Minilaparoscopic colorectal resections: technical note.

Laparoscopic colorectal resections have been shown to provide short-term advantages in terms of postoperative pain, general morbidity, recovery, and quality of life. To date, long-term results have been proved to be comparable to open surgery irrefutably only for colon cancer. Recently, new trends keep arising in the direction of minimal invasiveness to reduce surgical trauma after colorectal surgery in order to improve morbidity and cosmetic results. The few reports available in the literature on single-port technique show promising results. Natural orifices endoscopic techniques still have very limited application. We focused our efforts in standardising a minilaparoscopic technique (using 3 to 5 mm instruments) for colorectal resections since it can provide excellent cosmetic results without changing the laparoscopic approach significantly. Thus, there is no need for a new learning curve as minilaparoscopy maintains the principle of instrument triangulation. This determines an undoubted advantage in terms of feasibility and reproducibility of the procedure without increasing operative time. Some preliminary experiences confirm that minilaparoscopic colorectal surgery provides acceptable results, comparable to those reported for laparoscopic surgery with regard to operative time, morbidity, and hospital stay. Randomized controlled studies should be conducted to confirm these early encouraging results.

Parathyroidectomy erase increased myocardial electrical vulnerability in patients with primary hyperparathyroidism.

BACKGROUND: Patients with primary hyperparathyroidism (pHPT) show an increased bioelectrical risk not related to cardiovascular complications, this risk seems to persist after surgery and this last finding is still controversial and probably related to follow-up length. METHODS: The aim of the study is to evaluate QT parameters in 11 patients with primary hyperparathyroidism (pHPT) 18 months after parathyroid surgery using computed standard 12-leads ECG compared to those of 29 healthy subjects (HS). RESULTS: In pHPT patients, 4 months after parathyroidectomy QT and QTc dispersion persist significantly higher than HS. 18 months after surgery, QT and QTc dispersion resulted comparable with HS. QT dispersion was found significantly higher in pHPT at 4 months respect 18 months after parathyroidectomy. CONCLUSIONS: ECG alteration after parathyroidectomy gradually return within normal limits and we can affirm that surgery erase bioelectrical risk in pHPT.

Transoral surgical removal of a giant fibrolipoma of the esophagus: case report.

An esophageal mass of more than 20 cm in length was diagnosed in a patient who presented with persistent dysphagia. Diagnosis of an endo-esophageal tumour was made by barium swallow; esophagoscopy confirmed the presence of a capsulated pink endo-esophageal mass. MRI confirmed the presence of a large capsulated mass within the esophagus, that appeared to be adipose tissue; a small stalk originating at the level of the upper esophageal sphincter was described and the polyp extended down to the gastroesophageal junction. Demonstration of the site and length of the stalk allowed a transoral removal of the mass, performed through a Weerda diverticuloscope (Karl Storz Endoskopie Gmbh, Tuttlingen Germany), a technique that has never been described before. Histology confirmed the mass as a fibrolipoma. The authors discuss both the role of MRI in diagnosis and treatment planning and the technique of transoral excision.

Persistent dysphagia after laparoscopic fundoplication for gastro-esophageal reflux disease.

Persistent postoperative dysphagia is a potentially severe complication of fundoplication for gastroesophageal reflux disease (GERD). The aim of this retrospective study was to analyze our experience of laparoscopic fundoplication for GERD in 276 consecutive patients, to determine the frequency of postoperative dysphagia and assess treatments and outcomes. There was no relation between preoperative dysphagia, present in 24 patients (8.7%), and postoperative DeMeester grade 2 or 3 dysphagia, present in 25 patients (9.1%). Ten (3.6%) patients had clinically significant postoperative dysphagia, eight (2.9%) underwent esophageal dilation, with symptom improvement in five. Four (1.4%) of our patients (two with failed dilation) and 11 patients receiving antireflux surgery elsewhere, underwent re-operation for persistent dysphagia 12 months (median) after the first operation. DeMeester grade 0 or 1 dysphagia was obtained in 10/13 evaluable patients. Our experience is fully consistent with that of the recent literature. Redo surgery is necessary in only a small fraction of operated patients with GERD with good probability of resolving the dysphagia. Best outcomes are obtained when an anatomical cause of the dysphagia is documented preoperatively.

Long-term sequelae after 1,311 primary inguinal hernia repairs.

BACKGROUND: Aim of this study was to analyze long-term sequelae, risk factors, and satisfaction after inguinal hernia primary repair. METHODS: A postal questionnaire was mailed to all patients operated between January 1997 and December 2004 for inguinal hernia repair. Patients who had a lump in the groin and patients who experienced chronic problems were invited for a physical examination. Patients who reported having chronic pain were asked to fill out the short-form McGill Pain Questionnaire (SF-MPQ). RESULTS: Chronic pain was present in 18.1% of cases. The strongest risk factors were presence of recurrence, use of heavyweight mesh, and age younger than 66 years. By means of the SF-MPQ, we found that the pain reported by most patients was sensory-discriminative in quality, with "tender" and "aching" being the most common descriptors used. About 71.3% of replies used descriptors typical of nociceptive pain, 8.9% of neuropathic pain, and 19.8% of nociceptive plus neuropathic. Chronic pain was severe in 2.1% of patients and interfered with normal activities, work, and exercise. The cumulative recurrence rate was 2.1%. There was a strong correlation between lump and recurrence. Patients declared themselves satisfied with the result of the operation in 93.1% of cases. Due to chronic pain, 6.5% of patients were unsatisfied. CONCLUSIONS: This study demonstrates that the main problem after inguinal hernia repair remains chronic pain, which was the primary reason of dissatisfaction. The SF-MPQ is feasible and easy to administer to all patients and provides important information about qualitative features of the pain.

Analysis of post-surgical pain after inguinal hernia repair: a prospective study of 1,440 operations.

BACKGROUND: Pain remains a significant clinical problem after inguinal hernia repair. We prospectively assessed post-surgical pain following herniorrhaphy in 1,440 operations with the aim of describing the characteristics and identifying predisposing factors for pain. METHODS: Pain quality was assessed with the short-form McGill Pain Questionnaire (SF-MPQ); pain character was estimated as either nociceptive or neuropathic in nature. RESULTS: A total of 38.3% of replies reported pain (acute or chronic), and 18.7% reported chronic pain. Independent risk factors for pain were young age, BMI >25, day surgery, and use of Radomesh. In patients with chronic pain, independent risk factors were young age, BMI >25 and use of Radomesh. Analysis of the SF-MPQ revealed that the pain reported by most patients was sensory-discriminative in quality. The most common descriptors were tender and aching. Patients with chronic pain reported more intense pain and used sensory descriptors of greater mean intensity than patients with acute pain. A total of 73.9% of replies used descriptors typical of nociceptive pain, 6.5% used descriptors typical of neuropathic pain and 19.6% used nociceptive plus neuropathic descriptors. Patients considered to have nociceptive pain used significantly more sensory descriptors than those considered to have neuropathic pain. By contrast patients with neuropathic pain used more affective descriptors than those with nociceptive pain. Neuropathic pain was reported as more difficult to treat with analgesics than nociceptive pain and neuropathic plus nociceptive pain. CONCLUSIONS: Our study confirms that herniorrhaphy frequently produces chronic pain, which can reduce quality of life. The SF-MPQ is a useful instrument to administer to all patients and provides important information about qualitative properties of the pain.

Bioprofiling over grid for eHealthcare.

A trend in modern medicine is towards individualization of healthcare and, potentially, grid computing can play an important role in this by allowing sharing of resources and expertise to improve the quality of care. In this paper, we present a new test bed, the BIOPATTERN Grid, which aims to fulfil this role in the long term. The main objectives in this paper are 1) to report the development of the BIOPATTERN Grid, for biopattern analysis and bioprofiling in support of individualization of healthcare. The BIOPATTERN Grid is designed to facilitate secure and seamless sharing of geographically distributed bioprofile databases and to support the analysis of bioprofiles to combat major diseases such as brain diseases and cancer within a major EU project, BIOPATTERN (www.biopattern.org); 2) to illustrate how the BIOPATTERN Grid could be used for biopattern analysis and bioprofiling for early detection of dementia and for brain injury assessment on an individual basis. We highlight important issues that would arise from the mobility of citizens in the EU, such as those associated with access to medical data, ethical and security; and 3) to describe two grid services which aim to integrate BIOPATTERN Grid with existing grid projects on crawling service and remote data acquisition which is necessary to underpin the use of the test bed for biopattern analysis and bioprofiling.

Diaphragmatic acute massive herniation after laparoscopic gastroplasty for esophagectomy.

Minimally invasive techniques are increasingly being used for oesophagectomy. Diaphragmatic hernia is a rare complication of gastroplasty in open surgery. One of the advantages of the laparoscopic technique, the lack of peritoneal adhesions, may lead to an increased rate of this complication. We report two cases of diaphragmatic acute massive herniation after laparoscopic gastroplasty for esophagectomy out of a series of 44 laparoscopic gastroplasties performed over 33 months. We discuss some technical aspects related to its occurrence. Prevention should include a limited crural division and fixation of the gastric tube to the diaphragmatic crura at primary surgery.

Pre-operative endoscopic ultrasonography can optimise the management of patients undergoing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocholithiasis: a prospective study.

BACKGROUND: Pre-operative endosonography has been proposed as a cost-effective procedure in the management of patients who undergo laparoscopic cholecystectomy having an intermediate risk of common bile duct stones. We prospectively evaluated the impact of pre-operative endosonography on the management of patients facing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocolithiasis. METHODS: Among 587 consecutive patients scheduled for laparoscopic cholecystectomy, 47 (8%) patients having one or more abnormal liver function tests but a normal appearance of common bile duct at abdominal ultrasound, underwent pre-operative endosonography. In patients with endosonography-detected common bile duct stones, a pre-operative endoscopic retrograde cholangiography was performed, or an intra-operative endoscopic retrograde cholangiography was scheduled. In all endosonography-negative patients, an intra-operative trans-cystic cholangiography was performed. RESULTS: Endosonography detected common bile duct stones in nine patients (19%) but only in five of them stones were radiologically confirmed (PPV 0.55). Endosonography-detected stones were confirmed in four of four (100%) patients in whom cholangiography was performed within 1 week, but only in one of five (20%) patients in whom radiology was further delayed (P < 0.05). In three of four cases (75%), stones detected at endosonography but not confirmed at X-rays, were smaller than 2.0 mm. Among 38 patients with negative endosonography, common bile duct stones were found in two patients (NPV 0.95), whereas unplanned endoscopic stone extraction was needed only in one patient (NPV 0.97). CONCLUSIONS: Pre-operative endosonography can spare unnecessary pre-operative endoscopic retrograde cholangiography as well as inappropriate scheduling of intra-operative endoscopic retrograde cholangiography in patients undergoing laparoscopic cholecystectomy with abnormal liver function tests. To maximise the impact of endosonography on the management of these patients, the procedure should be performed immediately before laparoscopic cholecystectomy.

Laparoscopic treatment of epiphrenic diverticula.

BACKGROUND AND PURPOSE: Epiphrenic diverticula are a rare disease probably caused by long-standing impairment of esophageal motor activity. Symptomatic disease, which may worsen clinically during follow-up even to severe symptoms, is usually considered an indication for surgical treatment. Surgery for epiphrenic diverticula consists of diverticulectomy, which traditionally is performed through a left thoracotomy; a myotomy and partial fundoplication are generally included in order to treat the underlying motor disorder and to prevent or correct reflux. The same principles of surgical treatment can be achieved through the laparoscopic transhiatal approach. The aim of this paper is to describe the technique and the results of laparoscopic diverticulectomy combined with esophageal myotomy and antireflux wrap to treat epiphrenic diverticula of the esophagus. PATIENTS AND METHODS: From January 1994 through May 2001, 11 patients underwent laparoscopic transhiatal diverticulectomy, esophageal myotomy, and partial fundoplication at our institution. RESULTS: In all patients, the operation was completed through the minimally invasive access. The postoperative course was complicated in one patient (9%), who had a leak from the staple line, which was repaired through a thoracotomy. At follow-up, this patient had persistence of a small pouch at the diverticuletomy site. However, he was asymptomatic. All other patients were free of symptoms and without recurrence. CONCLUSION: Laparoscopy offers good access to the distal esophagus and the inferior mediastinum. Removal of the diverticulum, treatment of the motor disorder, and prevention of postoperative reflux can all be obtained through this approach. The immediate postoperative and long-term results are satisfactory.

Evaluating results of laparoscopic surgery for esophageal achalasia.

BACKGROUND: Extramucosal myotomy of the lower esophagus and cardia, combined with anterior fundoplication, is, in our opinion, the procedure of choice to treat stage I-III esophageal achalasia. METHODS: After a successful experience with open surgery in over 280 patients, from January 1992 through February 1997, 61 patients underwent laparoscopic Heller-Dor for stage I-III achalasia. Conversion to laparotomy was done in three cases. All procedures were performed under intraoperative endoscopic control. Intraoperative complications were seven mucosal tears, which were sutured laparoscopically in five cases. The sole postoperative complication was bleeding from an acute gastric ulcer (conservative treatment). RESULTS: Follow-up consisted of clinical and radiographic study 1 month after surgery, and endoscopy and manometry within 1 year. After a mean follow-up (F.U.) of 21 months (1-62), clinical results range from excellent to good in 98.2%. One patient (1.7%) complaining of recurrent dysphagia improved after endoscopic dilation. Esophageal diameter reduced from 52 to 27 mm. LES pressure reduced from 30.3 +/- 12.4 to 10.7 +/- 3.5 mmHg (basal) and from 14. 8 +/- 9.3 to 2.9 +/- 2.1 mmHg (residual). CONCLUSIONS: Laparoscopic Heller-Dor operation is feasible, safe, and effective. Special care should be taken in patients with previous endoscopic dilations.

Diverticulectomy, myotomy, and fundoplication through laparoscopy: a new option to treat epiphrenic esophageal diverticula?

OBJECTIVE: To describe the technique and the results of laparoscopic diverticulectomy combined with esophageal myotomy and antireflux wrap for epiphrenic diverticula of the esophagus. SUMMARY BACKGROUND DATA: The epiphrenic diverticulum of the esophagus is a rare disease probably caused by a longstanding impairment of the esophageal motor activity. Although there is almost universal agreement to operate only on symptomatic patients, the optimal treatment is controversial. The best-accepted guideline is to treat the underlying motor disorder. This is generally done through a left thoracotomic approach that allows diverticulectomy, esophageal myotomy, and partial fundoplication. METHODS: From January 1994 through February 1996, 4 patients underwent laparoscopic transhiatal diverticulectomy, esophageal myotomy, and partial fundoplication at our institution. A thorough preoperative study was done with barium swallow, esophagoscopy, and manometry in all patients; 24-hour pH monitoring was done in one case. RESULTS: No postoperative complications were observed. Short- and medium-term results are satisfactory. CONCLUSIONS: No theoretical objection should be made to this approach, because the principle of treatment of the diverticular pouch and the underlying motor disorder and the prevention of reflux is respected. Longer follow-up and a wider series are mandatory to substantiate these initially favorable results.

Thoracoscopic esophagectomy: are there benefits?

Between 1991 and 1995, 18 patients affected by a resectable intramural tumor of the esophagus underwent esophagectomy with thoracoscopic dissection of the esophagus. All patients had a relative contraindication to transthoracic esophagectomy with radical lymphadenectomy. All esophagectomies were completed thoracoscopically and reconstruction of the digestive tract was performed in 17 cases through cervical gastroplasty, and in 1 case, through cervical coloplasty. One cirrhotic patient died in the postoperative period due to a cervical anastomotic leak. Six other patients experienced a postoperative complication (mortality rate, 5.5%; morbidity rate, 33.3%). After a median follow-up of 17 months, 14 patients are alive without evidence of disease. One patient, who had excision of a cutaneous metastasis at a trocar insertion site 6 months postoperatively, eventually died with locoregional recurrence 14 months postoperatively. Another patient died 20 months after surgery with mediastinal recurrence. One patient died 28 months postoperatively after massive hematemesis with a suspect abdominal recurrence. The results of the present series, and those reported by other authors, do not seem to indicate evident advantages at present for the minimally invasive procedure during resection of the esophagus for cancer. Currently, there is no indication that this procedure should be used for standard clinical use. Wider randomized trials, performed in selected centers only, and longer follow-up are needed to further evaluate the procedure.

Thoracoscopic dissection of the esophagus for cancer.

Eighteen patients affected by a resectable intramural tumor of the esophagus have undergone esophagectomy with thoracoscopic dissection of the esophagus in the last 4 years. All patients had a relative contraindication to transthoracic esophagectomy with radical lymphadenectomy. All esophagectomies were completed thoracoscopically and reconstruction of the digestive tract was performed in 17 cases through cervical gastroplasty and in 1 case through cervical coloplasty. One cirrhotic patient died in the postoperative period due to cervical anastomotic leak. Six other patients experienced a postoperative complication (mortality rate 5.5%; morbidity rate 33.3%). After a median follow up of 17 months, 14 patients are alive without evidence of disease. One patient, who had excision of a cutaneous metastasis at a trocar insertion site 6 months postoperatively, eventually died with locoregional recurrence 14 months postoperatively. Another patient died 20 months after surgery with mediastinal recurrence. One patient died 28 months postoperatively after massive hematemesis with a suspect abdominal recurrence. The results of the present series and those reported by other authors do not seem to indicate presently evident advantages from the minimally invasive procedure during resection of the esophagus for cancer. At the present time, no indication to this procedure exists for standard clinical use; wider randomized trials and longer follow-up to be performed only in selected centers are needed to further evaluate the procedure.

[Video laparoscopic surgery and rectal prolapse. Our experience in rectopexy]. / Chirurgia videolaparoscopica e prolasso rettale. Nostra esperienza in tema di rettopessia.

BACKGROUND: Laparoscopy is gaining an important role in the treatment of benign colorectal disorders. The aim of this study is the evaluation of clinical and functional results in 4 patients submitted to a laparoscopy rectopexy according to Wells. METHODS: Four females (22-76, mean 53.7 years) affected from a total rectal prolapse with fecal incontinence underwent this procedure from 1993 through 1995. Six months after surgery, at the end of a rehabilitation program consisting of kinesitherapy, bio-feedback and electrostimulations, all patients have been re-evaluated by means of a clinical exam, anorectal manometry, defecography. RESULTS AND CONCLUSIONS: Preliminary results seem satisfactory and may allow to prefer this approach instead of the traditional open one.

A special instrument for a safe and effective laparoscopic esophageal myotomy.

The authors describe the use of particular endoscopic scissors that allow a safe and easy laparoscopic performance of Heller myotomy. Although originally designed for another use, these scissors are extremely useful for esophageal myotomy, their most important feature being the smooth and insulated protection of the lower jaw. This feature keeps the mucosa constantly away from the myotomy and allows the safe use of electrocautery, resulting in a perfect hemostasis.

Laparoscopic treatment of paraesophageal and large mixed hiatal hernias.

BACKGROUND: Laparoscopic treatment of large mixed hiatal hernias was attempted in eight patients. METHODS: One patient (12.5%) was converted to open surgery due to difficulty in repositioning the LES into the abdomen resulting from a shortened esophagus. One left pleural tear occurred intraoperatively and was repaired without further consequence. Median duration of the operation was 150 min (range 120-300 min). RESULTS: No postoperative complications were recorded. All patients are asymptomatic after a median follow-up of 14 months (range 7-15 months). Correct repositioning of the stomach was confirmed by radiological evaluation 1 month after surgery. Early functional results are good. (One asymptomatic gastroesophageal reflux was detected and medical treatment was undertaken). CONCLUSIONS: Laparoscopic crural repair and fundoplication are feasible even in paraesophageal and large mixed hiatal hernias. Advantages of the minimally invasive approach are clear in terms of morbidity, patient comfort, and duration of hospital stay. Nevertheless, long-term assessment is required to confirm the effectiveness of the laparoscopic approach in patients with large mixed hiatal hernias.

Laparoscopic treatment of functional diseases of the esophagus.

The possibilities of laparoscopic surgery in the treatment of functional esophageal diseases (gastroesophageal reflux, achalasia and epiphrenic diverticula) are illustrated with special emphasis on the technical aspects, including intraoperative complications and postoperative care. Results are discussed on the ground of the following experience. Thirty-seven laparoscopic fundoplications were performed with 13% conversion rate, 2.7% postoperative morbidity (1 slipped Nissen requiring redo laparoscopic surgery). Median operative time was 140 min. One patient complained of dysphagia relieved by endoscopic dilation (2.7%). All patients are not asymptomatic after a median follow-up of 16 months although one has gastroesophageal reflux (GER) at 24-hrs pH monitoring. forty laparoscopic Heller-Dor procedures: 7% conversions, 5% postoperative morbidity. Median duration 120 min. One patient complained of persistent dysphagia requiring endoscopic dilation (2.5%) and asymptomatic GER was detected in 8% of patients. Finally, 2 patients underwent laparoscopic diverticulectomy, esophagomyotomy and Dor fundoplication without morbidity and excellent postoperative result. Laparoscopic treatment of functional diseases of the esophagus is safe and effective, provided it is performed by an experienced surgeon with respect for some important technical details. Further follow-up is needed to evaluate long-term results.

Laparoscopic approach to esophageal achalasia.

Certain technical details are considered important to ease the laparoscopic performance of a Heller myotomy combined with a Dor antireflux procedure for esophageal achalasia. A special emphasis is given to intraoperative esophagoscopy combined with a mild balloon distension of the esophagogastric junction. These maneuvers prove helpful in identifying the esophagogastric region, easing the myotomy, and controlling its completeness.