Stapled haemorrhoidopexy transiently decreases rectal compliance and sensitivity

Aim Stapled haemorrhoidopexy may damage the anorectal musculature and its sensorimotor function. Most studies have not used a barostat for the measurement of compliance. This study aimed to investigate the effect of stapled haemorrhoidopexy on rectal compliance and sensitivity. Method After Ethical Committee approval, we studied 10 male patients (mean age 33.8 years) with third- or fourth-degree haemorrhoids. Rectal compliance and sensitivity were measured with a 600-ml bag and an electronic barostat. Volunteers were submitted to two consecutive rectal distension protocols, including continuous distension at 2, 4 and 6 months after stapled haemorrhoidopexy. Intraluminal volume and pressure were recorded, including the first rectal sensation, desire to defecate and onset of rectal pain. Another group of 10 male control patients (mean age 24.9 years) with pilonidal sinus and no haemorrhoids was also included in the study. Results Two months after stapled haemorrhoidopexy, rectal compliance decreased (7.1 +/- 0.2 vs 5.3 +/- 0.1, 6.4 +/- 0.1 vs 5.1 +/- 0.1 and 5.6 +/- 0.2 vs 4.7 +/- 0.1 ml/mmHg for first rectal sensation, desire to defecate and rectal pain, respectively; P < 0.05). The sensitivity threshold volume did not change for the first sensation but decreased significantly for the desier to defecate and pain (p < 0.05) (116.8 +/- 13.8 vs 148.4 +/- 14.61, 251.1 +/- 8.9 vs 185.8 +/- 8.6 and 293.3 +/- 16.6 vs 221.2 +/- 6.0 ml for first rectal sensation, desire to defecate and rectal pain, respectively). Four and 6 months after surgery, rectal compliance and sensitivity returned to levels similar to those in the basal period. Muscle tissue was found in only three of the 10 resected doughnuts. Controls remained without any change in rectal compliance and sensitivity. Conclusion Stapled haemorrhoidopexy transiently decreases rectal compliance and sensitivity threshold in young male patients.

Improved surgical technique for laparoscopic Roux-en-Y gastric bypass reduces complications at the gastrojejunostomy.

Roux-en-Y gastric bypass (RYGBP) is one of the most commonly performed bariatric procedures for morbidly obese patients. It is associated with effective long-term weight loss, but can lead to significant complications, especially at the gastrojejunostomy (GJS). All the patients undergoing laparoscopic RYGBP at one of our two institutions were included in this study. The prospectively collected data were reviewed retrospectively for the purpose of this study, in which we compared two different techniques for the construction of the GJS and their effects on the incidence of complications. In group A, anastomosis was performed on the posterior aspect of the gastric pouch. In group B, it was performed across the staple line used to form the gastric pouch. A 21-mm circular stapler was used in all patients. A total of 1,128 patients were included between June 1999 and September 2009-639 in group A and 488 in group B. Sixty patients developed a total of 65 complications at the GJS, with 14 (1.2%) leaks, 42 (3.7%) strictures, and 9 (0.8%) marginal ulcers. Leaks (0.2% versus 2%, p = 0.005) and strictures (0.8% versus 5.9%, p < 0.0001) were significantly fewer in group B than in group A. Improved surgical technique, as we propose, with the GJS across the staple line used to form the gastric pouch, significantly reduces the rate of anastomotic complications at the GJS. A circular 21-mm stapler can be used with a low complication rate, and especially a low stricture rate. Additional methods to limit complications at the GJS are probably not routinely warranted.

Improved Surgical Technique Reduces Complications at the Gastro-jejunostomy After Laparoscopic Roux-en-Y Gastric Bypass

Introduction: Roux-en-Y gastric bypass (RYGBP) is one of the commonest procedure for morbid obesity. It is associated with effective long-term weight loss, but can lead to significant complications, especially at the gastrojejunostomy (GJS) Patients and Methods: All the patients undergoing laparoscopic RYGBP at one of our two institutions were included in this study, in which we compared two different techniques for the construction of the GJS and their effects on the incidence of complications. In group A, anatomosis was performed on the posterior aspect of the gastric pouch. In group B it was performed across the staple line used to form the gastric pouch. A 21-mm circular stapler was used in all patients. Results: A total of 1128 patients were included between June 1999 and September 2009, 639 in group A and 488 in group B. Sixty patients developed a total of 65 complications at the GJS, with 14 (1,2 %) leaks, 42 (3,7 %) stricture, and 9 (0,8 %) marginal ulcers. Leaks (0,2 versus 2 %, p=0,005) and strictures (0,8 versus 5,9%, p<0,0001) were significantly fewer in group B than in group A. Conclusions: Improved surgical technique, with the GJS across the staple line used to form the gastric pouch, significantly reduces the rate of anastomotic complications at the GJS. A circular 21-mm stapler can be used with a low complication rate, and especially a low stricture rate. Additional methods to limit complications at the GJS are probably not routinely warranted.

Transrectal specimen extraction after laparoscopic left colectomy: a case-matched study.

Aim  Avoiding 'mini-laparotomy' to extract a colectomy specimen may decrease wound complications and further improve recovery after laparoscopic surgery. The aim of this study was to develop a new technique for transrectal specimen extraction (TRSE) and to compare it with conventional laparoscopy (CL) for left sided colectomy. Method  Eleven patients with benign disease requiring either sigmoid or left colon resection underwent TRSE. The unfired circular stapler was inserted transanally and used as a guide to suture-close the recto-sigmoid junction laparoscopically and as a handle to pull the sutured sigmoid through the opened rectum inside a laparoscopic camera bag. The anvil was inserted into the lumen of the intussuscepted sigmoid and pushed to the level of the anastomosis. The anastomosis was fashioned end-to-end in the first patients and side-to-end in the following patients to improve safety. Intra-operative and postoperative outcomes of patients undergoing TRSE were compared with those of a group of 20 patients undergoing CL, who were matched for type of resection, body mass index and age. Results  The procedure was successful in all but the first patient who was converted to conventional laparoscopic colectomy without any additional morbidity. Two patients in the end-to-end anastomosis group, but none in the side-to-end group, developed peri-anastomotic sepsis. Compared with CL, patients undergoing TRSE did not show any significant differences in operative time, recovery or morbidity. Conclusion  Transrectal specimen extraction after left colectomy using the circular stapler technique is feasible. A side-to-end anastomosis appears safer than an end-to-end anastomosis. Further studies are needed to explore the potential advantages of this procedure over CL.

Distal Roux-en-Y gastric bypass for the treatment of morbid obesity

Background: Classical Roux-en-Y gastric bypass (cRYGB) is a combined restrictive and slightly malabsorptive operation. Excess-BMI-loss (EBMIL) in cRYGB is ~60%, but is diminished for super obese patients (BMI > 50 kg/m2). We therefore designed a modified, mainly malabsorptive distal RYGB (dRYGB). Methods: We report mid-term results after 77 consecutive dRYGB in which malabsorption is inversely related to the length of the common channel. The common channel was 100–150 cm long depending on preoperative BMI, the biliopancreatic limb was 100 cm long, which left >>250 cm for the alimentary channel. To avoid the potentially dangerous combination of malabsorption with sustained restriction the pouch size was increased to ~50ml and a 25 mm circular stapler was used for the gastro-jejunostomy. Results: 33 open and later on 44 laparoscopic interventions have been performed. Median preoperative BMI was 50.2 kg/m 2. No severe intraoperative complications have been observed and no anastomotic leakage was noted in the postoperative period. 5 patients needed balloon dilation of an anastomotic stricture. 3 marginal ulcers occurred at the gastrojejunostomy. The 54 patients with a follow-up time of over 12 months (median 24 months) showed an overall median BMI-reduction of 17 to an actual median BMI of 31.6 kg/m2, corresponding to a EBMIL of 74.5%. Obesity-related comorbid conditions were significantly reduced or cured. Intermittent diarrhea or steatorrhea in 12 patients was easily treated by pancreatic enzyme supplementation. Conclusion: dRYGB is technically more demanding than cRYGB, but shows excellent results in terms of weight-loss and therefore also in reduction of comorbidity especially in super-obese patients. Measuring all three limb lengths allows for a calibration of the malabsorption. The quality of food-intake being important to (super-) obese patients in terms of quality of life, a less restrictive pouch seems more adapted to them. Lifelong multidisciplinary follow-up is mandatory.

Stapled haemorrhoidopexy vs. Milligan-Morgan haemorrhoidectomy for grade III haemorrhoids: a randomized clinical trial

The aim of this double blind randomized clinical trial was to compare the short-term and long-term outcomes of stapled haemorrhoidopexy (SH group) performed using a circular stapler with that of the Milligan-Morgan haemorrhoidectomy (MMH group). A total of 79 consecutive patients with grade III haemorrhoids were randomized into two groups treated with SH (n. 39) and MMH (n. 40). The outcomes of the procedures were evaluated postoperatively and over a follow-up period of minimum 2 years. Patients undergoing the SH procedure showed greater short term advantages than MMH group with reduced pain, shorter length of hospital stay, earlier return to work and high patient satisfaction. Long-term follow-up has indicated more favourable results in MMH group in terms of resumption of symptoms with absence of residual prolapse and risk of recurrence of prolapse. At two years follow-up recurrent prolapse was confirmed in six patients of SH group (13%) whereas in none of the MMH group. At six months follow-up there weren’t significant difference in the mean satisfaction score for the two groups. At two years the mean satisfaction score was higher in the MMH group vs SH group. Seven patients in the SH group needed a reoperation whereas none in MMH group. From January 2009, in our Surgery Unit the patients are always informed about a higher recurrence rate of SH and we perform this technique only when the patient choices to accept this risk to take advantage of the short-term benefits of this procedure.

Forced convection to laminar flow of liquid egg yolk in circular and annular ducts

The steady-state heat transfer in laminar flow of liquid egg yolk - an important pseudoplastic fluid food - in circular and concentric annular ducts was experimentally investigated. The average convection heat transfer coefficients, determined by measuring temperatures before and after heating sections with constant temperatures at the tube wall, were used to obtain simple new empirical expressions to estimate the Nusselt numbers for fully established flows at the thermal entrance of the considered geometries. The comparisons with existing correlations for Newtonian and non-Newtonian fluids resulted in excellent agreement. The main contribution of this work is to supply practical and easily applicable correlations, which are, especially for the case of annulus, rather scarce and extensively required in the design of heat transfer operations dealing with similar shear-thinning products. In addition, the experimental results may support existing theoretical analyses.

Possible states in the flow around two circular cylinders in tandem with separations in the vicinity of the drag inversion spacing

The possible states in the flow around two identical circular cylinders in tandem arrangements are investigated for configurations in the vicinity of the drag inversion separation. By means of numerical simulations, the hysteresis in the transition between the shedding regimes is studied and the relationship between (three-dimensional) secondary instabilities and shedding regime determination is addressed. The differences observed in the behavior of two- and three-dimensional flows are analyzed, and the regions of bistable flow are delimited. Very good agreement is found between the proposed scenario and results available in the literature. (C) 2010 American Institute of Physics. [doi: 10.1063/1.3420111]

Reliability-based evaluation of design code provisions for circular concrete-filled steel columns

This paper presents an investigation of design code provisions for steel-concrete composite columns. The study covers the national building codes of United States, Canada and Brazil, and the transnational EUROCODE. The study is based on experimental results of 93 axially loaded concrete-filled tubular steel columns. This includes 36 unpublished, full scale experimental results by the authors and 57 results from the literature. The error of resistance models is determined by comparing experimental results for ultimate loads with code-predicted column resistances. Regression analysis is used to describe the variation of model error with column slenderness and to describe model uncertainty. The paper shows that Canadian and European codes are able to predict mean column resistance, since resistance models of these codes present detailed formulations for concrete confinement by a steel tube. ANSI/AISC and Brazilian codes have limited allowance for concrete confinement, and become very conservative for short columns. Reliability analysis is used to evaluate the safety level of code provisions. Reliability analysis includes model error and other random problem parameters like steel and concrete strengths, and dead and live loads. Design code provisions are evaluated in terms of sufficient and uniform reliability criteria. Results show that the four design codes studied provide uniform reliability, with the Canadian code being best in achieving this goal. This is a result of a well balanced code, both in terms of load combinations and resistance model. The European code is less successful in providing uniform reliability, a consequence of the partial factors used in load combinations. The paper also shows that reliability indexes of columns designed according to European code can be as low as 2.2, which is quite below target reliability levels of EUROCODE. (C) 2009 Elsevier Ltd. All rights reserved.

Volumetric reconstruction of the mean flow around circular cylinders fitted with strakes

The volumetric reconstruction technique presented in this paper employs a two-camera stereoscopic particle image velocimetry (SPIV) system in order to reconstruct the mean flow behind a fixed cylinder fitted with helical strakes, which are commonly used to suppress vortex-induced vibrations (VIV). The technique is based on the measurement of velocity fields at equivalent adjacent planes that results in pseudo volumetric fields. The main advantage over proper volumetric techniques is the avoidance of additional equipment and complexity. The averaged velocity fields behind the straked cylinders and the geometrical periodicity of the three-start configuration are used to further simplify the reconstruction process. Two straked cylindrical models with the same pitch (p = 10d) and two different heights (h = 0.1 and 0.2d) are tested. The reconstructed flow shows that the strakes introduce in the wake flow a well-defined wavelength of one-third of the pitch. Measurements of hydrodynamic forces, fluctuating velocity, vortex formation length, and vortex shedding frequency show the interdependence of the wake parameters. The vortex formation length is increased by the strakes, which is an important effect for the suppression of vortex-induced vibrations. The results presented complement previous investigations concerning the effectiveness of strakes as VIV suppressors and provide a basis of comparison to numerical simulations.

On the wake-induced vibration of tandem circular cylinders: the vortex interaction excitation mechanism

The mechanism of wake-induced vibrations (WIV) of a pair of cylinders in a tandem arrangement is investigated by experiments. A typical WIV response is characterized by a build-up of amplitude persisting to high reduced velocities; this is different from a typical vortex-induced vibration (VIV) response, which occurs in a limited resonance range. We suggest that WIV of the downstream cylinder is excited by the unsteady vortex-structure interactions between the body and the upstream wake. Coherent vortices interfering with the downstream cylinder induce fluctuations in the fluid force that are not synchronized with the motion. A favourable phase lag between the displacement and the fluid force guarantees that a positive energy transfer from the flow to the structure sustains the oscillations. If the unsteady vortices are removed from the wake of the upstream body then WIV will not be excited. An experiment performed in a steady shear flow turned out to be central to the understanding of the origin of the fluid forces acting on the downstream cylinder.

Experimental investigation of flow-induced vibration on isolated and tandem circular cylinders fitted with strakes

The effect of varying the geometric parameters of helical strakes on vortex-induced vibration (VIV) is investigated in this paper. The degree of oscillation attenuation or even suppression is analysed for isolated circular cylinder cases. How a cylinder fitted with strakes behaves when immersed in the wake of another cylinder in tandem arrangement is also investigated and these results are compared to those with a single straked cylinder. The experimental tests are conducted at a circulating water channel facility and the cylindrical models are mounted on a low-damping air bearing elastic base with one degree-of-freedom, restricted to oscillate in the transverse direction to the channel flow. Three strake pitches (p) and heights (h) are tested: p = 5, 10, 15d, and h = 0.1, 0.2, 0.25d. The mass ratio is 1.8 for all models. The Reynolds number range is from 1000 to 10000, and the reduced velocity varies up to 21. The cases with h = 0.1d strakes reduce the amplitude response when compared to the isolated plain cylinder, however the oscillation still persists. On the other hand, the cases with h = 0.2, 0.25d strakes almost completely suppress VIV. Spanwise vorticity fields, obtained through stereoscopic digital particle image velocimetry (SDPIV), show an alternating vortex wake for the p = 10d and h = 0.1d straked cylinder. The p = 10d and h = 0.2d cylinder wake has separated shear layers with constant width and no roll-up close to the body. The strakes do not increase the magnitude of the out-of-plane velocity compared to the isolated plain cylinder. However, they deflect the flow in the out-of-plane direction in a controlled way, which can prevent the vortex shedding correlation along the span. In order to investigate the wake interference effect on the strake efficiency, an experimental arrangement with two cylinders in tandem is employed. The centre-to-centre distance for the tandem arrangement varies from 2 to 6. When the downstream p = 10d and h = 0.2d cylinder is immersed in the wake of an upstream fixed plain cylinder, it loses its effectiveness compared with the isolated case. Although the oscillations have significant amplitude, they are limited, which is a different behaviour from that of a tandem configuration with two plain cylinders. For this particular case, the amplitude response monotonically increases for all gaps, except one, a trait usually found in galloping-like oscillations. SDPIV results for the tandem arrangements show alternating vortex shedding and oscillatory wake. (C) 2010 Elsevier Ltd. All rights reserved.

Secondary instabilities in the flow around two circular cylinders in tandem

Direct stability analysis and numerical simulations have been employed to identify and characterize secondary instabilities in the wake of the flow around two identical circular cylinders in tandem arrangements. The centre-to-centre separation was varied from 1.2 to 10 cylinder diameters. Four distinct regimes were identified and salient cases chosen to represent the different scenarios observed, and for each configuration detailed results are presented and compared to those obtained for a flow around an isolated cylinder. It was observed that the early stages of the wake transition changes significantly if the separation is smaller than the drag inversion spacing. The onset of the three-dimensional instabilities were calculated and the unstable modes are fully described. In addition, we assessed the nonlinear character of the bifurcations and physical mechanisms are proposed to explain the instabilities. The dependence of the critical Reynolds number on the centre-to-centre separation is also discussed.

Wake instability issues: From circular cylinders to stalled airfoils

Some recent results regarding the global dynamical behaviour of the wake of circular cylinders and airfoils with massive separation are reviewed in this paper. In order to investigate the effect of interference, the three-dimensional instability modes are analysed for the flow around two circular cylinders in tandem. In the same way, the flow around a stalled airfoil is investigated in order to provide a better understanding of the three-dimensional characteristics of wakes forming downstream of a lifting body with massive separation. These results are compared with those found for an isolated cylinder. Some fundamental differences among these flows are discussed. (C) 2011 Elsevier Ltd. All rights reserved.