Valerie J. Halpin

Outcomes analysis of laparoscopic resection of pancreatic neoplasms

BackgroundExperience with laparoscopic resection of pancreatic neoplasms remains limited. The purpose of this study is to critically analyze the indications for and outcomes after laparoscopic resection of pancreatic neoplasms.MethodsThe medical records of all patients undergoing laparoscopic resection of pancreatic neoplasms from July 2000 to February 2006 were reviewed. Data are expressed as mean ± standard deviation.ResultsLaparoscopic pancreatic resection was performed in 22 patients (M:F, 8:14) with a mean age of 56.3 ± 15.1 years and mean body mass index (BMI) of 26.3 ± 4.5 kg/m2. Nine patients had undergone previous intra-abdominal surgery. Indications for pancreatic resection were cyst (1), glucagonoma (1), gastrinoma (2), insulinoma (3), metastatic tumor (2), IPMT (4), nonfunctioning neuroendocrine tumor (3), and mucinous/serous cystadenoma (6). Mean tumor size was 2.4 ± 1.6 cm. Laparoscopic distal pancreatectomy was attempted in 18 patients and completed in 17, and enucleation was performed in 4 patients. Laparoscopic ultrasound (n = 10) and a hand-assisted technique (n = 4) were utilized selectively. Mean operative time was 236 ± 60 min and mean blood loss was 244 ± 516 ml. There was one conversion to an open procedure because of bleeding from the splenic vein. The mean postoperative LOS was 4.5 ± 2.0 days. Seven patients experienced a total of ten postoperative complications, including a urinary tract infection (UTI) (1), lower-extremity deep venous thrombosis (DVT) and pulmonary embolus (1), infected peripancreatic fluid collection (1), pancreatic pseudocyst (1), and pancreatic fistula (6). Five pancreatic fistulas were managed by percutaneous drainage. The reoperation rate was 4.5% and the overall pancreatic-related complication rate was 36.4%. One patient developed pancreatitis and a pseudocyst 5 months postoperatively, which was managed successfully with a pancreatic duct stent. There was no 30-day mortality.ConclusionsLaparoscopic pancreatic resection is safe and feasible in selected patients with pancreatic neoplasms. With a pancreatic duct leak rate of 27%, this problem remains an area of development for the minimally invasive technique.

Effect of Marked Weight Loss on Adiponectin Gene Expression and Plasma Concentrations

Objective: Adiponectin is the most abundant protein secreted by adipose tissue and is inversely associated with adiposity and insulin resistance. The aim of this study was to evaluate the hypothesis that marked weight loss, induced by gastric bypass surgery (GBS), would increase adiponectin gene expression in both upper and lower subcutaneous body fat and increase plasma adiponectin concentration.

Laparoscopic intracorporeal ultrasound vs fluoroscopic intraoperative cholangiography: After the learning curve

Background: The purpose of this study was to compare the results of laparoscopic intracorporeal ultrasound (LICU) to those of fluoroscopic intraoperative cholangiography (FIOC) during laparoscopic cholecystectomy (LC) after the initial learning curve for LICU. Methods: Data were prospectively collected on patients undergoing LC. A consecutive series of 394 LICU patients was compared to a consecutive series of 400 FIOC patients when each imaging procedure was preferentially performed. Patients during the transition period, including the first 100 LICU patients, were excluded. Results: Demographics and preoperative diagnoses were similar in the two groups. Excluding those who were converted to open cholecystectomy and those in whom an imaging exam was not attempted, FIOC was successful in 361 of 374 (97%) patients and LICU was successful in 377 of 380 (99%) patients (p < 0.03). The mean times (±SEM) to complete FIOC and LICU were 16.0 (±0.5) min and 5.1 (±0.1) min (p < 0.0001), respectively, Choledocholithiasis was detected in 25 patients (7%) undergoing FIOC and in 39 patients (10%) undergoing LICU (p = 0.1). During LICU the common bile duct was visualized in continuity from the cystic duct to ampulla in 90% of cases. The common bile duct could not be completely visualized in continuity at the middle or distal portion of the common bile duct in 5% and 6% of LICU cases, respectively. One LICU patient (0.3%) with an incompletely visualized duct had a suspected stone confirmed by postoperative endoscopic retrograde cholangiopancreaticography (ERCP). One patient with negative FIOC (0.3%) had a retained stone treated by postoperative ERCP. Conclusion: LICU is safe and accurate, and it permits a more rapid evaluation of bile duct stones than FIOC during laparoscopic cholecystectomy. The false-negative rate of both imaging techniques is less than 1%.

Histologic results 1 year after bioprosthetic repair of paraesophageal hernia in a canine model

BackgroundThe use of prosthetic materials for the repair of paraesophageal hiatal hernia (PEH) may lead to esophageal stricture and perforation. High recurrence rates after primary repair have led surgeons to explore other options, including various bioprostheses. However, the long-term effects of these newer materials when placed at the esophageal hiatus are unknown. This study assessed the anatomic and histologic characteristics 1 year after PEH repair using a U-shaped configuration of commercially available small intestinal submucosa (SIS) mesh in a canine model.MethodsSix dogs underwent laparoscopic PEH repair with SIS mesh 4 weeks after thoracoscopic creation of PEH. When the six dogs were sacrificed 12 months later, endoscopy and barium x-ray were performed, and biopsies of the esophagus and crura were obtained.ResultsThe mean weight of the dogs 1 year after surgery was identical to their entry weight. No dog had gross dysphagia, evidence of esophageal stricture, or reherniation. At sacrifice, the biomaterial was not identifiable grossly. Biopsies of the hiatal region showed fibrosis as well as muscle fiber proliferation and regeneration. No dog had erosion of the mesh into the esophagus.ConclusionsThis reproducible canine model of PEH formation and repair did not result in erosion of SIS mesh into the esophagus or in stricture formation. Native muscle ingrowth was noted 1 year after placement of the biomaterial. According to the findings, SIS may provide a scaffold for ingrowth of crural muscle and a durable repair of PEH over the long term.

Does Morbid Obesity Worsen Outcomes After Esophagectomy

BACKGROUND With worldwide increases in esophageal cancer and obesity, esophagectomies in the morbidly obese (MO) will only increase. Risk stratification and patient counseling require more information on the morbidity associated with esophagectomy in the obese. METHODS We studied nonemergent subtotal or total esophagectomies with reconstruction in the National Surgical Quality Improvement Project (NSQIP) database from 2005 to 2010. After excluding patients with disseminated disease and body mass index (BMI) less than 18.5, we compared outcomes of patients with normal BMI (18.5-25) to those of MO patients (BMI ≥ 35). Outcomes were mortality and morbidity. Multivariable regression controlled for age and comorbidities differing between groups. RESULTS Of 794 patients, 578 (73%) had a normal BMI and 216 (27%) patients were morbidly obese (MO). The population was 75% men, with a mean age of 62 years. Patients with a normal BMI were older and more likely to smoke (p < 0.001). MO patients had a higher incidence of hypertension (65% versus 41%) and diabetes (20% versus 10%), and fewer had preoperative weight loss greater than 10% (9% versus 31%) (p < 0.001). Overall, morbidity was 48.5% and mortality was 3%; there was no difference between the groups. On multivariable analysis, all outcomes were the same between groups except deep space infections and pulmonary embolism (PE), for which the obese were at 52% and 48% higher risk, respectively (p = 0.02). CONCLUSIONS In our study, postoperative mortality and pulmonary, cardiac, and thromboembolic morbidity were similar between MO patients and patients with a normal BMI. MO increased the odds of deep wound infections. Overall, BMI greater than 35 does not confer significant morbidity after esophagectomy. Patients with esophageal pathologic conditions should not be denied resection based on MO alone.

Pneumoperitoneum does not influence trocar site implantation during tumor manipulation in a solid tumor model.

BackgroundThe purpose of this study was to assess tumor implantation at abdominal wound sites following manipulation of a solid abdominal tumor.MethodsGW-39 human colon cancer cells were injected into the omentum of golden Syrian hamsters. At 2 weeks, an omental tumor was harvested and animals were randomized to bivalve (A), crush (B), strip (C), or excision (D), with or without pneumoperitoneum. Four 5-mm trocars were inserted into the abdomen, and the tumor was reinserted through the midline, swept through four quadrants, and removed. The incision was closed and pneumoperitoneum at 7 mmHg was maintained for 10 min. Tumor implantation at wound sites was documented at 7 weeks.ResultsImplantation at trocar sites was 53 and 49% with and without pneumoperitoneum in the manipulated groups (A, B, C), respectively (p = 0.993). Implantation at trocar sites was reduced in the control group (D) at 9 and 10% with and without pneumoperitoneum, respectively (p < 0.001).ConclusionsTumor implantation at trocar sites is due to spillage of tumor during manipulation and not to pneumoperitoneum.