Linear-Stapled Gastrojejunostomy with Transverse Hand-Sewn Enterotomy Closure Significantly Reduces Strictures for Laparoscopic Roux-en-Y Gastric Bypass

Background

Gastrojejunostomy (GJ) stricture is a common complication after Roux-en-Y gastric bypass (RYGB) for morbid obesity, and the optimal anastomotic technique remains uncertain. The objective of this study was to use cumulative summation (CUSUM) analysis to compare rates of gastrojejunostomy strictures after linear stapling with longitudinal versus transverse enterotomy closure in gastric bypass patients.

Methods

Charts of all consecutive patients with at least 60 days of post-operative follow-up after laparoscopic RYGB (LRYGB) at our tertiary care institution from Nov 2009 to Dec, 2011 were retrospectively reviewed. Gastrojejunostomy stricture was diagnosed by history and upper endoscopy. CUSUM method of quality control analysis was used to determine sequential improvement in stricture rates with the change in technique.

Results

A total of 197 patients were included (97 longitudinal closure, median age 44 (21–67), median BMI 47 (35–80), 85.8 % female). Gastrojejunostomy strictures occurred in 16 % of longitudinal and 0 % of transverse patients (p?=?<0.0001). CUSUM analysis demonstrated sequential statistically significant improvement in stricture rates after the change in technique was applied. The longitudinal group had a statistically significant increased rate of surgery-related readmissions (15.5 vs 6.0 %, p?=?0.038), with 43.7 % of those readmissions related to GJ strictures. There were no other significant outcome differences between groups.

Conclusions

Linear-stapled anastomosis with a transverse enterotomy closure significantly reduces the rate of gastrojejunostomy stricture for LRYGB, considerably reducing procedural morbidity.     

A Comparative Study of Contrasting Surgical Residency Programs

Background

Postgraduate training is completed in a 5-year surgical residency program in the USA, compared with 10 years in the UK. The UK Joint Committee on Surgical Training (JCST) has described quality indicators for surgical training. Similar indicators can be inferred from the American Board of Surgery and Accreditation Council for Graduate Medical Education. This exploratory study compares postgraduate surgical training between two regions following their respective national programs.

Methods

A questionnaire was developed based on JCST quality indicators. This was distributed electronically to all general surgical residents in the University of Pennsylvania (UPenn) (N = 64) and North and South West Thames general surgical registrars in London (N = 182).

Results

A total of 76 residents (31 %) completed the questionnaire and all data presented are self-reported. When residents operate electively, an attending is scrubbed for 57 % of cases in London versus 83 % at UPenn (p < 0.001). During emergency surgery, residents operate without an attending in the operating room (OR) for 60 % of cases in London versus 2 % in UPenn (p < 0.001). London versus UPenn residents have a mean 3.6 versus 5.0 (p < 0.001) operating sessions and 0.7 versus 2.3 (p < 0.001) teaching hours per week. In London, 68 % of residents have regular gastrointestinal endoscopy sessions compared with 39 % at UPenn (p = 0.036).

Conclusions

UPenn residents receive more supervised operating opportunities and scheduled teaching than their London counterparts. However, they have less independent operating experience and less exposure to gastrointestinal endoscopy training.     

A comparison of the Supreme™ laryngeal mask airway with the Proseal™ laryngeal mask airway in anesthetized paralyzed adult patients: a randomized crossover study

Purpose

The Supreme? laryngeal mask airway (SLMA) is a new single-use advanced form of the Proseal? laryngeal mask airway (PLMA). This study tested the hypothesis that the SLMA is equally as effective as the PLMA as a supraglottic ventilatory device in anesthetized paralyzed adult patients.

Methods

Size 4 SLMAs and PLMAs were compared in a randomized crossover study involving 60 patients aged 21-75 yr and American Society of Anesthesiologists physical status I and II. Once the patients were anesthetized and paralyzed, the SLMA and the PLMA were inserted into each patient in random order. The primary outcome measure was the laryngeal seal pressure (LSP) at an intracuff pressure of 60 cm H₂O. Secondary outcome measures included the ease of inserting the laryngeal mask airway devices (LMADs) and the fibreoptic position of the airway tube.

Results

There was no statistically significant difference in LSP between the SLMA and the PLMA. The mean LSP was 19.6 ± 5.8 cm H₂O and 20.9 ± 6.7 cm H₂O for the SLMA and the PLMA, respectively. There was a similarity between the SLMA and the PLMA regarding the number of attempts required and the duration for insertion. However, fibreoptic positioning was better with the PLMA than with the SLMA (P < 0.0001).

Conclusion

The clinical performance of the SLMA as a ventilatory device is comparable with that of the PLMA, as illustrated by the similar LSPs. The inferior position of the SLMA airway tube compared with that of the PLMA does not affect its ease of ventilation.     

A novel method to position an endotracheal tube at the correct depth using an infrared sensor stylet

Purpose

This study is a feasibility assessment to determine the ability of novice users to utilize an infrared (IR) sensor stylet as a guide to position the tip of the endotracheal tube (ETT) 40 mm proximal to the carina in the swine trachea.

Methods

We developed a stylet system using an IR sensor attached to the tip of a stylet to facilitate measuring the distance of the ETT from the carina. The indicator lamp of the IR sensor system turns on through calibration when the ETT tip arrives at a point 20 mm proximal to the carina. In order to place the ETT tip 40 mm (middle of 20-60 mm) from the carina after the indicator lamp turns on, the operator uses the ETT marker to withdraw the ETT 20 mm. For this study, five fresh swine airways were used in random order after drawing lots, and ten novices were recruited to attempt the procedure ten times on each swine’s airway.

Results

Five hundred endotracheal intubations were performed. For the target distance of 40 mm from the ETT tip to the carina, the mean (standard deviation) of the total data set was 37.9 (3.5) mm; all data were within a 20-60 mm range (500/500), and 98.2% (491/500) of the attempts fell within the 30-50 mm range.

Conclusions

The IR sensor stylet system can facilitate correct positioning of the ETT tip at an appropriate depth above the carina in the swine trachea. Evaluation of the IR sensor stylet methodology in human subjects is warranted.     

Improved esophageal patency when inserting the ProSeal™ laryngeal mask airway with an Eschmann™ tracheal tube introducer

Purpose

We hypothesized that a more accurate alignment of the tip of the drain tube with the upper esophageal opening would be achieved in adult patients, as confirmed by fibreoptic bronchoscopy, by placing the ProSeal? laryngeal mask airway (PLMA) by means of guiding it over an Eschmann? tracheal tube introducer, commonly know as a gum elastic bougie (GEB), that was previously inserted into the esophagus, rather than by placing the PLMA with a curved metal introducer (IT).

Methods

Seventy-five adult elective surgery patients, whose airway management involved a PLMA, were randomly allocated to either the GEB- or IT-guided techniques. After inserting the PLMA, alignment of the tip of the drain tube relative to the esophageal opening was verified by a fibrescope introduced through the drain tube. Placing the fibrescope through the PLMA identified the glottic structures. The primary endpoint indicating the proper alignment of the tip of the drain tube of the PLMA with the upper esophageal opening was the ability to pass the fibrescope into the esophagus through the drain tube by a distance >35 cm without obstruction and the ability to simultaneously visualize the esophageal mucosa.

Results

The overall success rates of PLMA insertion were similar in the GEB and IT groups. However, the mean airway insertion times were longer with the GEB than with the IT-PLMA. The GEB group achieved proper alignment of the drain tube and the upper esophageal opening more frequently than the IT group (97% confidence interval (CI₉₅) 91.5–100% vs 81% CI₉₅ 68.5–93.5% of subjects, respectively; P = 0.027). When the GEB was used to place the PLMA, the patients’ vocal cords were visualized more frequently than when the IT technique was used (100% vs 73% CI₉₅ 58.9–87.1% of subjects, respectively; P = 0.003).

Conclusion

Fibreoptic bronchoscopy confirmed that GEB is superior to the IT technique in ensuring precise alignment of the tip of the drain tube of the PLMA with the upper esophageal opening. Accurate positioning may better preserve gastroesophageal drainage function of the PLMA.     

The McIvor blade improves insertion of the LMA ProSeal™ in children

Background

The McIvor blade, a tongue retractor with a thin curved blade, is used to improve the operating field during a tonsillectomy. We compared the success rate and incidence of complications between digital insertion and McIvor blade-guided insertion of the laryngeal mask airway (LMA?) ProSeal? when performed by anesthesia residents in children.

Methods

A total of 134 anesthetized non-paralyzed pediatric patients were included in the study. Patients were allocated randomly to one of two groups, i.e., Digital group (LMA ProSeal insertion using the digital insertion technique) or McIvor group (LMA ProSeal insertion using the Mclvor blade-guided technique). All patients were managed by anesthesia residents who were unskilled in using each technique. We assessed success rates of insertion at the first attempt, insertion time for an effective airway, and postoperative blood staining.

Results

The success rate of insertion at the first attempt was higher in the McIvor group than in the Digital group (97% vs 78%, respectively; P = 0.003), and insertion time with a successful first attempt was shorter in the McIvor group than in the Digital group (20.5 [4.5] sec vs 22.8 [6.7] sec, respectively; P = 0.021). The overall insertion time for an effective airway was also shorter in the McIvor group than in the Digital group (20.9 [5.7] sec vs 26.0 [9.8] sec, respectively; P < 0.001). Blood staining was more frequent in the Digital group than in the McIvor group (23% vs 6%, respectively; P = 0.035).

Conclusion

When inserting the LMA ProSeal in children, anesthesia residents were more successful using the McIvor blade-guided insertion technique than using the digital insertion technique. (ClinicalTrials.gov number, NCT01191619).     

Tracheal palpation to assess endotracheal tube depth: an exploratory study

Purpose

Correct placement of the endotracheal tube (ETT) occurs when the distal tip is in mid-trachea. This study compares two techniques used to place the ETT at the correct depth during intubation: tracheal palpation vs placement at a fixed depth at the patient’s teeth.

Methods

With approval of the Research Ethics Board, we recruited American Society of Anesthesiologists physical status I-II patients scheduled for elective surgery with tracheal intubation. Clinicians performing the tracheal intubations were asked to “advance the tube slowly once the tip is through the cords”. An investigator palpated the patient’s trachea with three fingers spread over the trachea from the larynx to the sternal notch. When the ETT tip was felt in the sternal notch, the ETT was immobilized and its position was determined by fibreoptic bronchoscopy. The position of the ETT tip was compared with our hospital standard, which is a depth at the incisors or gums of 23 cm for men and 21 cm for women. The primary outcome was the incidence of correct placement. Correct placement of the ETT was defined as a tip > 2.5 cm from the carina and > 3.5 cm below the vocal cords.

Results

Movement of the ETT tip was readily palpable in 77 of 92 patients studied, and bronchoscopy was performed in 85 patients. Placement by tracheal palpation resulted in more correct placements (71 [77%]; 95% confidence interval [CI] 74 to 81) than hospital standard depth at the incisors or gums (57 [61%]; 95% CI 58 to 66) (P = 0.037). The mean (SD) placement of the ETT tip in palpable subjects was 4.1 (1.7) cm above the carina, 1.9 cm (1.5-2.3 cm) below the ideal mid-tracheal position.

Conclusion

Tracheal palpation requires no special equipment, takes only a few seconds to perform, and may improve ETT placement at the correct depth. Further studies are warranted.     

Less perilaryngeal gas leakage with SLIPATM than with LMA-ProSealTM in paralyzed patients

Purpose

The aim of this study was to compare the Streamlined Liner of the Pharynx Airway (SLIPA?) with the ProSeal Laryngeal Mask Airway (LMA-ProSeal?) in mechanically ventilated paralyzed patients undergoing laparoscopic gynecologic surgery.

Methods

One hundred and one patients were allocated randomly to SLIPA (n = 50) or to LMA-ProSeal (n = 51) treatment groups. After induction of general anesthesia and insertion of the assigned supralaryngeal airway (SLA) device, we made note of the occurrence of any gastric insufflation and perilaryngeal leakage. We then evaluated the anatomical fit of the SLA device using a fibreoptic bronchoscope, and we assessed the airway sealing pressure and respiratory mechanics with change in head position and during peritoneal insufflation. After surgery, we evaluated the severity of postoperative sore throat and the presence of blood or regurgitated fluid on the SLA device.

Results

The insertion success rate, gastric insufflation, perilaryngeal leakage, anatomical fit, airway sealing pressure, respiratory mechanics, severity of sore throat, and incidence of blood and regurgitated fluid on the device were similar between the two groups. The incidence of perilaryngeal leakage with changes in the patient’s head position was lower with the SLIPA group than with the LMA-ProSeal group (3/50 vs 11/51, respectively; P = 0.026). During peritoneal insufflation, perilaryngeal leakage did not occur with the SLIPA but occurred in four cases with the LMA-ProSeal (P = 0.045).

Conclusion

Both the SLIPA and the LMA-ProSeal can be used effectively and without severe complications in paralyzed patients undergoing laparoscopic gynecological surgery. However, the SLIPA offers the advantage of less perilaryngeal gas leakage than the LMA-ProSeal with change in head position and during insufflation of the peritoneal cavity. This trial is registered with ANZCTR (ACTRN12609000914268).     

Oral chlorhexidine and microbial contamination during endoscopy: possible implications for transgastric surgery. A randomized, clinical trial

Background

One of the biggest concerns associated with transgastric surgery is contamination and risk of intra-abdominal infection with microbes introduced from the access route. The purpose of this study was to evaluate the effect of oral decontamination with chlorhexidine on microbial contamination of the endoscope.

Methods

In a prospective, randomized, single-blinded, clinical trial the effect of chlorhexidine mouth rinse was evaluated. As a surrogate for the risk of intra-abdominal contamination during transgastric surgery, microbial contamination of the endoscope during upper endoscopy was examined. Patients referred to upper endoscopy were assessed for eligibility and randomized to either chlorhexidine or no mouth rinse. Culture samples were collected from gastric aspirates and endoscopes. The primary outcome measure was colony forming units (CFU) in the endoscope samples. Secondary outcome measures were species specific effect of chlorhexidine on micro-organisms with abscess forming capabilities and the effect of proton pump inhibitor (PPI) treatment on CFU.

Results

Chlorhexidine mouth rinse resulted in a significant reduction of CFU in the endoscope samples (p = 0.001). There was no species specific effect and micro-organisms with abscess forming capabilities were equally present. PPI treatment was associated with significantly higher CFU counts in both the gastric (p = 0.004) and endoscope samples (p = 0.049).

Conclusions

Chlorhexidine mouth rinse was effective in reducing microbial contamination of the endoscope, but micro-organisms with abscess forming capabilities were still present. PPI treatment significantly increased CFU and should be discontinued before transgastric surgery.     

Head rotation, flexion, and extension alter endotracheal tube position in adults and children

Purpose

The purpose of this study was to evaluate the effect of head rotation in adults and children on endotracheal tube (ETT) position and to confirm previous results regarding the influence of head flexion and extension on ETT position.

Methods

After inducing anesthesia in 24 young adults and 22 children (aged 1–9 yr), ETTs were secured on the right corner of each of their mouths. Using a fiberoptic bronchoscope, the distance from the carina to the tip of the ETT was measured with each patient’s head and neck placed in a neutral position, flexed, extended, rotated to the right, and rotated to the left.

Results

In all patients, flexing the head resulted in the ETT moving towards the carina, and extension resulted in the tube being displaced in the opposite direction. In adults, head rotation to the right resulted in withdrawal of the ETT in all but one patient; displacement was 0.8 ± 0.5 cm (mean ± SD) (P < 0.001). Head rotation to the left resulted in the endotracheal tube being displaced in an unpredictable direction by 0.1 ± 0.6 cm. In children, head rotation to the right resulted in withdrawal of the ETT in all patients; displacement was 1.1 ± 0.6 cm (P < 0.001). Head rotation to the left also resulted in partial withdrawal in all patients; displacement measured 0.6 ± 0.4 cm (P < 0.001).

Conclusions

In adult patients under general anesthesia, head rotation towards the side of ETT fixation resulted in partial withdrawal of the tube tip away from the carina, whereas head rotation to the opposite side displaced the tube in an unpredictable manner. In children, head rotation to either side resulted in withdrawal of the ETT away from the carina.     

Endoscopic and Pathologic Findings Associated with Clinical Outcomes of Melanoma in the Upper Gastrointestinal Tract

Background

Melanoma that involves the upper gastrointestinal (GI) tract is rare and studies relating to endoscopic and pathologic findings with clinical outcomes are lacking. We reviewed the gross and microscopic patterns of the upper GI tract in primary and metastatic melanoma, and examined their association with clinical outcomes.

Methods

Twenty-nine cases of primary esophageal (n = 19) and metastatic gastric and/or duodenal melanoma (n = 10) that were detected during upper GI endoscopy between 1995 and 2011 were retrospectively analyzed.

Results

Three types of gross patterns were recognized—nodular pattern in 7 cases, mass-forming pattern in 18 cases, and flat pigmented pattern in 4 cases. In primary esophageal melanoma, 13 patients (68.4 %) underwent surgery and 9 received palliative therapy. Of all cases, 22 patients (75.9 %) died of disease progression; the median overall survival period was 12 months (interquartile range [IQR] 4.5–24.5 months), and from recognition of upper GI tract melanoma the median overall survival period was 9 months (IQR 3.5–17.0 months). In primary esophageal cases, skin melanoma stage better discriminated the patients with good prognosis than the esophageal cancer stage. The flat pigmented gross pattern proved to be a good prognostic factor in primary and metastatic GI tract melanomas (p = 0.016 and p = 0.046, respectively).

Conclusions

Melanoma of the GI tract is a highly aggressive disease with a poor prognosis, both in primary and metastatic cases. However, in primary esophageal melanoma, careful inspection of the mucosa during endoscopic examination followed by surgical resection may result in extended survival.     

Foreign material erosion after laparoscopic Roux-en-Y gastric bypass: findings and treatment

Background

Patients after laparoscopic Roux-en-Y gastric bypass (LRYGB) can have nonspecific, upper gastrointestinal (UGI) complaints. During postoperative endoscopy, we have noted the erosion of nondissolvable material, such as Peri-Strips® or silk sutures, into the gastric pouch. This study reports the incidence and presentation of foreign material erosion into the gastric pouch after a LRYGB and the outcome after therapeutic endoscopy.

Methods

From a prospective LRYGB database, postoperative endoscopies from February 2002 to June 2005 that found foreign material in the gastric pouch were reviewed. Presenting symptoms, time until endoscopy, and patient outcomes were evaluated. A therapeutic endoscopy was performed by using endo-shears and biopsy forceps to remove the foreign material.

Results

A total of 23 patients underwent 29 therapeutic endoscopies. From February 2002 to November 2004, 208 LRYGB were performed using silk suture for the outer layer of the gastrojejunostomy, and 21 patients (10%) had silk suture found on endoscopy. Peri-Strips were used from February 2002 to December 2003 (n = 153) and 6 patients (4%) had erosions. Since converting to Vicryl suture and Seamguard®, we have had 173 and 228 patients, respectively, without pouch erosion. The most common presenting symptom was abdominal pain (n = 15, 65%). Other symptoms included nausea (n = 13, 57%), vomiting (n = 12, 52%), dysphagia (n = 5, 22%), and melena (n = 3, 13%). Foreign material was found by a mean of 34 weeks. Of 29 therapeutic endoscopies, 20 resulted in resolution of symptoms (69%), 4 led to improvements (14%), and 5 had no effect (17%). There were no endoscopic complications and no anastomotic leaks.

Conclusions

Nonabsorbable material used during a LRYGB can migrate into the gastric pouch and cause UGI complaints. A therapeutic endoscopy will resolve most UGI symptoms. Using absorbable material in the creation of the gastric pouch and the gastrojejunostomy will avoid foreign material erosion.     

Proper preparation to reduce endoscopic reexamination due to food residue after distal gastrectomy for gastric cancer

Background

Reducing food residue by proper preparation methods before endoscopy after distal gastrectomy can increase the quality of examination and decrease patient discomfort. We evaluated the risk factors for food residue and proper methods of preparation for endoscopy after distal gastrectomy.

Methods

Follow-up endoscopy with questionnaires was performed on 1,001 patients who underwent distal gastrectomy at Asan Medical Center between December 2010 and July 2011.

Results

Endoscopic examination failed in 94 patients (9.4 %) as a result of large amounts of food residue. Rates of failure were significantly higher in patients who ate a regular diet rather than a soft diet at last dinner before examination (13.9 vs. 6.1 %, p = 0.050), and in those who ate lunch rather than not eating lunch on the day before examination (14.6 vs. 7.7 %, p = 0.020). Multivariate analysis showed that the rate of failed examination was lower in patients who had a history of abdominal surgery (p = 0.011), those who ate a soft (p < 0.001) or liquid (p = 0.003) diet as a last meal rather than a regular diet, those who underwent Billroth I rather than Billroth II reconstruction (p = 0.035), patients with longer fasting time (p = 0.009), and those with a longer gastrectomy-to-endoscopy time interval (p < 0.001).

Conclusions

Patients who undergo follow-up endoscopy after surgery should fast more than 18 h and ingest a soft or liquid diet on the day before examination.     

Multidimensional analyses of the learning curve of robotic low anterior resection for rectal cancer: 3-phase learning process comparison

Background

Robotic surgery has advantages to perform rectal cancer by its ergonomic designs and advanced technologies. However, it was uncertain whether these core robotic technologies could shorten the learning curve. The aim of this study is to investigate the learning curve of robotic rectal cancer surgery and to compare the learning curve phases with respect to perioperative clinicopathologic outcomes.

Methods

From April 2006 to August 2011, a total of 130 consecutive patients who were diagnosed with rectal cancer underwent a robotic low anterior resection (LAR) using the hybrid technique by a single surgeon at Severance Hospital. The moving average method and the cumulative sum (CUSUM) were used to analyze the learning curve. The risk-adjusted CUSUM (RA-CUSUM) analysis was used to evaluate the points, which showed completion of surgical procedures in terms of R1 resection, conversion, postoperative complications, harvested lymph nodes less than 12, and local recurrence. Perioperative clinical outcomes and pathologic results were compared among the learning curve phases.

Results

According to the CUSUM, the learning curve was divided into three phases: phase 1 [the initial learning period (1st–44th case), n = 44], phase 2 [the competent period (45th–78th case), n = 34], and phase 3 [the challenging period (79th–130th case), n = 52]. RA-CUSUM showed the minimum value at the 75th case, which suggested technical competence to satisfy feasible perioperative outcomes. The total operation time tended to decrease after phase 1 and so did the surgeon console time and docking time. Postoperative complications and pathologic outcomes were not significantly different among the learning phases.

Conclusions

The learning curve of robotic LAR consisted of three phases. The primary technical competence was achieved at phase 1 of the 44th case according to the CUSUM. The technical completion to assure feasible perioperative outcomes was achieved at phase 2 at the 75th case by the RA-CUSUM method.     

Colonoscopy performance correlates with scores on the FES™ manual skills test

Introduction

Achieving proficiency in flexible endoscopy is a major priority for general surgery training programs. The Fundamentals of Endoscopic Surgery (FES?) is a high-stakes examination of the knowledge and skills required to perform flexible endoscopy. The objective of this study was to establish additional evidence for the validity of the FES? hands-on test as a measure of flexible endoscopy skills by correlating clinical colonoscopy performance with FES? score.

Methods

Participants included FES?-naïve general surgery residents, gastroenterology fellows at all levels of training and attending physicians who regularly perform colonoscopy. Each participant completed a live colonoscopy and the FES? hands-on test within 2 weeks. Performance on live colonoscopy was measured using the Global Assessment of Gastrointestinal Endoscopic Skills—Colonoscopy (GAGES-C, maximum score 20), and performance on the FES? hands-on test was assessed by the simulator’s computerized scoring system. The clinical assessor was blinded to simulator performance. Scores were compared using Pearson’s correlation coefficient.

Results

A total of 24 participants were enrolled (mean age 30; 54 % male) with a broad range of endoscopy experience; 17 % reported no experience, 54 % had <25 previous colonoscopies; and 21 % had >100. The FES? and GAGES scores reflected the broad range of endoscopy experience of the study group (FES? score range 32–105; GAGES score range 5–20). Pearson’s correlation coefficient between GAGES-C scores and FES? hands-on test scores was 0.78 (0.54–0.90, p < 0.0001). All eight participants with GAGES-C score >15/20 achieved a passing score on the FES? hands-on test.

Conclusion

There is a strong correlation between clinical colonoscopy performance and scores achieved on the FES? hands-on test. These data support the validity of FES? as a measure of colonoscopy skills.     

The multiphasic learning curve for robot-assisted rectal surgery

Background

Robotic rectal surgery is gaining in popularity. We aimed to define the learning curve of an experienced laparoscopic colorectal surgeon in performing robot-assisted rectal surgery. We hypothesized that there are multiple phases in this learning process.

Methods

We performed a retrospective analysis. Consecutive patients who underwent robot-assisted rectal surgery between July 2007 and August 2011 were identified. Operating times were analyzed using the CUSUM (cumulative sum) technique. CUSUMs were model fitted as a fourth-order polynomial. χ², Fisher’s exact, two independent samples t test, one-way ANOVA, Kruskal–Wallis, and Mann–Whitney tests were used. A p value of <0.05 was considered statistically significant.

Results

We identified 197 patients. The median (range) total operative, robot, console, and docking times (min) were 265 (145–515), 140 (59–367), 135 (50–360), and 5 (3–40), respectively. CUSUM analysis of docking time showed a learning curve of 35 cases. CUSUM analysis of total operative, robot, and console times demonstrated three phases. The first phase (35 patients) represented the initial learning curve. The second phase (93 patients) involved more challenging cases with increased operative time. The third phase (69 patients) represented the concluding phase in the learning curve. There was increased complexity of cases in the latter two phases. Of phase 1 patients, 45.7 % had tumors ≤7 cm from the anal verge compared to 64.2 % in phases 2 and 3 (p = 0.042). Of phase 1 patients, 2.9 % had neoadjuvant chemoradiotherapy compared to 32.7 % of patients in phases 2 and 3 (p < 0.001). Splenic flexure was mobilized in 8.6 % of phase 1 patients compared to 56.8 % of patients in phases 2 and 3 (p < 0.001). Median blood loss was <50 ml in all three phases. The patients in phases 2 and 3 had a longer hospital stay compared to those in phase 1 (9 vs. 8 days, p = 0.002). There were no conversions.

Conclusion

At least three phases in the learning curve for robot-assisted rectal surgery are defined in our study.     

Massive Hemobilia: A Diagnostic and Therapeutic Challenge

Background

Massive hemobilia is a rare but potentially life-threatening cause of upper gastrointestinal hemorrhage. In this retrospective analysis, we have evaluated the challenges involved in the diagnosis and management of massive hemobilia.

Methods

Between 2001 and 2011, a total of 20 consecutive patients (14 males) who were treated in our department for massive hemobilia were included in the study and their records were retrospectively analyzed.

Results

Causes of hemobilia were blunt liver trauma (n = 9), hepatobiliary intervention (n = 4), post-laparoscopic cholecystectomy hepatic artery pseudoaneurysm (n = 3), hepatobiliary tumors (n = 3), and vascular malformation (n = 1). Melena, abdominal pain, hematemesis, and jaundice were the leading symptoms. All patients had undergone upper GI endoscopy, abdominal ultrasound, and computerized tomography of the abdomen. An angiogram and therapeutic embolization were done in 12 patients and was successful in nine but failed in three, requiring surgery. Surgical procedures performed were right hepatectomy (n = 4), extended right hepatectomy (n = 1), segmentectomy (n = 1), extended cholecystectomy (n = 1), repair of the pseudoaneurysm (n = 3), and right hepatic artery ligation (n = 1).

Conclusion

The successful diagnosis of hemobilia depends on a high index of suspicion for patients with upper GI bleeding and biliary symptoms. Although transarterial embolization is the therapeutic option of choice for massive hemobilia, surgery has a definitive role in patients with hemodynamic instability, after failed embolization, and in patients requiring laparotomy for other reasons.     

Excision of bronchogenic cysts in children using an ultrathin fibreoptic bronchoscope

Purpose

We report the use of an ultrathin fibreoptic bronchoscope (Olympus N20: external diameter: 2.2 mm) as the means of airway endoscopic monitoring during anaesthesia for the excision of mediastinal bronchogenic cysts in two young children.

Clinical features

The first, a four-month old boy, presented with stridor and wheezing due to a subcarinal bronchogenic cyst compressing the two main bronchi. The second, an eight-day-old girl whose trachea was intubated, presented with respiratory noise in relation to a bronchogenic cyst compressing the end of the trachea. In both cases, airway endoscopy was performed during anaesthesia with the ultra thin fibreoptic bronchoscope. Endoscopie monitoring allowed, first, a good evaluation of the degree of cyst compression on the airways. Second, the endotracheal tube could be positioned or repositioned with precision in order to avoid severe compression or spilling of liquid into the airways and to allow protection of the suture. Finally, video transmission helped the surgeon to visualize the surgical repair from the inside.

Conclusion

When added to the classical monitoring using SpO₂,PetCO₂ and airway pressure, peroperative endoscopie control provides complementary information which can help to detect possible complications more rapidly. This technique could be extended to all airway surgery on very young children.     

Endoscopic Findings of Asymptomatic Patients One Year After Roux-en-Y Gastric Bypass for Treatment of Obesity

Background

In the late post-operative period, the necessity of performing an upper gastrointestinal endoscopy (GIE) to check for complications is controversial. Some authors suggest it should be routine for all patients, others selectively, but not all patients with endoscopic abnormalities are symptomatic and some abnormalities are potentially severe. The study was conducted to evaluate the endoscopic findings from asymptomatic obese patients after Roux-en-Y gastric bypass (RYGB) and correlate them with the demographic data and the presence of Helicobacter pylori (Hp).

Methods

A total of 715 asymptomatic patients were prospectively submitted to an upper GIE at the end of their first post-operative year. These examinations were evaluated for the presence of abnormalities, their prevalence and their potential severity.

Results

Abnormalities were found in 189 patients (26.5 %). Eighty-four (11.7 %) presented esophageal abnormalities, with 72 (10.1 %) characterized as esophagitis and 12 (1.7 %) as hiatal hernia. Forty-five patients (6.3 %) presented abnormalities of the stomach and the anastomosis, with 26 (3.6 %) characterized as anastomotic ulcers, nine (1.3 %) as stenosis of the gastrojejunal anastomosis, ten (1.4 %) as band erosion and 72 (10.1 %) as jejunitis. There was a statistically significant correlation between super obesity and band erosion.

Conclusions

An upper GIE at the end of the first year of RYGB plays an important role, even for asymptomatic patients. One fourth of these asymptomatic patients had their treatment modified after the upper GIE was performed.