Robot-assisted laparoscopic radical cystectomy

Recent reports have demonstrated that robot-assisted laparoscopic cystectomy is technically feasible. However, wide-spread acceptance of this promising technique is limited due to long operating times and lacking long-term data especially on oncological outcome. After establishing robot-assisted laparoscopic prostatectomy (n=250) we report technical and functional results of a large series of patients undergoing laparoscopic cystectomy with the da Vinci surgical system (DVSS).27 patients (24 males) underwent laparoscopic radical cystectomy with the DVSS (Intuitive Surgical) between Jan 2004 and Dec 2006. Indications for cystectomy were muscle-invasive transitional cell carcinoma (TCC) or leiomyosarcoma of the urinary bladder (n=24) and bladder shrinking following prior radiotherapy for TCC (n=3). A pelvic lymphadenectomy was routine part of the procedure. Urinary diversions were ilieal conduits (n=19) and ileal neobladders (n=8).Mean operating time was 340 minutes (range 150-450) with a mean blood loss of 301 mL (range 50-550). The mean number of lymph nodes retrieved during lymphadenectomy was 23. Surgical margins were negative except in one case. After a mean follow-up of 10.2 months, 2 perioperative (anastomotic leakage, adhesions) and 3 postoperative complications (ileus, intestinal fistula) occurred. 6/7 patients reported satisfying erectile function following nerve-sparing surgery. Day-time continence was completely restored after a mean 3.5 months in 7/8 patients.Robot-assisted laparoscopic cystectomy is a safe procedure. Satisfying functional and oncological short-term results can be achieved within acceptable operating time limits.     

Emergency Left Colon Resection for Acute Perforation. Primary Anastomosis or Hartmann’s Procedure? A Case-matched Control Study

Background The optimal treatment remains controversial for acute left-sided colon perforation. Therefore, the effectiveness and safety of primary anastomosis versus Hartmann’s operation (HP) was compared in a case-matched control study. Methods Thirty consecutive patients with primary anastomosis and protective ileostomy (PAS) were matched to 30 HP patients, controlling for age, gender, American Society of Anesthesiologists (ASA) score, body mass index (BMI), and peritonitis severity (Hinchey). In a second analysis, PAS patients with purulent peritonitis (Hinchey 3) were matched to patients with primary anastomosis without ileostomy (PA). Results Hospital mortality was similar between HP (17%) and PAS (10%). Complication frequency and severity (requiring re-intervention or admission to the Intensive Care Unit [ICU]) were comparable for the first operation (60% versus 56% and 30% versus 32%). The stoma reversal rate was higher in PAS than in HP (96% versus 60%, p = 0.001), with significantly fewer complications (23% versus 66%, p = 0.02), and lower severity (7% versus 33%, p = 0.02). Additional analysis of PAS versus PA showed similar morbidity (52% versus 41%, p = 0.45) and complication severity (18% versus 24%, p = 0.51), whereas overall operation time and hospital stay were significantly shorter in PA (169 versus 320 min, p = 0.003, 17 versus 28 days, p < 0.001). Conclusions Primary anastomosis and protective ileostomy is a superior treatment to HP in acute left-sided colon perforation. In the absence of feculent peritonitis an ileostomy appears unnecessary. Presented at the 13th Annual Meeting of the European Surgical Association (ESA), Zurich, 2006.     

Prospective evaluation of vacuum-assisted closure in abdominal compartment syndrome and severe abdominal sepsis

BACKGROUND: Open abdomen treatment because of severe abdominal sepsis and abdominal compartment syndrome remains a difficult task. Different surgical techniques are available and are often used according to the surgeon's personal experience. Recently, the abdominal vacuum-assisted closure (VAC) system has been introduced, providing a new possibility to treat an open abdomen. In this study, we evaluate the role of this treatment option. STUDY DESIGN: This prospective observational cohort study includes 37 consecutive patients who were temporarily treated with VAC for severe abdominal sepsis or abdominal compartment syndrome, or both. Patients with abdominal trauma were excluded from the study. Thirty-seven patients undergoing major elective laparotomy and primary abdominal closure served as control group. Primary end points were fascial closure rate, physicoemotional recovery, and appearance outcomes 1 year after closure. Secondary end points included mortality, duration of open abdomen, length of ICU stay, and hospitalization time. RESULTS: Abdomens were left open for 23 days (range 3 to 122 days) with 3.8 dressing changes (range 1 to 22) per patient. Abdominal closure was achieved in 70% (n = 26), with no marked relation to duration of open abdomen treatment (p > 0.05). After 3 months, patients with VAC treatment recovered to a physical and mental health status similar to patients in the control group (p > 0.05). This status remained stable until the end of the study. Aesthetic outcomes (according to the Vancouver Scar Scale) were considerably poorer in the VAC group compared with controls (p < 0.01). CONCLUSIONS: Treatment of laparostomy with VAC for abdominal sepsis and abdominal compartment syndrome results in a high rate of successful abdominal closure. In addition, patients recover more rapidly, although hypertrophic scars might interfere with body perception. We recommend abdominal VAC system as first option if open abdomen treatment is indicated.     

Model of end stage liver disease (MELD) score greater than 23 predicts length of stay in the ICU but not mortality in liver transplant recipients

Introduction  

The impact of model of end stage liver disease (MELD) score on postoperative morbidity and mortality is still elusive, especially for high MELD. There are reports of poorer patient outcome in transplant candidates with high MELD score, others though report no influence of MELD score on outcome and survival.     

Comparison of arterialized and nonarterialized orthotopic liver transplantation in mice: prowess or relevant model?

BACKGROUND: New insights into mechanisms of injury in orthotopic liver transplantation (OLT) often come from experiments in small animal models. Mice are particularly suitable because of the growing availability of gene-altered animals and specific antibodies. A validated model of OLT in mice is not available and, in particular, the role of rearterialization is unknown. Therefore, we developed a new model of OLT in mice, and we compared liver injury and animal survival in the presence and the absence of arterial blood supply. METHODS: Syngenic OLT was performed in male Balb/c mice. An arterial segment was removed en bloc with the graft in the donor animal and subsequently implanted in a recipient animal using a combination of suture and cuff technique. In some animals, rearterialization was performed with an end-to-side anastomosis between the recipient aorta and the graft artery using a running suture. Rewarming ischemia time was consistently kept below 20 min. RESULTS: All animals (8/8) survived permanently in the presence of a rearterialized graft, whereas only 50% (4/8) were alive at 2 weeks in the absence of arterial supply ( P=0.025). Serum aspartate aminotransferase levels were significantly lower in the presence of arterial supply at 1 and 3 days and 2 weeks after OLT. Serum levels of alkaline phosphatase normalized within 2 weeks in animals with arterialized grafts, whereas levels remained high (3x normal values) in nonarterialized animals. Histologic examination supported a primary injury to the small bile ducts. Viability of arterialized grafts preserved for 16 hr in cold University of Wisconsin solution was 100%. CONCLUSIONS: This study established a new model of arterialized OLT in mice, which opens new avenues for research.     

Pancreatic cancer in cystic fibrosis after bilateral lung transplantation

Cystic fibrosis (CF) is the most common lethal genetic disease affecting 1 in 2500 white patients. Chronic obstructive lung disease and pancreatic insufficiency are the main clinical manifestations of CF. Lung transplantation has become a treatment option for advanced pulmonary disease during the last decade. On the other hand, there is evidence from large cohort studies that CF and immunosuppression are risk factors for pancreatic cancer. Here, we report the case of an 18-year-old female patient with CF and bilateral lung transplantation who underwent Whipple procedure for pancreatic adenocarcinoma at the age of 12 years. Because of growth retardation, the patient underwent a 2-year period of growth hormone treatment before the diagnosis of pancreatic cancer. This case should sensitize physicians to be aware of the increased risk for pancreatic cancer in CF patients especially in those after lung transplantation with immunosuppression and prolonged survival.