Featured Articles in June 2019

Bradycardia During Laparoscopic Surgeries

 

 

 Author list

Inbal Dabush-Elisha, Or Goren, Aviram Herscovici, Idit Matot

 

Abstract

 

Background

A recent analysis found bradycardia during laparoscopy as a potential early warning sign of cardiac arrest. Knowledge regarding bradycardia frequency and its consequences during laparoscopy is limited.

 

Methods

Using the computerized record database, files of 9915 patients undergoing laparoscopic surgery, between June 2008 and August 2013 at a tertiary, academic medical center, were screened for intraoperative bradycardia (heart rate

 

Results

Intraoperative bradycardia occurred in 1540 (15.5%) patients, in the majority (945, 61.3%) heart rate decreased to

 

Conclusions

Bradycardia is common during laparoscopy. Despite being more prevalent in older and sicker patients, bradycardia did not significantly affect outcome, suggesting that routine preventive measures do not need to be implemented. Rather, intraoperative bradycardia events should be wisely followed with prompt response, when hemodynamic perturbations occur, the threshold of which is yet to be defined.

 

URL https://rdcu.be/byAAX

 


Evaluation of Parathyroid Glands with Indocyanine Green Fluorescence Angiography After Thyroidectomy

 

Author list 

Anatoliy V. Rudin, Travis J. McKenzie, Geoffrey B. Thompson, David R. Farley, Melanie L. Lyden

 

Abstract

 

Background

Indocyanine green fluorescence angiography (ICGA) is a new adjunct that has been used in surgical procedures to assess blood flow. This study evaluated the utility of ICGA compared to visual inspection to predict parathyroid function, guide autotransplantation and potentially decrease permanent hypoparathyroidism.

 

Methods

This was a retrospective study of patients who underwent total or near-total thyroidectomy (T-NT) between January 2015 and March 2018. Patients with preoperative hyperparathyroidism and those undergoing reoperation were excluded. Patients who had ICGA were compared to T-NT patients without ICGA. Data were analyzed to assess the frequency of autotransplantation and incidence of hypoparathyroidism between groups.

 

Results

In total, 210 patients underwent T-NT: 86 with ICGA and 124 without. Autotransplantation was more common in the ICGA group at 36% compared to 12% in the control (p = 0.0001). There was no correlation with at least one normal parathyroid gland on ICGA and postoperative PTH levels (p = 0.75). There was a difference in having normal postoperative PTH when there were at least two normal parathyroid glands (n = 50) compared to patients with less than two normal ICGA glands (n = 36, p = 0.044). Visual assessment and ICGA assessment of vascularity were in agreement, 245/281 (87%). There were 19 glands (6.8%) that would have undergone autotransplant based on visual inspection that had adequate blood supply on ICGA. Transient hypoparathyroidism was present in 45 out of 124 controls (36%) and 32 out of 86 (37%) in the ICG group.

 

Conclusions

ICGA is a novel technique that may improve the assessment of parathyroid gland blood supply compared to visual inspection. ICGA can guide more appropriate autotransplantation without compromising postoperative parathyroid function. At least two vascularized glands on ICGA may predict postoperative parathyroid gland function.

 

URL https://rdcu.be/byACe

 

 


Short- and Long-term Outcomes after Robotic and Laparoscopic Liver Resection for Malignancies: A Propensity Score-Matched Study

 

Author list 

Chetana Lim, Chady Salloum, Antonella Tudisco, Claudio Ricci, Michael Osseis, Niccolo Napoli, Eylon Lahat, Ugo Boggi, Daniel Azoulay

 

Abstract

 

Background

A laparoscopic approach improves short-term outcomes and maintains long-term outcomes compared to an open approach. In turn, the recent development of robotic surgery raises the question whether it performs as well as laparoscopic surgery. The aim of this study was to compare the short- and long-term outcomes of laparoscopic liver resection (LLR) and robotic liver resection (RLR) for malignancies.

 

Methods

From 2011 to 2017, the study population included 111 patients in the LLR group and 61 in the RLR group. Short- and long-term outcomes were compared before and after propensity score matching (PSM).

 

Results

Operative mortality rate was nil. The intraoperative blood transfusion rate was higher during RLR (15% vs. 2%, p = 0.0009). Major morbidity and hospital stay were not different between the two groups. The resection margin width (LLR 7 mm vs. RLR 10 mm, p = 0.13) and R1 resection rates (resection margin width < 1 mm; LLR 15% vs. RLR 11%, p = 0.49) were similar. After PSM (55 patients in each group), the blood transfusion, major morbidity, hospital stay and R1 resection were similar between the two groups. When considering the largest subset of patients with hepatocellular carcinoma including 114 patients (66%), the 3-year overall survival rate was 80% in the LLR group and 97% in the RLR group (p = 0.10) and remained similar after PSM (p = 0.27). The 3-year recurrence-free survival rate was 50% in the LLR group and 64% in the RLR group (p = 0.30) and remained similar after PSM (p = 0.26).

 

Conclusions

No differences were found in blood transfusion, incidence of positive resection margins and long-term outcomes between the two techniques. RLR does not compromise short-term and oncologic outcomes in patients with liver cancers.

 

URL https://rdcu.be/byAJT

 


Evidence-Based Management of Postoperative Pain in Adults Undergoing Laparoscopic Sleeve Gastrectomy

 

Author list 

Hoani Macfater, Weisi Xia,Sanket Srinivasa, Andrew Graham Hill, Marc Van De Velde, Girsh P. Joshim on behalf of the PROSPECT collaborators


Abstract

 

Background

Laparoscopic sleeve gastrectomy (LSG) is a common weight loss operation that is increasingly being managed on an outpatient or overnight stay basis. The aim of this systematic review was to evaluate the available literature and develop recommendations for optimal pain management after LSG.

 

Methods

A systematic review utilizing preferred reporting items for systematic reviews and meta-analysis with PROcedure SPECific Postoperative Pain ManagemenT methodology was undertaken. Randomized controlled trials (RCTs) published in the English language from inception to September 2018 assessing postoperative pain using analgesic, anesthetic, and surgical interventions were identified from MEDLINE, EMBASE and Cochrane Databases.

 

Results

Significant heterogeneity was identified in the 18 RCTs included in this systematic review. Gabapentinoids and transversus abdominis plane blocks reduced LSG postoperative pain. There was limited procedure-specific evidence of analgesic effects for acetaminophen, non-steroidal anti-inflammatory drugs, dexamethasone, magnesium, and tramadol in this setting. Inconsistent evidence was found in the studies investigating alpha-2-agonists. No evidence was found for intraperitoneal local anesthetic administration or single-port laparoscopy.

 

Conclusions

The literature to recommend an optimal analgesic regimen for LSG is limited. The pragmatic view supports acetaminophen and a non-steroidal anti-inflammatory drug, with opioids as rescue analgesics. Gabapentinoids should be used with caution, as they may amplify opioid-induced respiratory depression. Although transversus abdominis plane blocks reduced pain, port-site infiltration may be considered instead, as it is a simple and inexpensive approach that provides adequate somatic blockade. Further RCTs are required to confirm the influence of the recommended analgesic regimen on postoperative pain relief.

 

URL https://rdcu.be/byALe

 


Feasibility and Safety of Laparoscopic Partial Splenectomy: A Systematic Review

 

Author list 

Gangshan Liu, Ying Fan

 

Abstract

 

Background

Laparoscopic partial splenectomy (LPS) is a challenging procedure. The aim of this review was to evaluate its feasibility, safety, and potential benefits.

 

Methods

We conducted a comprehensive review for the years 1995–2018 to retrieve all relevant articles.

Results

A total of 44 studies with 252 patients undergoing LPS were reviewed. Six studies described combined operations. Ranges of operative time and estimated blood loss were 50–225 min and 0–1200 ml, respectively. There are eight patients need blood transfusion in 231 patients with available data. The conversion rate was 3.6% (9/252). Overall, 27 patients (10.7%;27/252) developed postoperative or intraoperative complications. Overall mortality was 0% (0/252). The length of postoperative stay (POS) varied (1–11 days). Among four comparative studies, one showed LPS could reduce POS than laparoscopic total splenectomy (LTS) (LTS 5.4 ± 1.8 days, LPS 4.2 ± 0.8 days, p = 0.027) and complications (pleural effusion (LTS 9/22, LPS 0/15, p = 0.005), splenic vein thrombosis (LTS 10/22, LPS 0/15, p = 0.002)). Another comparative study showed LPS may benefit emergency patients. However, one comparative study showed LPS was associated with more pain, longer time to oral intake, and longer POS in children with hereditary spherocytosis. The fourth comparative study showed robotic subtotal splenectomy was comparable to laparoscopy in terms of POS and complication. The main benefits were lower blood loss, vascular dissection time, and a better evaluation of splenic remnant volume.

 

Conclusions

In early series of highly selected patients, LPS appears to be feasible and safe when performed by experienced laparoscopic surgeons.

 

URL https://rdcu.be/byAMT

 

 


Anterior Dor or Posterior Toupet with Heller Myotomy for Achalasia Cardia: A Systematic Review and Meta-Analysis

 

Author list 

Manjunath Siddaiah-Subramanya, Rossita Mohamad Yunus, Shahjahan Khan, Breda Memon, Muhammed Ashraf Memon

 

Abstract

 

Background

Partial fundoplication is commonly performed in conjunction with Heller Myotomy. It is, however, controversial whether anterior Dor or posterior Toupet partial fundoplication is the antireflux procedure of choice. The aim was to perform a systematic review and meta-analysis of studies comparing these two procedures.

 

Materials and Methods

A search of PubMed, Cochrane database, Medline, Embase, Science Citation Index, Google scholar and current contents for English language articles comparing Dor and Toupet fundoplication following HM between 1991 and 2018 was performed. The outcome variables analyzed included operating time, length of hospital stay (LOHS), overall complication rate, quality of life (QOL), postoperative reflux, residual postoperative dysphagia, treatment failure and reoperations. The meta-analysis was prepared in accordance with the PRISMA-P statement.

 

 

Results

Seven studies totaling 486 patients (Dor = 245, Toupet = 241) were analyzed. LOHS was significantly shorter for Toupet repair compared to Dor procedure (WMD 0.73, 95% CI 0.47 to 0.99; P < 0.0001). Furthermore, patients after Toupet experienced significantly better QOL than those after Dor (WMD 1.68, 95% CI 0.68 to 2.73, P < 0.001). All other variables showed comparable effects for these two procedures.

 

Conclusions

Our systematic review and meta-analysis revealed that Toupet fundoplication is superior to Dor in terms of LOHS and QOL following HM. For other variables such as postoperative reflux, postoperative dysphagia, complication rates and treatment failure, both Dor and Toupet fundoplication produced effective and equivalent results.

 

URL https://rdcu.be/byAPm

 


Revisiting Laparoscopic Reconstruction for Billroth 1 Versus Billroth 2 Versus Roux-en-Y After Distal Gastrectomy: A Systematic Review and Meta-Analysis in the Modern Era

 

 

Author list 

Min Seo Kim, Yeongkeun Kwon, Eun Pyung Park, Liang An, Haeyeon Park, Sungsoo Park

 

Abstract

 

Background

In this modern era, laparoscopic distal gastrectomy (LDG) has largely replaced open distal gastrectomy for the treatment of gastric cancer; however, a quantitative review of reconstruction methods applied exclusively using LDG has not yet been published. Thereafter, we compared three reconstruction methods (Billroth I, Billroth II, and Roux-en Y) using the data derived solely from LDG patients.

 

Methods

A systematic search was conducted using electronic bibliographic databases (Google Scholar, PubMed, and Embase), for articles that compared reconstruction methods in LDG, published within the last decade. A systematic review comparing 12 outcome parameters and sensitivity analyses were performed to increase the statistical power and minimize the inconsistency and heterogeneity of results.

 

Results

Twenty-three clinical trials involving 5797 patients were included in the meta-analysis. There were no significant differences in the postoperative recovery and intraoperative parameters, except for operation time. B1 demonstrated a significantly shorter operation time when compared with B2 and RY by 21.6 min (P < 0.0001) and 44.69 min (P < 0.0001), respectively. In terms of postoperative endoscopic symptoms, RY was significantly superior to B1 and B2 for bile reflux (P < 0.001) and remnant gastritis (P < 0.001). For postoperative complications, B1 showed a significantly lower rate of postoperative morbidity than did RY and B2 (P = 0.0006 and P = 0.0005, respectively).

 

 

Conclusions

Our study is the first meta-analysis comparing anastomoses in LDG and introduces novel criteria for consideration when selecting reconstructions in LDG. Considering the significant differences in postoperative complications and endoscopic symptoms, these two parameters lay reasonable groundwork for guiding the surgeon’s choice of reconstruction.

 

URL https://rdcu.be/byAQv

 

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