Luca Milone

Totally Transumbilical Laparoscopic Cholecystectomy

A recently convened Consortium at the Cleveland Clinic agreed on the term Laparo-Endoscopic Single-Site (LESS) surgery to describe minimally invasive techniques that use a single incision to accomplish laparoscopic procedures. These procedures are done by using either a single port through one fascial incision or multiple ports placed through separate fascial incisions. Because of cost containment issues and the lack of widespread availability of a single port, we currently use multiple reusable ports placed through three separate fascial incisions via a transumbilical incision. As opposed to standard laparoscopic cholecystectomy, a deflecting laparoscope and one articulating instrument are utilized to improve the safety and ease of this procedure. Presented in this video are the steps necessary to perform a LESS cholecystectomy via a transumbilical incision with commercially available instruments.

Incidence and management of enteric leaks after gastric bypass for morbid obesity during a 10-year period

BACKGROUND To describe the incidence, etiology, outcomes, and management of enteric leaks in patients who had undergone open or laparoscopic gastric bypass. METHODS From November 1996 to November 2006, 1133 patients underwent primary gastric bypass at Columbia University, New York-Presbyterian Hospital. A retrospective review of our prospective bariatric surgery registry identified 17 patients (1.5%) who developed a clinically apparent enteric leak after surgery. The demographic and outcome data were studied. RESULTS The mean body mass index was 52 kg/m(2) (range 35-65), and 15 (88%) of the 17 patients were women. The mean number of co-morbidities per patient was 1.3 and included hypertension in 11, diabetes in 9, and sleep apnea in 6. Ten patients had previously undergone abdominal surgery. The enteric leak was diagnosed by radiographic studies in 12 patients (9 of 12 by upper gastrointestinal series and 3 of 6 by computed tomography); the remaining 5 patients were diagnosed at re-exploration. Of the 17 patients, 12 (70%) were treated by laparoscopy and 5 (29%) by laparotomy. The mean time from completion of the index procedure to the diagnosis of the leak was 2 days (range 1-5) for patients treated by laparoscopy versus 4 days (range 1-6) for patients treated by laparotomy (P <.05). The patients treated by laparoscopy experienced a shorter hospital stay, but the difference was not statistically significant (mean 11.4 days, range 6-36, versus 18 days, range 7-33; P >.05). One of the laparoscopic patients (5.9%) died. CONCLUSION Enteric leak is a significant complication after gastric bypass. Prompt treatment should be based on clinical suspicion, because contrast and cross-sectional imaging studies might not be reliable diagnostic tests. A laparoscopic index procedure might be associated with an earlier diagnosis.

Outcomes of laparoscopic adjustable gastric banding in patients with low body mass index

BACKGROUND The current National Institutes of Health guidelines have recommended bariatric surgery for patients with a body mass index (BMI) >40 kg/m(2) or BMI >35 kg/m(2) with significant co-morbidities. However, some preliminary studies have shown that patients with a BMI that does not meet these criteria could also experience similar weight loss and the benefits associated with it. METHODS An institutional review board-approved protocol was obtained to study the effectiveness of laparoscopic adjustable gastric banding in patients with a low BMI. A total of 66 patients with a BMI of 30-35 kg/m(2) and co-morbidities (n = 22) or a BMI of 35-40 kg/m(2) without co-morbidities (n = 44) underwent laparoscopic adjustable gastric banding. These patients were compared with 438 standard patients who had undergone laparoscopic adjustable gastric banding who met the National Institutes of Health criteria for bariatric surgery. The excess weight loss at 3, 6, 12, and 18 months and the status of their co-morbidities were compared between the 2 groups. RESULTS The average BMI for the study group was 36.1 +/- 2.6 kg/m(2) compared with 46.0 +/- 7.3 kg/m(2) for the control group. Both groups had significant co-morbidities, including hypertension, diabetes, hyperlipidemia, arthritis, gastroesophageal reflux disease, stress incontinence, and obstructive sleep apnea. The mean percentage of excess weight loss was 20.3% +/- 9.0%, 28.5% +/- 14.0%, 44.7% +/- 19.3%, and 42.2% +/- 33.7% at 3, 6, 12, and 18 months, respectively. This was not significantly different from the excess weight loss in the control group, except for at 12 months. Both groups showed similar improvement of most co-morbidities. CONCLUSION Moderately obese patients whose BMI is less than the current guidelines for bariatric surgery will have similar weight loss and associated benefits. Laparoscopic adjustable gastric banding is a safe and effective treatment for patients with a BMI of 30-35 kg/m(2).

The utility of [11C] dihydrotetrabenazine positron emission tomography scanning in assessing β-cell performance after sleeve gastrectomy and duodenal-jejunal bypass

BACKGROUND The aim of this study was to evaluate the effect of sleeve gastrectomy (SG) and duodenal-jejunal bypass (DJB) on glucose homeostasis and to evaluate the utility of positron emission tomography (PET) scanning for assessing beta-cell mass. METHODS Goto-Kakizaki rats were divided into 4 groups: control, sham, SG, or DJB. Oral glucose tolerance, insulin, and glucagon-like peptide-1 (GLP-1) were measured before and after surgery. Before and 90 days after treatment, [(11)C] DTBZ micro PET scanning was performed. RESULTS The control and sham animals gained more weight compared with SG and DJB animals (P < or = .05). Compared with control animals, the glucose area under the curve was lower in DJB animals 30 and 45 days after operations (P < or = .05). At killing, GLP-1 levels were greater in the DJB group compared with sham and SG (P < or = .05), whereas insulin levels were greater in both DJB and SG compared with sham (P < or = .05). With PET scanning, the 90-day posttreatment mean vesicular monoamine transporter type 2 binding index was greatest in the DJB animals (2.45) compared with SG (1.17), both of which were greater than baseline control animals (0.81). CONCLUSION In type 2 diabetic rodents, DJB leads to improved glucose homeostasis and an increase in VMAT2 density as measured by PET scanning.

A rodent model of metabolic surgery for study of type 2 diabetes and positron emission tomography scanning of beta cell mass

BACKGROUND Type 2 diabetes mellitus is a worldwide healthcare problem with major socioeconomic implications. Metabolic surgical procedures have been shown to improve diabetes, but the mechanism of action is poorly understood. The Goto-Kakizaki (GK) rodent is a type 2 diabetic animal model that is ideally situated for studying the effect of surgery on diabetes; however, the operative mortality is high. The aim of this study was to describe the operative technique, improvements in perioperative management, and the technique of micro-positron emission tomography (PET) scanning of the beta-cell mass in GK rodents. METHODS A total of 53 GK rats were divided into 1 of 3 operative groups: sham, sleeve gastrectomy, and duodenojejunal bypass. A subset of animals underwent micro-PET scanning with [11C]-dihydrotetrabenazine to determine the vesicular monoamine transporter 2 binding index, an indicator of beta-cell mass. RESULTS The 30-day mortality in the sham and sleeve gastrectomy rodents was 0; however, 2 sleeve gastrectomy rodents developed enterocutaneous fistula and 1 developed an abscess. In the duodenojejunal bypass group, the initial mortality rate was close to 90%; however, refinements in the surgical technique and perioperative management (fluids, antibiotics, pain control) lowered the mortality rate to 60%. The surgical technique is discussed in detail. [11C]-Dihydrotetrabenazine uptake in the pancreas was demonstrated on micro-PET scanning in the sham and duodenojejunal bypass rodents. CONCLUSION Intensive medical management in the perioperative period and attention to the operative technique lowered the mortality. [11C]-Dihydrotetrabenazine micro-PET scanning is a feasible method for assessing the beta-cell mass in GK rodents and could prove to be an important modality for evaluating beta-cell performance in type 2 diabetes.

Contribution of obesity to pancreatic carcinogenesis

c [ i t i h According to the most recent National Program of Caner Registries analysis, pancreatic cancer is the 10th most ommon malignancy in the United States, occurring in 2.3/100,000. This incidence increases to 15.1 in the black opulation [1]. Although it is estimated that 2% of all ancers are pancreatic in origin, it is the fourth leading cause f cancer-related death, accounting for 32,000 deaths/yr 2,3]. Familial pancreatic cancer is believed to account for 10% of all pancreatic cancer cases, and the genetics are ot well understood. Because of its relative rarity, the etilogic factors of exocrine pancreatic carcinogenesis have een difficult to ascertain. Also, because of the highly varible incidence rates throughout the world, it is believed that everal environmental factors play a role in pancreatic carinogenesis. Although 210,000 people die each year from ancreatic cancer, the mortality rates are similar to the ncidence rates, making the epidemiology of this cancer articularly difficult to study [4]. In an effort to better characterize the etiologic agents esponsible for pancreatic carcinogenesis, studies have ooked at numerous disease states and environmental facors, including chronic pancreatitis, nonsteroidal anti-inammatory drug use, and alcohol consumption. Although he prevalence rates have remained steady for the past 3 ecades, the 1 factor accepted as contributing to pancreatic arcinogenesis has been steadily decreasing in incidence in he U.S. population—tobacco consumption [4,5]. A possile explanation for the steady prevalence could be the conomitant increase in obesity in the United States. Obesity nd other etiologic factors, such as late-onset diabetes mel-

Resultados de la hemorroidopexia con sistema hemorpex en el tratamiento quirúrgico ambulatorio de las hemorroides

INTRODUCTION We present a new technique for the surgical treatment of haemorrhoids, consisting of the repositioning of haemorrhoid cluster, using a rotating Proctoscope called Hemor Pex System((R)) (HPS). This procedure is performed as an outpatient procedure, with minimal postoperative pain and rapid integration into working life. OBJECTIVES To present the experience with this technique during 3 years of follow up in two institutions in Genoa, Italy. PATIENTS AND METHODS from January 2003 to June 2006, 1112 patients with grade II, III and IV haemorrhoids were operated on using the HPS technique, in two different hospitals. Prospectively analyzed the following parameters: postoperative pain, incidence of complications and recurrence of symptoms. RESULTS A total of 1112 patients were operated, of whom 719 have completed the follow-up. The mean age was 47 years. In 92% of cases the intervention was performed under local anaesthesia. The average time of surgery time was 20+/-5min. A total of 97% of patients were discharged at 6h after surgery. The immediate postoperative pain, according to the Visual Analogue Scale (VAS): absent (0) in 38 cases, slight (1-3) in 431 cases, 218 medium and intense in 32 cases. CONCLUSIONS We believe HPS is a safe procedure, with a short learning curve for surgeons, and in particular leads to a great reduction in post-operative pain for the patient.

Reply to Letter by Klaus and Weiss (00464-008-0163-y): Re: ‘Esophageal Dilation After Laparoscopic Adjustable Gastric Banding’ (2008: 22(6)1482–1486)

Klaus et al. [3] described 164 (27.9%) of 587 patients with GERD-like symptoms before adjustable gastric banding. For 52 of these patients (8.8%), the symptoms persisted after surgery. These 52 patients were found to have poorer esophageal motility than those without symptoms postoperatively (20.7 vs. 12%). In the group with esophageal dysmotility, 18 patients (34.6%) (3% of the total series) experienced esophageal dilation after adjustable gastric banding, as did 20 patients (17.9%) in the group without dysmotility. Of the 18 patients, 3 (0.5%) required band removal.

Hemorpex system: A new procedure for the treatment of haemorrhoids

Abstract Introduction We present a new technique for the surgical treatment of haemorrhoids, consisting of the repositioning of haemorrhoid cluster, using a rotating proctoscope called Hemor Pex System® (HPS). This procedure is performed as an outpatient procedure, with minimal postoperative pain and rapid integration into working life. Objectives To present the experience with this technique during 3 years of follow-up in 2 institutions in Genoa, Italy. Patients and methods From January 2003 to June 2006, 1112 patients with grade II, III, and IV haemorrhoids were operated on using the HPS technique, in 2 different hospitals. Prospectively analyzed the following parameters: postoperative pain, incidence of complications, and recurrence of symptoms. Results A total of 1112 patients were operated, of whom 719 have completed the follow-up. The mean age was 47 years. In 92% of cases the intervention was performed under local anaesthesia. The average time of surgery time was 20 (5) min. A total of 97% of patients were discharged at 6 h after surgery. The immediate postoperative pain, according to the Visual Analogue Scale (VAS): absent (0) in 38 cases, slight (1–3) in 431 cases, 218 medium, and intense in 32 cases. Conclusions We believe HPS is a safe procedure, with a short learning curve for surgeons, and in particular leads to a great reduction in post-operative pain for the patient.