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Front & Back Matter

Int Arch Allergy Immunol 2012;157:X (DOI:10.1159/000336950)

The Loss of Smell in Persistent Allergic Rhinitis Is Improved by Levocetirizine due to Reduction of Nasal Inflammation but Not Nasal Congestion (the CIRANO Study)

Int Arch Allergy Immunol 2012;158:184–190 (DOI:10.1159/000331329)

Multiorgan Infiltration by CD8+ T Cells and 1p;16p Translocation in a Patient with Hypogammaglobulinemia and a Reduced Number of B Cells

Int Arch Allergy Immunol 2012;158:206–210 (DOI:10.1159/000331117)

The Impact of Cigarette Smoking on Asthma: A Population-Based International Cohort Study

Int Arch Allergy Immunol 2012;158:175–183 (DOI:10.1159/000330900)

Effects of Bepotastine and Fexofenadine on Histamine-Induced Flare, Wheal and Itch

Int Arch Allergy Immunol 2012;158:191–195 (DOI:10.1159/000330663)

Susceptibility to Vaccinia Virus Infection and Spread in Mice Is Determined by Age at Infection, Allergen Sensitization and Mast Cell Status

Int Arch Allergy Immunol 2012;158:196–205 (DOI:10.1159/000330647)

Expression and Characterization of Natural-Like Recombinant Der p 2 for Sublingual Immunotherapy

Int Arch Allergy Immunol 2012;158:157–167 (DOI:10.1159/000331143)

Induction of Specific Th1 Responses and Suppression of IgE Antibody Formation by Vaccination with Plasmid DNA Encoding Cyn d 1

Int Arch Allergy Immunol 2012;158:142–150 (DOI:10.1159/000331140)

Higher Frequencies of CD161+ Circulating T Lymphocytes in Allergic Rhinitis Patients Compared to Healthy Donors

Int Arch Allergy Immunol 2012;158:151–156 (DOI:10.1159/000330903)

Prevalence of Atopy and Allergic Diseases in Korean Children: Associations with a Farming Environment and Rural Lifestyle

Int Arch Allergy Immunol 2012;158:168–174 (DOI:10.1159/000330820)

Erratum

Int Arch Allergy Immunol 2012;157:212 (DOI:10.1159/000335957)

The Role of Natural Killer T Cells in the Pathogenesis of Acute Exacerbation of Human Asthma

Int Arch Allergy Immunol 2012;158:131–141 (DOI:10.1159/000330908)

Pulmonary Endotoxin Tolerance Protects against Cockroach Allergen-Induced Asthma-Like Inflammation in a Mouse Model

Int Arch Allergy Immunol 2012;158:120–130 (DOI:10.1159/000330896)

Profilin as an Aeroallergen by Means of Conjunctival Allergen Challenge with Purified Date Palm Profilin

Int Arch Allergy Immunol 2012;158:115–119 (DOI:10.1159/000330822)

Effect of Polymorphism of the β<sub>2</sub>-Adrenergic Receptor on Response to Regular Use of Albuterol in Asthma

Int Arch Allergy Immunol 2001;124:183–186 (DOI:10.1159/000053705)

Basophil Activation Test in Allergy: Time for an Update

Int Arch Allergy Immunol 2012;158:99–114 (DOI:10.1159/000331312)

Clinical Utility of IgE Antibodies to ω-5 Gliadin in the Diagnosis of Wheat Allergy: A Pediatric Multicenter Challenge Study

Int Arch Allergy Immunol 2012;158:71–76 (DOI:10.1159/000330661)

Immunotherapy Is Allergen-Specific: A Double-Blind Trial of Mite or Timothy Extract in Mite and Grass Dual-Allergic Patients

Int Arch Allergy Immunol 2012;158:63–70 (DOI:10.1159/000330649)

Parental Eczema Increases the Risk of Double-Blind, Placebo-Controlled Reactions to Milk but Not to Egg, Peanut or Hazelnut

Int Arch Allergy Immunol 2012;158:77–83 (DOI:10.1159/000330645)

Assessing Degree of Flowering Implicates Multiple Chenopodiaceae/Amaranthaceae Species in Allergy

Int Arch Allergy Immunol 2012;158:54–62 (DOI:10.1159/000330105)

The burden of endoscopic retrograde cholangiopancreatography (ERCP) performed with the patient under conscious sedation

Abstract Background Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure that proves burdensome to patients. Nevertheless, very little data are available on patient tolerance of this procedure that may improve practice guidelines and could aid in decreasing the burden of ERCP. This study therefore investigated the burden of ERCP performed with the patient under conscious sedation. Methods Consecutive patients receiving ERCP under conscious sedation between November 2007 and December 2008 at the University Medical Center Utrecht and Erasmus MC Rotterdam (The Netherlands) were asked to participate in this study. The patients completed questionnaires on demographics, medical history, burden of ERCP (mental health, discomfort, and pain), symptoms and the EuroQol-5D (EQ-5D), including the EQ-VAS (lower EQ-5D scores and higher EQ-VAS scores represent a better quality of life). The paired t-test, the Kruskal–Wallis test, Pearson correlation, and logistic regression were used to evaluate the results. Results The questionnaire was returned by 149 (54%) of 276 eligible patients, 139 of whom completed the entire questionnaire (54% males; mean age, 60 ± 14 years). Throat ache (p < 0.001) was the only symptom higher than baseline value 1 day after the ERCP. On day 1, about one-tenth of the patients experienced moderate to severe mental health problems, which were associated with a higher EQ-5D score before ERCP (p = 0.01). Slightly fewer than half of the patients experienced pain and discomfort during and immediately after ERCP. More discomfort was experienced by patients who underwent therapeutic ERCP (p < 0.05) and those with a higher EQ-5D score (p < 0.001) or lower VAS (p < 0.01). Pain was associated with younger age (p < 0.01), higher EQ-5D score (p < 0.001), and lower VAS (p < 0.01). Conclusion One-third to one-half of patients experience pain and discomfort during and immediately after ERCP when it is performed with conscious sedation for the patient. Other sedation strategies, such as the use of general anesthesia or propofol, may well reduce the burden of ERCP, particularly for patients with a higher EQ-5D score, younger age, or therapeutic ERCP treatment. However, randomized trials are warranted. Content Type Journal ArticlePages 1-7DOI 10.1007/s00464-012-2162-2Authors S. M. Jeurnink, Department of Gastroenterology and Hepatology, University Medical Center, P.O. Box 85500, 3508 GA Utrecht, The NetherlandsE. W. Steyerberg, Department of Public Health, Erasmus MC/University Medical Center, Rotterdam, The NetherlandsE. J. Kuipers, Department of Gastroenterology and Hepatology, Erasmus MC/University Medical Center, Rotterdam, The NetherlandsP. D. Siersema, Department of Gastroenterology and Hepatology, University Medical Center, P.O. Box 85500, 3508 GA Utrecht, The Netherlands Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

The use of novel hemostatic sealant (Tisseel®) in laparoscopic myomectomy: a case–control study

Abstract Background This is the first case–control study on the use of a fibrin sealant (Tisseel®) on uterine suture during laparoscopic myomectomy (LM), with the primary endpoint to evaluate the intraoperative bleeding and postoperative blood loss. In addition, we evaluated the time required to achieve hemostasis using Tisseel® and how much it can influence operative time. Methods From December 2009 to January 2011, consecutive patients older than 18 years with symptomatic isolate intramural myoma with maximal diameter ≤6 cm and ≥4 cm and with a sonographically diagnosed free myometrium margin ≥0.5 cm were included in the study. We selected from our institute’s database a group of consecutive patients with homogeneous features of the study group, who underwent laparoscopic myomectomy without Tisseel® application. Results Fifteen women with symptomatic myoma were enrolled in the study (group A). Regarding the control group (group B), we selected a homogenous group of 15 patients with the same preoperative characteristics of the study group. Mean operative time was 47.7 min and 62.1 min, for groups A and B respectively (p < 0.05). Mean time required to achieve complete haemostasis was 195.5 s in group A and 361.8 in control group B (p < 0.0001). Mean estimated blood loss was 111.3 mL and 230 mL in groups A and B, respectively (p < 0.05). Mean hemoglobin decrease was 1.36 g/dL and 2.04 g/dL in groups A and B, respectively (p < 0.05). Conclusions The use of Tisseel® during LM may represent a valid alternative solution for obtaining hemostasis, reducing intra- and postoperative bleeding. Furthermore, it may help the surgeon to obtain a rapid healing of the injured surfaces, probably reducing the use of electrocoagulation and traumatisms. Content Type Journal ArticlePages 1-8DOI 10.1007/s00464-012-2154-2Authors Roberto Angioli, Department of Obstetrics and Gynecology, “Campus Bio Medico” University of Rome, Via Álvaro del Portillo, 200-00128 Rome, ItalyFrancesco Plotti, Department of Obstetrics and Gynecology, “Campus Bio Medico” University of Rome, Via Álvaro del Portillo, 200-00128 Rome, ItalyRoberto Ricciardi, Department of Obstetrics and Gynecology, “Campus Bio Medico” University of Rome, Via Álvaro del Portillo, 200-00128 Rome, ItalyCorrado Terranova, Department of Obstetrics and Gynecology, “Campus Bio Medico” University of Rome, Via Álvaro del Portillo, 200-00128 Rome, ItalyMarzio Angelo Zullo, Department of Obstetrics and Gynecology, “Campus Bio Medico” University of Rome, Via Álvaro del Portillo, 200-00128 Rome, ItalyPatrizio Damiani, Department of Obstetrics and Gynecology, “Campus Bio Medico” University of Rome, Via Álvaro del Portillo, 200-00128 Rome, ItalyRoberto Montera, Department of Obstetrics and Gynecology, “Campus Bio Medico” University of Rome, Via Álvaro del Portillo, 200-00128 Rome, ItalyFederica Guzzo, Department of Obstetrics and Gynecology, “Campus Bio Medico” University of Rome, Via Álvaro del Portillo, 200-00128 Rome, ItalyGiuseppe Scaletta, Department of Obstetrics and Gynecology, “Campus Bio Medico” University of Rome, Via Álvaro del Portillo, 200-00128 Rome, ItalyLudovico Muzii, Department of Obstetrics and Gynecology, “Campus Bio Medico” University of Rome, Via Álvaro del Portillo, 200-00128 Rome, Italy Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Randomized controlled trial of laparoscopic gastric ischemic conditioning prior to minimally invasive esophagectomy, the LOGIC trial

Abstract Introduction Minimally invasive esophagectomy (MIE) is a viable alternative to open resection for the management of esophagogastric cancer. However, the technique may relate to a higher incidence of ischemia-related gastric conduit complications. Laparoscopic ischemic conditioning (LIC) by ligating the left gastric vessels 2 weeks before MIE may have a protective role, possibly through an improvement of conduit perfusion. This project was designed to evaluate whether LIC influenced ultimate conduit perfusion. Methods A randomized controlled trial was designed to compare MIE with LIC (L) against MIE without (N). The project began in May 2009 and was offered to consecutive patients with the objective of recruiting 22 in each arm. Sample size calculations were based on data from previous clinical series. The main outcome measure was perfusion recorded by validated laser Doppler fluximetry, at the fundus (F) and greater curve (G); performed at routine staging laparoscopy and every stage of an MIE. A perfusion coefficient measured as ratio at stage of MIE over baseline was used for statistical analysis. Results Sixteen patients were recruited before an interim analysis of the trial data. At staging laparoscopy perfusion at F was higher than at G (p = 0.016). In the L cohort, an apparent rise in perfusion at G is observed post intervention (p = 0.176). At MIE, baseline perfusion is comparable for both arms; however, a significant drop is observed at both locations once the stomach is mobilized and exteriorized (p = 0.001). Once delivered at the neck, perfusion coefficient is approximately 38% of baseline levels. However, there was no discernible difference between the L (38.3 ± 12) and N (37.7 ± 16.8) cohorts (p = 0.798). Conclusions LIC does not translate into an improved perfusion of the gastric conduit tip. The benefits reported from published clinical series suggest that the resistance of the conduit to ischemia occurs through alternative possibly microcellular mechanisms. Content Type Journal ArticlePages 1-8DOI 10.1007/s00464-011-2123-1Authors Darmarajah Veeramootoo, Department of Upper Gastro-Intestinal Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, EX2 5DW UKAngela C. Shore, Institute of Biomedical and Clinical Science, Peninsula College of Medicine and Dentistry, University of Exeter, Exeter, UKShahjehan A. Wajed, Department of Upper Gastro-Intestinal Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, EX2 5DW UK Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Endoscopic laser fragmentation and removal of a nonremovable metal esophageal stent for persistent dysphagia: a technical note

Abstract Background Self-expanding metal stents are widely used in the palliation of esophageal diseases (Todd, N Engl J Med 344(22):1681–1687, 2001). The majority are inserted for end-stage malignancy and are not designed to be removed. Methods We report the first recorded successful endoscopic removal of an “irremovable” stent by laser fragmentation after its placement became redundant. A 72-year-old man who had persistent dysphagia after esophageal stent insertion for Boerhaave’s syndrome had his stent removed by Nd-YAG laser fragmentation at staged endoscopies. Results The stent was removed in its entirety and the patients’ symptoms resolved. Conclusions We describe a successful technique for the removal of a nonretrievable stent using laser fracture and endoscopic retrieval. This method of stent removal has not been previously reported. Content Type Journal ArticleCategory TechniquePages 1-3DOI 10.1007/s00464-011-2111-5Authors Ross S. Coomber, Department of Upper GI Surgery, West Herts NHS Trust, Watford General Hospital, Vicarage Road, Watford, WD18 0HB UKPranav H. Patel, Department of Upper GI Surgery, West Herts NHS Trust, Watford General Hospital, Vicarage Road, Watford, WD18 0HB UKAnubhav Dhir, Department of Healths Clinical Advisor Scheme, Bupa Health Dialog, London, UKJeremy I. Livingstone, Department of Upper GI Surgery, West Herts NHS Trust, Watford General Hospital, Vicarage Road, Watford, WD18 0HB UK Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

The optimal strategy for proximal mesh fixation during laparoscopic ventral rectopexy for rectal prolapse: an ex vivo study

Abstract Background Laparoscopic ventral rectopexy (LVR) is an established technique for the treatment of rectal prolapse. Several techniques and devices can be used for proximal mesh fixation on the sacral promontory during this procedure. The aim of this study was to compare the fixation strength of a recently introduced screw for mesh fixation on the promontory during LVR with two other frequently used techniques. Methods An ex vivo experimental model using a porcine spinal column was designed to measure the strength of proximal mesh fixation. In a laparoscopic box trainer, a polypropylene mesh was anchored on the spinal column using three different fixation methods, i.e., the Protack 5-mm tacker device, Ethibond Excel 2-0 stitches, and the Karl Storz screw. Subsequently, increasing traction was applied to the mesh. This traction was applied at a standardized angle as determined by measuring the mean angle between the site of distal mesh fixation on the rectum and a line straight through the sacral promontory on 12 random dynamic MR scans of the pelvic floor after the LVR procedure. The applied force was measured at the moment that the fixation broke, using a calibrated electronic Newton meter. All fixation methods were tested ten times. Results The mean angle, as measured on the MR scans, was 100°. The mean disruption force, which led to a break of the proximal mesh fixation, was 58 N for the three Protack tacks, 55 N for the two stitches, and 70 N for the new screw. The use of a screw therefore led to a significantly stronger fixation compared to the use of stitches (p ≤ 0.05). No significant difference was determined between the tacks and the screw fixation and between the tacks and the stitches fixation. Conclusion The new screw for proximal mesh fixation during LVR procedures offers similar fixation strength when compared to tacks. The use of one screw for proximal mesh fixation is therefore a reasonable alternative to the use of several tacks or sutures. Content Type Journal ArticlePages 1-5DOI 10.1007/s00464-012-2161-3Authors Hendrik A. Formijne Jonkers, Department of Surgery, Meander Medical Centre, Amersfoort, The NetherlandsHarm J. van de Haar, Department of Surgery, Meander Medical Centre, Amersfoort, The NetherlandsWerner A. Draaisma, Department of Surgery, Meander Medical Centre, Amersfoort, The NetherlandsBen G. F. Heggelman, Department of Radiology, Meander Medical Centre, Amersfoort, The NetherlandsEsther C. J. Consten, Department of Surgery, Meander Medical Centre, Amersfoort, The NetherlandsIvo A. M. J. Broeders, Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Comparable early changes in gastrointestinal hormones after sleeve gastrectomy and Roux-En-Y gastric bypass surgery for morbidly obese type 2 diabetic subjects

Abstract Background Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGBP) are associated with similar type 2 diabetes mellitus (T2DM) resolution rates for morbidly obese subjects. However, the mechanisms underlying the resolution of T2DM after SG have not been clarified to date. This study aimed to compare the early changes in gastrointestinal hormones involved in insulin and glucagon secretion in morbidly obese T2DM subjects undergoing SG or RYGBP. Methods This prospective study investigated 12 subjects with T2DM who had undergone SG (n = 6) or RYGBP (n = 6). Five body mass index (BMI)-matched obese non-diabetic subjects and five BMI-matched obese diabetic subjects served as control subjects. Glucose, insulin, glucagon, glucagon-like peptide 1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), and GLP-2 were determined after a standardized mixed liquid meal before surgery and 6 weeks afterward. Results After 6 weeks, five of the six subjects in each surgical group presented with T2DM remission, although the area under the curve (AUC)0–120 of glucose was greater than that of the non-diabetic control subjects (P < 0.01). Postsurgically, the indices of insulin and glucagon secretion were comparable between the two surgical groups. The AUC0–120 of GLP-1 (P < 0.05) and GLP-2 (P < 0.05) was significantly and comparably enlarged after SG and RYGB. The postsurgical GIP response was significantly associated with the glucagon response throughout the meal test (ρ = 0.747; P < 0.01). Conclusions The data show that in a cohort of morbidly obese T2DM subjects, SG and RYGBP are associated with an early improvement in glucose tolerance, similar changes in insulin and glucagon secretion, and a similar GLP-1, GIP, and GLP-2 response to a standardized mixed liquid meal. Content Type Journal ArticlePages 1-9DOI 10.1007/s00464-012-2166-yAuthors Fabiola Romero, Endocrinology and Diabetes Department, Obesity Unit, Hospital Clinic Universitari, Villarroel 170, 08036 Barcelona, SpainJoana Nicolau, Endocrinology and Diabetes Department, Obesity Unit, Hospital Clinic Universitari, Villarroel 170, 08036 Barcelona, SpainLílliam Flores, Endocrinology and Diabetes Department, Obesity Unit, Hospital Clinic Universitari, Villarroel 170, 08036 Barcelona, SpainRoser Casamitjana, Endocrinology and Diabetes Department, Obesity Unit, Hospital Clinic Universitari, Villarroel 170, 08036 Barcelona, SpainAinitze Ibarzabal, Endocrinology and Diabetes Department, Obesity Unit, Hospital Clinic Universitari, Villarroel 170, 08036 Barcelona, SpainAntonio Lacy, Endocrinology and Diabetes Department, Obesity Unit, Hospital Clinic Universitari, Villarroel 170, 08036 Barcelona, SpainJosep Vidal, Endocrinology and Diabetes Department, Obesity Unit, Hospital Clinic Universitari, Villarroel 170, 08036 Barcelona, Spain Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Minimally invasive intrathoracic anastomosis after Ivor Lewis esophagectomy for cancer: a review of transoral or transthoracic use of staplers

Abstract Background Minimally invasive Ivor Lewis esophagectomy is one of the approaches used worldwide for treating esophageal cancer. Optimization of this approach and especially identifying the ideal intrathoracic anastomosis technique is needed. To date, different types of anastomosis have been described. A literature search on the current techniques and approaches for intrathoracic anastomosis was held. The studies were evaluated on leakage and stenosis rate of the anastomosis. Methods The PubMed electronic database was used for comprehensive literature search by two independent reviewers. Results Twelve studies were included in this review. The most frequent applied technique was the stapled anastomosis. Stapled anastomoses can be divided into a transthoracic or a transoral introduction. This stapled approach can be performed with a circular or linear stapler. The reported anastomotic leakage rate ranges from 0 to 10%. The reported anastomotic stenosis rate ranges from 0 to 27.5%. Conclusions This review has found no important differences between the two most frequently used stapled anastomoses: the transoral introduction of the anvil and the transthoracic. Clinical trials are needed to compare different methods to improve the quality of the intrathoracic anastomosis after esophagectomy. Content Type Journal ArticleCategory ReviewPages 1-8DOI 10.1007/s00464-012-2149-zAuthors K. W. Maas, Department of Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The NetherlandsS. S. A. Y. Biere, Department of Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The NetherlandsJ. J. G. Scheepers, Department of Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The NetherlandsS. S. Gisbertz, Department of Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The NetherlandsV. Turrado Rodriguez, Department of Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The NetherlandsD. L. van der Peet, Department of Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The NetherlandsM. A. Cuesta, Department of Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Training in laparoscopic colorectal surgery: a new educational model using specially embalmed human anatomical specimen

Abstract Background With an increasing percentage of colorectal resections performed laparoscopically nowadays, there is more emphasis on training “before the job” on operative skills, including the comprehension of specific laparoscopic surgical anatomy. As integration of technical skills with correct interpretation of the anatomical image must be incorporated in laparoscopic training, a human specimen training model with special emphasis on surgical anatomy was developed. Methods The new embalming method Anubifix™ combines long-term high-quality embalming of human bodies with almost normal flexibility and plasticity, and the body can be kept operational as long as conventionally embalmed human specimens. A colorectal training model was created in a specimen in which anatomical landmarks of colorectal anatomy were permanently colored to explore laparoscopic colorectal anatomy in a skills training setting. Airtight closure of the abdominal wall permits the creation of pneumoperitoneum. Residents were asked to test the model by mobilizing the small and large bowels and expose the central vessels and ureters. Afterward they were asked to fill out an eight-item questionnaire about the model. Results Eleven surgical residents in their first and second year of training participated. Responses to the questionnaire showed that a majority of residents considered the model to be representative of the real situation and superior to animal models or virtual reality simulators, and helped to improve the knowledge of three-dimensional anatomy and laparoscopic skills. Conclusion The new training model for laparoscopic colorectal surgery proved to be a high-quality tool, concentrating on laparoscopic colorectal anatomy in a skills training setting. We believe it may be a valuable adjunct to residency training programs based on the principle of “training before the job.” Content Type Journal ArticlePages 1-6DOI 10.1007/s00464-012-2158-yAuthors Juliette C. Slieker, Department of Surgery, Erasmus University Medical Center, Rotterdam, The NetherlandsHilco P. Theeuwes, Department of Anatomy and Neurosciences, Erasmus University Medical Center, Rotterdam, The NetherlandsGöran L. van Rooijen, Department of Anatomy and Neurosciences, Erasmus University Medical Center, Rotterdam, The NetherlandsJohan F. Lange, Department of Surgery, Erasmus University Medical Center, Rotterdam, The NetherlandsGert-Jan Kleinrensink, Department of Anatomy and Neurosciences, Erasmus University Medical Center, Rotterdam, The Netherlands Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Educational and training aspects of new surgical techniques: experience with the endoscopic–laparoscopic interdisciplinary training entity (ELITE) model in training for a natural orifice translumenal endoscopic surgery (NOTES) approach to appendectomy

Abstract Background Natural orifice translumenal endoscopic surgery (NOTES) is a new surgical concept that requires training before it is introduced into clinical practice. The endoscopic–laparoscopic interdisciplinary training entity (ELITE) is a training model for NOTES interventions. The latest research has concentrated on new materials for organs with realistic optical and haptic characteristics and the possibility of high-frequency dissection. This study aimed to assess both the ELITE model in a surgical training course and the construct validity of a newly developed NOTES appendectomy scenario. Methods The 70 attendees of the 2010 Practical Course for Visceral Surgery (Warnemuende, Germany) took part in the study and performed a NOTES appendectomy via a transsigmoidal access. The primary end point was the total time required for the appendectomy, including retrieval of the appendix. Subjective evaluation of the model was performed using a questionnaire. Subgroups were analyzed according to laparoscopic and endoscopic experience. Results The participants with endoscopic or laparoscopic experience completed the task significantly faster than the inexperienced participants (p = 0.009 and 0.019, respectively). Endoscopic experience was the strongest influencing factor, whereas laparoscopic experience had limited impact on the participants with previous endoscopic experience. As shown by the findings, 87.3% of the participants stated that the ELITE model was suitable for the NOTES training scenario, and 88.7% found the newly developed model anatomically realistic. Conclusions This study was able to establish face and construct validity for the ELITE model with a large group of surgeons. The ELITE model seems to be well suited for the training of NOTES as a new surgical technique in an established gastrointestinal surgery skills course. Content Type Journal ArticleCategory Endoluminal SurgeryPages 1-7DOI 10.1007/s00464-012-2165-zAuthors Sonja Gillen, Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strässe 22, 81675 München, GermanyJörn Gröne, Department of Surgery, Charité–Campus Benjamin Franklin, Berlin, GermanyFritz Knödgen, Research Group MITI, Minimally Invasive Therapy and Intervention, Munich, GermanyPetra Wolf, Institute of Medical Statistics and Epidemiology, Technische Universität München, Ismaninger Strässe 22, 81675 München, GermanyMichael Meyer, Research Institute of Leather and Plastic Sheeting, FILK, Freiberg, GermanyHelmut Friess, Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strässe 22, 81675 München, GermanyHeinz-Johannes Buhr, Department of Surgery, Charité–Campus Benjamin Franklin, Berlin, GermanyJörg-Peter Ritz, Department of Surgery, Charité–Campus Benjamin Franklin, Berlin, GermanyHubertus Feussner, Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strässe 22, 81675 München, GermanyKai S. Lehmann, Department of Surgery, Charité–Campus Benjamin Franklin, Berlin, Germany Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Endoscopic treatment of large colorectal tumors: comparison of endoscopic mucosal resection, endoscopic mucosal resection–precutting, and endoscopic submucosal dissection

Abstract Background Endoscopic mucosal resection (EMR) is a useful therapeutic technique for colorectal tumors. However, for tumors larger than 20 mm, the chance of piecemeal resection is high. Recently introduced endoscopic submucosal dissection (ESD) enables en bloc resection regardless of the tumor size. This study aimed to compare the effectiveness and outcomes of EMR, EMR-precutting (EMR-P), and ESD in the treatment of colorectal tumors 20 mm in size or larger. Methods This study reviewed 523 nonpedunculated colorectal tumors (499 patients) 20 mm or larger that received endoscopic treatment (EMR in 140 cases, EMR-P in 69 cases, and ESD in 314 cases) from January 2004 to November 2009. Results The mean sizes of the tumors were 21.7 ± 3.5 mm (EMR), 23.5 ± 5.6 mm (EMR-P), and 28.9 ± 12.7 mm (ESD). The ratios of adenocarcinomas were 15.7% (EMR), 29% (EMR-P), and 37.9% (ESD). The en bloc resection rates were 42.9% (EMR), 65.2% (EMR-P), and 92.7% (ESD), and the complete resection rates were 32.9% (EMR), 59.4% (EMR-P), and 87.6% (ESD). Perforation occurred in 2.9% of the EMR-P cases and 8% of the ESD cases. The recurrence rates were 25.9% (EMR; median follow-up period, 26 months), 3.2% (EMR-P; median follow-up period, 16 months), and 0.8% (ESD; median follow-up period, 17 months). Conclusion For the treatment of large, nonpedunculated colorectal tumors, ESD is more effective than either EMR or EMR-P. Although ESD is technically demanding, it has clinical significance by overcoming the limitations of both EMR and EMR-P. Content Type Journal ArticlePages 1-11DOI 10.1007/s00464-012-2164-0Authors Eun-Jung Lee, Department of Surgery, Daehang Hospital, 481-10 Bangbae Seocho, Seoul, 137-820 KoreaJae Bum Lee, Department of Surgery, Daehang Hospital, 481-10 Bangbae Seocho, Seoul, 137-820 KoreaSuk Hee Lee, Department of Pathology, Daehang Hospital, Seoul, KoreaEui Gon Youk, Department of Surgery, Daehang Hospital, 481-10 Bangbae Seocho, Seoul, 137-820 Korea Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Laparoscopic splenectomy and azygoportal disconnection with intraoperative splenic blood salvage

Abstract Background Intraoperative blood salvage can reduce or avoid perioperative allogeneic blood transfusion. Salvaging the blood in the portal hypertension-induced enlarged spleen becomes an issue of concern during devascularization surgery because an enlarged spleen accommodates a large red cell pool. We report 20 cases of laparoscopic splenectomy and azygoportal disconnection and present the advantages of the use of intraoperative splenic blood salvage during the procedure. Methods A total of 20 cirrhotic patients with esophagogastric variceal bleeding refractory to treatment with β-blockers and endoscopic therapy were studied. Laparoscopic splenectomy with azygoportal disconnection was performed. During the procedure, an intraoperative autologous blood salvage device recovered the splenic blood. The perioperative data were recorded from various viewpoints. Results The operative time was 3.1 ± 0.3 h and the blood loss was 70.5 ± 32.5 ml. The weight of the excised and morcellated spleen was 826.0 ± 155.1 g. The volume of autotransfused blood was 541.0 ± 150.4 ml. No patient received a perioperative allogeneic blood transfusion. There were no significant complications either intraoperatively or postoperatively. The hemoglobin value increased from 9.3 ± 0.8 to 11.5 ± 1.1 g/dl at postoperative day 1 (p < 0.01). During a postoperative follow-up period of 18.0 ± 9.0 months for 18 patients, neither esophageal variceal bleeding nor encephalopathy recurred. Conclusion Laparoscopic splenectomy with azygoportal disconnection is a feasible, effective, and safe surgical method for the treatment of bleeding portal hypertension. Intraoperative splenic blood salvage can avoid the risk associated with allogeneic transfusion during the procedure, with an advantage of significantly increased postoperative hemoglobin levels. Content Type Journal ArticlePages 1-7DOI 10.1007/s00464-012-2159-xAuthors Yuedong Wang, Department of General Surgery, Zhejiang Provincial People’s Hospital, 158 Shangtang Rd, Hangzhou, 310014 ChinaYun Ji, Department of General Surgery, Zhejiang Provincial People’s Hospital, 158 Shangtang Rd, Hangzhou, 310014 ChinaYangwen Zhu, Department of General Surgery, Zhejiang Provincial People’s Hospital, 158 Shangtang Rd, Hangzhou, 310014 ChinaZhijie Xie, Department of General Surgery, Zhejiang Provincial People’s Hospital, 158 Shangtang Rd, Hangzhou, 310014 ChinaXiaoli Zhan, Department of General Surgery, Zhejiang Provincial People’s Hospital, 158 Shangtang Rd, Hangzhou, 310014 China Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Nerve-sparing laparoscopic eradication of deep endometriosis with segmental rectal and parametrial resection: the Negrar method. A single-center, prospective, clinical trial

Abstract Background The weight of surgical radicality, together with a lack of anatomical theoretical basis for surgery and inappropriate practical skills, can lead to serious impairments to bladder, rectal, and sexual functions after laparoscopic excision of deep infiltrating endometriosis. Although the “classical” laparoscopic technique for endometriosis excision involving segmental bowel resection has proven to relieve symptoms successfully, it is hampered by several postoperative long-term and/or definitive pelvic dysfunctions. Methods In this prospective cohort study, we compare the laparoscopic nerve-sparing approach to the classical laparoscopic procedure in a series of 126 cases. Satisfactory data for bowel, bladder, and sexual function were considered as primary endpoints. Results A total of 126 patients were considered for analysis: 61 treated with nerve-sparing radical excision of pelvic endometriosis with segmental bowel resection (group B), and 65 treated with the classical technique (group A). Intraoperative, perioperative, and postoperative complications were similar between the two groups. Mean days of self-catheterization were significantly lower in the nerve-sparing group (39.8 days) compared with the non-nerve-sparing group (121.1 days; p < 0.001). The relapse rate within 12 months after surgery was comparable between the two groups. Patients of group A suffered from urinary retention more frequently between 1 and 6 months (p = 0.035) compared with group B and did not experience any improvement between 6 months and 1 year (p = 0.018). Overall detection of severe bladder/rectal/sexual dysfunctions was significantly different between the two groups, and 56 patients of group A (86.2%) reported a significantly higher rate of severe neurologic pelvic dysfunctions vs. 1 patient (1.6%) of group B (p < 0.001). Conclusions Our technique appears to be feasible and offers good results in terms of reduced bladder morbidity and apparently higher satisfaction than the classical technique. Considering that this kind of surgery requires uncommon surgical skills and anatomical knowledge, we believe that it should be performed only in selected reference centers. Content Type Journal ArticlePages 1-17DOI 10.1007/s00464-012-2153-3Authors Marcello Ceccaroni, Division of Gynecologic Oncology, International School of Surgical Anatomy, Sacred Heart Hospital, “Ospedale Sacro Cuore-Don Calabria”, Via Don A.Sempreboni no. 5, 37024 Negrar, VR, ItalyRoberto Clarizia, Division of Gynecologic Oncology, International School of Surgical Anatomy, Sacred Heart Hospital, “Ospedale Sacro Cuore-Don Calabria”, Via Don A.Sempreboni no. 5, 37024 Negrar, VR, ItalyFrancesco Bruni, Division of Gynecologic Oncology, International School of Surgical Anatomy, Sacred Heart Hospital, “Ospedale Sacro Cuore-Don Calabria”, Via Don A.Sempreboni no. 5, 37024 Negrar, VR, ItalyElisabetta D’Urso, Department of Obstetrics and Gynecology, European Gynecology Endoscopy School, Sacred Heart Hospital, Negrar, VR, ItalyMaria Lucia Gagliardi, Department of Obstetrics and Gynecology, A. Gemelli University Hospital, Catholic University of Sacred Heart, Rome, ItalyGiovanni Roviglione, Division of Gynecologic Oncology, International School of Surgical Anatomy, Sacred Heart Hospital, “Ospedale Sacro Cuore-Don Calabria”, Via Don A.Sempreboni no. 5, 37024 Negrar, VR, ItalyLuca Minelli, Department of Obstetrics and Gynecology, European Gynecology Endoscopy School, Sacred Heart Hospital, Negrar, VR, ItalyGiacomo Ruffo, Division of Gynecologic Oncology, International School of Surgical Anatomy, Sacred Heart Hospital, “Ospedale Sacro Cuore-Don Calabria”, Via Don A.Sempreboni no. 5, 37024 Negrar, VR, Italy Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Use of fibrin sealant (Tisseel/Tissucol) in hernia repair: a systematic review

Abstract Background Abdominal wall and inguinal hernia repair are the most frequently performed surgical procedures in the United States and Europe. However, traditional methods of mesh fixation are associated with a number of problems including substantial risks of recurrence and of postoperative and chronic pain. The aim of this systematic review is to summarize the clinical safety and efficacy of Tisseel/Tissucol fibrin sealant for hernia mesh fixation. Methods A PubMed title/abstract search was conducted using the following terms: (fibrin glue OR fibrin sealant OR Tisseel OR Tissucol) AND hernia repair. The bibliographies of the publications identified in the search were reviewed for additional references. Results There were 36 Tisseel/Tissucol studies included in this review involving 5,993 patients undergoing surgery for hernia. In open repair of inguinal hernias, Tisseel compared favorably with traditional methods of mesh fixation, being associated with shorter operative times and hospital stays and a lower incidence of chronic pain. Similarly, after laparoscopic/endoscopic inguinal hernia repair, Tisseel/Tissucol was associated with less use of postoperative analgesics and less acute and chronic postoperative pain than tissue-penetrating mesh-fixation methods. Other end points of concern to surgeons and patients are the risks of inguinal hernia recurrence and of complications such as hematoma formation and intraoperative bleeding. Comparative studies show that Tisseel/Tissucol does not increase the risk of these outcomes and may, in fact, decrease the risk compared with tissue-penetrating fixation methods. When used in the repair of incisional hernias, Tisseel/Tissucol significantly decreased both postoperative morbidity and duration of hospital stay. Conclusions Clinical evidence published to date supports the use of Tisseel/Tissucol as an option for mesh fixation in open and laparoscopic/endoscopic repair of inguinal and incisional hernias. Guidelines of the International Endohernia Society recommend fibrin sealant mesh fixation, especially in inguinal hernia repair. Nonfixation is reserved for selected cases. Content Type Journal ArticleCategory ReviewPages 1-10DOI 10.1007/s00464-012-2156-0Authors René H. Fortelny, Department of General, Visceral and Oncological Surgery, Wilhelminenspital, Vienna, AustriaAlexander H. Petter-Puchner, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, AustriaKarl S. Glaser, Department of General, Visceral and Oncological Surgery, Wilhelminenspital, Vienna, AustriaHeinz Redl, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Laparoendoscopic single site (LESS) surgery for left-lateral hepatic sectionectomy as an alternative to traditional laparoscopy: case-matched analysis from a single center

Abstract Background Laparoscopy is considered the “gold standard” to perform left-lateral sectionectomy with results identical to those of open surgery, yielding decreased postoperative pain and disability, reduced hospital stay, and shortened patient recovery time. As the emphasis on minimizing the invasiveness of surgical techniques continues, laparoendoscopic single site (LESS) surgery is quickly evolving. The purpose of this study was to compare the results of laparoscopic left-lateral sectionectomy performed using the traditional approach or LESS approach with a case-matched analysis for tumor size, type of resection, and surgical indications. Methods Thirteen patients who underwent LESS left-lateral sectionectomy are considered the study group (LESS group) and compared with 13 patients who underwent left-lateral sectionectomy with traditional laparoscopic approach (conventional group). Results There were no significant differences between groups for length of surgery (165 min in conventional group vs. 195 min in LESS group), blood loss (150 mL in conventional group vs. 175 mL in LESS group), conversion to open surgery, histological tumor exposure, and requirements of postoperative analgesics. One patient in the LESS group died of cardiac failure due to an unknown severe aortic valve stenosis. No differences were recorded for postoperative complications (23.1% in both groups) and median length of postoperative stay (4 days in both groups). Conclusions For left-lateral hepatic sectionectomy, LESS surgery is technically feasible and as safe as traditional laparoscopic surgery in terms of intraoperative and postoperative results, even though requiring both hepatobiliary and laparoscopic technique experience. Content Type Journal ArticlePages 1-7DOI 10.1007/s00464-012-2147-1Authors Luca Aldrighetti, Department of Surgery, Hepatobiliary Surgery Unit, Vita-Salute S. Raffaele University, Via Olgettina 60, 20132 Milano, MI, ItalyFrancesca Ratti, Department of Surgery, Hepatobiliary Surgery Unit, Vita-Salute S. Raffaele University, Via Olgettina 60, 20132 Milano, MI, ItalyMarco Catena, Department of Surgery, Hepatobiliary Surgery Unit, Vita-Salute S. Raffaele University, Via Olgettina 60, 20132 Milano, MI, ItalyCarlo Pulitanò, Department of Surgery, Hepatobiliary Surgery Unit, Vita-Salute S. Raffaele University, Via Olgettina 60, 20132 Milano, MI, ItalyFabio Ferla, Department of Surgery, Hepatobiliary Surgery Unit, Vita-Salute S. Raffaele University, Via Olgettina 60, 20132 Milano, MI, ItalyFederica Cipriani, Department of Surgery, Hepatobiliary Surgery Unit, Vita-Salute S. Raffaele University, Via Olgettina 60, 20132 Milano, MI, ItalyGianfranco Ferla, Department of Surgery, Hepatobiliary Surgery Unit, Vita-Salute S. Raffaele University, Via Olgettina 60, 20132 Milano, MI, Italy Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Laparoscopic extraperitoneal aortic dissection: does single-port surgery offer the same possibilities as conventional laparoscopy?

Abstract Background This study aimed to demonstrate the feasibility of single-port surgery (SPS) for laparoscopic extraperitoneal aortic dissection. Methods From December 2010 to April 2011, all patients referred for aortic lymph node staging underwent a laparoscopic extraperitoneal approach with a single-port device. The extraperitoneal approach was performed using only one 3–4 cm incision on the left side. Gelpoint from Applied Medical (Rancho Santa Margarita, CA, USA), a 10-mm 0° laparoscope, and 5-mm standard instruments were used. Results The study enrolled 13 patients. Aortic dissection was complete for 11 patients and incomplete for 2 patients. The mean lymph node count was 16 (range, 7–40). The mean blood loss was 40.7 ml (range, 0–100 ml), and no transfusion was necessary. The mean hospital stay was 1.7 days (range, 1–4 days) for this series. Conclusion The study results demonstrate the feasibility of single-port-access laparoscopy for extraperitoneal aortic lymphadenectomy. The lymph node count was similar to that described in the published experience of conventional laparoscopic extraperitoneal dissection. This preliminary report shows that SPS is usable for extraperitoneal aortic dissection and that it is possible to perform this procedure using only one skin incision compared with the three or four incisions required for conventional laparoscopy. Content Type Journal ArticlePages 1-4DOI 10.1007/s00464-011-2126-yAuthors Eric Lambaudie, Department of General and Oncological Surgery, Paoli Calmettes Institute, Marseille, FranceFrancesco Cannone, Department of General and Oncological Surgery, Paoli Calmettes Institute, Marseille, FranceMarie Bannier, Department of General and Oncological Surgery, Paoli Calmettes Institute, Marseille, FranceMax Buttarelli, Department of General and Oncological Surgery, Paoli Calmettes Institute, Marseille, FranceGilles Houvenaeghel, Department of General and Oncological Surgery, Paoli Calmettes Institute, Marseille, France Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Comparison of preoperative and surgical measurements of Zenker’s diverticulum

Abstract Background Zenker’s diverticulum (ZD) may be treated with a variety of endoscopic or open surgical techniques; the choice of treatment depends partly on the size of the diverticulum. The purpose of this study was to correlate ZD measurements obtained preoperatively and during surgery. Methods From March 2006 to November 2008, 20 consecutive patients (19 males; median age 64.5 (range 37–88) years) with dysphagia secondary to ZD were enrolled for this study. All patients had preoperative barium radiography of the pharynx and esophagus, and diagnostic endoscopy. Ten patients underwent transoral stapling diverticulostomy and ten had open surgery. The depth of the ZD was measured on radiographic views, at endoscopy and during surgery, focusing on the distance from the top of the septum to the bottom of the pouch. The ZD dimensions obtained radiologically and endoscopically were compared with those found during surgery. Correlations and agreements between measurements were assessed using Pearson’s correlation coefficients and method-comparison analysis, respectively. Results The median depth of the ZD was 2.9 cm (mean 2.95 ± 1.12 cm; range 1.5–6 cm), 3.0 cm (mean 3.24 ± 1.27 cm; range 1.7–6.8 cm), and 3.0 cm (mean 2.99 ± 1.01 cm; range 1.5–6 cm) when measured during surgery, radiology, and endoscopy, respectively. The correlation and agreement between the radiographic and surgical ZD measurements were good, whereas those between the endoscopic and surgical measurements were poor. Conclusions These findings confirm that preoperative barium radiography is mandatory in order to choose the most appropriate surgical treatment for ZD. Content Type Journal ArticlePages 1-6DOI 10.1007/s00464-012-2146-2Authors Fabio Pomerri, Istituto Oncologico Veneto IOV—IRCCS, via Gattamelata 64, 35128 Padova, PD, ItalyMario Costantini, Department of Surgical and Gastrointestinal Sciences, 1st Surgical Clinic, University of Padua, Padua, ItalyChiara Dal Bosco, Istituto Oncologico Veneto IOV—IRCCS, via Gattamelata 64, 35128 Padova, PD, ItalyGiorgio Battaglia, Istituto Oncologico Veneto IOV—IRCCS, via Gattamelata 64, 35128 Padova, PD, ItalyRaffaele Bottin, Department of Otolaryngology, Head and Neck Surgery, University of Padua, Padua, ItalyLisa Zanatta, Department of Surgical and Gastrointestinal Sciences, 1st Surgical Clinic, University of Padua, Padua, ItalyErmanno Ancona, Istituto Oncologico Veneto IOV—IRCCS, via Gattamelata 64, 35128 Padova, PD, ItalyPier Carlo Muzzio, Istituto Oncologico Veneto IOV—IRCCS, via Gattamelata 64, 35128 Padova, PD, Italy Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Use of mesh for hiatal hernia repair: a survey of SAGES members

Abstract Background Mesh use during hiatal hernia repair (HHR) has been suggested to be safe and effective. Concern has been raised about the risk of mesh-related complications, and the higher risk of complications if revisional hiatal surgery is undertaken after mesh has been used. Available data have not established a clear role for mesh in HHR. To assess surgeons’ adoption of the use of mesh for HHR, SAGES members were surveyed regarding their practice related to mesh use for HHR. Methods Between April and September 2010, an internet-based survey tool was used to survey SAGES members. Potential participants were contacted via e-mail and invited to complete the survey. Of the 5,323 attempted contacts, 5,024 reached active e-mail accounts. From these, 2,518 members responded (50% response rate). Results The majority of respondents currently perform HHR (69%), but only 18% perform more than 20 per year. Of those who perform HHR, 94% use a laparoscopic approach for the majority of repairs. Whereas 25% of surgeons use mesh for the majority of repairs, 23% of surgeons never use mesh. When mesh is used, an absorbable mesh is most commonly used (67%). An onlay technique is used by 93% of respondents. Only 7% of surgeons who have been in practice more than 20 years use mesh compared with 59% of surgeons in practice less than 10 years. Fifty-seven percent of surgeons have never performed revisional foregut surgery on a patient with prior mesh. Conclusions Although the majority of surgeons have used mesh for HHR, it is the minority who use it routinely, with younger surgeons more likely to use mesh than older surgeons. Absorbable mesh is most commonly used. When mesh is used, an onlay technique is most commonly used. There is no clear accepted use of mesh in hiatal hernia repair. Content Type Journal ArticlePages 1-6DOI 10.1007/s00464-012-2150-6Authors Jason M. Pfluke, Department of Surgery, Mayo Clinic-Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USAMichael Parker, Department of Surgery, Mayo Clinic-Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USASteven P. Bowers, Department of Surgery, Mayo Clinic-Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USAHoracio J. Asbun, Department of Surgery, Mayo Clinic-Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USAC. Daniel Smith, Department of Surgery, Mayo Clinic-Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Challenging a classic myth: pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients. A 10-year experience with a nonoperative treatment

Abstract Background In patients presenting with acute diverticulitis (AD) and signs of acute peritonitis, the presence of extradigestive air (EDA) on a computer tomography (CT) scan is often considered to indicate the need for emergency surgery. Although the traditional management of “perforated” AD is open sigmoidectomy, more recently, laparoscopic drainage/lavage (usually followed by delayed elective sigmoidectomy) has been reported. The aim of this retrospective study is to evaluate the results of nonoperative management of emergency patients presenting with AD and EDA. Methods The outcomes of 39 consecutive hemodynamically stable patients (23 men, mean age = 54.7 years) who were admitted with AD and EDA and were managed nonoperatively (antibiotic and supportive treatment) at a tertiary-care university hospital between January 2001 and June 2010 were retrospectively collected and analyzed. These included morbidity (Clavien-Dindo) and treatment failure (need for emergency surgery or death). A univariate analysis of clinical, radiological, and laboratory criteria with respect to treatment failure was performed. Results of delayed elective laparoscopic sigmoidectomy were also analyzed. Results There was no mortality. Thirty-six of the 39 patients (92.3%) did not need surgery (7 patients required CT-guided abscess drainage). Mean hospital stay was 8.1 days. Duration of symptoms, previous antibiotic administration, severe sepsis, PCR level, WBC concentration, and the presence of abdominal collection were associated with treatment failure, whereas “distant” location of EDA and free abdominal fluid were not. Five patients had recurrence of AD and were treated medically. Seventeen patients (47.2%) underwent elective laparoscopic sigmoidectomy for which mean operative time was 246 min (range = 100–450) and the conversion rate was 11.8%. Mortality was nil and the morbidity rate was 41.2%. Mean postoperative stay was 7.1 days (range = 4–23). Conclusions Nonoperative management is a viable option in most emergency patients presenting with AD and EDA, even in the presence of symptoms of peritonitis or altered laboratory tests. Delayed laparoscopic sigmoidectomy may be useless in certain cases and its results poorer than expected. Content Type Journal ArticlePages 1-11DOI 10.1007/s00464-012-2157-zAuthors Renato Costi, Service de Chirurgie Digestive, Hôpital Antoine Béclère, Clamart, Assistance Publique–Hôpitaux de Paris, Université Paris XI, Clamart, FranceFrançois Cauchy, Service de Chirurgie Digestive, Hôpital Antoine Béclère, Clamart, Assistance Publique–Hôpitaux de Paris, Université Paris XI, Clamart, FranceAlban Le Bian, Service de Chirurgie Digestive, Hôpital Antoine Béclère, Clamart, Assistance Publique–Hôpitaux de Paris, Université Paris XI, Clamart, FranceJean-François Honart, Service de Chirurgie Digestive, Hôpital Antoine Béclère, Clamart, Assistance Publique–Hôpitaux de Paris, Université Paris XI, Clamart, FranceNicolas Creuze, Service de Radiologie et Imagerie, Hôpital Antoine Béclère, Clamart, Assistance Publique–Hôpitaux de Paris, Université Paris XI, Clamart, FranceClaude Smadja, Service de Chirurgie Digestive, Hôpital Antoine Béclère, Clamart, Assistance Publique–Hôpitaux de Paris, Université Paris XI, Clamart, France Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Can both residents and chief physicians assess surgical skills?

Abstract Background It is known that structured assessment of an operation can provide trainees with useful knowledge and potentially shorten their learning curve. However, methods for objective assessment have not been widely adopted into the clinical setting. This might be because of a lack of expertise using an assessment tool. The aim of this present study was to investigate if a validated laparoscopic procedure-specific assessment tool could be used by doctors with different levels of experience. Methods The study was conducted as an observer-blinded, prospective cohort study. Three video recordings of a right-side laparoscopic salpingectomy were distributed to ten chief physicians, eight residents (fourth year trainees), and two expert assessors (all in gynecology) in order to be assessed using a validated procedure-specific assessment tool. The three salpingectomies were selected because they easily showed the different operational levels: novice, intermediate, and expert. The two expert assessors, i.e., our gold standard, were familiar with the OSA-LS assessment scale, but the chief physicians and the residents were not. All participants were blinded to the fact that surgeons with different experience had performed the salpingectomies. Results No significant differences between the residents and chief physicians were observed in any of the three assessed operations: novice, p = 0.63; intermediate, p = 0.93; and expert, p = 0.93. The chief physicians and residents matched our gold standard in assessing the intermediate operation (p = 0.177), but not the novice operation (p = 0.005) or the expert operation (p = 0.001). Conclusions Residents and chief physicians generated similar performance scores when assessing operations using a laparoscopic procedure-specific assessment scale, and they could distinguish performance levels between the surgeons. They matched the assessment score of our expert on the intermediate operation. We conclude that a procedure-specific assessment scale can be used by both residents and chief physicians when giving formative feedback. Content Type Journal ArticlePages 1-7DOI 10.1007/s00464-012-2155-1Authors Jeanett Oestergaard, Department of Gynaecology and Obstetrics, The Juliane Marie Centre for Children, Women and Reproduction, Rigshospitalet, University Hospital of Copenhagen, Section 4074, Door 7248, Blegdamsvej 9, 2100 Copenhagen, DenmarkChristian Rifbjerg Larsen, Department of Gynaecology and Obstetrics, The Juliane Marie Centre for Children, Women and Reproduction, Rigshospitalet, University Hospital of Copenhagen, Section 4074, Door 7248, Blegdamsvej 9, 2100 Copenhagen, DenmarkMathilde Maagaard, Department of Gynaecology and Obstetrics, The Juliane Marie Centre for Children, Women and Reproduction, Rigshospitalet, University Hospital of Copenhagen, Section 4074, Door 7248, Blegdamsvej 9, 2100 Copenhagen, DenmarkTeodor Grantcharov, Department of Surgery, St. Michael’s Hospital, University of Toronto, Toronto, ON, CanadaBent Ottesen, Department of Gynaecology and Obstetrics, The Juliane Marie Centre for Children, Women and Reproduction, Rigshospitalet, University Hospital of Copenhagen, Section 4074, Door 7248, Blegdamsvej 9, 2100 Copenhagen, DenmarkJette Led Sorensen, Department of Gynaecology and Obstetrics, The Juliane Marie Centre for Children, Women and Reproduction, Rigshospitalet, University Hospital of Copenhagen, Section 4074, Door 7248, Blegdamsvej 9, 2100 Copenhagen, Denmark Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Surgical techniques of laparoscopic peritonectomy plus paraaortic lymph node dissection for the treatment of patients with positive lymph node metastasis and peritoneal seeding from rectosigmoid cancer

Abstract Background This multimedia article demonstrates the surgical techniques of laparoscopic pelvic peritonectomy plus aggressive lymph node dissection over the abdominal aorta and inferior vena cava for the treatment of rectosigmoid cancer. Methods The surgical procedures are detailed in the attached video. Results This study enrolled 17 patients. All the patients successfully underwent surgery by the described surgical technique and had a zero conversion rate, an acceptable operation time (median 284 min, range 240–360 min), and moderate blood loss (median 294 ml, range 140–740 ml) through five small wounds (four 1-cm wounds for 5–12-mm abdominal ports and one 5-cm wound for tumor retrieval). The number of dissected lymph nodes was adequate (median 44, range 32–68). The operative complications represented 29.4% of all cases including anastomotic leakage in two cases, wound infection in two cases, and urinary retention followed by repeated urinary tract infection in one case. The patients had quick functional recovery, as evaluated by the length of the postoperative ileus (median 72 h, range 36–144 h), the hospital stay (median 14 days, range 12–28 days), and the degree of postoperative pain (visual analog scale median 4.0, range 3–6). Conclusion Laparoscopic surgery can be performed safely for rectosigmoid cancer patients with pelvic peritoneal seeding and extensive abdominal paraaortic lymph node metastases requiring an extended abdomino-iliac lymphadenectomy plus curative pelvic peritonectomy. Content Type Journal ArticleCategory Dynamic ManuscriptPages 1-5DOI 10.1007/s00464-012-2163-1Authors Jin-Tung Liang, Division of Colorectal Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan, ROC Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

The effect of perioperative psychological intervention on fatigue after laparoscopic cholecystectomy: a randomized controlled trial

Abstract Background Fatigue is one of the main complaints after surgery and may last longer than physical symptoms. It prevents return to normal function and activity. Relaxation interventions, performed prior to abdominal surgery, have been shown to reduce pain, wound erythema, and systemic cortisol levels. However, there is a lack of data on the impact of this intervention on patient well-being, functional recovery, activities of daily living, and fatigue after discharge from hospital. Methods The study was a randomised single-blinded trial. Patients who were to undergo elective laparoscopic cholecystectomy for any indication between April 2008 and May 2010 were screened for inclusion. Those in the intervention group attended a standardised 45 min relaxation session with a health psychologist and were given relaxation exercise CDs to take home. The control group did not have the intervention. Patients were followed for 30 days. Fatigue was measured using the identity-consequence fatigue scale. Results Seventy-five patients were randomised. Fifteen patients were excluded after randomization for various reasons; hence, 60 patients were followed up and analysed. Both groups had similar fatigue at baseline. There was improved fatigue and consequence of fatigue on postoperative day 30 in the intervention group. There was no difference in fatigue at any other time point postoperatively. Conclusion This was the first interventional study targeting fatigue after laparoscopic cholecystectomy by using a brief psychological relaxation intervention. It has shown a reduction of fatigue and impact of fatigue at 30 days postoperatively in the intervention group. Content Type Journal ArticlePages 1-7DOI 10.1007/s00464-011-2101-7Authors Arman Kahokehr, Department of Surgery, South Auckland Clinical School, Middlemore Hospital, University of Auckland, P.O. Box 93311, Otahuhu, Auckland, New ZealandElizabeth Broadbent, Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New ZealandBenjamin R. L. Wheeler, Department of Surgery, South Auckland Clinical School, Middlemore Hospital, University of Auckland, P.O. Box 93311, Otahuhu, Auckland, New ZealandTarik Sammour, Department of Surgery, South Auckland Clinical School, Middlemore Hospital, University of Auckland, P.O. Box 93311, Otahuhu, Auckland, New ZealandAndrew G. Hill, Department of Surgery, South Auckland Clinical School, Middlemore Hospital, University of Auckland, P.O. Box 93311, Otahuhu, Auckland, New Zealand Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

A comparative study of endoscopic full-thickness and partial-thickness myotomy using submucosal endoscopy with mucosal safety flap (SEMF) technique

Abstract Background Esophageal myotomy using submucosal endoscopy with mucosal safety flap (SEMF) has been proposed as a new treatment of achalasia. In this technique, a partial-thickness myotomy (PTM) preserving the longitudinal outer esophageal muscular layer is advocated, which is different from the usual full-thickness myotomy (FTM) performed surgically. The aim of this study was to compare endoscopic FTM and PTM and analyze the outcomes of each method after a 4 week survival period. Methods Twenty-four pigs were randomly assigned into group A (FTM, 12 animals) and group B (PTM) to undergo endoscopic myotomy. Lower esophageal sphincter (LES) pressure was assessed using pull-through manometry. For statistical analysis we compared the average esophageal sphincter pressure values at baseline, after 2 weeks, and after 4 weeks between groups A and B. The P value was set as <0.05 for significance. Results Eighteen animals were included for statistical analysis. Mean (SD) LES pressures were similar between groups A and B (nine animals each) at baseline [group A = 23 (10.4) mmHg; group B = 20.7 (8.7) mmHg; P = 0.79], after 2 weeks [group A = 19 (7.7) mmHg; group B = 21.8 (8.4) mmHg; P = 0.79], and after 4 weeks [group A = 22.6 (10.2) mmHg; group B = 20.7 (9) mmHg; P = 0.82]. LES pressures were significantly reduced in three animals after 4 weeks: one animal (1%) in group A and two animals (2.5%) in group B. An extended myotomy (3 cm below the cardia) was achieved in three animals and was responsible for the significant drop in LES pressure seen in the two animals from group B. Conclusion Esophageal myotomy using SEMF is a feasible yet challenging procedure in pigs. Full-thickness myotomy does not seem to be superior to partial-thickness myotomy as demonstrated by pull-through manometry. Endoscopic esophageal myotomy results are greatly influenced by obtaining adequate myotomy extension into the gastric cardia. Content Type Journal ArticlePages 1-8DOI 10.1007/s00464-011-2105-3Authors Eduardo A. Bonin, Developmental Endoscopy Unit, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USAErica Moran, Department of Surgery, Mayo Clinic, Rochester, MN, USAJuliane Bingener, Department of Surgery, Mayo Clinic, Rochester, MN, USAMary Knipschield, Developmental Endoscopy Unit, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USAChristopher J. Gostout, Developmental Endoscopy Unit, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Minilaparoscopy-assisted natural orifice total colectomy: technical report of a minilaparoscopy-assisted transrectal resection

Abstract Background Experimental experience and the technological evolution of minimally invasive surgical devices have allowed initial reports describing the clinical applicability of natural orifice translumenal endoscopic surgery (NOTES). Colorectal resections are an interesting target for the NOTES platform. Theoretically, the transrectal approach could overcome the proposed limitations of transvaginal access, increasing NOTES clinical applicability. Hybrid procedures such as minilaparoscopy-assisted natural orifice surgery (MA-NOS) are the safe progression to pure NOTES. This report describes the first clinical case of a transrectal MA-NOS total colectomy. Methods The patient was a 36-year-old man with severe ulcerative colitis (UC) who experienced failure of immunosuppressive therapy. The standard steps of laparoscopic total colectomy were respected, with basic triangulation maintained throughout the case. A transrectal endoscopic device was used for optic assistance, colon dissection, ileum section, and specimen retrieval. Transrectal MA-NOS total colectomy was assisted by three laparoscopic ports: a 12-mm port used as the terminal ileostomy site, a 2-mm needle epigastric port, and a 5-mm umbilical port used as a drain site at the final intervention. No intraoperative complications occurred. Results The total operative time was 240 min. Oral intake was initiated on postoperative day 2. Because of UC rectal activity, a course with azathioprine was completed, and the patient was discharged receiving 1 g of rectal mesalazine for maintenance. The final pathology demonstrated pancolonic inflammatory bowel disease in the form of UC with severe activity. Conclusions Transrectal MA-NOS total colectomy was feasible and safe in the reported case. Improvement in NOTES instrumentation and selective clinical applications are mandatory before clinical trials. Content Type Journal ArticleCategory TechniquePages 1-6DOI 10.1007/s00464-011-2117-zAuthors Antonio M. Lacy, Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clínic, University of Barcelona, Villarroel 170, 08036 Barcelona, SpainDavid Saavedra-Perez, Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clínic, University of Barcelona, Villarroel 170, 08036 Barcelona, SpainRaquel Bravo, Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clínic, University of Barcelona, Villarroel 170, 08036 Barcelona, SpainCedric Adelsdorfer, Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clínic, University of Barcelona, Villarroel 170, 08036 Barcelona, SpainMontserrat Aceituno, Department of Gastroenterology, Institute of Digestive and Metabolic Diseases, Hospital Clínic, University of Barcelona, Villarroel 170, 08036 Barcelona, SpainJaume Balust, Department of Anesthesiology, Hospital Clínic, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Perioperative polyphenon E- and siliphos-inhibited colorectal tumor growth and metastases without impairment of gastric or abdominal wound healing in mouse models

Abstract Introduction Perioperative anticancer therapy that does not impair wound healing is needed to counter the persistent proangiogenic plasma compositional changes that occur after colorectal resection. Polyphenon E (PolyE), a green tea derivative (main component EGCG), and Siliphos (main component silibinin), from the milk thistle plant, both have antitumor effects. This study assessed the impact of PolyE/Siliphos (PES) on wound healing and the growth of CT-26 colon cancer in several murine models. Methods One wound healing and three tumor studies were performed. Tumor Study (TS)1 assessed the impact of PES on subcutaneous tumor growth, whereas TS2 assessed PES’s impact on subcutaneous growth when given pre- and post-CO2 pneumoperitoneum (pneumo), sham laparotomy, or anesthesia alone. TS3 determined the ability of PES to limit hepatic metastases (mets) after portal venous injection of tumor cells. In the final study, laparotomy and gastrotomy wound healing were assessed several ways. BALB/c mice were used for all studies. The drugs were given via drinking water (PolyE) and gavage (Siliphos), daily, for 7–9 days preprocedure and for 7–21 days postoperatively. Tumor mass, number/size of hepatic mets, and proliferation and apoptosis rates were assessed. The abdominal breaking strength and energy to failure were measured postmortem as was gastric bursting pressures. Results PES significantly inhibited subcutaneous growth in the nonoperative setting. PES also significantly decreased the number/size of liver mets when given perioperatively. Abdominal wound breaking strength, energy to wound failure, and collagen content were not altered by PES; gastrotomy bursting strength also was not affected by PES. Neither drug alone had a significant impact on tumor growth. Conclusions The PES combination inhibited subcutaneous and hepatic tumor growth yet did not impair wound healing. PES holds promise as a perioperative anticancer therapy. Content Type Journal ArticlePages 1-9DOI 10.1007/s00464-011-2114-2Authors Xiaohong Yan, Colon & Rectum Surgery, St. Luke’s Roosevelt Hospital Center, 432 West, 58th Street, Room 517, New York, NY 10019, USAThomas R. Gardner, Orthopaedic Surgery, Columbia University, 630 West, 168th Street, Black building 14th Floor, New York, NY 10032, USAMichael Grieco, Surgery, Saint Barnabas Medical Center, 94 Old Short Hills Road, Livingston, NJ 07039, USASonali A. C. Herath, Colon & Rectum Surgery, St. Luke’s Roosevelt Hospital Center, 432 West, 58th Street, Room 517, New York, NY 10019, USAJoon Ho Jang, Colon & Rectum Surgery, St. Luke’s Roosevelt Hospital Center, 432 West, 58th Street, Room 517, New York, NY 10019, USADaniel Kirchoff, Colon & Rectum Surgery, St. Luke’s Roosevelt Hospital Center, 432 West, 58th Street, Room 517, New York, NY 10019, USALinda Njoh, Colon & Rectum Surgery, St. Luke’s Roosevelt Hospital Center, 432 West, 58th Street, Room 517, New York, NY 10019, USAH. M. C. Shantha Kumara, Colon & Rectum Surgery, St. Luke’s Roosevelt Hospital Center, 432 West, 58th Street, Room 517, New York, NY 10019, USASamer Naffouje, Colon & Rectum Surgery, St. Luke’s Roosevelt Hospital Center, 432 West, 58th Street, Room 517, New York, NY 10019, USARichard L. Whelan, Colon & Rectum Surgery, St. Luke’s Roosevelt Hospital Center, 425 West, 59th Street, Suite 7B, New York, NY 10019, USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Elective laparoscopic versus open colectomy for diverticulosis: an analysis of ACS-NSQIP database

Abstract Background The benefits of laparoscopic (LC) versus open (OC) colectomy for symptomatic colonic diverticulosis as an elective operation remain unclear. Methods Using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) participant-user file, patients were identified who underwent elective colon resection for symptomatic colonic diverticulosis, between 2005 and 2008. Demographic, clinical, intraoperative variables, and 30-day morbidity and mortality were collected. Logistic regression analysis was performed to determine the association between the surgical approach (LC vs. OC) and risk-adjusted overall mortality, overall morbidity, serious morbidity, and wound complications. Results A total of 7,629 patients were identified who underwent colon resection for symptomatic diverticulosis. They were subdivided into two groups: OC (3,870 (50.7%)) and LC (3,759 (49.3%)). Patients who underwent OC were significantly older (59.0 vs. 55.7 years, P < 0.0001) with more comorbidities compared with those who underwent LC. After risk-adjusted analysis, it was noted that the patients treated with LC were significantly less likely to experience overall morbidity (11.9% vs. 23.2%), serious morbidity (4.6% vs. 10.9%), and wound complications (9.1% vs. 17.5%), but not mortality (0.3% vs. 0.8%). Operative duration was significantly longer with LC (176.64 vs. 166.70 min, P < 0.0001), but the length of stay was significantly shorter (4.77 vs. 7.68 days, P < 0.0001). Using logistic regression analysis, patients with history of peripheral vascular disease, percutaneous coronary interventions, current steroid use, and hypertension requiring medication were at an increased risk of morbidity and mortality at 30 days. Patients with history of chronic obstructive pulmonary disease and smoking experienced more wound complications at 30 days. Conclusions In the elective setting for symptomatic diverticulosis, LC seems to be associated with lower 30-day morbidity and complication rates compared with OC. Content Type Journal ArticlePages 1-6DOI 10.1007/s00464-011-2142-yAuthors Venkata R. Kakarla, Department of Surgery, New York Hospital Queens, 56-45 Main Street, Flushing, NY 11355, USASteven J. Nurkin, Department of Surgery, New York Hospital Queens, 56-45 Main Street, Flushing, NY 11355, USASaurab Sharma, Department of Surgery, New York Hospital Queens, 56-45 Main Street, Flushing, NY 11355, USADan E. Ruiz, Department of Surgery, New York Hospital Queens, 56-45 Main Street, Flushing, NY 11355, USAHoward Tiszenkel, Department of Surgery, New York Hospital Queens, 56-45 Main Street, Flushing, NY 11355, USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Laparoscopic ultrasound-assisted liposuction for lymph node dissection: a pilot study

Abstract Background Lymphadenectomy is a surgical technique for staging and treating cancer. Laparoscopic lymphadenectomy for obese patients is challenging. Laparoscopic ultrasound-assisted liposuction (UAL) has been successful in porcine models. The current study aimed to evaluate whether UAL facilitates pelvic laparoscopic lymphadenectomy in obese subjects. Methods The UAL technique was evaluated in two human cadavers and in six obese Ossabaw pigs. Both a standard and a prototype ultrasonic probe with a wider contact surface were tested. Pelvic lymphadenectomy comparing UAL with standard monopolar cautery was performed using obese Ossabaw pigs. The animals were survived for 2 weeks. Descriptive data regarding intra- and postoperative outcomes were recorded, including histologic analysis of dissected tissue after 2 weeks. Cytologic analysis of aspirated fluid coming from UAL also was recorded. Results The UAL procedure was safely performed for all the cadavers and animals. Lymph node exposure and clean exposure of surrounding structures were dramatic compared with monopolar assisted dissection. One animal was excluded from further analysis due to ultrasonic device malfunction (a broken footswitch cord). In general, UAL notably debulks adipose tissue with dramatic field exposure. Postoperative adhesions were present in all animals undergoing either monopolar or UAL dissection. Histology showed areas of foreign body reaction from mild to severe, with no predominance of either extreme seen with monopolar or UAL dissection. Cytologic analysis of collected pooled oil emulsion did not contain lymph node tissue. Conclusion The UAL approach permits pelvic lymphadenectomy in the obese animal and cadaver model, with excellent exposure of lymph nodes and surrounding pelvic anatomy. The use of a new ultrasonic prototype probe with a wider contact surface allowed dissection with less mechanical and thermal penetration of tissue. Further studies are needed to assess oncologic safety (cancer cell dissemination), postoperative healing, and adhesion formation. Content Type Journal ArticlePages 1-8DOI 10.1007/s00464-011-2136-9Authors Eduardo A. Bonin, Developmental Endoscopy Unit, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USAAndrea Mariani, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USAJames Swain, Department of Surgery, Mayo Clinic, Rochester, MN, USAJuliane Bingener, Department of Surgery, Mayo Clinic, Rochester, MN, USAKazuki Sumiyama, Department of Endoscopy, Jikei University School of Medicine, Tokyo, JapanMary Knipschield, Developmental Endoscopy Unit, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USAThomas J. Sebo, Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USAChristopher J. Gostout, Developmental Endoscopy Unit, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Indications, safety, and feasibility of conversion of failed bariatric surgery to Roux-en-Y gastric bypass: a retrospective comparative study with primary laparoscopic Roux-en-Y gastric bypass

Abstract Background Roux-en-Y gastric bypass (RYGB) is considered the “gold standard” revision procedure. The purpose of this study was to compare the surgical outcome of primary laparoscopic RYGB (pLRYGB) to revisional open or laparoscopic Roux-en-Y gastric bypass surgery (rRYGB). Methods A retrospective analysis of all patients who underwent pLRYGB or rRYGB from January 2003 to December 2009 has been performed. Demographics, indications for revision, and complications have been reviewed. The rRYGB and pLRYGB patients have been compared. Results Seventy-two patients underwent rRYGB, and 652 patients underwent pLRYGB. Mean follow-up was 35 and 45 months, respectively. Fifty-six rRYGB procedures were performed laparoscopically. The primary operations had consisted of laparoscopic gastric banding (n = 28), laparoscopic vertical banded gastroplasty (n = 19), laparoscopic sleeve gastrectomy (n = 6), laparoscopic RYGB (n = 3), and biliopancreatic diversion with duodenal switch (n = 16). Indications included weight regain (n = 29), malabsorption (n = 16), gastrogastric fistula (n = 5), band-associated problems (n = 3), and refractory stomal ulceration (n = 1). There was no significant difference in early or late postoperative complications when comparing rRYGB to pLRYGBP patients (11.1% vs. 5.52%, P = 0.069 and 19.4% vs. 24.2%, P = 0.465 respectively). Five rRYGB patients (7.04%) required reintervention (3 internal hernias, 1 ventral hernia, 1 laparoscopic exploration) compared with 101 pLRYGB patients (15.71%; P = 0.051). None of the patients died. Mean hospital stay was not significantly longer in the rRYGB group (5.38 vs. 4.95 days, P = 0.058). Conclusions In our series, hospital stay, morbidity, and mortality of rRYGB were not significantly higher compared with pLRYGB. Furthermore, we believe that this type of revisional bariatric surgery should be performed in high-volume bariatric centers. Content Type Journal ArticlePages 1-6DOI 10.1007/s00464-011-2140-0Authors Bert Deylgat, Department of Digestive Surgery, Groeninge Hospital, Kortrijk, BelgiumMathieu D’Hondt, Department of Digestive Surgery, Groeninge Hospital, Kortrijk, BelgiumHans Pottel, Interdisiciplinary Research Center, KULeuven Campus Kortrijk, Kennedylaan 4, 8500 Kortrijk, BelgiumFranky Vansteenkiste, Department of Digestive Surgery, Groeninge Hospital, Kortrijk, BelgiumFrank Van Rooy, Department of Digestive Surgery, Groeninge Hospital, Kortrijk, BelgiumDirk Devriendt, Department of Digestive Surgery, Groeninge Hospital, Kortrijk, Belgium Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Laparoscopic and open surgical treatment of left-sided pancreatic lesions: clinical outcomes and cost-effectiveness analysis

Abstract Background Previous studies comparing open distal pancreatectomy (ODP) and laparoscopic distal pancreatectomy (LDP) have found advantages related to minimal-access surgery. Few studies have compared direct and associated costs after LDP versus ODP. The purpose of the current study was to compare perioperative outcomes of patients undergoing LDP and ODP and to assess whether LDP was a cost-effective procedure compared with the traditional ODP. Methods A retrospective analysis of a prospectively maintained database of 52 distal pancreatic resections that were performed during a 10-year period was performed. Results Patients included in the analysis were 16 in the LDP group and 29 in the ODP. Tumors operated laparoscopically were smaller than those removed at open operation, but the length of pancreatic resection was similar. The mean operating time for LDP was longer than ODP (204 ± 31 vs. 160 ± 35; P < 0.0001), whereas blood loss was higher in the open group (365 ± 215 vs. 160 ± 185, P < 0.0001). Morbidity (25 vs. 41; P = 0.373) and pancreatic fistula (18 vs. 20%; P = 0.6) rates were similar after LDP and ODP, as was 30-day mortality (0 vs. 2%; P = 0.565). LDP had a shorter mean length of hospital stay than ODP (6.4 (2.3) vs. 8.8 (1.7) days; P < 0.0001). Operative cost for LDP was higher than ODP (€2889 vs. €1989; P < 0.0001). The entire cost of the associated hospital stay was higher in the ODP group (€8955 vs. €6714; P < 0.043). The total cost was comparable in LDP and ODP groups (€9603 vs. €10944; P = 0.204). Conclusions Laparoscopic distal pancreatectomy for left-sided lesions can be performed safely and effectively in selected patients, with reduced hospital stay and operative blood loss. Major complications, including pancreatic leak, were not reduced, whereas total cost was comparable between LDP and ODP. A selective use of LDP seems to be an effective and cost-efficient alternative to ODP. Content Type Journal ArticlePages 1-7DOI 10.1007/s00464-011-2141-zAuthors Paolo Limongelli, Department of General and Hepato-Pancreato-Biliary Surgery, S.M. Loreto Nuovo Hospital, Via A. Vespucci, 80142 Naples, ItalyAndrea Belli, Department of General and Hepato-Pancreato-Biliary Surgery, S.M. Loreto Nuovo Hospital, Via A. Vespucci, 80142 Naples, ItalyGianluca Russo, Department of General and Hepato-Pancreato-Biliary Surgery, S.M. Loreto Nuovo Hospital, Via A. Vespucci, 80142 Naples, ItalyLuigi Cioffi, Department of General and Hepato-Pancreato-Biliary Surgery, S.M. Loreto Nuovo Hospital, Via A. Vespucci, 80142 Naples, ItalyAlberto D’Agostino, Department of General and Hepato-Pancreato-Biliary Surgery, S.M. Loreto Nuovo Hospital, Via A. Vespucci, 80142 Naples, ItalyCorrado Fantini, Department of General and Hepato-Pancreato-Biliary Surgery, S.M. Loreto Nuovo Hospital, Via A. Vespucci, 80142 Naples, ItalyGiulio Belli, Department of General and Hepato-Pancreato-Biliary Surgery, S.M. Loreto Nuovo Hospital, Via A. Vespucci, 80142 Naples, Italy Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Collaborative eye tracking: a potential training tool in laparoscopic surgery

Abstract Background Eye-tracking technology has been shown to improve trainee performance in the aircraft industry, radiology, and surgery. The ability to track the point-of-regard of a supervisor and reflect this onto a subjects’ laparoscopic screen to aid instruction of a simulated task is attractive, in particular when considering the multilingual make up of modern surgical teams and the development of collaborative surgical techniques. We tried to develop a bespoke interface to project a supervisors’ point-of-regard onto a subjects’ laparoscopic screen and to investigate whether using the supervisor’s eye-gaze could be used as a tool to aid the identification of a target during a surgical-simulated task. Methods We developed software to project a supervisors’ point-of-regard onto a subjects’ screen whilst undertaking surgically related laparoscopic tasks. Twenty-eight subjects with varying levels of operative experience and proficiency in English undertook a series of surgically minded laparoscopic tasks. Subjects were instructed with verbal queues (V), a cursor reflecting supervisor’s eye-gaze (E), or both (VE). Performance metrics included time to complete tasks, eye-gaze latency, and number of errors. Results Completion times and number of errors were significantly reduced when eye-gaze instruction was employed (VE, E). In addition, the time taken for the subject to correctly focus on the target (latency) was significantly reduced. Conclusions We have successfully demonstrated the effectiveness of a novel framework to enable a supervisor eye-gaze to be projected onto a trainee’s laparoscopic screen. Furthermore, we have shown that utilizing eye-tracking technology to provide visual instruction improves completion times and reduces errors in a simulated environment. Although this technology requires significant development, the potential applications are wide-ranging. Content Type Journal ArticlePages 1-7DOI 10.1007/s00464-011-2143-xAuthors Andrew S. A. Chetwood, Hamlyn Centre for Robotic Surgery, Institute of Global Health Innovation, Imperial College, London, UKKa-Wai Kwok, Hamlyn Centre for Robotic Surgery, Institute of Global Health Innovation, Imperial College, London, UKLoi-Wah Sun, Hamlyn Centre for Robotic Surgery, Institute of Global Health Innovation, Imperial College, London, UKGeorge P. Mylonas, Hamlyn Centre for Robotic Surgery, Institute of Global Health Innovation, Imperial College, London, UKJames Clark, Hamlyn Centre for Robotic Surgery, Institute of Global Health Innovation, Imperial College, London, UKAra Darzi, Hamlyn Centre for Robotic Surgery, Institute of Global Health Innovation, Imperial College, London, UKGuang-Zhong Yang, Hamlyn Centre for Robotic Surgery, Institute of Global Health Innovation, Imperial College, London, UK Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Pylorus- and spleen-preserving total pancreatoduodenectomy with resection of both whole splenic vessels: feasibility and laparoscopic application to intraductal papillary mucin-producing tumors of the pancreas

Abstract Background Total pancreatectomy is recommended for intraductal papillary mucinous tumors with widespread involvement of the entire pancreas. Organ-preserving and minimally invasive surgery should be applied in benign and borderline pancreatic lesions. Methods Pylorus- and spleen-preserving total pancreatoduodenectomy (PpSpTPD) with segmental resection of both splenic vessels was attempted for five patients. The technique was based on the concepts of two surgical procedures: pylorus-preserving pancreatoduodenectomy and distal pancreatectomy with segmental resection of splenic vessels (“extended” Warshaw’s procedure). Results Three patients underwent laparoscopic-assisted PpSpTPD and two underwent open surgery. No mortality was noted. Short-term follow-up (median, 28 months) suggested that all patients tolerated the insulin therapy and showed relatively good nutritional status. Only minimal to moderate perigastric fundal varices were noted without gastrointestinal bleeding. Conclusions PpSpTPD with segmental resection of both splenic vessels is feasible and safe. Even a minimally invasive approach can be indicated in selected patients. Content Type Journal ArticleCategory Dynamic ManuscriptPages 1-6DOI 10.1007/s00464-011-2113-3Authors Sung Hoon Choi, Division of Hepatobiliary and Pancreas, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752 KoreaHo Kyoung Hwang, Division of Hepatobiliary and Pancreas, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752 KoreaChang Moo Kang, Division of Hepatobiliary and Pancreas, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752 KoreaChang Ik Yoon, Division of Hepatobiliary and Pancreas, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752 KoreaWoo Jung Lee, Division of Hepatobiliary and Pancreas, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752 Korea Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Laparoscopic colorectal resection for cancer: effects of conversion on long-term oncologic outcomes

Abstract Background The effects of conversion to open surgery during laparoscopic resection for colorectal cancer on long-term oncologic outcomes still are unclear. Methods All 450 laparoscopic colorectal resections for cancer performed at a single center between 1994 and 2008 and included in a prospectively maintained database were considered. Patients who required conversion to open surgery (CONV) were matched 1:2 with laparoscopically completed cases (LAP) and 1:5 with open surgery cases (OPEN) for age, American Society of Anesthesiologists (ASA) score, year of surgery, tumor location, and tumor stage. Fisher’s exact, chi-square, and Wilcoxon tests were used as appropriate. Kaplan–Meier curves were compared to analyze survival. Results In this study, 31 CONV cases were independently compared with 62 LAP and 155 OPEN cases. Compared with the LAP and OPEN patients, the CONV patients were characterized by a numerically higher rate of preoperative comorbidity (61.3% vs LAP, 51.6; P = 0.4 and OPEN, 48.4%; P = 0.2), male gender (77.4% vs LAP, 59.7%; P = 0.09 and OPEN, 58.1%; P = 0.05), and a significantly higher mean body mass index (29.6 vs LAP, 26.8; P = 0.012 and OPEN, 28.8; P = 0.3). The pathologic tumor stage, location, and chemotherapy and radiotherapy rates were comparable among the groups. After a median follow-up period of 4.1, 4.2, and 4.6 years, the 5-year disease-free survival rate was significantly lower for the CONV patients (40.2%) than for the LAP (70.7%, P = 0.01) or the OPEN (63.3%, P = 0.04) patients. However, the 5-year cancer-specific survival rates were similar among the CONV (94.4%), LAP (86.1%, P = 0.36), and OPEN (84.9%, P = 0.14) patients. Conclusions Conversion to open surgery does not affect oncologic outcomes, although CONV patients have increased comorbidity rates affecting long-term mortality. Content Type Journal ArticlePages 1-6DOI 10.1007/s00464-011-2137-8Authors Matteo Rottoli, Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USALuca Stocchi, Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USADan P. Geisler, Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USARavi P. Kiran, Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Pure natural orifice transluminal endoscopic surgery (NOTES) with ultrasonography-guided transgastric access and over-the-scope-clip closure: a porcine feasibility and survival study

Abstract Background Most natural orifice transluminal endoscopic surgery (NOTES) procedures to date rely on the hybrid technique with simultaneous laparoscopic access to protect against access-related complications and to achieve adequate triangulation for dissection. This is done at the cost of the potential benefits of this new minimally invasive technique. This study aimed to evaluate the feasibility and safety of a transgastric (TG) pure-NOTES procedure in a diagnostic setting. Methods A TG pure-NOTES procedure with endoscopic ultrasonograpy (EUS)-guided access and over-the-scope-clip (OTSC) closure was performed for 10 pigs in a survival and feasibility study. A full macroscopic necropsy with subsequent histologic evaluation was performed on postoperative day (POD) 14. The outcome parameters were uncomplicated follow-up assessment, survival, intraoperative complications, intraabdominal pathology, macroscopic full-thickness closure, and histology-proven full-thickness healing of the gastrotomy. Results An uncomplicated postoperative course was reported for 9 of the 10 pigs, and survival was reported for all 10 pigs. For all the pigs, EUS-guided access was performed successfully with a median duration of 25 min (range, 12–62 min) and without intraoperative complications or access-related lesions at necropsy. An OTSC closure was achieved with a median duration of 11 min (range, 3–28 min). The OTSC provided immediate closure, but according to the authors’ definition of a full-thickness healing evaluated by histologic examination, this was not achieved in any of the cases. Although all the animals survived until POD 14, intraabdominal chronic abscesses were present in 3 of the 10 pigs at necropsy. Conclusions The EUS-guided TG access proved to be feasible without access-related complications. Although OTSC provided an immediate closure, the histopathology raised concerns regarding the risk of perforation. Together with the high risk of intraabdominal infection, TG pure-NOTES is not yet ready for routine clinical practice. Content Type Journal ArticlePages 1-11DOI 10.1007/s00464-011-2135-xAuthors Anders Meller Donatsky, Department of Surgical Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, 2730 Herlev, DenmarkLuise Andersen, Department of Pathology, Herlev Hospital, University of Copenhagen, 2730 Herlev, DenmarkOle Lerberg Nielsen, Department of Veterinary Disease Biology, Faculty of Life Sciences, University of Copenhagen, Frederiksberg, DenmarkBarbara Juliane Holzknecht, Department of Clinical Microbiology, Herlev Hospital, University of Copenhagen, Herlev, DenmarkPeter Vilmann, Department of Surgical Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, 2730 Herlev, DenmarkSøren Meisner, Department of Surgical Gastroenterology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, DenmarkLars Nannestad Jørgensen, Department of Surgical Gastroenterology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, DenmarkJacob Rosenberg, Department of Surgical Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, 2730 Herlev, Denmark Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Hysteroscopic placement of tubal sterilization implants: virtual reality simulator training

Abstract Study objective To assess face and construct validity of a new virtual reality (VR) training simulator for hysteroscopic placement of tubal sterilization implants. Design Nonrandomized, controlled trial comparing responses and performance of novices and experts on the simulator. Design classification Canadian task force II-1. Setting Forty-six gynecologists were personally invited or recruited at the 33rd Conference of the French National College of Gynecologists and Obstetricians (CNGOF) from December 9 to 12, 2009, grouped as 20 experts and 26 novices. They all performed the defined sequence of virtual procedures on the simulator (case 1 for familiarization, case 4 for study assessment) and finally completed the study questionnaire. Measurements and main results Responses to realism, educational potential, and general opinion were excellent, proving face validity. Significant differences between novices and experts were assessed for 7 of the 15 metrics analyzed, proving construct validity. Conclusions We established face and construct validity for EssureSim™, an educational VR simulator for hysteroscopic tubal sterilization implant placement. The next steps are to investigate convergent and predictive validity to affirm the real capacity of transferring the skills learned on the training simulator to the patient in the operating room. Content Type Journal ArticlePages 1-11DOI 10.1007/s00464-011-2139-6Authors Pierre Panel, Service de Gynécologie-Obstétrique, Centre Hospitalier de Versailles, Hôpital André Mignot, 177 avenue de Versailles, 78157 Le Chesnay, FranceMichael Bajka, Clinic of Gynecology, Department of Obstetrics and Gynecology, University Hospital Zurich, 8091 Zurich, SwitzerlandArnaud Le Tohic, Service de Gynécologie-Obstétrique, Centre Hospitalier de Versailles, Hôpital André Mignot, 177 avenue de Versailles, 78157 Le Chesnay, FranceAlaa El Ghoneimi, Service de chirurgie viscérale et urologique, Centre Hospitalier Universitaire Robert Debré, 48 boulevard Sérurier, 75935 Paris Cedex 19, FranceCarmen Chis, Service de gynécologie-obstétrique, Centre Hospitalier Universitaire Bichat-Claude Bernard, 46, rue Henri-Huchard, 75877 Paris Cedex 18, FranceStéphane Cotin, INRIA, 40 Avenue Halley, 59650 Villeneuve-d’Ascq, France Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Management of pyloric stricture in children: endoscopic balloon dilatation and surgery

Abstract Background Surgical correction is the most preferred treatment modality in pyloric stricture (PS). Recently a few studies reported the experience of balloon dilation in children with PS. This study was designed to present our experiences of the management of the patients with PS with balloon dilation and corrective surgery. Methods The records of 14 patients who were treated with the diagnosis of PS between August 2003 and August 2011 were reviewed retrospectively. Results There were nine boys and five girls (mean age, 3.4 ± 1.7 years). The history of caustic ingestion was detected in eight patients; six of them were admitted on the day of ingestion. Two patients were admitted with nonbilious vomiting more than 2 weeks after ingestion. Four patients did not have a remarkable medical history, including caustic ingestion. They admitted with the complaint of nonbilious vomiting. PS was detected during endoscopy in two patients who had a diagnosis of peptic ulcer disease. PS was shown by barium meal study in all patients. Endoscopy was performed in all patients. Endoscopic balloon dilation was tried in 12 patients. Overall eight patients required surgical procedures for PS. The complaints were resolved by endoscopic balloon dilation of pylorus in the remaining six patients. Conclusions Although endoscopic balloon dilatation for benign PS in adults is a generally accepted method of treatment, there is less experience with endoscopic balloon dilatation for PS in children. PS due to benign disorders can be effectively and successfully treated through endoscopic balloon dilatation in suitable patients. In patients with successful pyloric balloon dilatation, surgery can be avoided. Content Type Journal ArticlePages 1-6DOI 10.1007/s00464-011-2124-0Authors Abdulkerim Temiz, Department of Pediatric Surgery, Baskent University Faculty of Medicine, Ankara, TurkeyPelin Oguzkurt, Department of Pediatric Surgery, Baskent University Faculty of Medicine, Ankara, TurkeySemire Serin Ezer, Department of Pediatric Surgery, Baskent University Faculty of Medicine, Ankara, TurkeyEmine Ince, Department of Pediatric Surgery, Baskent University Faculty of Medicine, Ankara, TurkeyHasan Ozkan Gezer, Department of Pediatric Surgery, Baskent University Faculty of Medicine, Ankara, TurkeyAkgun Hicsonmez, Department of Pediatric Surgery, Baskent University Faculty of Medicine, Ankara, Turkey Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

The revised ACGME laparoscopic operative requirements: how have they impacted resident education?

Abstract Background Laparoscopic surgery has been an essential component of surgical education for the last two decades. The Accreditation Council for Graduate Medical Education (ACGME) changed the requirements for laparoscopic cases beginning with graduates in 2008, and the Fundamentals of Laparoscopic Surgery program was introduced over a decade ago as a method of measuring competency with laparoscopic techniques. The purpose of this study was to determine what changes have been made to meet these requirements and how these changes have impacted general surgery residents in their preparation to perform both basic and complex laparoscopic procedures upon completion of residency. Methods A 23-question survey was distributed electronically to all fourth- and fifth-year residents of United States general surgery residency programs. Respondents were queried about demographics, perception of surgical education, and their level of preparedness to perform laparoscopic cases upon graduation. Results The survey was completed by a total of 321 residents (174 fourth-year and 147 fifth-year). Nineteen percent of respondents indicated that they anticipated problems meeting the new ACGME guidelines and 18.7% of all respondents indicated that changes had been made to their program to meet those new requirements. The majority of residents felt they had adequate laparoscopic training upon graduation, but there was a disparity between program types. Despite this finding, more than one-third of respondents believed that it would be necessary to seek additional laparoscopic training post-residency graduation. Conclusion Residency training programs have had to keep pace with evolving technology while preparing future surgeons to perform with confidence upon completion of residency training. The majority of residents feel their training has been adequate, but there are also a great number who believe they will need to continue their education in laparoscopic surgery to keep pace with this ever-evolving field. Content Type Journal ArticlePages 1-7DOI 10.1007/s00464-011-2103-5Authors Nicholas M. Brown, Department of Surgery, Room 3082, The University of Kansas School of Medicine-Wichita, 929 N. Saint Francis St, Wichita, KS 67214, USAStephen D. Helmer, Department of Surgery, Room 3082, The University of Kansas School of Medicine-Wichita, 929 N. Saint Francis St, Wichita, KS 67214, USAChristine L. Yates, Department of Surgery, Room 3082, The University of Kansas School of Medicine-Wichita, 929 N. Saint Francis St, Wichita, KS 67214, USAJacqueline S. Osland, Department of Surgery, Room 3082, The University of Kansas School of Medicine-Wichita, 929 N. Saint Francis St, Wichita, KS 67214, USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Assessment of joystick and wrist control in hand-held articulated laparoscopic prototypes

Abstract Background Various steerable instruments with flexible distal tip have been developed for laparoscopic surgery. The problem of steering such instruments, however, remains a challenge, because no study investigated which control method is the most suitable. This study was designed to examine whether thumb (joystick) or wrist control method is designated for prototypes of steerable instruments by means of motion analysis. Methods Five experts and 12 novices participated. Each participant performed a needle-driving task in three directions (right → left, up → down, and down → up) with two prototypes (wrist and thumb) and a conventional instrument. Novices performed the tasks in three sessions, whereas experts performed one session only. The order of performing the tasks was determined by Latin squares design. Assessment of performance was done by means of five motion analysis parameters, a newly developed matrix for assigning penalty points, and a questionnaire. Results The thumb-controlled prototype outperformed the wrist-controlled prototype. Comparison of the results obtained in each task showed that regarding penalty points, the up → down task was the most difficult to perform. Conclusions The thumb control is more suitable for steerable instruments than the wrist control. To avoid uncontrolled movements and difficulties with applying forces to the tissue while keeping the tip of the instrument at the constant angle, adding a “locking” feature is necessary. It is advisable not to perform the needle driving task in the up → down direction. Content Type Journal ArticlePages 1-9DOI 10.1007/s00464-011-2138-7Authors Linde M. Okken, Department of Gynecology, Leiden University Medical Center, Leiden, The NetherlandsMagdalena K. Chmarra, Department of BioMechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD Delft, The NetherlandsEllen Hiemstra, Department of Gynecology, Leiden University Medical Center, Leiden, The NetherlandsFrank Willem Jansen, Department of Gynecology, Leiden University Medical Center, Leiden, The NetherlandsJenny Dankelman, Department of BioMechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD Delft, The Netherlands Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Single-incision video-assisted thoracoscopic right pneumonectomy

Abstract Background The most common approach for Video-assisted thoracoscopic (VATS) lobectomy is undertaken with three or four incisions, including a utility incision of about 3–5 cm. However, major pulmonary resections are amenable by using only a single utility incision. This video shows the technical procedure of a right pneumonectomy by single-incision approach with no rib spreading. Methods A 52-year-old woman was proposed for single-incision VATS resection of a 5-cm right lower lobe adenocarcinoma. A 4-cm incision was made in the fifth intercostal space. We placed a 30-degree, high-definition, 10-mm thoracoscope in the posterior anterior part of the incision. Digital palpation confirmed that the tumor involved the fissure and the posterior portion of the upper lobe, which indicated the need for right pneumonectomy. We inserted the instruments through the anterior part of the utility incision to start the detachment of the right upper lobe by using a harmonic scalpel. The first step was dissecting the inferior pulmonary vein. The hilar structures were exposed by using harmonic scalpel and a long dissector (Fig. 1A). The upper and middle-lobe pulmonary veins were dissected and transected, allowing visualization of truncus anterior, which was then stapled. The inferior pulmonary vein and the intermediate truncus artery were divided, allowing optimal exposure to the main bronchus, which was stapled. The lung was removed in a protective bag by adding 1 cm to the incision, and a systematic lymph node dissection was performed. A single chest tube was placed in the posterior part of the utility incision. Results Total surgery time was 210 min. The chest tube was removed on postoperative day 2 (Fig. 1B), and the patient was discharged home on day 4 with no complications. Conclusions Single-port VATS pneumonectomy for selected cases is a feasible procedure, especially when performed from a center with previous experience in double-port VATS approach. Discussion Recent advances in surgical and video-assisted techniques have allowed minimally invasive pneumonectomy to be undertaken safely. VATS pneumonectomy is not a new procedure and in fact was initially reported 15 years ago and was felt to result in less postoperative pain and a faster return to normal activities [1]. Despite this, there have been only a few case reports or series published of VATS pneumonectomies [2, 3]. Content Type Journal ArticleCategory VideoPages 1-2DOI 10.1007/s00464-011-2127-xAuthors Diego Gonzalez-Rivas, Department of Thoracic Surgery, Coruña University Hospital, Xubias 84, 15006 Coruña, SpainMercedes de la Torre, Department of Thoracic Surgery, Coruña University Hospital, Xubias 84, 15006 Coruña, SpainRicardo Fernandez, Department of Thoracic Surgery, Coruña University Hospital, Xubias 84, 15006 Coruña, SpainJose Garcia, Department of Thoracic Surgery, Coruña University Hospital, Xubias 84, 15006 Coruña, Spain Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Laparoendoscopic single-site minor hepatectomy for liver tumors

Abstract Background Laparoscopic liver surgery is gaining increasing acceptance worldwide, but its frontiers are constantly challenged. Laparoendoscopic single-site surgery (LESS) has been performed for various organs, but the feasibility of LESS hepatectomies has yet to be explored fully. Methods From May 2010 to March 2011, seven patients underwent LESS minor hepatectomies. Patient demographic, operative, and clinical data were reviewed. Results Five left lateral sectionectomies, one segment 3, and one segment 5 resection were performed. The median operative time was 142 min (range, 104–171 min), and the median blood loss was 200 ml (range, 100–450 ml). The median hospital stay was 3 days (range, 1–11 days). For all the patients, the indications for surgery were suspected malignant tumors, and the surgical resection margins were clear for every patient. Conclusions Laparoendoscopic single-site minor hepatectomy is a novel modification to traditional laparoscopic surgery. The method is safe and feasible without any compromise to oncologic safety for selected patients with hepatocellular carcinoma (HCC) and colorectal liver metastases that are peripheral and smaller than 5 cm in size. Content Type Journal ArticleCategory TechniquePages 1-6DOI 10.1007/s00464-011-2128-9Authors Ek Khoon Tan, Department of Surgery, National University Hospital Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 8, Singapore, 119228 SingaporeVictor Tswen-Wen Lee, Department of Surgery, National University Hospital Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 8, Singapore, 119228 SingaporeStephen Kin Yong Chang, Department of Surgery, National University Hospital Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 8, Singapore, 119228 SingaporeIyer Shridhar Ganpathi, Department of Surgery, National University Hospital Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 8, Singapore, 119228 SingaporeKrishnakumar Madhavan, Department of Surgery, National University Hospital Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 8, Singapore, 119228 SingaporeDavide Lomanto, Department of Surgery, National University Hospital Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 8, Singapore, 119228 Singapore Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Laparoscopic restoration of intestinal continuity (the LapRICon procedure): a safe and feasible technique for restoration of transanal defecation

Abstract Background The restoration of intestinal continuity after open abdominal surgery can be technically challenging. The authors describe their experience with the laparoscopic approach to attempted reversal for patients with an exteriorized intestine. Methods A consecutive series of patients under the care of a single surgeon (D.B.) underwent laparoscopic restoration of intestinal continuity (LapRICon). All the patients first underwent exclusion of intraabdominal sepsis with computed tomography (CT) scanning and then preoperative localization of proximal and distal bowel ends via water-soluble contrast studies. Stomal sites were used for initial access, establishment of capnoperitoneum, and formation of anastomoses extracorporeally. All adhesiolysis and mobilization of bowel ends were performed intracorporeally. Pre-, intra-, and postoperative data were collected for all the patients. Return of intestinal function, overall hospital length of stay, and postoperative complications were collected. Nonparametric statistics were used to analyze the data. Results A total of 13 patients (6 women) were followed up for 9 months (interquartile range [IQR], 5–16 months). The median age of the patients was 39 years (IQR, 28–64 years). Nine patients were categorized as American Society of Anesthesiology (ASA) class 1. One patient was ASA 2, and the remaining patients were ASA 3. The median colorectal physiologic and operative severity scores for the enumeration of mortality and morbidity (CR-POSSUM) were 0.68 (IQR, 0.68–1.72). The intraoperative blood loss was minimal (median 30 ml; IQR, 20–125 ml). The median operative duration was 240 min (IQR, 180–240 min), and a median of 4 ports (IQR, 3–5 ports) were used. Enterocolonic anastomoses were fashioned in six patients, enterorectal anastomoses in two patients, and enteroentero anastomoses in three patients. A single patient had multiple anastomoses. The median time to return of intestinal function was 5 days (IQR, 3–13 days), and the overall hospital stay was 8 days (IQR, 5–24 days). Four complications (25%) (2 recurrent fistulas, 1 anastomotic leak, and 1 open conversion) occurred in this series of patients. Conclusions The LapRICon procedure is a feasible technique with acceptable morbidity. Several principles and techniques are described to aid the surgeon who wishes to embark on use of such a technique. Content Type Journal ArticlePages 1-6DOI 10.1007/s00464-011-2132-0Authors Michael Lim, John Goligher Department of Colorectal Surgery, St James’s Hospital, Beckett St, Leeds, LS9 7TF UKMohammed El-Haddad, John Goligher Department of Colorectal Surgery, St James’s Hospital, Beckett St, Leeds, LS9 7TF UKKiran Bonam, John Goligher Department of Colorectal Surgery, St James’s Hospital, Beckett St, Leeds, LS9 7TF UKDermot Burke, John Goligher Department of Colorectal Surgery, St James’s Hospital, Beckett St, Leeds, LS9 7TF UK Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Predictive factors of excess body weight loss 1 year after laparoscopic bariatric surgery

Abstract Background Bariatric surgery (BS) is widely accepted for the treatment of patients with morbid obesity (MO). We aimed to determine presurgical predictors of and surgical technique-related differences in excess weight loss (EWL) 1 year after BS. Methods This retrospective study included 407 subjects (F/M 3:1, median age = 44 years) who underwent laparoscopic Roux-en-Y gastric bypass (RYGB, n = 307) or sleeve gastrectomy (SG, n = 100) at our University Hospital and were evaluated 1 year after surgery. Results Baseline median (min–max) body mass index (BMI) was 47 kg/m2 (range = 36–71). BMI was higher in the SG than in the RYGB group (53 vs. 46 kg/m2, p < 0.0001). Simple correlation analysis showed negative associations between EWL and age, BMI, waist circumference (WC), fasting glucose, HbA1c, triglycerides (TG), blood pressure, and total cholesterol (all p < 0.01). EWL (mean ± SD) did not differ by gender (p = 0.2), was lower in diabetic than in nondiabetic subjects (71 ± 17% vs. 79 ± 17%, p < 0.0001), and higher in the RYGB vs. SG group (76 ± 18% vs. 68 ± 15%, p < 0.0001). However, SG vs. RYGB differences in EWL disappeared (p = 0.4) after taking into account baseline BMI. Multiple regression and logistic analysis showed that younger individuals with lower BMI but higher WC, and lower HbA1c and TG, had higher EWL and a higher rate of successful (EWL ≥ 60%) weight loss. Conclusions Our data indicate that some of the characteristics that would have subjects referred early for BS were associated with higher weight loss. Therefore, the timing of laparoscopic BS might be an important factor for MO individuals in which medical weight loss intervention has failed. Content Type Journal ArticlePages 1-7DOI 10.1007/s00464-011-2104-4Authors Emilio Ortega, Obesity Unit, Department of Diabetes and Endocrinology, IDIBAPS, ICMDM, Hospital Clínic i Universitari, C/Villarroel 170, 08036 Barcelona, SpainRosa Morínigo, Obesity Unit, Department of Diabetes and Endocrinology, IDIBAPS, ICMDM, Hospital Clínic i Universitari, C/Villarroel 170, 08036 Barcelona, SpainLilliam Flores, Obesity Unit, Department of Diabetes and Endocrinology, IDIBAPS, ICMDM, Hospital Clínic i Universitari, C/Villarroel 170, 08036 Barcelona, SpainVioleta Moize, Obesity Unit, Department of Diabetes and Endocrinology, IDIBAPS, ICMDM, Hospital Clínic i Universitari, C/Villarroel 170, 08036 Barcelona, SpainMartin Rios, Department of Statistics, Faculty of Biology, University of Barcelona, Avda. Diagonal 645, 08028 Barcelona, SpainAntonio M. Lacy, Obesity Unit, Department of Gastrointestinal Surgery, Centro de Investigaciones Biomédicas Esther Koplowitz, ICMDM, IDIBAPS, Hospital Clínic, University of Barcelona, Villarroel 170, 08036 Barcelona, SpainJosep Vidal, Obesity Unit, Department of Diabetes and Endocrinology, IDIBAPS, ICMDM, Hospital Clínic i Universitari, C/Villarroel 170, 08036 Barcelona, Spain Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Advanced stereoscopic projection technology significantly improves novice performance of minimally invasive surgical skills

Abstract Background Three-dimensional (3D) surgical imaging systems provide stereoscopic depth cues that are lost in conventional two-dimensional (2D) display systems. Recent improvements in stereoscopic projection technology using passive polarising displays may improve performance of minimally invasive surgical skills. This study aims to identify the effect of passive polarising stereoscopic displays on novice surgeon performance of minimally invasive surgical skills. Methods 20 novice surgeons performed 10 repetitions of 4 surgical skills tasks using a new passive polarising stereoscopic display under 3D and 2D conditions. The previously validated tasks used were rope pass, paper cut, needle capping and knot tying. Outcome measures included total error rate and time for task completion. Results Novice surgeons demonstrated a significant reduction in error rates for sequential repetitions of each task using the passive polarising stereoscopic display compared with the 2D display. Mean errors for the 3D versus the 2D mode were 2.0 versus 4.3 for rope pass (P ≤ 0.001), 0.8 versus 1.6 for paper cut (P = 0.001), 1.3 versus 4.2 for needle capping (P ≤ 0.001) and 2.8 versus 8.0 for knot tying (P ≤ 0.001). Novice surgeons demonstrated a significant improvement in mean time for completion for all four tasks when using the 3D system. Mean time (in seconds) for 3D versus 2D were 106.5 versus 134.4 for rope pass (P ≤ 0.001), 116.1 versus 176.3 for paper cut (P ≤ 0.001), 76.3 versus 141.6 for needle capping (P ≤ 0.001) and 153.4 versus 252.6 for knot tying (P ≤ 0.001). Conclusion Passive polarising stereoscopic displays significantly improve novice surgeon performance during acquisition of minimally invasive surgical skills. Content Type Journal ArticlePages 1-6DOI 10.1007/s00464-011-2080-8Authors R. Smith, Minimal Access Therapy Training Unit, Post Graduate Medical School, University of Surrey, Manor Park, Guildford, Surrey GU2 7WG, UKA. Day, Minimal Access Therapy Training Unit, Post Graduate Medical School, University of Surrey, Manor Park, Guildford, Surrey GU2 7WG, UKT. Rockall, Minimal Access Therapy Training Unit, Post Graduate Medical School, University of Surrey, Manor Park, Guildford, Surrey GU2 7WG, UKK. Ballard, Postgraduate Medical School, University of Surrey, Surrey, UKM. Bailey, Minimal Access Therapy Training Unit, Post Graduate Medical School, University of Surrey, Manor Park, Guildford, Surrey GU2 7WG, UKI. Jourdan, Minimal Access Therapy Training Unit, Post Graduate Medical School, University of Surrey, Manor Park, Guildford, Surrey GU2 7WG, UK Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Minimally invasive esophagectomy: current status and future direction

Minimally invasive esophagectomy: current status and future direction Content Type Journal ArticleCategory Letter to the EditorPages 1-1DOI 10.1007/s00464-011-2106-2Authors Kirsten Maas, Department of Surgery, VU Medical Center, Amsterdam, The NetherlandsSurya Biere, Department of Surgery, VU Medical Center, Amsterdam, The NetherlandsDonald Van der Peet, Department of Surgery, VU Medical Center, Amsterdam, The NetherlandsMiguel Cuesta, Department of Surgery, VU Medical Center, Amsterdam, The Netherlands Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Revisiting vascular patency after spleen-preserving laparoscopic distal pancreatectomy with conservation of splenic vessels

Abstract Background We evaluated vascular patency and potential changes in preserved spleens after laparoscopic spleen-preserving distal pancreatectomy (SPDP) with conservation of both splenic vessels. Methods We retrospectively analyzed the patency of conserved splenic vessels in patients who underwent laparoscopic or robotic splenic vessel-conserving SPDP from January 2006 to August 2010. The patency of the conserved splenic vessels was evaluated by abdominal computed tomography and classified into three grades according to the degree of severity. Results Among 30 patients with splenic vessel-conserving laparoscopic SPDP, 29 patients with complete follow-up data were included in this study. During the follow-up period (median: 13.2 months), grades 1 and 2 splenic arterial obliteration were observed in one patient each. A total of five patients (17.2%) showed grade 1 or 2 obliteration in conserved splenic veins. Most patients (82.8%) had patent conserved splenic vein. Four patients (13.8%) eventually developed collateral venous vessels around gastric fundus and reserved spleen, but no spleen infarction was found, and none presented clinical relevant symptoms, such as variceal bleeding. There was no statistical difference in vascular patency between the laparoscopic and robotic groups (P > 0.05). Conclusions Most patients showed intact vascular patency in conserved splenic vessels and no secondary changes in the preserved spleen after laparoscopic splenic vessel-conserving SPDP. Content Type Journal ArticlePages 1-7DOI 10.1007/s00464-011-2108-0Authors Ho Kyoung Hwang, Division of Hepatobiliary and Pancreas, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752 KoreaYoung Eun Chung, Department of Radiology, Yonsei University College of Medicine, Seoul, KoreaKyoung Ah Kim, Department of Radiology, Yonsei University College of Medicine, Seoul, KoreaChang Moo Kang, Division of Hepatobiliary and Pancreas, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752 KoreaWoo Jung Lee, Division of Hepatobiliary and Pancreas, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752 Korea Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Laparoscopic transabdominal preperitoneal inguinal hernia repair using needlescopic instruments: a 15-year, single-center experience in 317 patients

Abstract Background Laparoscopic inguinal hernia repair is associated with a decrease in postoperative pain, shortened hospital stay, earlier return to normal activity, and decrease in chronic pain. Moreover, laparoscopic surgery performed with needlescopic instruments has more advantages than conventional laparoscopic surgery. However, there are few reports of large-scale laparoscopic transabdominal preperitoneal inguinal hernia repair using needlescopic instruments (nTAPP). This report reviews our experiences with 352 nTAPP in 317 patients during the 15-year period from April 1996 to April 2011. Methods We performed nTAPP as the method of choice in 88.5% of all patients presenting with inguinal hernia. To perform the nTAPP, 3-mm instruments were used. A 5-mm laparoscope was inserted from the umbilicus, and surgical instruments were inserted through 5- and 3-mm trocars. After reduction of the hernia sac and dissection of the preperitoneal space, we placed polyester mesh or polypropylene soft mesh with staple fixation. The peritoneum was closed with 3–0 silk interrupted sutures. Results The mean operative time was 102.9 min for unilateral hernias and 155.8 min for bilateral hernias. There was no conversion to open repair. Forty-three patients (13.6%) used postoperative analgesics, and the mean frequency of use was 0.5 times. Regarding intraoperative complications, we observed one bladder injury, but no bowel injuries or major vessel injuries. Postoperative complications occurred in 32 patients (10.1%). One patient with a retained lipoma required reoperation. There was no incidence of chronic pain or mesh infection. The operative time for experienced surgeons (≥20 repairs) was significantly shorter than that of inexperienced surgeons (<20 repairs; P < 0.05). Conclusions The nTAPP was a safe and useful technique for inguinal hernia repair. Large prospective, randomized controlled trials will be required to establish the benefit of nTAPP. Content Type Journal ArticlePages 1-5DOI 10.1007/s00464-011-2122-2Authors Hidetoshi Wada, First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192 JapanTaizo Kimura, Department of Surgery, Fujinomiya City General Hospital, 3-1 Nishiki-cho, Fujinomiya, Shizuoka, 418-0076 JapanAkihiro Kawabe, Department of Surgery, Fujinomiya City General Hospital, 3-1 Nishiki-cho, Fujinomiya, Shizuoka, 418-0076 JapanMasanori Sato, First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192 JapanYuichirou Miyaki, First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192 JapanJunpei Tochikubo, First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192 JapanKouji Inamori, First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192 JapanNorihiko Shiiya, First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192 Japan Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Histology classification challenges for the endoscopic treatment of early gastric cancer

Histology classification challenges for the endoscopic treatment of early gastric cancer Content Type Journal ArticleCategory Letter to the EditorPages 1-2DOI 10.1007/s00464-011-2134-yAuthors Christof Hottenrott, Chirurgische Klinik, St. Elisabethenkrankenhaus, Ginnheimer Straße 3, 60487 Frankfurt, Germany Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Ex vivo pig training model for esophageal endosopic submucosal dissection (ESD) for endoscopists with experience in gastric ESD

Abstract Background Esophageal endoscopic submucosal dissection (ESD) has developed in recent years because of its high rate of en bloc resection. However, for many endoscopists, technical difficulty and risks of complications are great barriers to performing esophageal ESD. In this study, we developed an original training model for esophageal ESD using isolated pig esophagus and assessed this ex vivo model in endoscopists with experience in gastric ESD. Methods Three endoscopists without experience in esophageal ESD but with some experience in gastric ESD performed esophageal ESD of artificial lesions in 10 consecutive sessions using this ex vivo model. The en bloc resection rate, operation time, number of muscularis propria layer injuries, and presence of perforation were recorded. We evaluated the effectiveness of this training in the three endoscopists by comparing results from the first five sessions (former period) with those from the last five sessions (latter period). Results All three endoscopists achieved en bloc resections in all trials. In the former period, injury to the muscularis propria layer for each of the three endoscopists occurred a mean of 2.2 (1–3), 0.6 (0–1), and 3.2 (1–6) times, respectively. Perforation occurred in one session performed by one endoscopist. In the latter period, the mean number of muscularis propria layer injuries for each of the three endoscopists decreased to 0.2 (0–1), 0.2 (0–1), and 0.8 (0–2), respectively. The time of operation shortened from 35.0 (25–40), 36.4 (30–50), and 29.8 (23–43) min to 23.0 (16–31), 25.6 (23–28), and 29.2 (21–37) min, respectively. Conclusions This original ex vivo training model was helpful to endoscopists with experience in gastric ESD in acquiring the basic skills for performing esophageal ESD. Content Type Journal ArticlePages 1-8DOI 10.1007/s00464-011-2074-6Authors Shinwa Tanaka, Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, 7-5-1 Chu-o-ku, Kusunoki-Cho, Kobe, Hyogo, 650-0017 JapanYoshinori Morita, Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, 7-5-1 Chu-o-ku, Kusunoki-Cho, Kobe, Hyogo, 650-0017 JapanTsuyoshi Fujita, Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, 7-5-1 Chu-o-ku, Kusunoki-Cho, Kobe, Hyogo, 650-0017 JapanChika Wakahara, Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, 7-5-1 Chu-o-ku, Kusunoki-Cho, Kobe, Hyogo, 650-0017 JapanAtsuki Ikeda, Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, 7-5-1 Chu-o-ku, Kusunoki-Cho, Kobe, Hyogo, 650-0017 JapanTakashi Toyonaga, Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, 7-5-1 Chu-o-ku, Kusunoki-Cho, Kobe, Hyogo, 650-0017 JapanTakeshi Azuma, Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, 7-5-1 Chu-o-ku, Kusunoki-Cho, Kobe, Hyogo, 650-0017 Japan Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Impact of the English National Training Programme for laparoscopic colorectal surgery on training opportunities for senior colorectal trainees

Abstract Background There is growing concern that the recently introduced National Training Programme for consultants in laparoscopic colorectal surgery will have a negative impact on the training of senior colorectal trainees by minimizing the opportunities available. This study aimed to determine the impact that local implementation of the National Training Programme has had on the operating experience of senior colorectal trainees. Methods A prospective study was conducted at a designated national training center for laparoscopic colorectal surgery based in a large district general hospital in England, United Kingdom. All patients undergoing laparoscopic colorectal surgery in our unit between October 2006–September 2008 and October 2008–September 2010 were included in the study. The study variables included number and type of procedure, patient demographics, American Society of Anesthesiology grade, body mass index, conversion rates, previous abdominal surgery, and median operating time. The main outcome measure was the number of procedures performed by senior colorectal trainees before and after commencement of National Training Programme training in October 2008. Results A total of 746 laparoscopic colorectal resections were performed. Senior colorectal trainees performed 175 cases before commencement of the National Training Programme and 184 cases afterward. The difference was not significant. National Training Programme consultants performed 126 cases. Data were analyzed using Fisher’s exact test and the Mann–Whitney U test. The study groups were found to be well matched. The median operating time was significantly longer after commencement of the National Training Programme. The study was limited in terms of ability to extrapolate results to smaller units wishing to participate in training programs. Conclusion Implementation of the National Training Programme in our hospital has not had a negative impact on the training opportunities for senior colorectal trainees. However, any unit wishing to participate in the National Training Programme must ensure that an adequate operative caseload and extra resources for operative lists are available for training. Content Type Journal ArticlePages 1-7DOI 10.1007/s00464-011-2131-1Authors Anil K. Hemandas, Queen Alexandra Hospital, Southwick Hill Road, Portsmouth, PO6 3LY UKShady Zeidan, Queen Alexandra Hospital, Southwick Hill Road, Portsmouth, PO6 3LY UKKaren G. Flashman, Queen Alexandra Hospital, Southwick Hill Road, Portsmouth, PO6 3LY UKJim S. Khan, Queen Alexandra Hospital, Southwick Hill Road, Portsmouth, PO6 3LY UKAmjad Parvaiz, Queen Alexandra Hospital, Southwick Hill Road, Portsmouth, PO6 3LY UK Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Plasma soluble vascular adhesion molecule-1 levels are persistently elevated during the first month after colorectal cancer resection

Abstract Introduction Plasma from the second and third weeks after minimally invasive colorectal resection (MICR) has high levels of the proangiogenic proteins VEGF and angiopoietin 2 and also stimulates, in vitro, endothelial cell (EC) proliferation and migration, which are critical to wound and tumor angiogenesis. Soluble vascular cell adhesion molecule-1 (sVCAM-1) stimulates EC chemotaxis and angiogenesis. The impact of MICR on blood levels of sVCAM-1 is unknown. This study’s purpose was to determine plasma sVCAM-1 levels after MICR in colorectal cancer (CRC) patients. Methods Blood samples from 90 patients (26% rectal, 74% colon) were obtained preoperatively, on postoperative days (POD) 1 and 3, and at other points during the next 2 months. The late samples were bundled into 7-day time blocks. sVCAM-1 levels were determined in duplicate via ELISA and reported as ng/ml. Student’s t test was used for data analysis (significance, P < 0.008 after Bonferroni correction). Results The mean incision length was 7.3 ± 3.1 cm, and the conversion rate was 3%. Compared with preoperative (PreOp) levels (811.3 ± 233.2), the mean plasma sVCAM-1 level was significantly higher on POD 1 (905.7 ± 292.4, P < 0.001) and POD 3 (977.7 ± 271.8, P < 0.001). Levels remained significantly elevated for the POD 7–13, POD 14–20, POD 21–27, and POD 28–67 time blocks. Conclusions MICR for CRC is associated with a persistent increase in plasma sVCAM-1 levels during the first month. This sustained increase may promote angiogenesis and stimulate the growth of residual tumor cells early after surgery. Content Type Journal ArticlePages 1-6DOI 10.1007/s00464-011-2112-4Authors H. M. C. Shantha Kumara, Division of Colon and Rectal Surgery, Department of Surgery, St Luke-Roosevelt Hospital Center, Suite 7B, 425 West, 59th Street, New York, NY 10019, USASamer T. Tohme, Division of Colon and Rectal Surgery, Department of Surgery, St Luke-Roosevelt Hospital Center, Suite 7B, 425 West, 59th Street, New York, NY 10019, USASonali A. C. Herath, Division of Colon and Rectal Surgery, Department of Surgery, St Luke-Roosevelt Hospital Center, Suite 7B, 425 West, 59th Street, New York, NY 10019, USAXiaohong Yan, Division of Colon and Rectal Surgery, Department of Surgery, St Luke-Roosevelt Hospital Center, Suite 7B, 425 West, 59th Street, New York, NY 10019, USAAnthony J. Senagore, Spectrum Health, 25, Michigan Ave SE, Suite 4300, MC 038, Grand Rapids, MI 49503, USAAbu Nasar, Division of Colon and Rectal Surgery, Department of Surgery, St Luke-Roosevelt Hospital Center, Suite 7B, 425 West, 59th Street, New York, NY 10019, USAMatthew F. Kalady, Department of Colorectal Surgery, Digestive Disease Institute, 9500, Euclid Avenue, A 30, Cleveland, OH 44195, USARaymond Baxter, Division of Colon and Rectal Surgery, Department of Surgery, St Luke-Roosevelt Hospital Center, Suite 7B, 425 West, 59th Street, New York, NY 10019, USARichard L. Whelan, Division of Colon and Rectal Surgery, Department of Surgery, St Luke-Roosevelt Hospital Center, Suite 7B, 425 West, 59th Street, New York, NY 10019, USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Body temperature evaluation during induced pneumoperitoneum with CO2: an experimental study in pigs

Abstract Background In prolonged laparoscopic procedures, hypothermia is frequently observed. The possible influence of the vasodilating action of CO2, due to its increased levels in the blood during the laparoscopic procedures, has yet to be studied. The objective of this study was, therefore, to evaluate body temperature patterns in pigs subjected to pneumoperitoneum with CO2. Methods Thirty male pigs were allocated into three groups of ten animals each: group I, anesthetic procedure and abdominal puncture only; group II, the same as for group I and insufflation with CO2; and group III, the same as for group I and insufflation with medical grade compressed air. After anesthetic induction and surgical preparation, rectal and esophageal temperatures were measured every 10 min. Blood was collected during the experiment for the gasometric measurement of pCO2. Animals were insufflated with no gas loss and were kept anesthetized for 180 min. For statistical analysis, Friedman and Kruskal–Wallis tests were used at a level of significance of 95% (P < 0.05). Results Animals in groups I and II (P = 0.000) had a statistically significant drop in both esophageal and rectal temperatures during the experiment, but not animals in group III. However, when the groups were compared among themselves, no statistically significant differences were found at any of the times measured. A statistically significant drop in pCO2 levels was observed for groups I and III, but not for animals in groups II. Conclusions The use of CO2 did not significantly affect body temperature variation in pigs subjected to pneumoperitoneum. However, CO2 produced a temperature drop pattern different than that of compressed air, indicating that CO2 may lead to thermoregulatory changes and influence the peripheral temperature drop. Content Type Journal ArticlePages 1-6DOI 10.1007/s00464-011-2099-xAuthors Marcelo Rezende, Department of General Surgery, State University of Maringá (UEM), University Hospital, Av. Mandacarú, 1590, Maringá, PR 87083-240, BrazilOrlando Prado, Department of General Surgery, State University of Maringá (UEM), University Hospital, Av. Mandacarú, 1590, Maringá, PR 87083-240, BrazilCesar Bandeira, Department of General Surgery, State University of Maringá (UEM), University Hospital, Av. Mandacarú, 1590, Maringá, PR 87083-240, BrazilAndré Petri, Department of General Surgery, State University of Maringá (UEM), University Hospital, Av. Mandacarú, 1590, Maringá, PR 87083-240, BrazilEdna Montero, Surgery Department, Experimental Surgery Division, São Paulo Federal University (UNIFESP), São Paulo, Brazil Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Evaluation of a knitted polytetrafluoroethylene mesh placed intraperitoneally in a New Zealand white rabbit model

Abstract Background The intraperitoneal application of surgical mesh remains a controversial issue because of possible complications, especially adhesion and fistula formation. This study aimed to assess the potential of a knitted polytetrafluoroethylene (PTFE) mesh for intraabdominal implantation. Methods Twenty-eight 5 × 5 cm samples of knitted macroporous PTFE mesh and light-weight polypropylene mesh (LW-PP) were implanted intraperitoneally in 14 New Zealand white rabbits in a randomized manner and fixed using eight polypropylene stitches. After 90 days, the adhesion formation, adhesion score, shrinkage, strength of fixation to the abdominal wall, and histologic biocompatibility were assessed. Results No intraoperative or anesthesia-related complications or mesh infection were recorded. The average area covered by adhesions was 4.7 ± 7.2% for the PTFE and 36.4 ± 36.1% for the LW-PP. The median adhesion score was 0 for the PTFE and 8 for the LW-PP. Shrinkage was 36.9 ± 12.9% for the PTFE mesh and 12.6 ± 8.72% for the LW-PP. The mesh-to-abdominal wall fixation strength was almost the same for both materials (PTFE 3.6 ± 1.9 vs. LW-PP 3.6 ± 2.9). The inflammatory cell count was almost the same for the two groups, with no statistically significant difference. The width of the inner granuloma was equal (PTFE 10.5 ± 0.9 vs. LW-PP 11.1 ± 0.9). The outer granuloma was reduced significantly in the PTFE group (PTFE 23.0 ± 2.1 vs. LW-PP 33.6 ± 7.9). One of the animals in the PTFE group died on postoperative day 12 because of ileus. The reason was an adhesion of the small intestine to the polypropylene fixation stitch, which caused small intestine strangulation. Conclusions The knitted PTFE mesh induces fewer intraperitoneal adhesions of lower density than the light-weight polypropylene mesh. The strength of the knitted PTFE mesh fixation to the abdominal wall is comparable with that of the light-weight polypropylene mesh, but the shrinkage is greater. The biocompatibility of the knitted PTFE mesh is comparable with that of the light-weight polypropylene implant. Content Type Journal ArticlePages 1-8DOI 10.1007/s00464-011-2120-4Authors Tomáš Novotný, 2nd Department of Surgery, St. Anne’s University Hospital, Faculty of Medicine, Masaryk University, Pekařská 53, 656 91 Brno, Czech RepublicJiří Jeřábek, 1st Department of Surgery, St. Anne’s University Hospital, Faculty of Medicine, Masaryk University, Pekařská 53, 656 91 Brno, Czech RepublicKarel Veselý, Institute of Pathologic Anatomy, St. Anne’s University Hospital, Faculty of Medicine, Masaryk University, Pekařská 53, 656 91 Brno, Czech RepublicRobert Staffa, 2nd Department of Surgery, St. Anne’s University Hospital, Faculty of Medicine, Masaryk University, Pekařská 53, 656 91 Brno, Czech RepublicMartin Dvořák, 2nd Department of Surgery, St. Anne’s University Hospital, Faculty of Medicine, Masaryk University, Pekařská 53, 656 91 Brno, Czech RepublicJan Cagaš, 1st Department of Surgery, St. Anne’s University Hospital, Faculty of Medicine, Masaryk University, Pekařská 53, 656 91 Brno, Czech Republic Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Recurrent diarrhea in a 26-year-old man.

Recurrent diarrhea in a 26-year-old man. Allergy Asthma Proc. 2011 Nov;32(6):482-5 Authors: Baker TW, Stokes S, Clawson J, Garrett T, Sacha JJ, Gonzalez-Reyes E Abstract This is a case report of a 26-year-old healthy man with chronic diarrhea for 2 years. He was initially believed to have irritable bowel syndrome by his primary care physician after all stool studies yielded negative results. His symptoms persisted, which prompted a referral to a gastroenterology specialist. The patient's esophagogastroduodenoscopy revealed variable villous blunting and a paucity of CD 138 plasma cells, which helped reveal the final diagnosis. This cases illustrates a unique presentation of a common primary immunodeficiency that allergy/immunology specialists, along with primary care specialists, will likely encounter. PMID: 22221444 [PubMed - in process]

Characterization of patients with suspected seminal plasma hypersensitivity.

Characterization of patients with suspected seminal plasma hypersensitivity. Allergy Asthma Proc. 2011 Nov;32(6):467-71 Authors: Sublett JW, Bernstein JA Abstract The epidemiology of seminal plasma hypersensitivity (SPH) is unknown. Case reports and a previous survey have identified two distinct phenotypes: localized and systemic reactors. The objective of this study was to use an Internet-based questionnaire to characterize and examine the differences among a population of women with suspected SPH. A questionnaire designed to distinguish women with probable SPH was made available via the Internet. Systemic symptoms included generalized pruritus, urticaria, angioedema, wheezing, chest tightness, shortness of breath, dizziness, and loss of consciousness whereas localized symptoms included vaginal burning, pain, swelling, erythema, or blister formation. Respondents with localized or systemic symptoms and whose symptoms were prevented with the use of a condom were included in the analysis. Frequency and means were calculated and further analyzed using chi-square and t-test analyses. A total of 165 women with probable SPH, 79 with systemic symptoms and 86 with only localized symptoms, were included in the analysis. Systemic compared with localized respondents were significantly older (mean age, 29.2 years versus 26.4 years; p = 0.01), had longer duration of symptoms (mean, 58 months versus 40.8 months; p = 0.03), and more frequently reported a family history of atopy (65.8% versus 50%; p < 0.05). Interestingly, significantly more systemic compared with localized respondents reported dog sensitization (11.4% versus 2.3%; p = 0.02). Localized and systemic SPH are more common than previously realized and should be considered in the differential diagnosis of anaphylaxis, vulvovaginitis, and dyspareunia. Additional research investigating the epidemiology, immunopathogenesis, and treatment of this disorder is warranted. PMID: 22221443 [PubMed - in process]

Ultrashort-specific immunotherapy successfully treats seasonal allergic rhinoconjunctivitis to grass pollen.

Ultrashort-specific immunotherapy successfully treats seasonal allergic rhinoconjunctivitis to grass pollen. Allergy Asthma Proc. 2011 Nov;32(6):466 Authors: Dubuske LM, Frew AJ, Horak F, Keith PK, Corrigan CJ, Aberer W, Holdich T, von Weikersthal-Drachenberg KJ PMID: 22221442 [PubMed - in process]

Clinical and laboratory features of antihistamine-resistant chronic idiopathic urticaria.

Clinical and laboratory features of antihistamine-resistant chronic idiopathic urticaria. Allergy Asthma Proc. 2011 Nov;32(6):460-6 Authors: Magen E, Mishal J, Zeldin Y, Schlesinger M Abstract Chronic idiopathic (spontaneous) urticaria (CIU) is sometimes resistant to the conventional and high doses of antihistamines (AHs). This study compares the clinical and laboratory characteristics of AH responsive and AH-resistant CIU subjects. Clinical and laboratory data were retrospectively collected from 385 CIU patients. Urticaria activity score (UAS), concomitant angioedema, dermatographism, positive autologous serum skin (ASST), and laboratory data were collected. The control group consisted of 44 sex- and age-matched healthy individuals. Two hundred forty-five CIU patients controlled with AH medications were included in the CIU group. Forty-six patients failed to show clinical improvement during 8 weeks of treatment with fourfold AH doses and were included in the resistant CIU (R-CIU) group. The R-CIU group was characterized with a higher incidence (58.7%) of angioedema than the CIU group (28.5%; p < 0.001), more cases concomitant physical urticaria (23.9% in R-CIU versus 12.2% in CIU; p = 0.014), more positive ASST (73.9% in R-CIU versus 45.4% in CIU; p < 0.001), and higher baseline UAS (5.28 ± 0.81 in R-CIU versus 3.32 ± 1.25 in CIU; <0.001). R-CIU was characterized with more severe basopenia (0.04 ± 0.07 cell/mm(3) versus 0.16 ± 0.13 cell/mm(3); p < 0.001), higher mean platelet volume (10.87 ± 2.21 femtoliter (fl) versus 8.65 ± 1.74 fl; p < 0.001), higher levels of C-reactive protein (8.62 ± 3.91 mg/L versus 2.49 ± 1.34 mg/L; <0.001), and higher levels of serum C3 (1.66 ± 0.36 g/L versus 1.19 ± 0.35 g/L; p < 0.001. R-CIU is a clinically more severe disease with laboratory features of low-grade inflammation and platelet activation. PMID: 22221441 [PubMed - in process]

Onset and duration of attenuation of exercise-induced bronchoconstriction in children by single-dose of montelukast.

Onset and duration of attenuation of exercise-induced bronchoconstriction in children by single-dose of montelukast. Allergy Asthma Proc. 2011 Nov;32(6):453-9 Authors: Wasfi YS, Kemp JP, Villarán C, Massaad R, Xin W, Smugar SS, Knorr BA, Philip G Abstract Single-dose montelukast attenuates exercise-induced bronchoconstriction (EIB) in adults within 2 hours postdose and lasting through 24 hours. This study evaluated the onset and duration of EIB attenuation in children after a single dose of montelukast. A randomized, double-blind, placebo-controlled, two-period crossover study was performed. Patients (n = 66) aged 4-14 years, with preexercise forced expiratory volume in 1 second of (FEV(1)) ≥70% predicted and maximum percentage fall in FEV(1) of ≥20% at two screening exercise challenges were eligible. Patients were to receive single-dose montelukast (4 or 5 mg) or placebo before performing standardized exercise challenges at 2 and 24 hours postdose. A 3- to-7-day washout separated the two crossover periods. The primary end point was maximum percentage fall in FEV(1) after exercise challenge 2 hours postdose. Secondary end points included maximum percentage fall in FEV(1) after the 24-hour postdose challenge; each of the following at 2 and 24 hours postdose-maximum percentage fall in FEV(1) categorized as <10%, 10-20%, or >20%; area under the curve (AUC) during 60 minutes postchallenge; time to recovery of FEV(1) to within 5% of preexercise baseline; and need for rescue medication. The mean maximum percentage fall in FEV(1) after the 2-hour postdose exercise challenge was significantly attenuated after single-dose montelukast compared with placebo (15.35% versus 20.00%; p = 0.020). Montelukast was also significantly more effective than placebo for maximum percentage fall after the 24-hour challenge (12.92% versus 17.25%; p = 0.005), the categorized maximum percent fall in FEV(1) at 2 hours (p = 0.034), and AUC at 2 hours (p = 0.022) and 24 hours (p = 0.013). Single-dose montelukast provided rapid and sustained EIB attenuation in children. Clinicaltrials.gov identifier: NCT00534976. PMID: 22221440 [PubMed - in process]

Serum 25-hydroxyvitamin D is associated with enhanced pneumococcal antibody levels in individuals with asthma.

Serum 25-hydroxyvitamin D is associated with enhanced pneumococcal antibody levels in individuals with asthma. Allergy Asthma Proc. 2011 Nov;32(6):445-52 Authors: Lee J, Zhao H, Fenta Y, Kita H, Kumar R, Juhn YJ Abstract Recent studies suggest that vitamin D modulates innate immunity and reduces the risk of microbial infections. Little is known about the role of vitamin D in antipneumococcal immunity in individuals with asthma. We determined the correlation between serum 25-hydroxyvitamin D (25[OH]D) levels and pneumococcal antibody levels in individuals with asthma, atopic dermatitis, or allergic rhinitis, and atopic sensitization status. A cross-sectional study was conducted for 21 subjects with asthma and 23 subjects without asthma. Pearson's correlation coefficient between serum 25(OH)D concentrations and the number of positive serotype-specific antibody levels was calculated among individuals with and without asthma, atopic dermatitis, and/or allergic rhinitis and atopic sensitization status. The overall correlation between serum 25(OH)D concentrations and positive pneumococcal antibody levels in all subjects regardless of asthma was not significant (r = -0.14; p = 0.38). Stratified analysis results showed that there was a positive correlation between serum 25(OH)D concentrations and positive pneumococcal antibody levels in asthmatic patients (r = 0.45; p < 0.05) and an inverse correlation was observed in nonasthmatic patients (r = -0.53; p < 0.05). These trends were similar for subjects with and without atopic dermatitis and/or allergic rhinitis (r = 0.58 and p = 0.008 versus r = -0.63 and p = 0.001). Despite similar trends in the correlation between serum 25(OH)D and pneumococcal antibody concentrations among those with and without atopic sensitization status (r = 0.27 and p = 0.19 versus r = -0.41 and p = 0.08), they did not reach statistical significance. The 25(OH)D may enhance humoral immunity against Streptococcus pneumonia in subjects with atopic conditions but not without atopic conditions. Atopic conditions may have an important effect modifier in the relationship between serum 25(OH)D concentrations and immune function. PMID: 22221439 [PubMed - in process]

Vitamin D deficiency as a risk factor for allergic disorders and immune mechanisms.

Vitamin D deficiency as a risk factor for allergic disorders and immune mechanisms. Allergy Asthma Proc. 2011 Nov;32(6):438-44 Authors: Frieri M, Valluri A Abstract Vitamin D deficiency (VDD) has been reported in very high rates in the U.S. population. Deficiency has been implicated in various diseases such as diabetes, high blood pressure, cardiovascular disease, and many cancers. It has also been implicated in several allergic disorders and immune system dysregulation. The National Health and Nutrition examination survey (NHANES) in 2005-2006 was a cross-sectional survey performed in the noninstitutionalized population of the United States by the Center for Disease Control and Prevention and National Center for Health Statistics. It consists of an extensive interview performed at home and an examination performed at a mobile center. An allergy questionnaire was provided as interview data on self-reported allergic diseases including allergic rhinitis, allergies, and atopic dermatitis. Data were collected using the question, "Has the doctor or other health professional ever told you that you have allergies?" The laboratory parameter of vitamin D < 10 ng/mL was used to define severe VDD. The data were analyzed by logistic regression with SAS Version 9.1 (SAS Institute, Inc., Cary, NC) using the Procedure survey methods. Of 10,348 people who participated in the 2005-2006 NHANES survey, our final sample consisted of 4979 people in whom serum 25-hydroxyvitamin D levels were completed after excluding subjects <20 years of age and those with missing vitamin D values. The VDD was positively correlated with prevalence of allergies. After adjusting the model for age, gender, race, smoking, alcohol, and educational status, the odds ratio still remained significant. There was also a positive correlation with allergy subtypes such as prevalence of rashes, sneezing, and sinus infections with low vitamin D. VDD related to the immune system dysregulation has been extensively reviewed. PMID: 22221438 [PubMed - in process]

Impact of exercise-related respiratory symptoms in adults with asthma: Exercise-Induced Bronchospasm Landmark National Survey.

Impact of exercise-related respiratory symptoms in adults with asthma: Exercise-Induced Bronchospasm Landmark National Survey. Allergy Asthma Proc. 2011 Nov;32(6):431-7 Authors: Parsons JP, Craig TJ, Stoloff SW, Hayden ML, Ostrom NK, Eid NS, Colice GL Abstract An estimated 5-20% of the general population and up to 90% of people with asthma experience exercise-induced bronchospasm (EIB). The EIB Landmark Survey is the first comprehensive study on exercise-related respiratory symptoms in the United States. Two surveys were conducted: the first surveyed adults (≥18 years) in the general public and the second surveyed adults with asthma or taking medications for asthma in the prior year. Parameters assessed included exercise-related respiratory symptoms, activity levels, and short-acting beta-antagonist (SABA) use. In the general public survey (n = 1085), 8% were currently diagnosed with asthma. However, 29% reported experiencing one or more of six respiratory-related symptoms during or immediately after exercising. In the EIB in adult asthma survey (n = 1001), although >80% of adults experienced one or more of six exercise-related respiratory symptoms, only 30.6% reported a diagnosis of EIB. Almost one-half (45.6%) of adults with asthma reported that they avoid physical activities because of symptoms. Despite symptoms, only 22.2% of respondents took SABAs before exercise "always" or "most of the time"; 36.3% took rescue medications after or during exercise. Exercise-related respiratory symptoms limit physical activities and negatively impact daily lives. However, adults in the United States lack awareness of EIB. Although many subjects stated that their asthma symptoms limit their physical activity, few adhered to treatment guidelines by using SABAs appropriately before exercising. Findings from this survey support the need for better communication about the proper evaluation and management of EIB in the community and in asthma patients. PMID: 22221437 [PubMed - in process]

Exercise-induced bronchospasm in children with asthma in the United States: Results from the Exercise-Induced Bronchospasm Landmark Survey.

Exercise-induced bronchospasm in children with asthma in the United States: Results from the Exercise-Induced Bronchospasm Landmark Survey. Allergy Asthma Proc. 2011 Nov;32(6):425-30 Authors: Ostrom NK, Eid NS, Craig TJ, Colice GL, Hayden ML, Parsons JP, Stoloff SW Abstract Despite the availability of effective therapies, uncontrolled asthma remains a common problem. Previous large surveys suggest that exercise-related respiratory symptoms may be a significant element of uncontrolled asthma. The Exercise-Induced Bronchospasm (EIB) Landmark Survey is the first comprehensive, national survey evaluating EIB awareness and impact among the general public, asthma patients, and health care providers. This study was designed to evaluate the prevalence and impact of exercise-related respiratory symptoms in children (aged 4-17 years) with asthma. A national survey was conducted with parents of 516 children diagnosed with asthma or taking medications for asthma in the prior year. The majority of parents reported that their child experienced one or more exercise-related respiratory symptom and almost one-half (47.4%) experienced four or more symptoms. Most commonly reported symptoms were coughing, shortness of breath, and wheezing. Respondents reported that asthma limited their child's ability to participate either "a lot" or "some" in sports (30%), other outdoor activities (26.3%), and normal physical exertion (20.9%). Only 23.1% of children with exercise-related respiratory symptoms were reported to take short-acting beta-agonists such as albuterol "always" or "most of the time" before exercising. Exercise-related respiratory symptoms among pediatric asthma patients are common and substantially limit the ability of children to participate normally and perform optimally in physical activities. Such symptoms may reflect uncontrolled underlying asthma that should be evaluated and treated with appropriate controller medications. Despite the availability of preventative therapy, many children do not use short-acting bronchodilators before exercise as recommended in national guidelines. PMID: 22221436 [PubMed - in process]

Antidepressants in chronic idiopathic urticaria.

Antidepressants in chronic idiopathic urticaria. Allergy Asthma Proc. 2011 Nov;32(6):419-24 Authors: Yasharpour MR, Randhawa I Abstract Chronic idiopathic urticaria (CIU) is a common disease estimated to affect 0.1% of the population and can be very difficult to treat. Many psychotropic medications have been reported to be successful in treating refractory CIU. The purpose of this article was to discuss the pathophysiology of chronic urticaria and provide practicing allergists and dermatologists alternative treatment options in the management of refractory CIU, especially in those who have concurrent psychiatric comorbidity. A review was performed of pertinent literature pertaining to the pathophysiology of CIU and the many psychotropic medications reportedly successful in disease management. Although more research is needed, this article serves to broaden the mind of the physician treating CIU. PMID: 22221435 [PubMed - in process]

Safety update regarding intranasal corticosteroids for the treatment of allergic rhinitis.

Safety update regarding intranasal corticosteroids for the treatment of allergic rhinitis. Allergy Asthma Proc. 2011 Nov;32(6):413-8 Authors: Blaiss MS Abstract Intranasal corticosteroids (INSs) are the most efficacious medication for the treatment of allergic rhinitis. In 2006, the Joint Task Force of the American College of Allergy, Asthma, and Immunology, and the American Academy of Allergy, Asthma, and Immunology, published a white paper on the potential over-the-counter switch of INS (Bielory L, Blaiss M, Fineman SM, et al. Concerns about intranasal corticosteroids for over-the-counter use: Position statement of the Joint Task Force for the American Academy of Allergy, Asthma and Immunology and the American College of Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol 96:514-525, 2006). The concern of the paper was the safety of the use of these agents without oversight by a health care professional. The objective of this paper was to review published literature on the safety of INS since the publication of the task force white paper. Recent studies, which evaluated topical and systemic adverse events associated with ciclesonide (CIC), fluticasone furoate (FF), mometasone furoate (MF), triamcinolone acetonide, fluticasone propionate, budesonide, and beclomethasone dipropionate were summarized. In general, no significant topical or systemic complications were observed in these studies, although none were >1 year in duration. The newer formulations of topical corticosteroids for allergic rhinitis, such as CIC, FF, and MF, which have less systemic bioavailability, may be safer for long-term use. New studies continue to add to the reassurance of the safety of INSs in the treatment of allergic rhinitis but still do not answer the question if these agents are appropriate for long-term use without oversight by a health care professional. PMID: 22221434 [PubMed - in process]

Update on angioedema: Evaluation, diagnosis, and treatment.

Update on angioedema: Evaluation, diagnosis, and treatment. Allergy Asthma Proc. 2011 Nov;32(6):408-12 Authors: Bernstein JA Abstract Hereditary Angioedema (HAE) is a multisystem, autosomal dominant disease that affects ∼1:10,000 to 1:50,000 individuals in the United States. The disease has several clinical characteristics that distinguish it from other forms of angioedema. Recurrent swelling attacks involve the abdomen, face, extremities, genitalia, oropharynx, or larynx without urticaria. The swelling attacks are typically unilateral, nonpitting, nonpruritic, and, although uncomfortable, are often painless. Other forms of isolated angioedema such as acquired angioedema and angiotensin-converting enzyme-induced angioedema have similar characteristics of HAE. Therefore, evaluation of patients with recurrent angioedema should be directed at excluding these different forms of angioedema before a diagnosis of idiopathic angioedema is made. The objective of this article is to provide an overview of the differential diagnosis of angioedema that reflects the angioedema guidelines that are currently in development. PMID: 22221433 [PubMed - in process]

Hereditary angioedema: Classification, pathogenesis, and diagnosis.

Hereditary angioedema: Classification, pathogenesis, and diagnosis. Allergy Asthma Proc. 2011 Nov;32(6):403-7 Authors: Banerji A Abstract Hereditary angioedema (HAE) is a rare autosomal dominant genetic disorder associated with a deficiency in C1 inhibitor. More than 200 mutations in this gene, located on chromosome 11, have been identified. Although HAE is often inherited, 20-25% of cases are from new spontaneous mutations and they have no family history of swelling. Decreased C1 inhibitor activity leads to inappropriate activation of multiple pathways, including the complement and contact systems and the fibrinolysis and coagulation systems. Reduced C1 inhibitor activity results in increased activation of plasma kallikrein-kinin system proteases and increased bradykinin levels. Bradykinin is felt to be the main mediator of symptoms in HAE. Patients with HAE have recurrent episodes of swelling of the extremities, abdomen, face, and upper airway. Angioedema involving the gastrointestinal tract can lead to intestinal wall edema, which results in abdominal pain, nausea, vomiting, and diarrhea. Laryngeal swelling is life-threatening and may lead to asphyxia. Common triggers of an attack include trauma, stress, infection, menstruation, oral contraceptives, hormone replacement therapy, and angiotensin-converting enzyme inhibitors. Laboratory testing including C4, C1 inhibitor level, and function is needed to confirm or rule out the diagnosis of HAE. The treatment of HAE has improved significantly in recent years with the availability of several safe and effective therapies. Several consensus guidelines have been created to further assist in the management of HAE patients. This review will provide an update on the classification, pathophysiology, clinical presentation, and diagnosis of HAE. PMID: 22221432 [PubMed - in process]