Treatment of ring slippage after gastric bypass: long-term results after endoscopic dilation with an achalasia balloon (with videos)

Background: Silastic rings are used in gastric bypass procedures for the treatment of obesity, but ring slippage may lead to gastric pouch outlet stenosis (GPOS). Conventional management has been ring removal through abdominal surgery. Objective: To describe a novel, safe, minimally invasive, endoscopic technique for the treatment of GPOS caused by ring slippage after gastric bypass. Design: Case series. Setting: Federal University of Pernambuco and sao Paulo University. Patients: This study involved 39 consecutive patients who-were screened for inclusion. Intervention: Endoscopic dilation with an achalasia balloon. Main Outcome Measurements: Technical success and safety of the procedure. Results: Among the 39 patients, 35 underwent endoscopic dilation at the ring slippage site for the relief of GPOS. The 4 patients who did not undergo endoscopic dilation underwent surgical removal of the ring, based on the exclusion criteria. The endoscopic approach was successful in 1 to 4 sessions in 100% of cases with radioscopic control (n = 12). The duration of the procedures ranged from 5 to 30 minutes, and the average internment was 14.4 hours. Dilation promoted either rupture (65.7%) or stretching (34.3%) of the thread within the ring, thereby increasing the luminal diameter of the GPOS. Complications included self-limited upper digestive tract hemorrhage (n = 1) and asymptomatic ring erosion (n = 4). There were no recurrences of obstructive symptoms during the follow-up period (mean of 33.3 months). Limitations: This was not a randomized, comparison study, and the number of patients was relatively small. Conclusion: The technique described promotes the relief of GPOS with low overall morbidity and avoids abdominal reoperation for ring removal. (Gastrointest Endosc 2010;72:44-9.)

Evaluation of two round baling systems for harvesting understory biomass

The objective of this study was to evaluate the performance and to estimate costs of two round baling systems for harvesting understory biomass. One system was a cutter-shredderbaler prototype (Bio-baler). The other system required two successive operations. The first operation was cutting and shredding with a Supertrak tractor equipped with a Fecon mulcher head. The second operation was baling with a Claas baler. The machines were evaluated in three different pine stands on the Osceola National Forest in Florida, United States. Data collection included time study, fuel consumption and bale measurements. Material was collected from a sample of bales for heat and moisture content determination. On the most representative site (Site 2), the Bio-baler recovered 8.05 green t ha(-1) while the mulcher and the Claas baler recovered 9.75 green t ha(-1) (43 and 52 percent of original understory biomass, respectively). Productivity was 0.30 ha h(-1) for the Bio-baler and 0.51 ha h(-1) for the Claas baler. Density of the bales was 321 green kg m(-3) for the Bio-baler and 373 green kg m(-3) for the Claas baler. Average net heat content was 6263 MJ bale(-1) for the Bio-baler and 6695 MJ bale(-1) for the Claas baler with biomass containing 38 percent of moisture content on a wet basis. cost per unit area was less with the Bio-baler (US$320.91 ha(-1)) than with the mulcher-baler system (US$336.62-US$596.77 ha(-1)). Published by Elsevier Ltd.

Complex rearrangements in patients with duplications of MECP2 can occur by fork stalling and template switching

Duplication at the Xq28 band including the MECP2 gene is one of the most common genomic rearrangements identified in neurodevelopmentally delayed males. Such duplications are non-recurrent and can be generated by a non-homologous end joining (NHEJ) mechanism. We investigated the potential mechanisms for MECP2 duplication and examined whether genomic architectural features may play a role in their origin using a custom designed 4-Mb tiling-path oligonucleotide array CGH assay. Each of the 30 patients analyzed showed a unique duplication varying in size from similar to 250 kb to similar to 2.6 Mb. Interestingly, in 77% of these non-recurrent duplications, the distal breakpoints grouped within a 215 kb genomic interval, located 47 kb telomeric to the MECP2 gene. The genomic architecture of this region contains both direct and inverted low-copy repeat (LCR) sequences; this same region undergoes polymorphic structural variation in the general population. Array CGH revealed complex rearrangements in eight patients; in six patients the duplication contained an embedded triplicated segment, and in the other two, stretches of non-duplicated sequences occurred within the duplicated region. Breakpoint junction sequencing was achieved in four duplications and identified an inversion in one patient, demonstrating further complexity. We propose that the presence of LCRs in the vicinity of the MECP2 gene may generate an unstable DNA structure that can induce DNA strand lesions, such as a collapsed fork, and facilitate a Fork Stalling and Template Switching event producing the complex rearrangements involving MECP2.