Incisionless near-infrared fluorescent cholangiography (NIFC) is emerging as a promising tool to enhance the visualization of extrahepatic biliary structures during laparoscopic cholecystectomies.
We ...conducted a single-blind, randomized, 2-arm trial comparing the efficacy of NIFC (n = 321) versus white light (WL) alone (n = 318) during laparoscopic cholecystectomy. Using the KARL STORZ Image1 S imaging system with OPAL1 technology for NIR/ICG imaging, we evaluated the detection rate for 7 biliary structures-cystic duct (CD), right hepatic duct (RHD), common hepatic duct, common bile duct, cystic common bile duct junction, cystic gallbladder junction (CGJ), and accessory ducts -before and after surgical dissection. Secondary calculations included multivariable analysis for predictors of structure visualization and comparing intergroup biliary duct injury rates.
Predissection detection rates were significantly superior in the NIFC group for all 7 biliary structures, ranging from 9.1% versus 2.9% to 66.6% versus 36.6% for the RHD and CD, respectively, with odds ratios ranging from 2.3 (95% CI 1.6-3.2) for the CGJ to 3.6 (1.6-9.3) for the RHD. After dissection, similar intergroup differences were observed for all structures except CD and CGJ, for which no differences were observed. Significant odds ratios ranged from 2.4 (1.7-3.5) for the common hepatic duct to 3.3 (1.3-10.4) for accessory ducts. Increased body mass index was associated with reduced detection of most structures in both groups, especially before dissection. Only 2 patients, both in the WL group, sustained a biliary duct injury.
In a randomized controlled trial, NIFC was statistically superior to WL alone visualizing extrahepatic biliary structures during laparoscopic cholecystectomy.
NCT02702843.
Background
Intraoperative incisionless fluorescent cholangiography (IOIFC) has been described to identify extrahepatic biliary anatomy. Potential advantages of the routine use of intraoperative ...incisionless fluorescent cholangiography were evaluated in a consecutive series of cases.
Methods
A total of 45 patients undergoing laparoscopic cholecystectomy between January and July 2013 were consented and included in this study. We analyzed a prospectively collected database for feasibility, cost, time, usefulness, teaching tool, safety, learning curve, X-ray exposure, complexity, and real-time surgery of IOIFC. A single dose of 0.05 mg/kg of Indocyanine green was administered prior to surgery. During the procedure, a laparoscopic fluorescence system was used.
Results
IOIFC could be performed in all 45 patients, whereas intraoperative cholangiography could be performed in 42 (93 %). Individual median cost of performing IOFC was cheaper than IOC (13.97 ± 4.3 vs 778.43 ± 0.4 USD) per patient,
p
= 0.0001). IOFC was faster than IOC (0.71 ± 0.26 vs 7.15 ± 3.76 minutes,
p
< 0.0001). The cystic duct was identified by IOFC in 44 out of 45 patients (97.77 %).
Conclusion
IOIFC appears to be a feasible, low-cost, expeditious, useful, and effective imaging modality when performing LC. It is safe, easy to perform and interpret, and does not require a learning curve or X-ray. It can be used for real time surgery to delineate the extrahepatic biliary structures
Background
Intraoperative incisionless fluorescent cholangiogram (IOIFC) has been demonstrated to be a useful tool to increase the visualization of Calot’s triangle. This study evaluates the ...identification of extrahepatic biliary structures with IOIFC by medical students and surgery residents.
Methods
Two pictures were taken, one with xenon light and one with near-infrared (NIR) light, at the same stage during dissection of Calot’s triangle in ten different cases of laparoscopic cholecystectomy (LC). All twenty pictures were organized in a random fashion to remove any imagery bias. Twenty students and twenty residents were asked to identify the biliary anatomy.
Results
Medical students were able to accurately identify the cystic duct on an average 33.8 % under the xenon light versus 86 % under NIR light (
p
= 0.0001), the common hepatic duct (CHD) on an average 19 % under the xenon light versus 88.5 % under NIR light (
p
= 0.0001), and the junction on an average 24 % under xenon light versus 80.5 % under NIR light (
p
= 0.0001). Surgery residents were able to accurately identify the cystic duct on an average 40 % under the xenon light versus 99 % under NIR light (
p
= 0.0001), the CHD on an average 35 % under the xenon light versus 96 % under NIR light (
p
= 0.0001), and the junction on an average 24 % under the xenon light versus 95.5 % under NIR light (
p
= 0.0001).
Conclusions
IOIFC increases the visualization of Calot’s triangle structures when compared to xenon light. IOIFC may be a useful teaching tool in residency programs to teach LC.
The aim of the present study was to report the outcomes of bariatric surgery in patients >70 years of age at a community hospital in the United States.
A retrospective review was performed of ...prospectively collected data from patients aged >70 years who had undergone bariatric surgery at a single institution from 2002 to 2008. The data analyzed included age, preoperative and postoperative weight and body mass index, postoperative complications, and co-morbidities.
Of 42 patients aged >70 years who underwent bariatric surgery, 22 patients (52.4%) had undergone laparoscopic gastric banding, 12 patients (28.6%) laparoscopic sleeve gastrectomy, and 8 patients (19%) laparoscopic Roux-en-Y gastric bypass. The mean preoperative weight and body mass index was 127.4 ± 25.5 kg and 46.8 ± 9.3 kg/m(2), respectively. The mean postoperative weight and body mass index was 100.2 ± 17 kg and 35.5 ± 5.4 kg/m(2), respectively. The median length of follow-up was 12 months (range 1-66). The mean percentage of excess weight loss was 47.7% at 12 months, with 73.1% follow-up data. Complications included wound infections in 4 patients (9.5%), band removal in 3 patients (7.1%), anastomotic leak in 1 patient (2.3%), and megaesophagus in 1 patient (2.3%). No mortality occurred. The postoperative use of medications for hypertension, hyperlipidemia, diabetes mellitus, and degenerative joint disease were reduced by 56%, 54%, 53%, 66%, and 50%, respectively.
Bariatric surgery in carefully screened patients aged >70 years can be performed safely and can achieve modest improvement in co-morbidities.
Abstract Background Paraesophageal hernia patients are often elderly with complicating medical comorbidities, making surgical management complex in formulating a management strategy. Methods Between ...January 2005 and July 2009, 93 patients underwent surgical treatment of paraesophageal hernia, including 8 recurrent cases after multiple repairs. Open transabdominal surgeries were performed in 14 (15%) patients, and combined thoracotomy was performed in 1 (1%). Laparoscopic surgeries were performed in 78 (84%) patients with 4 (5%) conversions. Artificial prosthetics were used in 27 (29%) patients. Fundoplication was performed in 82 (88%) patients. Gastropexy or feeding tube gastrostomy was performed in 10 (11%) patients. Results The average length of the surgery was 125 minutes (range, 51–304 min). The mean blood loss was 100 mL. The average length of stay was 4 days (range, 1–14 d). There were 2 mortalities (2%) and 4 re-operations, with a recurrence rate of 2%. Conclusions Laparoscopic paraesophageal hernia repair can be performed safely with acceptable results when following a standard approach.
Outcomes from some recent clinical trials have helped to improve the management of necrotizing pancreatitis over the last 2 decades. The location of the retroperitoneal collection, previous gastric ...surgery, patient preference, and medical expertise dictates a minimally invasive surgical step-up versus endoscopic approach. Endoscopic drainage is facilitated by either a plastic or metallic stent. Direct endoscopic necrosectomy is performed for lack of improvement after endoscopic drainage. The surgical approach is accomplished by minimally invasive surgery with either video-assisted retroperitoneal debridement or laparoscopic drainage. A multidisciplinary team with appropriate expertise should care for patients with necrotizing pancreatitis. This brief review summarizes the landmark clinical trials, compares the benefits and roles of endoscopic, surgical, and percutaneous interventions, and discusses treatment algorithms for necrotizing pancreatitis in the modern era.
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