Surgery News- July 2008

J U LY 2 0 0 8 • SURGERY NEWS GENERAL SURGERY 13 NOTES Proves Feasible for Cholecystectomy, but Is It Safe? B Y J E F F E VA N S Else vier Global Medical Ne ws P H I L A D E L P H I A — Cholecystectomy performed transvaginally through natural orifice transluminal endoscopic surgery appears to be just as feasible as the standard four-port laparoscopic procedure, according to a small, prospective comparison of the two approaches. In a Brazilian study, investigators compared the results of 16 patients who underwent transvaginal NOTES cholecystectomy with 15 patients who underwent laparoscopic cholecystectomy using a standard technique with four trocars. The NOTES procedure was performed with one 3-mm umbilical trocar for retraction of the gallbladder. Each patient had symptomatic, uncomplicated cholelithiasis. The NOTES patients had a mean age of 37 years and a mean body mass index of 28 kg/m2. Patients who underwent laparoscopy had similar characteristics, Dr. Ricardo Zorrón said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons. The investigators used conventional instruments to cut through the vaginal wall under direct vision. After an endoscope was inserted through the peritoneal cavity and insufflated with CO2, the investigators used endoscopic instruments from two free channels in the endoscope to dissect ducts and arteries, and used endoscopic clips and loops for ligation. They dissected and retrieved the gallbladder specimen with a polypectomy snare because they had found through previous experience that if the specimen were removed with a grasper, it could be lost in the body cavity, said Dr. Zorrón of the surgery department at University Hospital Teresópolis, Rio de Janeiro. Compared with the laparoscopy group, the NOTES patients had significantly lower mean intra-abdominal pressure (8.8 mm Hg vs. 13 mm Hg) and significantly lower end-tidal CO2 pressure (24 mm Hg vs. 42 mm Hg). There were no complications in the laparoscopic group, but one NOTES patient had a vaginal laceration and another NOTES patient complained of vaginal discomfort. Compared with the laparoscopic procedure, NOTES cholecystectomy required a longer mean operative time (125 minutes vs. 97 minutes) and incurred greater mean blood loss (60 mL vs. 25 mL). The patients were given postoperative analgesics only by request. Only 8 of the 16 NOTES patients asked for analgesia, compared with all 15 laparoscopic patients. Dr. Zorrón said that NOTES patients described a short duration of “general visceral pain” in the immediate postoperative period that was unrelated to the 3-mm umbilical trocar port. Although Dr. Zorrón called the NOTES procedure “as safe and feasible as laparoscopy,” the moderator of the session cautioned that “we do need to be careful about the conclusions we can draw about safety. Obviously, when you’re con- cerned about complications such as common [bile] duct injury, you have to have a series larger than 16 to say that it’s safe. It’s certainly feasible—you’ve demonstrated that. The safety, I think, is still an open question.” He added that the safety of transvaginal NOTES cholecystectomy will be questioned until larger prospective studies comparing it with laparoscopy are conducted. But NOTES patients appear to require less postoperative analgesia and may have lower CO2 insufflation and end-tidal pressures than patients undergoing laparoscopy, according to the reactions of audience members during Dr. Zorrón’s presentation. Dr. Zorrón and his colleagues received institutional review board approval to perform transvaginal cholecystectomies after doing experimental transgastric, transvaginal, and transcolonic retroperitoneal NOTES procedures with a flexible endoscope for about 1 year. Dr. Zorrón reported having no conflicts of interest. ■ 1.08% works a number that WE CUT OUR EXPENSE RATIO Recognizing the goal of offering members of the American College of Surgeons and afﬁliated organizations a reasonably priced investment product, the expense ratio of the College’s Surgeons Diversiﬁed Investment Fund (SDIF) has been lowered to just over 1%. The lower expense ratio will have an immediate positive impact on our shareholders, and, over time, will positively impact the performance returns for prospective and current shareholders. The new expense ratio, including ETF costs, is 1.08%. Moving forward, all current and prospective investors will have the ability to invest at a lower cost in a no-load, open-end, diversiﬁed, actively managed mutual fund. SDIF is broadly modeled after the ACS’s endowment utilizing the same investing principles of asset allocation, diversiﬁcation and rebalancing. For more information about SDIF, please contact Tom Kiley at 312/202-5019, tkiley@facs.org, or Savi Pai at 312/202-5056, spai@facs.org. TALK BACK Are you concerned about the safety of NOTES, compared with laparoscopy? Share your thoughts! Send e-mail to surgerynews@facs.org or write to Surgery News, 5635 Fishers Lane, Suite 6000, Rockville, MD 20852 An investor should consider the charges, risks, expenses and investment objective carefully before investing. For more information or for a free copy of the prospectus, please download a copy at www.surgeonsfund.com or call 1-800-208-6070 and a copy will be mailed to you. Read the prospectus carefully before you invest or send money. SDIF is distributed by Ultimus Fund Distributors, LLC, 225 Pictoria Dr., Suite 450, Cincinnati, OH 45246. The phone number is 513-587-3400. http://www.surgeonsfund.com http://www.surgeonsfund.com

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Surgery News- July 2008 Contents The 20/20 Vision: Health Reform Trauma: Airway Anchor News From the College: Jacobson Winner General Surgery: Worth the Trouble

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