Christiano Marlo Paggi Claus

Late laparoscopic reoperation of failed antireflux procedures.

Failures of antireflux procedures occur in 5% to 10% of the patients. Our objective is to report our experience with laparoscopic management of failed antireflux operations. Of 1698 patients who underwent laparoscopic treatment of gastroesophageal reflux disease (GERD), 53 were reoperations following either a previous open or laparoscopic antireflux procedure. The indications for surgical reoperation were persistent or recurrent GERD in 35 patients (66%), presence of paraesophageal hiatal hernia in 4 (7.5%), and severe dysphagia in 14 (26.4%). Hospital stay varied from 1 to 8 days, with an average of 1.2 days. Conversion to open laparotomy occurred in 10 patients (18.8%). The main causes for persistent or recurrent GERD were herniation (n=20) and disruption (n=12) of the fundoplication. Two patients had both herniation and disruption of the fundoplication. The main reason for severe dysphagia was tight hiatus. The most common reoperations were hiatal repair for hernia correction (n=26), redo fundoplication (n=16), and widening of the hiatus (n=12). Two patients had both hiatal repair and redo fundoplication. Intra (n=5) and postoperative (n=16) complications were frequent, but they were usually minor. There was no mortality. The present study demonstrated that laparoscopic reoperation for failed antireflux procedures may be performed safely in most patients with excellent result, low severe morbidity, and no mortality.

Minimally invasive transhiatal esophagectomy: lessons learned

BackgroundMinimally invasive esophagectomy has the potential to minimize the morbidity of esophageal resection and is particularly suited to the transhiatal approach. This report details our experience with this technique and the lessons we have learned.MethodsA retrospective analysis of patients who underwent minimally invasive transhiatal esophagectomy was performed. Parameters assessed included patient demographics, tumor pathology, operative and postoperative course, and survival.ResultsEighteen patients underwent minimally invasive transhiatal esophagectomy [median age = 69 years (range = 36–79)]. Seventeen were operated on for cancer, including 13 adenocarcinomas and 4 squamous cell carcinomas (median histological stage = 2, range = 1–3), and 1 for high-grade dysplasia in Barrett’s. One patient had neoadjuvant chemotherapy. Two patients underwent nonemergency conversion to open surgery. The median duration of operation was 300 min (range = 180–450). All anastomoses were end-to-side hand-sewn. No patients received a red cell transfusion. The 30-day mortality was zero. Complications developed in 15 patients, including 7 respiratory and 10 recurrent laryngeal nerve injuries. There were two anastomotic leaks. Six patients developed stenosis requiring dilatation. The median length of stay was 15 days (range = 10–39). The median number of nodes harvested was 10 (range = 2–26). At a median follow-up of 13 months (range = 4–42), 13 patients were alive.ConclusionsMinimally invasive transhiatal esophagectomy is feasible in our unit, with acceptable mortality. The high rate of anastomotic stenosis has resulted in a change to a semimechanical, side-to-side isoperistaltic technique. The high rate of recurrent laryngeal nerve injuries has resulted in the avoidance of metal retractors at the tracheo-esophageal groove.

Liver resection: 10-year experience from a single Institution

BACKGROUND Liver resection constitutes the main treatment of most liver primary neoplasms and selected cases of metastatic tumors. However, this procedure is associated with significant morbidity and mortality rates. AIM To analyze our experience with liver resections over a period of 10 years to determine the morbidity, mortality and risk factors of hepatectomy. PATIENTS AND METHODS Retrospective review of medical records of patients who underwent liver resection from January 1994 to March 2003. RESULTS Eighty-three (41 women and 42 men) patients underwent liver resection during the study period, with a mean age of 52.7 years (range 13-82 years). Metastatic colorectal carcinoma and hepatocellular carcinoma were the main indications for hepatic resection, with 36 and 19 patients, respectively. Extended and major resections were performed in 20.4% and 40.9% of the patients, respectively. Blood transfusion was needed in 38.5% of the operations. Overall morbidity was 44.5%. Life-threatening complications occurred in 22.8% of cases and the most common were pneumonia, hepatic failure, intraabdominal collection and intraabdominal bleeding. Among minor complications (30%), the most common were biliary leakage and pleural effusion. Size of the tumor and blood transfusion were associated with major complications (P = 0.0185 and P = 0.0141, respectively). Operative mortality was 8.4% and risk factors related to mortality were increased age and use of vascular exclusion (P = 0.0395 and P = 0.0404, respectively). Median hospital stay was 6.7 days. CONCLUSION Liver resections can be performed with low mortality and acceptable morbidity rates. Blood transfusion may be reduced by employing meticulous technique and, whenever indicated, vascular exclusion.

Minilaparoscopic technique for inguinal hernia repair combining transabdominal pre-peritoneal and totally extraperitoneal approaches.

A minilaparoscopic combined approach for inguinal hernia appears to be safe and feasible for a more simple endoscopic hernia repair.

Thoracoscopic enucleation of esophageal leiomyoma in prone position and single lumen endotracheal intubation

IntroductionEsophageal leiomyomas are the most common benign tumors of the esophagus. Surgical enucleation is warranted for symptomatic patients. Thoracoscopic enucleation is the preferable approach for being less invasive by avoiding the discomfort and complications associated to larger thoracic incisions. The purpose of this study was to review our experience with enucleation of esophageal leiomyoma using a prone-position thoracoscopy technique.MethodsBetween January 2009 and July 2012, ten patients underwent resection of esophageal leiomyoma by thoracoscopy approach in prone position. Indications for surgical treatment were symptomatic tumors (dysphagia). All patients were followed postoperatively for at least 3 months with contrast x-ray of the esophagus. After single-lumen endotracheal intubation (nonselective intubation) in supine, patients were placed in prone position. Pneumothorax was kept at 6 to 8 mmHg using CO2 insufflation. A myotomy was performed over the tumor using hook cautery carefully protecting the mucosa from injuries. The myotomy was closed with continuous sutures.ResultsThe procedures were completed in the prone position in all cases, without any conversion. Mean operative time was 89.2 ± 28.7 minutes. Bleeding was negligible, and there were no intraoperative or postoperative complications. No intensive care unit support was needed for any patient. Chest x-ray in the first postoperative day showed no significant changes in any patient. The mean hospital stay was 3.2 days. Contrast x-ray of the esophagus was normal in all patients at 3 months postoperatively.ConclusionsThoracoscopic enucleation of esophageal leiomyoma is a feasible, simple, and safe procedure. Thoracoscopy in the prone position with CO2 insufflation allows the use of usual technique of intubation and also provides optimal operative field. The advantages of the thoracoscopic approach are less postoperative discomfort and lower risk of complications from open thoracotomy (especially pulmonary).

Umbilical hernia in patients with liver cirrhosis: A surgical challenge

Umbilical hernia occurs in 20% of the patients with liver cirrhosis complicated with ascites. Due to the enormous intraabdominal pressure secondary to the ascites, umbilical hernia in these patients has a tendency to enlarge rapidly and to complicate. The treatment of umbilical hernia in these patients is a surgical challenge. Ascites control is the mainstay to reduce hernia recurrence and postoperative complications, such as wound infection, evisceration, ascites drainage, and peritonitis. Intermittent paracentesis, temporary peritoneal dialysis catheter or transjugular intrahepatic portosystemic shunt may be necessary to control ascites. Hernia repair is indicated in patients in whom medical treatment is effective in controlling ascites. Patients who have a good perspective to be transplanted within 3-6 mo, herniorrhaphy should be performed during transplantation. Hernia repair with mesh is associated with lower recurrence rate, but with higher surgical site infection when compared to hernia correction with conventional fascial suture. There is no consensus on the best abdominal wall layer in which the mesh should be placed: Onlay, sublay, or underlay. Many studies have demonstrated several advantages of the laparoscopic umbilical herniorrhaphy in cirrhotic patients compared with open surgical treatment.

Surgical treatment of cystic neoplasms of the pancreas

CONTEXT Diagnosis and treatment of cystic neoplasms of the pancreas increased significantly in the last decades. There are only a few Brazilian publications on these tumors. The majority of them are limited to reports of one or few cases. OBJECTIVE To present our experience with 27 patients with cystic neoplasms of the pancreas. METHODS Demographic data, clinical manifestations, diagnostic exams, surgical procedures, postoperative complications, and follow-up data of 27 patients with cystic neoplasms of the pancreas were analyzed, according to the histological type of the tumor. RESULTS There were 10 (37%) serous cystic tumors, 10 (37%) mucinous cystic tumors, 4 (15%) intraductal papillary mucinous tumors, and 3 (11%) solid pseudopapillary tumors or Frantz tumor. All serous cystic tumors, 6 (60%) mucinous tumors, 2 (50%) intraductal papillary mucinous tumors, and 2 (67%) solid pseudopapillary tumors were benign. The age of the patients varied from 31 to 82 years and all tumors were more common in female. Two patients had been treated previously as a pseudocyst. Surgical procedures depended on the location and extension of the tumor. Two patients underwent only laparotomy with tumor biopsy, one cholecystectomy with Roux-en-Y hepaticojejunostomy for jaundice treatment, 6 pancreatoduodenectomy, and 18 partial pancreatectomy. The most common postoperative complication was pancreatic fistula (n = 5; 19%). One patient died of necrotic pancreatitis. Of the 10 patients with serous cystic tumor, only 1 had tumor recurrence at the section border. The three patients with mucinous cystoadenocarcinoma in which was not possible to resect the tumor, died 6 to 24 months after laparotomy. The six patients with benign mucinous tumors did not have tumor recurrence. CONCLUSIONS The most common cystic neoplasms of the pancreas are serous and mucinous cysts. These tumors are more frequent in female. Although almost all serous cysts are benign, 40% of mucinous cysts are malign. Misdiagnosis may delay appropriate treatment and increase mortality.

Development of laparoscopic skills in Medical students naive to surgical training

Objective To assess the acquisition of basic laparoscopic skills of Medical students trained on a surgical simulator. Methods First- and second-year Medical students participated on a laparoscopic training program on simulators. None of the students had previous classes of surgical technique, exposure to surgical practice nor training prior to the enrollment in to the study. Students´ time were collected before and after the 150-minute training. Skill acquisition was measured comparing time and scores of students and senior instructors of laparoscopic surgery Results Sixty-eight students participated of the study, with a mean age of 20.4 years, with a predominance of first-year students (62%). All students improved performance in score and time, after training (p<0,001). Score improvement in the exercises ranged from 294.1 to 823%. Univariate and multivariate analyses identified that second-year Medical students have achieved higher performance after training. Conclusions Medical students who had never been exposed to surgical techniques can acquire basic laparoscopic skills after training in simulators. Second-year undergraduates had better performance than first-year students.

LAPAROSCOPIC RESECTION OF GASTROINTESTINAL STROMAL TUMORS (GIST)

Background Gastrointestinal mesenchymal or stromal tumors (GIST) are lesions originated on digestive tract walls, which are treated by surgical resection. Several laparoscopic techniques, from gastrectomies to segmental resections, have been used successfully. Aim Describe a single center experience on laparoscopic GIST resection. Method Charts of 15 operated patients were retrospectively reviewed. Thirteen had gastric lesions, of which ten were sub epithelial, ranging from 2-8 cm; and three were pure exofitic growing lesions. The remaining two patients had small bowel lesions. Surgical laparoscopic treatment consisted of two distal gastrectomies, 11 wedge gastric resections and two segmental enterectomies. Mechanical suture was used in the majority of patients except on six, which underwent resection and closure using manual absorbable sutures. There were no conversions to open technique. Results Mean operative time was 1h 29 min±92 (40-420 min). Average lenght of hospital stay was three days (2-6 days). There were no leaks, postoperative bleeding or need for reintervention. Mean postoperative follow-up was 38±17 months (6-60 months). Three patients underwent adjuvant Imatinib treatment, one for recurrence five months postoperatively and two for tumors with moderate risk for recurrence . Conclusion Laparoscopic GIST resection, not only for small lesions but also for tumors above 5 cm, is safe and acceptable technique.

Hernioplastia incisional laparoscópica: experiência de 45 casos

INTRODUCAO: Hernia incisional e uma complicacao frequente da laparotomia. O reparo por sutura simples tem elevadas taxas de recorrencia, e apesar do uso de protese diminuir o risco de recidiva, ainda e elevado. Na decada de 1990, o reparo laparoscopico da hernia incisional ganhou popularidade. Os beneficios incluem reducao no risco de complicacoes, menos dor e rapido retorno as atividades. Alem disso, pode diminuir a taxa de recorrencia. OBJETIVO: Apresentar experiencia com o tratamento laparoscopico das hernias incisionais. METODO: Entre janeiro de 2007 e julho de 2010, 45 pacientes foram submetidos a reparo laparoscopico de hernia incisional. Indicacoes incluiram espaco suficiente para posicionamento dos trocarteres e adequada sobreposicao da protese em relacao ao defeito herniario. As contra-indicacoes foram: co-morbidades severas que limitavam o uso de pneumoperitonio e/ou anestesia geral, assim como historico de peritonite difusa devido ao risco elevado de aderencias intra-abdominais. RESULTADOS: O tempo operatorio medio foi de 76 minutos. Houve apenas uma (2,2%) complicacao intra-operatoria. Nao houve nenhuma conversao. O tempo de internamento hospitalar foi igual ou inferior a 24 horas em 38 pacientes (84,4%). Quinze pacientes (33%) apresentaram complicacoes. Entretanto, 14 foram complicacoes menores (11 seromas indolores e 3 dor prolongada) e apenas uma complicacao maior (perfuracao tardia de ceco). Houve apenas uma recidiva (2,2%) apos seguimento medio de 24,6 meses. CONCLUSOES: O reparo laparoscopico das hernias incisionais e alternativa segura, viavel e eficaz. Parece estar associado a menores taxas de complicacoes perioperatorias e tempo de internamento quando comparado ao reparo aberto.