Defining the role of laparoscopic-assisted sigmoid colectomy for diverticulitis.

PURPOSE: The purpose of this study was to evaluate the safety and efficacy of laparoscopic-assisted sigmoid colectomy for the treatment of diverticulitis. METHODS: The Norfolk Surgical Group Laparoscopic Surgery Registry identified all patients undergoing laparoscopic colon and rectal surgery. Retrospective chart review was performed for all patients undergoing elective sigmoid resection for a final diagnosis of diverticulitis and minimum follow-up of 12 months. Demographic data, indications for surgery, operative data, conversion rate, reason for conversion, complications, postoperative course (days to flatus and regular diet), and length of stay were identified. A telephone survey determined the incidence of recurrent diverticulitis. Statistical analysis was performed to evaluate the frequency of conversion over time, to determine risk factors for conversion, and to compare the laparoscopic-assisted and conversion groups with regard to postoperative days to flatus, regular diet, and discharge. RESULTS: From June 1992 to September 1997, elective laparoscopic-assisted sigmoid colectomy was attempted in 69 patients. Uncomplicated recurrent diverticulitis was the most common indication for surgery, occurring in 51 of 69 patients (75 percent). No deaths occurred. Complications were identified in seven patients (10.1 percent) including one wound infection and one incarcerated port-site hernia with small bowel obstruction. There were no anastomotic leaks or major septic complications. Conversion to laparotomy occurred in 18 of 69 patients (26 percent). Uncomplicated, recurrent diverticulitis was associated with conversion in 7 of 51 patients (14 percent), whereas complicated diverticulitis required conversion in 11 of 18 patients (61 percent). Logistic regression identified fistula and abscess as predictors of conversion (P = 0.0009). Comparison of the laparoscopic-assisted sigmoid colectomy group with the conversion group revealed that postoperative days to regular diet were 3.5 and 5.2 (P = 0.0004), respectively, and lengths of stay were 4.2 and 6.4 days (P < 0.0001), respectively. No difference was noted with regard to operative time or postoperative complications. Median follow-up was 48 (range, 13-76) months, and a single recurrence of diverticulitis has been identified. CONCLUSIONS: Laparoscopic-assisted sigmoid colectomy for diverticulitis can be safely performed. Conversion appears to be associated with complicated diverticulitis (fistula or abscess), which may be better approached by laparotomy. Short-term follow-up indicates that recurrence is rare and suggests that laparoscopic-assisted sigmoid colectomy achieves adequate resection. Laparoscopic-assisted sigmoid colectomy offers benefits of decreased ileus and length of stay and may represent the procedure of choice for elective resection for uncomplicated sigmoid diverticulitis.

Minimally invasive surgery for colorectal cancer. Initial follow-up.

OBJECTIVE: An analysis was performed to evaluate early patterns of recurrence and survival in patients undergoing laparoscopic-assisted colectomies for primary colorectal cancer. Thirty-nine patients are available with a minimum of 24 months postoperative follow-up. SUMMARY BACKGROUND DATA: The techniques and expected surgical outcomes for patients undergoing laparoscopically assisted colectomies are slowly being defined as these procedures become more common and more widely available. One of the areas of greatest concern is the use of laparoscopic-assisted colectomy for the surgical treatment of patients with primary colorectal cancer. There are anecdotal reports in the literature describing both port site recurrence and wound recurrence in patients undergoing laparoscopic-assisted colectomies for colorectal cancer. This raises concerns about whether these recurrences are more common in patients undergoing laparoscopic procedures and whether overall survival is compromised. Wound recurrences and laparoscopic port site recurrences have been described with numerous other intra-abdominal tumors, but the precise incidence remains unknown. The authors reviewed data from 39 patients to determine early patterns of recurrence and overall survival. METHODS: Two-hundred thirty-eight laparoscopic-assisted colectomies were performed by the Norfolk Surgical Group between June 1992 and September 1995. Thirty-nine of the patients who underwent resection for colorectal cancer between June 1992 and September 1993 currently are available for at least a 2-year follow-up. Preoperative evaluation included physical examination, liver function studies, carcinoembryonic antigen, chest x-ray, computed tomography scans, and endoscopies with biopsy. Postoperative follow-up data consisted of physical examination, liver function tests, CEA, chest X-ray, computed tomography scan of the abdomen, and endoscopy of the colon. No patients have been lost to follow-up. Survival rates and patterns of recurrence were compared between node-negative and node-positive patients and compared with conventional data after open surgery. RESULTS: There were 22 men and 17 women ranging in age from 33 to 89 years. Mean follow-up was 30 months, with a range of 24 to 40 months. There were three patients with recurrence and nine deaths. Recurrence and tumor-related death rates, respectively, for each Dukes' stage were 0/1 and 0/1 for stage A, 0/7 and 0/7 for stage B-1, 1/16 and 2/16 for stage B-2, 0/1 and 0/1 for stage C-1, and 2/8 and 1/8 for Stage C-2. All six patients with Dukes' stage D disease died of metastatic colorectal cancer within 4 to 14 months of surgery. There were two patients with anastomotic recurrence. No unusual patterns of recurrent disease were noted, and there were no wound or port site recurrences. CONCLUSIONS: In this group of patients undergoing laparoscopic-assisted colectomies for primary colorectal malignancy, no adverse patterns of recurrence or decreased survival has been noted at 2-year follow-up when compared with standard open colorectal cancer surgery statistics. Prospective randomized studies with long-term follow-up will be required to better define the potential benefits and adverse effects of laparoscopic surgery for colorectal malignancy.

Laparoscopic cholecystectomy in pregnancy. A report of 6 cases and review of the literature.

BACKGROUND: Although pregnancy was initially considered an absolute contraindication to laparoscopic cholecystectomy, there have been several case reports of successful laparoscopic cholecystectomy in pregnant patients in the literature over the past 4 years. We report our experience with six patients managed successfully with laparoscopic cholecystectomy during pregnancy. METHODS: More than 1,300 laparoscopic cholecystectomies were performed by the Norfolk Surgical Group between May 1991 and June 1994. Six of these patients (approximately 0.5%) were operated on during pregnancy. We reviewed the management and operative technique used in these patients compared to our standard approach. The available literature was reviewed to identify any other factors which might be helpful in the management of these patients. RESULTS: In this series we were able to perform laparoscopic cholecystectomy successfully in all six patients in whom it was attempted, with an overall course similar to that of nonpregnant patients. There were no significant complications to the patient or the fetus. All six patients have delivered healthy children and continue to do well. DISCUSSION: With the addition of our 6 patients, there have been 32 successful laparoscopic cholecystectomies during pregnancy reported in the English literature. We feel laparoscopic cholecystectomy can be performed safely in pregnant patients and should be considered in any patient who presents with symptomatic cholelithiasis during pregnancy.

Laparoscopic-assisted colectomy. The learning curve.

One hundred fifty consecutive laparoscopic-assisted colectomies performed by a surgical team were analyzed in an attempt to define a learning curve. These colectomies performed by the Norfolk Surgical Group over a 24-month period, were divided chronologically into six groups of 25 patients each. The groups were then compared to determine if any improvement in length of procedure, complication rate, conversion rate, or length of stay developed as experience increased. Colon cancer and diverticular disease were the most common indications for surgery in all groups. Right hemicolectomy, left colectomy, and low anterior resection accounted for the majority of procedures in all groups. A significant decrease in mean operative time, from 250 min to 156 min over the first 35-50 cases was observed before leveling off at approximately 140 min for the remaining group. Intraoperative complications were low in all groups (range zero to two) and did not show any trend. There was no statistically significant difference in the conversion rate (23.3% overall) among the six groups. Length of stay decreased from 6 days in the first two groups to 5 days in the last four groups, although the difference was not statistically significant. The learning curve for laparoscopic-assisted colectomies is longer than appreciated by many surgeons, requiring as many as 35-50 procedures to decrease operative time to baseline. Complications can be kept at an acceptably low level while on the curve if a cautious approach is taken and the surgeon realizes that a prolonged operative time is not only acceptable, but appropriate during this long learning process. A conversion rate of 20-25% at any phase of the learning process may in fact represent a limitation of current technology. When combined with a low complication rate it may be the sign of a careful surgeon.

Laparoscopic-assisted colectomy. Initial experience.

OBJECTIVE: The authors studied the results of laparoscopic colectomies performed by a surgical team on 80 consecutive patients and compared these results with standard open colectomies. METHODS: Eight consecutive laparoscopic-assisted colectomies were performed by Norfolk Surgical Group in a 14-month period and compared to 53 patients who had a conventional open colectomies. Analysis included indications for surgery, types of procedure, complications, incidence and causes for conversion, length of procedure, duration of postoperative ileus, hospital stay, operating room and total hospital charges, and examination of the pathologic specimens. RESULTS: Many different types of colectomies were performed successfully and safely for a variety of surgical indications. The conversion rate was 22.5%, which decreased to 15% in the second half of the series. Complications in patients who underwent laparoscopic operations were not severe in number of type. The length of the operative procedure, operating room charge, and the total hospital charge were greater for patients undergoing laparoscopic-assisted colectomies. Patients who underwent laparoscopic operations had a shorter period of postoperative ileus and less pain, resumed a regular diet sooner, and were discharged from the hospital sooner than patients who underwent open colectomies. There was no significant difference in the pathology specimens obtained by laparoscopic-assisted colectomies compared with conventional open colectomies for length of specimen, surgical margins, and number of lymph nodes retrieved. CONCLUSIONS: This study indicated that laparoscopic techniques can be applied safely and effectively to a broad range of colonic operations. Laparoscopic-assisted colectomies take longer to perform and are more costly, but are associated with less paralytic ileus, less pain, and reduced hospital stay. Laparoscopic colectomies for the treatment of malignancy are achievable technically, but will require careful long-term study.

Obstructing malignant lesions of the colon.

Evidence has been presented to suggest that the patient with an obstructed carcinoma of the colon may have a more malignant form of the disease independent of lymph node status or tumor encirclement of the bowel. Rate of tumor growth is never consistent in patients with this disease. Patients who develop colon obstruction early in the course of the disease seem to have more aggressive tumors with rapid growth and a much poorer long-term prognosis. Perforations frequently accompany obstructions of the colon. Patients in this group have a dismal prognosis. Individuals with obstructed carcinoma of the colon have a higher operative mortality and morbidity and a shorter long-term survival. The higher operative mortality and morbidity may depend entirely on the choice of operative procedures. Tumor location affects prognosis. Obstructing tumors in the left colon have a more favorable prognosis than those in the right colon. Obstructing right colon tumors have a much poorer survival (three times worse) than nonobstructing carcinomas of the right colon. Obstructing tumors in the rectum have a very poor prognosis. Evidence exists that resection of the tumor without preliminary proximal decompression may reduce hospital mortality and morbidity and increase long-term survival. In selected cases, primary resection can be done as safely as staged operative procedures. Primary anastomosis with resection of the left colon carries a higher operative mortality because of anastomotic leaks. Resection without anastomosis is much safer. Primary resection with anastomosis is the procedure of choice in obstructing lesions of the right colon. This has a lower operative mortality and morbidity than a staged procedure. This primary resection with anastomosis is certainly as safe as an ileotransverse colostomy. It is important not to abandon the time-honored surgical principle of never suturing obstructed bowel. Primary resection without anastomosis confirms this surgical principle. Meticulous preoperative and postoperative care employing physiological monitoring, multiple antibiotics, total parenteral hyperalimentation, and respiratory and circulatory support will further reduce the hospital mortality and morbidity. Patients who initially appear to be obstructed on barium enema, but who in truth are only partially obstructed, can be properly managed so that an elective primary resection with anastomosis can be done with the same operative mortality and morbidity as in other elective colon cancer patients.

Major rectal complications following interstitial implantation of 125iodine for carcinoma of the prostate.

From April 1975 through April 1983, 152 patients were treated for localized adenocarcinoma of the prostate with interstitial implantation of 125iodine seeds. In each case bilateral pelvic lymph node dissection was performed at implantation. Five rectal complications developed: 2 rectal ulcers and 3 prostatic urethrorectal fistulas. Our method to treat these problems is presented together with our technique of reconstruction in patients with persistent fistulas despite fecal diversion. While urethrorectal fistulas represent potentially devastating complications of the 125iodine implantation procedure, reconstructive techniques can minimize and have reduced their long-term effects.

Clinical significance of osmotic matrix errors in automated hematology: the frequency of hyperglycemic osmotic matrix errors producing spurious macrocytosis.

Sporadic examples of spurious macrocytosis due to hyperglycemic osmotic matrix effects have been reported. The present study defines the degree of macrocytosis expected under hyperglycemic normonatremic conditions using a Coulter S + II Isoton + System and its frequency in a large inpatient and outpatient population. No examples of spurious macrocytosis due to hyperglycemia were encountered in a sample comprising 28,471 complete blood counts, of which 564 had macrocytosis.

Acid phosphatase staining pattern as an indicator of T-cell acute leukemia.

Acid phosphatase staining pattern has been variably advocated and discouraged as an indicator of T-cell differentiation of acute lymphoblastic leukemias. This study indicates that acid phosphatase staining pattern will correlate with the results of E rosette testing in both T-cell and non-T, non-B acute lymphoblastic leukemias in over 90% of cases. Acid phosphatase staining pattern may reliably be used to indicate T-cell differentiation in acute lymphoblastic leukemia in cases where insufficient material for E rosette testing is available.

Morphology and cytochemistry of "microgranular" acute promyelocytic leukemia (FAB M3m).

Three cases of a newly recognized "microgranular" variant of acute promyelocytic leukemia (FAB M3) are described. This poor-prognosis variant is easily confused with myelomonocytic (M4) or monocytic (M5) leukemia, but is associated with disseminated intravascular coagulation as is "hypergranular" M3. Such patients may be inappropriately treated unless the promyelocytic nature of the leukemia is recognized.

Acute nonlymphocytic leukemia in patients receiving chemotherapy for nonmalignant diseases.

The occurrence of acute leukemia in patients receiving chemotherapeutic agents for malignant disease has been well established. Recent reports have suggested that chemotherapeutic drugs used to treat inflammatory conditions may have an oncogenic potential. From 1969 to 1977, 11 patients with a variety of collagen-vascular diseases who developed acute nonlymphocytic leukemia were seen at the Cleveland Clinic. Rheumatoid arthritis was the most common underlying disease, in addition to giant cell arteritis, polyarteritis nodosa, chronic glomerulonephritis, and scleroderma. All patients were treated with alkylating agents, and 10 of the 11 received multiple cytotoxic agents. According to the French-American-British classification there were six examples of M4 (myelomonocytic leukemia), with single examples of M1 (myeloblastic leukemia without maturation), M2 (myeloblastic leukemia with maturation), M5a (monocytic leukemia, poorly differentiated), M5b (monocytic leukemia, differentiated), and M6 (erythroleukemia). Cytogenetic studies were abnormal in five patients studied, showing varying degrees of aneuploidy. All patients died, and the mean duration of time from the diagnosis of leukemia to death was four and one-half months, with only one complete remission.

Prognostic factors affecting remission, remission duration, and survival in adult acute nonlymphocytic leukemia.

The medical records of 94 consecutive patients with acute nonlymphocytic leukemia (ANLL) were reviewed to identify significant prognostic factors. The data were analyzed using 1) Cox's linear hazard and linear logistic models, 2) chi-square comparison of the groups living longer than 2 years and those living less than 2 years, and 3) the Gehan-Breslow test of equal survival curves. The only statistically significant finding was that the presence of promyelocytic cell type and complete remission correlated with increased survival (p less than .05), but this was negated by the small number of patients with this cell type. There was a suggestive association between higher initial hemoglobin and survival (p = .09). The Gehan-Breslow test revealed a possible difference in survival between those patients more than 51 years of age and those less than 51 (p = .10). Thus none of the commonly accepted prognostic factors in acute nonlymphocytic leukemia was definitely shown to be useful. The findings of this study support an aggressive approach toward all patients with this disease.