Single-incision versus conventional laparoscopic cholecystectomy: a case control study.

BACKGROUND: Single-incision laparoscopic surgery (SILS) is a minimally invasive technique which can be used for treatment of gallbladder disease. To evaluate our initial experience, patients treated with SILS cholecystectomy were compared with a comparable group of patients treated with a conventional four trocart technique (LC). METHODS: Between May 2009 and April 2010, 60 SILS cholecystectomies were performed. These patients were matched by Body Mass Index (BMI) with 60 cases of conventional LC. RESULTS: The operative time was significantly longer in the SILS group 55 min (range, 25-126 min) compared to 49 min (range, 28-75 min) for the LC group. Excluding the first 15 SILS cases the operative time became comparable to the conventional technique, with a mean operative time of 51 min (range, 25-90 min). No patients were converted to open cholecystectomy. In the SILS group 3 patients developed a wound infection, in the conventional LC group 2. CONCLUSION: SILS cholecystectomy seems to be a safe and feasible procedure when performed by an experienced laparoscopic surgeon. Complication rates are comparable to conventional LC. With a learning curve of around 10 to 15 procedures, operative times approach those of conventional LC.

Transanal single-port surgery for the resection of large polyps.

INTRODUCTION: Transanal endoscopic microsurgery (TEM) is widely used for the excision of both benign and malignant rectal tumours. It is relatively expensive and can be a challenging technique. A recent development in laparoscopic surgery is the single-port technique (single-incision laparoscopic surgery, SILS). The SILS port is a flexible multichannel port for transumbilical laparoscopic surgery. Even though not developed for transanal use the port could be ideal because of its shape and texture. METHODS: 12 patients underwent transanal resection using an SILS port and normal laparoscopic instruments. RESULTS: 10 out of 12 patients were treated successfully with the SILS port. Two polyps were resected using an open transanal technique because the distance between the SILS port and the polyp was too small. The average operative time was 55 min (range 40-80 min). All patients could be discharged on the first postoperative day. There were no major complications. CONCLUSION: Our current data show that transanal surgery using a single port is a relatively easy procedure with operative times comparable to TEM. More surgeons will therefore be able to perform transanal endoscopic surgery.

Comparative expression analysis of isolated human adipocytes and the human adipose cell lines LiSa-2 and PAZ6.

OBJECTIVE: To obtain insight in the extent to which the human cell lines LiSa-2 and PAZ6 resemble isolated primary human adipocytes. DESIGN: A combination of cDNA subtraction (representative difference analysis; RDA) and cDNA microarray analysis was used to select adipose specific genes to compare isolated (pre-)adipocytes with (un)differentiated LiSa-2 and PAZ6 cells. MEASUREMENTS: RDA was performed on adipose tissue against lung tissue. A total of 1400 isolated genes were sequenced and cDNA microarray technology was used for further adipose related gene selection. 30 genes that were found to be enriched in adipose tissue were used to compare isolated human adipocytes and LiSa-2 and PAZ6 cells in the differentiated and undifferentiated states. RESULTS: RDA and microarray analysis resulted in the identification of adipose enriched genes, but not in adipose specific genes. Of the 30 most differentially expressed genes, as expected, most were related to lipid metabolism. The second category consisted of methyltransferases, DNMT1, DNMT3a, RNMT and SHMT2, of which the expression was differentiation dependent and higher in differentiated adipocytes. Using the 30 adipose expressed genes, it was found that isolated adipocytes on one hand, and PAZ6 and LiSa-2 adipocytes on the other, differ primarily in lipid metabolism. Furthermore, LiSa-2 cells seem to be more similar to isolated adipocytes than PAZ6 cells. CONCLUSION: The LiSa-2 cell line is a good model for differentiated adipocytes, although one should keep in mind that the lipid metabolism in these cells deviates from the in vivo situation Furthermore, our results imply that methylation may have an important function in terminal adipocyte differentiation.

Staging laparoscopy and laparoscopic ultrasonography in more than 400 patients with upper gastrointestinal carcinoma.

BACKGROUND: Resection offers the only chance of cure to patients with esophageal, gastroesophageal junction, and hepatopancreatobiliary tumors. Staging is essential to select patients who will benefit from operation because palliation can also be performed nonoperatively. Several studies, including limited numbers of patients, have shown that laparoscopic staging prevents unnecessary laparotomies, but it is doubtful whether general application of this staging method can be advised. The aim of this study was to assess the benefit of diagnostic laparoscopy for staging patients with esophageal, gastroesophageal junction, and hepatopancreatobiliary tumors. STUDY DESIGN: Between June 1992 and December 1996, 420 patients with a resectable tumor after conventional staging underwent diagnostic laparoscopy combined with laparoscopic ultrasonography. Histologic proof of metastases or ingrowth was used to cancel laparotomy. RESULTS: Laparoscopic staging avoided laparotomy in 20% of patients (sensitivity 0.70): 5% with an esophageal tumor, 20% with a gastroesophageal junction tumor, 15% with a periampullary tumor, 40% with a proximal bile duct tumor, 35% with a liver tumor, and 40% with a pancreatic body or tail tumor. Complications and port-site metastases were seen in 4% and 2% of patients, respectively. CONCLUSIONS: Laparoscopic staging is a safe procedure with low morbidity and without mortality in this series. It has shown no benefit in esophageal cancer, but seems beneficial for staging tumors located at the gastroesophageal junction, proximal bile duct tumors, liver tumors, and pancreatic body and tail tumors. The value of laparoscopic staging for patients with periampullary tumors is not as great as stated in previous studies and is still the subject of investigation.

CD44 splice variants as prognostic markers in colorectal cancer.

BACKGROUND: Splice variants of CD44 play a causal role in the metastatic spread of pancreatic carcinoma in the rat. In previous studies we have shown that homologues of these CD44 isoforms (CD44v6) are overexpressed during colorectal tumorigenesis in man and that CD44v6 overexpression is associated with an unfavorable prognosis in this disease. In the present study we have assessed the prognostic significance of CD44 variants containing exon v5. In addition, we have used a panel of different antibodies against CD44v6 and applied a combined scoring system to improve its value as prognosticator. METHODS: Expression of CD44 variants was studied by immunohistochemistry on frozen tissue sections, and the prognostic value of the CD44 variant expression was assessed using univariate and multivariate analysis. RESULTS: Our studies show that expression of CD44v6, but not CD44v5, has significant prognostic value. Analysis of CD44v6 expression by means of a combined scoring system, on the basis of a panel of three different monoclonal antibodies (mAbs), makes CD44v6 a highly significant prognostic marker that is independent of Dukes stage, tumor grade, or tumor localization. CONCLUSION: Assessment of CD44v6 expression by a combination of mAbs yields an independent prognosticator that may be of value in identifying patients with a high propensity to develop distant metastasis.

Added value of CT criteria compared to the clinical SAP score in patients with acute pancreatitis.

BACKGROUND: To assess the added value of established computed tomography (CT) scores versus the Simplified Acute Physiology (SAP) score in predicting outcome in patients with acute pancreatitis. METHODS: Contrast-enhanced CT was performed in 45 patients with acute pancreatitis. The Balthazar score, CT severity index (CTSI), and Schröder score were assessed, and the SAP score was calculated. The predictive values of CT score and SAP score for mortality, need for one or more interventions, and length of hospital stay were compared. The added value of the SAP score to the CT scores was assessed by using ROC (receiver operating curve) analysis. RESULTS: The positive predictive values of the higher Balthazar, CTSI, Schröder, and SAP scores, reflecting severe disease, were 50%, 41%, 41%, and 48%, respectively, for mortality, 85%, 84%, 84%, and 83%, respectively, for need for one or more interventions, and 55%, 66%, 66%, and 65%, respectively, for longer hospital stay. The negative predictive values of the lower Balthazar, CTSI, Schröder and SAP scores were 84%, 92%, 92%, and 42%, respectively, for mortality, 44%, 69%, 69%, and 45%, respectively, for need for one or more interventions, and 44%, 69%, 69%, and 55%, respectively, for longer hospital stay. When CT scores were added to the SAP score, there was no improvement in discriminating power for mortality. CONCLUSION: To identify patients with severe outcome, there is no clear benefit using established CT scores as opposed to the SAP score. However, the Balthazar score and CTSI are better than the SAP score in predicting a favorable outcome.

Descending necrotizing mediastinitis causing pleuroesophageal fistula. Successful treatment by combined transcervical and pleural drainage.

Descending necrotizing mediastinitis (DNM) develops as a complication of an oropharyngeal infection and can be life-threatening. Aggressive therapy is generally advised; usually, treatment consists of cervicomediastinal and transthoracic drainage combined with broad-spectrum antimicrobial therapy, especially when the necrotizing process extends below the level of the fourth thoracic vertebra. A rare case of DNM secondary to a retropharyngeal abscess with fistula to both pleural cavities and to the hypopharynx is reported. The patient was successfully treated by cervicomediastinal surgical drainage and percutaneous drainage of both pleural cavities. In our opinion, even complicated DNM can be treated without aggressive surgery if the patient is in good condition.

Difference in expression of CD44 splice variants between proximal and distal adenocarcinoma of the large bowel.

To help determine whether adenocarcinomas of the proximal and distal large bowel reflect distinct entities, the expression of two splice variants of the metastasis-associated cell adhesion molecule CD44, carrying exons v5 and v6 respectively, was investigated retrospectively in fresh frozen samples of 23 proximal and 41 distal carcinomas by immunohistochemical staining with specific anti-CD44v5 monoclonal antibody VFF8 and anti-CD44v6 monoclonal antibodies VFF4 and VFF7. Tumours were staged as: Dukes A, 0; Dukes B, 27; Dukes C, 31; and Dukes 'D', six. Compared with distal tumours, proximal lesions expressed significantly more CD44v5 (96 versus 87 per cent, P = 0.02) and CD44v6 (83 versus 61 per cent, P = 0.01). CD44v5 and CD44v6 are considered markers for tumour progression and aggressive behaviour. Their high expression in proximal carcinomas seems to contrast with the general belief that these tumours show less aggressive behaviour than left-sided lesions. Further study of the biological significance of the expression of CD44 splice variants is therefore needed.

Colorectal cancer prognosis and expression of exon-v6-containing CD44 proteins.

CD44 variants containing v6 confer metastatic potential to rat carcinoma cell-lines. In man, CD44v6 is increasingly expressed during colorectal tumour progression. In 68 colorectal carcinoma patients, survival analysis showed that CD44v6 expression in the tumours was associated with tumour-related death. In patients who had an apparently radical resection of their primary tumour, CD44v6 expression had prognostic value independent of Dukes' stage. CD44v6 expression may reflect propensity for metastasis after apparently curative surgery, making adjuvant therapy an option in these patients.

A pseudo-aneurysm of the internal mammary artery: a very rare complication of subclavian vein puncture.

An extensive number of complications after insertion of a subclavian catheter is described in the literature. In this case report a patient with a pseudo-aneurysm of the internal mammary artery after insertion of a subclavian catheter is described. If one finds a shadow on the X-ray of the chest after insertion of a subclavian catheter, the possibility of a pseudo-aneurysm should be considered first.

Occupational reintegration of long-term cancer survivors.

To determine the long-term psychosocial consequences of cancer related to work, a postal survey was conducted among 849 long-term survivors of cancer in the southwest Netherlands. Forty-four percent of the responders who worked at the time of the diagnosis of cancer returned to their job, 24% of them part-time. Fourteen percent experienced impediments at work after return. Absenteeism in this group does not differ from that in the year prior to the moment of diagnosis. There is a small decrease in promotional and financial prospects.

Problems at social re-integration of long-term cancer survivors.

To assess the long-term consequences of cancer for everyday life, a postal survey in the Netherlands was done among 849 ex-cancer patients. Almost all responders were self-supporting to a large extent. Compared with the period before diagnosis, the socioeconomic position had not changed in 62%. 28% of the responders who were employed at the time of diagnosis (10% of all responders), were now housekeepers (99% female). Absence from work at survey did not differ significantly from absence in the year before diagnosis. A history of cancer tended to have a negative impact on promotional prospects and income. Ex-cancer patients were often confronted with problems when they tried to take out insurance or to modify an existing policy. The psychological well-being of the responders was low, compared to the average Dutch population.