The Impact of Preoperative Weight Loss Before Laparoscopic Gastric Bypass

Background

The impact of preoperative weight loss on outcomes following laparoscopic Roux-en-Y gastric bypass (LRYGB) is a controversial issue. We evaluated our outcomes of LRYGB in patients who lost different amount of weight prior to surgery.

Methods

Patients who underwent primary LRYGB were divided in three groups on the basis of preoperative weight loss percentage. Group A comprised 166 patients, who lost <5 % of their weight preoperatively; group B comprised 239 patients who lost >5 to 10 % and group C included 143 patients who lost >10 %. Intra- and postoperative complications at 30 days, hospital stay, and outcomes were evaluated.

Results

Significant difference was found in operative (mean ± SD) time [104.43?±?36.40 min in group A, 80.08?±?23.07 min in group B, and 76.99?±?23.23 min in group C; p?<?0.001 in group A versus group B or group C; p?=?0.210 in group B versus group C]. Difference in hospital stay was significant (3.33?±?3.22 days in group A, 2.10?±?2.77 in group B, and 1.87?±?1.44 in group C; p?<?0.001 in group A versus groups B or C). Overall postoperative morbidity rate was 33.13 % in group A, 19.25 % in group B, and 11.89 % in group C, with significant difference in group A versus groups B or C (p?=?0.002 and p?<?0.001). Mean excess weight loss was significantly higher (72.7 %) in group C versus group A (63.1 %) (p?=?0.015) at 12 months.

Conclusions

Weight loss >5 % prior to LRYGB may reduce morbidity, and preoperative weight loss >10 % may improve weight loss outcomes at 1-year follow-up.     

Laparoscopic cholecystectomy—comparison of early postoperative results in an Australian rural centre and a German university hospital

Background

Laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstone disease. Cultural as well as organisational differences can result in significant variations of postoperative length of stay.

Aim of the present study

The aim of this study is to evaluate whether differences in postoperative length of stay and early postoperative outcome can be observed by comparison of an Australian rural centre and a German university hospital.

Results

Between February 2006 and August 2007 (18 months), 359 patients (140 Australia, 219 Germany) underwent laparoscopic cholecystectomy. Mean patient age was 50.4?±?1.5 and 53.5?±?1.0 years, respectively. Seventy-seven percent of the Australian and 62% of the German patients were female. Twenty-one percent and 20% of the procedures were emergencies, respectively. Median American Society of Anaesthesiologists score of all patients was two. The conversion rate was 8% in both centres. A 4% complication rate was observed in Australia (N?=?5, 3× bile leak, 1× postoperative bleeding and 1× wound infection) as opposed to 3% in Germany (N?=?7, 2× bile leak, 2× postoperative bleeding and 3× wound infection). Postoperative length of stay in Australia was 1.8?±?0.1 days (median 1 day) and was significantly longer in patients after emergency surgery (1.6?±?0.1 versus 2.6?±?0.3 days, p?<?0.018). Postoperative length of stay in Germany was 3.7?±?0.2 days (median 3 days), and no significant differences were observed when elective and emergency procedures were compared (3.5?±?0.2 versus 3.9?±?0.5 days, p?>?0.05). Comparison of treatment results indicates a significantly shorter postoperative stay in Australia (3 days versus 1 day, p?<?0.001).

Discussion/conclusion

In rural Australia, a median postoperative stay of 1 day after laparoscopic cholecystectomy can be safely achieved. Postoperative length of stay is significantly longer in the German setting with otherwise comparable patients and surgical techniques. Simple changes of pre- and postoperative management of elective as well as emergency laparoscopic cholecystectomy will allow, for substantial cost savings, for the German health system.     

Is laparoscopic surgery for recurrent Crohn’s disease beneficial in patients with previous primary resection through midline laparotomy? A case-matched study

Background

Patients undergoing abdominal surgery for Crohn??s disease are predisposed to recurrence requiring reoperation. The effectiveness of laparoscopic versus open resection in patients with previous intestinal resection for Crohn??s through midline laparotomy is controversial.

Methods

Patients with previous open resection for intestinal Crohn??s disease undergoing elective laparoscopic surgery for recurrent bowel disease from 1997 to 2011 were case-matched with open counterparts based on age (±5?years), gender, body mass index (±2?kg/m²), American Society of Anesthesiologists (ASA) score, surgical procedure, and year of surgery (±3?years). Groups were compared using Chi-square or Fisher exact tests for categorical and the Wilcoxon rank-sum test for quantitative data.

Results

26 patients undergoing laparoscopic ileocolectomy (n?=?14), proctocolectomy (n?=?5), small bowel resection (n?=?4), abdominoperineal resection (n?=?1), extended right colectomy (n?=?1), and strictureplasty (n?=?1) were well matched to 26 patients undergoing open surgery. The number of previous operations, disease phenotypes, steroid use, and comorbidities were comparable in the two groups. There were no deaths, and three patients (12?%) required conversion because of adhesions. Laparoscopic and open groups had statistically similar operating times (169 versus 158?min, p?=?0.94), estimated blood loss (222 versus 427?ml, p?=?0.32), overall morbidity (39 versus 69?%, p?=?0.051), reoperation rates (8 versus 0?%, p?=?0.5), postoperative return of bowel function (3.5?±?1.4 versus 3.9?±?1.7?days, p?=?0.3), mean length of hospital stay (6.4?±?6.2 versus 6.9?±?3.5?days, p?=?0.12), and readmission rates (8 versus 12?%, p?=?0.64). Wound infection rate was decreased after laparoscopic surgery (0 versus 27?%, p?=?0.01).

Conclusions

Surgery for recurrent Crohn??s disease in patients with previous primary resection through laparotomy can be frequently and safely completed laparoscopically. Wound infection rates are reduced, but the recovery advantages of a minimally invasive approach are not maintained when compared with open surgery. The decision to operate laparoscopically should therefore be carefully calibrated.     

A safety,length of stay,and cost analysis of minimally invasive microsurgery for anterior circulation aneurysms

Objectives

The aim of our study was to evaluate minimally invasive techniques for the treatment of anterior circulation aneurysms versus standard surgery, and to calculate the impact of these techniques on health resources, length of stay, and treatment costs.

Methods

A consecutive series of 24 patients with ruptured and 30 with unruptured anterior circulation aneurysms treated with minimally invasive microsurgery (MIM) by the same surgeon was compared with a matched series of standard microsurgeries (SM) conducted for 23 ruptured and 22 unruptured aneurysms. Complication rates, aneurysm obliteration, modified Rankin Scale (mRS) outcomes, length of stay, and treatment costs were assessed.

Results

Surgical complications, aneurysm obliteration rates and mRS outcomes were comparable between MIM and SM groups in ruptured and unruptured aneurysm cohorts. MIM resulted in shorter operative times both in unruptured (102.7?±?4.35 vs 194.7?±?10.26 min, p?<?0.0001) and ruptured aneurysms (124.3?±?827 vs 209?±?13.84 min, p?<?0.0001). Length of stay was reduced in patients with MIM for unruptured aneurysms (1.55?±?24 vs 4.28?±?0.71 days, p?<?0.000,1) but not in those with ruptured aneurysms. MIM reduced treatment costs of unruptured aneurysm patients, mainly through reduced utilization of inpatient resources (non-acute bed costs in CAD: 371.2?±?80.99 vs 1440?±?224.1, p?<?0.0001), whereas costs were comparable in patients with ruptured aneurysms.

Conclusion

Minimally invasive surgery is a safe and effective approach for the treatment of ruptured and unruptured aneurysms of the anterior circulation. In patients with unruptured aneurysms, reduced invasiveness and shorter operative times decreased length of stay, which reflects improved patient postoperative recovery. Overall, this translated into bed resource economy and cost reduction.     

Long-Term Outcomes of Laparoscopic Surgery for Advanced Transverse Colon Cancer

Background

The role of laparoscopic surgery for advanced transverse colon cancer (TCC) remains controversial, especially in terms of long-term oncologic outcomes.

Methods

This retrospective cohort study enrolled 157 consecutive patients who underwent curable resections for advanced TCC between January 2002 and June 2011 (laparoscopic-assisted colectomy (LAC), n?=?74; open colectomy (OC), n?=?83). Short-term outcomes and oncologic long-term outcomes were compared between the two groups.

Results

Compared to the OC group, patients in the LAC group had less blood loss (LAC vs. OC, 79.6?±?70.3 vs. 158.4?±?89.3 ml, p?<?0.001), faster return of bowel function (2.6?±?0.7 vs. 3.8?±?0.8 days, p?<?0.001), and shorter postoperative hospital stay (10.3?±?3.7 vs. 12.6?±?6.0 days, p?=?0.007). Conversions were required in four (5.4 %) patients. Rates of short-term complication, mortality, and long-term complication were comparable between the two groups. The median follow-up time was 54 (26–106) months in the LAC group and 58 (29–113) months in the OC group (p?=?0.407). There were no statistical differences in the rates of 5-year overall survival (73.6 vs. 71.1 %, p?=?0.397) and 5-year disease-free survival (70.5 vs. 66.7 %, p?=?0.501) between the two groups.

Conclusions

Laparoscopic surgery for advanced TCC yield short-term benefits while achieving equivalent long-term oncologic outcomes.     

Renal calcium, phosphorus, magnesium and uric acid handling: comparison between stage III chronic kidney disease patients and healthy oldest old

Introduction

It is known that chronic kidney disease (CKD) and senescence bring about a progressive reduction in glomerular filtration rate (GFR) and that in the former this is usually associated with an increase in the fractional excretion of calcium, phosphorus, magnesium, and uric acid. However, it has not yet been explained how these substances are excreted in the healthy oldest old. Thus, in the present study, we examined the renal handling of these substances in very aged people in comparison with CKD patients with similar GFR levels (stage III??CKD).

Materials and methods

Twenty volunteers were studied; 10 of them were healthy very old (VO) (??75?years old) individuals and 10 were stage III CKD patients. Exclusion criteria were as follows: presence of altered (abnormally high or low) plasma calcium, phosphorus, magnesium and uric acid, as well as previous diagnoses of diabetes mellitus and obstructive uropathy and use of drugs that could alter plasma levels of the studied substances. All volunteers were on a diet with the same content of these elements (3-day dietary register). We measured calcium, phosphorus, magnesium, uric acid, creatinine in serum plasma and morning urine, as well as serum parathyroid hormone level, in each volunteer. From these data, fractional excretion (FE) of these substances was obtained. A statistical analysis was carried out using the Wilcoxon test.

Results

Serum creatinine: 1.8?±?0.4?mg/dl (CKD) versus 0.8?±?0.2?mg/dl (VO), p?=?0.0002; serum calcium: 9.1?±?0.3?mg/dl (CKD) versus 8.7?±?0.4 (VO), p?=?0.022; serum magnesium: 2.3?±?0.2?mg/dl (CKD) versus 2.0?±?0.1 (VO), p?=?0.05; serum phosphorus: 3.9?±?0.5?mg/dl (CKD) versus 3.0?±?0.4?mg/dl (VO), p?=?0.002; serum uric acid: 6.6?±?1.5 (CKD) versus 5.2?±?1.4?mg/dl (VO), p?=?0.04; FE of calcium: 2.5?±?1?% (CKD) versus 0.8?±?0.3?% (VO), p?=?0.04; FE of magnesium: 7.2?±?4.1?% (CKD) versus 2.9?±?0.9?% (VO), p?=?0.02; FE of phosphorus: 25?±?9?% (CKD) versus 9.1?±?5.7(VO), p?=?0.001; FE of uric acid: 10?±?3?% (CKD) versus 8?±?5?% (VO), p?=?0.05.

Conclusion

Serum levels and FE of calcium, phosphorus, magnesium and uric acid were significantly higher in CKD patients compared to healthy very old people with similar GFR, except for serum magnesium and FE of uric acid, which were similar in both groups.     

Usefulness of an enhanced recovery after surgery protocol for perioperative management following open repair of an abdominal aortic aneurysm

Purpose

To achieve early recovery and early discharge from the hospital by applying an enhanced recovery after surgery (ERAS) protocol, which is mainly used with colonic surgery, for the perioperative management of open AAA surgery.

Method

One hundred twenty-seven open AAA surgery cases successfully carried out between 2003 and 2011 were included in this study. The ERAS protocol was used for the cases from April 2008 onward, and we performed a comparison of the conventionally treated cases with ERAS cases regarding the start of postoperative oral consumption, the postoperative hospital stay, and hospitalization medical costs.

Results

The time to restarting oral consumption and the postoperative hospital stay were significantly shorter for the ERAS group (n?=?52) compared to the conventionally managed group (n?=?75); with values of 59?±?15 and 93?±?25?h (p?=?0.021), 9?±?3 and 16?±?5?days (p?=?0.001), respectively. The medical costs for the ERAS group were 92?% of the costs of the conventionally managed group.

Conclusion

Use of the ERAS protocol for the perioperative management of open AAA surgery shortened the time before recommencing oral consumption, the postoperative hospital stay, and reduced the medical costs compared to the conventional approach.     

Is it worthwhile to preserve adult spleen in laparoscopic distal pancreatectomy? Perioperative and patient-reported outcome analysis

Background

Despite the emphasis on its role, the spleen has commonly been removed in distal pancreatectomy. We designed this study to evaluate the efficacy of spleen salvage during laparoscopic distal pancreatectomy for patients with benign and borderline malignant tumors.

Materials and methods

From February 2005 to December 2010, 40 patients underwent spleen-preserving laparoscopic distal pancreatectomy (Sp-Lap DP) and 32 patients underwent laparoscopic distal pancreatosplenectomy (Lap DPS). Medical records were retrospectively reviewed, and a specially designed questionnaire was administered to the patients for the follow-up study.

Results

The demographics and final diagnoses were similar between the two groups. The operative time was significantly longer in the Sp-Lap DP group (303.9?±?136.0 versus 239.0?±?94.9?min, p?=?0.024). Patients in the Lap DPS group had more postoperative pancreatic fistulas of higher grade (p?=?0.026). A higher grade of postoperative complications occurred more frequently in the Lap DPS group (p?=?0.003). Consequently, postoperative hospital stay was significantly shorter for Sp-Lap DP than for Lap DPS patients (7.1?±?2.3 versus 12.5?±?10.8?days, p?=?0.004). On the follow-up survey, episodes of common cold or flu were apparently more frequent in the Lap DPS group (p?=?0.026). Despite the similar recovery period between the two groups, significantly more patients who underwent Lap DPS felt fatigue (p?=?0.014) and poorer health condition (p?=?0.042).

Conclusions

In addition to frequent higher-grade complications and prolonged hospital stays, Lap DPS appeared to impair patient quality of life based on follow-up survey. Even an effort to preserve adult spleen in distal pancreatectomy is worthwhile.     

Transvaginal cholecystectomy versus single-incision laparoscopic cholecystectomy versus four-port laparoscopic cholecystectomy: a prospective cohort study

Objective

This report describes the first prospective cohort study comparing transvaginal cholecystectomies (TVC) with single incision laparoscopic cholecystectomies (SILC) and four-port laparoscopic cholecystectomies (4PLC).

Methods

Between May 2009 and August 2010, 14 patients underwent a TVC. These patients were compared with patients who underwent SILC (22 patients) or 4PLC (11 patients) in a concurrent, randomized, controlled trial. Demographic data, operative time, numerical pain scales, complications, and return to work were recorded.

Results

Mean age (TVC: 33.5?±?3.0?year; SILC: 38.4?±?3.3?year; 4PLC: 35.5?±?4.1?year; p?=?0.58) and mean BMI (TVC: 28.8?±?1.5?kg/m²; SILC: 31.8?±?1?kg/m²; 4PLC: 31.4?±?2.2?kg/m²; p?=?0.35) were not statistically significant. However, mean operative time (TVC: 67?±?3.9?min; SILC: 48.9?±?2.6?min; 4PLC: 42.3?±?3.9?min; p?p?=?0.02) with equilibration of pain scores by days 14 and 30. Return to work (TVC: 6.4?±?1.5?days; SILC: 13.1?±?1.3?days; 4PLC: 14.1?±?1.4?days; p?Conclusions Transvaginal cholecystectomy is a safe and well-tolerated procedure with statistically significantly less pain at 1 and 3?days after surgery, with a faster return to work but longer operative times compared with single incision and four-port laparoscopic cholecystectomy.     

Magnetically anchored camera and percutaneous instruments maintain triangulation and improve cosmesis compared with single-site and conventional laparoscopic cholecystectomy

Background

This study evaluated operative outcomes and ergonomics for a magnetic camera (MAGS) used in conjunction with percutaneous instruments [percutaneous surgical set (PSS)] compared with single-site laparoscopic (SSL) and conventional laparoscopic (LAP) cholecystectomy techniques.

Methods

Four surgical trainees each performed three porcine cholecystectomies using three randomized techniques including MAGS/PSS, SSL, and LAP. The operative outcomes, procedure-specific ratings (1?C5 scale; 1?=?superior), workload (1?C10 scale; 1?=?superior), and global impressions (1?C10 scale; 10?=?superior) were recorded. Comparisons used analysis of variance (ANOVA) on ranks (Kruskal-Wallis), and p values lower than 0.05 were considered significant.

Results

The operative outcomes were similar except for significantly higher blood loss with SSL (16.3?±?10.3) versus LAP (2.8?±?1.5; p?<?0.05) but not with MAGS/PSS (4.8?±?3.8). Several inadvertent tissue-damaging events occurred with SSL but not with MAGS/PSS or LAP. The incision was significantly shorter with MAGS/PSS (29.3?±?2.8?mm) and SSL (29.3?±?2.5?mm) than with LAP (48.0?±?3.6?mm; p?<?0.05). Compared with SSL (3.6?±?0.5), the procedure-specific ratings significantly favored MAGS/PSS (2.8?±?0.4) and LAP (1.7?±?0.2; p?<?0.05). Ergonomics and technical challenges both were rated significantly inferior with SSL (4.3?±?1.0 and 3.8?±?0.5, respectively) versus LAP (1.5?±?0.6 and 2.0?±?0.8, respectively; p?<?0.05) but not with MAGS/PSS (2.5?±?1.0 and 3.0?±?0.8, respectively). Both MAGS/PSS (4.5?±?0.5) and SSL (4.8?±?1.0) were associated with a significantly greater workload than LAP (2.5?±?0.6; p?<?0.05). Global impression ratings were significantly higher for LAP (8.7?±?1.3) versus SSL (5.8?±?2.0; p?<?0.05) but not for MAGS/PSS (7.1?±?1.8). Cosmesis was significantly better with MAGS/PSS (9.5?±?0.6) versus LAP (6.5?±?2.4; p?<?0.05) but not with SSL (8.8?±?1.3).

Conclusion

The MAGS/PSS technique allows better triangulation and fewer technical difficulties than SSL and better cosmesis than LAP. Further development of these devices is warranted.     

Evaluating the porcine dermis graft InteXen® in three-compartment transvaginal pelvic organ prolapse repair

Introduction and hypothesis

The aim was to assess the efficacy of three-compartment pelvic organ prolapse (POP) vaginal repair using the InteXen® biocompatible porcine dermal graft as compared to traditional colporrhaphy with sacrospinous ligament suspension.

Methods

Preoperative, operative, postoperative and follow-up data were collected retrospectively. Objective recurrence was defined as POP quantification ≥ stage II and subjective recurrence as a symptomatic bulge.

Results

Each group consisted of 63 patients. Surgery time was longer using InteXen® (72?±?24.5 vs 55?±?23.5 min, p?=?0.0002). Length of hospital stay (4.6?±?1.6 vs 4.9?±?2.1 days, p?=?0.34) as well as duration of follow-up (37.1 vs 35.7 months, p?=?0.45) were equivalent between the two groups. No case of mesh erosion or infection was noted. The objective (17% vs 8%, p?=?0.12) and subjective recurrence rates (13% vs 5%, p?=?0.12) between the two groups were not statistically different.

Conclusions

InteXen® was well tolerated but had similar efficacy to traditional colporrhaphy and sacrospinous ligament suspension.     

Air-Filled vs Water-Filled Intragastric Balloon: a Prospective Randomized Study

Background

The positioning of an intragastric saline-filled balloon has been developed as temporary and reversible therapeutic option for treatment of morbid obesity. Recently, an air-filled balloon was also developed. The aim of this study is to prospectively compare these two devices in terms of weight loss parameters, safety, and tolerance.

Methods

Sixty patients were randomized into two groups: group A (Bioenterics Intragastric Balloon?CBIB; n?=?30; 20?F/10?M, mean age 36.7?±?10.9; mean BMI 46.5?±?5.9) and group B (Endobag-Heliosphere; n?=?30; 20?F/10?M, mean age 37.8?±?10.6; mean BMI 46.1?±?5.6). All patients of both groups were sedated with midazolam (5?mg)?+?Propofol (2?mg/kg i.v.). The Heliosphere Bag was air-filled with 950?ml while BIB? was inflated with 500?ml of saline and 10?ml of methylene blue. Percentage of excess weight loss (%EWL) and body mass index (BMI) were evaluated. Student t test, Fisher exact test, and ?? ² test were used for statistical analysis.

Results

Similar weight loss parameters were observed in patients treated with liquid or air-filled balloon at time of removal: mean BMI was 40.8?±?6.2 and 41.9?±?6.5(p?=?ns), and mean %EWL was 20?±?12 and 18?±?14 (p?=?ns) in groups A and B, respectively. Significant longer extraction time, with high patient discomfort, was observed in group B due to difficult passage through the cardia and the lower pharynx.

Conclusions

Air-filled balloon can be another valid therapeutic option in the temporary treatment of obesity, but at this time, the quality of the device must be improved to ameliorate the patient compliance at removal and avoid the spontaneous deflations.     

Robotic Versus Laparoscopic Resection of Large Adrenal Tumors

Background

Although recent studies have shown the feasibility and safety of robotic adrenalectomy, an advantage over the laparoscopic approach has not been demonstrated. Our hypothesis was that the use of the robot would facilitate minimally invasive resection of large adrenal tumors.

Methods

Adrenal tumors ??5?cm resected robotically were compared with those removed laparoscopically from a prospective institutional review board-approved adrenal database. Clinical and perioperative parameters were analyzed using t and chi-square tests. All data are expressed as mean?±?standard error of mean.

Results

There were 24 patients with 25 tumors in the robotic group and 38 patients with 38 tumors in the laparoscopic group. Tumor size was similar in both groups (6.5?±?0.4 [robotic] vs 6.2?±?0.3?cm [laparoscopic], P?=?.661). Operative time was shorter for the robotic versus laparoscopic group (159.4?±?13.4 vs 187.2?±?8.3 min, respectively, P?=?.043), while estimated blood loss was similar (P?=?.147). The conversion to open rate was less in the robotic (4%) versus the laparoscopic (11%) group; P?=?.043. Hospital stay was shorter for the robotic group (1.4?±?0.2 vs 1.9?±?0.1?days, respectively, P?=?.009). The 30-day morbidity was 0 in robotic and 2.7% in laparoscopic group. Pathology was similar between groups.

Conclusions

Our study shows that the use of the robot could shorten operative time and decrease the rate of conversion to open for adrenal tumors larger than 5?cm. Based on our favorable experience, robotic adrenalectomy has become our preferred minimally invasive surgical approach for removing large adrenal tumors.     

A Prospective Proteomic-Based Study for Identifying Potential Biomarkers for the Diagnosis of Cholangiocarcinoma

Background

Cholangiocarcinoma (CCA) is becoming a common fatal hepatic tumor. Early detection of CCA is hampered by the absence of a sufficiently accurate and noninvasive diagnostic test. Proteomic analysis would be a powerful tool to identify potential biomarkers of this cancer.

Aims

This study aims to identify new protein markers that are specific for CCA using proteomic approaches and to evaluate the performance of S100 calcium-binding protein A9 (S100A9) and chaperonin-containing TCR1, subunit 3 (CCTγ) as diagnostic markers for screening test of CCA.

Methods

Two-dimensional differential gel electrophoresis (2-D DIGE) coupled with matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry were used to analyze and screen biomarker candidates in the proteomes of five human CCA samples and five healthy control samples. Subsequently, two potential biomarkers, S100A9 and CCTγ, were chosen for validation and analysis by immunohistochemical methods using CCA tissue microarrays.

Results

Twenty protein spots were significantly elevated and five protein spots were downregulated in all patients (p?<?0.05). The positive rate was significantly higher in patients with CCA (48?±?35 %) compared with the normal liver control group (5?±?10 %, p?<?0.001), the hepatocellular carcinoma group (15?±?20 %, p?<?0.001), and the cirrhosis group (12?±?16 %, p?<?0.001). A greater proportion of patients with CCA were positive for CCTγ (72?±?18 %) compared with the normal liver control group (43?±?22 %, p?<?0.001), the hepatocellular carcinoma group (45?±?20 %, p?<?0.001), and the cirrhosis group (39?±?25 %, p?<?0.001).

Conclusions

Combined comparative proteomic analysis using 2-D DIGE and MALDI-TOF is an effective method for identifying differentially expressed proteins in CCA tissues. The expression of S100A9 and CCTγ showed promise as novel diagnostic markers for CCA.     

Laparoscopic appendectomy as a teaching procedure: experiences with 1197 patients in a community hospital

Purpose

Since laparoscopic procedures have become more common, resident surgeons have to learn complex laparoscopic skills at an early stage of their career. The aim of this study was to compare the short-term clinical outcome parameters of laparoscopic appendectomy (LA) performed by resident surgeons (RS) or attending surgeons (AS).

Methods

A total of 1197 LA and 57 open appendectomies were performed in a Swiss community hospital between 1999 and 2009. RS performed 684 operations. Parameters including the duration of the operation and hospital stay, intraoperative complications, surgical reinterventions, and a 30-day morbidity and mortality were observed.

Results

The mean age of the patients was 35.6?±?18.17?years. The duration of the operation was longer (61.34?±?25.73?min [RS] vs. 53.65?±?29.89 [AS]?min; p?=?0.0001), but the hospital stay was shorter, in patients treated by RS (3.92?±?2.61?days [RS] vs. 4.87?±?3.23 [AS]?days; p?=?0.0001). The rate of intraoperative complications was not significantly different between the two groups (1.02?% [RS] vs. 0.8?% [AS]; p?=?0.6). The need for surgical reintervention (0.6?% [RS] vs. 2.5?% [AS]; p?=?0.005) and the 30-day morbidity were higher in patients treated by AS (3.7?% [AS] vs. 1.8?% [RS]; p?=?0.04). There was no postoperative mortality.

Conclusions

Under appropriate supervision, surgical residents are able to perform LA with results comparable to those of experienced surgeons.     

Robot-assisted total gastrectomy is comparable with laparoscopically assisted total gastrectomy for early gastric cancer

Background

Laparoscopically assisted total gastrectomy (LATG) is technically difficult. Robot surgery has theoretical advantages such as increased degrees of freedom of instruments and a three-dimensional view. The current study aimed to determine whether a robot-assisted total gastrectomy (RATG) has a real benefit over LATG in terms of surgical and oncologic outcomes.

Methods

A single-center case–control study was conducted. The study included 36 patients who underwent RATG and 65 patients who underwent LATG at the National Cancer Center in Korea between February 2009 and May 2011. No patients were excluded from the analysis within the study period. Clinicopathologic data, operative data, postoperative morbidity, and pathologic data were analyzed by Student’s t-tests and Chi-square tests, as indicated.

Results

The mean age of the patients was 53.9?±?11.7?years in the RATG group and 56.9?±?12.3?years in the LATG group (P?=?0.236). The mean BMI was 23.2?±?2.5?kg/m² in the RATG group and 23.6?±?3.4?kg/m² in the LATG group (P?=?0.494). The mean postoperative hospital stay was 8.8?±?3.3?days in the RATG group and 10.3?±?10.8?days in the LATG group (P?=?0.416). The mean operative time was 305.8?±?115.8?min in the RATG group and 210.2?±?57.7?min in the LATG group (P?P?=?0.209). Postoperative complications were experienced by 6 patients (16.7%) in the RATG group and 10 patients (15.4%) in the LATG group (P?=?0.866).

Conclusion

Despite early experiences, RATG was shown to be comparable with LATG in terms of surgical and oncologic outcomes. However, no apparent benefit is associated with RATG to date.     

Fast Track Care for Gastric Bypass Patients Decreases Length of Stay Without Increasing Complications in an UnselectedPatient Cohort

Background

Retrospective studies investigating fast track care involve selected patients. This study evaluates the implementation of fast track care in unselected bariatric patients in a high volume teaching hospital in the Netherlands.

Methods

Consecutive patients who underwent a primary laparoscopic gastric bypass in our center were reviewed in the years before (n?=?104) and after implementation of fast track care (n?=?360). Fast track involved the banning of tubes/catheters, anesthetic management and early ambulation. Primary outcome was the length of stay. Perioperative times, complications (<30 days), readmissions and prolonged length of stay were secondary outcomes.

Results

The median length decreased after implementation of fast track (3 days versus 1 day, p?<?0.001). Overall complication rate remained stable after implementation of fast track care (17.3 % versus 18.3 %, not significant). Readmission rate did not differ between groups (4.8 % conventional care versus 8.1 % fast track, not significant). More grades I–IVa complications occurred outside the hospital after the implementation of fast track care (24.8 % versus 51.5 %). Lower age (b?=?0.118, 95 % CI: 0.002–0.049, p?<?0.05) and the implementation of fast track (b?=??0.270, 95 % CI: -1.969 to ?0.832, p?<?0.001) were the only factors that significantly shortened the length of stay.

Conclusions

Patients that received fast track care had a decreased length of stay. Although more complications occurred after discharge in the fast track care group, this did not lead to adverse outcomes. Fast track does enhance recovery and is suitable for unselected patients. Care providers should select their patients for early discharge and pursue a low threshold for readmission.     

Urine neutrophil gelatinase-associated lipocalin to predict acute kidney injury in preterm neonates. A pilot study

Background

The efficacy of urine neutrophil gelatinase-associated lipocalin (uNGAL) as an early acute kidney injury (AKI) biomarker in preterm neonates was evaluated.

Methods

Thirty-five preterm neonates were prospectively evaluated for serum creatinine (sCre)-documented AKI during the first 14 days of life. Urine samples were collected daily throughout the study period. Of the neonates evaluated, we analyzed 11 who developed AKI (cases) and an equal number of neonates without AKI (controls) matched for gestational and postnatal age (case–control study). uNGAL was measured on the day of AKI occurrence (day 0) and on the 2 days preceding the event (day ?1 and day ?2, respectively) using an enzyme-linked immunosorbent assay.

Results

Cases had significantly higher sCre levels than controls on day 0 (1.21?±?0.48 vs. 0.83?±?0.16 mg/dL, p?=?0.031) but not on days ?1 and ?2. Similarly, uNGAL levels (ng/mL) were significantly higher in cases than in controls only on day 0 (19.1?±?3.5 vs. 13.3?±?7.3, p?=?0.017) and not on days ?1 (18.8?±?3.4 vs. 16.3?±?5.9, p?=?0.118) and ?2 (19.3?±?1.8 vs. 19.4?±?0.8, p?=?0.979). The receiver operating characteristic curve analysis showed no significant ability of uNGAL to predict AKI on days ?2 and ?1.

Conclusions

In this pilot study in preterm neonates, although uNGAL detected sCre-based AKI upon its documentation, it failed to predict its development 1–2 days earlier.     

Sugammadex Allows Fast-Track Bariatric Surgery

Background

Morbidly obese (MO) patients are at increased risk for postoperative anesthesia-related complications. We evaluated the role of sugammadex versus neostigmine in the quality of recovery from profound rocuronium-induced neuromuscular blockade (NMB) in patients with morbid obesity.

Methods

We studied 40 female MO patients who received desflurane and remifentanil anesthesia for laparoscopic removal of adjustable gastric banding. NMB was achieved with rocuronium. At the end of the surgical procedure, complete reversal of NMB was obtained with sugammadex (SUG group, n?=?20) or neostigmine plus atropine (NEO group, n?=?20) in the presence of profound NMB.

Results

No difference in surgical time or anesthetic drugs was found between the groups. Anesthesia time was significantly greater in the NEO group than in the SUG group (95?±?21 vs. 47.9?±?6.4 min, p?<?0.0001), which was mainly due to a longer time to reach a train-of-four ratio (TOFR)?≥?0.9 in the NEO group (48.6?±?18 vs. 3.1?±?1.3 min, p?<?0.0001) during reversal of profound NMB. Upon admission to the postanesthesia care unit, level of SpO₂ (p?=?0.018), TOFR (p?<?0.0001), ability to swallow (p?=?0.0027), and ability to get into bed independently (p?=?0.022) were better in the SUG group than in the NEO group. Patients in the SUG group were discharged to the surgical ward earlier than patients in the NEO group were (p?=?0.013).

Conclusions

Sugammadex allowed a safer and faster recovery from profound rocuronium-induced NMB than neostigmine did in patients with MO. Sugammadex may play an important role in fast-track bariatric anesthesia