Laparoscopic fundoplication: a 10-year learning curve.

BACKGROUND: Laparoscopic Nissen fundoplication (LNF) has become the most common surgical treatment for gastroesophageal reflux disease (GERD). Controversies still exist regarding the operative technique and the durability of the procedure. METHODS: A retrospective study of 808 patients undergoing 838 LNF for GERD at a tertiary referral center was undertaken. Demographic, perioperative, and follow-up data had been entered onto the unit database. RESULTS: During a median follow-up period of 60 months (range, 2-120 months), heartburn decreased to 3% of the patients (19/645) and regurgitation to 2% (11/582) (p < 0.01). Respiratory symptoms improved in 69 (85%) of 81 patients (p < 0.01). The incidence of postoperative dysphagia was unaffected by the use of an intraesophageal bougie (odds ratio [OR], 1.16; 95% confidence interval [CI], 0.82-1.64; p = 0.41) or division of the short gastric vessels (OR, 0.84; 95% CI, 0.42-1.07; p = 0.72). In the immediate postoperative period, the incidence of abdominal symptoms increased by 10% (p < 0.01) and dysphagia by 16% (p < 0.01). After 10 postoperative years, only 3% (30/484) were found to have abdominal symptoms, whereas the incidence of dysphagia declined to zero. CONCLUSION: The findings show that LNF is a safe and effective procedure with long-term durability. Abdominal symptoms and dysphagia are the principal postoperative complaints, which improve with time. Personal preference should dictate the use of a bougie, division of the short gastric vessels, or both.

Day case laparoscopic herniorraphy. A NICE procedure with a long learning curve.

BACKGROUND: The aim of this study was to evaluate day case laparoscopic herniorraphy (LH) and to ascertain the impact of trainee surgeons on its performance. METHODS: We performed a prospective study of ambulatory laparoscopic transabdominal preperitoneal herniorraphies performed in a dedicated day surgical unit between March 1996 and October 2003. RESULTS: A total of 840 herniorraphies were performed in 706 consecutive patients. Surgery was performed by 15 higher surgical trainees and three consultant surgeons. The mean operating times for trainees were longer for unilateral (48.4 +/- 0.98 vs 41.4 +/- 0.87 min, p < 0.05) and bilateral (69.0 +/- 3.24 vs 53.0 +/- 1.68 min, p < 0.05) repairs than for consultants. Subgroup analysis demonstrated that after an experience of 40 procedures, trainee times approached those of the consultants (41.39 +/- 1.17 vs 41.4 +/- 0.87 min, p= 0.31). LH repair was well tolerated and associated with minimal postoperative pain and nausea. Mean pain scores postoperatively and at 24 h were 2.69 +/- 0.11 and 2.07 +/- 0.09, respectively. Mean nausea scores postoperatively and at 24 h were 0.34 +/- 0.06 and 0.22 +/- 0.06, respectively. Ninety-three percent of patients (n = 657) were discharged within 8 h. There were two conversions to an open procedure (0.1%) and two significant complications (0.1%). Ninety-five percent of patients who responded to our questionnaire (n = 398/419) were satisfied with surgery and would undergo day case laparoscopic herniorraphy again. CONCLUSIONS: Laparoscopic herniorraphy is a safe technique suitable for day case surgery. Operator experience dictates duration of surgery. Trainees' operating times approach those of consultants after 40 procedures. Prolonged operating times and increased cost are not justifiable reasons for not recommending LH.

A prospective study of ambulatory laparoscopic cholecystectomy: training economic, and patient benefits.

BACKGROUND: Even though ambulatory laparoscopic cholecystectomy (ALC) is safe and cost effective, this approach has yet to gain acceptance in the United Kingdom. We report our 5-year experience of ALC with emphasis on its appropriateness for higher surgical training. METHODS: Between July 1997 and July 2002, patients with symptomatic cholelithiasis who met with appropriate criteria underwent ALC. Surgery was performed either by a consultant surgeon or a higher surgical trainee (HST) under direct supervision in our dedicated day surgery unit. Data were recorded prospectively and patients were interviewed postoperatively by an independent researcher. RESULTS: There were 269 patients (231 female and 38 male) with a median age of 46 years (range 17-76). Conversion to open cholecystectomy was necessary in three cases (1%). Of the patients, 79% (213) were discharged within 8 hours of surgery; 95% (256) were discharged on the same day. Thirteen patients (5%) required overnight admission as inpatients. An HST performed 166 (62%) of the procedures. There was a statistically significant difference in operating time between consultants (41 min) and trainees (47 min, P = 0.001) but no significant difference in clinical outcome or patient satisfaction. The mean procedural cost to the hospital was 768 pound sterling for ALC compared with 1430 pound sterling for an inpatient operation. Of patients, 87% expressed satisfaction with the day case operation. CONCLUSION: Our results for ALC compare favorably with published series. In addition, we have demonstrated that the operation can be performed safely by HST under direct supervision without compromising operating lists or safety.

Successful laparoscopic repair of a traumatic pubic symphysis hernia.

A 48-year-old woman presented with a hernia through the center of her pubic symphysis 6 months after conservative treatment of an open-book fracture of the pelvis. This was repaired laparoscopically with a prosthetic mesh using a transperitoneal approach. Hernia through the pubic symphysis is a rare complication after traumatic symphysis diastasis, but repair using the laparoscopic approach is feasible and associated with rapid recovery from surgery.

Technical aspects and complications of laparoscopic banding for morbid obesity--a radiological perspective.

Morbid obesity is a significant clinical problem in the western world. Various surgical restrictive procedures have been described as an aid to weight reduction when conservative treatments fail. Adjustable laparoscopic gastric banding (LAPBAND) has been popularized as an effective, safe, minimally invasive, yet reversible technique for the treatment of morbid obesity. Radiological input is necessary in the follow-up of these patients and the diagnosis of complications peculiar to this type of surgery. In this review we will highlight the technical aspects of radiological follow-up and the lessons learnt over the last 5 years.

Laparoscopic transperitoneal adrenalectomy.

BACKGROUND: From November 1993 to May 2002 a total of 172 laparoscopic adrenalectomies were attempted in 152 patients in centers throughout the United Kingdom. RESULTS: The median age was 52 years (18-77 years). Sixty-three percent were female. Indications for resection were Conn's syndrome (60), pheochromocytoma (35), Cushing's disease (24), Cushing's adenoma (8), cortisol-secreting carcinoma (1), other secreting tumor (2), nonfunctioning adenoma (17), congenital adrenal hyperplasia (4), metastatic disease (7), nonsecreting adrenal carcinoma (2), others (12). Median size of the lesions was 3.0 cm (0.5-20 cm). Median operating time was 65 min (30-170 min). Conversion to an open procedure was necessary in 10 patients (7%). Minor morbidity occurred in nine patients (5%). Major morbidity occurred in two patients (pancreatitis, peritonitis). Median hospital stay was 3 days (1-16 days). At median follow-up of 36 months (1-105 months) five patients (4%) had persistent hypertension. No patient had evidence of recurrent hormonal excess. CONCLUSIONS: Laparoscopic removal of the adrenal gland should be considered the surgical procedure of choice in experienced minimally invasive centers.

Laparoscopic adjustable gastric banding: surgical and radiological approach.

BACKGROUND: The laparoscopically-placed adjustable gastric band (LAGB) is a minimally invasive, adjustable and completely reversible operation. We report 3 years experience. METHODS: Between May 1998 and January 2001, we operated on a consecutive series of 50 patients (8 male/42 female). Mean age of patients was 37 years (30-48). Mean preoperative BMI was 43 kg/m2 (range 38-55). RESULTS: Mean operative time was 130 minutes (range 75-150), and the conversion rate was 6%. Mean hospital stay was 2.8 days (range 2-10). Postoperatively 7/50 (14%) of patients had dysphagia and subsequently 2 (4%) developed gastric pouch dilatation. 2/50 (4%) had non-fatal pulmonary embolism and 2/50 (4%) developed gastroesophageal reflux. Overall morbidity was 32%. There has been no mortality. 6 weeks postoperatively, patients had adjustment of the band by the radiologists. Follow-up has been up to 30 months. Mean excess weight loss at 6 months was 30% (range 26-35%, N = 50), at 12 months 52% (range 44-55%, N = 42), at 24 months 60% (range 55-65%, N = 14) and at 30 months 62% (range 58-64%, N = 8). 5 patients have reached their ideal body weight. CONCLUSIONS: LAGB is safe and effective, even early in the learning curve. The radiologist plays a distinct role. A multi-disciplinary team approach is essential for optimal results. Long-term results are pending.

Laparoscopic transabdominal preperitoneal (TAPP) hernia repair. A 7-year two-center experience in 3017patients.

BACKGROUND: This report reviews our experience with 3530 transabdominal preperitoneal (TAPP) hernia repairs in 3017 patients (513 bilateral) over the 7-year period from May 1992 to July 1999. We have continually audited our practice and modified the techniques in response. METHODS: Unless contraindicated, laparoscopic TAPP repair is considered the procedure of choice at our institution for all reducible inguinal hernias. We initially stapled an 11 x 6 cm polypropylene mesh in the preperitoneal space but now place a 15 x 10 cm mesh in the preperitoneal space with sutured peritoneal closure. RESULTS: There have been a total of 22 recurrences, of which 17 were identified in the first 325 repairs (5%) using the 11 x 6 cm mesh. Five recurrences occurred in the later 3205 repairs (0.16%) (median follow up of 45 months). There was one 30-day death unrelated to the procedure. There have been seven conversions (four due to irreducibility, two due to extensive adhesions, one due to bleeding). Bladder perforations have occurred in seven cases, of which six were recognized immediately and treated laparoscopically without sequelae. There have been seven cases of small bowel obstruction from herniation through the peritoneal closure. Sutured repair of the peritoneum has reduced the incidence of this complication. Four patients had mesh infections, of whom three were treated conservatively. The incidence of postoperative seroma and hematoma was 8%. Median operation time remains at 40 min with a mean hospitalization of 0.9 nights. Sixty percent of TAPP hernia repairs are now performed on the Day Surgical Unit with a 3% admission rate. Median return to normal activities is 7 days. Forty percent of patients require no postoperative analgesia. These figures remain the same whether the hernia is primary, recurrent, unilateral, or bilateral. Consultants performed most operations early in the series, but latterly surgical trainees have performed the majority of these procedures under supervision. CONCLUSIONS: Laparoscopic TAPP hernia repair is technically difficult, but in the hands of a well-trained surgeon, it is safe and effective with a high degree of patient satisfaction. The low recurrence rate compares favorably to other tension-free mesh hernia repairs.

Symptomatic malignant gastroesophageal anastomotic leak: management with covered metallic esophageal stents.

OBJECTIVE: Gastroesophageal anastomotic leak after cancer resection has a mortality rate of up to 60% and significant morbidity, whatever the mode of treatment. We assessed the efficacy of esophageal stenting as a therapeutic option to reduce the mortality and morbidity associated with symptomatic intrathoracic anastomotic leakage. SUBJECTS AND METHODS: During a 52-month period, 14 patients had placement of stents for clinically significant postoperative leaks: 10 patients had an esophagogastrectomy and four patients had a total gastrectomy with esophagojejunal anastomosis. Thirteen of 14 patients had tumors that were histologically staged as T3 N1 M0 or worse. Significant anastomotic leaks were revealed by a contrast-enhanced study at 3-28 days after surgery. Stents were inserted in patients in whom the leakage was debilitating or initial conservative treatment had failed. Stenting outcome in terms of clinical and radiologic healing, hospital stay, survival, and complications was assessed. RESULTS: No procedural morbidity or 30-day mortality occurred. Immediate postprocedural leak occlusion was obtained in all patients. Clinical healing of the leak occurred in 13 (92.8%) of 14 patients, with a median healing time of 6 days. Of the 13 patients, healing occurred within 10 days in 10 patients (76.9%). Eight of these 10 early closures received a knitted nitinol stent (p = 0.02). One patient (7%) died as a consequence of leakage at 135 days. Median survival for all 14 patients was 11 months (Kaplan-Meier method). Complications included five episodes of food blockages in three patients, which required endoscopic clearance, and one case of stent-related upper gastrointestinal hemorrhage. No patients developed anastomotic stricture or occlusive epithelial hyperplasia. CONCLUSION: Covered esophageal stenting appears to reduce the mortality and morbidity of symptomatic anastomotic leakage after surgery for gastroesophageal cancer. Knitted nitinol stents may be best suited to this purpose.

Iatrogenic thoracic migration of the stomach complicating laparoscopic nissen fundoplication.

BACKGROUND: Intrathoracic gastric herniation after laparoscopic Nissen fundoplication is an uncommon but potentially life-threatening complication that may present in the early or late postoperative period. METHODS: A retrospective analysis was performed on all patients undergoing antireflux surgery from December 1991 to June 1999. RESULTS: Nine cases of gastric herniation occurred after 511 operations (0.17%). Patients presented with the condition 4 days to 29 months after surgery. Eight of these nine patients (89%) had reported vomiting in the immediate postoperative period. Seven patients (78%) reported persistent odynophagia. A factor common to all patients was that posterior crural repair had not been performed. CONCLUSIONS: Measures should be undertaken to prevent postoperative vomiting after laparoscopic Nissen fundoplication. Posterior crural repair is essential after surgery in all cases.

Stapled and nonstapled laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair. A prospective randomized trial.

BACKGROUND: Controversy exists regarding whether it is necessary to secure the mesh prosthesis during laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair. It is unknown whether stapling the mesh affects recurrence rate, incidence of neuralgia, or port-site hernia. METHODS: We conducted a prospective randomized trial comparing stapled with nonstapled laparoscopic TAPP inguinal hernia repairs in a series of 502 consecutive patients undergoing elective inguinal hernia repair at two institutions between January 1995 and March 1997. RESULTS: In all, 263 nonstapled and 273 stapled repairs were performed in 502 patients. Patients were evaluated at a median follow-up of 16 months (range, 1-32 months) by independent surgeons. There was no statistical difference in the incidence of recurrence (0 to 263 nonstapled, 3 to 273 stapled; chi-square p = 0.09). The overall recurrence rate was 0.6%. There was no significant difference in operative time, port-site hernia, chronic pain or neuralgia between the two groups. CONCLUSION: It is not necessary to secure the mesh during laparoscopic TAPP inguinal hernia repair, allowing a reduction in the size of the ports.

Microbiology of bacterial translocation in humans.

BACKGROUND: Gut translocation of bacteria has been shown in both animal and human studies. Evidence from animal studies that links bacteria translocation to the development of postoperative sepsis and multiple organ failure has yet to be confirmed in humans. AIMS: To examine the spectrum of bacteria involved in translocation in surgical patients undergoing laparotomy and to determine the relation between nodal migration of bacteria and the development of postoperative septic complications. METHODS: Mesenteric lymph nodes (MLN), serosal scrapings, and peripheral blood from 448 surgical patients undergoing laparotomy were analysed using standard microbiological techniques. RESULTS: Bacterial translocation was identified in 69 patients (15.4%). The most common organism identified was Escherichia coli (54%). Both enteric bacteria, typical of indigenous intestinal flora, and non-enteric bacteria were isolated. Postoperative septic complications developed in 104 patients (23%). Enteric organisms were responsible in 74% of patients. Forty one per cent of patients who had evidence of bacterial translocation developed sepsis compared with 14% in whom no organisms were cultured (p < 0.001). Septic morbidity was more frequent when a greater diversity of bacteria resided within the MLN, but this was not statistically significant. CONCLUSION: Bacterial translocation is associated with a significant increase in the development of postoperative sepsis in surgical patients. The organisms responsible for septic morbidity are similar in spectrum to those observed in the mesenteric lymph nodes. These data strongly support the gut origin hypothesis of sepsis in humans.

Gastric rupture secondary to successful Heimlich manoeuvre.

A fatal case of gastric rupture following the Heimlich manoeuvre is reported. This life-threatening complication has only been reported previously in seven patients with a high mortality rate. All patients should be assessed immediately following this manoeuvre for any potentially life-threatening complications.

Laparoscopic cholecystectomy without operative cholangiogram: 2038 cases over a 5-year period in two district general hospitals.

The place of cholangiography in laparoscopic cholecystectomy is debatable. This retrospective study reviews the outcome of 2061 patients operated upon for symptomatic gallstones in two district general hospitals. Intraoperative cholangiography was not used because all patients were submitted to a policy of selective preoperative investigation of the extrahepatic ducts. The conversion rate to open cholecystectomy was 3.1% and 88% of patients were discharged home within 48 h of surgery. No major duct injuries occurred and only 12 patients have presented with a proven retained stone after operation (0.7%). This policy of preoperative investigation and treatment for extrahepatic bile duct stones without intraoperative cholangiography has been employed in over 2000 patients and is at least as safe as published results using routine intraoperative cholangiography.

Gallstone ileus--beware the silent second stone.

Gallstone ileus remains a rare but important cause of small bowel obstruction. We report a case of recurrent gallstone ileus, presumably caused by an unidentified second stone resident within the gallbladder at the time of the initial laparotomy. This raises important questions about the traditional surgical management of this interesting condition.

Preoperative total parenteral nutrition is not associated with mucosal atrophy or bacterial translocation in humans.

Concerns have recently been expressed at suggestions that postoperative sepsis may be more common in patients who have received preoperative total parenteral nutrition (TPN). The mechanism suggested for this is that TPN causes intestinal mucosal atrophy leading to increased bacterial translocation from the gut as a source of systemic sepsis. This hypothesis was examined in 203 patients who had an elective laparotomy, 28 of whom required at least 10 days of preoperative TPN. Neither mucosal atrophy nor bacterial translocation was more common in parenterally fed patients than in enterally fed controls. In humans theoretical concerns about the adverse effects of TPN on intestinal integrity are unfounded.

Comparative audit of colorectal resection with the POSSUM scoring system.

Comparison of outcome after colorectal resection between different surgical units is difficult. Crude rates of morbidity and mortality may give a distorted picture as such rates fail to account for variations in case mix and physiological status of patients. The simple and validated scoring system POSSUM (Physiological and Operative Severity Score for enUmeration of Mortality and morbidity) was used to compare outcome after colorectal resection in two units. Consecutive series of patients who underwent colorectal resection in unit 1 (a university teaching hospital) or unit 2 (a district general hospital) were scored with the POSSUM system. Postoperative complications and 30-day mortality were recorded. In unit 1, 66 patients underwent colorectal resection with a mortality rate of 6 per cent and a morbidity rate of 9 per cent. In unit 2 the rates of mortality and morbidity were 9 and 26 per cent respectively for 182 patients undergoing colorectal resection. However, application of POSSUM predicted a mortality rate of 5.2 per cent for patients in unit 1 and 9.8 per cent for those in unit 2 with predicted morbidity rates of 11.2 and 23.9 per cent respectively. Direct comparison of outcome between these two units would be misleading. Application of POSSUM allows more realistic comparative audit of colorectal resection.

The prevalence of gut translocation in humans.

BACKGROUND/AIMS: Gut translocation of enteric organisms across the intact intestinal mucosa has been postulated as a potential source of sepsis in susceptible patients. However, little is known of its occurrence or significance in humans. The aim of this study was to determine the prevalence of gut translocation of bacteria in humans and attempt to identify any predisposing factors to its occurrence. METHODS: A consecutive series of 267 general surgical patients were examined for evidence of bacterial translocation by bacterial analysis of intestinal serosa and mesenteric lymph nodes taken at the time of surgery. RESULTS: Translocation occurred in 10.3% of patients overall. Both aerobic and anaerobic bacteria translocated. Excluding patients with distal intestinal obstruction and those with inflammatory bowel disease in whom translocation was more common, the prevalence was 5%. Neither jaundice, nutritional status, nor total parenteral nutrition predisposed to translocation. Similarly, mucosal atrophy did not predispose to this phenomenon. The development of postoperative septic complications was twice as common in patients with translocation as in those without, but mortality was unaffected. CONCLUSIONS: Translocation occurs as a spontaneous event in humans, but its clinical significance remains to be defined.

Perioperative immunotherapy with recombinant interleukin 2 in patients undergoing surgery for colorectal cancer.

Major surgery impairs the cellular immune response. We have therefore studied the immunological effects of low-dose recombinant interleukin 2 given to patients undergoing surgery for colorectal cancer to determine whether this agent has potential in perioperative adjuvant immunotherapy. Patients were randomly allocated to control (n = 13) or treatment groups (n = 12). Immunological studies of both lymphocyte function and subset number were performed preoperatively and on Days 1, 4, 7, and 10. Treatment with recombinant interleukin 2 prevented the postoperative fall in both natural killer and lymphokine-activated killer cell cytotoxicity, clearly demonstrated in the control group. The treatment group also showed in vivo T-cell activation with an initial lymphopenia followed by a rebound lymphocytosis and upregulation of the subset markers CD25 (interleukin 2 receptor) and CD45RO (T-memory cells). These combined effects may have important consequences in controlling metastatic dissemination of tumor during the vulnerable perioperative period.