Laparoscopic transgastric pancreatic pseudocystogastrostomy--first experience with extraluminal approach

BACKGROUND/AIMS

Transgastric cystogastrostomy (Jurasz procedure) became a standard procedure in the treatment of mature pancreatic pseudocysts contacting the stomach. The first experience with laparoscopically performed transgastric cystogastrostomy under performing anterior gastrostomy is discussed.

METHODOLOGY

Five ports were used. The anterior stomach wall was opened 2 cm in length. The communication channel with the pseudocyst was created by means of precise coagulation of the posterior stomach as well as the pseudocyst wall. The pseudocyst was evacuated and the stoma was completed by stapling with the EndoGIA lineal stapler 3 cm in length. The anterior stomach wall was also closed with EndoGIA stapler.

RESULTS

Excellent results could be achieved. The pseudocyst resoluted within 1 month after the operation, and the anastomosis healed completely. The patient was discharged on the 8th post-operative day. The follow-up for 1 year was free of complications.

CONCLUSIONS

Laparoscopic pseudocystogastrostomy appears to be a reliable method for treatment of large size mature pancreas pseudocysts because it is a minimally invasive procedure with standardized stapler-performed anastomosis. However, this initial experience has to be confirmed with a large number of patients.

The effect of contrast variation on task performance in video evaluation

BACKGROUND

Luminosity and brightness of the organs viewed on the screen are important for orientation during teleoperating. They can impair the precision of our orientation ability.

METHODS

The way in which organs scatter light during laparoscopic operation was detected and analyzed by means of reflection spectrophotometry with the Photoshop program package (ADOBE). The arithmetical skill was measured during different illumination conditions of the screen created randomly, using values of the liver, gallbladder, and omental fat.

RESULTS

Separate human tissues and organs could be divided on the basis of their luminosity into three basic groups: the luminous tissues such as fat, the stomach, and the bowel; medium-luminous organs such as diaphragm and gallbladder; and dark, mostly parenchymatous organs such as the liver and the spleen. The most luminous tissue illuminated the screen intensely. In experiments the hyperillumination impaired arithmetical skills of 15 volunteers. The errors appeared constantly and the time needed to count the generated points was significantly longer when 40% of intensively illuminated view was exceeded.

CONCLUSIONS

A situation may occur wherein the imaging system lacks the capacity to transmit needed optical information. Intense brightness of the screen may suppress surgical skills during teleoperating. Critical limit was achieved in our experiment with 40% of the view illuminated by omentum fat. This limit can be important for robotic surgical systems such as automated robotic camera control.

Anterior luxtasphincteric stapled rectumresection

BACKGROUND/AIMS

Sphincter saving deep anterior rectumresection improved the live quality of the rectal cancer patients. With the technical progress the resection level could be moved significant distally. The initial experiences are referred with the use of the stapler with flexible shaft in six patients operated due to very deep rectal cancer.

METHODOLOGY

After the usual rectum mobilization the Proximate access AX55 mm (Ethicon) is positioned onto the stretched rectum. The flexible shaft has to be curved to the front and the jaw has to be angled parallel to the handle. The partially closed jaw of the stapler is then pushed towards the anus and then fired. The rectum is the resected. The operation is completed with EEA stapled anastomosis.

RESULTS

Excellent results in all six patients could be noticed 3-18 months after the procedure. No cancer recurrence occurred. Functional sphincter investigation was performed in two patients with result of physiologic sphincter function. Stolen frequency has been stabilised between 2-8 a day.

CONCLUSION

Improved transabdominal stapled method of rectum resection guarantees comfortable and oncologically safe resection of the distal rectum with maintenance of the sphincter function.

The "balanced" operation for life threatening complications of severe "non responding" form of gastroesophageal reflux disease. A case report

The fate of patients developing life-threatening complications of the Barret's non-responding ulcer during an acute treatment is lacking in the literature. Medical therapy with proton pump inhibitors (PPI) for severe forms of gastroesophageal reflux disease fails in 15-20%. Emergency operation is indicated in failed cases. We present an operation which restores anatomical and functional deviations causing reflux disease. Two patients required early surgery due to bleeding and penetration of Barret's ulcer during PPI therapy. Both patients had reflux disease, a Savary Miller stage of IV, and/or the M3; U1; S0; E3 and M3; U3; S0; E3 stage of "MUSE" assessment respectively. The modified "balanced operation" was performed consisting of a truncal vagotomy, hiatus hernia reposition, posterior crura repair, fundoplication and extramucosal pyloroplasty. Both patients had excellent outcomes after surgery. Visick I and II, or M3; U0; S0; E1 and M3; U0; S0; E0 respectively and remained well over the year without any medication. The modified "balanced" operation seems to be the method of choice for treatment of severe, "non responding" form of GERD when complications occur. Various pathophysiological factors such as hyperacidity, the cardia valve and gastric emptying are affected simultaneously. The rationale for the performance of all steps of the "balanced" operation is based on the fact that we do not know before the operation, which steps will be necessary to produce a good result.

Theoretical basis for camera control in teleoperating

BACKGROUND

The triangle paralaxis method for camera control in teleoperating is presented.

METHODS

For orientation in the 3D space of the corporic cavity there are three points necessary for the creation of the paralaxis triangle. This triangle is then imagined and compared with topography during surgery. The first and second points are created in one's mind at the locus of the entry of the instruments into the viewing field of the camera. The third apex of the triangle is the area of dissection-the point in which the instruments converge. The fourth point to be viewed determines the course of dissection. Triangle paralaxis may be applied in dissection with only one instrument as well as in the zooming technique, closely viewing a part of the dissecting instrument.

RESULTS

Using this technique a 7.78% rate of conversion and 2.15% rate of reoperation could be achieved in 334 evaluated laparoscopic cholecystectomies performed in a small public hospital.

CONCLUSIONS

Triangle paralaxis seems to be a simple method for ensuring an optimal camera view during laparoscopic surgery.

In vitro and in vivo viability assessment of unpurified pancreatic islet tissue

The viability of porcine collagenase-prepared islet preparations (n = 16) was classified by 31P-NMR spectroscopy, staining by neutral red and trypan blue, and in vitro insulin secretion following glucose challenge. Vital islets exhibited a phosphate diester/phosphate monoester (PDE/PME) ratio of 0.5-0.9, a staining score of 18-30 and an insulin secretion responding well to glucose challenge. Damaged islets performed at a PDE/PME of 0.2-0.49 and a staining score of 9-17 and necrotic islets had 0.0-0.49 and a staining score of 9-17 and necrotic islets had 0.0-0.19 and 0-8, respectively. The islets of the latter two groups did not adequately respond to glucose. The in vivo function following autotransplantation of these islets into the spleen was investigated in five recipients of more than 3000/kg vital islets of which 4 expressed daily normoglycemia (< 200 mg%), normalized intravenous glucose tolerance (K = -2.21), and a prolonged survival (mean +/- SD) of 167 +/- 12 days compared to five recipients of > 3000/kg damaged islets (K = -0.814) (P = 0.0017) and a survival of 86 +/- 21 days (P = 0.0096). It is suggested that 31P-NMR spectroscopy is a valuable and practical method to predict islet graft viability prior to transplantation in order to assure good graft function in the recipient.

[The pig--an experimental model for transplantation of isolated islets pancreatic islets]

The authors present results of autotransplantation of the islets of Langerhans of the pancreas in pigs and miniature pigs ("Troll"). Diabetes was induced by total pancreatomy. From the removed pancreas the islets of Langerhans were separated by the method of intraductal perfusion with collagenase and implanted into the spleen or liver via the portal vein. The mortality on operation in pigs was 33%, in miniature pigs 20%. In domestic pigs normal blood sugar levels were achieved in 25% after implantation of the islets of Langerhans into the liver (in 2 of 8 animals) and in 50% after implantation into the spleen (in 4 of 8 animals). In miniature pigs autotransplantation of the islets of Langerhans was equally successful when transplanted into the liver or the spleen -50%. The 50% success of autotransplantations justifies the use of pigs as a model for further investigations of allo- or xenotransplantations of the islets of Langerhans.

[Extracorporeal lithotripsy--a new possibility in the treatment of gallstones?]

In the submitted review the author presents the results of treatment of cholelithiasis by extracorporeal lithotripsy by shock waves. Provided there is strict selection of patients with 1-3 cholesterol concrements in the gallbladder, treatment is successful in 70-90%. Complications occur in cca one third of the patients, the mortality rate is zero. The author gives criteria for indication which are met by cca 15-20% patients with cholelithiasis. In the discussion the author analyzes possibilities of urgent and preventive lithotripsy of gallstones, the number of relapses and biological effectiveness of shock sound waves, problems of competence and the economic effect of treatment.

31P NMR spectroscopy for in vitro viability testing of porcine pancreatic islets

The quality of pancreatic islets prepared by an intraductal pancreas collagenase perfusion technique was tested using three independent methods: 31P NMR spectroscopy, an insulin secretion test, and a staining method. The viability of pancreatic islet tissue was evaluated using the ratio of phosphate diester to phosphate monoester (PDE/PME) as a new criterion obtained by 31P NMR spectroscopy. According to this criterion, three types of tissue fragments could be characterized: vital (PDE/PME 0.5-0.9), damaged (PDE/PME less than 0.2), and necrotic (no PDE, no PME). The findings in the three different groups could be correlated to three trends of insulin secretion of the preparations following glucose challenge: good response to the glucose challenge, continuous decrease of insulin production, and no insulin secretion. We feel that 31P NMR spectroscopy offers a rapid and suitable method for classifying the viability of isolated pancreatic islets.

[In vitro and in vivo studies of isolation, transplantation and function of Langerhans islets in the swine]

Limits and possibilities of the transplantation of islets of Langerhans in pigs were studied. 6 x 10(4) to 3 x 10(6) islets and insulin producing fragments per pancreas were obtained by intraductal collagenase digestion of the pancreatic gland following total pancreatectomy. Islets grafted into the spleen or liver rendered normoglycemia to the pancreatectomized animals as demonstrated by normal fasting blood sugars and normal intravenous glucose tolerance tests as compared to not operated animals permitting a survival time of up to one year. Apancreatic controls died of ketoacidosis and diabetic coma 10 to 12 days posttransplant. The number of isolated and transplanted islets correlated well to the normoglycemic state of the animal. Beyond that the in vitro challenge of the islets with glucose and resulting insulin secretion was a very important indicator for the functional status and integrity of the islets after transplantation. Thus the pig appears to be a suitable model for the preclinical studying of islet transplantation especially since immunologic, physiologic and anatomic features of the pig are similar to those in the human regarding pancreas and nutrition.