Laparoscopically assisted colon resection for colon carcinoma: perioperative results and long-term outcome.

BACKGROUND: The role of laparoscopic colon resection in the management of colon cancer is unclear. The aims of this study were to compare perioperative results and long-term outcomes in patients randomized to either open (O) or laparoscopically assisted (LA) colon resection for colon cancer. METHODS: A prospective randomized trial comparing O to LA colon resection was conducted from January 1993 to November 1995. Preoperative workup, intraoperative results, complications, length of stay, pathologic findings, and long-term outcomes were compared between the two groups. Statistical analysis was performed with t-test. Follow-up periods ranged from 3.5 to 6.3 years (mean, 4.9 years). RESULTS: No port-site or abdominal wall recurrences were noted in any patients. [table: see text] CONCLUSIONS: These results suggest that laparoscopically assisted colon resection for malignant disease can be performed safely, with morbidity, mortality, and en bloc resections comparable with those of open laparotomy. Long-term (5-year) follow-up assessment shows similar outcomes in both groups of patients, demonstrating definite perioperative advantages with LA surgery and no perioperative or long-term disadvantages.

Ogilvie's syndrome in the surgical patient: a new therapeutic modality.

Acute colonic pseudo-obstruction, Ogilvie's syndrome, most often appears as a complication of other clinical conditions. It is characterized by massive colonic dilation in the absence of a mechanical cause. Therapy for this condition has traditionally been colonoscopic decompression via a flexible colonoscope. We performed a retrospective study to assess the efficacy of Cystografin enema for colonic decompression in Ogilvie's syndrome. We present a series of 18 patients who developed Ogilvie's syndrome while hospitalized for trauma (n = 10), burn (n = 1), gastrointestinal surgery (n = 4), and hip replacement (n = 3). The mean pre-enema cecal size was 13 cm (range 10 to 15 cm). The mean postenema cecal size was 8.5 cm (range 6 to 15 cm). Fifteen of the 18 patients underwent Cystografin enema as the primary mode of decompression. Three had undergone prior colonoscopy, which had failed. One of the 18 patients required repeat enema for inadequate decompression after the first enema and one underwent colonoscopy for recurrence. Two patients underwent operative intervention after the enema. There were no complications related to the enema. In all patients we were able to rule out a mechanical cause of large bowel obstruction. We believe the safety, efficacy, and ease of this procedure make Cystografin enema optimal first-line treatment for acute colonic pseudo-obstruction.

Differential effects of heparin on the early and late phases of hepatic ischemia and reperfusion injury in the pig.

The mechanisms by which heparin protects the liver during induced episodes of liver ischemia-reperfusion are poorly understood. Previous work in a swine model demonstrated that serum levels of glycohydrolases and lipid peroxide peaked within 3 h after 45 minutes of hepatic ischemia followed by reperfusion. Serum levels of lactate dehydrogenase and aspartate aminotransferase peaked 20-24 h later. The aim of this study was to evaluate the effect of heparin on these two-phases of enzyme release, using a pig model of hepatic ischemia-reperfusion injury. Twenty male swine were divided into control (n = 8) and heparin (n = 12) groups. In the heparin group, heparin was administered prior to and concurrent with ischemia-reperfusion. Following 45 min of hepatic ischemia, the levels of beta-galactosidase, beta-glucosidase, acid phosphatase, purine nucleoside phosphorylase, lipid peroxides, lactate dehydrogenase, and aspartate aminotransferase in serum were monitored for up to 166 h and compared to pre-ischemic and control levels. With heparin infusion, the peak levels of beta-galactosidase, beta-glucosidase, and the lipid peroxide were reduced to 50-60% of the control levels. Acid phosphatase and purine nucleoside phosphorylase activities in serum were reduced to 25% and 60%, respectively. The peak concentrations of lactate dehydrogenase and aspartate aminotransferase were reduced to about 25% of the control level. In addition, the serum enzymes of control pigs did not return to pre-ischemic levels until 2 weeks after hepatic ischemia, while they normalized in less than 1 week in the heparin-treated animals. Systemic heparinization had different protective effects on the first and secondary phases of liver injury. These differences may reflect heparin protection of different types of liver cells. The protection of the parenchymal cells may be the combined result of reduced sinusoidal cell injury and the anticoagulant properties of heparin.

Laparoscopic intraperitoneal onlay inguinal herniorrhaphy.

BACKGROUND: This study presents intermediate follow-up data on a randomized prospective series of patients undergoing either a modified laparoscopic intraperitoneal onlay mesh herniorrhaphy (IPOM) or conventional anterior inguinal herniorrhaphy (CH). METHODS: All patients from two university affiliated hospitals with primary or recurrent inguinal hernias were recruited for randomization to either the IPOM technique utilizing a meshed expanded polytetrafluorethylene (ePTFE) soft tissue patch or CH. Follow-up data were gathered from postoperative clinic visits and telephone and mail surveys. RESULTS: Previously reported early recurrence and complication rates at a mean follow-up of 8 months were 1 of 30 (3%) and 5 of 30 (17%) for IPOM, and 2 of 28 (7%) and 5 of 28 (18%) for CH. Intermediate follow-up with 50 (23 IPOM and 27 CH) of the original 58 patients (86%) at a mean of 41 months reveals a recurrence rate of 10 of 23 (43%) for the IPOM group and 4 of 27 (15%) for the CH group (P = 0.053). Five delayed complications occurred in 4 IPOM patients (port site hernia 4, painful neuroma 1), while 2 delayed complications (unilateral testicular atrophy 2) occurred in 2 patients in the CH group. One IPOM versus 5 CH patients subsequently developed previously unrecognized contralateral hernias. There was 1 death unrelated to previous herniorrhaphy in each group. CONCLUSIONS: IPOM recurrence rates (43%) at a mean follow-up of 41 months are excessively high when compared with CH (15%) or with preliminary results of IPOM at 8 months of follow-up (3%). Despite reduced perioperative pain and disability and promising preliminary results in the IPOM group, these intermediate follow-up data strongly suggest that the IPOM technique should not be used for repair of inguinal hernias.

Laparoscopy during pregnancy.

OBJECTIVE: To compare the safety and efficacy of laparoscopic surgery with that of open laparotomy in pregnant patients. DESIGN: Six-year case-control study. SETTING: Tertiary care, university and community hospitals. PATIENTS: Population-based sample. From 1990 through 1995, 16 pregnant patients underwent laparoscopic surgery (study group) and 18 underwent open laparotomy (control group) during the first or second trimester. Follow-up ranged from 1 month to 6 years. INTERVENTION: In the study group, 4 patients underwent appendectomies and 12 underwent cholecystectomies. The control group included 7 appendectomies and 11 cholecystectomies. MAIN OUTCOME MEASURES: The 2 groups were compared for age, trimester, surgical time, oxygen saturation, end-tidal carbon dioxide, return of gastrointestinal tract function, duration of intravenous or intramuscular narcotics, postoperative stay, gestational age of delivery, 1- and 5-minute Apgar scores, birth weights, and complications. RESULTS: Age, trimester, oxygenation, end-tidal CO2, gestational age at delivery, Apgar scores, and birth weights were not different between the 2 groups. The patients who underwent laparoscopy had significantly longer operative times 82 vs 49 minutes), shorter stay (1.5 vs 2.8 days), earlier resumption of regular diet (1.0 vs 2.4 days), and shorter duration of intravenous or intramuscular narcotics (1.2 vs 2.6 days) (all P < .01). Four complications were found in the laparotomy group vs 6 in the laparoscopy group. CONCLUSIONS: Laparoscopic surgery in pregnant women significantly decrease hospitalization, decreases narcotic use, and quickens return to a regular diet when compared with open laparotomy in pregnant women. No significant differences between the 2 groups in perioperative morbidity or mortality were present. These data suggest that therapeutic laparoscopy during pregnancy in the first or second trimester is safe.

Successful laparoscopic repair of paraesophageal hernia.

OBJECTIVE: To evaluate prospectively the safety and efficacy of laparoscopic surgical techniques in the repair of types II and III paraesophageal hernias. DESIGN: Case series. SETTING: Tertiary-care, university-affiliated hospitals. PATIENTS: Twelve consecutive patients undergoing elective laparoscopic repair of type II or type III paraesophageal hernias. Patients were available for follow-up for 1 to 17 months postoperatively. INTERVENTIONS: All patients underwent laparoscopic paraesophageal hernia reduction and repair. Eight patients with gastroesophageal reflux disease underwent concurrent laparoscopic Nissen fundoplication. MAIN OUTCOME MEASURES: Operative times, operative complications, and estimated blood loss were recorded. Postoperative outcome measurements included length of hospital stay, postoperative complications, postoperative gastrointestinal tract symptoms, and patient satisfaction. RESULTS: All patients had successful completion of paraesophageal hernia repair laparoscopically with no recurrences, and with an overall minor morbidity rate of 25%, major morbidity rate of 8%, and no deaths. Eight of 12 patients with concomitant reflux disease underwent successful laparoscopic Nissen fundoplication with complete control of reflux symptoms. The average hospital stay for patients with uncomplicated courses was 2.5 days. Long-term (> 6 weeks) postfundoplication symptoms occurred in 13% of those patients who underwent fundoplication. Eleven (92%) of 12 patients described good to excellent results with complete or near complete control of all preoperative symptoms. CONCLUSIONS: Laparoscopic repair of types II and III paraesophageal hernias can be performed under elective circumstances by experienced laparoscopic surgeons, with acceptable morbidity and comparable short-term efficacy. Addition of a concomitant antireflux procedure should be reserved for those patients with clear preoperative evidence of reflux disease secondary to a mechanically defective lower esophageal sphincter. Patients with a normal lower esophageal antireflux barrier do not need a concomitant antireflux procedure.

Laparoscopic antegrade sphincterotomy. A new technique for the management of complex choledocholithiasis.

OBJECTIVE: Laparoscopic antegrade sphincterotomy represents a new technique that expands the ability of the surgeon to manage complex choledocholithiasis at the time of laparoscopic cholecystectomy. The authors describe their experience with six patients with cholelithiasis and complex common bile duct stone disease who underwent successful laparoscopic cholecystectomy and antegrade sphincterotomies. SUMMARY BACKGROUND DATA: Patients with complex choledocholithiasis have represented a technical challenge to the minimally invasive surgeon. Recently, a laparoscopic technique of antegrade biliary sphincterotomy has been reported by DePaulo in Brazil. This technique has been successful at clearing the common bile duct at the time of laparoscopic cholecystectomy. METHODS: Laparoscopic antegrade sphincterotomy was performed in six patients with multiple common bile duct stones. A standard endoscopic sphincterotome was introduced antegrade via the cystic duct or common bile duct and guided through the ampulla. A side-viewing duodenoscope was used to confirm proper positioning of the sphincterotome. Then a blended current was applied until the sphincterotomy was complete. RESULTS: There was no mortality or morbidity associated with laparoscopic antegrade sphincterotomy. The mean additional operative time to complete laparoscopic antegrade sphincterotomy was 19 minutes. Three of the six patients were noted to have transient, asymptomatic elevation in serum amylase levels immediately after surgery (average 252 international units/L; normal < 115), which normalized within 72 hours. The mean postoperative hospital stay was 2.9 days. At a mean follow-up of 5 months (range 1 to 10 months), five patients remain asymptomatic. One individual with acquired immune deficiency syndrome had persistent symptoms, and a diagnosis of cytomegalovirus pancreatitis was eventually made. CONCLUSIONS: Laparoscopic antegrade sphincterotomy appears to be a safe and effective technique for the management of complex biliary tract disease.

Preliminary results of a prospective randomized trial of laparoscopic onlay versus conventional inguinal herniorrhaphy.

BACKGROUND: To compare laparoscopic onlay hernia repair with conventional surgery, 61 patients were randomized to either open or laparoscopic surgery. METHODS: Traditional repairs were done according to the surgeons' preference. Laparoscopic repairs utilized a modified onlay technique with a meshed prototype prosthesis. RESULTS: Mean operative time was 62.5 minutes for the laparoscopic group and 80.9 minutes for the open group. Each group had five complications. There were two conversions from laparoscopic to open surgery. Individuals undergoing laparoscopic surgery reported a mean intake of 5 doses of an oral narcotic analgesic versus 16 doses in the open group. Return to normal activity (nonstrenuous) was 7.5 days in the laparoscopic group and 18.5 days in the open group. After a mean follow-up of 8 months (range 1 to 14), there have been two recurrences in the open group and one in the laparoscopic group. CONCLUSION: Laparoscopic onlay inguinal herniorrhaphy is a viable alternative for those who prefer a minimally invasive treatment for this disease.

Successful management of severe gastroesophageal reflux disease with laparoscopic Nissen fundoplication.

BACKGROUND: Nissen fundoplication has been shown to be superior to medical treatment in the management of severe or complicated gastroesophageal reflux disease (GERD). Rapid advances in minimally invasive surgical technique and recognition of the advantages of reduced incision-related morbidity have fostered application of laparoscopic techniques to antireflux surgery. A prospective evaluation of 70 patients undergoing laparoscopic Nissen fundoplication for severe GERD was undertaken. PATIENTS AND METHODS: Rigid selection criteria for laparoscopic Nissen fundoplication included severe or refractory disease with documentation of abnormal esophageal acid exposure by 24-hour pH probe monitoring, documentation of a mechanically defective lower esophageal sphincter by esophageal manometry, and absence of severe esophageal and/or gastric motility disorders. RESULTS: Sixty-eight of 70 patients were completed laparoscopically with an intraoperative morbidity rate of 9%. Major postoperative complications occurred in 3 patients (4%) and included deep venous thrombosis (n = 1), delayed gastric leak (n = 1), and trocar site hernia (n = 1). The average hospital stay was 3.0 days, and the average time to return to normal activity was 7.0 days. All patients experienced relief of symptoms of reflux with mean follow-up of 7.7 months. Transient, mild dysphagia was experienced by 37% of patients, and persistent, severe dysphagia by 7%. The mean increase in lower esophageal sphincter pressure was 16.2 mm Hg. The total and intra-abdominal sphincter lengths increased an average of 1.5 and 1.4 cm, respectively. CONCLUSIONS: These preliminary data suggest that laparoscopic Nissen fundoplication can be performed by experienced laparoscopic surgeons with excellent symptomatic and physiologic results and a morbidity rate comparable to conventional open antireflux procedures. Rigid patient selection criteria will help identify the patients most likely to benefit from reconstruction of a mechanically defective lower esophageal sphincter. Adherence to established operative principles for Nissen fundoplication will reduce the incidence of significant postfundoplication symptoms.

Laparoscopic and endoscopic management of common bile duct stones.

The rapid evolution and acceptance of laparoscopic cholecystectomy for the management of symptomatic cholelithiasis and acute and chronic cholecystitis are unprecedented in modern surgical practice. With rapid advances in laparoscopic and endoscopic instrumentation and surgical skills, many surgeons are developing minimally invasive techniques and strategies for treating the patient with known, suspected, or unsuspected choledocholithiasis. Recent articles describing the current status, complications, results, and future directions of laparoscopic and endoscopic management of common bile duct stones are reviewed. The role of endoscopic retrograde cholangiopancreatography and sphincterotomy, laparoscopic exploration of the common bile duct, choledochoscopy, and percutaneous transhepatic extraction techniques are discussed.

Laparoscopic-assisted colon resection.

The popularity and success of laparoscopic biliary tract surgery have persuaded surgeons to explore other applications for rigid endoscopic surgery. From July 1990 to February 1993 a total of 65 patients (mean age 57 years; range 41-82) underwent attempted laparoscopic colon resection. Indications for surgical intervention included cancer (39), adenomatous polyps (14), diverticulosis (10), stricture (1), and foreign-body perforation (1). A laparoscopic-assisted technique whereby the specimen was removed and the anastomosis was completed outside of the abdomen was used in all patients. A dilated umbilical opening was used for right-sided lesions and a left-lower-quadrant muscle-splitting incision for descending and sigmoid colon resections. Two patients required conversion to open laparotomy. There were no deaths and only four complications (pneumonia 1, urinary tract infection 1, prolonged ileus 1, and subfascial abscess 1). The mean postoperative stay was 4.4 days (range 3-8 days) and the average interval for return to normal activity was 8 days. Laparoscopic-assisted colon resection appears to be a safe and beneficial option for many patients with pathologic disorders of the large intestine. Future clinical trials are needed to fully determine the appropriateness of this procedure in patients with localized malignancies.

Antibiotic treatment for surgical peritonitis.

The charts of 480 patients with secondary bacterial peritonitis were reviewed. The antibiotics used were compared with the culture and sensitivity data obtained at surgery, and the outcomes of patients were evaluated. Patients treated with a single broad-spectrum antibiotic had a better outcome than patients treated with multiple drug treatment. Inadequate empiric antibiotic treatment was associated with poorer outcome than any other type of treatment. The outcome of this inadequate treatment group could not be improved by any antibiotic response to culture and sensitivity information after operation. Those patients treated with antibiotic coverage for anticipated organisms and having no cultures taken did as well as patients having cultures taken. Surgeons typically ignore culture data after operation, and only 8.8% of patients in this study had an appropriate change in antibiotic treatment after operation. A benefit from obtaining operative cultures could not be identified.

Antibiotic pharmacokinetics in surgery.

Pharmacokinetics is the study of variables that affect drug concentrations at the effector site. The descriptive terms peak concentration, elimination half-life, volume of distribution, and bioavailability are commonly used to express pharmacokinetic variability among drugs used in patient care. The pharmacokinetic characteristics of drugs are important for surgeons to understand because they represent differences that may assume clinical significance when selecting antibiotics for preoperative preventive indications. In addition, the changing hemodynamic pattern of the stressed and septic patient may result in changing pharmacokinetic patterns for an antibiotic, which, in turn, may require changes in the dosing regimen during the course of treatment.