Laparoscopic Adrenalectomy: Where Do We Stand Now?

Laparoscopic adrenalectomy (LA) has become the procedure of choice for the surgical removal of the vast majority of small sized adrenal tumors (<= 6 cm), because of its significant and multiple advantages: reduced hospital stay and wound morbidity, decreased transfusion requirements, postoperative pain and complications. The role of LA in patients with large adrenal lesions or potential malignancy remains controversial. The aim of this article is to review the current and up-to-date surgical approaches for LA, which include: 1) transabdominal anterior or flank approach and 2) retroperitoneal technique with the patient in either lateral or prone position. Specific advantages and disadvantages are referred to for each of them. The choice of each of these techniques is determined particularly by the preference and the experience of the surgeon, but other objective criteria must be taken into consideration, such as the size of the adrenal and history of previous abdominal surgeries

Superior Mesenteric Artery Dissection after Extracorporeal Shockwave Lithotripsy

The use of shockwave lithotripsy is currently the mainstay of treatment in renal calculosis. Several complications including vessel injuries have been implied to extracorporeal shockwave lithotripsy. We report an isolated dissection of the superior mesenteric artery in a 60-year-old male presenting with abdominal pain which occurred three days after extracorporeal shockwave lithotripsy. The patient was treated conservatively and the abdominal pain subsided 24 hours later. The patient's history, the course of his disease, and the timing may suggest a correlation between the dissection and the ESWL

Morbid Obesity and Sleeve Gastrectomy: How Does It Work?

Laparoscopic sleeve gastrectomy is known to be a safe and effective procedure for treating morbid obesity and is performed with increasing frequency both in Europe and the USA. Despite its broad use, many questions about the remaining gastric tube diameter, its long-term efficacy, its effects on gastric emptying, and the hormones involved still remain to be answered. In order to use such a relatively new surgical procedure wisely, it is essential for every surgeon and physician to understand how sleeve gastrectomy acts in obesity and what its potential benefits on the patients’ metabolism are. This review focuses on the most important pathophysiologic questions referred to sleeve gastrectomy on the literature so far, in an attempt to evaluate the different issues still pending on the subject

Barrett's esophagus with high-grade dysplasia: Focus on current treatment options

High-grade dysplasia (HGD) in Barrett’s esophagus (BE) is the critical step before invasive esophageal adenocarcinoma. Although its natural history remains unclear, an aggressive therapeutic approach is usually indicated. Esophagectomy represents the only treatment able to reliably eradicate the neoplastic epithelium. In healthy patients with reasonable life expectancy, vagal-sparing esophagectomy, with associated low mortality and low early and late postoperative morbidity, is considered the treatment of choice for BE with HGD. Patients unfit for surgery should be managed in a less aggressive manner, using endoscopic ablation or endoscopic mucosal resection of the entire BE segment, followed by lifelong surveillance. Patients eligible for surgery who present with a long BE segment, multifocal dysplastic lesions, severe reflux symptoms, a large fixed hiatal hernia or dysphagia comprise a challenging group with regard to the appropriate treatment, either surgical or endoscopic

Circulating lymphangiogenic growth factors in gastrointestinal solid tumors, could they be of any clinical significance?

Metastasis is the principal cause of cancer mortality, with the lymphatic system being the first route of tumor dissemination. The glycoproteins VEGF-C and VEGF-D are members of the vascular endothelial growth factor (VEGF) family, whose role has been recently recognized as lymphatic system regulators during embryogenesis and in pathological processes such as inflammation, lymphatic system disorders and malignant tumor metastasis. They are ligands for the VEGFR-3 receptor on the membrane of the lymphatic endothelial cell, resulting in dilatation of existing lymphatic vessels as well as in vegetation of new ones (lymphangiogenesis). Their determination is feasible in the circulating blood by immunoabsorption and in the tissue specimen by immunohistochemistry and reverse transcription polymerase chain reaction (RT-PCR). Experimental and clinicopathological studies have linked the VEGF-C, VEGF-D/VEGFR3 axis to lymphatic spread as well as to the clinical outcome in several human solid tumors. The majority of these data are derived from surgical specimens and malignant cell series, rendering their clinical application questionable, due to subjectivity factors and post-treatment quantification. In an effort to overcome these drawbacks, an alternative method of immunodetection of the circulating levels of these molecules has been used in studies on gastric, esophageal and colorectal cancer. Their results denote that quantification of VEGF-C and VEGF-D in blood samples could serve as lymph node metastasis predictive biomarkers and contribute to preoperative staging of gastrointestinal malignancies. (C) 2008 WJG. All rights reserved

Outcome analysis of laparoscopic cholecystectomy in patients aged 80 years and older with complicated gallstone disease

Background: The aim of this study was to evaluate the outcome of laparoscopic cholecystectomy (LC) in octogenarians with complicated gallstone disease. Materials and Methods: This study was a retrospective analysis of prospectively collected data of 51 patients aged 80 years or older who underwent an LC for complicated gallstone disease between 2001 and 2006. This group was compared with 41 octogenarian patients with uncomplicated gallstone disease. Results: There were 51 patients (26 men) with a median ( range) age of 87 years ( range, 80-93) who underwent an LC for complicated biliary disease, including acute cholecystitis in 29 (57%), gallstone pancreatitis in 14 (27%), cholangitis in 4 (7.8%), and obstructive jaundice in 4 ( 7.8%). Significantly more patients in the complicated disease group underwent preoperative endoscopic retrograde cholangiopancreatography (33.3% vs. 12.1%; P = 0.026) The median operative time was 110 minutes ( range, 55-165) and this was significantly longer, compared to the uncomplicated disease group ( P = 0.031). Postoperative morbidity was 27.3%, a significantly higher rate, compared to the uncomplicated group (27.4% vs. 7.3%; P = 0.015) with zero mortality. The conversion rate was 7.8% and this was not significantly different from the uncomplicated disease group. The median length of hospital stay was 6 days, which was significantly longer than the uncomplicated disease group ( P = 0.021). Conclusions: The LC can be performed with acceptable morbidity in octogenarians with complicated gallstone disease. Early treatment of gallstone disease in this age group could further improve outcomes

Circulating lymphangiogenic growth factors in gastrointestinal solid tumors, could they be of any clinical significance?

Metastasis is the principal cause of cancer mortality, with the lymphatic system being the first route of tumor dissemination. The glycoproteins VEGF-C and VEGF-D are members of the vascular endothelial growth factor (VEGF) family, whose role has been recently recognized as lymphatic system regulators during embryogenesis and in pathological processes such as inflammation, lymphatic system disorders and malignant tumor metastasis. They are ligands for the VEGFR-3 receptor on the membrane of the lymphatic endothelial cell, resulting in dilatation of existing lymphatic vessels as well as in vegetation of new ones (lymphangiogenesis). Their determination is feasible in the circulating blood by immunoabsorption and in the tissue specimen by immunohistochemistry and reverse transcription polymerase chain reaction (RT-PCR). Experimental and clinicopathological studies have linked the VEGF-C, VEGF-D/VEGFR3 axis to lymphatic spread as well as to the clinical outcome in several human solid tumors. The majority of these data are derived from surgical specimens and malignant cell series, rendering their clinical application questionable, due to subjectivity factors and post-treatment quantification. In an effort to overcome these drawbacks, an alternative method of immunodetection of the circulating levels of these molecules has been used in studies on gastric, esophageal and colorectal cancer. Their results denote that quantification of VEGF-C and VEGF-D in blood samples could serve as lymph node metastasis predictive biomarkers and contribute to preoperative staging of gastrointestinal malignancies

Fibrinolytic and coagulation pathways after laparoscopic and open surgery: a prospective randomized trial

Tissue injury poses increased risk for postoperative thromboembolic complications. Laparoscopic surgery, by causing limited tissue injury, is associated with lower risk for thromboembolism than is open surgery. We conducted a prospective randomized study in order to detect potentially existing differences in activation of coagulation and fibrinolytic pathways between open and laparoscopic surgery. Forty patients with chronic cholelithiasis were randomly assigned to undergo open (group A) or laparoscopic cholecystectomy (group B). Blood samples were taken preoperatively, at the end of the procedure, and at 24 and 72 h postoperatively. Prothrombin time (PT), activated partial thromboplastin time (APTT), international normalized ratio (INR), platelets (PLT), soluble fibrin monomer complexes (F.S. test), fibrin degradation products (FDP), D-dimers (D-D), and fibrinogen (FIB) were measured and compared within each group and between groups: Thrombin-antithrombin complexes (TAT) and prothrombin fragments (F1 + 2) were measured at 24 and 72 h postoperatively. Demographics were comparable between groups. Immediately postoperatively, TAT and F1 + 2 were significantly higher in group A (p < 0.05). They also increased significantly postoperatively as compared with preoperative levels within each group (p < 0.05). D-dimers were significantly higher in group A (p < 0.01) immediately postoperatively. D-dimers also increased significantly postoperatively in group B as compared with preoperative levels (p < 0.001). FIB decreased slightly in both groups at 24 h postoperatively but there was a significant increase in group A (p < 0.01). Soluble fibrin monomer complexes (SFMC) were detected twice in group A and only once in group B. FDP levels over 5 mu g/ml were detected more often in group A (p < 0.05). There was not any case of thromboembolism or abnormal bleeding. Open surgery leads to higher activation of the clotting system than do laparoscopic procedures. Although of a lower degree, hypercoagulability is still observed in patients undergoing laparoscopic surgery and therefore routine thromboembolic prophylaxis should be considered