Tyco Healthcare Research Articles

The History of Surgical Staplers: A Combination of Hungarian, Russian, and American Innovation

Since their development in 1908, surgical staplers have been used as a method of "mechanical suturing" in efforts to divide hollow viscera and create anastomoses in an efficient and sterile manner. The concept for the surgical stapler was first developed by Humér Hultl, a Hungarian professor and surgeon, and designed by Victor Fischer, a Hungarian businessman and designer of surgical instruments. The design was highly acclaimed; however, it was bulky, cumbersome, and expensive to manufacture. In 1920, Aladár Petz, a student of Hultl, incorporated two innovations to the Fischer-Hultl stapler to create a more lightweight model, which was named the Petz clamp. In 1934, Friedrich of Ulm designed what would be the predecessor to the modern-day linear stapler. In the 1950s, Russian and American staplers began to emerge. Throughout the 1960s, a variety of stapling instruments were developed in the United States, manufactured by the United States Surgical Corporation. In the 1970s, Johnson & Johnson Ethicon brand joined the market. The United States Surgical Corporation was later bought by Tyco Healthcare and became Covidien in 2007. Through the collaboration of Felicien Steichen, Mark Ravitch, and Leon Hirsch, surgical staplers were further modified to incorporate interchangeable cartridges with various designs. With the advent of minimally invasive surgery began production of laparoscopic surgical staplers. Since its inception, the surgical stapler has provided a means to efficiently create safe and effective visceral and vascular anastomoses. The surgical stapler design continues to evolve while still maintaining the basic principles that were implemented in the original design.

Lower preoperative quality of life increases postoperative risk of adverse events in women with endometrial cancer: Results from the LACE trial

ObjectiveTo examine the association between preoperative quality of life (QoL) and postoperative adverse events in women treated for endometrial cancer. Methods760 women with apparent Stage I endometrial cancer were randomised into a clinical trial evaluating laparoscopic versus open surgery. This analysis includes women with preoperative QoL measurements, from the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire, and who were followed up for at least 6weeks after surgery (n=684). The outcomes for this study were defined as (1) the occurrence of moderate to severe adverse events within 6months (Common Toxicology Criteria (CTC) grade ≥3); and (2) any serious adverse event (SAE). The association between preoperative QoL and the occurrence of AE was examined, after controlling for baseline comorbidity and other factors. ResultsAfter adjusting for other factors, odds of occurrence of AE of CTC grade ≥3 were significantly increased with each unit decrease in baseline FACT-G score (OR=1.02, 95% CI 1.00-1.03, p=0.030), which was driven by physical well-being (PWB) (OR=1.09, 95% CI 1.04-1.13, p=0.0002) and functional well-being subscales (FWB) (OR=1.04, 95% CI 1.00-1.07, p=0.035). Similarly, odds of SAE occurrence were significantly increased with each unit decrease in baseline FACT-G score (OR=1.02, 95% CI 1.01-1.04, p=0.011), baseline PWB (OR=1.11, 95% CI 1.06-1.16, p<0.0001) or baseline FWB subscales (OR=1.05, 95% CI 1.01-1.10, p=0.0077). ConclusionWomen with early endometrial cancer presenting with lower QoL prior to surgery are at higher risk of developing a serious adverse event following surgery. FundingCancer Council Queensland, Cancer Council New South Wales, Cancer Council Victoria, Cancer Council, Western Australia; NHMRC project grant 456110; Cancer Australia project grant 631523; The Women and Infants Research Foundation, Western Australia; Royal Brisbane and Women's Hospital Foundation; Wesley Research Institute; Gallipoli Research Foundation; Gynetech; TYCO Healthcare, Australia; Johnson and Johnson Medical, Australia; Hunter New England Centre for Gynaecological Cancer; Genesis Oncology Trust; and Smart Health Research Grant QLD Health.

Non-invasive positive pressure ventilation for the treatment of severe stable chronic obstructive pulmonary disease: a prospective, multicentre, randomised, controlled clinical trial

Evidence is weak for the ability of long-term non-invasive positive pressure ventilation (NPPV) to improve survival in patients with stable hypercapnic chronic obstructive pulmonary disease (COPD). Previous prospective studies did not target a reduction in hypercapnia when adjusting ventilator settings. This study investigated the effect of long-term NPPV, targeted to markedly reduce hypercapnia, on survival in patients with advanced, stable hypercapnic COPD. This investigator-initiated, prospective, multicentre, randomised, controlled clinical trial enrolled patients with stable GOLD stage IV COPD and a partial carbon dioxide pressure (PaCO2) of 7 kPa (51.9 mm Hg) or higher and pH higher than 7.35. NPPV was targeted to reduce baseline PaCO2 by at least 20% or to achieve PaCO2 values lower than 6.5 kPa (48.1 mm Hg). Patients were randomly assigned (in a 1:1 ratio) via a computer-generated randomisation sequence with a block size of four, to continue optimised standard treatment (control group) or to receive additional NPPV for at least 12 months (intervention group). The primary outcome was 1-year all-cause mortality. Analysis was by intention to treat. The intervention was unblinded, but outcome assessment was blinded to treatment assignment. This study is registered with ClinicalTrials.gov, number NCT00710541. Patients were recruited from 36 respiratory units in Germany and Austria, starting on Oct 29, 2004, and terminated with a record of the vital status on July 31, 2011. 195 patients were randomly assigned to the NPPV group (n=102) or to the control group (n=93). All patients from the control group and the NPPV group were included in the primary analysis. 1-year mortality was 12% (12 of 102 patients) in the intervention group and 33% (31 of 93 patients) in the control group; hazard ratio 0.24 (95% CI 0.11-0.49; p=0.0004). 14 (14%) patients reported facial skin rash, which could be managed by changing the type of the mask. No other intervention-related adverse events were reported. The addition of long-term NPPV to standard treatment improves survival of patients with hypercapnic, stable COPD when NPPV is targeted to greatly reduce hypercapnia. German Lung Foundation; ResMed, Germany; Tyco Healthcare, Germany; and Weinmann, Germany.

Case Scenario: Residual Curarization in Diabetic Polyneuropathy

Case Scenario: Residual Curarization in Diabetic Polyneuropathy

Influence of Ambient Temperature and Minute Ventilation on Passive and Active Heat and Moisture Exchangers

During invasive mechanical ventilation, inspired gases must be humidified. We previously showed that high ambient temperature greatly impaired the hygrometric performance of heated wire-heated humidifiers. The aim of this bench and clinical study was to assess the humidification performance of passive and active heat and moisture exchangers (HMEs) and the impact of ambient temperature and ventilator settings. We first tested on the bench a device with passive and active humidification properties (Humid-Heat, Teleflex), and 2 passive hydrophobic/hygroscopic HMEs (Hygrobac and Hygrobac S, Tyco Healthcare). The devices were tested at 3 different ambient temperatures (from 22 to 30 °C), and at 2 minute ventilation settings (10 and 20 L/min). Inspired gas hygrometry was measured at the Y-piece with the psychrometric method. In addition to the bench study, we measured the hygrometry of inspired gases in 2 different clinical studies. In 15 mechanically ventilated patients, we evaluated Humid-Heat at different settings. Additionally, we evaluated Humid-Heat and compared it with Hygrobac in a crossover study in 10 patients. On the bench, with the Hygrobac and Hygrobac S the inspired absolute humidity was ∼ 30 mg H2O/L, and with the Humid-Heat, slightly < 35 mg H2O/L. Ambient temperature and minute ventilation did not have a clinically important difference on the performance of the tested devices. During the clinical evaluation, Humid-Heat provided inspired humidity in a range from 28.5 to 42.0 mg H2O/L, depending on settings, and was only weakly influenced by the patient's body temperature. In this study both passive and active HMEs had stable humidification performance with negligible influence of ambient temperature and minute ventilation. This contrasts with previous findings with heated wire-heated humidifiers. Although there are no clear data demonstrating that higher humidification impacts outcomes, it is worth noting that humidity was significantly higher with the active HME.

Single-port thoracoscopic surgery using the SILS port

We read with interest the article by Yang et al. [1]. We appreciate the novelty of the technique and how important it is to incorporate the development of new technologies into daily practice, and we also know how hard it is to convince colleagues to begin using new technologies. Surgeons who have already learned and mastered a technique are reluctant to start using a new one because of the inconvenience that this represents, the difficulty in obtaining new materials and learning a new surgical technique, and the trouble of convincing patients and families of the efficacy of the new method. After reviewing the article and taking into consideration the details of the variables to be analyzed, the homogeneity of the sample, and the extensive literature on the matter, we would like to make some comments. To our knowledge, there are very few published studies of the use of the single-incision laparoscopic surgery (SILS) port in thoracic surgery. There are case reports [2] and the retrospective series published by Yang et al. However, one of us (JMM) has recently had accepted for publication in this journal a prospective, nonrandomized, comparative pilot study [3]. This forthcoming series and the study of Yang et al. have several results in common that we would like to highlight. Both the duration of hospital stay and the cost were similar in our forthcoming series and in the study by Yang et al. Although they did not mention it, presumably the permanence of the chest tube drainage was also similar to that found in our study. Our results differ from their series in regard to pain. We used the visual analog scale for pain assessment, as did Yang et al., but we obtained significantly better results for patients with a SILS port than the three-port technique. In support of the finding that in the SILS technique pain and scarring satisfaction is better than with the classic three-port technique, Yang et al. mentioned that six of their patients had been previously operated on the contralateral side, and five of them were more satisfied with the SILS method than with the classic three-port method. The SILS port had lower postoperative neurological sequelae such as paresthesia and better cosmetic results. However, our study found higher rates of surgical wound complications, which we attribute to the fact that, with the SILS port being a single port, the tissues are compressed, and in addition it is the same wound used for chest tube placement. We find two points that diverge from the study of Yang et al.. First is the routine use of fibrin glue spray in all patients. Even after making the air leak test under the solution and finding none, we regard this as an excessive measure. It also raises intraoperative costs significantly, and there is no current evidence to suggest that this practice is universally accepted. Second is the fact that some of the cases of pneumothorax in patients who underwent surgery were their first event of pneumothorax. According to some of the most often used protocols in the world, such as the SEPAR guidelines for pneumothorax [4], surgery is only considered in the first event if the first episode is hypertensive pneumothorax, if there is prolonged air leak ([7 days), and if the patient is at risk as a result of practices involving changes in atmospheric pressure, among others. A disadvantage of the SILS technique is the requirement of prior training in the simulator provided by Covidien SILS (Tyco Health-Care, Norwalk, CT, USA) for the use of an instrumental angular tip. J. M. Mier (&) G. F. S. Otaola E. G. de Alba P. S. Doherty Thoracic Surgery Department, Instituto Nacional de Enfermedades Respiratorias ‘‘Ismael Cosio Villegas’’ (INER), Calzada de Tlalpan 4502. Col. Seccion XVI., Tlalpan, Mexico D.F., Mexico e-mail: jmmo50@hotmail.com

Endoscopic knot tying:In vitroassessment in a porcine stomach model

To determine if surgical knotting performed via endoscopy is an effective closure method for natural orifice translumenal endoscopic surgery. The proposed method was tested on an in vitro pig stomach model using standard endoscopy suite materials. A single use laparoscopy trocar (Versaport Plus manufactured by Tyco Healthcare) was fixed onto a plastic rectangular box in a horizontal position. A fresh pig stomach was tightly attached via its esophageal end to the trocar opening on the inner side of the box. The stomach cavity was closed at the duodenal end with Kocher forceps. A standard upper gastrointestinal endoscope fitted at its tip with a transparent plastic cap was introduced into the stomach through the outer trocar opening, so that the passage of the surgical trocar would mimic the passage of an esophagus. The stomach was subsequently inflated, followed by irrigation and washing. A neutral electrode of an electrocautery unit was placed inside the plastic box, underneath the pig stomach. The stomach's outer surface was kept moist using normal saline in order to maintain the natural elasticity and to ensure good contact with the electrode. The submucosal space on the anterior face of the stomach was accessed using the technique of endoscopic submucosal dissection. First, a site on the anterior face of the stomach was chosen, near the angle. Then, saline was injected into the submucosa with a standard endoscopic needle, so as to create a 20 mm diameter elevation. A linear 15 mm vertical incision was created at its center using a Dual Knife (KD650U manufactured by Olympus). This incision was used to access the submucosal space, and about 10 mm was dissected on both sides of the incision. The endoscope was then pushed through to the outside of the stomach after dilating a small puncture made by the Dual Knife in the muscularis propria, which simulated the peritoneoscopy procedure. Then, a 0.025" guidewire (Jagwire/450 cm manufactured by Boston Scientific) was inserted into the puncture, followed by a dilating balloon (Quantum TT manufactured by Cook Medical) that was used to enlarge the aperture orifice. After withdrawing the scope back into the stomach, the procedure continued with guidewires being passed from the submucosal space into the gastric lumen through small orifices on the left and right sides of the mucosal opening. These orifices were made with the Dual Knife, and the guidewires were inserted via a guiding catheter (HGC-6 manufactured by Cook Medical). As the guidewires were pulled outside of the stomach, they were replaced with a single surgical suture that had been initially attached to their tip and was now untied. Finally, one loop of this surgical suture was formed on the exterior. One loop end was fixed while the opposite suture end was pulled by biopsy forceps through the endoscope channel as the scope was inserted into the stomach. The loop was advanced until it approached and fixed the two mucosal incision margins. Three alternating loops were made in this manner to create a genuine tight surgical knot. Endoscopic knotting of the gastric wall is feasible, but an in vitro survival study is necessary to validate clinical significance.

The next step? Use of tissue fusion technology to perform the serial transverse enteroplasty—proof of principle

BackgroundSerial transverse enteroplasty (STEP) is an established procedure for intestinal lengthening and tapering. A gastrointestinal linear stapler is used to taper the bowel sequentially. We report preliminary experience with tissue fusion technology to perform STEP in a porcine model. MethodsFour weaned male pigs (mean age, 4 ± 0 weeks; mean weight, 6.8 ± 0.1 kg) first underwent a 60-cm reversed intestinal segment followed by a STEP 4 to 6 weeks later. The LigaSure Impact (Covidien, Valleylab, Tyco Healthcare Group LP, Boulder, CO) was used to perform the procedure. Animals were fed on postoperative day 2 and terminated 1 week later. Morphometric data were collected, and intestinal tissue was obtained for histology. ResultsMean bowel caliber of 5.1 ± 0.5 cm was tapered to 1.8 ± 0.3 cm post-STEP with a mean increase in the length of the dilated segment of 82% ± 20%. All animals tolerated enteral feeding, and all survived to termination on day 7. Histologic evaluation revealed the zone of tissue fusion to be 7.1 ± 1.5 mm. Masson trichrome, hematoxylin and eosin, and polarized picrosirius red stains demonstrated that the fusion zone was well healed with overlying granulation tissue. ConclusionThis is the first report of the successful application of radiofrequency energy to perform the STEP procedure in animals. Although further evaluation is required, tissue fusion devices may eventually provide an alternative to the linear stapler for the STEP procedure.

Heat and Moisture Exchangers and Humidification Efficacy in Pediatrics: Effects of Ventilator Settings and ETT Leakage

Heat and moisture exchangers (HMEs) have been increasingly used for humidification during mechanical ventilation in pediatric patients [1]. However, efficacy of HMEs in the pediatric population has not yet been fully evaluated and there is limited information in the literature regarding the effects of ventilator settings and endotracheal tube (ETT) leakage on the humidification performance of HMEs. Chikata et al. [2] tested ten pediatric HMEs in a model lung, measuring performance under different respiratory rates, tidal volumes TVs (achieved with different pressure control levels), and leakage conditions. They found that eight of the ten HMEs maintained absolute humidity (AH) at more than 30 mg/L, the minimum level recommended by the American Association for Respiratory Care (AARC). With a small leak, AH decreased below 30 mg/L (26.6 to 29.5 mg/L), decreasing further (19.7 to 27.3 mg/L) with a larger leak. Pressure control (tidal volume) level did not statistically significantly affect AH values, although there was a trend to decreased AH at higher tidal volumes. In three of the HMEs, increased respiratory rate resulted in a significantly higher AH. In six of the other seven HMEs, there was a nonstatistically significant trend to higher AH with increased respiratory rate, with one HME showing a nonsignificant trend to lower AH. We think this is a well-designed and conducted study and provides valuable information regarding the use of HMEs in pediatric patients under different conditions. The effect of ETT leakage on AH is nicely demonstrated and is consistent with previously published data on mechanically ventilated adults. However, we had some questions regarding the study's other findings and their possible explanation as follows the study found that 8 out of 10 pediatric HMEs maintained AH at more than 30 mg/L, while they quote the Luchetti et al. [3] study they reference as showing “AH of less than 28 mg/L in all HMEs used with pediatric patients” despite using similar one-way valve methodology in their circuit to prevent mixing of inspired and expired gases? This finding is even more puzzling given that one of the two HMEs used in the Luchetti study, the Hygroboy (Covidien [formerly Tyco Healthcare], Mirandola, Italy), in the present study was found to produce the highest AH (32.4 mg/L) of the ten HMEs tested. How is this difference in findings between the 2 studies of the same HME explained? the finding that increased respiratory rates resulted in a trend to higher AH that reached significance in 3 of the tested humidifiers is interesting. Previous studies of HMEs in adults and children have found lower AH associated with higher tidal volumes [4, 5] and minute volumes (MVs) [1, 6, 7]. It would seem more logical that an increasing respiratory rate presumably would result in a higher MV, with resultant lower AH, but Chikata et al. found the opposite. The authors did not comment on this in their paper, and we wonder if they have a plausible explanation for this; finally, the authors speculate that the finding of a linear relationship between increasing dead space and increasing AH might possibly be related to improved humidification in those HMEs with larger internal volume and dead space. Since it is generally recommended to minimize dead space with HMEs, in particular in pediatric use, would the authors care to comment on striking a balance between maximizing humidification capacity and minimizing dead space?

A Pilot Study of the Use of Biocide-Impregnated Gauze as an Adjunct to Wound Care in a Burn Population

The aim of this study was to evaluate the use of a polyhexamethylene biguanide biocide-impregnated gauze (Kerlix™ AMD gauze dressing, Covidien d/b/a Tyco Healthcare Group LP) as an adjuvant to routine burn care and its impact on the incidence of hospital-associated infections in burn population. One hundred eight burn patients admitted to the Burn Treatment Center were prospectively enrolled from August 2008 to June 2009 and matched 1:2 with historic controls who were admitted from March 2006 to July 2008. Clinical care remained otherwise unchanged; however, several hospital initiatives (the national surgical improvement project, the surgical care improvement project, and a central venous line bundle) were initiated before and during the study. There were significantly less infections in the study population (18.52% of case patients vs 28.70% of control patients had infections, P = .047). Although there was a decrease in each infection subtype analyzed, a statistically significant reduction was only reached for pneumonias (1.85% in cases vs 5.86 in controls, P = .042). Implementation of polyhexamethylene biguanide biocide-impregnated gauze was temporally correlated with a significant decrease in healthcare-associated infections in burn population. As there was no corresponding decrease in wound infections, the impact of the gauze on healthcare-associated infections, if any, cannot be conclusively determined by this study. A larger prospective study powered to detect a decrease in wound-related infections is warranted.

Curved cutter stapler for the application of bronchial sutures in anatomic pulmonary resections: the clinical experience of 139 cases

One of the fundamental steps in an anatomical pulmonary resection is the main and lobar bronchus suture. Nowadays, two different types of staplers are on the market: the linear TA stapler for open surgery (Tyco Healthcare Group LP, Norwalk, CT, USA), which is based on a 'guillotine' mechanism, sewing, but not cutting the bronchus, and the endoscopic linear stapler which both cuts and sews. This study aimed to fill the void in the use of an instrument used to staple and cut at the same time in 'open' thoracic surgery, eliminating the need for a scalpel: the curved cutter stapler (Contour Curved Cutter Stapler; Ethicon Endo-Surgery, Inc., Cincinnati, OH, USA). Between May 2009 and March 2011, the Contour Curved Stapler (Ethicon) was used for the bronchus in 139 cases of non-small cell lung carcinoma (NSCLC)-29 females and 110 males ranging between 48 and 85 years (average 71.1)-and comprising 115 lobectomies (8 bilobectomies) and 24 pneumonectomies (8 on the right lung, 16 on the left lung). All patients underwent a bronchoscopic check-up 30 days after they were discharged: in all cases, the bronchial stump was clearly within normal limits. No cases of bronchopleural fistulas were observed in the 139 patients. On the basis of this study, the curved cutter stapler showed to be a satisfactory device for securing the bronchus during an anatomic resection (whether lobar or main), in 'open' thoracic surgery. However, even though there were no cases of fistula, we consider that our data is still too limited to be statistically significant.

Transanal specimen retrieval using the transanal endoscopic microsurgery (TEM) system in minimally invasive colon resection

During laparoscopic colectomy, the specimen is retrieved through substantial incisions, which increase postoperative pain, wound infections, and incisional hernias. In the era of natural orifice transluminal endoscopic surgery (NOTES), incisionless transrectal approaches for colon resections have been investigated with promising results [4-6]. Transanal retrieval of the colonic specimen in laparoscopic colectomy has been described but not widely adopted, although it seems to be an appealing step towards NOTES colectomy. We have used the TEM rectoscope (Richard Wolf Medical Instruments Corporation, Vernon Hills, IL, USA) as a retrieval conduit, which facilitates transanal extraction of the specimen, and protects the rectal edge and anal sphincter during laparoscopic left colectomy. After standard laparoscopic dissection and vascular control, the colon is divided distally, whereas the proximal colonic end is ligated to prevent fecal spillage. The TEM rectoscope is advanced through the rectal stump. The proximal colon is grasped and withdrawn through the rectoscope. The colon is stapled off proximally, and the specimen is removed transanally. An anvil is introduced into the pelvis through the rectoscope and inserted in the descending colon through a colotomy, which is subsequently sealed with an endo-loop. The rectoscope is withdrawn, and the rectal stump edge is stapled off. A circular stapler is introduced in the rectum, and end-to-end anastomosis is performed. The extraction incisions in laparoscopic colectomy increase invasiveness and compromise the "purity" of the laparoscopic approach. Retrieval of the specimen through natural orifices constitutes a stepping stone in the transition to future incisionless NOTES colectomy. These techniques have not been widely adopted because of technical difficulties and concerns regarding trauma. In our experience, transanal retrieval of the colonic specimen is hampered by friction between the specimen and the rectum, which requires countertraction to the edges of the open rectal stump. These manipulations are time consuming and increase the risk of injury, even when retrieval bags are used. The TEM rectoscope allows gentle dilation of the anus, provides stability during extraction, and protects the edges of the rectum, therefore decreasing the risk of rectal or anal canal injuries. It maintains pneumoperitoneum and eases retrieval of the specimen through the large-caliber metal conduit. Alternative options in the form of a rigid conduit would be the use of the transanal endoscopic operation device (Karl Storz, Tuttlingen, Germany), the plastic McCartney tube (Tyco Healthcare, Norwalk, CT, USA) used for transvaginal operations, or an anecdotally reported, "homemade" rectoscope from a customized polyvinyl chloride tube. Potential limitations of this technique include the increased cost of acquiring and using the TEM rectoscope, although this should not be significant if this reusable system is already available for transanal procedures. The 4 cm diameter of the TEM rectoscope can also be a limiting factor in the case of large, bulky, incompressible specimens or large colonic tumors. We have also avoided using this technique in patients with preexisting anal sphincter dysfunction and fecal incontinence, as well as in the presence of severe perianal disease (i.e., fistulae or fissures). Naturally, the open lumen in the peritoneal cavity raises concerns regarding bacterial contamination and potential tumor cell seeding in cases of cancer. Preliminary evidence on these issues comes from TEM and NOTES research without obvious signs of increased risk currently. We do not perform preoperative bowel preparation for our colectomies, but we do perform rectal enema with Betadine solution at the beginning of the procedure. Use of the TEM system facilitates transanal removal of the specimen and protects the anorectum during laparoscopic colectomy.

Late tracheostomy tube decannulation by progression of a laryngeal tumour: an approach for airway control

Malpositions of tracheostomy tubes constitute serious complications. We describe a unique case of insidious dislodgement of the tracheostomy tube from the trachea due to aggressive growth of cancer. We highlight the importance of recognizing this unusual late decannulation and describe an approach for airway management. Written patient consent was obtained for this report. A 59-yr-old male with a T4 N2B laryngeal carcinoma presented for laryngopharyngectomy and free flap reconstruction. He had previously undergone a tracheostomy to relieve airway obstruction. Despite treatment with chemoradiation, the tumour progressed rapidly as evidenced by a computed tomography scan seven months later which showed cancer invading the thyroid, neck musculature, and tracheostomy site. Furthermore, the tracheostomy tube was seen pushed out of the tracheal lumen by progression of the tumour (Figure, Panel A). On the day of surgery, the patient was examined in the holding area. He was not in respiratory distress; his O2 saturation was 97% on room air, and a size 6.0 uncuffed Shiley tube (Tyco Healthcare Group LP, Pleasanton, CA, USA) located in the region of his neck was encased by tumour. Based on physical examination alone, there was no indication to arouse suspicion of decannulation. A new tracheostomy could not be performed below the existing dislodged tube due to tumour covering surface anatomic landmarks of the patient’s neck. Similarly, attempts at awake fibreoptic intubation (following airway topicalization with nebulized lidocaine) were unsuccessful because of diffuse carcinoma obstructing the glottic opening. The decision was made to use the existing tracheostomy site to achieve endotracheal intubation. A flexible fibreoptic bronchoscope was inserted into the Shiley tube, and the tip of the bronchoscope was confirmed to lie outside of the tracheal lumen, partially obstructed by tumour (Figure, Panel B). A path to the trachea was established by carefully advancing the bronchoscope through the gap between the distal end of the Shiley and the tracheal lumen. The scope was then removed and loaded with an Aintree catheter (Cook Incorporated, Bloomington, IN, USA). Bronchoscopy was again performed to insert the Aintree catheter into the airway. Since the tissues around the catheter were friable, a well-lubricated 6.0 reinforced endotracheal tube was chosen for smooth sliding over the catheter as well as for minimizing the possibility of dislodging tumour fragments into the airway, which could occur with forceful advancement of a larger endotracheal tube. With the Aintree catheter securely in place, the Shiley tube was removed, and the endotracheal tube was guided successfully over the catheter into the trachea (Figure, Panel C). General anesthesia was induced after the airway was secured, and the patient’s surgery and postoperative course proceeded uneventfully. Complications related to tracheostomy can be early or late. Decannulation is usually an early event involving a recently placed tracheostomy tube. Four weeks is generally sufficient time for the tracheostomy tract to mature. In contrast, late decannulation is a rare complication since a mature well-formed tracheostomy tract establishes airway patency. When a patient with a tracheostomy presents for surgery, positive pressure ventilation is usually required. This is customarily achieved by removing the Shiley tube and A. Truong, MD (&) D.-T. Truong, MD MD Anderson Cancer Center, Houston, TX, USA e-mail: atruong@mdanderson.org

Primary placement technique of jejunostomy using the entristar™ skin-level gastrostomy tube in patients with esophageal cancer

BackgroundWe developed a skin-level jejunostomy tube (SLJT) procedure for patients undergoing esophagectomy using a skin-level gastrostomy tube (G-tube) (Entristar™; Tyco Healthcare, Mansfield, Mass), in order to improve their nutrition status and quality of life (QOL). We describe the procedure and the adverse effects of SLJT in patients with esophageal cancer (EC).MethodsOver a 24-month period (March 2008 to March 2010), there were 16 patients (mean age: 61.8 years; age range: 49-75 years; 15 men, 1 woman) who had Stage II or III EC. Primary jejunostomy was performed under general anesthesia during esophagectomy. The technical success and the immediate and delayed complications of the procedure were recorded.Jejunostomy techniquesSLJT placement using the G-tube (20Fr) was performed 20 cm from the Treitz ligament on the side opposing the jejunal mesenterium. The internal retention bolster was exteriorized through an incision in the abdominal wall. A single purse string suture using a 4-0 absorbable suture was performed. The internal retention bolster was then inserted into the jejunal lumen via the small incision. The intestine adjacent to the tube was anchored to the peritoneum using a single stitch.ResultsThe SLJT was successfully inserted in all 16 patients. No early complications were documented. Follow-up for a median of 107 days (range, 26-320 days) revealed leakage to the skin in four patients, including superficial wound infections in two patients. There were no cases of obstruction of the tube or procedure-related death.ConclusionsThis SLJT placement technique using the G-tube is a safe procedure in patients with EC and allows the creation of a long-term feeding jejunostomy.

Traditional laparoscopic colorectal resections can be performed effectively using a three-port technique

Dear Editor, With the increasingly widespread use of laparoscopic surgery to treat colorectal diseases, many innovations have been made in attempts to develop the best technique. While the use of four or more ports has been routine in most laparoscopic colorectal resections, the drawbacks are the need for added manpower, consisting of the camera-person and another assistant to provide counter-traction, as well as costs and the unaesthetic effects of additional ports. Specimen extraction through an additional muscle-cutting incision may also result in increased postoperative pain and spoil the cosmetic results of laparoscopic surgery. We describe our technique of colorectal laparoscopy using only two ports and one camera port with extraction of specimen via the camera port. Between June 2008 and June 2009, we performed 49 colorectal resections using a three-port technique. This series includes 13 cases of segmental colectomy, 29 cases of anterior resection and 7 cases of total colectomy or total proctocolectomy. We recently published this technique of three-port laparoscopic ultra low anterior resection [1]. In applying the three-port technique to any resection, a sensible placement of the two manipulation ports is absolutely essential. Our manpower in the three-port laparoscopic procedure involved the operating surgeon, a nurse to hold the camera port and a scrub nurse who also held the uterine manipulator as the need arose. We utilized the umbilicus to remove the specimen in these cases, extending it to extract the specimen as needed. For left hemicolectomy and anterior resection or ultra low anterior resection, the first manipulation port (10/ 12 mm) was inserted medial to the right anterior superior iliac spine, and the second port (5 mm) was inserted in between the umbilical port and the first manipulation port (Fig. 1). The 5-mm port was used for tissue retraction and the 10/12-mm port was for the energy device as well as for insertion of staplers. In females, we used a Zumi 4.5TM (UA Medical Products Inc, Charlotte, NC, USA) uterine manipulator inserted via the vagina to manipulate the uterus when needed as this obviated the use of an additional port (Fig. 2). For right hemicolectomy, a 5-mm port a palms length below the umbilicus either in the midline or in the left iliac fossa and a 10/12-mm port to the left of the midline a palms length above the umbilicus were sufficient. In all cases, after dissection and sufficient mobilization, the umbilical port was removed and the wound lengthened only to the size needed for specimen extraction. After insertion of the stapler head in cases of left-sided colon cancer, the proximal colon was returned to the abdomen and the umbilical wound closed around the camera port for completion of the anastomosis after re-insufflation of the abdomen (Fig. 3). For right hemicolectomy and some cases of left hemicolectomy where the retained sigmoid colon was very long, the colon and tumor were exteriorized and transected and the anastomosis was performed extra-corporeally. We used either the Harmonic ACE (Ethicon Endo-Surgery Inc., Cincinnati, OH, USA) or the LigaSure Atlas (Tyco Healthcare UK Ltd, Gosport, UK) device for dissection and I. Seow-En K.-Y. Tan M. A. B. Mohd Daud F. Seow-Choen (&) Seow-Choen Colorectal Centre, #03-09 Mt Elizabeth Medical Centre, Singapore 228510, Singapore e-mail: seowchoen@colorectalcentre.com

Laparoscopic preperitoneal mesh repair using a novel self-adhesive mesh

Prosthetic mesh is now used routinely in inguinal hernia repairs, although its fixation is thought to be a potential cause of chronic groin pain. The Parietene ProGrip™ (TYCO Healthcare) mesh, which is semi-resorbable and incorporates self-fixing properties, has been shown to provide satisfactory repair in open surgery. We describe the use of this mesh in TAPP hernia repair, which has not previously been reported in the literature. A prospective study of 29 patients showed a mean operative time to be 47.6 min, with 96% of patients discharged home on the day of surgery or the day after. Visual analog pain scales (out of 10) reduced from 4 preoperatively to 0 at 6 months, and only 1 patient suffered a minor wound complication. The use of this mesh in transabdominal preperitoneal hernia repair is therefore feasible, safe, and may reduce postoperative pain.

Cavernous Hemangioma of the Posterior Mediastinum

A 71-year-old nonsmoking woman, with no significant past medical history, except for mild osteoporosis currently treated with calcium and vitamin D, was admitted for an incidental radiologic finding of a left paravertebral pulmonary opacity. Magnetic resonance imaging highlighted a 45 × 30 mm well-defined, oval-shaped lesion, placed in the left costovertebral space in contact with the ascending aorta (Fig 1; T2-weighted contrast-enhanced sections showing marked hyperintensity of the mass; [A] coronal section; [B] sagittal section; [C] transversal section). A minimally invasive resection was proposed. A 7-mm incision was made vertically over the fifth rib along the mid-axillary line and a 30° rigid thoracoscope was placed. During exploration, a brownish, well-circumscribed lesion was found (Fig 2A ). Two additional 7-mm ports were placed at the anterior–axillary line in the fourth intercostal space and at the posterior axillary line in the fifth intercostal space. The mass was easily resected and the sample was intact extracted in an Endo-Bag (United States Surgical, Division of Tyco Healthcare Group LP, Norwalk, CT) prolonging one Trocar incision. The intercostal muscles or the ribs were not invaded by the tumor. Grossly, the tumor was capsulated and measured 50 × 30 × 25 mm in size. Histopathology of the specimen revealed a cavernous hemangioma (Fig 2B; microscopic view showing vascular lacunas with flattened endothelium. No cellular atypia was present; 20×). The patient's postoperative course was uneventful. No recurrence was noted after a 5-year period.Fig 2View Large Image Figure ViewerDownload (PPT)Cavernous hemangiomas of the chest wall or intercostal hemangiomas are extremely rare vascular tumors [1Shimizu K. Yamashita Y. Hihara J. Seto Y. Toge T. Cavernous hemangioma of the rib.Ann Thorac Surg. 2002; 74: 932-934Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 2Hashimoto H. Oshika Y. Obara K. Takeshima S. Sato K. Tanaka Y. Intercostal venous hemangioma presenting as a chest wall tumor.Gen Thorac Cardiovasc Surg. 2009; 57: 228-230Crossref PubMed Scopus (4) Google Scholar, 3Winchester D.J. Victor T.A. Fry W.A. Intercostal hemangioma presenting as a chest wall tumor.Ann Thorac Surg. 1992; 54: 145-146Abstract Full Text PDF PubMed Scopus (14) Google Scholar]. Complete resection is the treatment of choice [2Hashimoto H. Oshika Y. Obara K. Takeshima S. Sato K. Tanaka Y. Intercostal venous hemangioma presenting as a chest wall tumor.Gen Thorac Cardiovasc Surg. 2009; 57: 228-230Crossref PubMed Scopus (4) Google Scholar]. A 71-year-old nonsmoking woman, with no significant past medical history, except for mild osteoporosis currently treated with calcium and vitamin D, was admitted for an incidental radiologic finding of a left paravertebral pulmonary opacity. Magnetic resonance imaging highlighted a 45 × 30 mm well-defined, oval-shaped lesion, placed in the left costovertebral space in contact with the ascending aorta (Fig 1; T2-weighted contrast-enhanced sections showing marked hyperintensity of the mass; [A] coronal section; [B] sagittal section; [C] transversal section). A minimally invasive resection was proposed. A 7-mm incision was made vertically over the fifth rib along the mid-axillary line and a 30° rigid thoracoscope was placed. During exploration, a brownish, well-circumscribed lesion was found (Fig 2A ). Two additional 7-mm ports were placed at the anterior–axillary line in the fourth intercostal space and at the posterior axillary line in the fifth intercostal space. The mass was easily resected and the sample was intact extracted in an Endo-Bag (United States Surgical, Division of Tyco Healthcare Group LP, Norwalk, CT) prolonging one Trocar incision. The intercostal muscles or the ribs were not invaded by the tumor. Grossly, the tumor was capsulated and measured 50 × 30 × 25 mm in size. Histopathology of the specimen revealed a cavernous hemangioma (Fig 2B; microscopic view showing vascular lacunas with flattened endothelium. No cellular atypia was present; 20×). The patient's postoperative course was uneventful. No recurrence was noted after a 5-year period. Cavernous hemangiomas of the chest wall or intercostal hemangiomas are extremely rare vascular tumors [1Shimizu K. Yamashita Y. Hihara J. Seto Y. Toge T. Cavernous hemangioma of the rib.Ann Thorac Surg. 2002; 74: 932-934Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 2Hashimoto H. Oshika Y. Obara K. Takeshima S. Sato K. Tanaka Y. Intercostal venous hemangioma presenting as a chest wall tumor.Gen Thorac Cardiovasc Surg. 2009; 57: 228-230Crossref PubMed Scopus (4) Google Scholar, 3Winchester D.J. Victor T.A. Fry W.A. Intercostal hemangioma presenting as a chest wall tumor.Ann Thorac Surg. 1992; 54: 145-146Abstract Full Text PDF PubMed Scopus (14) Google Scholar]. Complete resection is the treatment of choice [2Hashimoto H. Oshika Y. Obara K. Takeshima S. Sato K. Tanaka Y. Intercostal venous hemangioma presenting as a chest wall tumor.Gen Thorac Cardiovasc Surg. 2009; 57: 228-230Crossref PubMed Scopus (4) Google Scholar].

Comparison of Two Different Energy-Based Vascular Sealing Systems for the Hemostasis of Various Types of Arteries: A Porcine Model—Evaluation of Ligasure ForceTriad™

The ForceTriad™ generator has been recently developed. This new electrosurgical generator would demonstrate improved quality and efficiency in blood vessel sealing. To compare currently available 10-mm laparoscopic electrosurgical devices with the LigaSure™ Vessel Sealing System and ForceTriad generator (Valleylab, Inc., a division of Tyco Healthcare) for use in vessel sealing. Blood vessels of various types and diameters were harvested from alive four pigs using three instruments: LigaSure Atlas™ with LigaSure Vessel Sealing Generator (LSAt), LigaSure Atlas with ForceTriad Generator (LSAtFT), and Endoclip™ II (Autosuture, USSC; a division of Tyco Healthcare). A total of 100 arteries were processed by removal of fatty and connective tissue from the adventitia before sealing. An additional set of specimens was sealed and histopathologically analyzed after being stained with hematoxylin and eosin. The mean burst pressure was significantly higher with LSAtFT compared to LSAt (P < 0.01). The sealing process was significantly shorter with LSAtFT (P < 0.05). With regard to the degree of thermal injury, adventitial collagen denaturation and proximal thermal injury to the smooth muscle in the media of the vessel wall were less common with LSAtFT; however, the numbers were too small for statistical analysis. Both the LSAt and LSAtFT secured all vessel sizes to well above physiologic levels. The LSAtFT could be used more confidently in vessels up to 7 mm. Our findings indicate that LSAtFT could be a safer and more efficient instrument for advanced laparoscopic surgery.

Electrothermal bipolar vessel sealing device LigaSureV™ for pulmonary artery ligation – burst pressure and clinical experiences in complete video-assisted thoracoscopic major lung resection for lung cancer

Intraoperative bleeding is one of the main severe complications in complete video-assisted thoracoscopic surgery (c-VATS). We investigated whether one sealing device, the LigaSureV (LSV) vessel sealing system (Valleylab, Tyco Healthcare, Boulder, CO, USA) was experimentally and clinically safe and effective for c-VATS. The burst pressures (BP) of each pulmonary artery (PA) in resected lungs were measured and were compared between a thin PA group (<5 mm) and a thick PA group (> or =5 mm). To investigate the influences of the sealing situations to the adequacy of sealing, BPs were measured after dry or wet conditioned PA (soaked with 0.9% saline) were sealed and cut by the LSV. Clinically, a total of 203 PA were divided with the LSV in c-VATS. The BP of the thin PA with small diameters (<5 mm) were higher than the thick PA (607 mmHg vs. 447 mmHg; P<0.05). The sealing effect was higher when the thick PA was sealed in a dry state than in a wet state (447 mmHg vs. 399 mmHg; P<0.05). However, average BP was physiologically high enough to inhibit a burst even for thick PA sealed in a wet state. There was single case of delayed bleeding sealed PA resulted from seal contact with a sucton device. These studies demonstrated the safety and efficacy of the LSV to sealed PA in c-VATS.

Quality of life after total laparoscopic hysterectomy versus total abdominal hysterectomy for stage I endometrial cancer (LACE): a randomised trial

This two-stage randomised controlled trial, comparing total laparoscopic hysterectomy (TLH) with total abdominal hysterectomy (TAH) for stage I endometrial cancer (LACE), began in 2005. The primary objective of stage 1 was to assess whether TLH results in equivalent or improved quality of life (QoL) up to 6 months after surgery compared with TAH. The primary objective of stage 2 was to test the hypothesis that disease-free survival at 4.5 years is equivalent for TLH and TAH. Here, we present the results of stage 1. Between Oct 7, 2005, and April 16, 2008, 361 participants were enrolled in the QoL substudy at 19 centres across Australia, New Zealand, and Hong Kong; 332 completed the QoL analysis. Randomisation was done centrally and independently from other study procedures via a computer-generated, web-based system (providing concealment of the next assigned treatment), using stratified permuted blocks of three and six patients. Patients with histologically confirmed stage I endometrioid adenocarcinoma and Eastern Cooperative Oncology Group performance status less than 2 were randomly assigned to TLH (n=190) or TAH (n=142), stratified by histological grade and study centre. Patients and study personnel were not masked to treatment assignment. QoL was measured at baseline, 1 and 4 weeks (early), and 3 and 6 months (late) after surgery, using the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire. The primary endpoint was the difference between groups in QoL change from baseline at early and late timepoints (a 5% difference was considered clinically significant). Analysis was done according to the intention-to-treat principle. Patients for both stages of the trial have now been recruited and are being followed up for disease-specific outcomes. The LACE trial is registered with ClinicalTrials.gov, number NCT00096408. Eight of 332 patients (2.4%) had treatment conversion-seven from TLH to TAH and one from TAH to TLH (patient preference). In the early phase of recovery, patients who had TLH reported significantly greater improvement in QoL from baseline compared with those who had TAH, in all subscales apart from emotional and social wellbeing. Improvements in QoL up to 6 months after surgery continued to favour TLH, except in the emotional and social wellbeing measures of FACT and the visual analogue scale of the EuroQoL five dimensions (EuroQoL-VAS). Operating time was significantly longer in the TLH group (138 min [SD 43]) than in the TAH group (109 min [34]; p=0.001). Although the proportion of intraoperative adverse events was similar between groups (TAH eight of 142 [5.6%] vs TLH 14 of 190 [7.4%]; p=0.53); postoperatively, twice as many patients in the TAH group experienced adverse events of grade 3 or higher (33 of 142 [23.2%] vs 22 of 190 [11.6%] in the TLH group; p=0.004). Postoperative serious adverse events occurred more in the TAH group (27 of 142 [19.0%]) than in the TLH group (16 of 190 [7.9%]; p=0.002). QoL improvements from baseline during early and later phases of recovery, and the adverse event profile, favour TLH compared with TAH for treatment of stage I endometrial cancer. Cancer Council Queensland, Cancer Council New South Wales, Cancer Council Victoria, Cancer Council Western Australia; NHMRC project grant 456110; Cancer Australia project grant 631523; The Women and Infants Research Foundation, Western Australia; Royal Brisbane and Women's Hospital Foundation; Wesley Research Institute; Gallipoli Research Foundation; Gynetech; TYCO Healthcare, Australia; Johnson and Johnson Medical, Australia; Hunter New England Centre for Gynaecological Cancer; Genesis Oncology Trust; and Smart Health Research Grant QLD Health.