Outcomes assessment and minimally invasive surgery

Background: Outcomes assessment is being used increasingly to shape practice patterns in all areas of medicine. Although outcomes assessment is not a new concept, the widespread application of outcomes measurement for modifying practice is novel. Instead of focusing on results of interventions in highly controlled environments, outcomes studies usually report results as they occur in uncontrolled, real-world environments. Recently, the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) has initiated a society-wide initiative to monitor outcomes in patients undergoing various laparoscopic operations. Methods: Pertinent literature is reviewed as it relates to outcomes assessment. The historical background underpinning the modern interest in outcomes is outlined. Definitions of terms useful for understanding outcomes research are given. The impact of outcomes assessment on minimally invasive surgery, both positive and negative, are examined. The SAGES outcome initiative is introduced. Conclusions: Although outcomes studies usually do not provide information on the causes of observations made, they have gained in popularity because they provide information about patient perceptions of disease, disability, and treatment. Minimally invasive surgical procedures often are reported in terms of outcomes assessment because a controlled clinical trial was rendered impossible by early and widespread application of laparoscopic surgery. The SAGES outcomes initiative will provide the necessary tools for the participation of surgeons in the process of practice profiling. Received: 17 December 1999/Accepted: 4 April 2000/Online publication: 29 August 2000     

Effects of perioperative alpha1 block on haemodynamic control during laparoscopic surgery for phaeochromocytoma

Background. Laparoscopic surgery for phaeochromocytoma can causeexcessive catechol amine release with severe hypertension andsinus tachycardia. I.V. calcium antagonists may be used to preventincreases in blood pressure during phaeochromocytoma resection.We investigated the effects of perioperative     

Hypolgcaemic encephalopathy following surgery on phaeochromocytoma

Severe hypoglycaemia as a complication of excision of a phaeochromocytoma has been reported seven times in the world literature. The eighth case, reported here, is unusual for the severity of the hypoglycaemic neurological damage which persisted for 10 weeks before ultimate recovery.     

Cystic phaeochromocytoma is a distinctive subgroup with special clinical, imaging and histological features that might mislead the diagnosis

OBJECTIVE

To report and analyse cases of cyctic phaeochromocytoma at our institution and in previous publications, as adrenal cystic masses are usually associated with nonfunctional lesions, but they can be phaeochromocytoma.

PATIENTS AND METHODS

The prospective adrenalectomy database at our institution was reviewed to identify patients with phaeochromocytoma and cystic lesions. The clinical, radiological and histological features of cystic phaeochromocytoma were evaluated. Other previously published data were identified and compared with the present series.

RESULTS

In all, there were 107 adrenalectomies at our institution from November 2000 to March 2007; 31 of these patients had a confirmed diagnosis of phaeochromocytoma and six (19%) were cystic phaeochromocytomas. Three of the six cases were asymptomatic and had a negative biochemical evaluation (one male and five females, mean tumour size 6.6 cm); the imaging diagnosis was mainly based on computed tomography and magnetic resonance imaging, and the foremost feature was the enhancement of the tumour rim associated with a central cystic mass. Nine other previously published cases were reviewed.

CONCLUSIONS

From the present large series and previous anecdotally reported cases, patients with cystic phaeochromocytomas are more likely to be asymptomatic, to complain of chronic abdominal pain, and to have a negative biochemical evaluation, which might deter physicians from conducting a full evaluation for phaeochromocytoma and mislead the final diagnosis. As such, there could be an even higher prevalence of this entity that is yet to be determined.     

Open versus minimally invasive surgery for suspected adrenocortical carcinoma

Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis. Although laparoscopy has been widely adopted for management of benign adrenal tumors, minimally invasive surgery for ACC remains controversial. Retrospective analyses, frequently with fewer than one hundred participants, comprise the majority of the literature. High-quality data regarding the optimal surgical approach for ACC are lacking due to the rarity of the disease and the fact that determination of tumor type (e.g., adenoma or carcinoma) is determined after adrenalectomy, since adrenal tumors are generally not biopsied. While the benefits of minimally invasive surgery including lower intra-operative blood loss and decreased hospital length-of-stay have been consistently demonstrated, clinical equipoise for long-term survival and recurrence outcomes between open and minimally invasive adrenalectomy (MIA) remains. This review examines retrospective studies that directly compare patients with ACC who underwent either open or laparoscopic adrenalectomy, and considers these findings in the context of current guideline recommendations for surgical management of ACC.     

The clinical spectrum of phaeochromocytoma: analysis of 115 patients

OBJECTIVE

To analyse the presentation, manifestations and outcome in consecutive patients with phaeochromocytoma, as this disease has a wide range of pathological and clinical expressions.

PATIENTS AND METHODS

The records of 115 patients with phaeochromocytoma were analysed retrospectively, recording the patients’ age, sex, presenting symptoms and clinical signs, chemical, radiological and pathological findings and associated conditions.

RESULTS

Of the 115 patients, 90 had adrenal tumours, 18 extra‐adrenal and seven combined adrenal and extra‐adrenal tumours. Ten patients had malignant and 105 had benign phaeochromocytoma. Eighty‐six patients had sporadic and 29 had familial phaeochromocytoma, comprising eight with von Hippel‐Lindau (VHL) disease, 17 with multiple endocrine neoplasia type II (MEN II) and four with von Recklinghausen disease. Two patients with sporadic phaeochromocytoma had Grave’s disease. Ten patients (8.7%) had malignant phaeochromocytoma, of whom two had MEN II. A pregnant woman required prolonged intensive‐care management before adrenalectomy and lost a fetus.

CONCLUSION

Phaeochromocytoma is an interesting clinical entity with a wide spectrum of pathological and clinical manifestations. The diagnosis of phaeochromocytoma is confirmed by chemical methods, and located using imaging techniques, with computed tomography, magnetic resonance imaging and ¹³¹I‐meta‐iodobenzyl guanidine radioisotope scanning being the most common. This series reflects the pathological and clinical spectrum of phaeochromocytoma. The presence of other manifestations of familial phaeochromocytoma influenced the presentation and prognosis of these patients.     

The perioperative management of children with phaeochromocytoma

The safe anaesthetic management of a child with a phaeochromocytoma requires an understanding of the pathophysiology of the disease, together with a thorough knowledge of its pharmacology, in order to avoid or minimize the potentially harmful cardiovascular changes that may occur during anaesthesia. Although there is a considerable amount of information on the management of the adult with phaeochromocytoma, much less has been written concerning children with the disease. Children differ significantly from adults in the incidence, location, presentation and management of this condition and these differences are discussed here together with some of the more controversial issues of management.     

微创经椎间孔减压腰椎融合内固定术与传统后路开放手术治疗腰椎退变性疾病的疗效比较

目的:比较Quadrant通道辅助下微创经椎间孔减压腰椎融合内固定术与传统后路开放手术治疗腰椎退变性疾病的临床效果.方法:2008年3月～2010年6月,选择经保守治疗无效的单一节段腰椎退变性疾病的患者80例,随机分为两组,每组40例,两组患者年龄、性别、体重、临床诊断与手术节段差异无统计学意义(P＞0.05),分别进行Quadrant通道辅助下微创经椎间孔减压腰椎融合内固定术与传统后路开放手术.随访24～36个月,平均29个月,比较两组患者的手术时间、术中出血量、术后引流量、住院时间、血清肌酸磷酸激酶、MRI-T2驰豫时间、VAS评分、Oswestry功能障碍指数(ODI)及融合率等.结果:两组手术时间(141.0±27.3min与139.5±33.7min)无统计学差异(P＞0.05).微创手术组的术中出血量、术后引流量分别为268.0±122.2ml和25.6±32.4ml,明显少于传统开放手术组的370.0±147.1ml和277.8±167.4ml (P＜0.05);术后住院时间为7.3±3.2d,短于传统开放手术组的9.5±2.7d(P＜0.05).每组患者术后1个月、24个月时的VAS评分与ODI与术前比较均有明显改善(P＜0.05),术后1个月时微创手术组腰、腿痛VAS评分优于传统开放手术组(P＜0.05),术后24个月时腰、腿痛VAS评分及术后1个月、24个月时ODI两组比较均无统计学差异(P＞0.05).肌酸磷酸激酶在术后1、3、5d时明显升高(P＜0.05),术后1d达到高峰,7d时基本恢复正常,并在术后1、3d时微创手术组明显低于传统开放手术组(P＜0.05).术后3个月时手术节段多裂肌的T2驰豫时间微创手术组明显低于传统开放手术组(P＜0.05).术后6个月及24个月随访时两组融合率无统计学差异(P＞0.05).结论:Quadrant通道辅助下微创经椎间孔减压腰椎融合内固定术与传统开放手术治疗单节段腰椎退变性疾病均可取得较好的近期疗效,但前者肌肉和软组织损伤小,有助于早期功能恢复.     

Recognition and management of phaeochromocytoma

Phaeochromocytomas and paragangliomas (PPGL) are catecholamine-secreting neuroendocrine tumours. These tumours may be identified incidentally, as part of a work-up for multiple endocrine neoplasia or following haemodynamic surges during unrelated procedures. Advances in preoperative management and improved management of intraoperative haemodynamic instability have significantly reduced surgical mortality from around 40% to less than 3%. Surgery is the definitive treatment in most cases and laparoscopic resection where possible is associated with improved outcomes. Anaesthetic management of PPGL cases represents a unique haemodynamic challenge both before, during and after tumour resection. In this article we describe the physiology of these tumours, their diagnosis, preoperative optimization methods, intraoperative anaesthetic management and management of postoperative complications.     

Laparoscopic adrenalectomy for phaeochromocytoma: with caution

INTRODUCTION: Laparoscopic adrenalectomy is well described and many series include patients with phaeochromocytoma. Our aim was to establish whether laparoscopic adrenalectomy for phaeochromocytoma was a safe and feasible technique at our institution. METHODS: Patients requiring adrenalectomy were entered into a prospective database that included patient details, operative data, hormone excretion, tumour size, hospital stay and complications. All operations were performed under the supervision of a single surgeon. Analysis was performed for those patients with a diagnosis of phaeochromocytoma. RESULTS: Of 60 patients having laparoscopic adrenal surgery, 18 had phaeochromocytoma as the indication. Seventeen (89%) of 19 tumours in these 18 patients were successfully removed laparoscopically. Median operative time was 180 min (range 130-300 min) and this was significantly longer compared with other adrenal pathology. The median tumour size was 6 cm which was significantly larger than other adrenal tumours. Seven (38%) patients developed complications and median postoperative inpatient stay was 5 days (range 3-8 days). CONCLUSIONS: The postoperative stay was equivalent to other laparoscopic series and laparoscopic removal was successful in 89%. The laparoscopic approach to the adrenal gland in phaeochromocytoma is safe and effective treatment.     

Anaesthesia for phaeochromocytoma removal in a 5-year-old boy

We describe the case of a 5-year-old boy with phaeochromocytoma of the left adrenal gland, treated surgically by removal of the tumour under general anaesthesia. Phaeochromocytoma is a particularly rare tumour in children and surgical excision is the definitive treatment. We discuss the clinical and laboratory characteristics of the case, the diagnostic approach, the preoperative and intraoperative management and the postoperative course.     

Instruments for minimally invasive surgery

Although the advantages of minimally invasive surgery (MIS) have been clearly established for the patient, the surgeon must cope with disadvantages caused by unergonomic instrument handles. Pressure areas and persisting nerve lesions have been described in the literature. The shape of the instrument handles has been identified as the reason for these disorders. To prevent these, it is necessary to use ergonomically designed handles for MIS instruments. Anatomic, physiologic, and ergonomic facts as well as the results of the authors' own experiences and tests are presented. On this basis, an ideal ergonomic working posture for the laparoscopic surgeon and an optimal grasp for manipulating the instruments' functional elements are recommended. To enable the surgeon to evaluate ergonomic handles for MIS instruments according to his own needs, 14 criteria for genuine ``ergonomic handles' are established. On the basis of these criteria, deficiencies of handles currently available (ring and shank handles at an angle or with axial extension to the instrument shaft, and pistol handles) are discussed. Furthermore, new handles, developed by the authors according to the criteria for genuine ergonomic handles, are presented. Received: 12 September 1997/Accepted: 28 May 1998     

Anesthesia for minimally invasive surgery

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -     

Training for minimally invasive surgery

Summary Controversy exists regarding the training of surgeons for the performance of minimally invasive surgical procedures. The use of live animals is essential, especially in teaching dissection techniques. Seventeen percent of animals experienced excessive operative hemorrhage, which contributed to premature mortality during training exercises, demonstrating the need for live animals in this component of the training. A number of abdominal procedures can be performed with minimally invasive techniques without suturing by utilizing a rapidly expanding array of devices. However, other procedures cannot be successfully accomplished without suturing skills. Laparoscopic suturing skills are particularly demanding; thus specific training and practice prior to hands-on exercises in animal models is recommended. Emphasis on acquisition of advanced laparoscopic surgical skills is a necessity.Presented at the Third World Congress of Endoscopic Surgery, June 20, 1992, Bordeaux, France     

快速康复外科在微创食管癌切除术中的应用

目的 观察在胸腹腔镜联合食管癌根治术患者中应用快速康复外科的围手术期疗效.方法 2010年3月至2012年12月,99例食管癌患者随机抽签分组,接受胸腹腔镜联合食管癌根治术(微创组,50例)和开放食管癌根治术(开放组,49例).除肠内营养置管方式外,两组采用相同的快速康复外科方案.收集患者围手术期资料.计量资料数据经正态性分析,正态分布数据以x-±s表示,采用两独立样本的t检验；非正态分布数据以中位数(最小值～最大值)表示,采用非参数检验.各时间点数据经对数转换后,符合平行性检验的采用含有重复测量设计的协方差分析,不符合平行性检验的采用单因素协方差分析和配对t检验.计数资料采用x2检验.结果 术前两组临床资料差异无统计学意义.术中清扫腹部淋巴结数,微创组多于开放组[13(6 ～40)枚对4(0 ～20)枚,P＜0.05].同组内比较,两组患者总白蛋白、血红蛋白和总胆固醇水平术后第8天均优于术后第1天(P＜0.05).微创组术后48 h自控镇痛泵使用少(74.0％对94.9％,P＜0.05),术后镇痛效果好,术后疼痛评分低(48 h安静/活动0.0/1.0对1.0/2.0,p＜0.05).微创组术后肌酸激酶水平、术后第8天白细胞计数和C-反应蛋白水平低于开放组(74.0％对94.9％,P＜0.05).微创组患者肠外营养使用时间短[(7.9±2.4)天对(8.6±2.9)天,P＜0.05],进食时间早(6天对9天,P＜0.05),术后住院时间短[(12.5±3.1)天对(17.1±6.3)天,P＜0.05].结论 食管癌根治术中应用快速康复外科安全、可行.对微创食管癌切除术患者采用快速康复外科,在减轻患者术后疼痛、改善营养状况、减少炎症反应和缩短住院时间等方面更具优势.     

Outcomes after minimally invasive esophagomyotomy

Background. Thoracic surgeons traditionally performed thoracotomy and myotomy for achalasia. Recently minimally invasive approaches have been reported with good success. This report summarizes our single-institution experience using video-assisted thoracoscopy (VATS) or laparoscopy (LAP) for the treatment of achalasia.

Methods. A review of 62 patients undergoing minimally invasive myotomy for achalasia was performed. There were 27 male and 35 female patients. Mean age was 53 years (range 14 to 86). Thirty-seven (59.7%) had failed prior treatments (balloon dilation, botulinim toxin injection, or prior surgery). Outcomes studied were dysphagia score (1 = none, 5 = severe), Short-Form 36 quality of life (SF36 QOL) score, and heartburn-related QOL index (HRQOL).

Results. Surgery included myotomy and partial fundoplication (5 VATS and 57 LAP). Mortality was zero, and complications occurred in 9 (14.5%) patients. There were 6 perforations (4 repaired by LAP and 2 open). Median length of stay was 2 days, time to oral intake was 1 day. At a mean of 19 months follow-up, 92.5% of patients were satisfied with outcome. Dysphagia scores improved from 3.6 to 1.5 (p < 0.01) but 3 patients ultimately required esophagectomy for recurrent dysphagia. HRQOL scores for heartburn and SF-36 QOL scores were comparable with control populations.

Conclusions. Minimally invasive myotomy and partial fundoplication for achalasia improved dysphagia in 92.5% of patients with heartburn and QOL scores were comparable with normal values at 19-month follow-up. The laparoscopic approach offers excellent results and was the preferred approach by our thoracic group for treating achalasia. Thoracic residency training should strive to include laparoscopic esophageal experience.     

Patient response to marketing minimally invasive surgery for heartburn

Background: Over 40% of Americans suffer from ``heartburn' at least once a month. This and other manifestations of gastroesophageal reflux (GERD) are often treated with neglect by both patients and their primary care physicians. Diagnostic evaluation is all too often sought only in late stages of the disease. We studied the response to a media campaign promoting minimally invasive surgery as a cure for longstanding heartburn. Methods: The information was publicized on 14 TV and six radio stations over 4 weeks. Patients were referred to an 800-number and data on the following topics were obtained using a standardized questionnaire: demographics, reflux symptoms, previous specialist referral, diagnostic evaluation and treatment, insurance information, and reasons for and expectations in calling. All questionnaires were screened for likelihood of GERD (high, medium, low). A return call was placed to triage patients (surgical or medical appointment, information only, no contact). Results: We received calls from 1,389 potential patients. Based on symptoms, medical therapy, and previous evaluation, 891 (64%) were judged to likely have GERD and assigned high-priority status. Of the patients providing insurance information, 32% were enrolled in an HMO; 29% commercial; 16% Medicare; 14% employer based; and 9% had no insurance. Six hundred ninety-eight high-priority patients were contacted. Of these, 402 (58%) wanted information only; 228 (33%) desired surgical and 68 (%) medical appointments. Two hundred fifteen patients (16% of callers) were seen by a surgical or medical consultant. One hundred thirty-five underwent diagnostic studies, of which 77 (57%) had pathologic esophageal acid exposure. Eighty-three patients have undergone surgery to date—60 laparoscopic and 14 open antireflux procedures; nine had other surgical procedures. Conclusions: Surprisingly, 64% of patients responding to a marketing campaign for heartburn have typical symptoms of GERD, have consulted one or more physicians and/or received medical treatment. More than half the patients tested (77/135) were found to have a positive 24-h pH study, and 78% (60/77) of these elected antireflux surgery to control their reflux symptoms. Received: 3 April 1997/Accepted: 10 June 1997     

Cardiomyopathy and phaeochromocytoma

A case is presented of phaeochromocytoma with catecholamine-induced cardiomyopathy. The difficulties in the management when left ventricular failure occurred are reported and the importance of monitoring pulmonary artery pressure during the anaesthetic procedure is stressed.