Comparison of laparoscopic and open resections for gastric gastrointestinal stromal tumors (GISTs).

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are the most common mesencyhmal tumors of the gastrointestinal tract. Today surgical resection is still the treatment of choice for primary gastric GISTs. This study compares the laparoscopic versus open surgical resection approaches of gastric GISTs. METHODS: A retrospective chart review was conducted from our database, and 68 primary gastric GIST resections were found to be performed in our center between 2008- 2020. Of these 68 patients, 57 were included for the study. Open resection was performed in 32 patients, and laparoscopic resection was performed in 25 patients. The medical records were examined and compared for clinical, pathologic and surgical results according to preferred surgical method of choice. RESULTS: Fifty-seven patients were qualified for the study. The average diameter of the tumor was 4.8 1.91 cm in the laparoscopic group, and 6,8 4,27 cm in open group. Estimated blood loss during the surgery was significantly lower in laparoscopic group patients (100.7 ml vs 287.5 ml) (p< 0.001) and also length of stay was shorter compared with open at 4.4 versus 11.9 days (p < 0.001). Laparoscopic group patients needed less pain medication, and they had quicker return to daily life. CONCLUSIONS: Laparoscopic approach is safe and feasible with acceptable oncologic outcomes and certain benefits like decreased length of stay, less complication rates and better comfort. The preference of laparoscopic resection should be decided not only on tumor location or diameter but also surgeon's laparoscopic surgical experience. KEY WORDS: Laparoscopic, Gastric resection, GISTs.

Laparoscopic Colorectal Surgery in Patients With Previous Abdominal Surgery: A Single-center Experience and Literature Review.

To present the outcomes of laparoscopic colorectal surgery in colorectal cancer patients with a previous history of abdominal surgery. Data of a total of 121 patients with primary colorectal cancer who underwent laparoscopic surgery were retrospectively analyzed. The patients were divided into 2 groups as those with previous abdominal surgery (PAS, n=34) and those without (non-PAS, n=87). Gastric and colonic surgeries were the most common procedures in the major PAS group, whereas gynecologic and obstetric surgeries and appendectomy were the most common procedures in the minor PAS group. However, there were statistically significant differences in the overall complication rates, wound complications, and anastomotic leaks, although there were no significant differences in the rates of postoperative ileus, pneumonia, port site herniation, and postoperative bleeding between the groups. Our study results suggest that laparoscopic colorectal surgery can be safely performed in patients with colorectal cancer who underwent abdominal surgery previously.

Management of perforation after endoscopic retrograde cholangiopancreatography.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP)-related perforation is an infrequent complication. It is associated with significant morbidity and mortality. The present study is an evaluation of experience with management and outcomes of ERCP-related perforations and a review of relevant literature. METHODS: Between January 2008 and January 2015, a total of 9383 ERCPs were performed in endoscopy unit. A total of 29 perforations (0.33%) were identified and retrospectively reviewed. RESULTS: Of the 29 patients, 18 were female and 11 patients were male, with mean age of 70.5 years (range 33-99 years). According to Stapfer's classification, the 29 patients with ERCP related perforations included 5 type 1 perforations, 14 type 2 perforations, 7 type 3 perforations, and 3 cases of type 4 perforation. In total, 15 of 29 patients with ERCP perforation were operated on. Nine (60%) of those who underwent surgery were discharged uneventful, but 6 (40%) patients died due to postoperative complications and/or associated comorbidities. Seven (24.1%) of 29 patients had undergone endoscopic treatment and 5 of the 7 were discharged from the hospital without any problems; however, peritonitis occurred in 2 patients whose initial endoscopic treatment failed. The first of these 2 patients underwent surgery and was discharged uneventfully, but second patient, who refused surgery, died due to sepsis. Six patients were successfully treated with conservative management. Surgery could not be performed in the remaining 2 patients, who died of sepsis following peritonitis; 1 refused surgery, the other had sudden cardiopulmonary arrest during induction of general anesthesia. Mean hospital stay was 13.2 days (range: 2-57 days). In all, 9 (31%) patients died during period of the study. CONCLUSION: ERCP-related perforation is uncommon complication, but an extremely serious condition. Early diagnosis and prompt management are most important to reduce associated significant morbidity and mortality rates. The most appropriate treatment course should be determined on case-by-case basis.

Case Report of the Descending Colon Located Completely in the Right Extraperitoneal Cavity and Sigmoid Colon Located in the Right Quadrant in a Patient with a Splenic Flexure Tumor: a Rare Anomaly.

Cases in which congenital anomalies of the colon and colon tumors are observed together are very rare. The aim of this article is to present a splenic flexure tumor case, which possessed the anomaly of the descending colon in the right extraperitoneal space and the sigmoid colon located in the right quadrant. Similar findings have previously been reported in two cases in cadaveric studies.

Primary mucinous cystadenocarcinoma of the breast with amplification of the HER2 gene confirmed by FISH - case report and review of the literature.

Fifty five-years-old woman was presented to the general surgery upon the palpation of a mass in her left breast. In the excisional biopsy performed, partially cystic tumor of 2 × 1 cm with solid areas was macroscopically observed. After through microscopic examination, the patient was diagnosed as invasive mucinous cystadenocarcinoma and the tumor was found to be ER- and PR-negative and C-erbB2 (2+). In the fluorescent in situ hybridization, HER2/neu gene amplification was observed. Here, we present the clinical, cytological, morphological and immunohistochemical features of a very rare type of breast carcinoma, mucinous cystadenocarcinoma of the breast, with the review of the relevant literature.

Laparoscopic cholecystectomy in patients aged 80 years and older: an analysis of 111 patients.

INTRODUCTION: The incidence of cholelithiasis increases with age. More octogenarian (≥80 y) patients are undergoing laparoscopic cholecystectomy (LC) operation throughout the world. PATIENTS AND METHODS: A retrospective study was conducted on patients older than 80 years (group 1: 111 patients) and those in the 18 to 79 years age group (group 2: 185 patients), who underwent LC between July 2005 and October 2009. The variables analyzed were the presentation, demographics, comorbid illnesses, American Society of Anaesthesiology (ASA) scores, history of previous abdominal surgery, the operative time, postoperative morbidity and mortality, and the length of hospital stay. A comparison was made between the two groups. Data was evaluated by using the χ and the Fisher exact test. P<0.005 was considered significant. RESULTS: The difference in both groups in the mean age and ASA scores were significant. The indication for LC was gallstone disease in 87 (78.4%) patients, acute cholecystitis in 16 (14.4%), and gallstone pancreatitis in 8 (7.2%) of group 1 patients. The conversion rate was not statistically significant. The mean operative time was 77 minutes in group 1 patients, and this was significantly longer than that of group 2 patients. The postoperative oral intake within 24 hours of surgery was significantly earlier in group 2 patients. Other parameters were not significantly different between the 2 groups. CONCLUSIONS: LC in octogenarians is a relatively safe procedure that can be performed with low morbidity and mortality rates. The comorbidities and higher ASA scale are major risk factors for postoperative complications in this age group of patients.

The Feasibility and Safety of Laparoscopic Cholecystectomy Approach without the Intraopertative Cholangiography Use: A Retrospective Study on 750 Consecutive Patients.

BACKGROUND: We have retrospectively reviewed the results of all common bile duct (CBD)-stone preoperative asymptomatic patients operated on our unit to point out the feasibility and safety of the laparoscopic cholecystectomy approach without the IOC use. METHODS: From January 2004 and June 2008 we analyzed all the data from hospital records and follow up results of all the patients who underwent LC. The indications for performing preoperative endoscopic retrograde cholangiopancreatography (ERCP) or selective IOC were abnormal liver function tests, history of jaundice, cholangitis or pancreatitis, and ultrasonographic evidence of CBD stone or dilation (≥ 10 mm). These patients were excluded from study. The follow up of the all patients were done by liver function tests and abdominal ultrasonography when needed at the time of the visit. RESULTS: Between January 2006 and June 2010, 750 patients were operated in our clinic. In 34 patients, operations were converted to open cholecystectomy (OC). Of these 750 patients, 98 of them had one or more exclusion criteria and were excluded from the further analyzes. We did not perform any IOC during LC. Regular follow up of at least two years was obtained in 618 (618/657, 94.0%) patients. No operative mortality was encountered among the patients. Postoperative morbidity was detected in 15 of the patients (2.5%). In one patient, CBD injury was detected (0.017%). The mean follow up was 35 (24 - 74) months. Retained stone was detected in three patients (3/577, 0.5%) during the follow up. CONCLUSION: This approach allows to omit routine IOC and to perform LC safely in selected patients group given the low percentage of both CBD injuries and symptomatic retained stones observed in the late follow up period in our 618 operated patients, we consider our approach a feasible and safe approach to manage patients with gallbladder stones re-confirming the results of other studies.

The effect of argon gas pressure on ice ball size and rate of formation.

INTRODUCTION: Contemporary cryoablation technology utilizes the Joule-Thomson effect, defined as a change in temperature that results from expansion of a nonideal gas through an orifice or other restriction. We evaluated the effect of initial gas tank pressures on freezing dynamics in a single-probe model and in a multiprobe model using contemporary cryoablation technology. MATERIALS AND METHODS: Cryoablation trials were performed in a standardized system of transparent gelatin molds at 25°C. Two sets of trials were performed. The first trial evaluated temperature and ice ball size for a given tank pressure when a single needle was deployed. The second trial recorded ice ball temperatures for each probe when multiple probes were fired simultaneously. RESULTS: Trial 1: The rate of temperature change is directly related to the initial pressure of the gas being released, and the group with the highest starting pressures reached the lowest mean temperature and had the largest mean ice ball size (p < 0.01). Trail 2: Multiple-probe ablation did not affect the rate of temperature change or final temperature compared with firing a single probe (p > 0.7). CONCLUSIONS: In accordance with the Joule-Thomson effect, higher initial gas pressures used for cryoablation in a transparent gel model demonstrate statistically significant lower temperatures, faster decreases in temperature, and formation of larger ice balls than lower gas pressures do. With contemporary technology, multiple simultaneous cryoprobe deployment does not compromise individual probe efficacy. The use of higher initial tank pressures will theoretically help future cryoprobes be more effective, creating a greater volume of cell necrosis and a smaller indeterminate zone.

Intragastric balloon treatment for obesity: prospective single-center study findings.

BACKGROUND: The intragastric balloon (IGB) procedure is an obesity treatment. METHODS: A BioEnteric IGB was used in 33 patients between February 2006 and February 2009. RESULTS: Of the 31 patients, 19 were female (61.3%). Mean age was 35.48 +/- 9.31 years. Following intravenous sedation, the balloon was inserted and inflated under direct vision by using saline (600 ml) and methylene blue (10 ml) solution. Average weight and mean BMI scores were as follows: 119.34 +/- 22.64 (range 80-170) kg and 41.84 +/- 8.28 (range 30-63.2) kg/m(2). Mean weight and BMI were measured as 104.31 +/- 21.33 (range 64-151) kg and 36.43 +/- 7.36 (range 26-52) kg/m(2) 6 months after the index procedure. Percent of excess weight loss (%EWL) and percent of excess body mass index loss (%EBMIL) were as follows: 29.16 +/- 15.99% (range 0.00-56.91%) and 35.45 +/- 19.46% (0-75.2%), respectively. All patients lost weight constantly for the 6-month period. Patients showed statistically significant weight and BMI losses for the first 3-month period but these decrements reached a plateau between the 4th and 6th month. Weight loss was not statistically significant during the second 3-month period. Few patients had mild complaints following balloon insertion; there was no balloon intolerance. CONCLUSIONS: IGB is safe and effective for short-term weight reduction in obese patients. Weight reduction during the second half of the treatment period needs closer follow-up.

Complete ileal neobladder intracorporeal construction with standard sutured technique and novel technology.

PURPOSE: We compared the surgical efficacy and efficiency of a completely suture based procedure with a novel entero-urethral anastomosis device and an EndoGIA stapler to create an ileal neobladder. MATERIALS AND METHODS: Two groups of 7 pigs each were survived for 8 weeks. In group 1 the neobladder was constructed using a U-shaped segment of ileum sealed with the stapler. The entero-urethral anastomosis was created with a novel sutureless anastomosis device. All other procedures were completed with standard intracorporeal suturing techniques. In group 2 animals completely intracorporeal sutured technique was used. Total procedure, and enteroenteric, ileal neobladder, uretero-enteric and entero-urethral anastomosis times were recorded. Cystograms done immediately postoperatively, at 2 weeks and at sacrifice to evaluate the newly constructed system were rated from 0-no leakage to 3-severe leakage. RESULTS: In group 1 vs 2 the overall procedure, and enteroenteric, ileal neobladder, uretero-enteric and entero-urethral anastomoses were completed in 285.3, 32.3, 58.8, 54.2 and 5.5 vs 350.1, 29.9, 139.1, 58.0 and 46.3 minutes, respectively. In groups 1 and 2 the average postoperative cystogram rating was 0.83 and 1.6, respectively (p = 0.63). At 2 weeks and at sacrifice cystograms showed no extravasation in either group. The overall surgical procedure, pouch creation and entero-urethral anastomosis were statistically briefer in group 1 (p = 0.036, 0.01 and 0.039, respectively). Average survival in groups 1 and 2 was 30 (range 4 to 56) and 41 days (range 1 to 56), respectively (p = 0.36). All animals had voiding complications within 1 week after ureteral and urethral catheters were removed. One neobladder ruptured in group 1. CONCLUSIONS: Combining stapled ileal neobladder construction and the entero-urethral anastomosis device significantly decreases operative time, pouch creation and urethral anastomoses.

Rupture of liver hydatid cysts into the peritoneal cavity. A challenge in endemic regions.

OBJECTIVE: To evaluate the clinical presentation and early and long-term outcomes of patients treated surgically for intraperitoneal ruptured liver hydatid cysts. METHODS: The medical records of 21 patients with rupture of hydatid cysts were evaluated retrospectively between January 2000 and April 2009 at Izmir Ataturk Training and Research Hospital, Izmir, Turkey, as were the records of 368 patients with hydatid cysts. Age, gender, symptoms, laboratory findings, diagnostic procedures, surgical treatment modalities, in-hospital stay, morbidity, mortality, and recurrence were evaluated. RESULTS: Sixteen of these patients (76.2%) were women. The mean age was 43.8 years. Cysts were single in 16 cases (76.2%). In 14 cases (66.7%) cysts were localized only in the right lobe. There was also a cyst in the spleen in 4 patients (19%). Simple falls or direct abdominal minor trauma was responsible in 8 patients (38.1%), and pedestrian mishaps in 4 (19%). Nine (42.8%) patients experienced spontaneous rupture. External drainage was performed in 12 (57.1%) patients and omentoplasty in 9 patients (42.8%) to manage the cyst cavity. A total of 11 morbidities developed in 9 patients (42.8%). There was no postoperative mortality. The mean hospital stay was 11.37.4 days, and mean follow-up was 63.131.3 months. The recurrence rate was 23.8%. CONCLUSION: The morbidity and recurrence rates of surgical interventions for ruptured hydatid cysts are high. This pathology, although rare, should be included in the differential diagnosis of an acute abdomen in endemic areas.

The utility of [(11)C] dihydrotetrabenazine positron emission tomography scanning in assessing beta-cell performance after sleeve gastrectomy and duodenal-jejunal bypass.

BACKGROUND: The aim of this study was to evaluate the effect of sleeve gastrectomy (SG) and duodenal-jejunal bypass (DJB) on glucose homeostasis and to evaluate the utility of positron emission tomography (PET) scanning for assessing beta-cell mass. METHODS: Goto-Kakizaki rats were divided into 4 groups: control, sham, SG, or DJB. Oral glucose tolerance, insulin, and glucagon-like peptide-1 (GLP-1) were measured before and after surgery. Before and 90 days after treatment, [(11)C] DTBZ micro PET scanning was performed. RESULTS: The control and sham animals gained more weight compared with SG and DJB animals (P < or = .05). Compared with control animals, the glucose area under the curve was lower in DJB animals 30 and 45 days after operations (P < or = .05). At killing, GLP-1 levels were greater in the DJB group compared with sham and SG (P < or = .05), whereas insulin levels were greater in both DJB and SG compared with sham (P < or = .05). With PET scanning, the 90-day posttreatment mean vesicular monoamine transporter type 2 binding index was greatest in the DJB animals (2.45) compared with SG (1.17), both of which were greater than baseline control animals (0.81). CONCLUSION: In type 2 diabetic rodents, DJB leads to improved glucose homeostasis and an increase in VMAT2 density as measured by PET scanning.

The efficacy of Nutrition Risk Screening-2002 (NRS-2002) to decide on the nutritional support in general surgery patients.

INTRODUCTION: Nutritional Risk Screening-2002 (NRS-2002) has been recently used to evaluate the nutritional status of patients according to the recommendation of ESPEN. In this prospective study, we aimed to find the effectiveness of NRS-2002 on preoperative patients who were candidates for elective procedure at a general surgery clinic. MATERIAL AND METHOD: The NRS-2002 scores of 698 patients were recorded in first 24 hours subsequent to their admission to hospital. The patients who had NRS-2002 score of 3 or 4 were accepted, and the scores were correlated with their age and clinical diagnosis. RESULTS: The nutritional status was good in 655 (93.9%) patients, and 43 patients (6.1%) were malnourished. A total of 135 patients had malignant disorders, among them 37 had concomitant malnutrition. The rate of malnutrition was 28.1% in patients with malignancy. The latter rate was 1.1% in patients with benign disorders. In patients who had gastrointestinal malignancy, the malnutrition rate was 31% (35/89), and the latter ratio was 6.5% (3/46) in patients who had malignancies arising from other than the gastrointestinal system. The NRS-2002 score was changed significantly according to age and malignancies (p<0.05). CONCLUSION: NRS-2002 can be easily used to evaluate the nutritional status of patients. This system is significant in deciding on nutritional support (Tab. 2, Ref. 12). Full Text (Free, PDF) www.bmj.sk.

A rodent model of metabolic surgery for study of type 2 diabetes and positron emission tomography scanning of beta cell mass.

BACKGROUND: Type 2 diabetes mellitus is a worldwide healthcare problem with major socioeconomic implications. Metabolic surgical procedures have been shown to improve diabetes, but the mechanism of action is poorly understood. The Goto-Kakizaki (GK) rodent is a type 2 diabetic animal model that is ideally situated for studying the effect of surgery on diabetes; however, the operative mortality is high. The aim of this study was to describe the operative technique, improvements in perioperative management, and the technique of micro-positron emission tomography (PET) scanning of the beta-cell mass in GK rodents. METHODS: A total of 53 GK rats were divided into 1 of 3 operative groups: sham, sleeve gastrectomy, and duodenojejunal bypass. A subset of animals underwent micro-PET scanning with [11C]-dihydrotetrabenazine to determine the vesicular monoamine transporter 2 binding index, an indicator of beta-cell mass. RESULTS: The 30-day mortality in the sham and sleeve gastrectomy rodents was 0; however, 2 sleeve gastrectomy rodents developed enterocutaneous fistula and 1 developed an abscess. In the duodenojejunal bypass group, the initial mortality rate was close to 90%; however, refinements in the surgical technique and perioperative management (fluids, antibiotics, pain control) lowered the mortality rate to 60%. The surgical technique is discussed in detail. [11C]-Dihydrotetrabenazine uptake in the pancreas was demonstrated on micro-PET scanning in the sham and duodenojejunal bypass rodents. CONCLUSION: Intensive medical management in the perioperative period and attention to the operative technique lowered the mortality. [11C]-Dihydrotetrabenazine micro-PET scanning is a feasible method for assessing the beta-cell mass in GK rodents and could prove to be an important modality for evaluating beta-cell performance in type 2 diabetes.

Independent Predictors of Treatment Modality for Penetrating Colon Injury.

BACKGROUND AND AIMS: We aimed to evaluate the independent factors of the treatment of penetrating colon injuries in a teaching and research hospital in light of some of the most commonly cited considerations affecting the decision as to whether to perform primary repair or divert. METHODS: Hospital records of patients between January 2004 and January 2007 were reviewed retrospectively. Fifty-seven patients were included and divided into two groups. Group A consisted of patients (n = 43) who had primary repair or resection and anastomosis, and Group B consisted of patients (n = 14) who had diverting colostomy. The degree of fecal contamination was assessed by reviewing the detailed operative dictation. The type of colon injury, as determined from the colon injury scale (CIS) of the American Association for the Surgery of Trauma (AAST), and the penetrating abdominal trauma index (PATI) were recorded. RESULTS: Age, sex, presence of shock on admission, location of the injury, and colon-related or non-colonrelated complications between the two groups were not significant. Stab or gunshot injury, operation time, degree of fecal contamination (grade 1/2/3), transfusion, PATI score, hospital stay, and associated organ injury were significantly different in the two groups (p < 0.05). CONCLUSION: Despite the fact that CIS, fecal contamination, transfusion, PATI and delayed operation affect the decision about the procedure, primary repair can be performed safely on patients with penetrating colon injuries.

The effect of intraluminal content on the bursting strength of vessels ligated with the harmonic ACE and LigaSure V.

PURPOSE: Energy-based surgical devices (ESDs) are critical for maintaining hemostasis during laparoscopy; however, there are no studies that have evaluated the function of ESDs under different physiologic conditions. We evaluated the effect of intraluminal vessel content on bursting pressure (BP) after ligation with two ESDs: the Harmonic ACE and the LigaSure V. MATERIALS AND METHODS: Bursting trials were performed on the vasculature of 24 pigs. Blood vessels were distended with blood of different hematocrit concentrations or an albumin solution of varying protein content. The vessel size and BP of each vessel was recorded after ligation with each ESD. RESULTS: In arteries 0 to 3 mm and veins 0 to 3 mm in size ligated with the Harmonic ACE or the LigaSure V, there were significantly elevated vessel BPs with supraphysiologic intraluminal hematocrits. In arteries and veins ligated with the Harmonic ACE, increasing albumin concentrations also led to increasing BPs, though these maximal BPs were lower than those obtained with supraphysiologic hematocrit levels. Increasing albumin concentrations did not increase the BP of the LigaSure V. Within the ranges tested, there was no decrease in vessel BP associated with anemia. CONCLUSION: In small vessels, a supraphysiologic hematocrit increased the BP of both arteries and veins when using the Harmonic ACE or the LigaSure V. With the devices tested, anemia did not seem to affect BP. While factors such as intraluminal protein concentration may play a role with ultrasonic energy devices, the mechanism of the increased BP remains unclear. Better understanding of ESDs will help in the design of future devices.

Risk factors associated with renal parenchymal fracture during laparoscopic cryoablation.

OBJECTIVE: To assess the risk factors for haemorrhage and renal fracture associated with renal cryoablation. MATERIALS AND METHODS: In a porcine model, 120 cryoablations were administered in 26 pigs, with five groups of 24 ice-balls each; in groups 1 and 2 asynchronous cryoprobe activation was evaluated for the 1.47- and 3.4-mm cryoprobes (IceRods, Galil Medical, Plymouth Meeting, PA, USA), respectively; in group 3, three-3.4 mm cryoprobes were used to examine synchronous probe activation; in group 4 the 1.47-mm cryoprobe was used to examine single-probe activation with premature cryoprobe extraction; and in group 5 we used a new 'guillotine' technique for upper-pole renal cryoablation. Ice-ball fractures and haemorrhage were characterized by the location, length and depth of each fracture, was well as the degree of bleeding. RESULTS: In all, 26 domestic pigs successfully had renal cryoablation procedures. In group 1 and 4 there were no episodes of renal fracture; in group 2 renal fracture occurred in 10 (42%) trials. Group 3 had 22 (92%) renal fractures during the freeze/thaw cycle. Group 5 had 13 (54%) renal fractures during the freeze/thaw cycle, and there was an additional ice-ball fracture during probe removal once in 24 times. CONCLUSIONS: Renal fracture is most common with the application of larger 3.4-mm cryoprobes in the synchronous and asynchronous setting. Under standard application, smaller (1.47-mm) cryoprobes result in little renal fracture or bleeding. The use of the guillotine technique is associated with a greater risk of renal fracture.

Incidence and management of enteric leaks after gastric bypass for morbid obesity during a 10-year period.

BACKGROUND: To describe the incidence, etiology, outcomes, and management of enteric leaks in patients who had undergone open or laparoscopic gastric bypass. METHODS: From November 1996 to November 2006, 1133 patients underwent primary gastric bypass at Columbia University, New York-Presbyterian Hospital. A retrospective review of our prospective bariatric surgery registry identified 17 patients (1.5%) who developed a clinically apparent enteric leak after surgery. The demographic and outcome data were studied. RESULTS: The mean body mass index was 52 kg/m(2) (range 35-65), and 15 (88%) of the 17 patients were women. The mean number of co-morbidities per patient was 1.3 and included hypertension in 11, diabetes in 9, and sleep apnea in 6. Ten patients had previously undergone abdominal surgery. The enteric leak was diagnosed by radiographic studies in 12 patients (9 of 12 by upper gastrointestinal series and 3 of 6 by computed tomography); the remaining 5 patients were diagnosed at re-exploration. Of the 17 patients, 12 (70%) were treated by laparoscopy and 5 (29%) by laparotomy. The mean time from completion of the index procedure to the diagnosis of the leak was 2 days (range 1-5) for patients treated by laparoscopy versus 4 days (range 1-6) for patients treated by laparotomy (P <.05). The patients treated by laparoscopy experienced a shorter hospital stay, but the difference was not statistically significant (mean 11.4 days, range 6-36, versus 18 days, range 7-33; P >.05). One of the laparoscopic patients (5.9%) died. CONCLUSION: Enteric leak is a significant complication after gastric bypass. Prompt treatment should be based on clinical suspicion, because contrast and cross-sectional imaging studies might not be reliable diagnostic tests. A laparoscopic index procedure might be associated with an earlier diagnosis.

Evaluation of a protective laser sheath for application in flexible ureteroscopy.

OBJECTIVES: Despite the obvious utility of the holmium laser, laser fibers frequently damage flexible ureteroscope components, such as the working channel, flexible component cable system, and fiber optical systems during routine ureteroscopic procedures. As such, we investigated the effects of the use of a flexible protective sheath on ureteroscope operation and its ability to protect ureteroscopes from laser fiber damage. METHODS: The effects of insertion of the FlexGuard sheath into the working channel on endoscope deflection and irrigant flow rate were documented. Additionally, the force required to advance the laser fiber through a fully deflected endoscope, as well as the amount of laser energy required to penetrate the FlexGuard sheath, were assessed using two different ureteroscopes. RESULTS: The FlexGuard sheath was easily inserted through the maximally deflected ureteroscopes. The presence of the laser sheath and a laser fiber in the working channel decreased the maximum deflection angle of the ureteroscopes by a mean of 7 degrees (from 73 degrees to 66 degrees). FlexGuard sheath insertion into the working channel also significantly diminished irrigant flow rates, from 0.55 mL/sec to 0.02 mL/sec, at an irrigation pressure of 100 cm H(2)O. The FlexGuard sheath reduced the amount of maximum force required to insert the laser fiber through each ureteroscope from 0.8 N to 0.2 N. The FlexGuard sheath was unable to protect the ureteroscope from laser energy damage. CONCLUSION: The FlexGuard laser sheath significantly reduced the amount of force required to insert the laser fiber through the working channel. This reduction in force may have be protective against mechanical damage caused by laser fiber insertion. However, deployment of the sheath significantly diminished the rate of irrigant flow and the maximal deflection of the two ureteroscopes tested. Also, the sheath does not protect the ureteroscope from damage caused by laser energy. In each case the urologist will need to determine if the mechanical protective value of the sheath outweighs the negative impact on flow and deflection.

Multimedia article: Transvaginal laparoscopic cholecystectomy: laparoscopically assisted.

Natural orifice transluminal endoscopic surgery (NOTES) is considered the new frontier for minimally invasive surgery. NOTES procedures such as peritoneoscopy, splenectomy, and cholecystectomy in animal models have been described. The aim of our experiment was to determine the feasibility and technical aspects of a new endoluminal surgical procedure. After approval from Columbia's IACUC, a transvaginal laparoscopically assisted endoscopic cholecystectomy was performed on four 30 kg Yorkshire pigs. The first step was to insert a 1.5 cm endoscope into the vagina under direct laparoscopic vision. Then the gallbladder was reached and, with the help of a laparoscopic grasper to hold up the gallbladder, the operation was performed. At the end of the procedure the gallbladder was snared out through the vagina attached to the endoscope. There were no intraoperative complications such as bleeding, common bile duct or endo-abdominal organ damage. Total operative time ranged between 110 and 155 min. Based on our experience in the porcine model, we believe that a transvaginal endoscopic cholecystectomy is feasible in humans.