1,721,026 research outputs found
Laparoscopic adjustable gastric banding, the past, the present and the future
No full textThe laparoscopic implantation of an adjustable gastric banding (LAGB) was first described in 1993. Thereafter, the LAGB underwent to a lot of modifications, revision and refinements to become as it is currently defined. This procedure quickly became one of the most common bariatric surgical operations in the world in the first decade of the 2000s but, over the last few years, it has turned into the fourth more common procedure. A series of more or less clear reasons, led to this decrease of LAGB. The knowledge of the history of the LAGB, of its evolution over the years and its limitations can be the key-point to recognize the reasons that are leading to its decline. The adjustability and the absolute reversibility characteristic of LAGB, make this surgical procedure a "bridge treatment" to allow the specific goal of eradicating obesity
New perspectives about the role of robot-assisted surgery for the treatment of endometriosis
No full textWe read with great interest the recently published article by Comptour et al. entitled “Patient Quality of Life and Symptoms after Surgical Treatment for Endometriosis”.
Painful gynecological and digestive symptoms of endometriosis have been shown to severely affect the patients’ quality of life (QoL), and various studies have described the benefits of surgery in the treatment of endometriosis, particularly in its worst presentation, namely, Deep Infiltrating Endometriosis (DIE). Comptour et al. have designed a prospective and multicenter cohort study to assess the impact of surgical treatment of endometriosis on quality of life and pain, and their results seem to confirm these benefits
Comment on: ‘Money for nothing’. The role of robotic-assisted laparoscopy for the treatment of endometriosis
No full textTo the Editor:
We read with great interest the published article by Berlanda et al. entitled “Money for nothing”. The role of robotic-assisted laparoscopy for the treatment of endometriosis [1].
Deep infiltrating endometriosis (DIE) with colorectal involvement is one of the most aggressive forms of endometriosis. At present, a minimally invasive surgery (MIS) and in particular the direct manual laparoscopy (DML), is considered the gold standard for radical treatment of DIE with colorectal involvement, as it results in faster recovery, reduced in-hospital stay, improved cosmesis, and lower postoperative morbidity compared to laparotomy. Robot-assisted surgery (RAS), is a technological advancement of DML, introduced with the aim to overcome its kinematics limitations.
In recent years, the diffusion of the da Vinci System has created much enthusiasm has grown between surgeons of different specialties, with a constantly growing application of RAS, and several studies have been published to describe safety and efficacy of RAS, as well as to compare RAS to DML. In particular, colorectal surgeons and gynecologists have explored RAS and have also applied it to the treatment of DIE [2].
In the article, Berlanda et al. describe a very well structured critical review of the literature about the role of RAS for the treatment of endometriosis. In particular, they reported that RAS treatment of endometriosis did not provide clear benefits over standard laparoscopy, in the face of a longer operative time and higher costs. They, therefore, express concern for economic sustainability in the face of increasing use of the widely diffusion of da Vinci system, and they made conclusions against the use of robot for the treatment of DIE.
However, we have noticed that in all of the article the authors uses generically the terms of “robotic-assisted laparoscopy”, without specifying which system they refer to and in truth, the whole study is based on the da Vinci Si system, the most widespread version to date until recently. Indeed, only in the last 2–3 years, in many centers it has been gradually replaced by the most recent version, the da Vinci Xi. Therefore, we can agree with the conclusions reached by the authors only if applied to a specific robotic system, namely the da Vinci Si, but not if generalized to the broader concept of “RAS”.
In fact, recent works have shown that many of the conclusions reached to date, in the comparison between DML and RAS, unfavorable to the latter because of the longer operating times and higher costs, without clear evidence of clinical benefits, are referred to results obtained by comparing expert laparoscopists with novice robotic surgeons, using a now almost obsolete robotic system, the da Vinci Si.
Indeed, recently data published by our group on rectal resections performed with the two different da Vinci systems, showed that with the new robot, and with the increase of the surgeon’s experience, the results improve, and the costs are significantly reduced [3, 4, 5].
In conclusion, the article by Berlanda et al. deals with a very interesting topic using objective and critical methods. However, today the use of da Vinci Xi with case series being performed by expert robotic surgeons, and the use of new robotic system that will enter in the market, represents a totally different proposition from what is reported in this study, requiring careful objective re-evaluation of cost–benefit of RAS, also in the surgical treatment of DIE
Total abdominal proctocolectomy: what is new with the da Vinci Xi?
No full textTo the Editor:
We read with great interest the recently published article by Rodriguez et al. entitled “Use of the Xi robotic platform for total abdominal colectomy: a step forward in minimally invasive colorectal surgery” [1].
Although possible benefits regard the use of robotic assistance in performing a total colectomy have been already reported with the da Vinci Si, until now the main limits to the widespread of this technique in this field, were the low versatility, the long operative times and the high costs.
In order to overcome some of these limitations, we previously reported a possible application of robotic technology in total procto-colectomy for Familiar Adenomatous Polyposis or severe Ulcerative Colitis, describing a hybrid laparoscopic/robotic technique with da Vinci Si, capable to save time respect to the multiple docking techniques and simultaneously to maintain the advantages of the robot in the pelvic phase [2]. In line with other published results with the da Vinci Si on rectal surgery [3-5], we reported very good functional outcomes with this technique also in proctocolectomies with ileal pouch anal-anastomosis. However, we acknowledge that the simultaneous use of both laparoscopic and robotic devices is still costly (paradoxically more than robotic alone), and has the disadvantage of loosing benefits coming from the full use of the robotic technology.
As the advent of da Vinci Xi® into clinical practice has overpassed several limits of the previous version, thanks to the functionality of a boom-mounted system combined with the greater flexibility of the robotic arms, we completely agree with the authors that its use in total abdominal proctocolectomy could represent a good application, and could find more spread. The very good results reported by the authors are in line with those of our previously published articles on rectal surgery, and on multiquadrant robotic surgery [6,7]. Indeed, although not specifically applied to total proctocolectomy, we reported significantly shorter docking and operative time during rectal resection for cancer if performed with the Xi versus the Si, as well as a significantly higher rates of fully-robotic approach, also avoiding the need of hybrid phases and higher percentage of complete mobilization of splenic flexure [6-8]. Furthermore, we used the da Vinci Xi in several multiple-organs resections, with very satisfactory results.
Thus, we completely agree with the authors about the capability of the da Vinci Xi to enhance the surgical workflow, and the possibility to obtain similar operative times and even better clinical results respect standard laparoscopy. We think that a further improvement of these promising results can be obtained by adding to the described technique the use of the da Vinci Table Motion (dVTM). Indeed, in our experience the dVTM allows to further increase the flexibility of the robotic system, providing access to different parts of the anatomy even faster and more efficiently respect to the da Vinci Xi alone [9]. The da Vinci Xi plus the new operating table enables the surgeon to optimize gravity exposure and provides the quick access to different surgical targets, bringing advantages in term of operative time and indirectly of personnel costs.
In conclusion, because we also observed a significant reduction of costs with increasing robotic experience and changing from the Si to the Xi version [10], we think that the da Vinci Xi plus dVTM in perfoming total proctcolectomies could represent a combination capable of increase versatility, further reduce operative time and costs, and promote the dissemination of this application. Comparative studies are strongly suggested to draw definitive conclusions
Impact of COVID-19 on vascular patients worldwide: analysis of the COVIDSurg data
No full textBACKGROUND: The COVIDSurg collaborative was an international multicenter prospective analysis of perioperative data from 235 hospitals in 24 countries. It found that perioperative COVID-19 infection was associated with a mortality rate of 24%. At the same time, the COVER study demonstrated similarly high perioperative mortality rates in vascular surgical patients undergoing vascular interventions even without COVID-19, likely associated with the high burden of comorbidity associated with vascular patients. This is a vascular subgroup analysis of the COVIDSurg cohort. METHODS: All patients with a suspected or confirmed diagnosis of COVID-19 in the 7 days prior to, or in the 30 days following a vascular procedure were included. The primary outcome was 30-day mortality. Secondary outcomes were pulmonary complications (adult respiratory distress syndrome, pulmonary embolism, pneumonia and respiratory failure). Logistic regression was undertaken for dichotomous outcomes. RESULTS: Overall, 602 patients were included in this subgroup analysis, of which 88.4% were emergencies. The most common operations performed were for vascular-related dialysis access procedures (20.1%, N.=121). The combined 30-day mortality rate was 27.2%. Composite secondary pulmonary outcomes occurred in half of the vascular patients (N.=275, 45.7%). CONCLUSIONS: Mortality following vascular surgery in COVID positive patients was significantly higher than levels reported pre-pandemic, and similar to that seen in other specialties in the COVIDSurg cohort. Initiatives and surgical pathways that ensure vascular patients are protected from exposure to COVID-19 in the peri-operative period are vital to protect against excess mortality. (Cite this article as: Hitchman L, Machin M; The COVIDSurg Collaborative and Vascular and Endovascular Research Network. Impact of COVID-19 on vascular patients worldwide: analysis of the COVIDSurg data. J Cardiovasc Surg 2021;62:558-70. DOI: 10.23736/S0021-9509.21.12024-5
Comment on “Lessons learnt from living donor liver transplantation with ABO-incompatibility: A single-center experience from southern India”
No full textTo the Editor:
We read with great interest the article by Shajahan et al. entitled “Lessons learnt from living donor liver transplantation with ABO-incompatibility: A single-centre experience from southern India” [1] recently published on Indian Journal of Gastroenterology.
ABO-incompatible living donors liver transplantation (ABO-I LDLT) represents a precious opportunity to shorten the waiting time for surgery, avoiding the disease progression that might occur waiting for an ABO-compatible living or deceased donor. However, ABO-I LDLT is still associated with a high risk of antibody-mediated rejection (AMR), lower patient and graft survival and a high risk of vascular thrombosis and ischemic bile duct complications if compared to ABO-compatible LT.
The study of Shajahan et al. represents the largest report of ABO-I LDLT from India, even if the sample size is still small. The authors retrospectively analyzed data of 12 patients undergone ABO-I LDLT using Rituximab and preoperative plasmapheresis for desensitisation, adjusting doses after facing a very high mortality rate in the first 7 patients (5 deaths), mostly due to septic complications.
Rituximab, a murine/human monoclonal chimeric antibody against CD20 depleting B-lymphocytes, has traditionally been used to treat haematological malignancies and autoimmune diseases. More recently, it has been gained interest as an immunomodulatory agent in solid organ transplantations. [2] Although if current literature is more and more supporting the effectiveness of Rituximab in antibody-mediated rejection (AMR) as a desensitizing regimen, several reports have shown that concerns still remain in the high incidence of complication rates, such as biliary strictures, ischemic-type biliary lesions and postoperative infections. [3,4,5]
Particularly this latter complication afflicted the study of Shajahan et al. who faced a dramatically high rate of postoperative infections involving 9 out of 12 patients, of whom 5 died due to overwhelming sepsis from multidrug-resistant pathogens. Several works such as a Japanese multicenter study have demonstrated that multiple or large Rituximab doses significantly increase the incidence of infection [3], advocating for a “minimization” of the desensitizing protocols. Even if authors have reduced the Rituximab doses after the first 7 cases, the overall septic complications and morality rates still remain very high (75% and 50% respectively), raising the issue of the desensitizing regimen’s adequacy.
Actually, different modalities of Rituximab free immunosuppressive regimens to prevent AMR have been successfully reported in literature, such as the use of high-dose polyclonal intravenous immunoglobulin associated with plasmapheresis without the use of steroid pulses or monoclonal antibodies, or even of everolimus-based immunosuppressive regimen under a strict monitoring of anti-A/B antibodies titres [6,7].
In conclusion, we strongly believe that more and more efforts should be make to minimize the desensitization regimen in ABO-I LDLT in order to reduce the rates of septic complications and improve patients’ and grafts’ survival.
Moreover, prospective studies with bigger sample sizes are required to validate the Indian ABO-I LDLT experience
MR staging of rectal cancer: Comparison between the 2012 and 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) Guidelines
No full textPurpose: To compare the adherence of the interpretation and reporting staging system, respectively proposed in the 2012 and 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) Guidelines for Magnetic Resonance Imaging (MRI) staging of rectal cancer, focusing on the improvement offered by the criteria introduced by 2016 ESGAR guidelines. Method: Fifty-six patients affected by rectal cancer were included; 25/56 patients underwent upfront surgery; 31 underwent to neo-adjuvant chemo-radiotherapy before surgery. All patients underwent 3 T MRI examination for local staging. All MR exams were evaluated by two radiologists with 20- and 4-years’ experience, who were blinded to each other; the T and N stages, the Mesorectal Fascia (MRF) status and the Extramural Vascular Invasion (EMVI) were assessed according to both 2012 and 2016 ESGAR guidelines. The correlation between radiological and pathological findings, as well as the MRI staging were evaluated. Results: As to the expert reviewer, no significant differences were found by comparing the MR T and N stages, T and N restaging, MRF status and EMVI according to 2012 and 2016 ESGAR guidelines. As to the 4-years’ experience radiologist the MR staging agreement between 2012 and 2016 guidelines was “moderate” in N-stage evaluation and “fair” in T-restaging evaluation. No significant discrepancies were found for other parameters. Conclusions: MRI is a reliable method in rectal cancer staging/restaging. The assessment of T-restaging is improved by adopting the 2016 ESGAR guidelines, especially for non-expert readers; this result could be justified by the introduction of diffusion-weighted imaging. On the contrary, the newest guidelines do not improve the diagnostic performance in assessing nodal staging and restaging
Robot-assisted trans-gastric drainage and debridement of walled-off pancreatic necrosis using the EndoWrist stapler for the da Vinci Xi: A case report
No full textBACKGROUND Walled-off pancreatic necrosis (WOPN) is a late complication of acute pancreatitis. The management of a WOPN depends on its location and on patient's symptoms. Trans-gastric drainage and debridement of WOPN represents an important surgical treatment option for selected patients. The da Vinci surgical System has been developed to allow an easy, minimally invasive and fast surgery, also in challenging abdominal procedures. We present here a case of a WOPN treated with a robotic trans-gastric drainage using the da Vinci Xi. CASE SUMMARY A 63-year-old man with an episode of acute necrotizing pancreatitis was referred to our center. Six wk after the acute episode the patient developed a walled massive fluid collection, with an extensive pancreatic necrosis, causing obstruction of the gastrointestinal tract. The patient underwent a robotic transgastric drainage and debridement of the WOPN performed with the da Vinci Xi platform. Firstly, an anterior ideal gastrotomy was carried out, guided by intraoperative ultrasound (US)-scan using the TileProTM function. Then, through the gastrotomy, the best location for drainage on the posterior gastric wall was again US-guided identified. The anastomosis between the posterior gastric wall and the walled-off necrosis wall was carried out with the new EndoWrist stapler with vascular cartridge. Debridement and washing of the cavity through the anastomosis were performed. Finally, the anterior gastrotomy was closed and the cholecystectomy was performed. The postoperative course was uneventful and a post-operative computed tomography-scan showed the collapse of the fluid collection. CONCLUSION In selected cases of WOPN the da Vinci Surgical System can be safely used as a valid surgical treatment option
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