Patients with coronary artery disease are at 3 times higher risk for thromboembolic complications if off Aspirin1. Distinct guidelines for use of antiplatelet agents don’t exist for all major urological procedures. Significant blood loss during laparoscopic procedures requiring transfusion or conversion to open occur at 4% to 6%2. Continuation of antiplatelet therapy may disrupt homeostasis and compromise oncological outcomes. The purpose of this study was to determine outcomes associated with continued aspirin use during laparoscopic partial nephrectomy (LPN).

Authors performed a retrospective evaluation of 434 patients who underwent LPN from Jan 2012- Oct 2014. The patient’s age, gender, MBI, comorbidities, use and duration of aspirin and other antiplatelet or anticoagulant therapies, indication for antiplatelet therapy, tumor characteristics, ASA score, EBL, volume of IV fluids administered, operative time, and warm ischemia time were recorded. Chronic aspirin users were split into two groups: those continuing and non-continuing aspirin use perioperatively. All patients underwent transperitoneal LPN.

Of 434 patients 101 were on chronic antiplatelet therapy. 17 remained on Aspirin at this time of the procedure and 84 stopped aspirin use perioperatively. Those on Aspirin had higher ASA scores. The operative time was longer for those on aspirin (181 minutes vs. 136 minutes) (p<0.01). No difference in ischemia time of estimated blood loss between the two groups. There was a change between preoperative and postoperative nadir hematocrit and transfusion rate. Length of stay was the same between the two groups. No intraoperative complications and no significant difference in complications. One complication in the group that stayed on aspirin. The patient had an endophytic 5cm mass involving the collecting system (RENAL score-8 PADUA-10). Had a bleed post operatively on day 1 requiring transfusion and renal angioembolism and an ICU stay. The same patient 2 weeks later had bleeding from a duodenal ulcer. One experienced a myocardial infarction. No perioperative thromboembolic events. The hospital readmission rate was similar in both groups. All patients had negative margins and there were no urinary leaks.

Evidence supports antiplatelet therapy perioperatively especially in high-risk cardiovascular patients3. Transfusion rate for those on aspirin was 12%. The bleeding duodenal ulcer 2 weeks after may have had underlying bleeding diathesis. 5.5% incidence of major clinical complication. Since only one patient it is considered a low absolute risk. Increased procedure length probably due to more time spent on hemostasis and careful dissection. Also insufflation and inspection in the OR.

This study is limited because it is retrospective, and complex tumors were most likely managed after cessation of aspirin use. They don’t have a full range in the group that stayed on aspirin. Patients in the on group are not standardized for cardiovascular risk level. There is also a small sample size. There is a need for larger prospective studies.

Written By: David Leavitt, Mohamed Keheila, Michael Siev, Paras Shah, Daniel Moreira, Arvin George, Simpa Salami, Michael Schwarz, Lee Richstone, Manish Vira, Louis Kavoussi
Department of Urology, Smith Institute for Urology

UCLA researchers have discovered an optimal way to image the bile ducts during gallbladder removal surgeries using a tested and safe dye and a real-time near-infrared florescence laparoscopic camera, a finding that will make the procedure much safer for the hundreds of thousands of people who undergo the procedure each year.

The new imaging procedure can also be used any time surgeons look laparoscopically at the liver and surrounding anatomy.
The gallbladder and liver can be hard to access and visualize when the areas around them are inflamed or surrounded by fat. Using the conventional imaging technique, in which the bile ducts are not as clearly delineated, injuries to the ducts can occur. Those injuries sometimes remain undetected during the surgery, which can lead to serious problems for the patients, said study first author Dr. Ali Zarrinpar, an assistant professor of surgery in the Division of Liver and Pancreas Transplantation.
"Removal of the gallbladder is one of the most commonly performed operations in the United States, with more than 100,000 surgeries performed each year. Injuries to the bile ducts, which carry bile from the liver to the intestines, are rare. But when they do occur, the outcomes can be quite serious and cause life-long consequences," Zarrinpar said. "Gallbladder removals are one of the most litigated cases in general surgery because of these injuries. Any technique that can reduce the rate of bile duct injury and increase the safety of the operation is good for patients and for surgeons."
The study appears March 10, 2016 in the early online edition of the peer-reviewed journal Surgical Innovations.
The dye, called indocyanine green (ICG), is approved by the U.S. Food and Drug Administration and has been in use medically for 60 years. The near-infrared florescence laparoscopic camera also is approved for use in colorectal surgeries. This is the first study to optimize the timing and dosing of the dye using his device, Zarrinpar said.
After being injected into a vein, ICG is taken up by the liver and excreted into the bile. The laparoscopic device then detects the fluorescence of the dye in the bile ducts and superimposes that image onto the conventional white light image that surgeons use routinely. This augmented image improves the surgeons' visualization of the bile ducts, making it easier for them to identify the appropriate anatomy.
Prior to this study, it was unclear just how long before the procedure the dye had to be injected and exactly how much for optimal imaging. Timing, and dosage, often varied widely among practioners. Sometimes, patients got the ICG injected the day prior to their surgery, requiring an extra doctor visit.
However, Zarrinpar and his team found that the dye could be injected as little as 25 to 30 minutes before with good result, although one to four hours prior did improve the image. They also found that patients could receive much less of the dye than many were getting, allowing them to clear the substance in the bile from their bodies much more quickly.
The finding also could lead to a reduction in the number of "open" gallbladder removals and partial liver resections. When the surgeons have trouble visualizing the bile duct and surrounding anatomy, they often will switch from laparoscopic to open surgeries, which make it easier to avoid injuring the bile duct but result in a more difficult and lengthy recovery time for patients.
The prospective UCLA study, which took six months, was small, with 37 patients enrolled. Going forward, Zarrinpar is working to put together a much larger clinical trial to confirm his findings and see if the imaging process and the resulting benefits are cost effective, Zarrinpar said.
"This study provides guidance on the timing and dosing of indocyanine green with respect to anticipated visualization of the biliary tree," the study states. "NIRFC is practical and effective in delineating extrahepatic biliary anatomy during laparoscopic biliary and hepatic operations, and its use should therefore be considered over traditional methods."

When
Thursday, March 17, 2016
6:00 PM - 8:00 PM
Eastern Time
Add to Calendar
Add to Calendar
Where
Boston Hynes Convention Center
900 Boylston St
Room #312
Boston, Massachusetts 02115
USA

Robotic Surgery Symposium by intuitive surgical

Miami, FL—Beginning next month, SLS, the largest multi-disciplinary surgical society in North America, will introduce the latest in minimally invasive surgical techniques to younger surgeons around the world who need additional support and education in the newest research in surgical technology and techniques.

The program involves multispecialty surgeons experienced in laparoscopy, who will teach a series of lectures on conditions common to all minimally invasive disciplines. It also includes basic laparoscopic suturing instructions with tips and tricks from the experts. The subjects of the didactic lectures include; adhesions, entry techniques, pain, education complex surgical conditions and complications. The skills sessions are the basics of laparoscopic suturing and robotics.

“Residents are increasingly stressed, trying to accommodate all that they can in their new careers,” says Dr. Paul Wetter, chairman of SLS. “This is an opportunity for us as a society to present what we know directly to residents who need our support in addition to their teaching institution and medical meetings, where they can come face to face with experts in our fields of discipline.”

The SLS course, which will be called “Tips and Tricks in Minimally Invasive Surgery,” will be taught by SLS-academics from a variety of medical disciplines in China, Romania, Puerto Rico, Brazil, Columbia and the U.S. as a part of a ten city tour that will also reach American military bases. Primarily funded by SLS, the two day course will allow academic experts in general surgery, gynecology, urology and other disciplines to teach basic minimally invasive surgical (MIS) techniques, using the latest research, which will include specific, common illnesses, how to avoid complications, pain, and complex surgical conditions.

“The major medical meeting attendee is usually already established,” says Dr. Maurice Chung, president of SLS, director of women’s health service Van Wert County Hospital, Ohio, and a professor at University of Toledo School of Medicine. “This course has been developed for the younger student, and along with the guidance of their institution, it gives them a chance to become an expert in their field.”

The course will also be developed for the military, with the first lecture at Tripler Army Medical Center in Hawaii. The six-hour course, which has not yet been advertised, has already attracted dozens of attendees and is scheduled for February 16th, 2016.

Preparing residents for the changing landscape of surgery around the world is something our medical society needs to do, says Dr. Richard Satava, professor emeritus of surgery, University of Washington Medical Center and a former senior science advisor at the US Army Medical Research and Materiel Command. “Supporting residents is in line with everything else that SLS does, including its values and mission and I look forward to hearing more as the program takes off.”

The Society of Laparoendoscopic Surgeons (SLS), a 501(c)(3) organization, is the nation’s leading group of multi-specialty surgeons, including general surgery, urology, OB-GYN and others, SLS advocates for minimally invasive surgery and improved surgical outcomes for all these specialties. It is a voluntary, nonprofit membership organization of roughly 6,000 surgeons. www.sls.org

Indore: A 45-year-old man weighing an enormous 385 kg underwent bariatric surgery at a private medical institution here to reduce flab and look fab.

The surgery to whittle the waist was performed recently through laparoscopic sleeve gastrectomy method by a 30-member team, led by bariatric surgeon Dr Mohit Bhandari, at city-based Sri Aurobindo Institute of Medical Sciences.

"This is for the first time in Asia that a man weighing 385 kg went under the scalpel for reducing weight through laparoscopic surgery. Earlier, we had operated upon a woman weighing 350 kg," he said.

The man, a resident of Gujarat's Gandhi Nagar, was suffering from diabetes, sleep apnea and pulmonary hypertension since past five years while being confined to his bed, Bhandari said. He said the patient was under supervision of doctors for past 15 days before being taking him for operation.

"After the three-hour marathon surgery, the team performed sleeve gastrectomy procedure. The condition of the patient is stable and we hope his weight will tumble to somewhere around 150 kg in next five months," the doctor said.

Before surgery, the man's BMI (Body Mass Index) was above 132, which is five times more than that of a normal person.

According to dietitians, persons having BMI of 25 are considered "normal", those above 25 and below 30 "weighty" while being above 30 earns one "heavyweight" tag.

Bariatric surgery includes a variety of procedures performed on people who are obese. It is of three types: Laparoscopic Sleeve Gastrectomy, Laparoscopic Bypass and Mini Gastric bypass. The three procedures are slightly different but in each surgery, the stomach size is reduced that in turn cuts down on food intake and helps in weight loss.