Successful patient-oriented surgical outcomes in robotic vs laparoscopic right hemicolectomy for cancer - a systematic review.

AIM: Minimally invasive surgical approaches for cancer of the right colon have been well described with significant patient and equivalent oncological benefits. Robotic surgery has advanced in its ability to provide multi-quadrant abdominal access, leading the surgical community to widen its application outside of the pelvis to other abdominal compartments. Globally it is being realized that a patient's surgical episode of care is becoming the epicentre of cancer treatment. In order to establish the role of robotic surgery in a patient's episode of care, 'successful patient-oriented surgical' parameters in right hemicolectomy for malignancy were measured. The objective was to examine the rates of successful patient-oriented surgical outcomes in robotic right hemicolectomy (RRH) compared to laparoscopic right hemicolectomy (LRH) for cancer. METHODS: A systematic search of MEDLINE (Ovid: 1946-present), PubMed (NCBI), Embase (Ovid: 1966-present) and Cochrane Library was conducted using PRISMA for parameters of successful patient-oriented surgical outcomes in RRH and LRH for malignancy alone. The parameters measured included postoperative ileus, anastomotic complication, surgical wound infection, length of stay (LOS), incisional hernia rate, conversion to open, margin status, lymph node harvest and overall morbidity and mortality. RESULTS: There were 15 studies which included 831 RRH patients and 3241 LRH patients, with a median age of 62-74 years. No study analysed the concept of successful patient-oriented surgical outcomes. There was no significant difference in the incidence of postoperative ileus, with less time to first flatus in RRH (2.0-2.7 days, compared with 2.5-4.0 days, P < 0.05). Anastomotic leak rate in one study reported a significant increase in LRH compared to RRH (P < 0.05, 0% vs 8.3%). Significantly decreased LOS following RRH was outlined in six studies. One study reported a significantly higher rate of incisional hernias following LRH with extracorporeal anastomoses compared to RRH with intracorporeal anastomoses. Overall rates of conversion to open surgery were less with RRH (0%-3.9% vs 0%-18%, P < 0.001, 0.05). One study outlined significantly higher rates of incomplete resection with an open right hemicolectomy compared with minimally invasive laparoscopic and robotic resections, with positive margin rates of 2.3%, 0.9% and 0% respectively (P < 0.001). Two studies reported significantly higher lymph node harvest in RRH (P < 0.05). Overall morbidity and 30-day mortality were comparable in both approaches. CONCLUSION: Thirty-day morbidity and mortality were comparable between the two approaches, with patients undergoing RRH having lower anastomotic complications, increased lymph node harvest, and reduced LOS, conversion to open and incisional hernia rates in a number of studies. There are limited data on surgical approach and impact on quality of life and what patients deem successful surgical outcomes. There is a further need for a randomized controlled trial examining successful patient-oriented outcomes in right hemicolectomy for malignancy.

Medullary thyroid carcinoma in multiple endocrine neoplasia types 2A and 2B.

BACKGROUND: Considerable emphasis has been placed on early diagnosis and surgery for multiple endocrine neoplasia (MEN)-related medullary thyroid carcinoma (MTC) during the past two decades. Genetic screening now promises earlier and more accurate diagnosis. We examine our experience with MTC in MEN 2A and MEN 2B and assess the benefits of biochemical screening during the past 20 years. PATIENTS AND METHODS: Seventy-seven patients undergoing 63 primary total thyroidectomies and 14 reoperative procedures for MEN-related invasive MTC and/or preinvasive C-cell hyperplasia are reported. Fifty-eight patients had MEN 2A and 19 had MEN 2B; 79% of patients had a family history of MTC; 27% had pheochromocytoma, and 25% had hyperparathyroidism. RESULTS: Patients with MEN 2B had more advanced disease than those with MEN 2A, in spite of presentation at a younger age (15 years versus 24 years). Every patient with MEN 2B had invasive carcinoma, whereas 14% of patients with MEN 2A had C-cell hyperplasia without invasive disease. Nodal metastases were found less frequently in MEN 2A (14%) than MEN 2B (38%), and biochemical cure was achieved in 56% of patients with MEN 2A compared with none in patients with MEN 2B. Among patients with MEN 2A the occurrence of invasive carcinoma increased with age (p = 0.0003); 40% of patients for less than 5 years had invasive MTC compared with 100% at more than 20 years. Cause-specific mortality among patients with MEN and invasive tumors at 6, 12, and 18 years was 2%, 4%, and 7%, respectively, lower than that of patients with sporadic MTC (12%, 17%, and 23%, respectively) treated during the same time period (p = 0.028). CONCLUSIONS: Intensive biochemical screening of MEN 2 kindreds for MTC can result in detection of early disease and a significant prospect of surgical cure. Genetic testing promises additional benefits through more reliable detection of preinvasive disease, allowing prophylactic thyroidectomy in infancy. In MEN 2B, MTC is considerably more aggressive than in MEN 2A. A policy of routine thyroidectomy in infants with MEN 2B, regardless of serum calcitonin levels, is justified.

Long-term outcome of bilateral adrenalectomy in patients with Cushing's syndrome.

BACKGROUND: Bilateral adrenalectomy provides an effective surgical option for patients with Cushing's syndrome. Knowledge of the long-term outcome of the patient who has undergone adrenalectomy is an important factor in determining management strategy in this situation. METHODS: Fifty consecutive patients undergoing bilateral adrenalectomy (1980 to 1991) were studied. Twenty-five had Cushing's disease, 18 ectopic adrenocorticotrophic hormone production, and seven primary adrenal hyperplasia. Median age was 43 years (range, 14 to 82 years); male-to-female ratio was 13:37. At follow-up 17 patients had died; the remaining 33 were interviewed at a median of 62 months after operation. RESULTS: Operative mortality was 4%. Late mortality included two patients with Cushing's disease who died of progressive pituitary disease and eight patients with ectopic adrenocorticotrophic hormone production who died of metastatic disease. Five-year survival was: 100% for patient with adrenal hyperplasia, 86% for patients with Cushing's disease, and 39% for patients with ectopic adrenocorticotrophic hormone production. Of 33 survivors followed for a median of 62 months, three (9%) were hospitalized with acute steroid deficiency. The principal complaint among survivors was chronic fatigue (60%). Only 10 (30%) patients had no symptoms. No steroid-related complications resulted after 16 surgical procedures subsequently performed. Of 20 survivors of Cushing's disease, three had Nelson's syndrome. CONCLUSIONS: Bilateral adrenalectomy for Cushing's syndrome is associated with occasional morbidity and mortality consequent to adrenal insufficiency. These patients suffered a high incidence of chronic physical complaints that may reflect the residual sequelae of chronic Cushing's syndrome. An active program of long-term rehabilitation is essential.

Multiple endocrine neoplasia type 2B: more than an endocrine disorder.

BACKGROUND: Multiple endocrine neoplasia type 2B (MEN 2B) is a rare disorder differentiated from MEN 2A primarily by its extraendocrine features. This report describes the clinical spectrum and outcome of MEN 2B. METHODS: Twenty-one patients underwent operation for manifestations of MEN 2B between 1970 and 1993. Median follow-up was 16.9 years. Diagnosis was made through family screening in nine, the development of medullary thyroid carcinoma (MTC) in seven, phenotypic features in four, and constipation in one. Median age at presentation of colonic dysfunction, MTC, and pheochromocytoma was 0.1, 16, and 28 years, respectively. RESULTS: Every patient had MTC. Fifteen (94%) of 16 patients undergoing primary thyroidectomies had multicentric disease, and seven (44%) had nodal metastases. Seven patients (33%) had pheochromocytoma, six bilateral and one malignant. Adrenalectomy was curative in every patient. Nineteen patients (90%) had colonic disturbances, typically chronic constipation from birth. Megacolon developed in 14 patients, and eight required colonic surgery. Every patient had the characteristic phenotype. Dominant features included neuromas of the tongue, buccal mucosa, lips, conjunctivae, and eyelids and a marfanoid habitus. Other features included high arched palate, corneal nerve thickening, and dental and skeletal abnormalities. Four patients died, two of metastatic MTC, one after operation for metastatic MTC, and one as a consequence of colonic perforation. Of 17 survivors, three have hepatic metastases from MTC, eight have nodal metastases, and six are well with normal or mildly elevated calcitonin levels. CONCLUSIONS: MEN 2B is characterized by a relatively aggressive form of MTC, bilateral pheochromocytoma, severe colonic dysfunction, and a multitude of other extraendocrine abnormalities. Early recognition of MEN 2B and early prophylactic thyroidectomy are essential. Colonic dysfunction has previously received little attention, and further investigation of the pathogenesis and treatment of this disorder is warranted.

Surgical management of primary hyperparathyroidism in multiple endocrine neoplasia types 1 and 2.

BACKGROUND: The surgical management of primary hyperparathyroidism in multiple endocrine neoplasia type 1 (MEN 1) remains controversial. In addition, the rarity of MEN 2A-related hyperparathyroidism has not allowed for a separate strategy for this condition. This study examines our surgical experience with MEN 1- and MEN 2A-related hyperparathyroidism and attempts to define a rational therapeutic approach to each. METHODS: Between 1970 and 1991, 124 patients underwent surgery for MEN-related hyperparathyroidism at our institution. Primary cervical explorations were performed in 84 patients with MEN 1 and 18 with MEN 2A. An additional 22 patients with MEN 1 underwent reoperative surgery. All patients with MEN 2A underwent concomitant thyroidectomy for medullary thyroid cancer. RESULTS: Compared with patients with MEN 1, patients with MEN 2A, had a lower preoperative serum Ca2+ level and fewer symptoms or complications of hypercalcemia. Multiple gland disease was evident in 90% and 83%, respectively, of patients with MEN 1 and MEN 2A. Primary explorations in patients with MEN 1 resulted in surgical cure in 94%, persistent hypercalcemia occurring in no patient undergoing subtotal resection compared with 17% of patients in whom more conservative resections were performed (p = 0.005). In patients with MEN 1, 10-year recurrence of hypercalcemia was 16% for primary explorations and 30% for reoperative procedures. In contrast, all patients with MEN 2A, whether treated by total, subtotal, or lesser resections, were cured after surgery and none had recurrence during a median follow-up of 5.8 years. CONCLUSIONS: In MEN 1 the surgical principles should be (1) identification of all four glands, (2) subtotal resection to ensure cure and facilitate possible reoperation, and (3) excision of supernumerary thymic glands. In MEN 2A we should identify and resect all enlarged glands for cure, but routine subtotal resection need not be performed because this condition is readily cured and recurrence is rare.

Molecular mechanisms of decreased interleukin-2 production after thermal injury.

BACKGROUND: Among the fundamental immunologic abnormalities induced by serious traumatic or thermal injury are alterations in T cell activation, reduced lymphocyte interleukin-2 (IL-2) production, and associated depression of T lymphocyte proliferation. This study attempts to localize the cellular mechanisms underlying abnormal IL-2 production in thermal injury. METHODS: Following National Institutes of Health guidelines, 150 A/J mice were anesthetized, subjected to a 20% full-thickness scald burn injury or sham burn, and killed at intervals from 4 to 21 days later; splenocytes were harvested for in vitro studies. For measurement of IL-2 production, cells were cultured with either concanavalin A or a combination of the phorbol ester PMA, which directly activates protein kinase C, and the calcium ionophore A23187, which increases intracellular calcium. Cytokine mRNA expression was measured by Northern blot analysis and IL-2 production by bioassay. RESULTS: Both IL-2 production and IL-2 mRNA expression were consistently suppressed in concanavalin A-stimulated cells from burned mice compared with sham burns. This suppression of IL-2 and IL-2 mRNA also occurred when T cells were activated with PMA and A23187, bypassing the earlier stages of the signal transduction mechanism. IL-1 beta and tumor necrosis factor-alpha mRNA expression were consistently increased in burned animals, indicating that decreased IL-2 mRNA expression was specific to IL-2 and not representative of a global decrease in cytokine mRNA expression. CONCLUSIONS: These results suggest that the principal cellular abnormalities that result in altered T cell activation and IL-2 production after thermal injury lie downstream of the initiating signal transduction events and before IL-2 gene transcription.

The role of cyclic adenosine monophosphate in the suppression of cellular immunity after thermal injury.

BACKGROUND AND OBJECTIVE: Cyclic adenosine monophosphate (cAMP) is an intracellular second messenger that is known to convey inhibitory signals for T-cell proliferation and function. We investigated the association between this molecule and the profound immunosuppression that accompanies thermal injury. DESIGN: Mice were randomized into two groups: one group was subjected to a 20% full-thickness scald burn; the second to a sham burn (control). The mice were killed on days 4, 7, or 10 after the burn injury and splenocytes were pooled and cultured for 15 minutes in the presence or absence of prostaglandin E2 (PGE2). RESULTS: Levels of cAMP in splenocytes were significantly elevated on day 7 after burn in the burn group compared with the sham controls (P < .05, Wilcoxon Rank Sum Test). Incubation of splenocytes with PGE2 resulted in significantly greater levels of intracellular cAMP in cells from the burn group compared with controls on days 4, 7, and 10. Incubation of normal splenocytes with dibutyryl cAMP in the presence of concanavalin A significantly decreased cell proliferation and the production of interleukin-2. The decrease in interleukin-2 production was evident at the level of messenger RNA expression. Stimulation of splenocytes with a combination of phorbol ester and calcium ionophore, bypassing all membrane-associated events prior to protein kinase C activation, reversed the inhibitory effects of dibutyryl cAMP. Incubation of splenocytes from burned animals with H-8, a selective inhibitor of cAMP-dependent protein kinases, restored the proliferative response to that of sham controls on days 4, 7, and 10 after thermal injury. CONCLUSIONS: These data indicate that elevated levels of intracellular cAMP, combined with an increased production of cAMP in response to circulating PGE2, may play a fundamental role in suppression of the immune response following thermal injury and that cAMP exerts its immunomodulatory effects prior to protein kinase C activation.

Interleukin-2 receptor expression and function following thermal injury.

BACKGROUND/OBJECTIVE: Serious traumatic or thermal injury is associated with depression of cellular immunity, including the failure of T-lymphocyte proliferation in response to stimulation that depends both on production of interleukin-2 (IL-2) and on expression of functional IL-2 receptors (IL-2R). While decreased IL-2 production following thermal injury is undisputed, the status of IL-2R expression and function in this setting is controversial; therefore, we sought to investigate this issue. DESIGN: A total of 220 male A/J mice (n = 22 per group) were subjected to a 20% scald burn injury or sham burn, killed 4, 7, 10, 14, or 21 days later, and splenocytes harvested. In vitro parameters of both IL-2R expression and function were measured. RESULTS: On day 7, splenic lymphocyte proliferation and IL-2 production in response to mitogenic stimulation were both suppressed following burn injury to 50% and 60% of controls, respectively. Northern blot analysis revealed normal IL-2R p55 messenger RNA expression in response to mitogenic stimulation on days 7, 10, and 14 in thermally injured animals. Phenotypic IL-2R p55 expression in concanavalin A-stimulated CD3+ cells was unchanged following burn injury. Binding of fluorescein-labeled IL-2 to cell membranes was increased in burned animals at days 10 and 14. The addition of IL-2 to cultures of spleen cells from burned mice consistently restored the mitogenic response to that of the controls. CONCLUSIONS: Thermal injury in this model does not result in either quantitative or functional suppression of IL-2R. Suppression of T-cell activation and proliferation, seen following thermal injury, appears primarily related to abnormal IL-2 production.

Second hepatic resection for metastatic colorectal cancer.

We report a case where repeat hepatic resection was successfully performed 3 years after extended right hepatic lobectomy for metastatic colorectal cancer. The patient remains well and disease free 2.5 years after the second hepatic resection.

Polytetrafluoroethylene in above-knee arterial bypass surgery for critical ischemia.

Seventy-one consecutive above-knee polytetrafluoroethylene (PTFE) femoropopliteal arterial bypasses performed between 1981 and 1989 for critical ischemia were followed prospectively to determine graft patency and limb salvage. Cumulative graft patency and limb salvage rates were calculated by life table analysis. Graft patency was 80%, 68%, 55%, 39%, and 39%, and limb salvage 97%, 87%, 84%, 77%, and 77% at 1, 2, 3, 4, and 5 years, respectively. Twenty-nine grafts have occluded with re-emergence of critical ischemia in 14, treated by 5 amputations and 9 reconstructions using autogenous saphenous vein (ASV) in 6 and PTFE in 3. These favorable results are not as good in terms of primary patency as those reported with ASV, but good limb salvage, good early patency, ease of use, and preservation of the saphenous vein for use later have encouraged us toward primary use of PTFE in selected patients. This experience strongly questions the wisdom of an "all autogenous" policy for reconstruction at this level.

A randomized controlled trial of extraperitoneal bupivacaine analgesia in laparoscopic hernia repair.

BACKGROUND: The limited space developed in totally extraperitoneal laparoscopic inguinal hernia repair (TEP) provides the ideal setting for direct instillation of local anesthetic. This study evaluates the efficacy of extraperitoneal bupivacaine analgesia in patients undergoing day-care TEP. METHODS: Fifty-six consecutive patients were randomized to intraoperative extraperitoneal instillation of bupivacaine (n = 29) or normal saline control (n = 27). Patients were blindly assessed on discharge from hospital, at 24 hours, 1 week, and 1 month postoperatively. RESULTS: Compared with controls, patients treated with bupivacaine had lower median (range) visual analogue pain scores on discharge (1.5 [0 to 5.9] versus 3.7 [0.2 to 6.9], P = 0.03), and were more frequently pain free (54% versus 31%, P = 0.078). Although this difference had gone by 24 hours, the bupivacaine group continued to recover faster; stopping analgesia earlier (2 [0 to 7] days versus 3 [0 to 21] days, P = 0.01) and returning to full activity earlier (2.5 [1 to 14] days versus 5 [1 to 21] days, P = 0.013). Of bupivacaine patients 100% were completely satisfied with the procedure compared with 81% of controls (P = 0.02). CONCLUSION: Extraperitoneal bupivacaine minimizes pain following day-care TEP repair, facilitates recovery, and increases patient satisfaction. Benefits persist beyond the pharmacological action of bupivacaine.

Coexistent Hirschsprung's disease and esophageal achalasia in male siblings.

Achalasia of the esophagus developed in two male siblings soon after birth, and they were successfully treated by surgery. Persistent signs resulted in the later diagnosis of Hirschsprung's disease. One required subtotal colectomy and ileoanal anastomosis, and the other is managing well on conservative treatment. Genetic analysis of the genes encoding the RET protooncogene, endothelin-3, and the endothelin-3 receptor did not show any defect. Familial achalasia of the esophagus in combination with Hirschsprung's disease has never been reported.

Colonic pseudo-obstruction following acute pancreatitis.

The purpose of this case presentation is to illustrate the rate association between acute pancreatitis and colonic pseudo-obstruction and to highlight the difficulties of assessing intestinal motility in a defunctioned segment of bowel prior to closure of a defunctioning stoma.

Low potassium cardioplegia: its effect on the incidence of complete heart block following cardiac surgery.

To investigate whether the concentration of potassium ion in cardioplegic solution was related to the incidence of complete heart block in patients undergoing myocardial revascularisation 163 consecutive cases were studied. Cardiac arrest was with St. Thomas' hospital cardioplegic solution in all patients. Ongoing myocardial protection was provided with St. Thomas' hospital solution (potassium concentration 20 mmol/l) in 56 patients (group A) and with Ringer's injection (potassium concentration 4 mmol/l) in 107 patients (group B). These two groups were studied sequentially. The incidence of complete heart block was higher in group A than in group B. Following aortic unclamping, 27 per cent of patients in group A compared to 14 per cent in group B exhibited the phenomenon (p less than 0.05). At the time of weaning from cardiopulmonary bypass the incidence was 20 per cent in group A compared to 10 per cent in group B (p less than 0.1). No differences were demonstrated between the two groups in terms of myocardial recovery, morbidity or mortality.

Duplex imaging of lower limb arterial bypass grafts.

A non-invasive programme of post-operative surveillance and intervention where necessary is essential to optimise results with arterial reconstruction. We report our experience with duplex ultrasonography in the follow-up lower limb arterial bypass grafts. One hundred and three duplex studies were performed in 58 patients with 59 lower limb arterial bypass grafts. Grafts were visualised throughout their length and haemodynamic characteristics including peak systolic velocity (PSV) were measured. Angiography was performed on the basis of any significant anatomical or haemodynamic abnormality on duplex. All grafts were visualised throughout their length with ease. Satisfactory visualisation of 86% of anastomoses was achieved. PSV was found to be the most easily reproducible haemodynamic index and the best indicator of graft function. PSV had a median value of 79 cm/sec and a range of 51-117 cm/sec in normal grafts compared to 26 cm/sec (range 19-42 cm/sec) in grafts with stenosis. Twelve pre-occlusive lesions which were not evident clinically, 5 within and 7 outside the graft, have been detected. Eight have been treated by transluminal angioplasty. Two grafts with stenosis and PSVs of less than 25 cm/sec had occluded by the time angiography was performed 2 weeks later. Duplex is an excellent, non-invasive, and repeatable method of screening of grafts at risk of failure, allowing earlier intervention with improved secondary patency.

Abdominal aortic aneurysms: the importance of elective repair.

Repair of abdominal aortic aneurysms (AAA) is being performed with a progressively lower mortality and morbidity. We reviewed 111 patients who underwent repair of their AAA. Sixty-two were electively repaired and 49 had emergency surgery. Eight patients had cocomitant non-vascular procedures carried out. Operative mortality was 3.2% and 49% for elective and emergency cases respectively. Postoperative complications occurred in 40% of elective cases and 72% of emergency cases, respiratory complications being the most common, occurring in 25% and 40% of elective and emergency cases respectively. Subsequent graft complications occurred in six patients, five following emergency surgery.

Long term results of polytetrafluoroethylene in above knee femoropopliteal bypass for critical ischaemia.

Ninety-six consecutive above-knee femoropopliteal bypasses, using polytetrafluoroethylene (PTFE) preferentially, were performed for limb-threatening ischaemia. Cumulative primary graft patency was 68 per cent, 49 per cent and 36 per cent and limb salvage 93 per cent, 85 per cent and 75 per cent at 1, 3 and 5 yr respectively. As a result of poor long term survival (51 per cent at 5 yr), and the healing of remedial lesions before graft occlusion, 68 patients (72 per cent) required no further intervention. Eighteen secondary bypasses were undertaken, 12 using ipsilateral saphenous vein. In this group of elderly patients with poor life expectancy, where a limited operation is desirable, the use of PTFE provided excellent limb salvage with low morbidity. Although we can no longer justify our continued use of PTFE in every case of critical ischaemia because of its inferior patency to autogenous vein, we continue to use it preferentially in patients whose lifespan is likely to be short and in cases where a remedial lesion is present.