Randomized controlled trial of robotic-assisted versus conventional laparoscopic fundoplication: 12 years follow-up.

AIMS: Numerous reports have addressed the feasibility and safety of robotic-assisted (RALF) and conventional laparoscopic fundoplication (CLF). Long-term follow-up after direct comparison of these two minimally invasive approaches is scarce. The aim of the present study was to assess long-term disease-specific symptoms and quality of life (QOL) in patients with gastroesophageal reflux disease (GERD) treated with RALF or CLF after 12 years in the randomized ROLAF trial. METHODS: In the ROLAF trial 40 patients with GERD were randomized to RALF (n = 20) or CLF (n = 20) between August 2004 and December 2005. At 12 years after surgery, all patients were invited to complete the standardized Gastrointestinal Symptom Rating Scale (GSRS) and the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD). Failure of treatment was assessed according to Lundell score. RESULTS: The GSRS score was similar for RALF (n = 15) and CLF (n = 15) at 12 years´ follow-up (2.1 ± 0.7 vs. 2.2 ± 1.3, p = 0.740). There was no difference in QOLRAD score (RALF 6.4 ± 1.2; CLF 6.4 ± 1.5, p = 0.656) and the QOLRAD score sub items. Long-term failure of treatment according to the definition by Lundell was not different between RALF and CLF [46% (6/13) vs. 33% (4/12), p = 0.806]. CONCLUSION: In accordance with previous short-term outcome studies, the long-term results 12 years after surgery showed no difference between RALF and CLF regarding postoperative symptoms, QOL and failure of treatment. Relief of symptoms and patient satisfaction were high after both procedures on the long-term. REGISTRATION NUMBER: DRKS00014690 ( https://www.drks.de ).

Virtual reality simulation in robot-assisted surgery: meta-analysis of skill transfer and predictability of skill.

BACKGROUND: The value of virtual reality (VR) simulators for robot-assisted surgery (RAS) for skill assessment and training of surgeons has not been established. This systematic review and meta-analysis aimed to identify evidence on transferability of surgical skills acquired on robotic VR simulators to the operating room and the predictive value of robotic VR simulator performance for intraoperative performance. METHODS: MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science were searched systematically. Risk of bias was assessed using the Medical Education Research Study Quality Instrument and the Newcastle-Ottawa Scale for Education. Correlation coefficients were chosen as effect measure and pooled using the inverse-variance weighting approach. A random-effects model was applied to estimate the summary effect. RESULTS: A total of 14 131 potential articles were identified; there were eight studies eligible for qualitative and three for quantitative analysis. Three of four studies demonstrated transfer of surgical skills from robotic VR simulators to the operating room measured by time and technical surgical performance. Two of three studies found significant positive correlations between robotic VR simulator performance and intraoperative technical surgical performance; quantitative analysis revealed a positive combined correlation (r = 0.67, 95 per cent c.i. 0.22 to 0.88). CONCLUSION: Technical surgical skills acquired through robotic VR simulator training can be transferred to the operating room, and operating room performance seems to be predictable by robotic VR simulator performance. VR training can therefore be justified before operating on patients.

Metabolic disorders in patients operated for pancreatic cancer.

Adenocarcinoma of the pancreas presents a major threat with a 5-years survival rate of 5%. Whipple pancreaticoduodenectomy (PD) is the standard procedure for cephalo-pancreatic neoplasm. After an extended resection and reconstruction of superior gastrointestinal tract the digestive physiology might be heavily disrupted. A literature review of metabolic alterations of patients who suffered a major pancreatic resection is performed, regarding micronutrients, lipid absorption and pancreatogenic diabetes. Long-term survivors following PD generally have a satisfactory nutritional status although with subclinical iron, vitamin D and selenium deficiency. These patients should be followed-up also regarding these micronutrients and properly dietary supplemented when necessary, also considering the increased life expectancy. Approximately 17-25% of patients will develop insulin-dependent diabetes but pancreatogenic diabetics have elevated levels of serum insulin and minimal or absent response to food intake, as opposed to a type I diabetics, where insulin serum is normal or elevated and there is an exaggerated response to ingestion of sugar.

Prognostic factors in resectable pancreatic cancer.

The pancreatic cancer is a disease with exponentially increased incidence, especially over the last decades, being the sixth or even fifth cause of death by cancer in most of the modern societies. Moreover, it is estimated that almost 95% of the patients with this disease are presenting to the doctor in the advanced and unresectable stages. Also, over the past few decades the development and advance of the surgical methods and techniques have improved only morbidity and hospital postoperative mortality, without significant impact on survival. In this way, in the present mini-review we want it to make a short description for some modern aspects regarding the factors implicated in pancreatic cancer survival.

Laparoscopic treatment of perforated duodenal ulcer -- a multicenter study.

AIM: The aim of this study is to evaluate the results of the laparoscopic treatment of perforated duodenal ulcer performed in 6 Romanian surgical centres with experience in the field of laparoscopic surgery. MATERIAL AND METHOD: Between 1996 and 2005, 186 patients with perforated duodenal ulcer were operated on in the centers participating in this retrospective study, all patients being ASA I-II. Thirty-nine patients (20.0%) presented mild peritonitis, 120 (64.5%) medium peritonitis and 27 (15.5%) severe (20.0%) simple suture was performed, in 110 (59.1%) suture with epiplonoplasty, for 1 (0.5%) only epiplonoplasty and 1 (0.5%) underwent excision of the perforation and suture. RESULTS: The operative time was between 30-120 minutes, with an average of 75 minutes. No death was noted. Average hospitalization time was 6 days, with periods varying between 3 and 18 days. Postoperative complications included: 5 patients (2,6%) presented infections of the abdominal walls, 1 patient (0.5%) duodenal fistula, 1 patient (0.5%) intra-abdominal abscess, 1 patient (0.5%) a superior digestive hemorrhage by "mirrored ulcer" and 1 patient (0.5%) duodenal stenosis 6 months after operation. The patients were administered 50% less analgesics, used 70% less dressings, 30% less antibiotics and had 60% less complications in comparison with those operated by the classical approach. CONCLUSION: The laparoscopic approach of perforated duodenal ulcer constitutes the first choice for patients without important co-morbidities, allowing a quick recovery and a significant reduction in the consumption of analgesics, antibiotics and dressing materials.

Laparoscopic surgery for the treatment of rectal cancer: short-term results.

UNLABELLED: The aim of this study was to establish the efficiency, safety and feasibility of laparoscopic surgery for rectal cancer by assessing the short-term outcomes. MATERIALS AND METHODS: In this prospective clinical study, from 2008 to 2011, 60 patients with laparoscopic resection for rectal cancer were included, treated in "Prof. Dr. Octavian Fodor" Gastroenterology and Hepatology Institute, Department of Surgery and Surgery Clinic I, Cluj-Napoca. RESULTS: Surgical procedures included 38 abdominal-perineal resections, 21 anterior resections and 1 Hartmann procedure. Average blood loss was 250 ml (100-800 ml) and median length of postoperative hospital stay was 9 days (4-91 days). Blood loss was significantly higher in patients with low rectal cancer than those with upper rectal cancer (300 ml vs 200 ml, p=0.031). Conversion to open surgery was required in 8 patients (13.3%). Overall postoperative complications were 28.8%. Positive circumferential margins occurred in 1 patient (1.7%), while distal margins were negative in all patients. CONCLUSIONS: Laparoscopic surgery is safe and feasible in selected patients with rectal cancer, with favorable shortterm results.

The trapped human experiment.

This experiment observed the evolution of metabolite plumes from a human trapped in a simulation of a collapsed building. Ten participants took it in turns over five days to lie in a simulation of a collapsed building and eight of them completed the 6 h protocol while their breath, sweat and skin metabolites were passed through a simulation of a collapsed glass-clad reinforced-concrete building. Safety, welfare and environmental parameters were monitored continuously, and active adsorbent sampling for thermal desorption GC-MS, on-line and embedded CO, CO(2) and O(2) monitoring, aspirating ion mobility spectrometry with integrated semiconductor gas sensors, direct injection GC-ion mobility spectrometry, active sampling thermal desorption GC-differential mobility spectrometry and a prototype remote early detection system for survivor location were used to monitor the evolution of the metabolite plumes that were generated. Oxygen levels within the void simulator were allowed to fall no lower than 19.1% (v). Concurrent levels of carbon dioxide built up to an average level of 1.6% (v) in the breathing zone of the participants. Temperature, humidity, carbon dioxide levels and the physiological measurements were consistent with a reproducible methodology that enabled the metabolite plumes to be sampled and characterized from the different parts of the experiment. Welfare and safety data were satisfactory with pulse rates, blood pressures and oxygenation, all within levels consistent with healthy adults. Up to 12 in-test welfare assessments per participant and a six-week follow-up Stanford Acute Stress Response Questionnaire indicated that the researchers and participants did not experience any adverse effects from their involvement in the study. Preliminary observations confirmed that CO(2), NH(3) and acetone were effective markers for trapped humans, although interactions with water absorbed in building debris needed further study. An unexpected observation from the NH(3) channel was the suppression of NH(3) during those periods when the participants slept, and this will be the subject of further study, as will be the detailed analysis of the casualty detection data obtained from the seven instruments used.

Emergency laparoscopy combined with radiofrequency ablation for hemostasis after percutaneous liver biopsy.

There are no data in the literature on the use of radiofrequency ablation (RFA) in emergency laparoscopy as a means of hemostasis after liver biopsy. In this case report we have described a case of a patient with Waldenstrom macroglobulinemia and hypervascularised hepatic tumor who developed severe hepatic bleeding after liver biopsy. Innovative, minimally invasive treatment consisted in a laparoscopic approach with introduction of RFA needle into the biopsy site, followed by immediate hemostasis with no complications. Laparoscopic surgery with RFA avoids unnecessary laparotomy in case of severe bleeding from a known source. It is therefore the optimal choice, even in patients for whom percutaneous biopsy would be a high-risk procedure.

Detection of volatile organic compounds in breath using thermal desorption electrospray ionization-ion mobility-mass spectrometry.

A thermal desorption unit has been interfaced to an electrospray ionization-ion mobility-time-of-flight mass spectrometer. The interface was evaluated using a mixture of six model volatile organic compounds which showed detection limits of <1 ng sample loaded onto a thermal desorption tube packed with Tenax, equivalent to sampled concentrations of 4 microg L(-1). Thermal desorption profiles were observed for all of the compounds, and ion mobility-mass spectrometry separations were used to resolve the probe compound responses from each other. The combination of temperature programmed thermal desorption and ion mobility improved the response of selected species against background ions. Analysis of breath samples resulted in the identification of breath metabolites, based on ion mobility and accurate mass measurement using siloxane peaks identified during the analysis as internal lockmasses.

Evaluation of the combined laparoscopic and mediastinoscopic esophagectomy technique.

BACKGROUND: Laparoscopic esophagectomy is technically difficult especially during dissection in the upper mediastinum. This limitation may be surpassed with the help of mediastinoscopy or of the recently introduced robotic surgical systems. The aim of the present study was to evaluate in an experimental porcine model the feasibility of the combined laparoscopic and mediastinoscopic transhiatal esophagectomy technique and to compare it with the robotic-assisted transhiatal and conventional approaches. MATERIALS AND METHODS: Transhiatal esophagectomy was performed in Landrace pigs under general anesthesia using three different techniques: Group A (n = 9): combined laparoscopic and mediastinoscopic, group B (n = 4): robotic-assisted and group C (n = 8): conventional "open". The feasibility, difficulty and accuracy of the procedure along with operative time, blood loss, intraoperative incidents and overall satisfaction of the surgical team were assessed for each technique. RESULTS: Operations in group A were feasible and reproducible. Although the procedure was technically difficult, the constant view on the operative field was highly appreciated by the operative team and facilitated an accurate and safe dissection. The main intraoperative complications were related to the side-effects of tension pneumothorax accompanying pleural injuries. In group B the features of the robotic system reduced the difficulty of dissection and obviated the need for mediastinoscopy. Operations in group C were quick and almost incident-free, facilitated also by the particularities of the animal model that could not reproduce identically the clinical situation. CONCLUSIONS: The combined laparoscopic and mediastinoscopic esophagectomy technique is feasible and offers certain advantages over the open approach while the robotic-assisted approach is an emerging less difficult alternative. Further studies are required to establish whether the advantages of minimally-invasive approach compensate for the increased technical difficulty and prolonged operative time.

Gas-chamber mediastinoscopy for dissection of the upper esophagus.

AIM: Mediastinoscopy has the potential to bring under view the upper mediastinum, the area most difficult to dissect during transhiatal esophagectomy. The aim of the present study was to evaluate in an animal model the feasibility of the gas-chamber mediastinoscopy technique for dissection of the upper esophagus. METHODS: Operations were performed in nine Landrace pigs using a 30 degrees laparoscope and conventional 35-cm laparoscopic instruments. Through a left collar incision a virtual space was created with sharp and blunt dissection around the cervical esophagus and insufflated with CO2 at a pressure of 5 mmHg. Using one 10-mm optical trocar and two 5-mm working trocars dissection advanced in the periesophageal space with the aim to reach at least to the tracheal bifurcation. RESULTS: Performed under visual control, the procedure was accurate and safe, the level of tracheal bifurcation being reached in all cases. Anatomical structures such as trachea and its bifurcation, pleura, pericardium, arch of the azygos vein and periesophageal lymph nodes were visible during the operation. There were no major intraoperative incidents and blood loss was minimal. CONCLUSIONS: The technique of gas-chamber mediastinoscopy is feasible. It allows a fair amount of freedom of movement for the working instruments and offers a good view on the operative field for a controlled and accurate dissection. Further evaluation in experimental and clinical studies is required to establish the role of this procedure in esophageal surgery.

Robot-assisted versus conventional laparoscopic fundoplication: short-term outcome of a pilot randomized controlled trial.

BACKGROUND: Robotic technology represents the latest development in minimally-invasive surgery. Nevertheless, robotic-assisted surgery seems to have specific disadvantages such as an increase in costs and prolongation of operative time. A general clinical implementation of the technique would only be justified if a relevant improvement in outcome could be demonstrated. This is also true for laparoscopic fundoplication. The present study was designed to compare robotic-assisted (RALF) and conventional laparoscopic fundoplication (CLF) with the focus on operative time, costs und perioperative outcome. METHODS: Forty patients with gastro-esophageal reflux disease were randomized to either RALF by use of the daVinci Surgical System or CLF. Nissen fundoplication was the standard anti-reflux procedure. Peri-operative data such as length of operative procedure, intra-and postoperative complications, length of hospital stay, overall costs and symptomatic short-term outcome were compared. RESULTS: The total operative time was shorter for RALF compared to CLF (88 vs. 102 min; p = 0.033) consisting of a longer set-up (23 vs. 20 min; p = 0.050) but a shorter effective operative time (65 vs. 82 min; p = 0.006). Intraoperative complications included one pneumothorax and two technical problems in the RALF group and two bleedings in the CLF group. There were no conversions to an open approach. Mean length of hospital stay (2.8 vs. 3.3 days; p = 0.086) and symptomatic outcome thirty days postoperatively (10% vs. 15% with ongoing PPI therapy; p = 1.0 and 25% vs. 20% with persisting mild dysphagia; p = 1.0) was similar in both groups. Costs were higher for RALF than for CLF (3244 euros vs. 2743 euros, p = 0.003). CONCLUSION: In comparison with CLF, operative time can be shorter for RALF if performed by an experienced team. However, costs are higher and short-term outcome is similar. Thus, RALF can not be favoured over CLF regarding perioperative outcome.

Surgical treatment of severe acute pancreatitis.

Surgical treatment of severe necrotizing pancreatitis (SNP) is still controversial, inadequate indications and timing of operations being associated with high rates of mortality and morbidity. The aim of the present study is to analyze the indications and results of surgery in patients with SNP. Between 1989 and 2005, necrosectomy followed by open packing drainage (OPD) was performed in 80 patients with SNP. Timing of operations was individualized according to presence of pancreatic necrosis infection. Major postoperative complications were present in 34 patients (42.5%), pancreatic, enteric and biliary fistula, sepsis, iatrogenic bleeding and stress-ulcers being among the most frequently encountered. Secondary contamination of sterile pancreatic necrosis after OPD occurred in 13 patients (35.1%). The overall mortality rate was 32.5%, aggravation of MOF and septic shock being the main causes of death. Late surgical cure for OPD-related incisional hernia was required in 10% of the patients. Infection of pancreatic necrosis is an indication for urgent surgical necrosectomy and repeated re-debridements. Due to technical impossibility to perform adequate necrosectomy and the risk of MOF aggravation, early surgery is not recommended in patients with sterile necrosis. It should be postponed beyond the third week, when the biological condition of the patient is improved and delimitation of necrosis is complete. OPD is an adequate and efficient drainage procedure following necrosectomy. "Prophylactic" OPD for sterile necrosis is not recommended because it is associated with high morbidity rates and secondary infection of necrosis.