Female population perception of conventional laparoscopy, transumbilical LESS, and transvaginal NOTES for cholecystectomy

Background: Recent population survey has shown a preference for transumbilical laparoendoscopic single-site surgery (U-LESS) compared with natural orifice transluminal endoscopic surgery (NOTES) for cholecystectomy, assuming similar surgical risk. This study was designed to evaluate the perception and preference of women regarding conventional laparoscopy, U-LESS, and transvaginal NOTES (TV-NOTES) with particular interest to access perception. Methods: An anonymous questionnaire on laparoscopic, U-LESS, and TV-NOTES cholecystectomy, without regards to risks or advantages, was given to female medical/paramedical staff (n=100), patients (n=100), and the general population (n=100). Women participants (median age, 35 (range, 16-79) years) were queried about preference, perception of the different accesses, and personal informations. Of the respondents, 54% had children, 79% had stable relationships, and 96% were sexually active (vaginal intercourse). Results: With similar operative risk, 87% preferred U-LESS, 4% TV-NOTES and 8% laparoscopy. LESS/NOTES choice was influenced by a desire of improved cosmetics (82%) and lower pain (44%). 96% had worries regarding transvaginal access, among them: dyspareunia (68%), decreased sensibility during intercourse (43%), refuse of short-term sexual abstinence (40%), and infertility (23%). Transumbilical access evocated worries in 35%: umbilical pain (19%), postoperative umbilical sensibility (15%), and incisional hernia (11%). Postoperative intercourse abstinence after TV-NOTES evocated worries in 76% (defined as 3weeks in survey): feel less attractive (40%), less feminine (32%), tension with their intimate (35%), lover non-acceptation (20%), possible abortion of new relationship (26%), and feel less comfortable socially (16%). Conclusions: The high acceptation rate for U-LESS approach compared with TV-NOTES may be related to fears regarding postoperative sexuality and fertility. The importance of temporary postoperative sexual abstinence (vaginal intercourse) is high and may be difficult to influence. Future research on TV-NOTES should focus on the access risk to be able to scientifically reassure our patients. For now, U-LESS seems to be favor compared with TV-NOTES for cholecystectomy in female patient

Population perception of surgical safety and body image trauma: a plea for scarless surgery?

Background: Laparoendoscopic single-site surgery (LESS) and natural orifice translumenal endoscopic surgery (NOTES) are prospected as the future of minimally invasive surgery. While scarless surgery (NOTES and LESS) is gaining increasing popularity, perception of these approaches should be investigated. Methods: An anonymous questionnaire describing laparoscopy, LESS, and NOTES was given to medical staff (n=120), paramedical staff (n=100), surgical patients (n=100), and the general population (n=100). The survey participants (median age, 37 years; range, 18-81years) were queried about their expectations for surgical treatment and their approach preference. Results: The first concern of the survey responders was the risk of surgical complications (92%). When asked about the respective importance of surgical safety, cure, and cosmetics, cure was placed first by 74%, safety by 33%, and cosmetics by 3%. These results were not influenced by sex, age, prior surgery or endoscopy, or education. When operative risk was similar, 90% of the participants preferred a scarless approach (75% preferred LESS and 15% preferred NOTES) to laparoscopy. The scarless approach preference was significantly higher among the younger participants (age <40years; p=0.026), whereas sex showed no influence. The LESS preference was significantly higher among patients and the general population (86%) than among medical (67%) and paramedical (70%) staffs (p<0.001). A decreasing trend of preference for LESS and NOTES was observed with increased procedural risks. Conclusion: Although cure and safety remain the main concern, the population has a favorable perception of scarless surgery, even in the case of increased procedural risk, with LESS favored over NOTES. Such a popular adoption of scarless surgery should warrant the promotion of further research, technological innovations, and the establishment of surgeon training to improve its safet

Single Port Access Laparoscopic Cholecystectomy (with video)

Background: Single port access (SPA) surgery is a rapidly evolving field due to the complexity of NOTES (natural orifice translumenal endoscopic surgery). SPA combines the cosmetic advantage of NOTES and possibility to perform surgical procedure with standard laparoscopic instruments. We report a technique of umbilical SPA cholecystectomy using standard laparoscopic instruments and complying with conventional surgical principle and technique of minimally invasive cholecystectomy. Methods: Preliminary, prospective experience of SPA cholecystectomy in 11 patients (median age, 46 (range, 27-63) years) scheduled for cholecystectomy was evaluated. Diagnoses for cholecystectomy were: symptomatic gallbladder lithiasis (n=7), previous acute cholecystitis (n=3), and biliary pancreatitis (n=1). Results: SPA cholecystectomy was feasible in all patients (median body mass index, 24 (range, 20-34) kg/m2) who were scheduled for preliminary experience using conventional laparoscopic instruments. Median operative time was 52 (range, 40-77) minutes. Intraoperative cholangiography was performed in all patients, except one, and was considered normal. No peroperative or postoperative complications were recorded. Median hospital stay was less than 24 h. Conclusions: SPA cholecystectomy is feasible and seems to be safe when performed by experienced laparoscopic surgeons using standard laparoscopic instrumentation. SPA cholecystectomy may be safer than the NOTES approach at this time. It has to be determined whether this approach would benefit patients, other than cosmesis, compared with standard laparoscopic cholecystectom

Enhanced recovery programs after colorectal surgery in two high-risk populations: elderly patients and after emergency surgery

Enhanced recovery programs (ERPs) are multimodal, multidisciplinary perioperative care programs designed to reduce perioperative surgical stress, decrease postoperative morbidity, shorten hospital stay, reduce health care costs, improve patient well-being and satisfaction. ERPs reduce postoperative complications by 50%, resulting in shorter hospital stay. ERPs were later extended to other digestive surgery and surgical specialties with similar results. Recently, ERPs showed a beneficial impact on 5-year survival after colorectal cancer, and on racial disparities. ERPs have also proved useful in some specific high-risk patient populations, such as elderly patients and after emergency colorectal surgery. This work set out to review the EBM literature concerning the feasibility and efficacy of ERP in elderly patients and after emergency colorectal surgery. The results of our RCT comparing a dedicated ERP to non-selected elderly patients after colorectal surgery and our prospective cohort studies are commented in a second in the light of the literature review

Dissection coronarienne spontanée et déficit en lysyl oxydase

BORDEAUX2-BU Santé (330632101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Cost of temozolomide therapy and global care for recurrent malignant gliomas followed until death

Effectiveness and costs of care and treatment of recurrent malignant gliomas are largely unknown. In this study, 49 patients (32 males, 17 females; mean age, 49; age range, 23–79) were treated with temozolomide (TMZ) for recurrent or progressive malignant gliomas after standard radiation therapy. Cost assessment (payer’s perspective) singled out treatment for first recurrence and all costs of care until death. We computed personnel costs as wages; drugs, imaging, and laboratory tests as prices; and hospitalizations as day rates. Patients were administered a median of five TMZ cycles at recurrence. Drug acquisition costs amounted to €2206 per cycle (76% of total costs). Seven patients showed no second recurrence (two are still alive), 16 received no further chemotherapy and died after 3.9 months, and 26 received second-line chemotherapy. After the second progression, median survival was 4.0 months (95% confidence interval, 1.8–6.1). Overall monthly costs of care varied between €2450 and €3242 among the different groups, and median cost-effectiveness and cost utility ranged from €28,817 to €38,450 and from €41,167 to €53,369 per life of year and per quality-adjusted life-year gained, respectively. We conclude that despite high TMZ drug acquisition costs, care of recurrent malignant gliomas is comparable to other accepted therapies