Revision bariatric surgery: laparoscopic conversion of failed gastric bypass to biliopancreatic diversion with duodenal switch.

With more than 40% failures of gastric bypass in Body Mass Index>50 kg/m2, a successful alternative has to be proposed. Laparoscopic conversion of failed Roux-en-Y gastric bypass to biliopancreatic diversion with duodenal switch is technically feasible, safe and can be performed in 1 or 2 stages. This revision surgery is the most effective treatment to date, and should also be proposed for failed vertical-banded gastroplasty, adjustable gastric banding and Magenstrasse and Mill procedure, as it may provide the most durable weight loss of all revision surgeries with acceptable morbidity. This may result in lesser degrees of hypoproteinemia, commonly seen after distal gastric bypass.

A prospective multicenter study of 163 sleeve gastrectomies: results at 1 and 2 years.

BACKGROUND: Good results obtained after laparoscopic sleeve gastrectomy (LSG), in terms of weight loss and morbidity, have been reported in few recent studies. Our team has designed a multicenter prospective study for the evaluation of the effectiveness and feasibility of this operation as a restrictive procedure. METHODS: From January 2003 to September 2006, 163 patients (68% women) with an average age of 41.57 years, were operated on with a LSG. Indications for this procedure were morbid obese [body mass index (BMI)>40 kg/m2] or severe obese patients (BMI>35 kg/m2) with severe comorbidities (diabetes, sleep apnea, hypertension...) with high-volume eating disorders and superobese patients (BMI>50 kg/m2). RESULTS: The average BMI was 45.9 kg/m2. Forty-four patients (26.99%) were superobese, 84 (51.53%) presented with morbid obesity, and 35 (21.47%) were severe obese patients. Prospective evaluations of excess weight loss, mortality, and morbidity have been analyzed. Laparoscopy was performed in 162 cases (99.39%). No conversion to laparotomy had to be performed. There was no operative mortality. Perioperative complications occurred in 12 cases (7.36%). The reoperation rate was 4.90% and the postoperative morbidity was 6.74% due to six gastric fistulas (3.66%), in which four patients (2.44%) had a previous laparoscopic adjustable gastric banding. Long-term morbidity was caused by esophageal reflux symptoms (11.80%). The percentage of loss in excessive body weight was 48.97% at 6 months, 59.45% at 1 year (120 patients), 62.02% at 18 months, and 61.52% at 2 years (98 patients). No statistical difference was noticed in weight loss between obese and extreme obese patients. CONCLUSIONS: The sleeve gastrectomy seems to be a safe and effective restrictive bariatric procedure to treat morbid obesity in selected patients. LSG may be proposed for volume-eater patients or to prepare superobese patients for laparoscopic gastric bypass or laparoscopic duodenal switch. However, weight regained, quality of life, and evolution ofmorbidities due to obesity need to be evaluated in a long-term follow up.

Symptomatic internal hernias after laparoscopic bariatric surgery.

BACKGROUND: The aim of this study was to describe the occurrence and clinical characteristics of symptomatic internal hernias (IH) after laparoscopic bariatric procedures. METHODS: We conducted a retrospective review of cases of IH after 1,064 laparoscopic gastric bypasses (LGB) and biliopancreatic diversions with duodenal switch (LBPD-DS) performed from September 1998 to August 2002. RESULTS: We documented 35 cases of IH (overall incidence of 3.3%). The IH occurred in 6.0% of patients with retrocolic procedures and 3.3% of patients with antecolic procedures. Most were in the Petersen defect (55.9%) and at the enteroenterostomy site (35.3%). A bimodal presentation was observed, with 22.9% of patients with IH diagnosed in the early postoperative period (2-58 days) and 77.1% in a delayed fashion (187-1,109 days). A laparoscopic approach to the repair of IH was possible in 60.0% of patients. Complications occurred in 18.8% of patients, including one death (2.9%). CONCLUSION: Complete closure of all mesenteric defects is strongly recommended during laparoscopic bariatric procedures to avoid IH and their associated complications.

Surgery of the adrenal glands.

Because widespread use of imaging techniques has led to the frequent detection of incidentalomas, radiologists, endocrinologists, and endocrine surgeons must be knowledgeable about the appropriate evaluation of patients, and the selection of the appropriate surgical approach, including conventional open and laparoscopic adrenalectomy. This article reviews the authors' preferences based on experience with nearly 200 laparoscopic adrenalectomies.

Early results of laparoscopic biliopancreatic diversion with duodenal switch: a case series of 40 consecutive patients.

BACKGROUND: Biliopancreatic diversion with duodenal switch (BPD-DS) is an operation which provides one of the greatest maintained weight losses of any bariatric procedure. We looked at the safety and efficacy of laparoscopic BPD-DS for morbid obesity. METHODS: A 150-200 ml sleeve gastrectomy was created and anastomosed to the distal 250 cm of divided ileum. The median length of the common channel was 100 cm. All patients were prospectively followed up to 12 months. RESULTS: 40 consecutive patients underwent laparoscopic BPD-DS as a primary procedure for morbid obesity. Median patient body mass index (BMI) was 60 kg/m2 (range 42-85 kg/m2). Mean age was 43 +/- 1 years (+/- SEM), with 12 males and 28 females. One patient was converted to open laparotomy (2.5%). Median operative time was 210 +/- 9 minutes (range 110-360 minutes) with a significant correlation between BMI and operative time (p = 0.04). Median length of stay was 4 days (range 3-210 days). There was one 30-day mortality (2.5%). Major morbidities occurred in 6 patients (15%), including 1 anastomotic leak (2.5%), 1 venous thrombosis (2.5%), 4 staple-line hemorrhages (10%) and 1 subphrenic abscess (2.5%). Median follow-up at 6 months (range 1-12 months) resulted in 46% +/- 2% excess weight loss (EWL) and at 9 months 58% +/- 3% EWL. CONCLUSION: Laparoscopic BPD-DS is a complex, yet feasible, procedure resulting in effective weight loss with an acceptable morbidity. A BMI >65 was associated with increased morbidity and mortality. A long-term study is needed to confirm efficacy and proper patient selection.

Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient.

BACKGROUND: Surgical management of the supersuper obese patient (BMI >60 kg/m2) has been a challenging problem associated with higher morbidity, mortality, and long-term weight loss failure. Current limited experience exists with a two-stage biliopancreatic diversion and duodenal switch in the supersuper obese patient, and we now present our early experience with a two-stage gastric bypass for these patients. METHODS: We completed a retrospective bariatric database and chart review of super-super obese patients who underwent laparoscopic sleeve gastrectomy as a first-stage procedure followed by laparoscopic Roux-en-Y gastric bypass as a second-stage for more definitive treatment of obesity. RESULTS: During a two-year period, 7 patients with BMI 58-71 kg/m2 underwent a two-stage laparoscopic Roux-en-Y gastric bypass by two surgeons at the Mount Sinai Medical Center. 3 patients were female, 4 patients were male, and the average age was 43. Prior to the sleeve gastrectomy, the mean weight was 181 kg with a BMI of 63. Average time between procedures was 11 months. Prior to the second-stage procedure, the mean weight was 145 kg with a BMI of 50 and average excess weight loss of 37 kg (33% EWL). Six patients have had follow-up after the second-stage procedure with an average of 2.5 months. At follow-up the mean weight was 126 kg with a BMI of 44 and average excess weight loss of 51 kg (46% EWL). The mean operative times for the two procedures were 124 and 158 minutes respectively. The average length of stay for all procedures was 2.7 days. 4 patients had 5 complications, which included splenic injury, proximal anastomotic stricture, left arm nerve praxia, trocar site hernia, and urinary tract infection. There were no mortalities in the series. CONCLUSIONS: Laparoscopic sleeve gastrectomy with second-stage Roux-en-Y gastric bypass are feasible and effective procedures based on short-term results. This two-stage approach is a reasonable alternative for surgical treatment of the high-risk supersuper obese patient.

A biodegradeable membrane from porcine intestinal submucosa to reinforce the gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass: preliminary report.

BACKGROUND: A Silastic ring has been used to prevent dilation of the gastrojejunostomy in Roux-en-Y gastric bypass (RYGBP). The use of a bio-membrane may prevent dilation of the anastomosis without the risks associated with prostheses. The aim of this study was to evaluate the feasibility and safety of applying such a bio-membrane around the gastrojejunostomy in Laparoscopic RYGBP (LRYGBP). METHODS: We used a new bio-membrane, that is derived from porcine small intestinal submucosa (SIS) and acts as a scaffolding for the ingrowth of connective tissue. Over a 4-month period, 14 LRYGBP patients had their proximal anastomosis wrapped with 10 x 2.5 cm SIS by a single surgeon. We compared these patients to a control group of LRYGBP patients matched for BMI. RESULTS: The average age of the patients was 35.0 years (control group: 45.1 years). The patients had a mean initial BMI of 44.7 kg/m2 (+/- 5.9) standard error, and the control subjects had a mean initial BMI of 46.7 kg/m2 (+/- 6.5). SIS application took a mean time of 11 (+/- 3) minutes without any intraoperative complication. The median hospital stay was 3.5 days in the experimental group and 3.7 days in controls. Three patients developed a symptomatic stenosis at the gastrojejunostomy following surgery. In the control group there were two stenoses. At an average follow-up of 87 days (controls: 95 days), the mean reduction in BMI was 7.8 (+/- 0.8) kg/m2 [controls 8.6 kg/m2 (+/- 1.5)]. CONCLUSION: Application of SIS around the gastrojejunostomy in patients undergoing LRYGBP is feasible and safe. Further follow-up is required, however, to evaluate the effectiveness in preventing dilation of the anastomosis.

The effect of interleukin-1 and interleukin-2 on the adrenergic control of hormone-sensitive lipase in the human adipocyte.

The effect of interleukin-1 and interleukin-2 on lipolysis and the adrenergic control of lipolysis was studied. Biopsy specimens of human adipose tissue were incubated in media containing 3H-palmitate and 14C-glucose, and the ratio of these isotopes was used to determine adipocyte lipolysis. Isoproterenol, clonidine, and theophylline were used in the media to stimulate the beta 1- and alpha 2-receptors and the subreceptor mechanism, respectively. Interleukin-1 had no effect on basal lipolysis, and at maximal receptor stimulation, it had no effect on the adrenergic receptor control of lipolysis. Interleukin-2 had no effect on basal lipolysis or on the beta-adrenergic receptor. Interleukin-2 significantly (p less than 0.02) decreased the alpha 2-inhibition of lipolysis by 68%. The effect of interleukin-2 on the alpha-receptor was demonstrated to be a significant 45% decrease (p less than 0.03) in the receptor responsiveness (a measure of the postreceptor mechanism) with no alteration in receptor sensitivity (a measure of receptor number). This data suggest that interleukin-2 stimulates lipolysis by decreasing the alpha 2-adrenergic inhibition of hormone-sensitive lipase.

Early experience with laparoscopic resections of islet cell tumors.

BACKGROUND: Diagnostic laparoscopy and laparoscopic ultrasonography have been applied recently for diagnosis and localization of islet-cell tumors. A further step was taken by performing resection of these tumors with laparoscopic techniques. METHODS AND RESULTS: We studied a retrospective series of 12 patients operated on with laparoscopic techniques since January 1992. The seven female and five male patients had a mean age of 43 years. The mean tumor size was 3 cm. Thirty-six percent of the tumor site could not be identified before operation. Eight patients underwent planned laparoscopic distal pancreatectomy (five insulinomas, two gastrinomas, and one unknown origin), and four underwent planned laparoscopic enucleation (one insulinoma and three unknown origin). Of the eight distal procedures, three had conversions (one inability to localize the tumor and two metastatic gastrinomas). Average operating time was 4.5 hours, with an average hospital stay of 5 days. Of the four explorations for possible enucleation, one was performed and one was converted to a Whipple procedure for nesidioblastoma of the head of the pancreas. The other two had negative explorations. The successful enucleation of an insulinoma of the anterior body of the pancreas was performed in 3 hours, and the hospital stay was 4 days. No recurrence was seen in the enucleated or distal pancreatectomy group in follow-up (15 to 38 months). CONCLUSIONS: Laparoscopic enucleation or resection of benign islet tumors results in a shorter hospital recovery and is a good alternative to open surgery.

Is laparoscopic adrenalectomy indicated for pheochromocytomas?

BACKGROUND: Since the introduction of laparoscopic adrenalectomy there has been major concern about proper indications for its use, including in pheochromocytoma. In this study we reviewed pheochromocytomas resected by means of laparoscopy to establish that procedure's usefulness. METHODS: Between January 1992 and June 1995, 90 laparoscopic adrenalectomies were performed in 82 patients. Three to five trocars were used intraperitoneally in each patient to remove the gland, and extraction was performed with a sterile plastic bag. RESULTS: Twenty-three pheochromocytomas were operated on. Six patients had a bilateral adrenalectomy. Pheochromocytomas were significantly larger than other tumors, required more operating time, and necessitated longer hospital stays in patients. Of all the intraoperative complications 87% occurred in the pheochromocytoma group; 67% of all postoperative complications occurred in this group. In four patients metastasis from pheochromocytoma to the liver was unexpectedly found, and in one case metastasis from a medullary thyroid carcinoma was found. There has been no local recurrence after laparoscopic adrenalectomy. CONCLUSIONS: Laparoscopic adrenalectomy for pheochromocytomas is difficult because tumors are larger and more complications are seen related to their hormonal secretions, in spite of adequate pharmacologic blockade. However, metastatic extensions can be diagnosed and laparoscopic ablation can be performed in most instances without recurrence. It is not, therefore, a contraindication for this approach.

Pancreaticobronchial fistula causing lung abscess: case report and brief discussion of the literature.

A case report of a patient with an abscess of the lung caused by a pancreaticobronchial fistula is presented. The patient was treated by pulmonary resection and distal pancreatectomy-splenectomy.

The role of intraoperative ultrasonography during laparoscopic adrenalectomy.

BACKGROUND: The role of laparoscopic intraoperative ultrasonography (IOUS) in intraoperative decision making has grown rapidly in recent years. The purpose of this study was to evaluate its usefulness during laparoscopic adrenalectomy. METHODS: Since 1995, laparoscopic ultrasonography has been used to evaluate the adrenal gland and surrounding organs in selective laparoscopic adrenalectomies. IOUS was performed in 19 of 114 laparoscopic adrenalectomies. RESULTS: IOUS effected a change in management in 68% of these patients. IOUS displayed the location of the gland after a failed attempt at open resection; the adrenal vein, expediting control in four operations; no extraadrenal involvement by two large lesions (benign); vascular invasion in one tumor (carcinoma), prompting open resection; periadrenal invasion by one metastatic cancer and lymph node involvement in another; a 7 mm hyperaldosteronoma; no adenoma in two cases; bilateral hyperplasia; and a 14 cm cyst originating from the adrenal gland. IOUS facilitated partial adrenalectomy in two patients and revealed centrally located adenomas in two others requiring total adrenalectomy. CONCLUSIONS: Laparoscopic IOUS during adrenal operation is valuable in selected cases. It is helpful to locate the gland and vein, confirm the presence or absence of abnormality, discern the resectability of large masses, and facilitate a partial adrenalectomy when desirable.

Analysis of morbidity and mortality rates in right hepatectomy with the preoperative APACHE II score.

Morbidity and mortality rates in 70 patients who underwent major liver resection for liver tumors (primary and metastatic) were determined and correlated with the preoperative APACHE II score. Patients were divided into three groups according to their preoperative APACHE II score: low (0 to 3), mid (4 to 7), and high (8 and above). A higher score was closely correlated with increased postoperative morbidity and operative mortality rates. The group with low scores had a postoperative morbidity rate of 34% and a mortality rate of 0%, the group with mid scores had a postoperative morbidity rate of 54% and a mortality rate of 3%, and the group with high scores had a postoperative morbidity rate of 80% and a mortality rate of 20%. Age did not correlate with morbidity. It was therefore postulated that morbidity and mortality rates were related to the combination of points for abnormal physiologic variables and points for chronic health, or APACHE II score minus points for age. As the combination of these points increases the postoperative morbidity and operative mortality rates increase significantly (from 24% in the 0-point group to 69% in the greater than or equal to 3-point group). Also the two deaths occurred in the group with 3 or more points. The preoperative APACHE II score may be used by clinicians to evaluate before surgery the risk of postoperative morbidity and death in elective major liver surgery.

Endoscopic endocrine neck surgery with carbon dioxide insufflation: the effect on intracranial pressure in a large animal model.

BACKGROUND: Endoscopic endocrine neck surgery requires insufflation with carbon dioxide (CO(2)) at 10 to 15 mm Hg, which may decrease the cerebral venous return and increase intracranial pressure. This study evaluated the effect of CO(2) neck insufflation on intracranial pressure (ICP) and hemodynamic parameters. METHODS: Fifteen pigs underwent endoscopic thyroid dissection. Insufflation was performed with CO(2) at 0 (sham), 10, 15, and 20 mm Hg and with helium at 20 mm Hg with 3 pigs in each group. ICP, mean arterial pressure, central venous pressure (CVP), cardiac output, and blood gas were measured at baseline, 30, 60, and 120 minutes. RESULTS: There were no differences in mean ICP between the sham group and CO(2) insufflation at 10 mm Hg. Mean ICP increased significantly with CO(2) at 15 and 20 mm Hg and with helium at 20 mm Hg. A significant increase in CVP occurred in pigs operated with CO(2) at 20 mm Hg. We observed jugular vein collapse under all insufflation pressures; however, pigs operated at 10 mm Hg were able to maintain an intermittent blood flow. CONCLUSIONS: A severe increase in ICP occurs with insufflation pressures higher than 15 mm Hg, possibly as a result of decreased cervical venous blood flow. Carbon dioxide insufflation up to 10 mm Hg does not alter ICP and is recommended for clinical application in endoscopic neck surgery.

Early experience with laparoscopic approach for adrenalectomy.

BACKGROUND: Adrenalectomy performed by a posterior or transabdominal approach causes substantial postoperative pain. The purpose of this study was to evaluate laparoscopy as a potential approach for adrenalectomy. METHODS: We performed 25 consecutive laparoscopic adrenalectomies on 22 patients from April 1, 1992, to March 30, 1993. Laparoscopic surgery was performed by using a lateral decubitus flank approach with four 11 mm trocars. RESULTS: Twelve right and 13 left adrenal glands were removed in a mean time of 2.3 hours. Three patients underwent bilateral adrenalectomies in a mean time of 5.3 hours. The 15 women and 7 men range in age from 31 to 60 years (mean, 42 years). The adrenal gland diseases were nonfunctional adenoma (seven), pheochromocytoma (five), Cushing's disease (four), Cushing's adenoma (four), primary aldosteronism (two), dehydroepiandrostenedione sulfate hypersecretion (one), angiomyolipoma (one), and medullary cyst (one). Average tumor size was 4.1 cm (range, 1 to 15 cm). Laparoscopic adrenalectomy was successful in 96% of patients, with one patient requiring a laparotomy because of inadequate exposure. The median postoperative stay was 4 days (range, 2 to 19), with a mean of five narcotic injections. There were no deaths, and morbidity was minor. CONCLUSIONS: Laparoscopy can be used successfully for adrenalectomy. It produces less postoperative pain and rapid return to normal activity. It may be the preferred method for removing most adrenal gland lesions that require operation.

Laparoscopic inferior and superior lumbar hernia repair.

Lumbar hernias are rare defects that involve the extrusion of retroperitoneal fat or viscera through a weakness in the posterior abdominal wall. Repairing these hernias is often difficult because of the weakness of the surrounding structures. Techniques for reconstruction usually include an incision from the 12th rib to the iliac crest with mobilization of local flaps or onlay fascial flaps or the use of prosthetic mesh. Contemporary reports have advocated extensive retroperitoneal dissection with the placement of permanent mesh extraperitoneally. We have recently repaired an extensive, primary lumbar hernia laparoscopically, securing the mesh to the 12th rib superiorly, iliac crest inferiorly, erector spinae fascia medially, and external oblique fascia laterally. The patient resumed normal activities in less than 2 weeks; 4 months postoperatively, he seems to have a solid repair. To our knowledge, this is the first report of this technique.

Arterial PCO2 and cardiovascular function during endoscopic neck surgery with carbon dioxide insufflation.

BACKGROUND: Endoscopic parathyroidectomy and thyroidectomy were introduced into clinical practice in 1995. Concerns about the use of carbon dioxide insufflation in the neck exist owing to reports of potential adverse metabolic and hemodynamic changes. HYPOTHESIS: Carbon dioxide insufflation in the neck may cause adverse effects on hemodynamic and blood gas levels. These adverse effects may reflect the level of pressure and duration of insufflation. METHODS: Fifteen pigs, 5 per group, underwent endoscopic thyroidectomy at 10, 15, and 20 mm Hg. Partial pressure of carbon dioxide (arterial), pH, cardiac output, central venous pressure, heart rate, and mean arterial pressure (MAP) were measured at baseline, 1 and 2 hours after carbon dioxide insufflation, and 30 minutes after desufflation. RESULTS: At 10 mm Hg, PaCO2 increased slightly but not significantly, and neither acidosis nor adverse hemodynamic changes were observed. Hypercarbia, moderate acidosis, and a slight increase in MAP occurred in pigs undergoing surgery at 15 mm Hg (MAP increased to 88 +/- 2.4 mm Hg from a baseline value of 78 +/- 3.53 mm Hg; P<.05). Pigs undergoing surgery at 20 mm Hg experienced severe hypercarbia and acidosis, as well as a significant decrease in MAP (P<.05). Central venous pressure decreased at 1 hour (P<.05) and increased at 2 hours (P<.05) in pigs undergoing surgery at 15 and 20 mm Hg. After desufflation, PaCO2 and pH levels were normal for the 10 and 15 mm Hg groups, while pigs undergoing surgery at 20 mm Hg developed a higher degree of hypercarbia and acidosis (P =.001). CONCLUSIONS: Carbon dioxide neck insufflation is safe at 10 mm Hg. The use of insufflation pressures higher than 15 mm Hg should be avoided due to the potential risk for metabolic and hemodynamic complications.

Manual vs robotically assisted laparoscopic surgery in the performance of basic manipulation and suturing tasks.

OBJECTIVE: To compare the surgical performance of manual and robotically assisted laparoscopic instruments on basic maneuvers and intracorporeal suturing in inanimate models. DESIGN: A set of laparoscopic tasks was used to evaluate basic endoscopic movements and intracorporeal suturing: positioning a cylinder on a Peg-Board, dropping beads into receptacles, running a 25-cm rope, and capping a hypodermic needle. Intracorporeal knot tying and running a suture through predetermined points were evaluated separately. The sutures used for these tasks were 2-0 and 4-0 silk and 6-0 and 7-0 polypropylene. PARTICIPANTS: Twenty surgeons completed the set of laparoscopic tasks manually and then with a robotically assisted system. None had used the robotic system before. MAIN OUTCOME MEASURES: Time required to complete the tasks and the precision in performing them. RESULTS: The robotic system accurately reproduced the movements of the surgeons and filtered their hand tremors efficiently. In the basic tasks, operative times were significantly longer for the robotic system (P<.001). In the suturing tasks, operative times were longer with the use of the robotic system for sutures sizes 2-0 and 4-0 (P<.001). However, time differences were not significant for suture sizes 6-0 and 7-0 (P> or =.07). Precision measurements were similar for all tasks using the manual instruments and the robotically assisted system. No significant differences were found between the performance of advanced laparoscopic surgeons and laparoscopic fellows. CONCLUSIONS: Laparoscopic maneuvering and suturing is faster and just as precise when performed manually as when performed with the prototype robotic system. These differences in speed are inversely proportional to the size of the suture. Future generations of the robotic system may eliminate these differences.

Laparoscopic cryoablation of hepatic metastases.

OBJECTIVE: To evaluate the feasibility of laparoscopic cryoablation for the management of hepatic metastases. DESIGN: Retrospective review. SETTING: Tertiary referral center. PATIENTS: Nine patients were evaluated by laparoscopy for planned laparoscopic cryoablation of hepatic metastases at The Cleveland Clinic Foundation, Cleveland, Ohio, from April 1996 to May 1997. RESULTS: Laparoscopic exploration revealed diffuse extrahepatic disease not identified by preoperative studies in 2 patients. The remaining 7 patients underwent 9 cryotherapy sessions. During 4 of the cryotherapy sessions, ultrasonography demonstrated unrecognized additional treatable hepatic lesions. An average of 3 lesions (range, 2-5) were treated. Operative time averaged 3.5 hours with a mean intraoperative blood loss of 235 mL. One patient had significant intraoperative hemorrhage requiring conversion to open hepatic resection for bleeding control. Eight of the 9 patients tolerated normal diets and ambulated independently on the first postoperative day. Following cryotherapy, 4 of the patients developed fever without an infectious source. One patient developed a postoperative bile leak requiring percutaneous biliary stenting. Postoperative hospital stay averaged 4.5 days (median, 4 days; range, 2-14 days). At a mean follow-up of 9 months, 4 of the 7 patients treated are alive without evidence of disease, 2 are alive with disease, and 1 patient with a pancreatic primary tumor has died of disease. CONCLUSIONS: Laparoscopy with laparoscopic ultrasonography is a useful tool in evaluating patients with hepatic metastases. Laparoscopic cryoablation is feasible and may result in lower postoperative morbidity in patients receiving aggressive treatment for inoperable hepatic metastases.

Catheter-assisted totally thoracoscopic coronary artery bypass grafting: a feasibility study.

BACKGROUND: The purpose of this study is to examine the feasibility of performing totally thoracoscopic internal mammary-to-coronary artery bypass grafting with the assistance of radiologically guided catheter intervention. METHODS: Fourteen dogs were subjected to mobilization of the internal mammary artery and anastomosis of it to the left anterior descending coronary artery over an angiographic catheter inserted into the internal mammary artery under fluoroscopy. The anastomosis was completed over the catheter using sutures and the application of fibrin glue. Eight animals underwent the anastomosis after their sacrifice. The other 6 animals were put on closed chest cardiopulmonary bypass and had their anastomosis done after intraaortic balloon occlusion and cardioplegic arrest of the heart. All animals had an angiographic and pathologic examination at the completion of the anastomosis. RESULTS: Anastomosis was completed in all dogs. Three anastomoses leaked and two were noted to be stenosed at completion of the anastomosis. One leak was sealed by application of fibrin glue. Both stenotic anastomoses were caused by suturing of the back wall when a short angiographic catheter could not be positioned across the anastomosis. CONCLUSIONS: Minimally invasive totally thoracoscopic mammary-to-coronary artery bypass grafting with catheter assistance is feasible. Technical improvement and appropriate instrumentation are required to minimize anastomotic failure.