Using three-dimensional laparoscopy as a novel training tool for novice trainees compared with two-dimensional laparoscopy.

BACKGROUND: Laparoscopic skills training is an essential component of general surgery training. This study proposes the use of three-dimensional (3D) laparoscopy as the initial training tool for beginners to shorten the learning curve. METHODS: This study evaluates the surgical performance and subjective experience of junior and senior trainees with 3D versus two-dimensional laparoscopy. Peg transfer task was used as the objective time measurement. A subjective evaluation of the 2 systems using a questionnaire was also used. RESULTS: The mean difference in the juniors was 16.33 seconds, while in the seniors it was only 3.46 seconds (P = .036). The time difference between groups was much smaller in the 3D than the two-dimensional (P = .14 vs .02) laparoscopy. In the subjective evaluation, the novice group also scored significantly higher for the 3D system in the bimanual dexterity category (P = .004, .007). CONCLUSION: Our study demonstrates the feasibility of using 3D laparoscopy for laparoscopic skills training in novices.

HIV and liver transplantation: The British Columbia experience, 2004 to 2013.

BACKGROUND: The demand for definitive management of end-stage organ disease in HIV-infected Canadians is growing. Until recently, despite international evidence of good clinical outcomes, HIV-infected Canadians with end-stage liver disease were ineligible for transplantation, except in British Columbia (BC), where the liver transplant program of BC Transplant has accepted these patients for referral, assessment, listing and provision of liver allograft. There is a need to evaluate the experience in BC to determine the issues surrounding liver transplantation in HIV-infected patients. METHODS: The present study was a chart review of 28 HIV-infected patients who were referred to BC Transplant for liver transplantation between 2004 and 2013. Data regarding HIV and liver disease status, initial transplant assessment and clinical outcomes were collected. RESULTS: Most patients were BC residents and were assessed by the multidisciplinary team at the BC clinic. The majority had undetectable HIV viral loads, were receiving antiretroviral treatments and were infected with hepatitis C virus (n=16). The most common comorbidities were anxiety and mood disorders (n=4), and hemophilia (n=4). Of the patients eligible for transplantation, four were transplanted for autoimmune hepatitis (5.67 years post-transplant), nonalcoholic steatohepatitis (2.33 years), hepatitis C virus (2.25 years) and hepatitis B-delta virus coinfection (recent transplant). One patient died from acute renal failure while waiting for transplantation. Ten patients died during preassessment and 10 were unsuitable transplant candidates. The most common reason for unsuitability was stable disease not requiring transplantation (n=4). CONCLUSIONS: To date, interdisciplinary care and careful selection of patients have resulted in successful outcomes including the longest living HIV-infected post-liver transplant recipient in Canada.

HISTORIQUE: La demande d'une prise en charge définitive des maladies organiques terminales chez les Canadiens infectés par le VIH est en hausse. Jusqu'à tout récemment, malgré des données internationales faisant foi de résultats cliniques positifs, les Canadiens atteints d'une maladie hépatique terminale infectés par le VIH n'étaient pas admissibles à une transplantation, sauf en Colombie-Britannique (C.-B.), où le programme de transplantations de BC Transplant les accepte en vue d'un aiguillage, d'une évaluation, de l'inscription sur la liste d'attente et de l'exécution d'une allogreffe du foie. L'évaluation de l'expérience de la C.-B. s'impose pour déterminer les enjeux entourant la transplantation hépatique chez les patients infectés par le VIH. MÉTHODOLOGIE: Les chercheurs ont procédé à l'étude des dossiers des 28 patients infectés par le VIH qui ont été orientés vers BC Transplant pour subir une transplantation hépatique entre 2004 et 2013. Ils ont colligé les données sur l'état du VIH et de la maladie hépatique, l'évaluation initiale de la transplantation et les résultats cliniques. RÉSULTATS: La plupart des patients étaient des habitants de la C.-B. qui avaient été évalués par l'équipe multidisciplinaire de la clinique de C.-B. La majorité présentait des charges virales indétectables du VIH, prenaient des antirétroviraux et étaient infectés par le virus de l'hépatite C (n=16). Les comorbidités les plus courantes étaient l'anxiété et les troubles des humeurs (n=4), ainsi que l'hémophilie (n=4). Parmi les patients admissibles à la transplantation, quatre ont subi une transplantation consécutive à une hépatite auto-immune (5,67 ans après la transplantation), à une stéatose hépatique non alcoolique (2,33 ans), à un virus de l'hépatite C (2,25 ans) et à une co-infection par l'hépatite B et le virus delta (transplantation récente). Un patient est décédé d'une insuffisance rénale aiguë alors qu'il était en attente de transplantation. Dix sont décédés pendant la préévaluation et dix n'étaient pas des candidats adéquats pour la transplantation. La principale raison de ne pas être un candidat adéquat était une maladie stable ne nécessitant pas de transplantation (n=4). CONCLUSIONS: Jusqu'à présent, les soins interdisciplinaires et une sélection attentive des patients permettent d'obtenir des résultats positifs, y compris la présence au Canada du greffé hépatique infecté par le VIH ayant vécu le plus longtemps depuis sa transplantation.

Minireview on laparoscopic hepatobiliary and pancreatic surgery.

The first laparoscopic cholecystectomy was performed in the mid-1980s. Since then, laparoscopic surgery has continued to gain prominence in numerous fields, and has, in some fields, replaced open surgery as the preferred operative technique. The role of laparoscopy in staging cancer is controversial, with regards to gallbladder carcinoma, pancreatic carcinoma, hepatocellular carcinoma and liver metastasis from colorectal carcinoma, laparoscopy in conjunction with intraoperative ultrasound has prevented nontherapeutic operations, and facilitated therapeutic operations. Laparoscopic cholecystectomy is the preferred option in the management of gallbladder disease. Meta-analyses comparing laparoscopic to open distal pancreatectomy show that laparoscopic pancreatectomy is safe and efficacious in the management of benign and malignant disease, and have better patient outcomes. A pancreaticoduodenectomy is a more complex operation and the laparoscopic technique is not feasible for this operation at this time. Robotic assisted pancreaticoduodenectomy has been tried with limited success at this time, but with continuing advancement in this field, this operation would eventually be feasible. Liver resection remains to be the best management for hepatocellular carcinoma, cholangiocarcinoma and colorectal liver metastases. Systematic reviews and meta-analyses have shown that laparoscopic liver resections result in patients with equal or less blood loss and shorter hospital stays, as compared to open surgery. With improving equipment and technique, and the incorporation of robotic surgery, minimally invasive liver resection operative times will improve and be more efficacious. With the incorporation of robotic surgery into hepatobiliary surgery, donor hepatectomies have also been completed with success. The management of benign and malignant disease with minimally invasive hepatobiliary and pancreatic surgery is safe and efficacious.

Best single time point correlations with AUC for cyclosporine and tacrolimus in HIV-infected kidney and liver transplant recipients.

BACKGROUND: Interactions between antiretrovirals (ARVs) and transplant immunosuppressant agents (IS) among HIV-infected transplant recipients may lead to lack of efficacy or toxicity. In transplant recipients not infected with HIV, tacrolimus (TAC) trough levels (C0) or cyclosporine (CsA) drawn at C0 or 2 hours after dosing (C2) correlate with drug exposure (area under the curve [AUC]/dose) and outcomes. Because of ARV-IS interactions in HIV-infected individuals, and the high rate of rejection in these subjects, this study investigated the correlations between IS concentrations and exposure to determine the best method to monitor immunosuppressant levels. METHODS: This study prospectively studied 50 HIV-infected transplant recipients undergoing kidney or liver transplantation evaluating the pharmacokinetics of the IS in 150 studies over time after transplantation (weeks 2 to 4, 12, 28, 52, and 104). IS levels were measured with liquid chromatography-tandem mass spectrometry and AUC calculated using WinNonlin 9.0. Correlation analyses were run on SAS 9.2. RESULTS: CsA concentration at C4 correlated better with AUC than C0 or C2, and over time TAC concentration correlated better at C0 or C2. CONCLUSIONS: It is suggested that C0 is acceptable for TAC monitoring, but poor predictability will occur at C0 with CsA. The low correlation of C0 with CsA AUC could be responsible for the higher rejection rates on CsA that has been reported in these subjects.

The benefits of laparoscopic appendectomies in obese patients.

BACKGROUND: Systematic reviews and randomized controlled trials comparing laparoscopic appendectomy (LA) with open appendectomy (OA) show a reduction in wound infections associated with LA but a 3-fold increase in intra-abdominal abscess with LA. Surgical time and operation costs are higher with LA. The advantage of LA over OA is small. Although these patients have not been specifically analyzed in the report, the systematic review recommends the routine use of LA in young women and obese people. The purpose of this study is to determine if obese patients benefit in a shorter length of stay (LOS) by having LA versus OA surgery compared with their nonobese counterparts. METHODS: A retrospective chart review of 315 adult patients who have undergone appendectomies at Royal Columbian and Burnaby Hospitals between April 1, 2010 and March 31, 2011. Appendectomies performed in pregnant women combined with other surgeries and those converted to OA were excluded. Outcomes and the postoperative stay for obese and nonobese patients were assessed. RESULTS: The LOS is shorter with LAs than with OAs (2.06 vs 4.13 days, P < .05). The LOS, in obese patients, is much shorter with LAs than with OAs (1.69 vs 6.82 days, P < .05). The variability in LOS is much higher in obese patients as compared with nonobese patients (standard deviation = 8.57 vs 2.67). The body mass index and the type of surgery contribute to a significant difference in LOS. CONCLUSIONS: Obese patients who undergo LA have a decreased LOS as compared with obese patients who undergo OA for appendicitis. This is the first study showing specifically that LA benefits obese patients and the health care system.

Liver and kidney transplantation in HIV-infected patients.

HIV infection has evolved into a chronic condition as a result of improvements in therapeutic options. Chronic exposure with HIV and associated co-pathogens as well as toxicities from prolonged therapy with antiviral medications has resulted in increased morbidity and mortality rates from end-stage liver and kidney disease in the HIV-infected population. Since the definitive treatment for end-stage organ failure is transplantation, demand has increased among HIV-infected patients. Although the transplant community has been slow to recognize HIV as a chronic condition, many transplant centers have eliminated HIV infection as a contraindication to transplantation as a result of better patient management and demand. This review examines the current clinical strategies and issues surrounding liver and kidney transplantation in HIV-infected patients.

Renal transplantation in patients with HIV.

HIV infection has been a major global health problem for almost three decades. With the introduction of highly active antiretroviral therapy in 1996, and the advent of effective prophylaxis and management of opportunistic infections, AIDS mortality has decreased markedly. In developed countries, this once fatal infection is now being treated as a chronic condition. As a result, rates of morbidity and mortality from other medical conditions leading to end-stage liver, kidney and heart disease are steadily increasing in individuals with HIV. Presence of HIV infection used to be viewed as a contraindication to transplantation for multiple reasons: concerns for exacerbation of an already immunocompromised state by administration of additional immunosuppressants; the use of a limited supply of donor organs with unknown long-term outcomes; and, the risk of viral transmission to the surgical and medical staff. This Review examines open questions on kidney transplantation in patients infected with HIV-1 and clinical strategies that have resulted in good outcomes. It also describes the clinical concerns associated with the treatment of renal transplant recipients with HIV.