Endoscopic RSS : Gourt

Endoscopic closure of gastric access in perspective NOTES: an update on techniques and technologies

Abstract Background Natural orifice transluminal endoscopic surgery (NOTES) is currently of major research interest as it may offer significant clinical potential for endoscopic procedures in the future. Nevertheless, many issues are still unresolved. The aim of this study is a systematic review of the literature to evaluate techniques and technologies to address the issue of achieving a secure gastric wall defect closure. Methods Studies were identified by searching MEDLINE, EMBASE, Current Contents, Cochrane Library, Entrez PubMed and Clinical Trials Database until December 2008. We divided the different technologies into four groups: clipping, stitching, stapling and occluding systems. We analysed the different technologies in terms of (1) simplicity of manoeuvring for port closure, (2) security of introduction, (3) permanent implantation of the device into the organ, (4) effectiveness of port closure and (5) availability on the market. Results Twenty-eight published studies were identified, while nine clinical trials are ongoing. Among proposed technologies, staplers and occluders have greater effectiveness but lack of security, and in the case of staplers also lack of simplicity of use. None of the stitching technologies can really be considered effective except for the Flexible Endostitch, which on the other side is difficult to handle in the current fashion. Standard clips, although easy to handle, have never been proved to be reliable, as only mucosal layer closure has been demonstrated to date. On the other side, the over-the-scope clip is likely to be effective, secure to introduce and simple to handle within the hollow organ. Conclusions Achieving reliable closure of the hollow organ defect represents the first step towards implementation of clinical NOTES. The current data do not yet allow definitive and clear advantages or disadvantages of the different options to be determined. The introduction of the EURONOTES registry will help us to understand in which direction to proceed. Content Type Journal ArticleCategory ReviewDOI 10.1007/s00464-009-0593-1Authors Alberto Arezzo, University of Turin Centre for Minimally Invasive Surgery Corso Dogliotti 14 10126 Turin ItalyMario Morino, University of Turin Centre for Minimally Invasive Surgery Corso Dogliotti 14 10126 Turin Italy Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Partial amniotic carbon dioxide insufflation (PACI) during minimally invasive fetoscopic surgery: early clinical experience in humans

Abstract Background The technical performance of minimally invasive fetoscopic surgery may be severely hindered by poor visualization of intra-amniotic contents. Partial amniotic carbon dioxide insufflation (PACI) allows the visual limitations of operating within the fluid environment to be overcome. Patients and methods When amniotic fluid exchange failed to improve fetoscopic visualization, PACI was attempted during 37 fetoscopic procedures between 17 + 5 and 33 + 2 weeks of gestation. PACI was attempted with filtered carbon dioxide using a commercially available insufflator via one to three trocars that were percutaneously introduced into the amniotic cavity. The maximum pressure during PACI was limited by the maximum insufflation pressure (30 mmHg) generated by the insufflator. Improvement of fetoscopic visualization as well as technical, maternal, and fetal safety aspects surrounding PACI were analyzed. Results PACI could successfully be instituted in 36 of the 37 procedures. In one case, when in the presence of increased uterine tone the opening pressure exceeded the maximum insufflation pressure of the insufflator, the strategy was abandoned. In all cases where PACI could be instituted successfully, the approach offered far superior visualization of the fetoscopic procedure than would have been possible within amniotic fluid. Acute or chronic maternal or fetal complications were observed in only one case (intraoperative membrane rupture). Conclusion PACI greatly improves fetal visualization during fetoscopic interventions when fetoscopy within fluid meets with difficulties. Continued assessment of its benefits, risks, and safety margins at specialist centers is required. Content Type Journal ArticleDOI 10.1007/s00464-009-0579-zAuthors Thomas Kohl, University of Bonn Medical School German Center for Fetal Surgery & Minimally-Invasive Therapy (DZFT)—Department of Obstetrics & Prenatal Medicine 53105 Bonn GermanyKristina Tchatcheva, University of Bonn Medical School German Center for Fetal Surgery & Minimally-Invasive Therapy (DZFT)—Department of Obstetrics & Prenatal Medicine 53105 Bonn GermanyJulia Weinbach, University of Bonn Medical School German Center for Fetal Surgery & Minimally-Invasive Therapy (DZFT)—Department of Obstetrics & Prenatal Medicine 53105 Bonn GermanyRudolf Hering, Bonn University Hospital Department of Anesthesiology and Intensive Care Medicine Bonn GermanyPeter Kozlowski, University of Bonn Medical School German Center for Fetal Surgery & Minimally-Invasive Therapy (DZFT)—Department of Obstetrics & Prenatal Medicine 53105 Bonn GermanyRüdiger Stressig, University of Bonn Medical School German Center for Fetal Surgery & Minimally-Invasive Therapy (DZFT)—Department of Obstetrics & Prenatal Medicine 53105 Bonn GermanyUlrich Gembruch, University of Bonn Medical School German Center for Fetal Surgery & Minimally-Invasive Therapy (DZFT)—Department of Obstetrics & Prenatal Medicine 53105 Bonn Germany Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Telesimulation: an effective method for teaching the fundamentals of laparoscopic surgery in resource-restricted countries

Abstract Background Several challenges exist with laparoscopic skills training in resource-restricted countries, including long travel distances required by mentors for onsite teaching. Telesimulation (TS) is a novel concept that uses the internet to link simulators between an instructor and a trainee in different locations. The purpose of this study was to determine the effectiveness of telesimulation for teaching the Fundamentals of Laparoscopic Surgery (FLS) to surgeons in Botswana, Africa. Methods A total of 16 surgeons from two centers in Botswana participated in this 8-week study. FLS TS was set up using two simulators, computers, webcams, and Skype™ software for eight surgeons in the TS group. A standard FLS simulator was available for the eight surgeons in the self-practice (SP) group. Participants in the TS group had one remote training session per week with an FLS proctor at the University of Toronto who provided feedback and demonstrated proper technique. Participants in the SP group had access to the FLS DVD and were instructed to train on FLS at least once per week. FLS post-test scores were obtained in Botswana by a trained FLS proctor at the conclusion of the study. Results Participants in the TS group had significantly higher post-test FLS scores than those in the SP group (440 ± 56 vs. 272 ± 95, p = 0.001). All trainees in the TS group achieved an FLS simulator certification passing score, whereas only 38% in the SP group did so (p = 0.03). Conclusion Remote telesimulation is an effective method for teaching the Fundamentals of Laparoscopic Surgery in Africa, achieving a 100% FLS skills pass rate. This training platform provides a cost-effective method of teaching in resource-restricted countries and could be used to teach laparoscopic skills anywhere in the world with internet access. Content Type Journal ArticleDOI 10.1007/s00464-009-0572-6Authors Allan Okrainec, Toronto Western Hospital – University Health Network Department of Surgery 8th Floor, Main Pavilion, Room 325 Toronto ON M5T 2S8 CanadaOscar Henao, University of Toronto Department of Surgery Toronto ON M5S 1A1 CanadaGeorges Azzie, University of Toronto Department of Surgery Toronto ON M5S 1A1 Canada Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

News and notices

News and notices Content Type Journal ArticleCategory News and noticesDOI 10.1007/s00464-009-0603-3 Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Combined percutaneous–endoscopic stenting of malignant biliary obstruction: results from 106 consecutive procedures and identification of factors associated with adverse outcome

Abstract Background In patients in whom attempted endoscopic stenting of malignant biliary obstruction fails, combined percutaneous–endoscopic stenting and percutaneous stenting using expandable metallic endoprostheses offer alternative approaches to biliary drainage. Despite the popularity of the percutaneous route, there is no available evidence to support its superiority over combined stenting in this patient group. The objective of this study was to present the short- and long-term results of a large series of combined percutaneous–endoscopic stenting procedures and identify factors associated with adverse outcome. Methods Data were retrospectively collected on patients undergoing combined percutaneous–endoscopic biliary stenting for malignant biliary obstruction between January 2002 and December 2006. Short- and long-term outcomes were recorded, and pre-procedure variables correlated with adverse outcome. Results Combined biliary stenting was technically successful in 102 (96.2%) of 106 patients. Procedure-associated mortality rate was 0%. In-hospital morbidity and mortality rates were 24.5% and 16.7%, respectively, with the majority of deaths resulting from biliary sepsis. Median survival was 100 days, with a 13.7% stent occlusion rate. On multivariable analysis, baseline American Society of Anaesthesiologists (ASA) grade, decreasing serum albumin and increasing leucocyte count were independently associated with in-hospital mortality following combined stenting. Conclusion Combined biliary stenting is associated with short- and long-term outcomes equal to those reported in recent series of percutaneous transhepatic stenting. Randomised control trials, including cost-effectiveness analyses, are required to further compare these techniques. Outcomes following combined stenting may be further improved by early recognition and treatment of sepsis and scrupulous management of co-morbid disease. Content Type Journal ArticleDOI 10.1007/s00464-009-0586-0Authors C. P. Neal, Leicester General Hospital Department of Hepatobiliary and Pancreatic Surgery Gwendolen Road Leicester LE5 4PW UKS. C. Thomasset, Leicester General Hospital Department of Hepatobiliary and Pancreatic Surgery Gwendolen Road Leicester LE5 4PW UKD. Bools, Leicester General Hospital Department of Hepatobiliary and Pancreatic Surgery Gwendolen Road Leicester LE5 4PW UKC. D. Sutton, Leicester General Hospital Department of Hepatobiliary and Pancreatic Surgery Gwendolen Road Leicester LE5 4PW UKG. Garcea, Leicester General Hospital Department of Hepatobiliary and Pancreatic Surgery Gwendolen Road Leicester LE5 4PW UKC. D. Mann, Leicester General Hospital Department of Hepatobiliary and Pancreatic Surgery Gwendolen Road Leicester LE5 4PW UKY. Rees, Leicester General Hospital Department of Hepatobiliary and Pancreatic Surgery Gwendolen Road Leicester LE5 4PW UKC. Newland, Leicester General Hospital Department of Hepatobiliary and Pancreatic Surgery Gwendolen Road Leicester LE5 4PW UKR. J. Robinson, Leicester General Hospital Department of Hepatobiliary and Pancreatic Surgery Gwendolen Road Leicester LE5 4PW UKA. R. Dennison, Leicester General Hospital Department of Hepatobiliary and Pancreatic Surgery Gwendolen Road Leicester LE5 4PW UKD. P. Berry, Leicester General Hospital Department of Hepatobiliary and Pancreatic Surgery Gwendolen Road Leicester LE5 4PW UK Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Treatment of rectal adenomas by transanal endoscopic microsurgery: 15 years’ experience

Abstract Background The authors present their experience with rectal adenomas managed by transanal endoscopic microsurgery (TEM). The goals of this study were to examine our institution’s experience by evaluating surgical morbidity, mortality, and local recurrence rate. Methods This retrospective study investigated 402 patients who underwent TEM a for preoperative diagnosis of adenoma from January 1993 to October 2008. The mean age was 65 years (range = 22–92 years). All patients were regularly followed up to determine treatment efficacy in terms of local recurrence rate. Results No 30-day perioperative mortality occurred. No conversion to laparoscopic or open procedures was reported. Minor complications occurred in 28 (7%) patients, whereas major complications were found only in 2 (0.5%) patients. Definitive histology confirmed adenomas in 366 cases (91%). At a mean follow-up of 84 months (range = 1–190 months), 16 (4%) adenomas recurred and were successfully retreated by TEM [14 cases (87.5%)] and by conventional surgery [2 patients (12.5%)]. No further recurrences were observed at subsequent follow-up. Conclusion The findings warrant the conclusion that TEM is a safe, effective treatment for rectal adenomas where endoscopic removal is not applicable and has low morbidity and no mortality. Content Type Journal ArticleDOI 10.1007/s00464-009-0585-1Authors Mario Guerrieri, Università Politecnica delle Marche Clinica di Chirurgia Generale e Metodologia Chirurgica, Azienda Ospedaliera Umberto I 22, P. Roma 60126 Ancona ItalyMaddalena Baldarelli, Università Politecnica delle Marche Clinica di Chirurgia Generale e Metodologia Chirurgica, Azienda Ospedaliera Umberto I 22, P. Roma 60126 Ancona ItalyAngelo de Sanctis, Università Politecnica delle Marche Clinica di Chirurgia Generale e Metodologia Chirurgica, Azienda Ospedaliera Umberto I 22, P. Roma 60126 Ancona ItalyRoberto Campagnacci, Università Politecnica delle Marche Clinica di Chirurgia Generale e Metodologia Chirurgica, Azienda Ospedaliera Umberto I 22, P. Roma 60126 Ancona ItalyMassimiliano Rimini, Università Politecnica delle Marche Clinica di Chirurgia Generale e Metodologia Chirurgica, Azienda Ospedaliera Umberto I 22, P. Roma 60126 Ancona ItalyEmanuele Lezoche, Sapienza University of Rome Department of General Surgery and Organ Transplantion Piazzole Aldo Moro 5 00185 Rome Italy Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Hospital cost categories of one-stage versus two-stage management of common bile duct stones

Abstract Background In the era of cost-conscious healthcare, hospitals are focusing on costs. Analysis of hospital costs per cost category may provide indications for potential cost-saving measures in the management of common bile duct stones (CBDS) with gallbladder in situ. Methods Between October 2005 and September 2006, 53 consecutive patients suffering from CBDS underwent either a one-stage procedure [laparoscopic common bile duct exploration (LCBDE) with stone clearance and cholecystectomy (LCCE)] or a two-stage procedure [endoscopic retrograde cholangiopancreatography with sphincterotomy and stone clearance (ERCP/ERS) followed by LCCE]. Costs were defined in different cost categories for each activity centre and were linked to the individual patient via the “bill of activities”. Only patients (n = 38) with an uneventful post-procedural course and with available cost data were considered for cost analysis. Total length of hospital stay (LOS) was 2 (0–6) days after one-stage and 8 (3–18) days after two-stage procedure (p < 0.0001). Results Costs per patient were significantly (p < 0.0001) less after one-stage versus two-stage management, i.e. total hospital costs (€2,636 versus €4,608), hospitalisation costs (€701 versus €2,190), consumables/pharmacy (€645 versus €1,476) and para-medical personnel (€1,035 versus €1,860; p = 0.0002). Operation room (OR) costs were comparable for one-stage and two-stage management (€1,278 versus €1,232; p = 0.280). Total hospital costs during ERCP were €2,648 (€729–4,544), during LCCE without LCBDE were €2,101 (€1,033–4,269), and during LCCE with LCBDE were €2,636 (€1,176–4,235). Conclusion In the management of patients with CBDS and gallbladder in situ a one-stage procedure is associated with significantly less costs as compared with a two-stage procedure. From the economical point of view these patients should preferably be treated via a one-stage procedure as long as safety and efficacy of this approach are provided. Content Type Journal ArticleDOI 10.1007/s00464-009-0594-0Authors B. Topal, University Hospital Leuven Department of Abdominal Surgery Leuven BelgiumK. Vromman, University Hospital Leuven Department of Management Information & Reporting Leuven BelgiumR. Aerts, University Hospital Leuven Department of Abdominal Surgery Leuven BelgiumC. Verslype, University Hospital Leuven Department of Internal Medicine Leuven BelgiumW. Van Steenbergen, University Hospital Leuven Department of Internal Medicine Leuven BelgiumF. Penninckx, University Hospital Leuven Department of Abdominal Surgery Leuven Belgium Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Liver ablation techniques: a review

Abstract Background Ablation techniques for unresectable liver carcinomas have evolved immensely since their introduction. Results of studies involving these techniques are restricted to reports of patient case series, which are often not presented in a standardised manner. This review aims to summarise the major studies in ablation technologies and present them in a way that may make comparison between the major modalities easier. Methods All major databases (Medline, Cochrane, Embase and Pubmed) were searched for studies using microwave, radiofrequency or cryoablation to treat unresectable liver tumours. Only studies with at least 30 patients and 3-year follow-up were included. Complication, recurrence and survival rates of all studies are summarised and presented. Results and conclusion It is difficult to compare ablation modalities, as probe design and energy sources have evolved rapidly over the last decade. Ablation offers an invaluable palliative option and in some cases it may offer rates of cure approaching that of surgical resection with lower morbidity and mortality. Perhaps the time has come, therefore, for prospective large-scale randomised control trials to take place comparing ablation modalities to each other and surgical resection. Content Type Journal ArticleCategory Review ArticleDOI 10.1007/s00464-009-0590-4Authors N. Bhardwaj, Leicester Royal Infirmary Department of HPB surgery c/o Helen Southam, Mr DM Lloyd’s Secretary Consultant HPB Surgeon, 6th Floor Balmoral Building, Infirmary Square Leicester LE1 5WW UKA. D. Strickland, Leicester Royal Infirmary Department of HPB surgery c/o Helen Southam, Mr DM Lloyd’s Secretary Consultant HPB Surgeon, 6th Floor Balmoral Building, Infirmary Square Leicester LE1 5WW UKF. Ahmad, Leicester Royal Infirmary Department of HPB surgery c/o Helen Southam, Mr DM Lloyd’s Secretary Consultant HPB Surgeon, 6th Floor Balmoral Building, Infirmary Square Leicester LE1 5WW UKA. R. Dennison, Leicester General Hospital Department of HPB surgery Leicester UKD. M. Lloyd, Leicester Royal Infirmary Department of HPB surgery c/o Helen Southam, Mr DM Lloyd’s Secretary Consultant HPB Surgeon, 6th Floor Balmoral Building, Infirmary Square Leicester LE1 5WW UK Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Laparoscopy: a safe approach to appendicitis during pregnancy

Abstract Background The aim of this study was to evaluate laparoscopic versus open surgery for suspected appendicitis during pregnancy. Methods A hospital-based retrospective review of 65 consecutive pregnant patients who underwent surgery for suspected appendicitis from 1999 to 2008 was performed. Significance was determined by Pearson’s χ2 test, Fisher’s exact test, Mann–Whitney test, and Kruskal–Wallis test. Results Of the 65 patients, 48 cases were laparoscopic and 17 open. Use of the laparoscopic versus open approach was significantly increased in the first (100% vs. 0%, p < 0.001) and second trimesters (73% vs. 27%, p < 0.001). The open approach was used more frequently in third-trimester patients (71% vs. 29%, p = NS). Significance was demonstrated in mean length of hospital stay in the laparoscopic versus open group (3.4 vs. 4.2 days, p = 0.001). No maternal mortalities occurred. Follow-up of fetal outcome was achieved in 89% of patients. No difference was demonstrated in fetal loss (1 in laparoscopic group), APGAR score, birth weight, and preterm delivery rate by operative approach. Adverse outcome was associated with maternal temperature greater than 38°C, leukocytosis greater than 16 × 109/l, or more than 48 h between onset of symptoms and emergency room presentation. Conclusions This article is the largest hospital-based series evaluating the laparoscopic versus open approach for pregnant patients with presumed acute appendicitis. While methodological limitations preclude a definitive recommendation, laparoscopy appears to be a safe, feasible, and efficacious approach for pregnant patients with presumed acute appendicitis. We conclude that it is likely not the surgical approach but the underlying diagnosis combined with maternal factors that determine the risk for pregnancy complications. A benefit of laparoscopy is the diagnostic ability to identify other intra-abdominal pathology which may mimic appendicitis and harbor pregnancy risks. Content Type Journal ArticleDOI 10.1007/s00464-009-0571-7Authors Eran Sadot, The Mount Sinai Hospital Department of Surgery, Division of General Surgery New York NY 10029 USADana A. Telem, The Mount Sinai Hospital Department of Surgery, Division of General Surgery New York NY 10029 USAManjit Arora, The Mount Sinai Hospital Department of Surgery, Division of General Surgery New York NY 10029 USAParag Butala, The Mount Sinai Hospital Department of Surgery, Division of General Surgery New York NY 10029 USAScott Q. Nguyen, The Mount Sinai Hospital Department of Surgery, Division of General Surgery New York NY 10029 USACelia M. Divino, The Mount Sinai Hospital Department of Surgery, Division of General Surgery New York NY 10029 USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Prospective randomized comparison of clinical results between hand-assisted laparoscopic and open splenectomies

Abstract Background Although some studies have compared laparoscopic and hand-assisted laparoscopic splenectomy (HALS) in splenomegaly cases, no study has analyzed the differences between HALS and open splenectomy (OS). This study aimed to compare the HALS and OS techniques in splenomegaly cases. Methods This prospective study included 27 patients undergoing splenectomy for splenic disorders at the Department of General Surgery, Istanbul Medical Faculty between February and October 2007. Open splenectomy was performed for 14 patients and HALS for the remaining 13 patients. Results The end points compared included incision length, operative time, intraoperative blood loss, postoperative drain output and duration, postoperative pain scores, length of postoperative hospitalization, and perioperative complications. The authors found benefits of HALS over OS for incision length, postoperative pain score, postoperative drain output and duration, and hospital stay. The main advantages of the HALS technique over OS were less postoperative pain (p = 0.0002), shorter hospital stay (p = 0.004), and shorter abdominal incision (p = 0.012). Conclusions For splenomegaly, HALS significantly facilitates the surgical procedure and reduces the hospital stay while maintaining the advantages of OS such as tactile sense as well as easy and atraumatic manipulation of enlarged spleens. Content Type Journal ArticleDOI 10.1007/s00464-009-0528-xAuthors Umut Barbaros, Istanbul University, Istanbul Faculty of Medicine Department of General Surgery Capa, Istanbul TurkeyAhmet Dinççağ, Istanbul University, Istanbul Faculty of Medicine Department of General Surgery Capa, Istanbul TurkeyAziz Sümer, Kas State Hospital Department of General Surgery Kas Antalya TurkeyRosario Vecchio, University of Catania, Vittorio Emanuele Hospital Department of Surgery Catania ItalyDomenico Rusello, University of Catania, Cannizzaro Hospital Department of Surgical Sciences, Transplantation, and Advanced Technologies Catania ItalyValentina Randazzo, University of Catania, Cannizzaro Hospital Department of Surgical Sciences, Transplantation, and Advanced Technologies Catania ItalyHalim Issever, Istanbul University, Istanbul Faculty of Medicine Department of Public Health Istanbul TurkeyCavit Avci, Istanbul University, Istanbul Faculty of Medicine Department of General Surgery Capa, Istanbul Turkey Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

The impact of proton-pump inhibitors on intraperitoneal sepsis: a word of caution for transgastric NOTES procedures

Abstract Background During transgastric natural orifice transluminal endoscopic surgery (NOTES), there is an iatrogenic perforation of the gastric wall with leakage of gastric contents into the peritoneal cavity. The aim of this study is to determine the effect of proton-pump inhibitors (PPI) and alterations of gastric pH on infection during transgastric surgery. Methods Thirty 250-g male Sprague–Dawley rats were divided into a study group (SG, n = 15) and a control group (CG, n =15). SG were given 5 mg/kg pantoprazole for 3 days before procedure and another dose 1 h before. CG received saline at similar time points. A mini-laparotomy with gastrotomy was performed. Aspiration of 2.0 cc gastric contents was removed from the stomach and injected into the peritoneal cavity of both groups. Gastric pH and peritoneal pH levels were obtained. Gastric aspirate was sent for culture. White blood cell counts (WBC) were obtained on postoperative days 1, 7, and 14, and C-reactive protein (CRP) levels were obtained on postoperative day 1. At day 14, a necropsy was performed and aerobic and anaerobic cultures of the peritoneal cavity were obtained. Results There were no deaths in either group. The average gastric pH in the SG was 5.13 versus 3.26 (p = 0.03) in the CG. The average peritoneal pH was similar in both groups. The WBC in the SG was 4.5 vs. 3.5 (1,000 cells/mm) in the CG. There was no elevation in CRP levels in either group. Bacterial cultures were positive in 3/15 (20%) rats in the CG and in 9/15 (60%) in the SG (p = 0.008). Intra-abdominal abscesses were found in 2/15 (13%) rats in the CG and in 5/15 (33%) in the SG (p = 0.08). Conclusions Pretreatment with a PPI resulted in a higher rate of peritoneal bacterial contamination and abscess formation. The acidic environment of the stomach appears to be protective against infection when intraperitoneal contamination occurs as a result of gastrotomy. Content Type Journal ArticleDOI 10.1007/s00464-009-0559-3Authors Sonia L. Ramamoorthy, UC San Diego Medical Center Center for the Future of Surgery- Department of Surgery 3855 Health Sciences Drive, Suite 2073 La Jolla CA 92093-0987 USAJeffrey K. Lee, University of California Department of Medicine, San Diego Medical Center San Diego CA USAYoav Mintz, UC San Diego Medical Center Center for the Future of Surgery- Department of Surgery 3855 Health Sciences Drive, Suite 2073 La Jolla CA 92093-0987 USAJohn Cullen, UC San Diego Medical Center Center for the Future of Surgery- Department of Surgery 3855 Health Sciences Drive, Suite 2073 La Jolla CA 92093-0987 USAMichelle K. Savu, UC San Diego Medical Center Center for the Future of Surgery- Department of Surgery 3855 Health Sciences Drive, Suite 2073 La Jolla CA 92093-0987 USADavid W. Easter, UC San Diego Medical Center Center for the Future of Surgery- Department of Surgery 3855 Health Sciences Drive, Suite 2073 La Jolla CA 92093-0987 USAAlana Chock, Northwest Weight Loss Surgery 125 30th St. SE Everett WA 98208 USARavi Mittal, University of California Department of Medicine, San Diego Medical Center San Diego CA USASantiago Horgan, UC San Diego Medical Center Center for the Future of Surgery- Department of Surgery 3855 Health Sciences Drive, Suite 2073 La Jolla CA 92093-0987 USAMark A. Talamini, UC San Diego Medical Center Center for the Future of Surgery- Department of Surgery 3855 Health Sciences Drive, Suite 2073 La Jolla CA 92093-0987 USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Effectiveness of stent placement for palliative treatment in malignant colorectal obstruction and predictive factors for stent occlusion

Abstract Background Self-expandable metallic stent (SEMS) for malignant colorectal obstruction is widely used in palliative treatment and as an alternative to surgery. The aims of this study are to evaluate the effectiveness of stent placement for palliative treatment and to identify the predictive factors associated with stent occlusion. Methods A retrospective analysis was performed in 55 patients who had undergone placement of an uncovered SEMS from February 2004 to April 2007 for palliative treatment of malignant colorectal obstruction with metastatic or locally advanced cancer that was surgically unresectable. We analyzed the technical and clinical outcomes of stent placement, complications related to the procedure, stent patency rate, and predictive factors associated with stent occlusion. Results The causes of colorectal obstruction before stent placement were primary colorectal cancer in 42 patients and noncolorectal extrinsic cancer in 13 patients. The initial technical success rate was 98.2%, and the clinical success rate was 94.4%. Complications occurred in 17 patients (30.9%). These included stent occlusion (n = 8), migration (n = 6), bowel perforation (n = 1), stent distortion (n = 1), and fistula formation (n = 1). The mean and median stent patency periods were 184 days [95% confidence interval (CI), 137–230 days] and 141 days (95% CI, 69–213 days), respectively. The degree of expansion 48 h after stent placement was significantly better in the nonocclusion group than in the stent occlusion group. In the multivariate Cox proportional hazard model, insufficient stent expansion (<70%) 48 h after stent placement was significantly associated with an increase in stent occlusion during the follow-up period (odds ratio, 12.55; p = 0.002). Conclusions Uncovered SEMS placement is an effective palliative treatment for malignant colorectal obstruction. The degree of stent expansion 48 h after stent placement is significantly associated with the maintenance of stent patency and is a predictive factor for stent occlusion. Content Type Journal ArticleDOI 10.1007/s00464-009-0589-xAuthors Jung Pil Suh, The Catholic University of Korea College of Medicine Division of Gastroenterology, Department of Internal Medicine 505 Banpo-dong, Seocho-gu 137-040 Seoul KoreaSang Woo Kim, The Catholic University of Korea College of Medicine Division of Gastroenterology, Department of Internal Medicine 505 Banpo-dong, Seocho-gu 137-040 Seoul KoreaYu Kyung Cho, The Catholic University of Korea College of Medicine Division of Gastroenterology, Department of Internal Medicine 505 Banpo-dong, Seocho-gu 137-040 Seoul KoreaJae Myung Park, The Catholic University of Korea College of Medicine Division of Gastroenterology, Department of Internal Medicine 505 Banpo-dong, Seocho-gu 137-040 Seoul KoreaIn Seok Lee, The Catholic University of Korea College of Medicine Division of Gastroenterology, Department of Internal Medicine 505 Banpo-dong, Seocho-gu 137-040 Seoul KoreaMyung-Gyu Choi, The Catholic University of Korea College of Medicine Division of Gastroenterology, Department of Internal Medicine 505 Banpo-dong, Seocho-gu 137-040 Seoul KoreaIn-Sik Chung, The Catholic University of Korea College of Medicine Division of Gastroenterology, Department of Internal Medicine 505 Banpo-dong, Seocho-gu 137-040 Seoul KoreaHyung Jin Kim, The Catholic University of Korea College of Medicine Department of Surgery Seoul KoreaWon Kyung Kang, The Catholic University of Korea College of Medicine Department of Surgery Seoul KoreaSeong Taek Oh, The Catholic University of Korea College of Medicine Department of Surgery Seoul Korea Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Preventing and managing complications of laparoscopic gastrectomy

Preventing and managing complications of laparoscopic gastrectomy Content Type Journal ArticleCategory LetterDOI 10.1007/s00464-009-0581-5Authors E. Hanisch, Akademisches Lehrkrankenhaus der JWG-Universitat, Klinik fur Allgemein-, Viszeral-, und Endokrine Chirurgie, Asklepios Klinik Langen Langen Germany Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Anatomical changes after inguinal hernia treatment: a reason for chronic pain and recurrent hernia?

Abstract Background Chronic pain and hernia recurrence are the most frequent long-term complications of treating inguinal hernia. One reason may be postsurgical changes in the anatomy of the groin. Methods In a retrospective investigation from 1994 to 2008, 1,194 patients undergoing 1,421 laparoscopic transabdominal preperitoneal (TAPP) herniorrhaphies were studied. Anatomical structures in the groin, seen in 1,214 primary and 207 recurrent hernias, were charted by means of video analysis. Hernia orifices, myopectineal orifice (MPO), and Hesselbach’s and Hessert’s triangles were measured in their respective vertical and horizontal diameters in order to calculate the surface area. Other anatomical changes were also recorded. Results The mean surface area of hernial orifices was 3.00 ± 2.01 cm2 in primary hernias and 3.60 ± 3.81 cm² in recurrent hernias. The mean surface area of Hesselbach’s triangle was 4.23 ± 2.21 cm² in the former group and 2.09 ± 2.10 cm² in the latter (p < 0.0001). The mean surface area of Hessert’s triangle in primary hernias (9.03 ± 6.17 cm²) was significantly larger than that in recurrent hernias (3.11 ± 3.67 cm²; p < 0.0001). Further anatomical changes in suture-treated recurrent hernias included a dislocated spermatic cord, a raised inguinal ligament, and asymmetry in the region. Conclusion The treatment of inguinal hernia by the suture technique is followed by significant anatomical changes such as reduction of the surface area and a subsequent increase of tension in the inguinal region. This could be one of the main reasons for chronic pain and hernia recurrence. Content Type Journal ArticleDOI 10.1007/s00464-009-0595-zAuthors Roland Kocijan, Hospital of Floridsdorf Department of Surgery Hinaysgasse 1 1210 Vienna AustriaSimone Sandberg, Hospital of Floridsdorf Department of Surgery Hinaysgasse 1 1210 Vienna AustriaYi-Wei Chan, Hospital of Floridsdorf Department of Surgery Hinaysgasse 1 1210 Vienna AustriaChristian Hollinsky, Hospital of Floridsdorf Department of Surgery Hinaysgasse 1 1210 Vienna Austria Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Minimally invasive colon resection for malignant colonic conditions is associated with a transient early increase in plasma sVEGFR1 and a decrease in sVEGFR2 levels after surgery

Abstract Introduction Plasma VEGF levels increase after minimally invasive colorectal resection (MICR) and remain elevated for 2–4 weeks. VEGF induces physiologic and pathologic angiogenesis by binding to endothelial cell (EC) bound VEGF-Receptor-1 (VEGFR1) and VEGFR2. Soluble forms of these receptors sequester plasma VEGF, decreasing the amount available to bind to EC-bound receptors. Ramifications of surgery-related plasma VEGF changes partially depend on plasma levels of sVEGFR1 and sVEGFR2. This study assessed perioperative sVEGFR1 and sVEGFR2 levels after MICR in patients with colorectal cancer. Methods Forty-five patients were studied; blood samples were taken from all patients preoperatively (preop) and on postoperative days (POD) 1 and 3; in most a fourth sample was drawn between POD 7–30. Late samples were bundled into two time points: POD 7–13 and POD 14–30. sVEGFR1 and sVEGFR2 levels were measured via ELISA. sVEGFR2 data are reported as mean ± SD and were assessed with the paired samples t test. sVEGFR1 data were not normally distributed. They are reported as median and 95% confidence interval (CI) and were assessed with the Wilcoxon signed-Rank test (p < 0.05). Results Preoperatively, the mean plasma sVEGFR2 level (7583.9 pg/ml) was greater than the sVEGFR1 result (98.3 pg/ml). Compared with preop levels, sVEGFR2 levels were significantly lower on POD 1 (6068.2 pg/ml, ±2034.5) and POD 3 (6227.6 pg/ml, ±2007.0), whereas sVEGFR1 levels were significantly greater on POD 1 (237.5 pg/ml; 95% CI, 89.6–103.5), POD 3 (200.2 pg/ml; 95% CI, 159–253), and POD 7−13 (102.9 pg/ml; 95% CI, 189.7–253). No differences were found on POD 7–13 for sVEGFR2 or POD 14–30 for either protein. Conclusions sVEGFR2 values decreased and sVEGFR1 levels increased early after MICR; sVEGFR2 changes dominate due to their much larger magnitude. The net result is less plasma VEGF bound by soluble receptors and more plasma VEGF available to bind to ECs early after surgery. Content Type Journal ArticleDOI 10.1007/s00464-009-0575-3Authors H. M. C. Shantha Kumara, New York-Presbyterian Hospital-Columbia Campus Section of Colon and Rectal Surgery, Department of Surgery 177 Fort Washington Avenue New York NY 10032 USAJ. C. Cabot, New York-Presbyterian Hospital-Columbia Campus Section of Colon and Rectal Surgery, Department of Surgery 177 Fort Washington Avenue New York NY 10032 USAA. Hoffman, New York-Presbyterian Hospital-Columbia Campus Section of Colon and Rectal Surgery, Department of Surgery 177 Fort Washington Avenue New York NY 10032 USAM. Luchtefeld, Ferguson Clinic Division of Colon and Rectal Surgery 4100, Lake Dr. SE, Suite 205 Grand Rapids MI 49546 USAM. F. Kalady, Cleveland Clinic Department of Colorectal Surgery 9500, Euclid Avenue, A30 Cleveland OH 44195 USAN. Hyman, University of Vermont, College of Medicine Department of Surgery, Fletcher 465 Burlington VT 05401 USAD. Feingold, New York-Presbyterian Hospital-Columbia Campus Section of Colon and Rectal Surgery, Department of Surgery 177 Fort Washington Avenue New York NY 10032 USAR. Baxter, New York-Presbyterian Hospital-Columbia Campus Section of Colon and Rectal Surgery, Department of Surgery 177 Fort Washington Avenue New York NY 10032 USAR. L. Whelan, New York-Presbyterian Hospital-Columbia Campus Section of Colon and Rectal Surgery, Department of Surgery 177 Fort Washington Avenue New York NY 10032 USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

A systematic review of methods to palliate malignant gastric outlet obstruction

Abstract Background The traditional approach to palliating patients with malignant gastric outlet obstruction (GOO) has been open gastrojejunostomy (OGJ). More recently endoscopic stenting (ES) and laparoscopic gastrojejunostomy (LGJ) have been introduced as alternatives, and some studies have suggested improved outcomes with ES. The aim of this review is to compare ES with OGJ and LGJ in terms of clinical outcome. Method A systematic literature search and review was performed for the period January 1990 to May 2008. Original comparative studies were included where ES was compared with either LGJ or OGJ or both, for the palliation of malignant GOO. Results Thirteen studies met the inclusion criteria (10 retrospective cohort studies, two randomised controlled trials and one prospective study). Compared with OGJ, ES resulted in an increased likelihood of tolerating an oral intake [odds ratio (OR) 2.6, p = 0.02], a shorter time to tolerating an oral intake (mean difference 6.9 days, p < 0.001) and a shorter post-procedural hospital stay (mean difference 11.8 days, p < 0.001). There were no significant differences between 30-day mortality, complication rates or survival. There were an inadequate number of cases to quantitatively compare ES with LGJ. Conclusion This review demonstrates improved clinical outcomes with ES over OGJ for patients with malignant GOO. However, there is insufficient data to adequately compare ES with LGJ, which is the current standard for operative management. As these conclusions are based on observational studies only, future large well-designed randomised controlled trials (RCTs) would be required to ensure the estimates of the relative efficacy of these interventions are valid. Content Type Journal ArticleCategory ReviewDOI 10.1007/s00464-009-0577-1Authors Jasen Ly, University of Auckland Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences Private Bag 92019 Auckland New ZealandGregory O’Grady, University of Auckland Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences Private Bag 92019 Auckland New ZealandAnubhav Mittal, University of Auckland Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences Private Bag 92019 Auckland New ZealandLindsay Plank, University of Auckland Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences Private Bag 92019 Auckland New ZealandJohn A. Windsor, University of Auckland Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences Private Bag 92019 Auckland New Zealand Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Current technique of laparoscopic total mesorectal excision (TME): an international questionnaire among 368 surgeons

Abstract Background Current literature shows no consensus for the technique of laparoscopic total mesorectal excision (LTME). This study aimed to assess the current practice of LTME. Methods From January to March 2008, members of the European Association for Endoscopic Surgery (EAES), the Indian Association of Gastrointestinal Endo-Surgeons (IAGES), and the Society of Laparoscopic Surgeons (SLS), together with renowned surgeons in the field of LTME, were invited to fill out an online questionnaire concerning aspects of LTME. Results The 368 questionnaires showed that 77% of the study participants performed 1–20 LTMEs per year (low volume) and that 33% performed more than 20 LTMEs per year (high volume). Preoperative bowel preparation (PBP), Trendelenburg position, periumbilical insertion of a 30º laparoscope, medial-to-lateral dissection, ultrasonic hemostasis, high-tie ligation, splenic flexure mobilization, left ureteral identification, partial sigmoid resection, extraction of the specimen by a new minilaparotomy and wound protector, end-to-end stapled anastomosis using a 28- to 29-mm anvil with 3.5-mm staples, abdominal lavage, pelvic drainage, and diverting ileostoma were performed by a majority of the surgeons. Less consistency was observed in identification of the right ureter, dissection of Denonvilliers’ fascia, location of the minilaparotomy, and construction of a colonic pouch. There were significant differences between high and low volume and between American and European surgeons. Significantly more low-volume surgeons indicated a preference for an open TME depending on the age and gender of the patient, the presence of comorbidity, previous laparotomy, and locally advanced tumor. More low-volume surgeons applied PBP (83.4% vs. 71.8%; p = 0.017). On the average, high-volume surgeons identified more autonomic pelvic nerves during dissection (2.6 vs. 1.8 nerves). The right ureter was identified by 66% of the American and 31.2% of the European surgeons. In the United States 91.5% and in Europe 61.2% created an end-to-end anastomosis. Pouches were created by 32% of the European and 6.8% of the American surgeons. Conclusion The respondents showed an apparent preference for several aspects of LTME. Differences were related to expertise and still more to continent. Content Type Journal ArticleDOI 10.1007/s00464-009-0566-4Authors Y. M. Cheung, Erasmus University Medical Center Department of Surgery P.O. Box 2040 3000 CA Rotterdam The NetherlandsM. M. Lange, Leiden University Medical Center Department of Surgery Leiden The NetherlandsM. Buunen, Erasmus University Medical Center Department of Surgery P.O. Box 2040 3000 CA Rotterdam The NetherlandsJ. F. Lange, Erasmus University Medical Center Department of Surgery P.O. Box 2040 3000 CA Rotterdam The Netherlands Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Is a bougie required for the performance of the fundal wrap during laparoscopic Nissen fundoplication?

Abstract Background It has been claimed that oesophageal intubation with a bougie during laparoscopic Nissen fundoplication (LNF) reduces the risk of a tight crural repair and wrap, and thereby decreases the prevalence of post-operative dysphagia. The aim of this study is to assess the benefit of routinely inserting a bougie during LNF, in relation to post-operative dysphagia. Methods All patients who underwent LNF by a single surgeon between March 2005 and March 2007 were reviewed. Oesophageal intubation during surgery was routinely performed in all patients who underwent LNF during the first 11 months of the study period, whilst during the second phase, routine oesophageal intubation was not performed. The main outcome measures were the prevalence of post-operative dysphagia and complication rates. Dysphagia severity was assessed clinically by a scoring system at discharge, and again at 6 weeks, 3 months, 6 months and 1 year. Results Forty patients had a bougie inserted (group 1) and 42 had no bougie (group 2). The mean age was 49.1 (SD, standard deviation ± 8.1) years in group 1 and 49.4 (SD ± 8.4) years in group 2 (p = 0.88). There were no major complications. When assessed at 12 weeks, 60% of group 1 and 51% of group 2 patients still had some degree of dysphagia (p = 0.635) but by 1 year dysphagia had resolved in all patients (p = 1.00). There was no significant difference in the median dysphagia scores between the two groups at: discharge (p = 0.181), 6 weeks (p = 0.234), 12 weeks (p = 0.504), 24 weeks (p = 0.182) or 1 year (p = 0.530). Analysis of the progression of dysphagia over the first post-operative year using Cox regression analysis did not show any significant difference between the two groups (p = 0.375). Conclusions LNF can be safely performed without the routine use of an oesophageal bougie and this practice does not result in increased post-operative dysphagia rates. Content Type Journal ArticleDOI 10.1007/s00464-009-0592-2Authors Krishnamurthy Somasekar, Royal Gwent Hospital Department of Surgery Cardiff road NP20-2UB Newport UKGareth Morris-Stiff, Royal Glamorgan Hospital Department of Surgery Llantrisant UKHasan Al-Madfai, University of Glamorgan Division of Mathematics and Statistics Pontypridd UKKaren Barton, Princess of Wales Hospital Department of Surgery Bridgend UKAhmed Hassn, Princess of Wales Hospital Department of Surgery Bridgend UK Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Laparoscopic Heller myotomy for achalasia: results after 10 years

Abstract Background Laparoscopic Heller myotomy was first undertaken in the early 1990s, and appreciable numbers of patients with 10-year follow-up periods are now available. This study was undertaken to determine long-term outcomes after laparoscopic Heller myotomy used to treat achalasia. Methods Of 337 patients who have undergone laparoscopic Heller myotomy since 1992, 47 who underwent myotomy more than 10 years ago have been followed through a prospectively maintained registry. Among many symptoms, patients scored dysphagia, chest pain, vomiting, regurgitation, choking, and heartburn before and after myotomy using a Likert scale with choices ranging from 0 (never/not bothersome) to 10 (always/very bothersome). Symptom scores before and after myotomy were compared using a Wilcoxon matched-pairs test. Data are reported as median (mean ± standard deviation). Results The median length of the hospital stay was 2 days (mean, 3 ± 8.6 days; range, 1–60 days). Notable complications were infrequent after myotomy. There were no perioperative deaths. One patient required a redo myotomy after 5 years due to recurrence of symptoms. At this writing, 33 patients (70%) are still alive. The causes of death after discharge were unrelated to myotomy. The frequency and severity scores for dysphagia, chest pain, vomiting, regurgitation, choking, and heartburn all decreased significantly after laparoscopic Heller myotomy (p < 0.0001 for all). Conclusions Laparoscopic Heller myotomy can be undertaken with few complications. This procedure significantly decreases the frequency and severity of achalasia symptoms without promoting heartburn. The symptoms of achalasia are durably ameliorated by laparoscopic Heller myotomy during long-term follow-up evaluation, thereby promoting application of this procedure. Content Type Journal ArticleDOI 10.1007/s00464-009-0508-1Authors Sarah M. Cowgill, Tampa General Hospital Digestive Disorders Center Tampa FL USADesiree Villadolid, Tampa General Hospital Digestive Disorders Center Tampa FL USARobert Boyle, Tampa General Hospital Digestive Disorders Center Tampa FL USASam Al-Saadi, Tampa General Hospital Digestive Disorders Center Tampa FL USASharona Ross, Tampa General Hospital Digestive Disorders Center Tampa FL USAAlexander S. Rosemurgy, Tampa General Hospital Digestive Disorders Center Tampa FL USA Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794

Establishing construct validity of a virtual-reality training simulator for hysteroscopy via a multimetric scoring system

Abstract Background The aims of this study are to determine construct validity for the HystSim virtual-reality (VR) training simulator for hysteroscopy via a new multimetric scoring system (MMSS) and to explore learning curves for both novices and experienced surgeons. Methods Fifteen relevant metrics had been identified for diagnostic hysteroscopy by means of hierarchical task decomposition. They were grouped into four modules (visualization, ergonomics, safety, and fluid handling) and individually weighted, building the MMSS for this study. In a first step, 24 novice medical students and 12 experienced gynecologists went through a self-paced teaching tutorial, in which all participants received clearly stated goals and instructions on how to carry out hysteroscopic procedures properly for this study. All subjects performed five repeated trials on two different exercises on HystSim (exploration and diagnosis exercises). After each trial the results were presented to the participants in the form of an automated objective feedback report (AOFR). Construct validity for the MMSS and learning curves were investigated by comparing the performance between novices and experienced surgeons and in between the repeated trials. To study the effect of repeated practice, 23 of the novices returned 2 weeks later for a second training session. Results Comparing novices with the experienced group, the ergonomics and fluid handling modules resulted in construct validity, while the visualization module did not, and for the safety module the experienced group even scored significantly lower than novices in both exercises. The overall score showed only construct validity when the safety module was excluded. Concerning learning curves, all subjects improved significantly during the training on HystSim, with clear indication that the second training session was beneficial for novice surgeons. Conclusions Construct validity for HystSim has been established for different modules of VR metrics on a new MMSS developed for diagnostic hysteroscopy. Careful refinement and further testing of metrics and scores is required before using them as assessment tools for operative skills. Content Type Journal ArticleDOI 10.1007/s00464-009-0582-4Authors Michael Bajka, University Hospital Zurich Division of Gynaecology, Department of OB/GYN Zurich 8091 SwitzerlandStefan Tuchschmid, ETH Zurich Zurich 8092 SwitzerlandDaniel Fink, University Hospital Zurich Division of Gynaecology, Department of OB/GYN Zurich 8091 SwitzerlandGábor Székely, ETH Zurich Zurich 8092 SwitzerlandMatthias Harders, ETH Zurich Zurich 8092 Switzerland Journal Surgical EndoscopyOnline ISSN 1432-2218Print ISSN 0930-2794