First experience in laparoscopic surgery in low and middle income countries: A systematic review

BACKGROUND

Laparoscopic surgery has reduced morbidity and mortality rates, shorter postoperative recovery periods and lower complication rates than open surgery. It is routine practice in high-income countries and is becoming increasingly common in countries with limited resources. However, introducing laparoscopic surgery in low-and-middle-income countries (LMIC) can be expensive and requires resources, equipment, and trainers.

AIM

To report the challenges and benefits of introducing laparoscopic surgery in LMIC as well as to identify solutions to these challenges for countries with limited finances and resources.

METHODS

MEDLINE, EMBASE and Cochrane databases were searched for studies reporting first experience in laparoscopic surgery in LMIC. Included studies were published between 1996 and 2022 with full text available in English. Exclusion criteria were studies considering only open surgery, ear, nose, and throat, endoscopy, arthroscopy, hysteroscopy, cystoscopy, transplant, or bariatric surgery.

RESULTS

Ten studies out of 3409 screened papers, from eight LMIC were eligible for inclusion in the final analysis, totaling 2497 patients. Most reported challenges were related to costs of equipment and training programmes, equipment problems such as faulty equipment, and access to surgical kits. Training-related challenges were reliance on foreign trainers and lack of locally trained surgeons and theatre staff. The benefits of introducing laparoscopic surgery were economic and clinical, including a reduction in hospital stay, complications, and morbidity/mortality. The introduction of laparoscopic surgery also provided training opportunities for junior doctors.

CONCLUSION

Despite financial and technical challenges, many studies emphasise the overall benefit of introducing laparoscopic surgery in LMICs such as reduced hospital stay and the related lower cost for patients. While many of the clinical centres in LMICs have proposed practical solutions to the challenges reported, more support is critically required, in particular regarding training.

Parastomal hernia containing the stomach-a rare complication

A lady in her 70s presented to hospital with sudden onset nausea and excessive vomiting. She had a constant and worsening abdominal pain that radiated to the back but was focused on her stoma in the left iliac fossa. The patient had bilateral hernias and colostomy following a Hartman's procedure for perforated diverticulosis in 2018 and had presented twice before in the last 6 months with similar symptoms. CT abdomen pelvis showed a large portion of the stomach in the parastomal hernia leading to a narrowing of the stomach at the hernia neck but no ischaemic changes. She was diagnosed with bowel obstruction and successfully treated with fluid resuscitation, proton pump inhibitors, analgesia, antiemetics and decompression of the stomach using large bore nasogastric tube. A total of 2600 ml fluid was aspirated in 24 h and her stoma restarted normal output. After 10 days she was discharged home.

A keyhole approach gives a sound repair for ileal conduit parastomal hernia

PURPOSE

The purpose of this study was to report and evaluate a laparoscopic surgical technique for the treatment of parastomal hernia (PSH) after ileal conduit urinary diversion aiming to minimize PSH recurrence and perioperative complications.

METHODS

We retrospectively evaluated all patients who underwent a PSH (after ileal conduit urinary diversion) repair at Addenbrookes Hospital, Cambridge. As a surgical approach, a laparoscopic repair with mesh was utilized in all cases. Subsequently, we performed a voluntary follow-up of the patients to evaluate long-term recurrence and complication rates. In addition, we conducted a reassessment of the cross-sectional imaging available.

RESULTS

Between November 2008 and December 2019, 27 patients underwent hernia repair due to a clinically significant hernia. Out of those patients, one suffered from a post-operative wound infection. In total 23 patients participated in the follow-up with a median follow-up period of 91 months. Follow-up examination revealed two cases of recurrent PSH (8.7% of patients followed up), four patients suffered from minor complications (14.8%).

CONCLUSION

Repair of PSH associated with ileal conduit is particularly scarce. Our surgical approach presents the only laparoscopic case series of an effective method for treating a PSH from an ileal conduit with a low complication and recurrence rate.

Rate of local recurrence in a cohort of 125 patients treated by transanal total mesorectal excision due to rectal cancer

Objective

Transanal total mesorectal excision (taTME) is an alternative to conventional TME owing to its reported superior ability to achieve clear resection margins in low rectal cancers. Yet, nationwide Norwegian data claimed a 12-month local recurrence rate of up to 10%, a three-fold increase compared to conventional TME, questioning the oncological safety of taTME.

Methods

Consecutive patients with low rectal cancer treated by taTME were prospectively included. Patients who required a partial mesorectal excision were excluded. Perioperative outcomes were reported as median and interquartile range (IQR). Data were independently audited and certified.

Results

125 patients (88 men : 37 women) with a low rectal cancer (7 cm to anal verge, IQR 5-9) underwent a taTME. Age and body mass index were 65 years (IQR 56-76) and 26 kg/m2 (IQR 23-29). 87 (70%) patients had neoadjuvant radiochemotherapy. Surgery time was 357 minutes (IQR 303-435), including an ileostomy in all patients. 1 patient (0.8%) required a conversion to laparotomy. Performing taTME in a 2-team technique saved 94 minutes or 19% operating time (p < 0.005, t-test one-team (n = 52, 420 minutes, IQR 349-494) vs. 2-team (n = 73, 326 minutes, IQR 285-372). 30-day morbidity amounted to 36% minor complications (Dindo Clavien I-II) and 25% major complications (Dindo Clavien III-V), including 11 anastomotic leaks (9%) and 3 reoperations (3%). Most of the leaks could be managed endoscopically and the ileostomy reversed at last. Median length of hospital stay was 10 days (IQR 8-14).

Median follow-up was 45 months (IQR 25-67; range 13-95). Dissection of the mesorectum was excellent (Quirke 1 incomplete mesorectal excision rate: 1.6%) with 100% clear margins (distal margin 16mm, IQR 10-30; circumferential margin 10mm, IQR 5-15). Median T stage was 3 (IQR 2-3). 24 patients had positive lymphnodes (median 27, IQR 21-38). Local recurrence occurred in 7 (6%) patients and development of metachronous metastasis was present in 36 (29%) patients. This led to a 5-year disease-free survival of 56% and a 5-year overall survival of 86%.

Conclusion

Transanal total mesorectal excision allows good surgical and oncologic quality to the expenses of a reasonable surgery time and morbidity.

Extended lymph node resection versus standard resection for pancreatic head and peri-ampullary adenocarcinoma: A systemic review

Objective

For patients with pancreatic and peri-ampullary adenocarcinoma, it has been hypothesized that extended lymphadenectomy may result in higher R0 resection rates and improved survival. As such, the objective of this systematic review was to compare the oncologic outcomes after pancreaticoduodenectomy (PD) with standard lymphadenectomy (SLA) versus PD with extended lymphadenectomy (ELA).

Methods

A Cochrane systematic review was conducted to identify all randomized controlled trials comparing PD with SLA versus PD with ELA for participants with periampullary or pancreatic cancer. The following electronic databases were reviewed: the Cochrane Central Register of Controlled Trials; MEDLINE; PubMed and EMBASE. The methodological quality of the included studies was assessed using the Cochrane risk of bias criteria and the quality of evidence for important outcomes using GRADE. Extended lymphadenectomy included the interaortocaval space, left side of the celiac trunk, and superior mesenteric artery.

Results

Seven randomized controlled trials were included with 843 patients (421 ELA and 422 SLA). No difference in overall survival (1- and 3-years after surgery) was seen between groups. Mortality and morbidity rates (including pancreatic fistula, delayed gastric emptying, and postoperative bleeding) were similar between the two groups. Operative time was significantly longer following extended resection (Mean Difference 50.1 min; 95% CI 19.2 to 81.1 min; P = 0.001). Total amount of blood loss during surgery was significantly increased following extended resection (Mean Difference 137 ml; 95% CI 12 to 263 ml; P = 0.03), as well as transfusion requirements (Mean Difference 0.15 units; 95% CI 0.13 to 0.17 units; P < 0.00001).

More lymph nodes were retrieved during ELA (Mean Difference 11 nodes; 95% CI 7 to 15 nodes; P < 0.00001). Incidence of positive resection margins was not different between groups.

Conclusion

There is no indication for extended lymphadenectomy in pancreatic head resection as a routine procedure.

Extended lymph node resection versus standard resection for pancreatic and periampullary adenocarcinoma

BACKGROUND

Pancreatic and periampullary adenocarcinomas account for some of the most aggressive malignancies, and the leading causes of cancer-related mortalities. Partial pancreaticoduodenectomy (PD) with negative resection margins is the only potentially curative therapy. The high prevalence of lymph node metastases has led to the hypothesis that wider excision with the removal of more lymphatic tissue could result in an improvement of survival, and higher rates of negative resection margins.

OBJECTIVES

To compare overall survival following standard (SLA) versus extended lymph lymphadenectomy (ELA) for pancreatic head and periampullary adenocarcinoma. We also compared secondary outcomes, such as morbidity, mortality, and tumour involvement of the resection margins between the two procedures.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PubMed, and Embase from 1973 to September 2020; we applied no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCT) comparing PD with SLA versus PD with ELA, including participants with pancreatic head and periampullary adenocarcinoma.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened references and extracted data from study reports. We calculated pooled risk ratios (RR) for most binary outcomes except for postoperative mortality, for which we estimated a Peto odds ratio (Peto OR), and mean differences (MD) for continuous outcomes. We used a fixed-effect model in the absence of substantial heterogeneity (I² < 25%), and a random-effects model in cases of substantial heterogeneity (I² > 25%). Two review authors independently assessed risk of bias, and we used GRADE to assess the quality of the evidence for important outcomes.

MAIN RESULTS

We included seven studies with 843 participants (421 ELA and 422 SLA). All seven studies included Kaplan-Meier curves for overall survival. There was little or no difference in survival between groups (log hazard ratio (log HR) 0.12, 95% confidence interval (CI) -3.06 to 3.31; P = 0.94; seven studies, 843 participants; very low-quality evidence). There was little or no difference in postoperative mortality between the groups (Peto odds ratio (OR) 1.20, 95% CI 0.51 to 2.80; seven studies, 843 participants; low-quality evidence). Operating time was probably longer for ELA (mean difference (MD) 50.13 minutes, 95% CI 19.19 to 81.06 minutes; five studies, 670 participants; moderate-quality evidence). There was substantial heterogeneity between the studies (I² = 88%; P < 0.00001). There may have been more blood loss during ELA (MD 137.43 mL, 95% CI 11.55 to 263.30 mL; two studies, 463 participants; very low-quality evidence). There was substantial heterogeneity between the studies (I² = 81%, P = 0.02). There may have been more lymph nodes retrieved during ELA (MD 11.09 nodes, 95% CI 7.16 to 15.02; five studies, 670 participants; moderate-quality evidence). There was substantial heterogeneity between the studies (I² = 81%, P < 0.00001). There was little or no difference in the incidence of positive resection margins between groups (RR 0.81, 95% CI 0.58 to 1.13; six studies, 783 participants; very low-quality evidence).

AUTHORS' CONCLUSIONS

There is no evidence of an impact on survival with extended versus standard lymph node resection. However, the operating time may have been longer and blood loss greater in the extended resection group. In conclusion, current evidence neither supports nor refutes the effect of extended lymph lymphadenectomy in people with adenocarcinoma of the head of the pancreas.

Glomus tumour of the stomach

Glomus tumours are benign tumours typically arising from the glomus bodies and primarily found under the fingernails or toenails. These rare neoplasms account for <2% of all soft tissue tumours and are generally not found in the gastrointestinal tract. We report a case of a 40-year-old man presenting with recurrent epigastric pain and pyrosis. Endoscopy revealed a solitary tumour in the antrum of the stomach. Fine-needle aspiration biopsy was suspicious for a gastrointestinal stroma tumour. After CT indicated the resectability of the tumour, showing neither lymphatic nor distant metastases, a laparoscopic-assisted gastric wedge resection was performed. Surprisingly, histology revealed a glomus tumour of the stomach.

Muscle ischaemia in patients with orthostatic hypotension assessed by velocity recovery cycles

OBJECTIVE

Patients with orthostatic hypotension may experience neck pain radiating to the occipital region of the skull and the shoulders while standing (so-called coat-hanger ache). This study assessed muscle membrane potential in the trapezius muscle of patients with orthostatic hypotension and healthy subjects during head-up tilt (HUT), by measuring velocity recovery cycles (VRCs) of muscle action potentials as an indicator of muscle membrane potential.

METHODS

Eight patients with multiple system atrophy (MSA), orthostatic hypotension and a positive history for coat-hanger pain and eight normal controls (NCs) were included in this study. Repeated VRCs were recorded from the trapezius muscle by direct muscle stimulation in the supine position and during HUT for 10 min.

RESULTS

Muscle VRC recordings did not differ between MSA patients and NCs in the supine position. During HUT, early supernormality decreased progressively and relative refractory period increased in MSA patients whereas VRC measures remained unchanged in NCs. Ten minutes after the start of HUT, early supernormality was reduced by 44% and relative refractory period was increased by 17%.

CONCLUSIONS

Muscle membranes in patients with orthostatic hypotension become progressively depolarised during standing. Membrane depolarisation is most likely the result of muscle ischaemia, related to the drop in perfusion pressure caused by orthostatic hypotension. Coat-hanger ache is most likely a consequence of this muscle ischaemia.

Velocity recovery cycles of human muscle action potentials: repeatability and variability

OBJECTIVE

Velocity recovery cycles (VRCs) of human muscle action potentials have been proposed as a new technique for assessing muscle membrane function in myopathies. This study was undertaken to determine the variability and repeatability of VRC measures such as supernormality, to help guide future clinical use of the method.

METHODS

To assess repeatability, VRCs with one and two conditioning stimuli were recorded from brachioradialis muscle by direct muscle stimulation in 20 normal volunteers, and the measurements repeated 1 week later. To further assess variability and dependence on electrode separation, age and sex, recordings from an additional 20 normal volunteers were added.

RESULTS

There was a high intraclass correlation between repeated recordings of early supernormality, indicating excellent reliability of this VRC measure. However, relative refractory period had a smaller coefficient of repeatability in relation to the changes previously described during ischemia. We found no evidence that any of the excitability measures depended on electrode separation, conduction time or apparent velocity. There were also no significant differences between the recordings from men and women, or between the recordings from older (mean 44.9 y) and younger (26.5 y) subjects.

CONCLUSIONS

VRC measures are sufficiently consistent to be suitable for comparing muscle membrane function both within subjects and between groups. Early supernormality measurements benefit most from within subject comparisons.

SIGNIFICANCE

These normative data sets provide a firm basis for planning clinical studies.