Routine near infra-red indocyanine green fluorescent cholangiography versus intraoperative cholangiography during laparoscopic cholecystectomy: a case-matched comparison.

BACKGROUND: The aim is to evaluate safety and efficacy of near infra-red (NIR) indocyanine green (ICG) fluorescence structural imaging during laparoscopic cholecystectomy (LC) (Group A) and to compare perioperative data, including operative time, with a series of patients who underwent LC with routine traditional intraoperative cholangiography (IOC) (Group B). METHODS: Forty-four patients with acute or chronic cholecystitis underwent NIR-ICG fluorescent cholangiography during LC. ICG was administered intravenously at different time intervals or by direct gallbladder injection during surgery. Fluorescence intensity and anatomy identification were scored according to a visual analogue scale between 1 (least accurate) and 5 (most accurate). Group B patients (n = 44) were chosen from a prospectively maintained database of patients who underwent LC with routine IOC, matched for age, sex, body mass index, and diagnosis with group A patients. RESULTS: No adverse reactions were recorded. In group A, mean time between intravenous administration of ICG and surgery was 10.7 ± 8.2 (range 2-52) h. Administered doses ranged from 3.5 to 13.5 mg. Fluorescence was present in all cases, scoring ≥ 3 in 41 patients. Mean operative time was 86.9 ± 36.9 (30-180) min in group A and 117.9 ± 43.4 (40-220) min in group B (p = 0.0006). No conversion to open surgery nor bile duct injuries were observed in either group. CONCLUSIONS: LC with NIR-ICG fluorescent cholangiography is safe and effective for early recognition of anatomical landmarks, reducing operative time as compared to LC with IOC, even when residents were the main operator. NIR-ICG fluorescent cholangiography was effective in patients with acute cholecystitis and in the obese. Data collection into large registries on the results of NIR-ICG fluorescent cholangiography during LC should be encouraged to establish whether this technique might set a new safety standard for LC.

Effects of Laparoscopic Sleeve Gastrectomy on Quality of Life Related to Gastroesophageal Reflux Disease.

Purpose: Effects of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) symptoms are controversial. Our aim is to evaluate the effects of LSG on GERD symptoms in obese patients using a validated quality-of-life questionnaire. Methods: Records of 100 patients (median body mass index [BMI] 44.4 kg/m2, range 35-63.6) without hiatal hernia or severe GERD were analyzed. GERD symptoms were evaluated by GERD Health-Related Quality-of-Life (HRQL) questionnaire before and after surgery. Weight loss and comorbidity resolution were recorded. Results: Median GERD-HRQL scores decreased from 7 (range 0-44) to 3 (0-34) (P = .025) (median follow-up 56 months [range 7-136]). GERD-HRQL scores improved in 55 patients and worsened in 21; de novo GERD was observed in 10; no change occurred in 14 patients (differences being statistically significant: P = <.0001). On multilinear regression analysis, total preoperative GERD-HRQL score and postoperative BMI were independent variables for overall postoperative GERD-HRQL score: higher total preoperative GERD-HRQL score was associated with improved postoperative GERD-HRQL scores, whereas higher postoperative BMI was associated with worse total postoperative GERD-HRQL score. Resolution of diabetes, hypertension, and sleep apnea syndrome occurred in 84.4%, 68%, and 89.7% of patients, respectively. Conclusions: In obese patients, although LSG was associated with statistically significantly improved postoperative GERD-HRQL scores at mid-term follow-up in 55% of patients, only preoperative GERD-HRQL score and postoperative BMI were independent predictors of GERD after LSG. Higher overall preoperative GERD-HRQL score was associated with improved postoperative GERD-HRQL score. However, further research is needed to assess how to predict GERD outcome.

Hiatoplasty with Crura Buttressing versus Hiatoplasty Alone during Laparoscopic Sleeve Gastrectomy.

INTRODUCTION: In obese patients with hiatal hernia (HH), laparoscopic sleeve gastrectomy (LSG) with cruroplasty is an option but use of prosthetic mesh crura reinforcement is debated. The aim was to compare the results of hiatal closure with or without mesh buttressing during LSG. METHODS: Gastroesophageal reflux disease (GERD) was assessed by the Health-Related Quality of Life (GERD-HRQL) questionnaire before and after surgery in two consecutive series of patients with esophageal hiatus ≤ 4 cm2. After LSG, patients in group A (12) underwent simple cruroplasty, whereas in group B patients (17), absorbable mesh crura buttressing was added. RESULTS: At mean follow-up of 33.2 and 18.1 months for groups A and B, respectively (p = 0.006), the mean preoperative GERD-HRQL scores of 16.5 and 17.7 (p = 0.837) postoperatively became 9.5 and 2.4 (p = 0.071). In group A, there was no difference between pre- and postoperative scores (p = 0.279), whereas in group B, a highly significant difference was observed (p = 0.002). The difference (Δ) comparing pre- and postoperative mean scores between the two groups was significantly in favor of mesh placement (p = 0.0058). CONCLUSIONS: In obese patients with HH and mild-moderate GERD, reflux symptoms are significantly improved at medium term follow-up after cruroplasty with versus without crura buttressing during LSG.

Laparoscopic Sleeve Gastrectomy Changes in the Last Decade: Differences in Morbidity and Weight Loss.

PURPOSE: Aim is to report the learning curve and standardization process of Laparoscopic Sleeve Gastrectomy (LSG), describing the evolution in surgical technique and patient management in the authors' experiences. METHODS: One hundred twenty-seven patients were divided in three Groups (A, B, and C), based on bougie size and technical details, and included 36, 46, and 45 patients, respectively. RESULTS: Mean operative time in Groups A, B, and C was 201.5, 150.8, and 172 minutes, respectively. Conversion to open surgery occurred in 1 Group A case. Eleven postoperative complications (8.6%) were observed (1 Group A, 8 Group B, 2 and Group C). Mean hospital stay in Groups A, B, and C, was 7.1, 6.9, and 3.1 days, respectively. At a mean follow-up of 69.7 months (Group A), 33.3 months (Group B), and 14.8 months (Group C), mean postoperative body mass index is 32.6, 28.1, and 31.5 kg/m2, respectively. Percentage estimated body mass index loss (%EBMIL) was 74.8% for Group A, 85.7% for Group B, and 68.1% for Group C. CONCLUSIONS: LSG is a safe and effective procedure. In the postoperative course, meticulous alertness to early warning signs of sepsis and aggressive patient management are mandatory to prevent mortality. The use of a larger bougie size was associated with weight regain.

Recto-Urinary Fistula (RUF) treated by Transanal Endoscopic Microsurgery (TEM) Review of the literature and surgical technique.

AIM: Recto-Urinary Fistula (RUF) is a rare complication of pelvic surgery. Different approaches are reported in literature but a gold standard treatment has not yet been achieved. Transanal Endoscopic Microsurgery (TEM) is a miniinvasive approach with well known advantages as magnification, 3D view and lighting of the operative field. Aim of the present review is to report the current evidence in literature about technique and results of RUF treatment by TEM and to suggest some key points for its correct management. MATERIALS OF STUDY: After a medline in Pubmed and Scopus databases, seven papers were eligible for the present study. Data were reviewed on the basis of the cases reported, patient's characteristics, surgical techniques and results. RESULTS: Eighteen cases have been reported in the literature from 1996 to 2005. The healing success rate was 77.8%. Fecal and urinary diversion were performed before TEM-assisted procedure in the 83% and 94% of cases, respectively. Recurrence was observed in four patients (22%). DISCUSSION: A gold standard treatment of RUF should ensure the complete removal of scar tissue around the fistula, in order to perform a tension free suture on healthy margins with adequate vascularization. Preoperative stoma improves the healing of the fistula, reducing local inflammation and infections. CONCLUSIONS: There is not common view of this topic in literature and clarify which could be the best treatment is a key condition due to high failure rate of the surgical proposed techniques. Recurrences treatment has a lower cure rate if compared to primary lesions, nevertheless more studies are required to confirm this data. KEY WORDS: Recto-Urinary Fistula (RUF), Transanal Endoscopic Microsurgery (TEM), Transanal approach.