Negative Diagnostic Laparoscopy Research Articles

Safety of preventive HIPEC in combination with perioperative FLOT versus FLOT alone for resectable diffuse type gastric and gastroesophageal junction type II/III adenocarcinoma: An interim safety analysis from the phase III PREVENT trial of the AIO/CAOGI/ACO.

359 Background: Peritoneal relapse is seen in 60-70% of patients with diffuse type gastric cancer (gc), compared to 20-30% with intestinal type according to Laurens`s classification. Hyperthermic intraperitoneal chemoperfusion (HIPEC) is an increasingly used therapy method for patients (pts) with peritoneal metastases. The preventive use of HIPEC could represent an approach for diffuse type cell gc pts before macroscopic peritoneal seeding has evolved, since pts with operable disease are fit and may have potential risk of microscopic involvement, thus having a theoretical chance of cure with HIPEC even without the need for cytoreduction. Methods: This is a multicenter, randomized, controlled, open-label phase III study including a total of 200 pts with localized and locally advanced diffuse type cell adenocarcinoma of the stomach and type II/III gastroesophageal junction (i.e. ≥cT3 any N or any T N positive). A negative diagnostic laparoscopy before treatment and 3-6 pre-operative cycles of FLOT are a prerequisite for enrollment (Docetaxel 50 mg/m2; Oxaliplatin 85 mg/m2; Leucovorin 200 mg/m2; 5-FU 2600 mg/m2, q2wk). Pts were randomized 1:1 to receive surgery only and postoperative FLOT (Arm A-control arm) or surgery + intraoperative HIPEC (cisplatin 75mg/m2 solution at 42°C for 90 min) and postoperative FLOT (Arm B-experimental arm). Surgery is carried out as subtotal, total gastrectomy or transhiatal extended gastrectomy. The scope of the trial is to evaluate the efficacy as well as the safety and tolerability of the combination of perioperative chemotherapy combined with an intraoperative prophylactic HIPEC. Here, we show safety results from the pre-specified safety analysis after 20 pts had undergone surgical resection plus HIPEC and the corresponding 20 pts in the control arm. Results: Treatment arms were balanced regarding age, ECOG and tumor parameters like localization of the primary, of lymph nodes or cTN stage. Most pts in both arms received a subtotal or total gastrectomy. In 15 out of 20 arm B pts the HIPEC was 6 pts (30%) in Arm A and 7 pts (35%) in Arm B were seen with at least one SAE. Perioperative complications resulted in overall 7 SAEs in Arm A and in 4 SAEs in Arm B. One postoperative mortality (grade 5) was documented in Arm B due to septic complication. 11 pts showed no complications in both arms according to Clavien-Dindo-Classification. 6 pts in Arm A and 2 in Arm B showed grade 3. No patient was grade 4. Conclusions: The incidence of perioperative morbidity with surgical and/or medical complications were nearly equal in both treatment groups. The safety data showed no abnormalities or evidence increase in toxicity-rates including postoperative complications or increased severity of documented events within the experimental HIPEC arm. Clinical trial information: NCT04447352 .

The Utility of Video Recording in Assessing Bariatric Surgery Complications.

Introduction: Recording every procedure could diminish the postoperative complication rates in bariatric surgery. The aim of our study was to evaluate the correlation between recording every bariatric surgery and their postoperative analysis in relation to the early or late postoperative complications. Methods: Seven hundred fifteen patients who underwent a bariatric procedure between January 2018 and December 2019 were included in a retrospective analysis. There were: 589 laparoscopic sleeve gastrectomies (LSGs); 110 Roux-en-Y bypasses (RYGBs) and 16 gastric bands (LAGBs). The video recording was systematically used, and all patients were enrolled in the IFSO registry. Results: There were 15 patients (2.1%) with surgical postoperative complications: 5 leaks, 8 hemorrhages and 2 stenosis. Most complications were consequent to LSG, except for two, which occurred after RYGB. In four cases a site of active bleeding was identified. After reviewing the video, in three cases the site was correlated with an event which occurred during the initial procedure. Three out of five cases of leak following sleeve were treated purely endoscopically, and no potential correlated mechanism was identified. Two other possible benefits were observed: a better evaluation of the gastric pouch for the treatment of the ulcer post bypass and the review of one per operative incident. Two negative diagnostic laparoscopies were performed. The benefit of the systematic video recording was singled out in eight cases. All the other cases were completed by laparoscopy with no conversion. Conclusion: To record every bariatric procedure could help in understanding the mechanism of certain complications, especially when the analysis is performed within the team. Still, recording the procedure did not prevent the negative diagnostic laparoscopy, but it could play a significant role for the medico-legal aspect in the future.

Diagnostic laparoscopy is underutilized in the staging of gastric adenocarcinoma regardless of hospital type: An US safety net collaborative analysis.

Diagnostic laparoscopy (DL) is a key component of staging for locally advanced gastric adenocarcinoma (GA). We hypothesized that utilization of DL varied between safety net (SNH) and affiliated tertiary referral centers (TRCs). Patients diagnosed with primary GA eligible for DL were identified from the US Safety Net Collaborative database (2012-2014). Clinicopathologic factors were analyzed for association with use of DL and findings on DL. Overall survival (OS) was analyzed by Kaplan-Meier method. Among 233 eligible patients, 69 (30%) received DL, of which 24 (35%) were positive for metastatic disease. Forty percent of eligible SNH patients underwent DL compared to 21.5% at TRCs. Lack of insurance was significantly associated with decreased use of DL (OR 0.48,p < 0.01), while African American (OR 6.87,p = 0.02) and Asian race (OR 3.12,p ≤ 0.01), signet ring cells on biopsy (OR 3.14,p < 0.01), and distal tumors (OR 1.62,p < 0.01) were associated with increased use. Median OS of patients with a negative DL was better than those without DL or a positive DL (not reached vs. 32 vs. 12 months, p < 0.005, Figure 1). Results from DL are a strong predictor of OS in GA; however, the procedure is underutilized. Patients from racial minority groups were more likely to undergo DL, which likely accounts for higher DL rates amongSNH patients.

Clostridium difficile infection secondary to ileostomy closure

Protective ileostomy may be a risk factor for the development of Clostridium difficile (CD) infection (CDI). In the postoperative period signs of CDI may be particularly difficult to differentiate from intra-abdominal sepsis. Presented here are 2 cases that developed CDI after ileostomy reversal. Two patients who underwent low anterior resections after neoadjuvant chemoradiation with protective ileostomy developed fever, leukocytosis and elevated serum C-reactive protein (CRP) levels. The first patient also had negative CD stool toxins and his signs were so severe that he underwent a negative diagnostic laparoscopy and re-creation of ileostomy. The second patient who presented in a similar fashion was more fortunate in that her CD stool toxin was positive and she was treated successfully with oral vancomycin. CDI after ileostomy reversal after low anterior resection can be difficult to diagnose. In the first patient, the situation was so misleading that diagnostic laparoscopy was required. Outcome was eventually favorable in both cases. CDI must be high on the list of differential diagnoses for febrile patients with a leukocytosis and elevated CRP level even in the setting of negative CD stool toxins. Prophylactic intravenous metronidazole and/or vancomycin enemas should be considered prior to colorectal surgery when a protective ileostomy is likely.

THE COMPARATIVE ANALYSIS OF ALVARADO AND PAS SCALES IN THE DIFFERENTIAL DIAGNOSTICS OF ACUTE ABDOMINAL PAIN IN CHILDREN

Introduction. Current trends in the diagnostics of acute appendicitis have the following main objectives: to improve the diagnostic accuracy in destructive forms; to reduce the number of negative appendectomies and diagnostic laparoscopies. Purpose. To compare the effectiveness of Alvarado and PAS scales and to find out which of them is more appropriate in the differential diagnostics of acute abdominal pain in children. Material and Methods. A prospective randomized blind clinical trial was performed. 326 children aged 5-17 years with abdominal pain were examined. Results. No significant advantages of any of the analyzed scales were found in the differential diagnostics of acute abdominal pain in children aged 5-17 years. Both scales can be used in the primary stratification of patients. With the conclusion “Acute appendicitis is likely possible,” the level of non-diagnosed cases of acute appendicitis will not exceed 3%. Conclusions. Further assessment of various scales for the diagnostics of acute appendicitis in children has to be done in order to select the optimal one. The obtained results urge to make scales’ modification so as to improve the diagnostic accuracy and to reduce the number of negative appendectomies and diagnostic laparoscopies.

Readmission and reoperation rates following negative diagnostic laparoscopy for clinically suspected appendicitis: The “normal” appendix should not be removed – A retrospective cohort study

BackgroundIn cases with clinically suspected appendicitis, there is controversy regarding the decision to remove a macroscopically normal appearing appendix during laparoscopy when no other intra-abdominal pathology is found. The aim of this study was to examine the rate of appendicitis, along with readmission and reoperation rates following diagnostic laparoscopy of clinically suspected appendicitis in patients where the appendix was not removed. MethodsWe performed a retrospective cohort analysis of patients who underwent a diagnostic laparoscopy due to clinical suspicion of appendicitis where no other pathology was found and the appendix was not removed. The study period was from 2008 to 2013 and involved patients from two university hospitals in the Copenhagen area. ResultsOf the 271 patients included (81.6% women, median age 27), 56 (20.7%) were readmitted with right iliac fossa pain after a median time of 10 months (range 1–84). Twenty-two patients (8.1%) underwent a new laparoscopic procedure. Appendix was removed in 18 patients, of which only one showed histological signs of inflammation. The median follow-up time was 5.6 years (range 1–109 months). ConclusionThere was a low rate of appendicitis after a previous negative diagnostic laparoscopy. Therefore, based on results from the current study, we do not consider that it is necessary to remove a macroscopic normal appendix during laparoscopy for clinically suspected appendicitis. The high readmission rate warrants the need for further investigation or follow-up.

Variation in the use of laparoscopy with inguinal hernia repairs in a sample of pediatric patients at children's hospitals

Metachronous contralateral inguinal hernias (MCH) occur in approximately 10% of pediatric patients following unilateral inguinal hernia repairs (UIHR). Laparoscopic evaluation of the contralateral internal ring is a method of identifying high-risk individuals for prophylactic contralateral exploration and repair. The objective of this study was to assess variation in utilization of diagnostic laparoscopy, and report costs associated with the evaluation of a contralateral patent processus vaginalis during hernia repair in pediatric hospitals. The Pediatric Health Information System database was searched to identify outpatient surgical encounters for pediatric patients with a diagnosis of inguinal hernia during a 1-year period (2014). Records were identified that contained diagnostic codes for unilateral or bilateral inguinal hernia in combination with a procedure code for open hernia repair with or without diagnostic laparoscopy. After exclusions there were 3952 hernia repairs performed at 30 hospitals; median age was 4 years (IQR 1-7), 78.8% were male, and 64.9% Caucasian. Three-quarters (76.7%) had UIHR, 8.6% had unilateral repairs with laparoscopy (UIHRL), 12.2% had bilateral inguinal hernia repairs (BIHR), and 2.4% had bilateral repairs with laparoscopy (BIHRL). Where laparoscopy was used, 78% resulted in a unilateral repair and 22% in a bilateral procedure. The percent of patients undergoing laparoscopy varied from 0 to 57% among hospitals, and 0-100% among surgeons. Pediatric surgeons were more than three times more likely to perform a diagnostic laparoscopy compared with pediatric urologists. Median adjusted costs were $2298 (IQR 1659-2955) for UIHR, $2713 (IQR 1873-3409) for UIHRL, $2752 (IQR 2230-3411) for BIHR, and $2783 (IQR 2233-3453) for BIHRL. Median costs varied over two-fold among hospitals ($1310-4434), and over four-fold among surgeons ($948-5040). Data suggested that <10% of patients with clinically unilateral inguinal hernias developed MCH. A negative diagnostic laparoscopy ensured that 0.9-1.31% developed MCH. However, up to 30% of patients underwent contralateral exploration/repair when diagnostic laparoscopy was used. The current study found increased costs associated with the use of laparoscopy, with considerable variation in costs among surgeons and hospitals. These data elucidate competing financial and clinical consequences associated with the use of diagnostic laparoscopy with clinically unilateral hernias. Variation existed in the use of laparoscopy during inguinal hernia repairs and associated costs within the current sample from children's hospitals in the United States. The additional costs of laparoscopic evaluation must be considered against the clinical utility and therapeutic consequences of identifying individuals with a higher risk of metachronous contralateral inguinal hernia.

Minimally Invasive Surgery in Pediatric Trauma: One Institution's 20-Year Experience.

Background:Minimally invasive surgery (MIS) for trauma in pediatric cases remains controversial. Recent studies have shown the validity of using minimally invasive techniques to decrease the rate of negative and nontherapeutic laparotomy and thoracotomy. The purpose of this study was to evaluate the diagnostic accuracy and therapeutic options of MIS in pediatric trauma at a level I pediatric trauma center.Methods:We reviewed cases of patients aged 15 years and younger who had undergone laparoscopy or thoracoscopy for trauma in our institution over the past 20 years. Each case was evaluated for mechanism of injury, computed tomographic (CT) scan findings, operative management, and patient outcomes.Results:There were 23 patients in the study (16 boys and 7 girls). Twenty-one had undergone diagnostic laparoscopy and 2 had had diagnostic thoracoscopy. In 16, there were positive findings in diagnostic laparoscopy. Laparoscopic therapeutic interventions were performed in 6 patients; the remaining 10 required conversion to laparotomy. Both patients who underwent diagnostic thoracoscopy had positive findings. One had a thoracoscopic repair, and the other underwent conversion to thoracotomy. There were 5 negative diagnostic laparoscopies. There was no mortality among the 23 patients.Conclusions:The use of laparoscopy and thoracoscopy in pediatric trauma helps to reduce unnecessary laparotomy and thoracotomy. Some injuries can be repaired by a minimally invasive approach. When conversion is necessary, the use of these techniques can guide the placement and size of surgical incisions. The goal is to shift the paradigm in favor of using MIS in the treatment of pediatric trauma as the first-choice modality in stable patients.

Utility of Preoperative Upper Gastrointestinal Series in Laparoscopic Gastrostomy Tube Placement.

An upper gastrointestinal (UGI) series is a standard preoperative test for patients being evaluated for gastrostomy tube placement. We have recently begun to question the value of the radiation-exposing series in patients who tolerate gastric feeds. A retrospective review was conducted in patients who underwent laparoscopic gastrostomy tube placement between 2000 and 2012. Demographics, indication for gastrostomy tube, comorbidities, preoperative imaging, and nutrition were analyzed. Patients with foregut pathology and those who underwent prior gastrointestinal surgery were excluded. Among 695 patients who underwent laparoscopic gastrostomy tube placement, the most common indications were failure to thrive (53%), neurologic disorder (25%), and dysphagia (12%). A UGI series was obtained for 420 patients (60%). Of these, 96 were found to have abnormalities (reflux, aspiration, anatomic). However, only 2 of these patients (0.3%) had a change in management, with 1 patient undergoing the Ladd procedure and 1 having negative diagnostic laparoscopy for suspected malrotation. In the subset analysis of 256 patients tolerating goal gastric feeds, 161 (63%) had a preoperative UGI series with only 2 patients (1.2%) having a resultant change in operative management: 1 undergoing the Ladd procedure and 1 having negative diagnostic laparoscopy. Of the 275 patients who did not have a preoperative UGI series, 1 patient (0.4%) was found to have malrotation postoperatively after two coins became lodged in the duodenum. This patient subsequently underwent an elective Ladd procedure. We found minimal impact of an UGI series during evaluation for gastrostomy alone. These studies may be able to be reserved for those with clear clinical indications.

Algorithmic approach to utilization of CT scans for detection of internal hernia in the gastric bypass patient

BackgroundWhile surgical exploration remains the gold standard for diagnosing internal hernia (IH) after certain bariatric surgeries, decisions for operative intervention are often based on computed tomography (CT) findings. ObjectivesThe aim of this study is to review our institutional experience and create an algorithm to approach patients presenting with abdominal pain and/or emesis after certain bariatric procedures. SettingsUniversity Hospital MethodsFollowing institutional review board approval, a retrospective chart review of all patients presenting with obstruction symptoms after laparoscopic Roux-en-Y gastric bypass (LRYGB) was performed at 2 institutions from 2008 to 2013. Patients without CT scans or with incidental hernia defect findings were excluded. CT and intraoperative findings were compared via univariate statistical analysis. ResultsFifty-two patients who underwent an operation for a suspected IH were identified. Of the 50 patients, 25 (50%) had IH at operation. Twenty-nine patients (58%) had positive CT scans read for IH and/or obstruction. Of these 29, 19 (66%) were found to have IH at operation and 10 (34%) underwent negative diagnostic laparoscopy. Of the 21 patients with negative CT scans, 6 (29%) had IH at operation versus 15 (71%) who were negative. The sensitivity of CT scan to detect an internal hernia is 76% with 95% confidence interval (CI) [53% to 90%] and specificity is 60% with 95% CI [39% to 78%]. Sensitivity increased to 96% with 95% CI [78% to 99.8%] when combining CT scans with neutrophilia findings. ConclusionPositive CT scans are sensitive for IH but not specific. CT scans will not detect IH in 1:4 patients; despite negative findings, surgical exploration should remain the gold standard for patients with acute abdominal pain after LRYGB or biliopancreatic diversion when IH is a consideration.

Mo1635 CT Scan Is Helpful for Internal Hernia Detection Following Weight Loss Surgery

Introduction: Radiographic imagingwith CT scan in patients presentingwith acute abdominal pain following Roux-en-Y gastric bypass (RYGB) or biliopancreatic diversion with duodenal switch (BPD/DS) is becoming commonplace. While surgical exploration remains the gold standard for diagnosing internal hernia, decisions for operative intervention are often based on CT findings. The accuracy of CT scan to reliably identify internal hernia in this subset of patients remains unknown. The purpose of this study is to evaluate the reliability of CT scan as a diagnostic tool to identify internal hernia (IH) in bariatric patients with acute abdominal pain. Methods: Following institutional review board approval, a retrospective chart review of all patients presenting with symptoms concerning for obstruction following Roux-en-Y gastric bypass or BPD/DS switch was performed. Patients without CT scans were excluded. Fifty two patients who underwent an operation for a suspected internal hernia from 2008-2013 were identified from surgeons' records at 2 institutions. CT and intraoperative findings were compared via univariate statistical analysis. Patients with incidental finding of a hernia defect were excluded. Results: Of the 52 patients, 50 had previous RYGB and 2 BPD/DS. There was a higher number of female patients in this population (Table 1). Mean time to presentation was 5 years following initial bariatric procedure (5 months to 14 years). Of the 52 patients, 27 had IH at operation. Thirty one (60%) patients had CT scans read as positive for IH and/or obstruction. Of these 31, 21(68%) were found to have IH at operation and 10 (32%) underwent negative diagnostic laparoscopy. Of the 21 patients with negative CT scans, 6 (29%) had IH at operation versus 15 (71%) who were negative. The sensitivity of CT scan to identify IH and/or obstruction is 78% with 95% CI [57% to 91%], specificity is 60% with 95% CI [39%-78%], positive predictive value is 68% with 95% CI [49%-83%], and negative predictive value is 71% with 95% CI [48%-88%]. Kappa statistics comparing the agreement between CT findings and operative findings was 0.380 with 95 CI 0.131-0.629, which was consistent with fair agreement. Conclusions: This study examined the utilization of CT scans in detection of internal hernias. Positive CT scan is highly predictive of IH, but not specific. As CT scan will not detect IH in 1:4 patients, despite negative findings surgical exploration should remain the gold standard for patients with acute abdominal pain following RYGB or BPD when IH cannot be ruled out.

Mo1636 Outcomes of Patients With Biopsy-Proven Sclerosing Mesenteritis

Introduction: Radiographic imagingwith CT scan in patients presentingwith acute abdominal pain following Roux-en-Y gastric bypass (RYGB) or biliopancreatic diversion with duodenal switch (BPD/DS) is becoming commonplace. While surgical exploration remains the gold standard for diagnosing internal hernia, decisions for operative intervention are often based on CT findings. The accuracy of CT scan to reliably identify internal hernia in this subset of patients remains unknown. The purpose of this study is to evaluate the reliability of CT scan as a diagnostic tool to identify internal hernia (IH) in bariatric patients with acute abdominal pain. Methods: Following institutional review board approval, a retrospective chart review of all patients presenting with symptoms concerning for obstruction following Roux-en-Y gastric bypass or BPD/DS switch was performed. Patients without CT scans were excluded. Fifty two patients who underwent an operation for a suspected internal hernia from 2008-2013 were identified from surgeons' records at 2 institutions. CT and intraoperative findings were compared via univariate statistical analysis. Patients with incidental finding of a hernia defect were excluded. Results: Of the 52 patients, 50 had previous RYGB and 2 BPD/DS. There was a higher number of female patients in this population (Table 1). Mean time to presentation was 5 years following initial bariatric procedure (5 months to 14 years). Of the 52 patients, 27 had IH at operation. Thirty one (60%) patients had CT scans read as positive for IH and/or obstruction. Of these 31, 21(68%) were found to have IH at operation and 10 (32%) underwent negative diagnostic laparoscopy. Of the 21 patients with negative CT scans, 6 (29%) had IH at operation versus 15 (71%) who were negative. The sensitivity of CT scan to identify IH and/or obstruction is 78% with 95% CI [57% to 91%], specificity is 60% with 95% CI [39%-78%], positive predictive value is 68% with 95% CI [49%-83%], and negative predictive value is 71% with 95% CI [48%-88%]. Kappa statistics comparing the agreement between CT findings and operative findings was 0.380 with 95 CI 0.131-0.629, which was consistent with fair agreement. Conclusions: This study examined the utilization of CT scans in detection of internal hernias. Positive CT scan is highly predictive of IH, but not specific. As CT scan will not detect IH in 1:4 patients, despite negative findings surgical exploration should remain the gold standard for patients with acute abdominal pain following RYGB or BPD when IH cannot be ruled out.

The impact of early diagnostic laparoscopy on the prognosis of patients with suspected acute mesenteric ischemia.

To assess the impact of early diagnostic laparoscopy in patients with suspected acute mesenteric ischemia in whom other diagnostic studies are inconclusive or unavailable. The medical records of patients who underwent diagnostic laparoscopy with a preoperative diagnosis of acute mesenteric ischemia between January 2008 and January 2012 were reviewed. The patients who had a preoperative diagnosis of acute mesenteric ischemia based on computed tomography or angiography were excluded. Outcome variables were the time between admission and diagnostic laparoscopy, overall revascularization rate, successful revascularization rate, and in-hospital mortality rate. Fifty-three patients were included in the study. Twelve patients (22.6%) had negative diagnostic laparoscopy. In 43 patients (77.4%) who were found to have acute mesenteric ischemia at diagnostic laparoscopy, the mean time between admission and diagnostic laparoscopy, overall revascularization rate, successful revascularization rate, and in-hospital mortality rate were 10.2h, 32.5%, 13.9%, and 74.4%, respectively. The mean time between admission and diagnostic laparoscopy was significantly shorter in patients who underwent successful revascularization, and in those who survived with or without developing short bowel syndrome. Diagnostic laparoscopy is a safe and reliable diagnostic tool that can have a positive impact on the prognosis of patients with suspected acute mesenteric ischemia if carried out in a timely manner when radiological diagnostic studies are inconclusive or unavailable.

Bladder injuries in emergency/expedited laparoscopic surgery in the absence of previous surgery: a case series

The use of laparoscopy as a diagnostic and therapeutic tool is being used increasingly in the emergency setting with many of these procedures being performed by trainees. While the incidence of iatrogenic injuries is reported to be low, we present six emergency or expedited cases in which the bladder was perforated by the suprapubic trocar. Three cases were related to the management of appendicitis, two to negative diagnostic laparoscopies for lower abdominal pain and one to an ectopic pregnancy. Management of the bladder injuries varied from a urinary catheter alone to laparotomy with debridement of the abdominal wall due to sepsis and later reconstruction. Four of the six cases were performed by registrars. Although the incidence of bladder injury is low, its importance is highlighted by the large number of laparoscopies being performed. In addition to catheterisation of the patient, care must be taken with the insertion of low suprapubic ports and consideration should be made regarding alternative sites. Adequate laparoscopic supervision and training in port site planning is required for surgical trainees.

Role of diagnostic laparoscopy in assessing resectability of pancreatic and periampullary cancer

Abstracts / International Journal of Surgery 9 (2011) 363–369 368s / International Journal of Surgery 9 (2011) 363–369 368 ROLE OF DIAGNOSTIC LAPAROSCOPY IN ASSESSING RESECTABILITY OF PANCREATIC AND PERIAMPULLARY CANCER Amun Kalia, K.S. Gurusamy, V. Allen, B.R. Davidson. Department of Surgery, Royal Free Campus UCL Medical School, 9 Floor Royal Free Hospital, Pond Street, London. NW3 2QG Background: Surgical resection is the only curative treatment for pancreatic and periampullary cancer. A significant proportion of patients undergo unnecessary laparotomy because of understaging of these tumours. There has been no systematic review or meta-analysis assessing the role of diagnostic laparoscopy in assessing resectability (with curative intent) of pancreatic and periampullary cancer. Methods: A systematic review of studies was performed. Medline, Embase, Cochrane trials register, and Science Citation Index were searched until November 2009. Two reviewers independently identified studies and extracted data. The gold standard was histological confirmation of metastases. Quality of studies was assessed by the QUADAS tool. Metaanalysis was performed using hierarchical summary operating characteristics curve method of combining studies of diagnostic accuracy. Results: 23 studies including a total of 2973 patients were included in the meta-analysis. Most of the patients included in the studies had undergone a staging computerized tomogram (CT scan). Most of the studies performed histological confirmation of metastases before declaring that diagnostic laparoscopy was positive. Most of the studies had low risk of bias in the important aspects of methodological quality. The summary sensitivity and specificity obtained bymeta-analysis were 0.726 and 0.999, corresponding to a post-test probability of 1.00 for a positive diagnostic laparoscopy and 0.14 for a negative diagnostic laparoscopy compared to a baseline probability of 0.36. Thus diagnostic laparoscopy can decrease the probability of unresectable cancer found on laparotomy from 36% to 14%. Conclusions: Routine diagnostic laparoscopy prior to laparotomy can decrease unnecessary laparotomies. PATHOGENESIS OF CYSTIC MEDIAL DEGENERATION IN IDIOPATHIC DILATION OF THE ASCENDING AORTA A.K. Kar , S.K. Nair , M.J. Goddard . University of Cambridge, School of Clinical Medicine, Papworth Hospital, Cambridge CB3 8RE, UK; Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge CB3 8RE, UK; Histopathology, Papworth Hospital, Cambridge CB3 8RE, UK Introduction: Although there have been advances in the surgical management for idiopathic dilation of the ascending aorta, the pathogenesis is still poorly understood. We investigated the histopathological features of cystic medial necrosis or degeneration (CMD). Methods: Tissue samples from sixty patients who underwent surgery for idiopathic dilation of the ascending aorta were fixed and stained so that histopathological features of CMN could be studied using a Leica DMLB microscope. We measured quantitatively loss of medial vascular smooth muscle cells and graded the fragmentation of elastic fibres, accumulation of mucopolysaccarides and elastocalcinosis of the media. Dividing the media into inner and outer segments, we considered regional differences in the aortic wall. Results: HE Welsh Institute of Minimal Access Technology Aims: Surgical simulation is of increasing importance with the advent of working time directives and may eventually fill the gaps in surgical education that have been created. We assessed the feasibility of establishing construct validity in a novel animal tissue model for laparoscopic right hemicolectomy. Materials and Methods: Participants performed two defined sections of a laparoscopic right hemicolectomy using the model developed. The procedures were marked independently by video using the L-CAT Objective Structured Assessment of Technical Skills (OSATS). Participants scores in all domains were compared to the number of real-world lead laparoscopic operator procedures they had performed. Results: Six participants completed a total of 16 procedures. Laparoscopic experience showed a statistically significant positive correlation with performance during the exposure (p1⁄40.005) and vascular pedicle (p1⁄40.05) sections, and the total time taken to complete the task (p1⁄4<0.001). Laparoscopic experience also correlated significantly and positively with technical skill (p1⁄40.02) and less errors (p1⁄40.04). A strong positive correlation was seen in all other measures. Conclusions: This study was able to distinguish surgeons based on their real-world laparoscopic experience using a novel animal tissue right hemicolectomymodel as assessed by OSATS. Thus, the construct validity of the platform is established in this feasibility study. Animal tissue models

Is herniography useful and safe?

117 consecutive herniograms were reviewed for patients who had symptoms suggestive of hernia but with no evidence or inconclusive findings on physical examination. The traditional approach has been to explore patients with suspected occult hernias. The aim of this study was to assess the impact of herniography in minimizing needless groin exploration and to evaluate its safety. Thirty-three herniograms were positive and showed unilateral and bilateral inguinal hernias. There were no false positive examinations and two false negative examinations. No complications were present. Patients with positive herniograms were explored, and operative findings correlated well with herniographic findings. Twenty-four patients were referred to other specialities. Follow-up in clinic and telephone interviews showed symptomatic improvement in the majority of patients. Herniography is useful in evaluating obscure groin pain and occult hernias. It is a safe procedure and more cost effective than a negative exploration or diagnostic laparoscopy.

Back to basics – clinical diagnosis in bariatric surgery. Routine drains and upper GI series are unnecessary

The routine use of closed suction drains and upper GI (UGI) series has been used to aid in the diagnosis and management of gastrojejunal leak after gastric bypass as well as diagnose intra-abdominal bleeding. 352 consecutive laparoscopic gastric bypass procedures were performed without the use of routine drains or post-operative UGI series. There were no adverse events related the lack of routine drains or UGI studies. Five patients (1.4%) did have a drain placed at the time of surgery, at the surgeon's discretion, due to a particularly difficult gastrojejunal anastomosis although none developed an anastomotic leak. UGI series were ordered post-operatively in seven patients all for unexplained tachycardia, none of who had abnormal radiographic findings. Two patients with tachycardia and normal UGIs had a negative diagnostic laparoscopy to rule out a leak. No UGI series demonstrated a leak although one tachycardic patient with a normal UGI did have a leak diagnosed at laparoscopy. Five patients had clinical signs of a severe gastrojejunal obstruction. Three resolved completely within 48 hours, and two patients required endoscopic intervention without the need for UGI. Six patients (1.7%) required a blood transfusion; all developed tachycardia and five were from bleeding in the GI tract. Routine use of drains and UGI series were not necessary for the safe management of gastric bypass patient in our series. In this small series, clinical indicators for leak, obstruction or bleeding were obvious without the additional data from a drain or UGI.

A dedicated ectopic pregnancy team leads to an improvement in patients’ management

The aim of the study is to determine whether a dedicated ectopic pregnancy team improves the management of haemodynamically stable patients with suspected ectopic pregnancy who do not require immediate life-saving surgery. A non-randomized population based study involving 210 patients admitted with a suspected ectopic pregnancy over a 2-year period in a university teaching hospital in the UK, was carried out to compare the management of those women before and after the introduction of the ectopic pregnancy team. Following the introduction of an ectopic pregnancy team, there were fewer laparotomies performed, fewer negative diagnostic laparoscopies, a reduced overall surgical intervention rate, and a reduced duration of hospital stay. Although, it was difficult to quantify the extent of improvement of training, yet there were fewer operations performed out-of-hours, more continuity of care, more learning opportunities and acquisition of laparoscopic skills of junior staff. The introduction of an ectopic pregnancy team led to an improvement in the management of patients with suspected ectopic pregnancies. Efforts aiming at setting up such a specialized team and its implementation in day-to-day clinical practice should be considered in hospitals where the mainstay of treatment remains laparotomy.

Papel da laparoscopia no trauma abdominal penetrante

OBJETIVO: O papel da laparoscopia na redução da taxa de laparotomias não-terapêuticas e da morbidade em pacientes vítimas de trauma abdominal penetrante tem sido amplamente discutido durante os últimos anos. O objetivo do presente estudo é relatar a experiência inicial de um hospital universitário no manejo laparoscópico de pacientes com trauma abdominal penetrante. MÉTODO: Durante um período de três anos, a laparoscopia foi realizada em 37 pacientes vítimas de trauma abdominal penetrante, hemodinamicamente estáveis. Os prontuários médicos foram revisados e os parâmetros analisados foram as indicações do procedimento, lesões associadas, necessidade de conversão, tempo de permanência hospitalar e complicações. RESULTADOS: Houve 18 (48,6%) casos de laparoscopias diagnósticas (LD) positivas e 19 (51,4%) negativas. Dos pacientes com LD positiva, oito (44,4%) foram submetidos à laparotomia exploradora com finalidade terapêutica ou para melhor delineamento da lesão. Houve 10 (55,6%) LD positivas nas quais não foi realizada conversão para cirurgia aberta. Quatro pacientes apresentaram lesões reparáveis laparoscopicamente, sendo realizado hepatorrafia (n=2) e frenorrafia (n=2). Os outros seis pacientes apresentavam lesões isoladas sem sangramento ativo, e a laparotomia não-terapêutica foi evitada. Os pacientes receberam dieta no primeiro dia de pós-operatório e o tempo médio de hospitalização foi de 3,8 dias. CONCLUSÕES: Nossa experiência inicial confirma que a laparoscopia é um bom método de avaliação e tratamento no trauma penetrante. A morbidade relacionada à laparotomias desnecessárias pode ser minimizada quando o procedimento é bem indicado, e o tratamento pode ser realizado com sucesso em casos selecionados.

Conservative treatment of interstitial pregnancy

ObjectiveTo report a case of interstitial pregnancy diagnosed and treated laparoscopically by cornual resection, and to review the literature in order to provide a perspective on alternative treatment options for this condition.Case reportA 42‐year‐old woman with persistent pelvic pain, elevated levels of beta‐human chorionic gonadotrophin (β‐hCG) and a negative ultrasound scan had an initial negative diagnostic laparoscopy. Symptoms continued and repeat ultrasound suggested an asymmetric fundal pregnancy. Repeat laparoscopy revealed an interstitial pregnancy and laparoscopic cornual resection was undertaken. Recovery was uneventful and she was discharged 2 days postoperatively.Current perspectiveWhen interstitial pregnancy is detected early, treatment options include expectant management, systemic methotrexate, or local injection of methotrexate, potassium chloride or prostaglandin into the gestational sac. Surgical intervention by hysteroscopic removal or laparoscopic cornual excision/cornuostomy can be employed in the case of failed medical treatment or advanced pregnancy.ConclusionThe early diagnosis of interstitial pregnancy should enable a conservative approach, whether medical or surgical, to be undertaken when treating this rare and potentially fatal condition.