Preventing bisphosphonate induced osteonecrosis of the jaw with a polyguanidine conjugate (GuaDex): A promising new approach.

Osteonecrosis of the jaw (ONJ) is a relatively rare side effect after prolonged use of bisphosphonates, which are drugs used to treat bone resorption in osteoporosis and certain cancers. This study introduces a novel ONJ model in rats by combining exposure to bisphosphonates, oral surgery, and bacterial inoculation. Potential ONJ preventive effects of polyguanidine (GuaDex) or antibiotics were evaluated. The study consisted of twenty-four male Wistar rats were divided into four groups. Groups 1 to 3 were given weekly doses of i.v. Zoledronic acid (ZA), four weeks before and two weeks after an osteotomy procedure on their left mandibular first molar. Group 4 was a negative control. Streptococcus gordonii bacteria were introduced into the osteotomy pulp chamber and via the food for seven days. On day eight, the rats were given different treatments. Group 1 was given a GuaDex injection into the osteotomy socket, Group 2 was given an intramuscular (i.m.) injection of clindamycin, Group 3 (positive control) was given an i.m. injection of saline, and Group 4 was given an i.m. injection of saline. Blood samples were taken two weeks after the osteotomy procedure, after which the rats were euthanized. Bone healing, bone mineral density, histology, and blood status were analyzed. The results showed that Group 1 (GuaDex) had no ONJ, extensive ongoing bone regeneration, active healing activity, vascularization, and no presence of bacteria. Group 2 (clindamycin) showed early stages of ONJ, avascular areas, and bacteria. Group 3 showed stages of ONJ, inflammatory infiltrates, defective healing, and bacterial presence, and Group 4 had normal healing activity and no bacterial presence. Conclusion: ZA treatment and bacterial inoculation after tooth extraction inhibited bone remodeling/healing and induced ONJ characteristic lesions in the rats. Only GuaDex apparently prevented ONJ development, stimulated bone remodeling, and provided an antimicrobial effect.

The use of porcine small intestinal submucosa as a prosthetic material for laparoscopic hernia repair in infected and potentially contaminated fields: long-term follow-up.

INTRODUCTION: The treatment of hernias remains controversial, with multiple prosthetic meshes being exalted for a variety of their characteristics. In the event of incarcerated/strangulated hernias and other potentially contaminated fields the placement of prosthetic material remains controversial because of increased risk of recurrence and infection. Porcine small intestinal submucosa mesh (Surgisis, Cook Bloomington, IN) has been demonstrated safe and feasible in laparoscopic hernia repairs in this scenario. We present our 5-year experience, with placement of Surgisis mesh in potentially or grossly contaminated fields. METHODS: From May 2000 to October 2006, 116 patients (52 male, 64 female) with 133 procedures were performed. Placement of Surgisis mesh for either incisional, umbilical, inguinal, femoral or parastomal hernia repairs in an infected or potentially contaminated setting were achieved, and studied in a prospective fashion. RESULTS: All procedures were laparoscopically with two techniques [intraperitoneal onlay mesh (IPOM) and two-layered "sandwich" repair]. Mean follow-up was 52 +/- 20.9 months. Thirty-nine cases were in an infected field and the rest in a potentially contaminated field. Ninety-one procedures were performed concurrently with a contaminated procedure. Twenty-five presented as intestinal obstruction, 16 strangulated hernias, and 17 required small bowel resection; 29 were inguinal hernias, 57 incisional, and 38 umbilical. In 13 patients more than two different hernias were repaired. Eighty-five percent 5-year follow-up was achieved, during which we identified 7 recurrences, 11 seromas (all resolved), and 10 patients reporting mild pain. Six second looks were performed and in all cases except one the mesh was found to be totally integrated into the tissue with strong scar tissue corroborated macro- and microscopically. CONCLUSIONS: In our experience the use of small intestine submucosa mesh in contaminated or potentially contaminated fields is a safe and feasible alternative to hernia repair with minimal recurrence rate and satisfactory results in long-term follow-up.

Laparoscopic intraluminal surgery for gastrointestinal malignancies.

INTRODUCTION: Intraluminal surgery began with the advent of endoscopy. Endoscopic endoluminal surgery has limitations; and its failure results in conventional open or laparoscopic interventions with increased morbidity. Laparoscopy-assisted intraluminal surgery is a novel alternative to open or laparoscopic surgery for a failed endoscopic endoluminal technique, minimizing the associated complications. Endoscopic resection of early gastric and duodenal cancers is restricted by the limited view of the endoscope, insufficient number of instrument channels, and inability to have adequate margins of resection without risking perforation. These cancers potentially can be treated by laparoscopy-assisted intraluminal surgery without resorting to major gastric or duodenal resection. This procedure is relatively easy to perform and oncologically effective. We present the experience of the Texas Endosurgery Institute (TEI) in treating early gastric and duodenal cancers, including large malignant polyps and carcinoid tumors, with laparoscopy-assisted endoluminal surgery. MATERIALS AND METHODS: The data for all patients with early gastric and duodenal cancers who underwent laparoscopy-assisted endoluminal surgery at TEI between 1996 and 2007 were prospectively recorded. All of the patients had been referred by the endoscopist as noncandidates for endoscopic resection. We prospectively collected data on preoperative diagnosis, operating time, estimated blood loss, postoperative complications, histopathology, and recurrence rate. All patients underwent endoluminal port placement under direct visualization after a pneumoperitoneum was established. Operations were performed in conjunction with upper endoscopy for assistance with port placement under endoluminal visualization, insufflation, and specimen retrieval. After the intraluminal portion of the operation was completed, the endoluminal port sites were closed with laparoscopic intracorporeal suturing. RESULTS: From 1996 to 2007, a total of 12 patients underwent laparoscopic endoluminal surgery. All cases were completed successfully, including 5 resections of early gastric cancer (stage I), 3 wedge resections of carcinoid tumor, 2 resections of duodenal adenocarcinoma, and 2 resections of a malignant polyp at the gastroesophagic junction; all the cases were completed with disease-free margins. No recurrence of the original pathology have been reported, and the complications were minimal. CONCLUSION: Laparoscopic intraluminal surgery for early gastric and duodenal cancer is a feasible alternative to open conventional therapies; and it is associated with a lower incidence of incisional hernia formation and a lower infection rate.

Long-term experience with the laparoscopic approach to perforated diverticulitis plus generalized peritonitis.

BACKGROUND: The treatment of perforated diverticulitis is changing form the current standard of laparotomy with resection, Hartmann procedure, and colostomy to a minimally invasive technique. In patients with complicated acute diverticulitis and peritonitis without gross fecal contamination, laparoscopic peritoneal lavage, inspection of the colon, and intraoperative drain placement of the peritoneal cavity appears to alleviate morbidity and improve the outcome. In this article, we report our experience of a laparoscopic peritoneal lavage technique with delayed definitive resection when necessary. METHOD AND MATERIALS: Records of patients who underwent intraoperative peritoneal lavage for purulent diverticulitis at the Texas Endosurgery Institute from April 1991 to September 2006 were retrospectively reviewed. RESULTS: Forty patients were included in the study, with a male/female ratio of 26:14. The average age was 60 years. Many had associated co-morbidities. The average operating time was 62 minutes. There were no conversions to an open procedure. Apart from mild postoperative paralytic ileus in six patients and chest infections in two, there were no significant peroperative or postoperative complications. Just over 50% underwent elective interval laparoscopic sigmoid colectomy. During the mean follow-up of 96 months, none of the other patients required further surgical intervention. CONCLUSION: Laparoscopic lavage of the peritoneal cavity and drainage is a safe alternative to the current standard of treatment for the management of perforated diverticulitis with or without gross fecal contamination. It is associated with a decrease in the overall cost of treatment; the use of a colostomy is avoided; patient improvement is immediate; and there is a reduction in mortality and morbidity as definitive laparoscopic resection can be performed in a nonemergent fashion. Perhaps the most important benefit, other than avoiding a colostomy, is the association of fewer wound complications such as dehiscence, wound infection, and the high risk of hernia formation. Laparoscopic lavage and drainage should be considered in all patients in whom medical and/or percutaneous treatment is not feasible. It carries minimal morbidity and should be considered the standard of care.

Bedside diagnostic laparoscopy in the intensive care unit: a 13-year experience.

BACKGROUND: Frequently, critically ill patients suffer from intraabdominal pathology, such as sepsis or ischemia, either as a cause of a critical illness or as a complication from another illness requiring an intensive care unit (ICU) admission. These complications are associated with high rates of morbidity and mortality (between 50% to 100%). The diagnosis of these problems can be difficult in these very ill patients because it may require transport of unstable patients to additional departments outside the ICU setting. One option in the diagnosis of these difficult patients is bedside laparoscopy, as it avoids patient transport, is very accurate, and maintains ICU monitoring. METHODS: From 1991 to 2003, 13 patients underwent bedside diagnostic laparoscopy in the ICU to diagnose intraabdominal pathology in critically ill patients. All the procedures were done at the bedside in the ICU with the patient under local anesthesia and intravenous sedation. RESULTS: Mean procedure time was 36 minutes (range, 17 to 55). Mean patient age was 75.5 years (range, 56 to 86). There were 8 males and 5 females. Forty-six percent of the patients were diagnosed with mesenteric necrosis and died within 48 hours with no further testing or procedures. One patient with massive fecal contamination died the same day. Thirty percent of patients had a normal intraabdominal examination; of these, 2 died of unrelated illnesses and 2 survived their nonabdominal illness. Fifteen percent were diagnosed with acute acalculous cholecystitis as a complication of their ICU illness, which resolved satisfactorily. No intraoperative complications occurred with the ICU procedure. CONCLUSION: Bedside diagnostic laparoscopy in the ICU is feasible, safe, and accurate in the assessment of possible intraabdominal problems in properly selected, critically ill patients.

Needlescopic cholecystectomy: lessons learned in 10 years of experience.

OBJECTIVES: Needlescopic cholecystectomy (NC) is a refinement of laparoscopic cholecystectomy (LC) using 2-mm instruments compared with the standard 5-mm and 10-mm ports. We review our experience with needlescopic cholecystectomy. METHODS: From 1994 to 2004, 303 patients underwent NC. All patients were operated on using 2-mm instruments and one 10-mm trocar for the laparoscope. The characteristics of patients, total operation time, complications, postoperative pain, and hospital course were documented. RESULTS: Patients' average age was 41.86 years; 262 were female and 41 were male. Mean BMI was 25.7. Mean length of surgery was 59.33 minutes. Intraoperative cholangiography was performed in all cases. Mean blood loss was 14.88 mL. One intraoperative complication occurred. Mean hospital stay was 22.68 hours. Postoperative pain was measured on a 0-10 pain scale; on day 0 it was 4.4 and on the first day it was 1.7. Analgesic doses required were 0 doses in 6.89%, 1 in 20.68%, 2 in 24.13%, 3 in 34.48%, 4 in 13.79%, and > 4 doses was not required. No postoperative complications occurred. At 3-month follow-up, patient satisfaction was 100%, and in 99% of patients scars were imperceptible. CONCLUSIONS: NC is safe and feasible without increased operative risk, with better cosmetic results, less pain, and good acceptance among patients.

Intraluminal approach for resection of a gastric ulcer: a case report.

Laparoscopy, both diagnostic and therapeutic, has been used in the management of gastric pathology because of all the benefits of a minimally invasive procedure, such as faster recovery, shorter hospital stay, fewer wound complications, and other benefits. We report a case involving the resection of a gastric ulcer in a 71-year-old patient. Endoscopy revealed a nonhealing antral ulcer that was not acutely bleeding. With a combined endoscopic and laparoscopic approach, we successfully performed a wide resection by using 2-mm instruments. Laparoscopy was needed to orient the lesion so that a transgastric intraluminal resection could be performed with 2-mm instruments. This case illustrates the feasibility of using a combined endoscopic and laparoscopic technique to treat a lesion that would otherwise require a formal resection.

The use of bioabsorbable staple line reinforcement for circular stapler (BSG "Seamguard") in colorectal surgery: initial experience.

Of all the complications associated with colorectal surgery, the most devastating and constant, despite all techniques being performed properly is anastomotic leakage, especially in left colon and rectal resections with rates as high as 50% when the rectum is involved. In 2005, our center published the preliminary experience with the use of linear staple line reinforcement for colon surgery. The purpose of this paper is to present a series of cases using a new conformation of bioabsorbable reinforcement for circular staplers in 5 patients, 2 patients with rectal cancer, 2 patients with diverticular disease, and 1 patient with sigmoid cancer. These initial data are very promising and has encouraged us to continue using this device on further patients.

Safety and efficacy of the use of bioabsorbable seamguard in colorectal surgery at the Texas endosurgery institute.

Bioabsorbable Seamguard (BSG) is a random-fiber web of polyglycolic acid/trimethylene carbonate. It is completely absorbed within 6 months or less due to its constitution of a bioabsorbable membrane with polyester braided suture. It has been used in obesity surgery and pulmonary surgery as staple-line reinforcement with good results. As such, we believe that BSG may be ideal to use in colorectal surgery as an aid during the healing process of an anastomosis and may help prevent anastomotic bleeding and staple-line disruption. From July 2003 through September 2004, 30 patients underwent placement of BSG for the following procedures: 12 right hemicolectomies, 7 low anterior resections, 5 sigmoid colectomies, 3 total colectomies, 2 partial resections, and 1 colostomy closure. Median follow-up was 7 months (range 1-13). There were no clinical leaks, no strictures, and no bleeding in our early postoperative follow-up period. The use of BSG as a staple-line reinforcer appears to be safe and may be useful in preventing anastomotic leakage, bleeding, and intraluminal stenosis.

Laparoscopic right hemicolectomy for cancer: 11-year experience.

INTRODUCTION: Laparoscopic surgery has emerged as the gold standard for many intra-abdominal procedures. Laparoscopic colon surgery is now entering its second decade of practice, and although there are many papers focusing on surgery of the distal colon, only a few have been published regarding right sided lesion approached totally laparoscopically. OBJECTIVE: Present data collected-in a prospective manner from a single institute over an eleven year period, focusing on laparoscopic right hemicolectomy for malignancy. METHODS: Patients elected for laparoscopic right hemicolectomy for colon cancer were analyzed prospectively. From May 1991 to May 2002, 98 patients underwent attempted laparoscopic right hemicolectomy for cancer, 44 male and 54 female, with a mean age of 70.6 years, emergent and non emergent cases were included Patients who underwent a diagnostic laparoscopy and those converted immediately to open procedure were excluded from this study. RESULTS: Ninety-two patients were included in the study, eighty-two of these had a totally intracorporeal anastomosis created, and ten had an extracorporeal anastomosis performed. The mean operative time for the intracorporeal group was 136 minutes, and for the extracorporeal group was 159 minutes. The average number of lymph nodes harvested was 10.8 and the final pathologic analysis showed 26 tumors stage I, 24 stage II, 31 stage III and 17 stage IV. CONCLUSIONS: In experienced hands, laparoscopic colectomy can be performed safely and effectively for the treatment of both benign and malignant diseases of the right colon. This study reaffirms the contention that laparoscopic approach to colon cancer offers equivalent, or in some instances, greater oncologic safety when compared to the open technique.