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Gastric cancer remains the fifth most common cancer diagnosed worldwide and the third most common cause of cancer-related death. (1) In Canada, the incidence of gastric adenocarcinoma is estimated to [...], Background: Despite guidelines recommending diagnostic laparoscopy in patients with gastric cancer, implementation is low. We aimed to explore trends in the use of laparoscopy for staging of gastric cancer in Alberta, Canada, determine the rate of positive findings and identify factors predictive of positive staging laparoscopy (SL) findings in this patient population. Methods: In August 2018, we sent a survey to all general surgeons in Alberta who were members of the Alberta Association of General Surgeons to identify those treating gastric cancer. The survey inquired about type of practice (academic or community), gastric cancer case volume, routine versus selective use of SL and, if selective use of SL, criteria used to select cases. Participants were also asked to provide data from their SL cases from July 2007 to February 2019. We double-checked surgeon records with chart review. The primary outcome was evidence of metastatic disease on SL or cytologic examination or both. We performed logistic regression analysis to identify factors predictive of positive laparoscopy findings. Results: The survey was completed by 41 of 127 surgeons (response rate 32.3%). We reviewed 116 cases from 5 surgeons at 4 centres. Gross metastatic disease or positive findings on cytologic examination or both were identified in 37 patients (31.9%). On univariate analysis, the following were associated with an increased risk of identification of metastatic disease at laparoscopy: visualization of the primary tumour on computed tomography (CT) (odds ratio [OR] 9.8, 95% confidence interval [CI] 1.2-76.5), presence of abdominal lymphadenopathy greater than 1 cm (OR 2.4, 95% CI 1.1-5.4) and presence of ascites (OR 19.1, 95% CI 2.2-161.8). Visualization of the primary tumour on CT (OR 8.4, 95% CI 1.0-68.3) and the presence of ascites (OR 15.9, 95% CI 1.8-137.0) remained statistically significant predictors on multivariate analysis. Conclusion: Metastatic disease was identified at SL in almost one-third of cases, which suggests that SL should still be used routinely in gastric cancer staging in Canadian centres. Our study identified several preoperative imaging findings associated with evidence of metastatic disease on laparoscopy; however, further studies are needed to establish robust predictors of positive findings before advocating for a selective SL approach. Contexte : Bien que les directives recommandent une laparoscopie diagnostique chez les patients atteints d'un cancer de l'estomac, cette intervention est peu utilisee. Nous avons voulu explorer les tendances du recours a la laparoscopie pour la stadification du cancer de l'estomac en Alberta, au Canada, etablir le taux de resultats positifs et cibler les facteurs predictifs de resultats positifs de la laparoscopie de stadification dans cette population de patients. Methodes : En aout 2018, nous avons envoye un sondage a tous les chirurgiens generaux de l'Alberta membres de l'Alberta Association of General Surgeons pour savoir lesquels traitaient le cancer de l'estomac. L'enquete portait sur le type de pratique (universitaire ou communautaire), le volume de cas de cancer de l'estomac, le recours systematique ou selectif de la laparoscopie de stadification et, en cas de recours selectif, les criteres de selection. Les participants ont egalement ete invites a fournir des donnees sur les cas ou la laparoscopie de stadification avait ete utilisee de juillet 2007 a fevrier 2019. Nous avons reverifie les dossiers des medecins. Le principal indicateur etait la presence d'une maladie metastatique lors de la laparoscopie de stadification ou de l'examen cytologique (ou les deux). Nous avons procede a une analyse de regression logistique pour cerner les facteurs predictifs de resultats positifs a la laparoscopie. Resultats : Sur 127 chirurgiens 41 ont repondu au sondage (taux de reponse de 32,3 %). Nous avons examine 116 cas traites par 5 chirurgiens dans 4 centres. Une maladie metastatique brute ou des resultats positifs a l'examen cytologique ou les deux ont ete identifies chez 37 patients (31,9 %). Une analyse univariee a revele que les elements suivants etaient associes a un risque accru d'identification de maladie metastatique lors de la laparoscopie : visualisation de la tumeur primaire a la tomodensito-metrie (TDM) (rapport des cotes [RC] 9,8, intervalle de confiance [IC] de 95 % 1,2-76,5), presence d'une lymphadenopathie abdominale superieure a 1cm (RC 2,4, IC de 95 % 1,1-5,4) et presence d'ascite (RC 19,1, IC de 95 % 2,2-161,8). La visualisation de la tumeur primaire a la TDM (RC 8,4, RC de 95 % 1,0-68,3) et la presence d'ascite (RC 15,9, RC de 95 % 1,8-137,0) sont demeurees des facteurs predictifs statistiquement significatifs dans l'analyse multivariee. Conclusion : Une maladie metastatique a ete identifiee a la laparoscopie de stadification dans pres d'un tiers des cas, ce qui suggere que la laparoscopie de stadification devrait con inuer d'etre utilisee de facon systematique dans la stadification du cancer de l'estomac dans les centres canadiens. Notre etude a montre plusieurs resultats d'imagerie preoperatoire associes a des signes de maladie metastatique a la laparoscopie; cependant, d'autres etudes sont necessaires pour etablir des predicteurs solides de resultats positifs avant de preconiser une approche selective de la laparoscopie de stadification.

Recent advances in laparoscopic techniques have led to an increased interest in minimally invasive pancreatic surgery. Compared with conventional open surgery, minimally invasive procedures allow for decreased postoperative pain, shorter [...], Background: Minimally invasive pancreatic surgery has evolved rapidly, but total laparoscopic pancreaticoduodenectomy has not been widely adopted owing to its technical complexity. Hybrid laparoscopy-assisted pancreaticoduodenectomy (HLAPD) combines the relative ease of open surgery with the benefits of a minimally invasive approach. This study evaluates the safety and effectiveness of the hybrid approach compared with open surgery. Methods: We retrospectively analyzed data of consecutive patients undergoing either hybrid or open pancreaticoduodenectomy (OPD) at our institution between September 2009 and December 2013. Demographic, operative and oncologic data were collected to compare outcomes between HLAPD and OPD. Results: Our analysis included 33 patients (HLAPD: n = 13; OPD: n = 20). There were no differences in patient demographics, comorbidities or surgical indications. The HLAPD group had significantly lower intraoperative blood loss (450 mL v. 1000 mL, p = 0.023) and shorter length of hospital stay (8 v. 12 d, p = 0.025) than the OPD group. Duration of surgery did not differ significantly between the groups. There were no differences in postoperative analgesic requirements, Clavien grade I/II or grade III/IV complications or 90-day mortality. Oncologic outcomes showed no significant differences in tumour size, R1 resection rate or number of lymph nodes harvested. Conclusion: In select patients, HLAPD is a safe and effective procedure with comparable outcomes to conventional open surgery. Wider adoption of the hybrid approach will allow a greater number of patients to benefit from a less invasive procedure while facilitating the transition toward purely minimally invasive pancreaticoduodenectomy. Contexte: La chirurgie pancreatique minimalement effractive a rapidement evolue, mais la pancreatoduodenectomie laparoscopique totale n'a pas ete largement adoptee en raison de sa complexite technique. La pancreatoduodenectomie hybride sous laparoscopie (PDHL) allie la relative facilite de la chirurgie ouverte aux avantages d'une approche minimalement effractive. Cette etude compare l'innocuite et l'efficacite de l'approche hybride a celles de la chirurgie ouverte. Methodes: Nous avons analyse de maniere retrospective les donnees concernant des patients consecutifs soumis a une pancreatoduodenectomie hybride ou ouverte (PDO) dans notre etablissement entre septembre 2009 et decembre 2013. Les donnees demographiques, operatoires et oncologiques ont ete recueillies pour comparer les resultats entre la PDHL et la PDO. Resultats: Notre analyse a inclus 33 patients (PDHL: n = 13; PDO: n = 20). Il n'y avait aucune difference quant aux caracteristiques demographiques, comorbidites ou indications chirurgicales chez les patients. Le groupe soumis a la PDHL a connu des pertes sanguines peroperatoires significativement moindres (450 mL c. 1000 mL, p = 0,023) et un sejour hospitalier significativement plus bref (8 j c. 12 j, p = 0,025) comparativement au groupe soumis a la PDO. La duree de la chirurgie n'a pas significativement differe entre les groupes. On n'a note aucune difference sur le plan des besoins en analgesiques postoperatoires, des complications de grade I/II ou III/IV sur l'echelle de Clavien ou de la mortalite a 90 jours. Quant aux parametres oncologiques, aucune difference significative n'a ete notee pour ce qui est de la taille de la tumeur, du taux de resection R1 ou du nombre de ganglions recueillis. Conclusion: Pour certains patients, la PDHL est une intervention securitaire et efficace qui donne des resultats comparables a la chirurgie ouverte classique. L'adoption a plus grande echelle de l'approche hybride permettra a plus de patients de beneficier d'une intervention moins effractive et facilitera la transition complete vers la pancreatoduodenectomie minimalement effractive.

Reactive oxygen species (ROS) are produced by living organisms as a result of normal cellular metabolism. At low to moderate concentrations, they function in physiologic cell processes, but at high [...], Background: Obesity may induce oxidative stress, causing oxidative damage of DNA. We examined associations between decreasing serum and urinary 8-hydroxy-2'-deoxyguanosine (8-OHdG) levels and weight loss in morbidly obese patients before and 6 months after laparoscopic adjustable gastric banding (LAGB). Methods: We compared patients who had surgery for morbid obesity with healthy, nonobese controls. Urine and fasting blood samples were collected once from the controls and from the morbidly obese patients before and 6 months after the LAGB. The serum and urinary 8-OHdG levels were evaluated in these groups using an enzyme-linked immunosorbent assay kit. Results: We included 20 patients who had surgery for morbid obesity (8 men, 12 women, mean body mass index [BMI] 46.82 [+ or -] 4.47) and 20 healthy, nonobese people (10 men, 10 women, mean BMI 22.52 [+ or -] 2.08) in our study. There was no significant difference in serum 8-OHdG levels between the groups, whereas urinary 8-OHdG levels were significantly higher in morbidly obese patients than in controls. Weight, BMI and serum and urinary 8-OHdG levels were significantly decreased in morbidly obese patients 6 months after LAGB. Conclusion: The LAGB provides efficient weight loss in patients with morbid obesity. The systemic oxidative DNA damage was increased by the morbid obesity, but this increase was not related to weight gain, and it was more evident in serum than urine samples. After LAGB for morbid obesity, the oxidative DNA damage declined both in serum and urine. Contexte: L'obesite peut provoquer stress oxydatif qui endommage l'ADN. Nous avons analyse les liens entre une baisse des taux de 8-OHdG (8-hydroxy-2'-desoxyguanosine) seriques et urinaires et la perte de poids chez des patients atteints d'obesite morbide avant, puis 6 mois apres la pose d'un anneau gastrique ajustable par laparoscopie (AGAL). Methodes: Nous avons compare des patients qui ont subi cette chirurgie pour un probleme d'obesite morbide a des temoins non obeses en bonne sante. Nous avons preleve des echantillons d'urine et de sang a jeun chez les temoins 1 fois et chez les patients atteints d'obesite morbide, avant, puis 6 mois apres l'intervention pour AGAL. Les taux de 8-OHdG seriques et urinaires ont ete mesures dans les 2 groupes a l'aide d'une trousse de test ELISA (enzyme-linked immunosorbent assay). Resultats: Notre etude a inclus 20 patients soumis a la chirurgie pour obesite morbide (8 hommes, 12 femmes; indice de masse corporelle [IMC] moyen 46,82 [+ or -] 4,47) et 20 temoins non obeses en bonne sante (10 hommes, 10 femmes; IMC moyen 22,52 [+ or -] 2,08). Nous n'avons note aucune difference significative des taux de 8-OHdG seriques entre les 2 groupes, mais les taux de 8-OHdG urinaires etaient significativement plus eleves chez les patients souffrant d'obesite morbide que chez les temoins. Le poids, l'IMC et les taux de 8-OHdG seriques et urinaires avaient significativement diminue chez les patients atteints d'obesite morbide 6 mois apres l'intervention pour AGAL. Conclusion: L'AGAL est une technique efficace de perte de poids chez les patients souffrant d'obesite morbide. L'atteinte oxydative systemique de l'ADN etait exacerbee par l'obesite morbide, mais cette hausse n'etait pas reliee au gain ponderal, et elle etait plus evidente dans les echantillons seriques que dans les echantillons urinaires. Apres la pose d'un AGAL pour obesite morbide, l'atteinte oxydative de l'ADN a diminue dans le serum et dans l'urine.

Gastric cancer is the fourth most common type of cancer in the world and is the leading cause of cancer-related death in Korea. (1,2) Curative treatment of gastric cancer can [...], Background: Pre-emptive intravenous lidocaine infusion is known to improve postoperative pain in abdominal surgery. We assessed the effect of intravenous lidocaine infusion in patients who underwent subtotal gastrectomy. Methods: We conducted a double-blind, placebo-controlled study with patients undergoing subtotal gastrectomy for early gastric cancer divided into 2 groups: 1 group received intravenous lidocaine infusion preoperatively and throughout surgery, and the other received normal saline infusion (placebo). We assessed postoperative outcomes, including pain scores on a visual analogue scale (VAS), administration frequency of patient-controlled analgesia (PCA) and the amount of consumed fentanyl. Postoperative nausea and vomiting, length of hospital stay (LOS), time to return to regular diet and patient satisfaction at discharge were evaluated. Results: There were 36 patients in our study. Demographic characteristics were similar between the groups. The VAS pain scores and administration frequency of PCA were significantly lower in the lidocaine group until 24 hours after surgery, and fentanyl consumption was significantly lower in this group until 12 hours postoperatively compared with the placebo group. The total amount of consumed fentanyl and the total administration frequency of PCA were significantly lower in the lidocaine than the control group. No significant differences were detected in terms of nausea and vomiting, return to regular diet, LOS and patient satisfaction, and there were no reported side-effects of lidocaine. Conclusion: Intravenous lidocaine infusion reduces pain during the postoperative period after subtotal gastrectomy. Contexte: Administree a titre preventif, la perfusion intraveineuse de lidocaine ameliorerait la douleur postoperatoire dans la chirurgie abdominale. Nous avons mesure l'effet d'une perfusion intraveineuse de lidocaine chez des patients soumis a une gastrectomie subtotale. Methodes: Nous avons realise une etude a double insu avec temoins sous placebo aupres de patients soumis a une gastrectomie subtotale pour un cancer de l'estomac au premier stade. Les patients ont ete repartis en 2 groupes: l'un a recti une perfusion intraveineuse de lidocaine en preoperatoire et tout au long de la chirurgie, tandis que l'autre a recu une perfusion de solution physiologique (placebo). Nous avons evalue les resultats postoperatoires, y compris les scores de douleur sur une echelle analogique visuelle, la frequence d'administration d'analgesie controlee par les patients (ACP) et la quantite de fentanyl utilisee. Les nausees et vomissements postoperatoires, la duree du sejour hospitalier, l'intervalle avant la reprise d'une alimentation reguliere et la satisfaction du patient au moment de son conge ont aussi ete consignes. Resultats: Notre etude a regroupe 36 patients. Les caracteristiques demographiques etaient similaires entre les groupes. Les scores de douleur a l'echelle analogique visuelle et la frequence d'administration de l'ACP ont ete significativement moindres dans le groupe sous lidocaine jusqu'a 24 heures apres la chirurgie et la prise de fentanyl a aussi ete significativement moindre dans ce groupe jusqu'a 12 heures apres la chirurgie, comparativement au groupe temoin. La quantite totale de fentanyl utilisee et la frequence totale d'administration de l'ACP ont ete significativement plus faibles dans le groupe sous lidocaine que dans le groupe temoin. Aucune difference significative n'a ete observee pour ce qui est des nausees et vomissements, du retour a une alimentation reguliere, de la duree du sejour hospitalier et de la satisfaction des patients et on n'a rapporte aucun effet secondaire associe a la lidocaine. Conclusion: La perfusion de lidocaine intraveineuse attenue la douleur durant la periode postoperatoire apres une gastrectomie subtotale.

According to the World Health Organization, obesity is reaching epidemic proportions. Canada is no exception to this epidemic: most Canadians are overweight or obese, (1) and 2% of men and [...], Background: Canada needs to increase capacity for bariatric surgery to reduce the wait for this cost-effective, life-saving surgery. The aim of this study was to test whether laparoscopic bariatric surgery, including gastric bypass, can be delivered safely in secondary health care centres (SHCCs). Methods: In this prospective cohort study, patients received bariatric surgery at an SHCC that had no intensive care unit but had a dedicated operating room and ward teams and a patient-monitoring environment. Patients with life-threatening complications were transferred to an affiliated tertiary health care centre (THCC) via a dedicated 'service corridor.' Results: In all, 830 patients were treated: 676 at the SHCC and 154 at the THCC. Gastric bypass was performed in 85.4%, gastric band in 11.1% and gastric sleeve in 3.5%. The body mass index (BMI) was significantly higher in the THCC than the SHCC group (mean 54.4 [standard deviation (SD) 9.7] v. 47.5 [SD 7.4]). Obesity-associated diseases were similar between the groups. Major complications occurred in 2.6% of SHCC patients and 1.7% of THCC patients. Seven patients (1%) required direct transfer to the THCC, and all were treated successfully. There were 2 deaths (1.3%) in the THCC and none in the SHCC groups (combined mortality 0.2%). Weight loss was equivalent up to the fourth year of the study. Conclusion: With proper patient selection, a dedicated health care team and a service corridor to an affiliated THCC, laparoscopic bariatric surgery, including gastric bypass can be performed safely in SHCCs. Further study is needed to determine whether the model can be applied across Canada. Contexte: Le Canada doit accroitre sa capacite en chirurgie bariatrique afin de reduire les temps d'attente pour cette intervention rentable qui sauve des vies. Le but de cette etude etait de verifier si la chirurgie bariatrique laparoscopique, y compris le pontage gastrique laparoscopique, peut se pratiquer en toute securite dans les centres hospitaliers de soins de deuxieme ligne (CHDL). Methodes: Dans cette etude de cohorte prospective, les patients ont subi une chirurgie bariatrique dans un CHDL sans unite de soins intensifs mais pourvu d'un bloc operatoire et d'equipes soignantes specialisees, ainsi que d'un systeme de surveillance des patients. Les patients qui ont presente des complications gravissimes ont ete transferes dans un centre hospitalier de soins tertiaires (CHST), par le bais d'un <> reserve. Resultats: En tout, 830 patients ont subi le traitement; 676 au CHDL et 154 au CHST. On a procede par pontage gastrique chez 85,4% patients, pose d'un anneau gastrique chez 11,1% et gastrectomie longitudinale en manchon (gastric sleeve) chez 3,5% des patients. L'indice de masse corporelle (IMC) etait significativement plus eleve dans le groupe transfere au CHST que dans le groupe traite au CHDL (moyenne 54,4 [ecart-type (ET) 9,7 c. 47,5 [ET 7,4]). Les maladies associees a l'obesite etaient similaires entre les groupes. Des complications majeures sont survenues chez 2,6% des patients du CHDL et 1,7% des patients du CHST. Sept patients (1%) ont du etre transferes directement au CHST et ils ont tous ete traites avec succes. On a deplore 2 deces (1,3%) dans le groupe du CHST; aucun n'est survenu chez les patients du CHDL (mortalite combinee 0,2%). La perte de poids a ete equivalente jusqu'a la quatrieme annee de l'etude. Conclusion: Avec une selection adequate des patients, une equipe soignante specialisee et un corridor de service vers un CHST affilie, il est possible d'effectuer securitairement des chirurgies bariatriques laparoscopiques, y compris par pontage gastrique, dans les CHDL. Il faudra approfondir la recherche pour determiner si ce modele peut etre applique partout au Canada.

Since Dubois and colleagues (1) reported the first experience with laparoscopic cholecystectomy, beginning in 1988, laparoscopic surgery has rapidly gained popularity. Many reports have highlighted the benefits of the laparoscopic [...], Background: The Eastern experience has reported the safety of laparoscopic assisted gastrectomy (LAG) for gastric cancer. Its use in Western countries is still debated owing to concerns about its oncologic equivalence to open gastrectomy (OG). We sought to review and compare their operative outcomes and oncologic specimen quality (number of harvested lymph nodes and surgical margins) for gastric adenocarcinoma (GA). Methods: We reviewed the charts of all patients undergoing LAG (2007-2010) and OG (2000-2010) for GA in a single institution. Several surgeons performed the OGs, whereas 1 fellowship-trained laparoscopic surgeon performed LAGs. The primary outcome was quality of the surgical specimen, assessed by the number of harvested lymph nodes (LNs) and margin status. Secondary outcomes were perioperative events. Data were analyzed as intention to treat. Results: We retrieved 60 cases (47 OGs, 13 LAGs). The conversion rate was 23%. Mean operative time was 115 minutes longer and blood loss was 425 mL less (both p < 0.001) for LAGs. A mean of 14.4 (standard deviation [SD] 9.8) and 11.2 (SD 8.2) LNs were harvested for OGs and LAGs, respectively (p = 0.29). Negative margins were achieved for all patients. Mean length of stay was similar (LAG: 19 d v. OG: 18.9 d; p = 0.91). The groups did not differ on major postoperative complications (12.7% v. 23.1%; p = 0.39) or operative mortality (2.1% v. 7.7%; p = 0.32). Conclusion: Laparoscopic assisted gastrectomy is a challenging but safe and feasible procedure in experienced hands. It offers the same radical resection as OG regarding negative margins and LN retrieval. Long-term follow-up is warranted. Contexte: La gastrectomie assistee par laparoscopie (GAL) a ete demontree dans des etudes orientales comme securitaire dans le traitement de l&apos;adenocarcinome gastrique (AG). En occident, l&apos;equivalence oncologique de la GAL avec la gastrectomie ouverte (GO) demeure cependant controversee. Cette etude vise a comparer le devenir postoperatoire et la qualite des specimens oncologiques de ces interventions, dans le traitement de l&apos;AG. Methodes: Tous les dossiers de patients operes par GAL (2007-2010) ou GO (2000-2010) pour AG dans un seul centre hospitalier ont ete revus. Differents chirurgiens ont realise les GO. Toutes les GAL ont ete realisees par un seul chirurgien sur-specialise en chirurgie laparoscopique. Le critere d&apos;evaluation principal etait la qualite du specimen chirurgical evaluee par le nombre de ganglions lymphatiques (GL) preleves et le statut des marges de resection. Le critere d&apos;evaluation secondaire etait la morbidite postoperatoire. Les donnees ont ete analysees en fonction de l&apos;intention de traiter. Resultats: Soixante cas ont ete inclus (47 GO, 13 GAL). Le taux de conversion s&apos;est etabli a 23 %. Le temps operatoire moyen etait plus long de 115 minutes, et les pertes sanguines moyennes moindres de 425 mL (p < 0,001 dans les 2 cas) pour la GAL que pour la GO. Une moyenne de 14,4 (ecart-type [ET] 9,8) et 11,2 (ET 8,2) GL ont ete preleves respectivement pour la GO et la GAL (p = 0.29). On a obtenu des marges negatives pour tous les patients. La duree moyenne du sejour ne differait pas (GAL 19 j c. GO 18,9 j;p = 0,91). Les complications majeures (12,7 % c. 23,1 %;p = 0,39) et la mortalite post-operatoires (2,1 % c. 7,7 %; p= 0,32) etaient similaires. Conclusion: La gastrectomie assistee par laparoscopie est une intervention complexe, mais peut etre realisee de maniere securitaire en des mains expertes. Elle offre un specimen oncologique comparable a la gastrectomie ouverte, en termes de lymphadenectomie et de marges de resection. Un suivi a long terme demeure necessaire.

Gastrointestinal stromal tumours (GISTs) are rare gastrointestinal cancers (0.1%-3%). (1-3) They most commonly affect the upper gastrointestinal tract with involvement of the stomach in more than 50% of cases. (1-4) [...], Background: Laparoscopic wedge resection has been widely accepted for small benign gastric tumours. Large gastrointestinal stromal tumours (GISTs), however, can be difficult to manipulate laparoscopically and are at risk for capsule disruption, which can then result in peritoneal seeding. Some authors have suggested that large GISTs (> 8 cm) are best approached using an open technique. However, there has been no consensus as to what the cut-off size should be. We conducted one of the largest Canadian series to date to assess outcomes and follow-up of the laparoscopic management of GISTs. Methods: All patients with gastric GISTs presenting to Vancouver General Hospital and University of British Columbia Hospital between 2000 and 2008 were reviewed. Most lesions were resected using a wedge technique with closure of the stomach facilitated by an endoscopic linear stapling device. Results: In all, 23 patients presented with GISTs; 19 patients underwent laparoscopic resection and, of these, 15 had a purely laparoscopic operation and 4 had a hand-assisted laparoscopic resection. Mean tumour size was 3.2 cm, with the largest tumour measuring 6.8 cm. There were no episodes of tumour rupture or spillage and no major intraoperative complications. All margins were negative. Mean follow-up was 13.3 (range 1-78) months. There was no evidence of recurrence or metastasis. Conclusion: The laparoscopic management of gastric GISTs is safe and effective with short hospital stays and good results over a mean follow-up of 13.3 months. We believe that it should be the preferred technique offered to patients. Contexte : La resection cuneiforme par laparoscopie est generalement acceptee pour les petites tumeurs gastriques benignes. Les grosses tumeurs du stroma gastrointestinal (TSGI) peuvent toutefois etre difficiles a manipuler par laparoscopie et une rupture possible de la capsule peut entrainer une atteinte du peritoine. Certains auteurs ont laisse entendre que la technique ouverte constitue la meilleure facon d&apos;aborder une TSGI de grande taille (> 8 cm). Il n&apos;y a toutefois pas de consensus sur la dimension limite. Nous avons effectue l&apos;une des plus importantes series canadiennes realisees jusqu&apos;a maintenant pour evaluer les resultats et le suivi du traitement de la TSGI par laparoscopie. Methodes : Nous avons etudie les dossiers de tous les patients qui avaient une TSGI gastrique et qui se sont presentes a l&apos;Hopital General de Vancouver et a l&apos;Hopital de l&apos;Universite de la Colombie-Britannique entre 2000 et 2008. La plupart des lesions ont ete retirees par resection cuneiforme et une agrafeuse lineaire endoscopique a facilite la fermeture de l&apos;estomac. Resultats : Au total, 23 patients se sont presentes avec une TSGI et 19 ont subi une resection laparoscopique. Sur ce total, 15 ont subi une laparoscopie pure et 4, une laparoscopie avec assistance manuelle. La taille moyenne de la tumeur s&apos;etablissait a 3,2 cm et la plus grosse mesurait 6,8 cm. Il n&apos;y a eu aucun cas de rupture ni de fuite, ni aucune complication majeure au cours de l&apos;intervention. Toutes les marges se sont revelees negatives. Le suivi moyen s&apos;est etabli a 13,3 (ecart 1-78) mois. Il n&apos;y avait aucun signe de recidive ni de presence de metastases. Conclusion : Le traitement par laparoscopie de la TSGI gastrique est securitaire et efficace, les sejours a l&apos;hopital sont courts et les resultats sont bons au cours d&apos;un suivi moyen de 13,3 mois. Nous sommes d&apos;avis qu&apos;il devrait s&apos;agir de la technique privilegiee a offrir aux patients.

Introduction Potassium is the principal intracellular ion, and its concentration and gradients greatly influence the electrical activity of excitable membranes. Hypokalemia is known to increase the incidence of perioperative arrhythmia [...], Purpose We investigated whether hypokalemia developed during the postoperative period and whether the use of intravenous patient-controlled analgesia (IV-PCA) could decrease the incidence of postoperative hypokalemia in patients who underwent laparoscopic cholecystectomy. Methods Sixty patients undergoing laparoscopic cholecystectomy were randomly assigned to either IV-PCA (n = 30) or control (n = 30) groups. We measured serum potassium concentration at the outpatient department (T1), at 8:00 a.m. on the day of surgery (T2), at 6 h after the end of surgery (T3), and at 8:00 a.m. on the first (T4), second (T5), and third (T6) postoperative days. Serum potassium concentration, incidence of hypokalemia, mean blood pressure, heart rate, respiratory rate, and the patient-reported visual analogue scale score were compared within each group and between groups at each time point. Results Serum potassium concentrations in all patients showed a significant decrease at T2-T4 compared to the preoperative concentration (T1). Serum potassium concentrations at T3 and T4 in the IV-PCA group were significantly higher than those in the control group. Also, the incidence of hypokalemia at T3 and T4 was significantly lower in the IV-PCA group. Mean blood pressure and heart rate were significantly lower in the IV-PCA group than in controls at T3 and T4. Conclusions The results show that hypokalemia developed during the perioperative period and the use of IV-PCA in patients undergoing laparoscopic cholecystectomy effectively decreased the degree and incidence of postoperative hypokalemia on the day of the operation and postoperative day one. Keywords Patient-controlled intravenous analgesia * Hypokalemia * Arrhythmia * Catecholamine * Laparoscopic cholecystectomy

Laparoscopic surgery has revolutionized the practice of most surgical subspecialties over the past 2 decades. In general, laparoscopic surgery results in smaller scars, less postoperative pain and a quicker recovery [...], Background: Laparoscopic surgery has gained popularity over open conventional surgery as it offers benefits to both patients and health care practitioners. Although the overall risk of complications during laparoscopic surgery is recognized to be lower than during laparotomy, inadvertent serious complications still occur. Creation of the pneumoperitoneum and placement of laparoscopic ports remain a critical first step during endoscopic surgery. It is estimated that up to 50% of laparoscopic complications are entry-related, and most injury-related litigations are trocar-related. We sought to evaluate the current practice of laparoscopic entry among Canadian general surgeons. Methods: We conducted a national survey to identify general surgeon preferences for laparoscopic entry. Specifically, we sought to survey surgeons using the membership database from the Canadian Association of General Surgeons (CAGS) with regards to entry methods, access instruments, port insertion sites and patient safety profiles. Laparoscopic cholecystectomy was used as a representative general surgical procedure. Results: The survey was completed by 248 of 1000 (24.8%) registered members of CAGS. Respondents included both community and academic surgeons, with and without formal laparoscopic fellowship training. The demographic profile of respondents was consistent nationally. A substantial proportion of general surgeons (> 80%) prefer the open primary entry technique, use the Hasson trocar and cannula and favour the periumbilical port site, irrespective of patient weight or history of peritoneal adhesions. One-third of surgeons surveyed use Veress needle insufflation in their surgical practices. More than 50% of respondents witnessed complications related to primary laparoscopic trocar insertion. Conclusion: General surgeons in Canada use the open primary entry technique, with the Hasson trocar and cannula applied periumbilically to establish a pneumoperitoneum for laparoscopic surgery. This surgical approach is remarkably consistent nationally, although considerably variant across other surgical subspecialties. Peritoneal entry remains an important patient safety issue that requires ongoing evaluation and study to ensure translation into safe contemporary clinical practice. Contexte : La chirurgie laparoscopique a gagne en popularite par rapport a la chirurgie ouverte classique en raison des avantages qu'elle offre, tant pour les patients que pour les professionnels de la sante. Meme si on reconnait que le risque global de complications est moindre durant la chirurgie laparoscopique que durant la laparotomie, il survient parfois par inadvertance des complications graves. La creation d'un pneumoperitoine et l'installation des dispositifs d'acces laparoscopiques demeurent une premiere etape cruciale lors de toute chirurgie endoscopique. On estime que jusqu'a 50 % des complications laparoscopiques sont liees a l'insertion et que la plupart des poursuites pour traumatisme mettent en cause une lesion causee par le trocart lui-meme. Nous avons voulu evaluer la pratique actuelle des chirurgiens generaux canadiens en matiere d'insertion des instruments laparoscopiques. Methodes : Nous avons realise un sondage a l'echelle nationale pour connaitre les preferences des chirurgiens generaux en matiere d'insertion laparoscopique. Plus specifiquement, nous avons voulu interroger les chirurgiens inscrits a la base de donnees des membres de l'Association canadienne des chirurgiens generaux (ACCG) en ce qui a trait aux methodes d'insertion, aux instruments d'acces, a la localisation des dispositifs d'insertion et aux profils de securite des patients. On a utilise la cholecystectomie laparoscopique comme intervention type en chirurgie generale. Resultats : Parmi les 1000 membres inscrits de l'ACCG, 248 (24,8 %) ont repondu au sondage. Les repondants provenaient du milieu communautaire et universitaire et pouvaient ou non avoir suivi un stage formel en laparoscopie. Le profil demographique des repondants etait uniforme a l'echelle nationale. Une proportion substantielle (> 80 %) de chirurgiens generaux preferent la technique d'insertion primaire ouverte, utilisent un trocart et une canule de Hasson et privilegient la region periombilicale pour l'insertion, independamment du poids ou des antecedents d'adherences peritoneales des patients. Le tiers des chirurgiens interroges utilisent l'insufflation par aiguille de Veress dans leurs pratiques. Plus de 50 % des repondants ont ete temoins de complications liees a l'insertion de trocarts laparoscopiques au site de l'orifice primaire. Conclusion : Les chirurgiens generaux du Canada utilisent la technique d'insertion primaire ouverte avec trocart et canule de Hasson et privilegient la region periombilicale pour etablir un pneumoperitoine en vue de la chirurgie laparoscopique. Cette approche chirurgicale semble appliquee avec une remarquable constance a l'echelle nationale, mais varie considerablement parmi les autres specialites chirurgicales. La question de l'insertion peritoneale demeure importante pour la securite des patients et il faudra continuer a evaluer et a examiner cet enjeu pour assurer une pratique clinique moderne securitaire.

Splenic and portal vein thrombosis (SPVT) is an alarming and potentially life-threatening complication of splenectomy. Prospective and retrospective studies have shown the incidence of symptomatic SPVT to be between 0% [...], Background: Splenic and portal vein thrombosis (SPVT) is a potentially life-threatening complication of splenectomy. There is a paucity of studies examining the role of prophylactic pre- and postoperative anticoagulation in the prevention of this complication. We designed a prospective randomized controlled trial (RCT) to more rigorously address the impact of prophylactic anticoagulation on the incidence of asymptomatic or symptomatic SPVT, detected on Doppler ultrasound, after laparoscopic splenectomy. Methods: This 2-centre, phase II, prospective, open-label, parallel-assignment RCT compared no postoperative anticoagulation to a regimen of 40 mg of enoxaparin subcutaneously once daily for 21 days. All patients underwent Doppler ultrasonography of the splenoportal system preoperatively and again 14-28 days after surgery to screen for nonocclusive or occlusive thrombosis. Results: From November 2006 to November 2008, 35 patients were enrolled in the RCT. Four patients withdrew, 1 required conversion to an open procedure and 1 died at 3 months (the cause of death was not related to the study). Of the 29 patients remaining, 15 were randomly assigned to the anticoagulation group and 14 to the nonanticoagulation group. One (3.4%) patient in the treatment group experienced portal thrombosis. Rates of postoperative bleeding were similar in both groups. Conclusion: This RCT of anticoagulation found a low overall risk of SPVT after laparoscopic splenectomy; however, this is an underpowered study, and further multicentred clinical trials are needed. Contexte : La thrombose de la veine splenique et porte (TVSP) est une complication de la splenectomie qui peut menacer la vie. Peu d&apos;etudes se sont penchees sur le role de l&apos;anticoagulation pre-operatoire et postoperatoire prophylactique dans la prevention de cette complication. Nous avons concu un essai controle randomise (ECR) prospectif afin d&apos;analyser plus rigoureusement l&apos;effet de l&apos;anticoagulation prophylactique sur l&apos;incidence de la TVSP asymptomatique ou symptomatique, detectee par echographie Doppler, apres une splenectomie par laparoscopie. Methodes : Au cours de cet ECR multicentrique de phase 2, prospectif, ouvert et a repartition en groupes paralleles, nous avons compare l&apos;absence d&apos;anticoagulation postoperatoire a un regime de 40 mg d&apos;enoxaparine administree par voie sous-cutanee 1 fois par jour pendant 21 jours. Tous les patients ont subi une echographie Doppler du systeme splenoporte avant l&apos;intervention et de nouveau de 14 a 28 jours apres l&apos;intervention afin de depister la presence d&apos;une thrombose non occlusive ou occlusive. Resultats : De novembre 2006 a novembre 2008, 35 patients ont ete inscrits a l&apos;ECR. Quatre patients s&apos;en sont retires, il a fallu dans 1 cas proceder a une intervention ouverte et 1 patient est decede a 3 mois (la cause du deces etant sans rapport avec l&apos;etude). Sur les 29 patients restants, 15 ont ete affectes par randomisation au groupe de ceux qui ont recu une anticoagulation et 14, au groupe des patients qui n&apos;en ont pas recu. Un patient (3,4 %) du groupe traite a subi une thrombose de la veine porte. Les taux de saignement postoperatoire etaient semblables dans les 2 cas. Conclusion : Cet ECR sur l&apos;anticoagulation a revele un faible risque global de TVSP apres une splenectomie par laparoscopie, mais il s&apos;agit d&apos;une etude qui manque de puissance et d&apos;autres essais randomises multicentriques s&apos;imposent.

According to the most recent estimates from the 2004 Canadian Community Health Survey, 59% of the adult population is overweight (i.e., body mass index [BMI] ≥ 25) and 1 in [...], Obesity can be considered to be one of the most important chronic diseases facing Canadians of all ages. Whereas patients with a very high body mass index may have the most to gain from procedures such as Roux-en-Y gastric bypass or biliopancreatic diversion/duodenal switch, the increased risk of postoperative complications often makes them poor surgical candidates. As a result, several 'bridging' procedures have been proposed to impart clinically effective weight loss and reduce the risk of complications and improve outcomes in the definitive weight-loss procedure. In this article, we provide a review of the evidence in support of laparoscopic sleeve gastrectomy as an innovative new surgical procedure used as a bridging procedure in patients with severe obesity and discuss new findings for its possible role as a definitive procedure for some individuals with less severe obesity. Finally, we comment on a possible approach to introduce this innovative new procedure to Canadian bariatric centres. On peut considerer l'obesite comme l'une des plus importantes maladies chroniques auxquelles les Canadiens de tous ages font face. Si les Canadiens dont l'indice de masse corporelle est tres eleve sont ceux qui pourraient le plus beneficier des avantages d'interventions telles que la derivation gastrique Roux en Y ou la diversion biliopancreatique avec commutation duodenale, en fait, le risque accru de complications operatoires fait d'eux de mauvais candidats a la chirurgie. C'est pourquoi on a propose plusieurs solutions de transition pour obtenir une perte de poids cliniquement efficace et ainsi reduire le risque de complications et ameliorer l'issue de l'intervention bariatrique definitive le temps venu. Dans le present article, nous presentons un apercu des preuves favorables a la gastrectomie laparoscopique en manchon comme intervention chirurgicale novatrice en guise de solution interimaire chez les patients atteints d'obesite morbide et nous presentons les resultats recents qui temoignent de son role possible a titre d'intervention definitive dans certains cas d'obesite moins prononcee. En terminant, nous commentons une demarche envisageable pour faire adopter cette intervention novatrice dans les centres bariatriques canadiens.

The case of a 52-year-old woman with severe obesity and depression, anxiety is discussed to better understand the consequences of the two most common bariatric surgical procedures for weight loss - Roux-en-Y gastric bypass and laparoscopic adjustable gastric binding. The efficacy of such forms of treatment is also highlighted.

The study aims to evaluate the efficacy of laparoscopic uterosacral nerve ablation (LUNA) in the reduction of chronic pelvic pain. The results indicate that LUNA was not very effective in alleviating pain among women with such pain; whereas, laparoscopy without pelvic denervation was more effective.

Byline: Hiroaki Fukuzawa (1), Naoto Urushihara (1), Kaoru Ogura (1), Eiji Miyazaki (1), Takanori Matsuoka (1), Koji Fukumoto (1), Syuri Kimura (1), Maki Mitsunaga (1), Shiro Hasegawa (1) Keywords: Wandering spleen; Laparoscopic splenopexy; Extraperitoneal Abstract: Wandering spleen is a very rare disease. It is a very dangerous condition due to the risk of splenic ischemia from persistent pedicle torsion. Here, we describe a case of wandering spleen diagnosed by ultrasound and computed tomography scans in an 11-year-old boy who suffered from frequent urination and enuresis. A laparoscopic splenopexy was successfully performed with fixation of the spleen in an extraperitoneal pocket. Since the operation, the organ has remained in place with good perfusion. The details of the procedure are described. Author Affiliation: (1) Department of Surgery, Shizuoka Children's Hospital, Shizuoka, Japan Article History: Registration Date: 01/08/2006 Online Date: 30/08/2006

Byline: K. R. Srimurthy (1,2), S. Ramesh (1) Keywords: Laparoscopy; Choledochal cyst (CDC); Minimally invasive surgery (MIS); Laparoscopic surgery Abstract: We report laparoscopic management of choledochal cysts (CDC) in 10 children. We dissect the CDC using conventional mono- and bi-polar diathermy up to the lower end, ligate or clip it at the lowest possible level and divide it. The proximal end is divided after leaving a sufficient cuff for anastomosis. In the first three cases, we formally opened to complete the biliary-enteric anastomosis. However, in the subsequent seven cases, we made a small midline incision to develop a Roux-en Y loop, and the anastomosis was then completed by intra-corporeal suturing after re-creating the pneumo-peritoneum. Apart from biliary leak in one case, we did not encounter any major complications. The mean operative time was 4.2 h. We have discussed the technical points in the study. We conclude that CDC is eminently suitable for laparoscopic correction it requires advanced skills and expertise for precise dissection and meticulous suturing in restricted spaces. If the case selection is good and if the team is experienced, CDC can be effectively managed using laparoscopy even without a sophisticated equipment. The wound- and scar-related morbidity is minimized. Author Affiliation: (1) Indira Gandhi Institute of Child Health , South Hospital Complex, 560 029, Bangalore, India (2) Bangalore Hospital, 202, R.V.Road, 560 029, Bangalore, India Article History: Registration Date: 04/11/2005 Accepted Date: 07/09/2005 Online Date: 07/12/2005

Byline: Tadaharu Okazaki (1), Go Miyano (1), Atsuyuki Yamataka (1), Hiroyuki Kobayashi (1), Hiroyuki Koga (1), Geoffrey J. Lane (1), Takeshi Miyano (1) Keywords: Cholangiography; Laparoscopy; Neonatal jaundice; Biliary atresia; Biliary hypoplasia Abstract: Cholangiography is often crucial for establishing the definitive cause of neonatal jaundice. We present our protocol for using laparoscopy-assisted cholangiography in infants with prolonged jaundice and discuss its benefits. Firstly, a 5 mm supra-umbilical trocar is introduced to create a port for a 0deg laparoscope. A 5 mm trocar is then inserted through a right subcostal incision to allow the liver and gallbladder to be visualized. If the gallbladder is of good size, the fundus is exteriorized through the right subcostal trocar site and a catheter is inserted into the gallbladder for cholangiography. If the gallbladder is atretic, the fundus is not exteriorized and a laparotomy is performed for open intraoperative cholangiography because the lumen of an atretic gallbladder is usually not fully patent and cholangiography through its exteriorized fundus often fails. We reviewed 18 jaundiced infants thought to have biliary atresia (BA) who had laparoscopy-assisted cholangiography. At laparoscopy, four patients had good sized gallbladders and minimal to mild liver fibrosis. They underwent cholangiography via the exteriorized fundus, and BA in two cases and biliary hypoplasia in two cases were identified. The remaining 14 had atretic gallbladders and varying degrees of liver fibrosis. Cholangiography via the exteriorized fundus was performed in one patient, but failed and converted to open cholangiography. Open intraoperative cholangiography identified BA in all 14 cases. All BA cases progressed to Kasai portoenterostomy directly after diagnosis. Laparoscopy is used to determine the type of cholangiography to be performed based on the appearance of the gallbladder and this simple, accurate, and safe protocol allows the anatomical structure of the biliary tree to be obtained accurately with minimal surgical intervention. Author Affiliation: (1) Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, 113-8421, Bunkyo-ku, Tokyo, Japan Article History: Registration Date: 14/11/2005 Accepted Date: 07/11/2005 Online Date: 08/12/2005