Results of a randomized trial of HERMES-assisted versus non-HERMES-assisted laparoscopic antireflux surgery.

BACKGROUND: Speech recognition technology is a recent development in minimally invasive surgery. This study was designed to assess the impact of HERMES on operating room efficiency and user satisfaction. METHODS: Patients undergoing laparoscopic antireflux operations by surgeons experienced in minimally invasive surgery were randomized to HERMES-assisted or standard laparoscopic operations. The variables of interest were circulating nurse's time spent adjusting devices that are voice-controlled by HERMES, number of adjustments to devices requested, and surgeon and nurse satisfaction measured on a scale from 1 (dissatisfied) to 10 (satisfied). RESULTS: A total of 30 cases were studied. In the non-HERMES cases, nurses were interrupted to make device adjustments an average of 15.3 times per case versus 0.33 times per case in the with-HERMES cases (p < 0.01). The interruptions during the non-HERMES cases averaged 4.35 min per case versus 0.16 min per case in the with-HERMES cases (p = 0.03). Average satisfaction scores for HERMES operations as opposed to non-HERMES operations were 9.2 versus 5.3 for nurses (p < 0.01) and 9.0 versus 5.1 for surgeons (p < 0.01). CONCLUSIONS: Physician and nurse acceptance of HERMES was very high because of the smoother interruption-free environment.

Thoracoscopic resection of an ectopic intrathoracic goiter.

We report a case of an ectopic intrathoracic goiter in a 79-year-old human. This uncommon finding presented as a symptomatic paratracheal mass that was resected using thoracoscopic techniques without complication.

Treatment of malignant mesothelioma.

Malignant pleural mesothelioma (MPM) is a rare tumor that predominantly afflicts men over 50 years of age. Nearly 3000 MPMs are reported annually in the United States with the incidence expected to rise into the new millenium. Over the past 40 years, MPM has been unequivocally linked to asbestos exposure worldwide. Recently, however, a new theory on the carcinogenesis of this tumor has been proposed with the isolation of a simian virus (SV 40)-like gene sequence in mesothelioma tumor cells. The clinical presentation of MPM is variable, although most patients typically present with dyspnea, chest pain, or pleural effusion. Obtaining a diagnosis of MPM has been greatly assisted by video-assisted surgery and the use of immunohistochemistry and electron microscopic techniques, which help distinguish MPM from other tumor pathologies such as adenocarcinoma. Computed tomography and magnetic resonance imaging have been also useful for determining tumor burden and resectability. Traditionally, strategies for the treatment of MPM have included supportive care, surgery, radiotherapy, and chemotherapy. Survival with supportive care alone ranges between 4 and 12 months. Single-modality therapy using traditional approaches (surgery, radiotherapy, chemotherapy) alone has failed to improve patient survival significantly. Recently, results using a multimodality approach have been favorable. In particular, cytoreductive surgery (pleuropneumonectomy) followed by sequential chemotherapy and radiotherapy have demonstrated improved survival, especially for patients with epithelial histology, negative resection margins, and no metastases to extrapleural lymph nodes. Innovative therapies such as the use of photodynamic, targeted cytokines and gene therapy are currently being investigated for management of MPM.

Minimally invasive approaches to acquired shortening of the esophagus: laparoscopic Collis-Nissen gastroplasty.

Acquired shortening of the esophagus remains a controversial finding. In some surgical series of patients with gastroesophageal reflux disease, the incidence of clinically significant shortening is low enough that some surgeons have questioned its existence. In the setting of massive hiatial hernia, esophageal shortening has been reported to occur in up to 100% of patients. In association with mild to moderate hiatal hernia, clinically significant esophageal shortening is reported from 2.6% to a much higher percentage of patients, depending on the severity and chronicity of gastroesophageal reflux disease. Failure to recognize this shortening may be responsible for a high failure rate after antireflux surgery. Open Collis gastroplasty is an effective way to manage acquired shortening of the esophagus, and it creates a tension-free intra-abdominal segment of neoesophagus for fundoplication. Minimally invasive approaches to Collis-Nissen procedures have been reported by our group and several others with good short-term results.

Malignant mesothelioma of the pleural space.

Malignant pleural mesothelioma is an aggressive tumor associated with exposure to asbestos. Although this disease is rare, with an annual incidence in the United States of 2,000 to 3,000 cases, a steady rise in cases has been reported. Malignant pleural mesothelioma has a variable clinical presentation and may be difficult to diagnose. Pathologically, the disease is subdivided into three microscopic subtypes: epithelial, sarcomatous, and mixed histologies. Although there is no widely accepted staging system for mesothelioma, the Butchart, TNM, and Brigham staging systems have been used most commonly. Diffuse malignant pleural mesothelioma is resistant to standard modes of therapy and, if untreated, results in death 4 to 12 months from the time of diagnosis. For selected patients, an aggressive approach combining radical surgery with chemotherapy and radiotherapy has demonstrated a long-term survival advantage. New and innovative therapeutic modalities are presently being investigated in an attempt to provide viable alternatives for patients with early and advanced disease.

Techniques of pneumonectomy. Pleural pneumonectomy.

This article reviews the preoperative assessment and selection of patients for extrapleural pneumonectomy, the surgical technique, and recent data outlining our experience with multimodality therapy for MPM.

Pleuropneumonectomy in the treatment of malignant pleural mesothelioma.

STUDY OBJECTIVES: Malignant pleural mesothelioma (MPM) is predominantly a local/regional disease that results in a survival time that ranges from 4 to 12 months without treatment. Single-modality therapy using surgery, chemotherapy, or radiotherapy alone is largely ineffective. The objective of the study was presentation of the use of pleuropneumonectomy in a multimodality treatment setting and the results. DESIGN: Didactic presentation. SETTING: Academic tertiary-care hospital. PATIENTS: One hundred eighty-three patients who underwent multimodality therapy. INTERVENTIONS: Of all the single-modality treatment approaches, pleuropneumonectomy has been associated most consistently with long-term disease-free survival and has provided the greatest amount of tumor cytoreduction. The technique of pleuropneumonectomy traditionally has been linked with high perioperative mortality and morbidity when compared with that of other cytoreductive techniques such as pleurectomy/decortication. Recently, improvements in operative mortality (< 5%) have been reported, largely due to improvements in patient selection and perioperative management. Multimodality therapy, including chemotherapy, radiotherapy, and extrapleural pneumonectomy, was used to treat patients. RESULTS: Outcomes were presented for 183 patients with MPM who underwent multimodality therapy. CONCLUSIONS: With the development of multimodality therapy, pleuropneumonectomy followed by sequential chemotherapy and radiotherapy has demonstrated a significant survival benefit, especially for patients who have epithelial tumor histology, tumor-free resection margins, and tumor-free extrapleural node status.