Single-incision transperitoneal laparoscopic left adrenalectomy.

BACKGROUND: Laparoscopic adrenalectomy via three or four trocars is a well-established procedure. This report describes the initial experience with single-incision laparoscopic surgery (SILS) using the transperitoneal approach for left adrenalectomy. METHODS: Between April 2010 and August 2011, all consecutive patients with adrenal masses, including Conn's syndrome, Cushing's adenoma, and nonfunctional adrenal tumors, who agreed to undergo SILS adrenalectomy were included in a prospective study. The left 2.5-cm subcostal incision was the sole point of entry. Data of patients who underwent SILS adrenalectomy were compared with those from an uncontrolled group of patients who underwent conventional laparoscopic adrenalectomy during the same study period. RESULTS: There were 20 patients in each study group (20 men, 20 women; mean age [SD] = 50 [6.5] years). SILS was successfully performed and none of the patients required conversion to an open procedure. In one case of SILS procedure, an additional lateral 5-mm port was needed for retraction of the kidney. The mean (SD) duration of the operation was 95 (20) min in the SILS group and 80 (8) min in the conventional laparoscopic adrenalectomy group (p = 0.052). There were no intraoperative or postoperative complications. There were no differences between the two study groups with respect to postoperative pain, number of patients who resumed oral intake within the first 24 h, final pathologic diagnosis, and length of hospital stay. CONCLUSION: SILS left adrenalectomy is a technically feasible and safe procedure in carefully selected patients. The definitive clinical, aesthetic and functional advantages of this technique require further analysis.

Pancreas and kidney transplantation: long-term endocrine function.

OBJECTIVE: To describe the characteristics of metabolic control and beta-cell function in the long-term follow-up of patients with type-1 diabetes (T1D) who have undergone pancreas and kidney transplantation (PKTx). PATIENTS AND METHODS: Twelve patients (eight males/four females) with normal pancreas and kidney graft function for more than 15 yr were included. Patient age at the time of transplantation was 35.8 ± 6.9, with a duration of diabetes of 19.0 ± 4.6 yr and time on dialysis of 18.7 ± 12.4 months. In all the cases, bladder derivation was performed to drain exocrine secretion, with subsequent conversion to the intestinal tract in 42% of the patients. The functional evaluation was made at one, five, 10, and 15 yr after PKTx determining: glycosylated hemoglobin (HbA1c), oral glucose tolerance test (OGTT), measuring insulinemia, and anti-GAD antibody. RESULTS: Comparing the results between one and 15 yr after transplantation: (i) no differences were observed in either HbA1c (4.68% vs. 4.76%) or basal glycemia (71 vs. 79 mg/dL), but an increase was seen in the area under the curve (AUC) of glucose (11,983 vs. 15,875 mg/dL/120', p = 0.02); (ii) a trend to a reduction in basal insulinemia (24 vs. 15 mU/L, p = 0.11) and a trend to a reduction in the AUC of insulinemia (8446 vs. 7057 mU/L/120', p = 0.22) were observed. The OGTT was normal in six patients, intolerant in two and diabetic in four patients. No variations were seen in insulin resistance (FIRI, QUICKI). Anti-GAD antibody became positive in one case. CONCLUSIONS: The results of this study demonstrate that pancreas transplantation has long-term functional viability, being an essential strategy for the treatment of patients with T1D with end-stage renal failure. Nevertheless, lesser response to OGTT can be expected suggesting certain deterioration in the functional capability of the pancreas graft during follow-up.

Pancreatogastrostomy with gastric partition after pylorus-preserving pancreatoduodenectomy versus conventional pancreatojejunostomy: a prospective randomized study.

OBJECTIVE: To compare the results of postoperative morbidity rate of a new pancreatogastrostomy technique, pylorus-preserving pancreaticoduodenectomy (PPPD) with gastric partition (PPPD-GP) with the conventional technique of pancreaticojejunostomy (PJ). SUMMARY AND BACKGROUND DATA: Pancreatojejunostomy and pancreatogastrostomy (PG) are the commonly preferred methods of anastomosis after pancreatoduodenectomy (PD). All randomized controlled trials failed to show advantage of a particular technique, suggesting that both PJ and PG provide equally results. However, postoperative morbidity remains high. The best technique in pancreatic anastomosis is still debated. METHOD: Described here is a new technique, PPPD-GP; in this technique the gastroepiploic arcade is preserved. Gastric partition was performed using 2 endo-Gia staplers along the greater curvature of the stomach, 3 cm from the border. This gastric segment, 10 to 12 cm in length is placed in close proximity to the cut edge of the pancreatic stump. An end-to-side, duct-to-mucosa anastomosis (with pancreatic duct stent) is constructed. One hundred eight patients undergoing PPPD for benign and malignant diseases of the pancreatic head and the periampullary region were randomized to receive PG (PPPD-GP) or end-to-side PJ (PPPD-PJ). RESULTS: The two treatment groups showed no differences in preoperative parameters and intraoperative factors. The overall postoperative complications were 23% after PPPD-GP and 44% after PPPD-PJ (P < 0.01). The incidence of pancreatic fistula was 4% after PPPD-GP and 18% after PPPD-PJ (P < 0.01). The mean + SD hospital stay was 12 +/- 2 days after PPPD-GP and 16 +/- 3 days after PPPD-PJ. CONCLUSIONS: This study shows that PPPD-GP can be performed safely and is associated with less complication than PPPD-PJ. The advantage of this technique over other PG techniques is that the anastomosis is outside the area of the stomach where the contents empty into the jejunum, but pancreatic juice drains directly into the stomach.

Surgical outcomes of total thyroidectomy using the LigaSure™ Small Jaw versus LigaSure Precise™: A retrospective study of 2000 consecutive patients.

BACKGROUND: We compared surgical outcomes of LigaSure™ Small Jaw, which is a multifunctional thermal device that incorporates a tissue divider versus LigaSure Precise™ in thyroid surgery. METHODS: A retrospective, single-center study was carried out in an acute-care teaching hospital in Barcelona, Spain. Between January 2008 and June 2015, consecutive patients scheduled for total thyroidectomy were included in the study. Surgical outcomes were operative time, length of skin incision, use of a suction drain, intraoperative bleeding, postoperative complications and length of hospital stay. RESULTS: A total of 2000 patients were included (LigaSure™ Small Jaw, n = 1000; LigaSure Precise™, n = 1000). Demographics and indication for surgery were similar in both groups. A significant and independent shorter operative time (median 40 vs. 65 min, P = 0.002), smaller length of the skin incision (mean [SD] 4 [2] vs. 7 [3] cm, P = 0.031), lower percentages of patients with suction drain (15% vs. 66%, P = 0.012) and intraoperative bleeding (4% vs. 9%, P = 0.045) and reduced length of stay (median 1 vs. 3 days, P = 0.039) were found in the LigaSure™ Small Jaw than in the LigaSure Precise™. Postoperative complications including haematoma, hypoparathyroidism and recurrent laryngeal nerve injury were similar. CONCLUSIONS: The LigaSure™ Small Jaw in thyroid surgery results in significant less blood loss and operative time as well as shorter hospital stay compared to LigaSure Precise™. These findings could have direct application in daily practice.

Laparoscopic surgery in patients with sporadic and multiple insulinomas associated with multiple endocrine neoplasia type 1.

There have recently been reports of a limited number of laparoscopic procedures in patients with clinically manifest hyperinsulinism. However, the precise role of laparoscopy remains unknown. Between January 1998 and September 2003, 11 consecutive patients (10 women and 1 man; mean age, 40 years; age range, 22-66 years) with sporadic insulinoma and two female patients (25 and 40 years old) with multiple insulinomas associated with multiple endocrine neoplasia type 1 (MEN-1) were operated on using the laparoscopic approach. Endoscopic ultrasonography was used to localize the tumor preoperatively in 90% of patients with sporadic insulinoma. In patients with MEN-1, computed tomography and octreoscan-(111)In demonstrated multiple tumors. Laparoscopic ultrasonography (LapUS) was performed in all patients for operative decision-making. Of 11 patients with sporadic insulinoma, laparoscopic enucleation (LapEn) was planned in 8 patients, but in 1 patient, the use of LapUS missed the tumor and the patient was converted to open surgery. Mean operating time after LapEn (seven patients) was 180 minutes, and the mean blood loss was 200 ml. The mean hospital stay was 5 days. In three of the 11 patients, laparoscopic spleen-preserving distal pancreatectomy (LapSPDP) was performed; the mean operative time was 240 minutes, and the mean blood loss was 360 ml. Postoperative complications occurred in three of seven patients after LapEn (three pancreatic fistulas managed conservatively, and one case of bleeding requiring reoperation). LapSPDP was performed in both patients with MEN-1; in one patient with splenic vessel preservation (SVP), the operating time was 210 minutes and blood loss was 650 ml, with a hospital stay of 6 days. In another patient without SVP, the operating time was 150 minutes and blood loss was 300 ml. The latter patient developed a 4-cm splenic infarct managed conservatively, and the hospital stay was 14 days. LapEn and LapSPDP are feasible and safe and achieved cure in patients with sporadic insulinoma and multiple insulinomas associated with MEN-1. However, the risk of pancreatic leakage after LapEn remains high, and LapSPDP without SVP may be associated with splenic infarct.

Laparoscopic distal pancreatectomy combined with preservation of the spleen for cystic neoplasms of the pancreas.

The precise role of laparoscopy in the resection of cystic neoplasms of the pancreas (CyNP) remains unknown. In addition, the question of spleen-preserving distal pancreatectomy is controversial. This report evaluates the feasibility and outcome of laparoscopic spleen-preserving distal pancreatectomy (LapSPDP) in 19 patients (17 women and 2 men) with CyNP. A prospective comparison was made between 11 consecutive patients (group I) with splenic vessel preservation (SVP) and 8 patients (group II) without SVP (Warshaw technique). This study used color-Doppler ultrasound (CDUS) as a tool to identify patients at high risk for postoperative splenic complications. The mean tumor size was, in both groups, 5 cm. In group I, with an intent-to-treat basis of SVP, only in 54.5% of patients the spleen was preserved with an intact splenic artery and vein; in the remainder, conversion to the Warshaw technique was required for intraoperative bleeding. Evaluation of intraoperative factors showed that the mean operative time was significantly shorter (165 vs. 222 minutes) and the mean blood loss significantly lower (225 vs. 495 mL) in the group of LapSPDP with the Warshaw technique. No patients required blood transfusion in both groups. The overall conversion rate was 0%. The overall rate of pancreatic fistula was 15% and it was classified as biochemical leak (no clinical symptomatology). Overall splenic complications were observed in 16.6% of patients but occurred only in three patients undergoing LapSPDP with the Warshaw technique; CDUS showed in 2 patients a focal splenic infarct; the third patient had an initial hospital stay of 5 days, was readmitted 2 days later for a massive splenic necrosis, and splenectomy was performed. The overall hospital stay was 5.7 days. At mean follow up of 22 months (range 6-42), there have been no local recurrences.

Clinical and autopsy correlation evaluated in a university hospital in Spain (1991-2000).

The authors present a 10-year retrospective study (1991-2000) of all autopsies performed at the Hospital Clinic, Barcelona (Catalonia, Spain) studied by a multidisciplinary committee. The clinicopathologic correlation of the primary underlying disease with the immediate cause of death was reviewed. Between 1991 and 2000, 2,495 autopsies were performed, 1933 of which were evaluated by the committee. The autopsy rate fell from 20% in 1993 to 9.1% in 2000. The clinicopathologic correlation in underlying primary disease was correct in 92.67% of the cases; there was a major discrepancy in 3.51% and a minor discrepancy in 3.82%. As regards the immediate cause of death, major errors were found in 5.89% of cases and minor errors in 6.17%. Despite the scientific and technologic advances in medicine, we have seen that there are still clinicopathologic discrepancies. The postmortem examination continues to play an important role in auditing clinical practice and diagnostic performance, and also for educational purposes. Evaluation by a multidisciplinary committee is the more reliable system for the study of the clinicopathologic correlation.

Single-port laparoscopic left adrenalectomy (SILS): 3 years' experience of a single institution.

BACKGROUND: Laparoscopic adrenalectomy by 3 or 4 trocars is a well-established procedure. This report describes the initial experience with single-incision laparoscopic surgery (SILS) using the transperitoneal approach for left adrenalectomy. METHODS: Between April 2010 and January 2013, all consecutive patients with adrenal masses who agreed to undergo SILS adrenalectomy were included in a prospective study. The left 2.5 cm subcostal incision was the sole point of entry. Data of patients undergoing SILS adrenalectomy were compared with those from an uncontrolled group of patients undergoing conventional laparoscopic adrenalectomy during the same study period. RESULTS: There were 40 patients in each study group. SILS was successfully performed and none of the patients required conversion to an open procedure. In 1 case of SILS procedure, an additional lateral 5 mm port was needed for retraction of the kidney. The mean (SD) duration of the operation was 80 (20) minutes in the SILS group and 75 (8) minutes in the conventional laparoscopic adrenalectomy group (P=0.150). No intraoperative or postoperative complications occurred. Differences between the 2 study groups in postoperative pain, number of patients resuming oral intake within the first 24 hours, final pathologic diagnosis (Conn syndrome, Cushing adenomas, nonfunctioning adrenal tumors), and length of hospital stay were not observed. CONCLUSIONS: SILS left adrenalectomy is a technically feasible and safe procedure in carefully selected patients and seems to have results similar to a conventional approach in our initial comparison.

[Acute necrotizing pancreatitis: therapeutic alternatives]. / Pancreatitis aguda grave: alternativas terapéuticas.

The management of acute necrotizing pancreatitis has changed significantly over the last few years. Currently, most patients survive the early phases of the disease due to improvements in intensive care unit management. The most important risk factor for morbidity and mortality is infection of the pancreatic necrosis. Ideally, surgery should be delayed until 4 weeks after the onset of symptoms of pancreatitis, as it is at this time that the necrosis is most clearly demarcated. Advances in diagnostic imaging and minimally invasive techniques in surgery and radiology have revolutionized the surgical management of this disease. However, minimally invasive techniques should be limited to critically-ill patients unfit for conventional surgery.

Pancreatitis aguda grave: alternativas terapéuticas / Acute necrotizing pancreatitis: therapeutic alternatives

El tratamiento de la pancreatitis aguda grave ha cambiado de manera significativa en los últimos años. Actualmente, la mayoría de los pacientes sobrevive a la primera etapa de la pancreatitis grave debido a una mejoría al tratamiento en la unidad de cuidados intensivos. Respecto a la morbimortalidad, la infección pancreática es el factor de riesgo más importante. La cirugía debe de ser idealmente pospuesta unas 4 semanas después del inicio de la sintomatología, ya que es en este tiempo cuando la necrosis se encuentra claramente demarcada. Los avances en el diagnóstico por imagen, el desarrollo de la radiología intervencionista y las intervenciones por acceso mínimo han revolucionado el tratamiento quirúrgico; sin embargo, estas técnicas de acceso mínimo para el tratamiento de la necrosis pancreática infectada deben de estar limitados únicamente a pacientes en estado crítico que no se encuentren en condiciones para ser sometidos a los procedimientos de cirugía convencional (AU)

The management of acute necrotizing pancreatitis has changed significantly over the last few years. Currently, most patients survive the early phases of the disease due to improvements in intensive care unit management. The most important risk factor for morbidity and mortality is infection of the pancreatic necrosis. Ideally, surgery should be delayed until 4 weeks after the onset of symptoms of pancreatitis, as it is at this time that the necrosis is most clearly demarcated. Advances in diagnostic imaging and minimally invasive techniques in surgery and radiology have revolutionized the surgical management of this disease. However, minimally invasive techniques should be limited to critically-ill patients unfit for conventional surgery (AU)

Abordaje laparoscópico para la resección de los tumores aparentemente benignos del páncreas: tumores inflamatorios y tumores quísticos / Laparoscopic approach for the resection of apparently benign tumors of the pancreas. Inflammatory and cystic tumors

Objetivo. Análisis de los resultados de la resección pancreática laparoscópica en pacientes con tumores pancreáticos aparentemente benignos no neuroendocrinos. Pacientes y método. Desde febrero de 1998 hasta marzo de 2003 se han realizado 26 resecciones pancreáticas con intento de preservación esplénica: grupo I, 7 pacientes con pancreatitis crónica obstructiva (4 varones y 3 mujeres), con una media de edad de 39,5 años, que presentaban tumores inflamatorios en el cuerpo y la cola de páncreas de un diámetro medio de 5 cm (5 pacientes) y seudoquistes de páncreas (2 pacientes) de 5 y 6 cm de diámetro, respectivamente; grupo II, 19 pacientes (17 mujeres y 2 varones), con una media de edad de 55 años, que presentaban tumores quísticos del páncreas (4 serosos y 15 mucinosos) con un tamaño medio tumoral de 5,5 cm. El abordaje laparoscópico se hizo con el paciente en posición de decúbito lateral-medio derecho; se llevó a cabo una insuflación con CO2 y se realizó la técnica de pancreatectomía, que osciló entre el 40 y 70 por ciento, con y sin preservación de los vasos esplénicos. Resultados. En el grupo I la duración media de la intervención fue de 210 min y la pérdida sanguínea media de 450 ml. Un paciente fue reintervenido por presentar una perforación de un ulcus duodenal. La estancia hospitalaria media fue de 6,5 días. En un subgrupo de 11 pacientes consecutivos del grupo II, se intentó la preservación de los vasos esplénicos. La duración media de la intervención fue 222 min y las pérdidas hemáticas medias de 495 ml. En otro subgrupo de 8 pacientes consecutivos se realizó de entrada la técnica de Warshaw. La duración media de la intervención fue de 165 min y las pérdidas hemáticas medias de 275 ml. Se observaron complicaciones postoperatorias globales en 6 pacientes (31,5 por ciento) después de la resección pancreática por tumores quísticos. La estancia media hospitalaria fue de 5,5 días. Conclusiones. La pancreatectomía distal con preservación esplénica por laparoscopia es una técnica segura tanto para el tratamiento de los tumores inflamatorios como de los tumores quísticos del páncreas. La preservación de los vasos esplénicos conlleva de una manera significativa un tiempo operatorio más prolongado y mayores pérdidas sanguíneas intraoperatorias que la técnica de Warshaw (AU)

Cirugía laparoscópica en pacientes con insulinoma esporádico e insulinomas asociados a neoplasia endocrina múltiple tipo 1 / Laparoscopic surgery in patients with sporadic insulinoma and insulinomas associated with multiple endocrine neoplasia type 1

Introducción. Las experiencias clínicas del abordaje laparoscópico en pacientes con hiperinsulinismo son escasas, pero sus resultados iniciales son prometedores. Material y métodos. En el período comprendido entre febrero de 1998 y marzo del 2003 se ha intervenido a 10 pacientes (9 mujeres y 1 varón) con hiperinsulinismo por insulinoma esporádico, con una edad media de 40 años (22-66 años) y 2 mujeres de 25 y 40 años, con insulinomas múltiples, que forman parte de la neoplasia endocrina múltiple tipo 1 (NEM-1).En los pacientes con insulinoma esporádico, la tomografía computarizada (TC) y la ecoendoscopia demostraron la presencia del tumor en el 30 y el 90 por ciento de los casos, respectivamente. La TC en una paciente con NEM-1 demostró 2 tumoraciones en el cuerpo y la cola del páncreas de 10 y 18 mm, respectivamente, y en la otra paciente con NEM-1, una tumoración de 7,5 cm en la cola del páncreas. En ambas pacientes la gammagrafía con octreótido-MIBI-111 fue positiva en la zona medial del páncreas. En todos los pacientes se planteó el abordaje laparoscópico y la utilización de la ultrasonografía laparoscópica (USLap). Resultados. La USLap confirmó, en pacientes con insulinoma esporádico, la presencia de tumor en el 90 por ciento de los casos (1 tumor de 20 mm en la cabeza del páncreas y 8 tumores con un diámetro medio de 17,1 mm en el cuerpo-cola del páncreas). En 6 pacientes se realizó la enucleación del tumor (tiempo operatorio medio, 160 min y pérdida sanguínea media, 200 ml) y en 3 pacientes se procedió a pancreatectomía distal de entre el 40 y el 60 por ciento del volumen glandular, con preservación esplénica (tiempo operatorio medio, 240 min y pérdida sanguínea media, 360 ml).Tres pacientes presentaron una fístula pancreática de bajo volumen después de la enucleación. La estancia hospitalaria media fue de 5 días. En una de las pacientes con NEM-1 se realizó una pancreatectomía del 70 por ciento con preservación esplénica (tiempo operatorio medio, 210 min y pérdida sanguínea media, 650 ml) y en la otra paciente con NEM-1 se realizó una pacreatectomía distal del 80 por ciento con preservación esplénica (tiempo operatorio medio, 210 min y pérdida sanguínea media, 650 ml). En ambas pacientes la estancia hospitalaria fue de 5 días. En todos los pacientes se consiguió la curación del hiperinsulinismo. Conclusiones. El abordaje laparosocópico y la utilización de la USLap constituyen una alternativa válida para el tratamiento del hiperinsulinismo orgánico, mediante la enucleación o la resección pancreática, y ofrece todas las ventajas de la cirugía mínimamente invasiva (AU)

Memorias de un cirujano: Segunda parte / Memories of a surgeon: Second part

Expone la vida del eminente cirujano Dr. Emiliano Crespo. Presenta sus experiencias durante los años de preparación profesional en Francia, así como la práctica médica y la docencia ejercidas en el Ecuador...