The increased angiogenic capacity and decreased inflammatory response when a mesh is used in combination with an omental flap. A prospective experimental study.

BACKGROUND: The use of a surgical mesh for abdominal wall reconstruction is well established and has been used for long with minor complications, whereas the omental flap has been used for decades in reconstructive surgery. AIM: To demonstrate the increased angiogenic capacity and the reduced inflammatory markers of a synthetic mesh when used in combination with an omental flap. Furthermore, we compare two independent meshes when used alone or in combination with the omental flap. MATERIALS AND METHODS: Twenty-eight rats were included in the study. To determine the effect of using an omental flap under two different meshes, the animals were separated into four groups, i.e., group A (flap + mesh 1), group B (flap + mesh 1 + silicone), group C (flap + mesh 2), and group D (flap + mesh 2 + silicone). A silicone sheet was placed as a barrier between the mesh and the flap. All groups were sacrificed 8 weeks post-operatively. RESULTS: The use of a silicone sheet barrier between any of the two synthetic meshes and the omental flap in an abdominal wall defect is accompanied by a markedly reduced angiogenesis in terms of a cluster of differentiation (CD)-34 (p < 0.001) and factor VIII (p = 0.0012) and by increased inflammatory response CD-68 (p = 0.0024) and visual scoring (p < 0.001). CONCLUSIONS: Τhe increased angiogenic capacity and the reduced inflammatory markers of a synthetic surgical mesh when used in combination with an omental flap make it a useful option in the reconstruction of an abdominal wall defect on a large or contaminated wound.

Association between genetic polymorphisms in long non-coding RNAs and pancreatic cancer risk.

BACKGROUND: Long non-coding RNAs (lncRNAs) are emerging as candidate biomarkers of cancer, having regulatory functions in both oncogenic and tumor-suppressive pathways. Concerning pancreatic cancer (PC), deregulation of lncRNAs involved in tumor initiation, invasion, and metastasis seem to play a key role. However, data is scarce about regulatory mechanism of lncRNA expression. OBJECTIVE: The aim of our study was to investigate the contribution of two lncRNAs polymorphisms (rs1561927 and rs4759313 of PVT1 and HOTAIR, respectively) in PC susceptibility. METHODS: A case-control study was conducted analysing rs1561927 and rs4759313 polymorphisms using DNA collected in a population-based case-control study of pancreatic cancer (111 pancreatic ductal adenocarcinoma cases (PDAC), 56 pancreatic neuroendocrine tumor (PNET), and 125 healthy controls). RESULTS: Regarding the PVT1 rs1561927 polymorphism the G allele was significantly overrepresented in both PDAC and PNET patients compared to the controls, while the presence of the HOTAIR rs4759314 G allele was found to be overrepresented in the PNET patients only compared to the controls. The PVT1 rs1561927 AG/GG genotypes were associated with poor overall survival in PDAC patients. CONCLUSIONS: Our results suggested that polymorphisms of these two lncRNA polymorphisms implicated in pancreatic carcinogenesis. Further large-scale and functional studies are needed to confirm our results.

Laparoscopic excision of rectosigmoid endometriotic plaque and cul de sac obliteration in deeply infiltrating endometriosis: a case report.

Endometriosis represents a main cause of infertility and pelvic pain affecting 3-43% among reproductive age women. Deep pelvic endometriosis is defined as subperitoneal infiltration of endometrial implants in the uterosacral ligaments, rectum, rectovaginal septum, vagina or bladder. The authors present a case of a 29-year-old patient who underwent laparoscopic excision of extensive endometriotic plaque in rectovaginal septum accompanied with deeply infiltrating endometriosis (DIE) and chronic pelvic pain (CPP).

Successful management of evisceration occurred after exploratory laparotomy for bilateral ovarian micropapillary serous borderline tumors.

Micropapillary serous borderline tumor of the ovary is characterized by a more frequent association with extraovarian, especially invasive, implants. The aim of this study was to report the clinicopathological findings of a rare case of micropapillary serous borderline tumor of the ovary since there are less than 100 similar cases in the published literature. Additionally, the successful management of evisceration that complicated the postoperative stay of the patient is analyzed. The incidence of this severe complication is estimated between 0.29-2.3%. There are four main causes: suture tearing through the fascia, knot failure, suture failure, and extrusion of abdominal contents between sutures placed too far apart. At least 50% of the cases are due to technical error with a potentially lethal result.

Pancreatoduodenectomy for pancreatic cancer in a low volume institution.

PURPOSE: To report the patient morbidity and mortality rates following pancreatoduodenectomy (PD) carried out in our low volume institution, and compare our results with results from other high volume institutions. METHODS: A retrospective analysis was conducted on patients with pancreatic malignancies surgically treated with PD from 2005 to 2010 in our institution. Data were collected with particular emphasis on morbidity and mortality rates. All patients were followed from the date of discharge to the date of death or status at the last follow-up (July 2011). RESULTS: In a period of 5 years 42 patients underwent PD. Morbidity rates were as follows: 11.9% wound infections, 21.4% pancreatic fistulae, 23.8% delayed gastric emptying (DGE), 14.3% hemorrhage, and 7.1% biliary leak. Two patients required re-laparotomy one for delayed hemorrhage and one for sepsis. The mortality rate was 7.1%. The 2-year survival rate was 45.17 percent; and the median survival 22 months. CONCLUSION: PD in our low volume institution had high morbidity and mortality rates compared with results published in the literature. There is a need, however, to establish a policy for referral of patients with pancreatic cancer to other centers with a higher number of resections, in order to decrease morbidity and mortality rates.

Randomized comparison between different insufflation pressures for laparoscopic cholecystectomy.

Laparoscopy using carbon dioxide insufflation induces adverse effects in both the cardiovascular and the respiratory function. The use of low pressure pneumoperitoneum has been shown to reduce adverse hemodynamic effects. However, its effect on tissue trauma and postoperative pain and recovery remains controversial. The aim of this study was to compare tissue trauma, postoperative pain, and recovery in two groups of patients undergoing laparoscopic cholecystectomy, one at insufflation pressure of 8 (LC8) and the other at 15 mm Hg (LC15). Forty patients were randomized, 20 in each group. The characteristics of the patients were similar in the two groups. The procedure was completed in all patients in the LC15 group, but in 2 patients in the LC8 group the pressure was increased to 15 mm Hg to complete the operation. There were no significant differences in postoperative pain scores, analgesic consumption, and the incidence of nausea, vomiting, and shoulder pain between the two groups. C-reactive protein concentrations and white blood cell count rose significantly after surgery, but the increase was similar in the two groups. The median duration of surgery was similar, 23 minutes (range 15-65) in the LC8 group and 25 minutes (range 15-80) in the LC15 group. Using our technique of laparoscopic cholecystectomy, there were no advantages to tissue damage, postoperative pain, and recovery when a low pressure pneumoperitoneum was used.

A new tension-free technique for the repair of umbilical hernia, using the Prolene Hernia System--early results from 48 cases.

Tension-free repair using the Prolene Hernia System (PHS) has been widely adopted for inguinal hernias with excellent results. In our department, a new technique for umbilical hernia repair, using the PHS, has been developed. Between 2000 and 2002, 48 patients underwent tension-free umbilical hernia repair, using the PHS. There were 20 male and 28 female patients, with a mean age of 54 years. The preperitoneal space was dissected to accumulate the underlay patch of the PHS. The onlay patch was placed on the anterior rectus sheath and the connector in the umbilical ring. The median operating time was 35 min (range, 28-40). Postoperative pain was minimal, and there were no complications associated with the mesh, except a seroma, which required needle aspiration. There were no recurrences after a median follow-up of 13 months (1-24). Our early results indicate that the described tension-free technique could become the standard treatment for umbilical hernia repair, but long-term results are required to establish the efficacy of the procedure.

Micropuncture cholecystectomy vs conventional laparoscopic cholecystectomy: a randomized controlled trial.

BACKGROUND: The aim of this study was to compare micropuncture laparoscopic cholecystectomy (MPLC), with three 3.3-mm cannulas and one 10-mm cannula with conventional laparoscopic cholecystectomy (CLC). METHODS: Patients were randomized to undergo either CLC or MPLC. The duration of each operative stage and the procedure were recorded. Interleukin-6 (IL-6), adrenocorticotropic hormone (ACTH), and vasopressin were sampled for 24 h. Visual analogue pain scores (VAPS) and analgesic consumption were recorded for 1 week. Pulmonary function and quality of life (EQ-5D) were monitored for 4 weeks. Statistical analysis was performed using the Mann-Whitney test or Fisher's exact test. Results are expressed as median (interquartile range). RESULTS: Forty-four patients entered the study, but four were excluded due to unsuspected choledocholithiasis (n = 3) or the need to reschedule surgery (n = 1). The groups were comparable in terms of age, duration of symptoms, and indications for surgery. Total operative time was similar (CLC, 63 [52-81] min vs MPLC 74 [58-95] min; p = 0.126). However, time to place the cannulas after skin incision (CLC, 5:42 [3:45-6:37] min vs MPLC, 7:38 [5:57-10:15] min; p = 0.015) and to clip the cystic duct after cholangiography (CLC, 1:05 [0:40-1:35] min vs MPLC, 3:45 [2:26-7:49] min; p <0.001) were significantly longer for MPLC. Six CLC patients and one MPLC patient required postoperative parenteral opiates (p = 0.04). Oral analgesic consumption was similar in both groups (p = 0.217). Median VAPS were lower at all time points for MPLC, but this finding was not significant (p = 0.431). There were no significant differences in postoperative stay, IL-6, ACTH or vasopressin responses, pulmonary function, or EQ-5D scores. CONCLUSIONS: The thinner instruments did not significantly increase the total duration of the procedure. MPLC reduced the use of parenteral analgesia postoperatively, which may prove beneficial for day case patients, but it did not have a significant impact on laboratory variables, lung function or quality of life.

Laparoscopic cholecystectomy: are patients with biliary pancreatitis at increased operative risk?

BACKGROUND: Previous reports of laparoscopic cholecystectomy (LC) in patients with biliary pancreatitis suggested increased operative difficulty, high rates of conversion, and greater morbidity and mortality. METHODS: Between 1990 and 1997, LC was performed for biliary pancreatitis in 63 patients (Group I) and for other causes in 829 patients (Group II). RESULTS: Patients with biliary pancreatitis were significantly older (median age 57 vs 50 years, p = 0.009), with greater co-morbidity (ASA III/IV 24% vs 11%, p = 0.008). The groups were comparable with respect to the frequency of previous abdominal operations, acute inflammation of the gallbladder, and the frequency of bile duct calculi detected by intraoperative cholangiography. Moderate to severe adhesions involving the gallbladder were significantly more frequent in patients with biliary pancreatitis (46% vs 29%, p = 0.004). No significant differences were observed between the two groups with respect to intraoperative (1.5% Group I vs 6.0% Group II, p = 0.109) or postoperative complications (10% vs 8%, p = 0.426), conversion rate (0 vs 2.7%, p = 0.181), or duration of operation (median 92 vs 85 min, p = 0.33). CONCLUSION: Despite increased age and co-morbidity and more frequent adhesions, our data showed no evidence that intraoperative or postoperative complications were more frequent in patients with biliary pancreatitis than in other patients undergoing LC.

Laparoscopic cholecystectomy in morbidly obese patients.

BACKGROUND: Morbid obesity is generally regarded as a risk factor for laparoscopic cholecystectomy due to increases in operative time, morbidity, and conversion rate to open cholecystectomy. The aim of this study was to evaluate the feasibility and outcome of laparoscopic cholecystectomy (LC) in morbidly obese patients. METHODS: A total of 864 consecutive patients underwent LC at our institution between 1990 and 1997. This series represents a continuing policy of LC for all comers. Data were collected prospectively. There were 659 nonobese (NO: BMI 40 kg/m2). Laparoscopic bile duct exploration was performed in 28 (4.2%), nine (4.8%), and one (5.9%) patients, respectively. RESULTS: Obesity and morbid obesity were associated with trends toward an increased conversion rate (2.3% NO; 4.3% OB; 5.9% MO), a longer operative time (median, 80, 85, and 107 mins, respectively), greater postoperative morbidity (4.7%, 5.9%, and 11.8%, respectively), and a reduced ability to obtain cholangiography (86.1%, 80.1%, and 71.4%, respectively). None of these differences, however, were statistically significant (c2 test, p > 0.05). Postoperative hospital stay for LC was similar for all three groups (median, 1 day). CONCLUSION: LC in morbidly obese patients is a safe procedure, but it may be associated with increased operative difficulty and morbidity, as compared with nonobese and obese patients.

Recurrent septic episodes following gallstone spillage at laparoscopic cholecystectomy.

A 51-year-old woman underwent emergency laparoscopic cholecystectomy. Stone loss occurred during gallbladder dissection. Histology showed empyema of the gallbladder. Postoperatively, she developed a subhepatic abscess that required percutaneous drainage. Two years after surgery, she re-presented with a right paracolic abscess. Transsciatic CT-guided drainage of the abscess was performed. Barium enema excluded colonic pathology. Two weeks later, she developed a right gluteal abscess deep to the recent drain site. Ultrasound-guided drainage was performed followed by a sonogram. The sonogram ruled out communication with the peritoneum. Two further subhepatic abscesses occurred during the next 5 years; the first abscess was drained percutaneously, but the second required open drainage: At laparotomy, gallstone fragments were found within the abscess cavity. The site of the previous gluteal drain continued to discharge intermittently. An MRI scan showed an uncomplicated sinus track. Subsequent sinography of the right gluteal track demonstrated an opacity at the apex of the sinus. The sinus was laid open and a gallstone retrieved. The patient has remained well for 3 years. Complications due to gallstone spillage generally manifest themselves shortly after surgery. This case demonstrates that lost stones may cause chronic abdominal and abdominal wall sepsis. In cases of chronic abdominal sepsis after laparoscopic cholecystectomy, the possibility of lost stones should be considered even if stones are not positively shown on imaging.

Laparoscopic treatment of Mirizzi syndrome.

Mirizzi syndrome is a rare disorder and remains a surgical challenge. It is generally considered as a contraindication to laparoscopic surgery. Three patients with Mirizzi type II syndrome and two patients with Mirizzi type I syndrome were treated laparoscopically. Partial cholecystectomy with fundus-first dissection of the gallbladder was performed, and closure of the fistula in type II syndrome was achieved over a T-tube. The common bile duct (CBD) was explored in one patient using a choledochoscope through the fistula. The procedure was completed laparoscopically in all five patients. The three patients with type II syndrome had residual CBD stones, which were associated with significant morbidity and mortality. Laparoscopic treatment of Mirizzi type I syndrome is technically feasible and safe. For Mirizzi type II syndrome, laparoscopic CBD exploration is demanding and experience, skill, and the full spectrum of modern technology are required.

Intraoperative cholangiography during laparoscopic cholecystectomy.

BACKGROUND: The routine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy remains controversial. METHODS: A retrospective review of 950 consecutive laparoscopic cholecystectomies performed during an 8-year period was performed. For the first 2 years, IOC was performed selectively, and thereafter routinely. RESULTS: Attempted in 896 patients, IOC was successful in 734 (82%). Bile duct stones were found in 77 patients (10%), dilated ducts without stones in 47 patients (6%), and anatomic variations in 4 patients (0.5%). There were four (0.4%) minor intraoperative complications related to the IOC, with no consequences for the patients. There were three (0.3%) minor injuries of the bile duct, which were identified with IOC and repaired at the time of cholecystectomy without any consequences for the patients. In two of these patients, the structure recognized and catheterized as the cystic duct was revealed by IOC to be the bile duct. Thus IOC prevented extension to a major common bile duct (CBD) injury. CONCLUSIONS: Findings show that IOC is a safe technique. Its routine use during laparoscopic cholecystectomy may not prevent bile duct injuries, but it minimizes the extent of the injury so that it can be repaired easily without any consequences for the patient. The prevention of a major bile duct injury makes IOC cost effective.

Routine vs "on demand" postoperative ERCP for small bile duct calculi detected at intraoperative cholangiography. Clinical evaluation and cost analysis.

BACKGROUND: The detection of small and often asymptomatic gallbladder calculi within the bile duct at intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) frequently poses a management dilemma. Therefore, we set out to compare the outcomes and costs of two management strategies for small stones that remain in the bile duct after LC-routine postoperative endoscopic retrograde cholangiopancreatography (ERCP) vs observation alone with "on-demand" ERCP. METHODS: We studied 70 patients with bile duct stones among 922 consecutive patients who underwent LC between 1990 and 1997. Data were collected prospectively. Bile duct calculi were detected in 70 of 705 patients (9.9%) with successful IOC. Of these, 44 patients had large calculi (> or =5 mm in diameter) and were subjected to a laparoscopic common bile duct exploration. The remaining 26 patients had small calculi (<5 mm in diameter); four of them had undergone preoperative endoscopic sphincterotomy and duct clearance and were therefore excluded from analysis. Patients with small duct calculi were assigned, according to individual surgeon policy, to either routine postoperative ERCP (group A, n = 8) or observation (group B, n = 14). ERCP was reserved for those who become symptomatic. The two groups were comparable for age and sex distribution. RESULTS: No complications developed during the follow-up period in patients assigned to observation, although four became symptomatic and underwent ERCP. In group A, ERCP demonstrated a clear biliary tree in four patients and bile duct calculi in three patients; it failed in one patient. In group B, ERCP demonstrated a clear bile duct in one patient and bile duct calculi in two patients; it also failed in one patient. Endoscopic sphincterotomy and duct clearance were achieved in all patients with demonstrable bile duct calculi at ERCP. There was no morbidity or mortality associated with ERCP. The overall hospital stay was significantly longer in group A than in group B (median 5 vs 1.5 days; p = 0.011); however, the number of outpatient clinic visits was significantly greater in group b (median 3 vs 5.5, p = 0.011). The mean hospital costs, including the costs of hospital stay, readmissions, ERCP, and follow-up, were significantly greater in group A than in group B (mean pound2669 vs pound1508, p = 0.008). CONCLUSION: A "wait and see" policy of observation alone for patients with small bile duct calculi detected at IOC during LC appears to be safe, and it is more cost-effective than routine postoperative ERCP. ERCP should be reserved for post-LC patients who become symptomatic.

Routine low-pressure pneumoperitoneum during laparoscopic cholecystectomy.

BACKGROUND: Pneumoperitoneum at 15 mmHg results in dangerous hemodynamic disturbances in some patients. The use of low-pressure insufflation may make laparoscopic surgery safer. METHODS: Data were collected prospectively from a consecutive series of patients who had undergone an elective laparoscopic cholecystectomy (LC) by the same surgeon, during the years 1993-94 (group 1, 77 patients) and 1996 (group 2, 50 patients). The groups were similar with respect to age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) grade, existence of abdominal scars due to previous surgery, and severity of gallbladder disease. Patients underwent LC with a mean intraabdominal pressure of 10.56 mmHg in group 1 and 7 mmHg in group 2, respectively. RESULTS: The mean operative time was 75 min and 78 min in groups 1 and 2, respectively (NS). Insertion of an additional cannula was required more frequently (24% versus 14%; NS) in group 2. There were no conversions in either group. The morbidity rate and the postoperative hospital stay were similar for both groups. CONCLUSIONS: LC can be performed routinely at low intraabdominal pressure, which may contribute to the safety and comfort of the procedure.

Randomized comparison between low-pressure laparoscopic cholecystectomy and gasless laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy using low-pressure pneumoperitoneum (8 mmHg) minimizes adverse hemodynamic effects, reduces postoperative pain, and accelerates recovery. Similar claims are made for gasless laparoscopy using abdominal wall lifting. The aim of this study was to compare gasless laparoscopic cholecystectomy to low-pressure cholecystectomy with respect to postoperative pain and recovery. METHODS: Thirty-six patients were randomized to low-pressure or gasless laparoscopic cholecystectomy using a subcutaneous lifting system (Laparotenser). RESULTS: The characteristics of the patients were similar in the two groups. The procedure was completed in all patients in the low-pressure group, but two patients in the gasless group were converted to pneumoperitoneum. There were no significant differences in postoperative pain and analgesic consumption, but patients in the gasless group developed shoulder pain more frequently (50% vs 11%, p < 0.05). Gasless operation took longer to perform (95 vs 72.5 min, p = 0.01). CONCLUSIONS: Gasless and low-pressure laparoscopic cholecystectomy were similar with respect to postoperative pain and recovery. The gasless technique provided inferior exposure and the operation took longer, but the technique may still have value in high-risk patients with cardiorespiratory disease.

Micropuncture laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy (LC) significantly reduces the discomfort and disability typically associated with open cholecystectomy, but there is still room for improvement. METHODS: In order to further reduce the trauma of access, we have introduced a technique of micropuncture laparoscopic cholecystectomy (MPLC) that utilizes three 3-mm cannulae in addition to the standard 10-mm cannula at the umbilicus. MPLC was performed in 25 patients (median age, 52 years; m/f, three of 22) with symptomatic cholelithiasis. RESULTS: The operation was completed in all patients. The median duration of surgery was 75 min (range, 45-180). Sixteen patients were discharged the same day and nine patients the next day. All the patients had an uncomplicated recovery. Only eight patients requested postoperative analgesia while in hospital. Micropuncture exploration of the bile duct was carried out in one patient. CONCLUSIONS: MPLC is a feasible and safe technique that appears to improve on the benefits of LC; it makes the operation even more feasible as a day-surgery procedure.

Laparoscopic surgery combined with preservation of the spleen for distal pancreatic tumors.

BACKGROUND: Laparoscopic distal pancreatectomy combined with spleen salvage by preservation of the splenic vessels has been described in selected patients with islet cell tumors. METHODS: Laparoscopic resection of the left side of the pancreas with spleen preservation on the vasa brevia was attempted in six consecutive patients. RESULTS: Four distal pancreatectomies with spleen preservation were completed laparoscopically. There were two conversions to laparotomy. The median operating time was 300 min (range, 240-360). There was no mortality, but two patients developed a pancreatic fistula. The median postoperative hospital stay was 34.5 days (range, 5-60). All the patients remain well at a median follow-up of 30 months (range, 22-41). CONCLUSIONS: Minimally invasive surgery for distal pancreatic tumors is feasible and appropriate for most benign tumors. The spleen can be safely preserved laparoscopically on its blood supply from the short gastric vessels. The operative technique and especially the closure of the pancreatic stump need further study.