Transgastric large-organ extraction: the initial human experience

Introduction

In laparoscopy, it often is the case that port sites are enlarged for specimen extraction. This leads to higher risk of trocar site complications, such as infection or incisional hernia. Natural orifice surgery (NOTES) is beneficial for minimizing these complications, and this is emphasized when the extracted specimen is of large volume. We have been using transgastric technique for appendectomy, cholecystectomy, and laparoscopic sleeve gastrectomy (LSG). Of these transgastric operations, we focus on the one with relatively large-organ extraction: LSG with transoral remnant extraction (TORE). We describe the details and feasibility of this procedure and compare the outcomes to conventional LSG.

Methods

All patients undergoing LSG were considered candidates for TORE and were consented for this procedure if interested after an informed discussion. Eighteen LSGs with TORE (TORE group) and ten conventional LSGs (non-TORE group) were performed from August 2010 to March 2011. We retrospectively compared these two groups for the age, sex, preoperative body mass index, operating room time, hospital stay, excess weight loss (EWL), and trocar site complications. Laparoscopic sleeve gastrectomy with TORE consists of conventional LSG and transgastric retrieval of the resected stomach. The procedure exceeds exactly the same manner as conventional LSG until the initial stapling of the stomach. For TORE, the gastrectomy is initiated 5 cm proximal to the pylorus than usual LSG to save the space for the gastrotomy used for specimen retrieval. After the gastrectomy is completed, the full thickness of the distal most part of the staple line is incised open as wide as 2 cm by using electric cautery or ultrasonic dissector. A flexible upper endoscope, which has been in the stomach already as a bougie for gastrectomy, is then guided into the peritoneal cavity through the gastrotomy. The specimen is grasped endoscopically with a snare and extracted transorally. Following this, the gastrotomy is closed laparoscopically. The final shape of the gastric sleeve is identical to the one of conventional LSG.

Results

There was no significant difference between the TORE and the non-TORE group for patients’ profile, operating room time, hospital stay, and EWL. Neither group has experienced perioperative complications. All specimens were extracted readily and safely in the TORE group. Of the ten cases in the non-TORE group, four required extension of the trocar site. No trocar site complications were found in the TORE group, whereas the extended trocar site developed panniculitis in two cases of the non-TORE group; one required panniculectomy for refractory induration.

Conclusions

TORE can be safely and easily performed by surgeons with laparoscopic and endoscopic skill, and with commonly available instruments. While producing identical outcomes, our initial experience with the TORE technique demonstrates an advantage over traditional LSG, because it minimizes trocar site complications. Transgastric organ extraction is potentially applicable to other large-organ extractions in laparoscopic surgery without excessive risk or resources. Larger case volume and longer follow-up period is awaited.     

Lamotrigine in epilepsy,pregnancy and psychiatry – a drug for all seasons?

Lamotrigine has been demonstrated to be effective as both an antiepileptic drug and a mood stabiliser. For epilepsy it is less efficacious than valproate in primary generalised epilepsy, but it is comparable to some traditional drugs in partial epilepsy. In psychiatry it has significant advantages over other mood stabilisers for the treatment and prevention of depressive phases of bipolar illness, but not for the treatment of mania. It has a more benign adverse effect profile than older antiepileptic agents and is not a proven teratogen. Risk of adverse reactions is reduced by commencing treatment at a markedly reduced dose that is gradually increased.     

Management of access to branded psychotropic medications in private health plans

BACKGROUND: In the past decade, health insurers have increased their reliance on cost control policies such as prior authorization and 3-tier formularies. Little is known about how these policies are being applied to psychotropic medications, many of which have low rates of patient adherence. OBJECTIVE: This study reports on plans' cost-sharing tier placement and authorization policies for 12 brand only psychotropic medications in 3 classes: antidepressants, anti-psychotics, and medications for attention deficit/hyperactivity disorder (ADFID). METHODS: Data were from a nationally representative survey of private health plans regarding mental health and substance-abuse services in 2003; 368 plans responded (83% response rate). Results were weighted and represent national estimates of health-plan characteristics. RESULTS: The majority of insurance products provided unrestricted placement on Tier 2 (medium copayment) for at least 2 brand-only antidepressants and at least 2 brand-only antipsychotics. This approach allows clinicians some limited leeway in initial medication selection. However, most patients who did not respond to the Tier-2 options typically faced a substantial escalation in copayment (Tier 3), possibly leading to premature medication discontinuation. For ADHI)5 the options were considerably more limited, with 22.1% of products applying some restriction to all 3 medications and only 15.9% of products leaving all 3 medications unrestricted. Plans with specialty contracts for mental health were considerably more likely to use Tier 3 (highest copayment) as their only restriction approach. CONCLUSIONS: Based on the results of this analysis,private plans were managing psychotropic costs using copayment incentives rather than administrative controls. This approach was less intrusive for clinicians, but resulting higher copayments could worsen already high rates of nonadherence; future research should examine this issue.     

Fast track surgery and preoperative optimization

Enhanced recovery pathways have been rapidly embraced by surgeons as a mechanism for improving patient care and driving down complications and costs. They seek to employ a holistic approach, reviewing all aspects of patient management, to improve care. Many components are dissimilar to traditional surgical teaching, involving early mobilization and enteral nutrition, as well as a strong emphasis on fluid balance and pain management. By addressing all components of the patient pathway from preoperative through to post-surgery, significant improvement in outcomes can be achieved for a range of surgical procedures.     

A systematic review of health service interventions to improve linkage with or retention in HIV care

The importance of early linkage to and continuing retention in HIV care is increasingly recognised, particularly in light of the implications poor linkage and retention rates have for the effectiveness of HIV treatment as prevention strategies. The purpose of this systematic review was to examine the effectiveness of healthcare interventions in improving patient linkage to or retention in HIV care. We systematically searched PubMed (MEDLINE and PubMed-only citations) and EMBASE databases for articles reporting the original results of randomised controlled trials, and used a standard data collection form to extract information on study characteristics and outcome data. Five articles met the inclusion criteria, of which two articles focused on linkage to care and three on retention in care. The methodological quality, both of internal and external validity, of most of the trials was suboptimal. Wide variation in the interventions and outcome measures meant synthesis of the results using meta-analysis was not appropriate. This review shows evidence that interventions based on supporting patient self-management improves linkage to, and possibly retention in, care. Interventions aimed at delivery service design may also be effective, although evidence in this review was limited. It is vital that interventions are developed to improve patient engagement in HIV care. The dearth of research identified by this review highlights the need for well-designed trials of interventions in this area in the future.