Flexible versus rigid single-port peritoneoscopy: a randomized controlled trial in a live porcine model followed by initial experience in human cadavers

A randomized, prospective, comparative trial of a variable-angle versus fixed-angle endoscope for exploratory thoracoscopy in canine cadavers

OBJECTIVE

To compare the efficacy of a variable-angle endoscope (VAE) for canine thoracoscopic exploration to a traditional fixed-angle endoscope (FAE).

STUDY DESIGN

Randomized, prospective, comparative study.

SAMPLE POPULATION

Five fresh canine cadavers.

METHODS

Twelve predetermined anatomical locations were labeled after median sternotomy in each cadaveric thorax. Two board-certified veterinary surgeons performed thoracoscopic evaluation of each thorax using a fixed-angle (30°) and a variable-angle (0°-120°) endoscope with and without lungs mechanically ventilated. The order of surgeon, lung ventilation, and endoscope were determined using a randomized block design. Time to visualize each anatomical location was compared for surgeon, endoscope, and lung ventilation status. Primary outcome measures were time to individual anatomical location, total simulated thoracoscopic exploration time, and ability to identify anatomical location within the designated time period.

RESULTS

Lung ventilation (difference = 184 seconds, P = .015, 95% CI = 45-342 seconds) and endoscope type (difference = 112 seconds, P = .029; 95% CI = 10-213 seconds) had an effect on the cumulative time for complete thoracoscopic exploration. The VAE shortened the time to identify three of the 12 anatomical locations when controlling for the effects of lung ventilation. Use of the VAE did not improve time to identification for any locations compared to the FAE when lungs were not ventilated. The VAE facilitated significantly shorter cumulative thoracoscopic exploration time compared with the FAE. Failure to identify predetermined locations was more common with the FAE than with the VAE.

CONCLUSION

Use of a rigid VAE decreased cumulative thoracoscopic exploration time and provided an alternative to one-lung ventilation for circumventing the visual impediments of lung ventilation.

CLINICAL SIGNIFICANCE

This cadaveric study provides evidence that one-lung ventilation and use of a VAE may improve surgeon efficiency during exploratory thoracoscopy.

Prediction of Resectability in Pseudomyxoma Peritonei with a New CT Score

BACKGROUND

Curative treatment of pseudomyxoma peritonei (PMP) is complete cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC).

OBJECTIVE

The aim of this study was to build and evaluate a preoperative imaging score to predict resectability.

PATIENTS AND METHODS

Between 2007 and 2014, all PMP patients in two tertiary reference centers who underwent laparotomy with intent to undergo CRS and HIPEC were included in this study retrospectively. Thickness of tumor burden was measured on preoperative multidetector-row computed tomography (MDCT) by two radiologists blinded to surgical results in five predetermined areas. Patients were divided into two cohorts with the same resectability rate (building and validation). The performances of the scores were assessed using receiver operating characteristic (ROC) curve analyses.

RESULTS

Overall, 126 patients were included, with compete CRS being achieved in 91/126 patients (72.2%). Two cohorts of 63 patients matched by age, sex, burden of disease, resectability rate, and pathological grade were constituted. The MDCT score was the sum of the five measures, and was higher in unresectable disease [median 46.2 mm (range 27.9-74.6) vs. 0.0 mm (range 0.0-14.0), p < 0.001]. Area under the ROC curve was 0.863 (range 0.727-0.968) and 0.801 (range 0.676-0.914) in the building and validation cohorts, respectively. A threshold of 28 mm yielded a sensitivity, specificity, positive predictive and negative predictive value of 94, 81, 81 and 94% in the building cohort, and 80, 68, 59 and 85% in the validation cohort, respectively. Using our score, overall and disease-free survival were increased in the group classified as resectable.

CONCLUSION

A simple preoperative MDCT score measuring tumor burden in the perihepatic region is able to predict resectability and survival of PMP patients.

Postoperative outcomes of laparoscopic vs open cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for treatment of peritoneal surface malignancies

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are considered the only curative treatment for many peritoneal surface malignancies. The purpose of this study was to evaluate feasibility and safety of CRS combined with HIPEC by laparoscopy for patients with limited peritoneal disease and to compare postoperative outcomes with those for an open procedure.

METHODS

Between January 2011 and November 2012, all patients with low-grade pseudomyxoma peritonei (PMP) or multicystic mesothelioma (MM) and limited peritoneal disease (Peritoneal Cancer Index [PCI] less than 10) underwent CRS and HIPEC by a laparoscopic approach. The study cohort was matched with a historical cohort of patients with the same characteristics (completeness of cytoreduction, HIPEC agent, PCI ± 11 and age ± 20 years) treated with CRS and HIPEC by laparotomy.

RESULTS

Eight patients (five low-grade PMP and three MM) treated by a laparoscopic approach were compared to eight patients treated by laparotomy. All patients underwent complete cytoreductive surgery with HIPEC, and no conversion to laparotomy was needed. The median surgical length was 210 min (150-300) vs 240 (210-360), with a median hospital stay of 12 days (9-18) vs 19 (13-33). One patient had a postoperative complication (intraperitoneal haematoma treated by radiological drainage) vs four in the laparotomy group.

CONCLUSION

Laparoscopic CRS combined with HIPEC is feasible and safe for curative treatment of strictly selected patients with peritoneal surface malignancy and might reduce postoperative complications and length of hospital stay.