Inside look at laparoscopic colectomy.

Laparoscopic colectomy has developed into a viable alternative to colon surgery. This paper presents an overview of the development and current status of laparoscopic surgery of the colon with a brief review of the evidence of efficacy of laparoscopic surgery in cancer management. The experience with laparoscopic surgery of the colon at a tertiary hospital in Puerto Rico is discussed with review of 142 consecutive cases treated for diverticulosis, cancer or polyps performed from 2005-2010. Data on operative time, technical issues, need for transfusions, specimen size, number of lymph nodes is presented. Data on time to start diet and length of hospital stay are discussed. Surgical complications in the series are discussed in detail and recommendations made on avoidance of technical problems during laparoscopic colon surgery. Recommendations are made on the development and advancement of laparoscopic colonic surgery in Puerto Rico.

Experience with hand assisted laparoscopic surgery of the colon.

BACKGROUND: Hand assisted laparoscopic colectomy (HALS) has been shown to have the advantages of laparoscopic colectomy in terms of pain, recovery and length of hospital stay. Studies have shown similar outcomes in laparoscopic colectomy as in open surgery. There is a learning curve to HALS, the operative time is longer, and it is more difficult than open surgery and requires specialized equipment. In this report we present our initial experience over a 2.5 year period using HALS for colon surgery for diverticulosis, polyps and colon cancer. METHODS: A retrospective review of office and hospital charts of patients undergoing HALS colectomy from June 2005 to January 2008 was performed at HIMA-San Pablo Hospital. Demographics, outcomes data including operative time, conversion rate to open surgery, reasons for conversion, time to start feedings, and length of stay were collected as well as staging and number of nodes for cancer patients. Complications are discussed along with comments pertinent to the experience of two surgeons going through the learning curves of LC and HALS colectomy. RESULTS: A total of 65 patients underwent attempted hand assisted laparoscopic colon resection. There were 33 males and 32 females between the ages of 26 and 87. Thirty-one patients underwent surgery for diverticulosis; 8 for pre-malignant lesions (large polyps or polyps with high grade dysplasia), and 26 for colon cancer. Mean operative time was 195 minutes (120 to 300); mean length of stay was six days (range 4-14 days). Conversion rate was (13.8%) overall; 21% during the first year and 10.8% after the first year. 5 (7.5%) of the patients in which HALS colon resection was completed had complications with prolonged length of stay. Patients without complication had an average length of stay of 4.5 days. The average number of lymph nodes was 14.8 (range 7-24); average length of specimens for diverticulosis was 17cm. Complications included postoperative bleeding in three patients who required early reoperation, prolonged ileus and small bowel obstruction in two patients. One patient developed a pelvic collection requiring a drain, and one patient had a wound infection requiring re-admission and antibiotics. No patient required colostomy due to a complication. There were no operative deaths. CONCLUSION: HALS colectomy is a safe and feasible alternative to open colectomy in a community hospital setting with proper expertise and equipment. Patients will benefit from faster recovery time and decreased length of stay in the hospital. Oncologic results are similar to open surgery. Operative times are longer than with open surgery and the operations are difficult to learn and master.

Comparison between open and laparoscopic appendectomy in non-complicated appendicitis.

BACKGROUND/OBJECTIVE: An extensive web search failed to provide studies from Puerto Rico regarding whether open (OA) or laparoscopic appendectomy (LA) should be performed for non-complicated appendicitis. Our goal is to compare these techniques in terms of time at operating room (OR), length of surgery, hospital stay, pain medication requirements, in-hospital complications and readmissions. METHODS: 126 patients (64 OA; 62 LA) with non-complicated appendicitis were studied retrospectively. Data obtained: demographics, CT-Scan use, surgery and operating room time, days in hospital, complications, diet commencement, pain medications doses, pathology and readmission. RESULTS: Difference was found in total time at OR (80.1+/-29 minutes OA; 105.7+/-22.6 LA) and in surgery length (41+/-28 OA; 48+/-16 LA), but not in hospital stay (2.1 days OA; 2.2 LA) nor in in-hospital complication rate. Negative appendectomy rate was 24% LA vs. 3% OA. Readmission rate was higher in OA with 5% wound infection rate. CONCLUSION: Techniques are similar in mean hospital stay, in-hospital complications, and pain medication requirements. LA had a higher negative appendectomy rate but of these patients five had surgical diagnosis of acute appendicitis and after appendectomy, signs and symptoms resolved; and two patients had interval appendectomies. As these patients were cured, the real negative appendectomy rate is 13%, similar to the historically accepted 16%. The other eight patients had an adequate diagnosis. We are concerned OA negative appendectomy rate is only 3%; we wonder if surgeons are waiting too long to operate patients. Readmission was higher in OA (wound infection rate of 5%). Although it takes more time in the OR, LA is as safe as OA, has a low rate of complications and lower readmission rate.

N,N-dimethyl-thioamphetamine and methyl-thioamphetamine, two non-neurotoxic substrates of 5-HT transporters, have scant in vitro efficacy for the induction of transporter-mediated 5-HT release and currents.

We studied two non-neurotoxic amphetamine derivatives (methyl-thioamphetamine, MTA and N,N-dimethylMTA, DMMTA) interacting with serotonin (5-HT) transporters (SERTs) with affinities comparable to that of p-Cl-amphetamine (pCA). The rank order for their maximal effects in inducing both [(3)H]5-HT release from rat brain synaptosomes or hSERT-expressing HEK-293 cells, and currents in hSERT-expressing oocytes, was pCA >> MTA > or = DMMTA. A correlation between drug-induced release and currents is also strengthened by the similar bell shape of the dose-response curves. Release experiments indicated that MTA and DMMTA are SERT substrates although MTA is taken up by HEK-293 cells with a V(max) 40% lower than pCA. The weak effects of MTA and DMMTA in vitro might therefore be due to their properties as 'partial substrates' on the mechanisms, other than translocation, responsible for currents and/or release. After either local or systemic in vivo administration, MTA and DMMTA release 5-HT in a manner comparable to pCA. These findings confirm that the neurotoxic properties of some amphetamine derivatives are independent of their 5-HT-releasing activity in vivo. It is worth noting that only those amphetamine derivatives with high efficiency in inducing 5-HT release and currents in vitro have neurotoxic properties.

Acute morphine administration increases extracellular DA levels in the rat lateral septum by decreasing the GABAergic inhibitory tone in the ventral tegmental area.

We studied the effect of an acute systemic administration of morphine and of a local intra-ventral tegmental area (VTA) infusion of the same drug on extracellular levels of dopamine (DA) in the lateral septum (LS) by in vivo microdialysis in anesthetized rats. The extracellular levels of 5-hydroxytryptamine (5-HT) were also measured in all dialysate samples. The acute systemic administration of morphine dose-dependently increased extracellular levels of DA but not of 5-HT in the LS, in the absence or presence of fluoxetine. This morphine effect was antagonized by the previous administration of naloxone, a specific opioid antagonist. The local infusion of morphine in the VTA also induced a significant increase of the extracellular levels of DA in the LS, concomitantly with a decrease of gamma-aminobutyric acid (GABA) extracellular levels in the VTA itself. Intriguingly, the LS extracellular levels of DA returned to basal values before the VTA GABA extracellular levels recovered. Our results show for the first time that an acute administration of morphine increases DA extracellular levels in the LS. The results also suggest that DA cells in the VTA and innervating the LS are under an inhibitory GABAergic tone sensitive to morphine. Taken together, our neurochemical data and previous studies involving LS DA in stress-related behavior support the hypothesis that DA in the LS plays a significant role in addictive behavior. The participation of LS DA and 5-HT systems in stress-induced relapse to drug seeking should be studied further.

Unusual cases of hyperparathyroidism

The history, physical and radiologic findings, treatment and pathology in five unusual cases of hyperparathyroidism is presented. The hyperparathyroidism was caused by a large (113 grams) mediastinal adenoma in the first patient, who is alive 25 years after surgery. A parathyroid carcinoma with compression of the esophagus was documented in the second patient. This patient is alive and normocalcemic 23 years after surgical treatment. A third patient with hyperplasia returned with hypercalcemia 20 years postsurgery requiring reoperation. A fourth patient with advanced bone findings was found to have a parathyroid adenoma. The fifth case is a patient with tertiary hyperparathyroidism secondary to hypophosphatemic rickets