Tinción de Gram intraoperatoria en bilis para la prevención de complicaciones infecciosas en la duodenopancreatectomía / Intraoperative gram staining of bile for the prevention of infectious complications in pancreaticoduodenectomy

Introducción Las complicaciones infecciosas presentan un papel destacado en la duodenopancreatectomía. Su incidencia aumenta en casos con drenaje biliar preoperatorio (DBP), por el mayor riesgo de bacterobilia. Se presenta un estudio con el objetivo de valorar un protocolo de antibioterapia guiado por una tinción de gram intraoperatoria de líquido biliar. Métodos Estudio retrospectivo en el que se analiza la incidencia de complicaciones infecciosas entre dos grupos de 25 pacientes, consecutivos en el tiempo, intervenidos de duodenopancreatectomía. En el grupo 1 se administró profilaxis con cefazolina en pacientes sin DBP y antibioterapia durante cinco días con piperacilina-tazobactam en casos con DBP. En el grupo 2 se realizó tinción de gram intraoperatoria de bilis de forma sistemática. Si no se detectaban microorganismos, la antibioterapia se limitaba a profilaxis con cefazolina. Si se apreciaba bacterobilia, se administraba antibioterapia dirigida durante cinco días. Resultados La incidencia de infección órgano-cavitaria fue del 24% en el grupo 1 y del 4% en el 2 (p=0,04) y la incidencia de sepsis fue del 32% en el primer grupo y del 4% en el segundo (p=0,01). No se apreciaron diferencias en el resto de variables de morbimortalidad. Los microorganismos más prevalentes en bilis fueron Enterococcus spp y Klebsiella spp. En cultivos postoperatorios, aunque también fueron los más frecuentes en el grupo 1 (28 y 24%), solo aparecieron en el 4% de los casos del grupo 2 (p<0,05) Conclusión La tinción de gram intraoperatoria de bilis podría ser útil para dirigir la antibioterapia en la duodenopancreatectomía y contribuir a reducir las complicaciones infecciosas (AU)

Introduction Infectious complications play a prominent role in pancreaticoduodenectomy. Their incidence increases in cases with preoperative biliary drainage (PBD), due to the higher risk of bacterobilia. The aim of this study is to evaluate an antibiotherapy protocol based on intraoperative gram staining of bile and its impact on postoperative infectious complications. Methods A retrospective study analysing the incidence of infectious complications between two groups of 25 consecutive patients undergoing pancreaticoduodenectomy. In group 1, cefazolin prophylaxis was administered to patients without PBD. In cases with PBD a five days antibiotherapy with piperacillin-tazobactam was administered. In group 2, intraoperative gram staining of bile was routinely performed. If no microorganisms were detected, antibiotherapy was limited to cefazolin prophylaxis. If bacterobilia was detected, targeted antibiotherapy was administered for five days. Results The incidence of sepsis and organ/space infection in group 2 was 4% compared to 32% and 24% in group 1 respectively (p<0.05). No differences were observed in the remaining morbimortality variables. The most prevalent microorganisms in bile were Enterococcus spp and Klebsiella spp. In postoperative samples, they only appeared in 4% of cases in group 2 (p<0.05), in favour of S. epidermidis, although they were also prevalent in group 1 (28 and 24% respectively). Conclusion Intraoperative gram staining of bile fluid could be a useful tool to conduct personalised antibiotic therapy in pancreaticoduodenectomy and contribute to the control of infectious complications (AU)

Dual role of miR-1 in the development and function of sinoatrial cells.

miR-1, the most abundant miRNA in the heart, modulates expression of several transcription factors and ion channels. Conditions affecting the heart rate, such as endurance training and cardiac diseases, show a concomitant miR-1 up- or down-regulation. Here, we investigated the role of miR-1 overexpression in the development and function of sinoatrial (SAN) cells using murine embryonic stem cells (mESC). We generated mESCs either overexpressing miR-1 and EGFP (miR1OE) or EGFP only (EM). SAN-like cells were selected from differentiating mESC using the CD166 marker. Gene expression and electrophysiological analysis were carried out on both early mES-derived cardiac progenitors and SAN-like cells and on beating neonatal rat ventricular cardiomyocytes (NRVC) over-expressing miR-1. miR1OE cells increased significantly the proportion of CD166+ SAN precursors compared to EM cells (23% vs 12%) and the levels of the transcription factors TBX5 and TBX18, both involved in SAN development. miR1OE SAN-like cells were bradycardic (1,3 vs 2 Hz) compared to EM cells. In agreement with data on native SAN cells, EM SAN-like cardiomyocytes show two populations of cells expressing either slow- or fast-activating If currents; miR1OE SAN-like cells instead have only fast-activating If with a significantly reduced conductance. Western Blot and immunofluorescence analysis showed a reduced HCN4 signal in miR-1OE vs EM CD166+ precursors. Together these data point out to a specific down-regulation of the slow-activating HCN4 subunit by miR-1. Importantly, the rate and If alterations were independent of the developmental effects of miR-1, being similar in NRVC transiently overexpressing miR-1. In conclusion, we demonstrated a dual role of miR-1, during development it controls the proper development of sinoatrial-precursor, while in mature SAN-like cells it modulates the HCN4 pacemaker channel translation and thus the beating rate.

Review of the scientific evidence and technical opinion on noncaloric sweetener consumption in gastrointestinal diseases. / Revisión de la evidencia científica y opinión técnica sobre el consumo de edulcorantes no calóricos en enfermedades gastrointestinales.

The present review of noncaloric sweeteners (NCSs) by the Asociación Mexicana de Gastroenterología was carried out to analyze and answer some of the most frequent questions and concerns about NCS consumption in patients with gastrointestinal disorders, through a thorough review of the medical literature. A group of gastroenterologists and experts on nutrition, toxicology, microbiology, and endocrinology reviewed and analyzed the published literature on the topic. The working group formulated conclusions, based on the scientific evidence published, to give an opinion with respect to NCS ingestion. Current evidence does not confirm the carcinogenic potential of NCSs. However, the studies analyzed showed that saccharin could have a proinflammatory effect and that polyols can cause gastrointestinal symptoms and manifestations, depending on the dose and type of compound. The ingestion of xylitol, erythritol, sucralose, aspartame, acesulfame K, and saccharin could increase the secretion of the gastrointestinal hormones that regulate intestinal motility, and stevia and its derivatives could have a favorable effect on the percentage of liver fat. Caution should be taken in recommending aspartame consumption in patients with chronic liver disease because it reduces the ratio of branched-chain amino acids to aromatic amino acids. In addition, NCS ingestion could modify the composition of the intestinal microbiota, having an effect on gastrointestinal symptoms and manifestations. It is important to continue conducting causality studies on humans to be able to establish recommendations on NSC consumption.

Compact radio emission indicates a structured jet was produced by a binary neutron star merger.

The binary neutron star merger event GW170817 was detected through both electromagnetic radiation and gravitational waves. Its afterglow emission may have been produced by either a narrow relativistic jet or an isotropic outflow. High-spatial-resolution measurements of the source size and displacement can discriminate between these scenarios. We present very-long-baseline interferometry observations, performed 207.4 days after the merger by using a global network of 32 radio telescopes. The apparent source size is constrained to be smaller than 2.5 milli-arc seconds at the 90% confidence level. This excludes the isotropic outflow scenario, which would have produced a larger apparent size, indicating that GW170817 produced a structured relativistic jet. Our rate calculations show that at least 10% of neutron star mergers produce such a jet.

Effects of 5-HT5A receptor blockade on amnesia or forgetting.

Previously the effects (0.01-3.0 mg/kg) of post-training SB-699551 (a 5-HT5A receptor antagonist) were reported in the associative learning task of autoshaping, showing that SB-699551 (0.1 mg/kg) decreased lever-press conditioned responses (CR) during short-term (STM; 1.5-h) or (3.0 mg/kg) long-term memory (LTM; 24-h); relative to the vehicle animals. Moreover, as pro-cognitive efficacy of SB-699551 was reported in the ketamine-model of schizophrenia. Hence, firstly aiming improving performance (conditioned response, CR), in this work autoshaping lever-press vs. nose-poke response was compared; secondly, new set of animals were randomly assigned to SB-699551 plus forgetting or amnesia protocols. Results show that the nose-poke operandum reduced inter-individual variance, increased CR and produced a progressive CR until 48-h. After one week of no training/testing sessions (i.e., interruption of 216 h), the forgetting was observed; i.e., the CR% of control-saline group significantly decreased. In contrast, SB-699551 at 0.3 and 3.0 mg/kg prevents forgetting. Additionally, as previously reported the non-competitive NMDA receptor antagonist dizocilpine (0.2 mg/kg) or the non-selective cholinergic antagonist scopolamine (0.3 mg/kg) decreased CR in STM. SB-699551 (0.3 mg/kg) alone also produced amnesia-like effect. Co-administration of SB-699551-dizocilpine or SB-699551-scopolamine reversed the SB-699551 induced-amnesic effects in LTM (24-h). Nose-poke seems to be a reliable operandum. The anti-amnesic and anti-forgetting mechanisms of amnesic SB-699551-dose remain unclear. The present findings are consistent with the notion that low doses of 5-HT5A receptor antagonists might be useful for reversing memory deficits associated to forgetting and amnesia. Of course, further experiments are necessary.

Intrahippocampal administration of 5-HT6 receptor drugs on memory consolidation and amnesia protocols.

To our knowledge the intrahippocampal serotonergic 5-HT6 receptor tone on memory and amnesia models remains unexplored. Hence, in the present work we tested intrahippocampal administration of serotonin or 5-hydroxytryptamine (5-HT)6 receptor experimental molecules with differential intrinsic activity. Methods: In the present study, Automatized Autoshaping memory task was used, useful measuring memory, neural markers, and pharmacological effects. We are hypothesizing that experimental molecules with differential intrinsic activity might reveal serotonergic tone. Particularly, intrahippocampal administration of 5-HT6 receptor compounds with differential intrinsic activity (i.e., agonistic and antagonistic) might evidencing a serotonergic tone via this receptor. Bilateral intrahippocampal dose-response curves show that administration of EMD386088 (10 and 100 µg) had no effect or (50 µg) decreased conditioned responses (CR) in short- and long-term memory (STM and LTM, respectively); while SB-399885 (10 or 100 µg) significantly decreased CR in STM and LTM (24 and 48-h) or (50 µg) had no effect; thus suggesting that there is a 5-HT6 receptor tone regulating both STM and LTM. Moreover, intrahippocampal inactive doses of EMD386088 (5 µg) plus SB-399885 (0.5 µg) did not affect STM and LTM; however, partially or completely prevented the scopolamine or dizocilpine-induced amnesia. Thus confirming that both drugs exerted their effects through 5-HT6 receptor and that there is a hippocampal serotonergic tone under amnesic states, similar to that striatal.

Clinical guidelines on the diagnosis and treatment of celiac disease in Mexico. / Guía clínica para diagnóstico y tratamiento de la enfermedad celíaca en México.

Celiac disease, celiac sprue, or gluten-sensitive enteropathy, is a generalized autoimmune disease characterized by chronic inflammation and atrophy of the small bowel mucosa. It is caused by dietary exposure to gluten and affects genetically predisposed individuals. In Mexico, at least 800,000 are estimated to possibly have the disease, prompting the Asociación Mexicana de Gastroenterología to summon a multidisciplinary group of experts to develop the "Clinical guidelines on the diagnosis and treatment of celiac disease in Mexico" and establish recommendations for the medical community, its patients, and the general population. The participating medical professionals were divided into three working groups and were given the selected bibliographic material by the coordinators (ART, LUD, JMRT), who proposed the statements that were discussed and voted upon in three sessions: two voting rounds were carried out electronically and one at a face-to-face meeting. Thirty-nine statements were accepted, and once approved, were developed and revised by the coordinators, and their final version was approved by all the participants. It was emphasized in the document that epidemiology and risk factors associated with celiac disease (first-degree relatives, autoimmune diseases, high-risk populations) in Mexico are similar to those described in other parts of the world. Standards for diagnosing the disease and its appropriate treatment in the Mexican patient were established. The guidelines also highlighted the fact that a strict gluten-free diet is essential only in persons with confirmed celiac disease, and that the role of gluten is still a subject of debate in relation to nonceliac, gluten-sensitive patients.

Indications for and diagnostic yield of capsule endoscopy in the elderly. / Indicaciones y rendimiento diagnóstico de la cápsula endoscópica en el anciano.

INTRODUCTION AND AIMS: The growing elderly population and wide use of capsule endoscopy have led to a higher number of procedures in those patients. The aim of the present study was to assess the usefulness of capsule endoscopy in older patients. MATERIALS AND METHODS: All consecutive patients undergoing capsule endoscopy at our center within the time frame of 2004-2016 were classified as older (≥75 years of age) and younger. Findings and diagnostic yield were comparatively assessed. RESULTS: Of 2311 patients (mean age: 59.5 ± 19.23 years, 44.48% male), 648 were in the older group and 1663 in the younger group. Gastric transit time was shorter in the older patients (p=0.001), whereas small bowel transit time was shorter in the younger patients (p<0.001). Overall diagnostic yield in the elderly was higher (50.66% vs. 41.19%, p<0.001). Obscure gastrointestinal bleeding was the most frequent indication for capsule endoscopy in the elderly (90.4% vs. 53.77%, p<0.001), achieving a higher diagnostic yield than in the younger population (51.47% vs. 42.76%, p=0.002), whereas Crohn's disease, suspected or known neoplasms/polyps, malabsorption syndrome, and abdominal pain were the indications in the younger patient group. Such indications were rare in the older group. Vascular lesions and active bleeding were more frequently diagnosed in the older patients, whereas ulcers/erosions and mucosal atrophy were more common in the younger patients (p<0.001). CONCLUSIONS: Capsule endoscopy achieved a higher overall diagnostic yield in the elderly patients. Obscure gastrointestinal bleeding indication for capsule endoscopy was much more frequent in the advanced-age group and had a higher diagnostic yield.

Effect of carbon sources on the growth and ethanol production of native yeast Pichia kudriavzevii ITV-S42 isolated from sweet sorghum juice.

The importance of non-Saccharomyces yeast species in fermentation processes is widely acknowledged. Within this group, Pichia kudriavzevii ITV-S42 yeast strain shows particularly desirable characteristics for ethanol production. Despite this fact, a thorough study of the metabolic and kinetic characteristics of this strain is currently unavailable. The aim of this work is to study the nutritional requirements of Pichia kudriavzevii ITV-S42 strain and the effect of different carbon sources on the growth and ethanol production. Results showed that glucose and fructose were both assimilated and fermented, achieving biomass and ethanol yields of 0.37 and 0.32 gg-1, respectively. Glycerol was assimilated but not fermented; achieving a biomass yield of 0.88 gg-1. Xylose and sucrose were not metabolized by the yeast strain. Finally, the use of a culture medium enriched with salts and yeast extract favored glucose consumption both for growth and ethanol production, improving ethanol tolerance reported for this genre (35 g L-1) to 90 g L-1 maximum ethanol concentration (over 100%). Furthermore Pichia kudriavzevii ITV-S42 maintained its fermentative capacity up to 200 g L-1 initial glucose, demonstrating that this yeast is osmotolerant.

Orbital liposarcoma. / Liposarcoma de la órbita.

CASE REPORT: The case is presented of a 46-year-old male with right eye proptosis and conjunctival hyperaemia, of 18 months onset. A well-defined intraconal mass was found in the computed tomography. In magnetic resonance this was hypo-intense on T1, enhanced with gadolinium and hyperintense on T2. Excisional biopsy was performed, which was reported as a well-differentiated liposarcoma in the histopathology study. DISCUSSION: Liposarcoma is a malignant adipose tissue tumour. It is very rare in the orbit, with 5 histological types, the most common being myxoid. The treatment of choice is wide surgical excision and may be accompanied with radiotherapy. As it is an infiltrative tumour, It has a high rate of recurrence.

Isolation, Identification and Partial Characterization of a Lactobacillus casei Strain with Bile Salt Hydrolase Activity from Pulque.

The aim of this study was to isolate, from pulque, Lactobacillus spp. capable of survival in simulated gastrointestinal stress conditions. Nine Gram-positive rods were isolated; however, only one strain (J57) shared identity with Lactobacillus and was registered as Lactobacillus casei J57 (GenBank accession: JN182264). The other strains were identified as Bacillus spp. The most significant observation during the test of tolerance to simulated gastrointestinal conditions (acidity, gastric juice and bile salts) was that L. casei J57 showed a rapid decrease (p ≤ 0.05) in the viable population at 0 h. Bile salts were the stress condition that most affected its survival, from which deoxycholic acid and the mix of bile salts (oxgall) were the most toxic. L. casei J57 showed bile salt hydrolase activity over primary and secondary bile salts as follows: 44.91, 671.72, 45.27 and 61.57 U/mg to glycocholate, taurocholate, glycodeoxycholate and taurodeoxycholate. In contrast, the control strain (L. casei Shirota) only showed activity over tauroconjugates. These results suggest that L. casei J57 shows potential for probiotic applications.

Efficiency of pragmatic search strategies to update clinical guidelines recommendations.

BACKGROUND: A major challenge in updating clinical guidelines is to efficiently identify new, relevant evidence. We evaluated the efficiency and feasibility of two new approaches: the development of restrictive search strategies using PubMed Clinical Queries for MEDLINE and the use of the PLUS (McMaster Premium Literature Service) database. METHODS: We evaluated a random sample of recommendations from a national guideline development program and identified the references that would potentially trigger an update (key references) using an exhaustive approach. We designed restrictive search strategies using the minimum number of Medical Subject Headings (MeSH) terms and text words required from the original exhaustive search strategies and applying broad and narrow filters. We developed PLUS search strategies, matching Medical Subject Headings (MeSH) and Systematized Nomenclature of Medicine (SNOMED) terms with guideline topics. We compared the number of key references retrieved by these approaches with those retrieved by the exhaustive approach. RESULTS: The restrictive approach retrieved 68.1 % fewer references than the exhaustive approach (12,486 versus 39,136), and identified 89.9 % (62/69) of key references and 88 % (22/25) of recommendation updates. The use of PLUS retrieved 88.5 % fewer references than the exhaustive approach (4,486 versus 39,136) and identified substantially fewer key references (18/69, 26.1 %) and fewer recommendation updates (10/25, 40 %). CONCLUSIONS: The proposed restrictive approach is a highly efficient and feasible method to identify new evidence that triggers a recommendation update. Searching only in the PLUS database proved to be a suboptimal approach and suggests the need for topic-specific tailoring.

GRB 130427A: a nearby ordinary monster.

Long-duration gamma-ray bursts (GRBs) are an extremely rare outcome of the collapse of massive stars and are typically found in the distant universe. Because of its intrinsic luminosity (L ~ 3 × 10(53) ergs per second) and its relative proximity (z = 0.34), GRB 130427A reached the highest fluence observed in the γ-ray band. Here, we present a comprehensive multiwavelength view of GRB 130427A with Swift, the 2-meter Liverpool and Faulkes telescopes, and by other ground-based facilities, highlighting the evolution of the burst emission from the prompt to the afterglow phase. The properties of GRB 130427A are similar to those of the most luminous, high-redshift GRBs, suggesting that a common central engine is responsible for producing GRBs in both the contemporary and the early universe and over the full range of GRB isotropic energies.

[Indications for corticosteroids in gastroenterology]. / Indicaciones de corticoesteroides en gastroenterología.

Since the discovery of anti- inflammatory and immunosuppressive properties of glucocorticoids in the late 40's, these drugs have been a cornerstone in the treatment of a variety of autoimmune and inflammatory diseases, being one of the most prescribed drugs in spite of their side effects occurring in up to 80% of patients treated. In Gastroenterology, as in other medical specialties, glucocorticoids are a widely used tool for the treatment of various diseases affecting the gastrointestinal tract, liver, bile ducts and pancreas, making it necessary to establish when and in which patients are indicated, as well as the glucocorticoid type, dose, route of administration and duration of treatment, taking into account that the long-term use without adequate control produces complications that may outweigh their beneficial effects.

[Thickening of the colon and terminal ileum documented with computer tomography and its correlation with colonoscopic findings at a third-level hospital]. / Engrosamiento colónico y de íleon terminal documentado por tomografía computarizada y su correlación con hallazgos colonoscópicos en un hospital de tercer nivel.

BACKGROUND: Tomographic finding of thickening of colon and terminal ileum and its correlation with colonoscopic findings has been poorly studied. Various radiographic patterns of intestinal thickening suggestive of benign disease have been described, but they cannot completely rule out malignancy. OBJECTIVE: To determine if a relationship exists between colonic wall or terminal ileum thickening documented by computed tomography with abnormal colonoscopic findings and colon cancer. METHODS: Retrospective study of radiology database of a tertiary hospital identifying patients with report of thickening of terminal ileum or colon and have colonoscopy performed. It was investigated the performance of endoscopic biopsies and histopathological outcome. RESULTS: We included 24 patients. The main site of colonic thickening on CT was sigmoid in 8 (33.3%) cases. The most common colonoscopic finding was colorectal tumor probably malignant in 7 (29.2%) patients, but adenocarcinoma was reported in 8 (33.3%) patients. There was a statistically significant relationship between colonic thickening and colorectal cancer (p < 0.001) but no statistically significant association was found between thickening and sigmoid colon cancer. There was statistical significant correlation between weight loss, melena, anemia, constipation, diarrhea, and hematochezia with diagnosis of cancer (p < 0.01). CONCLUSIONS: The finding of thickening of colon documented by computed tomography is significantly associated with the presence of colorectal carcinoma. Additional colonoscopy must always be performed in an attempt to elucidate the origin of this thickening.

Advanced glycosylation end products in skin, serum, saliva and urine and its association with complications of patients with type 2 diabetes mellitus.

BACKGROUND: The accumulation of advanced glycation end products (AGEs) has a key role in the pathophysiology of diabetes complications. Comparison of AGEs measurement in serum, skin, saliva and urine has not been reported. AIMS: To compare AGEs in serum, skin, saliva and urine in patients with Type 2 diabetes mellitus, with complications at different stages. MATERIALS AND METHODS: We examined 50 patients with Type 2 diabetes mellitus (40 women and 10 men) grouped according to the progression of neuropathy, nephropathy and retinopathy. The AGEs content in serum, skin, saliva and urine was measured by spectrofluorometry HPLC. RESULTS: The patients had a mean age of 56.5 +/- 7.7 yr and 12.8 +/- 6.7 yr since diagnosis. AGEs in skin correlated with years since diagnosis (p = 0.0005). AGEs in serum, skin and saliva increased with the progression of complications, nevertheless, in urine a trend to diminution was found. In the group with end-stage renal disease (ESRD), AGEs in serum increased in greater proportion. In order to account for the decreased AGEs clearance, we corrected the values for creatinine levels, and AGEs in skin gave a better association with complications. CONCLUSIONS: The AGEs measurement in skin, serum and saliva are useful to evaluate diabetes complications. AGEs in skin are associated with years since diagnosis of diabetes. Correction for renal function might discriminate AGEs in situ formation from accumulation.

European collaborative group on prostate brachytherapy: preliminary report in 1175 patients.

OBJECTIVE: To establish a multi-centre database of a large number of patients treated with brachytherapy across Europe. METHODS: A total of 1175 patient files were registered in the database and the completeness of the data on these patients resulted in the majority being included in the analysis. RESULTS: The database of patients treated with brachytherapy across Europe indicates that optimal patient selection for this procedure has been made, both in terms of outcome and side-effects, which will be subject of future analyses. This should enable refinement of the treatment choice and administration as well as provide useful guidance to other centres that want to establish this procedure for their patients. It will also set the ground for prospective studies. CONCLUSIONS: The established database indicates that brachytherapy as a treatment option for prostate cancer is well established in many centres.

Seed migration in prostate brachytherapy: a re-implant case report.

Seed embolisation to the lung is a possible risk following permanent prostate brachytherapy. The purpose of this work is to analyse a seed migration case and to suggest methods to reduce such occurrences. With this aim, the clinical history of the patient who experienced seed migration, the implant technique and the pre- and post-plan procedures have been investigated. The massive seed migration has been detected in the patient by means of a pelvic X-ray and a CT-scan of the thorax. The use of loose seeds, the implant technique and the presence of unfavourable anatomical characteristics, have been recognised as possible causes of this event. The use of linked seeds embedded in vicryl sutures for the peripheral portions of prostate, and the development of an implant technique based on both transverse and longitudinal ultrasound guidance are proposed in order to reduce seed migration.

Eight-year experience with transperitoneal laparoscopic adrenal surgery.

PURPOSE: Laparoscopic adrenalectomy is currently the technique of choice for removing benign adrenal lesions. Various laparoscopic techniques and approaches have been reported using the transperitoneal or retroperitoneal approach. We present our 8-year experience with and long-term results of transperitoneal laparoscopic adrenalectomy. MATERIALS AND METHODS: Between October 1992 and October 2000, 161 laparoscopic approaches to the adrenal gland were performed, including 145 unilateral and 10 bilateral adrenalectomies, and 6 conservative operations. Patients were placed in the 60-degree flank position with the bed flexed to increase the surgical field. To avoid hypertensive crisis, especially in patients with pheochromocytoma, the first step involved early ligation of the adrenal vein. RESULTS: The laparoscopic procedure was successfully completed in all except 4 cases, which were converted to open surgery. Mean operative time was 160 minutes in the unilateral, 245 in the bilateral and 90 in the conservative group. Delayed complications included hemoperitoneum in 3 patients, which was drained surgically, severe blood loss in 3 treated with blood transfusion and wound infection in 2. Patients were ambulatory on the morning of postoperative day 1 and were discharged home 2.8, 5 and 1.8 days after unilateral, bilateral and conservative surgery, respectively. CONCLUSIONS: Laparoscopic transperitoneal adrenalectomy is a safe, effective, minimally invasive approach in patients with benign functioning or nonfunctioning adrenal masses. This technique involves low morbidity, minimal postoperative analgesic requirements and a short hospital stay.