Adeline Germain

Radiofrequency ablation of unresectable liver tumors: factors associated with incomplete ablation or local recurrence.

BACKGROUND Radiofrequency ablation (RFA) of liver tumors is associated with a risk of incomplete ablation or local recurrence. METHODS One hundred sixty-eight patients with 311 unresectable liver tumors were included. Effects of different variables on incomplete ablation and local recurrence were analyzed. RESULTS There were 132 hepatocellular carcinomas and 179 liver metastases. Tumor size was 24 (±13) mm. Two hundred twenty-six tumors were treated percutaneously, and 85 through open approach (associated with liver resection in 42 cases). There was no mortality. Major morbidity rate was 7%. Incomplete ablation and local recurrence rates were 14% and 18.6%. Follow-up was 29 months. On multivariate analysis, factors associated with incomplete ablation were tumor size (>30 mm vs ≤30 mm, P = .004) and approach (percutaneous vs open, P = .0001). Factors associated with local recurrence were tumor size (>30 mm vs ≤30 mm, P = .02) and patient age (>65 years vs ≤65 years, P = .05). CONCLUSIONS RFA is effective to treat unresectable liver tumors. However, there is a risk of incomplete ablation when percutaneously treating tumors >30 mm. When tumor ablation is completely achieved, the main factor associated with local recurrence is tumor size >30 mm.

Serum aldosterone is correlated positively to parathyroid hormone (PTH) levels in patients with primary hyperparathyroidism

BACKGROUND Primary hyperparathyroidism is associated with an increased cardiovascular morbidity and mortality. However, mechanisms underlying this association are currently unclear. As there is clear evidence of the independent role of aldosterone on the cardiovascular system, the aim of this study was to evaluate aldosterone levels in patients with primary hyperparathyroidism. METHODS A prospective study of 134 consecutive patients with primary hyperparathyroidism before and 3 months after parathyroidectomy. RESULTS Pre-operative serum aldosterone and parathyroid hormone (PTH) levels were correlated positively in all patients (.238; P = .005). In the 62 patients (46%) that were not on antihypertensive medications, this correlation was stronger (.441; P = .0003). In the 72 patients (54%) treated with at least 1 antihypertensive medication, no correlation between preoperative aldosterone and PTH serum levels was observed. By multivariate analysis, pre-operative PTH level (.409; P = .005) was an independent predictor of aldosterone. Pre-operative PTH level >100 ng/L was an independent predictor of abnormally elevated plasma aldosterone level (odds ratio 3.5; P = .01). At 3 months after parathyroidectomy, no correlation was observed between postoperative PTH and aldosterone levels. CONCLUSION Aldosterone is correlated positively to preoperative PTH levels in patients with primary hyperparathyroidism. Aldosterone might be a key mediator of cardiovascular symptoms in patients with primary hyperparathyroidism.

Perioperative outcomes after totally robotic gastric bypass: a prospective nonrandomized controlled study

BACKGROUND Perioperative short-term outcomes could be improved after totally robotic Roux-en-Y gastric bypass (TR-RYGBP) compared with conventional laparoscopic gastric bypass. METHODS This is a nonrandomized controlled prospective study (N = 200) to evaluate perioperative short-term outcomes. The primary endpoint was to investigate risk factors for 30-day surgical complications. RESULTS Mean total operative time was shorter in patients who underwent TR-RYGBP (130 vs 147 minutes; P < .0001). However, postoperative surgical complications rate (13% vs 1%; P = .001), and mean overall hospital stay (9.3 vs 6.7 days; P < .0001) were higher after TR-RYGBP. By multivariate analysis, robotic surgery (hazard ratio [HR] = 15.1; 95% confidence interval [CI], 2.8 to 280; P = .01), and conversion to laparotomy (HR = 18.8; 95% CI, 1.7 to 250.8; P = .014) were independent risk factors for 30-day surgical complications. CONCLUSIONS Although robotic gastric bypass reduces mean operative time, TR-RYGBP is associated with an increased postoperative surgical complications rate and longer hospitalization.

Robot-assisted adrenalectomy.

Currently laparoscopic adrenalectomy (LA) is regarded as the preferred surgical approach for the management of most adrenal surgical disorders. Despite the benefits of LA, the procedure has shortcomings that are shared by other laparoscopic techniques. Commonly noted problems include the absence of 3-dimensional perception, reduced dexterity, and poor ergonomics for the surgeon. Recently, robotic technology has been introduced into laparoscopic clinical practice. The requirement for precise surgery in adrenalectomy is important, and the introduction of robotically assisted LA offers new possibilities. This review summarizes current available data regarding robotic adrenalectomy, including its indications, advantages, limitations, and comparison with conventional laparoscopic adrenalectomy. See the videos, Supplemental Digital Content 1, http://links.lww.com/SLE/A33, Supplemental Digital Content 2, http://links.lww.com/SLE/A34 and Supplemental Digital Content 3, http://links.lww.com/SLE/A35.

Urinary tract infections in hospitalized inflammatory bowel disease patients: a 10-year experience.

Background: Cystitis is the most common genitourinary complication in Crohns disease (CD). We assessed the prevalence of and risk factors for urinary tract infections (UTI) in inflammatory bowel diseases (IBD). Methods: Among the 1173 IBD patients of the “Nancy IBD cohort” seen between January 1, 2000 and December 31, 2009, 56 hospitalized patients had 76 documented UTI. Prevalence of UTI in IBD was calculated using rates of UTI among non‐IBD patients hospitalized during the same period. The cases were compared to 175 matched IBD patients without UTI hospitalized during the same period to identify risk factors for UTI. Results: Prevalence of UTI was 4% in IBD patients versus 3.3% in non‐IBD patients (P = 0.1). Prevalence of UTI was 4.5% and 2.1% in ulcerative colitis (UC) and CD patients, respectively (P = 0.6). Risk factors for UTI in CD patients were perianal disease (odds ratio [OR] = 2.28, 95% confidence interval [CI], 1.06–4.89; P = 0.04) and colonic disease (OR = 2.42, 95% CI, 1.05–5.58; P = 0.04). Male gender (OR = 0.38, 95% CI, 0.17–0.85, P = 0.02) and noncomplicated behavior (OR = 0.26, 95% CI, 0.11–0.60, P = 0.002) were protective factors against UTI in CD. In UC patients, age over 40 years (OR = 9.59, 95% CI, 1.93–47.74; P = 0.006) and disease duration over 11 months (OR = 10.77, 95% CI, 1.68–68.89, P = 0.01) were risk factors for UTI. Male gender was negatively associated with UTI (OR = 0.04, 95% CI, 0.01–0.36, P = 0.00006). Conclusions: Hospitalized IBD patients are not at increased risk of UTI. Risk factors for UTI include perianal disease and colonic disease in CD and age and longer disease duration in UC. (Inflamm Bowel Dis 2011;)

Robotic thyroid surgery using a gasless transaxillary approach: Cosmetic improvement or improved quality of surgical dissection?

In head and neck surgery, minimally invasive approaches have been typically avoided due to concerns about visualization, possible damage to vital structures, and limited availability of effective instrumentation. The incorporation of robotic technology in surgery is now an accepted fact, and because of the complexities of certain laparoscopic procedures, the extended capabilities offered by robotic technology have gained wide acceptance. We report the case of a patient who underwent a robotic total thyroidectomy using a gasless right transaxillary approach. This technique provides a high quality image leading to improved visualization of vital structures during thyroidectomy with the added advantage of avoidance of a neck incision. Several issues regarding this technique remain to be clarified and evaluated in multicenter studies: patient selection, surgeon training and learning curve, postoperative morbidity due to recurrent nerve and parathyroid injury, long term oncologic and cosmetic results. However, we believe that robotic thyroid surgery using a gasless transaxillary approach will advance the frontiers of minimally invasive endocrine surgery.

Long-term outcomes of robot-assisted laparoscopic rectopexy for rectal prolapse.

BACKGROUND: Robot-assisted laparoscopic rectopexy for total rectal prolapse is safe and feasible. Small series proved clinical and functional short-term results comparable with conventional laparoscopy. No long-term results have been reported yet. OBJECTIVE: The primary objective of the study was to evaluate long-term functional and anatomic results of robot-assisted laparoscopic rectopexy. The secondary objective was to evaluate the learning curve of this procedure. DESIGN: Monocentric study data, both preoperative and perioperative, were collected prospectively, and follow-up data were assessed by a telephone questionnaire. SETTINGS: The study was performed in an academic center by 3 different surgeons. PATIENTS: We evaluated all of the consecutive patients who underwent a robot-assisted laparoscopic rectopexy between June 2002 and August 2010. INTERVENTION: Rectopexy was performed with 2 anterolateral meshes or with 1 ventral mesh, and in 9 patients a sigmoidectomy was associated with rectopexy. MAIN OUTCOME MEASURES: The actuarial recurrence rate was evaluated using the Kaplan-Meier method. RESULTS: During the study period, 77 patients underwent a robot-assisted laparoscopic rectopexy, and the mean age was 59.9 years (range, 23–90 y). Average operating time was 223 minutes (range, 100–390 min); the learning curve was completed after 18 patients were seen. Two patients died of causes unrelated to surgery at 5 and 24 months. There were 5 conversions (6%) to open procedure. Overall morbidity was low and concerned only 8 patients (10.4%). Mean follow-up time was 52.5 months (range, 12–115 mo). Recurrences have been observed in 9 patients (12.8%). Preoperatively, 24 (34%) of the patients had constipation. Postoperatively, constipation disappeared for 12 (50%) of 24 and constipation appeared for 11 (24%) of 46 patients. Fecal incontinence decreased after surgery from Wexner score 10.5 to 5.1 of 20. LIMITATIONS: There was a lack of standardization of the surgical procedure. The study was monocentric. Seven patients (9%) were lost to follow-up. CONCLUSIONS: Long-term results of robot-assisted laparoscopic rectopexy are satisfying. Further studies comparing robot-assisted and conventional laparoscopy, including cost-effectiveness, are needed.

Surgical management of adrenal tumors

Laparoscopic adrenalectomy has become the preferred method for removal of almost all adrenal tumors. An important component in selecting patients for this operation is a thorough understanding of the clinical presentation (mainly hypertension) and diagnostic workup for the full variety of functioning and nonfunctioning adrenal tumors including genetic evaluation when necessary (MEN2, VonHippel-Landau [VHL], type 1 neurofibromatosis [NF1], succinate dehydrogenase mutations [SDH], and MEN1). The indications and contraindications for a laparoscopic approach are discussed with regard to each tumor type. Relevant literature about partial and bilateral adrenalectomy is also summarized. Main areas of controversy are discussed including the size threshold to avoid risk of adrenal capsular effraction and the appropriateness of laparoscopic resection for suspected and known malignancy. This article presents recent data to help the surgeon make well-informed decisions and to optimize the operative approach for a wide variety of adrenal pathologies (secreting vs. non-secreting, benign vs. malignant tumors).

Is intraoperative ultrasound still useful for the detection of colorectal cancer liver metastases

BACKGROUND Debate on the optimal mode of preoperative imaging in the management of colorectal liver metastases (CRLM) is ongoing and, despite its longstanding use, the precise role of intraoperative ultrasonography (IOUS) is not well established. This study evaluates the impact of IOUS in the era of high-quality, cross-sectional imaging techniques. METHODS All patients who underwent liver resection for CRLM in a tertiary care referral centre from January 2006 to December 2013 were included. All patients were submitted to computed tomography (CT) and/or liver magnetic resonance imaging (MRI) before surgery. Intraoperative US was performed mainly to detect previously non-diagnosed tumours that would change the surgical strategy. RESULTS A total of 225 liver resections were performed. Liver MRI and CT scans were available for 202 patients (89.8%) and 225 patients (100%), respectively. Radiological reports recorded 632 liver tumours in 219 patients (i.e. 2.9 lesions per patient). The median time between preoperative liver MRI and surgical resection was 36 days. Intraoperative inspection, palpation and US found 20 additional lesions in 18 patients (8.0%), in three of whom lesions were diagnosed only on IOUS (1.4%). Overall, only 12 of the 20 lesions were malignant. CONCLUSIONS Although CT and liver MRI are commonly used, IOUS alone allows the discovery of a few additional lesions that result in a change of surgical strategy in 1.4% of cases.

Prevalence of Bowel Damage Assessed by Cross-Sectional Imaging in Early Crohn's Disease and its Impact on Disease Outcome

Background and Aims Bowel damage in Crohns disease [CD] is defined as the presence of intestinal strictures, fistulas or abscesses. Early disease may represent a window of opportunity for timely intervention. We evaluated disease activity and severity by the Lémann Index [LI] and the Magnetic Resonance Index of Activity [MaRIA] score, and their prognostic value in early CD. Methods All consecutive patients diagnosed with CD in two referral centres, assessed by magnetic resonance imaging or computerized tomography, were prospectively included. Disease activity and bowel damage in early CD, the correlation between the LI and the MaRIA score, and the value of cross-sectional imaging findings in predicting disease progression were assessed. Statistical analyses employed time-to-event methods. Results We included 142 consecutive CD patients. Median time from diagnosis to baseline imaging was 0.3 years; median follow-up time was 4.9 years. At diagnosis, 39.4% of CD patients had bowel damage. At multivariable analysis, bowel damage and the LI were independent prognostic factors for intestinal surgery (hazards ratio [HR]: 3.21 and 1.11, respectively, p<0.001), and of CD-related hospitalization during patient follow-up [HR: 1.88, p=0.002, and 1.08, p<0.001, respectively]. Disease activity as expressed by the MaRIA score did not predict the disease course. The correlation between the LI and MaRIA score was weak [rho: +0.32; p<0.001]. Conclusion Four out of ten CD patients have bowel damage at the time of the first imaging study. The presence of bowel damage, and not the MaRIA score, in early CD is associated with a worse outcome, with increased risks of surgery and hospitalization.