Access for Laparoendoscopic Single Site Surgery

Laparoscopic surgery is the standard of care for many abdominal and pelvic operations and is widely applied today. LESS (Laparo-Endoscopic Single Site) surgery, originally attempted in the 1990s, is an advanced minimally invasive approach that allows laparoscopic operations to be undertaken through a small (<15 mm) incision in the umbilicus, a preexisting scar. The presence of a preexisting scar allows LESS surgery to be essentially scarless, which is the key benefit to LESS operations. Herein, we review our experience with over 500 LESS operations and discuss the key techniques to establishing access to the peritoneal cavity. We review the options for obtaining access, available instrumentation, common challenges and solutions for access. We conclude that LESS surgery is safe and provides outcomes with superior cosmesis relative to conventional laparoscopy. LESS surgery should be embraced, as patient demand is rapidly increasing

Prognostic significance of new onset ascites in patients with pancreatic cancer

BACKGROUND: The purpose of this study was to determine risk factors for development of malignant ascites and its prognostic significance in patients with pancreatic cancer. METHODS: A prospective database was queried to identify patients with pancreatic cancer who develop ascites. Stage at presentation, size, and location of primary tumor, treatment received and length of survival after onset of ascites were determined. RESULTS: A total of 15 patients were identified. Of which 4 patients (1 stage II, 3 stage III) underwent pancreaticoduodenectomy and manifested with ascites 2, 3, 24 and 47 months after surgery (tumor size 2.9 ± 1.32 cm). All but one of the remaining 11 patients (tumor size 4.4 ± 3.38 cm) presented with metastatic disease, and all developed malignant ascites 9 months after diagnosis, dying 2 months later. Resected patients lived longer before the onset of ascites, but not after. CONCLUSION: Once diagnosed, ascites in pancreatic cancer patients heralds imminent death. Limited survival should be considered when determining the aggressiveness of further intervention

Obesity portends increased morbidity and earlier recurrence following liver transplantation for hepatocellular carcinoma

AbstractBackgroundObesity has been associated with poor oncologic outcomes following pancreatoduodenectomy for pancreatic cancer. However, there is a paucity of evidence on the impact of obesity on postoperative complications, oncologic outcome and survival in patients with hepatocellular carcinoma (HCC) undergoing orthotopic liver transplantation (OLT).MethodsFrom a database of over 1000 patients who underwent OLT during 1996–2008, 159 patients with a diagnosis of HCC were identified. Demographic data, body mass index (BMI), perioperative parameters, recurrence and survival were obtained. Complications were grouped according to Clavien–Dindo grading (Grades I–V).ResultsThere were increased incidences of life‐threatening complications in overweight (58%) and obese (70%) patients compared with the non‐obese patient group (41%) (P < 0.05). Furthermore, the incidence of recurrence of HCC was doubled in the presence of overweight (15%) and obesity (15%) compared with non‐obesity (7%) (P < 0.05). Time to recurrence also decreased significantly. Differences in mean ± standard deviation survival in the overweight (45 ± 3 months) and obese (41 ± 4 months) groups compared with the non‐obese group (58 ± 6 months) did not reach statistical significance.ConclusionsThese findings indicate that BMI is an important surrogate marker for obesity and portends an increased risk for complications and a poorer oncologic outcome following OLT for HCC

Aszites, Pfortaderthrombose und hepatische Enzephalopathie bei Leberzirrhose: Aktuelle Therapieempfehlungen

Treatment of Ascites, Portal Vein Thrombosis and Hepatic Encephalopathy in Patients with Cirrhosis of the Liver Background: Ascites, portal vein thrombosis and hepatic encephalopathy are important complications of cirrhosis of the liver. Guidelines for the treatment of ascites have recently been published. Method: This manuscript summarizes up-to-date recommendations on the basis of the DGVS S3 guideline and of other guidelines as well as of the authors' experience. Results and Conclusions: TIPS (transjugular intrahepatic porto-systemic shunt) is the preferred treatment for refractory or recidivant ascites unless there are contraindications. The therapy of hepatorenal syndrome type 1 with albumin and the vasoconstrictor Terlipressin has been proven effective. Treatment of portal vein thrombosis comprises a strategy of anticoagulation, TIPS and liver transplantation. The most important therapeutic strategy for hepatic encephalopathy is the search for as well as the treatment of trigger events. Rifaximin is being increasingly used for the treatment and prophylaxis of hepatic encephalopathy

Endoscopic overtube

An over-tube was developed for receiving and guiding endoscopic instruments into a patient\u27s anus, through the colon, and into the peritoneum. The over-tube has a flexible sheath adapted for insertion into the anus through the colon and out the peritoneum of a patient. A stiffened region is used to protect the colonic wall from injury during insertion of medical instruments through the patient\u27s lower gastrointestinal tract. The proximal end of the over-tube is surrounded by two narrow inflatable balloons on either side of the colotomy to keep the device in place with its lumen open into the peritoneum and further prevent leakage of insufflation. The device may comprise two channels, one for duel channel endoscopes and larger medical instruments or single lumen endoscopes, and an additional channel for surgical instruments. A distal valve prevents insufflation leakage, making the device especially useful in NOTES surgeries