Minimally invasive colon resection is associated with a transient increase in plasma sVEGFR1 levels and a decrease in sVEGFR2 levels during the early postoperative period

Introduction  Plasma vascular endothelial growth factor (VEGF) levels are elevated for 2–4 weeks after minimally invasive colorectal resection (MICR). VEGF induces wound and tumor angiogenesis by binding to endothelial cell (EC)-bound VEGF-receptor 1 (VEGFR1) and VEGFR2. Soluble receptors (sVEGFR1, sVEGFR2) sequester VEGF in the blood and decrease VEGF’s proangiogenic effect. The importance of the MICR-related VEGF changes depends on the effect of surgical procedures on sVEGFR1 and sVEGFR2; this study assessed levels of these proteins after MICR for benign indications. Methods  Blood samples were taken (n = 39) preoperatively (preop) and on postoperative days (POD) 1 and 3; in most cases a fourth sample was drawn between POD 7 and 30. sVEGFR1 and sVEGFR2 levels were measured via enzyme-linked immunosorbent assay (ELISA), which detects free and VEGF bound soluble receptor. Late samples were bundled into POD 7–13 and POD 14–30 time points. Results are reported as mean and standard deviation. The data was assessed with paired-samples t-test. Results  Preop, mean plasma sVEGFR2 level (9,203.7 ± 1,934.3 pg/ml) was significantly higher than the sVEGFR1 value (132.5 ± 126.2 pg/ml). sVEGFR2 levels were significantly lower on POD 1 (6,957.8 ± 1,947.7 pg/ml,) and POD 3 (7,085.6 ± 2,000.2 pg/ml), whereas sVEGFR1 levels were significantly higher on POD 1 (220.0 ± 132.8 pg/ml) and POD 3 (182.7 ± 102.1 pg/ml) versus preop results. No differences were found on POD 7–13 or 14–30. Conclusions  sVEGFR2 values decreased and sVEGFR1 levels increased early after MICR; due to its much higher baseline, the sVEGFR2 changes dominate. The net result is less VEGF bound to soluble receptor and more free plasma VEGF.     

Altered plasma matrix metalloproteinase-9/tissue metalloproteinase-1 concentration during the early postoperative period in patients with colorectal cancer

Background The authors have previously demonstrated that insulin-like growth factor binding protein-3 (IGFBP-3) is depleted in plasma for 1 to 3 days after major open surgery (OS), but not after laparoscopic surgery (LS). After surgery, IGFP-3 cleavage occurs rapidly and is likely attributable to altered plasma proteolytic activity. This study aimed to assess plasma proteolysis after both open and closed colorectal resection and, if possible, to identify a protease/protease inhibitor system affected by surgery. Methods Plasma from 88 patients with colorectal cancer (stages I–III) who underwent resection was obtained preoperatively (pre-OP) and on postoperative days (POD) 1 to 3. Plasma proteolytic activity was assessed via zymography. On the basis of the results, specific protease and protease inhibitor concentrations were next measured via enzyme-linked immunoassay (ELISA). Statistical analysis was performed using Wilcoxon’s test. Results Early after surgery, zymography showed a predominant band representing a 92-kDa gelatinase corresponding to a proform of matrix metalloproteinase-9 (MMP-9), a protease known to cleave IGFBP-3. In OS patients, the mean concentration of plasma MMP-9 was significantly higher on POD 1 than at pre-OP (p < 0.003). On POD 2 and 3, no differences were noted. In the LS group, the mean levels of MMP-9 before and after surgery were comparable. The levels of a natural MMP-9 inhibitor, tissue inhibitor of metalloproteinase-1 (TIMP-1), also were measured. In the OS group, the level of TIMP-1 was significantly higher on POD 1 (p < 0.0003) and POD 2 (p < 0.01) and 3 (p < 0.01) than at pre-OP. In the LS group, a smaller but significant increase in TIMP-1 levels was found between the pre-OP sample and the POD 1 (p < 0.01) and POD 2 (p < 0.01) samples. No difference was noted on POD 3 (p = 0.1). Conclusions Open surgery, but not laparoscopic surgery, is accompanied by a short-lived significant increase in MMP-9 levels, which likely accounts for the decrease in IGFBP-3 levels observed after OS. The transitory nature of MMP-9 imbalance may be attributable to the increase in TIMP-1 levels postoperatively. An erratum to this article is available at .     

Immunologic parameters during NOTES compared with laparoscopy in a randomized blinded porcine trial

Background  It remains unclear if the natural orifice translumenal endoscopic surgery (NOTES) technique is less invasive than laparoscopy. Serum interleukins and peritoneal cellular response have been utilized to support the immunologic difference between open and laparoscopic surgery. We hypothesized that there would be no difference between cytokine levels during NOTES or laparoscopic peritoneoscopy. Methods  Twelve pigs were assigned to NOTES or standard laparoscopy with permuted block randomization. Each group underwent 90 min of diagnostic peritoneoscopy using CO₂ for laparoscopy and air for NOTES pneumoperitoneum. Blood draws were obtained at baseline, at procedure end, and on postoperative days (POD) 1, 2, and 7. Quantification of cytokines (IL-1b and TNF-α) was performed with a Duo Set Porcine enzyme-linked immunosorbent assay (ELISA). Laboratory results were captured by a technician blinded to the research question, and data analysis was performed by an investigator blinded to the procedure using t-test and repeated measures linear model. The study was approved by the institutional animal care and use committee (IACUC). Results  All procedures were successfully completed. One NOTES animal succumbed to hemorrhagic gastritis (day 3). All other animals thrived to POD 14, with no gross infections at necropsy. Animals undergoing laparoscopy had lower mean arterial pH than NOTES animals (p < 0.001). Serum and intraperitoneal white blood cell (WBC) counts were similar between the groups. Mean interleukin-1b levels at baseline, at the end of the procedure and at 48 h did not differ (0.50 and 0.31; p = 0.65). TNF-α levels did not differ at baseline or procedure end but increased in the NOTES group on POD 1, persisting to POD 7. Tumor necrosis factor-α (TNF-α) decreased in the laparoscopy group (p = 0.005). Conclusion  Cytokines and WBC did not differ between laparoscopic and NOTES groups during the initial 24 h. These findings do not currently support the assumption that NOTES is less invasive than laparoscopy. The late TNF-α elevation contradicts other studies and requires further examination. Presented at the 27th annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), April 9–12th, Philadelphia, PA.     

Minimally invasive adnexa-sparing surgery for benign ovarian and paratubal masses in children

BackgroundThe precision of minimally invasive surgery (MIS) to resect benign ovarian and paratubal masses while preserving adnexa in children is unclear. This study evaluated the integrity of laparoscopy to spare adnexa while resecting benign pathologies in children.MethodsThe institutional pathology database was queried to identify patients aged 18 years and younger having any ovarian or tubal lesion resected at a comprehensive children's hospital between 2006 and 2021. Adnexa-sparing surgery was defined as preserving both the ovary and tube from which the lesion was resected. Postoperative ultrasounds were reviewed to document ovarian follicles, blood flow, volumes, and lesion recurrence.ResultsAdnexal preservation was implemented in 168 of 328 pathological resections. MIS approach was used in 149 cases. Median age was 13.4 [11.0–15.3]. Among sparing surgeries, MIS associated with benign pathology, shorter operative time (median minutes: 78 MIS [59–111.5]; 130 open [92.8–149.8]; 174 MIS-to-open [132.8–199.5]; p = 0.010), and reduced hospital stay (median days: 1 MIS (Lindfors, 1971; Lovvorn III et al., 1998) [1-2]; 2 open [2–2.9], 2 MIS-to-open [1–3.3]; p = 0.001). Postoperative ovarian volume ipsilateral to the MIS procedure (median, 7.6 ml [4.3–12.1]) was relatively smaller than the contralateral ovary (median, 9.1 ml [5.5–15.0]). Blood flow was documented to the ovary in 70/94 (74.4%) of patients after MIS adnexal-sparing surgery. Distinct follicles were detected in 48/74 (64.8%) of post-menarchal patients after MIS adnexal-sparing surgery. Five ovarian cysts recurred.ConclusionsMIS preserves adnexa reliably, with postoperative ovarian follicles and blood flow detected in most patients, and maintains ∼80% of contralateral volume, while achieving definitive tumor resection.Level of evidenceIII     

腹腔镜和开腹结直肠手术的炎性反应比较

目的对比分析腹腔镜和开腹结直肠手术患者全身和腹腔炎性反应的差异,为腹腔镜手术对结直肠肿瘤中的应用提供理论依据。方法对51例2004年4-8月间收治的乙状结肠和直肠恶性肿瘤患者,采用腹腔镜辅助手术25例(LAP组),开腹手术26例(OPEN组)。术毕骶前留置引流管。观察并比较两组患者的一般情况和炎性反应及与手术相关的各项指标。结果两组患者在年龄、性别、ASA分级、术前血红蛋白及白蛋白水平、肿瘤Dukes分期和手术方式差异均无统计学意义(P＞0．05)。在切口长度、手术时间、肠道功能恢复时间、住院时间的比较中,LAP组占有明显优势(P＜0．05)。腹腔引流量在术后第1天,两组间差异无统计学意义(P＞0．05)；而术后2-4 d,LAP组明显低于OPEN组(P＜0．05)。LAP组术后第1天,周围血中性粒细胞[(7．30±2．62)×10~9/L]、白介素(IL)-10[(19．46±3．31)pg/ml]和C反应蛋白(CRP)[(2．76±2．17)mg/dl]水平均显著低于OPEN组(P＜0．05)。术后第4天两组间差异无统计学意义(P＞0．05)。术后第1天,两组腹腔引流液的IL-10、肿瘤坏死因子(TNF)及CRP水平差异无统计学意义(P＞0．05),术后第4天LAP组IL-10 [(22．53±15．47)pg/ml]明显低于OPEN组(P＜0．05)。结论术后早期,腹腔镜结直肠手术的腹腔炎性反应与开腹手术相当,而全身炎性反应较开腹手术轻。腹腔镜结直肠手术临床上体现出恢复快、并发症少、住院天数少的优势。     

Laparoscopic versus open liver segmentectomy: prospective, case-matched, intention-to-treat analysis of clinical outcomes and cost effectiveness

Introduction  Reduction in hospital stay, blood loss, postoperative pain and complications are common findings after laparoscopic liver resection, suggesting that the laparoscopic approach may be a suitable alternative to open surgery. Some concerns have been raised regarding cost effectiveness of this procedure and potential implications of its large-scale application. Our aim has been to determine cost effectiveness of laparoscopic liver surgery by a case-matched, case–control, intention-to-treat analysis of its costs and short-term clinical outcomes compared with open surgery. Methods  Laparoscopic liver segmentectomies and bisegmentectomies performed at Ninewells Hospital and Medical School between 2005 and 2007 were considered. Resections involving more than two Couinaud segments, or involving any synchronous procedure, were excluded. An operation-magnitude-matched control group was identified amongst open liver resections performed between 2004 and 2007. Hospital costs were obtained from the Scottish Health Service Costs Book (ISD Scotland) and average national costs were calculated. Cost of theatre time, disposable surgical devices, hospital stay, and high-dependency unit (HDU) and intensive care unit (ICU) usage were the main endpoints for comparison. Secondary endpoints were morbidity and mortality. Statistical analysis was performed with Student’s t-test, χ ² and Fisher exact test as most appropriate. Results  Twenty-five laparoscopic liver resections were considered, including atypical resection, segmentectomy and bisegmentectomy, and they were compared to 25 matching open resections. The two groups were homogeneous by age, sex, coexistent morbidity, magnitude of resection, prevalence of liver cirrhosis and indications. Operative time (p < 0.03), blood loss (p < 0.0001), Pringle manoeuvre (p < 0.03), hospital stay (p < 0.003) and postoperative complications (p < 0.002) were significantly reduced in the laparoscopic group. Overall hospital cost was significantly lower in the laparoscopic group by an average of ￡2,571 (p < 0.04). Conclusions  Laparoscopic liver segmentectomy and bisegmentectomy are feasible, safe and cost effective compared to similar open resections. Large-scale application of laparoscopic liver surgery could translate into significant savings to hospitals and health care programmes.     

Minimally invasive surgery for colorectal cancer: quality of life, body image, cosmesis, and functional results

Background  The aims of this cross-sectional study were to assess the long-term quality of life, the body image, and the cosmetic and functional results in patients who had laparoscopic-assisted for colorectal cancer. Methods  Forty-two patients were enrolled in this study: 21 consecutive patients who had undergone laparoscopic-assisted colonic resection and 21 patients who had open colonic resection, selected according to stage, gender, age, cancer site, and type of resection. The patients answered four questionnaires about their quality of life, body image, functional, and cosmetic results. Nonparametric tests were used for statistical analysis. Results  Postoperative hospital stay was shorter in patients who had laparoscopic-assisted resection. The cosmetic score was significantly better in the laparoscopic-assisted group than in the open group (p < 0.01). In spite of similar overall body image score, patients who had a laparoscopic-assisted resection reported a significantly better satisfaction with their own body (p = 0.05). Quality-of-life and functional results were similar in both groups. Conclusions  The cosmetic results and the consequent satisfaction with the body were significantly better after laparoscopic assisted resection compared to equivalent open procedure. These effects seemed to be temporary but they could help patients to accept the burden of surgery.     

Open surgery induces a dramatic decrease in circulating intact IGFBP-3 in patients with colorectal cancer not seen with laparoscopic surgery

Background As shown earlier by the authors via Western blot analysis, open (OS) but not laparoscopic surgery (LS) induces a qualitative decrease in plasma insulin-like growth factor–binding protein 3 (IGFBP-3) levels on postoperative day 1 (POD 1). Intact IGFBP-3 has tumor suppressive effects, but its degradation products do not. Enzyme linked immunoassay (ELISA) inevitably measures both. In this study, using a novel combined Western blot and ELISA analysis method, precise plasma levels of intact IGFBP-3 on POD2 after open and closed colorectal cancer resection (stage I–III) were determined.Methods This study included 15 OS patients with a mean incision length of 26.7 ± 15.5 cm and 16 LS patients with a mean incision length of 5.3 ± 3.1 cm. Intact IGFBP-3 levels were determined via ELISA and Western blot analysis in plasma collected preoperatively and postoperatively.Results In the OS patients, the mean preoperative concentration of intact 43–45 kDa IGFBP-3 protein was 1920 ± 1430 ng/ml. It decreased dramatically on POD2 to 355 ± 545 ng/ml (p < 0.005). In the LS group, no significant difference was noted between the preoperative level (1305 ± 807 ng/ml) and the POD2 level (922 + 714 ng/ml).Conclusions Open cancer resection, unlike its minimally invasive alternative, induces a dramatic decrease in concentration of intact IGFBP-3, which may have important implications with regard to colon cancer recurrence.     

Laparoscopic colonic resection in inflammatory bowel disease: minimal surgery,minimal access and minimal hospital stay

Objective Laparoscopic surgery for inflammatory bowel disease (IBD) is technically demanding but can offer improved short‐term outcomes. The introduction of minimally invasive surgery (MIS) as the default operative approach for IBD, however, may have inherent learning curve‐associated disadvantages. We hypothesise that the establishment of MIS as the standard operative approach does not increase patient morbidity as assessed in the initial period of its introduction into a specialised unit, and that it confers earlier postoperative gastrointestinal recovery and reduced hospitalisation compared with conventional open resection. Method A case–control study was undertaken on laparoscopic resection (LR) vs open colon resection (OR) for IBD. The LR group was collated prospectively and compared with a pathologically matched historical control set. Outcomes measured included: postoperative length of stay, time to normal bowel function and postoperative morbidity. Statistical analysis was performed using spss . Results Twenty‐eight patients were investigated (14 LR, 14 OR). The two groups were matched for type of operation, type of disease and age. There were no conversions in the LR group. Morbidity and readmissions did not differ significantly between the groups. Those undergoing laparoscopic resection had a quicker return to diet (median 2 vs 4 days; P = 0.000002), time to first bowel motion (2 vs 4 days; P = 0.019) and shorter postoperative length of stay (5.5 vs 12.5; P = 0.0067). Conclusion These findings support the routine use of MIS for the elective surgical management of IBD in our department. Patients undergoing laparoscopic colectomies for IBD can expect faster return of gastrointestinal function and shorter hospitalisation.     

Persistent elevation of plasma vascular endothelial growth factor levels during the first month after minimally invasive colorectal resection

Background Elevations of plasma vascular endothelial growth factor (VEGF) have been noted early after colorectal resection. The duration of this increase is unknown. Because VEGF is a potent promoter of angiogenesis, which is critical to tumor growth, a sustained increase in blood VEGF levels after surgery may stimulate the growth of residual metastases early after surgery. This preliminary study aimed to determine VEGF levels during the first month after colorectal resection. Methods Patients from three prospective studies that had late postoperative blood samples available comprised the study population. Demographic, perioperative, pathologic, and complication data were collected. Plasma samples were obtained preoperatively for all patients: on postoperative day (POD) 1 for most patients and at varying time points thereafter during the first month after surgery and beyond. Levels of VEGF were determined via enzyme-linked immunoassay (ELISA) and compared using Wilcoxon’s matched pairs test. Because the numbers of specimens beyond POD 5 were limited, samples from 7-day time blocks were bundled and averaged to permit statistical analysis. Results A total of 49 patients with cancer and 30 patients with benign indications, all of whom underwent minimally invasive colorectal resection, were assessed separately. With regard to the patients with cancer, the median preoperative plasma value was 150 pg/ml, and the peak postoperative median value for the POD 14 to 20 time block was 611.1 pg/ml. Furthermore, compared with the preoperative results, significant VEGF elevations were noted on POD 3 as well as during week 2 (POD 7–13), week 3 (POD 14–20), and week 4 (POD 21–27) (p < 0.05 for each). With regard to the benign patients, the median preoperative VEGF level was 112 pg/ml, and the peak postoperative value, 286 pg/ml, was noted during postoperative week 2. Significant elevations were noted on POD 3, and for weeks 2 and 3 as well as for POD 28 and later. Between 63% and 89% of the patients at each time point beyond POD 5 had elevated VEGF levels. Conclusion This preliminary study demonstrates that after minimally invasive colorectal resection for cancer, median VEGF levels are significantly elevated on POD 3 and remain increased for as long as 4 weeks. Significant elevations in a similar pattern also were noted for the benign patients. However, the baseline and postoperative median values were lower. The clinical impact from increased blood levels of VEGF is uncertain. It is possible that the growth of residual tumor deposits may be stimulated early after surgery. These results warrant a larger study as well as endothelial cell in vitro assays to determine whether postoperative plasma stimulates proliferation and invasion.     

Molecular mechanisms underlying postoperative peritoneal tumor dissemination may differ between a laparotomy and carbon dioxide pneumoperitoneum: a syngeneic mouse model with controlled respiratory support

Background  The mechanisms promoting postoperative peritoneal tumor dissemination are unclear. This study aimed to investigate postoperative tumor dissemination over time on both tissue and molecular levels. Methods  For this study, C57BL6 mice were randomized into four groups: anesthesia alone (control), carbon dioxide (CO₂) pneumoperitoneum at low (2 mmHg) or high (8 mmHg) intraperitoneal pressure (IPP), and laparotomy. A mouse ovarian cancer cell line (ID8) was injected intraperitoneally just before surgery. The groups were further subdivided into three groups, and a laparotomy was performed to evaluate tumor dissemination on postoperative day (POD) 7, 14, or 42. Results  The incidence of cancer cell invasion into the muscle layers of the abdominal wall was significantly higher in the laparotomy and high-IPP groups than in the low-IPP and control groups on PODs 7 and 42. Expression levels of beta 1 integrin, cMet, urokinase-type plasminogen activator (uPA), urokinase-type plasminogen activator receptor (uPAR), and type-1 plasminogen activator inhibitor (PAI-1) mRNA in the disseminated nodules were not significantly different among the four groups on POD 7. However, the expression levels of all these genes in the disseminated nodules in the laparotomy group were significantly higher on POD 14 than on POD 7. They then returned to control levels on POD 42. There were no significant differences in the expression levels of any of these genes among the groups on POD 42. Conclusions  The current study suggests that the molecular mechanisms underlying postoperative peritoneal tumor dissemination may differ between a laparotomy and CO₂ pneumoperitoneum. Therefore, strategies targeting postoperative tumor dissemination likely will need to account for the surgical environment.     

The influence of percutaneous nephrolithotomy on human systemic stress response, SIRS and renal function

The objective of this study is to investigate the influences of percutaneous nephrolithotomy (PNL) and open surgery nephrolithotomy on the systemic stress response, SIRS and renal function. Forty patients with kidney calculi were enrolled in the study. Twenty cases were randomized to the PNL group and the other twenty cases to the open surgery group. Levels of C-reactive protein (CRP), interleukin-6(IL-6), β₂-microglobulin (β₂-MG), respiration rate, heart rate, body temperature and white blood cell counts were examined. CRP and IL-6 were measured in all patients pre-operatively and on post-operative days 1, 3 and 6, respectively. There was significant difference in their pre- and post-operation levels (P < 0.05), with the peak of CRP and IL-6 observed at post-operative days 3 and 1, respectively. There was significant difference in both CRP and IL-6 between the two groups (P < 0.05). At post-operative day 1, there were 5 cases of SIRS in PNL group and 12 cases in open surgery group; there was significant difference between the two groups (P < 0.05). Serum β₂-MG levels were measured as the same time as CRP and no significant changes were observed within or between the groups (P > 0.05). Urine β₂-MG levels were also measured. There was significant difference between pre- and the first day post-PNL (P < 0.05); there was no significant difference between pre- and the third and sixth day post-PNL (P > 0.05). There was significant difference between pre- and first and third day post-open surgery (P < 0.05); but there was no significant difference between pre- and the sixth day post-open surgery (P > 0.05). There was significant difference between two groups at the first, third and sixth days (P < 0.05). Conclusions: The systemic stress response is activated both in PNL group and open surgery group to some extent. The degree of stress response of PNL is lower than that of open surgery, proving the advantages of PNL with reference to serum immunology. There were cases in both the groups with SIRS, but the degree of SIRS in PNL group was lesser than the other group. Both the groups have no obvious effect on glomerular filtration function after operation and have effect on renal tubular reabsorption in the early stage after operation; but the recovery of the PNL group is faster than the open surgery group. It is thus shown that PNL is much safer and more feasible and has lesser effect on renal function.     

Major abdominal surgery increases plasma levels of vascular endothelial growth factor: open more so than minimally invasive methods

INTRODUCTION: Vascular endothelial growth factor (VEGF) is a potent inducer of angiogenesis that is necessary for wound healing and also promotes tumor growth. It is anticipated that plasma levels would increase after major surgery and that such elevations may facilitate tumor growth. This study's purpose was to determine plasma VEGF levels before and early after major open and minimally invasive abdominal surgery. METHODS: Colorectal resection for cancer (n = 139) or benign pathology (n = 48) and gastric bypass for morbid obesity (n = 40) were assessed. Similar numbers of open and laparoscopic patients were studied for each indication. Plasma samples were obtained preoperatively and on postoperative days (POD) 1 and 3. VEGF levels were determined via ELISA. The following statistical methods were used: Fisher exact test, unmatched Student t test, Wilcoxon's matched pairs test, and the Mann Whitney U Test with P < 0.05 considered significant. RESULTS: The mean preoperative VEGF level of the cancer patients was significantly higher than baseline level of benign colon patients. Regardless of indication or surgical method, on POD3, significantly elevated mean VEGF levels were noted for each subgroup. In addition, on POD1, open surgery patients for all 3 indications had significantly elevated VEGF levels; no POD1 differences were noted for the closed surgery patients. At each postoperative time point for each procedure and indication, the open group's VEGF levels were significantly higher than that of the matching laparoscopic group. VEGF elevations correlated with incision length for each indication. CONCLUSION: As a group colon cancer patients prior to surgery have significantly higher mean VEGF levels than patients without tumors. Also, both open and closed colorectal resection and gastric bypass are associated with significantly elevated plasma VEGF levels early after surgery. This elevation is significantly greater and occurs earlier in open surgery patients. The duration and clinical importance of this finding is uncertain but merits further study.     

Stress response and well-being after open,laparoscopic, and NOTES transgastric uterine horn resection in a randomized porcine model

Background

NOTES is believed to induce less surgical trauma than open and laparoscopic surgery. The degree of surgical trauma can be assessed by measuring serum levels of acute-phase proteins such as CRP and TNF-α. We conducted a prospective randomized survival trial in which the inflammatory responses after laparoscopic, open, and NOTES transgastric uterine horn resection were compared. The aim of this study was to investigate whether NOTES procedures induce less inflammatory response.

Methods

Thirty pigs were randomized into three groups to undergo open, laparoscopic, or transgastric uterine horn resection. Weight, body temperature, and postoperative recovery were recorded and venous blood samples were taken for analysis of CRP and TNF-α at different time points. Analyses of CRP and TNF-α were performed using pig-specific ELISA assays.

Results

Procedure time was significantly longer for NOTES [median = 121 min (range = 94–155)] compared with that for open surgery [median = 22 min (14–27)] and laparoscopy [median = 37 min (20–45)] (p < 0.0001). There was a nonsignificant tendency for shorter recovery time for the NOTES animals. Twenty-seven animals survived for 4 weeks. One animal in each group was euthanized prior to 4 weeks. All animals gained weight during the 4-week period with no significant differences. Only animals in the NOTES group showed a significant weight gain during the first postoperative week (p = 0.007). On postoperative day (POD) 1, CRP was significantly lower in the NOTES group compared with the open and laparoscopic groups (mean = 0.72 ± 0.22, 0.98 ± 0.26, and 0.97 ± 0.20, respectively; p = 0.048). The CRP levels were normalized on day 14. Throughout the study there were no significant changes in TNF-α levels in the laparoscopic and NOTES groups. At POD 3 the open surgery group showed significantly higher TNF-α levels than the other groups (p = 0.036).

Conclusions

Despite the longer operating time, the transgastric NOTES approach seems to be less traumatic than open or laparoscopic uterine horn resection in this porcine model.     

Prospective randomized controlled study of gastric emptying assessed by 13C-acetate breath test after pylorus-preserving pancreaticoduodenectomy: comparison between antecolic and vertical retrocolic duodenojejunostomy

Background/Purpose  To examine whether vertical retrocolic duodenojejunostomy is superior to antecolic duodenojejunostomy with respect to gastric emptying in a prospective, randomized, controlled study of patients undergoing pylorus-preserving pancreaticoduodenectomy (PpPD). Methods  Thirty-five patients undergoing PpPD between March 2005 and July 2007 were enrolled in the study. All provided informed consent. During PpPD, the patients were randomly assigned to either the antecolic (antecolic group, n = 17) or vertical retrocolic route (vertical retrocolic group, n = 18) just before the reconstruction. Each patient ingested ¹³C-acetate in a liquid meal before surgery and on postoperative day (POD) 30. Gastric emptying variables (Tmax, T1/2) were determined and compared between groups. Results  Clinical delayed gastric emptying, defined as an inability of patients to take in an appropriate amount of solid food orally by POD 14, was found in 1 of 17 patients (6%) in the antecolic group and in 4 of 18 patients (22%) in the vertical retrocolic group, but the difference was not significant (P = 0.34). Tmax and T1/2 on POD 30 were prolonged in both groups in comparison to preoperative levels, but no significant difference was found between the two groups. Follow-up examinations revealed that gastric emptying had recovered to the preoperative level by POD 30 in approximately 80% of the patients, regardless of the reconstruction route. Conclusions  Vertical retrocolic duodenojejunostomy does not seem to offer an advantage with respect to gastric emptying.     

Open Versus Minimally Invasive Resection of Gastric GIST: A Multi-Institutional Analysis of Short- and Long-Term Outcomes

Background

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract. Overall surgical experience with minimally invasive surgery (MIS) has increased; however, published reports on MIS resection of GIST are limited to small, single-institution experiences.

Methods

A total of 397 patients who underwent open surgery (n = 230) or MIS (n = 167) for a gastric GIST between 1998 and 2012 were identified from a multicenter database. The impact of MIS approach on recurrence and survival was analyzed using propensity-score matching by comparing clinicopathologic factors between patients who underwent MIS versus open resection.

Results

There were 19 conversions (10 %) to open; the most common reasons for conversion were tumor more extensive than anticipated (26 %) and unclear anatomy (21 %). On multivariate analysis, smaller tumor size and higher body mass index (BMI) were associated with receipt of MIS. In the propensity-matched cohort (n = 248), MIS resection was associated with decreased length of stay (MIS, 3 days vs open, 8 days) and fewer ≥ grade 3 complications (MIS, 3 % vs open, 14 %) compared with open surgery. High rates of R0 resection and low rates of tumor rupture were seen in both groups. After propensity-score matching, there was no difference in recurrence-free or overall survival comparing the MIS and the open group (both p > 0.05).

Conclusions

An MIS approach for gastric GIST was associated with low morbidity and a high rate of R0 resection. The long-term oncological outcome following MIS was excellent, and therefore the MIS approach should be considered the preferred approach for gastric GIST in well-selected patients.     

A comparative study on the short-term clinicopathologic outcomes of laparoscopic surgery versus conventional open surgery for transverse colon cancer

Background  The long-term oncologic stability of laparoscopic surgery for colon cancer was established, and laparoscopic surgery was accepted as an alternative to conventional open surgery for colon cancer. However, transverse colon cancer was excluded from the majority of the previous prospective studies. As a result, debate on laparoscopic surgery for transverse colon cancer continues. This study aimed to compare the clinicopathologic outcome of laparoscopic surgery with that of conventional open surgery for transverse colon cancer. Methods  From August 2004 to December 2007, 106 cases of transverse colon cancer were managed by resection at our institution, and 89 of these cases were included in this study. Age, sex, body mass index (BMI), operation time, blood loss, time to first flatus, time to start of diet, hospital stay, complications, tumor size, distal resection margin, proximal resection margin, and number of nodes harvested were compared between the two groups. Results  No significant differences were found between the laparoscopic and conventional groups in terms of age, sex, BMI, operation time, or hospital stay. The mean blood loss during the operations was significantly less in the laparoscopic group (113.8 ± 128.9 ml) than in the conventional group (278.8 ± 268.7 ml; p < 0.05). Moreover, the time to the first flatus was shorter (2.8 ± 0.9 days vs. 4.4 ± 2.0 days; p < 0.00) and the diet was started earlier (3.9 ± 1.7 days vs. 5.4 ± 1.9 days; p < 0.00) in the laparoscopic group. No intergroup differences in tumor size, proximal resection margin, or number of lymph nodes were observed. The mean distal resection margin was longer in the laparoscopic group (12.5 ± 4.1 cm vs. 9.2 ± 6.2 cm; p < 0.05). Conclusion  Laparoscopic and conventional open surgeries were found to have similar clinical outcomes in transverse colon cancer, and the oncologic quality of laparoscopic surgery was found to be acceptable compared with conventional open surgery.     

Classification and early recognition of gastric conduit failure after minimally invasive esophagectomy

Background  Esophagectomy is a high-risk procedure, with significant morbidity resulting from gastric conduit failure. Early recognition and management of these complications is essential. This study aimed to investigate the clinical value of routine investigations after minimally invasive esophagectomy (MIO) and to propose a classification system for gastric conduit failure. Methods  For esophagogastric resection, MIO is the procedure of choice in the authors’ unit. Standard postoperative care similar to that for open esophagectomy is undertaken on a specialist ward. Routine investigations include daily assessment of C-reactive protein (CRP), white cell count (WCC), and a contrast swallow on postoperative day (POD) 5. The authors performed a retrospective analysis to assess the utility of these tests. Results  Of a prospective cohort of 50 patients from April 2004 to July 2006, 26 (52%) had an uneventful recovery (U), 24 (48%) experienced complications (C) of varying nature and severity, and 1 died (2%). All the patients demonstrated a transient abnormal rise in CRP until POD 3. In group U, the levels then fell, but in group C, they remained elevated (POD 5: U = 96, C = 180; p < 0.01). This discrepancy trend was further exaggerated in the nine patients with gastric conduit failure (POD 5: GC = 254; p < 0.01), whereas contrast swallow failed to identify this complication in six patients. Simple anastomotic leaks (type 1, n = 4) were managed conservatively. Patients with conduit tip necrosis (type 2, n = 3) and complete conduit ischemia (type 2, n = 2) were managed by repeat thoracotomy and either refashioning of the conduit or take-down and cervical esophagostomy. None of the patients with conduit failure died. Conclusion  Postoperative CRP monitoring is a highly effective, simple method for the early recognition of gastric conduit failure. This new system of classification provides a successful guide to conservative management or revisional surgery. Presented at the Annual Scientific Meeting of the Association of Laparoscopic Surgeons of Great Britain and Ireland (ALSGBI), Leeds, November 2006, and the Annual Meeting of the Association of Surgeons of Great Britain and Ireland (ASGBI), Manchester, April 2007.     

Effect of primary tumor resection on overall survival in patients with stage IV breast cancer

We aimed to evaluate the effect of primary tumor resection on overall survival in stage IV breast cancer patients. In total, 284 breast cancer patients presenting with breast cancer at stage IV at initial diagnosis, between 2001 and 2014, were enrolled in the study. Patients were divided into two groups based on surgical resection of the primary tumor. Overall survival (OS) between the two groups was analyzed. Patients in the surgery group (n = 92) had smaller tumors than those in the no‐surgery group (n = 192, T0‐1:17.7% vs 34.8%, P < 0.001). The surgery group more often had negative nodal status (5.7% vs 33.7%, P < 0.001). Multiple metastatic organ sites were more common in the no‐surgery group than in the surgery group (55.7% vs 15.2%, P < 0.001). The surgery group showed a better OS than the no‐surgery group (P = 0.01). Multivariate analysis showed that surgical resection of primary tumors tended to be associated with improved OS (HR = 0.67, P = 0.055). T stage, ER, HER2 and metastatic organ sites were independent prognostic factors for OS in multivariate analysis. Surgical resection of the primary tumor may be a treatment option for patients with stage IV disease and may not have a negative effect on overall survival.     

Laparoscopic resection of extraperitoneal rectal cancer: a comparative analysis with open resection

Purpose  The aim of this study was to compare the outcomes of laparoscopic surgery with those of open resection in patients with extraperitoneal rectal cancer. Methods  Five hundred forty-four patients with extraperitoneal rectal cancer who underwent curative resection between 1996 and 2007 were included. Patients were divided into a laparoscopic surgery group (LAP, n = 170) and an open surgery group (OPEN, n = 374). Results  Morbidity requiring surgical correction was 5.8% in the LAP group and 4.8% in the OPEN group (p = 0.75). The anastomotic leakage rate was similar in both groups (5.7% in both; p = 0.98). Differences were found in preoperative carcinoembryonic antigen (CEA) (LAP group 4.6 ng/ml, OPEN group 7.7 ng/ml, p = 0.001), sphincter preservation (LAP group 82.9%, OPEN group 69.8%, p = 0.001), and mean distance from anal verge (LAP group 4.6 cm, OPEN group 5.2 cm, p = 0.002). Local recurrence and metastasis were similar by stage. Conclusions  The results of this study show that laparoscopic resection of extraperitoneal rectal cancer was safe and effective.