What is the value of telerobotic technology in gastrointestinal surgery?

Background: Although telerobotic technology has entered clinical application, its value for gastrointestinal surgery is unclear. Our objective was to evaluate the performance characteristics of telerobotically assisted laparoscopic cholecystectomy (TALC). Methods: All TALCs performed using the da Vinci Surgical System between January 2000 and September 2001 at a tertiary academic medical center were analyzed. Results: For this study, 20 patients (80% female) with a mean age of 47 ± 4 years underwent TALC. All had symptomatic cholelithiasis, and all had successful TALC results without complications or need for conversion to conventional laparoscopic cholecystectomy (CLP). The mean procedure time was 152 ± 8 min. The procedures were performed by one of three staff surgeons experienced in laparoscopic surgery who had training in telerobotic surgery. The perceived advantages of TALC over CLP included easier tissue dissection, enhanced dexterity, and stimulated interest in biliary surgery. The disadvantages included increased operating time and lack of tactile feedback. Conclusions: The TALC procedure is effective and safe when performed by appropriately trained surgeons. Telerobotic technology has the potential to reinvigorate gastrointestinal surgery. Presented at the 8th World Congress of Endoscopic Surgery, New York, New York, USA, 13–16 March 2002.     

What kind of surgery for cervical carcinoma?

The incidence and mortality of cervical cancer have changed over the past 50 years in developed countries, but this kind of tumor still remains a significant clinical problem because it is the second most common cause of morbidity and mortality from cancer among women. After histological confirmation of invasive cervical cancer, the extent of disease was determined using clinical criteria to assign a stage. This assessment is important because, while for the other gynecologic cancers clinical information obtained by surgery and histopathological examination is implemented and concurs to define the staging of the disease, the cervical cancer tumor stage is given after the primary diagnosis. In this review we discuss how the surgical approach to cervical cancer has been evolved, in order to modulate the radicality of the intervention itself and thus to preserve the pelvic innervation. This step has been achieved by deepening knowledge of functional pelvic anatomy and modulating the radicality of hysterectomy according to well defined surgical landmarks.     

Are we ready for the use of intraoperative salvaged blood in metastatic spine tumour surgery?

Purpose

To evaluate the feasibility of using intraoperative cell salvage (IOCS) in combination with leucocyte depletion filter (LDF) in eliminating tumour cells from blood salvaged during metastatic spine tumour surgery (MSTS). This is with the view to pave the path for use of IOCS-LDF in MSTS and musculoskeletal oncological surgery.

Methods

Sixty consecutive patients with known primary epithelial tumour, who were offered surgery for metastatic spine disease at our university hospital, were recruited. Blood samples were collected at three different stages during surgery: from operative field prior to IOCS processing, after IOCS processing and after IOCS-LDF processing. Three separate samples (5 ml each) were taken at each stage. Samples were examined by cell block technique using immunohistochemical monoclonal antibodies to identify tumour cells of epithelial origin in the samples.

Results

Of 60 patients, ten were excluded for not fulfilling the inclusion criteria leaving 50 patients. Malignant tumour cells were detected in the samples from operative field prior to IOCS processing in 24 patients and in the samples from the transfusion bag post-IOCS processing in 4 patients. No viable malignant cells were detectable in any of the blood samples after passage through both IOCS and LDF.

Conclusions

The findings support the notion that IOCS-LDF combination works effectively in eliminating tumour cells from salvaged blood so this technique can possibly be applied in MSTS and even musculoskeletal oncological surgery. This concept can then be extended to other oncological surgeries in general with further appropriate clinical studies.

     

What defines a distracting injury in cervical spine assessment?

BACKGROUND: The National Emergency X-Radiography Utilization Study defined five criteria for obtaining cervical spine radiographic investigations in blunt trauma patients. Distracting injury was given as the indication for more than 30% of all x-ray studies ordered. The hypothesis of this study was that upper and lower torso injuries would have different effects on clinical cervical spine assessment. METHODS: This is a single-center, prospective, observational study of admitted, alert, adult blunt-trauma patients. All patients underwent cervical spine plain-film radiography. Data were collected on all injuries, physical examination findings, narcotic administration, and radiograph results. Patients with upper and lower torso injuries were compared in their ability complain of pain or midline tenderness relative to a cervical spine fracture. RESULTS: In all, 406 patients participated. All patients received narcotic analgesics before examination. Forty patients (9.9%) had cervical spine fractures, of whom seven had a nontender neck examination. All seven patients with a nontender cervical spine and a neck fracture had at least one upper torso injury. None of the 99 patients with injuries isolated to the lower torso and a nontender neck had a cervical spine fracture (p < 0.05). The frequency of cervical spine fracture among patients with cervical spine tenderness was 19.8% (n = 33). CONCLUSIONS: The National Emergency X-Radiography Utilization Study definition of a distracting injury may be narrowed. Upper torso injuries may be sufficiently painful to distract from a reliable cervical spine examination. Patients may detect spine tenderness in the presence of isolated painful lower torso injuries. Patients with spine tenderness warrant imaging.     

Fully endoscopic cervical spine surgery: What does the future hold?

Fully endoscopic cervical spine surgery is an emerging novel approach to address cervical spinal pathology. Techniques, both anterior and posterior have been adapted to address various cervical pathologies. The primary goal of these procedures like other open techniques is to surgically decompress the canal centrally and/or along the foramen. The narrative review aims to provide the reader an overview of the rapidly advancing field of endoscopic cervical spinal surgery and evaluate whether these newer approaches could potentially reduce the cost and the risk associated with instrumented cervical fusion.     

What is the value of available risk-scores in predicting postoperative complications after aorto-iliac surgery? A prospective non randomized study

AIM: With an aging population, atherosclerotic manifestations are steadily increasing. Beside the anatomical and pathophysiological preoperative risk-factors accompanying perioperative risk-factors like patient's age, length of operation, blood loss and skill of the surgeon, all need to be accounted for when assessing the risk of morbidity and mortality after vascular surgery. The demand for cost effectiveness may make a risk-score system useful. The aim of the present study was, therefore, to prospectively apply various scoring systems in order to estimate outcome in patients undergoing aortobifemoral surgery due to arterial occlusive disease at the aorto-iliac level. METHODS: A prospective non randomized study was carried out. The SPSS 9.0 statistical package for Windows and, for nominal data, chi-squared-tests were used to compare rates between groups. For continuous data analysis of variance (ANOVA) was performed. When appropriate, a multivariate analysis with binary-regression by Wald was used. Sensitivity and specificity was done using ROC-curves. P < 0.05 was considered significant. From May 1996 to June 2000, 107 patients were included in the study. Besides basic data, all postoperative complications were noted according to a specific definition. Four different risk-scoring systems were used: ASA-classification; the acute physiology and chronic health evaluation (APACHE-II) system; the physiological and operative severity score for enumeration of mortality and morbidity (POSSUM) classification and, finally, the simplified acute physiology score (SAPS) classification. RESULTS: We found no significant correlation between risk-scores and outcome. None of the scoring systems used was able to predict mortality. The independent factors that influenced the postoperative complication rate were operating time, blood loss, intraoperative assisted ventilation time and age. The endpoint using the relative operating characteristic (ROC) curves analysis was either mortality or morbidity. CONCLUSIONS: It can be concluded that none of the systems analyzed separately was useful for determining morbidity and mortality. We still lack a system, that can be used preoperatively in an individual case and the vascular surgeon still has to build up his own clinical judgement or to transfer a clinical judgement.     

Does thoracic injury impair the predictive value of base deficit in trauma patients?

Introduction

Base deficit (BD) has been shown to be a valuable indicator to be predictive of complications and mortality after trauma. Arterial carbon dioxide (PaCO₂) may be influenced by thoracic injuries, potentially diminishing the predictive value of BD. Therefore, the aim of this study was to assess the predictive value of admission BD for mortality and complications in trauma patients with thoracic injuries.

Methods

By a prospective database analysis of patients with an injury to the chest admitted to the University Medical Center Utrecht between 2000 and 2004 were studied. All patients with a blood gas analyses were included. Absolute BD was used for analyses. Clinical outcome parameters were recorded.

Results

The BD was higher in the non-surviving patients compared to the survivors (7.5 vs. 3.8, p < 0.001). Mortality rate of patients with an admission BD of ≥6 was increased in thoracic trauma patients (BD < 6 mortality rate 7%, BD ≥ 6 mortality rate 27%; p < 0.001). In patients who required ICU admittance the BD was increased compared to patients without ICU admission (5.2 vs. 2.9, p < 0.001). Within the subgroup of patients admitted to the ICU, the BD was higher in patients who required ventilation (3.8 vs. 5.5, p = 0.025). Patients who developed chest related complications had increased BD compared with those without complications (4.9 vs. 4.0, p = 0.025), the BD was particularly increased in patients who developed acute respiratory distress syndrome (ARDS) (4.1 vs. 6.4, p = 0.004). Carbon dioxide (PaCO₂) showed a predictive value for mortality (44 vs. 53, p < 0.001), ICU admission (42 vs. 46, p = 0.003) and hospital stay.

Conclusion

Admission BD is a predictive factor in thoracic trauma patients for mortality and chest related complications. Furthermore it is a predictive factor for ICU admission, required ventilation and hospital stay. The use of BD in thoracic trauma patients can potentially identify patients who require additional monitoring or early aggressive therapy.     

A multicentre retrospective review of muscle necrosis of the leg following spinal surgery with motor evoked potential monitoring: a cause for concern?

Purpose

There are very few reported cases of compartment syndrome of the leg following spinal surgery via a posterior approach. An association between compartment syndrome and muscle over-activity via nerve stimulation during evoked potential monitoring was first suggested in 2003. No further reports have suggested this link. We present a multicentre retrospective review of a series of five patients who developed compartment syndrome of the leg following spinal surgery via a posterior approach, whilst un-paralysed and with combined sensory (SSEP)/motor evoked potential (MEP) monitoring with an aim of highlighting this possible causative factor.

Methods

All data were collected contemporaneously and retrospective analysis was performed. We then arranged for a multidisciplinary review of the cases including surgeons, anaesthetists, radiologists, neurophysiologists and theatre and ward nursing staff. Finally, the literature was reviewed.

Results

All patients were operated on by three different surgeons, on different operating tables/mattresses in the prone position. The common factors were un-paralysed patients having motor/sensory monitoring, mechanical calf pumps and total intravenous anaesthesia. Three patients underwent surgical decompression of their compartments and two were treated expectantly. Three patients had confirmed intra-compartmental changes on MRI consistent with compartment syndrome and one had intra-compartmental pressure monitoring which confirmed the diagnosis.

Conclusions

Previous cases in the literature have related to mal-positioning on the Jackson table or use of the knee–chest position for surgery. This was not the case for our patients; therefore, we suspect an association between overactive muscle stimulation and muscle necrosis. Further experimental studies investigating this link are required.

     

What is the role of dynamic cervical spine radiographs in predicting pseudarthrosis revision following anterior cervical discectomy and fusion?

Background ContextPostoperative dynamic radiographs are used to assess fusion status after anterior cervical discectomy and fusion (ACDF) with comparable accuracy to computed tomography (CT) scans.PurposeTo (1) determine if dynamic radiographs accurately predict pseudarthrosis revision in a cohort of largely asymptomatic patients who underwent ACDF, (2) determine how adjacent segment motion is affected by fusion status, and (3) analyze how clinical outcomes differ between patients with symptomatic and asymptomatic pseudarthrosis.Study DesignRetrospective cohort study.Patient SamplePatients ≥ 18 years who underwent primary one- to four-level ACDF at a single institution over a 10-year period.Outcome MeasuresInterspinous motion on preoperative and postoperative flexion-extension radiographs and preoperative and postoperative Visual Analogue Scale for Neck Pain (VAS Neck) and Arm Pain (VAS Arm), Neck Disability Index (NDI), Modified Japanese Orthopaedic Association scale (mJOA), Mental and Physical Component Scores of the Short-Form 12 (SF-12) Health Survey (MCS-12 and PCS-12)MethodsThe difference in spinous process motion between flexion and extension radiographs was used to determine motion at each level of the ACDF construct. Pseudarthrosis was defined as ≥ 1 mm spinous process motion on dynamic radiographs. A receiver operating characteristic (ROC) curve was generated to predict the probability of surgical revision for pseudarthrosis based on millimeters of interspinous motion at each instrumented level. Patient reported outcome measures (PROMs) were used to assess the effect of pseudarthrosis on clinical outcomes. Alpha was set at p<.05.ResultsA total of 597 patients met inclusion criteria including 1,203 ACDF levels. Of those, 215 patients (36.0%) were diagnosed with a pseudarthrosis on dynamic radiographs with 29 patients (4.9%) requiring pseudarthrosis revision. ROC analysis identified a “cutoff” value of 1.00 mm of interspinous process motion for generating an optimal area under the curve (AUC). The negative predictive value (NPV) was 99.6%, whereas the positive predictive value (PPV) was 13.7%. When analyzing adjacent segment motion, the Δ supra-adjacent interspinous process motion (ISM) was significantly lower for patients with a superior construct pseudarthrosis (-1.06 mm vs. 1.80 mm, p<.001), whereas the Δ infra-adjacent level ISM was significantly lower for patients with an inferior construct pseudarthrosis (-1.21 mm vs. 2.15 mm, p<.001). Patients with a pseudarthrosis not requiring revision had worse postoperative NDI (29.3 vs. 23.4, p=.027), VAS Neck (3.40 vs. 2.63, p=.012), and VAS Arm (3.09 vs. 1.85, p=.001) scores at 3 months, but not 1-year, compared with patients who were fused. Patients requiring pseudarthrosis revision had higher 1-year postoperative NDI (38.0 vs. 23.7, p=.047) and lower 1-year postoperative Δ VAS Arm (-0.22 vs. -2.97, p=.016) scores.ConclusionsOne-year postoperative dynamic radiographs have a greater than 99% negative predictive value for identifying patients requiring pseudarthrosis revision, but they have a low positive predictive value. Most patients with a pseudarthrosis remain asymptomatic with similar 1-year postoperative patient-reported outcomes compared with patients without a pseudarthrosis.     

What is the value of neoadjuvant therapy in bronchial carcinoma?

Neoadjuvant chemotherapy is obligatory for small-cell lung cancer. When combined with radio-therapy, it reduces the incidence of recurrence and increases the survival rate to a level similar to that seen in non-small-cell lung cancer. Preliminary results suggest that complete remissions (3-year-survival rate 56%) can be achieved through the use of chemotherapy, possibly including high-dose chemotherapy for advanced stage III A cancer. The use of pre-operative chemotherapy in advanced stage III non-small-cell lung cancer is firmly established. In one study the 3-year-survival rate reached 25% in the chemotherapy group as compared to 15% in the group treated by surgery only. Early results of pre-operative chemo- and radiotherapy for stages III A and III B are encouraging. In studies comparing neoadjuvant chemotherapy alone to a combination of neoadjuvant chemo-radiotherapy a higher resection rate (32 to 76%) as well as a longer disease-free survival time could be shown for the combination therapy. To date, a number of innovative neoadjuvant chemoradiotherapy protocols using new substances as well as various modifications of radiotherapy are being studied. It is to be expected that new standard therapies for non-small-cell lung cancer will develop from these studies.     

Prehospital stabilization of the cervical spine for penetrating injuries of the neck - is it necessary?

The purpose of this study was to assess the specific indications, benefits and risks associated with cervical spine stabilization during pre-hospital care of penetrating neck injuries. We retrospectively reviewed hospital charts and autopsy reports of 44 military casualties in Israel with a penetrating neck injury during a period of 4.5 years. A review of the literature was also carried out. In eight of 36 hospitalized casualties (22%) a life-threatening sign was diagnosed in the exposed neck - large or expanding haematoma, or subcutaneous emphysema. Surgical stabilization of the cervical spine was not performed for any of the casualties. It was concluded that life threatening complications due to penetrating neck injury are common and may be overlooked if the neck is covered by a stabilization device. It is extremely rare for a penetrating injury to result in an unstable cervical spine. New management guidelines concerning pre-hospital stabilization are suggested.