Abstract:

Myasthenia gravis (MG) is a chronic autoimmune disease that usually responds positively to treatment with thymectomy. Standard surgical procedures have been shown to result in a beneficial outcome. This Chapter includes discussions regarding what are controversial, and opinions as to what constitutes the optimal access to be used for thymectomy. In a prospective study conducted between 8/97 and 12/03, 137 patients with MG underwent thoracoscopic thymectomy, for which a left-sided approach was generally applied. An analysis of the intraoperative and postoperative course was performed, as well as of the impact of the surgical procedure on further development of the disease. The results obtained were compared with those published in the literature, with particular reference to results obtained with open surgery. The patients in this study were 96 females and 41 males, with a mean age of 35.8 (range: 9-83) years. The mean preoperative duration of the disease was 22.9 (range: 1-140) months. In 8 (5.8%) patients, the procedure was converted to an anterolateral thoracotomy or sternotomy. The postoperative morbidity rate was 5.8%, one (0.7) patient died and the mean follow up was 24.7 (range: 1-57) months. Complete remission was noted in 19.4%, and improvements reflected either in a reduction in the medication required or a decrease in symptom severity, in a total of 76.8%. Complete thoracoscopic thymectomy is a technically feasible operation, equally as effective as conventional open surgery. Remissions or symptomatic improvements were observed in more than 70% of the patients. The low morbidity rate, coupled with excellent cosmetic results, have led to increasing acceptance of the operation both by patients and Neurologists. Therefore, thoracoscopic thymectomy represents a new, alternative method for use in patients with MG.

Authors:

Klaus Gellert, M.D.; Joachim Böttger, M.D.; Thomas Martin, M.D.; Jörg Werner, M.D.; Carola Mangler, M.D.; Hubert Martin, M.D.

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Abstract:

Laparoscopic gastrointestinal (GI) surgery often requires transection and reconstruction of the GI tract and division of vascular pedicles. Intraoperative staple line bleeding and postoperative GI hemorrhage are reported complications. Prevention of staple line bleeding includes oversewing of the staple line or more recently the use of staple line reinforcement sleeves as an adjunct on the stapler. The results of bioabsorbable glycolide copolymer sleeves (Seamguard, W.L. Gore & Associates, Inc., Flagstaff, AZ, USA) as staple line reinforcement during 44 laparoscopic GI operations were reviewed. The charts were analyzed retrospectively for demographics, quantity of staple line reinforcement material used, operative time, blood loss, intraoperative complications, postoperative bleeding or leak, and serial hemoglobin. The study group of 44 patients included 17 males and 27 females, with a median age of 44 years. The laparoscopic GI operations performed were laparoscopic cystgastrostomy (n=1), esophagus cancer staging (n=2), esophagectomy (n=2), colectomy (n=3), gastrectomy (n=5), appendectomy (n=9), and Roux-en-Y gastric bypass (n=22). The median number of staple line reinforcement sleeves used per operation was one for appendectomy and laparoscopic cancer staging, five for gastrectomy and esophagectomy, and seven for gastric bypass and colectomy. The mean blood loss was 86 +/- 22 mL. No intraoperative staple line disruptions occurred. Intraoperative staple line bleeding was minimal and few staple lines required oversewing. One patient developed GI hemorrhage on postoperative day five after being involved in a motor vehicle accident. The mean hemoglobin decreased from 13.9 +/- 1.6 g/dL at baseline to 12.6 +/-1.4 g/dL on the first postoperative day. No postoperative leaks or abscesses occurred. This study demonstrates that bioabsorbable glycolide copolymer staple line sleeves is safe and effective in prevention of intraoperative staple line bleeding and postoperative GI hemorrhage in 44 intra-abdominal GI operations.

Authors:

Ninh T. Nguyen, M.D., F.A.C.S.; Mario Longoria, M.D.; Sara Chalifoux, B.S., Samuel E. Wilson, M.D., F.A.C.S.

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Abstract:

Circular staplers are used to create the gastrojejunostomy of the Roux-en-Y gastric bypass. The anvil of the stapler can be placed within the pouch by way of the oropharynx or trans-abdominally, but these methods have limitations. The SurgASSIST Computer Mediated Stapler (Power Medical Interventions, New Hope, PA, USA) is a new technology that changes surgical stapling. The staplers are closed and fired under surgeon control by a computer for better accuracy and reliability. It has a 21-mm stapler, which can be passed orally for endoluminal stapling. The SurgASSIST has several advantages over the traditional circular stapled gastrojejunal anastomosis, including no need to dilate trocars to accommodate the stapler through the abdominal wall and decreased wound infections.

Authors:

Eric J. DeMaria, M.D.; Corrigan L. McBride, M.D.

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Abstract:

Laparoscopic linear cutting staplers are commonly used in bariatric surgery. Although many staple sizes are available, the clinical results of a staple line vary depending on the staple size and tissue environment. To help surgeons choose the proper staple size as well as establish design parameters for the development of new stapling devices, understanding the mechanical properties of the tissue is necessary. Knowing the distribution of the thickness of the stomach tissue would allow for increased accuracy in defining key design parameters for stapling devices, thus improving their performance in the operating theater. To this end, 50 sleeve/lateral gastrectomy specimens were obtained in a consecutive series from individuals undergoing weight loss surgery. Thickness measurements were performed at six predetermined sites. Results show that stomach thickness varies from thinnest at the proximal end near the esophageal junction to thickest near the pylorus. The data also suggest that the stomach is thinner along the greater curvature. Due to the variation in thickness of the stomach, laparoscopic linear cutting staplers with thicker staples are recommended when transecting the antrum. This thickness data will facilitate the development of devices with appropriate aperture closure for correct tissue compression.

Authors:

Hazem Elariny, M.D., Ph.D., F.A.C.S.;Hamilton González, B.S.; Bingshi Wang, Ph.D.

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Abstract:

Approximately 1 in 30 patients suffering from colorectal cancer (CRC) will develop peritoneal carcinomatosis (PC) in the absence of systemic spread. The mechanisms giving rise to PC in CRC are incompletely understood, but involve a complex stepwise interaction between the malignant cell and mesothelial layer. Systemic palliative chemotherapy is usually offered, but of limited activity in PC. Cytoreductive surgery followed by intraperitoneal hyperthermic chemoperfusion (HIPEC) has been described recently in management of isolated PC originating from CRC, based on a sound biological rationale of synergism and a pharmacokinetical advantage. Several retrospective series, one prospective randomized trial, and a meta analysis have clearly shown a survival benefit for patients treated with cytoreduction + HIPEC provided a complete (R0) resection is performed. Toxicity of the procedure is considerable, and mainly depends on the extent of surgery. Future trials are needed to provide more solid evidence in favor of surgery in PC originating from CRC in the era of modern chemotherapy and to better define the role of HIPEC as an adjunct to surgery.

Authors:

Wim P. Ceelen, M.D.; Gent University Hospital, Gent, Belgium

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Abstract:

The technique of transanal endoscopic microsurgery (TEM) was made available for clinical use in 1983. To our knowledge, this technique is currently the only one-port system in endoscopic surgery by which a direct endoluminal approach to the target organ by using a natural opening of the body. Use of the stereoscopic view also is unique in procedures performed routinely. The first indication for use of this new technique was excision of rectal adenomas. It provided the potential of low complications and low recurrence rates compared with the conventional surgical procedures. With the development of endorectal ultrasound for staging, and because many adenomatous polyps contained early rectal cancer, the question arose as to how to deal with these patients after successful local excision. Studies showed that the indication for use of the TEM-technique was extended to early, good differentiated rectal cancer-so-called, low-risk rectal cancer. Many studies showed that the TEM-technique is the optimal operation to avoid complications for patients with rectal polyps and low-risk pT1 tumours of the rectum. The main problem remains regarding how to identify these patients preoperatively and separate them from those who already have a high risk of local recurrence and lymph node metastasis at the time of operation. The effectiveness of any preoperative or postoperative combined treatment to reduce the risk of local recurrence and lymph node metastasis remains unclear. Combined treatment could be a future option to also cure more advanced cancer. Currently, the TEM-technique is the only endoscopic technique that uses a natural opening to reach the target organ, and is a valuable surgical technique with a low complication rate for patients with adenomatous rectal tumours and early rectal cancer.

Authors:

Jens Burghardt, M.D.;Gerhard Buess, M.D., F.A.C.S., F.R.C.S.

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Abstract:

This chapter addresses emergent endoluminal technologies available currently for treatment of gastroesophageal reflux disease (GERD). To date, the mainstay of GERD therapy has been achieved with either open or laparoscopic fundoplication, or life-long medical treatment. Endoluminal treatment modalities attempt to augment the gastroesophageal junction (GEJ) function by various techniques. We searched the PubMed database from 1980 to 2005 for studies on endoscopic GERD techniques. Product investigators were contacted for data presented mainly in Abstract form. Endoluminal management of GERD includes using radiofrequency energy, injection of biocompatible polymers, and endoluminal sutures to alter the GEJ and reduce reflux. With currently earned and further growing experience, endoscopic treatment of GERD has future promise; however, more experience and perhaps further refinement in techniques and technology must occur before widespread clinical application can be encouraged.

Authors:

Victor Bochkarev, M.D.; Syed Imram Ahmed, M.D.; Chad Ringley, M.D., Dmitry Oleynikov, M.D. Center, Omaha

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Abstract:

Biliary stone disease is a common disorder, usually associated with stones in the gallbladder, and can cause significant complications. Formations of stone usually occur in the presence of the following factors: abnormalities of the bile constituents, bile stasis, and the presence of nidus for stone formations. Numerous reports exist of foreign bodies (FBs) acting as nidus for stone formations within the biliary system. The FBs reported include surgical sutures, surgical clips, fragments of metal and plastics, ingested materials, and parasites. Surgical clips are reported to be the most commonly reported FBs that induce iatrogenic biliary stones. Surgical clips migration with subsequent stone formation is a well-recognized phenomenon since first used in surgery. Patients typically are first seen with symptoms of biliary obstruction and can be complicated by life-threatening cholangitis. These can occur from days to years after the initial surgical procedures. The underlying mechanism of the way in which FBs-including surgical clips-end up in the biliary system is unknown. Direct introduction during surgery, penetrating injuries, entero-bilio reflux, or erosions with eventual migration into the biliary system have been postulated. Bile-duct injuries, inappropriate clip placements, sub-clinical bile leak, and infections also have been postulated to contribute to clip migration. This Chapter reviews the literature regarding iatrogenic biliary stones as a result of FBs, and discusses the likely mechanisms involved with their migrations, stone formations, clinical presentations, and managements.

Authors:

Vui Heng Chong, M.R.C.P. (UK), F.A.M.S. (Singapore)

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Abstract:

With a growing understanding of abdominal wall mechanics and improving surgical technology, inguinal herniorrhaphy has undergone significant advancements in the past 100 years. As primary repair through an anterior approach gave way to the "tension-free" Lichtenstein technique in the later part of the 20th century, hernia recurrence rates fell dramatically. With this fall in recurrence rates, other postoperative factors became the measure of herniorrhaphy technique quality. The reductions of postoperative pain and recovery time have become the basis for comparison between techniques. To that end, the plug and patch methods of Millikan and Rutkow, as well as the Kugel memory recoil mesh repair system, adhere to the philosophy of minimal dissection and suturing. The Prolene Hernia System was similarly created to simplify hernia repair while improving postoperative recovery. The posterior approach to hernia fixation was well-described in the late 1800s. Although generally underused, this technique offered an excellent option for repairing all inguinal hernias, especially incarcerated ones. By combining the perspective of preperitoneal repair with laparoscopic technology, a truly novel option for herniorrhaphy was created. Laparoscopy offers lower recurrence and postoperative complication rates than standard primary open repair, with the potential for a faster and more comfortable recovery than the "tension-free" open repair.

Authors:

Daniel D. Klaristenfeld, M.D.; Eric Mahoney, M.D.; David A. Iannitti, M.D., F.A.C.S.

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Abstract:

Patients who undergo colorectal surgery are at a substantially higher risk for deep vein thrombosis (DVT) than their general surgery counterparts. The incidence of DVT in colorectal surgery patients who do not receive prophylaxis is approximately 30%; a four-fold increase exists in the incidence of pulmonary embolism. The precise reasons for the increased risk are uncertain; likely, contributing factors are the need for pelvic dissection, patient positioning (eg, use of stirrups), and indications for surgery (eg, inflammatory bowel disease, cancer). Despite the clear evidence that supports the safety and efficacy of DVT prophylaxis, appropriate preventive measures are frequently not used. Heparin preparations and mechanical compression in combination likely represents the most appropriate prophylactic regimen in these high-risk patients. Standard heparin appears to be as effective as low-molecular-weight heparin and considerably less costly. In the presence of relatively poor adherence to consensus guidelines for prophylaxis, critical pathways or electronic alerts may be useful to facilitate compliance with appropriate preventive measures.

Authors:

Kayvon Alizadeh, M.D.; Neil Hyman, M.D., F.A.C.S.

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Abstract:

We present our experience with the use of the intraluminal stapler device for the purpose of creating of a permanent dermal colostomy in patients requiring acute emergency operations and for regularly scheduled procedures. The advantages of this method for surgeons who use stapling devices are controlled safety of the colostomy, reduced operation time, and the creation of a stable diameter of the colostomy. Furthermore, this method can be used in patients where a secondary operation is needed due to shrinkage or stricture of the primary colostomy during the first operation. This method has now been used in our clinic for five years with excellent results. All patients, including those having procedures related to colon cancer, are placed on a follow up protocol for three years and are closely monitored. This protocol has allowed us to closely follow these patients and any related complications such as stricture, stenosis, prolapse, in situ hernia, and ecstomosis.

Authors:

Christos Christakis, M.D.; Em. Christakis, C. Chatzidimitrou, M.D.; M. Karanikas, M.D.

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Abstract:

Our intent was to evaluate whether laparoscopic radiofrequency ablation for patients with unresectable hepatocellular carcinoma and a high degree of liver damage has a role to play in the management of the disease. Laparoscopic and hand-assisted laparoscopic radiofrequency ablations were performed on five patients and the short-range outcome and complications of these patients were evaluated. The evaluation of the primary liver tumor by the radiofrequency ablation was carried out by computed tomography on the seventh day after surgery. Three patients underwent laparoscopic radiofrequency ablation, and the other two patients underwent hand-assisted laparoscopic radiofrequency ablation. The Child-Pugh status of all tumors was B status, and one patient had complications due to postoperative ascites. Laparoscopic and hand-assisted laparoscopic radiofrequency ablation with a cooled-tip electrode needle was found to be a safe and effective local treatment of hepatic focal lesions.

Authors:

Takehiro Okabayashi, M.D.; Michiya Kobayashi, M.D.; Toyokazu Akimori, M.D.; Naoaki Akisawa, M.D.; Shinji Iwasaki, M.D.; Saburo Onishi, M.D.; Keijiro Araki, M.D.

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