Synchronous Bilateral Adrenalectomy for Cushing’s Syndrome: Laparoscopic Versus Posterior Retroperitoneoscopic Versus Robotic Approach

Background

Synchronous endoscopic bilateral adrenalectomy (BilA) can effectively provide definitive cure of hypercortisolism in ACTH-dependent Cushing’s syndrome and in primary adrenal bilateral disease. We compared three different approaches for BilA: transabdominal laparoscopic BilA (TL-BilA), simultaneous posterior retroperitoneoscopic BilA (PR-BilA), and robot-assisted BilA (RA-BilA).

Methods

All patients who underwent BilA between January 1999 and December 2012 at two referral centers (one performing TL-BilA and PR-BilA and one performing RA-BilA) were included. A comparative analysis was performed.

Results

Twenty-nine patients were included: 5 underwent TL-BilA, 11 underwent PR-BilA, and 13 underwent RA-BilA. No significant difference was found concerning age, gender, diagnosis, and previous abdominal surgery. No conversion to open approach was registered. Operative time was significantly shorter for the PR-BilA group than for the TL-BilA and RA-BilA groups (157.4 ± 54.6 vs 256.0 ± 43.4 vs 221.5 ± 42.2 min, respectively) (P < 0.001). No significant difference was found concerning intraoperative and postoperative complications rate and time to first flatus. Drains were used routinely after PR-BilA and TL-BilA and electively in four RA-BilA patients (P < 0.001). Hospital stay was longer in the TL-BilA and PR-BilA groups than in the RA-BilA group (12.0 ± 5.7 vs 10.8 ± 3.7 vs 4.4 ± 1.7 days, respectively) (P < 0.001). No recurrence or disease-related death was registered.

Conclusions

Operative time was significantly shorter in the PR-BilA group, because it eliminates the need to reposition the patient. The number of drains and the length of hospital stay were reduced after RA-BilA, but this was likely related to different management protocols in different settings. Because no significant difference was found in terms of postoperative outcome, none of the three operative approaches can be considered the preferable one.     

Solid Versus Liquid—Satiety Study in Well-Adjusted Lap-Band Patients

Background

Patients following laparoscopic adjustable gastric banding (LAGB) are generally advised to avoid liquid calories, opt for solids and refrain from drinking with meals as this is believed to prolong satiety. The role of food consistency and satiety following LAGB is largely uninvestigated. The purpose of the study was to: (1) determine if food consistency impacts on post meal satiety in participants with well-adjusted LAGB and (2) compare the level of satiety achieved after consuming a solid versus a liquid meal between groups.

Methods

Twenty intervention (well-adjusted LAGB) and 20 control participants were recruited. All participants consumed three iso-caloric breakfasts that were randomised for nine mornings. Participants were asked to rate their satiety on visual analogue scales (VAS) at set times after the test meal. Areas under the curve (AUC) VAS scores were compared within and between groups.

Results

Solids (bars) with or without water provided greater satiety than the liquids (shakes) for both groups. Drinking water with the bar did influence satiety in the intervention group. For the intervention group (LAGB), AUC VAS values for the bar with water were 77.4?±?11.2* and 72.4?±?16.7* for the controls.

Conclusion

Solid meals are more satisfying in both LAGB and non-LAGB individuals. However, a solid meal with accompanying water did not alter meal satiety.     

Single Port Versus Multiple Port Laparoscopic Cholecystectomy—A Comparative Study

Single port laparoscopic cholecystectomy (SPLC) was introduced to minimize postoperative morbidity and improve cosmesis. We performed a comparative study to assess feasibility, safety and perceived benefits of SPLC. Two groups of patients (104 each) with comparable demographic characteristics were selected for SPLC and multiport laparoscopic cholecystectomy (MPLC) between May 2010 to March 2011. SPLC was performed using X cone® with 5 mm extra long telescope and 3 ports for hand instruments. MPLC was performed with traditional 4 port technique. A large window was always created during dissection to obtain the critical view of safety. Data collection was prospective. The primary end points were post-operative pain and surgical complications. Secondary end points were patient assessed cosmesis and satisfaction scores and operating time. The mean VAS scores for pain in SPLC group were higher on day 0 (SPLC 3.37 versus MPLC 2.72, p?=?0.03) and equivalent to MPLC group on day 1(SPLC 1.90 versus MPLC 1.79, p?=?0.06). Number of patients requiring analgesia for breakthrough pain (SPLC 21.1 % versus MPLC 26.9 %, p?=?0.31) was similar. Number and nature of surgical complications was similar (SPLC 17.3 % versus MPLC 21.2 %, p?=0.59). Mean patient assessed cosmesis scores (SPLC 7.96 versus MPLC 7.16, p?=?0.003) and mean patient satisfaction scores (SPLC 8.66 versus MPLC 8.16, p?=?0.004) were higher in SPLC group indicating better cosmesis and greater patient satisfaction. SPLC took longer to perform (61 min versus 26 min, p?=?0.00). Conversion was required in 5 patients in SPLC group. SPLC appears to be feasible and safe with cosmetic benefits in selected patients. However, challenges remain to improve operative ergonomics. SPLC needs to be proven efficacious with a high safety profile to be accepted as standard laparoscopic technique.     

A Case�Ccontrol Study of Single-Incision Versus Standard Laparoscopic Cholecystectomy

Background  

Single-incision laparoscopic cholecystectomy (SILC) has been increasingly performed recently. Although it seems plausible that SILC will be associated with less pain compared to standard 4-port laparoscopic cholecystectomy (LC), there is currently no conclusive comparative study on the postoperative pain issues of SILC against LC.     

Robotic Cystectomy Versus Open Cystectomy: Are We There Yet?

IntroductionOpen radical cystectomy (ORC) with extended pelvic lymph node dissection (PLND) represents the treatment of choice for muscle-invasive and/or high-risk non–muscle-invasive bladder cancer (BCa), especially when it does not respond to bacillus Calmette-Guérin. However, robotic cystectomy is steadily increasing as a minimally invasive option for the management of BCa. Some studies have shown the advantages of the robotic surgery over the laparoscopic approach, including a shortened learning curve, better precision, and comfort for the surgeon. Furthermore, short-term oncologic results as well as functional results appeared to be similar to those of ORC and laparoscopic radical cystectomy.Surgical techniqueThe patient is placed in a Trendelenburg position and the trocars placed similarly as for prostate cancer surgery. Then, an anatomic dissection of the ureter and paravesical space allows easy section with the use of LigaSure (Covidien, Boulder, CO, USA) on all the pedicles. When the seminal vesical is reached, the section of the pedicles and the plane (interfascial or extrafascial) are developed according to a nerve-sparing or non–nerve-sparing technique. After the cystectomy, we proceed to PLND. The urinary diversion (UD) is performed extracorporeally.ResultsRecent reports have demonstrated surgical and perioperative results similar to or even better than the open experience. From the oncologic point of view, there is still short follow-up in robot-assisted cystectomy, but the results about margins and the number of nodes are similar to open series. The UD is done extracorporeally to improve operative time. Preservation of the neurovascular bundle during radical cystectomy (RC) has been explored by some authors in order to maximise recovery for sexual function, and the results are promising. Postoperative complications in recent published series are globally decreased in comparison to open surgery. Further studies are warranted to validate these initial results.ConclusionsRobot-assisted laparoscopic radical cystectomy with extracorporeal UD reconstruction is slowly entering the realm of the urologist because it appears to incorporate the advantages of minimally invasive surgery with the safety of the open approach. Nevertheless, future data about long-term oncologic and functional results will have to prove the real position of robot-assisted cystectomy in the management of BCa.     

Proximal Versus Distal Gastric Carcinoma—What Are the Differences?

Background: The incidence of proximal gastric third carcinoma (PGC) has been rising in recent years. Classification and surgical therapy remain controversial.Methods: Between May 1986 and October 1997, 532 patients were operated for primary gastric carcinoma. All patient data were analyzed retrospectively comparing findings in patients with PGC and those with distal gastric carcinoma (DGC).Results: Two hundred fifty patients had a PGC, and 282 patients had a DGC. The rate of R0 resections was 79.3% for PGC and 81.6% for DGC. In 93.9% of the patients with PGC total gastrectomy was performed; for DGC total gastrectomy was done in 74.5% of patients. Postoperative morbidity and mortality were 29.2% for PGC and 23.8% for DGC, and 3.2% for PGC and 3.5% for DGC, respectively. Patients with advanced tumor stages (stage III and IV) were more common in the PGC group (73.3% vs. 53.6% in DGC). After R0 resection, the 5-year survival rate was 33.2% for PGC and 59.7% for DGC.Conclusions: There was no significant difference between the rates of R0 resections for PGC and DGC. Total gastrectomy can be performed with low postoperative morbidity and mortality. PGC and DGC represent the same tumor entity, and prognosis is similar, but due to more advanced tumor stages, the long-term survival is worse for patients with PGC than for those with DGC. Left retroperitoneal lymphadenectomy may be indicated for PGC.     

Endoscopic Versus Conventional Radial Artery Harvest—Is Smaller Better?

BACKGROUND: We sought to assess our initial experience with the recently introduced technique of endoscopic radial artery harvest (ERH) for coronary artery bypass grafting (CABG). METHODS: Data were prospectively collected on 108 consecutive patients undergoing isolated CABG with ERH, and compared to 120 patients having conventional harvest (CH). Follow-up was achieved in 227 patients (99%). At the time of follow-up the severity of motor and sensory symptoms, as well as cosmetic result in the harvest forearm, were subjectively graded using a 5-point scale. Grade 1-- high intensity deficits, poor cosmetic result. Grade 5 -- no deficits, excellent cosmetic result. RESULTS: Hospital mortality, myocardial infarction, and stroke rates were similar between the groups. Follow-up mortality, reintervention rate, and average angina class were also similar. Harvest time was longer in the ERH group (61 +/- 24 min vs. 45 +/- 11 min, p < 0.001). Three patients in the ERH group were converted to CH and one radial artery was discarded. There were no vascular complications of the hand in either group. Average score of motor (ERH 4.4 +/- 0.9, CH 4.2 +/- 1.0) or sensory symptoms (ERH 3.7 +/- 1.1, CH 3.8 +/- 1.2) were similar. In the CH group sensory deficits were observed in the distribution of both the lateral antebrachial cutaneous and the superficial radial nerves (SRN). In contrast, sensory deficits in the ERH group were limited to the distribution of the SRN. Cosmetic result score was higher in the ERH group (ERH 4.2 +/- 1.0, CH 3.1 +/- 1.4, p < 0.0001). CONCLUSIONS: ERH is safe. It is technically demanding with a significant learning curve. Motor and sensory symptoms are not completely eliminated by using a smaller incision, but cosmetic results are clearly superior.     

Laparoscopic Versus Open Subtotal Gastrectomy for Adenocarcinoma: A Case–Control Study

Objective  The aim of this study is to compare technical feasibility and oncologic efficacy of totally laparoscopic versus open subtotal gastrectomy for gastric adenocarcinoma. Background  Laparoscopic gastrectomy for adenocarcinoma is emerging in the West as a technique that may offer benefits for patients, although large-scale studies are lacking. Methods  This study was designed as a case-controlled study from a prospective gastric cancer database. Thirty consecutive patients undergoing laparoscopic subtotal gastrectomy for adenocarcinoma were compared with 30 patients undergoing open subtotal gastrectomy. Controls were matched for stage, age, and gender via a statistically generated selection of all gastrectomies performed during the same period of time. Patient demographics, tumor–node–metastasis (TNM) stage, histologic features, location of tumor, lymph node retrieval, recurrence, margins, and early and late postoperative complications were compared. Results  Tumor location and histology were similar between the two groups. Median operative time for the laparoscopic approach was 270 min (range 150–485 min) compared with median of 126 min (range 85–205 min) in the open group (p < 0.01). Hospital length of stay after laparoscopic gastrectomy was 5 days (range 2–26 days), compared with 7 days (range 5–30 days) in the open group (p = 0.01). Postoperative pain, as measured by number of days of IV narcotic use, was significantly lower for laparoscopic patients, with a median of 3 days (range 0–11 days) compared with 4 days (range 1–13 days) in the open group (p < 0.01). Postoperative early complications trended towards a decrease for laparoscopic versus open surgery patients (p = 0.07); however, there were significantly more late complications for the open group (p = 0.03). Short-term recurrence-free survival and margin status was similar between the two groups (p = not significant) with adequate lymph node retrieval in both groups. Conclusions  Laparoscopic subtotal gastrectomy for adenocarcinoma is comparable to the open approach with regard to oncologic principles of resection, with equivalent margin status and adequate lymph node retrieval, demonstrating technically feasibility and equivalent short-term recurrence-free survival. Additional benefits of decreased postoperative complications, decreased length of hospital stay, and decreased narcotic use make this a preferable approach for selected patients.     

Single-Incision Sleeve Gastrectomy Versus Conventional Laparoscopic Sleeve Gastrectomy—a Randomised Pilot Study

Background  

This is a prospective pilot study done to evaluate the feasibility and to assess the outcomes and complication rates of the single-incision sleeve gastrectomy versus the conventional five-port laparoscopic sleeve gastrectomy.     

Unicompartmental Versus Total Knee Arthroplasty Database Analysis: Is There a Winner?

Background  

TKA and unicompartmental knee arthroplasty (UKA) are both utilized to treat unicompartmental knee arthrosis. While some surgeons assume UKA provides better function than TKA, this assumption is based on greater final outcome scores rather than on change in scores and many patients with UKA have higher preoperative scores.     

Retropubic Versus Transobturator Midurethral Synthetic Slings: Does One Sling Fit All?

The purpose of this article is to evaluate the recent evidence base for the choice between transobturator and retropubic approaches to midurethral slings used to treat stress urinary incontinence. While the retropubic and transobturator approaches to midurethral sling surgery for stress urinary incontinence demonstrate equivalent efficacy across a number of randomized controlled trials, they do not appear to be equivalent when particular patient populations are considered separately. The retropubic approach appears to be a better option in patients with intrinsic sphincter deficiency and limited urethral mobility.