Accurate Preoperative Localization of Insulinomas Avoids the Need for Blind Resection and Reoperation: Analysis of a Single Institution Experience with 17 Surgically Treated Tumors over 19 Years

Introduction  Presently, the need for and choice of preoperative localization tests for insulinomas remain controversial. We report the results from a single institution experience whereby the management policy adopted was that of accurate preoperative localization before surgical exploration. Materials and Methods  From 1990 to 2008, 17 patients with a clinical and biochemical diagnosis of an insulinoma who underwent surgery were retrospectively reviewed. The diagnosis of all insulinomas were confirmed pathologically. Results  All tumors were localized preoperatively and an average of 2.2 preoperative localization studies including 1.4 noninvasive studies and 0.8 invasive studies were utilized per patient. Invasive localization modalities were more sensitive (92%) than noninvasive modalities in localizing insulinomas (71%). Intra-arterial calcium stimulation with hepatic venous sampling was the most sensitive invasive modality (100%), whereas magnetic resonance imaging was the most sensitive noninvasive modality (63%). Fifteen of 17 tumors (88%) were localized intraoperatively via inspection/palpation and/or intraoperative ultrasonography. Both insulinomas which were not localized intraoperatively were localized correctly to the distal pancreas via preoperative transhepatic portal venous sampling. None of the patients required a blind resection or surgical reexploration for failed localization. All 17 patients underwent complete surgical resection which included eight enucleations and nine distal pancreatectomies with a cure rate of 94% (16/17) at a median follow-up of 35 (range, 1–217) months. The postoperative morbidity and long-term outcome of enucleation was similar to distal pancreatectomy despite a higher rate of microscopic margin involvement. Conclusion  Accurate preoperative localization of insulinomas is useful as it eliminates the need for blind distal pancreatectomy and avoids reoperation. Complete surgical resection is the treatment of choice, and whenever possible, a pancreas-sparing approach such as enucleation should be adopted.     

Underutilization of laparoscopy for ovarian surgeries in the pediatric population: A nationwide analysis

PurposeOophorectomy and ovarian detorsion are some of the most frequent operations performed in the female pediatric population. Despite the advent of laparoscopy, many surgeons continue to utilize open surgical approaches in these patients. This study sought to compare nationwide trends and postoperative outcomes in laparoscopic and open ovarian operations in the pediatric population.MethodsFemales less than 21 years old who underwent ovarian operations (oophorectomy, detorsion, and/or drainage) from 2016 to 2017 were identified from the Nationwide Readmissions Database. Patients were stratified by surgical approach (laparoscopic or open). Hospital characteristics and outcomes were compared using standard statistical tests.ResultsThere were 13,202 females (age 17 [14–20] years) who underwent open (59%) or laparoscopic (41%) ovarian operations. The most common indications for surgery were ovarian mass (48%), cyst (36%), and/or torsion (19%) for which oophorectomy (88%), detorsion (26%), and drainage (13%) were performed most frequently. The open approach was utilized more frequently for oophorectomy (95% vs. 77% laparoscopic) and detorsion (33% vs. 16% laparoscopic), both p < 0.001. A greater proportion of laparoscopic procedures were performed at large (67% vs. 61% open), teaching (82% vs. 76% open) hospitals in patients with private insurance (47% vs. 42% open), all p < 0.001. Patients undergoing open procedures had significantly higher index length of stay (LOS) and rates of wound infections. Thirty-day and overall readmission rates, as well as overall readmission costs, were higher in patients who received open surgeries.ConclusionsDespite fewer overall complications, decreased cost, fewer readmissions, and shorter LOS, laparoscopic approaches are underutilized for pediatric ovarian procedures.Type of StudyRetrospective Comparative.Level of EvidenceLevel III.     

Hospital costs and length of stay related to robot-assisted versus open radical and partial nephrectomy for kidney cancer in the USA

There are scant national outcomes data for robot-assisted laparoscopic surgery. We assessed costs and length of stay (LOS) related to robot-assisted radical and partial nephrectomy in a nationally representative population database. We performed a cohort analysis of the US Nationwide Inpatient Sample database. Using ICD-9 procedure codes, we identified patients who underwent radical or partial nephrectomy for kidney cancer from October 2008 to December 2008. We excluded patients with non-robot-assisted laparoscopic procedures and those under age 18 years. We performed multivariate analyses of LOS and total hospital charges, adjusting for age, race, gender, Charlson comorbidity index, and teaching hospital status. Records of 2,242 patients were analyzed. On adjusted multivariate analysis, robot-assisted partial nephrectomy was associated with shorter LOS compared with open surgery (−2.0 days, P = 0.032). Robot-assisted radical nephrectomy was associated with shorter LOS compared with open surgery (−1.8 days, P = 0.077). There were no significant differences in total charges for robot-assisted compared with open surgery for either radical (P = 0.631) or partial (P = 0.713) nephrectomy. In this large, population-based analysis, robot-assisted radical and partial nephrectomy were associated with shorter LOS and equivalent hospital charges compared with their open surgery counterparts. These data suggest that, for renal surgery, diminished LOS offsets other hospital costs associated with robot-assisted procedures.     

Pancreatic Insulinoma: A Surgical Experience

Background  Small size, high benignity rate, and sporadic nature make insulinomas suitable for laparoscopic resection. On the other hand, occult location or multicentricity mandate open surgery. This study was designed to analyze a series of patients who had pancreatic insulinomas and underwent initial treatment at our institution. Methods  Clinical records of the 34 patients with pancreatic insulinomas who underwent surgical resection between 1995 and 2007 were reviewed. Main variables for analysis were cure of the disease and surgical complications. Results  There were 20 women and 14 men with a mean age of 40 ± 13 years. Mean size of the tumors was 2.2 ± 1 cm. Laparoscopic resection was completed in 14 of 21 patients. Most tumors that were resected by laparoscopy were solitary, benign, and located in the body and tail of the pancreas. Open surgery was selected for 13 patients, including 7 sporadic (5 in the head), 4 related to the MEN syndrome, and 2 malignant tumors. Surgical morbidity occurred in 23 patients. The most common complication was pancreatic fistula (3/13 in open, 4/14 in laparoscopic, and 6/7 in conversions). One patient in the open group died 15 days after surgery from massive PTE. Postoperative normoglycemia was achieved in all patients and persisted for a follow-up period of 4 ± 3.7 years. Conclusions  Most insulinomas in our series were small and benign. Tumors that were located in the body and tail were more often amenable for laparoscopic resection. The cure rate was very high. Pancreatic fistula was the most frequent complication.     

Laparoscopic colectomy for colonic polyps

Background  Benign colonic polyps not amenable to colonoscopic resection or those containing carcinoma require surgical excision. Traditionally, formal colectomy with clearance of the lymphatic basin has been performed. The aim of this study was to review our experience with the laparoscopic approach for retrieval of colonic polyps with specific emphasis on safety, feasibility, and tumor localization. Methods  Retrospective chart review of all patients who underwent laparoscopic colectomy for colonic polyps was performed. Initial colonoscopic biopsies were compared with the postoperative pathology report of the resected specimen. Results  Forty-nine patients (22 males, 27 males, mean age 66 years) underwent laparoscopic colectomy for colonic polyps. Indications for surgery were presumably benign polyps in 38 patients, and superficial carcinoma in a polyp, diagnosed by colonoscopy, in 11; twenty-three patients underwent preoperative localization procedures. In 19% of patients who did not have preoperative localization, difficulties locating the polyp were encountered during surgery, requiring intraoperative endoscopy or conversion to laparotomy. In 7 of the 38 patients with presumably benign lesion, colon cancer was diagnosed in the colectomy specimen. None of the 18 patients who had cancerous lesions had any positive lymph nodes. Conclusions  Laparoscopic surgery for the treatment of colonic polyps seems to be feasible and safe, with a low complication rate. Tumor localization is crucial for adequate resection. Although one-fifth of presumably benign polyps harbored cancer, none of these patients had positive lymph nodes. These preliminary results may question the need for radical lymph node clearance in these patients. Poster presentation at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Dallas, TX, USA, April 26–29, 2006. Poster presentation at the annual meeting of the European Society for Endoscopic Surgeons (EAES), Berlin, Germany, September 13–16, 2006.     

Robotic-assisted surgery in children: advantages and limitations

The use of surgical robots in minimally invasive surgery was developed to overcome difficulties seen with conventional laparoscopic surgery. I report my experience with pediatric robotic-assisted surgery and highlight its feasibility, safety, advantages, and limitations. Children and infants included in this study underwent robotic-assisted laparoscopic procedures performed by the author, using the original da Vinci surgical system, between July 2005 and July 2008. Their medical records were reviewed with respect to demographic data, robot setup times, techniques and operative procedures, complications, outcomes, and follow-up duration. Forty-three patients (20 female, 23 male), ranging in age from 2.5 months to 16 years, underwent 46 robotic-assisted procedures. Mean setup time was 17.6 min. One primary and two to four working ports were used, allowing insertion of 5- and 8-mm robotic instruments. Five- and 11-mm telescopes were used based on patient size. All procedures were successfully completed except for two. The most common procedure was Nissen fundoplication (N = 26). There were no intraoperative complications or deaths, but three patients developed postoperative complications. Mean follow-up time was 12 months. Robotic-assisted surgery in children is safe, feasible, and applicable to a wide range of procedures. Advantages include improved visibility, dexterity, and ergonomics, although it does have certain limitations. Technological refinements will allow its use in more complex procedures, with probable greater use of robots in pediatric surgery.     

The evaluation of clopidogrel use in perioperative general surgery patients: a prospective randomized controlled trial

Background

The perioperative safety profile of clopidogrel, a potent antiplatelet agent used in the management of cardiovascular disease, is unknown, and there are no evidence-based guidelines recommending for either its interruption or continuation at this time. The aim of this study was to determine whether patients who are maintained on clopidogrel before general surgical procedures are at increased risk of perioperative bleeding complications.

Methods

Patients receiving clopidogrel at the time of elective general surgery were randomized to either discontinue clopidogrel 1 week before surgery (group A) or continue clopidogrel into surgery (group B). All other antiplatelet and anticoagulant agents were discontinued before surgery. The primary end points were perioperative bleeding requiring intraoperative or postoperative transfusion of blood or blood components and bleeding-related readmission, reoperation, or mortality within 90 days of surgery. The secondary end points were perioperative myocardial infarction or cerebrovascular accidents within 90 days of surgery.

Results

Thirty-nine patients were enrolled and underwent 43 general surgical operations. Twenty-one procedures were randomized to group A and 22 to group B. The most commonly performed individual procedures were open inguinal hernia repair (23%), laparoscopic cholecystectomy (21%), open ventral hernia repair (15%), laparoscopic ventral hernia repair (11%), and laparoscopic inguinal hernia repair (9%). No perioperative mortalities, bleeding events requiring blood transfusion, or reoperations occurred. One readmission for intra-abdominal hematoma requiring percutaneous drainage occurred in each group (group A: 4.8% vs group B: 4.5%; P = 1.0). No myocardial infarctions or cerebrovascular accidents were observed or reported.

Conclusions

The outcomes from this prospective study suggest that, patients undergoing commonly performed elective general surgical procedures can be safely maintained on clopidogrel without increased perioperative bleeding risk.     

The impact of hospital grade,hospital-volume,and surgeon-volume on outcomes for adults undergoing appendicectomy

IntroductionAcute Appendicitis and appendicectomy are common surgical emergencies worldwide. However, there is a lack of published data on the impact of hospital grade, surgeon- and hospital-volumes on patient outcomes following appendicectomy.AimTo establish if hospital grade, hospital-volume, or surgeon-volume impacted patient outcomes following appendicectomy.MethodsUsing the National Quality Assurance and Improvement System (NQAIS) data for all appendicectomies performed in Ireland between January 2014 and November 2017 were examined. Data relating to patient demographics, type of surgery (open/laparoscopic/laparoscopic converted to open), length of stay (LOS), mortality, admission to critical care and re-admission rates were collected and analysed.ResultsDuring the study period, 15,896 adult appendicectomies were performed, 14,521 were laparoscopic procedures. Patients treated in district general hospitals (DGHs) had lower LOS (2.96 v 3.37 days, p < 0.0001) than patients treated in tertiary referral hospitals (TRHs), had lower rates of laparoscopic procedures (87.38% v 95.56% p < 0.0001) and higher admission rates to critical care (1.91% v 0.75% p < 0.0001). No significant outcome difference was seen between those treated by high-volume (>62 cases/year) or low volume surgeons (<20 cases/year). Patients treated in high-volume hospitals (>260 cases/year) had higher rates of laparoscopic procedures (94.9% v 83.5%, p < 0.0001), lower rates of admission to critical care (0.85% v 2.25%, p < 0.0001) and lower 7-day re-admission rates (2.54% v 3.55%, p = 0.02) than those operated in low-volume hospitals (<161 cases/year).ConclusionPatients operated on in high-volume hospitals benefit from higher rates of laparoscopic surgery and fewer critical care admissions. No significant difference in outcome was noted in those patients operated upon by high- or low-volume surgeons or based on hospital grade.     

Robotic versus laparoscopic hepatectomy: application of the difficulty scoring system

The development of robotic system may help to relieve the difficulties encountered during laparoscopic hepatectomy. A difficulty scoring system (DSS) was developed to assess the difficulty of various laparoscopic liver resection procedures. The aim of this study is to explore if the DSS is applicable in robotic hepatectomy and to compare the outcomes of robotic hepatectomy and laparoscopic hepatectomy among different difficulty levels. Clinical data from all consecutive patients who underwent robotic and conventional laparoscopic hepatectomy at the Prince of Wales Hospital, Hong Kong, were prospectively collected and reviewed. The difficulty level of operations was graded using the DSS. Perioperative outcomes of robotic and conventional laparoscopic hepatectomy were compared at each difficulty level. A total of 107 and 94 patients underwent robotic and laparoscopic hepatectomy during the study period, respectively. Among them, 16 and 2 patients were operated for recurrent pyogenic cholangitis, respectively, and were excluded because no mark for tumour location can be assigned. For robotic hepatectomy, a higher DSS was significantly correlated with higher minor complication rate (p = 0.001), more intraoperative blood loss (p = 0.002), longer operation time (p < 0.001) and longer post-operative hospital stay (p < 0.001). The mean DSS scores of robotic and laparoscopic hepatectomy were 4.5 and 3.6, respectively. (p = 0.004). For cases with low (DSS 1–3) and intermediate (DSS 4–6) difficulty level, there was no significant difference in operative blood loss, operation time and overall complications rate. Only 2 cases (2.2%) with high difficulty level were operated with laparoscopic approach while 20% of patients operated with robotic approach had DSS > 6. DSS significantly correlated with surgical outcomes in patient who underwent robotic hepatectomy. Perioperative outcomes following robotic and conventional laparoscopic hepatectomy were similar in cases with low and intermediate difficulty. However, robotic system allowed minimally invasive approach in cases with higher difficulty level.     

Is preoperative localization of insulinomas justified?

STUDY AIM: To appreciate the impact of preoperative localization in surgical treatment of insulinomas. PATIENTS AND METHOD: From 1986 to 2001, 29 patients were surgically treated for suspected insulinoma. Preoperative imaging assessment was performed in 26 patients: ultrasonography (n = 21), computed tomography (n = 23), endoscopic ultrasonography (n = 13), intraoperative ultrasonography (n = 22) (2 of them under laparoscopic approach). RESULTS: The sensibility of the localization procedures was as follows: ultrasonography = 9.6%, computed tomography = 39%, endoscopic ultrasonography = 92.3%, surgical exploration 79.3%, intraoperative ultrasonography 86.3%. The sensibility of intraoperative palpation associated which intraoperative ultrasonography was 100%. Surgical procedures included: 11 enucleations, 10 segmental resections of the tail, 1 left pancreatectomy, 3 median pancreatectomies, 4 subtotal pancreatectomies. There was no postoperative mortality and postoperative morbidity rate was 17%, including 4 pancreatic leakages. Histological examination found solitary tumor in 22 patients (1 of them was a malignant tumor), multiple tumors (MEN 1) in 4 patients and factitious hypoglycemia in 3 patients. All the insulinomas were resected. CONCLUSION: Intraoperative evaluation of the pancreas with intraoperative ultrasonography was associated which a right localization in 100% of insulinomas. The place for preoperative imaging seems to be limited. A laparoscopic approach in sporadic insulinomas could modify this attitude.     

Quality control and educational value of laparoscopy-assisted gastrectomy in a high-volume center

Background  Laparoscopy-assisted gastrectomy (LAG) is increasingly performed in Japan by a number of surgeons. As this is a relatively new technique, a training system is important, however there has been little discussion about an educational system for teaching trainees to perform LAG and the ideal training system has not yet been established. Patients and methods  Two hundred and sixty-three patients who underwent LAG at the Cancer Institute Hospital were included in this study. In all cases there was standardization of LAG (the way in which the surgical field was formed by the assistant and the way the operator dissected the lymph nodes was determined and all cases were performed using the same laparoscopic procedures) and a step-by-step training system was completed. Specialists performed the surgery in 213 patients (S group) while the remaining 50 patients had their surgery performed by trainees (T group). Early surgical outcomes were compared between specialists and trainees to clarify whether the standardization and our educational system are useful in maintaining the quality of LAG. Results  T-group patients had significantly longer operation times than those of S-group (262.3 ± 7.3 versus 233.3 ± 3.7 min), however, the trainees reached the plateau of their learning curve earlier than previously reported. All other early surgical outcomes examined, including intraoperative blood loss (76.7 ± 35.1 versus 64.9 ± 7.7 ml), number of retrieved lymph nodes (33.4 ± 1.4 versus 35.7 ± 0.8), morbidity (8 versus 14%), and mortality (0% in both groups), were not significantly different between the two groups. Conclusion  The surgical results of T-group were almost equal to those of S-group, showing that our educational system is effective and surgical quality is maintained. Standardized laparoscopic procedures and sufficient intensive experience in the short term are requisites for effectively learning how to perform LAG.     

Robot-assisted laparoscopic radical prostatectomy after previous cancer surgery

Robot-assisted laparoscopic radical prostatectomy has become a frequently used alternative treatment option in the management of prostate cancer. As more operations are performed, more challenging patient conditions are encountered, for example those with previous abdominal cancer surgery. We present our experience of robot-assisted laparoscopic radical prostatectomy (RALP) in patients with previous cancer surgery. Seven patients with a history of previous surgery for malignancy underwent RALP. All the prostatectomies were performed using the da Vinci™ S surgical system by a single surgeon. All operations were approached transperitoneally. We reviewed perioperative data and surgical outcomes retrospectively. The mean age at surgery was 68.43 years (range 63–82). The mean operative time was 214 ± 47.32 min, and the median estimated blood loss was 500 ml (range 200–1,300). The mean hospital stay was 6.57 ± 2.15 days, and the mean duration of catheterization was 8.29 ± 3.09 days. Nerve-sparing procedure and pelvic lymph node dissection were performed in six patients. Rectal injury occurred in one patient who had undergone hemi-colectomy 15 years previously and was resolved by primary closure. Positive surgical margin was found in three patients. Although one patient had an intraoperative rectal injury, RALP in a patient with previous cancer surgery seems to be feasible and safe in experienced hands.     

Laparoscopic vs. open intraoperative ultrasound examination of the liver: A controlled study

A prospective study was undertaken to determine whether the use of laparoscopy plus laparoscopic ultrasound examination can avoid unnecessary laparotomy, without missing potentially curable disease, in patients scheduled for curative liver surgery. Thirty-one consecutive patients who underwent surgery for planned curative liver surgery were prospectively evaluated by means of both laparoscopy plus laparoscopic ultrasound and laparotomy with intraoperative ultrasound. Laparoscopic ultrasound examination of the liver could not be performed in two patients, and in two other patients only partial examinations were possible because of dense adhesions. All patients underwent laparotomy with intraoperative ultrasound. A total of 50 malignant at laparotomy with intraoperative ultrasound, that is, there were no false positive results. An additional four malignant lesions in four patients were not seen at laparoscopic ultrasound examination but were identified at laparotomy with intraoperative ultrasound (sensitivity 93%, specificity 100%, positive predictive value 100%, negative predictive value 85%). Based on the laparoscopic ultrasound findings, nontherapeutic laparotomy could have been avoided in 10% of our patients. Laparoscopy with laparoscopic ultrasound is a promising technology that may allow some patients to avoid a nontherapeutic laparotomy without significant risk of missing potentially curable disease. Presented at the Thirty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, Calif., May 19–22, 1996.     

Value of intra-arterial calcium stimulated venous sampling for regionalization of pancreatic insulinomas

BACKGROUND: Intra-arterial calcium stimulation with hepatic venous sampling (ASVS) for insulin gradients has been reported to be the most sensitive preoperative localizing technique for insulinomas. We reviewed our experience with ASVS to localize and guide the treatment of insulinomas over the past decade. METHODS: Eighteen patients who underwent ASVS before surgical exploration for insulinoma were studied. The accuracy of ASVS was compared with intraoperative findings and other localizing studies. RESULTS: There were no complications arising from the procedures. A more than 2-fold step-up in insulin level 30 to 60 seconds after injection to at least 1 feeding artery was observed in 16 patients. Fourteen of the 16 solitary tumors (87.5%) were correctly located; 100% (6/6 tumors) at the head and 80% (8/10 tumors) at the body/tail. The overall accuracy of this test was 89%, compared with 11%, 33%, 38%, and 63% of ultrasonography, computed tomography, magnetic resonance imaging, and endoscopic ultrasonography, respectively. Six enucleations and 10 distal resections were performed, which included 2 laparoscopic procedures. The combination of intraoperative ultrasonography with preoperative ASVS identified all tumors. CONCLUSIONS: ASVS is the most accurate preoperative localization tool for the localization of insulinomas and, in combination with intraoperative ultrasonography, can enhance surgical success.     

Characteristics,comorbidity burden and outcomes in centenarians undergoing surgery in a university hospital: A case series

IntroductionAs the population ages, so too does the age of those requiring surgery. People over the age of 100, centenarians, often have a greater degree of comorbidity and frailty than their younger counterparts but may also have a greater incidence of events requiring surgical intervention. There is, however, a dearth of literature describing the clinical course and practical considerations for this vulnerable population undergoing surgery. We aimed to describe the demographics of centenarians undergoing surgery, the procedures they receive, their intraoperative anaesthesia management, and their postoperative outcomes.Presentation of casesA retrospective cohort study was completed to understand key perioperative and intraoperative variables linked to improved outcomes. Of the 25 patients included in this study, 22 (88%) were female and the median age was 101 years. Emergency cases predominated (72%) and 44% of surgeries occurred after hours. 60% underwent an intermediate risk surgery, and no centenarians underwent high risk surgery in this study period.Discussion64% of patients experienced at least one episode of intraoperative hypotension, with a median 3.5 epochs per patient. 68% of patients experienced postoperative complications and 20% of patients had a complication of Clavien-Dindo severity ≥ III. In centenarians, the risk of high severity postoperative complications was independent of the intrinsic procedural risk.ConclusionCentenarian patients have an elevated burden of comorbidity, presenting often in the emergent setting. However, age alone should not preclude surgical intervention as expert multidisciplinary care can have acceptable outcomes.     

Ten-year experience with laparoscopic pedicled omental flap for cerebral revascularization in patients with Moyamoya disease

BackgroundThe omental flap has numerous extraperitoneal applications in reconstruction and revascularization given its favorable immunologic and angiogenic properties. In patients with Moyamoya disease, cerebral revascularization using a pedicled omental flap has proven to be a viable option following direct revascularization procedures. Historically, harvesting omentum involved laparotomy with the associated risk of complications; herein we describe outcomes from a 10-year experience of laparoscopic harvesting of pedicled omental flap for cerebral revascularization in Moyamoya patients.MethodsA retrospective chart review was performed of all patients with Moyamoya disease who underwent laparoscopic omental cerebral transposition between 2011 and 2021. Intraoperative and postoperative complications, length of stay (LOS), and outcomes at follow-up were analyzed.ResultsTwenty-one patients underwent the procedure during the study period. Three intraoperative complications occurred (one segmental transverse colectomy for mesenteric injury, one converted to omental free flap, and one requiring micro anastomosis). Average overall LOS was 6 ± 6 days, with 3 ± 3.5 days in the ICU (mean±SD). Following discharge, complications included epigastric incisional hernia at the graft fascial exit site, recurrent neck pain at subcutaneous tunneling site, and partial scalp necrosis. One patient required subsequent direct bypass seven months after the initial procedure owing to the progression of the disease. All other patients had partial or complete resolution of symptoms.ConclusionOur retrospective observational study indicates that laparoscopic pedicled omental flap mobilization and transposition is a safe and effective method of indirect cerebral revascularization in patients with Moyamoya disease.Level of evidenceN/A.     

Laparoscopic surgery for common surgical emergencies: A population-based study

Background: Despite being controversial in the past, many reports on the safe use of laparoscopic surgery in emergency settings have been published. The aim of this study was to investigate the diffusion of laparoscopic surgery in three common surgical emergency operations, namely, appendectomy, cholecystectomy, and simple repair of perforated peptic ulcer (PPU), in a stable population.Methods: This was a retrospective analysis of the central database of the Hospital Authority (HA) in Hong Kong. Data for patients managed in 14 HA hospitals from 1998 to 2002 were studied. The operation record and discharge record of each patient were also investigated to verify the data.Results: A total of 12,708 patients underwent appendectomy, 2631 patients underwent cholecystectomy, and 2260 patients had simple repair of PPU performed. During the study period, 37.2% of appendectomies, 46.5% of cholecystectomies, and 23.1% of simple repairs of PPU were performed laparoscopically. More than a two-fold increase in the proportion of laparoscopic surgery was observed in each of these three operations. By the end of 2002, the percentage of laparoscopic surgery had increased to 53.5% for appendectomies, 61.3% for cholecystectomies, and 32.9% for simple repairs of PPU. Significantly lower hospital mortality rates and shorter postoperative hospital stay were consistenty observed in patients with laparoscopic surgery of the three emergencies. A wide variation in the use of laparoscopic surgery, ranging from 3.7% to 73.1%, was observed among the 14 HA hospitals. However, there was no correlation in the use of laparoscopic surgery with the volume of operation performed in each hospital (p = 0.933).Conclusion: A high diffusion rate on the use of laparoscopic surgery for common surgical emergency was observed in Hong Kong. However, there was also a wide variation in the diffusion rate among the 14 HA hospitals. Efforts to reduce hospital variation for the better dissemination of safe laparoscopic technique may be warranted.     

Management of Insulinomas: Analysis from a Tertiary Care Referral Center in India

The aim of this study was to describe the localization and management of patients with pancreatic insulinomas and determine the most effective localization and surgical techniques in the presence of significant financial constraints in the patient population. We retrospectively reviewed the case records of 18 patients with insulinomas treated at our institution over a period of 10 years. The medical records were reviewed for demographic data, clinical presentation, biochemistry, details of localization studies, intraoperative findings, postoperative outcome, and long-term follow-up. The sensitivities of the various localization procedures were calculated using the intraoperative findings as the gold standard. There were 10 men and 8 women in the study, with a median age of 43 years. All patients underwent a supervised 72-hour fast and developed symptomatic hypoglycemia within 48 hours. An average of 1.9 localization procedures was performed per patient. Computed tomography (CT) had a sensitivity of 62% and specificity of 100%. Magnetic resonance imaging and digital subtraction angiography had specificities of 85% and 100%, respectively, with a specificity of 66% and 50%, respectively. Fourteen patients underwent surgery. Intraoperatively the excised tumor was palpable in nine patients, and all patients had postoperative euglycemia. In five patients the tumor was not palpable during the time of surgery; three of these patients underwent blind distal pancreactomy, with two patients having persistent hypoglycemia during the postoperative period. Two patients had a negative exploratory laparotomy. Patients with a surgical cure were followed up for a mean period of 24 months. On the background of financial constraints in connection with patient care, CT scanning is a cost-effective option with good specificity. Intraoperative palpation of the tumor and enucleation is the most effective technique for surgical cure. Blind distal pancreactomy is not advocated for tumors that are not localized intraoperatively.     

Single-Incision Laparoscopic Right Hemi-Colectomy: a Systematic Review

As surgeons became more adept with laparoscopic colon surgery, other less invasive procedures, such as single-incision laparoscopic right hemi-colectomy (SIL-RH), have been applied. The objective of this study was to evaluate the safety of SIL-RH as well as its intraoperative and postoperative outcomes for right-sided colon diseases. A detailed search in PubMed for citations that included SIL-RH from 2000 to 2014 revealed 21 studies fulfilling the criteria of the present review. A total of 684 patients were analyzed. Of the patients, 50.2 % were men. Mean patient age was 64.8 years. Of the patients, 36.1 % had already undergone an abdominal operation before the performance of SIL-RH, while 69 % of the patients underwent SIL-RH for colon cancer. Relatively low rates of overall morbidity (15 %) and mortality (0.75 %) were reported in the included studies. Mean length of postoperative hospital stay (LOS) was 5.5 days. Bowel motility return had a mean value of 2.8 days. Mean number of harvested lymph nodes (LN) was 19.2 LN. All resection margins were tumor-free. SIL-RH was a safe alternative to multiport laparoscopic right hemi-colectomy (ML-RH) in terms of morbidity and mortality, postoperative gastrointestinal function recovery, LOS, as well as oncological radicalness.     

Single-center comparison of outcomes between laparoscopic appendectomy and transumbilical laparoscopic assisted appendectomy

PurposeAppendectomy is the most common pediatric emergency surgery performed to date. This study compared outcomes between laparoscopic appendectomy (LA) and transumbilical laparoscopic assisted appendectomy (TULAA) for 1154 uncomplicated patients across 5 years at a single institution. Primary outcomes include length of stay (LOS), post-operative complications, pain score, and operating room (OR) time.MethodsDemographic and clinical data was collected for 1154 eligible patients treated for uncomplicated appendicitis between August 2014–October 2019, with 830 patients in the LA group, and 324 in the TULAA group. Mixed effects modeling procedure using logistic and linear regression examined the effect of surgery type on the four primary outcomes after adjustment for potential clustering effect of surgeon and confounding factors.ResultsOf 1154 patients, 62.7% were male, and mean (SD) age was 10.9 (3.6) years. Median [IQR] LOS was 28.0 h [22.0, 36.0], mean (SD) OR time was 29.0 (10.0) minutes, and median [IQR] pain at maximum level was 5.5 (2.7). The complication rate overall was <5.0% and did not differ between TULAA and LA groups (p > 0.05). OR time was reduced by an average of 5.2 min in the TULAA group (p < 0.001), pain did not differ between groups overall (p > 0.05), and patients were more likely to be discharged within 24 h in patients who underwent TULAA (OR = 5.3 [1.6, 17.4], p = 0.007).ConclusionRetrospective analysis of 1154 pediatric appendectomies, found no difference in complications between single- and three-incision laparoscopic procedures (TULAA vs. LA). Findings suggest TULAA is a safe procedure for acute appendicitis in pediatrics.Level of EvidenceIV.