Abstract: Despite being considered the most effective method for colorectal cancer diagnosis, colonoscopy take-up as a mass-screening procedure is limited mainly due to invasiveness, patient discomfort, fear of pain, and the need for sedation. In an effort to mitigate some of the disadvantages associated with colonoscopy, this work provides a preliminary assessment of a novel endoscopic device consisting in a softly tethered capsule for painless colonoscopy under robotic magnetic steering.
Abstract: Endoscopic submucosal dissection (ESD) has been proposed for large colorectal lesions, due to the high risk of recurrence following endoscopic mucosal resection. However, data on the efficacy and safety of colorectal ESD are still controversial. The aim of the current systematic review was to assess the efficacy and safety of colorectal ESD.
Abstract: Much of the discussion pertaining to natural orifice transluminal endoscopic surgery (NOTES) focuses on technical issues, with little attention to women's perception and to their willingness to consent to this surgery, especially in the field of obesity. Aim of this study was to evaluate obese women's perception of NOTES and trans-vaginal access. Sixty two obese patients undergoing bariatric surgery were given a written description of NOTES with an anonymous questionnaire exploring their concerns and opinions regarding this technique. The risk of complications was the most important aspect with regard to surgical procedures for 87.1% of patients, while the aesthetic result counted only for 16.1%; none of the patients would accept an increased risk of surgical complications for a better aesthetic result, and 74.2% of them would prefer a standardized traditional surgical approach. Nulliparous women were more concerned about the potentially negative effects of NOTES on fertility than multiparous women and younger women were more worried about the effects on sexual function than older women. 83.9% of patients refusing NOTES stated that the main reason for their refusal was the lack of definitive data on the beneficial effects. Bariatric NOTES potentially offers obese women a scarless intervention, but only a few obese women expressed worries about the cosmetic/aesthetic effects of surgery, while most of them were worried about effects on future fertility and sexual life. Our study highlights a strong need for early reporting of outcome data to enlighten patients about this new approach to bariatric surgery.
Abstract: INTRODUCTION: Transanal endoscopic microsurgery (TEM) has revolutionized the technique and outcomes of transanal surgery, becoming the standard of treatment for large sessile rectal adenomas, and may represent a possible treatment modality for early rectal cancer. METHODS: A full-thickness excision is made on the rectal wall down to the perirectal fatty tissue. The specimen is retrieved transanally. After the parietal defect is disinfected, the wound is closed with one or more running sutures secured with silver clips. RESULTS: Peritoneal perforation during TEM is not associated with adverse short-term or oncologic outcomes. The postoperative morbidity rate ranges between 2Â % and 15Â %, and in most cases, complications can be conservatively managed. The local recurrence rate of large adenomas is about 6Â %, and most recurrences can be safely re-resected by TEM. TEM represents an effective treatment for pT1 sm1 rectal malignancies, while pT1 sm2-3 and pT2 should be considered at high risk of recurrence if treated by TEM alone. Finally, TEM does not influence anorectal function or quality of life. CONCLUSION: TEM is a safe procedure and provides excellent functional and oncologic outcomes in the treatment of large sessile benign rectal lesions and selected early rectal cancers.
Abstract: The natural history of acute diverticulitis (AD) is still unclear. This study investigated the recurrence rate, and the risks of emergency surgery, associated stoma and death following initial medical or surgical treatment of AD.
Abstract: Transanal endoscopic microsurgery (TEM) has revolutionized the technique and outcome of transanal surgery, becoming the standard of treatment for large sessile rectal adenomas. Nevertheless, only a few studies have evaluated the risk factors for local recurrence in order to recommend a "tailored" approach. The aim of this study was to identify predictor variables for recurrence after TEM to treat rectal adenoma.
Abstract: OBJECTIVE: The aim was to compare transanal endoscopic microsurgery (TEM) and laparoscopic resection (LR) in terms of short-term and oncologic outcomes in patients with a preoperatively diagnosed T2N0 extraperitoneal rectal cancer. METHODS: We conducted a retrospective analysis of a prospective database. All patients with a preoperatively staged T2N0 extraperitoneal rectal adenocarcinoma were considered for LR. Patients refusing LR or medically unfit for LR were considered for TEM, which was associated with neoadjuvant RT in the last cases. Only patients with a minimum follow-up of 36 months were included. RESULTS: Seventy-eight patients were included. TEM was indicated or preferred in 43 patients; of these, 11 underwent neoadjuvant RT. Morbidity was significantly lower after TEM (p < 0.001). The median follow-up was 70 (36-140) months. A higher local recurrence rate was noted after TEM (26 %), compared to neoadjuvant RT + TEM (0 %) and LR (9 %) (p = 0.070). Overall, 5-year survival rate was 76 % after TEM, 77.8 % after RT + TEM, and 96 % after LR, respectively (p = 0.134). CONCLUSIONS: While TEM alone may only be considered a palliative treatment, it might allow similar oncologic results to abdominal resection in responders to neoadjuvant RT. Large prospective randomized trials are awaited to confirm these findings.
Abstract: BACKGROUND: Peritoneal perforation (PP) is frequently reported as a complication of transanal endoscopic microsurgery (TEM). Nevertheless, these concerns have only rarely been addressed in the literature, with no mention of the long-term oncologic consequences of PP. METHODS: A prospective database was analyzed with the intent to evaluate the influence of PP on the short- and long-term outcomes for patients undergoing TEM. RESULTS: Peritoneal perforation occurred in 28 (5.8 %) of 481 patients who underwent TEM for a rectal neoplasm. The conversion rate to abdominal surgery was 10.7 % (3/28). All the conversions occurred during the first 100 TEM procedures (3/100 vs 0/381; p = 0.007). The postoperative morbidity rate was 3.6 % (1/28), and the 30-day mortality was nil. Compared with the group of patients who had no peritoneal perforation, the PP group showed a significantly longer operating time (120 vs 60 min; p < 0.001) and a significantly longer hospital stay (6 vs 4 days; p = 0.003). Nevertheless, the global morbidity rate and the type of complications according to Dindo's classification were similar. In the multivariate analysis, the only independent predictor of PP was tumor distance from the anal verge (p = 0.010). During a median follow-up period of 48 months (range, 12-150 months), no liver or peritoneal metastases were detected in 13 patients with rectal cancer. CONCLUSIONS: Peritoneal perforation does not seem to affect short-term or oncologic outcomes for patients submitted to TEM with full-thickness resection for upper rectum neoplasms. The use of TEM to resect rectal lesions involving the intraperitoneal rectum may therefore represent an intermediate step toward the development of transrectal natural orifice translumenal endoscopic surgery (NOTES) techniques.
Abstract: BACKGROUND: The ideal management of cholelithiasis and common bile duct stones still is controversial. Although the two-stage sequential approach remains the prevalent management, several trials have concluded that the so-called laparoendoscopic rendezvous (LERV) technique offers some advantages, such as a reduced risk of post-ERCP (endoscopic retrograde cholangiopancreatography) pancreatitis. This study aimed to compare the single-stage LERV technique with the two-stage endoscopic sphincterotomy followed by laparoscopic cholecystectomy. METHODS: A search for randomized controlled trials (RCTs) comparing LERV and the two-stage sequential approach was conducted. The outcomes considered were overall complications and pancreatitis. Medline, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from 1998 to July 2012. Odds ratios (ORs) were extracted and pooled using a fixed or random-effect model depending on I (2) used as a heterogeneity measure. RESULTS: Four RCTs, including a total of 430 patients, met the inclusion criteria. The incidence of overall complications was lower in the LERV group (11.2Â %) than in the two-stage intervention group (18.1Â %) (OR, 0.56; 95Â % confidence interval [CI], 0.32-0.99; PÂ =Â 0.04; I (2)Â =Â 45Â %). The findings showed that LERV was associated with less clinical pancreatitis (2.4Â %) than the two-stage technique (8.4Â %) (OR, 0.33; 95Â % CI, 0.12-0.91; PÂ =Â 0.03; I (2)Â =Â 33Â %). CONCLUSIONS: Despite the limitation of a small number of studies completed, the evidence of RCTs shows that LERV is superior to two-stage treatment due to a reduction in overall complications, particularly pancreatitis.
Abstract: Colorectal postsurgical leaks and fistulas are severe complications that dramatically increase morbidity and mortality. The aim of this study was to evaluate the clinical impact of over-the-scope clip (OTSC) closure to seal the visceral wall in the management of acute and chronic colorectal postsurgical leaks and fistulas.
Abstract: A recurrent episode of diverticulitis is a new distinct episode of acute inflammation after a period of complete remission of symptoms. Outdated literature suggested a high recurrence rate (>40%) and a worse clinical presentation with less chance of conservative treatment. More recent studies showed a more benign course with no need toward an aggressive policy of treatment.
Abstract: In order to minimize the invasiveness of laparoscopic surgery, different techniques are emerging from research to clinical practice. Whether the incision is performed on the outside - as in Single Port Laparoscopy (SPL) - or on the inside - as in Natural Orifice Transluminal Endoscopic Surgery (NOTES) - of the patient's body, inserting and operating all the instruments from a single access site seems to be the next challenge in surgery. Magnetic guidance has been recently proposed for controlling surgical tools deployed from a single access. However, the exponential drop of magnetic field with distance makes this solution suitable only for the upper side of the abdominal cavity in nonobese patients. In the present paper we introduce a polymeric anchoring mechanism to lock surgical assistive tools inside the gastric cavity, based on the use of mucoadhesive films. Mucoadhesive properties of four formulations, with different chemical components and concentration, are evaluated by using both in vitro and ex vivo test benches on porcine stomach samples. Hydration of mucoadhesive films by contact with the aqueous mucous layer is analyzed by means of in vitro swelling tests, whereas optimal preloading conditions and adhesion performances, in terms of detachment force, supported weight and size are investigated ex vivo. Mucoadhesion is observed with all the four formulations. For a contact area of 113 mm(2), the maximum normal and shear detachment forces withstood by the adhesive film are 2,6 N and 1 N respectively. These values grow up to 12,14 N and 4,5 N when the contact area increases to 706 mm(2). Lifetime of the bonding on the inner side of the stomach wall was around two hours. Mucoadhesive anchoring represents a fully biocompatible and safe approach to deploy multiple assistive surgical tools on mucosal tissues by minimizing the number of access ports. This technique has been quantitatively assessed ex vivo for anchoring on the inner wall of the gastric cavity or in gastroscopic surgery. By properly varying the chemical formulation, this approach can be extended to other cavities of the human body.
Abstract: Flexible endoscopic procedures in the gastric cavity are usually performed by operative instruments introduced through the working channels of a gastroscope. To enable additional functions and to widen the spectrum of possible surgical procedures, assistive internal surgical instruments (AISI) may be deployed through the esophagus and fixed onto the gastric wall for the entire duration of the procedure. This paper presents a solution for deploying, positioning, and anchoring AISI inside the stomach by exploiting a chemical approach.
Abstract: Surgical techniques and technologies are rapidly evolving. In the field of colorectal surgery the transanal video-assisted approach was introduced by Buess, 30 years ago, with transanal endoscopic microsurgery (TEM). In more recent years different techniques and technologies have been proposed, including natural orifice specimen extraction (NOSE), natural orifice transluminal endoscopic surgery (NOTES) and single-access surgery. Furthermore, a better understanding of the prognostic and risk factors of rectal cancer has allowed TEM to expand its indications to local resection of selected tumours, and more recently there have been proposals for sentinel node biopsy in colon and rectal cancer.
Abstract: Most patients with hemorrhoidal disease may be treated conservatively Along the years several surgical options have been proposed. including closed open and semiclosed hemorrhoidectomy (HC), radiofrequency HC (LigaSure), piles' suture or Farag operation, manual and stapled haemorrhoidopexy (PPH) with or without excision of anal tags, doppler hemorrhoidal artery ligation with or without recto-anal mucopexy ano-mucosal flap circumferential HC or Whitehead-Rand procedure. Randomized prospective trials and metanalyses have been carried out with the aim of finding the gold standard operation. When carried out for advanced disease, HC appears to be more effective than PPH, which achieves good results in third degree, but carries high reintervention rate in fourth degree piles. Almost all trials comparing open and closed HC show similar outcomes. None of the costly innovations appears to be superior when compared with conventional procedures in terms of cure of the disease in the long term. PPH carries less postoperative pain and a shorter convalescence than HC On the other hand, while carrying a higher rate of complications, it may be responsible of the so-called "PPH syndrome", consisting of proctalgia, tenesmus and urgency Occasional recto-vaginal fistulas have been described after PPH, if not even of rectal perforation and other life-threatening complications. Postoperative pain is very rare after Doppler hemorrhoidal arteries ligation and may be reduced following HC using nitrate ointments and botulin toxin injection, aimed at releasing anal spasm after surgery, more safely than by an internal sphincterotomy LigaSure HC decreases the risk of severe postoperative bleeding, which may be effectively treated by rectal balloon tamponade. Permanent and gross anal incontinence are unlikely to follow both HC and PPH Most cases of anal stricture following HC may be treated by anal dilation. Societies' guidelines recommend a tailored surgery, i.e., the use of different procedures according to the grade of haemorrhoids, which suggests that patients should be operated by a specialist colorectal surgeon, able to perform different surgeries and to deal with complications and failures.
Abstract: Indications and results of local excision of rectal lesions are currently under debate. Transanal endoscopic microsurgery (TEM), allowing a precise, full-thickness excision, could improve oncological results in early rectal tumors.
Abstract: Natural orifice transluminal endoscopic surgery (NOTES) is currently of major research interest as it may offer significant clinical potential for endoscopic procedures in the future. Nevertheless, many issues are still unresolved. The aim of this study is a systematic review of the literature to evaluate techniques and technologies to address the issue of achieving a secure gastric wall defect closure.
Abstract: Anastomotic leakage after rectal surgery is a very serious complication and is the main cause of postoperative morbidity and mortality. We describe three cases of rectal leakage which we treated with endoscopic vacuum-assisted closure. We used the Endo-SPONGE (B. Braun Aesculap AG, Germany), which consists of an open-cell, cylindrical polyurethane sponge connected to a drainage tube which is linked to a vacuum system to exert constant suction. The possible role of this new tool in the management of anastomotic leaks is also discussed.
Abstract: Capsular endoscopy holds promise for the improved inspection of the gastrointestinal tract. However, this technique is limited by a lack of controlled capsule locomotion. Magnetic steering has been proposed by the main worldwide suppliers of commercial capsular endoscopes and by several research groups. The present study evaluates and discusses how robotics may improve diagnostic outcomes compared with manual magnetic steering of an endoscopic capsule.
Abstract: Enterovesical fistula (EVF) is an abnormal communication between the intestine and the bladder. It represents a rare complication of inflammatory or neoplastic disease, and traumatic or iatrogenic injuries. The most common aetiologies are diverticular disease and colorectal carcinoma. Over 75% of affected patients describe pathognomonic features of pneumaturia, faecaluria and recurrent urinary tract infections. The diagnosis of EVF can be challenging, and frequently patients are monitored for months before the condition is recognised and treated effectively. Diagnostic tools include laboratory tests, imaging studies and endoscopic procedures. Although conservative management can be attempted in selected patients, in most cases, the treatment is mainly based on surgical interventions. Recently, the laparoscopic approach to EVF has been shown to be safe and effective. Although it is a rare condition in a general surgery setting, EVF is a challenging condition leading to high morbidity and mortality rates.
Abstract: The use of magnetic fields to control operative devices has been recently described in endoluminal and transluminal surgical applications. The exponential decrease of magnetic field strength with distance has major implications for precision of the remote control. We aimed to assess the feasibility and functionality of a novel wireless miniaturized mechanism, based on magnetic forces, for precise orientation of the camera.
Abstract: This study was designed to compare the efficacy and safety of laparoscopic colorectal surgery performed with the aid of LigaSure vessel-sealing system or Ultracision.
Abstract: The newly designed over-the-scope clip (OTSC) seems to overcome several limitations of current clipping system, such as size and opening-closing force, allowing better control of gastric or colonic bleeding and/or deep wall defect or perforation.
Abstract: Endoscopic mucosal resection (EMR) is today the treatment of choice for flat and sessile colorectal lesion, the only concern being completeness of resection. One of the major issues is the choice of the infiltrating substance to enable a long-lasting cushion under the lesion. The aim of this study was to prospectively evaluate safety and efficacy of hydroxy-propyl-methyl-cellulose (HPMC) injection for this purpose.
Abstract: Reducing the number of ports used to perform laparoscopic cholecystectomy (LC) is indicated as means of further minimising postoperative pain, allowing a rapid return to activity and work, and obtaining patient satisfaction and better cosmetic results. It is still debatable whether the three-port technique is comparably safe. Since 2001, 374 consecutive patients underwent laparoscopic cholecystectomy in elective and emergency surgery. Three ports were routinely positioned and the need for a fourth cannula was evaluated during the surgical procedure. Of the 374 consecutive cholecystectomies performed, 204 were completed with three ports and 161 needed a fourth port to be completed, while 9 required conversion to laparotomy. Patients who were operated on with just three ports were significantly younger and mostly female. Complications of procedures completed with three ports were negligible and those of procedures completed with four ports were in line with the recent literature. Our experience shows that the three-port technique is always a good initial option when performing laparoscopic cholecystectomy. It is safe and requires conversion to four-port placement in only a minority of cases overall.
Abstract: This review addresses the range of treatments suggested to be of contemporary value in the treatment of constipation with critical evaluation of efficacy data, complications, patient selection, controversies and areas for future research. Resection-rectopexy, stapled prolapsectomy, mesh procedures, rectocele repair, stapled rectal resection and anterograde enema are among the reported procedures, but none of them showed a clear superiority over the others due to the lack of prospective randomised trials. Both open and laparoscopic interventions have been used. The outcome is usually positive in the short-term, but long term follow up showed that most procedure carry a high recurrent rate, possibly because the target of surgery is represented by the evident organic lesions, whereas the occult functional causes tend to be underestimated. In conclusion, the authors recommend a strict and selective surgical policy when dealing with patents suffering from evacuation disorders.
Abstract: Abdominal resection for rectal neoplasms is associated with significant morbidity. Local excision with retractors can be proposed only for distal rectal lesions. With this retrospective review of our prospective series of transanal endoscopic microsurgery procedures, we wanted to verify the advantages of local treatment in terms of disease recurrence and complication rates.
Abstract: Natural orifice transluminal endoscopic surgery holds promise for surgical interventions. Before the feasibility of this technique can be established, however, secure sealing of the transluminal access needs to be thoroughly investigated.
Abstract: This paper describes a device and surgical techniques developed between 1999 and 2003 to enable an entirely transoral approach to fundoplication. The Endofundoplication System (EFS) system consisted of a multifunctional flexible tube for oral introduction (18 mm) as the key component, with a specially designed retroverted grasper that was used to grasp the lower esophageal sphincter (LES) area of the esophagus, for invaginating the LES into the stomach and folding the gastric wall onto the wall of the intraabdominal esophagus. The EFS system was finally studied in a consecutive series of animal experiments in the domestic pig (n = 10). In nine out of the ten cases the procedure could be successfully completed and the animals survived six weeks according to the study protocol. The clinical follow-up of the nine animals went without problems. The animals behaved normally the first day after the procedure and tolerated regular diet very well. No signs of pain or any abdominal pathology were found in the clinical follow-up. Follow-up by endoscopy and fluoroscopy showed a subsequent postoperative migration of fasteners within the tissue. After autopsy and macroscopic inspection of the gastroesophageal junction (GEJ), we found firm tissue indurations around the fasteners. This may indicate that the fastener as a foreign body leads to a sufficient amount of scar tissue formation to contribute to permanent fixation of the tissue layers. The basic advantage of the EFS technique was seen by our group in the fact that it comes closer to the shape and function of a classical fundoplication than any other techniques proposed at the time we did our development. The nipple valve created by the EFS technique is, however, geometrically not identical to any existing fundoplication technique and is not directly comparable to any such procedure.
Abstract: The closure of the gastrotomy in Natural Orifice Endoscopic Surgery (NOTES) is a prerequisite for transgastric endoscopic procedures in the abdominal cavity. Different techniques have been proposed and are under experimental or early clinical investigation. These include the use of conventional endoscopic clips, newly designed clips or T-BARS in different shapes or more complicated devices such as linear endoscopic staplers and septal occluders, originally used for the treatment of cardiac septal defects. We describe here a further alternative of endoscopic organ closure in NOTES, using the OTSC, a novel type of clip attached to the tip of the endoscope. The OTSC clip as a CE-marked device is widely used clinically for various endoscopic procedures, such as the treatment of gastrointestinal bleeding and iatrogenic defects of the digestive tract, e.g. colonic perforations after endoscopic interventions. Now an enlarged version of the OTSC clip can be applied for the closure of transluminal access to the abdominal cavity and is currently being evaluated for use in NOTES. In animal tests we could demonstrate the relatively easy achievement of a full thickness closure of the gastric wall after NOTES in the experimental model. The current data base on OTSC and on other techniques proposed for organ closure after NOTES does not yet allow determining clear advantages or disadvantages of the different options. We believe the hollow organ defect closure now represents the most important issue to decode whether or not we are going to proceed with NOTES. Ongoing surviving animal labs will give us indications on how to proceed.
Abstract: The closure of the gastrotomy in Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a prerequisite for transgastric endoscopic procedures in the abdominal cavity. Different techniques have been proposed and are under experimental or early clinical investigation. We describe the technique of using an over-the-scope-clip system (OTSC), made of super-elastic Nitinol and a specially designed tissue-approximating double jaw endoscopic grasper for gastric closure. The OTSC is a clipping system mounted at the tip of the endoscope and is used for the treatment of gastrointestinal bleeding or gastrointestinal organ perforations. An enlarged version of the OTSC is now under investigation for NOTES. The closure procedure consists of two steps. First the margins of the perforation are approximated by means of an endoscopic grasper that has two mobile and one fixed jaw, thus providing two independent tissue grasping areas. Each half of this twin grasper is used to grasp one side of the perforation wound margins. Then the margins are approximated and pulled towards the OTSC cap at the tip of the scope. Then the clip is released and the access hole is closed by compression. The OTSC clip can be applied for organ closure in NOTES in experimental studies. The technique allows closing the access site from inside the gastric cavity without leaving material on the peritoneal surface of the organ.
Abstract: Endoscopic mucosal resection (EMR) has been shown to be safe and effective. En bloc resection is often not achieved using conventional EMR. Insulated-tip knife (It-knife) EMR has been recently proposed for early gastric cancer dissection and removal. This study was conducted to evaluate the safety and efficacy in obtaining en bloc resection with It-knife EMR of large colonic lesions not resectable with standard endoscopic techniques.
Abstract: The assistance received by the surgeon from support personnel during operative laparoscopy is extremely important. This includes retraction of instruments and endoscope positioning. However, human assistance is costly and often does not provide satisfaction for the surgeon. The aim of this study was to develop a mechanical arm capable of allowing easy handling and holding of laparoscopic instruments under the surgeon's control.
Abstract: The advent of endoscopic techniques changed surgery in many ways. For the management of cholelithiasis, laparoscopic cholecystectomy (LC) is the treatment of choice. This has created a dilemma in the management of choledocholithiasis. Today a number of option exist, including endoscopic sphinterotomy (ES) before LC in patients with suspected common bile duct (CBD) stones, laparoscopic bile duct exploration, open CBD exploration, and postoperative endoscopic retrograde cholangiopancreatography (ERCP). Also, the alternative technique of peroperative ES is emerging.
Abstract: The advent of endoscopic techniques changed surgery in many regards. This paper intends to describe an overview about technologies to facilitate endoscopic surgery. The systems described have been developed for the use in general surgery, but an easy application also in other fields of endoscopic surgery seems realistic. The introduction of system technology and robotic technology enables today to design a highly ergonomic solo-surgery platform. This consists of a system of devices for endoscopic surgery (HF, light source, etc...) with which the surgeon interacts directly, positioning systems for optic and instruments that the surgeon drives as the likes without assistance, and a chair to increase the comfort of the surgeon during surgery. The system of endoscopic devices named OREST (Dornier, München) designed already in 1992 opened the way to a number of systems available today that allow to the surgeon a direct control of the instrumentation. A considerable step ahead in endoscopic technology is the introduction of robotic technology to design assisting systems for solo-surgery and microsurgical instrument manipulators. Results of a number of experimental trials on combinations of different positioning devices are presented and commented. A further step in the employment of robotic technology is the design of "master-slave manipulators" to provide the surgeon with additional degrees of freedom of instrumentation. In 1996 a first prototype of an endoscopic manipulator system, named ARTEMIS, designed in cooperation with the Research Center in Karlsruhe, could be used in experimental applications. Clinical use of the system, however, will require further development of the arm mechanics and the control system. The combination with the implementation of telecommunication technology will open new frontiers, such as teleconsulting, teleassistance and telemanipulation.
Abstract: Colonoscopy is commonly accepted as the procedure of choice for the detection and treatment of colonic lesions. The current study was undertaken to compare effectiveness and tolerance of different bowel preparations. Three hundred patients were randomized into three groups, to be administered either a senna compound, a polyethylene glycol lavage, or an oral sodium phosphate (NaP) solution. Tolerance of the preparation was considered. After each colonoscopy, the endoscopist blindly scored cleansing for each bowel segment and defined the quality of the examination as "optimal," "acceptable," or to be repeated. Significantly more patients in Group C (68%) achieved a "good" cleansing compared with Group B (50%; P < 0.0001) and with Group A (38%; P < 0.005). Sixty-three percent of constipated patients obtained a "good" preparation in Group C, which was significantly higher than in Group A (28%; P < 0.05) and than in Group B (42%; P < 0.02). Feasibility of the examination was considered "optimal" in 80% of procedures in Group C, which was higher than in Group A (59%; P < 0.005) and in Group B (62%; P < 0.005). The tolerance of preparation was "good" in 93% of the examinations for Group C. This prospective randomized trial showed good effectiveness of NaP solutions, with an optimal tolerance. Results of use of the NaP solution showed a clear advantage for constipated patients, with similar results for nonconstipated patients. The author believes that the NaP solution should be the standard preparation for elective colonoscopy.
Abstract: In the field of endoscopic solo surgery, the assistance received by the surgeon from ergonomical positioning devices is extremely important. They aid in both the retracting of instruments and the positioning of the endoscope. However, passive systems derived from open surgery have not proved satisfactory. Therefore, we set out to develop a remote-controlled arm capable of moving a rigid endoscope with about four degrees of freedom, while maintaining an invariant point of constraint motion coincident with the trocar puncture site through the abdominal wall. The system is driven by means of speaker-independent voice control or a finger-ring joystick clipped onto the instrument shaft close to the handle. When the joystick is used, the motion of the endoscope is controlled by the fingertip of the operating surgeon, which is inserted into the small ring of the controller in such a way as to make the motion of the fingertip correspond directly to the motion of the tip of the endoscope. A study was performed to compare the two different interfaces available for the system. With both interfaces, the guiding system allows for transparent and intuitive operation. Its set-up is easy; it is safe and reliable to use during the intervention; and it is faster than human assistance. With its improved ergonomy, this new generation of remote-controlled endoscope positioning system represents a further step toward the diffusion of solo surgery techniques in minimally invasive therapy. In our opinion, this prototype creates a valid compromise between human and robotic control of rigid endoscopes.
Abstract: Robotic aid in minimally invasive surgery (MIS) is becoming more and more common. We designed an experimental trial in a phantom model to verify the feasibility of solo surgery for MIS. By performing laparoscopic cholecystectomy on a phantom model, we compared combinations of different systems available in terms of safety, comfort, and time requirements.
Abstract: There is a need for secure and easy methods for suturing in laparoscopic surgery, no matter whether vessels are to be ligated, two structures sutured together, or the cystic duct is to be occluded in cholecystectomy. Laparoscopic suturing can be done with a suture, using automatic sewing devices or clips. Improper ligation of a vessel for example can result in bleeding, which is more difficult to treat in a laparoscopic procedure than in an open procedure. By using a Roeder knot in laparoscopic suturing, tying of the knot requires some expertise and makes the procedure more complicated and time-consuming.
Abstract: Endoscopic surgery has acquired undisputed importance in the field of both general and specialised surgery. The introduction of robotic technology in surgery has recently led to the development of new positioning systems for endoscopic surgery. These allow direct control of the endoscopic procedures by the surgeon, whose vision currently depends on the assistant in charge of positioning the optic camera in compliance with his wishes.
Abstract: Modern endoscopes use a single mid-frontal illumination source that yields an unnatural flat image. At the University of Tübingen, in collaboration with Gimmi GmbH (Tuttlingen, Germany), a new concept endoscope has been developed with an additional light source: the shadow optic. With the aid of a secondary light source along the axis of the endoscope, a shadow is obtained which gives an impression of spatial depth. The aim of the study was to assess this new endoscope objectively, focusing on the speed and safety of the surgical act. The shadow optic was used in an experimental setting by 20 probands, each of whom performed five different standardized procedures of increasing difficulty five times, with and without shadow optic in randomized sequence, making a total of 1000 experiments. The procedures consisted in spatial orientation tests, structure-surrounding maneuvers, tissue clamping, needle puncture and suturing. The evaluation criteria were the time required to perform the procedures and the number of predefined errors as determined by electronic control. In each procedure, the time needed to perform the experiments was shorter with the shadow optic, reductions of up to 18% being recorded, and the number of errors was up to 54% lower compared to the experiments conducted with the traditional endoscope. The results of the study demonstrate that, as a result of the more natural spatial view conditions, the procedures were performed faster and with greater precision when the shadow optic was used. The endoscopic imaging with the shadow optic makes for better spatial orientation and a more natural and manageable image.
Abstract: Visual perception is the main sensory input from the environment in most situations of daily life. It is the only sensory input from the operating field in endoscopic surgery, and thus the qualities of the optical imaging system have a considerable impact on the course of the surgical intervention. Significant improvements have been made recently in various fields of science and engineering, influencing endoscopic imaging systems in experimental and clinical use. Among these are technologies that improve the endoscope itself in terms of providing new visual features, such as fogging prevention and plastic images, using new illumination techniques. Other developments concern the improvement of image resolution and color fidelity through new charge-coupled device (CCD) sensors or alternative techniques for image creation. Finally, the combination of endoscopic technologies with robotics provides for intuitive and more efficient direction of the line of sight.
Abstract: The assistance received by the surgeon from support personnel during surgical laparoscopy is extremely important. This includes the retracting of instruments and the positioning of the endoscope. However, human assistance is costly and often does not provide satisfaction for the surgeon. The aim of the project was to develop a mechanical arm capable of manipulating a laparoscopic instrument under the control of the operating surgeon. The system design is based on a particular kinematic construction that maintains an invariant point of constraint motion coincident with the trocar puncture site through the abdominal wall. The guidance system allows transparent and intuitive operation, and its setup is easy and quick. It may be adapted either as an instrument retractor or as an optic positioning device. A new generation of instrument positioning systems, with improved ergonomy, will be a first step toward the diffusion of solo surgery techniques in minimally invasive therapy. We believe this prototype represents a valid compromise between human and robotic control for conventional laparoscopic instruments.
Abstract: The advent of endoscopic techniques changed surgery in many regards. This paper intends to describe an overview about technologies to facilitate endoscopic surgery. The systems described have been developed for the use in general surgery, but an easy application also in the field of cardiac surgery seems realistic. The introduction of system technology and robotic technology enables today to design a highly ergonomic solo-surgery platform. To relief the surgeon from fatigue we developed a new chair dedicated to the functional needs of endoscopic surgery. The foot pedals for high frequency, suction and irrigation are integrated into the basis of the chair. The chair is driven by electric motors controlled with an additional foot pedal joystick to achieve the desired position in the OR. A major enhancement for endoscopic technology is the introduction of robotic technology to design assisting devices for solo-surgery and manipulators for microsurgical instrumentation. A further step in the employment of robotic technology is the design of 'master-slave manipulators' to provide the surgeon with additional degrees of freedom of instrumentation. In 1996 a first prototype of an endoscopic manipulator system. named ARTEMIS, could be used in experimental applications. The system consists of a user station (master) and an instrument station (slave). The surgeon sits at a console which integrates endoscopic monitors, communication facilities and two master devices to control the two slave arms which are mounted to the operating table. Clinical use of the system, however, will require further development in the area of slave mechanics and the control system. Finally the implementation of telecommunication technology in combination with robotic instruments will open new frontiers, such as teleconsulting, teleassistance and telemanipulation.
Abstract: We report a case of mucoepidermoid carcinoma of the thyroid gland. The simultaneous association of papillary and mucoepidermoid carcinoma in a Hashimoto's thyroiditis makes the present observation unusual. Surgery was limited due to local extension of the neoplasm. The patient consequently underwent external radiotherapy followed by radiometabolic therapy. The patient survived 11 months after diagnosis. As far as the histogenesis of the neoplasm is concerned, we believe that mucoepidermoid areas correspond to squamous and mucinous metaplasia of a preexisting papillary carcinoma. Transition areas between elements morphologically characteristic of both neoplasms were observed. Histochemical and immunohistochemical studies confirmed the diagnosis of a carcinoma with multiple aspects showing a focal positive reaction for thyroglobulin or keratin antisera. Therefore, this demonstrates different functional activities of the neoplastic cells. There is still debate about adjuvant therapies, the results of which appear for the moment very poor.
Abstract: DNA point mutations of the TSH receptor and of the alpha subunit of the stimulatory GTP-binding protein (Gs alpha) have been suggested as major causes of hyperfunctioning thyroid adenomas. However, significant differences in the prevalence of these mutations (from 0.3 to 84%) have been found in different populations. The present study was designed to evaluate further the presence of mutations in discrete fragments of cDNA encoding critical regions of the TSH receptor and of the Gs alpha involved in signal transduction and cAMP production. Genomic DNA extracted from 15 thyroid adenomas and surrounding quiescent thyroid tissues was used as a template to amplify four DNA fragments of TSH receptor and one DNA fragment of Gs alpha. TSH receptor and Gs alpha DNAs were analyzed by a number of techniques. We did not detect any mutations (new or previously described) in our patients. These results confirm that the causes of solitary toxic adenomas are protean, and only some of them may be somatic DNA point mutations. Since the clinical features of solitary toxic adenoma are homogeneous, it could be important to establish the specific molecular defect underlying each case, in order to follow up the patients and to assess their clinical evolution.
Abstract: It is our habit to employ an open drainage after thyroid surgery in our department. We have also found a large number of surgical infections in these patients (5.8% vs 2.5). Aim of the study is to evaluate prospectively if contamination happens during surgical procedure or in a later time according to the presence of the open drainage.
Abstract: Drainage in thyroid surgery, although still controversial, is used at our service routinely, as it guarantees the output of serum, sometimes abundant after thyroidectomy, and allows the immediate check of hemorrhage. It is nevertheless known that the presence of drainage can favour the occurrence of infection of the surgical bed. Through a randomized trial, we tested the incidence of sepsis after thyroidectomy, using in one group a double open Silastic drain and in another group a double aspirative drain. We registered 3 cases of wound infection and 4 cases of seroma in the group treated with open drainage versus one case of wound infection and 2 cases of seroma in the group treated with aspirative drainage. Such difference, although evident, did not result significant. Nevertheless, it is our opinion to conclude that the aspirative draining system guarantees a better sterility of the surgical wound, and therefore a lower incidence of wound complications.
Abstract: Objective of this study is to establish which kind of stapled anastomosis is the most reliable in rectal surgery. 67 patients randomly assigned to three groups underwent low anterior resection of the rectum with end-to-end, side-to-end or double stapling anastomosis. Main outcome measures were incidence of leakage at the intraoperative check of the suture, postoperative leakage, stenosis, mortality, mean post-operative stay. Side-to-end anastomosis were followed by 4 intra-operative (19%) and one post-operative (4.7%) leakages with one case of mortality (4.7%). Four intra-operative (18.2%) and 5 post-operative (22.7%) leakages, 3 stenosis (13.6%) and one case of mortality (4.5%) were observed after double-stapling procedures. No intra- or post-operative anastomotic complications were seen after end-to-end anastomosis. Mean post-operative stay was 20, 31 and 13 days for the three methods respectively. Conclusions: In this series of colo-rectal anastomoses, the end-to-end stapling technique appears to be safer and more reliable than others.
Abstract: Early diagnosis of local and distant recurrences of colorectal cancer remains difficult and there is no agreement on the effectiveness of follow-up in these patients. The aim of this study is to assess the value of our method of follow-up. We consider 239 patients with colorectal cancer and at least 2 years follow-up following radical resection. A local recurrence appeared in 26 patients (10.9%), a distant metastasis in 41 (17.1%), while in seven (2.9%) local and distant recurrences appeared simultaneously. Local recurrence was detected because of an increase in carcinoembryonic antigen (CEA) level in 15 patients (57.7%), during a scheduled endoscopy in four (15.4%) and because of symptoms in seven (26.9%). In seven patients (26.9%) a radical resection was possible. Distant metastases were detected by CEA levels in 20 patients (48.8%), by ultrasonography (U.S.) in 12 (29.3%) and by chest X-ray in five (12.2%). In 13 of 26 patients with liver metastases a resection was performed. This study shows that few patients benefit from follow-up and only CEA levels and liver U.S. performed intensively between 15 and 36 months after surgery are useful in early detection of recurrences. A modification of the follow-up to the single patient, according to the stage, location and grading of cancer, could improve the results, so lowering the costs of this expensive practice.
Abstract: A homogeneous series of 361 patients operated on for multinodular goitre was analyzed. Minimum and mean follow-up were 10 and 18.6 years, respectively. In most cases a subtotal or near total thyroidectomy was performed, while total thyroidectomy was reserved for patients with cancer. The goal of the study was to verify the long term outcome of this therapeutic strategy in terms of complications, disease recurrence, need of complementary therapies (TSH-suppressive or substitutive) and reinterventions. Global recurrences were 14.7%, and 4.9% of these needed a second operation for indications similar to those of the first operation. Long term complications were vocal cord palsy 1.1% and permanent hypoparothyroidism 0.3%, while the global complications of reinterventions were 3% (n.s.). Nearly half of the patients had not followed any functional or instrumental check-up for at least 5 years nor undergone any hormonal therapy. Among the patients who had a TSH-suppressive therapy, the recurrence rate was not significantly different compared to the group that had no treatment. On the basis of these data, it seems that subtotal thyroidectomy is adequate intervention for multinodular goitre, as long as the number of clinical recurrences is not significantly high. On the contrary, it might be expected that total interventions, performed in non specialized centers, would introduce a higher rate of complications. The need for TSH-suppressive therapy to reduce recurrences was not proven.
Abstract: Reoperative surgery for thyroid disease still plays a predominant role in the treatment of goiter recurrences. At the moment, neither useful biological nor clinical indicators exist to prevent such recurrences. The effectiveness of TSH-suppressive therapy is still debatable and some authors have proposed total thyroidectomy for this benign disease in order to eliminate the risk of relapse. We analyzed 134 patients who underwent reintervention for recurrence of goitre in order to: 1) study possible clinical or epidemiological characteristics that could influence recurrence, 2) to verify the indications to reoperation, and 3) to evaluate the incidence of complications. For the study of complications, we adopted as a control group a series of 361 patients operated on by the same medical staff and undergoing subtotal thyroidectomy for multinodular goitre, with a minimal follow-up of 10 years. The surgical technique is described and several peculiarities are discussed. In the group of patients who had reoperation two cases (1.5%) of laryngeal palsy and two cases (1.5%) of hypoparathyroidism were recorded and this was not significantly different from the control group. A positive correlation was found between recurrence and young age at the time of first surgery (p < 0.006), female sex (p = 0.045) and esthetic results (p = 0.013). No further clinical recurrence was found in 101 patients after a mean follow-up of 122 months, while in 16 cases the echography revealed nodules in the residual parenchyma. In our opinion total thyroidectomy is not justified as a first standard procedure for this benign disease caused by the activity of various not yet well understood, growth factors.
Abstract: Over the last decades definitions and classifications of cervico-mediastinal goiters have been proposed. According to the definition of Valdoni and Tonelli, from 1968 to 1991 237 patients were operated on for cervico-mediastinal goiter. There were 168 simple forms (141 anterior and 27 posterior) and 69 complex forms according to Borrelly's classification. We analyse and discuss the clinical presentation, the diagnostic procedures and the surgical technique in relation to post-operative complications and long term results. The mean duration of symptoms before surgery in patients with cervico-mediastinal goiter was longer than in subjects with cervical goiters. All but 8 operations were performed through a cervical incision. Two patients, both with advanced tumor, died postoperatively. Post-operative complications were: hemorrhage 0.8%, dysphonia 4.6% and transient hypoparathyroidism 2.9%. A clinical follow-up was available for 194 patients. Permanent dyspnea was observed in 1.0%, dysphonia in 4.6% and transient hypoparathyroidism in 2.9%. Tracheotomy was necessary in 5 cases. Complications were more frequent after total thyroidectomy than after partial resection (p < 0.05), after surgery for malignancy than for benign disease (p < 0.05) and in complex than in simple forms (p < 0.05). Almost all cervico-mediastinal goiters can be treated by a cervical incision. Sternotomy, when required, does not influence mobility and mortality. The lacking of an alternative treatment, the relatively high incidence of malignancy and the risk of acute airway obstruction should induce the early removal of all substernal goiters.
Abstract: Between 1968 and 1991, 190 patients (51 men, 139 women) with a mean age of 46.3 years underwent surgery for differentiated thyroid cancer (148 papillary and 42 follicular carcinomas). In 29.5% of the cases a concomitant goitre was histologically demonstrated. These patients were significantly older (mean: 54.7 years) (P<0.01). The patients who had previously received cervical radiotherapy were significantly younger (mean: 29.7 years) (P<0.01). The analysis of historical and clinical findings failed to identify predictive factors of biological aggressiveness. Hyperthyroidism occurred in 5.7% of patients: this subgroup did not show any difference in clinical behaviour. Occult carcinoma (14.7%) and multifocality (9.4%) were found more frequently in the glands with a pre-existent goitre (P<0.05), but the clinical significance of these aspects is uncertain. The surgical treatment of choice was total thyroidectomy (135 patients); more conservative procedures were performed only in younger patients with small lesions, without a difference in survival. Post-operatively a permanent recurrent laryngeal nerve injury occurred in four patients (2.1%) and nine patients (4.7%) required a permanent calcium supplementation. Among patients in follow-up (91.6%), those who underwent a total thyroidectomy were studied using a total body scinti scan. A poor prognosis was associated with age (>40 years), pT, stage, pM and symptomatic metastases.
Abstract: Between 1968 and 1991, 237 patients underwent thyroidectomy for substernal goiter. Sixteen of them presented malignancies (6.8%). Mean age of the 159 women and 78 men was 57.7 years. Twenty-five patients had undergone previous thyroid surgery. The initial symptoms were cervical mass (72%), compression (16.2%), hyperthyroidism (13.1%), hypothyroidism (1.3%), and 5.5 per cent were asymptomatic. Most patients had long-standing goiter (mean duration: 12.9 yrs). All but eight operations were performed through a cervical incision. There were two postoperative deaths (0.8%), both in patients with advanced neoplasms. Early postoperative complications were hemorrhage (0.8%), dysphonia (4.6%), and transient hypocalcemia (2.9%). Five patients (2.1%) required tracheotomy. Complications were more frequent after total thyroidectomy than partial resection (P < 0.05), after surgery for malignancy than for benign disease (P < 0.05), and in complex than in simple forms (P < 0.05). One hundred ninety-four patients were followed after surgery; dyspnea was found in two patients (1.0%), dysphonia in seven (3.6%), and hypoparathyroidism in one. Analysis of our data indicates that 1) substernal goiter arose in elderly patients more than a decade later than cervical goiter; 2) goiters with a "complex" endothoracic development had an increased rate of short and long term complications; 3) cancer occurred in a significant number of patients, without any specific symptoms of malignancy; 4) the group of patients with hyperthyroidism was characterized by a significantly longer clinical history than euthyroid patients; 5) nearly all substernal goiters could be approached through a cervical collar incision; 6) the morbidity and mortality were low also after sternotomy.(ABSTRACT TRUNCATED AT 250 WORDS)
