ProMIS™ can serve as a da Vinci® simulator--a construct validity study.

PURPOSE: The purpose of this study was to investigate if the ProMIS™ simulator could serve as a training platform for the da Vinci® surgical system and if this constellation could prove construct validity. MATERIALS AND METHODS: The da Vinci system was connected to the ProMIS simulator, which registered objective data concerning how the surgeon performed in the box environment related to time, path, and smoothness. Five experienced robotic surgeons passed four different surgical tasks with progressive difficulty. A novice group-constituted of 13 consultants and 6 residents, none of them with any previous experience in the da Vinci system-passed the same tasks and the data were compared with the results from the expert group. RESULTS: A statistically significant difference between experts and novices was demonstrated in all tasks concerning time and smoothness. For the parameter path, significant difference was only noted in the more complex tasks. CONCLUSIONS: Our study showed that ProMis could differentiate between experienced robotic surgeons and novices, thereby proving construct validity. Smoothness appeared to be the most sensitive objective parameter in our study. Tasks with high complexity are recommended when designing the program for robotic training.

Massive fundic gland polyposis in a patient receiving protracted proton-pump inhibitor medication.

A case of massive fundic gland polyposis (MFGPsis) in a female patient receiving protracted proton-pump inhibitor (PPI) medication is described. At gross examination the majority of the polyps were overlapping, confluent, some of them having a "cauliflower-like" configuration. The fundic gland polyps (FGP) arose in the gastric acid secretory mucosa. The confluence of these polyps impeded their enumeration. The gross and histological characteristics of this case seemed to be at variance with syndromic or sporadic cases having multiple FGP, inasmuch as in this case, the FGP had a propensity to agglutinate, to overlap and to develop confluent macrocysts. Another difference was that this disease, refractory to antacid treatment, required surgical intervention. This case substantiates the notion that protracted PPI medication may encourage the development of MFGPsis in susceptible individuals.

Outpatient versus inpatient laparoscopic cholecystectomy: a prospective randomized study of symptom occurrence, symptom distress and general state of health during the first post-operative week.

BACKGROUND: Few randomized clinical trials focus on patients' symptoms of the first post-operative week following outpatient (OPS) versus inpatient (IPS) laparoscopic cholecystectomy (LC). The objective was to compare these treatment modalities with regard to patients' perceptions of pain and other post-operative symptoms, amount of distress, level of anxiety and general state of health during the first post-operative week. METHODS: One hundred patients were randomized. Seventy-three LC patients were valid for efficacy (OPS n=34, IPS n=39). Data were collected by means of questionnaires. RESULTS: The main result was that only minor [corrected] differences were seen between the groups regarding the occurrence of post-operative symptoms or symptom distress. Approximately 90% of the patients in both groups perceived pain, reduced mobility and tiredness on day 1. Nausea and loss of appetite were reported by half of the patients. Post-operative day 1, both groups reported much or very much distress related to pain and reduced mobility (approximately 40%) and nausea (approximately 20%). Although both groups reported less symptoms on day 7, one-third still experienced pain, but only one patient reported this to be distressing. CONCLUSION: Laparoscopic cholecystectomy patients in both groups recover equally well, indicating that a greater proportion of LC patients should be offered the outpatient modality.

Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies.

BACKGROUND: Virtual reality (VR) training has been shown previously to improve intraoperative performance during part of a laparoscopic cholecystectomy. The aim of this study was to assess the effect of proficiency-based VR training on the outcome of the first 10 entire cholecystectomies performed by novices. METHODS: Thirteen laparoscopically inexperienced residents were randomized to either (1) VR training until a predefined expert level of performance was reached, or (2) the control group. Videotapes of each resident's first 10 procedures were reviewed independently in a blinded fashion and scored for predefined errors. RESULTS: The VR-trained group consistently made significantly fewer errors (P = .0037). On the other hand, residents in the control group made, on average, 3 times as many errors and used 58% longer surgical time. CONCLUSIONS: The results of this study show that training on the VR simulator to a level of proficiency significantly improves intraoperative performance during a resident's first 10 laparoscopic cholecystectomies.

Prevalence of extraesophageal reflux in patients with symptoms of gastroesophageal reflux.

OBJECTIVES: To compare the prevalence of extraesophageal reflux (EER) in patients with heartburn, posterior laryngitis (PL), and in healthy controls. Study design and setting A retrospective and prospective study including a total of 101 subjects who underwent 24-hour dual-probe pH monitoring. RESULTS: 52% of the subjects with heartburn had EER. No significant differences were found between the PL and heartburn groups for any pharyngeal reflux parameters. However, supine pharyngeal reflux was significantly more prevalent in heartburn patients with GERD than in PL patients and healthy controls (P < 0.05). Significant positive correlation (P < 0.01) was found between the percentage of time pH <4 in the pharynx and in the distal esophagus. CONCLUSION: EER occurs in the majority of heartburn patients who are lacking laryngeal symptoms. Abnormal distal esophageal acid exposure makes the occurrence of EER more likely. SIGNIFICANCE: EER appears to be a continuum without clear-cut differences between the groups.

Early results of a single-blinded, randomized, controlled, Internet-based multicenter trial comparing Prolene and Vypro II mesh in Lichtenstein hernioplasty.

BACKGROUND: The standard polypropylene mesh used in Lichtenstein's operation induces a strong foreign-tissue reaction with potentially harmful effects. A mesh with less polypropylene could possibly be beneficial. PATIENTS AND METHODS: Six hundred men with inguinal hernias were randomized to Lichtenstein's operation with Prolene or Vypro II in a single-blinded multicenter trial. The randomization was performed by a computer algorithm in a database through the Internet. All data were entered and directly validated in the database through the Internet. RESULTS: The meshes had comparable results in return to work, return to daily activities, complications, postoperative pain, and quality of life during the first 8 weeks of rehabilitation. CONCLUSIONS: Lichtenstein's operation with either Prolene or Vypro II is safe and well tolerated with an acceptable postoperative rehabilitation time and a high quality of life 2 months after surgery. The study was facilitated by the use of a database through the Internet.

Barrett's esophagus: model of neoplastic progression.

Human cancer progression is characterized by clonal expansion of cells with accumulated genetic errors. Invasive carcinomas contain all the genetic errors that were acquired during neoplastic progression and then continue to accumulate further abnormalities, leading to tumor heterogeneity. Many investigations of human cancer have given valuable insights in genetic abnormalities important for tumor biology. Early events responsible for neoplastic progression, however, are often impossible to investigate in invasive cancers because the premalignant tissue in which the tumors develop are often overgrown and the premalignant conditions cannot be studied in vivo because they are either not detected owing to lack of symptoms or are removed before cancer develops. Unlike many other premalignant conditions Barrett's esophagus is often associated with symptoms leading to diagnosis at an early stage before cancer develops, and the premalignant epithelium is seldom removed at an early stage of cancer progression. Furthermore, in patients who present with invasive carcinoma the tumor is often surrounded by premalignant epithelium, which is available for further investigations. Therefore Barrett's esophagus is an excellent model in which to study the early events of neoplastic progression. It may not only contribute to a better understanding of the neoplastic process but also provide a base for safer assessment of cancer risk during surveillance for early detection of esophageal adenocarcinoma.

Tension-free inguinal hernia repair: TEP versus mesh-plug versus Lichtenstein: a prospective randomized controlled trial.

OBJECTIVE: To compare laparoscopic hernioplasty with two open tension-free hernia repairs. SUMMARY BACKGROUND DATA: Laparoscopic hernioplasty is associated with a short rehabilitation, but it is a technically difficult procedure. It is unclear if it has advantages over the technically easier open tension-free herniorrhaphy. METHODS: Two hundred ninety-nine men 30 to 75 years old were randomized to undergo laparoscopic totally extraperitoneal hernioplasty (TEP), open operation with mesh-plug and patch, or Lichtenstein's operation. RESULTS: Two hundred ninety-four (98%) patients were followed for 19.8 +/- 8.6 months. Over 90% of the patients in all groups were operated in day surgery; the rest of the patients were all discharged within 24 hours. Postoperative pain (visual analog score) was lower in the patients undergoing TEP than in those undergoing Lichtenstein and mesh-plug procedures. The median sick-leave period was 5 days in the TEP group, 7 days in the mesh-plug group, and 7 days in the Lichtenstein group. The median time to full recovery was significantly shorter in the TEP group compared to the other two groups. There were no major complications. Two recurrences were found in the TEP group and two in the mesh-plug group. CONCLUSIONS: Laparoscopic hernioplasty is superior to tension-free open herniorrhaphy in terms of postoperative pain and rehabilitation.

Extraesophageal reflux in patients with contact granuloma: a prospective controlled study.

The aim of this study was to compare the incidences of extraesophageal reflux in patients with contact granuloma and healthy controls. A 24-hour ambulatory pH monitoring technique was used to measure reflux parameters in the pharynx and distal esophagus. Pharyngeal acid reflux events occurred in 17 of 26 granuloma patients (1 to 20 episodes per patient) and 5 of 19 controls (1 to 8 episodes per subject). The reflux episodes were typically short and occurred predominantly in an upright position. A comparison between the groups showed a significant difference in the number of pharyngeal reflux episodes (p = .009) and in the total time of pH below 4 (p = .006). On the other hand, we found no significant differences in any esophageal reflux parameters, except for the percentage of distal esophageal reflux episodes that reached the pharynx (p = .006). In this study, pharyngeal acid exposure was significantly more prevalent in patients with contact granuloma than in healthy controls.

Gastroesophagopharyngeal reflux in patients with contact granuloma: a prospective controlled study.

The aim of this study was to compare the incidences of gastroesophagopharyngeal reflux in patients with contact granuloma and healthy controls. A 24-hour ambulatory esophagopharyngeal pH monitoring technique was used to measure reflux parameters in the pharynx and distal esophagus. Pharyngeal acid reflux events occurred in 17 of 26 granuloma patients (1 to 20 episodes per patient) and 5 of 19 controls (1 to 8 episodes per patient). The reflux episodes were typically short and occurred predominantly in an upright position. A comparison between the groups showed a significant difference in the number of pharyngeal reflux episodes (p = .009) and in the total time of pH below 4 (p = .006). On the other hand, we found no significant differences in any esophageal reflux parameters, except for the percentage of distal esophageal reflux episodes that reached the pharynx (p = .006). In this study, pharyngeal acid exposure was significantly more prevalent in patients with contact granuloma than in healthy controls.