Transition from laparoscopic to robotic liver surgery: clinical outcomes, learning curve effect, and cost-effectiveness

The reproducibility of the implementation of robotic liver surgery (RLS) is still debated. The aim of the present study is to evaluate short-term outcomes and cost differences during the implementation of RLS, performed by an early adopter in laparoscopic liver surgery (LLS). Patients undergoing RLS between February 2020 and May 2021 were included. Short-term outcomes of the robotic group (RG) were compared to the "Initial Phase" group (IP) of 120 LLS cases and the 120 most recent laparoscopic cases or "Mastery Phase" group (MP). A cost analysis per procedure for the three groups was performed. Seventy-one patients underwent RLS during the study period. Median operative time in the RG was comparable to the IP, but significantly shorter in the MP (140 vs 138 vs 120 min, p < 0.001). Median intraoperative blood loss in the RG was lower than in both laparoscopic groups (40 ml [20-90 ml] vs 150 ml [50-250 ml] vs 80 ml [30-150 ml], p < 0.001). Median hospital stay in the RG was significantly shorter than the IP group (p < 0.001). There were no significant differences in postoperative complication, conversion, or readmission rates. Procedural cost analysis was in favor of robotic surgery (€5008) compared to the IP (€ 6913) and the MP (€6099). Surgeons with sufficient experience in LLS can rapidly overcome the learning curve for RLS. In our experience, the short-term outcomes of the implementation phase of RLS are similar to the mastery phase of LLS. The total average cost per procedure is lower for RLS compared to LLS.

Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

Clinical added value of MRI to CT in patients scheduled for local therapy of colorectal liver metastases (CAMINO): study protocol for an international multicentre prospective diagnostic accuracy study

BACKGROUND

Abdominal computed tomography (CT) is the standard imaging method for patients with suspected colorectal liver metastases (CRLM) in the diagnostic workup for surgery or thermal ablation. Diffusion-weighted and gadoxetic-acid-enhanced magnetic resonance imaging (MRI) of the liver is increasingly used to improve the detection rate and characterization of liver lesions. MRI is superior in detection and characterization of CRLM as compared to CT. However, it is unknown how MRI actually impacts patient management. The primary aim of the CAMINO study is to evaluate whether MRI has sufficient clinical added value to be routinely added to CT in the staging of CRLM. The secondary objective is to identify subgroups who benefit the most from additional MRI.

METHODS

In this international multicentre prospective incremental diagnostic accuracy study, 298 patients with primary or recurrent CRLM scheduled for curative liver resection or thermal ablation based on CT staging will be enrolled from 17 centres across the Netherlands, Belgium, Norway, and Italy. All study participants will undergo CT and diffusion-weighted and gadoxetic-acid enhanced MRI prior to local therapy. The local multidisciplinary team will provide two local therapy plans: first, based on CT-staging and second, based on both CT and MRI. The primary outcome measure is the proportion of clinically significant CRLM (CS-CRLM) detected by MRI not visible on CT. CS-CRLM are defined as liver lesions leading to a change in local therapeutical management. If MRI detects new CRLM in segments which would have been resected in the original operative plan, these are not considered CS-CRLM. It is hypothesized that MRI will lead to the detection of CS-CRLM in ≥10% of patients which is considered the minimal clinically important difference. Furthermore, a prediction model will be developed using multivariable logistic regression modelling to evaluate the predictive value of patient, tumor and procedural variables on finding CS-CRLM on MRI.

DISCUSSION

The CAMINO study will clarify the clinical added value of MRI to CT in patients with CRLM scheduled for local therapy. This study will provide the evidence required for the implementation of additional MRI in the routine work-up of patients with primary and recurrent CRLM for local therapy.

TRIAL REGISTRATION

The CAMINO study was registered in the Netherlands National Trial Register under number NL8039 on September 20th 2019.

Radiofrequency ablation and chemotherapy versus chemotherapy alone for locally advanced pancreatic cancer (PELICAN): study protocol for a randomized controlled trial

Background

Approximately 80% of patients with locally advanced pancreatic cancer (LAPC) are treated with chemotherapy, of whom approximately 10% undergo a resection. Cohort studies investigating local tumor ablation with radiofrequency ablation (RFA) have reported a promising overall survival of 26–34 months when given in a multimodal setting. However, randomized controlled trials (RCTs) investigating the effect of RFA in combination with chemotherapy in patients with LAPC are lacking.

Methods

The “Pancreatic Locally Advanced Unresectable Cancer Ablation” (PELICAN) trial is an international multicenter superiority RCT, initiated by the Dutch Pancreatic Cancer Group (DPCG). All patients with LAPC according to DPCG criteria, who start with FOLFIRINOX or (nab-paclitaxel/)gemcitabine, are screened for eligibility. Restaging is performed after completion of four cycles of FOLFIRINOX or two cycles of (nab-paclitaxel/)gemcitabine (i.e., 2 months of treatment), and the results are assessed within a nationwide online expert panel. Eligible patients with RECIST stable disease or objective response, in whom resection is not feasible, are randomized to RFA followed by chemotherapy or chemotherapy alone. In total, 228 patients will be included in 16 centers in The Netherlands and four other European centers. The primary endpoint is overall survival. Secondary endpoints include progression-free survival, RECIST response, CA 19.9 and CEA response, toxicity, quality of life, pain, costs, and immunomodulatory effects of RFA.

Discussion

The PELICAN RCT aims to assess whether the combination of chemotherapy and RFA improves the overall survival when compared to chemotherapy alone, in patients with LAPC with no progression of disease following 2 months of systemic treatment.

Trial registration

Dutch Trial RegistryNL4997. Registered on December 29, 2015. ClinicalTrials.govNCT03690323. Retrospectively registered on October 1, 2018

Robotic versus laparoscopic distal pancreatectomy: multicentre analysis

BACKGROUND

The role of minimally invasive distal pancreatectomy is still unclear, and whether robotic distal pancreatectomy (RDP) offers benefits over laparoscopic distal pancreatectomy (LDP) is unknown because large multicentre studies are lacking. This study compared perioperative outcomes between RDP and LDP.

METHODS

A multicentre international propensity score-matched study included patients who underwent RDP or LDP for any indication in 21 European centres from six countries that performed at least 15 distal pancreatectomies annually (January 2011 to June 2019). Propensity score matching was based on preoperative characteristics in a 1 : 1 ratio. The primary outcome was the major morbidity rate (Clavien-Dindo grade IIIa or above).

RESULTS

A total of 1551 patients (407 RDP and 1144 LDP) were included in the study. Some 402 patients who had RDP were matched with 402 who underwent LDP. After matching, there was no difference between RDP and LDP groups in rates of major morbidity (14.2 versus 16.5 per cent respectively; P = 0.378), postoperative pancreatic fistula grade B/C (24.6 versus 26.5 per cent; P = 0.543) or 90-day mortality (0.5 versus 1.3 per cent; P = 0.268). RDP was associated with a longer duration of surgery than LDP (median 285 (i.q.r. 225-350) versus 240 (195-300) min respectively; P < 0.001), lower conversion rate (6.7 versus 15.2 per cent; P < 0.001), higher spleen preservation rate (81.4 versus 62.9 per cent; P = 0.001), longer hospital stay (median 8.5 (i.q.r. 7-12) versus 7 (6-10) days; P < 0.001) and lower readmission rate (11.0 versus 18.2 per cent; P = 0.004).

CONCLUSION

The major morbidity rate was comparable between RDP and LDP. RDP was associated with improved rates of conversion, spleen preservation and readmission, to the detriment of longer duration of surgery and hospital stay.

Risk of conversion to open surgery during robotic and laparoscopic pancreatoduodenectomy and effect on outcomes: international propensity score-matched comparison study

BACKGROUND

Minimally invasive pancreatoduodenectomy (MIPD) is increasingly being performed because of perceived patient benefits. Whether conversion of MIPD to open pancreatoduodenectomy worsens outcome, and which risk factors are associated with conversion, is unclear.

METHODS

This was a post hoc analysis of a European multicentre retrospective cohort study of patients undergoing MIPD (2012-2017) in ten medium-volume (10-19 MIPDs annually) and four high-volume (at least 20 MIPDs annually) centres. Propensity score matching (1 : 1) was used to compare outcomes of converted and non-converted MIPD procedures. Multivariable logistic regression analysis was performed to identify risk factors for conversion, with results presented as odds ratios (ORs) with 95 per cent confidence intervals (c.i).

RESULTS

Overall, 65 of 709 MIPDs were converted (9.2 per cent) and the overall 30-day mortality rate was 3.8 per cent. Risk factors for conversion were tumour size larger than 40 mm (OR 2.7, 95 per cent c.i.1.0 to 6.8; P = 0.041), pancreatobiliary tumours (OR 2.2, 1.0 to 4.8; P = 0.039), age at least 75 years (OR 2.0, 1.0 to 4.1; P = 0.043), and laparoscopic pancreatoduodenectomy (OR 5.2, 2.5 to 10.7; P < 0.001). Medium-volume centres had a higher risk of conversion than high-volume centres (15.2 versus 4.1 per cent, P < 0.001; OR 4.1, 2.3 to 7.4, P < 0.001). After propensity score matching (56 converted MIPDs and 56 completed MIPDs) including risk factors, rates of complications with a Clavien-Dindo grade of III or higher (32 versus 34 per cent; P = 0.841) and 30-day mortality (12 versus 6 per cent; P = 0.274) did not differ between converted and non-converted MIPDs.

CONCLUSION

Risk factors for conversion during MIPD include age, large tumour size, tumour location, laparoscopic approach, and surgery in medium-volume centres. Although conversion during MIPD itself was not associated with worse outcomes, the outcome in these patients was poor in general which should be taken into account during patient selection for MIPD.

Five-year single center experience of sacral neuromodulation for isolated fecal incontinence or fecal incontinence combined with low anterior resection syndrome

PURPOSE

Sacral neuromodulation (SNM) has proven to be a safe and effective treatment for fecal incontinence (FI). For low anterior resection syndrome (LARS), however, SNM efficacy is still poorly documented. The primary aim of this study was to report on efficacy of SNM therapy for patients with isolated FI or LARS. Furthermore, we evaluated the safety of the procedure and the relevance of adequate follow-up.

METHODS

A retrospective analysis was performed upon a prospectively maintained database of all patients who underwent SNM therapy for isolated FI or LARS between January 2014 and January 2019. The Wexner and LARS scores were evaluated at baseline, during test phase, after definitive implantation and annually during follow-up. Treatment success was defined as at least 50% improvement of the Wexner score or a reduction to minor or no LARS.

RESULTS

Out of 89 patients with isolated FI or LARS who had a SNM test phase, 62 patients were eligible for implantation of the permanent SNM device. At baseline, 3 weeks, and 1, 2, 3, 4 and 5 years after definitive implantation the median Wexner score of all patients was 18, 2, 4.5, 5, 5, 4 and 4.5, respectively, and 18, 4, 5.5, 5, 4, 3 and 4, respectively, for patients with FI and LARS. Patients with LARS more frequently required changes in program settings.

CONCLUSIONS

SNM therapy is a safe and effective treatment for patients with isolated FI and patients with FI and LARS. Adequate follow-up is essential to ensure long-term effectivity, especially for LARS patients.

A multicenter cohort analysis of laparoscopic hepatic caudate lobe resection

INTRODUCTION

Laparoscopic resection of the hepatic caudate lobe (LRCL) requires a high level of expertise due to its challenging anatomical area. Only case reports, case series, and single-center cohort studies have been published. The aim of this study was to assess the safety and feasibility of this laparoscopic procedure.

METHODS

A multicenter retrospective cohort study including all patients who underwent LRCL in 4 high-volume hepatobiliary units between January 2000 and May 2018 was performed. Perioperative, postoperative, and survival outcomes were assessed. Postoperative morbidity was stratified according to the Clavien-Dindo classification with severe complications defined by grade III or more. The Kaplan-Meier method was used for survival analysis.

RESULTS

A total of 32 patients were included, including 22 (68.8%) with colorectal liver metastasis (CRLM), one (3.1%) with cholangiocarcinoma, four (12.5%) with other malignancies, and five (15.6%) with symptomatic benign lesions. Simultaneous colorectal and/or additional liver resection was performed in 20 (62.5%) patients. The median (IQR) operative time was 155 (121-280) minutes, blood loss was 100 (50-275) ml, conversion rate was 9.4% (n = 3), severe complications were observed in 2 patients (6.3%), and median (range) length of hospital stay was 3 [1-39] days. No 90-day postoperative mortality was noticed. The median (IQR) follow-up for the CRLM group was 14 [10-23] months. Five-year overall survival rate was 82% in this subgroup. Small interinstitutional differences were observed without major impact on surgical outcomes.

CONCLUSION

LRCL is safe and feasible when performed in high-volume centers. Profound anatomical knowledge, advanced laparoscopic skills, and mastering intraoperative ultrasound are essential. No major interinstitutional differences were ascertained.

Adverse effects of bevacizumab in metastatic colorectal cancer : a case report and literature review

Colorectal cancer is one of the most frequently diagnosed malignancies worldwide. One of the most important developments in the management of metastatic colorectal cancer is targeted therapy. Bevacizumab, a monoclonal antibody inhibiting VEGF induced angiogenesis, has been accepted as safe and efficient in the treatment of metastatic colorectal cancer for more than a decade. Addition of bevacizumab to fluorouracil-based chemotherapy is also associated with severe adverse events. We present a case of bevacizumab-induced bowel ischaemia associated with gastrointestinal haemorrhage.

Multicentre propensity score-matched study of laparoscopic versus open repeat liver resection for colorectal liver metastases

BACKGROUND

Repeat liver resection is often the best treatment option for patients with recurrent colorectal liver metastases (CRLM). Repeat resections can be complex, however, owing to adhesions and altered liver anatomy. It remains uncertain whether the advantages of a laparoscopic approach are upheld in this setting. The aim of this retrospective, propensity score-matched study was to compare the short-term outcome of laparoscopic (LRLR) and open (ORLR) repeat liver resection.

METHODS

A multicentre retrospective propensity score-matched study was performed including all patients who underwent LRLRs and ORLRs for CRLM performed in nine high-volume centres from seven European countries between 2000 and 2016. Patients were matched based on propensity scores in a 1 : 1 ratio. Propensity scores were calculated based on 12 preoperative variables, including the approach to, and extent of, the previous liver resection. Operative outcomes were compared using paired tests.

RESULTS

Overall, 425 repeat liver resections were included. Of 271 LRLRs, 105 were matched with an ORLR. Baseline characteristics were comparable after matching. LRLR was associated with a shorter duration of operation (median 200 (i.q.r. 123-273) versus 256 (199-320) min; P < 0·001), less intraoperative blood loss (200 (50-450) versus 300 (100-600) ml; P = 0·077) and a shorter postoperative hospital stay (5 (3-8) versus 6 (5-8) days; P = 0·028). Postoperative morbidity and mortality rates were similar after LRLR and ORLR.

CONCLUSION

LRLR for CRLM is feasible in selected patients and may offer advantages over an open approach.

Development and validation of a difficulty score to predict intraoperative complications during laparoscopic liver resection

Background

Previous studies have demonstrated that patient, surgical, tumour and operative variables affect the complexity of laparoscopic liver resections. However, current difficulty scoring systems address only tumour factors. The aim of this study was to develop and validate a predictive model for the risk of intraoperative complications during laparoscopic liver resections.

Methods

The prospectively maintained databases of seven European tertiary referral liver centres were compiled. Data from two-thirds of the patients were used for development and one-third for validation of the model. Intraoperative complications were based on a modified Satava classification. Using the methodology of the Framingham Heart Study, developed to identify risk factors that contribute to the development of cardiovascular disease, factors found to predict intraoperative complications independently were assigned points, and grouped into low-, moderate-, high- and extremely high-risk groups based on the likelihood of intraoperative complications.

Results

A total of 2856 patients were included. Neoadjuvant chemotherapy, lesion type and size, classification of resection and previous open liver resection were found to be independent predictors of intraoperative complications. Patients with intraoperative complications had a longer duration of hospital stay (5 versus 4 days; P &lt; 0·001), higher complication rates (32·5 versus 15·5 per cent; P &lt; 0·001), and higher 30-day (3·0 versus 0·3 per cent; P &lt; 0·001) and 90-day (3·8 versus 0·8 per cent; P &lt; 0·001) mortality rates than those who did not. The model was able to predict intraoperative complications (area under the receiver operating characteristic (ROC) curve (AUC) 0·677, 95 per cent c.i. 0·647 to 0·706) as well as postoperative 90-day mortality (AUC 0·769, 0·681 to 0·858).

Conclusion

This comprehensive scoring system, based on patient, surgical and tumour factors, and developed and validated using a large multicentre European database, helped estimate the risk of intraoperative complications.

Sacral neurostimulation for low anterior resection syndrome after radical resection for rectal cancer: evaluation of treatment with the LARS score

PURPOSE

Sacral neurostimulation (SNS) has proven to be an effective treatment modality for low anterior resection syndrome (LARS). The primary aim of this study is to investigate the impact of SNS on all symptoms of LARS, not merely on fecal incontinence. Furthermore, we wanted to evaluate whether the LARS score could be useful as a tool to evaluate SNS treatment.

METHODS

All patients diagnosed with minor or major LARS, unresponsive to conservative therapy for fecal incontinence, who underwent sacral neuromodulation for LARS at Groeninge Hospital, Kortrijk, Belgium, were prospectively enrolled in the study. The primary endpoint was the reduction in the severity of LARS. This was assessed by validated questionnaires: the LARS score and the Wexner score.

RESULTS

Eleven patients underwent definite implantation of the SNS device. All patients showed a substantial decrease in their Wexner scores: The mean score was reduced from 17.7 to 4.6 (Z: 2.93; p: 0.0033). Additionally, the mean LARS score dropped from 36.9 to 11.4 (Z: 2.93; p: 0.0033). Furthermore, there was a significant amelioration of all symptoms of LARS.

CONCLUSIONS

Our study shows that SNS is effective for all symptoms of LARS. The authors believe that in patients who receive SNS for LARS, it could be useful to determine the LARS score to evaluate the complexity of the symptoms and their response to treatment.

Transanal endoscopic total mesorectal excision: technical aspects of approaching the mesorectal plane from below--a preliminary report

BACKGROUND

Laparoscopic total mesorectal excision (TME) for low rectal cancer can be technically challenging. This report describes our initial experience with a hybrid laparoscopic and transanal endoscopic technique for TME in low rectal cancer.

METHODS

Between December 2012 and October 2013, we identified patients with rectal cancer < 5 cm from the anorectal junction (ARJ) who underwent laparoscopic-assisted TME with a transanal minimally invasive surgery (TAMIS) technique. A standardized stepwise approach was used in all patients. Resection specimens were examined for completeness and measurement of margins. Preoperative magnetic resonance imaging (MRI) characteristics and short-term postoperative outcomes were examined. All values are mean ± standard deviation.

RESULTS

Ten patients (8 males; median age: 60.5 (range 36-70) years) were included. On initial MRI, all tumors were T2 or T3, mean tumor height from the ARJ was 28.9 ± 12.2 mm, mean circumferential resection margin was 5.3 ± 3.1 mm , and the mean angle between the anal canal and the levator ani was 83.9° ± 9.7°. All patients had had preoperative chemoradiotherapy, TME via TAMIS, and distal anastomosis. There were no intraoperative complications, anastomotic leaks, or 30-day mortality. The pathologic quality of all mesorectal specimens was excellent. The distal resection margin was 19.4 ± 10.4 mm, the mean circumferential resection margin was 13.8 ± 5.1 mm, and the median lymph node harvest was 10.5 (range 5-15) nodes.

CONCLUSIONS

A combined laparoscopic and transanal approach can achieve a safe and oncologically complete TME dissection for low rectal tumors. This approach may improve clinical outcomes in these technically difficult cases, but larger prospective studies are needed.

Transvaginal pure NOTES sigmoid resection using a single port device

BACKGROUND

The amount of published experience using natural orifice transluminal endoscopic surgery (NOTES) is increasing. However, approximately half of the technical approaches described include NOTES as part of a hybrid procedure. Colonic resections performed using NOTES have mainly been described using a hybrid approach.

METHODS

An 84-year-old female presented with a symptomatic volvulus of the sigmoid colon. Endoscopic detorsion and desufflation were successfully performed. Definitive treatment was accomplished by performing a sigmoid resection entirely via a transvaginal route using a single port device (SILS™ Covidien, Westbury, MA, USA).

RESULTS

Operative time was 135 min. No intraoperative or postoperative complications occurred. Only minimal narcotic analgesia was required and oral intake was initiated on postoperative day 3. At the last follow-up assessment, 2 months postoperatively, no complications or recurrent volvulus were observed.

CONCLUSION

Transvaginal NOTES sigmoid colectomy for sigmoid volvulus is feasible and can be performed safely.

Carcinoma of the gallbladder: patterns of presentation, prognostic factors and survival rate. An 11-year single centre experience

BACKGROUND

This report examines the patterns of presentation, prognostic factors and survival rate of all patients with gallbladder cancer (GBC) evaluated at our tertiary academic hospital over an 11-year period.

METHODS

A retrospective review of a prospectively collected database of all patients with GBC presenting between January 1998 and December 2008 was performed.

RESULTS

102 GBC-patients were included: 69 women and 33 men (median age: 65,5 years). Forty-five patients presented with incidental gallbladder cancer (IGC) and 57 with nonincidental cancer (NIGC). Curative surgery rate was 84.4% for IGC and 29.8% for NIGC (p < 0.001). Five-year actuarial survival rate was 63.2% for patients with curative intent surgery and 0% for patients with palliative approach. Patients with IGC had a longer survival rate compared to patients with NIGC (median: 25.8 vs. 4.4 months, p < 0.0001). For patients with radical resection (42 patients), there was no difference between IGC and NIGC. The incidence of liver involvement was respectively 0%, 20.8%, 58.3%, 100% for pT1, pT2, pT3 and pT4 tumors. Univariate analysis showed that survival rate was significantly affected by perineural invasion, T, N and M-stage, R0 resection, liver involvement, CA-19.9. In multivariate analysis, liver involvement was the only independent factor.

CONCLUSIONS

Majority of patients with a potentially curable disease had IGC. Almost 80% of patients with NIGC presented with unresectable disease. For patients who underwent resection with curative intent, actuarial 5-year survival was 63.2%. Liver involvement was the only independent prognostic factor. All patients with IGC and a pT2 or more advanced T stage should undergo a second radical resection.

Randomized clinical trial on the influence of anaesthesia protocol on intestinal motility during laparoscopic surgery requiring small bowel anastomosis

Background

Hyperperistalsis of the small bowel during laparoscopic surgery may cause mucosal prolapse and reduce exposure, making laparoscopic suturing or stapling more demanding for the surgeon. Although it is commonly accepted that both opioids and volatile anaesthetics induce intestinal paralysis, intestinal hyperactivity during anaesthesia is not uncommon. This randomized trial investigated the effect of different volatile anaesthetics on intestinal motility and the impact on surgeon satisfaction.

Methods

Patients scheduled for laparoscopic gastric bypass surgery were randomized to receive sevoflurane or desflurane in a balanced anaesthetic regimen. After surgical exposure peristaltic waves were counted over 1 min in a segment of the jejunum. Following evaluation of intestinal motility, N-butylhyoscine, an antimuscarinic anticholinergic agent that relaxes bowel smooth muscle cells, could be administered if the surgeon judged the intestinal motility as disturbing. The endpoints were number of peristaltic waves and incidence of N-butylhyoscine administration, a surrogate for surgeon satisfaction.

Results

Twenty-two patients were randomized to each group. The groups were similar in age, sex and body mass index. There was a statistically significant difference in intestinal motility between the desflurane and sevoflurane groups: median (range) 7 (0–12) versus 1 (0–10) waves counted over 1 min respectively (P &lt; 0·001). A higher proportion of patients in the desflurane group received N-butylhyoscine (10 of 22 versus 1 of 22 in the sevoflurane group; P = 0·004).

Conclusion

Desflurane increased intestinal motility and decreased surgeon satisfaction compared with sevoflurane during laparoscopic gastric bypass surgery. A sevoflurane-based anaesthetic protocol can help to avoid disturbing hyperperistalsis. Registration number: B39620097060 (http://www.clinicaltrials.be).

Can vacuum-assisted closure and instillation therapy (VAC-Instill therapy) play a role in the treatment of the infected open abdomen?

Severe superimposed infection during open abdomen treatment with development of intra-abdominal sepsis is a challenging complication associated with high mortality rates. We report our experience with VAC-Instill therapy (KCI, San Antonio, USA) used for treatment of an infected open abdomen following pancreatic surgery. A literature search revealed no analogous case reports using VAC-Instill therapy for treatment of an infected laparostomy. The encouraging result of the case presented seems to indicate that VAC-Instill therapy could be used as adjunctive treatment in the management of the infected open abdomen when traditional therapy fails to control the infection.

[Value of echography for measuring the volume of the thyroid and its lesions]

The sizes of thyroid lobes and lesions estimated by ultrasonography have been compared to surgical specimens in 92 cases of thyroid pathology. Volumes can be calculated with a reasonable accuracy for parenchymatous and cystic lesions from measurements of their diameters when considered as ellipsoids. This easy method, currently used by ultrasonographers, is however unsatisfactory for estimation of the volumes of thyroid lobes. More reliable results are obtained by computation of volumes from planimetry of cross-sections through the gland.