Martin Ruppert

A performance study comparing manual and robotically assisted laparoscopic surgery using the da Vinci system

Background: The objective of this study was to compare the efficacy of the da Vinci robotic system using both the three-dimensional view (3D) and two-dimensional (2D) view options with traditional manually assisted laparoscopic techniques in performing standardized exercises. Methods: To evaluate surgical efficiency in the use of robotically assisted and manual laparoscopic surgery for standardized exercises six, last-year medical students without any surgical experience were selected. The exercises consisted of placing rings over receptacles, grasping a free hanging suture and cutting three pieces of it, running a suture, and performing a surgical knot. Each student performed the exercise twice. The median times needed for completion of the exercises and the median number of errors in performing the tasks were noted. Results: The unexperienced students performed the standardized tasks significantly quicker and with fewer errors when assisted by the da Vinci robot in the 3D optical display mode, as compared with traditional manually assisted laparoscopic surgery. Even when the 2D mode was selected, a significant advantage favoring the da Vinci robotic system was seen both in time and efficacy for most exercises. When the 3D and 2D modes were compared, time differences in favor of the 3D mode remained, but a significant difference in efficacy favoring the 3D mode was seen only in one exercise (exercise 2: suture cutting). Conclusions: The da Vinci robotic system permits standardized minimal invasive surgical exercises to be performed quicker and more efficiently than traditional minimally invasive techniques. Therefore, with the aid of this robotic system, difficult laparoscopic interventions may become easier to perform, and indications for minimal invasive surgery may be expanded.

A gene variant of PNPLA3, but not of APOC3, is associated with histological parameters of NAFLD in an obese population

Mechanisms explaining the relationship in non‐alcoholic fatty liver disease (NAFLD), obesity, and insulin resistance are poorly understood. A genetic basis has been suggested. We studied the association between the genes patatin‐like phospholipase domain‐containing protein 3 (PNPLA3) and apolipoprotein C3 (APOC3) and metabolic and histological parameters of NAFLD in obese patients.

Roux-en-Y gastric bypass as a re-do procedure for failed restricive gastric surgery.

BackgroundGastric restrictive procedures such as laparoscopic gastric banding or vertical banded gastroplasty show, at longer follow up, more and more failures and complications. This study focuses on the results of Roux-en-Y gastric bypass procedure (RYGBP) done as a re-do procedure, both after a technically failed restrictive procedure or when the restrictive procedure failed to obtain substantial weight loss.MethodsWe reviewed data concerning the postoperative complications and weight loss of 36 patients undergoing re-do surgery for failed restrictive procedures.ResultsOver a period of two years, 36 patients with a mean age of 40.9 years were converted to a RYGBP. Median time to conversion was 4.9 years, median follow up after conversion was 6.6 months. Early postoperative complications (less than 30 days postoperatively) were noted in 11 patients (30%). A greater number of early complications were noticed in group A (technical complications) compared to group B (insufficient weight loss) (39% vs. 22%). Late postoperative complications were seen in six patients (16%). In this relatively short follow up period we noticed a drop in body mass index (BMI) from a mean of 38.8kg/m2 to 30.9 kg/m2 with a mean excess body weight loss (EBWL) of 33.1% after the re-do procedure. Body mass index decreased from a mean preoperative value of 37.6kg/m2 to 28.9 kg/m2 in group A patients with an EBWL 36%, while group B patients had a change in BMI from 40.1kg/m2 to 32.9 kg/m2 with a mean EBWL of 30%.ConclusionBased on the literature, we can presume that restrictive surgery for morbidly obese patients will require many reoperations in the future. The standard operation of choice is RYGBP. In our study this procedure showed a higher, but not significantly early morbidity rate when the indication for re-do surgery was a technical complication of the initial procedure.

What have we learnt after two years working with the da Vinci robot system in digestive surgery

Abstract Robotic-assisted surgery has been introduced recently in order to overcome some of the difficulties surgeons encounter during advanced laparoscopic surgery. Due to the 3D vision equipment, higher number of degrees of freedom in manipulating instruments and better ergonomics it is hoped that by using robot techniques the indications of minimally invasive surgery in the field of digestive surgery can be broadened or that difficult procedures will be easier to perform. Since the introduction of the system in our hospital now almost two years ago 70 procedures have been performed with the aid of the da Vinci® system covering the whole spectrum of GI surgery. Conversion took place in 2.5% and peroperative morbidity related to the use of robotic techniques was 10%. Although we had the subjective feeling that the procedures were indeed easier to perform and more relaxing for the surgeon, some major problems still exist as the complete lack of tactile feedback and the cost effectiveness of these procedures. Before robotics can be introduced in the every day clinical practice of the surgeon, its true benefit still needs to be established. This can only be done by well randomised prospective studies comparing one technique with the other.

Giant liposarcoma of the stomach involving the mediastinum.

Abstract A case of a liposarcoma of the stomach in a 27-year old woman is described. Initially the patient consulted with epigastric pain. MRI showed a giant tumour of the stomach wall, invading the surrounding organs, as well as the mediastinal region. After surgical ‘en-bloc’ resection of the tumour, histopathologic examination yielded a diagnosis of pleiomorphic liposarcoma. Because of the bad prognosis of this histologic type, the patient received adjuvant chemotherapy: a combination of doxorubicin and ifosfamide (MAI). Nine months after surgery, she represented with a relapse of the tumour that had become inoperable. Palliative chemotherapy was started with the intent to prolong the young patient’s life. However 6 months later, the patient died of the recurrent disease. Although liposarcoma is a very common soft tissue sarcoma, it is rarely seen in the stomach. The standard therapy is surgical excision. Over the last years, adjuvant therapy became more accepted. Drugs of choice are doxorubicin and ifosfamide, although the benefits of this therapy are still largely unknown and doubtful.

The Evaluation of Pyrosis and Long-term Satisfaction after Gastric Restrictive Procedures : a Retrospective Study

Abstract Objective: To compare gastric banding (GB) and vertical banded gastroplasty (VBG) with respect to the evolution of pyrosis and patient satisfaction. Summary Background Data: Although weight loss is the most immediate end-point in the evaluation of surgical treatment of obesity, the demonstration of changes in long-term patient satisfaction and in co-morbidity, like reflux, is an essential outcome measure. Material and methods: Retrospective study of 243 morbidly obese patients. All patients received a questionnaire regarding the evolution of pyrosis and their satisfaction after surgery. The evolution of pyrosis was compared between 2 patient groups who had different oesophagitis stages. Group A had oesophagitis I, or no oesophagitis, and group B had oesophagitis II, III or IV. Results: In group A of the GB group 57.8% had no complaints, 11.1% had improvement and 22.2% had aggravation of the pyrosis. In group B of the GB group 50.0% had improvement. In group A of the VBG group 51.4% had no complaints, 11.1% improvement and 23.6% aggravation of the pyrosis. In group B of the VBG group 16.7% had no complaints, 66.6% had improvement and 16.7% had aggravation of the pyrosis complaints. Statistically there is no significant difference between GB and VBG. The experience after GB is good with 67.9%, mediocre with 25.0% and bad with 7.1% of the patients; 60.7% is pleased with the weight loss. The experience after VBG is good with 47.4%, mediocre with 29.5% and bad with 23.1% of the patients. 52.6% is satisfied with the weight loss. Conclusion: VBG and GB have a similar effect on pyrosis. From our point of view it has been evidenced that the presence or absence of pyrosis before the operation is a possible predictor of the evolution afterwards. Long-term patient satisfaction is the same after GB and VBG. Other factors influence the satisfaction.

Cronkhite–Canada syndrome causing pouch outlet obstruction 5 years after roux-en-y gastric bypass

Abstract Objective: We present the case of a 57-year-old man with a history of Roux-en-Y gastric bypass (RYGB) and colonic polyps who presented with an upper gastrointestinal obstruction based on massive stomach polyposis in the pouch. Methods: Two months prior to this acute admission, he had undergone resection of the gastric remnant due to massive refractory intraluminal bleeding from a polypoid mass. Ten years earlier, right colectomy was performed due to hypertrophic polyposis unsuitable for endoscopic polypectomy. Upper gastrointestinal endoscopy showed a polypoid mass in the pouch causing obstruction. Benign biopsies were obtained. A resection of the stomach pouch with esophagojejunostomy was performed. Macroscopic evaluation of the pouch lumen showed massive polyposis with a sharp demarcation near the Z-line and at the gastrojejunostomy. On clinical examination, the presence of atrophic nail changes, alopecia, and palmar hyperpigmentation was noticed. Results: Postoperative course was uneventful and feeding was restarted successfully. Histological analysis revealed hyperplastic polypoid tissue, which resembled the polyps in the stomach remnant and colon. Together with the ectodermal changes, the diagnose of Cronkhite–Canada syndrome was established. Conclusion: Diffuse polyposis in Cronkhite–Canada syndrome is a rare cause for pouch obstruction after RYGB. Clinical examination should focus on dermatologic findings.

5-Year survival after splenectomy in a patient with recurrent cutaneous melanoma: a case report

Abstract Objective: Splenic metastases of melanoma are uncommon and generally part of a disseminated disease with a poor prognosis. In case of solitary visceral metastasis, surgical resection often remains an effective treatment. This case describes a long-term survival after splenectomy for a recurrent melanoma. Methods: We present a 55-year-old female with a solitary splenic metastasis. Her medical history revealed a melanoma of the foot in 2007 and an in-transit metastasis in 2011. A PET-CT revealed in 2012 the presence of a small aspecific lesion in the spleen. Close follow-up was chosen. Since PET-CT and MRI showed a progressive lesion, a laparoscopic splenectomy was performed. Results: Histological report confirmed the diagnosis of a metastatic lesion. Sixty months after the first radiographic evidence of the splenic metastasis, follow-up revealed no signs of residual disease. Conclusions: Although current systemic approaches demonstrate to provide clinically important benefit, patients with oligometastatic disease should be evaluated for surgical metastasectomy. A laparoscopic approach for splenic metastasis is shown to be a safe treatment. This disease-free survival of 60 months in a patient with a history of an in-transit metastasis has not been published before. A splenectomy for a solitary metastasis could prolong the survival, even in a recurrent melanoma.

76 THE EFFECT OF WEIGHT LOSS ON NONALCOHOLIC FATTY LIVER DISEASE IN AN OVERWEIGHT AND OBESE POPULATION

Background and Aims: Nonalcoholic steatohepatitis (NASH) is a serious public health problem. There is currently a lack of effective treatments and noninvasive diagnostic markers. We have recently demonstrated that hepatocyte-derived microparticles (MPs) are critical signals that contribute to angiogenesis and liver damage in NASH (Presidential Plenary AASLD 2012). Here we tested the hypothesis that circulating hepatocyte-MPs are novel targets for noninvasive monitoring of NASH. Methods: Male C57BL/6 mice were placed on Choline Deficient L-Amino Acid (CDAA) diet, Choline Supplemented L-Amino Acid (CSAA) or regular Chow diet for 4 and 20 weeks. These time points were chosen as they have been shown to be associated with early stage and established NASH, respectively. Circulating MPs were isolated from platelet-free plasma (PFP), detected by flow cytometry and extensively characterized by electron microscopy in liver tissue and circulation, dynamic light scattering and by LC MS/MS proteomic analysis. Liver specimens were collected and used for histological, biochemical, and molecular analysis of steatosis, inflammation, angiogenesis, fibrosis and cell death. Results: A marked increased in circulating levels of MPs were detected in mice with established NASH (20wks CDAA diet: 304,400 MPs/mL vs. 20 wks CSAA 34,300 MPs/mL vs. Chow 2,000 MPs/mL, p < 0.0052). The increase was time-dependent and the levels of MPs in blood strongly correlated with histological features of liver damage in particular with fibrosis as determined by morphologic quantification of Sirius Red staining (r = 0.736; p< 0.0002) and cell death determined by TUNEL assay (r = 0.804; p < 0.0001). We next characterized the antigenic composition of circulating MPs using a comprehensive proteomic approach by LC-MS/MS analysis. A gene ontology analysis of the proteins identified 26.5% plasma membrane proteins, 58.8% cytoplasmic proteins, 8.8% nuclear proteins and 5.9% extracellular proteins. Analysis of the molecular function of these proteins demonstrated that 35.3% were enzymes, 41.2% were cytoskeleton or vesiculation proteins, 2.9% protein of the nucleosome and 5.9% ribonucleoproteins. Conclusion: Our data identified circulating MPs with a unique antigenic composition as potential novel biomarkers for noninvasive diagnosis of NASH.

1329 CORRELATION OF NORMAL VERSUS ELEVATED ALT AND GGT IN AN OBESE POPULATION, ASSOCIATION WITH LIVER HISTOLOGY AND METABOLIC PARAMETERS

1329 CORRELATION OF NORMAL VERSUS ELEVATED ALT AND GGT IN AN OBESE POPULATION, ASSOCIATION WITH LIVER HISTOLOGY AND METABOLIC PARAMETERS A. Verrijken, S. Francque, I. Mertens, M. Ruppert, G. Hubens, E. Van Marck, P. Michielsen, L. Van Gaal. Endocrinology, Diabetology and Metabolic Diseases, Gastroenterology and Hepatology, Abdominal Surgery, Pathology, Antwerp University Hospital, Antwerp, Belgium E-mail: an.verrijken@uza.be