Health care disparity exists among those undergoing emergent hernia repairs in New York State.

INTRODUCTION: Socioeconomic factors predispose certain populations to an increased exposure to emergent operative procedures. The aim of this study is to evaluate the role socioeconomic factors play in emergent repairs of inguinal, ventral and umbilical hernias. METHODS: The SPARCS database was used to identify all patients undergoing emergent ventral hernia repair (EVR), emergent inguinal hernia repair (EIR), and emergent umbilical hernia repair (EUR) between 2008 and 2015. Chi-square test with exact p values from Monte Carlo simulation determined marginal associations between repairs (elective vs. emergent), and patient characteristics and comorbidities. Multivariable logistic regression models were further utilized to examine socioeconomic disparity. RESULTS: 107,887 ventral hernias, 66,947 inguinal hernias, and 63,515 umbilical hernias (total 238,349) were noted. African Americans were most likely to undergo an EVR compared to Caucasians (OR 1.55, 95% CI: 1.48-1.61), Asians (OR 1.31, 95% CI: 1.15-1.5), and Hispanics (OR 1.3, 95% CI: 1.23-1.37). African Americans were most likely to undergo EIR compared to Caucasians (OR 2.2, 95% CI: 2.06-2.36), Asians (OR 1.74, 95% CI: 1.49-2.02), and Hispanics (OR 1.22, 95% CI: 1.12-1.34). African Americans were most likely to undergo EUR compared to whites (OR 1.29, 95% CI: 1.22-1.36), Asians (26.62%, OR 1.21, 95% CI: 1.01-1.46) and Hispanic (28.03%, OR 1.08, 95% CI: 1.01-1.16). Medicaid patients were also more likely to undergo EVR (OR 1.31, OR 1.73), EIR (OR 2.92, OR 4.55) and EUR (OR 1.63, OR 2.31) compared to Medicare and commercial insurance. CONCLUSION: Race is a contributing factor in who undergoes an emergent hernia repair in New York State. A significantly larger proportion of the African American population is undergoing hernia repair in the emergent setting. Socioeconomic status, as indicated by the significant number of Medicaid patients undergoing emergent hernia repairs, also plays a role.

Are hepatocellular carcinoma patients more likely to receive liver resection in regions with longer transplant wait times?

In areas with longer liver transplantation (LT) wait times, liver resection (LR) offers an appropriate alternative in selected patients with hepatocellular carcinoma (HCC). We identified adults with HCC undergoing LT or LR from the United States Nationwide Inpatient Sample from 1998-2008. United Network for Organ Sharing regions were assigned lower rank indicating shorter wait time for patients with Model for End-Stage Liver Disease (MELD) scores of 19-24 or ≥ 25. We used multivariate adjusted analysis to assess the odds of LR versus LT comparing patients by region. Of 4,516 patients, 40% received LT and 60% received LR. When ranked by wait times for MELD 19-24, the 3rd, 8th, and 11th ranked regions had decreased odds of LR versus LT (region 3: odds ratio [OR] 0.3, 95% confidence interval [CI] 0.2-0.6; region 8: OR 0.5, 95% CI 0.3-0.9; region 5: OR 0.3, 95% CI 0.2-0.6), whereas the 10th ranked region had increased odds (region 1: OR 1.9, 95% CI 1.1-3.4) compared with the region with the shortest wait time, region 10. When ranked by wait times for MELD ≥25, all regions except the 10th ranked region (region 5) had increased odds compared with the region with the shortest wait time, region 3 (OR 1.6-5.6; P < .001). Regional variations of LT versus LR are not completely explained by transplant wait times.

Performance measures of surgeon-performed colonoscopy in a Veterans Affairs medical center.

BACKGROUND: Quality indicators are increasingly emphasized in the performance of colonoscopy. This study aimed to determine the standard of care rendered by surgeon-endoscopists in a Veterans Affairs (VA) medical center by evaluating the indications for colonoscopy and outcome performance measures according to established quality indicators for colonoscopy. METHODS: A prospective standardized computer endoscopic reporting database (ProVation MD) was retrospectively reviewed. All colonoscopies performed by attending surgeons at the San Diego VA medical center between 1 January 2004 and 31 July 2007 were included in the study. Patients with charts that had incomplete reporting were excluded. The quality indicators used included the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) criteria for colorectal cancer screening, the American Cancer Society (ACS) guidelines for postcancer resection surveillance, and the American Society of Gastrointestinal Endoscopists (ASGE) quality indicators for colonoscopy. RESULTS: The data for 558 patients (96% men) were analyzed. The average patient age was 63 years (range, 25-93 years). Almost all the colonoscopies (99%) were performed in accordance with established criteria. The most common indications for colonoscopy were screening (n = 143, 26%), non-acute gastrointestinal bleeding (n = 127, 23%), polyp surveillance (n = 100, 18%), postcancer resection surveillance (n = 91, 17%), abdominal pain (n = 19, 4%), and anemia (n = 14, 3%). Postcancer resection surveillance colonoscopies were performed according to recommended criteria in 98% of the cases. The cecal intubation rate was 97%, and the overall adenoma detection rate was 26%. Two patients (<1%) experienced complications requiring intervention. CONCLUSION: The study data indicate that surgeon-performed colonoscopies meet standard quality criteria for indications and performance measures. The authors therefore conclude that surgeon-endoscopists demonstrate proficiency in the standard of care for colonoscopy examinations.

Atropine treatment modifies LPS-induced inflammatory response and increases survival.

OBJECTIVE: To explore the effect that Atropine, a competitive antagonist for the muscarinic acetylcholine receptor (mAChR), has on the response to LPS. SUBJECTS: Eight-week-old, male, B6 mice. TREATMENT: Mice were treated with Atropine prior to, or after LPS challenge. METHODS: Survival was monitored and analyzed via Kaplan-Meier analysis using the log-rank test. The effects of atropine on the inflammatory response (TNF-alpha, IL-6 and IL-10) were monitored at various time intervals following LPS injection in mice that were treated and not treated with atropine. RESULTS: Atropine administration prior to LPS induction of the inflammatory response resulted in reduced TNF-alpha and elevated IL-10 plasma levels without affecting the production of IL-6. This reduction in TNF-alpha levels was independent of the increase in IL-10 production. Atropine pretreatment improved the rate of survival from endotoxic shock in mice. The improved survival of mice after endotoxic shock could still be observed when atropine was administered several hours after LPS injection. CONCLUSION: The administration of atropine after injury may have a beneficial clinical effect.

Dual-lumen natural orifice translumenal endoscopic surgery (NOTES): a new method for performing a safe anastomosis.

BACKGROUND: Bowel anastomosis is one of the most challenging and difficult tasks to perform during natural orifice translumenal endoscopic surgery (NOTES). The difficulty is mainly due to the technical limitations of the endoscopic instruments available. Currently, endoscopic clips, T-bar sutures, or cumbersome suturing devices are used. A dual-lumen NOTES approach can facilitate bowel resection in a pig model by allowing the use of laparoscopic staplers through the rectum. METHODS: Acute studies were performed on four 40-kg pig models. The dual-lumen NOTES approach was used to perform small bowel resection and anastomosis. An endoscope was passed into the stomach and pushed through the stomach wall into the peritoneal cavity (first lumen), and a 12-mm trocar was placed through the anterior rectal wall, allowing access to the peritoneum (second lumen). Handling of the bowel, resection, and anastomosis were performed using endoscopic instruments through the gastric lumen and laparoscopic instruments through the rectal lumen. The resected small bowel then was removed through the rectum. RESULTS: Small bowel resection and anastomosis was successfully completed in all four animals using the dual-lumen NOTES approach. The laparoscopic stapler was used one more time to close the gastrotomy through the rectal port. At autopsy, intact suture lines were noted at the bowel anastomosis and at the stomach, with no evidence of leak from either site. CONCLUSIONS: Performing a sutured anastomosis in NOTES is complex and time consuming. The use of stapling devices designed for laparoscopic procedures greatly facilitates gastrointestinal tract operations in NOTES. Using both the upper and lower gastrointestinal tract as entry sites for NOTES eliminates some of the current technical limitations of these procedures.

Carbon dioxide pneumoperitoneum prevents mortality from sepsis.

BACKGROUND: Carbon dioxide (CO2) pneumoperitoneum has been shown to attenuate the inflammatory response after laparoscopy. This study tested the hypothesis that abdominal insufflation with CO2 improves survival in an animal model of sepsis and investigated the associated mechanism. METHODS: The effect of CO2, helium, and air pneumoperitoneum on mortality was studied by inducing sepsis in 143 rats via intravenous injection of lipopolysaccharide (LPS). To test the protective effect of CO2 in the setting of a laparotomy, an additional 65 animals were subjected to CO2 pneumoperitoneum, helium pneumoperitoneum, or the control condition after laparotomy and intraperitoneal LPS injection. The mechanism of CO2 protection was investigated in another 84 animals. Statistical significance was determined via Kaplan-Meier analysis for survival and analysis of variance (ANOVA) for serum cytokines. RESULTS: Among rats with LPS-induced sepsis, CO2 pneumoperitoneum increased survival to 78%, as compared with using helium pneumoperitoneum (52%; p < 0.05), air pneumoperitoneum (55%; p = 0.09), anesthesia control (50%; p < 0.05), and LPS-only control (42%; p < 0.01). Carbon dioxide insufflation also significantly increased survival over the control condition (85% vs 25%; p < 0.05) among laparotomized septic animals, whereas helium insufflation did not (65% survival). Carbon dioxide insufflation increased plasma interleukin-10 (IL-10) levels by 35% compared with helium pneumoperitoneum (p < 0.05), and by 34% compared with anesthesia control (p < 0.05) 90 min after LPS stimulation. Carbon dioxide pneumoperitoneum resulted in a threefold reduction in tumor necrosis factor-alpha (TNF-alpha) compared with helium pneumoperitoneum (p < 0.05), and a sixfold reduction with anesthesia control (p < 0.001). CONCLUSION: Abdominal insufflation with CO2, but not helium or air, significantly reduces mortality among animals with LPS-induced sepsis. Furthermore, CO2 pneumoperitoneum rescues animals from abdominal sepsis after a laparotomy. Because IL-10 is known to downregulate TNF-alpha, the increase in IL-10 and the decrease in TNF-alpha found among the CO2-insufflated animals in our study provide evidence for a mechanism whereby CO2 pneumoperitoneum reduces mortality via IL-10-mediated downregulation of TNF-alpha.

Laparoscopic surgery and the parasympathetic nervous system.

BACKGROUND: Laparoscopic surgery preserves the immune system and has anti-inflammatory properties. CO2 pneumoperitoneum attenuates lipopolysaccharide (LPS)-induced cytokine production and increases survival. We tested the hypothesis that CO2 pneumoperitoneum mediates its immunomodulatory properties via stimulation of the cholinergic pathway. METHODS: In the first experiment, rats (n = 68) received atropine 1 mg/kg or saline injection 10 min prior to LPS injection and were randomization into four 30-min treatment subgroups: LPS only control, anesthesia control, CO2 pneumoperitoneum, and helium pneumoperitoneum. In a second experiment, rats (n = 40) received atropine 2 mg/kg or saline 10 min prior to randomization into the same four subgroups described previously. In a third experiment, rats (n = 96) received atropine 2 mg/kg or saline 10 min prior to randomization into eight 30-min treatment subgroups followed by LPS injection: LPS only control; anesthesia control; and CO2 or helium pneumoperitoneum at 4, 8, and 12 mmHg. In a fourth experiment, rats (n = 58) were subjected to bilateral subdiaphragmatic truncal vagotomy or sham operation. Two weeks postoperatively, animals were randomized into four 30-min treatment subgroups followed by LPS injection: LPS only control, anesthesia control, CO2 pneumoperitoneum, and helium pneumoperitoneum. Blood samples were collected from all animals 1.5 h after LPS injection, and cytokine levels were determined by enzyme-linked immunosorbent assay. RESULTS: Serum tumor necrosis factor-alpha (TNF-alpha) levels were consistently suppressed among the saline-CO2 pneumoperitoneum groups compared to saline-LPS only control groups (p < 0.05 for all four experiments). All chemically vagotomized animals had significantly reduced TNF-alpha levels compared to their saline-treated counterparts (p < 0.05 for all), except among the CO2 pneumoperitoneum-treated animals. Increasing insufflation pressure with helium eliminated differences (p < 0.05) in TNF-alpha production between saline- and atropine-treated groups but had no effect among CO2 pneumoperitoneum-treated animals. Finally, vagotomy (whether chemical or surgical) independently decreased LPS-stimulated TNF-alpha production in all four experiments. CONCLUSION: CO2 pneumoperitoneum modulates the immune system independent of the vagus nerve and the cholinergic pathway.

Transgastric endoscopic splenectomy: is it possible?

BACKGROUND: We have previously reported the feasibility of diagnostic and therapeutic peritoneoscopy including liver biopsy, gastrojejunostomy, and tubal ligation by an oral transgastric approach. We present results of per-oral transgastric splenectomy in a porcine model. The goal of this study was to determine the technical feasibility of per-oral transgastric splenectomy using a flexible endoscope. METHODS: We performed acute experiments on 50-kg pigs. All animals were fed liquids for 3 days prior to procedure. The procedures were performed under general anesthesia with endotracheal intubation. The flexible endoscope was passed per orally into the stomach and puncture of the gastric wall was performed with a needle knife. The puncture was extended to create a 1.5-cm incision using a pull-type sphincterotome, and a double-channel endoscope was advanced into the peritoneal cavity. The peritoneal cavity was insufflated with air through the endoscope. The spleen was visualized. The splenic vessels were ligated with endoscopic loops and clips, and then mesentery was dissected using electrocautery. RESULTS: Endoscopic splenectomy was performed on six pigs. There were no complications during gastric incision and entrance into the peritoneal cavity. Visualization of the spleen and other intraperitoneal organs was very good. Ligation of the splenic vessels and mobilization of the spleen were achieved using commercially available devices and endoscopic accessories. CONCLUSIONS: Transgastric endoscopic splenectomy in a porcine model appears technically feasible. Additional long-term survival experiments are planned.

Thirty robotic adrenalectomies: a single institution's experience.

BACKGROUND: Robotic adrenalectomy is a minimally invasive alternative to traditional laparoscopic adrenalectomy. To date, only case reports and small series of robotic adrenalectomies have been reported. This study presents a single institution's series of 30 robotic adrenalectomies, and evaluates the procedure's safety, efficacy, and cost. METHODS: Thirty patients underwent robotic adrenalectomy at the Johns Hopkins Hospital between April 2001 and January 2004. Patient morbidity, hospital length of stay, operative time, and conversion rate to traditional laparoscopic or open surgery are presented. Improvement in operative time with surgeon experience is evaluated. Hospital charges are compared to charges for traditional laparoscopic and open adrenalectomies performed during the same time period. RESULTS: Median operative time was 185 min. Patient morbidity was 7%. There were no conversions to traditional laparoscopic or open surgery. The median hospital stay was 2 days. Operative time improved significantly by 3 min with each operation. Hospital charges for robotic adrenalectomy (12,977 dollars) were not significantly different than charges for traditional laparoscopic (11,599 dollars) or open adrenalectomy (14,600 dollars). CONCLUSIONS: Robotic adrenalectomy is a safe and effective alternative to traditional laparoscopic adrenalectomy.

The role of the spleen in laparoscopy-associated inflammatory response.

BACKGROUND: Carbon dioxide (CO(2)) pneumoperitoneum alters the inflammatory response in animal models of sepsis. The spleen is a key organ in inflammation and its removal was predicted to modify this effect. METHODS: The acute phase inflammatory response to lipopolysaccharide (LPS) challenge in male rats was examined for the effects of splenectomy (spx) and the technique of removal (open or laparpscopic). A series of experiments compared LPS-only controls with LPS injection 2 or 9 days following open spx, lap CO2 spx, open sham, or lap CO2 sham. The method of splenectomy was studied by randomization to control, open spx, lap CO2 spx, lap helium (He) spx, or lap air spx with LPS challenge on postoperative day 2. Serum levels of tumor necrosis factor-alpha (TNF-alpha), interferon-gamma (INF-gamma) and, interleutin (IL) 10 were collected at multiple time points, assayed by commercial enzyme-linked immunosorbent assay, analyzed by analysis of variance. RESULTS: Levels of TNF-alpha at 1.5 were significantly lower following open sham than following lap sham (p < 0.05). Splenectomy drastically reduced INF-gamma and TNF-alpha levels compared to controls (p < 0.05) on postoperative day 2. No method of spx preserved TNF-alpha or INF-gamma responses. Recovery of TNF-alpha response on day 9 was delayed in the spx groups. CONCLUSIONS: Splenectomy dramatically reduces TNF-alpha and INF-gamma responses to LPS challenge, although by different mechanisms. Pneumoperitoneum-mediated modulation of the septic inflammatory response is partially dependent on the spleen.

Value of the SAGES Learning Center in introducing new technology.

BACKGROUND: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Learning Center is a group of educational "classrooms" designed to tutor meeting attendees on specific technology-intensive content areas. The objectives of the Robotics Station were to familiarize participants with basic laparoscopic skills as implemented with surgical robotic assistance and to help them explore the benefits and drawbacks of using robotics in their institutions. METHODS: Sixty-six volunteer surgeon attendees of the 2003 SAGES meeting representing a diverse group of backgrounds and possessing varying levels of surgical experience were directed through a series of drills on two different surgical robots. Each participant was directed through a series of three drills that practiced surgically relevant skills. Participants were given feedback on their performance. They then completed a 12-question computer-based questionnaire that surveyed their personal demographic backgrounds, their impressions of robotic surgery, and their opinions regarding the learning center's utility in educating them about new technology. RESULTS: Sixty-eight percent of participants had never used a surgical robot, and 89% had never used a robot clinically. Eighty-eight percent of respondents found one or both robots easier to use than they had expected, and 91% found that one or both robots made simple surgical tasks easier compared to standard laparoscopy. Sixty-four percent of participants stated that they were more likely to pursue purchase of a robotic system for use in their practice as a result of their exposure to robotics in the Learning Center. After completing the Robotics Station, 80% of surgeons believed that current surgical robots are of clinical benefit. However, 71% of participants stated that surgical robotic systems priced above $500,000 would not be financially viable in their practices. CONCLUSION: The structured learning environment used in the SAGES Learning Center fostered among participants a positive attitude toward surgical robotics. The format of their exposure to this technology at the Robotics Station also enabled participants to gauge the potential financial value of surgical robots in clinical practice. The SAGES Learning Center Robotics Station succeeded in exposing surgeons to surgical robotics in a way that helped them assess the value of this technology for their individual practices and institutions.

The effect of timing of pneumoperitoneum on the inflammatory response.

BACKGROUND: We examined the effects of an identical period of pneumoperitoneum applied at three different time points after lipopolysaccharide (LPS) challenge. Two different insufflation gases were also compared. METHODS: Male rats (n = 70) were injected intravenously with 1 mg/kg of LPS (time 0). The time relationship between a 1.5-h period of insufflation and initial LPS stimulation was the experimental variable. All rats were killed 6 h after injection. CO2 and helium insufflation were investigated. Ten control rats received LPS only. Serum interleukin-6 (IL-6) levels were determined by enzyme-linked immunosorbent assay (ELISA). Hepatic expression of alpha2-macroglobulin, beta-fibrinogen, and metallothionein were measured by Northern blot analysis. Statistical analysis was performed using one-way analysis of variance (ANOVA). RESULTS: Expression of alpha2-macroglobulin mRNA was lower in CO2 groups compared to the control group (p < 0.05 at time 120 and 270). beta-Fibrinogen message was diminished in CO2 0 and 120 groups compared to control. Serum levels of IL-6 and expression of metallothionein mRNA did not show significant differences between groups. CONCLUSIONS: These findings suggest that CO2 pneumoperitoneum downregulates the inflammatory response to LPS challenge. Start time of CO2 insufflation does not appear to alter hepatic expression of acute phase genes. The mechanism of alpha2-macroglobulin downregulation does not appear to be due to IL-6.

A comprehensive review of anti-reflux procedures completed by computer-assisted tele-surgery.

Gastro-esophageal reflux disease (GERD) is the most common esophageal disorder. Although GERD is an illness primarily treated by medical management, patients refractory to, or those unwilling to endure long-term medical therapy often undergo anti-reflux surgery. Laparoscopic surgery made the surgeon's task technically more challenging. While laparoscopy provides a good field of vision, all depth perception is lost. Furthermore, the movements of the chopstick-like instruments are counter-intuitive with limited degrees of freedom, diminished tactile feedback, and disassociated movement. Now that advanced minimally invasive surgeons have acquired the necessary skills to overcome these hurdles, technology has developed a way to make laparoscopic surgery easier. The latest advance in laparoscopic surgery is computer-assisted telesurgery (CATS) which allows the surgeon to be seamlessly submerged into the surgical field while being seated at a distance from the patient. The technological advances afforded by CATS make minimally-invasive surgery easier by adding stereoscopic vision, which provides depth perception, and the endo-wrist, which provides wrist-like dexterity within the abdominal cavity. The advantages of CATS are: the ergonomic positioning of the surgeon thus decreasing fatigue; stereoscopic vision with possibility of 10x magnification; wrist-like manual dexterity with intuitive motion; motion-scaling and tremor elimination all of which enhance precision and accuracy. A small yet growing body of evidence has provided information which suggests that the use of CATS for anti-reflux surgery is equivalent to the current gold standard, unassisted laparoscopy.

The Surgical Recovery Index.

BACKGROUND: We developed a tool, the Surgical Recovery Index (SRI), specifically to measure surgical recovery. We then tested the ability of the SRI to discriminate between patients undergoing laparoscopic (L) operations and patients undergoing open (O) operations. METHODS: We surveyed 50 patients drawn from the practice of a single surgeon to establish the types of activities that define recovery from surgery. Their responses were used to construct the SRI, a self-administered questionnaire using a numerical rank-order scale format. A total score and two subscale scores (pain and activity resumption) were calculated for each patient. Mean and median scores were calculated for each patient group. Chi-square tests were used to evaluate group differences for individual questions; t-tests and Kruskal-Wallis tests were used to evaluate group differences for summary scores. RESULTS: In all, 149 patients completed the SRI (60 L, 89 O). Cronbach's alphas were 0.91 for pain questions and 0.97 for activity resumption questions. The scores for pain level with time (L vs O, 1-10 scale) at week 1 (mean, 4.42 vs 6.06, p = 0.03), week 2 (mean, 3.08 vs 4.38, p = 0.04), week 3 (mean, 2.03 vs 3.16, p = 0.02), and week 4 (mean, 1.18 vs 2.28, p = 0.00) all favored laparoscopy. The scores for pain level with activity (L vs O, 1-3 scale) for getting out of bed (mean, 1.62 vs 1.85, p = 0.04), hygiene activities (mean, 1.38 vs 1.65, p = 0.04), and computer work (mean, 1.15 vs 1.56, p = 0.00) were all significant, although pain with exertion (mean, 1.87 vs 2.10, p = 0.13) was not. Delay until return to activity (L vs O, 1-4 scale) was significant, favoring L for 13 activities (all p < 0.02), but it was not significant for three activities. The scores for subscales for pain (L vs O, mean, 20.7 vs 34.4, respectively) and activity resumption delay (mean, 44.3 vs 62.0), as well as total scores (mean, 33.0 vs 49.0), were also significant (all p = 0.00). The same differences were observed when median scores were considered instead of mean scores, suggesting the robustness of the group difference. CONCLUSIONS: Reduction in time to full recovery (i.e., pain resolution and activity resumption) is a fundamental advantage of laparoscopic surgery, yet there are no tools designed to specifically measure recovery. These data provide preliminary evidence of the reliability and validity of the new SRI as a measure of recovery in patients undergoing laparoscopic operations.

A prospective analysis of 211 robotic-assisted surgical procedures.

BACKGROUND: The Academic Robotics Group prospectively studied 211 robotically assisted operations to assess the safety and utility of robotically assisted surgery. METHODS: All operations took place at one of four member institutions between June 2000 and June 2001 using the recently FDA-approved daVinci robotic system. A variety of procedures were undertaken, including antireflux surgery (69), cholecystectomy (36), Heller myotomy (26), bowel resection (17), donor nephrectomy (15), left internal mammery artery mobilization (14), gastric bypass (seven), splenectomy (seven), adrenalectomy (six), exploratory laparoscopy (three), pyloroplasty (four), gastrojejunostomy (two), distal pancreatectomy (one), duodenal polypectomy (one), esophagectomy (one), gastric mass resection (one), and lysis of adhesions (one). RESULTS: Average operating room time was 188 min (range 45 to 387, SD = 83), surgical time 143 min (range 35 to 462, SD = 63), and robot time 90 min (range 12 to 235, SD = 47). Median length of stay was 1 day (range 0 to 37). There were 8 (4%) technical complications during procedures, five minor (four hook cautery dislodgement, one slipped robotic trocar) and three major (system malfunctions, two of which required conversion to standard laparoscopy). In all cases, technical problems caused only delay, without apparent altered outcome. There were medical/surgical complications in nine patients (4%). Six (3%) were considered major, including one death unrelated to the robotic procedure. CONCLUSIONS: The results of robotic-assisted surgery compare favorably with those of conventional laparoscopy with respect to mortality, complications, and length of stay. Robotic-assisted surgery is safe and effective and is a new reality for American surgery. The role of these devices in surgery will expand as the technology evolves.

Carbon dioxide pneumoperitoneum alters acute-phase response induced by lipopolysaccharide.

BACKGROUND: As laparoscopic surgery continues to expand in scope, septic patients will be exposed to carbon dioxide (CO2) pneumoperitoneum in increasing numbers. The biologic advantages or disadvantages of laparoscopic surgery in the setting of sepsis/inflammation are not known. In a rat model, we investigated whether CO2 pneumoperitoneum alters the inflammatory response induced by bacterial lipopolysaccharide (LPS). METHODS: Male rats were injected via the penile vein with LPS (1 mg/kg). Five hours later, the animals (n = 5) were subjected to CO2 pneumoperitoneum (group I) for 1h; the animals of group II (n = 5) served as controls (no pneumoperitoneum). At 6 h, all animals were killed and the liver harvested for analysis of hepatic acute-phase gene expression. Total RNA was isolated and analyzed by Northern blot hybridization with probes for alpha-2 macroglobulin (A2M) and detected by autoradiography. The film in the linear range of exposure was quantitated using an imaging system. The signal intensity corresponding to A2M mRNA was normalized by the signal corresponding to 28S rRNA detected by staining with methylene blue. RESULTS: The mRNA levels in group II was 6.5 +/- 0.9 vs 2.8 +/- 0.4 in group I. As compared with rats that received LPS only, those that received a combination of LPS and CO2 showed a reduction in A2M mRNA levels (57.4%, p = 0.006). CONCLUSIONS: These data demonstrate that the presence of CO2 pneumoperitoneum reduces the inflammatory response established by LPS. This finding challenges the generally accepted notion that smaller incisions alone account for the observed benefits of laparoscopic surgery. It further suggests that CO2 pneumoperitoneum - aided laparoscopic surgery impedes the inflammatory response and may therefore offer specific benefits over conventional surgery.

Laparoscopic Nissen fundoplication with carbon dioxide pneumoperitoneum preserves cell-mediated immunity in an immature animal model.

PURPOSE: The aim of this study is to elucidate the effects of laparoscopic Nissen fundoplication (LNF) with carbon dioxide (CO(2)) or helium (He) on the cell-mediated immune response in a pediatric animal model compared with open Nissen fundoplication (ONF). METHODS: Cell immune response was evaluated in 45 1-week-old Sprague Dawley rats using the delayed type hypersensitivity (DTH) skin test. Animals were sensitized against keyhole limpet hemocyanin (KLH) by subcutaneous injection (0.5 mg) in complete Freund's adjuvant. Animals were challenged 2 weeks later by an intradermal injection of KLH (0.3 mg) in sterile saline (challenge 1, baseline). Rats with positive DTH skin reaction at 24 and 48 hours after challenge 1 were put randomly into 4 groups (n = 10 each): I, only anesthesia (control); II, LNF with CO(2), III, LNF with He; IV, ONF. Animals were injected intradermally with KLH (0.3 mg) immediately before the procedures (challenge 2) and 3 and 6 days postoperatively (challenges 3 and 4). RESULTS: DTH skin reactions were measured 24 and 48 hours after each challenge. There were no significant changes in cell-mediated immunosuppression after LNF with CO(2). However, a transient cell-mediated immunosuppression was observed after LNF with He and ONF. All fundoplications were intact at the time of necropsy. CONCLUSIONS: These data suggest a transient suppression of cell-mediated immunity in open procedures when compared with laparoscopic interventions using CO(2) in a pediatric animal model. In addition, the type of gas used during laparoscopy also may modulate this transient immunosuppression.

Laparoscopic surgery for Crohn's disease: reasons for conversion.

OBJECTIVE: To examine factors influencing conversion from a laparoscopic to an open procedure in patients requiring surgery for Crohn's disease. SUMMARY BACKGROUND DATA: Laparoscopic management of patients with complications of Crohn's produces better outcomes than traditional open approaches, but it is difficult to determine before surgery who will be amenable to laparoscopic management. In this series, a laparoscopic approach was offered to virtually all patients to determine reasons for laparoscopic failure. METHODS: Data regarding patients who underwent attempted laparoscopic procedures for Crohn's (January 1993 to June 2000) were collected prospectively. The bowel was mobilized laparoscopically and extracorporeal anastomoses were performed. Conversion to open surgery was defined as creation of an incision of more than 5 cm. RESULTS: One hundred ten patients (age 37 +/- 1.1 years, 58% female) underwent 113 attempted laparoscopic interventions. Indications for surgery included obstruction (77%), failure of medical management (35%), fistula (27%), and perineal sepsis (4%). Sixty-eight procedures (60%) were completed laparoscopically. Procedures completed laparoscopically included ileocecectomy (n = 46), small bowel resection (n = 22), fecal diversion (n = 7), intestinal stricturoplasty (n = 7), resection of prior ileocolonic anastomosis (n = 5), segmental colectomy (n = 1), and lysis of adhesions (n = 1). Forty-five procedures (40%) were converted as a result of adhesions (n = 21), extent of inflammation or disease (n = 9), size of the inflammatory mass (n = 7), inability to dissect a fistula (n = 5), or inability to assess anatomy (n = 3). Factors associated with conversion were internal fistula as an indication for surgery, smoking, steroid administration, extracecal colonic disease, and preoperative malnutrition. In laparoscopic patients, mean times to passage of flatus and first bowel movement were 3.6 +/- 0.2 days and 4.4 +/- 0.2 days, respectively. Mean time to discharge was 6 +/- 0.2 days. CONCLUSIONS: Attempted laparoscopic management is safe and effective if there is an appropriate threshold for conversion to an open procedure. Conversion factors identified in this study largely reflect technical challenge and severity of disease. Patients taking steroids and those with known fistulas or colonic involvement threaten laparoscopic failure, but many of these patients can be managed laparoscopically and have better outcomes. By understanding the reasons for conversion, it is hoped that the chances of laparoscopic success can be improved by modifying standard preoperative medical management or using additional technological capabilities (e.g., robotics).

Postoperative bile duct strictures: management and outcome in the 1990s.

OBJECTIVE: To describe the management and outcome after surgical reconstruction of 156 patients with postoperative bile duct strictures managed in the 1990s. SUMMARY BACKGROUND DATA: The management of postoperative bile duct strictures and major bile duct injuries remains a challenge for even the most skilled biliary tract surgeon. The 1990s saw a dramatic increase in the incidence of bile duct strictures and injuries from the introduction and widespread use of laparoscopic cholecystectomy. Although the management of these injuries and short-term outcome have been reported, long-term follow-up is limited. METHODS: Data were collected prospectively on 156 patients treated at the Johns Hopkins Hospital with major bile duct injuries or postoperative bile duct strictures between January 1990 and December 1999. With the exception of bile duct injuries discovered and repaired during surgery, all patients underwent preoperative percutaneous transhepatic cholangiography and placement of transhepatic biliary catheters before surgical repair. Follow-up was conducted by medical record review or telephone interview during January 2000. RESULTS: Of the 156 patients undergoing surgical reconstruction, 142 had completed treatment with a mean follow-up of 57.5 months. Two patients died of reasons unrelated to biliary tract disease before the completion of treatment. Twelve patients (7.9%) had not completed treatment and still had biliary stents in place at the time of this report. Of patients who had completed treatment, 90. 8% were considered to have a successful outcome without the need for follow-up invasive, diagnos tic, or therapeutic interventional procedures. Patients with reconstruction after injury or stricture after laparoscopic cholecystectomy had a better overall outcome than patients whose postoperative stricture developed after other types of surgery. Presenting symptoms, number of stents, interval to referral, prior repair, and length of postoperative stenting were not significant predictors of outcome. Overall, a successful outcome, without the need for biliary stents, was obtained in 98% of patients, including those requiring a secondary procedure for recurrent stricture. CONCLUSIONS: Major bile duct injuries and postoperative bile duct strictures remain a considerable surgical challenge. Management with preoperative cholangiography to delineate the anatomy and placement of percutaneous biliary catheters, followed by surgical reconstruction with a Roux-en-Y hepaticojejunostomy, is associated with a successful outcome in up to 98% of patients.