Ivo A.M.J. Broeders

Preoperative Sizing of Grafts for Transfemoral Endovascular Aneurysm Management: A Prospective Comparative Study of Spiral CT Angiography, Arteriography, and Conventional CT Imaging

PURPOSE To define the impact of spiral computed tomographic angiography (CTA) with image reconstruction on graft selection for Transfemoral Endovascular Aneurysm Management (TEAM) by comparing it to conventional computed tomography (CT) and contrast arteriography. METHODS Twenty-one candidates for TEAM were included. The diameters of the superior and inferior aneurysm necks and lengths between the graft attachment sites were measured using the three imaging techniques. These measurements and their consequences on graft selection were studied. RESULTS The difference in length sizing between spiral CTA and arteriography never exceeded 1 cm; however, lengths measured by conventional CT scanning resulted in underestimation of graft length in 91% of patients. Graft diameters were chosen too small in 62% of the patients when based on arteriographic diameter measurements. A graft of similar diameter was selected by spiral CTA and conventional CT scanning in 81% of the patients, while minor oversizing by conventional CT scanning was found in 14%. CONCLUSIONS Neither conventional CT scanning nor arteriography is adequate as a sole preoperative radiological investigation for TEAM graft sizing. Spiral CTA with image processing produces all information required for selection of the optimal graft size and should be regarded the method of first choice for this purpose.

Small gallstones, preserved gallbladder motility, and fast crystallization are associated with pancreatitis†‡

Acute pancreatitis is a severe complication of gallstones with considerable mortality. We sought to explore the potential risk factors for biliary pancreatitis. We compared postprandial gallbladder motility (via ultrasonography) and, after subsequent cholecystectomy, numbers, sizes, and types of gallstones; gallbladder bile composition; and cholesterol crystallization in 21 gallstone patients with previous pancreatitis and 30 patients with uncomplicated symptomatic gallstones. Gallbladder motility was stronger in pancreatitis patients than in patients with uncomplicated symptomatic gallstones (minimum postprandial gallbladder volumes: 5.8 ± 1.0 vs. 8.1 ± 0.7 mL; P = .005). Pancreatitis patients had more often sludge (41% vs. 13%; P = .03) and smaller and more gallstones than patients with symptomatic gallstones (smallest stone diameters: 2 ± 1 vs. 8 ± 2 mm; P = .001). Also, crystallization occurred much faster in the bile of pancreatitis patients (1.0 ± 0.0 vs. 2.5 ± 0.4 days; P < .001), possibly because of higher mucin concentrations (3.3 ± 1.9 vs. 0.8 ± 0.2 mg/mL; P = .04). No significant differences were found in types of gallstones, relative biliary lipid contents, cholesterol saturation indexes, bile salt species composition, phospholipid classes, total protein or immunoglobulin (G, M, and A), haptoglobin, and α‐1 acid glycoprotein concentrations. In conclusion, patients with small gallbladder stones and/or preserved gallbladder motility are at increased risk of pancreatitis. The potential benefit of prophylactic cholecystectomy in this patient category has yet to be explored. (HEPATOLOGY 2005.)

Robot-Assisted Endoscopic Surgery: A Four-Year Single-Center Experience

Background: Robotic systems were introduced in the late 1990s with the objective to overcome the technical limitations of endoscopic surgery. In this prospective cohort study the potential safety, feasibility, pitfalls and challenges of robotic systems in gastrointestinal endoscopic surgery are assessed and our vision on future perspectives is presented. Methods:Between August 2000 and December 2004, 208 procedures were performed with support of the Intuitive Surgical da Vinci™ robotic system. We started with cholecystectomies (40) and Nissen fundoplications (41) to gain experience with robot-assisted surgery. In the following years more complex procedures were carried out, i.e. colorectal procedures (7), type III/IV paraesophageal hernia repair (32), redo Nissen fundoplications (9), Heller myotomies (24), esophageal resections (22), rectopexies (16) and aortobifemoral bypasses (3). Results:The median robotic set-up time was 13 min, and 7 min in the last 50 procedures. The median operating time for the total of procedures was 120 min (45–420) and the median blood loss was 30 ml (0–800). Fourteen procedures were converted to open surgery (6.7%). Equipment-related problems, such as start-up failures and positioning difficulties of the robotic arms, were encountered in 11 cases (5.3%). Postoperative complications were seen in 11 patients (11/176, 6.3%) after robot-assisted laparoscopic procedures. Pulmonary complications occurred in 11 patients, cardiac in 3, anastomic leakage in 3, chylous leakage in 3 and vocal cord paralysis in 3 after thoracoscopic esophagolymphadenectomy for esophageal cancer. One patient died 12 days after esophageal resection (0.5%). Conclusion:During the implementation of this robotic system, we experienced an obvious learning curve, particularly with regard to the positioning of the robot cart and communication between the surgeon and operating team. After 4 years, we have experienced that the merits of the current generation of this technology probably is preserved to complex endoscopic procedures with delicate dissection and suturing. In the nearby future we will focus on the treatment of motility disorders and malignancies of the esophagus and stomach. The position of the robot in the endoscopic operating room will have to be clarified by the outcome of prospective research. Furthermore, priorities have to be acclaimed on technical sophistication and cost reduction of these systems.

Ursodeoxycholic acid exerts no beneficial effect in patients with symptomatic gallstones awaiting cholecystectomy

Ursodeoxycholic acid (UDCA) and impaired gallbladder motility purportedly reduce biliary pain and acute cholecystitis in patients with gallstones. However, the effect of UDCA in this setting has not been studied prospectively. This issue is important, as in several countries (including the Netherlands) scheduling problems result in long waiting periods for elective cholecystectomy. We conducted a randomized, double‐blind, placebo‐controlled trial on effects of UDCA in 177 highly symptomatic patients with gallstones scheduled for cholecystectomy. Patients were stratified for colic number in the preceding year (<3: 32 patients; ≥3: 145 patients). Baseline postprandial gallbladder motility was measured by ultrasound in 126 consenting patients. Twenty‐three patients (26%) receiving UDCA and 29 (33%) receiving placebo remained colic‐free during the waiting period (89 ± 4; median [range]: 75[4–365] days) before cholecystectomy (P = .3). Number of colics, non‐severe biliary pain, and analgesics intake were comparable. A low number of prior colics was associated with a higher likelihood of remaining colic‐free (59% vs. 23%, P < .001), without effects on the risk of complications. In patients evaluated for gallbladder motility, 57% were weak and 43% were strong contractors (minimal gallbladder volume > respectively ≤ 6 mL). Likelihood to remain colic‐free was comparable in strong and weak contractors (31% vs. 33%). In weak contractors, UDCA decreased likelihood to remain colic‐free (21% vs. 47%, P = .02). In the placebo group, 3 preoperative and 2 post‐cholecystectomy complications occurred. In contrast, all 4 complications in the UDCA group occurred after cholecystectomy. In conclusion, UDCA does not reduce biliary symptoms in highly symptomatic patients. Early cholecystectomy is warranted in patients with symptomatic gallstones. (HEPATOLOGY 2006;43:1276–1283.)

Robot-assisted thoracoscopic resection of a benign mediastinal neurogenic tumor: technical note.

OBJECTIVERobotic surgery systems were introduced recently with the objective of enhancing the dexterity and view during procedures that use a videoscope. The first case report of robot-assisted thoracoscopic removal of a benign neurogenic tumor in the thorax is presented. METHODSA 46-year-old woman presented with a history of paravertebral pain. A chest x-ray revealed a left paravertebral mass. A magnetic resonance imaging scan revealed a well-encapsulated mass that was suspected to be a neuroma at the level of T8–T9, separate from vascular structures, without extension in the foramina, and without a spinal canal component. RESULTSA left robot-assisted thoracoscopic resection of the tumor was performed. After placement of six trocars, the tumor was carefully dissected and removed through one of the trocar openings. The histopathological findings revealed an ancient schwannoma. CONCLUSIONThis case report demonstrates the feasibility of robot-assisted thoracoscopic extirpation of a thoracic neurogenic tumor. Robot-assisted surgery may prove to be of additional value in challenging thoracoscopic surgery, such as the delicate surgical removal of benign neurogenic tumors, because of the support in manipulation and visualization during videoscopic interventions.

The Visick score: A good measure for the overall effect of antireflux surgery?

Objective. In scoring the outcome of antireflux surgery, it is extremely difficult to combine the effect on reflux symptoms and esophageal acid exposure in one and the same single system – the Visick score revisited. The aim of this study was to correlate subjective outcome variables and objective outcome variables in an attempt to come to an overall reproducible scoring system. Material and methods. From 1997 to 1999, a randomized trial was set up to compare 98 patients who had undergone laparoscopic Nissen fundoplication (LNF) with 79 patients treated with conventional Nissen fundoplication (CNF). All patients were requested to complete a questionnaire, before and 3, 6, 12, 24 and 60 months after surgery. A subgroup of 87 patients agreed to undergo objective evaluation by pH-metry. The results of all these assessments were correlated with the effect of surgery on the Visick score. Results. After LNF and CNF, 79 and 69 patients, respectively, completed the questionnaires. After 5 years, complaints about heartburn, regurgitation and dysphagia were still significantly improved in the majority of patients, but in these groups, 6, 3 and 27% of patients, respectively, experienced deterioration. Visick score I or II (complaints resolved or improved) was recorded by 87% of patients. The Visick score correlated with the reduction of postoperative reflux symptom grades for heartburn, but not with the reduction of regurgitation, dysphagia and esophageal acid exposure. Conclusions. Although this study shows that the Visick score can be applied to monitor the subjective effect of primary antireflux surgery as it correlates well with the most prominent symptom of GERD (heartburn), it also underlines the difficulty in adequately scoring symptomatic outcome of antireflux surgery.

Manual robot assisted endoscopic suturing: Time-action analysis in an experimental model

BackgroundRobotic surgery systems were introduced to overcome the disadvantages of endoscopic surgery. The goal of this study was to assess whether robot assistance could support endoscopic surgeons in performing a complex endoscopic task.MethodsFive experienced endoscopic surgeons performed end-to-end anastomosis on post-mortem porcine small intestine. The procedure was performed both with standard endoscopic techniques and with robotic assistance (da Vinci system, Intuitive Surgical, Sunny vale, CA). It was performed in three different working directions with a horizontal, vertical, and diagonal position of the bowel. Anastomosis time, number of stitches, knots, time per stitch, suture ruptures, and the number of stitch errors were recorded. Also, an action analysis was performed.ResultsAnastomosis time, number of stitches, and the number of knots did not differ significantly between the two groups. The time needed per stitch was significantly shorter with robot assistance (81.4 sec/stitch vs 95.9 sec/stitch, p = 0.005). More suture ruptures occurred in the robot group (0 (0–2) vs 0 (0–0), p = 0.003). In the standard group more stitch errors were found (2 (0–5) vs 0 (0–3), p = 0.017). These results were comparable for three different working directions. The action analysis, however, showed significant benefits of robotic assistance. The benefits were greatest in a vertical bowel position.ConclusionRobot assistance might offer added value to experienced endoscopic surgeons in the performance of a small-bowel anastomosis in an experimental setup, even though total anastomosis time could not be demonstrated to be shorter and some suture tears occurred due to the lack of force feedback.

The role of infrarenal aortic side branches in the pathogenesis of endoleaks after endovascular aneurysm repair

AIM To investigate the relation between the number of preoperative patent side branches and the presence or absence of postoperative endoleaks, and to study the fate of patent branches after operation. PATIENTS AND METHODS Thirty consecutive patients were included. Cine mode viewing of axial CT angiography images was applied to detect infrarenal aortic side branches. The position of side branches relative to the renal arteries, branch patency and run-off pathways were studied. RESULTS A total of 160 patent side branches were found. All patients had two or more patent side branches. A patent inferior mesenteric artery was found in 22/30 patients (73%). Postoperative CT scans revealed major endoleaks in five patients (16%) and minor endoleaks in eight (27%). There was no significant difference in the number of preoperative patent side branches in patients with a completely thrombosed aneurysm sac (five; range 2-8) compared to patients with postoperative endoleaks (six; range 3-9; p = 0.12). Backbleeding from patent side branches as the sole cause of endoleak was seen in one patient only (3.3%). CONCLUSION Postoperative endoleaks are not related to the number of preoperative patent side branches. In patients without endoleaks, contrast enhancement of side branches was repeatedly seen in the vicinity of the aneurysm wall. Although close follow-up of these branches is warranted, they did not affect the outcome of endovascular aneurysm repair.

Analysis of Procedure Time in Robot-Assisted Surgery: Comparative Study in Laparoscopic Cholecystectomy

Introduction: Robotic surgery systems have been introduced to deal with the basic disadvantages of laparoscopic surgery. However, working with these systems may lead to time loss due to additional robot-specific tasks, such as set-up of equipment and sterile draping of the system. To evaluate loss of time in robot-assisted surgery, we compared 10 robot-assisted cholecystectomies to 10 standard laparoscopic cholecystectomies. Materials and Methods: The robot-assisted procedures were performed with the da Vinci telemanipulation system. The total time in the operating room (OR) was scored and divided into preoperative, operative, and postoperative phases. These phases were further divided into smaller timeframes to precisely define moments of time loss. Results: The most significant difference between the two groups was found in the preoperative phase. Robot-related tasks led to time loss in all time-frames of this phase. In the operative phase, the trocar entry time-frame was longer in robot-assisted cases than in standard procedures. Additionally, postoperative OR clearing was longer in the robot-assisted cases. Total operating time did not differ significantly between the two procedures. Conclusion: Robot-assisted surgery leads to time loss during preparation of routine laparoscopic procedures.

DIRECT trial. Diverticulitis recurrences or continuing symptoms: Operative versus conservative Treatment. A MULTICENTER RANDOMISED CLINICAL TRIAL

BackgroundPersisting abdominal complaints are common after an episode of diverticulitis treated conservatively. Furthermore, some patients develop frequent recurrences. These two groups of patients suffer greatly from their disease, as shown by impaired health related quality of life and increased costs due to multiple specialist consultations, pain medication and productivity losses.Both conservative and operative management of patients with persisting abdominal complaints after an episode of diverticulitis and/or frequently recurring diverticulitis are applied. However, direct comparison by a randomised controlled trial is necessary to determine which is superior in relieving symptoms, optimising health related quality of life, minimising costs and preventing diverticulitis recurrences against acceptable morbidity and mortality associated with surgery or the occurrence of a complicated recurrence after conservative management.We, therefore, constructed a randomised clinical trial comparing these two treatment strategies.Methods/designThe DIRECT trial is a multicenter randomised clinical trial. Patients (18-75 years) presenting themselves with persisting abdominal complaints after an episode of diverticulitis and/or three or more recurrences within 2 years will be included and randomised. Patients randomised for conservative treatment are treated according to the current daily practice (antibiotics, analgetics and/or expectant management). Patients randomised for elective resection will undergo an elective resection of the affected colon segment. Preferably, a laparoscopic approach is used.The primary outcome is health related quality of life measured by the Gastro-intestinal Quality of Life Index, Short-Form 36, EQ-5D and a visual analogue scale for pain quantification. Secondary endpoints are morbidity, mortality and total costs. The total follow-up will be three years.DiscussionConsidering the high incidence and the multicenter design of this study, it may be assumed that the number of patients needed for this study (n = 214), may be gathered within one and a half year.Depending on the expertise and available equipment, we prefer to perform a laparoscopic resection on patients randomised for elective surgery. Should this be impossible, an open technique may be used as this also reflects the current situation.Trial Registration(Trial register number: NTR1478)