. CC resumption was categorized into groups: CC1, 1 to 5 seconds; CC2, 6 to 10 seconds; CC3, 11 to 30 seconds; and CC4, >30 seconds. Eighty-eight subjects were analyzed, with a total of 285 shocks, with 226 shocks that achieved asystole (n=102), organized rhythm (n=120), or monomorphic ventricular tachycardia (n=4). After a successful shock, CC resumption occurred at a median (interquartile range) of 8 (5-18) seconds. VF recurred after 166 shocks (74%) and recurred within 30 seconds in 69 shocks. There was no significant relationship between VF recurrence and factors analyzed including CC resumption time, nor stratified by postshock rhythm. The hazard ratios (HRs) for VF recurrence within 30 seconds for later CC groups (CC2, CC3, and CC4) relative to early CC resumption (CC1) were as follows: HR(CC2)=1.05 (P=0.9); HR(CC3)=1.75 (P=0.1); and HR(CC4)=0.67 (P=0.4). VF recurrence within 30 seconds of a defibrillatory shock was not dependent on timing of CC resumption in patients with witnessed arrest and initial rhythm of VF.

Thirty-day mortality risk associated with the postoperative nonresumption of angiotensin-converting enzyme inhibitors: a retrospective study of the Veterans Affairs Healthcare System.

Angiotensin-converting enzyme inhibitors (ACE-Is) are a widely used class of cardiovascular medication. However, limited data exist on the risks of postoperative nonresumption of an ACE-I. To evaluate the factors and 30-day mortality risks associated with the postoperative nonresumption of an ACE-I. A retrospective cohort study. Veterans Affairs (VA) Healthcare System. A total of 294,505 admissions in 240,978 patients with multiple preoperative prescription refills (>3) for an ACE-I who underwent inpatient surgery from calendar years 1999 to 2012. None. We classified surgical admissions based upon the timing of postoperative resumption of an ACE-I prescription from the day of surgery through postoperative days 0 to 14 and 15 to 30, and collected 30-day mortality data. We evaluated the relationship between 30-day mortality and the nonresumption of an ACE-I from postoperative day 0 to 14 using proportional hazard regression models, adjusting for patient- and hospital-level risk factors. Sensitivity analyses were conducted using more homogeneous subpopulations and propensity score models. Twenty-five percent of our cohort did not resume an ACE-I during the 14 days following surgery. Nonresumption of an ACE-I within postoperative day 0 to 14 was independently associated with increased 30-day mortality (hazard ratio: 3.44; 95% confidence interval: 3.30-3.60; P < 0.001) compared to the restart group. Sensitivity analyses maintained this relationship. Nonresumption of an ACE-I is common after major inpatient surgery in the large VA Health Care System. Restarting of an ACE-I within postoperative day 0 to 14 is, however, associated with decreased 30-day mortality. Careful attention to the issue of timely reinstitution of chronic medications such as an ACE-I is indicated.

Benefit of oral feeding as early as one day after elective surgery for colorectal cancer: oral feeding on first versus second postoperative day.

The optimal timing of early oral intake after surgery has not been fully established. The objective of this study was to compare early oral intake at postoperative day 1 after resection of colorectal cancer with that of day 2 to identify the optimal timing for resumption of oral intake in such patients. Consecutive patients with colorectal cancer who underwent elective colorectal resection were separated into two groups. Sixty-two patients began a liquid diet on the first postoperative day (POD1 group) and 58 patients began on POD2 (POD2 group) and advanced to a regular diet within the next 24 hours as tolerated. As for gastrointestinal recovery, the first passage of flatus was experienced, on average, on postoperative day 3.1 ± 1.0 in the POD2 group and on day 2.3 ± 0.7 in the POD1 group. The first defecation was also significantly earlier in patients in the POD1 group than those in the POD2 group (POD 3.2 ± 1.2 versus 4.2 ± 1.4, respectively). No statistical difference was found between the two groups in terms of postoperative complications. Our results suggest that very early feeding on POD1 after colorectal resection is safe and feasible and that induced a quicker recovery of postoperative gastrointestinal movement in patients.

Tu1513 What Is the Optimal Timing for Resumption of Antithrombotic Therapy After Endoscopic Resection of Colorectal Tumors?

Tu1513 What Is the Optimal Timing for Resumption of Antithrombotic Therapy After Endoscopic Resection of Colorectal Tumors?

Changes of serum anti‐Müllerian hormone in a mare with granulosa cell tumour following surgery and reinitiation of follicular activity

SummaryAnti‐Müllerian hormone (AMH) has been reported to be elevated in mares with granulosa cell tumour (GCT). An 8‐year‐old Thoroughbred mare was presented for not being observed in oestrus after the beginning of the breeding season. Rectal palpation and ultrasonography revealed enlargement and cystic appearance of the left ovary while the right ovary was small with an anoestrous‐like appearance. The AMH concentration was 694.9 ng/ml. Presumptively diagnosed with GCT, the mare was subjected to tumour removal. Histopathology confirmed GCT. To evaluate changes of AMH concentration following surgery, blood samples were collected immediately prior to surgery, and on Days 1, 2, 4, 8, 16 and 32 after surgery. Thereafter, blood samples were collected monthly and also at the time the mare was observed in oestrus (148 days after tumour removal). The AMH concentrations decreased over the first 2 months after surgery (from 721.2 ng/ml to 0.1 ng/ml). Subsequently, AMH concentration increased and peaked at the time of oestrus expression (0.7 ng/ml). The mare then became anoestrous, and AMH concentration decreased and reached 0.2 ng/ml, which was not significantly different from the mean concentration of AMH in normal anoestrous mares (n = 5; 0.26 ± 0.07 ng/ml). In conclusion, the present report implies the potential use of AMH for determination of the time of follicular resumption in mares after GCT removal.

Perioperative Management of Target-Specific Oral Anticoagulants

Target-specific oral anticoagulants (TSOACs), which offer rapid onset and more predictable pharmacokinetics/dynamics compared with vitamin K antagonists, are rapidly growing in number and approved indications. At least 1 in 10 Americans receiving outpatient anticoagulant therapy requires interruption of anticoagulation for an invasive procedure annually, and management of these new agents in the perioperative setting is made challenging by difficulty measuring anticoagulant effect and the lack of effective reversal. Surgical planning must account for individual patient risks for bleeding and thrombosis, the type of procedure, and expected drug clearance. Based upon these considerations, a perioperative plan encompassing timing of TSOAC cessation and resumption, as well as bridging therapy, if needed, can be developed. Perioperative strategies remain largely predicated on extrapolations from pharmacokinetics and expert opinion, though a growing body of literature is providing greater guidance in this important area.

Exploring the role of haptic feedback in enabling implicit HCI-based bookmarking.

We examine how haptic feedback could enable an implicit human-computer interaction, in the context of an audio stream listening use case where a device monitors a user's electrodermal activity for orienting responses to external interruptions. When such a response is detected, our previously developed system automatically places a bookmark in the audio stream for later resumption of listening. Here, we investigate two uses of haptic feedback to support this implicit interaction and mitigate effects of noisy (false-positive) bookmarking: (a) low-attention notification when a bookmark is placed, and (b) focused-attention display of bookmarks during resumptive navigation. Results show that haptic notification of bookmark placement, when paired with visual display of bookmark location, significant improves navigation time. Solely visual or haptic display of bookmarks elicited equivalent navigation time; however, only the inclusion of haptic display significantly increased accuracy. Participants preferred haptic notification over no notification at interruption time, and combined haptic and visual display of bookmarks to support navigation to their interrupted location at resumption time. Our contributions include an approach to handling noisy data in implicit HCI, an implementation of haptic notifications that signal implicit system behavior, and discussion of user mental models that may be active in this context.

Laparoscopic Cholecystocolostomy

Conventionally, liver transplantation, ileoileal bypass, and partial external or internal biliary diversion are used in the treatment of progressive familial intrahepatic cholestasis (PFIC). However, postoperative recurrence, chronic diarrhea, and permanent stoma are the major concerns. We present a novel approach of laparoscopic cholecystocolostomy with antireflux Y-loop for the management of children with PFIC. Between August 2003 and April 2011, 20 children with PFIC (median age: 1.47 years; range: 10.8 months to 5.11 years) successfully underwent laparoscopic cholecystocolostomies for bile diversions. Gallbladder was incised longitudinally for cholecystocolostomy. Transverse colon was divided proximal to splenic flexure. End-to-side anastomosis was established between distal transverse colon and mid-descending colon. The mobilized splenic flexure and proximal descending colon, that is, the stem of the Y-loop, was anastomosed to the gallbladder. The mean operative time was 2.02 ± 0.18 hours (range: 2-2.5 hours). The mean postoperative hospital stay was 8 days (range: 5-10 days). Average time for full resumption of diet was 3 days (range: 2-4 days). Average Y-loop length was 17.65 cm (range: 15-20 cm). The median follow-up period was 54 months (range: 12-104 months). All patients were jaundice free after 7 to 20 days and pruritus subsided in 3 to 14 days. Liver function parameters significantly improved postoperatively. Success rate (normalization of serum bile acids at postoperative 12 months) was 85%. No mortality or morbidities associated with diarrhea, cholangitis, or intrahepatic reflux were observed. The novel approach of laparoscopic cholecystocolostomy offers a safe and effective treatment option for PFIC in children with good success rates and minimal morbidity.