R. Botchorishvili

Impact of intraperitoneal pressure of a CO2 pneumoperitoneum on the surgical peritoneal environment

BACKGROUNDnAnimal experiments have suggested that a high intraperitoneal pressure (IPP) might adversely affect the surgical peritoneal environment. The present experimental study investigates the impact of IPP of a CO(2) pneumoperitoneum on human peritoneum.nnnMETHODSnPatients undergoing laparoscopic surgery were subjected to either low (8 mmHg) or standard (12 mmHg) IPP. Normal peritoneum was collected from the parietal wall at the beginning of surgery and every 60 min thereafter. Expression levels of 168 genes that encode extracellular matrix proteins, adhesion molecules or inflammatory cytokine signaling molecules were measured in peritoneal tissues using real-time polymerase chain reaction (PCR)-based assay panels. Human peritoneal mesothelial cells (HPMCs) and human peritoneal fibroblasts (HPFBs) were incubated in a CO(2) insufflation chamber for 1 h at 12 or 8 mmHg. Hyaluronan (HA) synthesis and mRNA expression levels of hyaluronic acid synthases (HAS) and hyaluronidases (Hyal) in HPMCs and HPFBs were measured at 0, 4, 8, 12, 24 and 48 h after CO(2) gas exposure by ELISA and real-time PCR, respectively.nnnRESULTSnExpression levels of connective tissue growth factor (CTGF), matrix metalloproteinase-9, E-selectin, chemokine (C-X-C motif) ligand 2 (CXCL-2), Hyal-1 and Hyal-2 were significantly higher and those of HAS-1, HAS-3, thrombospondin-2 (TSP-2) and interleukin-10 were significantly lower in the 12 mmHg group compared with the 8 mmHg group. HA synthesis was significantly lower in the 12 mmHg group compared with the 8 mmHg group in HPMCs and HPFBs throughout the time course.nnnCONCLUSIONSnA low IPP (8 mmHg) may be better than the standard IPP (12 mmHg) to minimize the adverse impact on the surgical peritoneal environment during a CO(2) pneumoperitoneum.

Laparoscopic Ureteroneocystostomy: Be Prepared!

STUDY OBJECTIVEnTo assess the outcomes and complications of laparoscopic ureteroneocystotomy in gynecologic surgery.nnnDESIGNnWe retrospectively reviewed all medical records of patients who underwent ureteroneocystostomy between April 2008 and May 2012.nnnDESIGN CLASSIFICATIONnRetrospective case series study.nnnSETTINGnA university tertiary care hospital.nnnPATIENTSnNine patients underwent ureteroneocystostomy: 3 patients had ureteral endometriosis stenoses; and 6 patients had iatrogenic ureter injuries.nnnINTERVENTIONSnAll procedures were performed laparoscopically. The ureterovesical re-implantation was unilateral in 8 cases and bilateral for 1 patient.nnnMEASUREMENTS AND MAIN RESULTSnThe mean operating time was 226.7 min (range, 120-480). Average blood loss was 114.4 mL (range, 30-400). The mean duration of the in-dwelling catheter was 10.4 days (range, 7-21); the average hospital stay was 12.6 days (range, 6-26). The mean duration of the ureteral double J stent was 7.8 weeks (range, 6-16). One patient was re-operated for vaginal and laparoscopic drainage of a pelvic abscess on the sixth postoperative day. The median follow-up time was 20.8 months (range, 9-36), No patient had stenosis or breakdown of a suture line.nnnCONCLUSIONSnOur series confirms the feasibility and the effectiveness of laparoscopic ureteroneocystostomy. This minimally invasive approach, which avoids laparotomy, requires a multidisciplinary team.

Targeting the Wnt/β-catenin pathway in endometriosis: a potentially effective approach for treatment and prevention

Endometriosis is a chronic, estrogen-dependent disease associated with infertility and pelvic pain. Endometriosis is defined by the presence of extra-uterine endometrial tissue. It affects approximately 10% of reproductive-aged women. However, the underlying etiology, pathogenesis and pathophysiology remain to be fully elucidated. Knowledge of these factors is indispensable for the development of targeted therapies for prevention and treatment of endometriosis. Several studies, including those from our laboratory, have suggested that aberrant activation of the Wnt/β-catenin pathway may be involved in the pathophysiology of endometriosis. This is a review of the literature focused on the aberrant activation of the Wnt/β-catenin pathway in patients with endometriosis, and on how targeting the Wnt/targeting pathway may be a potentially effective approach for treating and/or preventing endometriosis.

Effects of low intraperitoneal pressure and a warmed, humidified carbon dioxide gas in laparoscopic surgery: a randomized clinical trial

Laparoscopic surgery technology continues to advance. However, much less attention has been focused on how alteration of the laparoscopic surgical environment might improve clinical outcomes. We conducted a randomized, 2u2009×u20092 factorial trial to evaluate whether low intraperitoneal pressure (IPP) (8u2009mmHg) and/or warmed, humidified CO2 (WH) gas are better for minimizing the adverse impact of a CO2 pneumoperitoneum on the peritoneal environment during laparoscopic surgery and for improving clinical outcomes compared to the standard IPP (12u2009mmHg) and/or cool and dry CO2 (CD) gas. Herein we show that low IPP and WH gas may decrease inflammation in the laparoscopic surgical environment, resulting in better clinical outcomes. Low IPP and/or WH gas significantly lowered expression of inflammation-related genes in peritoneal tissues compared to the standard IPP and/or CDxa0gas. The odds ratios of a visual analogue scale (VAS) pain score >30 in the ward was 0.18 (95% CI: 0.06, 0.52) at 12u2009hours and 0.06 (95% CI: 0.01, 0.26) at 24u2009hours in the low IPP group versus the standard IPP group, and 0.16 (95% CI: 0.05, 0.49) at 0u2009hours and 0.29 (95% CI: 0.10, 0.79) at 12u2009hours in the WH gas group versus the CD gas group.

Interest of Complex Tasks on Laparoscopic Virtual Reality Simulator: A Prospective Randomized Study Among Naive Medical Students

surgery establishes the presence of appendix abnormalities; because this is observerdependent and thus, subjective – an ongoing study was design to perform appendectomy in consecutive surgeries for DE involving the bowel. The objective of the present study is to report the frequency and range of histologically proven lesions in the removed appendix. Design: Patient database was compiled. Setting: Endoscopic surgery center of a Private Clinic. Patients: One hundred and nine women presenting infertility and/or pelvic pain with VAS>7 (mean age 35 years, ranging from 21-49 years) diagnosed with DE infiltrating the bowel by transvaginal ultrasound with bowel preparation and/or magnetic resonance imaging. Intervention: Appendectomy during laparoscopic (n=59) or robotic (n=50) surgery. The following approaches were performed: retossigmoidectomy (n=69/63.3%); shaving (n=25/23%); segmental resection (n=7/6.4%); segmental resection + shaving (n=6/5.5%) and segmental resection + retossigmoidectomy (n=2/1.8%), the two latter for multifocal/multicentric disease. Measurements and Main Results: A normal appendix was found in 29 cases (26.6%), endometriosis was found in 30 cases (27.6%) and a condition other than endometriosis was found in 50 cases (45.8%): fibrous obliteration (n=21/19.2%), lymphoid hyperplasia (n=20/18.3%), fibrosis (n=5/4.6%), acute appendicitis (n=1/0.9%), carcinoid tumor (n=1/ 0.9%), melanosis (n=1/0.9%) and hyperplastic polyp (n=1/0.9%). Conclusion: Systematic appendectomy in patients with DE infiltrating the bowel unveiled endometriosis and other pathological conditions in the majority of the patients; while some of these non-endometriosis conditions may not be clinically relevant (such as lymphoid hyperplasia), endometriosis of the appendix and chronic appendix inflammation could contribute to chronic pelvic/lower quadrant pain in these patients. Further studies are necessary to elucidate if systematic appendectomy could decrease the rate of surgery for recurrence of DE or the need of investigation of acute appendicitis in women with DE presenting lower quadrant pain.

5-aminolevulinic acid (ALA) induced fluorescence for laparoscopic diagnosis of peritoneal metastasis : an experimental study

Ovarian cancer is the most frequent cause of gynecologic cancer-related death in the United States. In patients with advanced disease, the initial steps of the treatment, surgical debulking and chemotherapy are efficacious as evidenced by negative second look laparotomies or laparoscopies. However 1 5% to 50% of the patients with negative second look will subsequently experience recurring disease whithin 5 years and will inevitably die from the disease.(1) Therefore any approach which would improve the sensitivity and decrease the invasiveness of this procedure would be very attractive to improve the management and the quality of life of these patients.