Evaluación de un nuevo método de sutura para la cirugía endoscopica transluminal a través de orificios naturales en un modelo animal

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a novel, potentially less invasive alternative to laparoscopic surgery. However, the problems of transluminal access and closure represent significant obstacles to its successful introduction in humans. Objective: to evaluate the feasibility and safety of a novel device designed for transluminal access and closure in a survival porcine model. Subjects: Four adult female Yorkshire pigs were used in the study. Interventions: While under general anesthesia, the animals were prepared with multiple tap water enemas followed by instillation of an antibiotic suspension and povidone-iodine lavage. At a distance of 15 to 20 cm from the anus, the prototype device (LSI Solutions, Victor, NY, USA) deployed a circumscribing purse-string suture around the planned incision site and subsequently used a blade mechanism to create a 2.5-cm linear incision. The transcolonic incision was then closed by cinching and securing the purse-string suture with a titanium knot by use of a separate hand-activated suture-locking device. Main Outcome Measurements: The animals were monitored daily for signs of peritonitis and sepsis and were survived for 14 days. The peritoneal cavity was examined for peritonitis, and the colonic incision site was examined for wound dehiscence, pericolic abscess formation, and gross adhesions. Tissue samples from both incisional and random peritoneal sites were obtained for histologic examination. Results: Transcolonic incision and closure were successful in all 4 animals. The device performed in a rapid and reproducible fashion. All animals recovered without septic complications. At necropsy, there was no evidence of peritonitis, abscesses, or wound dehiscence. Salpingocolonic and colovesicular adhesions were noted in 3 of 4 animals. Histologic examination revealed microabscesses at the incision site in all animals. Conclusions: The prototype incision and closure device represents a promising solution to the problems of transluminal access for NOTES. The presence of incision-related adhesions and microabscesses signal the need for further refinement in aseptic technique. 

Involvement of nuclear factor-kappaB in macrophage migration inhibitory factor gene transcription up-regulation induced by interleukin- 1 beta in ectopic endometrial cells.

OBJECTIVE: To investigate the involvement of the nuclear factor (NF)-kappaB in the interleukin (IL)-1 beta-mediated macrophage migration inhibitory factor (MIF) gene activation. DESIGN: Prospective study. SETTING: Human reproduction research laboratory. PATIENT(S): Nine women with endometriotic lesions. INTERVENTION(S): Endometriotic lesions were obtained during laparoscopic surgery. MAIN OUTCOME MEASURE(S): The MIF protein secretion was analyzed by ELISA, MIF mRNA expression by quantitative real-time polymerase chain reaction (PCR), NF-kappaB translocation into the nucleus by electrophoresis mobility shift assay, I kappaB phosphorylation and degradation by Western blot, and human MIF promoter activity by transient cell transfection. RESULT(S): This study showed a significant dose-dependent increase of MIF protein secretion and mRNA expression, the NF-kappaB translocation into the nucleus, I kappaB phosphorylation, I kappaB degradation, and human MIF promoter activity in endometriotic stromal cells in response to IL-1 beta. Curcumin (NF-kappaB inhibitor) significantly inhibited all these IL-1 beta-mediated effects. Analysis of the activity of deletion constructs of the human MIF promoter and a computer search localized two putative regulatory elements corresponding to NF-kappaB binding sites at positions -2538/-2528 bp and -1389/-1380 bp. CONCLUSION(S): This study suggests the involvement of the nuclear transcription factor NF-kappaB in MIF gene activation in ectopic endometrial cells in response to IL-1 beta and identifies a possible pathway of endometriosis-associated inflammation and ectopic cell growth.

Contemporary perioperative care strategies.

BACKGROUND: Historically, the preoperative and postoperative care of patients with gastrointestinal cancer was provided by surgeons. Contemporary perioperative care is a truly multidisciplinary endeavour with implications for cancer-specific outcomes. METHODS: A literature review was performed querying PubMed and the Cochrane Library for articles published between 1966 to 2012 on specific perioperative interventions with the potential to improve the outcomes of surgical oncology patients. Keywords used were: fast-track, enhanced recovery, accelerated rehabilitation, multimodal and perioperative care. Specific interventions included normothermia, hyperoxygenation, surgical-site infection, skin preparation, transfusion, non-steroidal anti-inflammatory drugs, thromboembolism and antibiotic prophylaxis, laparoscopy, radiotherapy, perioperative steroids and monoclonal antibodies. Included articles had to be randomized controlled trials, prospective or nationwide series, or systematic reviews/meta-analyses, published in English, French or German. RESULTS: Important elements of modern perioperative care that improve recovery of patients and outcomes in surgical oncology include accelerated recovery pathways, thromboembolism and antibiotic prophylaxis, hyperoxygenation, maintenance of normothermia, avoidance of blood transfusion and cautious use of non-steroidal anti-inflammatory drugs, promotion of laparoscopic surgery, chlorhexidine-alcohol skin preparation and multidisciplinary meetings to determine multimodal therapy. CONCLUSION: Multidisciplinary management of perioperative patient care has improved outcomes. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Assessment of construct validity of a virtual reality laparoscopy simulator.

BACKGROUND: The aim of this study was to assess whether virtual reality (VR) can discriminate between the skills of novices and intermediate-level laparoscopic surgical trainees (construct validity), and whether the simulator assessment correlates with an expert's evaluation of performance. METHODS: Three hundred and seven (307) participants of the 19th-22nd Davos International Gastrointestinal Surgery Workshops performed the clip-and-cut task on the Xitact LS 500 VR simulator (Xitact S.A., Morges, Switzerland). According to their previous experience in laparoscopic surgery, participants were assigned to the basic course (BC) or the intermediate course (IC). Objective performance parameters recorded by the simulator were compared to the standardized assessment by the course instructors during laparoscopic pelvitrainer and conventional surgery exercises. RESULTS: IC participants performed significantly better on the VR simulator than BC participants for the task completion time as well as the economy of movement of the right instrument, not the left instrument. Participants with maximum scores in the pelvitrainer cholecystectomy task performed the VR trial significantly faster, compared to those who scored less. In the conventional surgery task, a significant difference between those who scored the maximum and those who scored less was found not only for task completion time, but also for economy of movement of the right instrument. CONCLUSIONS: VR simulation provides a valid assessment of psychomotor skills and some basic aspects of spatial skills in laparoscopic surgery. Furthermore, VR allows discrimination between trainees with different levels of experience in laparoscopic surgery establishing construct validity for the Xitact LS 500 clip-and-cut task. Virtual reality may become the gold standard to assess and monitor surgical skills in laparoscopic surgery.

Critical appraisal of single port access cholecystectomy.

BACKGROUND: Single port access (SPA) cholecystectomy is a new concept in laparoscopic surgery. A review of existing results was performed to evaluate critically the current state of SPA with specific reference to feasibility, safety, learning curve, indications and cost-effectiveness. METHODS: All papers identified in MEDLINE until 15 February 2010 and all other relevant papers obtained from cited references were reviewed, without any language restriction. Case reports and series of fewer than three patients were excluded. RESULTS: After selection, 24 studies including 895 patients were analysed. None was randomized. Feasibility seems to be established, with a conversion rate of 2 per cent. SPA was not standardized and there was much technical variation. The learning curve could not be determined. Median follow-up time was 3 (range 0.25-12) months. The overall published complication rate was 5.4 per cent and the biliary complication rate 0.7 per cent. The rate of umbilical complications ranged from 2 to 10 per cent. CONCLUSION: SPA cholecystectomy seems feasible, but standardization, safety and the real benefits for patients need further assessment. Uncontrolled wide adoption of this approach may be responsible for a rise in biliary complications.

Management of transitional-cell carcinoma of the renal pelvis and ureter.

Transitional-cell carcinoma of the renal pelvis or ureter is a relatively rare disease. Several risk factors are smoking, occupational carcinogens, analgesic abuse or Balkan nephropathy. The grade and stage of the disease have the most significant impact on the outcome. The treatment of renal pelvis and ureter tumours is open or laparoscopic surgery varying from conservative to more extensive surgical procedures, i.e. radical nephroureterectomy including removal of the contents of Gerota's fascia with ipsilateral ureter and a cuff of bladder at its distal extent. Most available data are from retrospective studies and surgery is the mainstay of treatment. Chemotherapy and/or radiation therapy are possible adjuvant or primary treatment for selected patients; however, prospective studies are needed to confirm their use.

Laparoscopie abdominale: possibilités et limites [Abdominal laparoscopy: an update]

Laparoscopic surgery has become a standard approach for many interventions, including oncologic surgery. Laparoscopic instruments have been developed to allow advanced surgical procedure. Imaging and computer assistance in virtual reality or robotic procedure will certainly improve access to this surgery.

The expression of estrogen receptors as well as GREB1, c-MYC, and cyclin D1, estrogen-regulated genes implicated in proliferation, is increased in peritoneal endometriosis.

OBJECTIVE: To analyze the expression of estrogen receptors α and β as well as their target genes implicated in proliferation, c-myc, cyclin D1, and GREB1, in the endometrium of women with or without endometriosis. DESIGN: Expression analysis in human tissue. SETTING: University hospitals and a clinic. PATIENT(S): Ninety-one premenopausal women (59 patients with endometriosis and 32 controls) undergoing laparoscopic surgery. INTERVENTION(S): Biopsies were obtained at time of surgery, performed during the proliferative phase of the cycle. MAIN OUTCOME MEASURE(S): Estrogen receptors α and β as well as c-myc, cyclin D1, and GREB1 mRNA expression levels were determined by quantitative reverse transcriptase-polymerase chain reaction. Tissue localization of these estrogen-regulated genes was analyzed by immunohistochemistry. RESULT(S): Estrogen receptors α and β as well as c-myc, cyclin D1, and GREB1 mRNA expression levels were increased in ectopic tissue in comparison with both normal and eutopic endometrium. Estrogen receptor mRNA levels also were upregulated in the eutopic peritoneal tissue of patients with endometriosis. Cyclin D1 and GREB1 expression was augmented in eutopic endometrium. c-myc, cyclin D1, and GREB1 proteins exhibited a nuclear localization in ectopic endometrial tissue. CONCLUSION(S): This constitutes the first report of increased expression of GREB1, as well as cyclin D1 and c-myc, in peritoneal endometriotic lesions, implicating these proteins in estrogen-dependent growth in this context.

Ressecção videolaparoscópica de hemangiopericitoma do estômago

In the present case (77 years-old woman), the diagnosis on an extramucosal lesion by endosonography was leiomyoma or schwanoma. Radiological exam of the upper digestive tract with barium and abdominal computed tomography confirmed the site of the lesion at the level of the lesser curvature. The operative technique followed the steps of the laparoscopic partial gastric resection (wedge resection) for gastric mesenchymal tumours, described elsewhere. The Endo-GIA stapler was introduced through the 12mm port in the right upper quadrant. Proper positioning of the stapler over the lesser curvature and a satisfactory margin of tissue around the mass were attained. Nine sequential firings of the Endo-GIA 30 were needed to completely surround the mass. Histopathological diagnosis was a spindle-cell tumour measuring 3cm in diameter. Mitotic index was measured at almost null. The neoplastic cells were strongly reactive for vimentine and CD34 and negative for the immunohistochemical markers S-100 protein, muscle actin, desmin and Ag linked to VIII factor. There was a slight reaction with keratin (+/+++). The XIIIA factor reaction revealed less than 5% of dendritic elements. These data favour a vascular cell origin better than smooth muscle cell origin. In conclusion it was a gastric hemangiopericytoma. Follow-up showed no recurrence at seven years.

Hepaticojejunostomia em "y" de roux videoassistida

Management of common bile duct stones in the era of laparoscopic surgery is controversial. The biliary anastomosis is indicated in case of large common bile duct, recurrent stones, giant stones and concomitant common bile duct stricture and duct stones. The development of laparoscopic techniques permits to perform this type of surgery laparoscopically as well as the open procedure.

Banda gástrica ajustável laparoscópica: alternativa técnica

In these paper we are presenting a technical alternative to laparoscopic adjustable gastric banding. From January 1999 to April 2000, 60 patients with mean body mass index (BMI) of 40,7 kg/m2 underwent laparoscopic adjustable gastric banding. The new technique is performed in two steps. In the first step, an isolation instrument (laparoscopic finger) is inserted through the lesser sac, next to the junction of diaphragmatic crura, including the lesser omentum in order to pull the band catheter. The second step separates the lesser omentum from the right side of the stomach.There was no mortality and the morbidity was 11,6% (1 slippage of the band and 6 trocar port seroma). The new technique was performed in all patients with no conversion to open procedure. We didn't have respiratory complications. This technical alternative is safe and easily performed, helping to prevent transoperative perforations.

Extração de fitobezoar gástrico por videolaparoscopia: considerações técnicas originais

Videolaparoscopic surgery has been used for treatment of almost all surgical abdominal diseases, mainly where there are no large ressections, or operative field is limited. In these situations, laparoscopic surgery has the advantages of less morbidity, quick recovery and good cosmetic results. Bezoars removal, or its mobilization, is probably included in these possible proceedings. Three non-laparotomic procedures were described: 1. endoscopic-laparoscopic; 2. videolaparoscopy and mobilization of intestinal bezoar to the cecum; 3. laparoscopy and gastrotomy for bezoar removal, through suprapubic incision or the umbilical punction. There have been only two publications describing the videolaparoscopic method for bezoar removal, and the methods applied can be complications or morbidity related. We describe one case where the applied technique is simple and easy to perform, time saving and probably less complications-related. This technique, with four trocars, utilized a plastic bag besides the stomach to be opened, followed by gastrotomy, bezoar removal and immediate introduction in the plastic bag, suture of gastrotomy and removal through the left subcostal trocar. This technique was feasible and easy to perform, with short operative time, and there were no intra or post-operative complications; the patient was discharged in the second post-operative day, and is without further problems after one year follow-up. We believe that this could be an adequate technique to perform laparoscopic gastric bezoar removal, and the rigid sequence of operative events allows a quick procedure, with minimal contamination. The videolaparoscopy seems to be an adequate access to surgical treatment of gastro-intestinal bezoars, with or without obstruction, and should be the ellected the procedure of choice to begin the surgical treatment, with convertion to laparotomy in case of any intra-operative adversity.

Hérnia encarcerada em orifício de trocarte lateral diagnosticada por tomografia computadorizada

Incisional hernia is an uncommon complication in laparoscopic surgery. The majority of the hernias are located in the umbilical site. Nevertheless, they can occur in the lateral trocar site, although they are rarely diagnosed. We report a case of a 55 year-old patient who underwent a videolaparoscopic hysterectomy and developed small bowel obstruction on the third postoperative day. This initially gave rise to the diagnosis of paralytic ileum. The definitive diagnosis of incarcerated hernia in the lateral trocar site was established after an abdominal computed tomography was performed.

Complicações de procedimentos laparoscópicos em urologia: análise retropectiva de 1990 a 2002

Although laparoscopic surgery is a safe and effective procedure, it is not exempt from risks of complications and death. Complication rates have decreased in various procedures, with means of 1%, 3.9% and 9.2%, for those considered easy, difficult and very difficult, respectively, while death rates have ranged from zero to 0.09%. To analyze the characteristics and the incidence of complications regarding the technique, the patient, the surgeon and the various types of laparoscopic procedures used in urology. A literature review between January 1990 and June 2002 in Medline and Lilacs was undertaken, including approximately 22,000 patients submitted to laparoscopic surgery, classified according to the type of procedure. The complications were considered as major or minor in accordance with various criteria adopted by the authors for appraising their seriousness. The complications regarded as minor ones occurred mainly in the phases of access and insufflation, and were more common in the postoperative period. The ones considered as major were associated with the dissection phase, with more serious characteristics, with vascular lesions predominating over visceral ones. The laparoscopic urological procedures proved to be well tolerated by pediatric and obese patients. Complications rates with this technique were inversely proportional to theexperience of the surgeon; they were associated with the complexity of the procedures and were similar to those of the corresponding procedures performed through an open approach. Over ten years, in spite of the increasing complexity of laparoscopic procedures, complications rates have fallen to figures comparable to those of the corresponding open techniques.

Laparoscopy in uterine cervical cancer. Current state and literature review

Cervical cancer remains the most frequent gynecological tumor in Brazil and other developing countries. Minimally invasive techniques, especially laparoscopy, have been increasingly employed in such tumors. This article aims to describe the main applications of laparoscopy in the treatment and staging of cervical cancer. In the early stages, it is possible to provide a fertility-preserving surgery in the form of radical trachelectomy and, in a study protocol, the function-preserving surgery, avoiding parametrectomy and the associated morbidity. A fully laparoscopic radical hysterectomy is fairly standard in the literature and has the tendency to become the standard of care in early cases, for patients who want to bear no more children. In advanced stages, minimally invasive surgery can offer ovarian transposition, with intent to prevent actinic castration, without upsetting the time for the start of radiotherapy and chemotherapy. Staging laparoscopic surgery, including pelvic and para-aortic lymphadenectomy, has been the subject of studies, since it has the potential to modify the extension of radiotherapy depending on the extent of lymph node spread.