Comparison of short-term outcome of laparoscopic sleeve gastrectomy and gastric bypass in the treatment of morbid obesity: A prospective randomized controlled multicenter SLEEVEPASS study with 6-month follow-up.

BACKGROUND AND AIMS: The long-term efficacy of laparoscopic Roux-en-Y gastric bypass in the treatment of morbid obesity has already been demonstrated. Laparoscopic sleeve gastrectomy has shown promising short-term results, but the long-term efficacy is still unclear. The aim of this prospective randomized multicenter study is to compare the results of Roux-en-Y gastric bypass and sleeve gastrectomy. MATERIAL AND METHODS: A total of 240 morbidly obese patients were randomized to undergo either Roux-en-Y gastric bypass or sleeve gastrectomy. The primary end point of study was weight loss, and the secondary end points were resolution of comorbidities and morbidity. The short-term results at 6 months were analyzed. RESULTS: The mean excess weight loss at 6 months was 49.2% in the sleeve gastrectomy group and 52.9% in the Roux-en-Y gastric bypass group (p = 0.086). Type 2 diabetes was resolved or improved in 84.3% of patients in the sleeve gastrectomy group and 93.3% in the Roux-en-Y gastric bypass group (p = 0.585). The corresponding results for arterial hypertension were 76.8% and 81.9% (p = 0.707) and for hypercholesterolemia 64.1% and 69.0% (p = 0.485). There was no mortality at 6 months. There was one major complication following sleeve gastrectomy and two after Roux-en-Y gastric bypass (p = 0.531). Eight sleeve gastrectomy patients and 11 Roux-en-Y gastric bypass patients had minor complications (p = 0.403). CONCLUSION: The short-term results of sleeve gastrectomy and Roux-en-Y gastric bypass regarding weight loss, resolution of obesity-related comorbidities and complications were not different at 6 months.

Adoption of single incision laparoscopic cholecystectomy in small-volume hospitals: initial experiences of 51 consecutive procedures.

BACKGROUND AND AIMS: Laparoscopic cholecystectomy (LC) via three or four ports has been the standard operation for gallstone disease. Recently, the development of multichannel port devices has allowed LCs to be performed through a single fascial incision in the umbilicus. Here, we report our experiences of the adoption of the single incision laparoscopic cholecystectomy (SILC) in two small-volume community hospitals. MATERIAL AND METHODS: From January until July 2010, 51 consecutive patients (41 females and 10 males, the mean age 44 (21-75) years, BMI 26 (18-35)) underwent elective SILC for symptomatic gallstone disease in Salo (n = 29) and Loimaa (n = 22) hospitals. RESULTS: Of the 51 operations, 42 (82%) were accomplished without additional troacars. Seven (14%) procedures were converted to multiple-port technique and two (4%) to open cholecystectomy. In 25 (49%) operations, transabdominal retraction sutures through the gallbladder were used to maintain a good view of the triangle of Calot. The mean operative time was 74 (31-155) min. No major intraoperative complications occurred. The mean hospital stay was 0.6 (0-3) days. During a mean follow up of 4 (1-7) months, five (10%) patients had wound infection, and one (2%) had hematoma and prolonged pain in the insertion site of the retraction suture. One (2%) patient was reoperated for continuous pain in umbilical wound without findings at operation but with good results. One (2%) patient had subphrenic abscess seven months postoperatively. CONCLUSIONS: Our initial experiences indicate that SILC can be adopted without major complications in small-volume hospitals but the rate of wound infections seems to increase with the introduction of SIL.

Long-term outcomes after laparoscopic Nissen fundoplication for reflux laryngitis.

BACKGROUND: The surgical treatment of gastroesophageal reflux-induced reflux laryngitis remains controversial. The aim of this study was to determine both long-term objective endoscopic findings and subjective symptomatic outcomes after laparoscopic Nissen fundoplication in patients operated on for reflux laryngitis. METHODS: 40 consecutive patients with pH-proven reflux laryngitis underwent laparoscopic Nissen fundoplication between 1998 and 2002. 68% (n = 27) of these patients underwent an endoscopic evaluation and 90% (n = 36) were available for the subjective long-term outcome (personal interviews). RESULTS: At a median follow-up of 91 months there were no disrupted plications, none of the patients had esophagitis but 3 recurrent hiatal hernias were detected. 61% of the patients reported no or only mild reflux laryngitis symptoms postoperatively and 69% of the patients evaluated their voice quality improved after surgery. 94% of the patients were satisfied with their surgical result. With benefit of hindsight, 11% of the patients would not choose surgical treatment and 42% had reinitiated antireflux medications postoperatively. CONCLUSION: The majority of pH-proven gastroesophageal reflux-induced reflux laryngitis patients attain long-term symptomatic benefit and satisfaction on the surgical outcome, and with proper patient selection laparoscopic Nissen fundoplication provides a feasible long-term treatment option for reflux laryngitis.

Surgeons' experience with laparoscopic fundoplication after the early personal experience: does it have an impact on the outcome?

BACKGROUND: The adverse outcomes of laparoscopic fundoplication are more likely during the initial 20 cases performed by each individual surgeon. This study aimed to evaluate the impact of substantial surgical experience versus experience beyond the learning curve on the early and late objective and subjective results. METHODS: The patients were divided into two groups according to the surgeon. In group 1 (n = 230), all the patients underwent surgery by a surgeon with substantial experience in laparoscopic fundoplication. In group 2 (n = 118), the patients were treated by a total of seven surgeons whose personal experience exceeded the individual learning curve, but was distinctively less than that of the group 1 surgeon. RESULTS: The conversion rate was 2.2% in group 1 and 4.4% in group 2. The median operating time was 65 min in group 1 and 70 min in group 2 (p = 0.0020). The occurrence of immediate complications was 3.5% in group 1 and 7.6% in group 2 (p = 0.0892). At 6 months after surgery, 7.4% of the patients in group 1 and 16.1% of the patients in group 2 reported that dysphagia disturbed their daily lives (p = 0.0115). The late subjective results, including postoperative symptoms and evaluation of the surgical result, were similar in the two groups. CONCLUSIONS: Substantial experience with the procedure is associated with a shorter operating time and somewhat fewer complications, conversions, and early dysphagia episodes. This supports the provision of expert supervision even after the initial learning phase of 20 individual procedures. The patients' long-term subjective symptomatic outcome was similar in the two groups. Substantial experience does not provide better late results than surgical experience beyond the learning curve.

Laparoscopic versus open appendectomy in children: a prospective randomised study.

43 children between the ages of 7 and 15 years with clinical symptoms of acute appendicitis were randomised to an open appendectomy (OA) or a laparoscopic appendectomy (LA). There were 15 acute cases of appendicitis and 5 perforated appendices in the OA group and 17 acute appendicitis, 3 cases of perforated appendices and 3 other diagnoses in the LA group. The operative time was a little shorter in the OA group. There were no differences in hospital stay or the postoperative course of the patients. In the LA group, there were two minor complications, no other complications were seen. When comparing the two surgical methods in the consistent group of patients with non-perforated acute appendicitis no statistical differences were seen in the operative time, hospital stay or in the recovery of the patients between the OA and the LA groups.We conclude that LA has no significant benefit over OA in routine use. In paediatric patients we recommend an open approach for clinically typical acute appendicitis, but there should be no hesitation to choose laparoscopic approach when the clinical diagnosis is unclear.

Role of laparoscopy and laparoscopic ultrasound in staging of pancreatic tumours.

BACKGROUND AND AIMS: Radiological imaging alone is not reliable enough in staging of pancreatic cancer. Not only because of poor sensitivity but also because there is a tendency to overstage tumours. The aim of the study was to compare the efficiency of spiral computed tomography (CT), transabdominal ultrasound (US), laparoscopy (LAP) and laparoscopic ultrasound (LUS) in staging of pancreatic tumours. MATERIAL AND METHODS: In this prospective study 27 patients underwent pancreatic tumour staging with CT, US, LAP and LUS. The reference standard was operative evaluation or in case of disseminated disease laparoscopic assessment. RESULTS AND CONCLUSIONS: Although LAP was hindered by adhesions in 11% of the patients the benefit of LAP staging was evident in detecting peritoneal carcinomatosis. The assessment of the local tumour expansion of a pancreatic carcinoma was difficult for all staging modalities. LUS did not change the decision whether to proceed with laparotomy once. In our experience routine use of laparoscopic staging does not benefit patients with pancreatic tumour but in selected cases it may prevent unnecessary laparotomy.

Laparoscopy in the evaluation of the incarcerated mass in groin hernia.

BACKGROUND: In hernia patients, the preoperative diagnosis of strangulation is difficult. In this prospective study, we investigated the usefulness of an exploratory laparoscopy to evaluate the viability of a viscus incarcerated in a groin hernia. METHODS: Twenty-seven patients with an acute irreducible inguinal mass underwent exploratory laparoscopy. The hernia was reduced, and the viability of the incarcerated viscus was judged laparoscopically on the basis of color, congestion, and contractility. RESULTS: Twenty-four hernias were found. In sixteen patients, the contents of the hernia were viable. In five patients, a necrotic bowel segment was found, and a laparotomy and resection were done. In three patients, no hernias were found. The cause of inguinal pain was spermatic cord hematoma in one patient and inguinal abscess in another; however, the cause of pain in the third patient remained unclear. After laparotomy, one patient developed a fascial rupture that required reoperation. There were no other complications. CONCLUSION: At laparoscopy, the judgment of the viability of the contents of the hernia is similar to that at laparotomy. The early use of laparoscopy can prevent many unnecessary laparotomies.

Immune response after laparoscopic and conventional Nissen fundoplication.

OBJECTIVE: To compare the changes in the immune responses of patients undergoing laparoscopic or conventional Nissen fundoplication. DESIGN: Prospective randomised clinical study. SETTING: University hospital, Finland. SUBJECTS: 20 patients undergoing Nissen fundoplication for symptomatic erosive oesophagitis. INTERVENTION: Laparoscopic Nissen fundoplication (n = 10) or conventional open Nissen fundoplication (n = 10). MAIN OUTCOME MEASURES: Leucocyte and differential counts; percentages of lymphocyte subpopulations (CD3, CD4, CD8, CD16 and CD20 positive lymphocytes); and monocytes (CD 14); phytohemagglutinin, concanavalin A and pokeweed mitogen-induced and unstimulated proliferation of separated lymphocytes; plasma interleukin-6 (IL-6), serum C-reactive protein (CRP), albumin, and cortisol concentrations; and group II phospholipase A2 (PLA2) activity. RESULTS: Laparoscopic fundoplication was associated with less tissue damage (IL-6, and CRP concentrations) than the conventional open operation. However, although there were pronounced changes in immune responses over time, there were no differences between the groups. CONCLUSION: Laparoscopic fundoplication seemed to cause less tissue damage than the conventional open operation, but this difference was not reflected in patients' immune responses.

Laparoscopy for chronic abdominal pain.

The purpose of this study was to evaluate the usefulness of exploratory laparoscopy in patients with chronic abdominal pain. Forty-six patients underwent diagnostic laparoscopy for abdominal pain of unknown origin during 1992-1996. The average duration of the symptoms was 3.5 years. Patients with known malignancy were excluded. Seventy-two percent of the patients had undergone previous abdominal or groin surgery. An organic disease was found in 68% of the laparoscopies. Adhesions were found in 29 patients, inguinal hernia in 2 patients, and abnormal mesenteric lymph nodes in 1 patient. Adhesiolysis was carried out in 24 patients. Eighty-nine percent of patients could be contacted for follow-up. Mean follow-up time was 19 months. Seventy-seven percent of patients who had undergone adhesiolysis considered the result good or beneficial. Sixty percent of all patients reported a beneficial outcome after laparoscopy. No major complications were noted. This retrospective study suggests that laparoscopy is a safe and useful procedure in the diagnosis and treatment of chronic abdominal pain.

Cholecystectomy rates, gallstone prevalence, and handling of bile duct injuries in Scandinavia. A comparative audit.

BACKGROUND: This study was performed to assess three fields of surgical decision making: (a) selecting patients for cholecystectomy, (b) analyzing the value of intraoperative cholangiography (IOC), and (c) surveying the handling of bile duct (BD) injuries. METHODS: Yearly numbers of laparoscopic (LC) and open cholecystectomies (OC) were collected from official health care statistics. Data concerning handling of BD injuries were taken from each country's LC registry. RESULTS: From 1989 to 1995 the median cholecystectomy rate was 6.82 per 10,000 inhabitants in Denmark, 14.20 in Finland, 6.23 in Norway, and 12.17 in Sweden. Deviations from the median yearly rates in each country were -14.8% to +14.4%. Repair of BD injury was performed in the same local hospital where the injury had occurred in 68-98% of cases. CONCLUSIONS: Patient selection differed between countries before the introduction of LC, and these differences have persisted. Few patients with BD injury were treated in referral centers.

Laparoscopic vs conventional Nissen fundoplication. A prospective randomized study.

BACKGROUND: Laparoscopic Nissen fundoplication has gained wide acceptance among surgeons, but the results of the laparoscopic procedure have not been compared to the results of an open fundoplication in a randomized study. METHODS: Some 110 consecutive patients with prolonged symptoms of grade II-IV esophagitis were randomized, 55 to laparoscopic (LAP) and 55 to an open (OPEN) Nissen fundoplication. Postoperative recovery, complications, and outcome at 3- and 12-month follow-up were compared in the two groups. RESULTS: Five LAP operations were converted to open laparotomy due to esophageal perforation (two), technical difficulties (two), and bleeding (one). In the OPEN group (two) patients underwent splenectomy. There was no mortality. The mean hospital stay was 3.2 days in the LAP group and 6.4 in the OPEN group. Dysphagia and gas bloating were the most common complaints 3 months after the operation in both groups. These symptoms had disappeared at the 12-month follow-up examination. All patients in the LAP group and 86% in the OPEN group were satisfied with the result. CONCLUSIONS: Laparoscopic Nissen fundoplication is a safe and feasible procedure. Complications are few and functional results are good if not better than those of conventional open surgery.

Laparoscopic appendectomy-is it worthwhile? A prospective, randomized study in young women.

BACKGROUND: Clinical diagnosis of acute appendicitis is most difficult in fertile-age women. In this patient group up to 50% of open appendectomies are negative for appendicitis. We conducted a randomized study to compare laparoscopic and open appendectomy in young female patients with suspected acute appendicitis. METHODS: Fifty female patients between the ages of 16 and 40 years presenting with acute right lower abdominal pain were randomized, 25 to laparoscopy and 25 to an open appendectomy. Diagnostic accuracy, rate of negative appendectomies, safety, and final outcome were compared in the two groups. RESULTS: Diagnosis was established in 96% of patients in the laparoscopic group and in 72% in the open group. There were 11 (44%) unnecessary appendectomies in the open group, but only one (4%) in the laparoscopic group (p < 0.0005). CONCLUSIONS: In young women with right lower abdominal pain, laparoscopy can give precise diagnosis and reduce the rate of negative appendectomies.

A randomised study of colostomies in low colorectal anastomoses.

OBJECTIVE: To assess the value of covering colostomy for patients undergoing low anterior resection for rectal neoplasms. DESIGN: Prospective randomised study. SETTING: Two university hospitals, Finland. SUBJECTS: 38 patients with air-tight stapled end-to-end anastomoses and complete anastomotic tissue rings were randomly allocated to have a covering colostomy (n = 19) or not. MAIN OUTCOME MEASURES: Postoperative mortality, anastomotic leaks, reoperations for leaks. RESULTS: The clinical leak rate was 24% (9/38) and six patients (16%) had radiological leaks. The total number of leaks (clinical and radiological together) was similar in the two groups, 7/19 compared with 8/19, respectively. There were fewer clinical leaks in the colostomy group (3/19; 16% compared with 6/19; 32%), but the difference was not significant. Reoperations for leaks were necessary more often in patients who did not have a covering colostomy (6/19; 32% compared with 1/19; 5%, p = 0.09). Two patients who did not have a stoma died from the infective complications of their leaks and one died of heart failure in the colostomy group. One patient who had not been given a stoma initially was left with a permanent colostomy after a leak. CONCLUSIONS: Our results suggest that a covering colostomy does not reduce the leak rate after low anterior resection, but prevents most of the severe infective consequences of the leaks.

Laparoscopic cholecystectomy: the Finnish experience.

Between January 1992 and December 1994, 5,742 patients were treated by laparoscopic cholecystectomy in 35 Finnish hospitals. The operation was converted to open laparotomy in 360 (6.3%) patients, the most common causes for conversion being technical difficulties in dissection of the gall bladder (2.8%), bleeding (0.9%) and bile duct injury (0.48%). Intraoperative cholangiography was performed selectively in 18%, and common bile duct stones were found in 10.2% of these cases. Postoperative complications occurred in 208 (3.6%) patients, of whom 65 (1.1%) required reoperation. Twenty-eight (0.48%) of these patients had common bile duct injury. In eighteen patients bilio-digestive Roux-en-Y reconstruction was performed, whereas 10 cases could be handled by endoscopic drainage or suturing and T-tube drainage. Thus, the total number of patients with bile duct injury was 56 (0.96%). The reported hospital mortality was 0.08%. The mean hospital stay and the mean sick leave were three days (range 1-41) and 13 days (range 1-60), respectively. These data demonstrate that laparoscopic cholecystectomy can be performed with acceptable morbidity and mortality rates as a routine method in various different hospitals.

Laparoscopic removal of the acutely inflamed gall bladder.

Seventy-six patients underwent laparoscopic cholecystectomy for acute cholecystitis between June 1991 and April 1995 at our clinic and were retrospectively reviewed. Seventy per cent of the operations could be completed laparoscopically with uneventful recovery. In 15 cases the procedure was converted into an open one. Three patients had to be reoperated, one of them died in myocardial infarction three weeks after the reoperation. The mean operative time was 95 minutes (range 45-180). The average postoperative hospitalisation was 3.1 days. The laparoscopic method is suitable for removal of the acutely inflamed gall bladder. The procedure is more difficult and time-consuming than in elective cases, and conversion are more frequent.

Major haemorrhage associated with a pseudocyst in chronic pancreatitis: a gastro-surgical challenge.

During the fifteen years between 1979 and 1994, ten patients with alcohol-associated chronic pancreatitis were treated for acute haemorrhage from pancreatic pseudocyst. Five of the cases took place in the last two years of the period. All patients were men with a median age of 39.5 years and with a mean of six years of alcohol misuse. Seven patients presented with massive gastrointestinal bleeding, two with intraperitoneal and one with retroperitoneal bleeding. In six patients the pseudocyst had perforated into the stomach or duodenum. Pancreatic resection resulted in permanent haemostasis in those patients it was attempted to perform, whereas ligation of the bleeding site failed in three out of four patients. One angiographic embolisation resulted in a good primary result but after 77 days the patient was operated on for recurrent bleeding. There was no hospital mortality, but altogether five patients were reoperated on for recurrent haemorrhage and six patients had other postoperative complications. Haemorrhage from pancreatic pseudocyst must be suspected in patients with anamnestic alcohol misuse and major gastrointestinal bleeding. Aggressive diagnostic evaluation, experience in pancreatic surgery, and operative strategies consisting of either resection or extracystic ligation are mandatory in the treatment of this acute condition.