E. Christopher Ellison

Natural-orifice transgastric endoscopic peritoneoscopy in humans: Initial clinical trial

BackgroundNatural-orifice translumenal endoscopic surgery (NOTES) is a possible advancement for surgical interventions. We initiated a pilot study in humans to investigate feasibility and develop the techniques and technology necessary for NOTES. Reported herein is the first human clinical trial of NOTES, performing transoral transgastric diagnostic peritoneoscopy.MethodsPatients were scheduled to undergo diagnostic laparoscopic evaluation of a pancreatic mass. The findings of traditional laparoscopy were recorded by anatomical abdominal quadrant. A second surgeon, blinded to the laparoscopic findings, performed transgastric peritoneoscopy. Diagnostic findings between the two methods were compared and operative times and clinical course were recorded. Definitive care was based on findings at diagnostic laparoscopy.ResultsTen patients completed the protocol with an average age of 67.6 years. All patients underwent diagnostic laparoscopy followed by successful transgastric access and diagnostic endoscopic peritoneoscopy. The average time of diagnostic laparoscopy was 12.3 minutes compared to 24.8 minutes for the transgastric route. Transgastric abdominal exploration corroborated the decision to proceed to open exploration made during traditional laparoscopic exploration in 9 of 10 patients. Peritoneal or liver biopsies were obtained in four patients by traditional laparoscopy and in one patient by the transgastric access route. Findings were confirmed by laparotomy in nine patients. Eight patients underwent pancreaticoduodenectomy and two underwent palliative gastrojejunostomy and/or hepaticojejunostomy.ConclusionsTransgastric diagnostic peritoneoscopy is safe and feasible. This study demonstrates the initial steps of NOTES in humans, providing a potential platform for incisionless surgery. Technical issues, including instrumentation, visualization, intra-abdominal manipulation, and gastric closure need further development.

Oxidant-induced vascular endothelial growth factor expression in human keratinocytes and cutaneous wound healing.

Neutrophils and macrophages, recruited to the wound site, release reactive oxygen species by respiratory burst. It is commonly understood that oxidants serve mainly to kill bacteria and prevent wound infection. We tested the hypothesis that oxidants generated at the wound site promote dermal wound repair. We observed that H2O2 potently induces vascular endothelial growth factor (VEGF) expression in human keratinocytes. Deletion mutant studies with a VEGF promoter construct revealed that a GC-rich sequence from bp −194 to −50 of the VEGF promoter is responsible for the H2O2 response. It was established that at μm concentrations oxidant induces VEGF expression and that oxidant-induced VEGF expression is independent of hypoxia-inducible factor (HIF)-1 and dependent on Sp1 activation. To test the effect of NADPH oxidase-generated reactive oxygen species on wound healing in vivo, Rac1 gene transfer was performed to dermal excisional wounds left to heal by secondary intention. Rac1 gene transfer accelerated wound contraction and closure. Rac1 overexpression was associated with higher VEGF expression both in vivo as well in human keratinocytes. Interestingly, Rac1 gene therapy was associated with a more well defined hyperproliferative epithelial region, higher cell density, enhanced deposition of connective tissue, and improved histological architecture. Overall, the histological data indicated that Rac1 might be an important stimulator of various aspects of the repair process, eventually enhancing the wound-healing process as a whole. Taken together, the results of this study indicate that wound healing is subject to redox control.

Preoperative percutaneous transhepatic biliary decompression lowers operative morbidity in patients with obstructive jaundice

Percutaneous transhepatic biliary decompression is a safe and potentially helpful procedure. If done correctly, it will accomplish adequate decompression of the biliary tree and permit hepatic function to return to a more normal state preoperatively. The time gained while waiting for the bilirubin level to decrease can be used for adequate preoperative preparation of the patient. Use of this technique may make it possible for operative treatment of obstructive jaundice to return to a two-stage procedure, the first stage being percutaneous transhepatic biliary decompression.

A Randomized Prospective Multicenter Trial of Pancreaticoduodenectomy With and Without Routine Intraperitoneal Drainage

Objective:To test by randomized prospective multicenter trial the hypothesis that pancreaticoduodenectomy (PD) without the use of intraperitoneal drainage does not increase the frequency or severity of complications. Background:Some surgeons have abandoned the use of drains placed during pancreas resection. Methods:We randomized 137 patients to PD with (n = 68, drain group) and without (n = 69, no-drain group) the use of intraperitoneal drainage and compared the safety of this approach and spectrum of complications between the 2 groups. Results:There were no differences between drain and no-drain cohorts in demographics, comorbidities, pathology, pancreatic duct size, pancreas texture, baseline quality of life, or operative technique. PD without intraperitoneal drainage was associated with an increase in the number of complications per patient [1 (0-2) vs 2 (1-4), P = 0.029]; an increase in the number of patients who had at least 1 ≥grade 2 complication [35 (52%) vs 47 (68%), P = 0.047]; and a higher average complication severity [2 (0-2) vs 2 (1-3), P = 0.027]. PD without intraperitoneal drainage was associated with a higher incidence of gastroparesis, intra-abdominal fluid collection, intra-abdominal abscess (10% vs 25%, P = 0.027), severe (≥grade 2) diarrhea, need for a postoperative percutaneous drain, and a prolonged length of stay. The Data Safety Monitoring Board stopped the study early because of an increase in mortality from 3% to 12% in the patients undergoing PD without intraperitoneal drainage. Conclusions:This study provides level 1 data, suggesting that elimination of intraperitoneal drainage in all cases of PD increases the frequency and severity of complications.

Complications of Splenectomy: Etiology, Prevention, and Management

About 35,000 splenectomies are performed each year. Complications result from an interplay of technical factors, the disease for which splenectomy is performed, the associated surgical procedures, and possible associated injuries. Familiarity with the anatomic relationship of the spleen to other structures combined with meticulous operative technique will lower the morbidity and mortality associated with splenic surgery.

Computer-Enhanced vs. Standard Laparoscopic Antireflux Surgery☆

Computer-assisted telesurgical devices have recently been approved in the United States for general surgery. To determine the safety and efficacy of these procedures, we performed a prospective trial of computer-enhanced “robotic” fundoplication compared to standard laparoscopic control procedures. Consecutive patients undergoing surgical treatment for gastroesophageal reflux were included. The operating surgeon worked at a console using a three-dimensional image and manipulated hand controls. Operative times, complications, and length of hospital stay were recorded. A standardized questionnaire was administered to evaluate symptoms. Twenty patients were entered into each group. There were no differences in age, preoperative weight, or sex. Operative times were significantly longer in the robot group (97 vs. 141 minutes). There were no complications and most patients went home the first postoperative day. At follow-up, symptoms were similar in both groups; however, there was a significant difference in the number of patients taking antisecretory medication—none in the robotic group but six in the laparoscopic group reported regular use. Computer-assisted laparoscopic antireflux surgery is safe. However, operative times are longer, with little difference in outcomes. At the current level of technology and experience, robotic antireflux surgery appears to offer little advantage over standard laparoscopic approaches.

Laparoscopic skills enhancement

BACKGROUND Laparoscopy requires a unique subset of surgical skills that, for the inexperienced, can significantly delay the development of basic operative skills. We hypothesized that learning laparoscopic suturing and knot tying would improve laparoscopic skills. METHODS A laparoscopic training seminar for junior surgical residents was established to test this hypothesis. Emphasis was placed on laparoscopic knot tying and suturing. Skills were assessed at the beginning and the end of the course. RESULTS All residents showed significant improvement. Dominant and nondominant hand skills improved by 30.2% and 26.9%, respectively. Two-handed skills improved by 58.6% and 30.1%. Overall scores improved by 28.9%. CONCLUSIONS A structured laparoscopic skills course stressing knot tying and suturing is an effective way to develop dexterity and significantly improve the performance of laparoscopic tasks. These improvements can be accomplished in a cost-effective curriculum that should enhance the surgical education of residents and speed the acquisition of competent operative skills.

The impending shortage and the estimated cost of training the future surgical workforce.

Objectives:To estimate the workforce needed by 2030 in 7 surgical specialties to serve a population of 364 million people and to quantify the cost associated with training additional surgeons. Materials and Methods:A review of the certificates granted in otolaryngology, orthopedic surgery, thoracic surgery, obstetrics and gynecology, neurosurgery, urology, and general surgery was conducted. Using a population-based algorithm, we extended the results of Richard Coopers pioneering work to these fields of surgery. The assumptions were unchanged physician to population ratio, 30 years in practice from completion of residency to retirement, and no revision of the Balanced Budget Act of 1997, and therefore no additional residency positions offered. Per resident expenses were estimated annually at

Population analysis predicts a future critical shortage of general surgeons

80,000, including salaries, benefits, and other direct medical education costs. Results/Conclusions:(1) There will not be enough surgeons in the 7 surgical specialties studied. (2) We will have to train more than 100,000 surgeons by 2030 to maintain access for our citizens at an annual cost of almost

Transgastric instrumentation and bacterial contamination of the peritoneal cavity

2 Billion and total cost of about