Natural orifice specimen extraction in laparoscopic colorectal surgery: transanal and transvaginal approaches.

BACKGROUND: This study was designed to evaluate the outcomes of patients who underwent various laparoscopic colorectal procedures with natural orifice specimen extraction (NOSE) at our institute over a 20-year period. Specifically, the study aimed to investigate whether transanal and transvaginal approaches are safe and effective alternatives for extracting the specimen during laparoscopic colorectal surgeries. METHODS: We analyzed a prospectively designed database of a consecutive series of patients who underwent various laparoscopic colorectal surgeries for different rectal pathologies between April 1991 and May 2011 at the Texas Endosurgery Institute. The selection criteria for the NOSE approach were based on disease entities, site and size of tumors, and distance of colorectal lesions from the anal verge. RESULTS: A total of 303 patients underwent laparoscopic colorectal procedures with the NOSE approach for specimen extraction, including 277 transanal and 26 transvaginal extractions. The operative time for procedures with transanal specimen extraction was 164.7 ± 47.5 min, the estimated blood loss was 87.5 ± 46.7 ml, and the rate of postoperative complications was 3.6 %. For laparoscopic right hemicolectomy with transvaginal specimen extraction, the operative time was 159 ± 27.1 min and the estimated blood loss was 83.5 ± 14.4 ml. Intraoperatively, transvaginal extraction was associated with 2 complications (7.7 %); however, this procedure was not associated with any postoperative complications. The length of hospital stay was 6.9 ± 2.8 and 5.5 ± 2.5 days for patients who underwent transanal extraction and transvaginal extraction, respectively. CONCLUSIONS: Both transanal and transvaginal specimen extractions in laparoscopic colorectal surgeries are safe and effective approaches with comparable postoperative complication rates. In comparison with transanal specimen extraction, transvaginal extraction is more complicated due to the anatomy of the pouch of Douglas. The transvaginal approach thus needs more effective extraction devices for preventing injury to adjacent organs, especially the sigmoid colon and rectum.

Pediatric trichotillomania.

Trichotillomania (TTM) is an impulse control disorder characterized by chronic hair-pulling, distress, and impairment. Although the negative effects of TTM are documented and often readily evident, there remains a paucity of psychopathology and treatment research on this disorder, particularly in pediatric populations. In an effort to improve assessment of pediatric TTM, several TTM-specific instruments for youth have now been developed to reliably identify symptoms and examine related phenomenology. Instrument development has now yielded instruments to evaluate TTM and related symptoms in the context of clinical trials of youth, and the first randomized controlled trial of any treatment for pediatric TTM was recently published. Using the initial pediatric TTM studies as building blocks, future research is now needed to create a stronger body of knowledge about the relative and combined efficacy of potential interventions for TTM in youth, as well as to examine the effects of TTM phenomenology and comorbidity on treatment outcome. Dissemination efforts must also be heightened for this knowledge to best reach these vulnerable populations.

Laparoscopically monitored colonoscopic polypectomy: an established form of endoluminal therapy for colorectal polyps.

BACKGROUND: Benign polyps, the most common disorders of the colon, are considered by many to be premalignant lesions. Colonoscopy is widely used to remove the majority of these polyps. However, a variety of "difficult polyps" are not accessible for colonoscopic removal because of their location and size, the tortuosity of the colon, or the complexity of the lesion (sessile vs pedunculated). In the past, a formal segmental resection usually was suggested for these difficult polyps. METHODS: For 110 patients with a median age of 73 years, a total of 149 polyps were removed as follows: 88 from the right colon, 18 from the transverse colon, 10 from the left colon, and 33 from the rectosigmoid colon. Pathologic evaluation showed adenomatous polyps in 13 patients (11.81%), hyperplastic polyps in 1 patient (0.9%), adenocarcinomas in 10 patients (9.09%), carcinoma in situ in 1 patient (0.9%), and adenomas in the remaining patients (tubulovillous, 40.18%; villous, 19.31%, and tubular, 17.77%). All the specimens were evaluated for margins and depth of resection. RESULTS: The median size of the polyps was 2.30 cm (range, 0.2-6 cm). The average hospital stay was 1.14 days, with a liquid diet started 6 h postoperatively. Mild abdominal pain/trocar-site pain was the most common complaint. The patients were followed with colonoscopy 6 months postoperatively and yearly thereafter. CONCLUSIONS: A combined endoscopic-laparoscopic approach provides a valid alternative for treating difficult colonic polyps and eliminating the morbidity of a segmental resection. This approach seems to be safe and effective.

Preliminary results of a two-layered prosthetic repair for recurrent inguinal and ventral hernias combining open and laparoscopic techniques.

The use of prosthetic mesh has become the standard of care in the management of hernias because of its association with a low rate of recurrence. However, despite its use, recurrence rates of 1% have been reported in primary inguinal repair and rates as high as 15% with ventral hernia repair. When dealing with difficult recurrent hernias, the two-layer prosthetic repair technique is a good option. In the event of incarcerated or strangulated hernias, however; placement of prosthetic material is controversial due to the increased risk of infection. The same is true when hernia repairs are performed concurrently with potentially contaminated procedures such as cholecystectomy, appendectomy, or colectomy. The purpose of this study is to report our preliminary results on the treatment of recurrent hernias by combining laparoscopic and open techniques to construct a two-layered prosthetic repair using a four ply mesh of porcine small intestine submucosa (Surgisis, Cook Surgical, Bloomington, IN, USA) in a potentially infected field and a combination of polypropylene and ePTFE (Gore-Tex, W.L. Gore and Associates, Flagstaff, AZ, USA) in a clean field. From September 2002 to January 2004, nine patients (three males and six females) underwent laparoscopic and open placement of surgisis mesh in a two layered fashion for either recurrent incisional or inguinal hernias in a contaminated field. A total of eight recurrent hernia repairs were performed (five incisional, three inguinal) and one abdominal wall repair after resection of a metastatic tumor following open colectomy for colon carcinoma. Six procedures were performed in a potentially contaminated field (incarcerated or strangulated bowel within the hernia), two procedures were performed in a contaminated field because of infected polypropylene mesh, and one was in a clean field. Mean patient age was 56.4 years. The average operating time was 156.8 min. Operative findings included seven incarcerated hernias (four incisional and three inguinal), one strangulated inguinal hernia, and one ventral defect after resection of an abdominal wall metastasis for a previous colon cancer resection. In two of the cases, there was an abscess of a previously placed polypropylene mesh. All procedures were completed with two layers of mesh (eight cases with surgisis and one with combination of polypropylene/ePTFE). Median follow up was 10 months. Complications included two seromas, one urinary tract infection, two cases of atelectasis and one prolonged ileus. There were no wound infections. The average postoperative length of stay was 7.8 days. There have been no mesh-related complications or recurrent hernias in our early postoperative follow-up period. The use of a new prosthetic device in infected or potentially infected fields, and the two-layered approach shows promising results. This is encouraging and provides an alternative approach for the management of difficult, recurrent hernias.

Morbidity of laparoscopic surgery for complicated appendicitis: an international study.

BACKGROUND: Although laparoscopic appendectomy has some advantages over open appendectomy, some reports do show more postoperative intraabdominal abscesses. METHODS: A retrospective review of complicated appendicitis managed surgically by eight surgical groups from six countries was undertaken. Among 3,433 patients with appendicitis, 1,017 (29.5%) had complicated appendicitis, which included perforated or gangrenous appendicitis with or without localized or disseminated peritonitis. There were 74 preoperative abscesses (7.4%) and 5 small bowel obstructions. RESULTS: One patient died. There were 29 postoperative intraabdominal abscesses (2.8%) and 112 mostly minor complications. Conversion to laparotomy was necessary for 28 patients (2.7%). The surgical time ranged from 32 to 132 min (mean, 62 min), and the hospital stay ranged from 1 to 18 days (mean, 3.5 days). CONCLUSIONS: The morbidity rates, particularly for intraabdominal abscesses, were less for laparoscopic appendectomy in complicated appendicitis than those reported in the literature for open appendectomy, whereas operating times and hospital stays were similar.

Use of porcine small intestinal submucosa as a prosthetic device for laparoscopic repair of hernias in contaminated fields: 2-year follow-up.

BACKGROUND: Surgisis is a new four- or eight-ply bioactive, prosthetic mesh for hernia repair derived from porcine small intestinal submucosa (SIS). It is a naturally occurring extracellular matrix, which is easily absorbed, supports early and abundant new vessel growth, and serves as a template for the constructive remodeling of many tissues. As such, we believe that Surgisis mesh is ideal for use in contaminated or potentially contaminated fields in which ventral, incisional, or inguinal hernia repairs are required. METHODS: From November 2000-May 2003, 53 patients (23 male, 30 female) underwent placement of Surgisis mesh for a variety of different hernia repairs. A total of 58 hernia repairs were performed in our patient population. Twenty procedures (34%) were performed in a potentially contaminated setting (i.e., with incarcerated/strangulated bowel within the hernia or coincident with a laparocopic cholecystectomy/colectomy). Thirteen repairs (22%) were performed in a grossly contaminated field, including one in which an infected polypropylene mesh from a previous inguinal hernia repair was replaced with Surgisis mesh and one in which dead bowel was discovered within the hernia sac. Median follow-up is 19 months with a range of 1-30 months. RESULTS: Of the 58 total repairs, there was one wound infection complicated by enterocutaneous fistula in a patient originally operated on for ischemic bowel. The fistula was in a location independent of the Surgisis mesh. There have been no mesh-related complications or recurrent hernias in our early postoperative follow-up period. CONCLUSIONS: Surgisis mesh appears to be a promising new prosthetic material for hernia repair and appears to function well, especially in contaminated or potentially contaminated fields. Obviously, long-term follow-up is still required.

Laparoscopic diagnosis and treatment of intestinal obstruction.

BACKGROUND: Intestinal obstruction is a common reason for general surgical referral. The traditional approach has been conservative management, followed by laparotomy if conservative measures are unsuccessful. However, with the advent of minimally invasive surgery, the need for laparotomy for this common problem is being challenged. METHODS: From May 1991 to April 2001, 167 patients underwent laparoscopy for diagnosis and/or treatment of intestinal obstruction. Average patient age was 62 years (range, 21-98). The site of obstruction was the stomach in seven patients, small bowel in 116 patients, and colon in 44 patients. RESULTS: Laparoscopy successfully diagnosed the site of obstruction in all patients. In addition, 154 patients (92.2%) were successfully treated laparoscopically without conversion to laparotomy. Both intraoperative and postoperative complication rates were low (3.5 and 18.6%, respectively) and compared favorably with those of published reports. CONCLUSIONS: Intestinal obstruction can be approached safely and effectively by laparoscopy with the intent not only to correctly diagnose the patient but also to render treatment.

Laparoscopic ventral and incisional hernia repair: an 11-year experience.

Incisional hernias develop in 2%-20% of laparotomy incisions, necessitating approximately 90000 ventral hernia repairs per year. Although a common general surgical problem, a "best" method for repair has yet to be identified, as evidenced by documented recurrence rates of 25%-52% with primary open repair. The aim of this study was to evaluate the efficacy and safety of laparoscopic ventral and incisional herniorrhaphy. From February 1991 through November 2002, a total of 384 patients were treated by laparoscopic technique for primary and recurrent umbilical hernias, ventral incisional hernias, and spigelian hernias. The technique was essentially the same for each procedure and involved lysis of adhesions, reduction of hernia contents, closure of the defect, and 3-5 cm circumferential mesh coverage of all hernias. Of the 384 patients in our study group, there were 212 females and 172 males with a mean age of 58.3 years (range 27-100 years). Ninety-six percent of the hernia repairs were completed laparoscopically. Mean operating time was 68 min (range 14-405 min), and estimated average blood loss was 25 mL (range 10-200 mL). The mean postoperative hospital stay was 2.9 days and ranged from same-day discharge to 36 days. The overall postoperative complication rate was 10.1%. There have been 11 recurrences (2.9%) during a mean follow-up time of 47.1 months (range 1-141 months). Laparoscopic ventral and incisional hernia repair, based on the Rives-Stoppa technique, is a safe, feasible, and effective alternative to open techniques. More long-term follow-up is still required to further evaluate the true effectiveness of this operation.

Needlescopic appendectomy.

BACKGROUND: In this paper, we compare our experience with the techniques of needlescopic appendectomy (NA) (2-mm instruments) for the treatment of acute appendicitis with the more conventional approach of a laparoscopic appendectomy (LA). METHODS: We did a retrospective review of patients who underwent NA for the diagnosis of acute appendicitis between August 1996 and January 2002. Variables including operative time, blood loss, postoperative time to discharge, intra- and postoperative complications were analyzed and compared to data from control patients who had undergone an LA for acute appendicitis. RESULTS: The NA group had a longer average operating time (54.5 +/- l3 vs. 42.5 +/- 12.6 min, p = 0.0001) and a longer postoperative hospital stay (2.1 +/- 1.4 vs. 1.3 +/- 1.1 days, p = 0.01). Blood loss was similar for the two groups. CONCLUSIONS: With the exception of superior cosmesis, NA appears to have little advantage over the better-established LA; moreover, it has some disadvantages. A clearer benefit of this procedure over LA, as well as improvements in instrumentation, needs to be shown before it can be widely accepted.

Preliminary experience with new bioactive prosthetic material for repair of hernias in infected fields.

Surgisis (Cook Surgical, Bloomington, Ind., USA) is a new four-ply bioactive, prosthetic mesh for hernia repair derived from porcine small-intestinal submucosa. It is a naturally occurring extracellular matrix which is easily absorbed, supports early and abundant new vessel growth, and serves as a template for the constructive remodeling of many tissues. As such, we believe that Surgisis mesh is ideal for use in contaminated or potentially contaminated fields in which ventral, incisional, or inguinal hernia repairs are required. From November 2000 through May 2002, 25 patients (11 male, 14 female) underwent placement of Surgisis mesh for a variety of different hernia repairs. A total of 25 hernia repairs were performed in our patient population. Fourteen procedures (56%) were performed in a potentially contaminated setting (i.e. with incarcerated/strangulated bowel within the hernia or coincident with a laparoscopic cholecystectomy/colectomy). Eleven repairs (44%) were performed in a grossly contaminated field, including one in which an infected polypropylene mesh from a previous inguinal hernia repair was replaced with Surgisis and one in which necrotic bowel was discovered within the hernial sac. Median follow-up was 15 months with a range of 1-20 months. Of the 25 total repairs, there was one wound infection complicated by enterocutaneous fistula in a patient originally operated on for ischemic bowel. The fistula was in a location independent of the Surgisis mesh. There were no mesh-related complications or recurrent hernias in our early postoperative follow-up period. Surgisis mesh appears to be a promising new prosthetic material for hernia repair, especially in contaminated or potentially contaminated fields. Obviously, long-term follow-up is still required.

Laparoscopic repair of postoperative perineal hernia.

Perineal hernia is an uncommon complication of abdominoperineal resection and pelvic exenteration. We present an alternative not previously described for the surgical repair of this type of hernia: laparoscopic repair of postoperative perineal hernia.

The endoluminal management of duodenal lesions.

Benign duodenal lesions such as adenomas and webs have traditionally been approached endoscopically. Unfortunately, endoscopic polypectomies are limited by the size and villous nature of the lesions as well as their locations within the lumen. Duodenal web resections may be restricted by the size of the opening leading to inadequate lumen size and recurrence. When these procedures fail, conventional open or laparoscopic surgery with its attendant morbidity is often necessary. Recent advances in camera optics and mini-Iaparoscopic instrumentation have expanded the laparoscopic options available to treat mucosal and submucosal lesions of the upper GI tract. Laparoscopic endoluminal surgery has evolved into a viable option for the treatment of many intragastric lesions. We have successfully extrapolated this concept to the treatment of proximal duodenal lesions. Successful resection of a duodenal web and a large tubulovillous adenoma are presented. Laparoendoscopic intraluminal management of benign duodenal lesions is safe, feasible, and effective.

Efficacy of surgical measures in preventing port-site recurrences in a porcine model.

BACKGROUND: Port-site recurrences are serious complications of laparoscopy performed for cancer. Incidences reported in the literature vary between 0% and 21%, suggesting an influence of the surgeon. METHODS: The aim of this experimental, prospective, randomized, single-blind study was to investigate the influence that the quality surgery has on the incidence of port-site recurrences. After a 12-mmHg carbon dioxide (CO2) pneumoperitoneum was created, 10(7) human HeLa cell were injected into the peritoneal cavity of 18 pigs, creating a xenogeneic tumor. Laparoscopic sigmoid resections then were performed using four trocars and a transanal double-stapling technique. The following protective measures were applied in nine animals: trocar fixation, prevention of gas leaks, rinsing of instruments with povidone-iodine, minilaparotomy protection, rinsing of trocars before removal, peritoneal closure, and rinsing of all wounds with povidoneiodine. Surgeons and type of procedures were randomized. After 4 weeks, the animals were killed and all portsites excised. Blinded immunohistologic analysis with antihuman pancytokeratin antibody was performed. RESULTS: Tumor recurrence was present in 23 of 36 port sites (63.8%) in the control group, but only in 5 of 36 port sites (13.8%) in the group that received protective measures (p = 0.002; Fisher's exact test). No peritoneal carcinosis nor anastomotic recurrences were observed. CONCLUSION: These results strongly suggest that the quality of surgical technique has an influence on the incidence of port-site recurrences. From now on, we propose to use these protective measures routinely in cancer laparoscopy.

Initial evidence for the mixing and soft assembly of the ankle, suspensory, and hip muscle patterns.

The onset latencies of automatic muscle responses to backward translations of the support surface in standing subjects were assessed to test two longstanding hypotheses: that (1) the ankle, hip, and suspensory muscle patterns represent discrete synergies; and (2) the suspensory pattern cannot be mixed with the ankle and the hip patterns (based on theoretical modeling). Muscle responses were recorded at the leg (medial gastrocnemius and tibialis anterior), thigh (hamstring and quadriceps), lower trunk (paraspinals and abdominals), and the upper trapezius muscles. A principal factor analysis with orthogonal varimax rotation was conducted to describe the variation among the muscle onset latencies by means of the smallest possible set of newly defined variables, or factors. Muscles that were correlated with each other were grouped into a factor. The analysis produced three factors with eigenvalues > or =1, which accounted for 81% of the total variance. Based on the first muscle response in each factor, the muscle patterns resembled the hip, ankle, and suspensory synergies. Muscle responses within a synergy were activated before the completion of the muscle responses in the other synergies, indicating that the synergies, though mixed, are triggered separately. This is consistent with the hypothesis that the ankle, hip, and suspensory patterns represent discrete synergies. On the other hand, the results do not support the hypothesis that the three patterns cannot be combined.

The effect of diflunisal on the elimination of triamterene in human volunteers.

A major metabolic pathway for triamterene (a potassium sparing diuretic) is aromatic hydroxylation followed by sulphate conjugation. Diflunisal (a salicylate anti-inflammatory agent) also undergoes sulphate conjugation of its phenolic group as a major pathway. We investigated the possible effect of diflunisal on the elimination of triamterene (competition for phenolic sulphonation) in six healthy volunteers by studying the disposition of single doses of triamterene (100 mg) taken alone and in the presence of steady-state levels of diflunisal. Diflunisal coadministration (500 mg b.i.d.) had no effect on the pharmacokinetics of triamterene itself. However, plasma AUC of p-hydroxytriamterene sulphate was greater (4.6 times), and its renal clearance lower (0.24 times), in the presence of diflunisal. There was no change in the formation clearance or protein binding of p-hydroxytriamterene sulphate in the presence of diflunisal. The data point to competition for renal excretory pathways rather than sulphonation capacity. This interaction could have clinical relevance since p-hydroxytriamterene sulphate is pharmacologically active.

Laparoscopic-assisted colonoscopic polypectomy: the Texas Endosurgery Institute experience.

PURPOSE: The advent of laparoscopic surgery has altered the manner by which surgical specialties address pathologies of the abdominal cavity. This advance in technology has also changed colorectal surgery. One of the more common procedures of colorectal surgery is segmental resection for polyps that are large, broad based, or inaccessible for colonoscopic removal. We present a technique combining colonoscopy and laparoscopy to remove troublesome polyps without the need for segmental resections. METHODS: From May 1990 to September 1999 laparoscopic-monitored colonic polypectomies were performed in 47 patients, with a total of 60 polyps being removed. After laparoscopic mobilization of the involved segment of the colon, the proximal bowel is cross-clamped and the colonoscope passed to the involved portion of the colon. The polyp is then presented to the colonoscopist by the laparoscopist facilitating removal. The serosal surface is monitored for any indications of transluminal injury, and the area is repaired if needed. All polyps undergo immediate frozen section analysis. If the pathologic evaluation indicates malignancy then a segmental resection may be performed, otherwise the patients are decompressed and fed within a short time before discharge. RESULTS: The polyps were located most commonly in the ascending colon (18 polyps), transverse colon (12 polyps), and cecum (12 polyps). The most common histopathologic diagnosis was tubulovillous adenoma in 28 polyps followed by villous adenoma in 11 polyps. In three cases histopathologic diagnosis revealed malignancy necessitating segmental resection (1 low anterior resection and 2 right hemicolectomies), which were performed laparoscopically. Patients received a liquid diet within 6 hours, were discharged in an average of 21 hours, and returned to full activity, usually within days. The only complication presented in this group of patients was an umbilical port seroma. Virtually all patients (97 percent) behaved as if only a colonoscopy had been performed. Pain at the trocar sites was managed with acetaminophen 600 mg by mouth as needed. CONCLUSION: Laparoscopic-monitored colonoscopic polypectomy allows patients to undergo removal of colonic polyps without a segmental resection. This less invasive procedure yields recovery times similar to that of colonoscopy alone, and the potential complications of a segmental resection are avoided. All polyps are examined by frozen section, and if a malignancy is encountered, a laparoscopic resection can be performed.

Laparoscopic surgery for stage III colon cancer: long-term follow-up.

BACKGROUND: The role of laparoscopic surgery in the management of colorectal cancer is controversial. This study was undertaken to determine the oncological adequacy, in terms of margins of resection, lymph node harvest, and anastomotic and locoregional recurrence of laparoscopic colectomy in patients with stage III (node-positive) colorectal cancer. METHODS: The results of laparoscopic colectomy in 50 consecutive patients with stage III colorectal cancer operated on at a single hospital between 1991 and 1998 were analyzed with respect to postoperative morbidity, mortality, and long-term survival by the Kaplan-Meier method. Methodical patient follow-up was the mainstay of the study. RESULTS: There were 31 men (52%) and 19 women (38%) with a mean age of 67.7 years (range, 40-88). Low anterior resection was performed in 17 cases, abdominal perineal resection in five cases sigmoid colectomy in 10 cases, left hemicolectomy in six cases, right hemicolectomy in seven cases, transverse colectomy in one case, and subtotal colectomy in four cases. Conversion was necessary in three cases (6%). Major complications included one leak, one pelvic abscess, one perineal wound infection, and three anastomotic strictures early in the experience, with none in the past 4 years. One early death occurred due to massive stroke. Median length of stay was 6 days (range, 3-37). Forty-six patients were staged as CII and four as CI colon cancer. The average number of positive nodes was 5.1 (range, 3-58). The margins of resection were adequate in all patients. Follow-up ranged from 3 to 75 months (average, 29.3; median, 24). Overall cancer-related mortality was 34% (17 patients); three patients died of unrelated causes with no detectable cancer. All who died of cancer had distant disease; three of them also had pelvic recurrence. Mean time of death was 21.7 months. There were no anastomotic recurrences or trocar site implants. Overall 3- and 5-year survival was 54.5% and 38.5%, respectively; cancer-adjusted survival was 60.8% and 49.1%. CONCLUSIONS: Based on this study, laparoscopic colectomy in patients with stage III colorectal cancer is oncologically adequate. It results in a long-term outcome comparable to that of traditional open surgery and is associated with low perioperative mortality and morbidity (lower wound infection rate, lower wound recurrences at trocar sites) and a shortened length of stay.

Laparoscopic versus open appendectomy.

BACKGROUND: Laparoscopic appendectomy is commonly performed and has been presumed to offer economic benefits similar to those of laparoscopic cholecystectomy. This study was done to examine that premise. METHODS: Two surgical groups contributed consecutively operated patients with a clinical diagnosis of appendicitis. One group did all appendectomies open and the other group did them laparoscopically. Hospital expenses were compared using a single billing formula. Hospital length of stay, time to return to work, and complications were analyzed. RESULTS: Operating room times were longer for the laparoscopic group, median 80 minutes, versus median 50 minutes for the open group. Hospital length of stay and return to work were the same, median 1 day and median 10 days, respectively. Wound complications were less common in the laparoscopic group, 0 of 30, than in the open group, 3 of 18; however, there was 1 intra-abdominal abscess in the laparoscopic group. Median cost of the laparoscopic group was $2,915 versus $1,747 for the open group. CONCLUSIONS: Laparoscopic appendectomy is more expensive than appendectomy but does not reduce hospital length of stay nor change the time to return to work; however, wound complications are less common.

Effectiveness of exposure and ritual prevention for obsessive-compulsive disorder: randomized compared with nonrandomized samples.

The efficacy of exposure and ritual prevention (EX/RP) for reducing symptoms of obsessive-compulsive disorder (OCD) has been demonstrated in several randomized controlled trials (RCTs). However, procedures used in these studies to maximize experimental control may have limited their generalizability to typical clinical practice. Treatment outcome data from 110 clinical patients receiving EX/RP on an outpatient fee-for-service basis were compared with findings from 4 RCTs of EX/RP. Adult patients in the clinical sample were not excluded because of treatment history, concomitant pharmacotherapy, psychiatric comorbidity, age, or OCD severity. Clinical patients achieved substantial and clinically meaningful reductions in their OCD and depressive symptoms following EX/RP, which were comparable with those reported in the RCTs. Findings indicate that EX/RP is a potent treatment for OCD, and its benefits are not limited to select patient samples.

Laparoscopic management of enterocutaneous fistula.

Enterocutaneous fistulas develop in settings of prior abdominal surgery, inflammatory bowel disease, diverticulitis, radiation or malignancy. Traditional surgical management requires laparotomy with bowel resection and anastomosis and is associated with a high incidence of wound infection. Recent advances in instrumentation and accumulation of experience has allowed minimally invasive surgery to become an alternative and often preferred approach to handling complex surgical problems. We present a case of successful laparoscopic management of an enterocutaneous fistula that developed in the setting of prior colectomy and laparoscopic inguinal hernia repair with prosthetic mesh. Laparotomy and its attending complications were avoided facilitating recovery and return to work.