Actualities in the anaesthetic management of pheochromocytoma/ paraganglioma.

The anaesthetic management of pheochromocytoma is complicated and challenging. However, preoperative pharmacologic preparation, modern anaesthetic techniques and drugs associated with advanced monitoring in conjunction with the evolution of surgical techniques (open laparotomy to laparoscopic surgery and robotic approaches in the present day) improved significantly perioperative outcome, and intraoperative and postoperative hemodynamic stability. Although there are not randomised clinical trials to suggest one approach over another and there is a high international variability amongst intraoperative anaesthetic techniques, most management principles are still universal.

Robotically performed total mesorectal excision for rectal cancer.

BACKGROUND: Rectal cancer is an important health problem, due to the increasing number of new cases and the quality of life issues brought forth by surgical treatment in these patients. AIM: The aim of the study was to analyse the results of robotic surgery in the treatment of lower and middle rectal cancer,locations in which TME is performed. MATERIAL AND METHOD: Patients diagnosed with and operated on for rectal cancer by the means of robotic surgery between 2008-2012 at the Fundeni Clinical Institute were retrospectively analysed. RESULTS: A number of 117 patients with rectal cancer were operated on by robotic surgery, of which 79 (67.52%) were submitted to total mesorectal excision (TME). The most frequently performed surgery was low anterior resection, followed by rectal amputation through abdominoperineal approach.Anastomosis fistula was observed in 9 (11.39%) patients. Local recurrence was encountered in 2 (2.53%) of the robotically performed surgeries. CONCLUSIONS: 1. Robotically assisted total mesorectal excision is feasible, safe and can be performed with a small number of complications and a low local recurrence rate; 2. The main advantages are oncological safety and quality of life; 3.Conversion to open surgery is rarely encountered; 4. Protection loop ileostomy existence allows avoiding reintervention in case anastomotic fistula occurs in patients with low anterior resection. 5. Robotic surgery may become gold standard in the surgical treatment of rectal cancer.

A 5-year perspective over robotic general surgery: indications, risk factors and learning curves.

INTRODUCTION: Robotic surgery has opened a new era in several specialties but the diffusion of medical innovation is slower indigestive surgery than in urology due to considerations related to cost and cost-efficiency. Studies often discuss the launching of the robotic program as well as the technical or clinical data related to specific procedures but there are very few articles evaluating already existing robotic programs. The aims of the present study are to evaluate the results of a five-year robotic program and to assess the evolution of indications in a center with expertise in a wide range of thoracic and abdominal robotic surgery. MATERIAL AND METHODS: All consecutive robotic surgery cases performed in our center since the beginning of the program and prior to the 31st of December 2012 were included in this study, summing up to 734 cases throughout five years of experience in the field. Demographic, clinical, surgical and postoperative variables were recorded and analyzed.Comparative parametric and non-parametric tests, univariate and multivariate analyses and CUSUM analysis were performed. RESULTS: In this group, the average age was 50,31 years. There were 60,9% females and 39,1% males. 55,3% of all interventions were indicated for oncological disease. 36% of all cases of either benign or malignant etiology were pelvic conditions whilst 15,4% were esogastric conditions. Conversion was performed in 18 cases (2,45%). Mean operative time was 179,4Â+-86,06 min. Mean docking time was 11,16Â+-2,82 min.The mean hospital length of stay was 8,54 (Â+-5,1) days. There were 26,2% complications of all Clavien subtypes but important complications (Clavien III-V) only represented 6,2%.Male sex, age over 65 years old, oncological cases and robotic suturing were identified as risk factors for unfavorable outcomes. CONCLUSIONS: The present data support the feasibility of different and complex procedures in a general surgery department as well as the ascending evolution of a well-designed and well-conducted robotic program. From the large variety of surgical interventions, we think that a robotic program could be focused on solving oncologic cases and different types of pelvic and gastroesophageal junction conditions, especially rectal, cervical and endometrial cancer, achalasia and complicated or redo hiatal hernia.

Robotic surgery for rectal cancer: a single center experience of 100 consecutive cases.

BACKGROUND: Minimally invasive techniques have revolutionized the field of general surgery over the few last decades. Despite its advantages, in complex procedures such as rectal surgery, laparoscopy has not achieved a high penetration rate because of its steep learning curve, its relatively high conversion rate and technical challenges. The aim of this study was to present a single center experience with robotic surgery for rectal cancer focusing mainly on early and mid-term postoperative outcome. METHODS: A series of 100 consecutive patients who underwent robotic rectal surgery between January 2008 and June 2012 was analyzed retrospectively in terms of demographics, pathological data, surgical and oncological outcomes. RESULTS: Seventy-seven patients underwent robotic sphincter-saving resection, and 23 patients underwent robotic abdominoperineal resection. There were 4 conversions. The median operative time for sphincter-saving procedures was 180 min. The median time for robotic abdominoperineal resection was 160 min. The median distal resection margin of the operative specimen was 3 cm. The median number of retrieved lymph nodes was 14. The median hospital stay was 10 days. In-hospital mortality was nil. The overall morbidity was 30%. Four patients presented transitory postoperative urinary dysfunction. Severe erectile dysfunction was reported by 3 patients. The median length of follow-up was 24 months. The 3-year overall survival rate was 90%. CONCLUSIONS: Robotic surgery is advantageous for both surgeons (in that it facilitates dissection in a narrow pelvis) and patients (in that it affords a very good quality of life via the preservation of sexual and urinary function in the vast majority of patients and it has low morbidity and good midterm oncological outcomes). In rectal cancer surgery, the robotic approach is a promising alternative and is expected to overcome the low penetration rate of laparoscopy in this field.

Pathological characteristics and clinical specifications in gastroenteropancreatic neuroendocrine tumors: a study of 68 cases.

INTRODUCTION: Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) represent a group of tumors, having their origin in cells of diffuse endocrine system, with particular clinical course, diagnosis and treatment. PATIENTS AND METHODS: In our study, were included 68 patients with neuroendocrine digestive tumors admitted, diagnosed and treated in Fundeni Clinical Institute, Bucharest, in the last ten years--2000-2010 (retrospective study). RESULTS: Thirty-three (49%) patients were males, 35 (51%) females, and the main age was 58.9 years. In 62 (90.3%) cases was possible to find the primary tumor. The examined tumors had different localizations: pancreas--32 (47.04%) cases (head--17 (24.99%) cases, and body and tail--15 (22.05%) cases), stomach--7 (10.29%) cases, small intestine--7 (10.29%) cases, 6 (8.82%) cases--unknown primary site (diagnosis was established on metastases), right colon--6 (8.82%) cases, liver--6 (8.82%) cases, rectum--2 (2.94%) cases, and retroperitoneum--2 (2.94%) cases. Microscopic examination revealed 59 (86.8%) malignant tumors and 9 (13.2%) benign tumors. Using WHO 2000 Classification, 28 cases of malignant tumors were well-differentiated neuroendocrine carcinomas, and 31 cases were poor differentiated neuroendocrine carcinomas. From malignant cases, 25 (42.3%) have distant metastases and 15 (25.9%) lymph node metastases. CONCLUSIONS: Cases of gastroenteropancreatic neuroendocrine tumors included in our study had clinical and histopathological features in correspondence with data from literature--slight predominance in women, predominance in 5th and 6th decades of life, the most frequent localizations were at pancreatic level--both head and body and tail, but the rarest were in colon and retroperitoneum. Most of the cases studied, were malignant tumors, from these more than a half were poor differentiated, and a quarter of them having lymph node or distant metastases.

Updates in CT characterization of thymic epithelial tumors in patients with myasthenia gravis.

Thymic epithelial tumors have been traditionally classified into two main types: noninvasive and invasive thymoma. Several classifications have been proposed for thymic tumors, but according to these classifications, the prognosis of patients with thymomas varies considerably. Our purpose is to present different CT aspects according to various subtypes of thymic epithelial neoplasms based on the simplified World Health Organization classification. In this article, we will discuss and illustrate histologic and functional features of the thymus and a spectrum of thymic tumors associated with Myasthenia Gravis. Smooth contours and a round shape are the most suggestive of type A thymic epithelial tumors, whereas irregular contours and heterogeneous enhancement are the most suggestive of type C tumors. Calcifications are suggestive of type B tumors. CT findings may serve as predictors of postoperative recurrence or metastasis for the thymic epithelial tumors.

[Diagnosis and surgical management in gastrointestinal neuroendocrine tumors]. / Managementul diagnosticului si tratamentul chirurgical în tumorile neuroendocrine gastrointestinale.

Neuroendocrine tumors, known as carcinoid tumors constitute a heterogeneous group of neoplasms that present many clinical challenges. They secrete peptides and neuroamines that cause specific clinical syndromes. Assessment of specific or general tumors markers offers high sensitivity in establishing the diagnosis and they also have prognostic significance. Management strategies include curative surgery, whenever possible-that can be rarely achieved, palliative surgery, chemotherapy, radiologic therapy, such as radiofrequency ablation and chemoembolisations and somatostatin analogues therapy in order to control the symptoms. The aim of this paper is to review recent publications in this field and to give recommendations that take into account current advances in order to facilitate improvement in management and outcome.

The minimally invasive approach, laparoscopic and robotic, in rectal resection for cancer. A single center experience.

BACKGROUND: Robotic approach for rectal cancer competes with laparoscopy in centers dedicated to minimally invasive surgery (MIS) due to the technologic advantage. This is a report of our experience with MIS for rectal cancer. METHODS: A series of 84 consecutive patients with laparoscopic resection (between 1995-2010) and 38 consecutive patients with robotic resection (between 2008-2010) for primary rectal cancer were analyzed. Hartmann's procedures were excluded. Clinical and pathologic outcomes were reviewed retrospectively. RESULTS: In the laparoscopic group (LG), 50 anterior rectal resections (ARR), 34 abdominal perineal resections (APR) were performed while in the robotic group(RG) there were 30 ARR and 8 APR. The median operative time was 182 min (140-220 min) in LG and 208 min (180-300 min) in RG (p = 0.0002). No statistically significant difference was noticed between the groups in terms of conversion, morbidity, anastomotic leak and postoperative stay rates. Margin clearance was obtained in all patients and the median number of removed lymph nodes was similar: 11.37 in RG vs. 11.07 in the LG (p = 0.65) with a higher rate of metastatic lymph node involvement in laparoscopy (p = 0.0l012). Blood loss was higher in LG (150 ml vs. 100 ml; p = 0.0001). There were 5 (5.9%) local recurrences in the LG at a median follow-up of 27.5 months and 2 (5.2%) in the RG at a median follow-up of 13 months (p = 0.43). CONCLUSIONS: Minimally invasive surgery for rectal cancer proved to be safe and efficient with similar results in the two groups. Technological advances of robotic approach compared to laparoscopy allowed better ergonomics, more refined dissection, easier preserving of hypogastric nerves and less blood loss. Long term outcomes are to be assessed in prospective randomized studies.

[An experimental model of transgastric ooforectomy using a porcine model]. / Stabilirea modelului experimental de ooforectomie transgastrica pe model suin.

INTRODUCTION: Transabdominal routes for surgery entail general anaesthesia with its inherent risks and complications (prolonged hospital stay, abdominal incisions that may be difficult in obese patients). Minimally invasive procedures require shorter hospitalization, have shorter recovery periods, less postoperative discomfort, and lower morbidity and complications. The purpose of this study was to use a porcine model to determine the feasibility and the safety of organ resection (oophorectomy and tubectomy). MATERIALS AND METHODS: 10 Big White pigs between 25-30 kg underwent transgastric ooforectomy. The first 5 cases were performed in a hybrid procedure (laparoscopic-NOTES) in order to have a better control and supervise the maneuvers done by the mobile endoscope and to guide in the abdominal cavity. RESULTS: Adnexectomy was possible in all ten experiments. Full operative time (from starting endoscopy to complete gastrectomy closing) was 180 min to 270 min. The gastric defect closing was the most difficult manoever lasting from 10 min with OTSC clips to 100 using endoloops and clips. The animals have tolerated well the experiments and there have been no remarkable incidents during our 10 experments. In only one case a bleeding from gastotomy required electric coagulation. CONCLUSION: Transgastric ooforectomy in an experimental model is a procedure that requires advanced laparoscopical and endoscopical skills. Our early results are promissing. Its application in humans needs further confirmation of the method.

[Anesthesia for experimental surgery in swine]. / Anestezia pentru chirurgia experimentala la porci.

New surgical techniques cannot be safely and widely performed in human subjects unless they are first applied to large animal models. Experimental model using swine as surgical practice subject is one of the most reliable and widely practiced, taking into consideration the similarity between human and swine anatomy. Based on our large experience (around 100 pigs) we hereby present important aspects of handling and anesthesia procedures for pigs. Our goal is to share our experience with young surgical and anesthesia investigators who are planning investigations using pig as an experimental animal.

First year experience of robotic-assisted laparoscopic surgery with 153 cases in a general surgery department: indications, technique and results.

BACKGROUND: Robotic surgery was developed in response to the limitations and drawbacks of laparoscopic surgery. Since 1997 when the first robotic procedure was performed various papers pointed the advantages of robotic-assisted laparoscopic surgery, this technique is now a reality and it will probably become the surgery of the future. The aim of this paper is to present our preliminary experience with the three-arms "da Vinci S surgical system", to assess the feasibility of this technique in various abdominal and thoracic procedures and to point out the advantages of the robotic approach for each type of procedure. MATERIALS AND METHODS: Between 18 January 2008 and 18 January 2009 153 patients (66 men and 87 women; mean age 48,02 years, range 6 to 84 years) underwent robotic-assisted surgical procedures in our institution; we performed 129 abdominal and 24 thoracic procedures, as follows: one cholecystectomy, 14 myotomies with Dor fundoplication, one gastroenteroanastomosis for unresectable antral gastric cancer, one transthoracic esophagectomy, 14 gastrectomies, one polypectomy through gastrotomy, 22 splenectomies,7 partial spleen resections, 22 thymectomy, 6 Nissen fundoplications, one Toupet fundoplication, one choledocho-duodeno-anastomosis, one drainage for pancreatic abscess, one distal pancreatectomy, one hepatic cyst fenestration, 7 hepatic resections, 29 colonic and rectal resections, 5 adrenalectomies, 12 total radical hysterectomies and pelvic lymphadenectomy, 3 hysterectomies with bilateral adnexectomy for uterine fibroma, one unilateral adnexectomy, and 2 cases of cervico-mediastinal goitre resection. RESULTS: 147 procedures were robotics completed , whereas 6 procedures were converted to open surgery due to the extent of the lesion. Average operating room time was 171 minutes (range 60 to 600 minutes, Median length of stay was 8,6 days (range 2 to 48 days). One system malfunctions was registered. Post-operatory complications occurred in 14 cases. There were no deaths. CONCLUSIONS: Our preliminary experience suggests that robotic surgery is feasible and worth of clinical application. The best indications for robotic surgery are the procedures that require a small operating field, a fine a precise dissection (suitable for pelvic and gastric lymphadenectomy, nerve sparing in total mesorectal excision) and safe intracorporeal sutures.

The robotic-assisted left lateral hepatic segmentectomy: the next step.

INTRODUCTION: During the last decade, minimally invasive surgery had an astonishing development, progressing from minor hepatic interventions to major hepatectomies, thus creating a rich background for robotic-assisted hepatic surgery. Left lateral hepatic segmentectomy (left lobectomy, II-III bi-segmentectomy) is the first anatomic hepatic resection on the learning curve. The purpose of this report is to demonstrate that, due to the anatomical characteristics of the left lobe and to the technical facilities of the robot, this intervention is also feasible with the Da Vinci S robotic system. MATERIALS: In our department, robotic-assisted left lateral lobectomy was performed for both benign and malignant lesions by a surgeon experienced in both hepatic and laparoscopic surgery but traversing the beginning of the learning curve in robotic surgery. A Da Vinci S robotic system with three arms was used and two additional laparoscopic ports for the assistant surgeons were added. RESULTS: The lobectomies were safely performed in an average operatory time of 140 min (+/- 20), with minimal blood loss and without using the Pringle procedure. The dissection was carried out with the bipolar forceps on the left arm of the surgeon and the Harmonic curved shears on the right arm. The division of the vascular pedicles for segments II and III was performed with the LigaSure Atlas device. The other additional port was used for retraction. There were no conversions or reinterventions DISCUSSIONS: Robotic-assisted left lateral hepatic lobectomy was a feasible technique with the potential to reduce surgical trauma and pain and to improve surgeon's technical comfort.

[Laparoscopic left lateral segmentectomy of the liver: indications, technique, results]. / Bisegmentectomia II-III laparoscopica: indicatii, tehnica, rezultate.

INTRODUCTION: The laparoscopic approach of the hepatic lesions located in the left lobe is a frequently used procedure in liver surgery for both benign and malign tumors because of the minimal invasive character, anatomical particularities and modem devices used in hemostasis and biliary-stasis. The purpose of this study is to analyze our experience and report it to the literature data. METHODS AND MATERIAL: The study starts from the basic indications of laparoscopic left lateral segmentectomy, it emphasizes the main operating steps and analyzes the results of this method in a cohort retrospective study in which we included all the laparoscopic resections performed in our center between 1998-2007, both laparoscopic and hand-assisted laparoscopic procedures. We excluded exploratory laparoscopies and the cases in which after the tumor exploration, we decided conversion to open approach in the absence of any intraoperative incidents. RESULTS: Between 1998-2007 we performed 84 laparoscopic hepatic resections out of which 20 were located in the left liver lobe. There were 12 left lateral segmentectomy and in 4 cases we used hand assisted laparoscopy due to bigger tumour dimensions. The hepatic lesions approached laparoscopically were both benign (5 cases out of which 3 hemangioma and 2 adenoma) and malignant (7 cases hepatocellular carcinoma). The tumor diameter ranged between 2-10 cm. The Pringle manoeuvre was never used. CONCLUSIONS: Left lateral segmentectomy can be routinely performed laparoscopically in the absence of any contraindications. This intervention can be accurately performed respecting the limits of oncological security. The results obtained in our center are in accordance with the literature and emphasize the advantages of the minimal invasive approach. On a medium and long term, the results are comparable with those obtained in open surgery.

[Thoracoscopic sympathectomy for vascular disorders of the upper limbs: preliminary results]. / Simpatectomia toracoscopica înalta pentru afectiuni vasculare ale membrelor superioare: rezultate preliminare.

Between January 2005-December 2006 we have performed 12 sympathectomies in 10 patients with ischemic hand disease Indication, surgical techniques, and early results were discussed. Thoracoscopic sympathectomy in patients with severe ischemia of upper limb extremities and unsuccessful medical therapy and local care permits optimal symptomatic control and maximum tissue salvage. Because the procedure is minimally invasive, safe, and associated with a low rate of complications, it should be considered earlier in the natural course of this disease as the best therapeutic option.

[Hemodynamic changes induced by positive pressure capnothorax during thoracoscopic thymectomy]. / Consecintele hemodinamice ale aplicarii capnotoraxului cu presiuni pozitive în timectomia toracoscopica.

Low-flow insufflation of CO2 into the thorax helps the surgeon by increasing the surgical field during thoracoscopy, but older studies performed on animals (pigs and dogs) showed that positive pressure capnothorax had negative hemodynamic impact on animals and strongly recommended against using it on humans. We included in our study 24 ASA I-II myasthenic patients (20 females and 4 males) age 29 yo (+/- 10.2) weight 62.8 kg (+/- 10.6) whose thymuses were surgically removed by thoracoscopy. Using thoracic electrical bioimpedance (TEB) we assessed noninvasively cardiac index (CI) stroke index (SI) systemic stroke vascular resistance index (SSVRI) and end diastolic index (EDI). Well known for its hemodynamic stability we chose sevoflurane for induction and maintenance of anesthesia (VIMA). According to Copenhagen scale, adding minimal iv dose of fentanyl (3 mcg/kg) to sevoflurane induction, allowed us to endobronchial intubate in good and excellent conditions. During anesthesia almost all measured parameters (CI, SI, MAP, EDI) recorded statistically significant decrease but with minimal clinical significance. Thus, the maximal drop was measured during application of 10 mm Hg capnothorax: CI and SI dropped by 1.16 1/min/m2 (19%) (p = 0.02) and respectively 16.58 ml/m2 (21%) (p = 0.001). Thereby we are applying low-flow positive pressure insufflation of CO2 into the thorax, to almost all thoracoscopies performed in our clinic.