European Association For Endoscopic Surgery Research Articles

ESGE Newsletter

The following ten abstracts were chosen for presentation at the upcoming EURO-NOTES 2010 Workshop, a combined activity of the European Association for Endoscopic Surgery (EAES) and ESGE.

Training for laparoscopic Nissen fundoplication with a newly designed model: a replacement for animal tissue models?

BackgroundTo bridge the early learning curve for laparoscopic Nissen fundoplication from the clinical setting to a safe environment, training models can be used. This study aimed to develop a reusable, low-cost model to be used for training in laparoscopic Nissen fundoplication procedure as an alternative to the use of animal tissue models.MethodsFrom artificial organs and tissue, an anatomic model of the human upper abdomen was developed for training in performing laparoscopic Nissen fundoplication. The 20 participants and tutors in the European Association for Endoscopic Surgery (EAES) upper gastrointestinal surgery course completed four complementary tasks of laparoscopic Nissen fundoplication with the artificial model, then compared the realism, haptic feedback, and training properties of the model with those of animal tissue models.ResultsThe main difference between the two training models was seen in the properties of the stomach. The wrapping of the stomach in the artificial model was rated significantly lower than that in the animal tissue model (mean, 3.6 vs. 4.2; p = 0.010). The main criticism of the stomach of the artificial model was that it was too rigid for making a proper wrap. The suturing of the stomach wall, however, was regarded as fairly realistic (mean, 3.6). The crura on the artificial model were rated better (mean, 4.3) than those on the animal tissue (mean, 4.0), although the difference was not significant. The participants regarded the model as a good to excellent (mean, 4.3) training tool.ConclusionThe newly developed model is regarded as a good tool for training in laparoscopic Nissen fundoplication procedure. It is cheaper, more durable, and more readily available for training and can therefore be used in every training center. The stomach of this model, however, still needs improvement because it is too rigid for making the wrap.

Laparoscopic ultrasound: a survey of its current and future use, requirements, and integration with navigation technology

Laparoscopic ultrasound (LUS) increases surgical safety by allowing the surgeon to see beyond the organ surface, by visualizing vascular structures and by improving surgical precision of tumor resection. A questionnaire-based survey was used to investigate the current use and future expectations of LUS technology. A questionnaire consisting of 26 questions was distributed manually at four different conferences (60% at the European Association for Endoscopic Surgery (EAES) conference, Stockholm 2008). The answers were summarized with descriptive statistics and nonparametric tests at a significance level of 0.05. The questionnaire was answered by 177 surgeons from 40 different countries (85% from Europe). Of these surgeons, 43% use ultrasound during laparoscopic procedures. Generally, more LUS users are found at university hospitals than at general community hospitals. Surgeons use LUS primarily in procedures related to the liver (67% of the surgeons who use LUS), but LUS also is used in other procedures related to the pancreas, biliary tract, and colon. In a 5-year perspective, 82% of surgeons believe in an increased use of LUS, and 79% of surgeons also think that the use of LUS combined with navigation technology will increase and that the most important requirements for such a system are good image quality, easy interpretation, and a high degree of precision. Although the surgeons believe LUS has advantages, only 43% of the respondents reported using it. The surveyed surgeons were largely positive toward an increased use of LUS in a 5-year perspective and believe that LUS combined with navigation technology will contribute to improving the surgical precision of tumor resection.

Laparoscopic colorectal cancer resection: examining lymph nodes or standardizing surgery?

There is now debate about how many lymph nodes should be dissected during colorectal cancer (CRC) by surgery and subsequently retrieved from the specimen and examined by pathologists. Appropriate lymphadenectomy is crucial for the patient’s oncological outcome for two reasons. First, it reduces the risk of residual nodal disease, and second, examination of only a large number of lymph nodes allows for accurate nodal staging. The pathological tumor-nodemetastasis (pTNM) staging by examining a sufficient number of lymph nodes allows an accurate estimation of the ratio between positive and total number of lymph nodes evaluated. This global nodal status information is necessary for making a decision about adjuvant systemic chemotherapy. Recent guidelines from scientific associations and organizations, including the American College of Surgeons (ACS), the National Quality Forum (NQF), the National Comprehensive Cancer Network (NCCN), and the American Society for Clinical Oncology (ASCO), recommend that a minimum of 12 lymph nodes should be removed and histopathologically examined for appropriate treatment of patients with CRC [1]. However, two large retrospective studies question this strategy. Based on a retrospective analysis of the national Surveillance, Epidemiology, and End Results (SEER) Medicare-linked database (19952005) of patients in the U.S. (n = 30625) who underwent colectomy for nonmetastatic colon cancer, Wong et al. [2] came to the provocative conclusion that ‘‘Efforts by payers and professional organizations to increase node examination rates may have limited value as a public health intervention.’’ In another more recent retrospective analysis of 24,477 stage III colon cancer patients identified from the SEER cancer registry, Wang et al. [3] found that the total number of lymph nodes examined is not a reliable prognostic factor for stage III colon cancer. How many lymph nodes should be removed in laparoscopic CRC surgery? This question is relevant because laparoscopic resection has been increasingly used in dayto-day clinical practice not only for CRC but also other gastrointestinal cancers [4–8]. In a current review [9] and an international survey of surgeons about laparoscopic rectal surgery [10] it was found that there was more emphasis on the optimal extent of surgery rather than the number of lymph nodes retrieved. Indeed, most surgeons in the European Association for Endoscopic Surgery (EAES), the Indian Association of Gastrointestinal Endo-Surgeons (IAGES), and the Society of Laparoscopic Surgeons (SLS) and renowned surgeons who perform laparoscopic total mesorectal excision (LTME) agreed on the necessity and utility of standardized laparoscopic surgery. For example, standardization of the highly demanding laparoscopic low anterior resection with high ligation of the inferior mesenteric artery at its origin, splenic flexure mobilization, and TME with safety distal resection margins of at least 2 cm provides the greatest possibility for the good oncological and quality-of-life outcomes [9, 10]. In the January 2010 issue of this journal, El-Gazzaz et al. [11] added important information on laparoscopic CRC surgery. The authors emphasized assessing the number of lymph nodes dissected during surgery and examined by the pathologists after laparoscopic or open surgery. The authors compared 243 patients who underwent laparoscopic surgery C. Hottenrott (&) Chirurgische Klinik, St. Elisabethenkrankenhaus, Ginnheimer Strase 3, 60487 Frankfurt, Germany e-mail: info@gastricbreastcancer.com

17th International Congress of the European Association for Endoscopic Surgery (EAES) Prague, Czech Republic, 17–20 June 2009

Introduction: Laparoscopic splenectomy (LS) is the preferred choice for elective removal of normal and moderate sized spleens, but in the patients with spleen malignancies and with massive splenomegaly (MS) is still controversial. The aim of this prospective study was to analyse and compare the safety and efficacy of LS for benign and malignant splenic disease in the settings of the spleen enlargement. Methods: In the past 5 years operative and postoperative data were prospectively collected in 23 patients submitted to LS due to benign (15) and malignant (8) splenic disease. Results: There were no differences in the mean age between malignant and benign group. Mean spleen size in both groups was 19, 6 cm (range 11-28 cm) and total conversion rate 8, 6% (2 malignant group patients). Mean operative time in malignant group was not statistically longer (163, 8 ±43, 3 min vs 143, 3 ±28, 9 min, p = 0.1878) as well as the need for accessory incision for spleen retrieval (3 of 8 vs 2 of 15 patients, p = 0, 2076). Eight (35%) patients required intraoperative blood transfusion, 3 (37%) in malignant and 5 (33%) in benign group, with more blood replacement in benign group (428, 67 ml vs. 157, 5 ml, p = 0, 305). Estimated blood loss was significantly higher in this group (252 98 ml vs 151, 3 ml, p = 0.023) due to low platelet count. The length of hospital stay was the same for both groups. In MS (diameter > 20cm) operativetime was significantly longer (165, 45 ±34, 67 min vs 136, 67 ± 30, 56 min, p = 0, 0464). There were no differences between MS and moderate splenomegaly in requiring blood transfusion, blood replacement (425, 56 - 695, 11 ml vs. 428, 89 - 621, 72 ml, p = 0, 9904) and the length of hospital stay. Only one laparoscopic reoperation due to bleeding was performed. Conclusion: LS offers major clinical advantages but requires great technical care particularly in patients with malignant splenic disease and massive splenomegaly. It seems that there are no significant differences in operative time, need for accessory incision and the length of hospital stay as well as complication rate whether LS is preformed for benign or malignant disease.

17th International Congress of the European Association for Endoscopic Surgery (EAES) Prague, Czech Republic, 17–20 June 2009

17th International Congress of the European Association for Endoscopic Surgery (EAES) Prague, Czech Republic, 17–20 June 2009

17th International Congress of the European Association for Endoscopic Surgery (EAES) Prague, Czech Republic, 17--20 June 2009

17th International Congress of the European Association for Endoscopic Surgery (EAES) Prague, Czech Republic, 17--20 June 2009

EAES recommendations on methodology of innovation management in endoscopic surgery

Under the mandate of the European Association for Endoscopic Surgery (EAES) a guideline on methodology of innovation management in endoscopic surgery has been developed. The primary focus of this guideline is patient safety, efficacy, and effectiveness. An international expert panel was invited to develop recommendations for the assessment and introduction of surgical innovations. A consensus development conference (CDC) took place in May 2009 using the method of a nominal group process (NGP). The recommendations were presented at the annual EAES congress in Prague, Czech Republic, on June 18th, 2009 for discussion and further input. After further Delphi processes between the experts, the final recommendations were agreed upon. The development and implementation of innovations in surgery are addressed in five sections: (1) definition of an innovation, (2) preclinical and (3) clinical scientific development, (4) scientific approval, and (5) implementation along with monitoring. Within the present guideline each of the sections and several steps are defined, and several recommendations based on available evidence have been agreed within each category. A comprehensive workflow of the different steps is given in an algorithm. In addition, issues of health technology assessment (HTA) serving to estimate efficiency followed by ethical directives are given. Innovations into clinical practice should be introduced with the highest possible grade of safety for the patient (nil nocere: do no harm). The recommendations can contribute to the attainment of this objective without preventing future promising diagnostic and therapeutic innovations in the field of surgery and allied techniques.

The opinion and experience of surgeons with laparoscopic bowel grasper haptics

Background: In order to develop new and better laparoscopic bowel instruments, which reduces patient risks, the opinions and experience that surgeons have with current laparoscopic bowel grasper haptics is important. In this study we explored this by means of a questionnaire. Method: A total of 386 online- questionnaires, were sent to laparoscopic surgeons working in European hospitals. They were all members of the European Association of Endoscopic Surgery and perform laparoscopic obesities or bowel surgery. Surgeons where divided into different age and experience groups. Results: A total of 174 completely filled out forms were analyzed. In total, 16% of the surgeons cannot prevent damage when they pinch too hard, although they (10%) might have seen or felt it. Seven percent of the respondents were not able to see or feel tissue slippage. Whereas 31% can see or feel slippage they cannot do anything to prevent it. Overall, most of the respondents would appreciate technical changes in the laparoscopic bowel graspers to reduce tissue damage. Of all the respondents, 79% maintain that it is necessary to have a new laparoscopic grasper with augmented feedback. The majority of the respondents (77%) would like to have tactile feedback as an indication of the level of pinch force. There are not many differences in the opinions of surgeons at different skill levels. Conclusion: From the results of the questionnaire and the other comments made by respondents it is evident that research and developments in the field of new laparoscopic graspers should continue.

Laparoscopic splenectomy in portal hypertension: a single-surgeon 13-year experience

Although laparoscopic splenectomy (LS) has become the standard approach for most splenectomy cases, some areas still remain controversial. To date, the indications that preclude LS are not clearly defined. Portal hypertension from liver cirrhosis still is a contraindication to LS in the clinical practice guidelines of the European Association for Endoscopic Surgery published in 2008. This study aimed to evaluate the feasibility of LS for hypersplenism secondary to liver cirrhosis and portal hypertension. The study retrospectively analyzed 206 laparoscopic splenectomies performed for a variety of indications over 13 years. According to diagnosis, the patients were divided into group A (hypersplenism secondary to liver cirrhosis and portal hypertension, n = 96) and group B (hematologic and other disorders, n = 110). A detailed review of medical records was conducted. The perioperative data for the two groups were compared including patient characteristics, diagnosis, operative details, complication rates, and postoperative hospital stay. Laparoscopic splenectomy was completed for 201 patients. Conversion from laparoscopic to open surgery was necessary for 5 patients (2.4%) because of hemorrhage, and 26 patients (12.6%) had complications. There were significant differences between groups A and B in terms of mean operation time (2.8 vs. 2.1 h), complication rates (17.7% vs. 8.2%), and postoperative stay (7.1 vs. 4.7 days). However, the two groups showed no significant differences with respect to intraoperative blood loss, blood transfusion, and conversion rate. Laparoscopic splenectomy is a feasible, effective, and safe surgical procedure for patients who require splenectomy. Hypersplenism secondary to cirrhosis and portal hypertension should not be considered contraindications for LS.

Current technique of laparoscopic total mesorectal excision (TME): an international questionnaire among 368 surgeons

Current literature shows no consensus for the technique of laparoscopic total mesorectal excision (LTME). This study aimed to assess the current practice of LTME. From January to March 2008, members of the European Association for Endoscopic Surgery (EAES), the Indian Association of Gastrointestinal Endo-Surgeons (IAGES), and the Society of Laparoscopic Surgeons (SLS), together with renowned surgeons in the field of LTME, were invited to fill out an online questionnaire concerning aspects of LTME. The 368 questionnaires showed that 77% of the study participants performed 1-20 LTMEs per year (low volume) and that 33% performed more than 20 LTMEs per year (high volume). Preoperative bowel preparation (PBP), Trendelenburg position, periumbilical insertion of a 30º laparoscope, medial-to-lateral dissection, ultrasonic hemostasis, high-tie ligation, splenic flexure mobilization, left ureteral identification, partial sigmoid resection, extraction of the specimen by a new minilaparotomy and wound protector, end-to-end stapled anastomosis using a 28- to 29-mm anvil with 3.5-mm staples, abdominal lavage, pelvic drainage, and diverting ileostoma were performed by a majority of the surgeons. Less consistency was observed in identification of the right ureter, dissection of Denonvilliers' fascia, location of the minilaparotomy, and construction of a colonic pouch. There were significant differences between high and low volume and between American and European surgeons. Significantly more low-volume surgeons indicated a preference for an open TME depending on the age and gender of the patient, the presence of comorbidity, previous laparotomy, and locally advanced tumor. More low-volume surgeons applied PBP (83.4% vs. 71.8%; p = 0.017). On the average, high-volume surgeons identified more autonomic pelvic nerves during dissection (2.6 vs. 1.8 nerves). The right ureter was identified by 66% of the American and 31.2% of the European surgeons. In the United States 91.5% and in Europe 61.2% created an end-to-end anastomosis. Pouches were created by 32% of the European and 6.8% of the American surgeons. The respondents showed an apparent preference for several aspects of LTME. Differences were related to expertise and still more to continent.

Tattoo: a navigational tool, a lighthouse for biomolecular level precision in surgical endoscopy. Newton’s apple or Eve’s?

Unchanged for more than half a century, the World Health Organization (WHO) defines health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. Laparoscopic surgery has successfully managed the physical aspect of disease, enhanced mental well-being by its aesthetic virtues and by being less painful, and enhanced the social value by enabling early resumption of normal activity profile. The ongoing evolution of this revolutionary technique keeps bettering outcomes on all parameters. Surgical outcomes are the primary determinant of patient satisfaction [1]. Surgery leaves a scar not only on the body but on the mind as well [2]. Avoiding disruption of a tattoo is a welcome development that is sure to enhance the mental and psychosocial well-being of our patients [3]. The laparoscopic surgeon has continued to challenge his best outputs in a precise pursuit for perfection to better the best. Laparoscopic surgeons, who were ostracized in the early 1990s and called names such as ‘‘boys with toys’’ nearly killing their patients and disparagers married to ‘‘Nintendo surgery,’’ have come a long way to become the envy of once hostile brotherhood [4]. Consorting technology, laparoscopic surgeons have never failed to question and reshape themselves holistically with ever-evolving paradigms. Rising like a Phoenix from a breed of dying species, the laparoscopic surgeon has evolved with a larger canvas, the description of which goes by various names, i.e., cyber surgeon, endosurgeon, space surgeon, molecular surgeon, or biosurgeon [5]. This progress has been nurtured and sustained by societies, such as The Society of American Gastrointestinal and Endoscopic Surgeons and The European Association for Endoscopic Surgery, and above all by the Journal of Surgical Endoscopy. Surgery is a craft no different than art, because both of them are the result of some imitation and some variation [6]. Most renaissance intellectuals, including Leonardo da Vinci, had a common source of inspiration, as is the case with the biomedical scientists and the endosurgeon, the ambassador of the marriage of a craft with the art [6]. Surgical endoscopy is the common thread for all the good work that has contributed to the present status leading to improved patientperceived outcomes on physical, social, and mental parameters. Avoidance of tattoo disruption is one such benefit of laparoscopic surgery [3]. It not only preserves the tattoo but also the basic tenets of informed consent. It preempts the fiducial, coercive moments in the communication for an informed consent. Tattoos have adorned humankind for more than 5,000 years. Despite ridicule from orthodoxy (‘‘Ye shall not make any cuttings in your flesh for the dead, nor print any marks upon you’’ Leviticus 19:28), tattoos have gained social acceptance as status symbols, declaration of love/ sensuality/sexuality, or signs of religious beliefs. Tattoos, seen as a trivial appendage by some have become a fashion statement of visual expression of individuality to be seen as an extension of the wearer’s personality. Tattoos occupy the grey zone between virtue and vice on the perceptive social horizon. They evoke a potpourri of imagery in different souls, from sensual to intellectual to medicinal. It is something like the image of an apple that reminds us of either Eve or Newton or an iPod or simply the goodness of the fruit. It is in this light that the article by Gilliam et al. B. B. Agarwal (&) Dr. Agarwal’s Surgery & Yoga, F81 & 82, Street No. 4, Virender Nagar, New Delhi 10058, India e-mail: endosurgeon@gmail.com

16th International Congress of the European Association for Endoscopic Surgery (EAES) Stockholm, Sweden, 11–14 June 2008

16th International Congress of the European Association for Endoscopic Surgery (EAES) Stockholm, Sweden, 11–14 June 2008

16th International Congress of the European Association for Endoscopic Surgery (EAES) Stockholm, Sweden, 11–14 June 2008

16th International Congress of the European Association for Endoscopic Surgery (EAES) Stockholm, Sweden, 11–14 June 2008

16th International Congress of the European Association for Endoscopic Surgery (EAES) Stockholm, Sweden, 11–14 June 2008

16th International Congress of the European Association for Endoscopic Surgery (EAES) Stockholm, Sweden, 11–14 June 2008

15th International Congress of the European Association for Endoscopic Surgery (EAES) Athens, Greece, 4–7 July 2007

15th International Congress of the European Association for Endoscopic Surgery (EAES) Athens, Greece, 4–7 July 2007

15th International Congress of the European Association for Endoscopic Surgery (EAES) Athens, Greece, 4–7 July 2007

15th International Congress of the European Association for Endoscopic Surgery (EAES) Athens, Greece, 4–7 July 2007

15th International Congress of the European Association for Endoscopic Surgery (EAES) Athens, Greece, 4–7 July 2007

15th International Congress of the European Association for Endoscopic Surgery (EAES) Athens, Greece, 4–7 July 2007

15th International Congress of the European Association for Endoscopic Surgery (EAES) Athens, Greece, 4–7 July 2007

15th International Congress of the European Association for Endoscopic Surgery (EAES) Athens, Greece, 4–7 July 2007

Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

Although laparoscopic splenectomy (LS) has become the standard approach for most splenectomy cases, some areas still remain controversial. To date, the indications that preclude laparoscopic splenectomy are not clearly defined. In view of this, the European Association for Endoscopic Surgery (EAES) has developed clinical practice guidelines for LS. An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. A consensus development conference using a nominal group process convened in May 2007. Its recommendations were presented at the annual EAES congress in Athens, Greece, on 5 July 2007 for discussion and further input. After a further Delphi process between the experts, the final recommendations were agreed upon. Laparoscopic splenectomy is indicated for most benign and malignant hematologic diseases independently of the patient's age and body weight. Preoperative investigation is recommended for obtaining information on spleen size and volume as well as the presence of accessory splenic tissue. Preoperative vaccination against meningococcal, pneumococcal, and Haemophilus influenzae type B infections is recommended in elective cases. Perioperative anticoagulant prophylaxis with subcutaneous heparin should be administered to all patients and prolonged anticoagulant prophylaxis to high-risk patients. The choice of approach (supine [anterior], semilateral or lateral) is left to the surgeon's preference and concomitant conditions. In cases of massive splenomegaly, the hand-assisted technique should be considered to avoid conversion to open surgery and to reduce complication rates. The expert panel still considered portal hypertension and major medical comorbidities as contraindications to LS. Despite a lack of level 1 evidence, LS is a safe and advantageous procedure in experienced hands that has displaced open surgery for almost all indications. To support the clinical evidence, further randomized controlled trials on different issues are mandatory.