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Anderson B.,University of Alberta | Karmali S.,University of Alberta | Karmali S.,Center for the Advancement of Minimally Invasive Surgery
World Journal of Gastroenterology | Year: 2014

Laparoscopic pancreatic surgery is in its infancy despite initial procedures reported two decades ago. Both laparoscopic distal pancreatectomy (LDP) and laparoscopic pancreaticoduodenectomy (LPD) can be performed competently; however when minimally invasive surgical (MIS) approaches are implemented the indication is often benign or low-grade malignant pathologies. Nonetheless, LDP and LPD afford improved perioperative outcomes, similar to those observed when MIS is utilized for other purposes. This includes decreased blood loss, shorter length of hospital stay, reduced post-operative pain, and expedited time to functional recovery. What then is its role for resection of pancreatic adenocarcinoma? The biology of this aggressive cancer and the inherent challenge of pancreatic surgery have slowed MIS progress in this field. In general, the overall quality of evidence is low with a lack of randomized control trials, a preponderance of uncontrolled series, short follow-up intervals, and small sample sizes in the studies available. Available evidence compiles heterogeneous pathologic diagnoses and is limited by case-by-case follow-up, which makes extrapolation of results difficult. Nonetheless, short-term surrogate markers of oncologic success, such as margin status and lymph node harvest, are comparable to open procedures. Unfortunately disease recurrence and long-term survival data are lacking. In this review we explore the evidence available regarding laparoscopic resection of pancreatic adenocarcinoma, a promising approach for future widespread application. © 2014 Baishideng Publishing Group Inc. All rights reserved. Source


Shi X.,Center for the Advancement of Minimally Invasive Surgery | Karmali S.,University of Alberta | Sharma A.M.,University of Alberta | Birch D.W.,Center for the Advancement of Minimally Invasive Surgery
Obesity Surgery | Year: 2010

Laparoscopic sleeve gastrectomy (LSG) is an innovative approach to the surgical management of morbid obesity. Weight loss may be achieved by restrictive and endocrine mechanisms. Early data suggest LSG is efficacious in the management of morbid obesity and may have an important role either as a staged or definitive procedure. A systematic review of the literature analyzing the clinical and operational outcomes of LSG was completed to further define the status of LSG as an emerging treatment modality for morbid obesity. Data from LSG were compared to benchmark clinical data and local operational data from laparoscopic adjustable gastric band (LAGB) and laparoscopic gastric bypass (LRYGB). Fifteen studies (940 patients) were identified following systematic review. The percent excessive weight loss (%EWL) for LSG varied from 33% to 90% and appeared to be sustained up to 3 years. The mortality rate was 0-3.3% and major complications ranged from 0% to 29% (average 12.1%). Operative time ranged from 49 to 143 min (average 100.4 min). Hospital stay varied from 1.9 to 8 days (average 4.4 days). The operational impact of LSG has not been described in the literature. According to data from the Royal Alexandra Hospital, the estimated total cost of LSG was $10,317 CAD as compared to LAGB ($7,536 CAD) and LRYGB ($11,666 CAD). These costs did not include further surgical interventions which may be required for an undefined group of patients after LSG. Early, non-randomized data suggest that LSG is efficacious in the surgical management of morbid obesity. However, it is not clear if weight loss following LSG is sustainable in the long term and therefore it is not possible to determine what percent of patients may require further revisional surgery following LSG. The operational impact of LSG as a staged or definitive procedure is poorly defined and must be analyzed further in order to establish its overall health care costs and operational impact. Although LSG is a promising treatment option for patients with morbid obesity, its role remains undefined and it should be considered an investigational procedure that may require revision in a subset of patients. © 2010 Springer Science + Business Media, LLC. Source


Gill R.S.,University of Alberta | Birch D.W.,Center for the Advancement of Minimally Invasive Surgery | Shi X.,Center for the Advancement of Minimally Invasive Surgery | Sharma A.M.,University of Alberta | Karmali S.,Center for the Advancement of Minimally Invasive Surgery
Surgery for Obesity and Related Diseases | Year: 2010

Background Existing evidence has suggested that bariatric surgery produces sustainable weight loss and remission or cure of type 2 diabetes mellitus (DM). Laparoscopic sleeve gastrectomy (LSG) has garnered considerable interest as a low morbidity bariatric surgical procedure that leads to effective weight loss and control of co-morbid disease. The objective of the present study was to systematically review the effect of LSG on type 2 DM. Methods An electronic data search of MEDLINE, PubMed, Embase, Scopus, Dare, Clinical Evidence, TRIP, Health Technology Database, Conference abstracts, clinical trials, and the Cochrane Library database was completed. The search terms used included LSG, vertical gastrectomy, bariatric surgery, metabolic surgery, and diabetes (DM), type 2 DM, or co-morbidities. All human studies, not limited to those in the English language, that had been reported from 2000 to April 2010 were included. Results After an initial screen of 3621 titles, 289 abstracts were reviewed, and 28 studies met the inclusion criteria and the full report was assessed. One study was excluded after a careful assessment because the investigators had combined LSG with ileal interposition. A total of 27 studies and 673 patients were analyzed. The baseline mean body mass index for the 673 patients was 47.4 kg/m 2 (range 31.053.5). The mean percentage of excess weight loss was 47.3% (range 6.374.6%), with a mean follow-up of 13.1 months (range 336). DM had resolved in 66.2% of the patients, improved in 26.9%, and remained stable in 13.1%. The mean decrease in blood glucose and hemoglobin A1c after sleeve gastrectomy was -88.2 mg/dL and -1.7%, respectively. Conclusion Most patients with type 2 DM experienced resolution or improvement in DM markers after LSG. LSG might play an important role as a metabolic therapy for patients with type 2 DM. © 2010 American Society for Metabolic and Bariatric Surgery. Source


Gill R.S.,University of Alberta | Shi X.,Center for the Advancement of Minimally Invasive Surgery | Al-Adra D.P.,University of Alberta | Birch D.W.,Center for the Advancement of Minimally Invasive Surgery | Karmali S.,Center for the Advancement of Minimally Invasive Surgery
Surgical Laparoscopy, Endoscopy and Percutaneous Techniques | Year: 2012

Purpose: Acute appendicitis remains the common gastrointestinal emergency in adults. Single-incision laparoscopic appendectomy (SILA) has been proposed as the next evolution in minimally invasive surgery. SILA is postulated to reduce postoperative pain and enhance cosmesis, while effectively removing an inflamed appendix. However, the efficacy and benefits of SILA compared with conventional laparoscopic appendectomy (CLA) remain to be determined. Our objectives were to systematically review the literature comparing SILA with CLA for acute appendicitis and perform a pooled analysis on the efficacy of SILA. Methods: Published English-language manuscripts were considered for review inclusion. A comprehensive search of electronic databases (eg, MEDLINE, EMBASE, SCOPUS, BIOSIS Previews, and the Cochrane Library) using broad search terms was completed. All comparative studies were included if they incorporated adult patients undergoing appendectomy for acute appendicitis by SILA. The primary outcomes of interest were operative time and length of hospital stay. Results: From a total of 366 articles, 34 articles were identified. A total of 9 comparative studies were included for pooled analysis. There was no significant difference in operative time, length of stay, pain scores, and conversion or complication rates between SILA and CLA for acute appendicitis. Conclusions: This systematic review and pooled analysis demonstrates that SILA is comparable to CLA for acute appendicitis in adults. However, this review identifies the need for randomized controlled trials to clarify the efficacy of SILA compared with CLA. Copyright © 2012 by Lippincott Williams & Wilkins. Source


Anderson B.,University of Alberta | Switzer N.J.,University of Alberta | Almamar A.,University of Alberta | Shi X.,Center for the Advancement of Minimally Invasive Surgery | And 3 more authors.
Obesity Surgery | Year: 2013

Within the last decade, several authors have proposed laparoscopic sleeve gastrectomy (LSG) as a potential definitive treatment for morbid obesity. While initially perceived as being a solely restrictive procedure, it is now theorized to have additional hormonal effects (primarily the reduction of circulating levels of plasma ghrelin). However, there is limited supporting evidence for this claim. Therefore, the purpose of our study is to conduct a systematic review of the literature to clarify the effects of LSG on modulation of postoperative ghrelin concentrations. A comprehensive literature search for published or unpublished studies of sleeve gastrectomy (SG) and ghrelin written in English prior to February 2013 was performed using Pubmed, EMBASE, the Cochrane database, and Scopus. Gray literature was also searched through Google. Inclusion criteria for searches were: randomized controlled trials, non-randomized clinical trials, retrospective and prospective cohort studies, or case series. Seven studies were deemed suitable for analysis. The mean patient age was 43 ± 8.8 years and female percentage was 74.4 ± 15.3 %. The mean initial BMI was 46.2 ± 7.8 and mean follow-up time was 9.5 ± 15 months. The mean postoperative BMI was 37.3 ± 5.8 over the same follow-up period. Pooled mean preoperative ghrelin levels were 698.4 ± 312.4 pg/ml and postoperative levels were 414.1 ± 226.3 pg/ml (P < 0.0001). Pooled analysis of ghrelin levels at 3, 6, and 12 months showed a significant reduction in circulating levels. Our systematic review shows that LSG has a significant effect on ghrelin levels, leading to considerable reduction in circulation levels following surgery. Further research and standardization is necessary to clearly establish a causative relationship between LSG and reduction of circulating ghrelin levels. © 2013 Springer Science+Business Media New York. Source

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