Predicting postoperative hypocortisolism in patients with non-aldosterone-producing adrenocortical adenoma: a retrospective single-centre study.

BACKGROUND: Limited information exists on postoperative hypocortisolism and hypothalamus-pituitary-adrenal axis recovery in patients with adrenal incidentaloma following unilateral adrenalectomy. We evaluated frequency of postoperative hypocortisolism and predictors for recovery in non-aldosterone-producing adrenocortical adenoma patients after unilateral adrenalectomy. METHODS: A retrospective analysis of 32 adrenal incidentaloma patients originally included in the ITACA trial (NCT04127552) with confirmed non-aldosterone-producing adrenocortical adenoma undergoing unilateral adrenalectomy from September 2019 to April 2023 was conducted. Preoperative assessments included adrenal MRI, anthropometrics, evaluation of comorbidities, adrenal function assessed via ACTH, urinary free cortisol, and 1 mg dexamethasone suppression test. ACTH and serum cortisol or Short Synacthen test were performed within 6 days, 6 weeks, 6 months, and a year after surgery. RESULTS: Six days postoperative, 18.8% of patients had normal adrenal function. Among those with postoperative hypocortisolism, 53.8% recovered by 6 weeks. Patients with earlier adrenal recovery (6 weeks) had lower preoperative 1 mg dexamethasone suppression test (median 1 mg dexamethasone suppression test 76.2 [61.8-111.0] nmol/L vs 260.0 [113.0-288.5] nmol/L, p < 0.001). Univariate analysis showed preoperative 1 mg dexamethasone suppression test negatively related with baseline ACTH levels (r = - 0.376; p = 0.041) and negatively associated with the 6-week baseline (r = - 0.395, p = 0.034) and 30-min cortisol levels during Short Synacthen test (r = - 0.534, p = 0.023). Logistic regression analysis demonstrated preoperative 1 mg dexamethasone suppression test as the only biochemical predictor for 6-week adrenal recovery: ROC curve identified a 1 mg dexamethasone suppression test threshold of 131 nmol/L predicting 6-week recovery with 89.5% sensitivity and 72.7% specificity (AUC 0.87; 95% CI 66.9-98.7, p < 0.001). Other preoperative assessments (tumor size, ACTH levels and anthropometrics) were not associated with postoperative hypothalamus-pituitary-adrenal axis function, but the presence of diabetes was associated with a lower probability of recovery (OR = 24.55, p = 0.036). ACTH levels increased postoperatively in all patients but did not predict hypothalamus-pituitary-adrenal axis recovery. CONCLUSIONS: The preoperative 1 mg dexamethasone suppression test cortisol value and presence of diabetes are the only relevant predictor of hypothalamus-pituitary-adrenal axis recovery in patients with non-aldosterone- producing adrenocortical adenoma undergoing surgery, regardless other clinical and biochemical variables. Notably, pre- and postoperative ACTH levels did not predict hypothalamus-pituitary-adrenal axis recovery. These findings point towards the potential for saving resources by optimizing their allocation during follow-up assessments for patients with non-aldosterone-producing adrenocortical adenoma undergoing unilateral adrenalectomy.

Is transperitoneal laparoscopic adrenalectomy for pheochromocytoma really more challenging? A propensity score-matched analysis.

PURPOSE: Minimally invasive surgery is the gold standard treatment for adrenal masses, but it may be a challenging procedure in the case of pheochromocytoma (PHEO). The aim of the present study is to report the results of transperitoneal laparoscopic adrenalectomy (TLA) in cases of PHEO in comparison to other types of adrenal lesions. METHODS: From 1994 to 2021, 629 patients underwent adrenalectomy. Twenty-two and thirty-five patients, respectively, were excluded because they underwent bilateral and open adrenalectomy, leaving 572 patients for inclusion. Of these, 114 patients had PHEO (Group A), and 458 had other types of lesions (Group B). To adjust for potential baseline confounders, a propensity score matching (PSM) analysis was conducted. RESULTS: After PSM, 114 matched pairs of patients were identified from each group. Statistically significant differences were not observed when comparing the median operative time (85 and 90 min in Groups A and B, respectively, p = 0.627), conversion rate [6 (5.3%) in each group, p = 1.000], transfusion rate [4 (3.5%) and 3 (2.6%) in Groups A and B, respectively, p = 1.000], complication rate [7 (6.1%) and 9 (7.9%) in Groups A and B, respectively, p = 0.796), median postoperative hospital stay (3.9 and 3.6 days in Groups A and B, respectively, p = 0.110), and mortality rate [1 (0.9%) in each group, p = 1.000]. CONCLUSIONS: Based on this analysis, the results of TLA for PHEO are equivalent to those of TLA for other types of adrenal lesions, but the fundamental requirements are multidisciplinary patient management and adequate surgeon experience. Further prospective studies are required to draw definitive conclusions.

A modified sentinel lymph node technique combined with endoluminal loco-regional resection for the treatment of rectal tumours: a 14-year experience.

AIM: After endoluminal loco-regional resection (ELRR) by transanal endoscopic microsurgey (TEM) the N parameter may remain undefined. Nucleotide-guided mesorectal excision (NGME) improves the lymph node harvest. The aim of the present study is to evaluate the long-term oncological results after ELRR with NGME. METHOD: A total of 57 patients were enrolled over the period January 2001 to June 2015. All patients underwent ELRR by TEM. Prior to surgery, 99 m-technetium-marked nanocolloid was injected into the peritumoural submucosa. After removal of the specimen, the residual defect was probed to detect any residual radioactivity and 'hot' mesorectal fat was excised. All patients were included in a 5-year follow-up programme. RESULTS: Significant radioactivity in the residual cavity was found in 28 out of 57 patients (49%). The mean number of lymph nodes harvest in irradiated and nonirradiated patients was 1.66 and 2.76, respectively. After 68.2 months' follow-up overall survival was 91.2%, disease-related mortality 3.5% and disease-free survival 89.5%. Two patients developed pulmonary metastases: one ypT3N0 patient underwent lung lobectomy after chemotherapy and one pT2N0 patient was managed with lung radiotherapy. Both patients are currently alive and disease-free at 48 months' follow-up. Two patients developed local recurrence 1 year after ELRR, both treated with neoadjuvant chemo-radiotherapy and total mesorectal excision. Comparing the present series with previous patients who did not undergo NGME, an increased number of harvested lymph nodes were observed, with a statistically significant difference (P = 0.0085). CONCLUSION: NGME during ELRR improves the lymph node harvest and staging accuracy. The long-term results showed satisfactory local (3.5%) and distant (7%) recurrence rates.

Anal function after endoluminal locoregional resection by transanal endoscopic microsurgery and radiotherapy for rectal cancer.

AIM: In patients with rectal cancer, surgery and chemoradiotherapy may affect anal sphincter function. Few studies have evaluated anorectal function after neoadjuvant chemoradiotherapy (n-CRT) and/or transanal endoscopic microsurgery (TEM). The aim of this study was to evaluate the effects of n-CRT and TEM on anorectal function. METHOD: Thirty-seven patients with rectal cancer underwent anorectal manometry and Wexner scoring for faecal incontinence at baseline, after n-CRT (cT2-T3N0 cancer) and at 4 and 12 months after surgery. Water-perfused manometry measured anal tone at rest and during squeezing, rectal sensitivity and compliance. Twenty-seven and 10 patients, respectively, underwent TEM without (Group A) or with n-CRT (Group B). RESULTS: In Group A, anal resting pressure decreased from 68 ± 23 to 54 ± 26 mmHg at 4 months (P = 0.04) and improved 12 months after surgery (60 ± 30 mmHg). The Wexner score showed a significant increase in gas incontinence (59%), soiling (44%) and urgency (37%) rates at 4 months, followed by clinical improvement at 1 year (41%, 26% and 18%, respectively). In group B, anal resting pressure decreased from 65 ± 23 to 50 ± 18 mmHg at 4 months but remained stable at 12 months (44 ± 11 mmHg, P = 0.02 vs preoperative values - no significant difference compared with evaluation at 4 months). Gas incontinence, soiling and urgency were observed in 50%, 50%, 25% and in 38%, 12% and 12% of cases, respectively, 4 and 12 months after treatment. CONCLUSION: TEM does not significantly affect anal function. Instead, n-CRT does affect anal function but without causing major anal incontinence.

Treatment of rectal cancer by transanal endoscopic microsurgery: review of the literature.

Transanal endoscopic microsurgery (TEM) is a minimally invasive technique that was introduced by Buess in the early 1980s. The TEM procedure employs a dedicated rectoscope with a 3D binocular optic and a set of endoscopic surgical instruments. Since the beginning its advantages have been evident: magnification of the operative field, better access to proximal lesions with lower margin positivity and fragmentation over traditional transanal excision techniques. A non-systematic literature search was performed in the PubMed database to identify all original articles on rectal cancer treated by TEM. Only series including at least ten cases of adenocarcinoma with two years' mean minimum follow-up and published in English were selected. Nowadays more than two decades of scientific data support the use of TEM in the treatment of selected patients with non-advanced rectal cancer. This paper describes the indications and the surgical technique of TEM in the treatment of rectal cancer.

Randomized clinical trial of endoluminal locoregional resection versus laparoscopic total mesorectal excision for T2 rectal cancer after neoadjuvant therapy.

BACKGROUND: In selected patients with early low rectal cancer, locoregional excision combined with neoadjuvant therapy may be an alternative treatment option to total mesorectal excision (TME). METHODS: This prospective randomized trial compared endoluminal locoregional resection (ELRR) by transanal endoscopic microsurgery versus laparoscopic TME in the treatment of patients with small non-advanced low rectal cancer. Patients with rectal cancer staged clinically as cT2 N0 M0, histological grade G1-2, with a tumour less than 3 cm in diameter, within 6 cm of the anal verge, were randomized to ELRR or TME. All patients underwent long-course neoadjuvant chemoradiotherapy. RESULTS: Fifty patients in each group were analysed. Overall tumour downstaging and downsizing rates after neoadjuvant chemoradiotherapy were 51 and 26 per cent respectively, and were similar in both groups. All patients had R0 resection with tumour-free resection margins. At long-term follow-up, local recurrence had developed in four patients (8 per cent) after ELRR and three (6 per cent) after TME. Distant metastases were observed in two patients (4 per cent) in each group. There was no statistically significant difference in disease-free survival (P = 0·686). CONCLUSION: In selected patients, ELRR had similar oncological results to TME. Unique Protocol ID: URBINO-LEZ-1995; registration number: NCT01609504 (http://www.clinicaltrials.gov).

Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES).

BACKGROUND: Laparoscopic cholecystectomy is one of the most common surgical procedures in Europe (and the world) and has become the standard procedure for the management of symptomatic cholelithiasis or acute cholecystitis in patients without specific contraindications. Bile duct injuries (BDI) are rare but serious complications that can occur during a laparoscopic cholecystectomy. Prevention and management of BDI has given rise to a host of publications but very few recommendations, especially in Europe. METHODS: A systematic research of the literature was performed. An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. Statements and recommendations were drafted after a consensus development conference in May 2011, followed by presentation and discussion at the annual congress of the EAES held in Torino in June 2011. Finally, full guidelines were consented and adopted by the expert panel via e-mail and web conference. RESULTS: A total of 1,765 publications were identified through the systematic literature search and additional submission by panellists; 671 publications were selected as potentially relevant. Only 46 publications fulfilled minimal methodological criteria to support Clinical Practice Guidelines recommendations. Because the level of evidence was low for most of the studies, most statements or recommendations had to be based on consensus of opinion among the panel members. A total of 15 statements and recommendations were developed covering the following topics: classification of injuries, epidemiology, prevention, diagnosis, and management of BDI. CONCLUSIONS: Because BDI is a rare event, it is difficult to generate evidence for prevention, diagnosis, or the management of BDI from clinical studies. Nevertheless, the panel has formulated recommendations. Due to the currently limited evidence, a European registry should be considered to collect and analyze more valid data on BDI upon which recommendations can be based.

Long-term results of laparoscopic adrenalectomy for primary aldosteronism.

BACKGROUND: The management of primary aldosteronism is currently achieved by both medical and surgical treatment. Laparoscopy has in recent years unquestionably become the gold standard in adrenal surgery for benign lesions. This study aims to evaluate our clinical results among patients who underwent laparoscopic adrenalectomy (LA) for primary aldosteronism. METHODS: From January 1994 to January 2006, amid LA series, 59 primary aldosteronism patients were treated in our institution. Patients were 33 males and 26 females with mean age 49.3 yr (19-78). The mean body mass index was 25.9 kg/m2 (20.5-33.3). The mean size of lesion was 2.9 cm (1-5.5). Clinical symptoms were as follows: hypertension and symptomatic/asymptomatic hypokalemia (54), hypokalemia (5). RESULTS: Thirty-five left and 24 right LA were performed. On the left side, 22 procedures were carried out by anterior approach, 9 by anterior submesocolic route, and 4 by means of flank approach. All right procedures were completed by the anterior supine approach. The mean operative time was 103.5 min for left and 92.8 min for right adrenalectomy. There was one major complication, a colonic post-operative fistula, regarding a left adrenalectomy case. The mean post-operative hospital stay was 3 days (1-9). The cure rate of hypertension and hypokalemia was similar to the current literature results. CONCLUSIONS: LA is a safe and effective option in the treatment of primary aldosteronism. Appropriate selection of patients, larger adrenal masses and duration of symptoms are determining factors in the success rate of hypertension management.

A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy.

BACKGROUND: This study aimed to compare the oncologic results for local excision via transanal endoscopic microsurgery (TEM) and those for laparoscopic resection (LR) via total mesorectal excision in the treatment of T(2) N(0), G(1-2 )rectal cancer after neoadjuvant therapy with both treatments, incorporating a 5-year minimum follow-up period. METHODS: The study enrolled 70 patients whose malignancy was staged at admission as T(2) N(0), G(1-2 )rectal cancer located within 6 cm of the anal verge with a tumor diameter less than 3 cm. Of these patients, 35 were randomized to TEM and 35 to LR. The patients in both groups previously had undergone high-dose radiotherapy (5,040 cGy in 28 fractions over 5 weeks) combined with continuous infusion of 5-flurouracil (200 mg/m(2)/day). RESULTS: The median follow-up period was 84 months (range, 72-96 months). Two local recurrences (5.7%) were observed after TEM and 1 (2.8%) after LR. Distant metastases (2.8%) occurred in one case each after TEM and LR. The probability of survival for rectal cancer was 94% for TEM and 94% for LR. CONCLUSIONS: The study shows similar results between the two treatments in terms of local recurrences, distant metastases, and probability of survival for rectal cancer.

Thirteen years' experience with laparoscopic transcystic common bile duct exploration for stones. Effectiveness and long-term results.

BACKGROUND: The aim of the present study was to evaluate the effectiveness and long-term results of laparoscopic transcystic common bile duct exploration (TC-CBDE). METHODS: Ductal stones were present in 344 of 3212 patients (10.7%) who underwent laparoscopic cholecystectomy (LC). The procedure was completed laparoscopically in 329 patients (95.6%), with TC-CBDE performed in 191 patients (58.1%) who are the object of this study, or with a transverse choledochotomy in 138 cases (41.9%). RESULTS: Biliary drainage was employed in 71 of 191 cases (37.2%). Major complications occurred in 10 patients (5.1%), including retained stones in 6 (3.1%). Mortality was nil. No patients were lost to follow-up (median: 118.0 months; range: 17.6-168 months). No signs of bile stasis, no recurrent ductal stones and no biliary stricture were observed. At present 182 patients are alive with no biliary symptoms; 9 have died from unrelated causes. CONCLUSIONS: Long-term follow-up after laparoscopic TC-CBDE proved its effectiveness and safety for single-stage management of gallstones and common bile duct stones.

Long-term results of laparoscopic versus open colorectal resections for cancer in 235 patients with a minimum follow-up of 5 years.

BACKGROUND: Laparoscopic resection for cure of colorectal cancer is controversial. More investigations on long-term results are required. This study aimed to compare the long-term outcome with a minimum follow-up of 5 years between laparoscopic or open approach for the treatment of colo-rectal cancer. METHODS: The treatment modality (laparoscopic or open) was related to the patients (pts) choice. The following parameters between the two groups (laparoscopic and open) were assessed: wound recurrences rate, local recurrences rate, incidence of distant metastases and survival probability analysis. RESULTS: We report the long term outcome of 149 pts with colon cancer of which 85 treated by Laparoscopic Surgery (LS) and 64 by Open Surgery (OS) and of 86 patients with rectal cancer of which 52 treated by LS and 34 by OS. In the pts with colonic cancer, mean follow-up was 82.8 months. No Statistically Significant Difference (SSD) was observed in the local recurrences rate (3.5% after LS and 6.2% after OS) and in the incidence of distant metastases (10.5% after LS and 10.9% after OS). Cumulative survival probability in LS was 0.882 as compared to 0.859 after OS. In the pts with rectal cancer, mean follow-up was 78.5 months. No SSD was observed in the local recurrences rate (19.2% after LS and 17.6% after OS) and in the incidence of distant metastases (15.3% after LS and 20.5% after OS). Cumulative survival probability in LS was 0.711 as compared to 0.617 after OS. We report an interesting data about the time of recurrences between LS and OS: the recurrences were delayed after LS, both after colonic (22.6 months vs 6.5) and rectal (25.7 months vs 13.0) resections, respectively. CONCLUSION: We suppose that laparoscopic surgery in the treatment of colo-rectal cancer is quite safe. However, further investigation is needed.

Comparison of Two Questionnaires on Informed Consent in "Marginal" Donor Liver.

The necessity of liver donors has contributed to overcoming the traditional criteria and to propose new ones for the acceptance of livers for transplantation. For this reason expanded or extended criteria donation (ECD) or even overextended criteria for marginal or high-risk organ donors have been developed. Ethical, Legal and Psychological Aspects of Organ Transplantation (ELPAT) and European Liver and Intestine Transplant Association (ELITA) - European Liver Transplantation Registry (ELTR) coordinated the distribution of a previously reported questionnaire that was sent to 53 European liver transplant centers. Criteria were divided based on the response rate. Donor criteria such as steatosis and serum sodium >165 mmol/L, as well as recipient criteria such as previous history of cancer, were not considered contraindications to transplantation in more than 60% of cases. Criteria such as ICU (intensive care unit) stay, body mass index >30, serum bilirubin >3 mg/dL, and HIV infection or critical illness were not considered adequate for transplantation in 30% to 59% of cases. On the other hand, there was no agreement on other extended liver donor and recipient criteria, such as age up to 80 years, serum glutamic oxaloacetic transaminase >90 U/L, serum glutamic pyruvic transaminase >105 U/L, high-risk sex practices, drug users, patients older than 65 years, and patients younger than 65 years, respectively. Criteria such as serum sodium could not be considered ECD criteria. In conclusion, development of more studies and inclusion of more liver transplantation centers are required to confirm these data.

Laparoscopic colorectal resection for endometriosis.

BACKGROUND: The rectosigmoid colon is affected by deep pelvic endometriosis in 3-37% of cases. In the past, treatment of the affected gastrointestinal tract generally required conversion to conventional surgery. We describe our experience with complete laparoscopic management of deep pelvic endometriosis with bowel involvement. METHODS: From March 1995 to March 2003, 29 consecutive patients with endometriosis requiring laparoscopic intervention were evaluated. In seven patients (24%) colorectal involvement was identified prior to the operation. A low anterior resection was performed in four patients (57%) and a sigmoid resection in three (43%). In all cases, colonoscopy showed a normal mucosa. In all cases, treatment consisted of resection of the bowel involved together with the excision of all other implants. Data analysis included age, previous abdominal operations, previous history of endometriosis, operative time, conversion rate, complications, length of stay, and pain relief. RESULTS: There were seven patients with colorectal involvement whose median age was 32.8 years (range, 28-40), with a history of previous abdominal operation in two (28%). Preoperative symptoms were as follow: dysmenorrea in four patients (57%), dyspareunia in four (57%), pelvic pain in seven (100%), rectal bleeding in one (14%), and tenesmus in five (71%). Mean operative time was 190 min (range, 165-230). Length of stay was 8.3 days (range, 7-11). There were no anastomotic leak and no major postoperative complication. One patient had temporary urinary retention. At a median follow-up of 38.7 months (range, 1-84), complete relief of pelvic symptoms was achieved in five patients (71%), and there was improvement in one patient. In one patient complaining of persistent pain, a new colonic implant was diagnosed two years after the surgery requiring reoperation. CONCLUSIONS: The results show that provided that the surgeon is highly skilled in laparoscopy, laparoscopic resection of deep pelvic endometriosis with rectosigmoid involvement is feasible and effective in nearly all patients.

Long-term results after laparoscopic transverse choledochotomy for common bile duct stones.

BACKGROUND: The aim of this study was to evaluate the long-term results of laparoscopic transverse choledochotomy (TC) during laparoscopic cholecystectomy (LC). METHODS: Ductal stones were present in 344 of 3,212 patients (10.7%) who underwent LC. The procedure was completed laparoscopically in 329 cases (95.6%), with a TC in 138 cases (41.9%) (the subjects of this study), and with a transcystic duct approach in 191 cases (58.1%). RESULTS: Biliary drainage was used in 131 of 138 cases (94.9%). There were major complications in eight patients (5.7%), and one patient died (0.7%). Retained stones were seen in 11 cases (8%). None of the patients was lost to follow-up (mean, 72.3 months; range, 11-145). Ductal stones recurred in five patients (3.6%). No signs of bile stasis and no biliary strictures were observed. In all, 121 patients are alive with no biliary symptoms; 16 have died from unrelated causes. CONCLUSION: Long-term follow-up after laparoscopic TC during LC proved its safety and efficacy.

Sub-mesocolic access in laparoscopic left adrenalectomy.

BACKGROUND: This article reports an alternative laparoscopic access to left adrenal gland. METHODS: From January 1994 to August 2004, 209 laparoscopic adrenalectomies were performed in our Department. Indications were Conn adenoma (55 cases), incidentaloma (64), Cushing adenoma (45), pheochromocytoma (32), adreno-genital syndrome (two), mielolipoma (two), and metastatic mass(nine). Of 209, in 12 cases the left adrenalectomy was performed through a submesocolic access (seven pheochromocytoma, two incidentaloma, two Cushing adenoma, one Conn adenoma,). The identification and closure of the adrenal vein with minimal gland manipulation resulted the main benefit of this approach. Moreover, the adrenalectomy was performed with minimal anatomical dissection. RESULTS: No mortality or major complications occurred. During the operation, the blood pressure and cardiac rhythm were significantly more stable, in the group of patients who underwent a left adrenalectomy by the submesocolic approach compared to the anterior or flank lateral transperitoneal group. CONCLUSIONS: Left adrenal lesions, as selected cases of pheochromocytoma, can be safely treated by laparoscopic submesocolic access.

Transanal endoscopic versus total mesorectal laparoscopic resections of T2-N0 low rectal cancers after neoadjuvant treatment: a prospective randomized trial with a 3-years minimum follow-up period.

BACKGROUND: This study aimed to compare the results and the oncologic outcomes of transanal endoscopic microsurgery (TEM) with neoadjuvant radiochemotherapy and laparoscopic resection (LR), also with neoadjuvant radiochemotherapy, in the treatment of T(2)-N(0) low rectal cancer. METHODS: The study enrolled 40 patients with T2-N(0) rectal cancer, randomizing 20 to TEM (arm A) and 20 to LR (arm B). RESULTS: After neoadjuvant radiochemotherapy, tumor downstaging was observed for 13 patients (65%) in arm A (7 pT0 and 6 pT1) and in 11 patients (55%) in arm B (7 pT0 and 4 pT1). More than a 50% reduction of the tumor diameter was observed in four arm A cases and in six arm B cases. At a median follow-up period of 56 months (range, 44-67 months) in both arms, one local failure (5%) occurred after 6 months in arm A and one (5%) after 48 months in arm B. Distant metastases occurred in one arm A patient (5%) after 26 months of follow-up evaluation and in one arm B patient (5%) at 31 months. The probability of local or distant failure was 10% for TEM and 12% for laparoscopic resection, whereas the probability of survival was 95% for TEM and 83% for laparoscopic resection. CONCLUSIONS: The findings show comparative results between the two study arms in terms of probability of failure and survival.

Laparoscopic vs open hemicolectomy for colon cancer.

BACKGROUND: The role of laparoscopic resection in the management of colon cancer is still a subject of debate. In this clinical study, we compared the perioperative results and long-term outcome for two unselected groups of patients undergoing either laparoscopic or open hemicolectomy for colon cancer. METHODS: This prospective nonrandomized study was based on a series of 248 consecutive patients operated on by the same surgical team using the same type of surgical technique for right (RHC) and left (LHC) hemicolectomy, excluding segmental resections; the only difference was the type of access, which was either laparoscopic or open. The choice of type of access was left up to the patient after he or she had read the informed consent form. Operative time, length of stay, complications, and long-term outcome for the two groups were compared. Follow-up time ranged between 12 and 92 months (mean, 42). RESULTS: Between March 1992 and January 2000, 140 patients underwent a laparoscopic hemicolectomy (55 RHC and 86 LHC); at the same time, 107 patients (44 RHC and 63 LHC) were treated via an open approach. There were no conversions to open surgery in the laparoscopic RHC group, but six patients (7%) in the laparoscopic LHC group were converted. The mean operative time for laparoscopic surgery was significantly longer than the time for open surgery (190 vs 140 min for RHC, 240 vs 190 min for LHC,); however, with increasing experience, this time decreased significantly. The mean hospital stay for the patients who underwent laparoscopic procedures was significantly shorter in both the RHC and the LHC groups (9.2 vs 13.2 days for RHC, 10.0 vs 13.2 days for LHC). No statistically significant difference between the two laparoscopic and open groups was observed for the major complication rate (1.9% vs 2.3% for RHC, 7.5% vs 6.3% for LHC). The patient in the laparoscopic RHC group were lost to follow-up. The local recurrence rate was lower after laparoscopic surgery in both arms (5.4% vs 9% for RHC, 1.5% vs 7.5% for LHC), but the differences were not statistically significant. Two port site recurrences were observed in the laparoscopic groups, one after RHC (2.7%) and one after LHC (1.5%). Metachronous metastases rates were similar for the two groups (16.2% vs 15.1% for RHC, 4.4% vs 5.7% for LHC). Cumulative survival probability at 48 months after laparoscopic RHC was 0.865, as compared to 0.818 after open surgery, and 0.971 after laparoscopic LHC, as compared to 0.887 after open surgery. CONCLUSION: These results suggest that laparoscopic hemicolectomy for colonic cancer can be performed safely, with morbidity, mortality, and long-term results comparable to those of open surgery.

Results of laparoscopic vs open resections for colon cancer in patients with a minimum follow-up of 3 years.

BACKGROUND: Laparoscopic resection for colon cancer is still a controversial procedure, the major cause of concern being the lack of long-term results. The aims of this study was to compare long-term outcome in unselected patients undergoing either laparoscopic (LH) or open hemicolectomy (OH) for colonic cancer. METHODS: From March 1992 to August 1997, 197 elective patients were included in this prospective nonrandomized study. The patients were operated on by the same surgical team following the same type of surgical technique for both right and left hemicolectomy, excluding segmental resections; the only difference was the type of access, which was either laparoscopic or open. Each patient gave a written consent, and the allocation to each group (laparoscopic or open) was done on the basis of the patient's choice. The long-term outcomes of the two groups were compared. Follow-up for both groups ranged from 36 to 96 months (mean, 48.9). RESULTS: In all, 149 (74 LH, 75 OH) of 197 patients were studied, excluding palliative resections, conversions to open surgery, perioperative deaths, and deaths not related to cancer. Only two patients in the laparoscopic group were lost to follow-up. The local recurrence after LH was 1.3% vs 2.7% after OH (p = 0.105). Metachronous metastases rates were similar for the two groups (10.8% for LH and 10.7% for OH). Cumulative survival probability (CSP) in the LH group vs the OH group was 0.892 vs 0.867 (p = 0.513), respectively. CSP for Duke's stage B and C in the LH group vs the OH group was 0.910 vs 0.895 (p = 0.506) and 0.800 vs 0.734 (p = 0.544) respectively. Sixty-four LH patients (86.5%) and 65 OH patients (86.7%) are disease-free. CONCLUSION: In our series of patients, no statistically significant difference was found between the two groups in terms of long-term survival rate.

Laparoscopic cholecystectomy and common bile duct exploration are safe for older patients.

BACKGROUND: Laparoscopic common bile duct (CBD) exploration is a well-established treatment option in dedicated centers. However, few data are available on the results in elderly patients. METHODS: The outcome after laparoscopic CBD exploration in elderly patients (age <70 years) was compared with that in a concurrent control group of younger patients (age, <70 years). RESULTS: There were 77 elderly patients in group A and 207 younger patients in group B. American Society of Anesthesiology (ASA) III and IV patients and prior abdominal operations were more frequent in group A (p <0.001). Two patients from each group underwent conversion to open surgery. There was no significant difference frequency of use between the transcystic and choledochotomy approaches, although the latter tended to be more frequent in the group A because of larger stones, (group A 53.4%; group B, 37.6%). Minor and major morbidity (group A, 12%; group B, 13.6%), rate of recurrent stones (group A, 1.3%; group B, 1.9%), and mortality (group A, 1.3%; group B, 0%) were not significantly different between the two groups. The single death in group A involved a patient with acute toxic cholangitis who underwent emergency surgery after multiple failed attempts at endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy performed elsewhere. No CBD stenosis was observed at follow-up assessment. CONCLUSIONS: Elective laparoscopic CBD exploration is safe and effective. It may become the standard of care in both elderly and younger patients.

Anterior, lateral, and posterior retroperitoneal approaches in endoscopic adrenalectomy.

BACKGROUND: Three approaches are currently used for endoscopic adrenalectomy-the lateral (transperitoneal), the posterior (retroperitoneal), and the anterior (transperitoneal). Both the lateral and posterior approaches are performed with the patient placed in the flank decubitus position; in the anterior approach the patient is supine. This study was designed to compare these three types of access in a relatively large series of patients undergoing adrenalectomy at three different institutions. METHODS: Laparoscopic adrenalectomy was performed in 216 patients with a variety of adrenal disorders, including 66 patients with Conn's syndrome, 55 with incidentaloma, 58 with Cushing's syndrome, 33 with pheochromocytoma, two with virilizing adrenogenital syndrome, and two with other lesions. Seventy-two adrenalectomies were performed using the lateral access, 67 via the posterior approach, and 77 via the transperitoneal anterior approach. There were 111 right and 105 left lesions. RESULTS: One patient in the lateral access group and three patients in the posterior group required conversion to open surgery. No conversions were needed in the anterior group. The learning curve was statistically significant only in the anterior access group. In both of the transperitoneal approaches (lateral and anterior), a statistically significant correlation was found between the operative time and the patient's body mass index (BMI). The postoperative hospital stay and time needed to return to normal activities were similar for the three groups. One patient who underwent retroperitoneal adrenalectomy for Cushing' disease died in the postoperative period of Candida sepsis and peritonitis. CONCLUSIONS: The anterior access route requires that the surgeon be skilled in advanced laparoscopic surgery. Both of the transperitoneal approaches (anterior and lateral) are suitable to remove larger adrenal masses. The posterior access may represent a better option in obese patients or in cases with small lesions.