Allergist RSS : Gourt

Pediatric AI, University of New Mexico, #1 Place for Business and Careers by Forbes, #5278 :: New Mexico :: Timeline Recruiting

Nestled against the Sandia Mountains, Albuquerque is a dream destination. Impossible to avoid our incredible scenery, we offer four beautiful seasons with that Southwestern backdrop we are famous

Southern Metro SEC Academic Pediatric Allergy and Immunology, #5610 :: Mississippi :: Timeline Recruiting

As the only childrens hospital in the state, our more than 100 pediatric medical faculty provide outstanding medical services to millions of patients in our draw area. We are part of the Southeast

Oklahoma College town needs an Allergy and Immunol :: Oklahoma :: Enterprise Medical Service

Multi-specialty group in Muskogee, Oklahoma looking to add a BC/BE Allergist and Immunologist-Job #16506 due to growth and retirement. This clinic offers the highest quality medical care to the citizens

South Central KRC.1009.0813.04 :: Kansas :: Rural Health Education & Services

KRC.1009.0813.04 BC/BE certified Allergy and Immunologist needed for a 65 physician multispecialty group. This well-established group is located conveniently near the admitting 200-bed hospital. This

Call for information :: South Carolina :: Inhouse Physician Recruiters Network

The In-House Physician Recruiter Network, composed of over 500 hospital recruiters, represents over 10,000 hospitals and clinics. Our Network's special feature is to showcase outstanding physicians (who

Derry :: New Hampshire :: New England Physician Recruitment Center

Southern NH -40 minutes to Boston Established Medical Facility in Southern New Hampshire seeking Allergy Specialist. Providing exceptional Primary Care services for over 10 years, this group offers multiple

The Diabetic Antigen Glutamic Acid Decarboxylase (GAD 65) in the Human Peripheral Blood

Int Arch Allergy Immunol 2010;152:184194 (DOI:10.1159/000265540)

Anaphylaxis to Wheat Flour-Derived Foodstuffs and the Lipid Transfer Protein Syndrome: A Potential Role of Wheat Lipid Transfer Protein Tri a 14

Int Arch Allergy Immunol 2010;152:178183 (DOI:10.1159/000265539)

Human Leukocyte Antigen (DR1)-DQB10501 and (DR15)-DQB10602 Haplotypes Are Associated with Humoral Responses to Early Food Allergens in Children

Int Arch Allergy Immunol 2010;152:169177 (DOI:10.1159/000265538)

Exposure of Intestinal Epithelial Cells to UV-Killed Lactobacillus GG but Not Bifidobacterium breve Enhances the Effector Immune Response in vitro

Int Arch Allergy Immunol 2010;152:159168 (DOI:10.1159/000265537)

Occupational Endotoxin Exposure Reduces the Risk of Atopic Sensitization but Increases the Risk of Bronchial Hyperresponsiveness

Int Arch Allergy Immunol 2010;152:151158 (DOI:10.1159/000265536)

Regulation of CXCR/IL-8 in Human Airway Epithelial Cells

Int Arch Allergy Immunol 2010;152:140150 (DOI:10.1159/000265535)

A Toll-Like Receptor 2/6 Agonist Reduces Allergic Airway Inflammation in Chronic Respiratory Sensitisation to Timothy Grass Pollen Antigens

Int Arch Allergy Immunol 2010;152:131139 (DOI:10.1159/000265534)

Hydrolyzed Konjac Glucomannan Suppresses IgE Production in Mice B Cells

Int Arch Allergy Immunol 2010;152:122130 (DOI:10.1159/000265533)

Association of Plasma Soluble CTLA-4 with Lung Function and GenePolymorphism in Chinese Asthmatic Children

Int Arch Allergy Immunol 2010;152:113121 (DOI:10.1159/000265532)

Intranasal CpG Therapy Attenuated Experimental Fungal Asthma in a TLR9-Dependent and -Independent Manner

Int Arch Allergy Immunol 2010;152:98112 (DOI:10.1159/000265531)

Topical ‘Sydney’ Propolis Protects against UV-Radiation-Induced Inflammation, Lipid Peroxidation and Immune Suppression in Mouse Skin

Int Arch Allergy Immunol 2010;152:8797 (DOI:10.1159/000265530)

Reduced Immunoglobulin M Is Associated with Sinus Mucosal Thickening, Osteitis and Sinus Surgery in Patients with Common Variable Immunodeficiency

Int Arch Allergy Immunol 2010;152:8186 (DOI:10.1159/000260088)

Differential Mucosal IL-17 Expression in Two Gliadin-Induced Disorders: Gluten Sensitivity and the Autoimmune Enteropathy Celiac Disease

Int Arch Allergy Immunol 2010;152:7580 (DOI:10.1159/000260087)

Xolair Is Effective in Allergics with a Low Serum IgE Level

Int Arch Allergy Immunol 2010;152:7174 (DOI:10.1159/000260086)

Serum Transforming Growth Factor-ß Levels Depend on Allergen Exposure in Allergic Rhinitis

Int Arch Allergy Immunol 2010;152:6670 (DOI:10.1159/000260085)

Occupational Allergy in Strawberry Greenhouse Workers

Int Arch Allergy Immunol 2010;152:5865 (DOI:10.1159/000260084)

Airborne Study of Grass Allergen (Lol p 1) in Different-Sized Particles

Int Arch Allergy Immunol 2010;152:4957 (DOI:10.1159/000260083)

Sublingual Immunotherapy Efficacy of Dermatophagoides farinae Vaccine in a Murine Asthma Model

Int Arch Allergy Immunol 2010;152:4148 (DOI:10.1159/000260082)

A Six-SNP Haplotype of ADAM33 Is Associated with Asthma in a Population of Cartagena, Colombia

Int Arch Allergy Immunol 2010;152:3240 (DOI:10.1159/000260081)

Tryptase Is Not Cleared by the Kidneys into the Urine

Int Arch Allergy Immunol 2010;152:2831 (DOI:10.1159/000260080)

On the Cover

Comparison of allergen immunotherapy practice patterns in the United States and Europe

The effect of statin therapy on allergic patients with asthma

Detection and home management of worsening asthma symptoms

Relationship between visits to emergency departments for asthma and ozone exposure in greater Seattle, Washington

The effect of low-cost modification of the home environment on the development of respiratory symptoms in the first year of life

Regional variation in epinephrine autoinjector prescriptions in Australia: more evidence for the vitamin Danaphylaxis hypothesis

A retrospective review of clinical presentation, thyroid autoimmunity, laboratory characteristics, and therapies used in patients with chronic idiopathic urticaria

Angiotensin-converting enzyme inhibitorinduced angioedema in a community hospital emergency department

Biomolecular identification of allergenic pollen: a new perspective for aerobiological monitoring?

Clinical and immunobiochemical characterization of airborne Delonix regia (Gulmohar tree) pollen and cross-reactivity studies with Peltophorum pterocarpum pollen: 2 dominant avenue trees from eastern India

Effects of endogenous glucocorticoids on allergic inflammation and TH1/TH2 balance in airway allergic disease

IMPORTED FIRE ANT HYPERSENSITIVITY: A 1-DAY RUSH IMMUNOTHERAPY SCHEDULE WITHOUT PREMEDICATION

HANDLE WITH CARE ... NITROGLYCERIN ANAPHYLAXIS

PHENYTOIN-INDUCED DRESS

RAPID ORAL DESENSITIZATION TO FUROSEMIDE

OCULAR SYMPTOM EFFICACY AND INTRANASAL CORTICOSTEROIDS

Author index to volume 103, 2009

News and Notices

News and Notices Content Type Journal ArticleCategory News and noticesDOI 10.1007/s00464-010-0935-z Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Laparoscopic surgery for rectal cancer: the standard of care?

Laparoscopic surgery for rectal cancer: the standard of care? Content Type Journal ArticleCategory LetterDOI 10.1007/s00464-009-0876-6Authors Basilios Papaziogas, Aristotle University of Thessaloniki Second Surgical Clinic Thessaloniki GreeceDimosthenis Ziogas, University of Ioannina, School of Medicine Department of Surgery Ioannina GreeceGeorgios Baltogiannis, University of Ioannina, School of Medicine Department of Surgery Ioannina Greece Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Risk-sensitive events during laparoscopic cholecystectomy: the influence of the integrated operating room and a preoperative checklist tool

Abstract Background Awareness of the relative high rate of adverse events in laparoscopic surgery created a need to safeguard quality and safety of performance better. Technological innovations, such as integrated operating room (OR) systems and checklists, have the potential to improve patient safety, OR efficiency, and surgical outcomes. This study was designed to investigate the influence of the integrated OR system and Pro/cheQ, a digital checklist tool, on the number and type of equipment- and instrument-related risk-sensitive events (RSE) during laparoscopic cholecystectomies. Methods Forty-five laparoscopic cholecystectomies were analyzed on the number and type of RSE; 15 procedures were observed in the cart-based OR setting, 15 in an integrated OR setting, and 15 in the integrated OR setting while using Pro/cheQ. Results In the cart-based OR setting and the integrated OR setting, at least one event occurred in 87% of the procedures, which was reduced to 47% in the integrated OR setting when using Pro/cheQ. During 45 procedures a total of 57 RSE was observed—most were caused by equipment that was not switched on or with the wrong settings. In the integrated OR while using Pro/cheQ the number of RSE was reduced by 65%. Conclusions Using both an integrated OR and Pro/cheQ has a stronger reducing effect on the number of RSE than using an integrated OR alone. The Pro/cheQ tool supported the optimal workflow in a natural way and raised the general safety awareness amongst all members of the surgical team. For tools such as integrated OR systems and checklists to succeed it is pivotal not to underestimate the value of the implementation process. To further improve safety and quality of surgery, a multifaceted approach should be followed, focusing on the performance and competence of the surgical team as a whole. Content Type Journal ArticleDOI 10.1007/s00464-010-0892-6Authors Sonja N. Buzink, Delft University of Technology Faculty of Industrial Design Engineering Landbergstraat 15 2628 CE Delft The NetherlandsLotte van Lier, Delft University of Technology Faculty of Industrial Design Engineering Landbergstraat 15 2628 CE Delft The NetherlandsIgnace H. J. T. de Hingh, Catharina Hospital Eindhoven Department of Surgery Michelangelolaan 2 5623 EJ Eindhoven The NetherlandsJack J. Jakimowicz, Delft University of Technology Faculty of Industrial Design Engineering Landbergstraat 15 2628 CE Delft The Netherlands Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Re: Single incision multiport laparoendoscopic (SIMPLE) surgery

Re: Single incision multiport laparoendoscopic (SIMPLE) surgery Content Type Journal ArticleCategory LetterDOI 10.1007/s00464-010-0894-4Authors Paul G. Curcillo, Drexel University Department of Surgery, College of Medicine 219 North Broad Street, Tenth Floor Philadelphia PA USAErica R. Podolsky, Drexel University Department of Surgery, College of Medicine 219 North Broad Street, Tenth Floor Philadelphia PA USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Suprapapillary needleknife fistulotomy: a safe and effective method for accessing the biliary system

Abstract Background Suprapapillary needleknife fistulotomy is performed when standard biliary cannulation methods have failed. However, its role is controversial, with conflicting reports on its use. This study aimed to determine the efficacy and safety of needleknife fistulotomy after failure of conventional cannulation techniques. Methods All patients who underwent needleknife fistulotomy were identified from a single tertiary referral center database prospectively maintained from 1997 to 2007. Results A total of 2,603 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) over the 10-year period. Fistulotomy was performed for 352 patients (13.5%), with 317 of these patients (90.1%) experiencing successful biliary cannulation. With the use of fistulotomy, the total cannulation success rate increased from 79.0 to 91.2% (P < 0.0001). Endoscopic management of choledocholithiasis and hepatobiliary malignancy increased from 48.9 to 55.1% (P < 0.001), and from 12.0 to 16.0% (P < 0.001) for all cases. The complication rate was significantly higher for the patients who underwent fistulotomy than for those who did not (4.8% vs. 2.1%; P < 0.001), which can be explained by a higher rate of mild bleeding in the fistulotomy group. However, no significant difference in pancreatitis or perforation between the two groups was observed. In addition, no fatalities occurred after fistulotomy. Conclusion Suprapapillary needleknife fistulotomy is an effective method for accessing the biliary system after failed standard cannulation. Despite a higher rate of mild bleeding, fistulotomy was not associated with an increased risk of serious complications. Content Type Journal ArticleDOI 10.1007/s00464-010-0881-9Authors F. Donnellan, St. Luke’s Hospital Department of Gastroenterology Kilkenny Ireland, UKF. Zeb, St. Luke’s Hospital Department of Gastroenterology Kilkenny Ireland, UKG. Courtney, St. Luke’s Hospital Department of Gastroenterology Kilkenny Ireland, UKA. R. Aftab, St. Luke’s Hospital Department of Gastroenterology Kilkenny Ireland, UK Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Detection of gastric conduit ischemia or anastomotic breakdown after cervical esophagogastrostomy: the use of computed tomography scan versus early endoscopy

Abstract Background Concern over potential injury to the anastomosis has limited the use of early postoperative endoscopy to diagnose conduit ischemia or anastomotic breakdown. Alternatively, a computed tomography (CT) scan has been suggested as a noninvasive means for identifying these complications. This study aimed to compare CT scan with early endoscopy for diagnosing gastric conduit ischemia or anastomotic breakdown after esophagectomy with cervical esophagogastrostomy. Methods Between 2000 and 2007, 554 patients underwent an esophagectomy and gastric pull-up with cervical esophagogastrostomy at the University of Southern California. Records were reviewed to identify patients who had undergone endoscopy and CT scan within 24 h of each other during the first three postoperative weeks for suspicion of an ischemic conduit or anastomotic breakdown. The accuracies of CT scan and endoscopy in diagnosing an ischemic conduit were compared. Results A total of 76 patients had endoscopy and CT scan for clinical suspicion of conduit ischemia or anastomotic breakdown. Endoscopy was performed without complications in all 76 patients. The postoperative endoscopic findings were normal in 24 of the patients, and none subsequently experienced an ischemic conduit or anastomotic breakdown. Evidence of ischemia was present in 28 patients, 7 of whom had black mucosa throughout the gastric conduit with the anastomosis still intact and required removal of their conduit. The remaining 24 patients had partial or complete anastomotic breakdown. On the CT scan, 23 of the 76 patients showed evidence of conduit ischemia (n = 9) or anastomotic breakdown (n = 14). There was no evidence of ischemia or anastomotic breakdown on CT scan for the 24 patients with normal endoscopy or for 3 of the 7 patients who had their conduit removed for graft necrosis. Conclusion A normal CT scan does not rule out the possibility of an ischemic gastric conduit after esophagectomy. Early endoscopy is a safe and accurate method for assessing conduit ischemia. Content Type Journal ArticleDOI 10.1007/s00464-010-0884-6Authors Arzu Oezcelik, University of Southern California Department of Surgery, Keck School of Medicine 1510 San Pablo Street, Suite 514 Los Angeles CA 90033 USAFarzaneh Banki, University of Southern California Department of Surgery, Keck School of Medicine 1510 San Pablo Street, Suite 514 Los Angeles CA 90033 USAShahin Ayazi, University of Southern California Department of Surgery, Keck School of Medicine 1510 San Pablo Street, Suite 514 Los Angeles CA 90033 USAEmmanuele Abate, University of Southern California Department of Surgery, Keck School of Medicine 1510 San Pablo Street, Suite 514 Los Angeles CA 90033 USAJoerg Zehetner, University of Southern California Department of Surgery, Keck School of Medicine 1510 San Pablo Street, Suite 514 Los Angeles CA 90033 USAHelen J. Sohn, University of Southern California Department of Surgery, Keck School of Medicine 1510 San Pablo Street, Suite 514 Los Angeles CA 90033 USAJeffrey A. Hagen, University of Southern California Department of Surgery, Keck School of Medicine 1510 San Pablo Street, Suite 514 Los Angeles CA 90033 USASteven R. DeMeester, University of Southern California Department of Surgery, Keck School of Medicine 1510 San Pablo Street, Suite 514 Los Angeles CA 90033 USAJohn C. Lipham, University of Southern California Department of Surgery, Keck School of Medicine 1510 San Pablo Street, Suite 514 Los Angeles CA 90033 USASuzanne L. Palmer, University of Southern California Department of Radiology, Keck School of Medicine Los Angeles CA USATom R. DeMeester, University of Southern California Department of Surgery, Keck School of Medicine 1510 San Pablo Street, Suite 514 Los Angeles CA 90033 USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Technique of open laparoscopy for supramesocolic surgery in obese patients

Abstract Background Incidence of obesity and related diseases are increasing in the world. Visceral surgeons are more often confronted with laparoscopic surgery in obese patients. Besides validated surgery procedures, such as cholecystectomy and gastroesophageal reflux surgery, bariatric procedures are increasingly performed. In obese patients, the thickness of adipose panicle makes open laparoscopy hazardous. Methods In our department, we use systematically a technique of open laparoscopy in obese patients for supramesocolic surgery, which is safe, reproducible, and permits good closure of the abdominal wall. Results The surgical technique consists of opening the abdominal wall through the rectus abdominis. Helped by specific retractors called Descottes® (Medtronic Laboratory), both fascias are charged by sutures separately. Incision in the fascias is made safely by pooling on sutures. Introduction of port-site is made under view control. At the end of laparoscopy, closure of both fascias is easily done. Conclusions We present a technique of open laparoscopy in obese patients, systematically used, for supramesocolic surgery. This technique is safe, reproducible, and permits an efficient closure of the abdominal wall. Content Type Journal ArticleCategory TechniqueDOI 10.1007/s00464-009-0872-xAuthors Jean Baptiste Deguines, Université de Picardie Jules Verne Federation of Digestive Surgery, North Hospital Place Victor Pauchet 80054 Amiens Cedex 01 FranceQuentin Qassemyar, Université de Picardie Jules Verne Federation of Digestive Surgery, North Hospital Place Victor Pauchet 80054 Amiens Cedex 01 FranceAbdennaceur Dhahri, Université de Picardie Jules Verne Federation of Digestive Surgery, North Hospital Place Victor Pauchet 80054 Amiens Cedex 01 FranceOlivier Brehant, Université de Picardie Jules Verne Federation of Digestive Surgery, North Hospital Place Victor Pauchet 80054 Amiens Cedex 01 FranceDavid Fuks, Université de Picardie Jules Verne Federation of Digestive Surgery, North Hospital Place Victor Pauchet 80054 Amiens Cedex 01 FrancePierre Verhaeghe, Université de Picardie Jules Verne Federation of Digestive Surgery, North Hospital Place Victor Pauchet 80054 Amiens Cedex 01 FranceJean-Marc Regimbeau, Université de Picardie Jules Verne Federation of Digestive Surgery, North Hospital Place Victor Pauchet 80054 Amiens Cedex 01 France Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

The effect of mechanical ventilation tidal volume during pneumoperitoneum on shoulder pain after a laparoscopic appendectomy

Abstract Background Postlaparoscopic shoulder pain (PLSP) frequently occurs after various laparoscopic surgical procedures. Its mechanism is commonly assumed to be overstretching of the diaphragmatic muscle fibers due to the pressure of a pneumoperitoneum, which causes phrenic nerve-mediated referred pain to the shoulder. Based on this hypothesis, we speculated that during inspiration, the lung could squeeze out the phrenic nerve with carbon dioxide gas against the constantly pressurized abdominal cavity with increasing tidal volume (VT). Thus, we examined whether mechanical ventilation with a low VT (LTV, VT 7 ml/kg) during a pneumoperitoneum might reduce PLSP in patients undergoing laparoscopic appendectomy compared with ventilation with the traditional VT (TTV, VT 10 ml/kg). Methods In a prospective trial, 64 adult patients undergoing laparoscopic appendectomy were randomly assigned to two groups of 32 each (LTV and TTV groups). Intravenous ketorolac was used as a postoperative rescue analgesic. The 2-, 4-, 24-, and 48-h postoperative incidence and severity of PLSP, severity of surgical pain, and need for rescue analgesia was assessed. Results The overall incidence of PLSP was similar in both groups (57.1% in the LTV group vs. 65.5% in the TTV group). Compared with the TTV group, the incidence and PLSP verbal rating scale (VRS) did not decrease in the LTV group throughout the study period. No statistically significant differences were observed in the VRS surgical pain score, the cumulative ketorolac consumption at each time point, or the time to first rescue analgesia. Conclusions Mechanical ventilation with a reduced 7 ml/kg VT during a pneumoperitoneum does not reduce the frequency and severity of PLSP after laparoscopic appendectomy compared with ventilation with the traditional VT (10 ml/kg). Content Type Journal ArticleDOI 10.1007/s00464-010-0895-3Authors Hwa-Yong Shin, Konkuk University School of Medicine Department of Anesthesiology and Pain Medicine 1 Hwayang-Dong, Gwanggin-Gu Seoul 143-701 South KoreaSeong-Hyop Kim, Konkuk University School of Medicine Department of Anesthesiology and Pain Medicine 1 Hwayang-Dong, Gwanggin-Gu Seoul 143-701 South KoreaYeong-Ju Lee, National Police Hospital Department of Anesthesiology and Pain Medicine Seoul South KoreaDuk-Kyung Kim, Konkuk University School of Medicine Department of Anesthesiology and Pain Medicine 1 Hwayang-Dong, Gwanggin-Gu Seoul 143-701 South Korea Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Extraluminal laparoscopic wedge resection of gastric submucosal tumors: a retrospective review of 84 cases

Abstract Background Laparoscopic resection of gastric stromal tumors is being performed with increased frequency. This study aims to evaluate the feasibility and safety of the extraluminal laparoscopic gastric wedge resection (ELWR) technique. Methods Clinical data of 84 patients who underwent ELWR for gastric submucosal tumors between September 2000 and December 2007 were reviewed and analyzed retrospectively. The operation includes: localization of the tumor, dissection of the omentum, mobilization of the upper stomach and the upper pole of the spleen, exposure of esophago-cardiac junction (ECJ), and wedge resection of the upper part of gastric body and/or the gastric fundus with endoscopic gastrointestinal anastomosis (Endo GIA) stapler. Results All of the procedures were performed successfully, with mean operation time of 62.6 ± 8.9 min and mean intraoperative blood loss of 86.2 ± 8.1 ml. Through extraluminal laparoscopic wedge resection, complete R0 resection was achieved for all tumors. All surgical margins were negative microscopically. No lesions were missed, nor were there any significant postoperative complications or intraoperative conversions to open surgery. A total of 78.6% of the patients recovered their gastrointestinal functions and began to eat and ambulate within 36 h of the operation. The smallest surgical margins were 0.7–2.5 cm, with a mean distance of 1.4 ± 0.5 cm. Of the 84 cases of gastric submucosal tumors, 29 cases were leiomyomas, 51 cases were various types of stromal tumors, and 4 other cases were neurofibromas. Mean follow-up duration was 51 ± 4.3 months (overall follow-up rate 73.8%, 62/84 cases), during which no recurrences or metastases were found. Conclusion ELWR is a safe, simple, and effective procedure for treating submucosal tumors in the upper part of the stomach. It can avoid intraperitoneal contamination, possible tumor spillage, and postoperative esophageal stenosis, and provides unlimited scope for gastric resection. Content Type Journal ArticleDOI 10.1007/s00464-010-0888-2Authors Chong-wei Ke, Changhai Hospital Minimally Invasive Surgery Center Shanghai 200433 ChinaJing-li Cai, Changhai Hospital Minimally Invasive Surgery Center Shanghai 200433 ChinaDan-lei Chen, Changhai Hospital Minimally Invasive Surgery Center Shanghai 200433 ChinaCheng-zhu Zheng, Changhai Hospital Minimally Invasive Surgery Center Shanghai 200433 China Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Effort, safety, and findings of routine preoperative endoscopic evaluation of morbidly obese patients undergoing bariatric surgery

Abstract Background Obesity is becoming an epidemic health problem and is associated with concomitant diseases, such as sleep apnea syndrome and gastroesophageal reflux disease (GERD). There is no standardized diagnostic workup for the upper gastrointestinal tract in obese patients; many patients have no upper gastrointestinal symptoms, and few data are available on safety of endoscopy in morbidly obese patients. Methods Sixty-nine consecutive diagnostic upper gastrointestinal endoscopies in morbidly obese patients (26 men, 43 women; mean age 43.4 ± 10.9 years) were prospectively evaluated from January to December 2008 in an outpatient setting before bariatric procedures. Sedation was administered with propofol. Data on sedation, critical events, and examination times were recorded, as well as pathological findings. Results The patients’ mean body mass index was 47.6 ± 7.9 (range, 35.1–73.3) kg/m2; 17.4% reported GERD symptoms. The mean duration of the endoscopy procedure (including sedation) was 20.3 ± 9.3 (range, 5–50) min, and the whole procedure (including preparation and postprocessing) took 58.2 ± 19 (range, 20–120) min. The mean propofol dosage was 380 ± 150 (range, 80–900) mg. Two patients had critical events that required bronchoscopic intratracheal O2 insufflation due to severe hypoxemia (<60% Sao 2). Nearly 80% of patients had pathological findings in the upper gastrointestinal tract. Only 20% reported upper gastrointestinal symptoms. Pathologic conditions were found in the esophagus in 23.2% of the patients, in the stomach in 78.2%, and in the duodenum in 11.6%. The prevalence of Helicobacter pylori infection was 8.7%. Conclusions Upper gastrointestinal endoscopy can be performed safely. However, careful monitoring and anesthesiological support are required for patients with concomitant diseases and those receiving sedation. Because 80% of the patients with pathological findings were asymptomatic, every morbidly obese patient should undergo endoscopy before bariatric surgery because there may be findings that might change the surgical strategy. Content Type Journal ArticleDOI 10.1007/s00464-010-0893-5Authors M. A. Küper, Tübingen University Hospital Department of General, Visceral and Transplant Surgery Hoppe-Seyler-Strasse 3 72076 Tübingen GermanyT. Kratt, Tübingen University Hospital Department of General, Visceral and Transplant Surgery Hoppe-Seyler-Strasse 3 72076 Tübingen GermanyK. M. Kramer, Tübingen University Hospital Department of General, Visceral and Transplant Surgery Hoppe-Seyler-Strasse 3 72076 Tübingen GermanyM. Zdichavsky, Tübingen University Hospital Department of General, Visceral and Transplant Surgery Hoppe-Seyler-Strasse 3 72076 Tübingen GermanyJ. H. Schneider, Tübingen University Hospital Department of General, Visceral and Transplant Surgery Hoppe-Seyler-Strasse 3 72076 Tübingen GermanyJ. Glatzle, Tübingen University Hospital Department of General, Visceral and Transplant Surgery Hoppe-Seyler-Strasse 3 72076 Tübingen GermanyD. Stüker, Tübingen University Hospital Department of General, Visceral and Transplant Surgery Hoppe-Seyler-Strasse 3 72076 Tübingen GermanyA. Königsrainer, Tübingen University Hospital Department of General, Visceral and Transplant Surgery Hoppe-Seyler-Strasse 3 72076 Tübingen GermanyB. L. D. M. Brücher, Tübingen University Hospital Department of General, Visceral and Transplant Surgery Hoppe-Seyler-Strasse 3 72076 Tübingen Germany Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Stapled transanal rectal resection for symptomatic intussusception: morphological and functional outcome

Abstract Introduction Stapled transanal rectal resection (STARR) was developed to correct intussusception causing obstructed defecation. Some patients, however, do not profit from this operation as anticipated. We aimed to study the relationship between functional outcome and rectal morphology after STARR. Methods Fifteen consecutive female patients with median age of 64 years [interquartile range (IQR) 58–71 years] were studied before and after STARR. All patients had symptoms of obstructed defecation preoperatively. Pre- and postoperative workup consisted of standardized interview (including Wexner score) with physical examination including procto- and rectoscopy, anorectal manometry, and magnetic resonance (MR) defecography. Median follow up was 18 months (IQR 16–22 months). Results STARR was technically successful in all 15 patients without intra- or postoperative complications. Median (IQR) Wexner score of fecal incontinence was 0 (0–0) before and 3 (0–4.5) after surgery (p < 0.05). While all patients had repetitive incomplete defecation preoperatively, this symptom was present in seven patients postoperatively (p < 0.01). Third-degree intussusception was diagnosed during MR defecography in all patients preoperatively. After surgery, no patient had third-degree intussusception but one patient had first-degree and one patient had second-degree intussusception (p < 0.05). Size of rectocele was reduced from 2.9 cm (2.0–3.8 cm) to 0.8 cm (0.6–1.9 cm) (p < 0.05). Sphincter pressures were unchanged during anorectal manometry; however, first sensation during balloon distension in the rectum decreased from 50 ml (40–83 ml) before surgery to 30 ml (25–40 ml) after surgery (p < 0.05). Conclusion Stapled transanal rectal resection (STARR) achieved a high rate of morphological correction of intussusception; however, symptoms of obstructed defecation were not improved to the same extent, which warrants exploration in future studies. Content Type Journal ArticleDOI 10.1007/s00464-010-0889-1Authors Reinhold A. Lang, University of Munich Department of Surgery, Klinikum Großhadern Marchioninistrasse 15 81377 Munich GermanySonja Buhmann, University of Munich Institute of Clinical Radiology, Klinikum Großhadern Marchioninistrasse 15 81377 Munich GermanyChristine Lautenschlager, University of Munich Department of Surgery, Klinikum Großhadern Marchioninistrasse 15 81377 Munich GermanyMario H. Müller, University of Munich Department of Surgery, Klinikum Großhadern Marchioninistrasse 15 81377 Munich GermanyAndreas Lienemann, University of Munich Institute of Clinical Radiology, Klinikum Großhadern Marchioninistrasse 15 81377 Munich GermanyKarl-Walter Jauch, University of Munich Department of Surgery, Klinikum Großhadern Marchioninistrasse 15 81377 Munich GermanyMartin E. Kreis, University of Munich Department of Surgery, Klinikum Großhadern Marchioninistrasse 15 81377 Munich Germany Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Thoracoscopic robot-assisted extended thymectomy in the human cadaver

Abstract Methods Thoracoscopic robot-assisted extended thymectomy was performed in a human cadaver. The technique utilized the da VinciTM surgical system inserted through the subxiphoid approach with the sternum lifted upward (anteriorly). A small subxiphoid incision and two additional thoracoports were made in the chest wall, and the sternum was lifted by a new lifting retractor system. Results This method provided sufficient view and working space in the anterior mediastinum. A complete thymectomy was performed with facility. The robotic system provides superior optics and allows for enhanced dexterity. Conclusions Minimally invasive robotic-assisted thymectomy is an effective procedure and may add benefits for both surgeon and patients. Content Type Journal ArticleCategory LetterDOI 10.1007/s00464-009-0638-5Authors Norihiko Ishikawa, Brody School of Medicine at East Carolina University Center for Robotics and Minimally Invasive Surgery 600 Moye Blvd -LSB248 Greenville NC 27858 USAYou Su Sun, Brody School of Medicine at East Carolina University Center for Robotics and Minimally Invasive Surgery 600 Moye Blvd -LSB248 Greenville NC 27858 USAL. Wiley Nifong, Brody School of Medicine at East Carolina University Center for Robotics and Minimally Invasive Surgery 600 Moye Blvd -LSB248 Greenville NC 27858 USAMakoto Oda, Kanazawa University School of Medicine Department of General and Cardiothoracic Surgery Kanazawa JapanGo Watanabe, Kanazawa University School of Medicine Department of General and Cardiothoracic Surgery Kanazawa JapanW. Randolph Chitwood, Brody School of Medicine at East Carolina University Center for Robotics and Minimally Invasive Surgery 600 Moye Blvd -LSB248 Greenville NC 27858 USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

A prospective randomized trial comparing two-stage versus single-stage management of patients with gallstone disease and common bile duct stones

Abstract Background The optimal management of patients with concomitant common bile duct stones and gallstones is still evolving. With the introduction of laparoscopic common bile duct exploration, many centers prefer single-stage laparoscopic cholecystectomy and common bile duct exploration over preoperative endoscopic bile duct clearance followed by laparoscopic cholecystectomy. The present study was done to compare these two management options. Patients and methods 30 patients with symptomatic gallstones and common bile duct stones were randomized to either treatment option. Preoperative endoscopic ultrasound (EUS) and/or magnetic resonance pancreaticography (MRCP) was done in all patients to confirm the diagnosis. In group I, laparoscopic cholecystectomy and common bile duct exploration was done at the same sitting; in group II, endoscopic stone clearance was followed by laparoscopic cholecystectomy 4–6 weeks later. Success was defined as successful treatment by the intended modality. Results 15 patients were randomized to each group and the two groups had comparable demographic and clinical profile. In group I there was a success rate of 93.5% in comparison with 86.7% in group II (p = 0.32, Fisher’s exact test). The complications were similar in the two groups. Conclusions The results showed equivalent success rate in terms of morbidity and hospital stay. Laparoscopic approach seems to be favorable because of the smaller number of procedures and hospital visits. Content Type Journal ArticleDOI 10.1007/s00464-010-0891-7Authors Virinder K. Bansal, All India Institute of Medical Sciences Department of Surgical Disciplines Room No. 5045, 5th Floor, Teaching Block New Delhi IndiaMahesh C. Misra, All India Institute of Medical Sciences Department of Surgical Disciplines Room No. 5045, 5th Floor, Teaching Block New Delhi IndiaPramod Garg, All India Institute of Medical Sciences Department of Gastroenterology New Delhi IndiaManik Prabhu, All India Institute of Medical Sciences Department of Surgical Disciplines Room No. 5045, 5th Floor, Teaching Block New Delhi India Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Single-port-access (SPATM) cholecystectomy: a multi-institutional report of the first 297 cases

Abstract Background An important aspect of a new surgical technique is whether it can be performed by other surgeons in other institutions. The authors report the first 297 cases in a multi-institutional and multinational review of laparoscopic cholecystectomy performed via a single portal of entry. Methods Data were collected retrospectively for the initial patients undergoing single-port cholecystectomy by 13 surgeons who performed these procedures in their institutions after training by the authors. The review included operative time, blood loss, incision length, length of hospital stay (LOS), necessary additional trocars, and other parameters important to cholecystectomy. A database of all the single-port-access (SPA) surgeries performed by the surgeons included demographic and procedural details, LOS, complications, and initial follow-up data. Results To date, 297 single-port cholecystectomies have been performed for a variety of diagnoses, primarily cholelithiasis. The average operative time was 71 min, and the average LOS was 1–2 days. The average blood loss was minimal. The use of additional port sites outside the umbilicus occurred in 34 of the cases. Of the 35 intraoperative cholangiograms performed, 34 were successful. No significant complications occurred except for seromas and minor postoperative wound infections. These results are comparable with those for standard multiport cholecystectomy. In addition, no access site hernias (ASH) occurred. Conclusions The findings demonstrate that SPA surgery is an alternative to multiport laparoscopy with fewer scars and better cosmesis. One factor affecting the rate for adoption of SPA surgery among other surgeons is the reproducibility of this new procedure. Although this study had insufficient data to determine fully the benefits of SPA surgery, the feasibility of this procedure with safe, acceptable results was demonstrated in this initial large series across multinational institutions. Content Type Journal ArticleDOI 10.1007/s00464-009-0856-xAuthors Paul G. Curcillo, Drexel University College of Medicine Department of Surgery 219 North Broad Street Philadelphia PA 19107 USAAndrew S. Wu, Drexel University College of Medicine Department of Surgery 219 North Broad Street Philadelphia PA 19107 USAErica R. Podolsky, Drexel University College of Medicine Department of Surgery 219 North Broad Street Philadelphia PA 19107 USACasey Graybeal, Northeast Georgia Surgical Associates Gainesville GA USANamir Katkhouda, University of Southern California Los Angeles CA USAAlex Saenz, Clinica Sagrada Familia Department of Surgery Barcelona SpainRobert Dunham, Queen of the Valley Medical Center Napa CA USASteven Fendley, Wiregrass Surgical Associates Dothan AL USAMarc Neff, Surgical Care Associates Cherry Hill NJ USAChad Copper, Northeast Georgia Medical Center Gainesville GA USAMarc Bessler, Columbia University Medical Center New York NY USAAndrew A. Gumbs, Fox-Chase Cancer CenterDothan Philadelphia PA USAMichael Norton, Trinity Mother Frances Clinic Surgery Tyler TX USAAntonio Iannelli, University of Nice-Sophia-Antipolis Chirurgien des Hopitaux Nice FranceRodney Mason, University of Southern California Los Angeles CA USAAshkan Moazzez, University of Southern California Los Angeles CA USALarry Cohen, Surgical Care Associates Cherry Hill NJ USAAngela Mouhlas, Drexel University College of Medicine Philadelphia PA USAAlex Poor, Drexel University College of Medicine Philadelphia PA USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Is unilateral laparoscopic TEP inguinal hernia repair a job half done? The case for bilateral repair

Abstract Introduction Bilateral laparoscopic totally extraperitoneal (TEP) repair of unilateral hernia is conspicuous in published literature by its absence. There are no studies or data on the feasibility, advantages or disadvantages of bilateral repair in all cases or in any subset of patients with unilateral primary inguinal hernia. The objective of this study is to investigate the feasibility of bilateral laparoscopic exploration for all unilateral cases followed by laparoscopic TEP in all cases and to compare complications, recurrence rates, postoperative pain, patient satisfaction, and return to work retrospectively with a similar number of age-matched retrospective controls. Method One hundred fifty TEP operations were performed in 75 patients (group A) prospectively and were compared with 75 unilateral TEP operations (group B) in age-matched controls done previously by the same surgeon. All cases were performed under general anesthesia, and TEP repair was performed using three midline ports. All uncomplicated patients were discharged at 24 h, in keeping with departmental policy. Results Of 75 patients (group A), 25 (33.3%) were clinically diagnosed with bilateral hernia and the rest (50, 66.66%) with unilateral hernia. The distribution of the 25 bilateral cases was 11 bilateral direct and 14 bilateral indirect inguinal hernias. The distribution of the 75 age-matched controls (group B) was all unilateral hernia, of which 47 were right-sided and 28 were left-sided. There were 23 direct hernias and 52 indirect hernias among the control group. The mean operative time for all 150 cases was 76.66 ± 15.92 min. The operative time in the control group (unilateral hernias) was 66.16 ± 12.44 min, whereas the operative time in the test group (bilateral repair) was 87.2 ± 11.32 min. The operative time in the bilateral group was significantly higher, by 21.04 min or 31.88% (p = 0.000). The operative time in the true unilateral group was 82.45 ± 9.38 min, whereas the operative time in the former group [occult contralateral hernias (OCHs) + bilateral hernias] was 91.35 ± 11.95 min, which is a statistically significant difference (p = 0.0015). Occult hernia was seen in a total of 15 cases, of which 13 were OCHs (26%) and 2 were occult ipsilateral hernias (OIH). The mean operative time in the OCH cases was 81.46 ± 7.9 min, whereas in those without OCH it was 82.45 ± 9.38 min, which is not a statistically significant difference (p = 0.46). Regarding complications, there were no cases of seroma, hematoma, wound infection, visceral injury or postoperative neuralgia in either group A or B. On statistical analysis, visual analog score (VAS)-measured pain score, at 12 h only, was significantly higher in the unilateral repair group as compared with the bilateral TEP group; VAS scores at all other times were not statistically significantly different between the two groups. The average time of return to light routine or activities of daily living was 1 day in group A, whereas in group B it was 1.91 days (range 1–3 days), which is a statistically significant difference (p = 0.000). There was one case of recurrence in this study, in a left-sided hernia in group A, over a follow-up period of 60–72 (mean 66) months; all patients reported for follow-up by office visit or correspondence until 2 years, and two patients were lost to follow-up after 2 years. In group B, there was no recurrence over a follow-up period of 72–84 months, with three patients lost to follow-up after 3 years. Conclusion In the present study bilateral TEP was performed in three types of patients: those with clinically bilateral hernias, those with clinically unilateral hernia but with an OCH, and in truly unilateral hernias. All of these were compared with unilateral TEPs in clinically unilateral hernias, and we found no significant increase in morbidity, pain, recurrence or complications in bilateral repairs. Convalescence from surgery, as determined by return to activities of daily living and return to work parameters, was also comparable. Surgeons experienced in laparoscopic TEP, in high-volume centers, can provide bilateral repairs in patients with inguinal hernia, bearing in mind its advantages and comparable morbidity. We also feel that, in elective repair of inguinal hernia, the patient should be given the option of bilateral repair. Bilateral repair does not add to the risk of surgery in experienced hands and we strongly feel that unilateral TEP is actually a job half done. Content Type Journal ArticleDOI 10.1007/s00464-009-0841-4Authors Pawanindra Lal, Maulana Azad Medical College, University of Delhi Department of Surgery New Delhi 110002 IndiaPrejesh Philips, Maulana Azad Medical College, University of Delhi Department of Surgery New Delhi 110002 IndiaJagdish Chander, Maulana Azad Medical College, University of Delhi Department of Surgery New Delhi 110002 IndiaVinod K. Ramteke, Maulana Azad Medical College, University of Delhi Department of Surgery New Delhi 110002 India Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Safety of the laparoscopic adjustable gastric band: 7-year data from a U.S. center of excellence

Abstract Background Laparoscopic adjustable gastric banding (LAGB) has become one of the most common weight-loss procedures performed in the United States. The authors’ high-volume academic medical center has gathered a database of almost 3,000 patients who have undergone LAGB since January 2001. The goal of this series, the largest to date on LAGB outcomes at a single institution, was to assess complications associated with LAGB. Methods A retrospective analysis was performed using longitudinal data from adult patients who underwent LAGB between 1 January 2001, and 29 February 2008. General and band-related complications were reported for all patients. Death and reoperation for weight gain (LAGB followed by either a second band insertion or a gastric bypass) also were reported. Results Of the 2,965 patients who received LAGB during the study period, 2,909 met the criteria for inclusion in this analysis, and 363 (12.2%) experienced one or more complications. The most common complications were band slip (4.5%) and port-related problems (3.3%). Other complications were rare. Only seven patients (0.2%) had band erosion. Eleven patients (0.4%) underwent reoperation for weight gain. A total of 10 deaths (0.34%) occurred during the study period. Three patients died within 30 days of surgery. Two of these deaths (0.06%) were related to surgery, and one resulted from a motor vehicle accident. Seven patients died of causes unrelated to surgery during the course of the study. Conclusions The LAGB technique is a relatively safe procedure with few early or late complications. Few LAGB patients undergo reoperation for weight gain, and mortality is very rare. Content Type Journal ArticleDOI 10.1007/s00464-009-0858-8Authors Allison M. Carelli, NYU Langone Medical Center 530 First Avenue, Suite 10S New York NY 10016 USAHeekoung Allison Youn, NYU Langone Medical Center 530 First Avenue, Suite 10S New York NY 10016 USAMarina S. Kurian, NYU Langone Medical Center 530 First Avenue, Suite 10S New York NY 10016 USAChristine J. Ren, NYU Langone Medical Center 530 First Avenue, Suite 10S New York NY 10016 USAGeorge A. Fielding, NYU Langone Medical Center 530 First Avenue, Suite 10S New York NY 10016 USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Global Assessment of Gastrointestinal Endoscopic Skills (GAGES): a valid measurement tool for technical skills in flexible endoscopy

Abstract Background Simulators may improve the efficiency, safety, and quality of endoscopic training. However, no objective, reliable, and valid tool exists to assess clinical endoscopic skills. Such a tool to measure the outcomes of educational strategies is a necessity. This multicenter, multidisciplinary trial aimed to develop instruments for evaluating basic flexible endoscopic skills and to demonstrate their reliability and validity. Methods The Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) Upper Endoscopy (GAGES-UE) and Colonoscopy (GAGES-C) are rating scales developed by expert endoscopists. The GAGES scale was completed by the attending endoscopist (A) and an observer (O) in self-assessment (S) during procedures to establish interrater reliability (IRR, using the intraclass correlation coefficient [ICC]) and internal consistency (IC, using Cronbach’s alpha). Instrumentation was evaluated when possible and correlated with total scores. Construct and external validity were examined by comparing novice (NOV) and experienced (EXP) endoscopists (Student’s t-test). Correlations were calculated for GAGES-UE and GAGES-C with participants who had performed both. Results For the 139 completed evaluations (60 NOV, 79 EXP), IRR (A vs. O) was 0.96 for GAGES-UE and 0.97 for GAGES-C. The IRR between S and A was 0.78 for GAGES-UE and 0.89 for GAGES-C. The IC was 0.89 for GAGES-UE, and 0.95 for GAGES-C. There were mean differences between the NOV and the EXP endoscopists for GAGE-UE (14.4 ± 3.7 vs. 18.5 ± 1.6; p < 0.001) and GAGE-C (11.8 ± 3.8 vs. 18.8 ± 1.3; p < 0.001). Good correlation was found between the scores for the GAGE-UE and the GAGE-C (r = 0.75; n = 37). Instrumentation, when performed, demonstrated correlations with total scores of 0.84 (GAGE-UE; n = 73) and 0.86 (GAGE-C; n = 45). Conclusions The GAGES-UE and GAGES-C are easy to administer and consistent and meet high standards of reliability and validity. They can be used to measure the effectiveness of simulator training and to provide specific feedback. The GAGES results can be generalized to North American and European endoscopists and may contribute to the definition of technical proficiency in endoscopy. Content Type Journal ArticleDOI 10.1007/s00464-010-0882-8Authors Melina C. Vassiliou, McGill University Health Centre Montreal QC CanadaPepa A. Kaneva, McGill University Health Centre Montreal QC CanadaBenjamin K. Poulose, Vanderbilt University Nashville TN USABrian J. Dunkin, Methodist Hospital Houston TX USAJeffrey M. Marks, Case Medical Center Cleveland OH USARiadh Sadik, Sahlgrenska Hospital Gothenburg SwedenGideon Sroka, McGill University Health Centre Montreal QC CanadaMehran Anvari, McMaster University Hamilton ON CanadaKlaus Thaler, University of Missouri Columbus MO USAGina L. Adrales, Dartmouth-Hitchcock Medical Center Lebanon NH USAJeffrey W. Hazey, Ohio State University Columbus OH USAJenifer R. Lightdale, Children’s Hospital Boston Boston MA USAVic Velanovich, Henry Ford Hospital Detroit MI USALee L. Swanstrom, Legacy Health Portland OR USAJohn D. Mellinger, Medical College of Georgia Augusta GA USAGerald M. Fried, McGill University Health Centre Montreal QC Canada Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Whether robot-assisted laparoscopic fundoplication is better for gastroesophageal reflux disease in adults: a systematic review and meta-analysis

Abstract Background Although laparoscopic fundoplication is an effective, minimally invasive surgical technique for gastroesophageal reflux disease (GERD) that failed to be treated with medicine, with wide implementation its technical limitations have become increasingly clear. Recently, robot-assisted laparoscopic fundoplication (RALF) was considered a new approach that makes up for the deficiency of conventional laparoscopic fundoplication (CLF). This systematic review aimed to assess the feasibility and efficiency of robot-assisted laparoscopic fundoplication for GERD. Methods Two reviewers independently searched and identified seven randomized controlled trials (RCTs) and four clinical controlled trials (CCTs) of RALF versus CLF for GERD in the Cochrane database, Medline, Embase, and Science citation index between 2001 and 2009. The main outcomes were operating time, complication rate, hospital stay, and costs. The meta-analysis was performed by Review Manager 5.0 software. The effect size of the clinical outcomes was evaluated by odds ratio (OR), weighted mean difference (WMD), and standard mean difference (SMD) according to different data type. Heterogeneity and sensitivity analysis were used to account for rationality of pooling data and sources of heterogeneity. Results Of 483 studies found, a total of 11 trials were included in this review; among 533 patients, 198 patients underwent RALF and 335 patients underwent CLF. The results of meta-analysis showed that the postoperative complication rate (OR = 0.35, 95% CI = [0.13, 0.93], p = 0.04) is lower for RALF, but the total operating time (WMD = 24.05, 95% CI = [5.19, 42.92], p = 0.01) is longer for RALF compared with those for CLF. Statistically, there was no significant difference between the two groups with regard to perioperative complication rate (OR = 0.67, 95% CI = [0.30, 1.48], p = 1.00) and length of hospital stay (WMD = 0.00, 95% CI = [-0.25, 0.26], p = 0.04). Conclusions Systematic review of the literature indicates that RALF is a feasible and safe alternative to surgical treatment of GERD. However, since it lacks obvious advantages with respect to operating time, length of hospital stay and cost, RALF has limitations for its extensive application in clinics. Content Type Journal ArticleCategory ReviewDOI 10.1007/s00464-009-0873-9Authors Jun Mi, The Second Hospital of Lanzhou University Department of Surgery Lanzhou 730030 ChinaYingxin Kang, The Second Hospital of Lanzhou University Department of Surgery Lanzhou 730030 ChinaXiao Chen, The Second Hospital of Lanzhou University Department of Surgery Lanzhou 730030 ChinaBingjun Wang, The Second Hospital of Lanzhou University Department of Surgery Lanzhou 730030 ChinaZhiping Wang, The Second Hospital of Lanzhou University Department of Surgery Lanzhou 730030 China Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife for large superficial colorectal neoplasias including ileocecal lesions

Abstract Background Large superficial neoplasias of the ileocecal region pose an increased degree of complexity for endoscopic resection. This study aimed to evaluate the safety and efficacy of endoscopic submucosal dissection (ESD) for large superficial colorectal neoplasias including ileocecal lesions. Methods A total of 33 superficial colorectal neoplasias, including eight neoplasias in the ileocecal region, were treated with ESD from December 2005 to April 2009. Therapeutic efficacy, complications, and follow-up results were retrospectively evaluated among three groups: ileocecal region, colon, and rectum. Results The mean size of all resected neoplasias was 35 ± 15 mm (range, 20–80 mm) and that of all resected specimens was 41 ± 15 mm (range, 23–82 mm). The mean procedural time was 121 ± 90 min (range, 22–420 min). The difference in mean values among the three groups was not significant. The overall rate of en bloc resection was 91% (30/33). Histopathologically, both the lateral and vertical margins in the specimens resected en bloc tested negative (30/30). The rate for en bloc resection in the ileocecal region did not differ significantly from that for the other two groups (p = 0.20 compared with the rate for the colon and p = 0.12 compared with the rate for the rectum). Complications such as perforation and postoperative bleeding did not occur in the ileocecal group. No recurrence was observed in any cases during the mean follow-up period of 20 ± 12 months (range, 4–44 months). Conclusions The ESD approach is safe and effective for treating large superficial neoplasias of the ileocecal region such as other colorectal neoplasias. Content Type Journal ArticleDOI 10.1007/s00464-010-0883-7Authors Naoki Ishii, St. Luke’s International Hospital Department of Gastroenterology 9-1 Akashi-cho, Chuo-ku Tokyo 104-8560 JapanToshiyuki Itoh, St. Luke’s International Hospital Department of Gastroenterology 9-1 Akashi-cho, Chuo-ku Tokyo 104-8560 JapanNoriyuki Horiki, St. Luke’s International Hospital Department of Gastroenterology 9-1 Akashi-cho, Chuo-ku Tokyo 104-8560 JapanMichitaka Matsuda, St. Luke’s International Hospital Department of Gastroenterology 9-1 Akashi-cho, Chuo-ku Tokyo 104-8560 JapanTakeshi Setoyama, St. Luke’s International Hospital Department of Gastroenterology 9-1 Akashi-cho, Chuo-ku Tokyo 104-8560 JapanShoko Suzuki, St. Luke’s International Hospital Department of Gastroenterology 9-1 Akashi-cho, Chuo-ku Tokyo 104-8560 JapanMasayo Uemura, St. Luke’s International Hospital Department of Gastroenterology 9-1 Akashi-cho, Chuo-ku Tokyo 104-8560 JapanYusuke Iizuka, St. Luke’s International Hospital Department of Gastroenterology 9-1 Akashi-cho, Chuo-ku Tokyo 104-8560 JapanKatsuyuki Fukuda, St. Luke’s International Hospital Department of Gastroenterology 9-1 Akashi-cho, Chuo-ku Tokyo 104-8560 JapanKoyu Suzuki, St. Luke’s International Hospital Department of Pathology 9-1 Akashi-cho, Chuo-ku Tokyo 104-8560 JapanYoshiyuki Fujita, St. Luke’s International Hospital Department of Gastroenterology 9-1 Akashi-cho, Chuo-ku Tokyo 104-8560 Japan Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Comparison of intracorporeal versus extracorporeal anastomosis in laparoscopic-assisted hemicolectomy

Abstract Background Laparoscopic-assisted colon resection has been shown to result in earlier return of bowel function, decreased postoperative pain, decreased length of stay, and decreased morbidity when compared to open resection. Laparoscopic-assisted hemicolectomy often still involves externalization of the bowel for resection and anastomosis. The aim of this study was to determine short-term outcomes of performing intra- versus extracorporeal resection and anastomosis in laparoscopic-assisted hemicolectomy. Methods Retrospective chart review of 105 consecutive patients who underwent laparoscopic-assisted hemicolectomy or colectomy by a single surgeon from January 2006 through August 2008 was performed. Pearson χ2 and Student’s t test were used to test for significance. Results There were 105 patients in total who underwent laparoscopic-assisted ileocolic resection (66), right hemicolectomy (29), left hemicolectomy (9), and subtotal colectomy (1). There were more males in the extracorporeal group, but patients in the two groups were otherwise demographically comparable. An intracorporeal anastomosis was performed in 54 patients and extracorporeal in 51 patients. The operation was longer in the intracorporeal group (p ≤ 0.001), but estimated blood loss was less (p = 0.014). Postoperatively, there was no significant difference in time to bowel movement between the intra- and extracorporeal anastomosis groups; however, there was earlier return of flatus (2 vs. 2.4 days, respectively; p = 0.017). Postoperative narcotic use (16 vs. 49 mg morphine equivalents; p = 0.001), length of stay (3.2 vs. 3.8 days; p = 0.012), and perioperative morbidity (6 vs. 15 patients; p = 0.019) were all decreased in the intra- versus extracorporeal group, respectively. There was no perioperative mortality. Conclusion In comparison to the extracorporeal technique, resection and creation of the anastomosis intracorporeally produces superior results with earlier return of bowel function, decreased postoperative narcotic use, and decreased length of stay and morbidity. Further studies will be needed to verify our findings. Content Type Journal ArticleDOI 10.1007/s00464-009-0865-9Authors Jayleen Grams, Mount Sinai Medical Center Department of Surgery 5 East 98th Street Box 1259 New York NY 10029 USAWinnie Tong, Mount Sinai Medical Center Department of Surgery 5 East 98th Street Box 1259 New York NY 10029 USAAlex J. Greenstein, Mount Sinai Medical Center Department of Surgery 5 East 98th Street Box 1259 New York NY 10029 USABarry Salky, Mount Sinai Medical Center Department of Surgery 5 East 98th Street Box 1259 New York NY 10029 USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Single-incision laparoscopic cholecystectomy: the first 100 outpatients

Abstract Background Single-incision laparoscopic surgery (SILS) is a well-described technique for many general surgical procedures. The SILS techniques applied to cholecystectomy vary, and reporting has been sparse. Because most cholecystectomies are outpatient procedures performed by busy, practicing general surgeons, the authors report their initial experience adopting this technique. Methods From March, 2008 to January, 2009, SILS was performed for 100 consecutive outpatients needing cholecystectomy. All the patients underwent a single-incision, multiport laparoscopic (SIMPL) technique using existing instrumentation. The patients were followed postoperatively for at least 6 months. Results Of the 100 patients, 98 underwent SIMPL cholecystectomy and 2 required conversion to the standard laparoscopic technique because of bleeding from the cystic artery. No major postoperative complications occurred, including infections and hernias. Conclusions The findings show SIMPL cholecystectomy to be safe in the outpatient setting. It is an excellent alternative to traditional three- or four-port cholecystectomy for the ideal candidate with a lower body mass index (BMI), early disease, and no previous abdominal surgery. The authors’ initial outpatient experience shows that it can be performed using existing instrumentation without increasing costs by a reproducible technique that can be adopted by any practicing general surgeon. Content Type Journal ArticleDOI 10.1007/s00464-010-0886-4Authors Jose Erbella, Manatee Memorial Hospital Department of Surgery 206 Second Street East Bradenton FL 34208 USAGary M. Bunch, Manatee Memorial Hospital Department of Surgery 206 Second Street East Bradenton FL 34208 USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

The impact of intraoperative ultrasonography on the surgical treatment of patients with colorectal liver metastases

Abstract Introduction Intraoperative ultrasonography (IOUS) has been the standard in surgical decision making in oncologic liver surgery. Preoperative imaging techniques have improved substantially in resent years; therefore, the importance of IOUS might change. The current results of IOUS were compared with preoperative high-resolution helical CT scanning and the impact of IOUS on surgical decision making was evaluated. Methods A total of 100 consecutive patients who underwent open surgery for colorectal liver metastases within 4 weeks after preoperative imaging, performed with high-speed helical CT scanners, were included for this study. During surgery, IOUS was performed by a liver specialized radiologist. The findings on preoperative and intraoperative imaging and surgical exploration were compared regarding number, site, and size of the hepatic lesions. The preoperative surgical plan was compared with the final surgical treatment. Results One hundred patients with CRLM underwent 117 surgical treatments. In 38 patients IOUS differed from preoperative data. In 23 cases IOUS identified more metastatic lesions. In five patients, intraoperative findings identified smaller or less hepatic lesions. Additional information on the localization of the hepatic lesions was gathered by IOUS and changed the surgical treatment in ten cases. IOUS alone altered the surgical strategy 35 times during 117 procedures. In nearly all cases, discrepancy between the preoperative CT scan and IOUS resulted in a change of surgical treatment. Conclusions Despite improvement in preoperative imaging technology, the intraoperative use of ultrasonography remains of crucial importance. The detection of preoperatively unknown lesions remains high with great consequence on surgical therapy. Content Type Journal ArticleDOI 10.1007/s00464-009-0874-8Authors C. Sietses, Vrije Universiteit Medical Centre Department of Surgery P.O. Box 7057 1007 MB Amsterdam The NetherlandsM. R. Meijerink, Vrije Universiteit Medical Centre Department of Radiology Amsterdam The NetherlandsS. Meijer, Vrije Universiteit Medical Centre Department of Surgery P.O. Box 7057 1007 MB Amsterdam The NetherlandsM. P. van den Tol, Vrije Universiteit Medical Centre Department of Surgery P.O. Box 7057 1007 MB Amsterdam The Netherlands Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

The safety and utility of prophylactic pancreatic duct stents in the prevention of post-ERCP pancreatitis: an analysis of practice in a single UK tertiary referral center

Abstract Background The use of temporary prophylactic pancreatic duct (PD) stents in the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in high-risk patients has been shown to be effective in multiple trials. However, there are limited data on the clinical implications of PD stents and their impact on practice outside of the trial setting. Methods The utility of prophylactic pancreatic stenting was evaluated in a retrospective analysis of 1,000 consecutive ERCPs performed in a single tertiary referral pancreatobiliary center over a 24-month period, based upon a predetermined protocol to identify patients at high risk of postprocedure pancreatitis. Results One thousand procedures performed in 688 patients were studied. Sixty-one patients were considered for stent placement and stents were successfully placed in 58 cases. The overall rate of post-ERCP pancreatitis in our study population was 3.6%. The rate of pancreatitis in the stented patients was considered high at 22.4%, but the majority (69%) were classified as mild and there were no reported severe episodes. This compares to pancreatitis in the nonstented group, in whom the majority (73.9%) experienced either moderate or severe episodes. Conclusion A strategy of prophylactic PD stents in this study has eliminated severe post-ERCP pancreatitis in high-risk patients. However, the high pancreatitis rate in stented patients may represent the cost to achieve this, while stent type and size employed are likely contributing factors. To maximize the benefits of PD stenting, there is a need to identify and treat all those considered at high risk. Content Type Journal ArticleDOI 10.1007/s00464-009-0875-7Authors Patrick T. F. Kennedy, Imperial College Healthcare NHS Trust Department of Gastroenterology London UKEvangelos Russo, Imperial College Healthcare NHS Trust Department of Gastroenterology London UKNaveenta Kumar, Imperial College Healthcare NHS Trust Department of Gastroenterology London UKNick Powell, Imperial College Healthcare NHS Trust Department of Gastroenterology London UKDevinder Bansi, Imperial College Healthcare NHS Trust Department of Gastroenterology London UKAndrew Thillainayagam, Imperial College Healthcare NHS Trust Department of Gastroenterology London UKPanagiotis Vlavianos, Imperial College Healthcare NHS Trust Department of Gastroenterology London UKDavid Westaby, Imperial College Healthcare NHS Trust Department of Gastroenterology London UK Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Risk of clinical leak after laparoscopic versus open bowel anastomosis

Abstract Purpose This study was designed to investigate the safety of laparoscopic (Lap) colorectal surgery as reflected by the anastomotic bowel leak (ABL) rate compared with that seen in open surgery. Methods Between 2000 and 2007, 1,516 consecutive patients undergoing Lap-colorectal surgery with bowel anastomosis were covariate-adjusted to 3,258 patients undergoing open surgery by pathology and site of anastomosis using the institutional review board-approved laparoscopic, diverticular, Crohn’s, and colorectal cancer databases. Of these patients, 643 patients in each group were equally matched by pathology, site of anastomosis, date of surgery, age, gender, and body mass index. The clinical ABL rate was compared between the two groups by the location of bowel anastomosis and year of surgery. Results A total of 4,774 patients (1,516 Lap, 3,258 open; mean age, 55.8 ± 17.4 years; body mass index, 27.8 ± 6.2) underwent colorectal resection with bowel anastomosis (cancer 45.3%, Crohn’s 29.6%, diverticulitis 12.3%, other 12.8%). There was no difference in the overall clinical ABL between Lap (2.6%) and open procedures (2.1%; p = 0.5), between Lap right versus open right (p = 0.6), between Lap left versus open left (p = 0.8), and between patients operated on during different time periods (p = 0.4). For the case-matched 643 patients, there were no differences in clinical anastomotic bowel leak between laparoscopic versus open group based on site of anastomosis, pathology, and year of surgery. Conclusions A laparoscopic colorectal approach is not associated with a higher risk of clinical anastomotic bowel leak. Content Type Journal ArticleDOI 10.1007/s00464-009-0867-7Authors Galal El-Gazzaz, Cleveland Clinic Foundation A30 Department of Colorectal Surgery Cleveland OH 44195 USADaniel Geisler, Cleveland Clinic Foundation A30 Department of Colorectal Surgery Cleveland OH 44195 USATracy Hull, Cleveland Clinic Foundation A30 Department of Colorectal Surgery Cleveland OH 44195 USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Endoscopic thoracic sympathectomy for primary palmar hyperidrosis

Abstract Background Primary hyperhidrosis is a disorder that is characterized by excessive sweating in disproportion to that required for thermoregulation. In most cases, this is aggravated by emotional factors and by heat. Hyperhidrosis can be seen in the palms of the hands, armpits, soles of the feet and face. The principal characteristic of this disease is the intense discomfort of patients, which affects their social and professional life. Treatment modalities include topical application of aluminum chloride, iontophoresis, anticholinergics, botulinum toxin injection, liposuction, excision of sweat glands, and thoracic sympathectomy. Methods Between January 1998 and August 2007, a prospective study of endoscopic thoracic sympathectomies for palmar hyperhidrosis was undertaken based on case histories and a prospective pre- and postoperative questionnaire survey. The sample comprised of 322 patients with a mean age of 24 years. At Apollo Hospital, New Delhi, India, bilateral video-assisted thoracoscopic T3 level sympathectomies were performed in all cases. Results All patients had immediate cessation of palmar hyperhidrosis. The mean postoperative stay was 1.1 days. A questionnaire was completed based on their response to a telephone conversation or e-mail. A paired t test and Wilcoxon test was performed on these data and it showed significant improvement in quality of life. Compensatory sweating was found to be the most troublesome side effect for all patients. It was seen in 63% of the patients. This is similar to other reports of compensatory sweating; however, the figure decreases to 29% if we disregard the percentage of patients who reported only mild compensatory sweating. Conclusion In view of the low morbidity and zero mortality rate of this surgical technique, we recommend it as a method of treatment for palmar hyperhidrosis. Thoracic sympathectomy eliminates palmar hyperhidrosis with minimal recurrence (1% in our series) and produces a high rate of patient satisfaction. Content Type Journal ArticleDOI 10.1007/s00464-010-0885-5Authors Arun Prasad, Apollo Hospital Department of Minimal Access Surgery Sarita Vihar New Delhi 110044 IndiaMudasir Ali, Apollo Hospital Department of Minimal Access Surgery Sarita Vihar New Delhi 110044 IndiaSunil Kaul, Apollo Hospital Department of Minimal Access Surgery Sarita Vihar New Delhi 110044 India Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Safety of carbon dioxide insufflation for upper gastrointestinal tract endoscopic treatment of patients under deep sedation

Abstract Background It is well known that carbon dioxide (CO2) is absorbed faster in the body than air and also that it is rapidly excreted through respiration. This study aimed to investigate the safety of CO2 insufflation used for esophageal and gastric endoscopic submucosal dissection (ESD) in patients under deep sedation. Methods Patients with either early gastric or esophageal cancers that could be resected by ESD were enrolled in this study from March 2007 to July 2008 and randomly assigned to undergo ESD procedures with CO2 insufflation (CO2 group) or air insufflation (air group). A TOSCA measurement system and TOSCA 500 monitor were used to measure and monitor both transcutaneous partial pressure of CO2 (PtcCO2) and oxygen saturation (SpO2). Results The study enrolled 89 patients and randomly assigned them to a CO2 group (45 patients) or an air group (44 patients). The mean CO2 group versus air group measurements were as follows: PtcCO2 (49.1 ± 5.0 vs. 50.1 ± 5.3 mmHg; nonsignificant difference [NS]), maximum PtcCO2 (55.1 ± 6.5 vs. 56.8 ± 7.0 mmHg; NS), PtcCO2 elevation (9.1 ± 5.4 vs. 11.4 ± 5.6 mmHg; p = 0.054), SpO2 (99.0 ± 0.7% vs. 99.0 ± 1.0%; NS), minimum SpO2 (96.5 ± 2.4% vs. 95.4 ± 3.3%; p = 0.085), and SpO2 depression (2.4 ± 2.3% vs. 3.3 ± 2.9%; NS). The PtcCO2 and SpO2 measurements were similar in the two groups, but the CO2 group was better than the air group in PtcCO2 elevation and minimum SpO2. Conclusions The findings demonstrated CO2 insufflation to be as safe as air insufflation for upper gastrointestinal tract ESDs performed for patients under deep sedation without evidencing any adverse effects. Content Type Journal ArticleDOI 10.1007/s00464-009-0824-5Authors Satoru Nonaka, National Cancer Center Hospital Endoscopy Division 5-1-1 Tsukiji, Chuo-ku Tokyo 104-0045 JapanYutaka Saito, National Cancer Center Hospital Endoscopy Division 5-1-1 Tsukiji, Chuo-ku Tokyo 104-0045 JapanHajime Takisawa, National Cancer Center Hospital Endoscopy Division 5-1-1 Tsukiji, Chuo-ku Tokyo 104-0045 JapanYongmin Kim, National Cancer Center Hospital Endoscopy Division 5-1-1 Tsukiji, Chuo-ku Tokyo 104-0045 JapanTsuyoshi Kikuchi, National Cancer Center Hospital Endoscopy Division 5-1-1 Tsukiji, Chuo-ku Tokyo 104-0045 JapanIchiro Oda, National Cancer Center Hospital Endoscopy Division 5-1-1 Tsukiji, Chuo-ku Tokyo 104-0045 Japan Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Functional and comparative evaluation of flexible monopolar endoscopic scissors

Abstract Background The continued success of natural orifice translumenal endoscopic procedures requires reliable, accurate tissue dissection and suture cutting. This study aimed to evaluate a flexible endoscopic scissors prototype. Methods An acute study of two domestic swine was conducted. Laparoscopic access provided an overview and allowed comparison of the flexible endoscopic scissors with laparoscopic shears. The endoscopic cautery-compatible scissors consists of cutting blades with a flexible wire catheter assembly (outer diameter, 3.1 mm) for use within a therapeutic endoscopic channel. A dual-channel colonoscope was advanced through a gastrotomy created for peritoneal access. With the aide of a grasping forceps, multiple peritoneal biopsies were obtained using the endoscopic scissors. Cautery (Monopolar 18–30 W) then was attached to the scissors, and gallbladder dissection proceeded. The device then was used to perform a small bowel enterotomy. A timed comparison of this function with laparoscopic enterotomy was made. Finally, 3–0 Polyglactin 910 suture was cut using the endoscopic scissors. Results Peritoneal biopsies 2 cm2 in size were obtained from multiple abdominal locations and endoscopic positions, including the retroflexed position. The scissors cut effectively and accurately. Cutting performance was enhanced with parallel countertraction provided by grasping forceps passed through the second endoscopic channel. The use of cautery with the scissors controlled small vessels (2–3 mm) and permitted partial dissection of the gallbladder from the hepatic bed. Small bowel enterotomy sufficiently large for stapler passage was created in 4 min and 54 s. Laparoscopically, this was completed in 1 min and 22 s. Suture was successfully cut at the first attempt in a controlled, reproducible fashion. Conclusions Controlled tissue biopsy, dissection, enterotomy creation, and suture cutting can be performed with this endoscopic scissors. Endoscopic tissue dissection and enterotomy creation was completed effectively but less efficiently than with laparoscopy primarily due to parallel device use imposed by the dual-channel endoscope. Content Type Journal ArticleCategory New TechnologyDOI 10.1007/s00464-009-0855-yAuthors E. A. Moran, Mayo Clinic Developmental Endoscopy Unit, Charlton 8 200 First St SW Rochester MN 55905 USAJ. Bingener, Mayo Clinic Developmental Endoscopy Unit, Charlton 8 200 First St SW Rochester MN 55905 USAC. J. Gostout, Mayo Clinic Developmental Endoscopy Unit, Charlton 8 200 First St SW Rochester MN 55905 USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Two-stage laparoscopic liver resection for bilateral colorectal liver metastasis

Abstract Background Hepatectomy may prolong the survival of colorectal cancer patients with liver metastases. Two-stage liver surgery is a valid option for the treatment of bilobar colorectal liver metastasis. This video demonstrates technical aspects of a two-stage pure laparoscopic hepatectomy for bilateral liver metastasis. To the authors’ knowledge, this is the first description of a two-stage laparoscopic liver resection in the English literature. Methods A 54-year-old man with right colon cancer and synchronous bilobar colorectal liver metastasis underwent laparoscopic right colon resection followed by oxaliplatin-based chemotherapy. The patient then was referred for surgical treatment of liver metastasis. Liver volumetry showed a small left liver remnant. Surgical planning was for a totally laparoscopic two-stage liver resection. The first stage involved laparoscopic resection of segment 3 and ligature of the right portal vein. The postoperative pathology showed high-grade liver steatosis. After 4 weeks, the left liver had regenerated, and volumetry of left liver was 43%. The second stage involved laparoscopic right hepatectomy using the intrahepatic Glissonian approach. Intrahepatic access to the main right Glissonian pedicle was achieved with two small incisions, and an endoscopic vascular stapling device was inserted between these incisions and fired. The line of liver transection was marked following the ischemic area. Liver transection was accomplished with the Harmonic scalpel and an endoscopic stapling device. The specimen was extracted through a suprapubic incision. The falciform ligament was fixed to maintain the left liver in its original anatomic position, avoiding hepatic vein kinking and outflow syndrome. Results The operative time was 90 min for stage 1 and 240 min for stage 2 of the procedure. The recoveries after the first and second operations were uneventful, and the patient was discharged on postoperative days 2 and 7, respectively. Conclusion Two-stage liver resections can be performed safely using laparoscopy. The intrahepatic Glissonian approach is a useful tool for pedicle control of the right liver, especially after previous dissection of the hilar plate. Content Type Journal ArticleCategory Dynamic ManuscriptDOI 10.1007/s00464-009-0859-7Authors M. A. Machado, University of São Paulo LIM-37; Department of Gastroenterology Rua Evangelista Rodrigues 407-05463-000 Sao Paulo BrazilF. F. Makdissi, University of São Paulo LIM-37; Department of Gastroenterology Rua Evangelista Rodrigues 407-05463-000 Sao Paulo BrazilR. C. Surjan, University of São Paulo LIM-37; Department of Gastroenterology Rua Evangelista Rodrigues 407-05463-000 Sao Paulo BrazilG. T. Kappaz, University of São Paulo LIM-37; Department of Gastroenterology Rua Evangelista Rodrigues 407-05463-000 Sao Paulo BrazilN. Yamaguchi, University of São Paulo LIM-37; Department of Gastroenterology Rua Evangelista Rodrigues 407-05463-000 Sao Paulo Brazil Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Preoperative infliximab treatment and postoperative complications after laparoscopic restorative proctocolectomy with ileal pouch–anal anastomosis: a case-matched study

Abstract Background Infliximab offers promising new therapeutic options for treatment of moderate to severe ulcerative colitis. However, several studies suggest that it increases postoperative complication rates for patients who later require a restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA). This study aimed to assess the postoperative course of patients after laparoscopic IPAA, comparing those who had and those who had not received infliximab before surgery. Methods The authors identified patients from their institution’s IPAA database, finding 13 patients who had received preoperative infliximab treatment. Using age, gender, and type of procedure (2 or 3 stages) as criteria, they matched these cases with infliximab-naive patients drawn from the same database. The differences in perioperative data between the two groups were analyzed. Complications and their severity were assessed using the Strasberg classification. Results No significant difference was found between patients treated with and those treated without infliximab for each variable studied, namely, mean operative time (353 vs. 355 min), complication rate (23 vs. 38%), and mean hospital stay (22 vs. 25 days). Conclusion The study findings showed no adverse impact from previous infliximab therapy on the laparoscopic IPAA postoperative course. Content Type Journal ArticleDOI 10.1007/s00464-009-0861-0Authors Benjamin Coquet-Reinier, Hôpital Nord Department of Digestive Diseases Surgery Chemin des Bourrellys 13915 Marseille Cedex 20 FranceStéphane V. Berdah, Hôpital Nord Department of Digestive Diseases Surgery Chemin des Bourrellys 13915 Marseille Cedex 20 FranceJean-Charles Grimaud, Hôpital Nord Department of Digestive Diseases Surgery Chemin des Bourrellys 13915 Marseille Cedex 20 FranceDavid Birnbaum, Hôpital Nord Department of Digestive Diseases Surgery Chemin des Bourrellys 13915 Marseille Cedex 20 FrancePierre-Alain Cougard, Hôpital Nord Department of Digestive Diseases Surgery Chemin des Bourrellys 13915 Marseille Cedex 20 FranceMarc Barthet, Hôpital Nord Department of Digestive Diseases Surgery Chemin des Bourrellys 13915 Marseille Cedex 20 FranceAriadne Desjeux, Hôpital Nord Department of Digestive Diseases Surgery Chemin des Bourrellys 13915 Marseille Cedex 20 FranceVincent Moutardier, Hôpital Nord Department of Digestive Diseases Surgery Chemin des Bourrellys 13915 Marseille Cedex 20 FranceChristian Brunet, Hôpital Nord Department of Digestive Diseases Surgery Chemin des Bourrellys 13915 Marseille Cedex 20 France Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Advantages of fast-track recovery after laparoscopic right hemicolectomy for colon cancer

Abstract Background Fast-track (FT) recovery protocols have demonstrated advantages over historical recovery routines after open colectomy; however, their impact in recovery after laparoscopic colectomy is not clearly defined. This study was designed to determine whether patients who recover on FT protocol after laparoscopic colectomy have a shorter length of stay (LOS) and fewer complications compared with patients who recover on standard (non-FT) protocol. Methods A cohort of consecutive patients with colon cancer who underwent completed laparoscopic-assisted right hemicolectomy from 2005–2007 was identified. Univariate and multivariate logistic analyses were performed to identify risk factors for increased LOS and postoperative complications with recovery protocol as the primary predictor. Results A total of 197 patients were included: 115 (58%) patients recovered on a non-FT protocol, and 82 (42%) patients on FT protocol. Univariate analysis showed no differences with respect to age, gender, body mass index, or American Society of Anesthesiologists (ASA) class between groups. The median (interquartile range) LOS was 4 (range, 3–6) days and 3 (range, 3–4) days for the non-FT and FT recovery patients, respectively (p < 0.001). On multivariate analysis, independent risk factors for increased LOS were complications (p < 0.001) and non-FT recovery (p = 0.007). Non-FT recovery also was associated with increased complications (56 vs. 29%, p = 0.0002); this remained significant on multivariate analysis (p < 0.001). Readmissions were similar (p = 1.0) between recovery groups. No mortalities were observed at 30 days. Conclusions Fast-track recovery is independently associated with a shorter LOS and decreased morbidity after laparoscopic right hemicolectomy. Content Type Journal ArticleDOI 10.1007/s00464-009-0871-yAuthors Vassiliki L. Tsikitis, Mayo Clinic Division of Colorectal Surgery 200 First Street SW Rochester MN 66905 USAStefan D. Holubar, Mayo Clinic Division of Colorectal Surgery 200 First Street SW Rochester MN 66905 USAEric J. Dozois, Mayo Clinic Division of Colorectal Surgery 200 First Street SW Rochester MN 66905 USARobert R. Cima, Mayo Clinic Division of Colorectal Surgery 200 First Street SW Rochester MN 66905 USAJohn H. Pemberton, Mayo Clinic Division of Colorectal Surgery 200 First Street SW Rochester MN 66905 USADavid W. Larson, Mayo Clinic Division of Colorectal Surgery 200 First Street SW Rochester MN 66905 USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Clinical predictors of operative complexity in laparoscopic ventral hernia repair: a prospective study

Abstract Background Because of uncertainties about the complexity of laparoscopic ventral hernia repair for varying patient populations, surgeons may be reluctant to perform this procedure. This study aimed to delineate the risk factors that can be identified in the preoperative setting predictive of longer operative times and complexity in laparoscopic ventral hernia repair. Methods Patient demographics including body mass index (BMI), comorbidities, previous laparoscopic and open surgical procedures, ventral hernia repairs, and hernia characteristics (defect size and location, adhesions, incarceration) were recorded prospectively. Data are given as mean ± standard deviation. Times (min) required for abdominal access, adhesiolysis, and mesh placement as well as the total operative time were recorded during each case as outcome measures of operative difficulty. Univariate analyses were performed with the t-test or the Mann–Whitney U test as well as multivariate analyses using the stepwise analysis of covariance model to determine demographic and clinical variables influencing operative times. Result The study enrolled 180 patients (78 men and 102 women) with a mean age of 54.8 ± 12.2 years and a mean BMI of 33.3 ± 13.0 kg/m2. Multivariate analysis demonstrated significantly longer (p < 0.05) adhesiolysis and total operative times for patients with prior ventral hernia repairs, suprapubic hernia, bowel adhesion to the abdominal wall or hernia sac, and larger hernia defect. The total operative time also was increased (p < 0.05) with incarcerated hernia contents. Mesh placement time was increased (p < 0.05) with incarcerated hernia contents, suprapubic hernia location, hernias requiring larger mesh for repair, and decreased postgraduate year of the surgical assistant. The time required to obtain abdominal access was longer (p < 0.05) with a greater BMI and a higher American Society of Anesthesiology (ASA) classification. The operative times were not increased with a history of peritonitis, diabetes, immunosuppression, cancer, or with higher numbers of previous open or laparoscopic surgeries. Conclusions At least 10 preoperatively identifiable patient variables, either alone or in combination, are predictive of prolonged operative times during laparoscopic ventral hernia repair and may be used as surrogates to determine the complexity of a minimally invasive approach. Content Type Journal ArticleDOI 10.1007/s00464-009-0863-yAuthors Eric D. Jenkins, Washington University School of Medicine Department of Surgery 660 South Euclid Avenue, Campus Box #8109 St. Louis MO 63110 USAVictoria H. Yom, Washington University School of Medicine Department of Surgery 660 South Euclid Avenue, Campus Box #8109 St. Louis MO 63110 USALora Melman, Washington University School of Medicine Department of Surgery 660 South Euclid Avenue, Campus Box #8109 St. Louis MO 63110 USARichard A. Pierce, Washington University School of Medicine Department of Surgery 660 South Euclid Avenue, Campus Box #8109 St. Louis MO 63110 USARichard B. Schuessler, Washington University School of Medicine Department of Surgery 660 South Euclid Avenue, Campus Box #8109 St. Louis MO 63110 USAMargaret M. Frisella, Washington University School of Medicine Department of Surgery 660 South Euclid Avenue, Campus Box #8109 St. Louis MO 63110 USAJ. Christopher Eagon, Washington University School of Medicine Department of Surgery 660 South Euclid Avenue, Campus Box #8109 St. Louis MO 63110 USAL. Michael Brunt, Washington University School of Medicine Department of Surgery 660 South Euclid Avenue, Campus Box #8109 St. Louis MO 63110 USABrent D. Matthews, Washington University School of Medicine Department of Surgery 660 South Euclid Avenue, Campus Box #8109 St. Louis MO 63110 USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Totally laparoscopic right colectomy with transvaginal specimen extraction: the authors’ initial institutional experience

Abstract Background The persistence of early and delayed wound complications related to both open and laparoscopic colectomy remains a significant health burden. Furthermore, as interest in natural orifice translumenal endosurgery (NOTES) continues to grow, bridging techniques may help to attenuate the learning curve associated with NOTES. The authors present their technique and short-term outcomes for totally laparoscopic right colectomy with transvaginal specimen extraction in a series of four patients. Methods Four consecutive patients from a prospectively maintained laparoscopic colectomy database were analyzed under an institutional review board-approved protocol. Clinicopathologic characteristics and short-term outcomes were reviewed. Results All the patients were women with no prior pelvic surgery. A four-trocar laparoscopic right colectomy with intracorporeal anastomosis was performed for cancer in two cases and for adenomatous polyp in two cases. Transvaginal extraction was possible in all cases. The average operating room time was 212.25 min. No patient experienced complications associated with the colpotomy; nor did any patient have pain or drainage from the extraction site postoperatively. The median hospital stay was 4.5 days. One patient experienced a bowel obstruction unrelated to the extraction site. The mean specimen length was 27 cm, and the mean number of lymph nodes retrieved was 15.75. Conclusion Totally laparoscopic right colectomy with transvaginal extraction appears to be safe and feasible. This technique may provide both an attractive way to reduce abdominal wall morbidity and a bridge to NOTES colon surgery. Content Type Journal ArticleCategory TechniqueDOI 10.1007/s00464-009-0870-zAuthors Shaun McKenzie, City of Hope National Medical Center Department of General and Oncologic Surgery 1500 East Duarte Road Duarte CA 91010-3000 USAJeong-Heum Baek, Gachon University of Medicine and Science Department of Surgery Incheon KoreaMark Wakabayashi, City of Hope National Medical Center Department of General and Oncologic Surgery 1500 East Duarte Road Duarte CA 91010-3000 USAJulio Garcia-Aguilar, City of Hope National Medical Center Department of General and Oncologic Surgery 1500 East Duarte Road Duarte CA 91010-3000 USAAlessio Pigazzi, City of Hope National Medical Center Department of General and Oncologic Surgery 1500 East Duarte Road Duarte CA 91010-3000 USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

An Isolator System for minimally invasive surgery: the new design

Abstract Background The risk of obtaining a postsurgical infection depends highly on the air quality surrounding the exposed tissue, surgical instruments, and materials. Many isolators for open surgery have been invented to create a contained sterile volume around the exposed tissue. With the use of an isolator, a surgical procedure can be performed outside sterile environments. The goal of this study was to design an Isolator System (IS) for standard laparoscopic instruments while instrument movements are not restricted. Methods The developed IS consists of a sleeve to protect the instrument shaft and tip and a special balloon to protect the incision and trocar tube. A coupling mechanism connected at the sleeve allows instrument changes without contamination of the isolated parts. Smoke tests were performed to show that outside air does not enter the new IS during a simulated laparoscopic procedure. Eight test runs and one baseline run inside a contained volume filled with thick smoke were performed to investigate whether smoke particles entered the Isolator System. Filters were used to identify smoke entering the Isolator System. Results Seven filters showed no trace of smoke particles. In one test run, a part of the IS loosened and a small brown spot was visible. The filter from the baseline run was completely covered with a thick layer of particles, proving the effectiveness of the test. During all test runs, the isolated instrument was successfully locked on and unlocked from the isolated trocar. Instrument movements gave no complications. After removal of the isolated instrument, it took three novices an average of 3.1 (standard deviation (SD), 0.7) seconds to replace it correctly on the isolated trocar. Conclusions The designed IS for laparoscopy can increase sterility in environments where sterility cannot be guaranteed. The current design is developed for laparoscopy, but it can easily be adapted for other fields in minimally invasive surgery. Content Type Journal ArticleDOI 10.1007/s00464-009-0877-5Authors Tim Horeman, Delft University of Technology Department of BioMechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering (3mE) Mekelweg 2 2628 CD Delft The NetherlandsFrank-Willem Jansen, Leiden University Medical Center Department of Gynecology Leiden The NetherlandsJenny Dankelman, Delft University of Technology Department of BioMechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering (3mE) Mekelweg 2 2628 CD Delft The Netherlands Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Comparison of intraoperative enteroscopy and double-balloon enteroscopy for the diagnosis and treatment of Peutz-Jeghers syndrome

Abstract Background Double-balloon enteroscopy (DBE) is an enteroscopy method that allows examination and treatment of the small bowel. Intraoperative enteroscopy (IOE) was the only possibility of endoscopic treatment for patients with Peutz-Jeghers syndrome (PJS) before the DBE era. PJS is an inherited, autosomal dominant disorder distinguished by hamartomatous polyps in the gastrointestinal tract and pigmented mucocutaneous lesions. PJS predisposes sufferers to various malignancies. Bleeding, obstruction, and intussusception are common complications in patients with PJS. The goal of this study was compare our experience in diagnosis and treatment of small-bowel hamartomas by means of DBE and IOE. Methods From 1999 to 2006, we performed seven IOEs in seven patients (four women, three men), and since 2006, 14 DBEs in another ten patients (seven women, three men). Results A total of 182 polyps were removed during IOEs: 179 by the endoscopist and three were cut out by the surgeon. From 6 to 75 polyps were removed per session (mean, 26). The largest hamartoma measured 4 cm in diameter. The age of the patients ranged from 20 to 50 (mean, 31) years. In our DBE group, a total of 205 polyps were removed. From 1 to 37 polyps were removed per session (mean, 13). The age of the patients ranged from 12 to 48 (mean, 25) years. The largest hamartoma was 6 cm in diameter. We had no serious complications both in the IOE and the DBE group. Conclusions Polypectomy using DBE may obviate the need for repeated urgent operations and small-bowel resections leading to short-bowel syndrome. Patients are indicated for prophylactic procedure and polypectomy of the entire small bowel. Both DBE and IOE facilitate exploration and treatment of the small intestine. DBE is less invasive and more convenient for the patient. Both procedures are generally safe and useful. Content Type Journal ArticleDOI 10.1007/s00464-009-0868-6Authors Marcela Kopáčová, Charles University in Praha, University Teaching Hospital 2nd Department of Medicine, Faculty of Medicine at Hradec Králové Sokolská 581 Hradec Králové 500 05 Czech RepublicJan Bureš, Charles University in Praha, University Teaching Hospital 2nd Department of Medicine, Faculty of Medicine at Hradec Králové Sokolská 581 Hradec Králové 500 05 Czech RepublicAlexander Ferko, Charles University in Praha, University Teaching Hospital Department of Surgery, Faculty of Medicine at Hradec Králové Sokolská 581 Hradec Králové 500 05 Czech RepublicIlja Tachecí, Charles University in Praha, University Teaching Hospital 2nd Department of Medicine, Faculty of Medicine at Hradec Králové Sokolská 581 Hradec Králové 500 05 Czech RepublicStanislav Rejchrt, Charles University in Praha, University Teaching Hospital 2nd Department of Medicine, Faculty of Medicine at Hradec Králové Sokolská 581 Hradec Králové 500 05 Czech Republic Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Single-incision laparoscopic appendectomy for acute appendicitis: a preliminary experience

Abstract Background Natural orifice translumenal endoscopic surgery (NOTES) is a major conceptual change in the field of modern surgery. However, corresponding technological refinements are not yet available to fill the gap separating the current laparoscopy from the NOTES of the future. Meanwhile, “hybrid” NOTES techniques, including single-port procedures, have been increasingly reported. This report describes a technique of single-incision laparoscopic appendectomy (SILA) for selected patients with acute appendicitis. Methods Patients with noncomplicated acute appendicitis, excluding those with abscess, perforation, peritonitis, previous surgery, or obesity, underwent SILA. The procedure was performed using a single 15-mm-diameter umbilical incision with two 5-mm-diameter port sites. Results The study enrolled 36 women and 19 men with a mean age of 28 years (range, 18–78 years). The procedure was achieved for 41 patients (74.5%). The mean operative time was 39 min (range, 14–111 min). There was no mortality. The postoperative complication rate was 5.4% (3 complications in 3 patients), and the median hospital stay was 39 h (range, 8–240 h). Conclusion The SILA technique is safe and feasible for selected patients with noncomplicated acute appendicitis. Compared with other transumbilical techniques of appendectomy, SILA has the advantages of feasibility without endoscopic skills and an acceptable operative time. Technical refinements and accomplished learning probably will enable its wider use for more patients with acute appendicitis. Content Type Journal ArticleDOI 10.1007/s00464-009-0860-1Authors Elie Chouillard, Centre Hospitalier Department of General and Minimally Invasive Surgery 10 rue du Champ Gaillard 78300 Poissy FranceArnaud Dache, Centre Hospitalier Department of General and Minimally Invasive Surgery 10 rue du Champ Gaillard 78300 Poissy FranceAdriana Torcivia, Centre Hospitalier Department of General and Minimally Invasive Surgery 10 rue du Champ Gaillard 78300 Poissy FranceNada Helmy, Centre Hospitalier Department of General and Minimally Invasive Surgery 10 rue du Champ Gaillard 78300 Poissy FranceIvan Ruseykin, Centre Hospitalier Department of General and Minimally Invasive Surgery 10 rue du Champ Gaillard 78300 Poissy FranceAndrew Gumbs, Fox Chase Cancer Center Department of Surgical Oncology Philadelphia PA USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Nintendo Wii video-gaming ability predicts laparoscopic skill

Abstract Background Studies using conventional consoles have suggested a possible link between video-gaming and laparoscopic skill. The authors hypothesized that the Nintendo Wii, with its motion-sensing interface, would provide a better model for laparoscopic tasks. This study investigated the relationship between Nintendo Wii skill, prior gaming experience, and laparoscopic skill. Methods In this study, 20 participants who had minimal experience with either laparoscopic surgery or Nintendo Wii performed three tasks on a Webcam-based laparoscopic simulator and were assessed on three games on the Wii. The participants completed a questionnaire assessing prior gaming experience. Results The score for each of the three Wii games correlated positively with the laparoscopic score (r = 0.78, 0.63, 0.77; P < 0.001), as did the combined Wii score (r = 0.82; P < 0.001). The participants in the top tertile of Wii performance scored 60.3% higher on the laparoscopic tasks than those in the bottom tertile (P < 0.01). Partial correlation analysis with control for the effect of prior gaming experience showed a significant positive correlation between the Wii score and the laparoscopic score (r = 0.713; P < 0.001). Prior gaming experience also correlated positively with the laparoscopic score (r = 0.578; P < 0.01), but no significant difference in the laparoscopic score was observed when the participants in the top tertile of experience were compared with those in the bottom tertile (P = 0.26). Conclusions The study findings suggest a skill overlap between the Nintendo Wii and basic laparoscopic tasks. Surgical candidates with advanced Nintendo Wii ability may possess higher baseline laparoscopic ability. Content Type Journal ArticleDOI 10.1007/s00464-009-0862-zAuthors Shiraz Badurdeen, University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital Box 111, Hills Road Cambridge CB2 2SP UKOmar Abdul-Samad, University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital Box 111, Hills Road Cambridge CB2 2SP UKGiles Story, University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital Box 111, Hills Road Cambridge CB2 2SP UKClare Wilson, University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital Box 111, Hills Road Cambridge CB2 2SP UKSue Down, Hinchingbrooke Health Care NHS Trust, Hinchingbrooke Hospital Department of Surgery Hinchingbrooke Park Huntingdon Cambridgeshire PE29 6NT UKAdrian Harris, Hinchingbrooke Health Care NHS Trust, Hinchingbrooke Hospital Department of Surgery Hinchingbrooke Park Huntingdon Cambridgeshire PE29 6NT UK Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Peritoneal inflammatory response of natural orifice translumenal endoscopic surgery (NOTES) versus laparoscopy with carbon dioxide and air pneumoperitoneum

Abstract Background The immunologic and physiologic effects of natural orifice translumenal endoscopic surgery (NOTES) versus traditional surgical approaches are poorly understood. Previous investigations have shown that NOTES and laparoscopy share similar inflammatory cytokine profiles except for a possible late-phase tissue necrosis factor-α (TNF-α) depression with NOTES. The local peritoneal reaction and immunomodulatory influence of pneumoperitoneum agents in NOTES also are not known and may play an important role in altering the physiologic insult induced by NOTES. Methods In this study, 51 animals were divided into four study groups, which respectively underwent abdominal exploration via transgastric NOTES using room air (AIR) or carbon dioxide (CO2) or via laparoscopy (LX) using AIR or CO2 for pneumoperitoneum. Laparotomy and sham surgeries were additionally performed as control conditions. Measurements of TNF-α, interleukin-1β (IL-1β), and IL-6 were performed for peritoneal fluid collected after 0, 2, 4, and 6 h and on postoperative days (PODs) 1, 2, and 7. Results Of the 45 animals assessed, 6 were excluded because of technical operative complications. The findings showed that LX-CO2 generated the most pronounced response with all three inflammatory markers. However, no significant differences were detected between LX-CO2 and either NOTES group at these peak points. No differences were encountered between NOTES-CO2 and NOTES-AIR. Subgroup comparisons showed significantly higher levels of TNF-α and IL-6 with NOTES-CO2 than with LX-AIR on POD 1 (p = 0.022) and POD 2 (p = 0.002). The LX-CO2 subgroup had significantly higher levels of TNF-α than the LX-AIR subgroup at 4 h (p = 0.013) and on POD 1 (p = 0.021). No late-phase TNF-α depression occurred in the NOTES animals. Conclusion The local inflammatory reaction to NOTES was similar to that with traditional laparoscopy, and the previously described late-phase systemic TNF-α depression in serum was not reproduced. At the peritoneal level, NOTES is no more physiologically stressful than laparoscopy. Furthermore, regardless of which gas was used, the role of the pneumoperitoneum agent did not affect the cytokine profile after NOTES, suggesting that air pneumoperitoneum is adequate for NOTES. Content Type Journal ArticleDOI 10.1007/s00464-009-0839-yAuthors Joseph A. Trunzo, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine Department of Surgery 11100 Euclid Avenue, Lakeside Building 7th Floor Cleveland OH 44106 USAMichael F. McGee, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine Department of Surgery 11100 Euclid Avenue, Lakeside Building 7th Floor Cleveland OH 44106 USALeandro T. Cavazzola, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine Department of Surgery 11100 Euclid Avenue, Lakeside Building 7th Floor Cleveland OH 44106 USASteve Schomisch, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine Department of Surgery 11100 Euclid Avenue, Lakeside Building 7th Floor Cleveland OH 44106 USAMehrdad Nikfarjam, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine Department of Surgery 11100 Euclid Avenue, Lakeside Building 7th Floor Cleveland OH 44106 USAJessica Bailey, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine Department of Surgery 11100 Euclid Avenue, Lakeside Building 7th Floor Cleveland OH 44106 USATripurari Mishra, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine Department of Surgery 11100 Euclid Avenue, Lakeside Building 7th Floor Cleveland OH 44106 USABenjamin K. Poulose, Vanderbilt University Medical Center, Medical Center North Department of Surgery 1161 21st Avenue Nashville TN 37232 USAYoung-Joon Lee, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine Department of Surgery 11100 Euclid Avenue, Lakeside Building 7th Floor Cleveland OH 44106 USAJeffrey L. Ponsky, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine Department of Surgery 11100 Euclid Avenue, Lakeside Building 7th Floor Cleveland OH 44106 USAJeffrey M. Marks, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine Department of Surgery 11100 Euclid Avenue, Lakeside Building 7th Floor Cleveland OH 44106 USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Feasibility and safety of emergency ERCP and small-caliber pancreatic stenting as a bridging procedure in patients with acute biliary pancreatitis but difficult sphincterotomy

Abstract Background The aims of the present study were: (1) to assess the feasibility and safety of emergency endoscopic retrograde cholangiopancreatography (ERCP) and pancreatic duct (PD) stenting with small-caliber stents as a bridging procedure in acute biliary pancreatitis (ABP) patients in whom biliary endoscopic sphincterotomy (EST) proved difficult, failed or was contraindicated, and (2) to compare the clinical outcome of those patients having emergency ERCP with and without pancreatic stent. Method Eighty-seven consecutive patients with ABP were referred for emergency ERCP. In 60 of these ABP patients, ERCP, EST, and stone extraction (if necessary) were performed without PD stenting. In the remaining 27 patients, small-caliber (3–5 F, 4 cm) pancreatic stent insertion was initially applied. All patients were hospitalized for medical therapy and were followed up. Results The mean ages, the initial symptom-to-ERCP times, the Glasgow severity scores, and the peak amylase and CRP levels at initial presentation were not significantly different in the ERCP + EST with PD stent group versus the ERCP + EST without PD stent group. More importantly, the complication rate was significantly lower in the ERCP + EST with PD stent group versus the ERCP + EST without PD stent group (7.4% vs. 25%); while the mortality rates (0% vs. 6.7%) were comparable, reasonably low, and demonstrated no statistically significant differences. Conclusions Temporary PD stenting with small-caliber stents is a safe and effective procedure that may afford sufficient PD decompression to reverse the process of ABP and serve as a bridging procedure in severe ABP in patients with failed, complicated, or contraindicated biliary EST. Content Type Journal ArticleDOI 10.1007/s00464-009-0864-xAuthors Roland Fejes, Fejér Megyei Szent György Hospital Department of Gastroenterology and Endoscopy Unit Seregélyesi 3 Székesfehérvár 8000 HungaryGábor Kurucsai, Fejér Megyei Szent György Hospital Department of Gastroenterology and Endoscopy Unit Seregélyesi 3 Székesfehérvár 8000 HungaryAndrás Székely, Fejér Megyei Szent György Hospital Department of Gastroenterology and Endoscopy Unit Seregélyesi 3 Székesfehérvár 8000 HungaryIván Székely, Fejér Megyei Szent György Hospital Department of Gastroenterology and Endoscopy Unit Seregélyesi 3 Székesfehérvár 8000 HungaryÁron Altorjay, Fejér Megyei Szent György Hospital Department of Surgery Székesfehérvár HungaryLászló Madácsy, Fejér Megyei Szent György Hospital Department of Gastroenterology and Endoscopy Unit Seregélyesi 3 Székesfehérvár 8000 Hungary Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Reply to 00464-009-0844-1: Endoscopic submucosal dissection: can indications for a minimally invasive approach be expanded safely to patients with early gastric cancer?

Reply to 00464-009-0844-1: Endoscopic submucosal dissection: can indications for a minimally invasive approach be expanded safely to patients with early gastric cancer? Content Type Journal ArticleCategory Letter-ReplyDOI 10.1007/s00464-009-0845-0Authors Hae Yeon Kang, Seoul National University College of Medicine Department of Internal Medicine and Liver Research Institute Seoul KoreaSang Gyun Kim, Seoul National University College of Medicine Department of Internal Medicine and Liver Research Institute Seoul KoreaJoo Sung Kim, Seoul National University College of Medicine Department of Internal Medicine and Liver Research Institute Seoul KoreaHyun Chae Jung, Seoul National University College of Medicine Department of Internal Medicine and Liver Research Institute Seoul KoreaIn Sung Song, Seoul National University College of Medicine Department of Internal Medicine and Liver Research Institute Seoul Korea Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Is minimally invasive surgery beneficial in the management of esophageal cancer? A meta-analysis

Abstract Introduction Open esophagectomy for cancer is a major oncological procedure, associated with significant morbidity and mortality. Recently, thoracoscopic procedures have offered a potentially advantageous alternative because of less operative trauma compared with thoracotomy. The aim of this study was to utilize meta-analysis to compare outcomes of open esophagectomy with those of minimally invasive esophagectomy (MIE) and hybrid minimally invasive esophagectomy (HMIE). Methods Literature search was performed using Medline, Embase, Cochrane Library, and Google Scholar databases for comparative studies assessing different techniques of esophagectomy. A random-effects model was used for meta-analysis, and heterogeneity was assessed. Primary outcomes of interest were 30-day mortality and anastomotic leak. Secondary outcomes included operative outcomes, other postoperative outcomes, and oncological outcomes in terms of lymph nodes retrieved. Results A total of 12 studies were included in the analysis. Studies included a total of 672 patients for MIE and HMIE, and 612 for open esophagectomy. There was no significant difference in 30-day mortality; however, MIE had lower blood loss, shorter hospital stay, and reduced total morbidity and respiratory complications. For all other outcomes, there was no significant difference between the two groups. Conclusion Minimally invasive esophagectomy is a safe alternative to the open technique. Patients undergoing MIE may benefit from shorter hospital stay, and lower respiratory complications and total morbidity compared with open esophagectomy. Multicenter, prospective large randomized controlled trials are required to confirm these findings in order to base practice on sound clinical evidence. Content Type Journal ArticleDOI 10.1007/s00464-009-0822-7Authors Kamal Nagpal, Imperial College London London UKKamran Ahmed, Imperial College London London UKAmit Vats, Imperial College London London UKDanny Yakoub, Imperial College London London UKDavid James, Imperial College London London UKHutan Ashrafian, Imperial College London London UKAra Darzi, Imperial College London London UKKrishna Moorthy, Imperial College London Regional Oesophageal Unit London UKThanos Athanasiou, Imperial College London Department of Cardiothoracic Surgery London UK Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Bupivacaine use in the Insuflow® device during laparoscopic cholecystectomy: results of a prospective randomized double-blind controlled trial

Abstract Background Recent evidence [Surg Endosc (2007) 21: 602–606] demonstrates that intraperitoneal bupivacaine administered as an aerosol via a special catheter is safe and significantly decreases postoperative pain in laparoscopic surgery. We currently use the Insuflow® device (Lexion Medical) routinely to warm and humidify gas in laparoscopic surgery. The purpose of this study is to determine whether using bupivacaine instead of water in existing technology already in use (Insuflow) will result in decreased postoperative pain, without increasing operative time or cost. Methods Using a double-blind methodology, 50 patients undergoing elective outpatient laparoscopic cholecystectomy were randomized to a study drug: either 10 ml of 0.5% bupivacaine (50 mg) or 10 ml of sterile water. The study drug was injected into the Insuflow in the standard fashion and the operation commenced routinely. No perioperative nonsteroidal anti-inflammatory drugs were used. Using a standard 0–10 pain-scoring scale, patients were assessed by perioperative nurses at 1 and 2 h postoperatively. Pain was again assessed at 24 h by telephone interview, along with the number of narcotic oral analgesics used in the first 24 h. Results Fifty patients were randomized, 25 in each group; the groups were comparable. All patients completed the study and 100% follow-up was obtained. All patients were discharged the same day and there were no significant complications in either group, and specifically no complications attributed to bupivacaine or use of the Insuflow device. There were no differences in pain at 1 and 2 h. There was less pain in the bupivacaine group at 24 h, but this was not statistically significant (P = 0.055). Conclusions Bupivacaine use in the Insuflow device is safe. No significant differences in postoperative pain were noted in this study compared to using water. Content Type Journal ArticleDOI 10.1007/s00464-009-0804-9Authors Peter W. Zimmer, Penrose-St. Francis Health Services Department of Surgery 2222 North Nevada Avenue Colorado Springs CO 80907 USAMichael J. McCann, Penrose-St. Francis Health Services Department of Surgery 2222 North Nevada Avenue Colorado Springs CO 80907 USAMaureen M. O’Brien, University of Colorado Denver School of Medicine Campus Box C290, 13001 E 17th Place, Building 500, 1st Floor East Aurora CO 80045 USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

A monograph for academic career development

A monograph for academic career development Content Type Journal ArticleCategory CommentaryDOI 10.1007/s00464-009-0712-zAuthors Aurora D. Pryor, Duke University Medical Center 407 Crutchfield Street Durham NC 27704 USASAGES Research and Career Development Committee Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Industry relationships between physicians and professional medical associations: corrupt or essential?

Abstract Congress and others have called into question the propriety of relationships between professional medical associations (PMAs) and industry. These relationships are critical to the continued development of new and better devices and procedures for patients. Better guidelines are needed to help guide these relationships. Overrestrictive regulatory oversight risks overconstraint of these relationships and hindrance to medical progress. Content Type Journal ArticleCategory EditorialDOI 10.1007/s00464-009-0878-4Authors C. Daniel Smith, SAGES, Mayo Clinic in Florida 4500 San Pablo Road Jacksonville FL 33224 USABruce MacFadyen, Medical College of Georgia SAGES, Department of Surgery BI 4076 Augusta GA 30912 USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794 Journal Volume Volume 24 Journal Issue Volume 24, Number 2 / February, 2010

Robot-assisted laparoscopic pancreatic surgery: single-surgeon experience

Abstract Background Use of robotic surgery has gained increasing acceptance over the last few years. There are few reports, however, on advanced pancreatic robotic surgery. In fact, the indication for robotic surgery in pancreatic disease has been controversial. This paper retrospectively reviews one surgeon’s experience with robotic surgery to treat pancreatic disease, and analyzes its indications and outcomes, as well as the controversy that exists. Methods A retrospective review of the charts of all patients who underwent robotic surgery for pancreatic disease by a single surgeon at two different institutions was carried out. Results From October 2000 to January 2009, 134 patients underwent robotic-assisted surgery for different pancreatic pathologies. All procedures were performed using the da Vinci robotic system. Of the 134 patients, 83 were female. The average age of all patients was 57 years (range 24–86 years). Mean operating room (OR) time was 331 min (75–660 min). There were 14 conversions to open surgery. Mean length of stay was 9.3 days (3–85 days). Length of stay for patients with no complications was 7.9 days (3–15 days). The postoperative morbidity rate was 26% and the mortality rate was 2.23% (three patients). Among the procedures performed were 60 pancreaticoduodenectomies, 23 spleen-preserving distal pancreatectomies, 23 splenopancreatectomies, 3 middle pancreatectomies, 1 total pancreatectomy, and 3 enucleations. Another 21 patients underwent different surgical procedures for treatment of acute and chronic pancreatitis. Two cases of pancreaticoduodenectomy were performed in outside institutions and are not included in this series. Conclusions This is the largest series of robotic pancreatic surgery presented to date. Robotic surgery enables difficult technical maneuvers to be performed that facilitate the success of pancreatic minimally invasive surgery. The results in this series demonstrate that it is feasible and safe. Complication and mortality rates are comparable to those of open surgery but with the advantages of minimally invasive surgery. Content Type Journal ArticleDOI 10.1007/s00464-009-0825-4Authors Pier Cristoforo Giulianotti, University of Illinois at Chicago Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery 840 South Wood Street, Suite 435E Chicago IL 60612 USAFabio Sbrana, University of Illinois at Chicago Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery 840 South Wood Street, Suite 435E Chicago IL 60612 USAFrancesco Maria Bianco, University of Illinois at Chicago Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery 840 South Wood Street, Suite 435E Chicago IL 60612 USAEnrique Fernando Elli, University of Illinois at Chicago Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery 840 South Wood Street, Suite 435E Chicago IL 60612 USAGalaxy Shah, University of Illinois at Chicago Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery 840 South Wood Street, Suite 435E Chicago IL 60612 USAPietro Addeo, University of Illinois at Chicago Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery 840 South Wood Street, Suite 435E Chicago IL 60612 USAGiuseppe Caravaglios, Ospedale Misericordia Department of General Surgery Grosseto ItalyAndrea Coratti, Ospedale Misericordia Department of General Surgery Grosseto Italy Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

The combined laparoscopic approach for the treatment of incarcerated inguinal hernia

Abstract Background The traditional open approach to incarcerated inguinal hernia has several drawbacks including difficulty avoiding tension in the swollen and edematous tissues leading to a higher recurrence rate, possible contamination of the mesh if it is implanted in an area of bowel strangulation, and proper evaluation of whether ischemic bowel requires resection or not, which may mandate laparotomy. This study aimed to evaluate an approach that combines intraperitoneal laparoscopic exploration with hernia reduction and total extraperitoneal (TEP) repair of the hernia. Methods An exploratory laparoscopy is performed. The incarcerated content is gently retracted into the abdominal cavity and inspected. If no resection is needed, the gas is deflated, the umbilical trocar is removed, and the preperitoneal space is accessed with a Hasson trocar inserted behind the rectus muscle toward the pelvis. Two additional 5-mm trocars are inserted into the preperitoneal space in the lower midline. A standard TEP repair with mesh is performed. Results Between 2005 and 2008, 15 patients underwent laparoscopic exploration for incarcerated inguinal hernia followed by TEP repair. Of the 15 patients, 8 had acute incarceration and 7 had chronic irreducible hernia. Reduction of the incarcerated content was straightforward, and no bowel resection was needed. No major complications or wound or mesh infections occurred. Conclusion The combined laparoscopic approach offers a solution to incarceration of inguinal hernias while taking advantage of each separate approach. The first part of the procedure enables easy reduction of the incarcerated content and assessment of its viability. The second part enables a simple and standard repair, similar to that for an elective case. If bowel necrosis is suspected preoperatively, an open anterior approach should be taken to avoid possible intraabdominal contamination. Content Type Journal ArticleDOI 10.1007/s00464-009-0857-9Authors Aviad Hoffman, Tel Aviv University Department of General Surgery and Transplantation, Sheba Medical Center, Sackler School of Medicine 52621 Tel-Hashomer IsraelEyal Leshem, Tel Aviv University Infectious Diseases Unit, Sheba Medical Center, Sackler School of Medicine 52621 Tel-Hashomer IsraelOded Zmora, Tel Aviv University Department of General Surgery and Transplantation, Sheba Medical Center, Sackler School of Medicine 52621 Tel-Hashomer IsraelOrit Nachtomi, Tel Aviv University Department of Anesthesia, Sheba Medical Center, Sackler School of Medicine 52621 Tel-Hashomer IsraelMoshe Shabtai, Tel Aviv University Department of General Surgery and Transplantation, Sheba Medical Center, Sackler School of Medicine 52621 Tel-Hashomer IsraelAmram Ayalon, Tel Aviv University Department of General Surgery and Transplantation, Sheba Medical Center, Sackler School of Medicine 52621 Tel-Hashomer IsraelDanny Rosin, Tel Aviv University Department of General Surgery and Transplantation, Sheba Medical Center, Sackler School of Medicine 52621 Tel-Hashomer Israel Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Post-traumatic stress disorder (PTSD) is not a contraindication to gastric bypass in veterans with morbid obesity

Abstract Background The veteran population is routinely screened for post-traumatic stress disorder (PTSD). The prevalence of obesity in this population continues to increase. We examined whether weight loss outcomes in veterans with PTSD is comparable to results in veterans who do not suffer from PTSD, after gastric bypass. We also examined the effect of bariatric surgery on PTSD symptoms. Methods This retrospective review of prospective data compares veterans with and without PTSD who underwent laparoscopic gastric bypass. Differences between the means of age, initial BMI, and percent excess weight loss were compared between the groups using a Student’s t test. Pearson’s χ2 was used to evaluate the relationship between a diagnosis of PTSD, major depressive disorder (MDD), and other Axis I psychiatric disorders. A similar analysis was done to assess for a relationship between PTSD and obesity-related comorbidities, including diabetes mellitus (DM), hypertension (HTN), hyperlipidemia, and GERD. Results We identified 24 patients who had gastric bypass and a diagnosis of PTSD before surgery and compared them to those without PTSD. Both groups had a similar mean age and initial BMI. There was no significant difference between the percent excess weight lost after 1 year follow-up between the PTSD group (66%) and the non-PTSD group (72%) (p = 0.102). In assessing comorbid conditions, we found a significant association between the diagnosis of PTSD and MDD (p = 0.002), PTSD and other Axis I disorders (p = 0.004), and PTSD and GERD (p = 0.002). However, we saw no significant association between PTSD and DM (p = 0.977), HTN (p = 0.332), and obstructive sleep apnea (OSA) (p = 0.676). The severity of PTSD symptoms fluctuated in the postoperative period. Conclusions Veterans with PTSD have comparable weight loss to those without PTSD after gastric bypass. In addition, surgery does not seem to have an adverse effect on PTSD symptoms, although PTSD symptomatology tends to fluctuate over time. Further study in this patient population is warranted. Content Type Journal ArticleDOI 10.1007/s00464-009-0866-8Authors Danagra G. Ikossi, Stanford University School of Medicine Department of Surgery Stanford CA 94304 USAJose R. Maldonado, Stanford University School of Medicine Departments of Psychiatry and Medicine Stanford CA 94304 USATina Hernandez-Boussard, Stanford University School of Medicine Department of Surgery Stanford CA 94304 USADan Eisenberg, Stanford University School of Medicine Department of Surgery Stanford CA 94304 USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Left laparoscopic paraduodenal hernia repair

Abstract Background An internal hernia is a protrusion of bowel through a normal or abnormal orifice in the peritoneum or mesentery. Paraduodenal hernia is by far the most common form of congenital internal hernia, making up 53% of all reported cases. In recent years, as surgeons have become more comfortable with laparoscopic techniques, they are performing an increasing number of these procedures laparoscopically. Methods To highlight the technical steps of this technique, the case of a patient with a left paraduodenal hernia and a video of the laparoscopic repair are presented. Additionally, a PubMed search of the English medical literature was conducted using the search words “laparoscopic,” “paraduodenal,” and “hernia” as filters. The cases of laparoscopic paraduodenal hernia repair in the literature to date recording data on technique, complications, and hospital course were reviewed. Results In addition to the case described in this report, 14 cases of laparoscopic paraduodenal hernia were described in 10 published reports. Of the 15 cases, 11 (73%) were left-sided, likely representing the relative incidence of these cases. The hernia defect was closed in 10 (77%) of the 13 cases for which the repair method was described, whereas the defect was widely opened in the remaining cases. One report described an operative complication (6.7%), an internal mesenteric vein injury, and one recurrence (6.7%) occurred 18 months after surgery in the direct defect closure group. Conclusion The current data lead to the conclusion that laparoscopic paraduodenal hernia repair is a safe and feasible approach for selected patients. It can be expected that as surgeons become increasingly comfortable and facile with laparoscopic techniques, paraduodenal hernias and many other causes of acute small bowel obstruction will be increasingly managed laparoscopically. Content Type Journal ArticleCategory Dynamic ManuscriptDOI 10.1007/s00464-009-0794-7Authors Abed Khalaileh, Hadassah Hebrew University Medical Center Department of Surgery Kiryat Hadassah P.O.B. 12000 91120 Jerusalem IsraelAvraham Schlager, New York University Hospital Department of Surgery New York NY USAMiklosh Bala, Hadassah Hebrew University Medical Center Department of Surgery Kiryat Hadassah P.O.B. 12000 91120 Jerusalem IsraelSamir Abugazala, Hadassah Hebrew University Medical Center Department of Surgery Kiryat Hadassah P.O.B. 12000 91120 Jerusalem IsraelRam Elazary, Hadassah Hebrew University Medical Center Department of Surgery Kiryat Hadassah P.O.B. 12000 91120 Jerusalem IsraelAvraham I. Rivkind, Hadassah Hebrew University Medical Center Department of Surgery Kiryat Hadassah P.O.B. 12000 91120 Jerusalem IsraelYoav Mintz, Hadassah Hebrew University Medical Center Department of Surgery Kiryat Hadassah P.O.B. 12000 91120 Jerusalem Israel Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Single-session endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography for evaluation of pancreaticobiliary disorders

Abstract Background Endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) often are required in the evaluation and treatment of patients with pancreaticobiliary disorders. Few reports of single-session EUS-ERCP have raised questions regarding its safety and accuracy or about which procedure should be performed first. Methods Data from 2005 to 2009 were reviewed from a prospectively maintained EUS-ERCP database at a single tertiary care cancer center. Sensitivity and specificity of EUS and fine-needle aspiration (FNA), bile duct cannulation rate, duration of procedure, and complications were evaluated. Results Of the 35 patients (15 men and 20 women) studied, 28 had a final diagnosis of malignancy, and 7 had benign disorders. All the patients underwent ERCP and EUS, with FNA performed for 28 patients (80%). For 22 of the 35 patients (62.8%), EUS was the first procedure performed. The sensitivity of EUS-FNA for malignancy was 96.4%. The bile duct cannulation rate during ERCP was 97.1%. Five patients required a precut sphincterotomy for bile duct access, and one patient with chronic pancreatitis had a failed cannulation despite a EUS-guided rendezvous. A stent was successfully placed in 29 patients (96%). No major complications occurred, and no contrast leak was seen when FNA was performed before the cholangiogram. One patient had periduodenal bleeding after FNA, which was managed conservatively. The mean duration of the procedure was 83.7 min. Conclusion Single-session EUS-ERCP can be performed safely and with efficacy similar to that of the procedures performed separately. Content Type Journal ArticleDOI 10.1007/s00464-009-0798-3Authors Gil Ascunce, University of Miami Division of Gastroenterology, Miller School of Medicine P.O. Box 016960 Miami FL 33101 USAAfonso Ribeiro, University of Miami Division of Gastroenterology, Miller School of Medicine P.O. Box 016960 Miami FL 33101 USACaio Rocha-Lima, University of Miami Division of Hematology and Oncology, Miller School of Medicine Miami FL USAMarcelo Larsen, University of Miami Division of Gastroenterology, Miller School of Medicine P.O. Box 016960 Miami FL 33101 USADanny Sleeman, University of Miami Department of Surgery, Miller School of Medicine Miami FL USAJaime Merchan, University of Miami Division of Hematology and Oncology, Miller School of Medicine Miami FL USADeborah Szabo, University of Miami Division of Hematology and Oncology, Miller School of Medicine Miami FL USAJoe U. Levi, University of Miami Department of Surgery, Miller School of Medicine Miami FL USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Laparoscopic radical cholecystectomy and Roux-en-Y choledochojejunostomy for gallbladder cancer

Abstract Background Although laparoscopic cholecystectomy was one of the first laparoscopic procedures, gallbladder cancer has been one of the last malignancies tackled with minimally invasive techniques. This video reviews the minimally invasive approaches to preoperatively suspected gallbladder cancer. Methods Like the standard laparoscopic cholecystectomy, the minimally invasive procedure is performed with four trocars. The surgeon operates with the patient in the French position. A totally laparoscopic radical cholecystectomy including wedge resections of segments IVB and V is undertaken with hepatoduodenal lymphadenectomy and common bile duct excision. The biliary system is reconstructed via a laparoscopic choledochojejunostomy. Results Six patients have undergone laparoscopic radical cholecystectomy. Three of these patients were found to have gallbladder cancer according to the final pathology. All the final surgical margins were negative, and the average lymph node retrieval was 3 (range, 1–6). Conclusion The minimally invasive approach to gallbladder cancer is feasible and safe. It should currently be performed in high-volume centers with expertise in both hepatobiliary and minimally invasive surgery. Larger trials are needed to determine whether either the open or laparoscopic approach offers any advantage. Content Type Journal ArticleCategory Dynamic ManuscriptDOI 10.1007/s00464-009-0840-5Authors Andrew A. Gumbs, Fox Chase Cancer Center Department of Surgical Oncology 333 Cottman Avenue, C-308 Philadelphia PA 19111 USAJohn P. Hoffman, Fox Chase Cancer Center Department of Surgical Oncology 333 Cottman Avenue, C-308 Philadelphia PA 19111 USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Impact of the patient’s body position on the intraabdominal workspace during laparoscopic surgery

Abstract Background The effects of the patient’s body position on the intraabdominal workspace in laparoscopic surgery were analyzed. Methods The inflated volume of carbon dioxide was measured after insufflation to a preset pressure of 15 mmHg for 20 patients with a body mass index (BMI) greater than 35 kg/m2. The patients were anesthetized with full muscle relaxation. The five positions were (1) table horizontal with the legs flat (supine position), (2) table in 20° reverse Trendelenburg with the legs flat, (3) table in 20° reverse Trendelenburg with the legs flexed 45° upward at the hips (beach chair position), (4) table horizontal with the legs flexed 45° upward at the hips, and (5) table in 20° Trendelenburg with the legs flat. The positions were performed in a random order, and the first position was repeated after the last measurement. Repeated measure analysis of variance was used to compare inflated volumes among the five positions. Results A significant difference in inflated volume was found between the five body positions (P = 0.042). Compared with the mean inflated volume for the supine position (3.22 ± 0.78 l), the mean inflated volume increased by 900 ml for the Trendelenburg position or when the legs were flexed at the hips, and decreased by 230 ml for the reverse Trendelenburg position. Conclusions The Trendelenburg position for lower abdominal surgery and reverse Trendelenburg with flexing of the legs at the hips for upper abdominal surgery effectively improved the workspace in obese patients, even with full muscle relaxation. Content Type Journal ArticleDOI 10.1007/s00464-009-0785-8Authors Jan Paul J. Mulier, AZ Sint Jan Brugge-Oostende AV Department of Anaesthesiology Ruddershove 10 8000 Brugge BelgiumBruno Dillemans, AZ Sint Jan Brugge-Oostende AV Department of General Surgery Ruddershove 10 8000 Brugge BelgiumSebastiaan Van Cauwenberge, AZ Sint Jan Brugge-Oostende AV Department of General Surgery Ruddershove 10 8000 Brugge Belgium Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Cost effective analysis of ribosome-component immune modulation.

Related Articles Cost effective analysis of ribosome-component immune modulation. Allergy Asthma Proc. 2009 Jul-Aug;30 Suppl 1:S37-9 Authors: Fiocchi A, Olivieri D, Marcassa S, Zava D, Robberto E In childhood, recurrent airway infections are the most common cause for medical visits and hospitalizations. Their economic impact is considerable and their treatment accounts for a substantial quota of the health care budget. Despite documented efficacy and safety, ribosomal bacterial vaccine and membrane fraction use is still limited by being prevalently considered for prevention rather than treatment. The objective of this study was to analyze the economic benefit achieved with ribosomal immunotherapy. A review was performed of available literature data on economic parameters. Pharmacoeconomic studies published during the past few years showed how the use of ribosome component immune modulator is capable of reducing expenditure associated with treatment of recurrent respiratory infection and allows achievement of substantial savings in terms of cost, time, and loss of productivity. The initial cost of prevention in patients suffering from chronic respiratory infections is offset by a subsequent saving arising from less recurrence of disease. Direct management costs such as therapy courses, medical visits, medical exams, hospitalizations, etc., and indirect costs such as absence from school and work are not routinely considered by primary care physicians. PMID: 19679004 [PubMed - indexed for MEDLINE]

Safety and tolerability of ribosome-component immune modulator in adults and children.

Related Articles Safety and tolerability of ribosome-component immune modulator in adults and children. Allergy Asthma Proc. 2009 Jul-Aug;30 Suppl 1:S33-6 Authors: Olivieri D, Fiocchi A, Pregliasco F, Veehof S, Cantoni V Ribosomal preparations (ribosome-component immune modulators [RCIMs]) do not contain attenuated bacteria and, in contrast to live bacterial extracts, which may induce severe side effects, retain immune stimulating activity without infectious capability. This study was designed to profile the tolerability of RCIM by reviewing narratively all randomized, double-blind, placebo-controlled clinical trials and open-label studies as well as data from postmarketing surveillance studies representing >30 million prescriptions. In the various clinical trials, RCIM tolerability in terms of clinical and laboratory parameters was good. There were no significant differences between patients receiving active treatment or placebo in a survey of tolerability results from randomized, double-blind, placebo-controlled studies. Pharmacovigilance analysis does not show a change in the risk profile of RCIM. The only contraindication was correlated with known hypersensitivity to any of the product components. RCIM should not be used in case of acute streptococcal glomerulonephritis, acquired immune deficiency syndrome, severe viral disease, or severe autoimmune disease. Risk associated with the use of RCIM is negligible in recurrent upper and lower airway infections in selected populations, such as children and elderly people. PMID: 19679003 [PubMed - indexed for MEDLINE]

Ribosome-component immune modulation of respiratory tract infections in children.

Related Articles Ribosome-component immune modulation of respiratory tract infections in children. Allergy Asthma Proc. 2009 Jul-Aug;30 Suppl 1:S21-31 Authors: Fiocchi A, Terracciano L, Martelli A, Bernardo L, Calcinai E, Marcassa S More than 25% of infants in their first year of life and 18% of children aged between 1 and 4 years suffer from recurrent respiratory infections (RRIs) in Western countries. Although RRIs are self-limiting as a rule, complications may include otitis media, sinusitis, and bronchial and pulmonary infections. This study was designed to present the available data on immune modulators (defined as drugs that interact with the immune system and modulate immune function by stimulating a more rapid and effective immune response). A ribosome-component immune modulator (RCIM) designed to stimulate both specific and nonspecific immunity in children and thus prevent or alleviate RRI is also described. A narrative review of the literature was performed with a focus on clinical trials. Double-blind, placebo-controlled studies have shown that an RCIM effectively prevents recurrent bronchopulmonary and ear-nose-throat infections; in particular, the number, severity, and duration of infectious episodes and the numbers of antibiotic courses, concomitant medications, and days away from school (children) or the workplace (parents) were reduced. Use of a RCIM is clinically efficacious, incurs minimal risk of adverse events, and, thus, represents a consistent therapeutic approach for RRIs. PMID: 19679002 [PubMed - indexed for MEDLINE]

Ribosome-component immune modulation of respiratory tract infections in adults.

Related Articles Ribosome-component immune modulation of respiratory tract infections in adults. Allergy Asthma Proc. 2009 Jul-Aug;30 Suppl 1:S13-9 Authors: Olivieri D, Chiesa S, Tzani P, Marino P, Robberto E, Marcassa S The standard therapeutic strategy for bacterial episodes (and bacterial superinfections) is the repeated use of antibiotics. Although antibiotics are fast acting and curative, they do not prevent recurrence or complications. The incidence of recurrent respiratory infections and a substantial increase of costs justify preventive measures based on boosting the patients' immune system by immunomodulation using bacterial products, which, in the long term, stimulates immunity and reduces recurrence of infection. This study was designed to review the epidemiological features of respiratory infections and prevention strategies in adults. A narrative review was performed of the relevant literature. Several products of the immune modulator class are available: bacterial lysates, bacterial membrane component by-products, chemically synthesized compounds, and specific bacterial components (ribosome-component immune modulator [RCIM]). The clinical efficacy of the RCIM has specific and nonspecific immunostimulant properties. Efficacy is mainly documented by decreased recurrent episodes of infection and prescription and need for antibiotics. Benefits are generally observed after 3 months of treatment and are maintained for 6 months. Clinical trial evidence is accruing of the efficacy of RCIM in preventing recurrence of upper and lower airway infections or relapses in adults. PMID: 19679001 [PubMed - indexed for MEDLINE]

Rationale for the clinical use of a ribosome-component immune modulator.

Related Articles Rationale for the clinical use of a ribosome-component immune modulator. Allergy Asthma Proc. 2009 Jul-Aug;30 Suppl 1:S5-12 Authors: Pregliasco F, Terracciano L, Marcassa S, Zava D, Anselmi G Vaccines have long been used to boost the immune system and to confer protection against microbial infections. In contrast, immunotherapy based on ribosomal preparations has been proposed to enhance both specific and nonspecific immune responses (in particular, the mucosal immune defense system) against common respiratory tract pathogens. The aim of this review is to summarize current knowledge on the ability of a combination of four immunogenic ribosomal fractions from different bacteria species and of the extracted fraction from the membrane of Klebsiella pneumoniae to modulate several immune functions. The immunomodulatory activity of the ribosome component is attributed to the presence of highly purified epitopes from cellular fractions obtained by bacterial lysis. The ribosomal preparation is hypothesized to induce a T-dependent immune response consequent network with proliferation of B lymphocytes and production of secretory high-affinity antibodies (in particular, IgA), as well as the creation of a specific immune memory. Indeed, this agent stimulates the activity of macrophages, polymorphonuclear cells, and natural killer cells. The "ideal" vaccine is a highly purified protein bound to a carrier and an adjuvant that enhances the vaccination effect. PMID: 19679000 [PubMed - indexed for MEDLINE]

Bacterial vaccines and the innate immune system: a journey of rediscovery for the allergist-immunologist and all health care providers.

Related Articles Bacterial vaccines and the innate immune system: a journey of rediscovery for the allergist-immunologist and all health care providers. Allergy Asthma Proc. 2009 Jul-Aug;30 Suppl 1:S3-4 Authors: Bellanti JA, Settipane RA PMID: 19678999 [PubMed - indexed for MEDLINE]

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The Diabetic Antigen Glutamic Acid Decarboxylase (GAD 65) in the Human Peripheral Blood

Anaphylaxis to Wheat Flour-Derived Foodstuffs and the Lipid Transfer Protein Syndrome: A Potential Role of Wheat Lipid Transfer Protein Tri a 14

Human Leukocyte Antigen (DR1)-DQB1*0501 and (DR15)-DQB1*0602 Haplotypes Are Associated with Humoral Responses to Early Food Allergens in Children

Exposure of Intestinal Epithelial Cells to UV-Killed Lactobacillus GG but Not Bifidobacterium breve Enhances the Effector Immune Response in vitro

Occupational Endotoxin Exposure Reduces the Risk of Atopic Sensitization but Increases the Risk of Bronchial Hyperresponsiveness

Regulation of CXCR/IL-8 in Human Airway Epithelial Cells

A Toll-Like Receptor 2/6 Agonist Reduces Allergic Airway Inflammation in Chronic Respiratory Sensitisation to Timothy Grass Pollen Antigens

Hydrolyzed Konjac Glucomannan Suppresses IgE Production in Mice B Cells

Association of Plasma Soluble CTLA-4 with Lung Function and GenePolymorphism in Chinese Asthmatic Children

Intranasal CpG Therapy Attenuated Experimental Fungal Asthma in a TLR9-Dependent and -Independent Manner

Topical ‘Sydney’ Propolis Protects against UV-Radiation-Induced Inflammation, Lipid Peroxidation and Immune Suppression in Mouse Skin

Reduced Immunoglobulin M Is Associated with Sinus Mucosal Thickening, Osteitis and Sinus Surgery in Patients with Common Variable Immunodeficiency

Differential Mucosal IL-17 Expression in Two Gliadin-Induced Disorders: Gluten Sensitivity and the Autoimmune Enteropathy Celiac Disease

Xolair Is Effective in Allergics with a Low Serum IgE Level

Serum Transforming Growth Factor-ß Levels Depend on Allergen Exposure in Allergic Rhinitis

Occupational Allergy in Strawberry Greenhouse Workers

Airborne Study of Grass Allergen (Lol p 1) in Different-Sized Particles

Sublingual Immunotherapy Efficacy of Dermatophagoides farinae Vaccine in a Murine Asthma Model

A Six-SNP Haplotype of ADAM33 Is Associated with Asthma in a Population of Cartagena, Colombia

Tryptase Is Not Cleared by the Kidneys into the Urine

On the Cover

Comparison of allergen immunotherapy practice patterns in the United States and Europe

The effect of statin therapy on allergic patients with asthma

Detection and home management of worsening asthma symptoms

Relationship between visits to emergency departments for asthma and ozone exposure in greater Seattle, Washington

The effect of low-cost modification of the home environment on the development of respiratory symptoms in the first year of life

Regional variation in epinephrine autoinjector prescriptions in Australia: more evidence for the vitamin Danaphylaxis hypothesis

A retrospective review of clinical presentation, thyroid autoimmunity, laboratory characteristics, and therapies used in patients with chronic idiopathic urticaria

Angiotensin-converting enzyme inhibitorinduced angioedema in a community hospital emergency department

Biomolecular identification of allergenic pollen: a new perspective for aerobiological monitoring?

Clinical and immunobiochemical characterization of airborne Delonix regia (Gulmohar tree) pollen and cross-reactivity studies with Peltophorum pterocarpum pollen: 2 dominant avenue trees from eastern India

Effects of endogenous glucocorticoids on allergic inflammation and TH1/TH2 balance in airway allergic disease

IMPORTED FIRE ANT HYPERSENSITIVITY: A 1-DAY RUSH IMMUNOTHERAPY SCHEDULE WITHOUT PREMEDICATION

HANDLE WITH CARE ... NITROGLYCERIN ANAPHYLAXIS

PHENYTOIN-INDUCED DRESS

RAPID ORAL DESENSITIZATION TO FUROSEMIDE

OCULAR SYMPTOM EFFICACY AND INTRANASAL CORTICOSTEROIDS

OCULAR SYMPTOM EFFICACY AND INTRANASAL CORTICOSTEROIDS

Author index to volume 103, 2009

News and Notices

Laparoscopic surgery for rectal cancer: the standard of care?

Risk-sensitive events during laparoscopic cholecystectomy: the influence of the integrated operating room and a preoperative checklist tool

Re: Single incision multiport laparoendoscopic (SIMPLE) surgery

Suprapapillary needleknife fistulotomy: a safe and effective method for accessing the biliary system

Detection of gastric conduit ischemia or anastomotic breakdown after cervical esophagogastrostomy: the use of computed tomography scan versus early endoscopy

Technique of open laparoscopy for supramesocolic surgery in obese patients

The effect of mechanical ventilation tidal volume during pneumoperitoneum on shoulder pain after a laparoscopic appendectomy

Extraluminal laparoscopic wedge resection of gastric submucosal tumors: a retrospective review of 84 cases

Effort, safety, and findings of routine preoperative endoscopic evaluation of morbidly obese patients undergoing bariatric surgery

Stapled transanal rectal resection for symptomatic intussusception: morphological and functional outcome

Thoracoscopic robot-assisted extended thymectomy in the human cadaver

A prospective randomized trial comparing two-stage versus single-stage management of patients with gallstone disease and common bile duct stones

Single-port-access (SPATM) cholecystectomy: a multi-institutional report of the first 297 cases

Is unilateral laparoscopic TEP inguinal hernia repair a job half done? The case for bilateral repair

Safety of the laparoscopic adjustable gastric band: 7-year data from a U.S. center of excellence

Global Assessment of Gastrointestinal Endoscopic Skills (GAGES): a valid measurement tool for technical skills in flexible endoscopy

Whether robot-assisted laparoscopic fundoplication is better for gastroesophageal reflux disease in adults: a systematic review and meta-analysis

Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife for large superficial colorectal neoplasias including ileocecal lesions

Comparison of intracorporeal versus extracorporeal anastomosis in laparoscopic-assisted hemicolectomy

Single-incision laparoscopic cholecystectomy: the first 100 outpatients

The impact of intraoperative ultrasonography on the surgical treatment of patients with colorectal liver metastases

The safety and utility of prophylactic pancreatic duct stents in the prevention of post-ERCP pancreatitis: an analysis of practice in a single UK tertiary referral center

Risk of clinical leak after laparoscopic versus open bowel anastomosis

Endoscopic thoracic sympathectomy for primary palmar hyperidrosis

Safety of carbon dioxide insufflation for upper gastrointestinal tract endoscopic treatment of patients under deep sedation

Functional and comparative evaluation of flexible monopolar endoscopic scissors

Two-stage laparoscopic liver resection for bilateral colorectal liver metastasis

Preoperative infliximab treatment and postoperative complications after laparoscopic restorative proctocolectomy with ileal pouch–anal anastomosis: a case-matched study

Advantages of fast-track recovery after laparoscopic right hemicolectomy for colon cancer

Clinical predictors of operative complexity in laparoscopic ventral hernia repair: a prospective study

Totally laparoscopic right colectomy with transvaginal specimen extraction: the authors’ initial institutional experience

An Isolator System for minimally invasive surgery: the new design

Comparison of intraoperative enteroscopy and double-balloon enteroscopy for the diagnosis and treatment of Peutz-Jeghers syndrome

Human Leukocyte Antigen (DR1)-DQB10501 and (DR15)-DQB10602 Haplotypes Are Associated with Humoral Responses to Early Food Allergens in Children