Implantable endoscopic gastric bypass - device and experimental procedure.

Malabsorptive bariatric surgery is an effective treatment option for morbid obesity, but may be associated with complications and side effects. We have developed a new experimental approach to creating a gastric bypass through an intraluminal access. The goal is to reduce postoperative complications and to reduce mid-term side-effects of malabsorptive bypass food passage and to allow easy reversion of the procedure. The new procedure is based on an implantable gastric bypass device, installed by combined transoral flexible and minimally invasive abdominal access. The newly developed device and procedure were studied in a pilot experimental trial in the porcine animal model (n=8). Endpoints were the feasibility of the technical procedure, the ability of the animal to eat and digest food, the implant functionality over the survival period and the absence of major complications over a short-term follow-up (one week). The procedure was technically successful in all eight animals. Animals were able to take in food and water till sacrifice. Four animals had major complications (one abdominal wall dehiscence, one invagination ileus of the small bowel, one dehiscence of the gastro-jejunal anastomosis and one myocardial infarction) and did not complete follow-up. In two cases migration of the device into the stomach was observed. The difference between our experimental technique and the gold standard surgical methods for gastric bypass consists of the endoluminal approach by implanting an intraluminal gastric bypass device. This concept avoids gastric transsection and an additional anastomosis and enables an adjustable food passage between the bypass and the natural duodenal passage. Further long-term follow-up studies are required.

Early (1 hour) post-operative parathyroid hormone (PTH) measurement predicts hypocalcaemia after thyroidectomy: a prospective case-control single-institution study.

The aim of the study was to evaluate the efficacy of parathyroid hormone 1-hour assay for the early prediction of hypoparathyroidism after thyroidectomy. Candidates for total, subtotal, completion thyroidectomy or lobectomy were entered into the study. Pre- and postoperative calcium and parathyroid hormone (1 hour and postoperative day 1 after thyroidectomy) levels and clinical hypocalcaemia were recorded. Patients were divided into 3 groups and 2 subgroups: 1. patients who underwent lobectomy (control group); 2. patients who underwent total thyroidectomy with postoperative hypocalcaemia (2A: asymptomatic patients, 2B: symptomatic patients); 3. asymptomatic patients with normal calcium levels after total thyroidectomy. Of 119 patients, 109 underwent total thyroidectomy and 10 lobectomy. Of the 109 patients submitted to total thyroidectomy, 35 (32.11%) developed postoperative transient hypocalcaemia. Twenty-one patients (19.27%) were asymptomatic and 14 (12.84%) were symptomatic. Parathyroid hormone levels decreased after 1 hour in group 3 (32.98 pg/dl), 2A (9.84 pg/dl) and 2B (7.46 pg/dl). There was no significant difference in parathyroid hormone levels at 1 hour between group 2A and 2B (p = 0.06), but were significantly lower compared to groups 3 and 1 (p < 0.05). Parathyroid hormone levels at 1 hour after total thyroidectomy is a good predictor of early hypocalcaemia. It might be more useful than serum calcium monitoring for the early identification of patients requiring postoperative calcium supplementation.

RFA strongly modulates the immune system and anti-tumor immune responses in metastatic liver patients.

Radiofrequency tumor ablation (RFA) is a therapeutic modality for liver cancer patients inducing localized tumor necrosis with maximal preservation of normal liver parenchyma. We investigated the immunomodulatory effects exerted by RFA treatment in liver cancer patients with metastatic liver lesions (13 patients) or hepatocellular carcinoma (HCC) (4 patients). Analysis of lymphocyte subsets by flow cytometry revealed that after RFA, CD3+ T cells, in particular CD4+, were decreased in metastatic cancer patients, while no change was observed in HCC patients. Moreover, RFA induced trafficking of naïve and memory CD62L+ T cells from circulation to tissues. When characterizing the function of T cells, proliferative response to PHA was strongly increased after 48 h from RFA in metastatic cancer patients. Furthermore, T cells produced IFN-gamma in response to the tumor associated MUC1 antigen. In contrast, humoral immune responses against tumor antigens such as MUC1 and HCV proteins were unaffected by RFA treatment, although increase of circulating B cells was observed only in metastatic cancer patients. These results indicate that RFA application can exert an activating effect on the immune system in metastatic cancer patients, favouring trafficking of lymphocyte subsets and enhancing tumor antigen specific cellular immune responses.

Is digital image plethysmographic (DIP) acquisition a valid new tool for preoperative body composition assessment? A validation by dual-energy X-ray absorptiometry.

BACKGROUND: The increasing incidence of obesity and the wider acceptance of laparoscopic surgery, have lead to a 10-fold increase in bariatric operations in the last 10 years. Widely used indices of obesity (weight and body mass index - BMI) cannot adequately distinguish between fat mass (FM), represented by the sum of kilograms (kg) of lipid, and fat-free mass (FFM), inclusive of lean (kg of proteins), bone (kg of minerals), glycogen, and total body water (TBW), which are important parameters for clinical and physiological studies. METHODS: Anthropometric variables were measured in 19 Caucasian Italian individuals according to standard methods. Body weight (kg) and height (m) were measured, and BMI was calculated as kg/m(2). Body composition was evaluated, with a mean BMI of 25.95+/-5.04 kg/m(2), by dual X-ray absorptiometry (DXA) and by digital image plethysmographic (DIP) acquisition with a digital camera. The clear-colored body of the subjects was automatically converted into a front and lateral red-shaped figure, and then through algorithms the 2 pictures were transformed into a nominal volume; body weight was then divided by the estimated volume, so that the body density could be obtained. DXA was used as a comparison to assess fat mass and fat-free mass. Radiation exposure was <0.6 mSv. RESULTS: Significant positive correlation (R= 0.971, P<0.001) was found between data of body composition obtained by DXA and DIP. CONCLUSIONS: Body volume assessed using DIP or DXA did not differ. According to this validation study, DIP represents a new promising tool for clinical applications.

Minilaparoscopic appendectomy for acute appendicitis.

BACKGROUND: Minilaparoscopic appendectomy for appendicitis is not a well-established procedure. This approach provides less abdominal wall trauma, fewer complications, and excellent cosmetic results. Our aim was to show the feasibility and safety of the minilaparoscopic approach. METHODS: Minilaparoscopic appendectomy was performed in 37 patients. Two 2.2-mm trocars were used to manipulate a 2.2-mm, 0-degree laparoscope and for grasper access. A 5-mm trocar was used for the ultrasonic scalpel. RESULTS: No deaths occurred. In 3 patients (8%), appendectomy was aborted due to pathology of the ovary. Conversion to the open approach occurred in 2.7% of patients. The average operating time was 34 minutes (range, 15 to 80), and the median length of hospital stay was 1.2 day (range, 1 to 5). CONCLUSIONS: The minilaparoscopic approach a) has the same advantages as the conventional laparoscopic approach in terms of better diagnostic accuracy and safety; b) a low incidence of complications; and c) yields excellent cosmetic results.

Skeletal muscle metastases from renal cell carcinoma: a case report.

In this paper, we describe a case of a 73-year old female with late skeletal muscle metastases from a clear-type renal cell carcinoma 8 years after total nephrectomy. The metastases were located in the right femoral quadriceps, in the sartorius muscle and adductor magnus muscle. A full clinical work-up was performed with blood examinations, radiological and pathological assessment. A complete surgical resection with a wide margin was performed for all lesions, and the final pathological report deposed for metastatic renal carcinoma clear-type cells. In this case report, we discuss the crucial rule of accurate radiological and pathological assessment and aggressive surgical management.

[Trocars and hernias: a simple, cheap remedy]. / Trocar ed ernie: un rimedio semplice ed economico.

Trocar-site incisional hernias and their complications are reported in 1% to 6% of patients. Such hernias are attributed to the difficulty of applying standard suturing techniques to wound closure. We report our experience with a simple device, the Deschamps ligature needle.

Robotic systems and surgical education.

This experimental study aimed at evaluating the efficiency of robots in the learning of surgical techniques. We recruited 40 surgeons, divided them into 2 groups of 20, each of which used the robotic system. The first group consisted of experienced physicians, and the second group comprised physicians in training. Each surgeon was allowed to use the da Vinci robotic system for 30 minutes twice in the span of 24 hours. The practice time period was divided into 15 minutes for tying and placement of sutures and 15 minutes for incisions and vascular suturing. We recorded the times required for the performances, and a statistically significant outcome was obtained. With variance analysis (ANOVA), it has been shown that the time needed to perform the exercises depends in a statistically significant way on the kind of test to be performed (P<0.01), the experience of the surgeon (P<0.001), and the kind of operation (P<0.025). Robotic systems can be an optimal tool both for residents and experienced surgeons, for learning of basic surgical tasks and for perfection of clinical skills. The use of the system has great potential in surgical training, offering a reduction in the learning period, enabling checking for errors, and allowing an evaluation of the capabilities obtained. Final goals are a drastic reduction in the learning curve, a better technique, with a significant reduction in surgical errors and complications, with greater safety for the patient.

[Interdisciplinary use of a Day Surgery unit]. / La Day-Surgery interdivisionale ed interdisciplinare. Aspetti organizzativi ed economici.

BACKGROUND: A Day Surgery unit can be defined as a service dedicated to those patients which are not eligible for a simple ambulatory treatment, though requiring a short hospital stay for less than 12 hours. The Italian regulation for Day Surgery has been developed in the last 80's. Three models have been defined: 1) Autonomous unit; 2) Mono o multidisciplinary units: 3) Dedicated beds. Admission criteria are clinical data, age, familial support. METHODS: The Tor Vergata University Hospital has an autonomous multidisciplinary Day Surgery unit, opened on November 22, 2002. Cost and clinical data are independently calculated and stored, allowing as to evaluate the activity of the first 14 months of its life (Nov 02-Dec 03). RESULTS: 5288 patients have been treated, with a preliminary access for lab and clinical evaluation, a surgical procedure and postoperative controls. The Author have calculate that treating as in patients would have needed a dept of 40 beds. CONCLUSIONS: DS offers both 1) economics, and 2) social advantages: 1) lower cost for patients admission. highes. Rate of turn-over, reduction of human resources (no overnight cost), finally, rational use of the NHS funds. 2) Prompt and better response to pts needs and requests; more hospital beds dedicated to emergency and severe cases; reduction of cost for pts and relative quicker return to work; favourable psychological approach for the pts.

[Role of pulsed Doppler of the inferior thyroid artery in patients without hyperthyroidism]. / Contributo alla comprensione del ruolo del Doppler pulsato dell'arteria tiroidea inferiore nei pazienti non ipertiroidei.

The authors present their statistical results in terms of maximum velocity and resistive Index of the inferior thyroid artery in a group of 200 patients, all with different diseases of the gland, but without hyperthyroidism. Measurements were taken in the first tract of the inferior thyroid artery, deep and posterior to the common carotid, without encountering any significant difficulties in 83% of cases, the determinations taking less than one minute; in some patients stretching or rotation of the neck was necessary in order to obtain a good result. The maximum systolic velocities were in agreement with those reported in the literature, but statistical analysis showed a significant correlation between systolic peak and certain groups or types of disease and, albeit less reliably, between the Resistive Index and type of disease. The section of the individual vessels showed no statistically significant variations. The results indicate a possible correlation between peak systolic velocity and Reistive Index in patients without hyperthyroidism, and therefore it may now be useful to study the relationship between these two parameters also in patients with normal serum levels of thyroid hormones.

Delayed symptomatic hemobilia after ultrasound-guided liver biopsy: a case report.

The incidence of hemobilia following percutaneous liver biopsy ranges between 0 and 1%. It is an unpredictable complication and the lack of symptoms or delay in their presentation further complicates its diagnosis. We report a case of hemobilia after US-guided percutaneous liver biopsy for diffuse HCV-related liver disease. The diagnosis of hemobilia was established 6 days after the percutaneous liver biopsy by endoscopic retrograde cholangiopancreatography. After superselective catheterization of the feeding artery, vascular occlusion was successfully obtained with gel foam pledges and the patient was discharged 7 days after the procedure.

[Impact of laparoscopic surgery in the treatment of chronic abdominal pain syndrome]. / L'impatto della chirurgia laparoscopica nel trattamento della sindrome del dolore addominale cronico.

Chronic abdominal pain syndrome is becoming increasingly important with regard to the quality of life of the patients and its social and economic impact, in terms of cost of hospitalization, income loss due to sick leave, and pharmaceutical costs for treatments which fail to offer either significant clinical improvement or resolution of the pain symptoms. The main symptom is chronic abdominal pain, which may vary in intensity and may be associated with constipation and episodes of vomiting, when the clinical picture evolves toward one of subocclusion or total occlusion of the bowel. We considered the following criteria in our selection of patients for this study: 1) quality of life, 2) constant use of antispastic and analgesic medications, 3) absence of any other diagnosticable pathology prior to the operation. From August 1992 to April 2000 we operated on 105 patients with this syndrome (16 males and 89 females). Among these 8 patients had never been subjected to a laparotomy, while 97 had previously undergone surgical procedures (126 laparotomies). In the first 85 patients in the series (81%) we used a 10 mm laparoscope (0-30 degrees) to evaluate the presence of abdominal-visceral adhesions based on the type of surgery the patient had undergone previously, as well as the location of the pain reported by the patient. In 41 cases (48.2%) the pneumoperitoneum was obtained with the Veress needle. In another 44 cases (51.8%) the Hasson technique was used. Since June 1999, we have carried out the exploration of the abdominal cavity in 20 patients (19%) using a trocar and 2.2 mm laparoscope in the left hypochondrium along with a mini-trocar placed either in the right or left flank. (The positioning of the trocars depended on the previous surgical procedures performed). The exploration included inspection of the abdominal cavity. In 8 of the patients the procedure was carried out under local anaesthesia We performed laparoscopic adhesiolysis in 93 cases; in 7 cases no signs of adhesions were seen, while in another 5 cases it was necessary to convert the original laparoscopic procedure to a laparotomy. The types of adhesions found were fine-filmy (46%), dense-vascularised (46%), and cohesive (16%). In 6 cases during lysis of the adhesions complications of serous-muscular lesions occurred, which required laparotomic repair. In 5 cases we diagnosed a pathological condition which was not suspected. The average postoperative hospital stay was 2 days (range: 1-7); no major postoperative complications were noted. In the course of the follow-up of 78 patients over an average of 37 months (range: 6-72) the results obtained were as follows; 47 patients (60.2%) had complete pain relief, 18 patients (23.1%) had partial pain relief, and the remaining 13 patients (16.7%) had no significant pain relief. Laparoscopic exploration in patients with chronic abdominal pain is technically feasible in a simple manner in most patients. By means of careful and accurate preoperative selection of the patients partial if not complete pain relief can be achieved in a high percentage of cases (83.3% in our series).

Port-site closure: a new problem, an old device.

OBJECTIVE: Trocar-site incisional hernias and their complications are reported in 1% to 6% of patients. Such hernias are attributed to the difficulty of applying standard suturing techniques to wound closure. We report our experience with a simple device, the Deschamps ligature needle. METHODS: The Deschamps needle has a handle and a tip (sharp or blunt), with an opening to pass suture. The blunt tip is very effective for closing trocar sites. Disposable needles are obviously sharp, but can bend on the needle holder and break in a deep small incision. The Deschamps needle is a rigid, noncutting instrument that can be forced through fascia and peritoneum (around the surgeon's fingertip) avoiding loss of pneumoperitoneum. A full-thickness closure is accomplished. We perform closure under direct vision through the scope. Tactile sense is provided by the surgeon's finger. The last trocar site is closed in the same manner without the scope. RESULTS: We have used the Deschamps needle since 1992 in all (1400) laparoscopic procedures. We close 10-mm and 5-mm trocar sites and have not observed wound dehiscence or hernias at these sites. CONCLUSION: The Deschamps needle is effective in preventing incisional hernias and wound dehiscence. It is cost-effective. Disposable, single-use devices vary in price from $30 to $75 each. The Deschamps needle is sold in Italy at approximately $35 each. Considering that it may have been in the trays of most operating rooms for years (as in our case), and the number of procedures performed, we conclude that the real cost of this instrument is almost negligible.