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Background: To present the experience of management of leaks following laparoscopic sleeve gastrectomy for morbid obesity in Show-Chwan memorial Hospital. Patients and Methods: Laparoscopic sleeve gastrectomy is considered one of the surgical options for morbid obesity. It is effective, with an average loss of 50% of excessive weight after 2 years of follow-up. The first laparoscopic sleeve gastrectomy was performed in January 2010 at Show-Chwan Memorial Hospital. Between January 2010 and October 2016, 300 patients underwent laparoscopic sleeve gastrectomy for morbid obesity. There were 218 women and 82 men with a mean age of 35.4 years. Preoperative mean body weight was 90.7 kg and mean body mass index (BMI) was 37.3 kg/m2. Results: Mean operative time was 85 minutes. Mean hospital stay was 3.5 days. There were no deaths. There were 5 complications (1.67%): leakage of gastroesophageal junction. One patient was conservative treatment. Two patients were successfully treated by self-expandable metallic stents and the other two patients were treated with esophageal stent also, but failed and further treated with fibrin (Histoacryl) injection to the leak site to try to seal the fistula. In six months follow-up, mean BMI decreased from 37.3 to 29.2 kg/m2, and mean excess weight loss reached 42.8%. Conclusions: Laparoscopic sleeve gastrectomy is a beneficial operation in terms of excessive weight loss, with acceptably complications. The leaks were located in gastroesophageal junction mostly, and could be resolved with esophageal stent. For the patients failed in esophageal stents, we try Histoacryl injection to improve it.

Objective: The objective of this study was to evaluate augmented reality-assisted single-incision laparoscopic adrenalectomy (AR-SILA) and compare with pure SILA. Materials and Methods: Between January 2009 and March 2012, a total of 19 patients had received SILA. Eight cases were AR-SILA and the others were pure SILA. Results: Eight AR-SILA procedures and 11 SILA were successfully completed. There was no significant difference between the two groups in terms of age, body mass index, and tumor size. Operative times were shorter in the AR-SILA group (102.5 ± 12.8 vs. 150.9 ± 46.3, P = 0.005). The mean blood loss in the AR-SILA group was slightly less than that in the SILA group (60.0 ± 25.6 vs. 109.1 ± 80.1, P = 0.129). There was neither postoperative mortality nor morbidity at the time of discharge and during follow-up. Conclusion: AR-SILA provides important intraoperative information for surgeons to recognize where the pathological lesions and vessels are located beyond the surgeon's direct vision. It made SILA safer and easier.

Laparoscopic sleeve gastrectomy (LSG) is gaining acceptance as a stand-alone bariatric procedure with proven efficacy on weight loss and obesity-related comorbidities. A specific and potentially severe complication of LSG is the staple line leak (SLL). Our aim was to report the SLL rate and its management in a prospective cohort of 378 LSGs.A total of 378 patients underwent LSG from July 2005 to July 2011. The gastric transection was performed by an initial 60 mm firing of 4.5 mm staples at the antrum and successive 60 mm firings of 3.5 mm staples at the gastric body and fundus toward the left diaphragmatic crus. A 36 Fr bougie was used to calibrate the gastric tube. The staple line was systematically reinforced with a partial-thickness running suture.The overall complications and SLL rate were 20/378 (5.29%) and 9/378 (2.38%), respectively. SLLs were managed by laparoscopic (n=2) or open (n=1) exploration, drainage and endoscopic self-expandable covered stent, computed tomography-guided percutaneous drainage (n=2), or a self-expandable covered stent alone (n=4). Medical support including total parenteral nutrition and adapted antibiotics was started in all patients. The combined treatment modalities were successful in all cases.SLL was the most common complication of LSG accounting for half of the overall complications. Percutaneous drainage and self-covered stents combined with antibiotics and parenteral nutrition are effective for SLL and should be proposed as first-line treatment in stable patients.

Purpose: Perforated peptic ulcer is an emergency condition. Laparoscopic ulcer repair is a feasible and safe procedure. The aim of this study was to research the efficacy of laparoscopic repair of peptic ulcer and to discuss the causes of conversion from laparoscopy to laparotomy. Methods: We collected 34 patients with perforated peptic ulcer underwent laparoscopic surgery from October 2003 to October 2008. Thirty four patients with perforated peptic ulcer underwent laparoscopic intervention and 6 cases were converted to laparotomy. The demographics, laboratory data, perioperative data, morbidity and mortality were compared. Results: In demographics of two groups, there were no significant differences in sex, age, location, and mean duration of symptoms of acute abdominal pain. However, there were significant differences in median size of perforation, mean duration of history of peptic ulcer related pain, and the experiences of surgeon. There were no significant differences in the laboratory data and perioperative data of two groups. In morbidity and mortality of two groups, there were no significant differences in leakage, wound infection, intra-abdominal abscess, ileus, urinary tract infection, pneumonia, and mortality, but there was significant difference in overall morbidity in two groups. Conclusions: Laparoscopic repair of perforated peptic ulcer is safe and could be used in routine clinical practice. However, patients with larger perforations (>10 mm), longer duration of history peptic ulcer related pain (>2 years), and learning curve of surgeon could be associated with conversion rate. It is associated with higher morbidity in patients with conversion from laparoscopy to laparotomy.

Background: Ten-millimeter ports are often used in laparoscopic surgery. It could be difficult to close the ports sites, especially in obese patients. We described a new method to close ten-millimeter port-site wounds, effective and easily to perform. Methods: Forty cases of laparoscopic bariatric surgery were performed from April 2010 to September 2011 at IRCAD Taiwan. Among them, 30 patients received trocar hole closed with SURGICEL&reg Original Hemostat and the other 10 patients received trocar hole closed with autologous fat. The results were recorded. Results: In group of SURGICEL&reg Original Hemostat, includes 21 female and 9 male, age range from 18 to 54 with average 39.5 years. Average BMI is 42.4 (range from 32.6 to 55). The operations include 27 cases of laparoscopic sleeve gastrectomy, 2 cases of laparoscopic gastric bypass, and 1 case of laparoscopic mini-bypass. Group of autologous fat includes 3 female and 7 male, age range from 20 to 49 with average 38.6 years. Average BMI is 39 (range from 32.8 to 64.5). The operations include 9 cases of laparoscopic sleeve gastrectomy, and 1 case of laparoscopic mini-bypass. No complications of trocar wound including infection, hematoma, and hernia were found for a mean follow-up of 6 months. Conclusions: For obese patients, closure of port sites can be difficult. We described a method of closing 10-mm port-sites wounds, which are easy, effective, and not required any special instruments.

Breast cancer treatment is multimodality. Prognosis prediction models depend on the tumor characteristics, neoplastic stage, intrinsic subtypes of oncogenes, molecular targets and dominant driving pathway. Immunohistochemical scores 4 (IHC4) is one of the most common and simplest prognostic models for breast cancer. IHC4 consists of four standard breast cancer biomarkers, including estrogen receptor (ER), progesterone receptor (PR), Ki-67 proliferative factor and human epidermal growth factor receptor 2 (Her-2/＂neu＂). The IHC4 scoring method was created mathematically and correlated with other genetic prediction models for breast cancer statistically. We have published Cdk5 and p35 proteins overexpression in some cancers including breast cancer. We inspected the expression of Cdk5 and p35 proteins to the IHC4 model in statistics. To date, several interesting proteins and genes are under investigation for linkage to the documented pathway in breast cancer. Even our results did not satisfy our expectation. We build a research model for the interesting proteins from bench to bed. In practice, the method is as simple as the purpose of the IHC4 method itself.

Gastrointestinal stromal tumors (GISTs), are different from other mesenchymal tumors by immunohistochemistric biomarkers and are often encountered in the alimentary tract and less commonly originating from omentum, mesentery and peritoneum. They usually present as subepithelial tumors in the gastrointestinal tract or intraabdominal masses with malignant potential. The tumors might cause symptoms such as pain, intraluminal or extraluminal GI tract bleeding and obstruction but might also present as incidental findings. Gastroscopy, Ultrasonography and CT scan are employed for preoperative evaluation. The surgical principles are to excise the tumor with safe margin microscopically. Minimally invasive procedures are revolutionary innovation in surgery. Asian Institute of TeleSurgery training center is established in mid Taiwan in 2008 with the cooperation between Show Chwan Health Care System and European Institute of TeleSurgery in Strasbourg, France. We retrospectively reviewed 24 primary stomach GISTs operated at our institution in the past four years. The patients were divided into laparoscopy group (18 patients) and laparotomy group (6 patients) depending on the main surgical methods. The patients’ age, gender, hospital stay, operative time, blood loss, tumor size and complication rate were used for stastical analysis. There were significant differencesin tumor size and blood loss between the two groups with a p value of less than 0.05. In the past 4 years, 75% of primary gastric GISTs in our hospital were managed by laparoscopic surgery. Our experience showed that laparoscopic surgery is feasible for primary stomach GISTs in selective cases.

PURPOSE To assess the impact of mesh size and fixation devices on short-term outcomes in a consecutive series of tension-free laparoscopic abdominal wall repairs. METHODS Data for 120 consecutive, unselected patients undergoing tension-free laparoscopic incisional (n=63) or umbilical (n=57) hernia repair were prospectively collected. A multivariate analysis was performed to evaluate variables influencing outcomes. RESULTS Persistent seromas were observed in 13 patients (10.83%) and 2 recurrences (1.98%) occurred. Mesh size >300 cm was associated with increased hospital stay [odds ratio (OR) 4.83; 95% confidence interval (CI), 1.5-15.53; P=0.008], increased postoperative day 1 (POD1) pain assessed with visual analog scale (OR 5.51; 95% CI, 1.76-17.2; P=0.003), and the presence of complications (OR 10.4; 95% CI, 1.85-58.96; P=0.007). Body mass index >30 resulted in increased hospital stay (OR 3.05; 95% CI, 1.23-7.57; P=0.01) and increased POD1 visual analog scale (OR 2.28; 95% CI, 1-5.18; P=0.04). CONCLUSIONS Mesh size and obesity were the main factors influencing postoperative outcomes.

Laparoscopic surgery for choledocholithiasis is still evolving. Only a few reports of single-incision laparoscopic common bile duct exploration (LCBDE) have been published. One hundred and one consecutive patients underwent single-incision LCBDE (SILCBDE) by one surgeon with straight instruments during a 42-month period. Choledochotomies were performed on 61 patients (60.4%). The success rate of intrahepatic duct exploration was 68.0% (17/25) for patients undergoing transcystic choledochoscopic bile duct explorations following longitudinal cystic ductotomies. The ductal clearance rate was 100%. Eighteen procedures (17.8%) were converted, including one open surgery. Nineteen patients (18.8%) experienced 26 episodes of complications; the majority (19 episodes) were classified as Clavien–Dindo grade I. Excluding those patients with Mirizzi syndrome (McSherry type II), multivariate logistic regressions showed that patients who were older or had complicated cholecystitis had higher procedure conversion rates and that higher modified APACHE II scores, higher white blood cell counts, and longer operative times were independent risk factors for complications. Based on operative times, 20 successful SILCBDEs were needed to get through the learning phase. A higher transcystic approach rate (46.5 vs. 8.3%; P

Background. Endoscopy-assisted breast surgery performed through minimal axillary and/or periareolar incisions is a viable option for patients with breast cancer. In this study, we report the preliminary results of patients with breast cancer who underwent endoscopy-assisted total mastectomy (EATM) followed immediately by pedicled transverse abdominis musculocutaneous (TRAM) flap reconstruction. Methods. Patients in this study comprised women with breast cancer who received EATM and pedicled TRAM flap reconstruction. Clinicopathologic characteristics, type of surgery, complications, and rate of recurrence were recorded. The cosmetic outcomes were evaluated objectively by the surgeons and subjectively by the patients at 3-month postoperative follow-up. Results. A total of 48 patients underwent 49 EATM procedures followed by pedicled TRAM flap reconstruction. Of them, 79.6% underwent endoscopic-assisted nipple-sparing mastectomy and 20.4% received endoscopic-assisted skin-sparing mastectomy. The types of cancer among these patients included ductal carcinoma in situ in 34.7%, stage I cancer in 36.7%, stage II cancer in 24.5%, and stage IIIa cancer in 4.1% patients. Mean tumor size was 2.1 ± 1.4 cm. There were no cases of flap failure. Partial nipple areolar complex ischemia/necrosis occurred in 4 (10.3%) patients; however, all cases resolved after conservative treatment. In the aesthetic outcome evaluation, EATM + TRAM were associated with 89.8% good, 8.2% fair, and 2% unsatisfactory result. No local recurrence was observed during the follow-up period. Conclusion. EATM followed immediately by pedicled TRAM flap reconstruction is a safe procedure and results in good cosmetic outcome in women with early-stage breast cancer.

Summary Invasive pulmonary aspergillosis (IPA) is a rare, life-threatening infection in liver transplant recipients. Here, we report a case of primary cutaneous aspergillosis with following lung involvement in a liver transplant recipient. The survival rate of patients with IPA can be increased by early diagnosis using high-resolution computed tomography, a combination of two effective antifungal agents, temporal reduction or cessation of immunosuppressive drugs, and surgical intervention with video-assisted thoracoscopic surgery.

The aim of this study was to assess the accuracy of a novel imaging modality, three-dimensional (3D) metabolic and radiologic gathered evaluation (MeRGE), for localizing parathyroid adenomas (PAs).Consecutive patients presenting with primary hyperparathyroidism who underwent both thin-slice cervical computed tomography (CT) and (99m)Tc-sestamibi (MIBI) scanning were included. 3D-CT reconstruction was obtained using VR-RENDER, which was used to perform 3D virtual neck exploration (3D-VNE). The MIBI scan was then fused with the 3D reconstruction to obtain 3D-MeRGE. Sensitivity, specificity, and accuracy were assessed. Parathyroid gland volume and preoperative parathormone (PTH) levels were analyzed as predictive factors of correct localization (i.e., correct quadrant).A total of 108 cervical quadrants (27 patients) were analyzed. Sensitivities were 79.31, 75.86, 65.51, and 58.61 % with 3D-MeRGE, 3D-VNE, MIBI, and CT, respectively. Specificity was highest with CT (94.93 %) followed by 3D-VNE (92.4 %). MIBI and 3D-MeRGE had the same specificity (88.6 %). 3D-MeRGE and 3D-VNE achieved higher accuracy than MIBI or CT alone. Mean PTH values were significantly higher in patients with lesions that were correctly identified (true positive, TP) than in those whose lesions were missed (false negative, FN) with 3D-VNE (219.60 ± 212.77 vs. 98.75 ± 12.76 pg/ml; p = 0.01) and 3D-MeRGE (217.69 ± 213.76 vs. 09.75 ± 20.48 pg/ml; p = 0.02). The mean parathyroid gland volume difference between TP and FN was statistically significant with all modalities except CT.3D-MeRGE and 3D-VNE showed high accuracy for localization of PAs. 3D-MeRGE performed better than MIBI or CT alone for detecting small adenomas and those with a low PTH level.

Einfuhrung Divertikelerkrankungen sind in westlichen Gesellschaften sehr haufig. Allerdings gibt es eine Tendenz dazu, die Indikation fur eine chirurgische Therapie der Divertikulitis seltener zu stellen. Minimal-invasive Operationen bieten viele potenzielle Vorteile fur Patienten bei der Divertikulitisbehandlung und konnen zur Optimierung chirurgischer Indikationen fuhren.

Ectopic pancreatic tissue is an uncommon developmental anomaly. The condition mostly occurs in the gastrointestinal tract and is usually asymptomatic. It rarely causes symptoms of inflammation, bleeding and perforation, and has potential for malignant change. Though it is an uncommon condition, cases of ectopic pancreas have been reported worldwide. Preoperative diagnosis of ectopic pancreas is challenging because of its nonspecific symptoms and signs. Owing to the revolution of minimally invasive surgery, submucosal tumors of the stomach can be resected by laparoscopic techniques. We have earlier reported on a case of ectopic pancreas in the stomach treated by robotics-assisted laparoscopic wedge resection. Herein, we report a case of ectopic pancreas in the prepyloric region of the stomach. A 44-year-old female presented with a two-week history of epigastralgia with radiation to the back. She received endoscopy check-up which disclosed a mass in the stomach. By endoscopic findings, a submucosal lesion in the prepyloric region with umbilical folding on the mucosa was identified. The umbilical folding on the mucosa hint the orifice of the duct of ectopic pancreas into the gastric mucosa suggestive of ectopic pancreas. Contrast-enhanced abdominal computed tomography showed a 5 cm cystic mass with heterogeneous content. To sum it up, the patient was diagnosed as ectopic pancreas in the stomach. She underwent laparoscopy-assisted antrectomy with Billroth I anastomosis (excision of the antrum and prepyloric region with reconstruction of gastrointestinal continuity by gastroduodenostomy) and had an uneventful hospitalization course. The histopathology of the resected tumor demonstrated ectopic pancreatic tissue in the gastric wall. To the best of our knowledge, excision of gastric ectopic pancreas using laparoscopy-assisted antrectomy with Billroth I anastomosis has never been reported in the literature.

An expanding mosaic view is one of the possible solutions for narrow field of view during endoscopic surgery. The current work presents a system to create an expanding mosaic view of the video during laparoscopy where the laparoscope is held and moved by a customized robot arm.

Aim Parastomal herniation of end colostomies can be chronically debilitating for patients and a difficult problem to treat. To prevent parastomal hernia (PSH) formation an extraperitoneal colostomy (EPC) approach has been developed in open colorectal surgery and some studies have suggested a potential advantage to this approach. Here we describe our technique of laparoscopic extraperitoneal stoma formation and present our experience to date. Methods We performed a retrospective analysis of consecutive patients undergoing a laparoscopic abdominoperineal resection between March 1999 and March 2011. We performed the EPC technique as follows: under laparoscopic guidance, a smooth tip instrument was used to gently separate the peritoneum from the posterior aponeurotic plane to create an extraperitoneal tunnel running from the skin incision to the left flank of the abdominal cavity to join the previously dissected paracolic gutter. The colon was exteriorized and the position was checked to ensure the absence of torsion or kinking. Results Twenty-two patients underwent a standard laparoscopic abdominoperineal resection with total mesorectal excision. Colostomy was constructed extraperitoneally (EPC) or transperitoneally (TPC) in 12 and 10 patients respectively. There were five complications requiring operative intervention: two stomal necrosis and one surgical site infection in the TPC group and two small bowel occlusions in the EPC group. Four patients from the TPC group developed PSH at 24, 36, 48 and 72 months respectively while there were no cases of PSH in the EPC group. Conclusion Extraperitoneal laparoscopic colostomy showed a potential reduction of PSH in our series of patients.

Introduction. A transanal, posterior, retrorectal approach has been demonstrated as a feasible natural orifice transluminal endoscopic surgery (NOTES) total mesorectal excision (TME) procedure. The aim was to assess the feasibility of a transrectal approach with a completely retroperitoneal mobilization of the left colon and mesenteric vessels in an acute porcine model. Materials and methods. Eight pigs were used. A purse-string suture was made 3 cm above the anal sphincter. Next, the retroperitoneal, perirectal space was entered with an endoscope through a single (or twin) anterior lateral, transrectal viscerotomy. A retroperitoneal tunnel was created using pneumodissection or endoscopically guided dissection to the inferior mesenteric artery (IMA). The IMA was skeletonized and lymph nodes retrieved using the IsisScope or other instruments. The IMA was divided with the Ligasure, clips, or ligature performed with the IsisScope. The rectum was dissected transanally in the “Holy” plane. After achieving mobilization using a completely retroperitoneal approach, the peritoneal attachments were then divided and the rectosigmoid specimen exteriorized through the anus. An explorative laparoscopy was then performed to evaluate the quality of the mobilization. Results. The procedure was successfully completed and the IMA correctly identified and ligated in all cases. In all but one case, no further mobilization was possible, even by a laparoscopic approach. Conclusions. Perirectal oncologic gateway to retroperitoneal endoscopic single-site surgery for left-sided colonic resections using both flexible and rigid surgical endoscopic platforms was feasible and reproducible in an acute porcine model. This technique might represent a step toward pure NOTES left-sided colorectal procedures.

Diverticular disease is very common in Western societies. However, there is a trend towards reducing indications for the surgical management of diverticulitis. Minimally invasive surgery offers many potential advantages to patients in the treatment of diverticulitis and may optimise surgical indications. A systematic literature review of minimally invasive techniques was carried out for the treatment of diverticulitis. The following techniques were reviewed: laparoscopic, single-port, natural orifice specimen extraction, natural orifice transluminal endoscopic surgery and laparoscopic lavage for the treatment of diverticulitis. In total, 2,050 minimally invasive cases were reviewed. Of all the different minimally invasive techniques published regarding the management of diverticular disease, laparoscopic surgery is the only technique that has undergone the rigours of randomised controlled trials. The documented benefits are less blood loss, less pain and analgesic requirements, a reduction in major complications, a reduction in the frequency of drain usage, a reduction in the duration of postoperative ileus and shorter hospital stay. However, operative time does appear to be longer. It has also been demonstrated that elective laparoscopic surgery results in improved quality of life and social functioning. Minimally invasive surgery for the treatment of diverticular disease appears feasible and safe. The result of future randomised trials will more clearly define the role each minimally invasive technique will play in the future.

Purpose: Chilaiditi’s syndrome is the hepatodiaphragmatic interposition of the colon. Its diagnosis poses challenge to clinicians, and misdiagnosis may results in unnecessary exploratory laparotomy being performed. The purpose of this study was to report our experience in diagnosis, management, and clinical outcome of patients with Chilaiditi’s syndrome. Methods: Nine cases of Chilaiditi’s syndrome from April 2005 to January 2007 at one institute. The clinical characteristic, imaging studies, management and results were recorded. Results: Six patients presented with abdominal distension (2 patients with abdominal pain; 5 patients with constipation), while Chilaiditi’s syndrome in the other three patients were found incidentally. All patients underwent chest X-ray. The Chilaiditi’s sign could be detected in seven patients; while the other two patients presented with no specific finding. Abdominal plain films (KUB) were all reviewed. Most of the patients (n = 8) showed ileus and one patient showed no specific finding. Impacted stool could be detected in five of nine patients. Abdominal ultrasound was performed in two patients. Gallstones were detected in one of them while the other revealed no specific finding. Six of nine patients underwent CT of abdomen, one of them revealed bowel loops in bilateral subphrenic space. One patient underwent subtotal colectomy because of volvulus of sigmoid colon. Five patients were treated with laxative and enema successfully and had been remained asymptomaticcally for a mean follow-up of 6.6 months. The other three cases were under observation. Conclusions: Presence of haustral folds of bowel loops may help us in diagnosing Chilaiditi’s syndrome. The left lateral decubitus abdominal plain film can also help to differentiate between pneumoperitoneum to Chilaiditi’s sign. Most of the cases with Chilaiditi’s syndrome can be resolved with conservative treatment and surgical intervention was reserved for patients with sign of systemic toxicity or peritonitis.

The aim of this study is to evaluate the impact of an expert monitoring on the quality and results of laparoscopic reversal of Hartmann's procedure (LRHP) performed by trainee surgeons by comparing their results to the expert's outcomes. Forty-two LRHP were performed between 2000 and 2008 following a step-by-step, standardised, full laparoscopic procedure. Patients operated upon by a senior surgeon were compared to patients operated upon by trainee surgeons while being mentored by the senior surgeon. Operative time, conversion, complications and post-operative outcome were measured. Each group included 21 patients. All patients underwent LRHP successfully. Two procedures were converted. No significant difference was observed between the expert and the trainees: operative time, 132 min (SD ± 50) vs. 131 min (SD ± 47) and complications (2–14%), 4 vs. 2. Three complications required re-operation, and three other were treated medically, including one dilatation of an anastomosis. Post-operative outcomes were comparable (oral intake, 3 vs. 2 days; post-operative hospital stay, 6 vs. 7.5 days); no mortality occurred. Standardisation simplifies this difficult laparoscopic procedure and offers the same outcome whether it is performed by an expert or by mentored trainees. The complications were comparable to those occurring at experienced centres (anastomotic leak or stricture, ureteral injury, re-operation). The expert mentoring does not prevent all complications but can solve intra-operative technical problems, thus improving the trainee's confidence. Mentoring should be promoted as it can be performed locally or remotely using modern interactive technology.

Summary Background/Introduction The da Vinci robotic surgical system was developed to overcome the limitations of conventional laparoscopic surgery. Purpose/Aims We retrospectively reviewed our experience in performing robot-assisted laparoscopic hernioplasty (RALH) during robot-assisted laparoscopic radical prostatectomy (RALP) based on a single surgeon’s experience. Methods From December 2005 to December 2008, a total of 100 patients with prostate cancer underwent RALPs by a single surgeon. We retrospectively reviewed the medical records and analyzed the patients’ ages, body mass indices (BMI), levels of prostate-specific antigen, the biopsy percentage, the Gleason score and clinical stages of the biopsy specimens in 11 patients who had a RALP and a RALH simultaneously. The diagnosis of preoperative inguinal hernia (IH) was based on the results of a clinical physical examination, abdominal computed tomography or magnetic resonance imaging. The postoperative IHs were detected by the appearance of a protruding mass in the inguinal area on coughing, which was noticed during a physical examination. The total operative time, blood loss, type of the hernia, postoperative hospital stay, and the incidence of an IH after a RALP were evaluated. Results Of the 100 patients, 89 (89%) received a RALP only, 11 underwent a RALP and a RALH simultaneously, 7% had a preoperative IH and 4% had a subclinical IH, which were found during operations. Three patients (3%) developed an IH during follow-up. There were no significant differences between the RALP group and RALP combined with the RALH group in terms of age, BMI, tumor stage, and operative time. Blood loss and the time required for urethrovesical anastomosis were significantly higher in the subclinical IH group than in the preoperative IH group. Conclusions The incidence of an IH after a RALP was 3% with a mean follow-up of 32.42 ± 11.76 months in this study. Subclinical IHs were relatively easier to notice during a RALP because of a high degree of pneumoperitoneum, the realistic 3D imaging and the steady view of the da Vinci robotic system. Thus, such a robotic procedure can be regarded to facilitate a more precise detection of occult IHs during a RALP, and it possibly decreases the incidence of IHs after a RALP.

Minimally Invasive Surgery (MIS) is a growing surgical technique comparing to traditional open surgery since it dramatically reduces patient trauma and costs but MIS technique is difficult because of looking at a 2D screen to perform the surgery. Depth perception is thus lost due to 2D endoscopic capturing and display. Therefore, the paper proposes real-time 2D to 3D conversion for enhancing MIS to provide depth perception on 3D display for increasing surgical quality, improving in safety and speed of procedures, and also to lower learning curve. The proposed method to convert an endoscopic 2D video frame into a depth map and consequently into a pair of right and left image for viewing on a stereoscopic display is based on the use of a bilateral filter approximated by a bilateral grid. The architecture is to make edges sharp to enhance moving instruments and to preserve chamber geometry segmentation. Results of verification by simulated surgery and questionnaire for surgeons proof the feasibility of 2D to 3D conversion on MIS.

Natural orifice transluminal endoscopic abdominal surgery, or NOTES, allows invasive operations to be performed through a single or multiple natural-orifice approach either in isolation (“pure”) or in combination with a transparietal (”hybrid”) access format. Therefore, to facilitate a colonic or rectal resection, the transgastric, transrectal or transcolonic routes, as well as the transvaginal route in women, can all be used either alone or in combination. We are now performing resectional colonic techniques on our patients that have been inspired by this revolutionary concept, carefully planned with storyboarding and validated in porcine models with survival analysis. Adaptation of existing equipment along with the use of new instruments and some simple ideas, such as magnetic fields to retract and mobilize the colon, have allowed us to simplify and standardize the operative technique (the first steps to ensuring procedural reproducibility). Initial potential applications can easily be imagined for partial colonic resections for voluminous benign polyps and for small early cancers, but these applications may extend to incorporate inflammatory bowel diseases such as diverticular disease of the sigmoid colon. For these techniques to further improve and the concept to become a concrete reality, a change in current surgical practice is required, and conventional laparoscopic techniques must be understood to represent a point along the evolutional development of surgery and not considered the final destination. However, as important as technical capacity is, due consideration and assurance of oncological and immunological propriety is essential, as is the issue of clarifying precise patient harm:benefit risk ratios.

Background Totally implantable access ports are often used for the administration of chemotherapy or prolonged intravenous infusions in patients with cancer. The technique has been well described. However, some complications would happen. The pinch-off-syndrome is one of these complications. We report another presentation of pinch-off-syndrome and how to prevent. Methods From January 2005 to December 2007, 73 patients of catheter fracture were collected. The duration of Port-A implantation ranged from January 2003 to October 2007. During this period, 3358 port-catheters were implanted. There were three brands of Port-A implanted included 46% BardPort™ (Bard, Salt Lake City, UT, USA), 42% A Port (Arrow international, Reading, PA, USA) and 12% PORT-A CATH (Deltec, St. Paul, MN, USA). Results The most common clinical presentation was difficulty in injection in 32 cases (43.8%). The incidence of brand C was far lower than brand A and B. The most common site of fracture was at the proximal part (anastomosis between injection port and catheter) in 68 cases (93.2%). The incidence of fracture of Port-A was 6 in 738 (0.81%) in cut-down method; 67 in 2620 (2.56%) in percutaneous subclavian method. Most of thecases (34%) were no more than six months. Conclusion The most frequent location of fracture Port-A was in proximal part – anastomosis between injection port and catheter. The cause of easily fracture may be associated with pinch-off-syndrome and design of Port-A. This kind of fracture could be prevented by cut-down method and fixed one stitch in proximal part.

To treat secondary hyperparathyroidism with subtotal parathyroidectomy or total parathyroidectomy with autotransplantation might cause the disease to recur because of growth of the parathyroid remnant or the autografts. The aim of the present study was to determinate an alternative surgical treatment for secondary hyperparathyroidism. Of 94 uremic patients, 44 (median age: 50.5 years; 33 women/11 men) were assigned to group A, patients who were not expected to receive kidney transplantation for various reasons and had total parathyroidectomy without autotransplantation; 50 (median age 46 years; 33 women/17 men) were assigned to group B, patients who had either total parathyroidectomy with autotransplantation or subtotal total parathyroidectomy with preservation of parathyroid tissue in situ. Parameters measured included demographics, perioperative and follow-up biochemistry tests, operative time, postoperative complications, length of hospital stay, patients’ compliance with the postoperative calcium and 1,25 dihydroxy-viatmin D supplementation regimen, symptom relief, and presence of recurrence. Mean operative times were 103 and 122 min (P = 0.007); postoperative complication rates were 18.2% and 12.0% (P = 0.563); mean hospital stays were 6 and 9 days (P = 0.259); adequate patient compliance with the postoperative calcium and 1,25 dihydroxy-viatmin D regimens were 84.1% and 78.0%, respectively (P = 0.6); symptom relief rates were 88.6% and 80.0% (P = 0.277). Recurrence rates over 60 months in group A and group B were 4.5% and 18.0%, resectively (P = 0.028 by Kaplan-Meier analysis). Because of the lower recurrent rate and shorter operative time, total parathyroidectomy without autotransplantation may be an option for treating patients with symptomatic secondary hyperparathyroidism who are not expected to receive kidney transplantation.

Background: The purpose of this study was to report our experience in management of emphysematous cholecystitis. Patients and Methods: We reviewed the medical records of 11 cases (6 male, 5 female)

We propose a novel framework for reconstructing 3Dliver vessel model from CT images. The proposed algorithm consists of vessel detection, vessel tree reconstruction and vessel radius estimation. First, we employ the tubular-filter based approach to detect vessel structure and construct the minimum spanning tree to bridge all the gaps between vessels. Then, we propose an approach to estimate the radius of the vessel at all vessel centerline voxels based on the local patch descriptors. Using the proposed 3D vessel reconstruction system can provide detailed 3D liver vessel model very efficiently. Our experimental results demonstrate the accuracy of the proposed system for 3D liver vessel reconstruction from 3D CT images.

A review of the literature pertaining to percutaneous transhepatic cholangioscopic lithotomy (PTCSL) showed that more than 50% of reported patients had undergone earlier biliary surgery.A retrospective study investigated 74 patients undergoing initial PTCSL for hepatolithiasis who had undergone no prior biliary surgery or manipulation. The patients were followed for 1 to 23 years after PTCSL for effective evaluation of the procedure outcome.Complete clearance of hepatolithiasis was achieved for 61 (82%) patients. The incomplete clearance rate was higher for patients with intrahepatic duct stricture (11/37 [30%] vs 2/37 [5%]; p0.05), although it showed no relation to the actual lobar distribution of hepatolithiasis (left: 7/41 [17%] vs right: 2/11 [18%] vs bilateral: 4/22 [18%]; p0.05). The recurrence rate for hepatolithiasis also was higher for patients with intrahepatic duct stricture (18/26 [69%] vs 13/35 [37%]; p0.05), but the recurrence rate showed no relation to the lobar distribution of hepatolithiasis (left: 18/34 [53%] vs right: 4/9 [44%] vs bilateral: 9/18 [50%] p0.05) or the presence of gallbladder stones (5/12 [42%] vs 26/49 [53%]; p0.05). Patients showing the coexistence of retained or recurrent hepatolithiasis demonstrated a higher incidence of recurrent cholangitis (57% [13/23] vs 14% [7/51]; p0.01) or cholangiocarcinoma (17% [4/23]) vs 0% [0/51]; p0.01).The findings show that PTCSL is effective for treating primary hepatolithiasis, and that complete stone clearance is mandatory to diminish the sequelae of hepatolithiasis. Intrahepatic duct stricture was the main factor contributing to incomplete clearance and stone recurrence.

SummaryBackground: Stump appendicitis is a rare delayed complication of appendectomy. Several diseases present with right lower abdominal pain, and therefore it is occasionally difficult to make a differential diagnosis, especially in patients with a history of appendectomy. In this paper we present our experiences with acute appendicitis following an appendectomy. Patients and Method: We selected five cases from January 2002 to December 2010. The clinical characteristics, imaging studies, treatment, and outcome were recorded. Results: All patients presented with abdominal pain (4 patients with fever). The mean duration of onset was 2 days. All patients had a history of ruptured appendicitis (2 patients showed a combination with generalized peritonitis). The mean duration since the previous appendectomy was 7.54 years. 4 patients underwent an abdominal ultrasound, and all patients underwent abdominal computed tomography, showing again a ruptured appendicitis. 4 of 5 patients had a stump appendicitis. All of the patients showed a good prognosis following surgery. Conclusions: The stump following an appendectomy should be shortened as much as possible. However, sometimes recurrent appendicitis with perforation will develop in patients with complete resection of the appendix. Stump appendicitis is associated with a history of ruptured appendicitis.

AIM: The aim of this study was to evaluate the effectiveness of technetium-99m tetrofosmin (Tc-99m TF) single photon emission computed tomography (SPECT) of the neck and chest to detect metastatic lesions in papillary thyroid carcinoma (PTC) after near total thyroidectomy and radioiodine (I-131) treatment in patients who present with elevated serum human thyroglobulin (hTg) levels but negative I-131 whole body scan (WBS). MATERIALS AND METHODS: Twenty patients with PTC treated by near total thyroidectomy and I-131 treatments were included in this study. All 20 patients had negative I-131 WBS results and elevated hTg levels (hTg 2.0 μIU/ml) under thyroid-stimulating hormone (TSH) stimulation (TSH 30 μIU/ml). Nineteen of the 20 cases were confirmed to have metastases by operation/biopsy histopathological findings or clinical follow-up longer than 1 year by additional morphological imaging techniques. The remaining patient has been followed up closely and has been disease free for 10 months. Tc-99m TF SPECT was performed to detect metastatic lesions. RESULTS: Tc-99m TF SPECT demonstrated lesions in 11/19 patients; a sensitivity of 57.9%. Tc-99m TF SPECT failed to demonstrate lesions in eight patients including smaller lymph nodes and miliary lung metastases. CONCLUSIONS: We conclude that Tc-99m TF SPECT is a useful additional tool to detect metastatic lesions in PTC with elevated hTg but negative I-131 WBS. However, smaller lymph nodes and miliary lung metastases may be missed.

Our preliminary studies found technetium-99m tetrofosmin (Tc- TF) chest imaging was related to Pgp or MRP1 expression and successfully predict chemotherapy response and in SCLC in human. However, there was no published literature to study relationship of Tc-TF chest images and LRP expression in SCLC patients. Therefore, the aim of this study was to investigate the relationships among Tc- TF accumulation in untreated small cell lung cancer (SCLC), the expression of P-glycoprotein (Pgp), multidrug resistance related protein-1 (MRP1), and lung resistance-related protein (LRP), as well as the response to chemotherapy in patients with untreated SCLC. Thirty patients with SCLC were studied with chest images 15 to 30 minutes after intravenous injection of Tc-TF before chemotherapeutic induction. Tumor-to-background (T/B) ratios were obtained on the static and plantar Tc-TF chest images. The response to chemotherapy was evaluated upon completion of chemotherapy by clinical and radiological methods. These patients were separated into 15 patients with good response and 15 patients with poor response. No significant differences of prognostic factors (Karnofsky performance status, tumor size, or tumor stage) were found between the patients with good and poor responses. Immunohistochemical analyses were performed on multiple nonconsecutive sections of biopsy specimens to detect Pgp, MRP1, and LRP expression. The difference in T/B ratios on the Tc-TF chest images of the patients with good versus poor response was significant. The differences in T/B ratios of the patients with positive versus negative Pgp expression and with positive versus negative MRP1 expression were significant. The difference in T/B ratios of the patients with positive versus negative LRP expression was not significant. We concluded that Tc-TF chest images could accurately predict chemotherapy response of patients with SCLC. In addition, The Tc-TF tumor uptake was related to Pgp or MRP1 but not LPR expression in SCLC.

Papillary carcinomas are the most common thyroid malignancies. They invade the regional lymphatics and metastasize frequently to local lymph nodes in the neck. Distant metastasis, generally to the lungs, is also common.The aim of this study is to evaluate the effectiveness of F18-fluorodeoxyglucose (FDG) positron emission tomography (PET) to detect metastatic lesions in patients with papillary thyroid carcinomas (PTC) after nearly total thyroidectomy and I-131 treatments who present with elevated human serum thyroglobulin (hTg) levels but negative 1-131 whole body scan (WBS). Twenty patients with PTC who underwent nearly total thyroidectomy and radioiodine treatments were included in this study.All of the 20 patients had negative I-131 WBS results and elevated hTg levels (hTgor = 2.0 microIU/mL) under thyroid-stimulating hormone (TSH) stimulation (TSHor = 30 microIU/mL).FDG-PET was perform to detect metastatic lesions. F18-fluorodeoxyglucose-PET could detect hypermetabolic lesions in 17 patients but failed to demonstrate miliary pulmonary metastases in two patients. No definite lesion was found in FDG-PET, x-ray chest computed tomography (CT) and other imaging studies of the remaining one patient This study showed that FDG-PET is a useful tool in detecting metastatic lesions in PTC with elevated hTg but negative I-131 WBS. However, miliary lung metastases may be missed in FDG-PET. In this circumstance, chest CT should be included in the follow-up protocol.

Neutrophilic leukocytosis above 50 × 109/l exclude leukemia, defines a leukemoid reaction (LR). It is associated with several diseases. Although it simulates leukemia, most of the causes are benign. Tumor-related LR is more common. It is associated with ranulocyte colony-stimulating factor (G-CSF) secreted by the tumor cells. A 38-year-old woman, presented with advanced breast cancer and leukocytosis (79.9 × 103/uL) was found. After completion of MRM, the condition of leukocytosis subsided. Two months later, tumor local relapse was found and white blood cells (WBC) rose again. After completion of wide excision, the condition of leukocytosis subsided again. We think this case was associated with leukemoid reaction.

To evaluate the clinical benefits and disadvantages of adding metoclopramide to tramadol for patient-controlled analgesia (PCA).Forty adult patients, undergoing elective arthroplasties, were recruited into this prospective, randomized, double-blind study. During general anesthesia all patients received 2.5 mg x kg(-1) of tramadol as a loading dose at the beginning of wound closure. In the postanesthesia care unit (PACU) patients were randomly allocated to receive PCA containing either 20 mg tramadol + 1 mg metoclopramide per millilitre (n = 20, Group T+M) or tramadol 20 mg per millilitre (n = 20, Group T). The PCA setup was 1 mL/bolus with a lockout interval of five minutes. A blinded investigator assessed the vital signs, visual analogue scale, and severity of postoperative nausea and/or vomiting in the PACU. The PCA demand and delivery, overall satisfaction rate and adverse effects were recorded in the PACU and on postoperative days one and two.Nausea/vomiting scores were more severe (1.7 +/- 1.0 vs 0.2 +/- 0.5, 2.3 +/- 1.2 vs 0.6 +/- 0.6, 1.9 +/- 0.9 vs 0.2 +/- 0.5, at 12 hr, 18 hr, 24 hr, respectively, P0.05) and more frequent (7/20 vs 1/20, 5/20 vs 0/20 for nausea and vomiting respectively, P0.05) on postoperative day one in Group T compared to Group T+M. However, the incidence of sedation was higher in Group T+M (7/20 vs 1/20, P0.05).The incidence and severity of nausea/vomiting decreased if metoclopramide was added to tramadol for PCA. An increased incidence of sedation was noticed with this drug combination.

Background Findings related to the influence of the −160C → A promoter polymorphism and haplotypes of the E-cadherin (CDH1) gene have not been consistent in previous studies regarding the risk for sporadic gastric cancer. Investigators in most previous studies detected those genotypes using restriction fragment length polymorphism analysis. Therefore, we conducted a case–control study to investigate the association of the CDH1 − 160C → A promoter polymorphism and haplotypes for cancer risk related to sporadic diffuse and intestinal gastric cancer by direct sequencing analysis. Methods We included 107 diffuse gastric cancer cases, 60 intestinal gastric cancer cases and 134 controls. The genotypic polymorphisms in the −160 promoter region, exons and intron–exon boundaries of CDH1 were detected by direct sequencing analysis. Genotype frequencies were compared. The CDH1 − 160C → A promoter polymorphism and four polymorphisms (48 + 6 T → C, 2076C → T, 2253C → T and 1937–13 T → C) were included in the haplotype analyses, which were estimated using the expectation–maximization algorithm. Results Compared to controls, the frequency of the −160A allele was significantly higher in diffuse gastric cancer cases (P = 0.005), but it was not significantly different in intestinal gastric cancer cases (P = 0.119). Two sets of three-marker haplotypes (−160C → A, 48 + 6 T → C, 2076C → T and −160C → A, 1937–13 T → C, 2253C → T) were associated with the risk of diffuse gastric cancer (P = 0.011 and P = 0.042, respectively). Conclusion Based on direct sequencing analysis, our findings suggest that the CDH1 − 160C → A promoter polymorphism and haplotypes play significant roles in cancer risk for sporadic diffuse gastric cancer, but not for intestinal gastric cancer, in a Taiwanese population.

BACKGROUND The prognosis of anaplastic thyroid carcinoma (ATC) has been dismal. The objective of this study was to identify prognostic factors in patients who had prolonged survival. METHODS Patients with ATC were identified from a computer database at a tertiary referral center. Univariate and multivariate analyses for survival differences were performed using the Kaplan–Meier log-rank statistic and the Cox proportional hazards model, respectively. RESULTS Of the 33 evaluable patients, median survival was 3.8 months. Median age was 69 years. Prior goiter was present in 6 patients (18%), and 6 (18%) had prior thyroid carcinoma. Median tumor size was 6 cm, and 12 (36%) had adjacent well-differentiated carcinoma. Of the 26 patients who underwent neck exploration, 8 patients were potentially cured and received postoperative chemotherapy and irradiation; 4 (50%) were surgically macroscopically free of disease, and 4 (50%) patients had minimal residual disease after total thyroidectomy and resection of tumor adherent to adjacent structures. Four of these 8 patients survived longer than 2 years; their 5-year survival estimate was 50%. Eighteen patients underwent palliative resection of neck disease, leaving macroscopic residual disease or distant metastases; postoperative adjuvant chemotherapy and irradiation were administered in 16 of these 18 patients. Seven patients were treated with only chemotherapy and irradiation. In patients treated with potentially curative resection, median survival was 43 months compared with 3 months with palliative resection (P =0.002); the median survival of 3.3 months with only chemotherapy and irradiation was no different than palliative resection (P =0.63). No association was found between survival and age, prior goiter, prior thyroid carcinoma, adjacent differentiated carcinoma, or tumor size. CONCLUSIONS Although the prognosis of most patients with ATC continues to be poor, complete resection of ATC combined with postoperative adjuvant chemotherapy and irradiation resulted in long-term survival, even with persistent minimal disease that remained on vital structures. An aggressive attempt at maximal tumor debulking followed by adjuvant therapy was found to be warranted in patients with localized ATC. Cancer 2001;91:2335–42. © 2001 American Cancer Society.

The purpose of this study was to report our results of totally implantable access ports (TIAP) approached via the femoral vein. Patients and Methods: Seven patients were enrolled. The mean age was

Background: Hepatic resection for multiple hepatocellular carcinomas (HCCs) involving both lobes of the liver is rarely recommended because of high operative risks and low radicality. Thus the justification of hepatic resection for bilobar multicentric HCC remains undefined. Methods: Two hundred eleven patients with HCC, who underwent curative hepatic resection, were studied retrospectively. The patients were divided into two groups. Group A consisted of 39 patients with bilobar (both sides of Cantlie's line) multicentric HCCs. Group B consisted of 172 patients with HCC with solitary or unilobar lesions. The backgrounds and resectional results of patients in groups A and B were compared. Results; Patients in group A usually required multiple separate liver resections and a longer operative time. However, the operative blood loss, amount of blood transfused, and operative morbidity and mortality rates were not significantly different. Patients in group A showed higher incidences of associated satellite nodules, microscopic vascular invasion, and a lack of capsules. The 6-year disease-free and actuarial survival rates of patients in groups A and B were 30.5% and 41.8% (p = 0.17) and 42.9% and 51.4% (p = 0.12), respectively. For patients in group A the presence of satellite nodules in any resected tumor was the only independent unfavorable feature that influenced the actuarial survival rate after multivariate analysis. Conclusions: Liver resection is justified for bilobar multicentric HCCs in selected patients, if the tumors can be totally resected. Postoperative adjuvant therapies should be considered when satellite nodules are present in any resected tumor. (Surgery 1998;123:270-7.)

Laparoscopic surgery is indispensable from the current surgical procedures. It uses an endoscope system of camera and light source, and surgical instruments which pass through the small incisions on the abdomen of the patients undergoing laparoscopic surgery. Conventional laparoscope (endoscope) systems produce 2D colored video images which do not provide surgeons an actual depth perception of the scene. In this work, the problem was formulated as synthesizing a stereo image of the monocular (conventional) laparoscope image by incorporating into them the depth information from a 3D CT model. Various algorithms of the computer vision including the algorithms for the feature detection, matching and tracking in the video frames, and for the reconstruction of 3D shape from shading in the 2D laparoscope image were combined for making the system. The current method was applied to the laparoscope video at the rate of up to 5 frames per second to visualize its stereo video. A correlation was investigated between the depth maps calculated with our method with those from the shape from shading algorithm. The correlation coefficients between the depth maps were within the range of 0.70-0.95 (P

Operation in minimally invasive surgery is more difficult since the surgeons perform operations without haptic feedback or depth perception. Moreover, the field of view perceived by the surgeons through endoscopy is usually quite limited. The goal of this paper is to allow surgeons to see wide-angle images from endoscopy without the drawback of lens distortion. The proposed distortion correction process consists of lens calibration and real-time image warping. The calibration step is to estimate the parameters in the lens distortion model. We propose a fully automatic Hough-entropy-based calibration algorithm, which provides calibration results comparable to the previous manual calibration method. To achieve real-time correction, we use graphics processing unit to warp the image in parallel. In addition, surgeons may adjust the focal length of a lens during the operation. Real-time distortion correction of a zoomable lens is impossible by using traditional calibration methods because the tedious calibration process has to repeat again if focal length is changed. We derive a formula to describe the relationship between the distortion parameter, focal length, and image boundary. Hence, we can estimate the focal length for a zoomable lens from endoscopic images online and achieve real-time lens distortion correction.