Changes in T-lymphocytes' viability after laparoscopic versus open cholecystectomy.

Laparoscopic surgery results in decreased immune and metabolic stress response compared to open surgery. Our aim was to evaluate the suspension of host immune defense in terms of apoptosis, necrosis, and survival of peripheral T-lymphocytes in patients undergoing laparoscopic versus open cholecystectomy. Apoptosis, necrosis and viability of peripheral T-lymphocytes were measured preoperatively and postoperatively by means of flow cytometry in 27 patients undergoing laparoscopic cholecystectomy and 25 undergoing open cholecystectomy. White cell count, CRP, and serum glucose levels were also measured. Viable peripheral T-lymphocytes were significantly decreased in open cholecystectomy (P = 0.02), while their late apoptotic as well as the overall necrotic rate were significantly increased (P = 0.01 and P < 0.01, respectively). Open cholecystectomy was also associated with lower levels of surviving circulating T-lymphocytes (P = 0.01) and higher percentage of necrotic T lymphocytes (P = 0.03) 24 hours postoperatively compared to laparoscopic cholecystectomy. Serum CRP was increased 24 hours after open cholecystectomy (P = 0.04). All differences failed to sustain more than 48 hours postoperatively. Increased viability and decreased necrosis of circulating T-lymphocytes were observed in laparoscopic cholecystectomy. Necrosis (and not apoptosis) seems to be the predominant pathway of T-lymphocyte death in open cholecystectomy, in a process reaching its peak at 24 hours and further attenuating 48 hours postoperatively.

Laparoscopic sleeve gastrectomy for morbid obesity and glucose metabolism: a new perspective.

BACKGROUND: Global rise in the incidence of obesity and type 2 diabetes mellitus is widely recognized as one of the most challenging contemporary threats to public health. Weight loss surgery has proven to be an effective and durable solution for morbidly obese adults. Laparoscopic sleeve gastrectomy (LSG) was introduced as a restrictive procedure for obese patients, initially described as a possible first-stage operation, but now commonly performed as a stand-alone bariatric operation for both high-risk and super-morbid-obese patients, as well as for patients with lower body mass index. This study aims to evaluate the progression of glucose metabolism in patients undergoing LSG. METHODS: This prospective study investigated 62 patients who underwent LSG by the same surgical team in an 18-month period. Preoperative evaluation included demographic information, complete medical history including comorbidities and medication, clinical examination, evaluation of cardiopulmonary function, measurement of weight and height on a standard electronic scale, upper gastrointestinal endoscopy and upper abdominal ultrasound, as well as interviews with a psychologist and nutritionist. Glucose metabolism was evaluated by oral glucose tolerance test (OGTT), preoperatively and at 3, 6, and 12 months after surgery. RESULTS: The OGTT was significantly ameliorated in all groups during follow-up. Nine of 12 diabetic patients (75 %) ceased drug treatment at 3 months postoperatively (p = 0.004), increasing to 100 % at 1-year follow-up (p < 0.001). Normoglycemic patients and patients with borderline OGTT experienced mild or severe hypoglycemia during the glucose tolerance test at 3, 6, and 12 months' follow-up. CONCLUSIONS: LSG offers excellent results to morbidly obese patients with regard to type 2 diabetes mellitus. Implementation of OGTT in these patients can be a valuable tool in their postoperative management. Bariatric teams performing LSG for morbid obesity should heighten their sensitivity to postoperative hypoglycemia, even in patients with type 2 diabetes mellitus.

The effect of laparoscopic sleeve gastrectomy on the antireflux mechanism: can it be minimized?

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is a promising procedure for the treatment of morbid obesity. The stomach is usually transected near the angle of His; hence, the lower esophageal sphincter (LES) may be affected with consequences on postoperative gastroesophageal reflux disease (GERD). The purpose of this study was to examine the effect of LSG on the LES and postoperative GERD. METHODS: Severely obese asymptomatic patients submitted to LSG underwent esophageal manometry and GERD evaluation preoperatively and at least 6 weeks postoperatively. Data reviewed included patient demographics, manometric measurements, GERD symptoms, and pathology. Statistical analysis was performed by SPSS software. RESULTS: Twelve male and eleven female patients participated in the study. Mean age was 38.5 ± 10.9 years, and initial body mass index was 47.9 ± 5.1 kg/m(2). At follow-up examination, mean excess body mass index loss was 32.3 ± 12.7%. The LES total and abdominal length increased significantly postoperatively, whereas the contraction amplitude in the lower esophagus decreased. There was an increase in reflux symptoms postoperatively (p < 0.009). The operating surgeon who mostly approximated the angle of His resulted in an increased abdominal LES length (p < 0.01). The presence of esophageal tissue in the specimen correlated with increased total GERD score (p < 0.05). CONCLUSIONS: LSG weakens the contraction amplitude of the lower esophagus, which may contribute to postoperative reflux deterioration. It also increases the total and the abdominal length of the LES, especially when the angle of His is mostly approximated. However, if this approximation leads to esophageal tissue excision, reflux is again aggravated. Thus, stapling too close to the angle of His should be done cautiously.

Incidence, risk factors, and outcome of portal vein thrombosis after laparoscopic-assisted splenectomy in ß-thalassemia patients: a prospective exploratory study.

BACKGROUND: Portal vein system thrombosis (PVT) is an infrequent but potentially serious complication after laparoscopic splenectomy. Patients with ß-thalassemia are at higher risk as they have splenomegaly and hypercoagulability. SUBJECTS AND METHODS: Forty-eight ß-thalassemia patients who underwent hand-assisted laparoscopic splenectomy or laparoscopic splenectomy were studied prospectively with pre- and postoperative Doppler ultrasonography or computed tomography scanning. RESULTS: The incidence of PVT was 8.3% (95% confidence interval [CI] 0.2%-16.4%) (4 of 48 patients). Spleen weight was the only independent factor associated with the presence of PVT. The odds ratio for spleen weight (100 g increase) was 1.46 (95% CI 1.10-1.94, P=.010). Receiver operator characteristic curve analysis showed that the optimal cutoff of spleen weight to the prediction of PVT was 1543 g. Thrombosis resolution was observed after a median of 165 days. CONCLUSIONS: Patients with ß-thalassemia who undergo laparoscopic-assisted splenectomy are at high risk of postoperative PVT. Close postoperative surveillance and aggressive coagulation prophylaxis are needed in these patients. Larger studies are required to confirm the present findings.

C-reactive protein, white blood cells, and neutrophils as early predictors of postoperative complications in patients undergoing laparoscopic sleeve gastrectomy.

BACKGROUND: Early detection and treatment of complications after laparoscopic sleeve gastrectomy (LSG) are mandatory. This study aimed to evaluate C-reactive protein (CRP), white blood cell (WBC) count, and neutrophil (NEU) count in relation to the early diagnosis of major surgical complications after LSG. METHODS: A prospective study of 177 patients who underwent LSG during 2008-2011 was performed. Measurements of WBC, NEU, and CRP performed on postoperative days 0, 1, 3, 5, 7, 9, 11, 13, and 30 were correlated with postoperative surgical complications. RESULTS: Both WBC and NEU were correlated with leak or abscess on postoperative days 3, 5, 7, 9, and 11, whereas on day 1, only NEU was significantly increased. Elevated CRP was correlated with leak or abscess on all the days (p < 0.001). The parameters measured were not correlated with postoperative bleeding unless leak or abscess coexisted. According to receiver operating characteristic (ROC) analysis, CRP detected leak or abscess with remarkably higher sensitivity and specificity than WBC or NEU on all the days. Moreover, the area under the curve (AUC) of CRP was higher than the AUC of WBC or NEU, suggesting important statistical significance. On day 1, WBC and NEU achieved 77.8 and 78.3 % sensitivity, respectively, and an even lower specificity (68.4 and 52.6 %), whereas a CRP cutoff at 150 mg/l achieved 83.2 % sensitivity and 100 % specificity. On day 3, the sensitivity and specificity of CRP reached 100 % (cutoff level, 200 mg/l), and on day 5, CRP achieved 83.2 % sensitivity and 100 % specificity (cutoff level, 150 mg/l), whereas for WBC and NEU, specificity was high (>92 %), but sensitivity did not exceed 78.2 %. CONCLUSION: Because CRP detected leak or abscess after LSG with remarkably higher sensitivity and specificity than WBC or NEU, CRP seems to be a more accurate market for the early detection of these complications.

Novice surgeons versus experienced surgeons in laparoendoscopic single-site (LESS) surgery: a comparison of performances in a surgical simulator.

INTRODUCTION: During the past years, there has been increasing interest in simulation-based training of technical skills especially in laparoscopy. The purpose of this study was to compare the performances of novice and experienced laparoscopic surgeons on a LESS simulator. METHODS: The study recruited 20 surgeons classified into two groups: group NS consisted of ten residents without any laparoscopic experience, and group ES consisted of ten surgeons with experience in conventional laparoscopy (performed >90 laparoscopic cholecystectomies) but without any experience in LESS surgery. Both groups completed a mini-trainee course that included four repetitions of a standardized task of circle pattern cutting (CIRCLE). Time, path length, and economy of movement were measured and compared. RESULTS: Group ES presented significantly better time scores than group NS in all four repetitions. Economy of movement did not differ significantly between the two groups, whereas path length was shorter for beginners at the forth effort. Moreover, group ES failed to improve path length and economy of movement scores, whereas group NS improved their performance significantly in these parameters. CONCLUSIONS: It seems that previous laparoscopic experience in conventional laparoscopy may not necessarily be an advantage in all parameters of LESS surgery and the learning process can be longer than expected even for experienced surgeons.

Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing two different techniques. Preliminary results.

BACKGROUND: Sleeve gastrectomy involves the creation of small gastric reservoir based on lesser curvature of the stomach, which is fashioned by a longitudinal gastrectomy that preserves the antrum and pylorus together with its vagal innervation. The main complications in the early postoperative course are bleeding and gastric leak. In order to reduce these complications the staple line can be reinforced in many different ways. The purpose of this study was to randomly compare two different techniques in laparoscopic sleeve gastrectomy (LSG): buttressing the staple line at the gastroesophageal junction (angle of Hiss) with Gore Seamguard and staple-line suturing with PDS 2.0. METHODS: Between July 2009 and July 2010, 90 patients were prospectively and randomly enrolled in the two different techniques of handling the staple line during LSG. Forty-eight of these patients belonged in group A (application of Gore Seamguard) and 42 in group B (application of a continuous suture). Operative and postoperative complications were recorded. RESULTS: Postoperative leak affected two patients in group A (4.2%) and bleeding occurred in one patient of group A (2%). Total complication rate was 6.2% for group A. No major surgical complication occurred in group B. The differences between the two groups did not reach statistical significance. CONCLUSIONS: No significant difference is evidenced in terms of bleeding and postoperative leak between the two techniques of enhancing the staple line in LSG. Suturing of the staple line may be more time consuming but costs are considerably less.

Prospective comparative study of the efficacy of staple-line reinforcement in laparoscopic sleeve gastrectomy.

BACKGROUND: Staple-line reinforcement has been used with promising results in laparoscopic gastric bypass in order to reduce leakage, increase staple-line integrity, and diminish staple-site bleeding. The purpose of this study was to determine if staple-line reinforcement with bovine pericardial strips reduces surgical complications of laparoscopic sleeve gastrectomy (LSG). METHODS: This is a prospective comparative study of all patients who underwent LSG by a standard operative team in an 18-month period. Patients were enrolled in group A if they received staple-line reinforcement and in group B when not. The staple line was reinforced with bovine pericardium strips [Peri-Strips Dry (PSD)]. RESULTS: In total, 187 patients, with a median preoperative BMI of 45.3 kg/m(2) (range = 35.1-72.7), underwent LSG. Ninety-six patients were enrolled in group A and 91 in group B; the two groups were comparable in their various characteristics. Morbidity rate representing grade III-IV surgical complications reached 7.4% and mortality rate was 0.5%. Reinforcement with PSD significantly reduced the occurrence of bleeding from the staple line and intra-abdominal collections (P = 0.012 and 0.026). The leak rate was not significantly reduced in group A. Patients in group A required fewer days of hospitalization. CONCLUSIONS: Reinforcement of the staple line in LSG resulted in significantly fewer surgical complications compared to standard stapling of the gastric tube. The additional cost due to the reinforcement of the staple line may be counterbalanced by the reduction in the length of hospitalization.

[Education and teaching laparoscopic surgery in Europe: present constraints and role of the European Association for Endoscopic Surgery.]

As we move on to the second decade of the 21st century, many changes in education and, particularly, in training future surgeons, have come to pass. Several of these changes are the result of a natural evolution in teaching methods, but others have been dictated by global modifications in the educational and social systems reigning throughout the Western culture. The recent evolution to less aggressive therapy and, in particular, surgical techniques, attests to the desire to decrease patient harm. Laparoscopic surgery, based on less invasive parietal violation and insult, responding to the above-mentioned concerns, has rekindled the debate on patient safety but also has opened the debate on how to best teach the technique. This paper endeavors to describe the problems created by the social and economic changes in the last few decades, to assess the consequences on teaching and learning laparoscopic surgery for the surgeon and to review possible solutions.

Clinical implications of sleeve gastrectomy as a source of spleen infarction or ischemia.

Splenic arterial demarcation has been observed during laparoscopic sleeve gastrectomy (LSG). The present study aims to detect its actual incidence during LSG and clarify its clinical significance. This is a prospective observational study of 287 consecutive patients that underwent LSG by the same surgical team over 3 years. In all patients, the gastric fundus was mobilized using a standard technique. Before withdrawal of the pneumoperitoneum, the spleen was exposed and carefully inspected for evidence of arterial demarcation. Patients with a clear demarcation were followed with Doppler ultrasound. Computed tomography scan with oral contrast was performed to rule out septic complications. Median preoperative body mass index was 46 kg/m(2) (range 35.1-78). Median operative time was 58 min (range 42-185), median hospital stay was 3 days (range 3-45), and overall morbidity rate was 8.6%. Intraoperative demarcation of the upper splenic pole was evident in 12 patients (4.1%). Eleven patients had uneventful postoperative course. One patient raised temperature of 38.5°C at the 7th postoperative day and was readmitted for further treatment. Once afebrile, the patient was discharged on the 10th postoperative day and continued on prophylactic low molecular weight heparin (tinzaparin, 7,500 U sc.) for 20 days. Splenic discoloration following LSG is an uncommon complication with minimal clinical significance, which could be related to hematoma, venous congestion, or ischemia. The possibility of a late splenic abscess cannot be ruled out. No risk factors can be identified preoperatively.

Routine abdominal drains after laparoscopic sleeve gastrectomy: a retrospective review of 353 patients.

Complications after laparoscopic sleeve gastrectomy (LSG) are usually silent and difficult to interpret. Our purpose was to evaluate the utility of routine placement of intraperitoneal drains at the end of LSG in detection and management of postoperative complications. This is a retrospective study of all patients that underwent LSG by a standard operative team in a 3-year period. Patients were enrolled in Group A when an intraperitoneal drain was placed and Group B when not. Three hundred and fifty-three patients underwent LSG with a median preoperative BMI of 46.4 k/m2. Two hundred and one patients were enrolled in group A and 152 in group B; the two groups were comparable in their characteristics. Staple line leak, bleeding, and abscess were observed in 4%, 2.9%, and 2.5% of group A and 2.6%, 1.9%, and 1.9% of group B and the differences did not reach statistical significance. In 50% of patients with drain and leak, per os blue de methylene test was negative and in another 50% leak took place after the fourth postoperative day when drain was already taken off. Abscesses were observed significantly more often in patients that had suffered postoperative bleeding (p < 0.001) or had undergone laparoscopic adjustable gastric banding (LAGB) in the past (p = 0.02). Placement of drains does not facilitate detection of leak, abscess, or bleeding. Furthermore, they don't seem to eliminate the reoperation rates for these complications. Maybe patients with previous LAGB and intraperitoneal bleeding could benefit from placement of a drain that will remain for more than 5 days.

A virtual reality simulation curriculum for intravenous cannulation training.

OBJECTIVES: Although virtual reality (VR) simulators play an important role in modern medical training, their efficacy is not often evaluated using learning curves. In this study, the learning curves of novice and intermediate users were elicited during a VR simulation-based curriculum for intravenous (IV) cannulation. METHODS: This was a prospective observational study of subjects undergoing training using a VR model of IV cannulation. Participants were divided into two groups: novices (third-year medical students with no prior practical experience in IV catheterization) and intermediates (recent graduates with limited experience). Performance was measured with two endpoints: time to completion and errors committed. Errors were categorized as critical or noncritical. Learning curves (error score and time completion vs. session number) were analyzed using the Friedman's test. Performance before and after training was compared using the Kruskal-Wallis test. The Spearman rank correlation coefficient (r(s)) was used to determine the correlation between time completion and error score estimates. The number of attempts required to complete the training phase was also measured and compared between the two groups. RESULTS: Thirty subjects were enrolled: 17 in the novice group and 13 in the intermediate group. Learning curve plateaus of intermediates were reached in the sixth case scenario (session), whereas novices reached a plateau in the eighth session. Performance comparison of time to completion and errors showed significant improvement for both groups. Less time and fewer attempts were required by all trainees to complete a scenario while progressing through the curriculum. The overall number of IV cannulation attempts of novices was significantly higher than that of the intermediates throughout the course. CONCLUSIONS: Significant learning curves for novice and intermediate students were demonstrated after following the VR simulation-based curriculum. Competencies acquired during this educational course may provide an important advantage for training prior to actual clinical practice.

Optimal trocar placement for ergonomic intracorporeal sewing and knotting in laparoscopic hiatal surgery.

BACKGROUND: Trocar placement presently is mostly empiric. Our goal was to define simple distances from bony landmarks to locate the optimal ergonomic placement of manipulation trocars for access to the lower esophagus and hiatal orifice, for suture placement, and knotting of the gastric fundus and crura. Hypothesizing that the ideal ergonomic principles of a manipulation angle of 60°, an elevation angle (α(e)) of 30° to 60°, and an intracorporeal/extracorporeal length ratio (I/E) of working instruments close to 1:1 are interrelated by simple trigonometric functions, the variations of each of these parameters were calculated in a dependent manner for 2 standard lengths of needle holders: 48.5 cm and 58.5 cm. RESULTS: Trocar placement can be calculated easily according to simple formulas dependent on the α(e), the distance from the sternoxiphoid junction to the median of the intertrocar span (d) and the vertical distance from the stenoxiphoid junction to the average distance between the apex of the hiatal orifice and the anterior aspect of the esophagus (XH'): when the α(e) is 30°: d is XH' √2 and when α(e) is 45°, d is XH'/√2. Likewise, when α(e) is 30° the intertrocar span (LR) is 2XH', half on either side of the optical axis (d), and when α(e) is 45°, LR is XH' √2, XH'/√2 on either side of the optical axis. The most ergonomic solution is to work with an α(e) of 40° to 45° by placing the 2 working (manipulation) trocars, between 10 and 14 cm caudad from the sternoxiphoid junction, between 10 and 12 cm on either side of the longitudinal axis corresponding to the optic-target axis. The shorter needle holder works best in this configuration because the I/E ratio will be between .8 and 1. If, however, the surgeon wants to work with an α(e) closer to 30°, then the longer needle holder should be used, and the trocars should be placed between 20 and 21 cm from the sternoxiphoid junction, 14.5 to 15 cm on either side of the optical axis. The I/E ratio will vary between 1 and 1.1. When a 1/1 I/E ratio was prioritized, the α(e) would be 40° and 32°, for the shorter and longer instruments, respectively. The deeper crural closure requires increasing the α(e) by 2° and 3°, respectively. Hyperlordosis, as obtained by placing a cushion under the patient's back, shortens the distances, allowing placement of the trocars closer to the sternoxiphoid junction. CONCLUSIONS: Based on ergonomic principles (manipulation angle, 60°; α(e), 40°-45°; and an I/E ratio of working instruments, close to 1:1), simple trigonometric considerations allow easy calculation of the ideal placement of trocars corresponding to working instruments in hiatal surgery necessary for ergonomic dissection, suturing, and intracorporeal knotting. Ideal trocar placement is dependent only on the vertical depth of the target organ.

Bax, cytochrome c, and caspase-8 staining in parotid cancer patients: markers of susceptibility in radiotherapy?

OBJECTIVE: Negative bcl-2 and HLA-DR protein expression have been associated with responsiveness to adjuvant radiotherapy in surgically treated parotid cancer patients. The aim of this study was to investigate the prognostic significance of bax, cytochrome c, and caspase-8 protein expression in a group of surgically treated patients to determine whether they also suggest markers of responsiveness to adjuvant radiotherapy. STUDY DESIGN: Historical cohort study. SETTING: Otolaryngology department in a university hospital. SUBJECTS AND METHODS: The immunohistochemical expression of bax, cytochrome c, and caspase-8 were studied in paraffin-embedded tissue specimens originating from 27 surgically treated parotid cancer patients and nine patients with Warthin parotid tumors (control group) and correlated with the patients' clinicopathological characteristics and clinical outcome. RESULTS: Caspase-8 negative staining was more frequently observed in higher TNM stages and in tumors measuring more than 4 cm (P = 0.009 and P = 0.018, respectively). Caspase-8 (-)/cytochrome c (-) patients carried low-grade lesions without nodal involvement (P = 0.01 and P = 0.05, respectively). Caspase-8 (-) patients who received postoperative radiotherapy presented a significantly increased disease-free survival compared to those who did not (P = 0.04). Patients bearing bax (-) tumors who received postoperative radiotherapy presented an improved four-year disease-free survival compared to bax (-) patients who did not receive any type of adjuvant radiotherapy (P = 0.017). CONCLUSION: Bax, cytochrome c, and caspase-8 protein expression failed to independently predict survival in parotid cancer patients. However, patients with bax (-) or caspase-8 (-) tumors should be considered as candidates for adjuvant radiotherapy in order to achieve better local disease control.

Prospective appraisal of a 2-day training course on laparoscopic sleeve gastrectomy: the ELTC experience.

BACKGROUND: The increasing role of laparoscopic sleeve gastrectomy (LSG) in the treatment of morbid obesity dictates the need for greater acquaintance with this type of surgery. This study was designed to evaluate the impact of a 2-day LSG course and a 4-day laparoscopic bariatric mini-training program on the knowledge and training gained by participating surgeons. METHODS: A total of 73 trainees (31 residents and 42 surgeons) completed a question survey immediately after completion of the respective courses. Questions probed demographic data, training experience before and after course completion, evaluation of course content, and operative experience. RESULTS: All residents and four of the general surgeons found the laparoscopic bariatric mini-training program to be of value with respect to future professional orientations. Seven surgeons started performing LSGs, while another five surgeons decided to occupy themselves with various types of laparoscopic bariatric procedures. The most useful parts of the course included the identification and treatment of complications, the use of new instrumentation, and surgical demonstrations (video or live), as decided by more than 80% of the participants. On a 1-5 scale, the presentation of novel knowledge was evaluated to be ≥ 3 by all participants. CONCLUSION: The 2-day LSG course offered participants high-quality novel knowledge and excellent training quality, and exerted impact on their personal career.