Role of laparoscopic common bile duct exploration in the management of choledocholithiasis

Surgical fraternity has not yet arrived at any consensus for adequate treatment of choledocholithiasis. Sequential treatment in the form of pre-operative endoscopic retrograde cholangio-pancreatography followed by laparoscopic cholecystectomy(LC) is considered as optimal treatment till date. With refinements in technique and expertise in field of minimal access surgery, many centres in the world have started offering one stage management of choledocholithiasis by LC with laparoscopic common bile duct exploration(LCBDE). Various modalities have been tried for entering into concurrent common bile duct(CBD) [transcystic(TC) vs transcholedochal(TD)], for confirming stone clearance(intraoperative cholangiogram vs choledochoscopy), and for closure of choledochotomy(T-tube vs biliary stent vs primary closure) during LCBDE. Both TC and TD approaches are safe and effective. TD stone extraction is involved with an increased risk of bile leaks and requires more expertise in intra-corporeal suturing and choledochoscopy. Choice depends on number of stones, size of stone, diameter of cystic duct and CBD. This review article was undertaken to evaluate the role of LCBDE for the management of choledocholithiasis.

Evaluation of pneumatic inclined deck separator for high-ash Indian coals

Application of pneumatic separators in coal beneficiation is increasing rapidly over the last decade primarily due to their low capital and operating costs, and waste handling problems associated with traditional wet processing methods. Large amount of shale/rock that is extracted in coal production can be removed prior to transportation at the mine face by using this methodology. Due to the limited washing facilities in India, most of the thermal power plants burn raw coal from run-of-mine （ROM） to generate electricity. This practice causes poor utilization efficiency, high operating and maintenance costs, and high emission rates for the power plants. One potential method that can be utilized is the air-fluidized inclined vibrating deck technology. The technology was demonstrated on a pilot-scale at different coal washeries in India at a feed rate of 5-ton per hour. The pilot-scale evaluation showed that 20 %-25 % high-ash incombustible material can be eliminated from ROM feed with only minor losses in energy content （〈10 %） from respective ROM coal. Furthermore, a feasibility analysis showed significant economic gains in terms of transportation cost, improving power-plant efficiency, and reducing emissions rates by using the technology.

Pancreatic adenocarcinoma: A review of recent paradigms and advances in epidemiology, clinical diagnosis and management

Pancreatic cancer is one of the dreaded malignancies for both the patient and the clinician.The five-year survival rate of pancreatic adenocarcinoma(PDA)is as low as 2%despite multimodality treatment even in the best hands.As per the Global Cancer Observatory of the International Agency for Research in Cancer estimates of pancreatic cancer,by 2040,a 61.7%increase is expected in the total number of cases globally.With the widespread availability of next-generation sequencing,the entire genome of the tumors is being sequenced regularly,providing insight into their pathogenesis.As invasive PDA arises from pancreatic intraepithelial neoplasia and mucinous neoplasm and intraductal papillary neoplasm,screening for them can be beneficial as the disease is curable with resection at an early stage.Routine preoperative biliary drainage has no role in patients suffering from PDA with obstructive jaundice.If performed,metallic stents are preferred over plastic ones.Minimally invasive procedures are preferred to open procedures as they have less morbidity.The duct-to-mucosa technique for pancreaticojejunostomy is presently widely practiced.The role of intraperitoneal drains after surgery for PDA is controversial.Neoadjuvant chemoradiotherapy has been proven to have a significant role both in locally advanced as well as in resectable PDA.Many new regimens and drugs have been added in the arsenal of chemoradiotherapy for metastatic disease.The roles of immunotherapy and gene therapy in PDA are being investigated.This review article is intended to improve the understanding of the readers with respect to the latest updates of PDA,which may help to trigger new research ideas and make better management decisions.

Robotic assisted laparoscopic simple suprapubic prostatectomy--The Smith Institute for Urology experience with an evolving technique

Objective:Despite a multitude of minimally invasive surgical options available for benign prostatic enlargement,open simple prostatectomy(OSP)remains the standard for large prostates(typically greater than 100 g).OSP,however,is associated with significant morbidity.Recently,a few reports touting robotic application to simple prostatectomy have been published.Herein,we reviewed our series of robotic assisted laparoscopic simple suprapubic prostatectomy(RALSSP)and detailed modifications in our technique as our experience increased.Methods:All RALSSP cases performed between January 2013 and January 2014 were reviewed for demographics,pre-operative features,and perioperative outcomes.All parameters were tabulated and mean values were calculated.Student’s t-test was utilized with p<0.05 deemed significant.Details regarding surgical technique were reviewed and highlighted.Results:Fifteen patients underwent RALSSP during this period.Mean age of these men was 68.7 years.Mean body mass index(BMI)was 28.5 kg/m^2.American Society of Anesthesiologists(ASA)score was on average 2.6.Average International Prostate Symptom Score(IPSS)was 16.2 with the majority of men experiencing some adverse clinical sequela of such benign prostatic hyperplasia(BPH).For those patients not in retention,preoperative post-void residual(PVR)was 428 mL.All patients underwent successful RALSSP without need for conversion or need for blood transfusion.Mean estimated blood loss(EBL)was 290 mL.Five patients underwent other concurrent procedures(e.g.,cystolithotomy).Mean length of hospital stay(LOS)was 2.4 days and only five patients required continuous bladder irrigation(CBI)postoperatively.Postoperative PVR improved to a mean of 33 mL and IPSS improved to 4.5(p<0.001).No major complications were identified.Adaptation of low transverse cystotomy,utilization of a robotic tenaculum in the#3 arm with its control by a surgeon on a second console,and the utilization of mucosal advancement have all subjectively aided in performance of RALSSP and perioperative outcomes.Conclusion:RALSSP allows for feasible performance of prostate adenoma enucleation with low risk of blood transfusion,short LOS,and significant improvement in IPSS and PVR;all while maintaining a minimally invasive approach.The use of a robotic tenaculum controlled by the secondary console and the mucosal advancement facilitate excellent outcomes and may play a role in minimizing hematuria and need for CBI.

Evaluation of graphite depressants in a poly-metallic sulfide flotation circuit

Synthetic dyes are commonly used for graphite depression in poly-metallic flotation circuits; however,these dyes can be very expensive. The aim of this study is to evaluate performance of certain low-cost alternative depressants for a complex lead-zinc(Pb-Zn) ore rich in graphite(Gr-C) on a conventional mini pilot-scale flotation circuit. The reagents used were commercial and industrial grade starch; agro-based waste-sugarcane bagasse and charred(burnt) bagasse powder. The primary evaluation criteria were quality(grades) of lead and zinc concentrates, their recoveries(%), and graphite rejection(%) in the tails.Benchmark tests using nigrosine as graphite depressant showed 94.3% rejection of Gr-C. The results with commercial starch were found as effective with 93.8% graphite rejection. Furthermore, bagasse powder showed potential in improving product quality(36.4% and 65.6% Pb grade and recovery) with an intermediate effectiveness in graphite rejection(85.6%). The order of effectiveness in Gr-C rejection follows nigrosine % commercial starch > bagasse > industrial starch > charred bagasse. In addition, the effect these depressants on silver(byproduct) grade and recovery was also investigated.

Bulbocavernosus muscle area as a novel marker for hypogonadism

Objective:Late-onset hypogonadism,or androgen deficiency in the aging male,is a significant cause of morbidity in older men.Many men in the low normal or equivocal range for low testosterone level exhibit signs and symptoms of hypogonadism.Serum testosterone is an imperfect maker for hypogonadism as symptoms vary greatly within the low to low normal range in addition to variations among testosterone assays.Perineal ultrasound can be effectively used to examine the bulbocavernosus muscle(BCM),an androgenized tissue that may be impacted by androgen receptor activity.Methods:This study was a retrospective analysis of men who underwent perineal ultrasound for hypogonadism.The ultrasound data were used to calculate the area of the BCM and correlate it with indices of hypogonadismin symptomatic men including free and total testosterone and dual-energy X-ray absorptiometry(DEXA).Results:The results demonstrate that there is a significant correlation between total and free testosterone and BCM area in hypogonadal patients.Comparison between BCM area and total testosterone showed R^2=0.061 and p=0.0187 and comparison between BCM area and free testosterone showed R^2=0.0957 and p=0.0034.In addition,low BCM was also correlated with DEXA results showing osteoporosis and osteopenia(R^2=0.2239,p=0.0027).Conclusion:There has been recent controversy over the safety of testosterone replacement therapy.This might be particularly important in men with hypogonadal symptoms but a low normal testosterone level.Our study investigated the use of perineal ultrasound to measure BCM as a surrogate marker for poor androgenized men presenting with hypogonadism.

Triple tube drainage for “difficult” gastroduodenal perforations:A prospective study

AIMTo prospectively study the outcome of difficult gastroduodenal perforations (GDPs) treated by triple tube drainage (TTD) in order to standardize the procedure.METHODSPatients presenting to a single surgical unit of a tertiary hospital with difficult GDPs (large, unfavourable local and systemic factors) were treated with TTD (gastrostomy, duodenostomy and feeding jejunostomy). Postoperative parameters were observed like time to return of bowel sounds, time to start enteral feeds, time to start oral feeds, daily output of all drains, time to clamping/removal of all drains, time for skin to heal, complications, hospital stay, and, mortality. Descriptive statistics were used.RESULTSBetween December 2013 and April 2015, 20 patients undergoing TTD for GDP were included, with mean age of 44.6 ± 19.8 years and male:female ratio of 17:3. Mean pre-operative APACHE II scores were 10.85 ± 3.55; most GDPs were prepyloric (9/20; 45%) or proximal duodenal (8/20; 40%) and mean size was 1.83 ± 0.59 cm (largest 2.5 cm). Median times of resumption of enteral feeding, removal of gastrostomy, removal of duodenostomy, removal of feeding jejunostomy and oral feeding were 4 d (4-5 IQR), 13 (12-16.5 IQR), 16 (16.25-22.25 IQR), 18 (16.5-24 IQR) and 12 d (10.75-18.5 IQR) respectively. Median hospital stay was 22 d (19-26 IQR) while mortality was 4/20 (20%).CONCLUSIONTTD for difficult GDP is feasible, easy in the emergency, and patients recover in two-three weeks. It obviates the need for technically demanding and riskier procedures.

Advances in percutaneous stone surgery

Treatment of large renal stones has changed considerably in recent years.The increasing prevalence of nephrolithiasis has mandated that urologists perform more surgeries for large renal calculi than before,and this has been met with improvements in percutaneous stone surgery.In this review paper,we examine recent developments in percutaneous stone surgery,including advances in diagnosis and preoperative planning,renal access,patient position,tract dilation,nephroscopes,lithotripsy,exit strategies,and post-operative antibiotic prophylaxis.

Gallbladder and cystic duct agenesis diagnosed laparoscopically

To the Editor:Anatomical variations of the biliary tree are not un-common but isolated agenesis of the gallbladder is rare,[1]with a reported incidence of 0.013%-0.075%.[2]Thisvariation remains undiagnosed since the patient is oftenasymptomatic.

Role of optical coherence tomography in Barrett’s esophagus

Traditional endoscopic techniques for Barrett’s esophagus(BE)surveillance relied on factor of probability as endoscopists performed cumbersome random biopsies of low yield.Optical coherence tomography(OCT)is a novel technique based on tissue light interference and is set to break conventional barriers.OCT was initially introduced in ophthalmology but was soon adopted by other areas of medicine.When applied to endoscopy,OCT can render images of the superficial layers of the gastrointestinal tract and is highly sensitive in detecting dysplasia in BE.Volumetric laser endomicroscopy is a second generation OCT endoscope device which is able to identify buried glands after ablation.Addition of artificial intelligence to OCT has rendered it more productive.The newer additions to OCT such as angiogram and laser marking will increase the accuracy of investigation.In spite of the few inevitable drawbacks associated with the technology,it presently outperforms all newer endoscopic techniques for the surveillance of BE.

Optimal distributed generation allocation in radial distribution systems considering customer-wise dedicated feeders and load patterns

Distribution system planners usually provide dedicated feeders to its different class of customers,each of whom has its own characteristic load pattern which varies hourly and seasonally.A more realistic modeling should be devised by considering the daily and seasonal variations in the aggregate load patterns of different class of customers.This paper addresses a new methodology to provide integrated solution for the optimal allocation of distributed generations and network reconfiguration considering load patterns of customers.The objectives considered are to maximize annual energy loss reduction and to maintain a better node voltage profile.Bat algorithm(BA)is a new bio-inspired search algorithm which has shown an advance capability to reach into the promising region,but its exploration is inadequate.The problem is solved by proposing the improved BA(IBA).The proposed method is investigated on the benchmark IEEE 33-bus test distribution system and the results are very promising.

Strain-Rate-Dependent In-Plane Compressive Properties of 3D Fine Weave Pierced C/C Composite:Failure Mechanism and Constitutive Model

In-plane compression experiments are performed on 3D fine weave pierced C/C composite at a wide strain rate range of 0.0001/s-1000/s.The in-plane compressive failure mechanism of the composite at quasi-static and high strain rates is analyzed by a scanning electron microscope.The results show that the in-plane compressive modulus,maximum stress and the corresponding strain increase with increasing strain rate.The quasi-static in-plane compressive failure mode of the 3D fine weave pierced C/C composite is characterized by the shear failure at the angle of 45°and the local buckling of the^direction fiber bundles.In comparison,the high strain rate in-plane compression failure mode of the composite is characterized by the compressive fracture of the interlaminar matrix and the progressive compression failure of the a>direction fiber bundles.A strain-rate-dependent in-plane compressive constitutive model is proposed to predict the dynamic in-plane compressive response of the composite.The proposed constitutive model is verified by experimental data.