Perineal stapled prolapse resection for full-thickness external rectal prolapse: a multicentre prospective study.

AIM: Many different surgical techniques have been reported for the surgical treatment of full-thickness external rectal prolapse. Perianal stapled prolapse resection (PSP) is a relatively newly reported technique for full thickness external rectal prolapse. The aim of this prospective multicentre study was to evaluate the results of this procedure. METHOD: Consecutive patients who underwent a PSP resection for full-thickness external rectal prolapse at five centres were recruited to the study. Median operating time, hospital stay, complications, recurrence and functional results according to the Wexner Incontinence Scale and obstructive defaecation syndrome score were recorded. RESULTS: There were 27 patients treated by PSP. The median Wexner incontinence score improved from 10 presurgery to 5 after surgery (P < 0.001); the median obstructed defaecation syndrome score improved from 12 presurgery to 5 (range 4-10) after surgery (P < 0.001). A laparoscopically assisted procedure was performed in three patients (11.1%). The median number of cartridges used was six (range four to nine). The median operating time was 48 min. Early complications occurred in six patients (22.2%) and late complications in two (7.4%). The median length of hospital stay was 5 days. The recurrence rate at a median follow-up of 30.3 months was 14.8%. CONCLUSION: PSP appears to be an easy, fast and safe procedure. Early functional results are good. The recurrence rate compares favourably with other perineal procedures like the Delorme or the Altemeier operations. Long-term functional results need to be investigated further.

Laparoscopic gastrectomy for treatment of advanced gastric cancer: preliminary experience on 38 cases.

AIM: In the last 20 years the laparoscopic surgery rapidly and successfully diffused for the treatment of benign diseases and recently also for the treatment of malignancy; newerteless, the laparoscopic gastrectomy for gastric cancer is still controversial, in relation to extreme difficulty of a radical surgical resection performing with an accurate lymphadectomy. The authors present a surgical experience of patients affected by advanced gastric cancer who underwent total or subtotal gastrectomy with videoassisted or entirely laparoscopic technique in order to evaluate the safety, feasibility, advantages and limits of this surgical approach. METHODS: between January 2002 and August 2007 we performed 40 laparoscopic procedure for advanced gastric cancer; of these, 38 (95%) patients underwent a laparoscopic gastric resection and 2 (5%) patients underwent a palliative surgical treatment (laparoscopic gastro-entero-anastomosis). In the 38 patients which underwent laparoscopic gastrectomy, the anatomical localization of cancer, ASA score, pTNM classification, type of surgical laparoscopic technique (videoassisted or entirey laparoscopic technique), mean number of lymph nodes harvested, mean operative time, rate of conversion, postoperative morbidity and mortality and rate of local recurrence at 24 mounths follow-up were retrospectively analyzed. RESULTS: Thirty-eight laparoscopic gastrectomies for gastric cancer were performed: in relation to surgical technique, 4 (10.5%) of these were video-assisted gastric resection (left subcostal minilaparotomy and extracorporeal anastomosis) and 34 (89.5%) were entirely laparoscopic gastrectomy; regarding to extension of surgical resection, there were 16 (42%) total D2 gastrectomies and 22 (58%) subtotal gastrectomies, of which 19 D2 gastrectomy and 3 D1 gastrectomy. Regarding the ASA score, 23% of patients were in ASA I, 52% in ASA II, 25% in ASA III. The mean operative time was 225 minutes (range 160-285) for total gastrectomy and 183 minutes (range 70-270) for subtotal gastrectomy. Overall, on 38 laparoscopic gastric resection, the conversion rate was 7.8% (3 patients). The number of lymph nodes harvested was 28 (range 5-53). No major intraoperative complications were observed. Overall morbidity was 31.5% (12 patients); the rate of postoperative surgical complications was 8% (3 patients). One patient (2.6%) dead for a sepsis subsequent to leak of esophagojejunal anastomosis. Mean hospital stay was 16 days for total gastrectomies and 12 days for subtotal gastrectomies. Three cases (7.9%) of cancer recurrence were observed in 3 patients (2 patiens UICC IIIa, one patient UICC IIIb) at 20th, 23th, 24th postoperative month and one case (2.6%) of peritoneal carcinosis at 18th month. No port-site metastasis were observed at 24-month follow-up. CONCLUSIONS: On the basis of this surgical preliminary experience, laparoscopic gastrectomy for malignancy resulted a technically safe surgical procedure if performed by an advanced laparoscopic surgical team, with additional benefits, time to resumption of oral intake, morbidity rate, and acceptance from patients. A radical laparoscopic gastrectomy via laparoscopic approach is advisable until UICC stage II, in patients with ASA score I-III and minimal endoabdominal adhesion. The safe and efficacy of laparoscopic treatment in locoregional limph nodes dissection is still controversial. However, long-term results of prospective and comparative trials will be necessary to show the real oncologically benefits of laparoscopic approach.

Laparoscopic approach to morbid obesity: personal experience of 250 gastric bypasses. Analysis of different techniques and results.

AIM: Severe obesity is a major health problem affecting more than 1,000,000 people in Italy, with a 95% failure rate of nonsurgical treatments. We report our over five-years experience with laparoscopic Roux-en-Y gastric bypass (LRYGBP), evaluating the postoperative course of the patients undergoing 3 different gastro-esophageal anastomosis technique: Gagner procedure (87 cases) (34.8%), the purse-string approach (93 cases) (37.2%), robotic-assisted gastric bypass (68 cases) (27.2%) and by laparoscopic hand sewn anastomosis (2 cases) (0.8%). METHODS: Between October 2000 and February 2006, we performed LRYGBP on 250 patients (77 male and 173 female aged from 16 to 65 years [mean age 43.1 years] and with an average body mass index of 51.1 kg/m(2) [35-99]). Comorbidities were: hypertension, type II diabetes, hyperlipemia, osteoarthritis, chronic restrictive pulmonary insufficiency, sleep apnea, deep venous thrombosis. RESULTS: The mean operative time was 142.3 min (80-420) with a mean hospitalization of 9.8 days (5-44). Eighteen major complications were recorded. There were no deaths. The mean percent excess body weight loss was 47.2+/-18.2% after 1 year (212 patients), 66.2+/- 19.4% after 2 years (178 patients), 78.2+/-12.4% after 3 years (139 patients), 80.6+/-11.7% after 4 years (101 patients), and 82.5+/-10.2% after 5 years (67 patients). Nearly all of the comorbidities were solved or improved. Bariatric analysis and reporting outcome system results after 5 years were excellent, good or fair in 100% of the subject evaluated. CONCLUSIONS: Although requiring the skill of an expert surgeon, LRYGBP is one of the most effective procedure available today to induce long-term weight loss, with limited nutritional risks and better prospects for improved quality of life.

Laparoscopic gastric bypass performed with the Da Vinci Intuitive Robotic System: preliminary experience.

BACKGROUND: This study aimed to analyze retrospectively the authors' preliminary experience using the Da Vinci Intuitive Robotic System for gastric bypass in managing morbid obesity, and to determine its efficacy and safety in relation to other standardized laparoscopic surgical techniques. METHODS: From October 2000 to March 2004 the authors performed 146 laparoscopic gastric bypasses, 17 of which were robot assisted using the Da Vinci Intuitive Robotic System. The last patients were 7 men and 10 women with a mean age of 44 years. The mean weight was 139 kg, and the mean body mass index (BMI) was 49.8 kg/m at first postoperative recovery. The mean excess body weight (EBW) was 131%. Follow-up assessment, performed at months 1, 3, 6, and 12, then yearly thereafter, included evaluation of the variations in BMI and the percentage of excess body weight loss (EBWL%). All the patients were informed of the risks inherent with each surgical procedure as well as the potential benefits. RESULTS: The mean operative time was 201 min (range, 90-300 min). No intraoperative complications and no conversion occurred in this series. The mean hospital stay was 9 days (range, 6-18 days). The patients in this series experienced a normal postoperative course without anastomotic complications. The mortality rate was zero. No robot-related complications were noted. The analysis of follow-up assessment at months 1, 3, 6, and 12 showed a progressive decrease in BMI and an increment of EBWL%. CONCLUSIONS: The authors' early experience with robotic surgery suggests that it is safe and could be an effective alternative to conventional laparoscopic surgery. The authors believe that robotic surgery, with its ability to restore the hand-eye coordination and three-dimensional view lost in laparoscopic surgery, could allow complex procedures to be performed with greater precision and better results.

Gasless laparoscopy could avoid alterations in hepatic function.

BACKGROUND: In a previous clinical study, we showed that the duration and level of pneumoperitoneum are responsible for changes in hepatic function during laparoscopic procedures. These findings encouraged us to evaluate hepatic function during laparoscopy with and without carbon dioxide (CO(2)) pneumoperitoneum in a clinical setting. METHODS: We performed 63 laparoscopic cholecystectomies and 30 non-hepatobiliary laparoscopic procedures in 93 consecutive patients with normal preoperative liver function tests. The anesthesiologic protocol was uniform, using drugs at low hepatic metabolism. We performed laparoscopic cholecystectomies in 43 patients with a pneumoperitoneum; in the remaining 20, we used a gasless technique. We randomized the 43 laparoscopic cholecystectomies into 23 performed with pneumoperitoneum at 14 mmHg and 20 performed at 10 mmHg. All non-hepatobiliary laparoscopic procedures were performed with a pneumoperitoneum of 14 mmHg. The postoperative serologic levels of AST, ALT, and bilirubin, and the prothrombin time were measured at 6, 24, 48, and 72 h. The alterations in the serologic hepatic tests were then related to the type of procedure, its duration, and the level of pneumoperitoneum. RESULTS: The study group was comprised of 93 patients, 39 male and 54 female, with a mean age of 50.5 years (range, 15-74). There were no deaths. There was no morbidity in the pneumoperitoneum group, but there was one case of accidental omental injury during the placement of the abdominal, wall retractor in the gasless group. All patients had postoperative changes in serologic hepatic tests. Slow return to normality occurred 48 or 72 h after the operation. The increase in AST and ALT was statistically significant and correlated to the level and duration of pneumoperitoneum. The serologic change in the gasless group were significantly lower than in the laparoscopic cholecystectomy group with pneumoperitoneum at 14 mmHg. There was no statistically significant difference between the gasless group and the laparoscopic cholecystectomy group with pneumoperitoneum at 10 mmHg. There was a statistically the significant increase in the non-hepatobiliary laparoscopy group over the gasless group, despite the absence of hepatobiliary injuries in the first group. No symptoms were related to these serologic hepatic changes. CONCLUSIONS: The gasless technique causes smaller alterations in serological hepatic parameters than pneumoperitoneum at 14 mmHg. By contrast, the gasless technique and low-pressure pneumoperitoneum have the same effect on hepatic function. Therefore, the use of a subcutaneous abdominal wall retractor combined with a low-pressure pneumoperitoneum is recommended for patients with severe hepatic failure. Transaminases

Current management of common bile duct stones in northern Italy.

In order to obtain a complete picture of the current management of cholecystocholedocal lithiasis in northern Italy we've conducted the present survey. In the years 1992-1993, among 7,861 cholecystectomies, 665 patients with gallbladder and common bile duct stones were treated in 49 surgical departments. Some 271 (43%) were treated by traditional methods: open surgery or endoscopic sphincterotomy followed by laparotomic cholecystectomy; 313 patients (49%) were treated by endoscopic sphincterotomy followed by laparoscopic cholecystectomy and only 38 (6%) were treated by one-stage laparoscopy, either by a transcystic approach (27) or by laparoscopic choledochotomy (11). Morbidity and mortality were not significantly different in the different groups. We conclude that open surgery and sequential minimal invasive treatment are the standard approaches to cholecystocholedochal lithiasis in this first stage of the laparoscopic era. The laparoscopic management of common bile duct stones is at present confined to surgical departments specially devoted to laparoscopic surgery.