Lower Operative Blood Loss Research Articles

Comparative analysis of transabdominal and retroperitoneal approaches in adrenalectomy

Laparoscopic adrenalectomy has been recognised as the «gold standard» approach for benign adrenal tumours. The majority of surgeons opt for transabdominal laparoscopic adrenalectomies, while retroperitoneoscopic adrenalectomies in the prone position, which were pioneered by Waltz, offer certain advantages for patients. Objective — to compare the effectiveness and complication rates of transabdominal and retroperitoneoscopic laparoscopic adrenalectomies. Materials and methods. Between 2000 and 2021, our clinic performed 472 laparoscopic adrenalectomies. The age of the patients ranged from 19 to 79 years, with a mean age of 50.5±10.2 years. The patient pool consisted of 315 women and 157 men. The primary indications for operation were as follows: incidentaloma (32.5%), pheochromocytoma (30.2%), aldosteronoma (19%), corticosteroma (10.3%), myelolipoma (3.0%), and metastatic cancer (5.0%). Tumour sizes ranged from 1 to 10 cm. Results. A total of 316 patients underwent transabdominal adrenalectomies: 206 patients had right adrenalectomies and 110 patients had left adrenalectomies. A total of 156 patients underwent retroperitoneoscopic adrenalectomies. Seven patients required a conversion to a transabdominal approach, including three patients with tumours exceeding 6 cm in size and four patients with tumours ranging from 4 to 6 cm. The conversion rate amounted to 4.9%. The retroperitoneoscopic approach showed certain advantages for patients with small tumours, including shorter surgery duration, lower operative blood loss, diminished postoperative pain intensity, a lower incidence of shoulder‑tip pain, a faster transition to oral intake, and shorter hospital stays. Conclusions. Both approaches were equally safe. In patients with small tumours, retroperitoneoscopic adrenalectomies outperformed the transabdominal approach in terms of shorter surgery duration, lower blood loss, lower postoperative pain, faster recovery, and favourable cosmetic results. In patients with large tumours, the transabdominal approach demonstrated better outcomes, with lower complication and conversion rates.

Laparoscopic Splenectomy and Esophagogastric Devascularization Versus Endoscopic Varices Ligation Plus Laparoscopic Splenectomy in the Treatment of Portal Hypertension.

Background/Aims: To compare laparoscopic splenectomy and esophagogastric devascularization (LSED) with endoscopic variceal ligation (EVL) plus laparoscopic splenectomy (LS) in treating esophagogastric variceal bleeding (EGVB) caused by portal hypertension (PH). Methods: Between January 2015 and May 2022, 87 patients with PH caused by hepatitis B cirrhosis were included in the retrospective study (34 in LSED versus 53 in EVL + LS). Results: The clinical features of both groups were well-matched (P > .05). The EVL+LS group was associated with shorter operation time, lower operative blood loss, faster gastrointestinal (GI) recovery, lower C-reactive protein levels, and shorter hospital stays after operation (P < .05). Operative morbidity was more significant in the LSED group (19 55.9% versus 18 33.9%) (P < .05). On postoperative days 1 and 3, albumin levels were remarkably lower (P < .05) in the LSED group. The mean follow-up was 24.3 months for LSED and 26.5 for EVL+LS. Hematological parameters, hepatic functional status, hepatic hemodynamics, and endoscopy indicated a substantial improvement in both groups (P < .05), but no significant difference was identified (P > .05). There was no discernible difference in the incidence of GI bleeding between the two groups (P > .05). Conclusion: EVL+LS is a safer, simpler, and more minimally invasive treatment of EGVB secondary to PH.

Lymph node involvement is rare in mucinous cystic neoplasms of the pancreas: Role of minimally invasive surgery.

Mucinous cystic neoplasm (MCN) is a premalignant cystic tumor of the pancreas. Resection of MCN in the distal pancreas is a standard treatment; however, at present, there is no consensus on the necessity or extent of lymph node dissection, and minimally invasive pancreatectomy is commonly the preferred surgical technique. Thus, the present study aimed to assess the efficacy of minimally invasive surgery and the extent of lymph node metastasis as factors in determining an appropriate surgical treatment for MCN. The present study retrospectively analyzed 21 consecutive patients who underwent distal pancreatectomy (DP) for MCN under general anesthesia at Chiba University Hospital (Chiba, Japan) between April 2011 and July 2019. All 21 patients were female. DP with a splenectomy was performed in all the patients. A total of 14 patients underwent laparoscopic DP (LDP). No lymph node metastasis was found in any of the patients. The minimally invasive surgery group had lower operative blood loss and a shorter hospital stay than the open surgery group. There was no significant difference in the number of dissected lymph nodes between the open surgery group and the minimally invasive surgery group. Preoperative findings of malignancy in MCN included solid components on enhanced CT and endoscopic ultrasonography, high carbohydrate antigen 19-9 values and large tumor size. In conclusion, DP with spleen preservation, which is minimally invasive, may be preferentially considered as a surgical technique for MCN without malignant findings because lymph node metastases are rare in MCN and were not observed in the present study.

Comparaison des voies ilio-inguinale et Stoppa modifiée dans le traitement des fractures de l’acetabulum : mise à jour systématique de la littérature et méta-analyse

BackgroundThe modified Stoppa (MS) approach is an alternative to the ilioinguinal (IL) approach and three meta-analyses comparing these two approaches for the treatment of acetabular fractures were published previously. The aim of this study was to provide an updated systematic review and meta-analysis comparing the MS approach with the IL approach for the treatment of acetabular fractures and to answer the following question: Are the results of the MS approach superior to those of the IL approach in terms of reduction quality, operative time, operative blood loss, complications, and clinical outcomes for treatment of acetabular fractures? Patients and MethodsAn updated systematic literature review was conducted using relevant original studies from various databases (PubMed, Web of Science and the Cochrane Library). Pooling of data was performed using RevMan software (version 5,3, Cochrane Collaboration, Oxford, UK). A p-value of<0.05 was considered to be significant. We calculated the mean differences (MDs) for continuous data and odds ratio (OR) for dichotomous data with 95 % confidence intervals (CIs) for each outcome. Statistical heterogeneity was assessed based on I2 using the standard χ2 test. When I2>50 %, significant heterogeneity was assumed and a random-effects model was applied for the meta-analysis. A fixed-effects model was applied in the absence of significant heterogeneity. ResultsSix studies were included in this meta-analysis. The findings demonstrated that the rate of anatomical reduction was significantly higher in the MS approach than in the IL approach (I2=0 %, OR=1.75, 95 % CI: 1.13–2.69, p=0.01), the operative time was significantly shorter in the MS approach than in the IL approach (I2=88 %, MD=−63.60, 95 % CI: −93.01–(−34.20), p<0.0001) and operative blood loss was significantly lower in the MS approach than in the IL approach (I2=75 %, MD=−350.51, 95 % CI: −523.45–(−177.58), p<0.0001). There was no significant difference in the rate of nerve injury (I2=0 %, OR=0.47, 95 % CI: 0.16–1.39, p=0.17), the rate of vascular injury (I2=0 %, OR=0.51, 95 % CI: 0.17–1.49, p=0.22), the rate of infection (I2=0 %, OR=0.53, 95 % CI: 0.25–1.12, p=0.10), the rate of heterotopic ossification (I2=45 %, OR=0.63, 95 % CI: 0.22–1.85, p=0.40), and the rate of excellent or good clinical score (I2=21 %, OR=1.15, 95 % CI: 0.56–2.38, p=0.70) between the two approaches. DiscussionThe MS approach provided better reduction quality, shorter operative time, lower operative blood loss, although there were no significant differences in the rate of complications, and excellent or good clinical score between the two approaches. Level of evidenceIII.

Comparison between ilioinguinal approach and modified Stoppa approach for the treatment of acetabular fractures: An updated systematic review and meta-analysis

BackgroundThe modified Stoppa (MS) approach is an alternative to the ilioinguinal (IL) approach and three meta-analyses comparing these two approaches for the treatment of acetabular fractures were published previously. The aim of this study was to provide an updated systematic review and meta-analysis comparing the MS approach with the IL approach for the treatment of acetabular fractures and to answer the following question: are the results of the MS approach superior to those of the IL approach in terms of reduction quality, operative time, operative blood loss, complications, and clinical outcomes for treatment of acetabular fractures? Patients and methodsAn updated systematic literature review was conducted using relevant original studies from various databases (PubMed, Web of Science and the Cochrane Library). Pooling of data was performed using RevMan software (version 5.3, Cochrane Collaboration, Oxford, UK). A p-value of<0.05 was considered to be significant. We calculated the mean differences (MDs) for continuous data and odds ratio (OR) for dichotomous data with 95% confidence intervals (CIs) for each outcome. Statistical heterogeneity was assessed based on I2 using the standard Chi2 test. When I2>50%, significant heterogeneity was assumed and a random-effects model was applied for the meta-analysis. A fixed-effects model was applied in the absence of significant heterogeneity. ResultsSix studies were included in this meta-analysis. The findings demonstrated that the rate of anatomical reduction was significantly higher in the MS approach than in the IL approach (I2=0%, OR=1.75, 95% CI: 1.13–2.69, p=0.01), the operative time was significantly shorter in the MS approach than in the IL approach (I2=88%, MD=−63.60, 95% CI: −93.01 – (−34.20), p<0.0001) and operative blood loss was significantly lower in the MS approach than in the IL approach (I2=75%, MD=−350.51, 95% CI: −523.45 – (−177.58), p<0.0001). There was no significant difference in the rate of nerve injury (I2=0%, OR=0.47, 95% CI: 0.16–1.39, p=0.17), the rate of vascular injury (I2=0%, OR=0.51, 95% CI: 0.17–1.49, p=0.22), the rate of infection (I2=0%, OR=0.53, 95% CI: 0.25–1.12, p=0.10), the rate of heterotopic ossification (I2=45%, OR=0.63, 95% CI: 0.22–1.85, p=0.40), and the rate of excellent or good clinical score (I2=21%, OR=1.15, 95% CI: 0.56–2.38, p=0.70) between the two approaches. DiscussionThe MS approach provided better reduction quality, shorter operative time, lower operative blood loss, although there were no significant differences in the rate of complications, and excellent or good clinical score between the two approaches. Level of evidenceIII.

Beyond the learning curve: a review of complex cases in robotic thoracic surgery

The number of thoracic surgery cases performed on the robotic platform has increased steadily over the last two decades. An increasing number of surgeons are training on the robotic system, which like any new technique or technology, has a progressive learning curve. Central to establishing a successful robotic program is the development of a dedicated thoracic robotic team that involves anesthesiologists, nurses, and bed-side assistants. With an additional surgeon console, the robot is an excellent platform for teaching. Compared to current methods of video-assisted thoracoscopic surgery (VATS), the robot offers improved wristed motion, a magnified, high definition three-dimensional vision, and greater surgeon control of the operation. These advantages are paired with integrated adjunctive technology such as infrared imaging. For pulmonary resection, these advantages of the robotic platform have translated into several clinical benefits, such as fewer overall complications, reduced pain, shorter length of stay, better postoperative pulmonary function, lower operative blood loss, and a lower 30-day mortality rate compared to open thoracotomy. With increased experience, cases of greater complexity are being performed. This review article details the process of becoming an experienced robotic thoracic surgeon and discusses a series of challenging cases in robotic thoracic surgery that a surgeon may encounter “beyond the learning curve”. Nearly all thoracic surgery can now be approached robotically, including sleeve lobectomy, pneumonectomy, resection of large pulmonary and mediastinal masses, decortication, thoracic duct ligation, rib resection, and pulmonary resection after prior chest surgery and/or chemoradiation.

Minor laparoscopic liver resection for Hepatocellular Carcinoma is safer than minor open resection, especially for less compensated cirrhotic patients: Propensity score analysis

BackgroundLaparoscopic liver resection (LLR) has gained significant popularity over the last 10 years. First experiences of LLR compared to open liver resection (OLR) reported a similar survival and a better safety profile for LLR. Materials and methodsThis is a retrospective analysis of prospectively collected data of all consecutive patients treated by liver resection for HCC on liver cirrhosis between January 2005 and March 2017. The choice of procedure (LLR vs OLR) was generally based on tumor localization, history of previous upper abdominal surgery and patient's preference. The type of resection and indication for surgery were unrelated to the adopted technique. Based on pre-operative variables and confirmed cirrhosis, a 1:1 propensity score matching (PSM) model was developed to compare outcomes of LLR and OLR in patients with HCC. Outcomes of interest included morbidity, mortality and long-term cure potential. ResultsAfter-PSM, the LLR group demonstrated better perioperative results including: lower complication rate (50.7% in OLR vs 29.3% in LLR, p = 0.0035), significantly lower intra-operative blood loss (200 ml in OLR vs 150 ml in LLR, p = 0.007) and shorter hospital length of stay (median 9 days in OLR vs 7 days in LLR, p = 0.0018). Moreover there was no significant difference between the two groups in 3-year survival (76%, CI: 60%–86% in LLR vs 68%, CI: 55%–79% in OLR, p = 0.32) or recurrence-free survival rates (44%, CI: 28%–58%, vs 44%, CI: 31%–57%, p = 0.94). ConclusionsMinor LLR appeared significantly safer compared to minor OLR for HCC. LLR was associated with fewer post-operative complication, lower operative blood loss and a shorter hospital stay along with similar survival and recurrence-free survival rates

The Hand-Assisted Laparoscopic Approach to Resection of Pancreatic Mucinous Cystic Neoplasms: An Underused Technique?

Pancreatic mucinous cystic neoplasms (MCNs) are rare tumors typically of the distal pancreas that harbor malignant potential. Although resection is recommended, data are limited on optimal operative approaches to distal pancreatectomy for MCN. MCN resections (2000-2014; eight institutions) were included. Outcomes of minimally invasive and open MCN resections were compared. A total of 289 patients underwent distal pancreatectomy for MCN: 136(47%) minimally invasive and 153(53%) open. Minimally invasive procedures were associated with smaller MCN size (3.9 vs 6.8 cm; P = 0.001), lower operative blood loss (192 vs 392 mL; P = 0.001), and shorter hospital stay(5 vs 7 days; P = 0.001) compared with open. Despite higher American Society of Anesthesiologists class, hand-assisted (n = 46) had similar advantages as laparoscopic/robotic (n = 76). When comparing hand-assisted to open, although MCN size was slightly smaller (4.1 vs 6.8 cm; P = 0.001), specimen length, operative time, and nodal yield were identical. Similar to laparoscopic/robotic, hand-assisted had lower operative blood loss (161 vs 392 mL; P = 0.001) and shorter hospital stay (5 vs 7 days; P = 0.03) compared with open, without increased complications. Hand-assisted laparoscopic technique is a useful approach for MCN resection because specimen length, lymph node yield, operative time, and complication profiles are similar to open procedures, but it still offers the advantages of a minimally invasive approach. Hand-assisted laparoscopy should be considered as an alternative to open technique or as a successive step before converting from total laparoscopic to open distal pancreatectomy for MCN.

Standardization and streamlining of a pancreas surgery practice improves outcomes and resource utilization: A single institution's 20-year experience

BackgroundIn the past two decades, pancreas surgery (PS) has undergone significant advances in operative techniques and with a focus on multidisciplinary high-volume practices. MethodsA review of patients undergoing PS from 3/1995-2/2015 was conducted; dividing patients into group A (1995–2005) and group B (2005–2015) for a detailed comparison. Effect of surgeon volume in group B was determined. ResultsA total of 1001 patients underwent PS (group A: 259; group B: 742). The mean age was 62.7 years and 52.8% were female. Group B patients were associated with a higher rate of pylorus preservation and minimally invasive resection and a lower rate of morbidity, pancreas fistula (PF), and delayed gastric emptying (DGE) than group A. High-volume surgeons (HVS) had lower operative blood loss (300 mL vs 600 mL), transfusion requirements, PF (14% vs 20%), DGE, surgical site infections, reoperations, and major morbidity rate (15.5 vs 39%) than low-volume surgeons. ConclusionsThis study demonstrates improved patient outcomes and hospital resource utilization over the past 20 years. Concentration of PS to HVS results in superior results.

Efficacy of laparoscopic subtotal gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer: the protocol of the KLASS-02 multicenter randomized controlled clinical trial.

BackgroundDespite the well-described benefits of laparoscopic surgery such as lower operative blood loss and enhanced postoperative recovery in gastric cancer surgery, the application of laparoscopic surgery in patients with locally advanced gastric cancer (AGC) remains elusive owing to a lack of clinical evidence. Recently, the Korean Laparoscopic Surgical Society Group launched a new multicenter randomized clinical trial (RCT) to compare laparoscopic and open D2 lymphadenectomy for patients with locally AGC. Here, we introduce the protocol of this clinical trial.Methods/designThis trial is an investigator-initiated, randomized, controlled, parallel group, non-inferiority trial. Gastric cancer patients diagnosed with primary tumors that have invaded into the muscle propria and not into an adjacent organ (cT2–cT4a) in preoperative studies are recruited. Another criterion for recruitment is no lymph node metastasis or limited perigastric lymph node (including lymph nodes around the left gastric artery) metastasis. A total 1,050 patients in both groups are required to statistically show non-inferiority of the laparoscopic approach with respect to the primary end-point, relapse-free survival of 3 years. Secondary outcomes include postoperative morbidity and mortality, postoperative recovery, quality of life, and overall survival. Surgeons who are validated through peer-review of their surgery videos can participate in this clinical trial.DiscussionThis clinical trial was designed to maintain the principles of a surgical clinical trial with internal validity for participating surgeons. Through the KLASS-02 RCT, we hope to show the efficacy of laparoscopic D2 lymphadenectomy in AGC patients compared with the open procedure.Trial registrationClinicalTrial.gov, NCT01456598.

Utilization and timing of blood transfusions following open and robot-assisted radical prostatectomy.

Radical prostatectomy (RP) is associated with a high risk of intraoperative blood loss and subsequent blood transfusions. The shift in surgical technique from open radical prostatectomy (ORP) to robot-assisted radical prostatectomy (RARP) has resulted in lower operative blood loss, and reduced the need for transfusions. We analyzed the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database to compare real-world, contemporary trends in utilization and timing of blood transfusion following ORP and RARP. We identified men undergoing both RARP and ORP and then queried for patients who received a blood transfusion in the perioperative period. The outcomes of interest were need and timing of perioperative blood transfusion (PBT), which was categorized into early (postoperative day [POD] ≤1) or late (POD ≥2). Logistic regression analysis was used to identify variables associated with the need and timing for PBT. A total of 16,144 men who underwent RP were identified from 2007 to 2012. The overall PBT rate was 3.1%. Highest rate of transfusions occurred on day of surgery for patients undergoing ORP, and first POD for patients undergoing RARP. On multivariate analysis significant predictors of blood transfusion included history of bleeding disorder (OR: 2.8, p=0.002), preoperative dyspnea (odds ratio [OR]: 1.7, p=0.03), starting hematocrit <42% (OR: 1.9, p<0.001), open approach (OR: 0.09, p<0.001), year of surgery (OR: 0.5, p<0.001), resident involvement (OR: 1.6, p=0.003), and operative time (OR: 4.4, p<0.001). The only predictor of receiving a blood transfusion on POD 2 or later was having the procedure performed through a robot-assisted approach (OR: 3.7, p<0.001). In this study we found that the rate of perioperative transfusions is lower than previously published. A clear separation in timing of transfusion exists based on the utilized surgical approach. It is prudent that surgeons performing RARP be aware of the low, but present risk of a delayed blood transfusion.

Laparoscopic versus open distal pancreatectomy: a single-institution case-control study

Laparoscopic distal pancreatic surgery has gained popularity in the last decade. However, well-designed studies comparing laparoscopic distal pancreatectomy (LDP) to open distal pancreatectomy (ODP) are limited. We present a single-institution case-control study comparing outcomes of LDP to ODP. From a prospectively accruing database, 104 patients who underwent distal pancreatectomy for pancreatic pathologies were eligible. Of these, 30 LDPs were matched with 30 ODPs using a 1:1 case-match design. Matching criteria were final histopathologic diagnosis and lesion size. Twelve LDPs were excluded from analysis because of lack of adequate ODP controls. In all cases, an attempt was made at conservation of the spleen. There were more females in the LDP group (p = 0.001). Other clinicopathologic characteristics of the LDP and ODP groups such mean age (52.4 ± 17.2 vs. 59 ± 12.8, p = 0.104), prior history of upper abdominal surgery (6.7% vs. 20.0%, p = 0.254) or pancreatitis (13.3% vs. 10.0%, p = 1.000), histopathologic diagnosis (p = 1.000), lesion size on imaging (3.7 ± 2.7 vs. 4.4 ± 2.4 cm, p = 0.170), and histopathology (3.8 ± 2.3 vs. 4.3 ± 2.3, p = 0.386) were comparable. There were no significant differences in postoperative complication rates (50.0% vs. 43.3%, p = 0.604), major complication rates (20% vs. 20%, p = 0.829), grade B/C pancreatic fistula rates (16.7% vs. 13.3%, p = 0.717), or reoperation rates (3.3% vs. 6.7%, p = 1.000) between LDP and ODP groups, respectively. There was a significantly higher rate of splenic conservation in the LDP group (70% vs. 30%, p = 0.002). The intraoperative blood loss (294 ± 245 vs. 726 ± 709 ml, p < 0.001) and mean duration of hospitalization (8.7 ± 4.2 vs. 12.6 ± 8.7 days, p = 0.009) were significantly lower in the LDP group compared to the ODP group. LDP is a safe and feasible option for distal pancreatic resections in experienced centers. The postoperative complication rate is comparable to that of ODP. LDP is associated with lower operative blood loss, higher rate of splenic conservation, and shorter duration of hospitalization. These encouraging results demand further validation in prospective randomized trials.

Ileovesicostomy for the Neurogenic Bladder Patient: Outcome and Cost Comparison of Open and Robotic Assisted Techniques

To compare the outcomes and cost of open and robotic-assisted ileovesicostomy techniques for the adult neurogenic bladder patient. Consecutive open and robotic-assisted ileovesicostomy procedures were retrospectively reviewed for demographic, operative, and postoperative recovery data. Surgical outcome was assessed by examining the incidence of postprocedure urinary incontinence, urinary tract infections (UTIs), and upper tract compromise. Total cost was calculated through summation of inpatient costs, including room/board, operating/recovery room, surgical supplies, professional fees, intensive care unit, and robotic maintenance. Fifteen ileovesicostomy procedures (7 open, 8 robotic) were reviewed. Both groups had similar demographic and urodynamic data. Operative times (293 min open vs 330 min robotic, P = .24) were similar between techniques. There were trends toward lower operative blood loss (100 mL vs 257 mL, P = .09) and shorter hospital stays in the robotic group (8 days vs 11 days, P = .14). Ileovesicostomy was associated with improved urinary continence (P = .02) and trended toward a decreased incidence of postoperative chronic UTI (P = .13) for the entire group, and there was no difference between techniques regarding continence, chronic UTIs, and complications. No patients in either group developed postoperative hydronephrosis. Total inpatient cost for the open and robotic groups was $14,356 and $17,344 (P = .05), which differed primarily because of higher robotic operating room supply costs ($609 vs $3770, P <.001). Robotic and open ileovesicostomy had similar surgical outcomes in this patient cohort, although total inpatient costs were significantly higher in the robotic group.

Laparoscopic vs Open Hepatic Resection for Benign and Malignant Tumors

To compare laparoscopic hepatic resection (LHR) with open hepatic resection (OHR) for benign and malignant tumors. MEDLINE, CENTRAL, and EMBASE databases were searched for relevant studies published between January 1, 1998, and May 1, 2009. Studies clearly documenting a comparison of LHR with OHR for benign and malignant neoplasms were selected. Operative and postoperative measures, resection margins, complications, and survival outcomes were evaluated. Weighted mean differences, relative risks, and hazard ratios (HRs) were calculated using a random-effects model. Twenty-six studies were included in the meta-analysis. The HR of death for malignant tumors was significantly lower in the LHR group compared with the OHR group (HR, 0.64; P = .04). The HR of recurrence for malignant tumors was not significantly different between the 2 groups (HR, 0.79; P = .37). The LHR group had a lower operative blood loss (weighted mean difference, -161 mL; P < .001) and relative risk of total postoperative complications (relative risk, 0.40; P < .001). Duration of hospital stay, days of intravenous narcotic use, and days until oral intake were all significantly lower in the LHR group compared with the OHR group. Operative time between LHR and OHR was not significantly different. Laparoscopic hepatic resection for malignant tumors is associated with a long-term survival that is at least comparable, if not superior, to OHR with no difference in disease recurrence. The use of LHR for benign and malignant tumors is a safe alternative to OHR with potential operative and postoperative benefits.

Video-assisted thoracoscopic surgery or transsternal thymectomy in the treatment of myasthenia gravis?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was how video-assisted thoracoscopic surgery (VATS) compares to median sternotomy in the surgical management of patients with myasthenia gravis (MG)? Overall 74 papers were found using the reported search, of which 15 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We conclude that VATS produces equivalent postoperative mortality and complete stable remission (CSR) rates, with superior results in terms of hospital stay, operative blood loss and patient satisfaction at the expense of a doubling of operative time. Six studies comparing VATS and transsternal sternotomy in non-thymomatous myasthenia gravis (NTMG) patients found VATS to have lower operative blood loss (73.8±70.7 vs. 155.3±91.7 ml; P<0.05), reduced total hospital stay (5.6±2.2 vs. 8.1±3.0 days; P=0.008), whilst maintaining equivalent remission rates (33 vs. 44.7%; P=0.16) and mass of thymic tissue resection (37 vs. 34 g; P>0.05). One study comparing video-assisted thoracoscopic extended thymectomy to transsternal thymectomy in only thymoma-associated myasthenia gravis (T-MG) patients found equivalent CSR (11.3 vs. 8.7%, P=0.1090) at six-year follow-up. Thymoma recurrence rate (9.64%) was not significantly different (P=0.1523) between the two groups. Eight studies comparing VATS and transsternal approach in mixed T-MG and NTMG patients found a lower hospital stay (1.9±2.6 vs. 4.6±4.2 days, P<0.001), reduced need for postoperative medication (76.5 vs. 35.7%, P=0.022), lower intensive care unit stay (1.5 vs. 3.2 days, P=0.018), greater symptom improvement (100 vs. 77.9%, P=0.019) and better cosmetic satisfaction (100 vs. 83, P=0.042) with VATS. In concordance with NTMG and T-MG alone patient groups, VATS and transsternal methods had equivalent complication rates (23 vs. 19%, P=0.765) with no mortalities in either group. Even though VATS has a longer operative time (268±51 vs. 177±92 min, P<0.05), its improved cosmesis, reduced need for postoperative medication and equivalent disease resolution outcomes make it a preferable surgical option to the transsternal approach.

Comparative study between V-Y pushback technique and Furlow technique in cleft soft palate repair

Many methods of cleft palate repair have been described. Two effective methods are commonly used for repair of soft palate clefts: the Wardill-Kilner V-Y push back and the Furlow double opposing Z-plasty; each has advantages and disadvantages. The aim of this study was to compare between the V-Y push back technique and the Furlow Z-plasty technique regarding effectiveness in palatal reconstruction and improvement of velopharyngeal closure in cases of cleft soft palate. Also, operative duration time and blood loss were considered. This study was conducted on 60 patients diagnosed to have cleft soft palate. The patients were randomly classified into two equal groups A and B. In group A, the cleft palate was repaired using V-Y push back technique while in group B the cleft palate was repaired using Furlow double opposing Z-plasty technique. Flexible nasopharyngoscopy and perceptual speech resonance evaluation were used to assess the velopharyngeal closure and speech outcome, respectively. Nasalance score was measured for nasal and oral sentences in both groups. The average operative duration time and blood loss were lesser in Z-plasty than in V-Y pushback technique. Two of the cases subjected to V-Y pushback technique developed fistula while none of the cases subjected to Z-plasty showed this complication. Velopharyngeal closure and speech outcome was better after Z-plasty than after V-Y pushback technique with significant nasometric data. The Furlow Z-plasty is better than the V-Y pushback technique in the repair of clefts involving the soft palate as it has a higher success rate regarding speech outcome and velopharyngeal closure; also, it has a lower operative time and blood loss.

Evaluation of intrahepatic, extra-Glissonian stapling of the right porta hepatis vs. classical extrahepatic dissection during right hepatectomy

BackgroundControl of hepatic inflow is a key manoeuvre during right hepatectomy and has traditionally been achieved by extrahepatic dissection of the component right portal inflow structures at the hepatic hilum. An alternative technique is the anterior intrahepatic approach (AIA), in which the Glissonian sheath is isolated within the substance of the liver during parenchymal transection and secured using an endovascular stapling device. This study evaluates the intrahepatic, extra-Glissonian technique in comparison with classical extrahepatic dissection (EHD) in right hepatectomy. MethodsA retrospective case-controlled study referring to a 20-year period identified 342 consecutive patients who underwent right hepatectomy for colorectal liver metastases from a prospectively compiled database. The AIA to right hepatectomy was used in 182 of these patients and the extrahepatic approach in 160. The two groups were matched for age, gender, stage of primary tumour and number and size of metastases. Outcome measures included safety factors (bleeding, bile duct injury and gun failure), operative duration, oncological margin, morbidity and mortality. ResultsThere were no significant differences between the two groups in terms of operative duration (240min vs. 260min) or postoperative change in haemoglobin (1.3g/dl vs. 1.4g/dl). The AIA was associated with lower operative blood loss (355ml vs. 425ml; P≤ 0.001), a reduced rate of significant morbidity (14.6% vs. 23.1%; P= 0.005), better R0 resection rates (93% vs. 89%; P= 0.014) and a lower 90-day mortality rate (3% vs. 7%; P= 0.046). There was one minor bile leak in each group, two clinically significant bile leaks requiring endoscopic retrograde cholangiopancreatography and stenting in the extrahepatic group, and a further persistent bile leak requiring biliary reconstruction in each group. In two instances the endovascular stapler misfired. Both cases were dealt with at the time of surgery with no further sequelae. The length of hospital stay was equivalent in the two groups (8 days vs. 9 days). ConclusionsIn selected patients, intrahepatic, extra-Glissonian stapled right hepatectomy is feasible, safe and avoids the need for EHD. The anterior approach to right hepatectomy may achieve outcomes at least as good as those associated with the classical extrahepatic approach.

Perioperative outcomes of laparoscopic transhiatal inversion esophagectomy compare favorably with those of combined thoracoscopic–laparoscopic esophagectomy

Wide acceptance of laparoscopic esophagectomy has been hampered by the technical difficulty of the procedure and inconsistent improvements in morbidity and mortality. Most case series have utilized a combined thoracoscopic-laparoscopic approach (TLE), but laparoscopic inversion esophagectomy (LIE), a method of transhiatal esophagectomy, has been proposed as an alternative. Inversion esophagectomy simplifies retraction and improves exposure during the mediastinal dissection; however, no previous studies have directly compared LIE outcomes with those of the combined approach. Between July 2003 and March 2008, 70 consecutive patients underwent minimally invasive esophagectomy by LIE (N = 40) or TLE (N = 30). Data for all patients were collected prospectively and stored in a relational database. Recorded outcome measures included operative time, blood loss, length of hospital stay, intensive care unit stay, and perioperative complications. There were no significant differences in patient age, gender, body mass index (BMI), or American Society of Anesthesiologists (ASA) class between the groups, but LIE patients had lower stage of esophageal cancer, and were less likely to have received induction chemoradiotherapy than TLE patients. Patients undergoing LIE had significantly lower operative time (398 vs. 537 min, p < 0.001), intraoperative blood loss (100 vs. 200 ml, p < 0.001), and overall length of stay (9 vs. 14 days, p = 0.003) compared with TLE patients. LIE yielded a median of 10 lymph nodes removed compared with 13 for TLE (p = 0.016). Atrial arrhythmia and postoperative pneumonia were less common in LIE patients than in TLE patients, occurring in 17.5% vs. 27.1% (p = 0.036), and in 7.5% vs. 15.7% of cases (p = 0.029), respectively. LIE provides safe and effective approach to minimally invasive esophagectomy for patients with early esophageal cancer and high-grade dysplasia. Compared with TLE, inversion esophagectomy requires less operative time and has lower operative blood loss and length of hospital stay. LIE may also result in fewer perioperative cardiac and pulmonary complications compared with TLE. Based on these results, we reserve TLE for more advanced esophageal cancer and those undergoing preoperative radiochemotherapy.

Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures in the elderly

A total of 455 patients aged over 70 years with a displaced intracapsular fracture of the proximal femur was randomised to be treated either by hemiarthroplasty or internal fixation. The preoperative characteristics of the patients in both groups were similar. Internal fixation has a shorter length of anaesthesia (36 minutes versus 57 minutes, p &lt; 0.0001), lower operative blood loss (28 ml versus 177 ml, p &lt; 0.0001) and lower transfusion requirements (0.04 units versus 0.39 units, p &lt; 0.0001). In the internal fixation group 90 patients required 111 additional surgical procedures while only 15 additional operations on the hip were needed in 12 patients in the arthroplasty group. There was no statistically significant difference in mortality between the groups at one year (61/226 versus 63/229, p = 0.91), but there was a tendency for an improved survival in the older less mobile patients treated by internal fixation. For the survivors assessed at one, two and three years from injury there were no differences with regard to the outcome for pain and mobility. Limb shortening was more common after internal fixation (7.0 mm versus 3.6 mm, p = 0.004). We recommend that displaced intracapsular fractures in the elderly should generally be treated by arthroplasty but that internal fixation may be appropriate for those who are very frail.

Endoluminal versus open treatment of descending thoracic aortic aneurysms

This report describes the authors' initial experience with the Excluder thoracic endoprosthesis (W. L. Gore and Associates, Inc, Flagstaff, Ariz) and the thoracic Talent endoprosthesis (Medtronic AVE, Sunrise, Fla) and their safety and efficacy in the primary endovascular repair of descending thoracic aortic aneurysms (TAAs). In addition, comparison with a historic nonrandomized cohort of patients that had undergone open repair of descending TAAs is reported. Repair of TAA (mean diameter, 68 +/- 22 mm) was attempted in 19 patients with the Excluder (n = 14) and the Talent (n = 5) endoprostheses between March 1999 and January 2000. This group was compared with a historic nonrandomized cohort of 10 patients that had undergone open repair of anatomically similar descending TAA (mean diameter, 74 +/- 22 mm) between January 1996 and January 1998. The mean age in the endovascular group was 70.6 +/- 5.3 years versus 70.1 +/- 4.5 years in the historic open group. All the procedures were performed in a standard operating room with angiographic capabilities. In the historic open group, each standard tube graft repair of descending TAA was performed by one of three staff surgeons. Endograft deployment was successful in 18 patients (95%). The procedure was aborted in one patient (Excluder) because of small iliac arteries and access difficulty. The average operative time was 155 +/- 62 minutes, with a mean blood loss of 325 +/- 353 mL (versus 256 +/- 102 minutes and 1205 +/- 1493 mL, respectively, in the open group). Eight patients needed the planned use of more than one component for enhanced sealing or additional length in the endovascular group. No type I endoleaks were identified on the intraoperative completion angiography. One perioperative mortality occurred in the endovascular group and the open group. In the endovascular group, other complications included retroperitoneal hematoma and external iliac artery dissection (n = 1), lymphocele (n = 1), and common femoral artery pseudoaneurysm (n = 1). In the open group, other complications included ischemic colitis (n = 1), severe renal insufficiency (n = 2), wound infection (n = 1), and stroke (n = 1). In the endovascular group, the length of stay was 6.2 +/- 3.3 days (range, 1 to 13 days), with only nine patients needing intensive care, whereas in the open group, the length of stay was 16.3 +/- 6.7 days, with all patients needing intensive care. Endoleaks, graft migrations, or ruptures were not seen on the 1-month, 6-month, and 12-month follow-up computed tomographic scans in the endovascular group. On the average, aneurysm size decreased from 68 +/- 22 mm to 58 +/- 13 mm, to 51 +/- 14 mm, and to 49 +/- 12 mm at 1, 6, and 12 months after endovascular repair, respectively. No spinal cord ischemia was seen in either group. The endoluminal repair was effective in exclusion of descending TAAs from the systemic circulation in this selected group of patients. In this short-term follow-up, compared with the nonrandomized historic cohort of open descending TAA repair, the endovascular group had significantly shorter operating times and hospital and intensive care unit stays and lower operative blood loss. Further follow-up and continued assessment of the long-term durability of these devices in elective and emergency circumstances are warranted.