Background Alpha-blockade is the standard management preoperatively to prevent intraoperative hemodynamic instability (IHD) during resection of a pheochromocytoma. Calcium channel blockers also have ...been shown to lessen the risk of IHD. We aim to determine differences between these classes of antihypertensive agents in minimizing IHD. Methods This was a retrospective analysis from a tri-institutional database. Inclusion criteria were unilateral transabdominal adrenalectomy for pheochromocytomas between 2002 and 2012. IHD was defined as at least one systolic blood pressure (SBP) measurement >160 mm Hg and at least one episode of mean arterial pressure 60 mm Hg. Results A total of 155 patients were included: 110 receiving calcium channel blockers, 41 alpha-blockade, and 4 no medication. Intraoperatively, mean maximal SBP was less after alpha-blockade ( P < .0001) as well as the incidence and duration of episodes of SBP >200 mm Hg ( P < .01); however, severe hypotensive episodes (MAP <60 mm Hg) were more frequent ( P < .001) and longer ( P < .0001) with alpha-blockade. Consequently, intraoperative vasoactive drugs were used more frequently ( P = .03), and mean fluid volume infused was larger ( P < .001). Fifty-four patients had IHD, but these were independent of type of preoperative medication used. Familial disease was the only independent predictor of IHD. Conclusion IHD was independent of type of preoperative medical management but was dependent on familial disease. These findings broaden options for clinicians in the preoperative management of pheochromocytoma.
Background
Exponential development of minimally invasive techniques, such as robotic-assisted devices, raises the question of how to assess robotic surgery skills. Early development of virtual ...simulators has provided efficient tools for laparoscopic skills certification based on objective scoring, high availability, and lower cost. However, similar evaluation is lacking for robotic training. The purpose of this study was to assess several criteria, such as reliability, face, content, construct, and concurrent validity of a new virtual robotic surgery simulator.
Methods
This prospective study was conducted from December 2009 to April 2010 using three simulators dV-Trainers
®
(MIMIC Technologies
®
) and one Da Vinci S
®
(Intuitive Surgical
®
). Seventy-five subjects, divided into five groups according to their initial surgical training, were evaluated based on five representative exercises of robotic specific skills: 3D perception, clutching, visual force feedback, EndoWrist
®
manipulation, and camera control. Analysis was extracted from (1) questionnaires (realism and interest), (2) automatically generated data from simulators, and (3) subjective scoring by two experts of depersonalized videos of similar exercises with robot.
Results
Face and content validity were generally considered high (77 %). Five levels of ability were clearly identified by the simulator (ANOVA;
p
= 0.0024). There was a strong correlation between automatic data from dV-Trainer and subjective evaluation with robot (
r
= 0.822). Reliability of scoring was high (
r
= 0.851). The most relevant criteria were time and economy of motion. The most relevant exercises were Pick and Place and Ring and Rail.
Conclusions
The dV-Trainer
®
simulator proves to be a valid tool to assess basic skills of robotic surgery.
Background Our aim was to determine the learning curve for robotic adrenalectomy and factors that influence operative time and cost. Methods We prospectively evaluated of 100 consecutive patients who ...underwent robotic, unilateral, transperitoneal adrenalectomy. Results The mean operative time for robotic-assisted adrenalectomy was 95 minutes and conversion rate was 5%. Pathology was aldosteronoma ( n = 39), pheochromocytoma ( n = 24), nonfunctional adenoma ( n = 19), Cushing adenoma or hyperplasia ( n = 16), and cyst ( n = 2). Morbidity and mortality rates were 10% and 0%, respectively. The mean operative time decreased by 1 minute every 10 cases. Operative time improved more for junior surgeons than for senior surgeons ( P = .006) after the first 50 cases. By multiple regression analysis, surgeon's experience (−18.9 ± 5.5), first assistant level (−7.8 ± 3.2), and tumor size (3 ± 1.4) were independent predictors of operative time ( P < .001 each). The robotic procedure was 2.3 times more costly than lateral transperitoneal laparoscopic adrenalectomy (€4102 vs €1799). Conclusions Surgeon experience, resident training level, and tumor size are important variables for robotic-assisted, unilateral adrenalectomy and should be taken into account when this approach is evaluated. Controlled studies need to be performed to show potential relevant clinical benefits that could balance costs.
Intraoperative hemodynamic instability is a major challenge during adrenalectomy for pheochromocytoma. Typically, pheochromocytoma is performed laparoscopically either through the retroperitoneal or ...transperitoneal approach. We aimed to determine if the operative approach affects intraoperative hemodynamic instability during surgery for pheochromocytoma in a large multicenter multicenter cohort.
Retrospective, multicenter analysis of consecutive patients with pheochromocytoma who underwent total unilateral laparoscopic adrenalectomy without conversion were included. Statistical analysis was performed using established intraoperative criteria for intraoperative hemodynamic instability: 1) systolic blood pressure >160 mm Hg; 2) systolic blood pressure > 200 mm Hg; 3) mean arterial pressure <60 mm Hg; 4) systolic blood pressure >160 mm Hg + mean arterial pressure <60 mm Hg; and 5) systolic blood pressure >200 mm Hg + mean arterial pressure <60 mm Hg; and 6) intravenous vasopressor + vasodilator.
In total, 341 patients met the inclusion criteria, 101 (29.6%) underwent retroperitoneal adrenalectomy and 240 (70.4%) transperitoneal adrenalectomy. Multivariate analysis showed that retroperitoneal adrenalectomy carries greater risk for mean arterial pressure <60 mm Hg (odds ratio 6.255, confidence interval 1.134–34.235, P = .035) compared with transperitoneal adrenalectomy. Overall and cardiovascular morbidity rates were comparable between the 2 approaches. The medical center was a significant independent influencing factor for all 6 intraoperative hemodynamic instability definitions.
Variability in institutional management of pheochromocytoma intraoperatively has significant impact on all 6 intraoperative hemodynamic instability definitions. Standardization of anesthesia should be considered to reduce this variability.
Background
Since the 1950s, preoperative medical preparation has been widely applied in patients with pheochromocytoma to improve intraoperative hemodynamic instability and postoperative ...complications. However, advancements in preoperative imaging, laparoscopic surgical techniques, and anesthesia have considerably improved management in patients with pheochromocytoma. In consequence, there is no validated consensus on current predictive factors for postoperative morbidity. The aim of this study was to determine perioperative factors which are predictive for postoperative morbidity in patients undergoing laparoscopic adrenalectomy for pheochromocytoma.
Study design
It is a retrospective analysis of prospectively maintained databases in five medical centers from 2002 to 2013. Inclusion criteria were consecutive patients who underwent non-converted laparoscopic unilateral total adrenalectomy for pheochromocytoma.
Results
Two-hundred and twenty-five patients were included. All-cause and cardiovascular postoperative morbidity rates were 16 % (
n
= 36) and 4.8 % (
n
= 11), respectively. Preinduction blood pressure normalization after preoperative medical preparation had no impact on postoperative morbidity. However, past medical history of coronary artery disease (OR CI95 % = 3.39; 1.317–8.727) and incidence of intraoperative hemodynamic instability episodes (both SBP ≥ 160 mmHg and MAP < 60 mmHg) (OR CI95 % = 3.092; 1.451–6.587) remained independent predictors for postoperative all-cause morbidity. Similarly, past medical history of coronary artery disease (OR CI95 % = 14.41; 3.119–66.57), female sex (OR CI95 % = 12.05; 1.807–80.31), and incidence of intraoperative hemodynamic instability episodes (both SBP ≥ 200 mmHg and MAP < 60 mmHg) (OR CI95 % = 4.13; 1.009–16.90) remained independent predictors for postoperative cardiovascular morbidity.
Conclusions
This study identifies risk factors for cardiovascular and all-cause postoperative morbidity after laparoscopic adrenalectomy in current clinical setting. These data can help physicians to guide intra-operative blood pressure management and have to be taken into account in further studies.
Introduction
Pancreatectomies increase the risk of postoperative pancreatic fistula (POPF) and pancreatic insufficiency. Pancreatic enucleation preserves pancreatic parenchyma, lowers the risk of ...pancreatic insufficiency, but may induce specific complications (tumor recurrence or pancreatic fistulization). The aim of this study was to determine the risk factors for POPF following a pancreatic enucleation.
Methods
A retrospective analysis was designed based on data from patients who underwent pancreatic enucleation in five university hospitals (1998–2008). The presence of a pancreatic fistula was determined according to the criteria of the International Study Group of Pancreatic Fistula (Bassi et al. Surgery 138:8–13,
2005
).
Results
Fifty-two patients (mean age 52 years) were included. Histological analysis revealed 35 endocrine tumors (68.6 %), 6 mucinous and 2 serous cyst adenomas, 2 metastases of renal cancer, and 8 benign tumors. Nineteen patients (36.5 %) suffered postoperative complications including 14 POPF (27 %). Median postoperative hospital stay was 12.9 days; 9.1 days without POPF versus 29 days with POPF (
p
< 0.05). Size of the tumor, its location, histological differentiation, and use of somatostatin analogs were not predictors for POPF. We defined the cutoff for POPF at a distance of 2 mm from the main pancreatic duct based on 60 % risk (≤2 mm) versus 19 % (>2 mm) of POPF (
p
< 0.01). With a mean follow-up of 30.8 months, one patient experienced recurrence of the tumor. No patients exhibited a new onset of diabetes or pancreatic insufficiency.
Conclusion
Enucleation for resection of pancreatic tumors located at less than or equal to two 2 mm from the main pancreatic duct is a risk factor for POPF. Enucleation is a safe and effective treatment for benign or borderline pancreatic tumors.
Introduction
While uptake of laparoscopic hepatectomy has improved, evidence on laparoscopic re-hepatectomy (LRH) for colorectal liver metastases (CRLMs) is limited and has never been compared to the ...open approach. We sought to define outcomes of LRH compared to open re-hepatectomy (ORH).
Methods
Patients undergoing re-hepatectomy for CRLM at 39 institutions (2006–2013) were identified. Primary outcomes were 30-day post-operative overall morbidity, mortality, and length of stay. Secondary outcomes were recurrence and survival at latest follow-up. LRHs were matched to ORHs (1:3) using a propensity score created by comparing pre-operative clinicopathologic factors (number and size of liver metastases and major hepatectomy).
Results
Of 376 re-hepatectomies included, 27 were LRH, including 1 (3.7%) conversion. The propensity-matched cohort included 108 patients. Neither median operative time (252 vs. 230 min;
p
= 0.82) nor overall 30-day morbidity (48.1 vs. 38.3%;
p
= 0.37) differed. Non-specific morbidity (including cardiac, respiratory, infectious, and renal events) decreased with LRH (11.1 vs. 30.9%,
p
= 0.04), while surgical-specific morbidity, including liver insufficiency, was higher (44.4 vs. 22.2%,
p
= 0.03). One ORH and 0 LRH suffered 30-day mortality. Median length of stay (9 vs. 12 days;
p
= 0.60) was comparable. At latest follow-up, 26 (96.3%) LRH and 67 (82.7%) ORH patients were alive. Eight (29.6%) LRH and 36 (44.4%) ORH patients were alive without disease.
Conclusion
LRH for recurrent CRLM was associated with overall short-term outcomes comparable to ORH, but different morbidity profiles. While it may offer a safe and feasible approach, further insight is necessary to better define patient selection.
Abstract Background Perioperative short-term outcomes could be improved after totally robotic Roux-en-Y gastric bypass (TR-RYGBP) compared with conventional laparoscopic gastric bypass. Methods This ...is a nonrandomized controlled prospective study (N = 200) to evaluate perioperative short-term outcomes. The primary endpoint was to investigate risk factors for 30-day surgical complications. Results Mean total operative time was shorter in patients who underwent TR-RYGBP (130 vs 147 minutes; P < .0001). However, postoperative surgical complications rate (13% vs 1%; P = .001), and mean overall hospital stay (9.3 vs 6.7 days; P < .0001) were higher after TR-RYGBP. By multivariate analysis, robotic surgery (hazard ratio HR = 15.1; 95% confidence interval CI, 2.8 to 280; P = .01), and conversion to laparotomy (HR = 18.8; 95% CI, 1.7 to 250.8; P = .014) were independent risk factors for 30-day surgical complications. Conclusions Although robotic gastric bypass reduces mean operative time, TR-RYGBP is associated with an increased postoperative surgical complications rate and longer hospitalization.
Abstract Background Radiofrequency ablation (RFA) of liver tumors is associated with a risk of incomplete ablation or local recurrence. Methods One hundred sixty-eight patients with 311 unresectable ...liver tumors were included. Effects of different variables on incomplete ablation and local recurrence were analyzed. Results There were 132 hepatocellular carcinomas and 179 liver metastases. Tumor size was 24 (±13) mm. Two hundred twenty-six tumors were treated percutaneously, and 85 through open approach (associated with liver resection in 42 cases). There was no mortality. Major morbidity rate was 7%. Incomplete ablation and local recurrence rates were 14% and 18.6%. Follow-up was 29 months. On multivariate analysis, factors associated with incomplete ablation were tumor size (>30 mm vs ≤30 mm, P = .004) and approach (percutaneous vs open, P = .0001). Factors associated with local recurrence were tumor size (>30 mm vs ≤30 mm, P = .02) and patient age (>65 years vs ≤65 years, P = .05). Conclusions RFA is effective to treat unresectable liver tumors. However, there is a risk of incomplete ablation when percutaneously treating tumors >30 mm. When tumor ablation is completely achieved, the main factor associated with local recurrence is tumor size >30 mm.
Abstract Background This study evaluates the perioperative outcomes of robotic-assisted adrenalectomy (RA) compared with lateral transperitoneal laparoscopic adrenalectomy (LA). Methods Prospective ...evaluation of 50 patients who underwent unilateral RA versus 59 patients who underwent unilateral LA. Results RA was associated with lower blood loss (49 mL) but longer operative times (104 minutes) ( P <.001). However, the difference in operative time was not significant after the learning curve of 20 cases. In patients with body mass index (BMI) ≥30 kg/m2 , mean operative time was longer in the LA group (90 vs 78 minutes, P = .03) but not in the RA group. In patients with large tumors (≥55 mm), mean operative time was longer in the LA group (100 vs 80 minutes, P = .009) but not in the RA group. Conversion rate, morbidity, and hospital stay were similar in both groups. Conclusions After a learning curve of 20 cases, RA has similar perioperative outcomes compared to lateral transperitoneal LA. Several criteria (previous laparoscopic expertise, first assistant’s skill and tumor side) remain determinative on RA operative time.
