Alfred Cuschieri - Academia.edu (original) (raw)

Uploads

Papers by Alfred Cuschieri

Surgical Endoscopy and Other Interventional Techniques, Oct 11, 2004

B a c k g r o u n d. Surgical needles are usually held using dedicated grasping instruments. When... more B a c k g r o u n d. Surgical needles are usually held using dedicated grasping instruments. When the tissue to be penetrated is resilient, or the grasping force is low, the needle can swivel, causing it to deviate from the intended path, resulting in suboptimal tissue approximation. Needle swivel is particularly prevalent when needles are not held transversely in the jaws, but it is difficult to maintain a transverse grasp during surgery. An improved swivel-resistant grasper design is proposed. Methoe&." Conventional and swivel-resistant graspers were tested to quantify the benefits of the swivel-resistant design. Needles secured in the grasper were repeatedly distracted until swiveling occurred. The torque required to swivel the needles was statistically analyzed. Results." The swivel-resistant grasper offers greatly improved resistance to swivel (p = 0.01) when the needle is not held transversely. Conclusions." The four-point contact afforded by the modified needle graspers imparts improved needle retention and resistance to swivel.

British Journal of Cancer, Feb 26, 2002

Although tumour stage and nodal status are established prognostic factors for resectable gastric ... more Although tumour stage and nodal status are established prognostic factors for resectable gastric cancer, the relative importance of other pathological characteristics remains unclear. This study reports univariate and multivariate analyses of the prognostic value of various pathological and staging factors based on 324 patients entered into the MRC randomised surgical trial for gastric cancer. In the univariate analysis tumour stage, nodal status, UICC clinical stage, number of involved nodes, WHO predominant type, mixed Lauren type, Ming type, tumour differentiation, lymphocytic and tumour stromal eosinophilic infiltration were all found to have a significant impact on survival (logrank test, 5% level). In the multivariate analysis, UICC clinical stage and eosinophilic infiltration were found to have a significant influence. Risk of death increased for UICC stage II and III patients (Hazard Ratio for stage II compared to stage I=2.0, 95% Confidence Interval (CI) 1.4-2.9; Hazard Ratio for stage III compared to stage I=3.5, 95% CI 2.5-4.8). Patients with numerous eosinophils had a lower risk of death than those with none (Hazard Ratio=0.5, 95% CI 0.3-0.8). This association between survival and eosinophilic infiltration merits further study.

Surgical Endoscopy and Other Interventional Techniques, Oct 11, 2004

Background." Data on man machine interfaces in the operation theater are essential to the improve... more Background." Data on man machine interfaces in the operation theater are essential to the improvement of surgical efficiency. This study analyzed the activity of the operating team during laparoscopic cholecystectomy by surgical trainees. Methods. The endoscopic image and overview of the operating room were recorded during 20 laparoscopic cholecystectomies performed by specialist residents. Time-motion analysis of the recorded tapes was performed. Results: The median (interquartile range [IQR]) for theater time was 134 ~_ rain (IQR, 52 min). The components of operative time for the surgeon were 26% for insertion of access ports and wound closure, 57% for intracorporeal endoscopic work, and 17% for instrument change. Only 52% of the scrub nurse time was related to the operation. Machine and video setup, adjustment of ancillary equipment together, and delivery of instruments and items requested by the surgeon and scrub nurse accounted for 13% of the circulating nurse time. Conclusions: With the current nonergonomic theater design and structure, a significant proportion of theater time during routine uncomplicated laparoscopic surgery is used for nonoperative functions. The study highlights the need for improved ergonomic design, integrated bus operating systems under the control of the surgeon, and multifunctional laparoscopic instruments.

Surgical Endoscopy and Other Interventional Techniques, Feb 17, 2005

Choledochoduodenostomy is a well-established procedure and is indicated in patients with multiple... more Choledochoduodenostomy is a well-established procedure and is indicated in patients with multiple ductal calculi and dilated common bile duct (‡2.0 cm) because these patients require drainage for good long-term results without recurrence of jaundice or cholangitis [2, 9]. The technique most commonly used is that of a side-to-side hand-sutured anastomosis between the supraduodenal common bile duct and the duodenum. The merit of this technique is its simplicity, although it is prone to duodenobiliary reflux and to occasional symptomatic inspissation with food debris causing cholangitis (sump syndrome). It is the technique that has been adopted by most centers for laparoscopic choledochoduodelaostomy [3-8].The alternative operation, transection choledochoduodenostomy, excludes the distal (transpancreatic) segment of the bile duct from the end-to-side anastomosis of the transected common bile duct with the second part of the duodenum. The longterm results of this procedure are excellent [1], and for this reason we have used it for laparoscopic drainage of the common bile duct in six elderly patients (four females and two males; age range, 61-72 years) with multiple occluding ductal calculi and grossly dilated bile duct. Three of these patients (including the one shown in the multimedia video) were admitted acutely with bacterial cholangitis and required emergency insertion of pigtail stent to overcome the acute septic illness.There were no conversions. The first operation lasted 4 h but the operating times in the last two patients were 2.0 and 2.5 h. The results have been excellent, with no deaths and a low postoperative morbidity (chest infection in one patient) and median postoperative hospital stay of 5 days.

Surgical Endoscopy and Other Interventional Techniques, Feb 21, 2015

Laparoscopic gastrectomy was first used for early gastric cancer. With suitable modifications, th... more Laparoscopic gastrectomy was first used for early gastric cancer. With suitable modifications, the technique has been extended to more advanced tumors. Techniques have been developed for appropriate lymphadenectomies. This chapter reviews the evidence that supports use of the laparoscopic approach in these cases, and describes the author’s approach to hand-assisted laparoscopic resection of gastric cancer.

Nano Letters, Apr 3, 2017

One of the mechanisms responsible for cancer-induced increased blood supply in malignant neoplasm... more One of the mechanisms responsible for cancer-induced increased blood supply in malignant neoplasms is the overexpression of vascular endothelial growth factor (VEGF). Several antibodies for VEGF targeting have been produced for both imaging and therapy.

Surgical Endoscopy and Other Interventional Techniques, Sep 6, 2013

Background: This study hypothesized that patients in whom bradycardia and hypotension develop wit... more Background: This study hypothesized that patients in whom bradycardia and hypotension develop with induction of positive-pressure capnoperitoneum have an underlying autonomic cardiovascular dysfunction. Methods: A case-control study was conducted to examine the baseline autonomic function of patients in whom bradycardia and hypotension develop with induction of positive-pressure capnoperitoneum. The control group consisted of patients who maintained normal cardiac rhythm and blood pressure during the same procedure. Two groups of tests were performed: bedside stress tests of cardiovascular autonomic function (response graded 1 (normal) to 4 (severely abnormal) and heart rate variability analysis (spectral and time domain components). Results: The study evaluated 6 patients in the bradycardia group and 10 in the control group. The group in whom bradycardia had developed scored significantly worse on the bedside stress tests than the control group (for grades I to IV: v 2 = 6.5, p = 0.022; for trend: v 2 = 5.6, p = 0.018). In contrast, both groups had similar baseline autonomic tone, as measured by heart rate variability. Conclusions: Patients in whom bradycardia and hypotension develop with induction of positive-pressure capnoperitoneum have cardiovascular autonomic dysfunction, which is identifiable by bedside stress tests of autonomic function.

Surgical Endoscopy and Other Interventional Techniques, Mar 1, 2007

Surgical Innovation, Sep 1, 1998

ABSTRACT

Annals of Surgery, Jun 1, 2014

Surgical Innovation, Sep 1, 1998

The laparoscopic infracolic approach has been used to treat eight patients with large pseudocysts... more The laparoscopic infracolic approach has been used to treat eight patients with large pseudocysts. Early uncomplicated resolution was observed in seven and delayed resolution (at 3 months) in one. The median hospital stay was 6 days (range 5 to 15). The same approach was used to perform necrosectomy and postoperative lavage of the infected lesser sac in three patients with infected pancreatic necrosis. Two of these patients recovered without further treatment; however, the third patient required further open necrosectomy but survived after a prolonged illness complicated by pancreatic ascitis. The infracolic laparoscopic approach seems to be a useful technique for internal drainage of pancreatic pseudocysts. Its use for necrosectomy, drainage, and irrigation of the lesser sac merits further evaluation.

Surgical Endoscopy and Other Interventional Techniques, Oct 11, 2004

B a c k g r o u n d. Surgical needles are usually held using dedicated grasping instruments. When... more B a c k g r o u n d. Surgical needles are usually held using dedicated grasping instruments. When the tissue to be penetrated is resilient, or the grasping force is low, the needle can swivel, causing it to deviate from the intended path, resulting in suboptimal tissue approximation. Needle swivel is particularly prevalent when needles are not held transversely in the jaws, but it is difficult to maintain a transverse grasp during surgery. An improved swivel-resistant grasper design is proposed. Methoe&." Conventional and swivel-resistant graspers were tested to quantify the benefits of the swivel-resistant design. Needles secured in the grasper were repeatedly distracted until swiveling occurred. The torque required to swivel the needles was statistically analyzed. Results." The swivel-resistant grasper offers greatly improved resistance to swivel (p = 0.01) when the needle is not held transversely. Conclusions." The four-point contact afforded by the modified needle graspers imparts improved needle retention and resistance to swivel.

British Journal of Cancer, Feb 26, 2002

Although tumour stage and nodal status are established prognostic factors for resectable gastric ... more Although tumour stage and nodal status are established prognostic factors for resectable gastric cancer, the relative importance of other pathological characteristics remains unclear. This study reports univariate and multivariate analyses of the prognostic value of various pathological and staging factors based on 324 patients entered into the MRC randomised surgical trial for gastric cancer. In the univariate analysis tumour stage, nodal status, UICC clinical stage, number of involved nodes, WHO predominant type, mixed Lauren type, Ming type, tumour differentiation, lymphocytic and tumour stromal eosinophilic infiltration were all found to have a significant impact on survival (logrank test, 5% level). In the multivariate analysis, UICC clinical stage and eosinophilic infiltration were found to have a significant influence. Risk of death increased for UICC stage II and III patients (Hazard Ratio for stage II compared to stage I=2.0, 95% Confidence Interval (CI) 1.4-2.9; Hazard Ratio for stage III compared to stage I=3.5, 95% CI 2.5-4.8). Patients with numerous eosinophils had a lower risk of death than those with none (Hazard Ratio=0.5, 95% CI 0.3-0.8). This association between survival and eosinophilic infiltration merits further study.

Surgical Endoscopy and Other Interventional Techniques, Oct 11, 2004

Background." Data on man machine interfaces in the operation theater are essential to the improve... more Background." Data on man machine interfaces in the operation theater are essential to the improvement of surgical efficiency. This study analyzed the activity of the operating team during laparoscopic cholecystectomy by surgical trainees. Methods. The endoscopic image and overview of the operating room were recorded during 20 laparoscopic cholecystectomies performed by specialist residents. Time-motion analysis of the recorded tapes was performed. Results: The median (interquartile range [IQR]) for theater time was 134 ~_ rain (IQR, 52 min). The components of operative time for the surgeon were 26% for insertion of access ports and wound closure, 57% for intracorporeal endoscopic work, and 17% for instrument change. Only 52% of the scrub nurse time was related to the operation. Machine and video setup, adjustment of ancillary equipment together, and delivery of instruments and items requested by the surgeon and scrub nurse accounted for 13% of the circulating nurse time. Conclusions: With the current nonergonomic theater design and structure, a significant proportion of theater time during routine uncomplicated laparoscopic surgery is used for nonoperative functions. The study highlights the need for improved ergonomic design, integrated bus operating systems under the control of the surgeon, and multifunctional laparoscopic instruments.

Surgical Endoscopy and Other Interventional Techniques, Feb 17, 2005

Choledochoduodenostomy is a well-established procedure and is indicated in patients with multiple... more Choledochoduodenostomy is a well-established procedure and is indicated in patients with multiple ductal calculi and dilated common bile duct (‡2.0 cm) because these patients require drainage for good long-term results without recurrence of jaundice or cholangitis [2, 9]. The technique most commonly used is that of a side-to-side hand-sutured anastomosis between the supraduodenal common bile duct and the duodenum. The merit of this technique is its simplicity, although it is prone to duodenobiliary reflux and to occasional symptomatic inspissation with food debris causing cholangitis (sump syndrome). It is the technique that has been adopted by most centers for laparoscopic choledochoduodelaostomy [3-8].The alternative operation, transection choledochoduodenostomy, excludes the distal (transpancreatic) segment of the bile duct from the end-to-side anastomosis of the transected common bile duct with the second part of the duodenum. The longterm results of this procedure are excellent [1], and for this reason we have used it for laparoscopic drainage of the common bile duct in six elderly patients (four females and two males; age range, 61-72 years) with multiple occluding ductal calculi and grossly dilated bile duct. Three of these patients (including the one shown in the multimedia video) were admitted acutely with bacterial cholangitis and required emergency insertion of pigtail stent to overcome the acute septic illness.There were no conversions. The first operation lasted 4 h but the operating times in the last two patients were 2.0 and 2.5 h. The results have been excellent, with no deaths and a low postoperative morbidity (chest infection in one patient) and median postoperative hospital stay of 5 days.

Surgical Endoscopy and Other Interventional Techniques, Feb 21, 2015

Laparoscopic gastrectomy was first used for early gastric cancer. With suitable modifications, th... more Laparoscopic gastrectomy was first used for early gastric cancer. With suitable modifications, the technique has been extended to more advanced tumors. Techniques have been developed for appropriate lymphadenectomies. This chapter reviews the evidence that supports use of the laparoscopic approach in these cases, and describes the author’s approach to hand-assisted laparoscopic resection of gastric cancer.

Nano Letters, Apr 3, 2017

One of the mechanisms responsible for cancer-induced increased blood supply in malignant neoplasm... more One of the mechanisms responsible for cancer-induced increased blood supply in malignant neoplasms is the overexpression of vascular endothelial growth factor (VEGF). Several antibodies for VEGF targeting have been produced for both imaging and therapy.

Surgical Endoscopy and Other Interventional Techniques, Sep 6, 2013

Background: This study hypothesized that patients in whom bradycardia and hypotension develop wit... more Background: This study hypothesized that patients in whom bradycardia and hypotension develop with induction of positive-pressure capnoperitoneum have an underlying autonomic cardiovascular dysfunction. Methods: A case-control study was conducted to examine the baseline autonomic function of patients in whom bradycardia and hypotension develop with induction of positive-pressure capnoperitoneum. The control group consisted of patients who maintained normal cardiac rhythm and blood pressure during the same procedure. Two groups of tests were performed: bedside stress tests of cardiovascular autonomic function (response graded 1 (normal) to 4 (severely abnormal) and heart rate variability analysis (spectral and time domain components). Results: The study evaluated 6 patients in the bradycardia group and 10 in the control group. The group in whom bradycardia had developed scored significantly worse on the bedside stress tests than the control group (for grades I to IV: v 2 = 6.5, p = 0.022; for trend: v 2 = 5.6, p = 0.018). In contrast, both groups had similar baseline autonomic tone, as measured by heart rate variability. Conclusions: Patients in whom bradycardia and hypotension develop with induction of positive-pressure capnoperitoneum have cardiovascular autonomic dysfunction, which is identifiable by bedside stress tests of autonomic function.

Surgical Endoscopy and Other Interventional Techniques, Mar 1, 2007

Surgical Innovation, Sep 1, 1998

ABSTRACT

Annals of Surgery, Jun 1, 2014

Surgical Innovation, Sep 1, 1998

The laparoscopic infracolic approach has been used to treat eight patients with large pseudocysts... more The laparoscopic infracolic approach has been used to treat eight patients with large pseudocysts. Early uncomplicated resolution was observed in seven and delayed resolution (at 3 months) in one. The median hospital stay was 6 days (range 5 to 15). The same approach was used to perform necrosectomy and postoperative lavage of the infected lesser sac in three patients with infected pancreatic necrosis. Two of these patients recovered without further treatment; however, the third patient required further open necrosectomy but survived after a prolonged illness complicated by pancreatic ascitis. The infracolic laparoscopic approach seems to be a useful technique for internal drainage of pancreatic pseudocysts. Its use for necrosectomy, drainage, and irrigation of the lesser sac merits further evaluation.