Endoscopic Surgery: Fit for Malignancy?

Neither experimental nor clinical data confirm the repeatedly published opinion that video-endoscopic surgery promotes tumor growth or the occurrence of implantation metastases in cancer patients. On the contrary, alterations due to pneumoperitoneum by the application of different gases, pressures, and temperatures might provide the basis for a new therapeutic approach to cancer surgery. Oncologically adequate resections defined by such terms as “no touch isolation” and “monobloc resection” can be performed video-endoscopically in a variety of intraabdominally or intrathoracically located cancers if a standardized technique is used. The benefit of video-endoscopic surgery is limited in large tumors, especially if they have reached the organ surface. There is still a major deficit in the clinical evaluation of video-endoscopic interventions in most oncologic diseases. Randomized studies comparing video-endoscopic and conventional surgery have been reported only for the resection of colorectal carcinoma. They show that laparoscopic resections can be performed with a minimum of postoperative complications to the same extent as conventional resections and offer several advantages during the early postoperative period. No reliable data from comparative trials are as yet available on the long-term results.     

Subfascial Endoscopic Perforator Surgery: New Life for an Old Procedure?

Background:

Division of incompetent perforating veins has long been regarded as an appropriate approach for treatment of venous stasis ulcers. The development of endoscopic techniques using standard laparoscopic instrumentation has permitted the application of this therapy without the need for long open incisions, fraught with complications.

Methods:

We report our experience with 20 cases of subfascial endoscopic perforator surgery (SEPS) in 19 patients. Seventeen limbs had active ulceration at the time of operation. A gas insufflation technique with two 10 mm ports was used in most cases.

Results:

An average of four perforating veins were divided in each case. Mean operating time was 1.5 hours. At a mean follow-up of eight months, initial complete healing occurred in 14 of 17 ulcers, three ulcers improved, and three healed ulcers at the time of SEPS have remained healed. One patient developed a small area of recurrent ulceration after initial healing. There were no thromboembolic complications. One procedure was technically unsuccessful because of morbid obesity. One patient developed a wound infection, and one patient required re-exploration for a subfascial hematoma.

Conclusion:

SEPS is a safe, minimally invasive procedure which should become an important part of the surgical armamentarium in treating patients with venous ulcers.     

Endoscopic Surgery: What Has Passed the Test?

The use of endoscopic surgery has increased in gastrointestinal surgery since the introduction of laparoscopic cholecystectomy. It was the aim of this study to investigate the impact of endoscopic procedures in 1998. Laparoscopic cholecystectomy, fundoplication, repair of perforated peptic ulcer, gastric banding procedure, sigmoid resection for diverticulitis, and ileal pouch–anal anastomosis were investigated using techniques of technology assessment. Feasibility, efficacy, and effectiveness were used to evaluate the different types of operation. The statements were graded by three categories of evidence. Laparoscopic cholecystectomy and fundoplication have passed the test. Laparoscopic repair of perforated duodenal ulcer, gastric banding for morbid obesity, and sigmoid resection for diverticulitis are feasible and efficient but not effective today. Laparoscopy-assisted ileal pouch–anal anastomosis has been shown to be feasible but is not yet efficient and effective.     

Endoscopic Thoracic Sympathectomy: At What Level Should You Perform Surgery?

Several interventions are possible on the sympathetic chain and the nomenclature has been confusing. The authors propose a uniform nomenclature for each procedure, mainly, sympathectomy for resection or ablation of the ganglion, sympathicotomy for the transaction of the chain, ramicotomy for the procedure preserving the chain and ganglia and severing the rami, and finally, sympathetic block for clipping above and below the ganglia. They recommend intervention on the T2 ganglia for facial hyperhidrosis and rubor, on the T3 ganglia for palmar hyperhidrosis, and on the T3 and T4 ganglia for axillary hyperhidrosis.     

Incurable Stenosing Colorectal Carcinoma: Endoscopic Stent Implantation or Palliative Surgery?

Background Palliative surgery for the treatment of incurable obstructive colorectal carcinoma is associated with a considerable perioperative morbidity and mortality but no substantial improvement of the prognosis. The aim of the present study was to study the effectiveness of colorectal stenting compared with palliative surgery in incurable obstructive colorectal carcinoma. Patients and Methods From April 1999 to April 2005, data of consecutive patients with incurable stenosing colorectal carcinoma, either treated with stent implantation or palliative surgical intervention, were prospectively recorded with respect to age, sex, tumor location (including metastases), ASA-score, peri-interventional morbidity, mortality, rates of complications, and re-interventions as well as survival. Results Of 40 patients, 38 (95%) were successfully treated with a stent. Two patients (5%) underwent surgical intervention after stent dislocation. In contrast, 38 patients primarily underwent palliative surgical intervention. Stent patients were significantly older (P = 0.020), had a higher ASA-score (P = 0.012), and had more frequently distant metastases (P = 0.011). After successful stent implantation, no early complications were observed, but late complications occurred in 11 subjects (29%). Following palliative surgical intervention, postoperative complications occurred in 12 individuals (32%) . Postoperative mortality was 5% in the surgery group, whereas no patient died following stent implantation. There was no significant differences in the survival of both groups (9.9 vs. 7.8 months, respectively; log rank: 0.506). Conclusions Palliative treatment of incurable obstructive colorectal carcinoma using stents is an effective and suitable alternative to palliative surgery with no negative impact on the survival but less peri-interventional morbidity and mortality as well as comparable overall morbidity.     

Endoscopic Combined Intrarenal Surgery in Galdakao-Modified Supine Valdivia Position: A New Standard for Percutaneous Nephrolithotomy?

Background

Percutaneous nephrolithotomy (PCNL), the gold standard for the management of large and/or complex urolithiasis, is conventionally performed with the patient in the prone position, which has several drawbacks. Of the various changes in patient positioning proposed over the years, the Galdakao-modified supine Valdivia (GMSV) position seems the most beneficial. It allows simultaneous performance of PCNL and retrograde ureteroscopy (ECIRS, Endoscopic Combined Intra-Renal Surgery) and has unquestionable anaesthesiological advantages.

Objective

To prospectively analyse the safety and efficacy of endoscopic combined intrarenal surgery (ECIRS) in GMSV position for the treatment of large and/or complex urolithiasis.

Design, setting, and participants

From April 2004 to December 2007, 127 consecutive patients who were followed in our department for large and/or complex urolithiasis were selected for surgery (American Society of Anesthesiologists [ASA] score 1–3, no active urinary tract infection [UTI], any body mass index [BMI]).

Intervention

All the patients underwent ECIRS in GMSV position. Technical choices about percutaneous access, endoscopic instruments and accessories, and postoperative renal and ureteral drainage are detailed.

Measurements

Patients’ mean age plus or minus standard deviation (± SD) was 53.1 yr ± 14.2. Of the 127 patients, 5.5% had congenital renal abnormalities, 3.9% had solitary kidneys, and 60.6% were symptomatic for renal colics, haematuria, and recurrent UTI. Mean stone size ± SD was 23.8 mm ± 7.3 (range: 11–40); 33.8% of the calculi were calyceal, 33.1% were pelvic, 33.1% were multiple or staghorn, and 4.7% were also ureteral.

Results and limitations

Mean operative time ± SD was 70 min ± 28, including patient positioning. Stone-free rate was 81.9% after the first treatment and was 87.4% after a second early treatment using the same percutaneous access during the same hospital stay (mean ± SD: 5.1 d ± 2.9). We registered overall complications at 38.6% with no splanchnic injuries or deaths and no perioperative anaesthesiological problems.

Conclusions

ECIRS performed in GMSV position seems to be a safe, effective, and versatile procedure with a high one-step stone-free rate, unquestionable anaesthesiological advantages, and no additional procedure-related complications.     

Editorial Commentary: The Amsterdam Achilles Tendinopathy Endoscopic Treatment: Should We Start Booking Our Patients for Surgery?

Mid-portion Achilles tendinopathy remains an elusive clinical and pathologic condition, with only a limited treatment algorithm to guide us. Although the risk factors and natural history have been documented, the exact etiology and source of pain generation remains unclear in the literature. Several Level I studies have shown reasonable success with a myriad of nonoperative treatments over the long term. Surgery is often reserved as the last resort for those who have failed nonoperative treatment, with mixed techniques and results. The endoscopic surgery literature for this condition is lacking, and more studies are needed to clarify the proper indications, techniques, and results of this disabling problem.     

Do Future General Surgery Residents Have Adequate Exposure to Endocrine Surgery During Medical School?

During their general surgical rotations, medical students should ideally have exposure to a wide breadth of surgical procedures, especially if they are interested in pursuing surgical careers. To determine their exposure to endocrine surgery during medical school, we surveyed students from more than 20 medical schools who interviewed for general surgery residency positions at our institution over a 2-year period. Questions focused on the total number of index surgical procedures observed during all of their medical school education. Of 211 surveys sent, 146 were returned (66%). The mean age of the students was 26.0 +/- 0.3 years, and 21% were women. The average times spent on general surgery and surgery subspecialty rotations during medical school were 11.1 +/- 0.6 weeks and 7.6 +/- 0.4 weeks, respectively. The mean number of thyroidectomies (2.8 +/- 0.3), parathyroidectomies (1.9 +/- 0.3), and adrenalectomies (0.5 +/- 0.1) observed by the medical students were significantly lower than operations such as mastectomies (9.4 +/- 0.3), coronary bypass surgeries (8.7 +/- 1.4), and laparoscopic cholecystectomies (10.0 +/- 0.7). Furthermore, of these 146 future surgical residents, 34% failed to observe a single thyroid resection, 42% did not see a parathyroidectomy, and 65% failed to see an adrenalectomy. In conclusion, future general surgery residents seem to observe a wide variety of surgical cases, but most have little or no exposure to endocrine surgery. This paucity of exposure may have significant educational and career ramifications.     

Surgery for appendicitis: is it necessary?

ABSTRACT Background: Appendectomy for acute appendicitis is an effective, universally accepted procedure performed more than 300,000 times annually in the United States. It is generally believed that appendicitis progresses invariably from early inflammation to later gangrene and perforation, and that appendectomy is required for surgical source control. Although non-operative management with antibiotics of uncomplicated diverticulitis, salpingitis, and neonatal enterocolitis is now established, the non-operative management of appendicitis remains largely unexplored. Methods: Systematic review of published literature and derived expert opinion. Results: Clinical, epidemiologic, radiologic, and pathologic evidence is presented for spontaneous resolution of uncomplicated acute appendicitis. The pathogenesis of appendicitis is reviewed with specific consideration of the role of bacterial infection in the pathogenesis. Evidence is also provided documenting the clinical success of non-operative management. Conclusions: Appendectomy may not be necessary for the majority of patients with acute uncomplicated appendicitis, as many patients resolve spontaneously and others may be treatable with antibiotics alone. However, the supporting documentation is scant and of poor quality. A randomized, prospective trial of non-operative management versus early appendectomy of acute uncomplicated appendicitis corroborated by radiologic imaging is called for.     

Surgery for obesity: panacea or Pandora's box?

BACKGROUND: Given the increasing prevalence of obesity, healthcare providers should be cognizant of various non-operative (diet, exercise, behavior therapy, and medications) and operative obesity treatments. This review critically evaluates these treatments, especially bariatric surgeries. METHODS: Medline analyses using a combination of the following terms: obesity, bariatric surgery, and outcomes were performed with particular emphasis on prospective studies and randomized trials. RESULTS: Non-operative treatments result in modest sustained weight loss (5-8%) at one year. Surgery is recommended for those with BMI >40 or >35 with comorbidities. Laparoscopic adjustable gastric banding, a restrictive procedure, causes 35-54% excess weight loss (EWL) at 1 year. Malabsorptive procedures (biliopancreatic diversions with and without duodenal switch) induce 72-77% EWL but are only performed at few centers. Roux-en-Y gastric bypass, acting through a combination of restriction and malabsorption, results in 69% EWL at 1 year and 49% at 14 years. Each procedure is associated with unique anatomic and nutritional complications. Overall, operative treatment improves comorbidities and may improve all-cause mortality. CONCLUSIONS: Surgery is an effective long-term treatment for selected obese patients who have failed other treatments. Further research is needed on prospective comparisons of procedures, evaluation of long-term outcomes, especially between centers and increasingly unrealistic patient expectations.