Natural orifice specimen extraction in laparoscopic colorectal surgery: transanal and transvaginal approaches.

BACKGROUND: This study was designed to evaluate the outcomes of patients who underwent various laparoscopic colorectal procedures with natural orifice specimen extraction (NOSE) at our institute over a 20-year period. Specifically, the study aimed to investigate whether transanal and transvaginal approaches are safe and effective alternatives for extracting the specimen during laparoscopic colorectal surgeries. METHODS: We analyzed a prospectively designed database of a consecutive series of patients who underwent various laparoscopic colorectal surgeries for different rectal pathologies between April 1991 and May 2011 at the Texas Endosurgery Institute. The selection criteria for the NOSE approach were based on disease entities, site and size of tumors, and distance of colorectal lesions from the anal verge. RESULTS: A total of 303 patients underwent laparoscopic colorectal procedures with the NOSE approach for specimen extraction, including 277 transanal and 26 transvaginal extractions. The operative time for procedures with transanal specimen extraction was 164.7 ± 47.5 min, the estimated blood loss was 87.5 ± 46.7 ml, and the rate of postoperative complications was 3.6 %. For laparoscopic right hemicolectomy with transvaginal specimen extraction, the operative time was 159 ± 27.1 min and the estimated blood loss was 83.5 ± 14.4 ml. Intraoperatively, transvaginal extraction was associated with 2 complications (7.7 %); however, this procedure was not associated with any postoperative complications. The length of hospital stay was 6.9 ± 2.8 and 5.5 ± 2.5 days for patients who underwent transanal extraction and transvaginal extraction, respectively. CONCLUSIONS: Both transanal and transvaginal specimen extractions in laparoscopic colorectal surgeries are safe and effective approaches with comparable postoperative complication rates. In comparison with transanal specimen extraction, transvaginal extraction is more complicated due to the anatomy of the pouch of Douglas. The transvaginal approach thus needs more effective extraction devices for preventing injury to adjacent organs, especially the sigmoid colon and rectum.

Pediatric trichotillomania.

Trichotillomania (TTM) is an impulse control disorder characterized by chronic hair-pulling, distress, and impairment. Although the negative effects of TTM are documented and often readily evident, there remains a paucity of psychopathology and treatment research on this disorder, particularly in pediatric populations. In an effort to improve assessment of pediatric TTM, several TTM-specific instruments for youth have now been developed to reliably identify symptoms and examine related phenomenology. Instrument development has now yielded instruments to evaluate TTM and related symptoms in the context of clinical trials of youth, and the first randomized controlled trial of any treatment for pediatric TTM was recently published. Using the initial pediatric TTM studies as building blocks, future research is now needed to create a stronger body of knowledge about the relative and combined efficacy of potential interventions for TTM in youth, as well as to examine the effects of TTM phenomenology and comorbidity on treatment outcome. Dissemination efforts must also be heightened for this knowledge to best reach these vulnerable populations.

Laparoscopically monitored colonoscopic polypectomy: an established form of endoluminal therapy for colorectal polyps.

BACKGROUND: Benign polyps, the most common disorders of the colon, are considered by many to be premalignant lesions. Colonoscopy is widely used to remove the majority of these polyps. However, a variety of "difficult polyps" are not accessible for colonoscopic removal because of their location and size, the tortuosity of the colon, or the complexity of the lesion (sessile vs pedunculated). In the past, a formal segmental resection usually was suggested for these difficult polyps. METHODS: For 110 patients with a median age of 73 years, a total of 149 polyps were removed as follows: 88 from the right colon, 18 from the transverse colon, 10 from the left colon, and 33 from the rectosigmoid colon. Pathologic evaluation showed adenomatous polyps in 13 patients (11.81%), hyperplastic polyps in 1 patient (0.9%), adenocarcinomas in 10 patients (9.09%), carcinoma in situ in 1 patient (0.9%), and adenomas in the remaining patients (tubulovillous, 40.18%; villous, 19.31%, and tubular, 17.77%). All the specimens were evaluated for margins and depth of resection. RESULTS: The median size of the polyps was 2.30 cm (range, 0.2-6 cm). The average hospital stay was 1.14 days, with a liquid diet started 6 h postoperatively. Mild abdominal pain/trocar-site pain was the most common complaint. The patients were followed with colonoscopy 6 months postoperatively and yearly thereafter. CONCLUSIONS: A combined endoscopic-laparoscopic approach provides a valid alternative for treating difficult colonic polyps and eliminating the morbidity of a segmental resection. This approach seems to be safe and effective.

Morbidity of laparoscopic surgery for complicated appendicitis: an international study.

BACKGROUND: Although laparoscopic appendectomy has some advantages over open appendectomy, some reports do show more postoperative intraabdominal abscesses. METHODS: A retrospective review of complicated appendicitis managed surgically by eight surgical groups from six countries was undertaken. Among 3,433 patients with appendicitis, 1,017 (29.5%) had complicated appendicitis, which included perforated or gangrenous appendicitis with or without localized or disseminated peritonitis. There were 74 preoperative abscesses (7.4%) and 5 small bowel obstructions. RESULTS: One patient died. There were 29 postoperative intraabdominal abscesses (2.8%) and 112 mostly minor complications. Conversion to laparotomy was necessary for 28 patients (2.7%). The surgical time ranged from 32 to 132 min (mean, 62 min), and the hospital stay ranged from 1 to 18 days (mean, 3.5 days). CONCLUSIONS: The morbidity rates, particularly for intraabdominal abscesses, were less for laparoscopic appendectomy in complicated appendicitis than those reported in the literature for open appendectomy, whereas operating times and hospital stays were similar.

Preliminary results of a two-layered prosthetic repair for recurrent inguinal and ventral hernias combining open and laparoscopic techniques.

The use of prosthetic mesh has become the standard of care in the management of hernias because of its association with a low rate of recurrence. However, despite its use, recurrence rates of 1% have been reported in primary inguinal repair and rates as high as 15% with ventral hernia repair. When dealing with difficult recurrent hernias, the two-layer prosthetic repair technique is a good option. In the event of incarcerated or strangulated hernias, however; placement of prosthetic material is controversial due to the increased risk of infection. The same is true when hernia repairs are performed concurrently with potentially contaminated procedures such as cholecystectomy, appendectomy, or colectomy. The purpose of this study is to report our preliminary results on the treatment of recurrent hernias by combining laparoscopic and open techniques to construct a two-layered prosthetic repair using a four ply mesh of porcine small intestine submucosa (Surgisis, Cook Surgical, Bloomington, IN, USA) in a potentially infected field and a combination of polypropylene and ePTFE (Gore-Tex, W.L. Gore and Associates, Flagstaff, AZ, USA) in a clean field. From September 2002 to January 2004, nine patients (three males and six females) underwent laparoscopic and open placement of surgisis mesh in a two layered fashion for either recurrent incisional or inguinal hernias in a contaminated field. A total of eight recurrent hernia repairs were performed (five incisional, three inguinal) and one abdominal wall repair after resection of a metastatic tumor following open colectomy for colon carcinoma. Six procedures were performed in a potentially contaminated field (incarcerated or strangulated bowel within the hernia), two procedures were performed in a contaminated field because of infected polypropylene mesh, and one was in a clean field. Mean patient age was 56.4 years. The average operating time was 156.8 min. Operative findings included seven incarcerated hernias (four incisional and three inguinal), one strangulated inguinal hernia, and one ventral defect after resection of an abdominal wall metastasis for a previous colon cancer resection. In two of the cases, there was an abscess of a previously placed polypropylene mesh. All procedures were completed with two layers of mesh (eight cases with surgisis and one with combination of polypropylene/ePTFE). Median follow up was 10 months. Complications included two seromas, one urinary tract infection, two cases of atelectasis and one prolonged ileus. There were no wound infections. The average postoperative length of stay was 7.8 days. There have been no mesh-related complications or recurrent hernias in our early postoperative follow-up period. The use of a new prosthetic device in infected or potentially infected fields, and the two-layered approach shows promising results. This is encouraging and provides an alternative approach for the management of difficult, recurrent hernias.

Cognitive-behavioral treatment of pediatric obsessive-compulsive disorder: an open clinical trial.

OBJECTIVE: The purpose of this open clinical trial was to examine the efficacy of cognitive-behavioral treatment involving exposure and ritual prevention for pediatric obsessive-compulsive disorder (OCD). METHOD: Children and adolescents with diagnosed OCD (N = 14) received cognitive-behavioral treatment, seven patients received intensive treatment (mean = 18 sessions over 1 month) and seven received weekly treatment (mean = 16 sessions over 4 months). Eight of these patients received concurrent treatment with serotonin reuptake inhibitors and six received cognitive-behavioral treatment alone. Outcome was assessed via interviewer ratings on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Obsessive Compulsive Rating Scales for Main Fear and Main Ritual, and Hamilton Depression Rating Scale. RESULTS: Cognitive-behavioral treatment was effective in ameliorating OCD symptoms. Twelve of the 14 patients were at least 50% improved over pretreatment Y-BOCS severity, and the vast majority remained improved at follow-up; mean reduction in Y-BOCS was 67% at posttreatment and 62% at follow-up (mean time to follow-up = 9 months). CONCLUSIONS: Results suggest that cognitive-behavioral treatment by exposure and ritual prevention is effective for pediatric OCD. Controlled studies with random assignment to conditions are warranted to evaluate the relative efficacy of cognitive-behavioral pharmacological, and combined treatments.

Effectiveness of exposure and ritual prevention for obsessive-compulsive disorder: randomized compared with nonrandomized samples.

The efficacy of exposure and ritual prevention (EX/RP) for reducing symptoms of obsessive-compulsive disorder (OCD) has been demonstrated in several randomized controlled trials (RCTs). However, procedures used in these studies to maximize experimental control may have limited their generalizability to typical clinical practice. Treatment outcome data from 110 clinical patients receiving EX/RP on an outpatient fee-for-service basis were compared with findings from 4 RCTs of EX/RP. Adult patients in the clinical sample were not excluded because of treatment history, concomitant pharmacotherapy, psychiatric comorbidity, age, or OCD severity. Clinical patients achieved substantial and clinically meaningful reductions in their OCD and depressive symptoms following EX/RP, which were comparable with those reported in the RCTs. Findings indicate that EX/RP is a potent treatment for OCD, and its benefits are not limited to select patient samples.

Cognitive biases in generalized social phobia.

Judgmental biases for threat-relevant stimuli are thought to be important mechanisms underlying the etiology and maintenance of anxiety disorders. The authors hypothesized (a) that people with generalized social phobia (GSP) would rate negative social events but not nonsocial events as more probable and costly than would nonanxious controls (NACs) and (b) that cognitive behavioral treatment would decrease probability and cost estimates for social but not nonsocial events. Participants with GSP and NACs were assessed twice, 14 weeks apart, during which the former received cognitive behavioral therapy. Those with GSP evidenced socially relevant judgmental biases prior to treatment, and these were attenuated following treatment. Reduction in cost estimates for social events, but not in probability estimates, mediated improvement in social phobia. Results are discussed in light of emotional processing theory.

Laparoscopic versus open appendectomy.

BACKGROUND: Laparoscopic appendectomy is commonly performed and has been presumed to offer economic benefits similar to those of laparoscopic cholecystectomy. This study was done to examine that premise. METHODS: Two surgical groups contributed consecutively operated patients with a clinical diagnosis of appendicitis. One group did all appendectomies open and the other group did them laparoscopically. Hospital expenses were compared using a single billing formula. Hospital length of stay, time to return to work, and complications were analyzed. RESULTS: Operating room times were longer for the laparoscopic group, median 80 minutes, versus median 50 minutes for the open group. Hospital length of stay and return to work were the same, median 1 day and median 10 days, respectively. Wound complications were less common in the laparoscopic group, 0 of 30, than in the open group, 3 of 18; however, there was 1 intra-abdominal abscess in the laparoscopic group. Median cost of the laparoscopic group was $2,915 versus $1,747 for the open group. CONCLUSIONS: Laparoscopic appendectomy is more expensive than appendectomy but does not reduce hospital length of stay nor change the time to return to work; however, wound complications are less common.

Facile hydrolysis of mebeverine in vitro and in vivo: negligible circulating concentrations of the drug after oral administration.

The HPLC methods for the determination of plasma concentrations of the antispasmodic agent mebeverine (0.01-10 micrograms/mL) and its hydrolysis product veratric acid (0.1-50 micrograms/mL) are presented. Mebeverine was demonstrated to hydrolyze readily in fresh unbuffered human and rat plasma samples ex vivo. Hydrolysis in human plasma was completely inhibited in the presence of the esterase inhibitor physostigmine sulfate, at a concentration of 130 micrograms/mL. However, the inhibitor was only partially effective in blocking mebeverine hydrolysis in rat plasma. After oral administration of mebeverine.HCl (270 mg) to fasted human volunteers, measurable concentrations of the drug were not found in plasma. By contrast, the metabolite veratric acid achieved considerable concentrations (mean peak plasma concentration of 13.5 micrograms/mL at 40-80 min). After iv administration of mebeverine.HCl (2 mg) to rats, the drug was rapidly eliminated from plasma (mean half-life of 29 min) with simultaneous appearance of veratric acid (mean peak plasma concentration of 1.80 micrograms/mL at 15-30 min). However, after oral administration of the same dose, only traces of mebeverine were found in plasma, with the exception of one rat. Veratric acid again achieved considerable concentrations (mean peak plasma concentration of 0.90 micrograms/mL at 15 min-4 h). The results show that mebeverine undergoes rapid and extensive first-pass metabolism involving hydrolysis of the ester function, and that negligible circulating concentrations of the parent drug are found in humans.

Laparoscopic management of enterocutaneous fistula.

Enterocutaneous fistulas develop in settings of prior abdominal surgery, inflammatory bowel disease, diverticulitis, radiation or malignancy. Traditional surgical management requires laparotomy with bowel resection and anastomosis and is associated with a high incidence of wound infection. Recent advances in instrumentation and accumulation of experience has allowed minimally invasive surgery to become an alternative and often preferred approach to handling complex surgical problems. We present a case of successful laparoscopic management of an enterocutaneous fistula that developed in the setting of prior colectomy and laparoscopic inguinal hernia repair with prosthetic mesh. Laparotomy and its attending complications were avoided facilitating recovery and return to work.

Memory for actual and imagined events in OC checkers.

Information-processing theorists have suggested that obsessive-compulsive (OC) checking may be a function of either (1) an impaired memory of emotional events, (2) an attenuated ability to distinguish between real and imagined events or (3) a dissatisfaction with one's recall without actual memory impairment. These hypotheses were tested by having OC and control Ss engage in real and imagined actions. Some of the actions were designed to produce anxiety in the OC Ss while other events were designed to be emotionally neutral. No differences in reality-monitoring ability were found between OC and control Ss. Contrary to our prediction, OC Ss recall of their last actual behavior was superior to controls, but only for those actions that elicited anxiety. OC Ss, but not controls, reported that they desired higher levels of memory vividness than they were able to produce. The potential mechanism whereby dissatisfaction with memory vividness could contribute to repetitive checking is discussed.

Needlescopic appendectomy.

BACKGROUND: In this paper, we compare our experience with the techniques of needlescopic appendectomy (NA) (2-mm instruments) for the treatment of acute appendicitis with the more conventional approach of a laparoscopic appendectomy (LA). METHODS: We did a retrospective review of patients who underwent NA for the diagnosis of acute appendicitis between August 1996 and January 2002. Variables including operative time, blood loss, postoperative time to discharge, intra- and postoperative complications were analyzed and compared to data from control patients who had undergone an LA for acute appendicitis. RESULTS: The NA group had a longer average operating time (54.5 +/- l3 vs. 42.5 +/- 12.6 min, p = 0.0001) and a longer postoperative hospital stay (2.1 +/- 1.4 vs. 1.3 +/- 1.1 days, p = 0.01). Blood loss was similar for the two groups. CONCLUSIONS: With the exception of superior cosmesis, NA appears to have little advantage over the better-established LA; moreover, it has some disadvantages. A clearer benefit of this procedure over LA, as well as improvements in instrumentation, needs to be shown before it can be widely accepted.

Laparoscopic diagnosis and treatment of intestinal obstruction.

BACKGROUND: Intestinal obstruction is a common reason for general surgical referral. The traditional approach has been conservative management, followed by laparotomy if conservative measures are unsuccessful. However, with the advent of minimally invasive surgery, the need for laparotomy for this common problem is being challenged. METHODS: From May 1991 to April 2001, 167 patients underwent laparoscopy for diagnosis and/or treatment of intestinal obstruction. Average patient age was 62 years (range, 21-98). The site of obstruction was the stomach in seven patients, small bowel in 116 patients, and colon in 44 patients. RESULTS: Laparoscopy successfully diagnosed the site of obstruction in all patients. In addition, 154 patients (92.2%) were successfully treated laparoscopically without conversion to laparotomy. Both intraoperative and postoperative complication rates were low (3.5 and 18.6%, respectively) and compared favorably with those of published reports. CONCLUSIONS: Intestinal obstruction can be approached safely and effectively by laparoscopy with the intent not only to correctly diagnose the patient but also to render treatment.

How to prevent port-site metastases in laparoscopic colorectal surgery.

Various reports concerning port-site metastasis after laparoscopic surgery for colorectal cancer have created a new concern regarding the use of this technique for the treatment of this malignancy. The real incidence is not yet known; neither are its prognostic implications. Numerous experimental studies, both in vitro and in vivo, have been published since 1994. These studies have analyzed the possible role of pneumoperitoneum and carbon dioxide (CO(2)) and pathophysiology, as well as the influence of minimally invasive techniques on tumor response and immunity. There are no definitive results yet, but there is enough evidence to presume that the etiology of this new complication might derive from surgical technique. We present our 8-year experience with laparoscopic surgery for colorectal cancer. We also review our technique for preventing port-site implants. At this writing, we have had no port metastasis in our series of 320 colorectal cancer cases with a mean follow-up period of 54 months. The steps we follow as a routine in all cases of laparoscopic colorectal cancer are (a) fixation of trocars to the abdominal wall, (b) avoidance of touching the tumor, (c) high vascular ligation, (d) intraoperative colonoscopy and intraluminal irrigation with 5% iodine povidone, (e) specimen isolation before extraction from the abdominal cavity, and (f) intraperitoneal and trocar-site irrigation with a tumoricide solution.

Laparoscopic repair of postoperative perineal hernia.

Perineal hernia is an uncommon complication of abdominoperineal resection and pelvic exenteration. We present an alternative not previously described for the surgical repair of this type of hernia: laparoscopic repair of postoperative perineal hernia.

Use of porcine small intestinal submucosa as a prosthetic device for laparoscopic repair of hernias in contaminated fields: 2-year follow-up.

BACKGROUND: Surgisis is a new four- or eight-ply bioactive, prosthetic mesh for hernia repair derived from porcine small intestinal submucosa (SIS). It is a naturally occurring extracellular matrix, which is easily absorbed, supports early and abundant new vessel growth, and serves as a template for the constructive remodeling of many tissues. As such, we believe that Surgisis mesh is ideal for use in contaminated or potentially contaminated fields in which ventral, incisional, or inguinal hernia repairs are required. METHODS: From November 2000-May 2003, 53 patients (23 male, 30 female) underwent placement of Surgisis mesh for a variety of different hernia repairs. A total of 58 hernia repairs were performed in our patient population. Twenty procedures (34%) were performed in a potentially contaminated setting (i.e., with incarcerated/strangulated bowel within the hernia or coincident with a laparocopic cholecystectomy/colectomy). Thirteen repairs (22%) were performed in a grossly contaminated field, including one in which an infected polypropylene mesh from a previous inguinal hernia repair was replaced with Surgisis mesh and one in which dead bowel was discovered within the hernia sac. Median follow-up is 19 months with a range of 1-30 months. RESULTS: Of the 58 total repairs, there was one wound infection complicated by enterocutaneous fistula in a patient originally operated on for ischemic bowel. The fistula was in a location independent of the Surgisis mesh. There have been no mesh-related complications or recurrent hernias in our early postoperative follow-up period. CONCLUSIONS: Surgisis mesh appears to be a promising new prosthetic material for hernia repair and appears to function well, especially in contaminated or potentially contaminated fields. Obviously, long-term follow-up is still required.

Laparoscopic ventral and incisional hernia repair: an 11-year experience.

Incisional hernias develop in 2%-20% of laparotomy incisions, necessitating approximately 90000 ventral hernia repairs per year. Although a common general surgical problem, a "best" method for repair has yet to be identified, as evidenced by documented recurrence rates of 25%-52% with primary open repair. The aim of this study was to evaluate the efficacy and safety of laparoscopic ventral and incisional herniorrhaphy. From February 1991 through November 2002, a total of 384 patients were treated by laparoscopic technique for primary and recurrent umbilical hernias, ventral incisional hernias, and spigelian hernias. The technique was essentially the same for each procedure and involved lysis of adhesions, reduction of hernia contents, closure of the defect, and 3-5 cm circumferential mesh coverage of all hernias. Of the 384 patients in our study group, there were 212 females and 172 males with a mean age of 58.3 years (range 27-100 years). Ninety-six percent of the hernia repairs were completed laparoscopically. Mean operating time was 68 min (range 14-405 min), and estimated average blood loss was 25 mL (range 10-200 mL). The mean postoperative hospital stay was 2.9 days and ranged from same-day discharge to 36 days. The overall postoperative complication rate was 10.1%. There have been 11 recurrences (2.9%) during a mean follow-up time of 47.1 months (range 1-141 months). Laparoscopic ventral and incisional hernia repair, based on the Rives-Stoppa technique, is a safe, feasible, and effective alternative to open techniques. More long-term follow-up is still required to further evaluate the true effectiveness of this operation.

Preliminary experience with new bioactive prosthetic material for repair of hernias in infected fields.

Surgisis (Cook Surgical, Bloomington, Ind., USA) is a new four-ply bioactive, prosthetic mesh for hernia repair derived from porcine small-intestinal submucosa. It is a naturally occurring extracellular matrix which is easily absorbed, supports early and abundant new vessel growth, and serves as a template for the constructive remodeling of many tissues. As such, we believe that Surgisis mesh is ideal for use in contaminated or potentially contaminated fields in which ventral, incisional, or inguinal hernia repairs are required. From November 2000 through May 2002, 25 patients (11 male, 14 female) underwent placement of Surgisis mesh for a variety of different hernia repairs. A total of 25 hernia repairs were performed in our patient population. Fourteen procedures (56%) were performed in a potentially contaminated setting (i.e. with incarcerated/strangulated bowel within the hernia or coincident with a laparoscopic cholecystectomy/colectomy). Eleven repairs (44%) were performed in a grossly contaminated field, including one in which an infected polypropylene mesh from a previous inguinal hernia repair was replaced with Surgisis and one in which necrotic bowel was discovered within the hernial sac. Median follow-up was 15 months with a range of 1-20 months. Of the 25 total repairs, there was one wound infection complicated by enterocutaneous fistula in a patient originally operated on for ischemic bowel. The fistula was in a location independent of the Surgisis mesh. There were no mesh-related complications or recurrent hernias in our early postoperative follow-up period. Surgisis mesh appears to be a promising new prosthetic material for hernia repair, especially in contaminated or potentially contaminated fields. Obviously, long-term follow-up is still required.

The effect of diflunisal on the elimination of triamterene in human volunteers.

A major metabolic pathway for triamterene (a potassium sparing diuretic) is aromatic hydroxylation followed by sulphate conjugation. Diflunisal (a salicylate anti-inflammatory agent) also undergoes sulphate conjugation of its phenolic group as a major pathway. We investigated the possible effect of diflunisal on the elimination of triamterene (competition for phenolic sulphonation) in six healthy volunteers by studying the disposition of single doses of triamterene (100 mg) taken alone and in the presence of steady-state levels of diflunisal. Diflunisal coadministration (500 mg b.i.d.) had no effect on the pharmacokinetics of triamterene itself. However, plasma AUC of p-hydroxytriamterene sulphate was greater (4.6 times), and its renal clearance lower (0.24 times), in the presence of diflunisal. There was no change in the formation clearance or protein binding of p-hydroxytriamterene sulphate in the presence of diflunisal. The data point to competition for renal excretory pathways rather than sulphonation capacity. This interaction could have clinical relevance since p-hydroxytriamterene sulphate is pharmacologically active.