Prospective, blinded comparison of laparoscopic ultrasonography vs. contrast-enhanced computerized tomography for liver assessment in patients undergoing colorectal carcinoma surgery.

PURPOSE: To prospectively and blindly compare intraoperative laparoscopic ultrasonography to preoperative contrast-enhanced computerized tomography in detecting liver lesions in colorectal cancer patients. Additionally, we compared conventional (open) intraoperative ultrasonography with bimanual liver palpation to contrast-enhanced computerized tomography in a subset of patients. METHODS: From December 1995 to March 1998, 77 consecutive patients underwent curative (n = 63) or palliative (n = 14) resections for colorectal cancer. All patients undergoing curative resections were randomized to either laparoscopic (n = 34) or conventional (n = 29) surgery after informed consent. All patients underwent contrast-enhanced computerized tomography, diagnostic laparoscopy, and laparoscopic ultrasonography before resection. In those patients who had conventional procedures, intraoperative ultrasonography with bimanual liver palpation was also done. All laparoscopic ultrasonography and intraoperative ultrasonography evaluations were performed by one of two radiologists who were blinded to the CT results. All hepatic segments were scanned using a standardized method. The yield of each modality was calculated using the number of lesions identified by each imaging modality divided by the total number of lesions identified. RESULTS: In 43 of the 77 patients, both the laparoscopic ultrasonography and CT scan were negative for any liver lesions. In 34 patients, a total of 130 lesions were detected by laparoscopic ultrasonography, CT, or both. When compared with laparoscopic ultrasonography, intraoperative ultrasonography with bimanual liver palpation identified one additional metastatic lesion and no additional benign lesions. laparoscopic ultrasonography identified two patients with mets who had negative preoperative contrast-enhanced computerized tomography. CONCLUSIONS: Laparoscopic ultrasonography of the liver at the time of primary resection of colorectal cancer yields more lesions than preoperative contrast-enhanced computerized tomography and should be considered for routine use during laparoscopic oncologic colorectal surgery.

Laparoscopic management of colorectal endometriosis.

BACKGROUND: In the past, intestinal endometriosis diagnosed at laparoscopy has generally required conversion to conventional surgery. The purpose of this study was to describe the laparoscopic management of colorectal endometriosis at a tertiary referral center. METHODS: From November 1994 to March 1998, 509 consecutive patients with endometriosis requiring laparoscopic intervention were prospectively evaluated. Those with colorectal involvement were analyzed for stage of disease, procedure, operative time, conversion rate, length of hospitalization, and complications. RESULTS: In 30 of the 509 patients (5.9%), colorectal involvement was identified. Twenty-eight of these 30 had stage IV disease. Intestinal involvement was suspected preoperatively in 13 of 30. Twelve required superficial excision of colon or rectal endometriomas. Protectomy/proctosigmoidectomy was done in seven cases, and rectal disc excision was performed in five patients. Four cases required conversion due to the overall severity of the pelvic disease. For those who did (n = 12) and did not (n = 18) require full-thickness excisions/resections, the median operative time was 180 min (range, 90-390) and 110 min (range, 45-355), respectively; the median length of hospitalization was 4 days (range, 3-7) and 1 day (range, 0-4), respectively. A major complication occurred in one patient (colovaginal fistula). At a median follow-up of 10 months (range 1-32), 28 patients were improved, and 24 of these had near or total resolution of preoperative symptoms. CONCLUSIONS: Extensive pelvic endometriosis generally requires rectal disc excision or bowel resection. In our experience, laparoscopic treatment of colorectal endometriosis, even in advanced stages, is safe, feasible, and effective in nearly all patients.

Successful treatment of rectal prolapse by laparoscopic suture rectopexy.

BACKGROUND: A wide variety of procedures are used for management of rectal prolapse. The purpose of this study was to evaluate the results of laparoscopic suture rectopexy in the treatment of this condition. METHODS: From May 1991 to May 1998, 32 consecutive patients were treated by laparoscopic suture rectopexy. In four of them, an additional sigmoid colectomy was performed for refractory constipation or redundant large bowels. The clinical data were analyzed. RESULTS: Of our 32 patients, 27 were female and five were male. The median age was 51.5 years (range, 20-87). The median operative time was 150 min (range, 90-300), and the median hospital stay was 5 days (range, 2-20). There were no operative mortalities. Three postoperative complications required reoperations for bowel obstructions. At a median follow-up of 33 months (range 3-78), there were two complete recurrences. CONCLUSIONS: Our experience indicates that laparoscopic suture rectopexy, with and without sigmoid colectomy, is safe, feasible, and effective for the treatment of rectal prolapse.

Role of laparoscopy in the staging of gastrointestinal cancer.

Accurate staging plays a primary role in determining the appropriate treatment of gastrointestinal malignancies. Recently, laparoscopy has emerged as a staging modality that is more sensitive and specific in staging most gastrointestinal cancers than preoperative imaging modalities. The addition of laparoscopic ultrasonographic techniques has achieved even greater staging accuracy. Consequently, patients with disease that is amenable to resection are better identified, and others with locally advanced disease are spared unnecessary laparotomies. Since laparoscopic techniques may be associated with low morbidity and a rapid recovery, palliative procedures are being developed for patients with advanced gastrointestinal malignancies. This reviews summarizes the current status of laparoscopic staging of gastrointestinal malignancies and compares this technique to preoperative imaging modalities. Also discussed are promising staging technologies and therapeutic procedures that may soon play an important role in the management of gastrointestinal cancer patients.

Blunt intestinal injury in children: the role of the physical examination.

PURPOSE: Although blunt intestinal injury in children is uncommon, prompt recognition and treatment is imperative. Because the best method for diagnosis remains undetermined, the authors reviewed their experience with this injury in children to determine the most reliable diagnostic method and to identify factors associated with treatment delays. METHODS: From January 1989 through December 1995, 2,284 children were admitted to the level I trauma center after sustaining blunt abdominal trauma. Of these, 32 (1.4%) had intestinal injury confirmed during laparotomy. Each case was reviewed with particular attention to the initial physical examination, abdominal computed tomography (CT) scan, laparotomy observations, complications, and the hospital at which the child was initially treated, if applicable. Fisher's Exact test and Wilcoxon's rank sum test were used for statistical analyses, with P < .05 considered significant. RESULTS: Twenty-five patients (78%) had major intestinal injuries that required repair or resection; seven had minor intestinal injuries only. Two-thirds of the 32 were restrained passengers in motor vehicle crashes. The initial physical examination was suggestive of intestinal injury in 94% of children. Twenty-one children (84%) with major bowel injuries had diffuse abdominal tenderness at the time of initial physical examination, and only one of the seven (14%) with minor intestinal injury had generalized tenderness (P = .0014). Sixteen of 21 restrained passengers had seat-belt ecchymoses, and 13 of the 16 sustained major intestinal injuries. Only 1 of 13 abdominal CT scans performed was diagnostic of intestinal injury. Ten of 12 patients (83%) who underwent delayed laparotomy (more than 12 hours after injury) were initially evaluated at hospitals without trauma center designation; whereas 6 of the 20 nondelayed patients were evaluated at these hospitals (P = .0091). All four major complications occurred in the delayed group. CONCLUSION: The authors conclude that signs suggestive of major intestinal injury are present in children at the time of initial physical examination or shortly thereafter. The decision to operate can be based on this examination alone in the pediatric population. Abdominal CT scan is not reliable for the diagnosis of blunt intestinal injury in children. To expedite diagnosis and treatment, children who sustain blunt abdominal trauma should be examined immediately by a physician experienced in pediatric trauma care or be transferred to a designated trauma center where this service is available.