Outcomes of resection of extra-adrenal pheochromocytomas/paragangliomas in the laparoscopic era: a comparison with adrenal pheochromocytoma.

INTRODUCTION: Laparoscopic adrenalectomy (LA) is the standard for removal of adrenal pheochromocytomas (pheos), but laparoscopic (LAP) resection of paragangliomas (PGs) is controversial. This study analyzes our results of resection of PGs in the LAP era. METHODS: A retrospective record review of all patients who underwent resection of intra-abdominal PGs from 1998 to 2011 was performed. Pre- and postoperative clinical, radiologic, biochemical, and pathologic data for LAP resection of PGs were compared with patients who underwent LA for adrenal pheo (LA pheo; n = 62). Statistical analysis was performed and data are reported as mean ± SD. RESULTS: Fifteen patients had resection of PGs (6 OPEN, 9 LAP) and 62 had LA pheo. Most common PG locations were perirenal or renal hilum (n = 6) and para-aortic (n = 4). One LAP PG was converted to OPEN due to inflammation from a prior biopsy. Mean age of LAP PGs was 45.3 ± 13.2 years, and mean tumor size was 3.3 ± 2.1 cm. OPEN PGs were larger (5.1 vs. 3.3 cm), had shorter operative times (173 vs. 254 min), and longer hospitalization (5.7 vs. 2.6 days) and ICU stays (1.33 vs. 0.22 days) compared with LAP PGs (p ≤ 0.05). Compared with LA pheo, operative times for LAP PG were significantly longer (254 vs. 175 min, p = 0.001) but other outcomes were similar. Complications occurred in 5.9 % of LA pheos, 22 % of LAP PGs and 67 % of OPEN PGs. CONCLUSIONS: Patients with paragangliomas can safely benefit from LAP resection with outcomes similar to adrenal pheos. In the absence of a need for contiguous organ resection, LAP resection of paragangliomas seems to be the preferred surgical approach.

Paraesophageal hernia repair with biomesh does not increase postoperative dysphagia.

INTRODUCTION: Laparoscopic techniques have led to hiatal procedures being performed with less morbidity but higher failure rates. Biologic mesh (biomesh) has been proposed as an alternative to plastic mesh to achieve durable repairs while minimizing stricturing and erosion. This paper documents the lack of significant dysphagia after the placement of biomesh during hiatal hernia repair. METHODS: A retrospective chart review of patients who underwent paraesophageal hiatal hernia repairs with and without biomesh was performed. Hernias were diagnosed with esophagogastroscopy and esophageal manometry. Demographic, procedural, and pre- and post-surgery symptom data were recorded. RESULTS: Fifty-six patients underwent biomesh repair while 33 patients underwent non-mesh repairs. The procedure time for mesh repairs was significantly longer (p = 0.004). Hospital stays, resting lower esophageal sphincter pressure, and mean contraction amplitudes were similar between groups. Residual pressure was measured to be significantly higher in patients who had mesh repairs (p = 0.0001). Normal esophageal peristalsis was maintained in both groups. At first follow-up, mesh patients complained of more dysphagia and bloating, but non-mesh patients had more heartburn. At second follow-up, non-mesh patients had more symptom complaints than mesh patients. CONCLUSION: The addition of biomesh for hiatal hernia repair does not result in significantly increased patient dysphagia rates postoperatively compared with patients who underwent primary repair.

Postoperative impedance-pH testing is unreliable after Nissen fundoplication with or without giant hiatal hernia repair.

INTRODUCTION: Combined 24-h multichannel intralumenal impedance-pH monitoring (MII-pH) is gaining popularity as a diagnostic tool for gastroesophageal reflux. Since the surgical reduction of hiatal hernias and creation of a fundoplication anatomically restores the gastroesophageal reflux barrier, one would assume that it effectively stops all reflux regardless of composition. Our aim is to evaluate the results of routine MII-pH testing in successful Nissen fundoplication patients. MATERIAL AND METHODS: Sixty-two patients with normal acid exposure, confirmed by 24-h pH testing, after Nissen fundoplication were evaluated with symptomatic questionnaire, esophageal manometry and MII-pH testing more than 6 months after surgery. Patients were grouped into normal and abnormal based on postoperative impedance results. Patients with Nissen alone were separately compared to patients with Nissen + giant hiatal hernia (GHH). RESULTS: Twenty-nine (47%) patients exhibited abnormal impedance after successful Nissen fundoplication. Abnormal impedance was associated with GHH repair, lower bolus pressures, and lower distal esophageal contraction amplitudes. CONCLUSION: Postoperative testing with the standard MII-pH catheters using published normative values seems to be clinically irrelevant. Clinicians should analyze the results of routine MII-pH testing in the setting of a fundoplication critically as the current technology is associated with a high false positive rate.

Concomitant endoscopic radiofrequency ablation and laparoscopic reflux operative results in more effective and efficient treatment of Barrett esophagus.

BACKGROUND: Barrett esophagus (BE) caused by gastroesophageal reflux disease can lead to esophageal cancer. The success of endoscopic treatments with BE eradication depends on esophageal anatomy and post-treatment acid exposure. STUDY DESIGN: Between January 2008 and December 2009, 10 patients were selected for combination treatment of BE using laparoscopic anti-reflux surgery and endoscopic radiofrequency ablation. Retrospective review of preoperative, procedural, and postoperative data was performed. RESULTS: Seven study patients had a pathologic diagnosis of nondysplastic BE and 3 patients had a diagnosis of low-grade dysplasia. Average length of BE lesions was 6.4 ± 4.8 cm. Procedure time averaged 154.4 ± 46.4 minutes. At the time of surgery, the mean number of ablations performed was 4.39 ± 1.99. Six patients were noted to have major hiatal hernias requiring reduction. Five patients (80%) had 100% resolution of their BE at their first postoperative endoscopy. The remaining 3 patients had a ≥50% resolution and underwent subsequent endoscopic ablation. Symptomatic results revealed that 4 patients had substantial dysphagia to solids and other symptoms were minimal. Two patients were noted to have complications related to the ablative treatments. One stricture and 1 perforation were observed. CONCLUSIONS: Endoscopic radiofrequency ablation of BE at the time of laparoscopic fundoplication is feasible and can effectively treat BE lesions. A single combined treatment can result in fewer overall procedures performed to obtain BE eradication.

Efficacy of using a novel endoscopic lens cleaning device: a prospective randomized controlled trial.

INTRODUCTION: Clear visualization of the surgical field is critical in laparoscopic surgery. The authors evaluated a device that does not necessitate an external cleaning process for the laparoscope. It was hypothesized that it will minimize the interruption in operative workflow. METHODS: A total of 40 advanced laparoscopy patients were randomized to either the control or device group. Demographic data, procedural data, length of stay, frequency and duration of lens cleaning, and lens clarity scores (LCS) were recorded. Independent samples t test and Fisher's exact test were performed. RESULTS: No significant difference was found between the device and control groups in demographic data, procedure time (P = .922) or LCS (P = .124). Laparoscope cleaning in the device group was significantly shorter than in the control group (P < .001). No complications were observed. CONCLUSION: An intra-abdominal laparoscopic cleaning device can effectively clean the laparoscopic lens and lead to less workflow interruption. Although not documented in this study, it may also lead to shorter operative times.

A triangulating operating platform enhances bimanual performance and reduces surgical workload in single-incision laparoscopy.

BACKGROUND: Single-site laparoscopy (SSL) attempts to further reduce the surgical impact of minimally invasive surgery. However, crossed instruments and the proximity of the endoscope to the operating instruments placed through one single site leads to inevitable instrument or trocar collision. We hypothesized that a novel, single-port, triangulating surgical platform (SPSP) might enhance performance by improving bimanual coordination and decreasing the surgeon's mental workload. STUDY DESIGN: Fourteen participants, proficient in basic laparoscopic skills, were tested on their ability to perform a validated intracorporeal suturing task by either an SSL approach with crossed articulated instruments or a novel SPSP, providing true-right and true-left manipulation. Standard laparoscopic (SL) access served as control. Sutures were evaluated using validated scoring methods and the National Aeronautics and Space Administration Task Load Index was used to rate mental workload. RESULTS: All participants proficiently performed intracorporeal knots by SL (mean score 99.0; 95% CI 97.0 to 100.9). Performance decreased significantly (more than 50%, p < 0.001) with the SSL approach using 1 rigid and 1 articulating instrument in a cross-wise manner (mean score 39.2; 95% CI 28.3 to 50.1). The use of the SPSP significantly enhanced bimanual coordination (mean score 67.6; 95% CI 61.3 to 73.9; p < 0.001). Participants recorded lower mental workload when using true-right and true-left manipulation. CONCLUSIONS: This study objectively assessed SSL performance and current attempts for instrumentation improvement in single-site access. While SSL significantly impairs basic laparoscopic skills, surgical platforms providing true-left and true-right maneuvering of instruments appear to be more intuitive and address some of the current challenges of SSL that may otherwise limit its widespread acceptance.

Use of flexible endoscopes for NOTES: sterilization or high-level disinfection?

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) involves the use of flexible endoscopes to perform intra-abdominal or intra-thoracic surgeries. Surgery in the operating room usually involves sterile instrumentation, whereas in the endoscopy suite high-level disinfection seems to be sufficient. Our objective was to assess the necessity for endoscope sterilization for clinical NOTES and to develop an endoscope processing protocol based on a score for the available processing options. METHODS: Score and processing protocol development for clinical NOTES endoscopes was based on a comprehensive review of the available relevant literature. Options for sterilization for flexible endoscopes in the Good Samaritan Hospital, Legacy Health in Portland, Oregon, were analyzed for patient safety, potential for recontamination, cost, and validation. RESULTS: Literature survey indicated that there is controversy surrounding the necessity for sterilization of surgical endoscopes. However, standard of practice seems to call for sterile instrumentation for surgery and it is possible to terminally sterilize flexible endoscopes. Within our institution, a score was created to rank the available sterilization options. We successfully introduced a protocol for sterilization of endoscopes for use in clinical NOTES procedures. The protocol involved mechanical cleaning and high-level disinfection per Multi-Society Guidelines, with subsequent terminal sterilization using a validated peracetic acid protocol. CONCLUSIONS: It remains controversial whether sterile instrumentation is truly needed for surgery. It is difficult but possible to terminally sterilize flexible endoscopes. We recommend sterile instrumentation for clinical NOTES until well-designed, randomized, clinical trials are available and guidelines are published.

De novo production of K-alpha1 tubulin-specific antibodies: role in chronic lung allograft rejection.

Lung transplantation is the treatment option for a variety of end-stage pulmonary diseases. Posttransplant development of Abs against donor HLA and non-HLA Ags have been associated with acute and chronic rejection of transplanted organs. Development of bronchiolitis obliterans syndrome (BOS) following lung transplantation has been correlated with de novo production of anti-donor-HLA Abs. However, only a portion of the patients with BOS demonstrate detectable anti-donor-HLA Abs. Airway epithelium is considered as a major target for lung allograft rejection. In this study we demonstrate that many BOS(+) patients (12 of 36) develop Abs reactive to epithelial cell Ag that are distinct from HLA. Furthermore, de novo production of antiepithelial cell Ab precedes clinical onset of BOS. N-terminal sequencing and blastx analysis as well as blocking with K-alpha1 tubulin-specific Ab identified the epithelial Ag as K-alpha1 tubulin. Binding of the de novo-produced anti-K-alpha1 tubulin Abs to the airway epithelial cells resulted in the increased expression of transcription factors (TCF5 and c-Myc), leading to increased expression of fibrogenic growth factors, activation of cell cycle signaling, and fibroproliferation, the central events in immunopathogenesis of BOS following human lung transplantation.