Functional assessment after colectomy,mucosal proctectomy,and endorectal ileoanal pull-through

Radiographic, manometric, and clinical techniques were used to assess the functional results after colectomy, mucosal proctectomy, and endorectal ileoanal pull-through (IAP). In 40 patients with ulcerative colitis, Gardner's syndrome, or familial polyposis, anorectal manometry was performed before IAP and 2 months and 1 year afterward. At 4 weeks after IAP, a standardized water contrast radiograph allowed an estimation of the dimensions of the ileal pouch and the integrity of the ileoanal anastomosis. Radiographically, the mean ± SE length, width, and depth of the ileal pouch were 10.9±0.6 cm, 4.5±0.6 cm, and 3.9±0.2 cm, respectively. No anastomotic leaks were identified; however, 2 patients were incontinent to the contrast material. The mean maximal anal sphincter resting pressure decreased from a mean ± SEM of 87.1±3.2 mmHg preoperatively to 68.1±3.1 mmHg 8 weeks after operation, but by 1 year resting pressure increased to 72.3 ±4.9 mmHg. The change in sphincter pressure with voluntary squeeze was greater 8 weeks after IAP than before the operation (114.0±8.2 mmHg versus 97.7±6.2 mmHg) and increased further by 1 year. No patient experienced major episodes of incontinence. Mean ± SEM stool frequency per 24 hours decreased from 7.5±0.5 at 1 month after ileostomy closure to 6.4±0.7 at 12 months. Ileal pouch capacity increased with time and was inversely related to stool frequency. It was concluded that endorectal pull-through of an ileal J pouch, by providing an adequate intestinal reservoir and preserving nearly normal anal sphincter function, results in anal continence and acceptable stool frequency.

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Resumen Se utilizaron técnicas radiográficas, manométricas y clínicas para evaluar los resultados funcionales después de colectomía, protectomía mucosal y del descenso (pull-through) endorrectal ileoanal (PEI). La manometría anorrectal fué realizada en 40 pacientes con colitis ulcerativa, síndrome de Gardner o poliposis familiar, antes y 2 meses y 1 año después de la PEI. A las 4 semanas después de la PEI un estudio radiográfico estandarizado con agua permitió estimar las dimensiones de la bolsa ileal y la integridad de la anastomosis ileoanal. Radiográficamente el promedio de la longitud, ancho y profundidad de la bolsa ileal fué de 10.9± 0.6 cm, 4.5±0.6 cm y 3.9±0.2 cm respectivamente. No se identificaron escapes anastomóticos; sin embargo, dos pacientes aparecieron incontinentes con el material de contraste. La presión màxima promedio del esfínter anal en reposo disminuyó de un promedio de 87.1±3.2 mmHg a 68.1±3.1 mmHg ocho semanas después de la operación, pero al final de un año la presión en reposo había aumentado a 72.3±4.9 mmHg. El cambio en la presión esfinteriana al hacer una contracción voluntaria fué mayor ocho semanas después de la PEI que antes de la operación (114.0±8.2 mmHg vs 97.7±6.2 mmHg) y aumentó aún más después de un año. Ningún paciente exhibió episodios mayores de incontinencia. La frecuencia promedio de defecaciones diarias disminuyó de 7.5±0.5 al mes después del cierre de la ileostomía a 6.4±0.7 a los 12 meses. La capacidad de la bolsa ileal aumentó con el paso del tiempo y se halló en relación inversa a la frecuencia de las defecaciones. Se llegó a la conclusión de que el descenso (pull-through) endorrectal de una bolsa ileal en J, al proveer un adecuado reservorio intestinal y preservar una función casi normal del esfínter anal, resulta en continencia anal y en una aceptable frecuencia del número de defecaciones diarias.

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Résumé Des méthodes cliniques, manométriques et radiographiques ont été employées pour apprécier les résultats fonctionnels postopératoires après la colectomie associée à la protectomie muqueuse et à l'abaissement iléal transanal. Chez 40 malades qui présentaient une colite ulcéreuse, un syndrome de Gardner ou une polypose familiale, la manométrie anorectale fut pratiquée avant l'intervention puis respectivement 2 mois, 1 an après l'intervention. Quatre semaines après celle-ci une exploration radiographique standard permis d'apprécier les dimensions du réservoir iléal et l'intégrité de l'anastomose iléo-anale. En moyenne sur les radiographies la longueur, la largeur, la profondeur moyenne étaient respectivement 10.9± 0.6 cm 4.5±0.6 cm et 3.9±0.2 cm. Aucune fuite au niveau de l'anastomose ne fut constatée mais deux patients présentèrent une continence lors du lavement. La pression au repos du sphincter anal (moyenne de la maximale) décru de 87.1±3.2 mmHg à 68.1±3.1 mmHg 8 semaines après l'opération mais après un an elle se relèva jusqu'à 72.3±4.9 mmHg. La modification de la pression sphinctérienne lors de la contraction volontaire fut plus grande après l'intervention qu'avant l'opération (114.0±8.2 mmHg versus 97.7±6.2 mmHg) et s'accrut progressivement pendant un an. Aucun malade ne présenta d'épisodes importants d'incontinence. La fréquence moyenne des selles pendant 24 heures décrus de 7.5. ±0.5 un mois après la fermeture de l'iléostomie à 6.4 ±0.7 après 12 mois. La capacité du réservoir iléal augmenta avec le temps cependant que la fréquence des selles diminua. De ces faits, on peut conclure que ce type d'opération avec un réservoir iléal en J abouti à la constitution d'un réservoir intestinal adéquat tout en conservant une fonction sphinctérienne anale normale, une continence satisfaisante et un nombre acceptable de selles.

     

Anal sphincter function after colectomy, mucosal proctectomy, and endorectal ileoanal pull-through

Anal sphincter function in patients before and after colectomy, mucosal proctectomy, and endorectal ileoanal pull-through was assessed prospectively. In 21 patients with ulcerative colitis, Gardner's syndrome, or familial polyposis, anorectal manometry was performed before and eight weeks after ileoanal pull-through. The mean +/- SEM maximal anal sphincter resting pressure decreased from 86 +/- 5 to 68 +/- 4 mm Hg after operation. The net change in pressure with squeeze, however, was greater after ileoanal pull-through than before operation (100 +/- 9 v 92 +/- 7 mm Hg). In 19 of 21 patients after operation, balloon dilation of the ileal pouch resulted in relaxation of the internal anal sphincter and contraction of the external anal sphincter. Mean +/- SEM 24-hour stool frequency decreased from 7.6 +/- 0.6 at one month to 6.2 +/- 0.5 at three months. It was concluded that ileoanal pull-through preserves continence and an acceptable stool frequency by maintaining nearly normal anal sphincter function.     

Proctocolectomy and ileoanal anastomosis with an S pouch: functional results

Patients with total colonic ulcerative colitis or familial polyposis traditionally require a proctocolectomy. In an effort to preserve the normal pathway for defecation and avoid the nuisance of an abdominal stoma, a continence-preserving procedure involving a pelvic reservoir has been performed at the University of Minnesota Hospitals on 120 patients. The majority were operated on for colonic ulcerative colitis. There were no deaths. The mean hospital stay after restorative proctocolectomy was 10 days and after ileostomy takedown the mean stay was 7 days. Functional results were assessed in 52 patients. Daytime bowel movements averaged 6.4 and night-time movements 1.4. Major daytime incontinence occurred in 6% of the patients, 21% had moderate soiling at night and 70% wore a perineal pad in the evening. Ninety-two percent of the patients expressed satisfaction with the procedure. The most serious complication was pelvic sepsis. It occurred in nine patients, six of whom required subsequent surgery. The Parks S pouch provides a means of maintaining anal continence. This series and others have shown that young, healthy, well-motivated persons will benefit most from a restorative proctocolectomy.     

Changing management in familial polyposis. Role of ileoanal endorectal pull-through

Total colectomy with ileoproctostomy was performed in 32 members of a family spanning three generations and ranging in age from 10 to 54 years. In seven of these patients (22 percent) carcinoma developed in the retained rectum over a median follow-up period of 14 years. This high incidence of rectal carcinoma has demanded reevaluation of treatment recommendations in patients with polyposis coli. Ten patients aged 7 to 30 years have undergone total abdominal colectomy with ileoanal endorectal pull-through since 1980. All were one stage procedures without reservoir construction. Within 3 months the patients all had good control with 5 to 10 semiformed stools daily and had resumed normal activities. Follow-up date shows adequate dilatation of the distal ileum and no evidence of polyps. Total colectomy and ileoanal endorectal pull-through are effective treatment for familial polyposis in patients of all ages. It should be considered the primary procedure in new patients and an excellent method of converting those patients who have ileoproctostomy to a safer situation.     

Long-term prospective assessment of functional results after proctectomy with coloanal anastomosis

The objective of this study was to prospectively assess the long-term functional results after restorative proctectomy with coloanal anastomosis for rectal cancer. Thirty consecutive patients (18 males; mean age 59.6 ±9.8 years, range 40 to 75 years) underwent proctectomy with coloanal anastomosis for rectal cancer between January 1990 and March 1997. Cancers were located between 5 and 12 cm from the anal verge. Differences existed in the administration of adjuvant therapy and in the kind of anastomotic reconstruction. An 8 cm colonie J-pouch was fashioned in 11 patients. The coloanal anastomosis was protected by a diverting loop ileostomy in 22 patients. All patients were evaluated using a prospective patient-completed protocol to record daily bowel activity over a 1-week period at 3, 6, and 12 months, and yearly thereafter. Mean follow-up extends to 55.5 ±27 months (range 7 to 117 months). There were no perioperative deaths. Four patients (13.3%) developed a clinically evident anastomotic dehiscence. Overall, stool frequency decreased from 4.4 ±2.5 bowel movements per day at 3 months to 3.0 ±2.8 bowel movements per day at 5 years. Patients with a J-pouch had a lower stool frequency in comparison to patients with an end-to-end coloanal anastomosis during the entire study period (from 3.2 ±2.2 vs. 3.9 ± 2.7 bowel movements per day at 6 months to 2.8 ±1.9 vs. 3.4 ±4.0 bowel movements per day at 5 years; no statistical significance). The percentage of continent patients increased from 50% at 6 months to 75% at 5 years; the percentage of patients with incontinence for solid stool and with frequent incontinence (≥7 episodes per week) decreased from 35.7% at 6 months to 12.5% at 5 years. The influence of the type of anastomosis, dehiscence, protective stoma, J-pouch, radiation therapy, and gender was evaluated with univariate analysis. Although there was no statistically significant correlation between any of these variables and the development of incontinence, when incontinence occurred, a history of anastomotic dehiscence increased the number of episodes of incontinence per week and the percentage of episodes of incontinence for solid stools at 6 months, 2 years, and 5 years (P <0.05 and P <0.001, respectively); the use of preoperative radiation therapy increased the number of episodes of incontinence per week at 6 months, 1 year, 2 years, and 5 years (P <0.01) and the percentage of episodes of incontinence for solid stools at 3 and 6 months and 1 and 2 years (P <0.04); and the presence of a J-pouch increased the number of episodes of incontinence per week at 1 and 2 years (P <0.03 and 0.005, respectively) and the percentage of episodes of incontinence for solid stools at 2, 3, and 4 years (P <0.05). These data suggest that the functional results after proctectomy with coloanal anastomosis improve at least over the course of the first 5 postoperative years. Furthermore, when incontinence develops, its severity is made worse by the occurrence of an anastomotic dehiscence, the use of preoperative radiation therapy, and the presence of a J-pouch. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 21–24, 2000.     

Mucosal proctectomy and colo-anal anastomosis for distal ulcerative proctocolitis

Four patients with long-standing symptomatic ulcerative colitis confined to the left colon and rectum were treated by resection, mucosal proctectomy and colo-anal sleeve anastomosis. There was no operative mortality or anastomotic leakage. Follow-up has ranged from 12 to 66 months (mean 52 months). Loose bowel motions with urgency and frequency of defaecation were troublesome postoperative symptoms. Recurrence of the colitis in the neorectum with extension into the proximal colon occurred in all patients within 3 to 11 months (mean 6 months) of operation. This necessitated total proctocolectomy with ileostomy in three patients (mean 18 months postoperatively). In the fourth patient the recurrence is medically controlled without a stoma more than 5 years after operation. This operation is unsuitable for the treatment of segmental ulcerative proctocolitis.     

The elephant trunk technique: operative results in 100 consecutive patients.

OBJECTIVES: To describe morbidity and mortality in patients undergoing the elephant trunk (ET) implantation as the first stage in the repair of their mega aorta and to assess determinants for the occurrence of complications. METHODS: One hundred consecutive patients undergoing an ET implantation between 1984 and June 2001 were retrospectively analyzed. The ET was implanted as an extension of an isolated aortic arch (1%), an aortic valve replacement+ascending aorta+arch (14%), a root replacement+ascending aorta+arch (37%) and an ascending aorta+arch (48%). Indications for surgery were acute aortic dissection (1%), an inflammatory aneurysm (3%), chronic post-dissection (31%) or degenerative (65%) aneurysm. Marfan syndrome was present in six patients. For cerebral protection, we used isolated deep hypothermic circulatory arrest (7%), deep hypothermic circulatory arrest combined with uni- or bilateral antegrade cerebral perfusion (18%) or isolated uni- or bilateral antegrade cerebral perfusion (75%). Uni- and multivariate analysis was used. RESULTS: There were no intraoperative deaths. Hospital mortality was 8%. The causes of death were cardiac in one, rupture of a remote aneurysm in three, tamponade in one and sepsis in three. After multivariate analysis, no single factor emerged as a risk factor for hospital mortality. Permanent and transient neurologic dysfunction occurred in 4 and 2%, respectively. Univariate analysis showed the operative period before 1990 (P=0.029) and emergency (P=0.018) as significant factors for postoperative neurologic dysfunction; after stepwise logistic regression analysis, only emergent operation retained significance (P=0.005). Permanent hoarseness, total atrioventricular block requiring pacemaker implantation and re-thoracotomy for bleeding occurred in 17, 2 and 30%, respectively. CONCLUSIONS: The first step in the repair of a mega aorta, the implantation of an ET, can be performed with a low mortality and an acceptable morbidity. The risk of central neurologic damage is higher in emergency interventions.     

Studies on total colectomy, mucosal proctectomy and ileoanal anastomosis (ileoanostomy)

Studies have been made in order to establish a practical operative procedure of the ileoanostomy as well as to understand its postoperative pathophysiology using 45 patients including 34 with familial polyposis and 11 with ulcerative colitis those which have been followed up for 1 to 4 years. Three major technical problems here with challenged are how to minimize the complications, how to improve the bowel function and how to simplify the procedure. Our J-pouch method was found to have better bowel function compared with those without a pouch and those with H-pouch and also considered to be superior to S-pouch, with its consistent spontaneous evacuation and with a simpler construction. The length of rectal cuff was found to be able to be minimized down to just above the levator muscle without disturbing the bowel function, based on our experiences on two polyposis cases with rectal cancers. The short rectal cuff of about 7-6 cm was considered to be the method of choice for eliminating the cuff abscess in addition to routine use of a diverting ileostomy, and for technical simplification. Ano-abdominal rectal mucosectomy at prone-jack-knife position is recommended to achieve further technical feasibility. The pathophysiological studies including anorectal manometry, intestinal transit time, physical, chemical and bacteriological analysis of the stool, water absorption of the ileal neorectum as well as the systemic metabolic studies supported favorable clinical result of our method. Ileoanostomy by our principle consisting of J-pouch, short cuff and loop-ileostomy, was concluded to be a break through to avoid an abdominal ileostomy after total proctocolectomy.     

Endorectal ileoanal anastomosis with isoperistaltic ileal reservoir after colectomy and mucosal proctectomy.

Forty-nine patients with chronic ulcerative colitis refractory to medical therapy and four with multiple polyposis have undergone total colectomy, mucosal protectomy, and endorectal ileal pull-through with ileoanal anastomosis at the UCLA Medical Center during the past 12 years (mean age, 19.4 years). Thirty-eight patients underwent second-stage closure of the ileostomy with construction of a side-to-side isoperistaltic ileal reservoir (mean, 6 months) after the ileal pullthrough operation. The anastomosis extended over a 20-30 cm distance and the lower end was placed within 6-8 cm of the ileonanal anastomosis. Transient reservoir inflammation, which occurred in half of the patients, was reduced by the use of oral metranidazole and was rarely found 6 months after operation. No patients died during the early or late post-operative periods. Cuff abscess in two patients and obstruction of the ileal reservoir outlet have required takedown of the reservoir (two patients) or temporary ileostomy (three patients). Of the 38 patients who have undergone lateral ileal reservoir construction, 33 have achieved a good to excellent result with complete continence and an average of five stools per 24 hours after 6 months. At least 12 patients now participate in competitive athletics; normal sexual activity has been achieved in all but one patient. Seven patients await construction of the reservoir. Although a technically difficult operation, the long-term results (mean, 19.4 months) indicate that the pullthrough operation is a good alternative to standard proctocolectomy.     

Quality-of-life assessment after ileoanal pull-through for ulcerative colitis and familial adenomatous polyposis

BACKGROUND/PURPOSE: The ileoanal pull-through procedure (IAP) is gaining increasing favor and use in the surgical treatment of children with ulcerative colitis (UC) and familial adenomatous polyposis (FP). Although physiological studies have been performed to assess the outcome of these children, no long-term quality-of-life assessment after the procedure has been performed. METHODS: Forty-three patients were identified who had an IAP at our institution in the last 10 years and were at least 6 months postsurgery. Thirty-four were contacted, and 32 agreed to participate in the survey, which was approved by the Human Studies Committee. Participants completed the standardized Medical Outcome Study Short Form-36 (SF-36), which has well-established normative values. Several supplemental questions were prepared in a similar format dealing with issues specific to the ileoanal pull-through procedure. RESULTS: Of the 32 participants, 19 (59%) were girls and 26 (81%) had ulcerative colitis. Mean age at the time of survey was 18.1 years with 12 less than 18 years and 20 > or =18 years. Data from the latter group could be compared with national normative values for this age. The study group was not statistically different from age-appropriate US population normal values on all assessable scales of physical and mental health in the SF-36 survey including physical functioning, role limitations-physical, bodily pain, general health, vitality, social functioning, role limitations-emotional, and mental health (all P>.05 or mean difference SD units <0.8). The supplemental questionaire demonstrated little adverse effect of the surgery. There was limited consumption of medications to control bowel frequency and little restriction of activity because of the frequency of bowel movements or fear of incontinence. The surgical scar was the sole negative factor of significance. CONCLUSIONS: The ileoanal pull-through procedure is an excellent surgical option for children with ulcerative colitis or familial adenomatous polyposis, and it produced minimal, if any, adverse effects on their long-term quality of life.     

The pelvic pouch and ileoanal anastomosis procedure. Surgical technique and initial results

The pelvic pouch and ileoanal anastomosis procedure should be considered a reasonable alternative for selected patients with ulcerative colitis and familial polyposis. Patients can expect an improved quality of life without a stoma, particularly those with ulcerative colitis. The long-term effects of the reservoir are not completely known; however, from previous reports and from experience with the Kock's ileostomy reservoir, it seems unlikely that there will be a long-term metabolic problems. It appears that a reservoir is essential in adults to minimize stool frequency to an acceptable level and that there is an inverse correlation between pouch size and stool frequency. We still consider this to be an evolutionary procedure and, as such, it should be confined to specialized centers where larger experiences can be accumulated. For the majority of patients who are being considered for proctocolectomy and ileostomy, we urge that they be made aware of alternative forms of therapy and that retaining the rectum should be considered in these patients due to the possibility of reconstructive surgery at a future date.     

Preoperative terminal ileal and colonic resection histopathology predicts risk of pouchitis in patients after ileoanal pull-through procedure.

OBJECTIVE: This study seeks to compare the histopathology of preoperative terminal ileal and colonic resection specimens with pouch biopsies after the ileoanal pull-through (IAPT) procedure. SUMMARY BACKGROUND DATA: Pouchitis is the most frequent complication of transanal continent reservoirs in patients after IAPT. METHODS: The authors conducted 751 consecutive pouch biopsies on 73 patients with inflammatory bowel disease or familial adenomatous polyposis who underwent IAPT by a single surgeon over a 10-year period. In this preliminary report, a pathologist, in blinded fashion, has graded 468 of the IAPT pouch biopsies and 67 of the patients' preoperative terminal ileal and colonic resection histopathology to date. Colonic histopathology was graded by the extent and severity of disease, terminal ileal and pouch histopathology by active inflammation, chronic inflammation, lymphocyte aggregates, intraepithelial lymphocytes, eosinophils, and villous blunting. RESULTS: Extent of colonic disease (gross and microscopic) was a significant predictor of active inflammation in subsequent IAPT pouch biopsy specimens. Also, the gross extent of colonic disease exhibited a significant linear association with pouch inflammation. However, the severity of colonic disease was not significantly predictive of active inflammation in subsequent IAPT pouch biopsies. Terminal ileal active and chronic inflammation were significant predictors of subsequent IAPT pouch inflammation. Although lymphocyte aggregates and intraepithelial lymphocytes were not predictive, terminal ileum eosinophils and villous blunting were significant predictors of active inflammation in subsequent IAPT pouch biopsy specimens. CONCLUSIONS: Preoperative terminal ileal and colonic histopathology predicts active inflammation of pouches after IAPT. Patients who are preoperatively assessed to have extensive disease of the colon, ileal disease ("backwash ileitis"), or both appear to be at greater risk for the development of pouchitis after IAPT.     

Differences in ano‐neorectal physiology of ileoanal and coloanal reconstructions for restorative proctectomy

Objective Restorative proctectomy with straight coloanal anastomosis (CAA) and restorative proctocolectomy with ilealpouch‐anal anastomosis (IPAA) are options for maintaining bowel integrity after rectal resection. The aim of this study was to compare clinical function and anorectal physiology in patients treated with CAA and IPAA. Method Three‐dimensional vector‐manometry and neorectal volumetry were performed in straight CAA [53 patients (34 male)] and IPAA [61 patients (39 male)] for ulcerative colitis. Function was assessed using a 14 day incontinence diary. Results Function was similar in both groups, but neorectal compliance and threshold volumes for sensation, urge and maximum tolerated volume (MTV) were significantly higher after IPAA than after CAA. Mean pressure, vector volume and sphincter symmetry at rest were significant determinants of continence in both groups but squeeze pressure did not correlate significantly with function in either group. Threshold volume, MTV, and compliance were significantly correlated with frequency of defecation in patients with IPAA but not with CAA. Conclusion A strong consistent resting anal sphincter pressure is one determinant of continence after both IPAA and CAA. Squeeze pressures do not influence the functional result. In IPAA but not CAA, the neorectum has a reservoir function which correlates with the postoperative frequency of defaecation.     

Clinical and functional results after elective colonic resection in 75 consecutive patients with diverticular disease

BACKGROUND: Functional results after elective colonic resection in patients with diverticular disease have seldom been studied. METHODS: Seventy-five consecutive patients were reviewed and sent a questionnaire about abdominal symptoms and functional results. Possible associations between patients' characteristics and postoperative complications or functional outcome were analyzed. RESULTS: Major complications including anastomotic leakage, bleeding, and bowel obstruction occurred in 10 patients (13%). Six patients (8%) had recurrent diverticulitis. No significant associations were found between clinical characteristics and postoperative complications or recurrent disease. Fifty patients classified their final result as excellent or good. Functional symptoms or symptoms suggestive of irritable bowel syndrome before the operation predicted a less successful result (P <0.05). CONCLUSIONS: Elective surgery in patients with diverticular disease was hampered by postoperative complications but resulted in most cases in good functional outcome and a low rate of recurrent disease. Those with functional bowel symptoms before surgery had significantly worse results.     

23例次肺移植术后受者的临床分析

目的 评估23例次肺移植术后受者的临床预后情况.方法 总结2003年1月至2007年8月施行的23例次(21例患者)肺移植的临床资料.分析存活率及并发症.结果 肺移植围手术期死亡率为13%;术后3个月、1年、2年和3年的累积存活率分别为82.6%、82.6%、69.7%和58.1%.受者术后2个月时的通气和换气功能较术前明显改善(P<0.05).有10例受者术后6个月内出现轻度急性排斥反应,经激素冲击治疗后均缓解.4例受者分别于术后8个月、9个月、14个月和24个月时出现慢性排斥反应;术后6、12和24个月时未发牛慢性排斥反应的受者分别为95%、78.2%和71.1%.术后肺部感染发生率为33.3%;气管吻合口软化和狭窄发生率为14.3%.结论 肺移植术后受者的中期存活率较高;肺部感染和支气管吻合口软化及狭窄是肺移植术后主要并发症.     

Robotic liver resection: technique and results of 30 consecutive procedures

Background

Robotic surgery can enhance a surgeon’s laparoscopic skills through a magnified three-dimensional view and instruments with seven degrees of freedom compared to conventional laparoscopy.

Methods

This study reviewed a single surgeon’s experience of robotic liver resections in 30 consecutive patients, focusing on major hepatectomy. Clinicopathological characteristics and perioperative and short-term outcomes were analyzed.

Results

The mean age of the patients was 52.4?years and 14 were male. There were 21 malignant tumors and 9 benign lesions. There were 6 right hepatectomies, 14 left hepatectomies, 4 left lateral sectionectomies, 2 segmentectomies, and 4 wedge resections. The average operating time for the right and left hepatectomies was 724?min (range 648–812) and 518?min (range 315–763), respectively. The average estimated blood loss in the right and left hepatectomies was 629?ml (range 100–1500) and 328?ml (range 150–900), respectively. Four patients (14.8%) received perioperative transfusion. There were two conversions to open surgery (one right hepatectomy and one left hepatectomy). The overall complication rate was 43.3% (grade I, 5; grade II, 2; grade III, 6; grade IV, 0) and 40% in 20 patients who underwent major hepatectomy. Among the six (20.0%) grade III complications, a liver resection–related complication (bile leakage) occurred in two patients. The mean length of hospital stay was 11.7?days (range 5–46). There was no recurrence in the 13 patients with hepatocellular carcinoma during the median follow-up of 11?months (range 5–29).

Conclusions

From our experience, robotic liver resection seems to be a feasible and safe procedure, even for major hepatectomy. Robotic surgery can be considered a new advanced option for minimally invasive liver surgery.     

An infiltration technique for reduction mammaplasty: results in 192 consecutive breasts

The use of local anaesthetic infiltration with adrenaline is now considered safe in reduction mammaplasty. However, the technique of infiltration by those who support its use is often unclear. Any technique must take account of the neurovascular anatomy of the breast if it is to be effective. We propose the use of a large volume of dilute local anaesthetic (20 ml of 1% lignocaine and 1 mg of adrenaline made up to 400 ml with 0.9% saline) which is placed judiciously in the retroglandular space 15 minutes prior to surgery. The results in 96 consecutive patients (192 breasts) who had an inferior pedicle technique were analysed. The breast complication rate was 9.36% and the patient complication rate 19.79%. Postoperative blood loss ranged from 0 to 305 ml with a mean of 56.03 ml and a median of 50 ml. The described method could be considered a variation of the tumescent technique used in liposuction. The results is an almost bloodless dissection with minimal postoperative blood loss. It should be possible to dispense with the use of drains in most cases.