The intraoral inverted-L double-oblique osteotomy of the mandibular ramus: a new technique for correction of mandibular prognathism.

Use of a new technique for correction of mandibular prognathism has resulted in reduction of operating time, less loss of blood, and minimal change in muscle relationships. Wiring of the fragments and use of pressure dressing are unnecessary; edema is minimal.     

Faster Rate of Initial Fluid Resuscitation in Severe Acute Pancreatitis Diminishes In-Hospital Mortality

Background/Aims:We evaluated the impact of the initial intravenous fluid resuscitation rate within the first 24 h of presentation to the emergency room on important outcomes in severe acute pancreatitis. Methods: Patients presenting directly with a diagnosis of severe acute pancreatitis were identified retrospectively. Patients were divided into two groups — those who received ≥.33% (‘early resuscitation’) and <33% (‘late resuscitation’) of their cumulative 72-hour intravenous fluid volume within the first 24 h of presentation.The primary clinical outcomes were in-hospital mortality, development of persistent organ failure, and duration of hospitalization. Results: 17 patients were identified in the ‘early resuscitation’ group and 28 in the ‘late resuscitation’ group and there were no baseline differences in clinical characteristics between groups. Patients in the ‘late resuscitation’ group experienced greater mortality than those in the ‘early resuscitation’ group (18 vs. 0%,p<0.04) and demonstrated a trend toward greater rates of persistent organ failure (43 vs. 35%, p = 0.31). There was no difference in the total amount of fluid given during the first 72 h. Conclusions: Patients with severe acute pancreatitis who do not receive at least one third of their initial 72-hour cumulative intravenous fluid volume during the first 24 h are at riskfor greater mortality than those who are initially resuscitated more aggressively.     

Endoscopic retrograde cholangiopancreatography catheter and accessory exchange using a short hydrophilic guide wire: a prospective study

BACKGROUND AND STUDY AIMS: Although hydrophilic guide wires can be used to facilitate stricture cannulation during endoscopic retrograde cholangiopancreatography (ERCP), some endoscopists avoid using them because of concerns about wire loss during exchange. There are no data available on the outcomes of using a short hydrophilic guide wire during ERCP. The aim of this study was to assess the outcomes of therapeutic ERCP procedures in which a short, completely hydrophilic guide wire was used exclusively. PATIENTS AND METHODS: A total of 100 patients undergoing ERCP were studied prospectively. A 0.035-inch, 260-cm long, angled-tip hydrophilic wire (Terumo Glidewire) was used initially. Hydraulic catheter exchange was performed as follows: during catheter withdrawal the assistant advanced all the available wire into the catheter; a 12-ml syringe was then attached to the catheter and water was flushed under pressure to "float the wire" and maintain its position during catheter removal. Variables evaluated included exchange times and wire loss rates. RESULTS: A total of 223 catheter exchanges were performed, 132 (59%) using the Olympus V-Scope (which held the wire in 62% of cases): 15% of exchanges were with catheters/accessories designed for short-wire use (Boston Scientific Rapid Exchange Biliary System or Rx System), and 85% were with a variety of standard-length accessories. Overall, the mean exchange time was 26 seconds (range 6 - 90 seconds, standard deviation 12 seconds). The mean exchange time was faster with the V-Scope and with non-Rx-System accessories. Wire loss occurred in 5 % of all exchanges. Desired ductal/stricture access was achieved in all the patients. CONCLUSIONS: Exchange of short hydrophilic wires is quick and reliable. The Olympus V-Scope is able to hold the wire in some cases. Monorail-type devices and accessories slow catheter exchange down slightly because hydraulic exchange cannot be performed using these systems.     

A novel endoscopic approach to brachytherapy in the management of Hilar cholangiocarcinoma

OBJECTIVES: Traditionally, biliary brachytherapy sources are placed percutaneously via transhepatic drains or endoscopically via nasobiliary tubes (NBT). Another ERCP is needed for stent replacement after NBT removal. The aim of this study was to determine the feasibility and safety of endoscopic transpapillary insertion of irradiation sources through 10-Fr stents. METHODS: Medical records of Mayo Clinic Rochester patients undergoing biliary brachytherapy for hilar cholangiocarcinoma (CCA) were reviewed. Patients were part of a treatment protocol with curative intent including external beam radiation therapy (4,500 cGy), radiation sensitization (5-FU), and low dose rate (LDR) brachytherapy (<3,000 cGy) followed by liver transplantation. The 10-Fr biliary stent placed across the malignant biliary stricture was directly cannulated using a radiopaque (192)Ir embedded ribbon within a 300-cm long, 5.1-Fr plastic sheath. After withdrawal of the endoscope, the external end of the brachytherapy catheter was rerouted transnasally and secured. Each patient was hospitalized in a shielded room up to 24 h after which the brachytherapy catheter was removed by hand. RESULTS: Between 1999 and 2004, 32 patients underwent biliary brachytherapy via endoscopically placed 10-Fr plastic stents (mean age 50.6 yr, 69% PSC, bilateral brachytherapy catheters 28.1%). The technical complication observed was immediate brachytherapy catheter displacement (7 of 32, 22%) managed by prompt brachytherapy catheter repositioning. CONCLUSION: LDR biliary brachytherapy administration via endoscopically placed biliary stents is technically feasible and appears reasonably safe in select patients with unresectable perihilar CCA. Unlike NBTs, stents can potentially be placed in bilateral ductal systems to accommodate dual brachytherapy catheters when indicated.