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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.

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.

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.

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)

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.

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.)

Revisional surgery may be required in a high percentage of patients (up to 30 %) after laparoscopic adjustable gastric banding (LAGB). We report our institutional experience with revisional surgery.From January 1996 to November 2011, 90 patients underwent revisional surgery after failed LAGB. Both Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) were proposed. In the presence of gastroesophageal reflux disease, esophageal dysmotility, hiatal hernia, or diabetes, RYGB was preferentially proposed.In two cases, revisional surgery was aborted due to local severe adhesions. Eighty-eight patients (74 females; mean age 42.79 ± 10.03 years; mean BMI 44.73 ± 6.19 kg/m(2)) successfully underwent revisional SG (n = 48) or RYGB (n = 40). One-stage surgery was performed in 29 cases. Follow-up rate was 78.2 % (n = 61) and 40.9 % (n = 36) at 12 and 24 months respectively. One major complication after SG (staple-line leakage) was observed. Overall postoperative excess weight loss (%EWL) was 31.24, 40.92, 52.41, and 51.68 % at 3, 6, 12, and 24 months of follow-up respectively. There was a statistically significant higher %EWL at 1 year in patients50 years old (55.9 vs. 41.5 % in patients50 years old; p = 0.01), of female gender (55.22 vs. 40.73 % in male; p = 0.04), and in patients in which the AGB was in place for5 years (57.09 vs. 47.43 % if5 years p = 0.02).Revisional surgery is safe and effective. Patients50 years, of female gender, and with the AGB in place for5 years had better %EWL after revisional surgery.

This study aims to report glycolipid changes after sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) in the setting of a prospective randomized clinical trial.One hundred patients were randomly assigned to RYGB (n = 45) and SG (n = 55). Fasting glucose, insulin, glycated hemoglobin (HbA1c%), triglycerides, and serum cholesterol (total, HDL, and LDL) were evaluated at inclusion and after 1, 3, 6, and 12 months. The index for homeostasis model assessment of insulin resistance (HOMA-IR) and β cell function (HOMA-B) were assessed.Mean postoperative 1-, 3-, 6-, and 12-month excess weight loss was 25.39, 43.47, 63.75, and 80.38 % after RYGB and 25.25, 51.32, 64.67, and 82.97 % after SG, respectively. Mean fasting glucose and fasting serum insulin were similarly and statistically significantly reduced in both RYGB and SG. Mean HOMA-IR improved in both groups, particularly in case of high preoperative values, and mean HOMA-B improved at 1 year after RYGB. HbA1c% dropped from 5.66 % (SD = 0.61) to 5.57 % (SD = 0.32) after RYGB and from 5.64 % (SD = 0.43) to 5.44 % (SD = 0.43) after SG. Total cholesterol was significantly higher at 1 month (p = 0.04), 3 months (p = 0.03), and 1 year (p = 0.005) after SG as compared to RYGB. LDL cholesterol decreased significantly after RYGB at 1 month (p = 0.03), 3 months (p = 0.0001), and 1 year (p = 0.0004) as compared to SG. HDL cholesterol was increased at 1 year in the RYGB group but not in the SG group. Triglycerides decreased similarly in both groups.Short-term glycemic control was comparable after SG and RYGB. An improved lipid profile was noted after RYGB in patients with abnormal preoperative values.

Surgical procedures have undergone considerable advancement during the last few decades. More recently, the availability of some imaging methods intraoperatively has added a new dimension to minimally invasive techniques. Augmented reality in surgery has been a topic of intense interest and research. Augmented reality involves usage of computer vision algorithms on video from endoscopic cameras or cameras mounted in the operating room to provide the surgeon additional information that he or she otherwise would have to recognize intuitively. One of the techniques combines a virtual preoperative model of the patient with the endoscope camera using natural or artificial landmarks to provide an augmented reality view in the operating room. The authors’ approach is to provide this with the least number of changes to the operating room. Software architecture is presented to provide interactive adjustment in the registration of a three-dimensional (3D) model and endoscope video. Augmented reality including adrenalectomy, ureteropelvic junction obstruction, and retrocaval ureter and pancreas was used to perform 12 surgeries. The general feedback from the surgeons has been very positive not only in terms of deciding the positions for inserting points but also in knowing the least change in anatomy. The approach involves providing a deformable 3D model architecture and its application to the operating room. A 3D model with a deformable structure is needed to show the shape change of soft tissue during the surgery. The software architecture to provide interactive adjustment in registration of the 3D model and endoscope video with adjustability of every 3D model is presented.

With the advances in laparoscopic instruments and surgical techniques, the use of laparoscopic appendectomy (LA) has been increasing rapidly in recent years. In this retrospective analysis, we aimed to determine the competitive edge of LA versus open appendectomy (OA) in different settings of disease complexity, gender, and age difference.A retrospective analysis of the patients diagnosed with acute appendicitis at Changhua and Chang-Bing Show-Chwan Memorial Hospitals from January 1, 2004 to December 31, 2009 was conducted. Trend and indication of OA and LA were recorded, combined with a comparison of medical costs, complication rates, wound infection rates, and hospital stays in different settings of disease complexity, gender, and age group.A total of 1366 appendicitis patients were enrolled, and the rate of LA use increased rapidly, from 8.1% in 2004 to 90.3% in 2009. The increased use of LA was seen in both the uncomplicated and complicated appendicitis patients and in both gender and age groups (pediatric, adult, and elderly). Compared with OA, LA was associated with a lower complication rate (9.5% versus 5.8%; P = .013), a lower wound infection rate (8.6% versus 4.2%; P = .001), and a shorter hospital stay (4.60 ± 3.64 versus 4.06 ± 1.84 days; P = .001), but a higher mean cost (32,670 ± 28,568 versus 37,567 ± 12,064 New Taiwan dollars). In the subgroup analysis, the patients with complicated appendicitis, female patients, and pediatric and elderly patients benefited from a reduced hospital stay. LA is about 15% more expensive than OA.LA is as safe and effective as OA in many settings of appendicitis and may be selectively advantageous in patients with complicated appendicitis and in elderly subgroups.

Introduction: A novel technique for secure placement of the anvil for mechanical stapled anastomosis in the proximal colon without exteriorization of the bowel is described. Methods: After standard laparoscopic segmental colonic mobilization, a needle-cannula from a percutaneous endoscopic gastrostomy kit is passed under direct endoscopic vision transparietally into the colon at the site intended for anvil placement. A wire passed through the cannula into the colon is then withdrawn endoscopically per ano. The stapler anvil is fixed to the wire and pulled back along the intestine before being positioned by traction through the needle puncture site. After distal specimen transection, a standard stapled anastomosis is performed. Results: The technique is illustrated in 2 patients undergoing laparoscopic sigmoidectomy by either a single port or a multiport procedure with transanal specimen extraction. Conclusion: By positioning the anvil without colon exteriorization, this technique enables pure intraperitoneal colonic anastomoses that may advance natural orifice operating.

Acute appendicitis is the most common acute abdomen in general surgery. Show-Chwan Memorial Hospital began an AITS/IRCAD laparoscopic training program in late May 2008. In this retrospective analysis, we surveyed the impact of the AITS training program on surgeons’ preference for open appendectomy (OA) versus laparoscopic appendectomy (LA). From January 1, 2004 to July 31, 2009, patients diagnosed with acute appendicitis in Changhua Show-Chwan Memorial Hospital and Chang-Bing Show-Chwan Memorial Hospital were retrospectively analyzed. Demographic data, laboratory examinations, surgical methods, hospital stay, and complication rate data were collected and analyzed. The LA rate and effect of surgeons’ preference before and after AITS were compared. In all, 1,267 patients (58.2% male and 41.8% female; mean age, 36.6 years) were diagnosed with acute appendicitis during this period. Among them, 78.9% of patients had uncomplicated and 21.1% complicated appendicitis; 784 patients (61.9%) underwent OA, and 465 (36.7%) received LA. In 2004, only 8.1% of patients underwent LA, but the number increased rapidly to 90.4% in 2009 (P

Corrosive tracheobronchitis and lung perforation after caustic aspiration are not very common. We present a case of life-threatening acute respiratory system corrosion after aspiration of caustic alkaline crystals during a suicide attempt. The patient survived the severe burns of the tracheobronchial tract and the liquefaction necrosis of the lung lobe by aggressive airway protection procedures and surgical resection of the destroyed lung. We report this rare, clinical condition and discuss the possible mechanism and its management.

Rupture of hepatocellular carcinoma (HCC) is a life-threatening complication. Peritoneal metastasis of HCC after spontaneous rupture was seldom noted. We report a case of intraperitoneal metastasis of HCC after spontaneous rupture. A previously asymptomatic 72-year-old man was admitted due to dull abdominal pain with abdominal fullness. He had a history of HCC rupture 10 mo ago and transarterial embolization was performed at that time. Abdominal computer tomography (CT) scan showed a huge peritoneal mass over the right upper quadrant area. Surgical resection was arranged and subsequent microscopic examination confirmed a diagnosis of moderately-differentiated HCC.

The patency of patch-enlarged (capsule-shaped) brachial arteries for long-term hemodialysis access was evaluated retrospectively. Twelve brachial arteries were patched with polytetrafluoroethylene (PTFE) grafts (standard wall thickness), making 1 x 2 cm aneurysms proximal to the elbow joints in 10 patients (six men with six patches, four women with six patches; patient age: 53 to 76 years, mean age +/- SD: 65.4 +/- 8.5 years) between September 2001 and April 2002. Ten patches were needled for each hemodialysis session as blood-drawing ports. The port's 1-year primary patency rate was 90%, 2-year patency was 70%, and 3-year patency was 70%. Two patches were needled in each hemodialysis session for dialyzed blood infusion access; both clotted within 1 year, with intact vessel continuity. Patch enlargement (capsule-shaped) of the brachial artery with a PTFE graft can be used as a long-term blood-drawing access in selected patients. This novel access may help patients with central vein stenosis or occlusion (which some patients had) and may help patients who have comorbid conditions such as chronic congestive heart failure or liver cirrhosis with ascites.

Background Totally implantable access ports (TIAP) with cutdown method has few complications, but needs assessment of fluoroscopic system. Methods We present a method to confirm the position of TIAP catheter without fluoroscopic assessment. We use the cutdown method and trigger arrhythmia while introducing the TIAP catheter. Results This method was applied in 54 patients and no complications were found. Conclusions Checking the position by triggering arrhythmia while performing TIAP with cephalic vein cutdown in case of C-arm was not available is simple and safe. J. Surg. Oncol. 2007;96:436–437. © 2007 Wiley-Liss, Inc.

Laparoscopic adrenalectomy offers distinct benefits to patients and has now become the gold standard for the removal of adrenal lesions. Nonetheless, the procedure poses a challenge for surgeons in regards to the maneuverability of instruments, the two-dimensional operating field and the counterintuitive movements. This study reports our experience using the Zeus robotic surgical system in laparoscopic adrenalectomy compared with traditional laparoscopic adrenalectomy.From January 2003 to February 2005, a total of 12 patients were prospectively enrolled to receive robot-assisted laparoscopic adrenalectomy (RALA) or traditional laparoscopic adrenalectomy (TLA). The time necessary for robotic setup and operation was recorded, as well as complications, technical problems, postoperative hospital stay, morbidity, and mortality.Five RALA procedures and seven TLA were successfully completed. There was no significant difference between the groups in terms of age, body mass index, and tumor size. Resection times were longer in the RALA group (168.0 +/- 30.7 min vs. 131.4 +/- 29.0 min, p = 0.05). There were no perioperative complications. There was neither postoperative mortality nor morbidity at the time of discharge and during one year follow-up.RALA is as safe and technically feasible as TLA, It provides a real benefit for the surgeon with the three dimensional view, a comfortable sitting position, the elimination of the surgeon's tremor, and increased degrees of freedom of the operative instruments compared with TLA. However, patient outcomes and operative costs should be evaluated further.

Background and Aims: The aim of this study was to determine the prevalence and risk factors of gallstone disease (GSD) in an adult population of Taiwan through a population-based screening study. Methods: A cross-sectional community study in a rural village of Taiwan was conducted in 3333 Chinese adults (aged ≥18 years) undergoing ultrasonography. A questionnaire on personal history was completed to ascertain whether the removed gallbladder contained stones in all cholecystectomized subjects, the dietary habits (vegetarian/non-vegetarian diet), the history of GSD in the participant’s first-degree relatives, the history of gastrointestinal surgery (vagotomy, gastrectomy for peptic ulcer disease, or ileal resection), parity, and use of oral contraceptives. The demographic characteristics and biochemical parameters were recorded Results: The overall prevalence of GSD was 5.0% (4.6% in men, 5.4% in women) with no significant sex differences (men/women: odds ratio [OR] 0.71, 95% confidence interval [CI] 0.50–1.01, P = 0.058). Logistic regression analysis showed that increasing age (men: 40–64 years, OR 7.38, 95% CI 2.59–21.01, P

Minimally invasive surgery has revolutionized the treatment of gastrointestinal tumors. Submucosal tumors of the stomach can be resected using laparoscopic techniques. We report here a case of ectopic pancreas tissue in the gastric wall that was removed using robotic-assisted laparoscopic resection. The patient was a 15-year-old female who presented with abdominal discomfort and tarry stools. Laboratory analysis showed iron deficiency anemia. Preoperative endoscopy revealed a submucosal lesion in the posterior wall of the gastric high body. Intraoperative upper endoscopy clearly located the lesion. A robotic-assisted laparoscopic wedge resection of the putative gastric submucosal tumor was performed. The pathology results showed an ectopic pancreas. The patient had an uneventful recovery and we believe that this is a valid treatment option for this benign condition.

We previously established that a 5 mg x kg(-1) intraoperative dose can reduce the nausea/vomiting associated with tramadol patient-controlled analgesia (PCA). This study was conducted to identify the most appropriate initial dose to improve the quality of tramadol PCA.During general anesthesia, 60 patients undergoing knee arthroplasty were randomly allocated to receive 1.25 mg x kg(-1) (Group I), 2.5 mg x kg(-1) (Group II), 3.75 mg x kg(-1) (Group III), or 5 mg x kg(-1) (Group IV) tramadol. The emergence condition was recorded. The titration of additional tramadol 20 mg + metoclopramide 1 mg doses by PCA every five minutes was performed in the postanesthesia care unit (PACU) until the visual analogue scale (VAS) score wasor = 3. An investigator blinded to study group recorded the VAS and side effects every ten minutes.In the PACU, significantly more tramadol (8.4 +/- 3.1 vs 4.3 +/- 2.1, 2.5 +/- 1.8, and 0.4 +/- 0.3, P0.05), and a higher incidence (15/15 vs 5/15, 3/15, and 2/15, P0.05) of PCA use was observed in Group I compared to Groups II-IV. VAS was significantly higher in Group I than in Groups II-IV at zero and ten minutes (P0.05). Unexpected delayed emergence anesthesia (30 min) was observed in Group III (n = 1) and in Group IV (n = 2). Sedation was more important in Groups III and IV than in Groups I and II (P0.05).When considering efficacy and side-effect profile, 2.5 mg x kg(-1) of tramadol is the optimal intraoperative dose of this drug to provide effective postoperative analgesia with minimal sedation.

Background: Totally implantable access ports (TIAP) could be done in two methods: puncture of subclavian vein and cephalic vein cutdown. Cephalic vein cutdown method has fewer complications but has higher failure rates. We present a method to decrease the failure rates. Methods: We use the continuously injection with diluted heparin solution via catheter while introducing the TIAP catheter into the cephalic vein. Results: From January 2005 to January 2009, 20 patients were performed. This method was successfully applied in 11 patients with no complications. The other 9 patients were unsuccessfully and further underwent guidewire assisted. Conclusions: Continuously injection with diluted heparin solution via catheter while inserting TIAP catheter into the cephalic vein is safe and simple. It could be used for difficulties of insertion of TIAP and increased the successful rates of cephalic vein cut-down method.

We report a rare case of primary malignant mesothelioma of the greater omentum. To our knowledge, only one other such case has been described in the English literature. The patient was a 61-year-old Taiwanese woman without any history of exposure to asbestos, who presented with lower back pain. Abdominal sonography and computed tomography showed a 12 x 9 x 9-cm(3) mass occupying the lower abdomen. Laparotomy revealed a tumor in the greater omentum, invading the posterior wall of the uterus, without diffuse mesenteric thickening or multiple small nodules in the peritoneum. We performed en bloc resection of the mass, which involved omentectomy, hysterectomy, and bilateral salpingo-oophorectomy. Microscopically, the tumor cells were arranged in a tubulopapillary pattern lined by a single layer of uniform, cuboidal cells. A pattern of sclerotic stroma with irregular glandular elements was also recognized. Immunohistochemically, the tumor cells showed strong positivity for calretinin. The final pathologic diagnosis was malignant mesothelioma. The patient did not receive chemotherapy or radiotherapy, and has remained in good health without any evidence of recurrence for almost 3 years since her operation.

Background. The purpose of this study was to retrospectively evaluate technetium 99m tetrofosmin (Tc-TF) uptake in parathyroid adenomas and compare the results with their expression of multidrug resistance-mediated 170-kDa P-glycoprotein (Pgp). Methods. Twenty patients with larger parathyroid adenomas (> 1.5 g) and the other 40 patients with smaller parathyroid adenomas (0.5-1.5 g) underwent early and delayed (10-minute and 2-hour) Tc-TF parathyroid imaging before operation. In this retrospective study, immunohistochemical analyses were performed on multiple nonconsecutive sections of the 40 parathyroid adenomas and 40 normal control specimens (20 normal parathyroid glands and 20 normal thyroid specimens) to detect Pgp expression. Results. The Tc-TF parathyroid image accurately localized 17 larger and 16 smaller parathyroid adenomas, but not the remaining 3 larger and 4 smaller adenomas. The 17 larger and 16 smaller parathyroid adenomas with significant Tc-TF uptake on the delayed 2-hour parathyroid images revealed negative Pgp expression, but the 3 larger and 4 smaller adenomas without significant Tc-TF uptake, as well as 20 normal parathyroid glands and 20 normal thyroid specimens, revealed positive Pgp expression. Conclusions. Not only the size of parathyroid adenomas, but Pgp expression also limited the sensitivity of Tc-TF parathyroid image to localize parathyroid adenomas before the operation. (Surgery 2002;132:456-60.)

Alessandra D’Avanzo, Sareh Parangi, Eugene Morita, Nancy D. Perrier, Hurng± Sheng Wu, Allan E. Siperstein, Quan± Yang, Duh Patrick A. Treseler and Orlo H. Clark From the Endocrine Surgical Fellow, UCSF and aFederico IIo University of Naples, Naples, Italy, Department of Surgery, Beth Israel Medical Center, Boston, Mass, Department of Nuclear Medicine UCSF/Mt. Zion Medical Center, Department of Surgery, Wake Forest University School of Medicine, Taichung Veterans General Hospital± Division of General Surgery, Taichung 407, Taiwan, Department of General Surgery, The Cleveland Clinic Foundation, Department of Veteran Affairs, San Francisco, CA, Department of Pathology, UCSF/Mt. Zion Medical Center, Department of Surgery, UCSF/Mt. Zion Medical Center, San Francisco, CA, USA