Abdominal drainage after elective colorectal surgery: propensity score-matched retrospective analysis of an Italian cohort

BACKGROUND

In Italy, surgeons continue to drain the abdominal cavity in more than 50 per cent of patients after colorectal resection. The aim of this study was to evaluate the impact of abdominal drain placement on early adverse events in patients undergoing elective colorectal surgery.

METHODS

A database was retrospectively analysed through a 1:1 propensity score-matching model including 21 covariates. The primary endpoint was the postoperative duration of stay, and the secondary endpoints were surgical site infections, infectious morbidity rate defined as surgical site infections plus pulmonary infections plus urinary infections, anastomotic leakage, overall morbidity rate, major morbidity rate, reoperation and mortality rates. The results of multiple logistic regression analyses were presented as odds ratios (OR) and 95 per cent c.i.

RESULTS

A total of 6157 patients were analysed to produce two well-balanced groups of 1802 patients: group (A), no abdominal drain(s) and group (B), abdominal drain(s). Group A versus group B showed a significantly lower risk of postoperative duration of stay >6 days (OR 0.60; 95 per cent c.i. 0.51-0.70; P < 0.001). A mean postoperative duration of stay difference of 0.86 days was detected between groups. No difference was recorded between the two groups for all the other endpoints.

CONCLUSION

This study confirms that placement of abdominal drain(s) after elective colorectal surgery is associated with a non-clinically significant longer (0.86 days) postoperative duration of stay but has no impact on any other secondary outcomes, confirming that abdominal drains should not be used routinely in colorectal surgery.

Mechanical bowel preparation in elective colorectal surgery: a propensity score-matched analysis of the Italian colorectal anastomotic leakage (iCral) study group prospective cohorts

Retrospective evaluation of the effects of mechanical bowel preparation (MBP) on data derived from two prospective open-label observational multicenter studies in Italy regarding elective colorectal surgery. MBP for elective colorectal surgery remains a controversial issue with contrasting recommendations in current guidelines. The Italian ColoRectal Anastomotic Leakage (iCral) study group, therefore, decided to estimate the effects of no MBP (treatment variable) versus MBP for elective colorectal surgery. A total of 8359 patients who underwent colorectal resection with anastomosis were enrolled in two consecutive prospective studies in 78 surgical centers in Italy from January 2019 to September 2021. A retrospective PSMA was performed on 5455 (65.3%) cases after the application of explicit exclusion criteria to eliminate confounders. The primary endpoints were anastomotic leakage (AL) and surgical site infections (SSI) rates; the secondary endpoints included SSI subgroups, overall and major morbidity, reoperation, and mortality rates. Overall length of postoperative hospital stay (LOS) was also considered. Two well-balanced groups of 1125 patients each were generated: group A (No MBP, true population of interest), and group B (MBP, control population), performing a PSMA considering 21 covariates. Group A vs. group B resulted significantly associated with a lower risk of AL [42 (3.5%) vs. 73 (6.0%) events; OR 0.57; 95% CI 0.38-0.84; p = 0.005]. No difference was recorded between the two groups for SSI [73 (6.0%) vs. 85 (7.0%) events; OR 0.88; 95% CI 0.63-1.22; p = 0.441]. Regarding the secondary endpoints, no MBP resulted significantly associated with a lower risk of reoperation and LOS > 6 days. This study confirms that no MBP before elective colorectal surgery is significantly associated with a lower risk of AL, reoperation rate, and LOS < 6 days when compared with MBP.

The ChoCO-W prospective observational global study: Does COVID-19 increase gangrenous cholecystitis?

BACKGROUND

The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not.

METHODS

Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not.

RESULTS

A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001].

CONCLUSIONS

The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands.

Clear Cell Hidradenocarcinoma: a Rare Identity Difficult to Recognize - Case Report and Review of the Literature

Hidradenocarcinoma (HC) is a malignant and aggressive sweat gland tumour. It is a rare occurrence, accounting for about 6% of malignant eccrine cancers and less than 1% of all cutaneous neoplasms. It is a malignant tumor which can manifest itself in any area of the body, including the anterior surface of the trunk, the torso, scalp, face, and extremities. It is apparent that HC has a high propensity for lymphatic metastasis. The suggested treatment approach for HC implies making a wide surgical excision with negative margins. Nevertheless, such tumours are aggressive and recur locally in 50% of cases; they also produce metastases in 60% of cases. The overall five-year survival rate is 30%. Here, we present the case of a 68-year-old Caucasian male with unknown diagnosis of malignant neoplasm of inguinal cutaneous skin of sweat gland called hydrocarcinoma.

ERAS pathway in colorectal surgery: structured implementation program and high adherence for improved outcomes

Although there is clear evidence that an Enhanced Recovery After Surgery (ERAS) program in colorectal surgery leads to significantly reduced morbidity rates and length of hospital stay (LOS), it is still unclear what modalities and levels of implementation of the program are necessary to achieve these results. The purpose of this study is to analyze the methods and results of the first year of structured implementation of a colorectal ERAS program in two surgical units of the Azienda Sanitaria Unica Regionale (ASUR) Marche in Italy. A two-center observational study on a prospectively maintained database was performed on 196 consecutive colorectal resections (excluding emergencies and American Society of Anesthesiologists class > III cases) over a 1-year period. More than 50 variables including adherence to the individual items of the ERAS program were considered. Primary outcomes were overall morbidity, major morbidity, mortality and anastomotic leakage rates; secondary outcomes were LOS, re-admission and re-operation. The results were evaluated by univariate and multivariate analyses through logistic regression. After a median follow-up of 39.5 days, we recorded complications in 72 patients (overall morbidity 36.7%), major complications in 14 patients (major morbidity 7.1%), 6 deaths (mortality 3.1%), anastomotic dehiscence in 9 cases (4.9%), mean overall LOS of 6.6 days, 10 readmissions (5.1%) and 13 reoperations (6.7%). The mean adherence rate to the items of the ERAS program was 85.4%, showing a significant dose-effect curve for overall and major morbidity rates, anastomotic leakage rates and LOS. The implementation methods of a colorectal ERAS program in this study led to a high adherence (> 80%) to the program items. High adherence had significant effects also on major morbidity and anastomotic leakage rates.

Colorectal surgery in Italy during the Covid19 outbreak: a survey from the iCral study group

BACKGROUND

The COVID19 pandemic had a deep impact on healthcare facilities in Italy, with profound reorganization of surgical activities. The Italian ColoRectal Anastomotic Leakage (iCral) study group collecting 43 Italian surgical centers experienced in colorectal surgery from multiple regions performed a quick survey to make a snapshot of the current situation.

METHODS

A 25-items questionnaire was sent to the 43 principal investigators of the iCral study group, with questions regarding qualitative and quantitative aspects of the surgical activity before and after the COVID19 outbreak.

RESULTS

Two-thirds of the centers were involved in the treatment of COVID19 cases. Intensive care units (ICU) beds were partially or totally reallocated for the treatment of COVID19 cases in 72% of the hospitals. Elective colorectal surgery for malignancy was stopped or delayed in nearly 30% of the centers, with less than 20% of them still scheduling elective colorectal resections for frail and comorbid patients needing postoperative ICU care. A significant reduction of the number of colorectal resections during the time span from January to March 2020 was recorded, with significant delay in treatment in more than 50% of the centers.

DISCUSSION

Our survey confirms that COVID19 outbreak is severely affecting the activity of colorectal surgery centers participating to iCral study group. This could impact the activity of surgical centers for many months after the end of the emergency.

Esophagojejunal Anastomosis Leakage after Total Gastrectomy: Special Tretament with Thoracic Minimal Invasive Management. Case Report and Review

Background:Esophagojejunal leakage is one of the most serious complication in gastric surgery for cancer Case presentation:We report the case of a 74-year-old woman with severe leakage after d2 total gastrectomy that was treated without re-surgery. Conclusion:a multidisciplinary approach is the best choice for decision making leakage treatment demonstrating inferior morbidity and mortality then re-surgery.

Enhanced recovery pathways in colorectal surgery: a consensus paper by the Associazione Chirurghi Ospedalieri Italiani (ACOI) and the PeriOperative Italian Society (POIS)

Enhanced Recovery After Surgery (ERAS) pathway is a multi-disciplinary, patient-centered protocol relying on the implementation of the best evidence-based perioperative practice. In the field of colorectal surgery, the application of ERAS programs is associated with up to 50% reduction of morbidity rates and up to 2.5 days reduction of postoperative hospital stay. However, widespread adoption of ERAS pathways is still yet to come, mainly because of the lack of proper information and communication. Purpose of this paper is to support the diffusion of ERAS pathways through a critical review of the existing evidence by members of the two national societies dealing with ERAS pathways in Italy, the PeriOperative Italian Society (POIS) and the Associazione Italiana Chirurghi Ospedalieri (ACOI), showing the results of a consensus development conference held at Matera, Italy, during the national ACOI Congress on June 10, 2019.

A 23 year experience with laparoscopic common bile duct exploration

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) during laparoscopic cholecystectomy (LC) is as effective as two-stage endo-laparoscopic treatment, but with shorter hospital stay, lower cost and recurrent stone rate. Aim of this paper was to report the authors' experience with LCBDE during LC.

METHODS

A retrospective analysis of patients who underwent LCBDE for ductal stones was performed. Recurrent stones were defined as CBD stones detected beyond 6 months from the procedure. Postoperative biliary stricture was defined as a symptomatic reduction of CBD diameter.

RESULTS

Out of 3444 patients who underwent LC, 384 (11%) had CBD stones treated by trans-cystic duct exploration [214 (6%) patients, TCD-CBDE] or choledochotomy [170 (5%) patients, C-CBDE]. For TCD-CBDE and C-CBDE, mean operative time was 127 ± 69 and 191 ± 74 min, respectively. Major morbidity rate was 3% (n = 6) in TCD-CBDE and 6% (n = 11) in C-CBDE. The incidence of residual stones was 5% (n = 20) and complete ductal clearance rate was 95% (n = 364). After long-term follow-up (mean 189 ± 105 months) the recurrent stone rate was 2%.

DISCUSSION

In expert centers, LCBDE during LC is safe and effective with low short and long term morbidity rates.

Totally robotic vs 3D laparoscopic colectomy: A single centers preliminary experience

AIM: To compare robotic and three-dimensional (3D) laparoscopic colectomy based on the literature and our preliminary experience.

METHODS: This retrospective observational study compared operative measures and postoperative outcomes between laparoscopic 3D and robotic colectomy for cancer. From September 2013 to September 2014, 24 robotic colectomies and 23 3D laparoscopic colectomy were performed at our Department. Data were analyzed and reported both by approach and by colectomy side. Robotic left colectomy (RL) vs laparoscopic 3D left colectomy (LL 3D) and Robotic right colectomy (RR) vs laparoscopic 3D (LR 3D). Rectal cancer procedures were not included.

RESULTS: There were 18 RR and 11 LR 3D, 6 RL and 12 LL 3D. As regards LR 3D, extracorporeal anastomosis (EA) was performed in 7 patients and intracorporeal anastomosis (IA) in 4; the RR group included 14 IA and 4 EA. There was no mortality. Median operative time was higher for the robotic group while conversion rate (12.5% vs 13%) and lymph nodes removed (14 vs 13) were similar for both. First flatus time was 1 d for RR and 2 d the other patient groups. Oral intake was resumed in 1 d by LR and in 2 d by the other patients (P = 0.012). Overall cost was €4950 and €1950 for RL and LL 3D, and €4450 and €1450 for RR and LR 3D, respectively.

CONCLUSION: There were no differences between RR and LR 3D, except that IA was easier with RR, and probably contributed with the learning curve to the longer operative time recorded. Both techniques offer similar advantages for the patient with significantly different costs. In left colectomies robotic colectomy provided better outcomes, especially in resections approaching the rectum.

Prevention of hernia incision in laparoscopic left colon resection

AIM

Aim of this study was to assess the rate of incisional hernia in laparoscopic left colectomy comparing two different sites of mini-laparotomy: midline and oblique left iliac fossa.

METHODS

The study retrospectively analyzed data from 748 patients who underwent laparoscopic left colectomy, in which we performed a midline 6-7 cm incision of the umbilical pubic tract (438 patients - group A), and an oblique left iliac fossa incision (262 patients - group B). Usually a medial to lateral meso-colon dissection technique with vascular closure was performed as a first step. Electro-thermal bipolar energy was routinely used. The variables compared were operative time, hernia in site of mini-laparotomy, conversion, intraoperative bleeding, 30-day complications, wound infection, length of stay.

RESULTS

From early 2004 to April 2012, 748 patients underwent laparoscopic left colectomy, receiving a midline incision for specimen extraction in 438 cases, group A, and off midline in 262, group B. The mean operative time was 135 (90-245) min for group A and 110.5 (40-195) min for group B, and the mean hospital stay was 8 (5-28) days and 6 (4-30) days for group A and B respectively. Forty-eight patients underwent conversion in open surgery and were removed from the study (33 from group A and 15 from group B). Forty-five incisional hernia occurred in group A (10.2%) vs. 3 in group B (1.1%). We shifted to left iliac fossa incision since June 2010.

CONCLUSION

This study summarizes our experience in the effort to reduce incisional hernia in laparoscopic left colectomy. There was a significant difference in rate of hernia comparing midline and oblique left iliac fossa incision. We postulate anatomy of abdominal wall, dynamics and the higher rate of infection of umbilicus to be the key.

Treatment of rectal cancer by transanal endoscopic microsurgery: review of the literature

Transanal endoscopic microsurgery (TEM) is a minimally invasive technique that was introduced by Buess in the early 1980s. The TEM procedure employs a dedicated rectoscope with a 3D binocular optic and a set of endoscopic surgical instruments. Since the beginning its advantages have been evident: magnification of the operative field, better access to proximal lesions with lower margin positivity and fragmentation over traditional transanal excision techniques. A non-systematic literature search was performed in the PubMed database to identify all original articles on rectal cancer treated by TEM. Only series including at least ten cases of adenocarcinoma with two years' mean minimum follow-up and published in English were selected. Nowadays more than two decades of scientific data support the use of TEM in the treatment of selected patients with non-advanced rectal cancer. This paper describes the indications and the surgical technique of TEM in the treatment of rectal cancer.

Laparoscopic versus open colectomy for TNM stage III colon cancer: results of a prospective multicenter study in Italy

BACKGROUND AND PURPOSE

There is still debate about the practicality of performing laparoscopic colectomy instead of open colectomy for patients with curable cancer, although laparoscopic surgery is now being performed even for patients with advanced colon cancer. We compared the long-term results of laparoscopic versus open colectomy for TNM stage III carcinoma of the colon in a large series of patients followed up for at least 3 years.

METHODS

The subjects of this prospective non-randomized multicentric study were 290 consecutive patients, who underwent open surgery (OS group; n = 164) or laparoscopic surgery (LS group; n = 126) between 1994 and 2005, at one of the four surgical centers. The same surgical techniques were used for the laparoscopic and open approaches to right and left colectomy. The distribution of TNM substages (III A, III B, IIIC) as well as the grading of carcinomas (G1, G2, G3) were similar in each arm of the study. The median follow-up periods were 76.9 and 58.0 months after OS and LS, respectively.

RESULTS

There were 10 (6.1 %) versus 9 (7.1 %) deaths unrelated to cancer, 15 (9.1 %) versus 5 (4 %) cases of local recurrence, 7 (4.2 %) versus 5 (4 %) cases of peritoneal carcinosis, and 37 (22.5 %) versus 14 (11.1 %) cases of metastases in the OS and LS groups, respectively. There was also one case of port-site recurrence after LS (0.8 %). The OS group had a significantly higher probability of local recurrence and metastases (p < 0.001) with a significant higher probability of cancer-related death (p = 0.001) than the LS group.

CONCLUSIONS

These findings support that LS is safe and effective for advanced carcinoma of the colon. Although the LS group in this study had a significantly better long-term outcome than the OS group, further investigations are needed to draw a definitive conclusion.

Laparoscopic colectomy is a reliable option for colon cancer treatment

AIMS

To report oncological results in a remarkable single institution series of laparoscopic colectomy for cancer.

METHODS

340 not selected patients with adenocarcinoma of colon underwent laparoscopic colonic resection in a five years period (2004-2008). Of the 340 patients, there were 185 male and 155 female. The mean age was 68 years (31-92). Of the 340 procedures, 175 were laparoscopic right colectomy and 165 laparoscopic left colectomy. No tumor touch technique, ligation at vascular origin, adequate lymphadenectomy and minilaparotomy protection against cells implant was the main landmarks of all cases.

RESULTS

There was no intraoperative mortality. Twenty patients (5.8%) were converted to open surgery. Two patients (0,58%) died in the postoperative period. Five major complications occurred (1,5%) in the postoperative period. The average hospital stay for patients who underwent right colectomy was 6.7 days (4-27) and 6.9 for patients underwent left hemicolectomy (4-23). The average number of lymph nodes removed was 15.6. In a mean 38 months follow-up (25-78) there were 16 incisional hernias, 12 after right colectomy and 4 after left. Eight patients (4,5%) who underwent laparoscopic right colectomy and ten (6%) of the left colectomy group developed a metastatic disease. The overall mortality rate was 10.8%; 14.3% for patients who underwent resection of the right colon and 7.2% for the left colectomy series.

CONCLUSIONS

Laparoscopic colectomy for cancer is feasible, safe and not encumbered by an higher complications rate compared to open colectomy. If the oncological criteria are respected, the results are at least noniferior to the open access.

Laparoscopic adrenalectomy approaches: a 15-year experience in the search for a tailored procedure

AIM

This study reports single-institution experience with anterior, flank lateral and submesocolic approaches in laparoscopic adrenalectomy (LA).

METHODS

The study population was 267 patients who underwent LA from 1994 to 2008 at our institution. The choice of surgical route (anterior, anterior submesocolic or flank lateral) was based on patient characteristics (body-mass index, previous abdominal surgery) and lesion features (size, side, secreting mass, pheochromocytoma, suspected malignancy). The submesocolic approach, as described in 2005, was used for left-sided lesions ≤7-8 cm and in non-obese patients; the flank lateral approach was used in obese or previously operated patients. Of a total of 267 patients, 116 underwent right LA by the anterior and 4 by the flank lateral approach; 88 underwent left LA by the anterior, 37 by the submesocolic, and 22 by the flank lateral approach.

RESULTS

The mean operating time was: 80.1 min (range, 65-125) for right anterior and 93 min (range, 96-145) for right flank lateral LA; 108 min (range, 80-305) for left anterior, 56.2 min (range, 38-105) for submesocolic, and 80.5 min (range, 54-125) for flank lateral LA. Major intraoperative complications requiring conversion to open surgery occurred in 7 patients: bleeding (5); splenic colonic flexure tear (1); and hypertension with severe arrhythmia in pheochromocytoma removal (1). There were no significant statistically differences in length of hospital stay or analgesic medications after anterior, flank lateral or submesocolic LA; the mean operating time was significantly shorter with use of the anterior and submesocolic approaches.

CONCLUSION

In the authors' experience, tailoring the LA approach according to patient and lesion characteristics is both safe and effective. In selected cases, the operating time is shorter by the submesocolic appraoch. .

A flexible concept of fast track surgery for laparoscopic colorectal resections

AIM

Laparoscopy per se improves the patient outcome allowing low pain, reduction of pulmonary dysfunction or less fatigue, better mood and psychological status on the operated on patient. In this study a series of laparoscopic colorectal resections underwent fast track in a "flexible" way.

METHODS

From March 2006 to March 2009, 75 patients undergoing laparoscopic colectomy for cancer have been prospectively evaluated. There were 46 males and 29 females with 61.4 years mean age (26-87). The cohort was divided in three group, 25 patient each, on the basis of the fast track treatment used. In the series A fast track on the whole, in the B fast track partial and in the C fast track postoperatively only.

RESULTS

Mean operating time was 81, 118, 142/76, 110, 151/83, 126, 145 minutes for right colectomy, left colectomy and rectal resection respectively in group A, B and C. The postoperative pain rating was less in the group A compared to B and C, with no differences concerning mobilization, flatus, resumption of solid feeding and mean postoperative hospital stay.

CONCLUSION

Fast track management in laparoscopic colectomy is safe and effective, but it seems not essential in reducing the total hospital stay.

[Laparoscopic surgery of rectal cancer: state of art and long-term results]

BACKGROUND

From the first laparoscopic colectomy that we performed 18 years ago, several studies showed equivalent oncologic results of this technique compared to open surgery Despite this evidence traditional surgeons remain skeptical in the use of this technique, although it may favor an early return of bowel function and therefore a shorter hospitalization, as reported in recent comparative studies. Many colorectal surgeons, who have appreciated the advantages of laparoscopic colectomy, extended this approach also in rectal cancer, finding a better view in the pelvis during dissection.

METHOD

From 1992 to july 2009 we performed more than 400 laparoscopic resection and amputation for rectal cancer. One hundreds eighteen patients (TNM stage I-III) with a 36 month minimum follow-up were enrolled in this analysis. Converted patients to open surgery and patients staged as iT1N0 are not present in this series because we treat with local excision by TEM.

RESULTS

Mean operative time was 160 minutes (90-265). Mortality was 1% in 186 patients and conversion rate was 1.5%. Major complications occurred in 10.7%, including anastomotic leakage in 14 patients (7.5%) and mean hospital stay was 7.7 days. With a mean follow up of 96.8 (36-175) months in the stage I-III, the local recurrence rate was 12.5%. Systematic recurrence occurred in 13.1%.

CONCLUSION

Laparoscopic resection in rectal cancer would allow the use of the same Heald's technique, respecting the Heald's principle of meticulous dissection during total mesorectal excision, furthermore we are waiting 5 years data from randomized trials (COLOR II and CLASICC).

Primary adrenal hypercortisolism: minimally invasive surgical treatment or medical therapy? A retrospective study with long-term follow-up evaluation

BACKGROUND

Because the most suitable management of subclinical Cushing syndrome (SCS, which involves hypersecretion of cortisol without clinically evident disease) still is undefined, the current study aimed to compare retrospectively the outcome for a cohort of patients treated by medical therapy or laparoscopic adrenalectomy (LA).

METHODS

Over a 12-year period, 47 patients with SCS have been treated by means of LA (19 patients, group A) or medical therapy (28 patients, group B). Group A consisted of 15 women and 4 men with a mean age of 54.8 years. Eight patients had a left adrenal mass, whereas nine had a right adrenal mass, and one patient had bilateral lesion. Group B was composed of 18 women and 10 men with a mean age of 57.8 years. Of these patients, 14 had a left adrenal lesion, 12 had a right adrenal lesion, and 1 had bilateral lesion. The patients were followed up for a mean 4 years (range, 1-11 years) by both an endocrinologist and a surgeon.

RESULTS

In group A, hypertension improved for 66.3% of the patients; body mass index (BMI) decreased for 47.4%; and hyperlipidemia based on high-density lypoproteins (HDL) cholesterol, total cholesterol ratio, and triglyceridemic concentration improved for 63.2% of the patients. No changes in bone parameters were seen after surgery in SCS patients with osteoporosis. Some patients in group B, during their long-term medical therapy, experienced worsening hypertension (14.2%), hyperlipidemia (17.8%), and diabetes mellitus (8%).

CONCLUSIONS

This retrospective study focused on a cohort of patients with SCS. Their medium long-term follow-up evaluation showed that LA is better than medical therapy for treating this condition, especially by reducing the cardiovascular risk (hypertension-hyperlipidemia).

Is laparoscopic fiberoptic choledochoscopy for common bile duct stones a fine option or a mandatory step?

BACKGROUND

Because choledochoscopy often is a challenging maneuver, it would be advantageous to define the real utility of its use. This study aimed to compare blind exploration of the common bile duct (CBD) with choledochoscopy-assisted CBD stone removal in terms of patient outcome and complication rate.

METHODS

Two groups of patients were prospectively evaluated in a 4-year period. The study participants were 36 men and 27 women randomized to group A (n = 32) for a blind basket procedure or group B (n = 31) for a choledochoscopy-assisted procedure as the first step of laparoscopic CBD stone removal. Patients with preoperatively suspected CBD stones (n = 51) and those with unsuspected stones (n = 12) were included. The two groups did not differ significantly in terms of anagraphics, American Society of Anesthesiology (ASA) score, or previous surgery. All the procedures were performed by surgeons skilled in this surgical field. Choledochoscopy, when used, was always performed with the instrument connected to a camera monitor that had a wide vision, whether in a single-monitor, in a picture-in-picture manner, or with the use of an additional monitor.

RESULTS

From March 2004 to April 2008, 63 patients undergoing CBD exploration for stone removal were enrolled in the study. Five of these patients had undergone previous endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy (ES). The mean operative time was 107 min for group A and 122 min for group B. The mean hospital stay was 3 days for group A and 3.6 days for group B. Clearance of CBD stones was achieved laparoscopically in 62 cases. One patient required open combined transduodenal papilloplasty and transcholedochotomy. In seven cases, blind basket exploration was unable to remove the stones according to the cholangiogram, so choledochoscopy was required. Six patients underwent a transversal coledocothomy for stone removal. A Kehr T-tube was placed in four of these patients. In four group A cases, the papilla was inadvertently passed during the procedure. In six group A cases, including the four aforementioned cases, a high level of amylases was found on postoperative day 1. At this writing, no late complications or stone recurrences have been observed in either group.

CONCLUSIONS

The laparoscopic basket blind technique and choledochoscopy are safe and effective for CBD stone removal. However, the latter seems to be better in terms of a higher stone removal rate and fewer minor complications despite its longer operation time. In the authors' opinion, it may be preferable to reserve ERCP for very high-risk patients, taking into account that in addition to the related complications, it results in an approximate 10% rate of recurrent or persistent stones.

Treatment of rectal adenomas by transanal endoscopic microsurgery: 15 years' experience

BACKGROUND

The authors present their experience with rectal adenomas managed by transanal endoscopic microsurgery (TEM). The goals of this study were to examine our institution's experience by evaluating surgical morbidity, mortality, and local recurrence rate.

METHODS

This retrospective study investigated 402 patients who underwent TEM a for preoperative diagnosis of adenoma from January 1993 to October 2008. The mean age was 65 years (range = 22-92 years). All patients were regularly followed up to determine treatment efficacy in terms of local recurrence rate.

RESULTS

No 30-day perioperative mortality occurred. No conversion to laparoscopic or open procedures was reported. Minor complications occurred in 28 (7%) patients, whereas major complications were found only in 2 (0.5%) patients. Definitive histology confirmed adenomas in 366 cases (91%). At a mean follow-up of 84 months (range = 1-190 months), 16 (4%) adenomas recurred and were successfully retreated by TEM [14 cases (87.5%)] and by conventional surgery [2 patients (12.5%)]. No further recurrences were observed at subsequent follow-up.

CONCLUSION

The findings warrant the conclusion that TEM is a safe, effective treatment for rectal adenomas where endoscopic removal is not applicable and has low morbidity and no mortality.

Long-term results of laparoscopic adrenalectomy for primary aldosteronism

BACKGROUND

The management of primary aldosteronism is currently achieved by both medical and surgical treatment. Laparoscopy has in recent years unquestionably become the gold standard in adrenal surgery for benign lesions. This study aims to evaluate our clinical results among patients who underwent laparoscopic adrenalectomy (LA) for primary aldosteronism.

METHODS

From January 1994 to January 2006, amid LA series, 59 primary aldosteronism patients were treated in our institution. Patients were 33 males and 26 females with mean age 49.3 yr (19-78). The mean body mass index was 25.9 kg/m2 (20.5-33.3). The mean size of lesion was 2.9 cm (1-5.5). Clinical symptoms were as follows: hypertension and symptomatic/asymptomatic hypokalemia (54), hypokalemia (5).

RESULTS

Thirty-five left and 24 right LA were performed. On the left side, 22 procedures were carried out by anterior approach, 9 by anterior submesocolic route, and 4 by means of flank approach. All right procedures were completed by the anterior supine approach. The mean operative time was 103.5 min for left and 92.8 min for right adrenalectomy. There was one major complication, a colonic post-operative fistula, regarding a left adrenalectomy case. The mean post-operative hospital stay was 3 days (1-9). The cure rate of hypertension and hypokalemia was similar to the current literature results.

CONCLUSIONS

LA is a safe and effective option in the treatment of primary aldosteronism. Appropriate selection of patients, larger adrenal masses and duration of symptoms are determining factors in the success rate of hypertension management.

Electrothermal bipolar energy-based device in laparoscopic right colectomy: our experience

AIM

Aim of the present study was to evaluate effectiveness of bipolar electrothermal energy in laparoscopic right colectomy, both for vascular pedicle ligature and dissecting manoeuvres.

METHODS

Eighty-nine consecutive unselected patients underwent laparoscopic right colectomy between 2003 and 2006. All procedures were performed or supervised by the same surgical team (two staff of surgeons). Forty-four laparoscopic right colectomy were carried out with ultrasonic coagulating shears (UCS), (group 1) and forty-five by means of electrothermal bipolar atlas (EBA), (group 2). Intraoperative bleeding and postoperative blood loss, operating time, complication and hospital stay have been investigated within two groups.

RESULTS

No mortality and no major intraoperative were reported in both series. A conversion to open surgery occurred in one case in both groups. A duodenal perforation occurred in UCS group as major postoperative complication. Comparing 1 and 2 series statistically significant differences were found concerning mean operating time (122.7 vs 98.4) and blood loss (220 vs 115 mL), with a P value <0.05.

CONCLUSIONS

Both UCS and EBA devices were safe and effective in performing laparoscopic right colectomy. However, EBA did allow a statistically significant shorter operative time and bleeding/blood loss, tracing back its effectiveness in vessel sealing and dissection.

The learning curve in laparoscopic adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy (LA) is the procedure of choice for surgical management of most adrenal tumors. LA learning curve (LC) varies among surgeons and may be influenced by factors depending on surgeon, patient, and lesion peculiarities. The aim of this study was to evaluate the LC by multi-dimensional analysis.

METHODS

Between August 1994 and August 2005, 241 LA were performed in our department. Data were prospectively collected. The pre-operative variables evaluated were patient-related (age, gender, body mass index, co-morbidities) and disease-related (histology, size, and side of lesion). Level of experience of surgical team and surgical approach (anterior, flank, submesocolic routes) were evaluated as well. Flank approached and bilateral procedures were excluded, while submesocolic LA, were collected separately. Operating time (OpT), conversion rate (CR), intra-operative and post-operative complications were evaluated. Patient, surgeon, and procedure-related factors involved in LC were investigated by a multi-factorial logistic regression analysis.

RESULTS

Body mass index, side, size, histology, technology improvement, and experience of surgical team, evaluated through the progressive series of surgical procedures, were independent predictors of CR and OpT. The CR for right adrenalectomy was 3% (3 cases) compared to 4.2% for left side (6 cases). The submesocolic approach significantly influenced OpT, but not CR. Mean OpT for right and left LA was 83 and 109 min, respectively. Based on surgical experience increase, the OpT and CR flattened their curves, roughly at 30 and 40 procedures for right and left LA, respectively. Post-operative complications did not change considerably throughout the series. Readmission rate within 30 days was negligible.

CONCLUSIONS

Manifold factors may affect LC and outcome in LA. Their knowledge may support teaching activities as well as reducing conversion and complication rates.

Perioperative results of 214 laparoscopic adrenalectomies by anterior transperitoneal approach

BACKGROUND

The present study attempts to evaluate the perioperative results of the anterior approached laparoscopic adrenalectomy (LA) in a large cohort of patients, and report the advantages and disadvantages of this route.

METHODS

204 patients, 125 female and 79 male with a mean age 52.8 years (range, 19-75 years), underwent LA by the anterior transperitoneal approach from 1994 to 2005 in our institution. There were 100 right and 114 left LAs. Ten patients underwent bilateral LA. Associated surgical procedures were performed in 17 cases. During the same period 47 LAs had been performed by different approaches (flank and submesocolic).

RESULTS

Mean operative time was 80 minutes for right (40-150), 109 minutes for left (64-300) and 194 minutes for bilateral adrenalectomy. Intraoperative major complications were observed in six patients. Mortality occurred in one diabetic patient who was converted to open surgery because of a colonic perforation and subsequently developed a Candida sepsis in the postoperative course. The mean size of lesion removed was 6.2 cm (1.5-12 cm). Oral intake started within 24 hours and the mean hospital stay was 2.5 days (1-8 days). Histology results were as follows: nonsecreting adenoma 65, Cushing's adenoma 58, Conn's adenoma 53, pheochromocytoma 24, metastases 9, myelolipoma 3, adrenogenital syndrome 1, carcinoma 1.

CONCLUSIONS

LA by anterior transperitoneal approach is safe and effective in our experience, despite the inherent limitation that this was not a prospective randomized study. The main advantage of this route is early ligature of the adrenal vein on both sides, enabling the performance of associated surgical procedures and bilateral adrenalectomy.

Hepatic resections by means of electrothermal bipolar vessel device (EBVS) LigaSure V: early experience

BACKGROUND

Many techniques and devices are available for performing liver resection, such as clamp crushing, Cavitron Ultrasonic Surgical Aspirator (CUSA), Hydrojet and dissecting sealer, ultrasonic shears, and, more recently, electrothermal bipolar vessel sealing system (EBVS). In this prospective trial we sought to evaluate the impact of EBVS on hepatic resections.

METHODS

From March 2004 to December 2005, 24 patients from our consecutive liver resection series were enrolled in the present study. There were 17 males and 7 females with a mean age of 59.6 years (range = 41-80) who had colonic cancer metastases (18), hepatocarcinoma (3), angioma (2), and intrahepatic lithisasis (1). Patients were prospectively randomized to undergo liver resection via EBVS LigaSure V (12 patients, group A) or ultrasonic shears harmonic scalpel (HS) (12 patients, group B). Hepatic procedures did not differ significantly between the two groups and were as follows: right hepatectomy (2), left hepatectomy (1), bisegmentectomy (14), and segmentectomy (7).

RESULTS

There was no mortality in either group. The mean operative time was 136.7 min (range = 90-210) in group A and 187.9 min (range = 130-360) in group B. The Pringle maneuver was done in five patients in group A [mean time = 11.4 min (range = 6-12)] and in four patients in group B [mean time = 16 min (range = 9-26)]. The mean blood loss, total bile salts, and hemoglobin concentration from drained fluid on the second postoperative day were 205.8 vs. 506.7 ml, 0.6 vs. 1.1 mmol/L, and 1.0 vs. 2.1 g/L (p < 0.05) for groups A and B, respectively. Mean postoperative hospital stay was 6.1 vs. 7.8 days. In group B a patient who underwent right hepatectomy for colon cancer metastases had transient hepatic failure. No patients received blood transfusions in group A, while two or more blood units were administered in two cases in group B.

CONCLUSIONS

In the present study EBVS proved to be safe and effective for liver resection. By means of this device, statistically significant benefits concerning blood loss, total bile salts, and hemoglobin postoperative leakage were found.

Use of the electrothermal bipolar vessel system (EBVS) in laparoscopic adrenalectomy: a prospective study

BACKGROUND

Since laparoscopic adrenalectomy (LA) has been adopted as the gold standard for the treatment of adrenal diseases, the development of technology for vascular control and dissection manoeuvres, amongst other things, may play a pivotal role in its further improvement. We report our experience with the electrothermal bipolar vessel sealing (EBVS) device for LA.

METHODS

From January 2004 to January 2006, 50 patients (pts) undergoing LA were selected and randomized for use of the EBVS (25 pts, group A) versus the UltraSonic Shears (USS) device (25 pts, group B). Age, sex, body mass index (BMI), previous surgery and associated diseases were similar between the two groups. The main surgical parameters collected for each patient (pt) concerned operative time, major and minor complications, conversion rate, blood loss, hospital stay and histology.

RESULTS

There was no mortality in either group. The right adrenalectomy mean operative time (OpT) was 51.8 mins (range 40-90 mins) and 68.6 mins (range 50-130 mins) in group A and B, respectively (P not significant). The left adrenalectomy mean OpT was 72.2 mins (range 55-100 mins) and 94 mins (range 65-140 mins) for group A and B, respectively (P < 0.05). The mean blood loss was 83 ml (group A) and 210 ml (group B) (p < 0.05). Complications were not different for the two groups. The mean hospital stay was 2.9 and 3.1 days in group A and B, respectively (P not significant).

CONCLUSIONS

EBVS in LA may provide a significantly short operating time and blood loss.

Adrenal incidentaloma: surgical update

Nowadays, the role of surgery in the treatment of adrenal incidentalomas (AI), considering their biologic behavior, is still debated. Surgery is mandatory in cases of hyperfunctioning adrenal masses, in the presence of suspect radiological malignancy, in cases of discordant computed tomography (CT) and scintigraphy findings and when the maximum diameter is 4 cm or more. On the other hand, studies have suggested relative inaccuracy of conventional CT in evaluating the size. The aim of this paper was to evaluate the safety and effectiveness of laparoscopic adrenalectomy (LA) in the treatment of AI by reviewing our experience. Over the period from 1995 to 2005 we laparoscopically managed 78 AI by anterior transperitoneal approach. Two LA (2.6%) were converted to open surgery. Neither intra- nor post-operative major complications were observed. The mean size of lesions was 5.5 cm (range 3-9). Twenty-one large adrenal lesions (exceeding 6 cm) were removed (27%). Definitive histology resulted as follows: adrenocortical adenoma (63), pheochromocytoma (5), nodular hyperplasia (4), myelolipoma (3), cysts (2), and adrenocortical carcinoma (1, with a size of 3 cm). The patients were followed-up by hormonal and radiological evaluation every 12 months (6 for malignancy); their follow-up (median 60.4 months, range 6-123) was uneventful. Also larger AI were treated safely. Laparoscopy has been safe and effective in the treatment of AI in our experience, according to specific literature.

Electrothermal bipolar vessel sealing device vs. ultrasonic coagulating shears in laparoscopic colectomies: a comparative study

BACKGROUND

Many devices are available for vascular control during laparoscopic colorectal procedures. Ultrasonic coagulating shears (UCS), vascular staplers, titanium or plastic clips, and electrothermal bipolar vessel sealing (EBVS) are currently used according to the surgeon's preference. This study aimed to compare EBVS Ligasure with UCS.

METHODS

We report the outcome of 200 consecutive unselected patients who underwent laparoscopic colorectal resections of which 100 were performed with EBVS Ligasure (from September 2004 to December 2005, group 1) and 100 with UCS harmonic scalpel (from December 2002 to June 2004, group 2). Only the following three types of operation were performed: right colectomy (RC), left colectomy (LC), and low anterior resections (LAR). Emergency procedures have been excluded. The same attending surgical teams performed or supervised all procedures. Operating time, blood loss, complications, and postoperative hospital stay were investigated.

RESULTS

Age, gender, previous surgical abdominal procedures, and ASA risk were similar between the two groups, as well as was the percentage of malignant cases (74% vs. 71%, respectively). There were 32 vs. 37 RC, 50 vs. 47 LC, and 18 vs. 16 LAR in groups 1 and 2, respectively. There was no mortality in either group. A conversion to open surgery and two major complications occurred in group 2. There were no statistically significant differences in mean operating time (111 vs. 133, 140 vs. 176, and 153 vs. 201 min) and in the mean postoperative hospital stay (5.2 vs. 6.1, 6.5 vs. 7.1, and 6.8 vs 7.3 days) for RC, LC, and LAR between group 1 and 2, respectively. We do report interesting data about statistically significant differences in the blood loss: 115 vs. 370, 150 vs. 455, and 185 vs. 495 ml for RC (p < 0.001), LC (p < 0.001), and LAR (p = 0.002) between group 1 and group 2, respectively.

CONCLUSIONS

In our laparoscopic colorectal experience, EBVS Ligasure has proven safe and effective in vessel sealing. Patients in whom this device was used had less blood loss and slight advantages in operating time and postoperative hospital stay.

Laparoscopic Radiofrequency Renal Ablation in Patients with Simultaneous Visceral Tumors: Long-Term Follow-Up

PURPOSE

To report our experience with in situ laparoscopic radiofrequency ablation (RFA) of renal tumors.

PATIENTS AND METHODS

From September 2000 to May 2002, two men, 81 and 71 years old, and one woman, 75 years old, were referred to our department for right renal clear-cell carcinoma <3.5-cm diameter. The 71- year-old patient had only one kidney. Because of the tumor location, the percutaneous route was not considered the approach of choice. Moreover, a simultaneous large right adrenal incidentaloma (myelolipoma) and a right colon cancer were known to be present in the second and third patient, respectively. The aforementioned findings suggested the laparoscopic route as a preferable technique to treat both the renal and the other morbidities.

RESULTS

Under laparoscopic ultrasonography control of tine placement, a 20-minute thermoablation cycle at 100 degrees C mean temperature was performed. Including right colectomy and right adrenalectomy, the operative time was 120, 200, and 275 minutes, with postoperative hospital stays of 3, 4, and 6 days for the three patients, respectively. Abdominal CT scans after 1 and 4 weeks and then every 6 months confirmed complete treatment of the lesion at 44 months' average follow-up (range 36-56 months).

CONCLUSION

When percutaneous access is not feasible or the patient should undergo another laparoscopic procedure simultaneously, laparoscopic RFA of renal tumors is feasible and effective, as shown by long-term follow-up.

Long-term results of laparoscopic versus open colorectal resections for cancer in 235 patients with a minimum follow-up of 5 years

BACKGROUND

Laparoscopic resection for cure of colorectal cancer is controversial. More investigations on long-term results are required. This study aimed to compare the long-term outcome with a minimum follow-up of 5 years between laparoscopic or open approach for the treatment of colo-rectal cancer.

METHODS

The treatment modality (laparoscopic or open) was related to the patients (pts) choice. The following parameters between the two groups (laparoscopic and open) were assessed: wound recurrences rate, local recurrences rate, incidence of distant metastases and survival probability analysis.

RESULTS

We report the long term outcome of 149 pts with colon cancer of which 85 treated by Laparoscopic Surgery (LS) and 64 by Open Surgery (OS) and of 86 patients with rectal cancer of which 52 treated by LS and 34 by OS. In the pts with colonic cancer, mean follow-up was 82.8 months. No Statistically Significant Difference (SSD) was observed in the local recurrences rate (3.5% after LS and 6.2% after OS) and in the incidence of distant metastases (10.5% after LS and 10.9% after OS). Cumulative survival probability in LS was 0.882 as compared to 0.859 after OS. In the pts with rectal cancer, mean follow-up was 78.5 months. No SSD was observed in the local recurrences rate (19.2% after LS and 17.6% after OS) and in the incidence of distant metastases (15.3% after LS and 20.5% after OS). Cumulative survival probability in LS was 0.711 as compared to 0.617 after OS. We report an interesting data about the time of recurrences between LS and OS: the recurrences were delayed after LS, both after colonic (22.6 months vs 6.5) and rectal (25.7 months vs 13.0) resections, respectively.

CONCLUSION

We suppose that laparoscopic surgery in the treatment of colo-rectal cancer is quite safe. However, further investigation is needed.

Sub-mesocolic access in laparoscopic left adrenalectomy

BACKGROUND

This article reports an alternative laparoscopic access to left adrenal gland.

METHODS

From January 1994 to August 2004, 209 laparoscopic adrenalectomies were performed in our Department. Indications were Conn adenoma (55 cases), incidentaloma (64), Cushing adenoma (45), pheochromocytoma (32), adreno-genital syndrome (two), mielolipoma (two), and metastatic mass(nine). Of 209, in 12 cases the left adrenalectomy was performed through a submesocolic access (seven pheochromocytoma, two incidentaloma, two Cushing adenoma, one Conn adenoma,). The identification and closure of the adrenal vein with minimal gland manipulation resulted the main benefit of this approach. Moreover, the adrenalectomy was performed with minimal anatomical dissection.

RESULTS

No mortality or major complications occurred. During the operation, the blood pressure and cardiac rhythm were significantly more stable, in the group of patients who underwent a left adrenalectomy by the submesocolic approach compared to the anterior or flank lateral transperitoneal group.

CONCLUSIONS

Left adrenal lesions, as selected cases of pheochromocytoma, can be safely treated by laparoscopic submesocolic access.

Laparoscopic colorectal resection for endometriosis

BACKGROUND

The rectosigmoid colon is affected by deep pelvic endometriosis in 3-37% of cases. In the past, treatment of the affected gastrointestinal tract generally required conversion to conventional surgery. We describe our experience with complete laparoscopic management of deep pelvic endometriosis with bowel involvement.

METHODS

From March 1995 to March 2003, 29 consecutive patients with endometriosis requiring laparoscopic intervention were evaluated. In seven patients (24%) colorectal involvement was identified prior to the operation. A low anterior resection was performed in four patients (57%) and a sigmoid resection in three (43%). In all cases, colonoscopy showed a normal mucosa. In all cases, treatment consisted of resection of the bowel involved together with the excision of all other implants. Data analysis included age, previous abdominal operations, previous history of endometriosis, operative time, conversion rate, complications, length of stay, and pain relief.

RESULTS

There were seven patients with colorectal involvement whose median age was 32.8 years (range, 28-40), with a history of previous abdominal operation in two (28%). Preoperative symptoms were as follow: dysmenorrea in four patients (57%), dyspareunia in four (57%), pelvic pain in seven (100%), rectal bleeding in one (14%), and tenesmus in five (71%). Mean operative time was 190 min (range, 165-230). Length of stay was 8.3 days (range, 7-11). There were no anastomotic leak and no major postoperative complication. One patient had temporary urinary retention. At a median follow-up of 38.7 months (range, 1-84), complete relief of pelvic symptoms was achieved in five patients (71%), and there was improvement in one patient. In one patient complaining of persistent pain, a new colonic implant was diagnosed two years after the surgery requiring reoperation.

CONCLUSIONS

The results show that provided that the surgeon is highly skilled in laparoscopy, laparoscopic resection of deep pelvic endometriosis with rectosigmoid involvement is feasible and effective in nearly all patients.

Laparoscopic Anterior Adrenalectomy for the Treatment of Adrenal Metastases

Aim of this study was to evaluate the results in 6 patients undergoing laparoscopic adrenalectomy for the treatment of solitary adrenal gland metastases. One hundred forty-five patients underwent laparoscopic adrenalectomy by transperitoneal anterior approach. In 6 patients the indication was the presence of a solitary adrenal gland metastasis. Primary tumors were the following: truncal melanoma, gastric cancer, renal cancer, lung cancer, and breast cancer. Mean age was 57 years (range 44-70 years). Three patients underwent right adrenalectomy and 3 patients a left adrenalectomy. No conversion to open surgery occurred. No mortality or intraoperative complications were observed. Mean operative time was 103 minutes (range 70-150) for right adrenalectomy and 170 minutes (range 90-280) for left adrenalectomy. No postoperative complications occurred. Mean diameter of the tumor was 3.5 cm (range 2-5 cm). Tumor free margins were obtained in every case. Mean hospital stay was 2 days (range 2-3 days). At follow-up, 2 patients have died of systemic dissemination of the disease, one 15 months and one 24 months after the operation. The remaining 4 patients are alive and disease free at a mean follow-up of 7 months (range 4-11 months). So far, no port site metastases or local recurrence have been observed. In our experience adrenal gland metastasis can be treated safely and effectively by the laparoscopic transperitoneal anterior approach.

Long-term results of laparoscopic versus open resections for rectal cancer for 124 unselected patients

BACKGROUND

Controversy continues to surround laparoscopic rectal resection for malignancy. A longer follow-up period is required to evaluate the long-term efficacy of the procedure and its impact on survival. Furthermore, no data from ongoing randomized controlled trials are yet available. The aims of this study were to compare long-term outcomes for unselected patients undergoing either laparoscopic or open rectal resection for cancer.

METHODS

A series of 124 unselected consecutive patients with rectal cancer, who underwent surgery by the same surgical team, have been included in this study. Patients with T1N0 tumors underwent local excision, and emergency cases were excluded from the study. Written consent was submitted by each patient, and inclusion in either group (laparoscopic or open) was left to the patient's choice. The laparoscopic approach was chosen by 81 patients, and 43 patients chose open surgery. All the patients underwent preoperative radiotherapy (5,040 cGy), performed in selected cases with chemotherapy (for patients younger than 70 years). The following parameters were compared between the two groups: length of the surgical specimen, clearance of the margins of the specimen, number of lymph nodes identified, local recurrence rate, incidence of distant metastases, and survival probability analysis. The mean follow-up period for both groups was 43.8 months (range, l-9 years).

RESULTS

We performed 60 laparoscopic and 27 open anterior resections, as well as 21 laparoscopic and 16 open abdomino perineal resections, respectively. No mortality occurred in either group. The mean length of the resected specimens was 24.3 cm in the laparoscopic group and 23.8 cm in the open group ( p = 0.47). The mean tumor-free margin was 3.0 cm in the laparoscopic group and 2.8 cm in the open group ( p = 0.57), and the mean number of lymph nodes identified was 10.3 in the laparoscopic group and 9.8 in the open group ( p = 0.63). Of the 124 patients, 86 (52 laparoscopic and 34 open) were included in out study. We excluded patients who underwent a palliative resection (6 laparoscopic and 6 open patients) or conversion to open surgery ( n = 10) and patients who had undergone surgery in the past year ( n = 16). One laparoscopic patient was lost to follow-up evaluation, whereas three laparoscopic patients and one open patient died of causes not related to cancer. No wound recurrence was observed. The local recurrence rate after laparoscopic resection was 20.8%, as compared with 16.6% after open resection ( p = 0.687). Distant metastases occurred in 18.2% of the patients in the laparoscopic group, as compared with 21.2% in the open group ( p = 0.528). Cumulative survival probability was 0.709 after laparoscopic resection after LR and 0.606 after open resection ( p = 0.162), whereas for Dukes' stages A, B, and C in the laparoscopic group versus the open group, it was 0.875 vs 0.889 ( p = 0.392), 0.722 vs 0.584 ( p = 0.199), and 0.500 vs 0.417 ( p = 0.320), respectively. At this writing 20 laparoscopic patients (62.5%) and 20 open patients (60.6%) are disease free ( p = 0.623).

CONCLUSIONS

Oncologic surgical principles were respected. Long-term outcome after laparoscopic resection of rectal cancer was comparable with that after conventional resection. We should wait to draw conclusive scientific statements until the completion of ongoing international randomized controlled trials.

Laparoscopic versus open hemicolectomy

AIM

In the last decade, laparoscopic procedures are applied to the treatment of almost all colonic diseases, including both benign and malignant lesions. Focusing our attention to the laparoscopic operative technique, we compare the perioperative results and the oncological outcomes of laparoscopic hemicolectomy with those after open conventional hemicolectomy.

METHODS

This prospective non randomized study is based on a series of 469 consecutive patients (73.6% with malignant lesions) operated on by the same surgical team following the same type of surgical technique, for laparoscopic and open approach, to perform right (RH) and left (LH) hemicolectomy, respectively, excluding segmental resections, emergency operations as well as transverse colon, splenic flexure and recurrent carcinomas. The treatment modality was selected by the patients after reading the informed consent form. Conversion rate to open surgery (for the laparoscopic group) and causes were assessed. Statistical significance (p) for operative time, resumption of gastrointestinal functions, length of stay, complications, perioperative mortality, as well as length of specimen, number of lymph-nodes harvest, incidence of local recurrences and distant metastases, and survival probability analysis in malignant cases, was assessed between the 2 groups (laparoscopic and open).

RESULTS

From March 1992 to February 2003, 166 patients underwent RH and 303 LH. In the RH group, 108 patients underwent laparoscopic approach and 58 underwent open surgery (26 vs 13 for benign lesions and 82 vs 45 for adenocarcinomas, respectively). LH was performed by laparoscopy in 202 patients and by laparotomy in 101 (55 vs 30 for benign lesions and 147 vs 71 for adenocarcinomas, respectively). There were no conversions to open surgery in laparoscopic RH, while 10 patients (4.9%) in the laparoscopic LH group required conversion: 3 of 34 performed for diverticular disease and 7 of 147 performed for malignancy. Mean operative time for laparoscopic surgery was longer than for open surgery (182 vs 140 min for RH and 222 vs 190 min for LH, respectively), but with increasing experience this decreased significantly. Mean hospital stay in patients who underwent laparoscopic procedures was significantly shorter both in RH and LH groups (9.2 vs 13.2 days and 9.9 vs 13.2 days, respectively). Similar major complication rates were observed between the 2 laparoscopic and open groups (1.8% vs 1.7% for RH and 4.1% vs 4.9% for LH, respectively). Follow-up time ranged between 12 and 109 months (mean, 57.3 months) in RH groups and between 12 and 111 months (mean, 57.5 months) in LH groups. The follow-up dropout was of only 3 patients after RH (in the laparoscopic group) and 5 after LH (3 in the laparoscopic group and 2 in the open group). The local recurrence rate was lower after laparoscopic surgery in both arms (7% vs 8.8% for RH and 3.3% vs 7% for LH, respectively), but the differences were not statistically significant. Two port site recurrences were observed in the laparoscopic groups, 1 after a Dukes D palliative RH and 1 after a Dukes C LH converted to open surgery (1.7% and 0.9%, respectively). Metachronous metastases rates were similar between the laparoscopic and open groups (20.9% vs 17.6% for RH and 4.4% vs 5.3% for LH, respectively). Cumulative survival probability (CSP) at 72 months after laparoscopic RH was 0.791 as compared to 0.765 after open surgery (p=0.326) and 0.956 after laparoscopic LH as compared to 0.877 after open surgery (p=0.115). CSP for Dukes stage A, B and C in the laparoscopic RH group was 0.875, 0.846, and 0.727 as compared to 0.9 (p=0.815), 0.889 (p=0.87), and 0.6 (p=0.183) after open surgery, respectively. CSP for Dukes stage A, B and C in the laparoscopic LH group was 0.1, 0.966, and 0.885 as compared to 0.1 (p=0.936), 0.944 (p=0.466), and 0.7 (p=0.072) after open surgery, respectively.

CONCLUSION

These results suggest that laparoscopic hemicolectomy for both benign and malignant lesions can be performed safely. Oncological outcomes were comparable with those of open surgery.

Laparoscopic cholecystectomy and common bile duct exploration are safe for older patients

BACKGROUND

Laparoscopic common bile duct (CBD) exploration is a well-established treatment option in dedicated centers. However, few data are available on the results in elderly patients.

METHODS

The outcome after laparoscopic CBD exploration in elderly patients (age <70 years) was compared with that in a concurrent control group of younger patients (age, <70 years).

RESULTS

There were 77 elderly patients in group A and 207 younger patients in group B. American Society of Anesthesiology (ASA) III and IV patients and prior abdominal operations were more frequent in group A (p <0.001). Two patients from each group underwent conversion to open surgery. There was no significant difference frequency of use between the transcystic and choledochotomy approaches, although the latter tended to be more frequent in the group A because of larger stones, (group A 53.4%; group B, 37.6%). Minor and major morbidity (group A, 12%; group B, 13.6%), rate of recurrent stones (group A, 1.3%; group B, 1.9%), and mortality (group A, 1.3%; group B, 0%) were not significantly different between the two groups. The single death in group A involved a patient with acute toxic cholangitis who underwent emergency surgery after multiple failed attempts at endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy performed elsewhere. No CBD stenosis was observed at follow-up assessment.

CONCLUSIONS

Elective laparoscopic CBD exploration is safe and effective. It may become the standard of care in both elderly and younger patients.

Results of laparoscopic versus open resections for non-early rectal cancer in patients with a minimum follow-up of four years

BACKGROUND/AIMS

Laparoscopic rectal resection for malignancy is still debated. Concern has been expressed regarding the lack of significant data from larger patient series with longer periods of follow-up. The aims of this study were to compare long-term outcome with a minimum follow-up of four years in unselected patients undergoing either laparoscopic rectal resection or open rectal resection for cancer.

METHODOLOGY

From May 1992 to August 1997 all electively admitted patients with rectal cancer were included in a prospective non-randomized study. Written information was submitted to each patient and the location in each group (laparoscopic or open) was related to the patient's choice. The inclusion protocol criteria excluded T1 tumors. All 68 T2-T4 patients underwent preoperative radiotherapy (5.040 cGy), completed with chemotherapy in selected cases (patients below 70 years of age). Long-term results were compared between the two groups. Follow-up time of both groups ranged between 48 and 96 months (mean, 49.4 months).

RESULTS

Excluding patients who underwent a palliative resection or conversion to open surgery and deaths not related to cancer, 53 pts (29 laparoscopic rectal resection, 24 open rectal resection) out of 68 are available and are the object of this study. No patient was lost to follow-up. No wound recurrence was observed. The local recurrence rate after laparoscopic rectal resection was 24.1% vs. 25% after open rectal resection (P = 0.799). Distant metastases occurred in 20.7% of patients in the LLR group (laparoscopic rectal resection) vs. 25% in the ORR group (open rectal resection) (P = 0.980). Cumulative survival probability after laparoscopic rectal resection and open rectal resection was 0.690 and 0.625 (P = 0.492), respectively. Cumulative survival probability for Duke's stage A, B and C in the LRR group vs. the ORR group was 1.000 vs. 0.900 (P = 0.585), 0.667 vs. 0.636 (P = 0.496) and 0.429 vs. 0.445 (P = 0.501), respectively. Sixteen laparoscopic rectal resection patients (55.2%) and 12 open rectal resection patients (50%) are presently disease free (P = 0.979).

CONCLUSIONS

Long-term results after laparoscopic resection of rectal cancer were comparable to those after conventional resection, with a trend in favor of the laparoscopic approach that does not reach a statistically significant difference, possibly due to the limited size of the sample.

Results of laparoscopic vs open resections for colon cancer in patients with a minimum follow-up of 3 years

BACKGROUND

Laparoscopic resection for colon cancer is still a controversial procedure, the major cause of concern being the lack of long-term results. The aims of this study was to compare long-term outcome in unselected patients undergoing either laparoscopic (LH) or open hemicolectomy (OH) for colonic cancer.

METHODS

From March 1992 to August 1997, 197 elective patients were included in this prospective nonrandomized study. The patients were operated on by the same surgical team following the same type of surgical technique for both right and left hemicolectomy, excluding segmental resections; the only difference was the type of access, which was either laparoscopic or open. Each patient gave a written consent, and the allocation to each group (laparoscopic or open) was done on the basis of the patient's choice. The long-term outcomes of the two groups were compared. Follow-up for both groups ranged from 36 to 96 months (mean, 48.9).

RESULTS

In all, 149 (74 LH, 75 OH) of 197 patients were studied, excluding palliative resections, conversions to open surgery, perioperative deaths, and deaths not related to cancer. Only two patients in the laparoscopic group were lost to follow-up. The local recurrence after LH was 1.3% vs 2.7% after OH (p = 0.105). Metachronous metastases rates were similar for the two groups (10.8% for LH and 10.7% for OH). Cumulative survival probability (CSP) in the LH group vs the OH group was 0.892 vs 0.867 (p = 0.513), respectively. CSP for Duke's stage B and C in the LH group vs the OH group was 0.910 vs 0.895 (p = 0.506) and 0.800 vs 0.734 (p = 0.544) respectively. Sixty-four LH patients (86.5%) and 65 OH patients (86.7%) are disease-free.

CONCLUSION

In our series of patients, no statistically significant difference was found between the two groups in terms of long-term survival rate.

Laparoscopic vs open hemicolectomy for colon cancer

BACKGROUND

The role of laparoscopic resection in the management of colon cancer is still a subject of debate. In this clinical study, we compared the perioperative results and long-term outcome for two unselected groups of patients undergoing either laparoscopic or open hemicolectomy for colon cancer.

METHODS

This prospective nonrandomized study was based on a series of 248 consecutive patients operated on by the same surgical team using the same type of surgical technique for right (RHC) and left (LHC) hemicolectomy, excluding segmental resections; the only difference was the type of access, which was either laparoscopic or open. The choice of type of access was left up to the patient after he or she had read the informed consent form. Operative time, length of stay, complications, and long-term outcome for the two groups were compared. Follow-up time ranged between 12 and 92 months (mean, 42).

RESULTS

Between March 1992 and January 2000, 140 patients underwent a laparoscopic hemicolectomy (55 RHC and 86 LHC); at the same time, 107 patients (44 RHC and 63 LHC) were treated via an open approach. There were no conversions to open surgery in the laparoscopic RHC group, but six patients (7%) in the laparoscopic LHC group were converted. The mean operative time for laparoscopic surgery was significantly longer than the time for open surgery (190 vs 140 min for RHC, 240 vs 190 min for LHC,); however, with increasing experience, this time decreased significantly. The mean hospital stay for the patients who underwent laparoscopic procedures was significantly shorter in both the RHC and the LHC groups (9.2 vs 13.2 days for RHC, 10.0 vs 13.2 days for LHC). No statistically significant difference between the two laparoscopic and open groups was observed for the major complication rate (1.9% vs 2.3% for RHC, 7.5% vs 6.3% for LHC). The patient in the laparoscopic RHC group were lost to follow-up. The local recurrence rate was lower after laparoscopic surgery in both arms (5.4% vs 9% for RHC, 1.5% vs 7.5% for LHC), but the differences were not statistically significant. Two port site recurrences were observed in the laparoscopic groups, one after RHC (2.7%) and one after LHC (1.5%). Metachronous metastases rates were similar for the two groups (16.2% vs 15.1% for RHC, 4.4% vs 5.7% for LHC). Cumulative survival probability at 48 months after laparoscopic RHC was 0.865, as compared to 0.818 after open surgery, and 0.971 after laparoscopic LHC, as compared to 0.887 after open surgery.

CONCLUSION

These results suggest that laparoscopic hemicolectomy for colonic cancer can be performed safely, with morbidity, mortality, and long-term results comparable to those of open surgery.

Laparoscopic resection of a juxtaglomerular cell tumor of the right kidney

Juxtaglomerular cell tumor is an extremely rare neoplasm of the kidney that causes blood hypertension. A 45-year-old man with persistent hypertension was referred to our department because of a solid mass of unclear origin (kidney? colon?) located in the right mesorenal region that had been detected by Computed tomography (CT) scan, ultrasonography, and colonoscopy. Serum levels of renin, plasma renin activity (PRA), and aldosterone were all normal. Operatively, four 10/12-mm ports were placed, ultrasonography confirmed a well-encapsulated lesion of the kidney. Ultrasonic shears and cautery were used to resect the lesion, including 5 mm of free renal tissue. Postoperatively, a prompt normalization of blood pressure was observed. The pathological findings showed a juxtaglomerular cell tumor. The definitive diagnosis of juxtaglomerular cell tumor is made on the basis of laboratory findings, and imaging studies, Its definitive treatment is surgical excision which can be accomplished successfully with minimally invasive surgery.

Laparoscopic common bile duct exploration

BACKGROUND

Laparoscopic common bile duct (CBD) exploration is gaining favor in the treatment of patients with gallstones and CBD stones. Our aim is to report our results with this procedure, focusing on the technical aspects.

PATIENTS AND METHODS

All patients with proven CBD stones undergo laparoscopic transcystic CBD exploration, preferably, or a choledochotomy if the former is not feasible. According to CBD stone load and diameter, a biliary drainage tube is positioned for postoperative biliary decompression.

RESULTS

Among 284 patients who underwent laparoscopic CBD exploration, 4 (1.4%) were converted to open surgery. Transcystic CBD exploration was feasible in 163 cases (58.2%), but a choledochotomy was required in 117 (41.8%). Biliary drains were positioned in 204 patients (72.8%). Minor complications included hyperamylasemia (11; 3.9%) and minor subhepatic bile collection (7; 2.5%). Major complications were bile leakage (5; 1.8%), hemoperitoneum from cystic artery bleeding (2; 0.7%), subhepatic abscess (2; 0.7%), acute pancreatitis (1; 0.3%), and jejunal perforation (1; 0.3%). Retained CBD stones in 15 patients (5.3%) were removed through the biliary drainage sinus tract (8) or after endoscopy and sphincterotomy (6). In one patient, a small stone passed spontaneously (overall success rate 94.6%). Death from a cardiovascular complication was observed in one elderly high-risk patient (0.3%). Recurrent ductal stones in 5 patients (1.8%) were treated with ERCP and endoscopic sphincterotomy. One patient with re-recurrent ductal stones underwent hepaticojejunostomy.

CONCLUSIONS

Laparoscopic CBD exploration during LC in unselected patients solves two problems during the same anesthesia with high success rates (94.6%), low minor (6.4%) and major (3.8%) morbidity rates, and a low mortality rate (0.3%). Standardization of the technique is mandatory to achieve high success rates.

Laparoscopic colonic resection

BACKGROUND AND PURPOSE

In the last decade, laparoscopy has dramatically changed colonic surgery. Laparoscopic procedures are applied to the treatment of almost all colonic diseases, including both benign and malignant lesions. Focusing our attention on the laparoscopic oncologic operative technique, we compared the perioperative results and the long-term outcome of laparoscopic surgery (LS) with those of conventional open surgery (OS) in a series of 360 unselected consecutive patients.

PATIENTS AND METHODS

Between 1992 and 2001, excluding 102 patients with rectal tumors, 207 patients underwent laparoscopic colonic resection (72.5% for malignant lesions), whereas 153 (71.9% with malignant lesions) were treated by OS. The treatment modality was selected by the patients after reading the informed consent form. The statistical significance of differences in the morbidity and mortality rates, local recurrence rate, and incidence of distant metastases in the two groups was assessed by chi2 test. The survival probability analysis was performed by the Kaplan-Meier method. Significant differences in survival probability between groups were assessed by the log-rank test. A level of 5% was used as the criterion of statistical significance.

RESULTS

Laparoscopic surgery was technically feasible in 95.7% of the patients. No statistically significant difference was observed in the major complication rate (3.5% after LS and 3.3% after OS; P = 0.870) or in perioperative mortality (1.5% v 1.3%; P = 0.769). The mean follow-up in the patients with malignant disease was 42.2 months, during which time, we observed 2 cases of abdominal wall metastases (1.9%) in patients with advanced disease. The local recurrence rate was lower after LS than OS: 2.8% v 8.1%; P = 0.223). Distant metastases occurred in 8.6% of patients after LS and 9.3% after OS (P = 0.926). At 48 months of follow-up, the cumulative survival probability in the LS-completed malignant group was 0.934 compared with 0.860 after OS (P = 0.781).

CONCLUSION

Laparoscopic colonic resection for both benign and malignant lesions is technically feasible, without additional risks for the patients. However, oncologic outcomes have not been determined because no data from the ongoing randomized controlled trials are yet available.

[Single-stage laparoscopic surgery of cholelithiasis and choledocholithiasis in 268 unselected consecutive patients]

AIMS

The introduction of laparoscopic cholecystectomy (LC) has modified the treatment of gallstones and common bile duct (CBD) stones. Aim of this prospective study was to evaluate the results of single stage laparoscopic management of gallstones and CBD stones.

PATIENT AND METHODS

From January 1991 to October 1999, CBD stones were present at intraoperative cholangiography in 268 patients (pts) (169 females, 99 males, mean age 55.6 years, range 12-94 years) out of 2693 undergoing LC (10%) for gallstones. CBD stones were unsuspected in 123 (45.9%) and suspected in 145 (54.1%).

RESULTS

CBD exploration was successful in 264 cases (98.5%) (transcystic 164, choledochotomy 100). Four pts were converted to open surgery (1.5%). Retained stones in 15 patients (5.7%), were treated by ERCP/ES (6 pts) and by percutaneous endoscopic/fluoroscopic stone removal (6 pts). Spontaneous stones passage occurred in 2 pts, one patient is waiting for treatment. Major morbidities were hemoperitoneum (4 cases) and cystic duct bile leakage (3 cases). One high risk patient died postoperatively. Recurrent stones were observed in 5 pts (1.9%), at 1, 4, 8, 18, 26 months respectively after T-tube removal, and were treated by ERCP/ES in 4 cases. Spontaneous stone passage occurred in 1 case.

CONCLUSIONS

LC and CBD exploration has shown to be safe and feasible with low morbidity and mortality. The rationale of this approach is to solve two problems during the same procedure, limiting the role of endoscopic sphincterotomy to the treatment of residual ductal stones.

Laparoscopic colonic resections versus open surgery: a prospective non-randomized study on 310 unselected cases

BACKGROUND/AIMS

Laparoscopic colorectal surgery, particularly for malignancy, is still debated. The aim of this study was to prospectively evaluate the postoperative outcome as well as the short- and medium-term results of laparoscopic surgery compared with those after open conventional surgery.

METHODOLOGY

A series of 310 consecutive patients, operated on by the same surgical team, have been included in this study; 150 patients (75% with malignant lesions) underwent laparoscopic surgery, whereas 160 patients (73% with malignant lesions) were treated by open surgery. The treatment modality was selected by the patients after reading the informed consent form.

RESULTS

Laparoscopic surgery was technically feasible in 91.4% of cases. Mean operative time for laparoscopic surgery was longer than for open surgery (251 vs. 175 min) (P < 0.001). Mean postoperative hospital stay after laparoscopic surgery was 10.5 days, as compared to 13.3 days after open surgery (P < 0.05). In the laparoscopic surgery group minor complications' rate was 3.6% and compared favorably to the 7.5% observed after open surgery (P = 0.261). No statistically significant difference was observed in the major complications rate (9.4% after laparoscopic surgery and 6.8% after open surgery) and in operative mortality (1.4% for laparoscopic surgery and 0.6% for open surgery). The local recurrence rate was lower after laparoscopic surgery as compared to open surgery: 3% versus 9.2% (P = 0.152), respectively. Mean follow-up was 34.2 months during which time we observed 2 cases of port site recurrence. After implementing adequate prophylactic measures, no parietal implants were observed in the last 80 patients who underwent laparoscopic surgery for malignancy. Distant site metastases occurred in 11% in both groups. At 36 months cumulative survival probability in laparoscopic surgery completed malignant cases was 0.74% as compared to 0.66% after open surgery.

CONCLUSIONS

Morbidity and mortality were similar in the 2 groups. Laparoscopic patients experienced less pain. A slightly higher incidence of local recurrence was observed in the open surgery group, whereas the percentage of distant site metastases and the cumulative survival probability in the 2 groups were similar. Port site recurrences are a cause of concern but they can be prevented with adequate prophylactic measures. The short- and medium-term results of laparoscopic surgery compared favorably with those of open surgery in this prospective non-randomized study. Long-term oncological result are not known yet. In patients with malignancy prospective randomized trials on larger patient numbers are required.

Laparoscopic intra-arterial catheter implantation for regional chemotherapy of liver metastasis

In patients with unresectable metastatic disease confined to the liver, intra-arterial regional chemotherapy with implantable systems in an attractive option. Since April 1992, laparoscopic colorectal resections have been performed in our institution. Within this series of patients, three cases with bilateral liver metastasis from colon cancer were observed and underwent laparoscopic intra-arterial catheter implantation in the gastroduodenal artery for regional chemotherapy. In two patients the metastases were synchronous, and in both cases a laparoscopic colon resection was also performed, for tumors located in the cecum and in the sigmoid colon, respectively. The laparoscopic surgical technique for intra-arterial catheter implantation is described in detail. In this limited experience the procedure, from a purely technical point of view, was not considered difficult and was completed in 70 min on average. No complications were observed and the patient with metachronous liver metastasis was discharged on 3rd postoperative day.