Transferring Knowledge from Monitored to Unmonitored Areas for Forecasting Parking Spaces

Smart cities around the world have begun monitoring parking areas in order to estimate available parking spots and help drivers looking for parking. The current results are promising, indeed. However, existing approaches are limited by the high cost of sensors that need to be installed throughout the city in order to achieve an accurate estimation. This work investigates the extension of estimating parking information from areas equipped with sensors to areas where they are missing. To this end, the similarity between city neighborhoods is determined based on background data, i.e., from geographic information systems. Using the derived similarity values, we analyze the adaptation of occupancy rates from monitored- to unmonitored parking areas.

The effects of weight loss after bariatric surgery on health-related quality of life and depression

BACKGROUND

In severe obesity, impairments in health-related quality of life (HRQoL) and dysphoric mood are reported. This is a post-surgery analysis of the relationship between HRQoL and depressive symptoms, and weight change after four different types of bariatric procedures.

METHODS

A total of 105 consented patients completed the Short-Form-36 Health Survey (SF-36), the Impact of Weight on Quality of Life-Lite (IWQOL-Lite) and the Beck Depression Inventory (BDI) before and 25 months after surgery. Analysis of variance or Kruskal-Wallis test evaluated changes.

RESULTS

Patients with Roux-en Y gastric bypass (46 patients), decreased body mass indexes (BMIs; kg m(-)(2)) 47-31 kg m(-)(2) (P<0.0001); biliopancreatic diversion with duodenal switch (18 patients), decreased BMIs 57-30 kg m(-)(2) (P<0.0001); adjustable gastric banding (18 patients), decreased BMIs 45-38 kg m(-)(2) (P<0.0001); and sleeve gastrectomies (23 patients), decreased BMIs 58 42 kg m(-)(2) (P<0.0001). The excess percentage BMI loss was 69, 89, 36 and 53 kg m(-)(2), respectively (P<0.0001). Before surgery, the SF-36 differences were significant regarding bodily pain (P=0.008) and social functioning (P=0.01). After surgery, physical function (P=0.03), general health (P=0.05) and physical component (P=0.03) were different. IWQOL-Lite recorded no differences until after surgery: physical function (P=0.003), sexual life (P=0.04) and public distress (P=0.003). BDI scores were not different for the four groups at baseline. All improved with surgery, 10.6-4.4 (P=0.0001).

CONCLUSIONS

HRQoL and depressive symptoms significantly improvement after surgery. These improvements do not have a differential effect over the wide range of weight change.Nutrition & Diabetes (2014) 4, e132; doi:10.1038/nutd.2014.29; published online 1 September 2014.

Vitamin D insufficiency prior to bariatric surgery: risk factors and a pilot treatment study

OBJECTIVE

To assess vitamin D status and the influences of race, sun exposure and dietary vitamin D intake on vitamin D levels, and to evaluate two vitamin D repletion regimens in extremely obese patients awaiting bariatric surgery.

METHODS

A cross-sectional analysis of dietary vitamin D, sun exposure, PTH [intact (iPTH) and PTH(1-84)] and 25-hydroxyvitamin D (25OHD; differentiated 25OHD2 and 25OHD3) in 56 obese [body mass index (BMI) > 35 kg/m(2)] men and women (age 20-64 years). In a pilot clinical trial, 27 subjects with 25OHD levels < 62 nmol/l were randomized to receive ergocalciferol or cholecalciferol for 8 weeks.

RESULTS

Serum 25OHD was low (mean 45 +/- 22 nmol/l) and was inversely associated with BMI (r = -0.36, P < 0.01). Each BMI increase of 1 kg/m(2) was associated with a 1.3 nmol/l decrease in 25OHD (P < 0.01). BMI, sun exposure, African American race and PTH predicted 40% of the variance in 25OHD (P < 0.0001). Serum 25OHD significantly increased at 4 and 8 weeks in both treatment groups (P < 0.001), whereas PTH(1-84) declined significantly in subjects treated with cholecalciferol (P < 0.007) and tended to decrease following ergocalciferol (P < 0.09).

CONCLUSIONS

In severely obese individuals, those who are African American, have higher BMI and limited sunlight exposure are at greatest risk for vitamin D insufficiency. These demographic factors can help to identify at-risk patients who require vitamin D repletion prior to bariatric surgery. Commonly prescribed doses of ergocalciferol and cholecalciferol are effective in raising 25OHD. Further investigation is needed to evaluate whether these regimens have differential effects on PTH, and to determine the optimal regimen for vitamin D repletion in the extremely obese patient.

Sleeve gastrectomy

Much has been published over the last few years about sleeve gastrectomy. It is a bariatric operation that has evolved from both established restrictive and malabsorptive procedures. Originally used as a bridge to definitive surgery in high-risk patients, it has recently been forwarded as a stand-alone procedure. Technical details of laparoscopic sleeve gastrectomy (LSG) vary, but the premise is removal of the vast majority of the stomach, especially the fundus, leaving only a thin gastric tube between the esophagus and the duodenum. This results in weight loss from restrictive as well as neurohormal mechanisms. Review of the literature reveals an average expected excess weight loss (EWL) of 61%. Morbidity and mortality seem to be on par with laparoscopic adjustable gastric banding (LAGB), but with superior weight loss results and an improved long-term complication profile. Unlike popular mixed malabsorptive procedures like Roux en-Y gastric bypass (RYGB) and biliopancreatic diversion with duodenal switch (BPD-DS), there is no gastrointestinal segment exclusion, maintaining continuity for endoscopic interventions and surveillance. Comorbidity resolution with LSG is variable, though compares favorably with other bariatric procedures. While the early results seem promising, long-term data is still needed to define the place of LSG within the bariatric surgery armamentarium.

Syndrome of inappropriate secretion of antidiuretic hormone following laparoscopic inguinal hernia repair

Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) after cardiac surgery and traditional open abdominal surgery has been reported. This disorder also has been associated with minor operative procedures with the patient under local anesthesia. However, SIADH after laparoscopic surgery is not well documented in the literature. We report a case of SIADH after laparoscopic inguinal hernia repair in an elderly woman.

Symptomatic internal hernias after laparoscopic bariatric surgery

BACKGROUND

The aim of this study was to describe the occurrence and clinical characteristics of symptomatic internal hernias (IH) after laparoscopic bariatric procedures.

METHODS

We conducted a retrospective review of cases of IH after 1,064 laparoscopic gastric bypasses (LGB) and biliopancreatic diversions with duodenal switch (LBPD-DS) performed from September 1998 to August 2002.

RESULTS

We documented 35 cases of IH (overall incidence of 3.3%). The IH occurred in 6.0% of patients with retrocolic procedures and 3.3% of patients with antecolic procedures. Most were in the Petersen defect (55.9%) and at the enteroenterostomy site (35.3%). A bimodal presentation was observed, with 22.9% of patients with IH diagnosed in the early postoperative period (2-58 days) and 77.1% in a delayed fashion (187-1,109 days). A laparoscopic approach to the repair of IH was possible in 60.0% of patients. Complications occurred in 18.8% of patients, including one death (2.9%).

CONCLUSION

Complete closure of all mesenteric defects is strongly recommended during laparoscopic bariatric procedures to avoid IH and their associated complications.

Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient

BACKGROUND

Surgical management of the supersuper obese patient (BMI >60 kg/m2) has been a challenging problem associated with higher morbidity, mortality, and long-term weight loss failure. Current limited experience exists with a two-stage biliopancreatic diversion and duodenal switch in the supersuper obese patient, and we now present our early experience with a two-stage gastric bypass for these patients.

METHODS

We completed a retrospective bariatric database and chart review of super-super obese patients who underwent laparoscopic sleeve gastrectomy as a first-stage procedure followed by laparoscopic Roux-en-Y gastric bypass as a second-stage for more definitive treatment of obesity.

RESULTS

During a two-year period, 7 patients with BMI 58-71 kg/m2 underwent a two-stage laparoscopic Roux-en-Y gastric bypass by two surgeons at the Mount Sinai Medical Center. 3 patients were female, 4 patients were male, and the average age was 43. Prior to the sleeve gastrectomy, the mean weight was 181 kg with a BMI of 63. Average time between procedures was 11 months. Prior to the second-stage procedure, the mean weight was 145 kg with a BMI of 50 and average excess weight loss of 37 kg (33% EWL). Six patients have had follow-up after the second-stage procedure with an average of 2.5 months. At follow-up the mean weight was 126 kg with a BMI of 44 and average excess weight loss of 51 kg (46% EWL). The mean operative times for the two procedures were 124 and 158 minutes respectively. The average length of stay for all procedures was 2.7 days. 4 patients had 5 complications, which included splenic injury, proximal anastomotic stricture, left arm nerve praxia, trocar site hernia, and urinary tract infection. There were no mortalities in the series.

CONCLUSIONS

Laparoscopic sleeve gastrectomy with second-stage Roux-en-Y gastric bypass are feasible and effective procedures based on short-term results. This two-stage approach is a reasonable alternative for surgical treatment of the high-risk supersuper obese patient.

Effect of standard vs extended Roux limb length on weight loss outcomes after laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Increasing the length of the Roux limb in open Roux-en-Y gastric bypass (RYGB) effectively increases excess weight loss in superobese patients with a body mass index (BMI) >50 kg/m2. Extending the RYGB limb length for obese patients with a BMI < 50 could produce similar results. The purpose of this study was to compare the outcomes of superobese patients undergoing laparoscopic RYGB with standard (< or =100-cm) with those undergoing the procedure with an extended (150-cm) Roux limb length over 1-year period of follow-up.

METHODS

Retrospective data over 2.5 years were reviewed to identify patients with a BMI < 50 who underwent primary laparoscopic RYGB with 1-year follow-up ( n = 58). Forty-five patients (sRYGB group) received limb lengths < or = 100 cm, including 45 cm ( n = 1), 50 cm ( n = 2), 60 cm ( n = 6), 65 cm ( n = 1), 70 cm ( n = 1), 75 cm ( n = 3), and 100 cm ( n = 31). Thirteen patients (eRYGB group) received 150-cm limbs. Postoperative weight loss was compared at 3 weeks, 3 months, 6 months, and 1 year.

RESULTS

Comparing the sRYGB vs the eRYGB group (average +/- SD), respectively: There were no significant differences in age (41.5 +/- 11.0 vs 38.0 +/- 11.9 years), preoperative weight (119.2 +/- 11.9 vs 127.8 +/- 12.5 kg), BMI (43.7 +/- 3.0 vs 45.2 +/- 3.5 kg/m2), operative time (167.1 +/- 72.7 vs 156.5 +/- 62.4 min), estimated blood loss (129.9 +/- 101.1 vs 166.8 +/- 127.3 cc), or length of stay (median, 3 vs 3 days; range, 2-18 vs 3-19). Body weight decreased over time in both groups, except in the sRYGB group between 3 and 6 months and 6 and 12 months after surgery and in the eRYGB group between 6 and 12 months. BMI also decreased over time, except in the eRYGB group between 6 and 12 months. Absolute weight loss leveled out between 6 and 12 months in both groups, with no increase after 6 months. Percent of excess weight loss did not increase in the eRYGB group after 6 months. An extended Roux limb did not significantly affect body weight, BMI, absolute weight loss, or precent of excess weight loss at any time point when the two groups were compared. A trend toward an increased proportion of patients with >50% excess weight loss ( p = 0.07) was observed in the extended Roux limb group.

CONCLUSIONS

In this series, no difference in weight loss outcome variables were observed up to 1 year after laparoscopic RYGB. Thus, extending Roux limb length from < or =100 cm to 150 cm did not significantly improve weight loss outcome in patients with a BMI < 50 kg/m2.

Prospective, multicenter study of laparoscopic ventral hernioplasty. Preliminary results

BACKGROUND

A standard technique for laparoscopic ventral hernioplasty (peritoneal onlay using an expanded polytetrafluoroethylene [ePTFE] patch for hernias >/=4 cm2) is being used in a prospective, multicenter, long-term study.

METHODS

Demographic, operative, and postoperative data were collected and analyzed. Follow-up clinical evaluations were conducted 7-10 days, 4 weeks, 6 months, 1 year, and then annually after surgery in all patients.

RESULTS

In the first 2 years of the study, 144 patients were enrolled; nine were lost to follow-up. The mean operating time was 120 min. The mean follow-up was 222 days (range 5-731). Postoperative complications were five infections, three cases of prolonged ileus, one bowel obstruction, 23 seromas (15 resolved without intervention), and six hernia recurrences. Hospital discharge occurred a mean of 2.3 days after surgery and return to normal activity a mean of 15 days postoperatively.

CONCLUSIONS

Laparoscopic prosthetic ventral hernioplasty avoids the large wound required in open repairs, with attendant complications and recurrences, and appears safe, especially if an ePTFE mesh is used. Compared with conventional open ventral hernioplasty, the laparoscopic technique may also allow shorter hospitalization and a quicker return to normal activities after surgery.

Severity and impact of pain after day-surgery

PURPOSE

To assess the intensity, duration and impact of pain after day-surgery interventions. Predictors of pain severity were also evaluated along with the quality of analgesic practices and patient satisfaction.

METHODS

Eighty-nine consecutive day-surgery patients completed self-administered questionnaires before leaving the hospital and at 24, 48 hr and seven days after discharge. The survey instrument was composed of 0-10 pain intensity scales, selected items of the Brief Pain Inventory, of the Patient Outcome Questionnaire and of the Barriers Questionnaire. Analgesic intake in hospital and at home was recorded along with the use of other pain control methods.

RESULTS

Forty percent of the patients reported moderate to severe pain during the first 24 hr after hospital discharge. The pain decreased with time but it was severe enough to interfere with daily activities in a substantial number of patients. The best predictor of severe pain at home was inadequate pain control during the first few hours following the surgery. More than 80% of the participants were satisfied with their pain treatment. However, one patient in four (25%) needed contact with a health care provider because of pain at home. Many patients (33% to 51%) reported that instructions about pain control were either unclear or non-existent on several aspects. Medication use was low overall. Thirty-two percent of the patients did not take any pain medication during the first 24 hr after discharge although almost half of them (46%) rated their pain > or = 4. The most common concerns patients had about using pain medication were fear of drug addiction and side effects.

CONCLUSION

The severity and duration of pain after day-surgery should not be underestimated. Aggressive analgesic treatment during the hospital stay should be provided along with take-home analgesia protocols and comprehensive patient education programs.

Laparoscopic adrenalectomy: lessons learned from 100 consecutive procedures

One hundred consecutive laparoscopic adrenal procedures for a variety of endocrine disorders were reviewed. There was no mortality, morbidity was 12%, and conversions was 3%. During follow-up, none had recurrence of hormonal excess. Laparoscopic adrenalectomy is the procedure of choice for adrenal removal except in carcinoma or masses > 15 cm.

OBJECTIVE

The authors evaluate the effectiveness of laparoscopic adrenalectomy for a variety of endocrine disorders.

SUMMARY BACKGROUND DATA

Since the first laparoscopic adrenalectomy was performed in 1992, this approach quickly has been adopted, and increasing numbers are being reported. However, the follow-up period has been too short to evaluate the completeness of these operations.

METHODS

One hundred consecutive laparoscopic adrenal procedures from January 1992 until November 1996 were reviewed and followed for adequacy of resection.

RESULTS

Eighty-eight patients underwent 97 adrenalectomies and biopsies. The mean age was 46 years (range, 17-84 years). Indications were pheochromocytomas (n = 25), aldosterone-producing adenomas (n = 21), nonfunctional adenomas (n = 20), cortisol-producing adenomas (n = 13), Cushing's disease (n = 8), and others (n = 13). Fifty-five patients had previous abdominal surgery. Mean operative time was 123 minutes (range, 80-360 minutes), and estimated blood loss was 70 mL (range, 20-1300 mL). There was no mortality, and morbidity was encountered in 12% of patients, including three patients in whom venous thrombosis developed with two sustaining pulmonary emboli. During pheochromocytoma removal, hypertension occurred in 56% of patients and hypotension in 52%. There were three conversions to open surgery. The average length of stay has decreased from 3 days (range, 2-19 days) in the first 3 years to 2.4 days (range, 1-6 days) over the past 16 months. During follow-up (range, 1-44 months), two patients had renovascular hypertension and none had recurrence of hormonal excess.

CONCLUSION

Laparoscopic adrenalectomy is safe, effective, and decreases hospital stay and wound complications. Prior abdominal surgery is not a contraindication. Pheochromocytomas can be resected safely laparoscopically despite blood pressure variations. Venous thrombosis prophylaxis is mandatory. The laparoscopic approach is the procedure of choice for adrenalectomy except in the case of invasive carcinoma or masses > 15 cm.

Left hepaticogastrostomy for biliary obstruction: long-term results

PURPOSE

To evaluate the long-term results of peripheral biliary diversion by means of anastomoses of the left lobe of the liver to the stomach.

MATERIALS AND METHODS

Transhepatic perforation of the left lobe of the liver into the lesser curvature of the stomach was performed in 35 patients with a presumed diagnosis of malignant obstructive jaundice. Jaundice was found to be caused by a malignant stricture in 32 patients and a benign stricture in three. Perforation was performed under fluoroscopic, endoscopic, and laparoscopic guidance in 33 patients and without laparoscopy in the other two. The hepaticogastric anastomosis was secured with a gastrostomy tube; patency of the tract was maintained with placement of a metallic stent. Kaplan-Meier analysis was used to evaluate survival, anastomosis patency rate, and jaundice recurrence.

RESULTS

Technical success was achieved in all patients. Two (6%) patients had anastomotic obstruction. The actuarial survival rate was 91%, 80%, 59%, and 26% at 1, 3, 6, and 12 months. The mean patency was 234 days +/- 252. The jaundice-free rate among surviving patients was 100%, 96%, 93%, and 80% at 1, 3, 6, and 12 months. The reintervention rate was 14%. Late cholangitis occurred in seven (20%) patients.

CONCLUSION

This peripheral diversion procedure appears to be safe and shows good long-term patency.

Laparoscopic Roux-en-Y gastric bypass for morbid obesity: a feasibility study in pigs

According to randomized prospective studies in humans, the Roux-en-Y gastric bypass provides more effective weight loss than vertical banded gastroplasty for morbid obesity. Ten pigs underwent laparoscopic Roux-en-Y gastric bypass to assess the feasibility of this procedure with conventional laparoscopic techniques and instruments. The procedure took an average of 4 h 20 min. Of the first five pigs killed immediately, four had correct anastomoses. Of the five remaining pigs with postoperative follow-up, three survived with an intact anastomosis and staple line at autopsy. Two died within 48 h, one from peritonitis (perforation of the small bowel), the other from unknown causes. A definite learning curve exists for this procedure primarily because of the extent of gastrointestinal reconstruction, but there is potential for it to be used in humans.

The lateral approach to laparoscopic splenectomy

BACKGROUND

Laparoscopic splenectomy has been shown to result in shorter hospital stays and a quicker return to work than conventional splenectomy. Having tried the anterior 5 trocar approach, we developed a 4 trocar lateral approach and now present our experience with 22 cases.

METHODS

All patients were placed in the right lateral decubitus position. A 10-mm trocar was inserted in the left subcostal region, 2 in the flank, and a 5-mm trocar dorsally. A 30 degrees laparoscope was used. Splenectomy was performed for varying pathologies.

RESULTS

Operating room (OR) time averaged 169 minutes, spleen weight 513 grams, and postoperative (post-op) stays 5.4 days (median 3 days). One patient was converted to laparotomy. There were no deaths, post-op abscesses, pancreatic injuries, or bleeding complications.

CONCLUSIONS

The lateral approach affords superior exposure, allowing easier dissection of splenic hilar structures. Over varying patient habitus and spleen size it has been demonstrated to be the approach of choice for laparoscopic splenectomy.

Laparoscopic pancreatic resection: Is it worthwhile?

A series of 23 patients who had undergone an attempted laparoscopic Whipple (n = 10) or laparoscopic distal pancreatectomy (n = 9) or laparoscopic enucleation (n = 4) since January 1992 were retrospectively reviewed. In the laparoscopic Whipple group (6 women and 4 men; mean age 71 [range 33 to 82] years), eight had malignant periampullary tumors and two had chronic pancreatitis. The rate of conversion to an open procedure was 40%, and complications were seen in the nonconverted group. The average operative time was 8.5 hours, and the hospital stay was 22.3 days. However, in the laparoscopic distal pancreatectomy and enucleation groups, there were seven women and six men (mean age 46.5 [range 27 to 75] years). Of these, nine patients had a planned laparoscopic distal pancreatectomy (8 for islet cell tumors and 1 for chronic pancreatitis) and four had a planned laparoscopic enucleation (all 4 for islet cell tumors). The conversion rate for these patients was 36%, and the mean operative time was 4.5 hours for laparoscopic distal pancreatectomy and 3 hours for laparoscopic enucleation. The hospital stay was 5 days and 4 days, respectively. Although this series was small, no benefit seemed to be derived from the use of a complete laparoscopic Whipple procedure. Laparoscopic distal pancreatectomy and enucleation were technically easier to perform and seemed to benefit patients by shortening their hospital stay with no recurrence of disease.

Is laparoscopic adrenalectomy indicated for pheochromocytomas?

BACKGROUND

Since the introduction of laparoscopic adrenalectomy there has been major concern about proper indications for its use, including in pheochromocytoma. In this study we reviewed pheochromocytomas resected by means of laparoscopy to establish that procedure's usefulness.

METHODS

Between January 1992 and June 1995, 90 laparoscopic adrenalectomies were performed in 82 patients. Three to five trocars were used intraperitoneally in each patient to remove the gland, and extraction was performed with a sterile plastic bag.

RESULTS

Twenty-three pheochromocytomas were operated on. Six patients had a bilateral adrenalectomy. Pheochromocytomas were significantly larger than other tumors, required more operating time, and necessitated longer hospital stays in patients. Of all the intraoperative complications 87% occurred in the pheochromocytoma group; 67% of all postoperative complications occurred in this group. In four patients metastasis from pheochromocytoma to the liver was unexpectedly found, and in one case metastasis from a medullary thyroid carcinoma was found. There has been no local recurrence after laparoscopic adrenalectomy.

CONCLUSIONS

Laparoscopic adrenalectomy for pheochromocytomas is difficult because tumors are larger and more complications are seen related to their hormonal secretions, in spite of adequate pharmacologic blockade. However, metastatic extensions can be diagnosed and laparoscopic ablation can be performed in most instances without recurrence. It is not, therefore, a contraindication for this approach.

Early experience with laparoscopic resections of islet cell tumors

BACKGROUND

Diagnostic laparoscopy and laparoscopic ultrasonography have been applied recently for diagnosis and localization of islet-cell tumors. A further step was taken by performing resection of these tumors with laparoscopic techniques.

METHODS AND RESULTS

We studied a retrospective series of 12 patients operated on with laparoscopic techniques since January 1992. The seven female and five male patients had a mean age of 43 years. The mean tumor size was 3 cm. Thirty-six percent of the tumor site could not be identified before operation. Eight patients underwent planned laparoscopic distal pancreatectomy (five insulinomas, two gastrinomas, and one unknown origin), and four underwent planned laparoscopic enucleation (one insulinoma and three unknown origin). Of the eight distal procedures, three had conversions (one inability to localize the tumor and two metastatic gastrinomas). Average operating time was 4.5 hours, with an average hospital stay of 5 days. Of the four explorations for possible enucleation, one was performed and one was converted to a Whipple procedure for nesidioblastoma of the head of the pancreas. The other two had negative explorations. The successful enucleation of an insulinoma of the anterior body of the pancreas was performed in 3 hours, and the hospital stay was 4 days. No recurrence was seen in the enucleated or distal pancreatectomy group in follow-up (15 to 38 months).

CONCLUSIONS

Laparoscopic enucleation or resection of benign islet tumors results in a shorter hospital recovery and is a good alternative to open surgery.

Laparoscopic repair of large incisional hernias

Conventional repair of large incisional hernias is often associated with a painful postoperative recovery and a delayed return to normal activities. We describe here a technique of laparoscopic incisional hernia repair and review our experience with 30 cases. Hernias ranging in size from 10 to 420 cm2 (mean, 104 cm2) were repaired using a polytetrafluoroethylene patch (16 cases) and a Prolene mesh (14 cases). Operating room time ranged from 45 mins to 190 min (mean 108 mins). Postop stay ranged from 1 to 17 days (mean, 4.3 days; median, 3 days). Follow-up extends beyond 18 months. Postoperative complications included ileus (three cases) trocar site infection (one case) and urinary retention (two cases). There has been one hernia recurrence to date. Our experience with the laparoscopic repair of incisional hernias reveals it to be technically feasible with minimal morbidity, allowing patients prompt resumption of regular activities. Prospective comparison with conventional repair and longer follow-up are needed.

Laparoscopic transgastric suturing for bleeding peptic ulcers

BACKGROUND

Peptic ulcers are a frequent cause of upper G.I. bleeding. Since endoscopic methods may be unsuccessful, we have studied the feasibility of a new laparoscopic approach on a porcine model to control the bleeding of these ulcers with transgastric suturing.

METHODS

After approval of the Animal Ethics Committee, 20 pigs (20 kg) were anticoagulated with intravenous sodium heparin (400 U/kg), and anesthetized. A nasogastric tube was inserted and a 15 mmHg pneumoperitoneum was created. Two 10-mm trocars and one 5-mm trocar were inserted through the abdominal cavity for laparoscopic guidance of three 7-mm endoluminal trocars inside the stomach through the anterior wall. Two posterior gastric ulcers were mechanically made on each pig by a "lift and cut technique." Ulcers were observed for at least 1 min for evidence of continued bleeding. First, bleeding ulcers were treated with sclerosing agents (epinephrine and ethanolmine oleate 5%); following sclerotherapy, ulcers were sutured intraluminaly with 2-0 silk, with intracorporeal knots.

RESULTS

Ulcers created extended into the vascular submucosa and averaged 7 mm in diameter. Bleeding rate was variable, but significant (2 cm3/min) in 40%. It was technically possible to suture these ulcers in 80%. Bleeding was controlled in 95% of cases with sclerotherapy and intraluminal sutures. One perforation of the posterior gastric wall occurred and four endoluminal trocars had to be reinserted after dislodgement.

CONCLUSIONS

It is possible to technically control bleeding ulcers in most cases with a laparoscopic transgastric technique using sclerosing agent and intraluminal sutures. This approach is promising for future human application; also, the intragastric suturing skills developed may be useful for other surgical interventions.

A robotic camera for laparoscopic surgery: conception and experimental results

The aim of this project was to replace the surgical assistant for common laparoscopic procedures with a robotic camera. The motions of the human camera operator were defined and expressed mathematically by a spherical displacement model. A revolving robotic arm with six degrees of freedom was employed in conjunction with this model as an automated camera in the performance of cholecystectomy, Taylor and Nissen procedures in animals, and cholecystectomy in humans. It represents a first step toward the introduction of robotic technology in laparoscopic surgery.

Malignant biliary obstruction: preliminary results of palliative treatment with hepaticogastrostomy under fluoroscopic, endoscopic, and laparoscopic guidance

PURPOSE

To report a technique of peripheral biliary decompression by means of anastomosis of a bile duct in segment II of the liver to the lesser curvature of the stomach.

MATERIALS AND METHODS

Seven patients with unresectable biliary neoplasm were treated. After transhepatic catheterization of a segment II bile duct, the left lobe of the liver and the lesser curvature of the stomach were perforated under fluoroscopic and laparoscopic guidance. Anastomosis between the biliary tree and the stomach was maintained with a gastrostomy tube placed across the tract. After 2 weeks, the tube was removed and patency of the tract was preserved with a metallic stent.

RESULTS

Three patients died, at 3, 6, and 9 months, respectively, without reocclusion; the other four were alive at 5 months without jaundice. One patient had an episode of cholangitis, which was resolved with antibiotic therapy.

CONCLUSION

This method yields a good patency rate with few problems. Further investigation is required to evaluate long-term patency and the necessity of laparoscopic guidance.

Laparoscopic pylorus-preserving pancreatoduodenectomy

A case of chronic pancreatitis localized in the head of the pancreas with pancreas divisum was treated by laparoscopic pylorus-preserving pancreatoduodenectomy. The laparoscopic technique of resection and reconstruction with a gastrojejunostomy, hepaticojejunostomy, and pancreaticojejunostomy is described. The postoperative period was complicated by a jejunal ulcer and delayed gastric emptying necessitating a prolonged hospitalization and intravenous hyperalimentation. No fistulas occurred, a follow-up CT scan revealed no pancreatic abnormalities, and the patient was discharged in good condition on the 30th postoperative day. Although technically feasible, the laparoscopic Whipple procedure may not improve the postoperative outcome or shorten the postoperative recovery period.

Laparoscopic adrenalectomy. The importance of a flank approach in the lateral decubitus position

Adrenalectomy is usually performed via transabdominal or posterior approaches. Unfortunately, both approaches are associated with painful postoperative syndromes. Recently, laparoscopic surgery was applied to organ removal. During a period of 12 months, we performed a series of successful laparoscopic adrenalectomies (10 of the right and 11 of the left gland). The pathologies were medullary cyst (1), angiomyolipoma (1), DHEAS hyperplasia (1), primary aldosteronism (2), Cushing's adenoma (3), pheochromocytoma (4), Cushing's syndrome (4), and nonfunctional adenoma (5). A flank approach was taken with four 11-mm trocars. Electrocautery and blunt forceps were used for dissection. The vessels were secured with medium-large titanium clips, and the adrenal was removed in a sterile plastic bag. The average operating time was 2.3 h, and median postoperative stay was 4 days. Two patients required blood transfusion of 2 units postoperatively. We believe this technique is adequate for the surgical removal of adrenal tissue, resulting in less postoperative pain and in rapid recovery. It may also change the surgical management of asymptomatic adrenal lesions.

Early experience with laparoscopic approach for adrenalectomy

BACKGROUND

Adrenalectomy performed by a posterior or transabdominal approach causes substantial postoperative pain. The purpose of this study was to evaluate laparoscopy as a potential approach for adrenalectomy.

METHODS

We performed 25 consecutive laparoscopic adrenalectomies on 22 patients from April 1, 1992, to March 30, 1993. Laparoscopic surgery was performed by using a lateral decubitus flank approach with four 11 mm trocars.

RESULTS

Twelve right and 13 left adrenal glands were removed in a mean time of 2.3 hours. Three patients underwent bilateral adrenalectomies in a mean time of 5.3 hours. The 15 women and 7 men range in age from 31 to 60 years (mean, 42 years). The adrenal gland diseases were nonfunctional adenoma (seven), pheochromocytoma (five), Cushing's disease (four), Cushing's adenoma (four), primary aldosteronism (two), dehydroepiandrostenedione sulfate hypersecretion (one), angiomyolipoma (one), and medullary cyst (one). Average tumor size was 4.1 cm (range, 1 to 15 cm). Laparoscopic adrenalectomy was successful in 96% of patients, with one patient requiring a laparotomy because of inadequate exposure. The median postoperative stay was 4 days (range, 2 to 19), with a mean of five narcotic injections. There were no deaths, and morbidity was minor.

CONCLUSIONS

Laparoscopy can be used successfully for adrenalectomy. It produces less postoperative pain and rapid return to normal activity. It may be the preferred method for removing most adrenal gland lesions that require operation.

Routine operative cholangiography during laparoscopic cholecystectomy: feasibility and value in 107 patients

OBJECTIVE

Laparoscopic cholecystectomy is becoming a popular alternative to open cholecystectomy. However, the technical aspects of this new procedure increase the risk of injuring the bile ducts. The purpose of this study was to determine the feasibility and value of performing cholangiography during laparoscopic cholecystectomy.

MATERIALS AND METHODS

We retrospectively reviewed the clinical and operative cholangiographic findings of the first 107 patients undergoing laparoscopic cholecystectomy at Hôtel-Dieu de Montréal between August 1990 and August 1991.

RESULTS

Operative cholangiography was attempted in 98% of patients; the success rate was 71%. Eight anatomic anomalies of the biliary tract that were of surgical importance were found as well as 10 cases of stones in the common bile duct, eight of which were unsuspected. No biliary tract injuries occurred. With experience, surgical cannulation of the cystic duct for injection of contrast material can be done quickly without major difficulty, and cholangiograms of excellent diagnostic quality can be obtained.

CONCLUSION

Our results show that operative cholangiography is feasible and useful in patients undergoing laparoscopic cholecystectomy.

Dietary habits after ileal pouch-anal anastomosis

Dietary habits of patients who had undergone ileal pouch-anal anastomosis were assessed and correlated with bowel function. Twenty-four well-adapted patients (11 women, 13 men; mean age 32 years) voluntarily entered the study 30 +/- 4 months after closure of the diverting ileostomy. A standardized questionnaire on 108 food items and a 3-day food journal were used in the assessment. Twenty-one patients had no difficulty in selecting an appropriate diet. Caloric intake was adequate. Specific symptoms associated with several foods were as follows: increased stool frequency (beer, spirits, chinese food), decreased stool consistency (beer, wine, fried fish), perianal irritation (spicy foods), undigested particles (grapefruit, lettuce), odours (eggs). Pasta and bananas were associated with increased stool consistency. The authors believe that these observations may help in dietary counselling after ileal pouch-anal anastomosis.

Use of retinol-binding protein and prealbumin as indicators of the response to nutrition therapy

There is no single available measurement for evaluating the short-term response to nutrition therapy. The ideal parameter should have high sensitivity and specificity and should be unaffected by non-nutritional factors. A literature review suggested that plasma retinol-binding protein and prealbumin concentrations change earlier than albumin and transferrin levels and appear to correlate better with nitrogen balance during nutrition therapy. That conclusion was supported by our own findings in patients receiving total parenteral nutrition and following the transition to oral or enteral feedings. Although concentrations of these plasma proteins have been shown to be affected by stress and renal and hepatic disease, they appear to be more sensitive indicators of the adequacy of nutrition support than other more commonly used assessment parameters.

Demonstration of a bronchobiliary fistula by 99mTc-HIDA cholescintigraphy

A case of bronchobiliary fistula diagnosed by 99mTc-HIDA cholescintigraphy is presented. The fistula caused by a stenosing tumor of the left hepatic duct would probably have been missed without the use of delayed views and body fluids counting which increased the specificity of scintigraphic findings.