Conclusions: Chitosan-dextran gel appears to significantly reduce the formation of intra-abdominal adhesions without adversely affecting wound healing. This is a noteworthy advancement in the safe prevention of post operative, intra-abdominal adhesions.

Methods: A systematic review was conducted using MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Cochrane Methodology Register and the Database of Abstracts of Reviews of Effects from January 2000 until November 2010. Papers reporting on patients with HCC who were treated with RFA, either in comparison or in combination with other interventions, such as surgery or percutaneous ethanol injection (PEI), were eligible for inclusion.

Outcome data collected were overall survival, disease-free survival and disease recurrence rates. Only randomized controlled trials (RCTs), quasi-RCTs and non-randomized comparative studies with more than 12 months’ follow-up were included.

Results: Forty-three articles, including 12 RCTs, were included in the review. The majority of the articles reported the use of RFA for unresectable HCC, often in combination with other treatments such as PEI, transarterial chemoembolization and/or surgery. Overall and disease-free survival rates continue to improve, despite an increase in the size and numbers of tumours treated. More recently some clinicians have used RFA to treat selected patients with resectable HCC, with good outcomes.

Conclusion: RFA provides a valuable treatment option for patients with unresectable HCC. It improves survival in those previously considered to have advanced disease. As progress continues to be made, RFA is gradually being used to treat resectable HCC.

Methods: an international study group of hepatobiliary surgeons from high-volume centres was convened and a definition of PHH was developed together with a grading of severity considering the impact on patients' clinical management.

Results: the definition of PHH varies strongly within the hepatic surgery literature. PHH is defined as a drop in haemoglobin level>3 g/dl post-operatively compared with the post-operative baseline level and/or any post-operative transfusion of packed red blood cells (PRBC) for a falling haemoglobin and/or the need for radiological intervention (such as embolization) and/or re-laparotomy to stop bleeding. Evidence of intra-abdominal bleeding should be obtained by imaging or blood loss via the abdominal drains if present. Transfusion of up to two units of PRBC is considered as being Grade A PHH. Grade B PHH requires transfusion of more than two units of PRBS, whereas the need for invasive re-intervention such as embolization and/or re-laparotomy defines Grade C PHH.

Conclusion: The proposed definition and grading of severity of PHH enables valid comparisons of results from different studies. It is easily applicable in clinical routine and should be applied in future trials to standardize reporting of complications.

Methods: The ProMIS augmented reality surgical simulator was selected because performance data other than time could be obtained, and the simulator was adapted to create the laparoscopic trainer. Twenty candidates with differing laparoscopic surgical experience tested the model. Three groups were identified, novice, intermediate, and expert, according to previous exposure to the laparoscopic tasks. Candidates were required to identify a tumour ultrasonographically, mark and transect ex vivo liver, and perform two laparoscopic stitches with intracorporeal knots. The ProMIS recorded the performance data, including instrument path lengths and time.

Results: Measurements taken from the ProMIS simulator were analysed for statistical differences between the groups. Expert surgeons showed a statistically significant difference in the time taken to identify the liver lesion and transect the organ. The results also demonstrate that the more difficult tasks such as laparoscopic suturing are completed by the expert surgeons with statistically significant shorter times and path lengths compared to the less experienced surgeons.

Conclusion: The adapted ProMIS augmented reality simulator provided junior surgeons with a realistic learning environment in which to familiarise themselves with the equipment and techniques required for LLR. The model also allows assessment of the performance of individuals over time and within a peer group. Construct validity is proven for the suturing component of the model.

Methods: Livers explanted from 11 pigs were perfused extracorporeally with normothermic autologous blood. Four of them underwent EA after 1 h of reperfusion. Serum samples were obtained up to 6 h after the reperfusion and assayed for IL-1b, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12, IFN-ỵ, TNF-ά.

Results: Significant changes in the control group were observed for IL-6 after the second hour and IL-8 after the first hour compared with baseline levels (P < 0.001). In the EA group, IL-6 and IL-12 were raised after the second hour and IL-8 and IL-10 after the first hour (P < 0.001). The comparison between groups showed significant differences for IL-2, IL-4 (decreased in the EA group compared with controls), IL-10 and TNF-ά (EA group increased compared with controls; P < 0.001).

Conclusions: The ex vivo perfused liver model demonstrated changes in levels of IL-2, IL-4, IL-10 and TNF-ά following hepatic EA.

Methods: A PubMed search was performed using the keyword ‘‘LapSim,’’ with further papers identified from the citations of original search articles.

Results: Use of the LapSim to develop surgical skills has yielded overall results, although inconsistencies exist. Data regarding the transferability of learned skills to the operative environment are encouraging as is the validation work, particularly the use of a combination of measured parameters to produce an overall comparative performance score.

Conclusion: Although the LapSim currently does not have any proven significant advantages over video trainers in terms of basic skills instruction and although the results of validation studies are variable, the potential for such technology to have a huge impact on surgical training is apparent. Work to determine standardized learning curves and proficiency criteria for different levels of trainees is incomplete. Moreover, defining which performance parameters measured by the LapSim accurately determine laparoscopic skill is complex. Further technological advances will undoubtedly improve the efficacy of the LapSim, and the results of large multicenter trials are anticipated.

Background: Esophageal motility disorders and dilatation after LAGB have been reported. However, only a few studies present long-term follow-up data.

Methods: Between June 1998 and June 2009, all patients with implantation of a LAGB were enrolled in a prospective clinical trial including a yearly barium swallow. Esophageal motility disorders were recorded and classified over the period. An esophageal diameter of 35 mm or greater was considered dilated.

Results: Laparoscopic adjustable gastric banding was performed in 167 patients (120 females and 47males) with amean age of 40.1±5.2 years. Overall patient follow-up was 94%. Esophageal dysmotility disorders were found in 108 patients (68.8% of patients followed). Esophageal dilatation occurred in 40 patients (25.5%)with amean esophageal diameter of 47.3±6.9mm(35.0–94.6) after a follow-up of 73.8 ± 6.8 months (36–120) compared with 26.2 ± 2.8 mm (18.3–34.2) in patients without dilatation (diameter of <35mm) (P < 0.01). Thirty-four patients suffered from stage III dilatation (band deflation necessary) and 6 from stage IV (major achalasia-like dilatation, band removal mandatory). In 29 patients, upper endoscopy was carried out because of heartburn/dysphagia. In 18 patients, the endoscopy was normal; 9 patients suffered from gastroesophageal reflux disease, 1 from a stenosis, and 1 from a hiatus hernia.

Conclusions: This study demonstrates that esophageal motility disorders after LAGB are frequent, poorly apreciated complications. Despite adequate excess weight loss, LAGB should probably not be considered the procedure of first choice and should be performed only in selected cases until reliable criteria for patients with a low risk for the procedures long-term complications are developed.

Registration ID: ClinicalTrials.gov ID: NCT01234428

Methods: A systematic search strategy from 1997 until December 2006 was used to retrieve relevant studies. Inclusion of articles was established through application of a predetermined protocol, independent assessment by two reviewers and a final consensus decision.

Results: A total of 55 studies were identified of which 27 studies, representing 68 882 patients, met the inclusion criteria. Twenty-one of these solely examined hospital volume, 5 examined both hospital and surgeon volume, and 1 examined surgeon volume in isolation. All but one of the studies were retrospective in nature, and because of the heterogeneity of the literature, no meta-analysis could be performed. Of the studies exploring the relationship between hospital volume and mortality, 20 reported a statistically significant benefit to large volume centres. Five of six included studies showed significant evidence for a reduced mortality risk with greater surgeon volume.

Conclusions: Based on the evidence from these retrospective studies, oesophagectomy performed in high volume centres would appear to be associated with better outcome compared with low volume centres.

in response to Cunningham, Odonnell & Starker. Surgical outcomes following pancreatic resections at a low-volume community hospital. Do all patients need top be sent to a regional center? Am J Surg, 2009; 198: 227-30.

Methods: A PubMed literature search was undertaken using the keywords preoperative, biliary, and drainage. The primary end points were the effect of PBD on mortality, morbidity, and bile duct cultures. The secondary outcome measures were PBD and pancreatic leakage, intra-abdominal abscess, sepsis/infectious complications, wound infection, hemorrhage and bile leak rates. The impact of bile cultures positive for bacteria and the outcomes after surgery were also examined.

Results: Preoperative biliary drainage significantly increases woulnd and bile infection rates on meta-analysis (P<0.0005) using a fixed and random effect model but no adverse effect on mortality and morbidity was found. A bile culture positive for bacteria negatively impacts on both mortality and morbidity (P<0.005) after surgery.

Conclusions: Preoperative biliary drainage significantly increases the rates of bile culture positive for bacteria and the probability of wound infection. Bile cultures positive for bacteria adversely impact mortaility and morbidity after surgery in jaudiced patients. Although no evidence has been found by this reviewe that PBD directly increases mortality and morbidity, it is possible that in certain patients, PBD may deleteriously affect outcome by bacterial contamination of the bile.

Methods. A systematic search strategy was used to identify relevant studies. Studies were included based on the application of a predetermined protocol, an independent assessment by 2 reviewers, and a consensus decision. Nineteen articles formed the evidence base for this review.

Results. Little high-level evidence was available. The results of studies reporting on 5 different devices/ procedures were identified: the use of cut-resistant gloves/liners decreased the number of glove perforations in comparison with double latex gloves alone but lessened the wearer’s dexterity and tactile sensation; the benefit derived from the use of the hands-free passing technique seemed equivocal; ‘‘sharpless surgery’’ was found to be feasible; a single-handed blade remover prevented at least as many injuries as a safety scalpel; and some shoe materials provided superior foot protection.

Conclusion. The lack of available evidence highlights the need for the generation of a methodologically rigorous, clinically relevant, and statistically valid body of primary research in this area to support appropriate and effective safety interventions.