Perspectives of laparoscopic donors toward a new procedure: transvaginal donor nephrectomy.

BACKGROUND: Interest in natural orifice transluminal endoscopic surgery (NOTES) is increasing. Transvaginal NOTES (TVNOTES) donor nephrectomy with subsequent removal of the kidney via the vagina is technically possible. This approach may minimize the surgical insult to the donor and allow improved cosmesis. The acceptability to patients of such a technique is, however, unknown. The aim of this article is to explore the attitudes of women who have previously undergone laparoscopic donor nephrectomy (LDN). METHODS: A 15-point questionnaire was designed by a multidisciplinary group of surgeons interested in minimally invasive surgery to obtain the views of women who had previously undergone LDN at the Queen Elizabeth Hospital, Adelaide. It was sent to 150 female donors, and their views with regard to the acceptability of a TV approach to the peritoneal cavity for donor nephrectomy were recorded. RESULTS: Forty-nine patients returned the completed questionnaire. The majority (90%) of these women did not have adverse feelings toward scars. Thirty-seven percent of women would consider a TVNOTES donor nephrectomy; however, this was increased to 51% if they could be reassured that TVNOTES was as safe as LDN. Concerns regarding a negative impact on sexual function after this procedure were raised by 33% of patients. The majority (88%) did not cite surgeon gender as an important factor when deciding for or against this procedure. CONCLUSIONS: This study demonstrates that less postoperative pain, better cosmesis, and safety are factors that may influence a patient's decision to choose TVNOTES donor nephrectomy. The majority, however, would still prefer LDN.

Cytoplasmic beta-catenin accumulation is a good prognostic marker in upper and lower gastrointestinal adenocarcinomas.

AIMS: beta-Catenin is an important molecule in cancer biology. Membranous beta-catenin enhances cellular differentiation and inhibits invasion by its action on E-cadherin. The aim was to ascertain whether the cellular expression of these molecules in colorectal and oesophageal cancer specimens is associated with survival in patients with gastrointestinal cancer. METHODS AND RESULTS: Tumour samples from 149 patients undergoing resection for colorectal adenocarcinoma and 147 patients undergoing resection for oesophageal adenocarcinoma were retrospectively analysed using immunohistochemical techniques to assess beta-catenin expression. Increasing beta-catenin expression in the cytoplasm was associated with improved survival for colorectal cancer cases on both univariate (P = 0.003) and multivariate (P = 0.01) analysis. In addition, increased expression in the most recent cohort of oesophageal adenocarcinoma patients was associated with improved TNM staging (P = 0.007). Membrane expression was weakly associated with survival in colorectal cancer on univariate analysis (P = 0.09), but not on multivariate analysis (P = 0.21). Complete absence of beta-catenin expression at all three sites was associated with reduced 5-year survival in colorectal cancer. CONCLUSIONS: This is one of the largest prognostic studies of beta-catenin in gastrointestinal adenocarcinoma. It shows that low levels of cytoplasmic beta-catenin expression are associated with reduced survival in patients with colorectal cancer as well as worse TNM staging in oesophageal adenocarcinoma (a recognized surrogate end-point for survival). We believe this is the first time that this has been reported. This finding should be tested prospectively in oncological trials to validate whether the presence of cytoplasmic beta-catenin could be used as a prognostic marker for less aggressive disease.

Transvaginal natural orifice translumenal endoscopic surgery (NOTES): a survey of women's views on a new technique.

BACKGROUND: Laparoscopic and minimally invasive surgery has changed the surgical landscape irrevocably. Natural orifice translumenal endoscopic surgery (NOTES) offers the possibility of surgery without visible scars. Transvaginal entry offers potential benefits because it gains access to the peritoneal cavity without the need to open an abdominal viscus. Much of the discussion pertaining to NOTES focuses on technical and training issues, with little attention to date paid to the opinions of women. The perceptions of female health care workers and patients were sought in relation to their views on transvaginal NOTES. METHODS: This study surveyed 300 women using a 12-point questionnaire devised by a multidisciplinary group of surgeons interested in minimally invasive surgery. The questionnaire was designed to establish the opinions of women with respect to NOTES surgery versus standard laparoscopic procedures. Responses were de-identified. RESULTS: Three-fourths of the women surveyed were neutral or unhappy about the prospect of a NOTES procedure, and this remained constant even when it was stipulated that laparoscopic cholecystectomy and NOTES had equivalent safety and efficacy. Younger nulliparous women were most concerned about the potential negative effect of NOTES on sexual function. A minority were concerned about the cosmetic effect of surgery, although surgical scars were perceived as more important to younger respondents. CONCLUSIONS: Potentially, NOTES surgery offers women a scarless operation with the possibility of less pain than experienced in standard laparoscopic surgery. Few women, however, were troubled about the cosmetic effect of surgery. The effect of NOTES on sexual function was expressed as a particular concern by younger women. In all groups and across all ages, peritoneal access using the transvaginal route was met by significant scepticism. In Australia, women remain to be convinced about the potential advantages of the emerging NOTES technology.

Evaluation of level 1 care facilities for vascular patients.

BACKGROUND: A surgical acute care unit (SACU) was established within our hospital to specifically provide level 1 care to surgical patients. We assess the impact that this has had on outcome in vascular patients. METHODS: All patients undergoing carotid endarterectomy (CEA) and elective abdominal aortic aneurysm repair (AAA) during the first year of SACU were included in the present study. A control group was compiled from patients undergoing the same two procedures in the year preceding the opening of the SACU. Data were collected on admission time, time spent in critical care, outcome and operative cancellations. RESULTS: During the first year of the SACU there were 28 CEA and 42 AAA repairs performed. In the control group there were 18 CEA and 34 AAA repairs performed. There were no significant differences in death rate or length of hospital stay between the two groups for either AAA repair or CEA. CEA patients in the study group had a significantly reduced level 2 stay (P < 0.001 Mann-Whitney U-test), with 71% of patients being admitted directly to the level 1 facility from theatre. There were less CEA cancelled because of critical care bed shortages among the cases (n = 0) compared to the control group (n = 2), although this did not reach statistical significance (P = 0.15 Fisher's exact test). CONCLUSIONS: Designated level 1 care has reduced the need for the postoperative admission of CEA patients to level 2 care facilities. It has had no discernible impact on admission time or mortality, but might reduce the number of cancelled operations caused by a lack of level 2 beds.