Angelo De Sanctis

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 patients 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 Dukes 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 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.

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

BackgroundSince 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.MethodsFrom 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.ResultsThere 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).ConclusionsEBVS in LA may provide a significantly short operating time and blood loss.

Early Rectal Cancer: Definition and Management

Background: Local excision of rectal cancer is an alternative to radical resection but today its role surrounding the management of patients with early stage rectal cancer (T1-T2-N0) represents an important surgical issue. Aim: To analyze the results of 135 patients with early stage low rectal cancer treated with local excision by transanal endoscopic microsurgery and in the case of T2 also by neoadjuvant therapy. Study Design:135 patients with T1-T2-N0-M0 rectal cancer were enrolled in the study. Staging according to the definitive histological findings was as follows: pT0 in 24 patients (17.8%), pT1 in 66 patients (48.8%) and pT2 in 45 patients (33.4%). Results: Minor complications were observed in 12 patients (8.8%) whereas major complications were seen only in 2 patients (1.5%). At a median follow-up of 78 (36–125) months, local recurrences occurred in 4 patients and distal metastasis in 2 patients (all patients were staged preoperatively T2). Disease-free survival rates in T1 and T2 patients were 100 and 93% respectively at the end of follow-up. Conclusions: With respect to local recurrence and survival rate, the long-term results of early stage rectal cancer in patients treated with transanal endoscopic microsurgery were similar to those reported in the literature after conventional surgery (total mesorectal excision).

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.

Pancreatic Cancer: Pathological Factors and TNM Staging

Ductal adenocarcinoma, a solid, exocrine epithelial neoplasm, represents with its variations the large majority of primitive malignant tumors of the pancreas (about 90% of cases) [1]. It is typically characterized by insidious growth with a generally unfavorable prognosis. At the time of diagnosis in most cases there are already peripancreatic lymph node metastases, and at post mortem, liver (80%), peritoneal (60%), pulmonary (50–70%), and suprarenal metastases (25%) are also frequently found [2]. Despite the recent knowledge acquired in the biomolecular genetics of this neoplasm and the progress made in instrumental diagnostic technology, the prognosis of this tumor is still poor, with an average survival of 19% at 1 year after diagnosis and 2–4% after 5 years: pancreatic cancer still has the worst prognosis of the solid neoplasms [3].

Minimally Invasive Surgery for the Treatment of Rectal Tumors: 10 Years Experience

Traditional surgery has been used side by side with minimally invasive surgical techniques, which have been widely utilized in the field of benign diseases, as is demonstrated by the use of laparoscopy in cholecystectomy, appendectomy, fundoplication, hernioplasty, splenectomy and adrenalectomy etc. Such procedures are safe and have in common favorable postoperative course with minimal stress for the patient, as demonstrated by several reports (1–5). For this reason, also in malignant diseases, the concept of minimally invasive surgery that utilizes a laparoscopic or transanal endoluminal technique has been introduced. These techniques, associated with preoperative neoadjuvant radiotherapy, could guarantee the same oncological radicality, with minimal surgical stress for the patient. The aim of this study was to evaluate short and long-term results in 169 patients with rectal cancer, who underwent radiotherapy and laparoscopie surgery, or trans-anal endoscopic microsurgery (TEM).