Cristiano G.S. Huscher

Laparoscopic Versus Open Subtotal Gastrectomy for Distal Gastric Cancer: Five-Year Results of a Randomized Prospective Trial

Objective:The aim of this study was to compare technical feasibility and both early and 5-year clinical outcomes of laparoscopic-assisted and open radical subtotal gastrectomy for distal gastric cancer. Summary Background Data:The role of laparoscopic surgery in the treatment of gastric cancer has not yet been defined, and many doubts remain about the ability to satisfy all the oncologic criteria met during conventional, open surgery. Methods:This study was designed as a prospective, randomized clinical trial with a total of 59 patients. Twenty-nine (49.1%) patients were randomized to undergo open subtotal gastrectomy (OG), while 30 (50.9%) patients were randomized to the laparoscopic group (LG). Demographics, ASA status, pTNM stage, histologic type of the tumor, number of resected lymph nodes, postoperative complications, and 5-year overall and disease-free survival rates were studied to assess outcome differences between the groups. Results:The demographics, preoperative data, and characteristics of the tumor were similar. The mean number of resected lymph nodes was 33.4 ± 17.4 in the OG group and 30.0 ± 14.9 in the LG (P = not significant). Operative mortality rates were 6.7% (2 patients) in the OG and 3.3% (1 patient) in the LG (P = not significant); morbidity rates were 27.6% and 26.7%, respectively (P = not significant). Five-year overall and disease-free survival rates were 55.7% and 54.8% and 58.9% and 57.3% in the OG and the LG, respectively (P = not significant). Conclusions:Laparoscopic radical subtotal gastrectomy for distal gastric cancer is a feasible and safe oncologic procedure with short- and long-term results similar to those obtained with an open approach. Additional benefits for the LG were reduced blood loss, shorter time to resumption of oral intake, and earlier discharge from hospital.

Standard laparoscopic versus single-incision laparoscopic colectomy for cancer: early results of a randomized prospective study

BACKGROUND Standard laparoscopic colectomy (SLC) for cancer is a safe, feasible, and oncologically effective procedure with better short-term and similar long-term results of open colectomy. Conversely, owing to technical difficulties in colonic resection and full mesenteric dissection, single-incision laparoscopic colectomy (SILC) has been considered unsuitable for oncologic purposes. We compared the technical feasibility and early clinical outcomes of SLC and SILC for cancer. METHODS In this prospective randomized clinical trial, 16 (50%) patients underwent SLC (10 left and 6 right) and 16 (50%) patients underwent SILC (8 left and 8 right). RESULTS Demographics, preoperative data, and characteristics of the tumor were similar. The mean number of resected lymph nodes was 16 ± 5 in the SLC and 18 ± 6 in the SILC group (P = NS). Surgical time was 124 ± 8 minutes and 147 ± 5 minutes, respectively (P = NS). Surgical mortality was nil and the major morbidity rate was 6.3% in both groups. CONCLUSIONS SILC for cancer is a technically feasible and safe oncologic procedure with short-term results similar to those obtained with a traditional laparoscopic approach.

Laparoscopic cholecystectomy by ultrasonic dissection without cystic duct and artery ligature

Background: Laparoscopic cholecystectomy (LC) is the gold standard treatment of gallstones. Nevertheless, there are some pitfalls due to the limits of current technology and the use of inappropriate ligature material, with a relevant risk of injuries and postoperative, mainly biliary, complications. Ultrasonically activated scissors may divide both vessels and cystic duct, with no need of further ligature, and possibly reduce the risk of thermal injuries. Methods: A prospective nonrandomized clinical trial was started in 1999 to test harmonic shears (Ultracision, Ethicon Endo-Surgery, Cincinnati, OH, USA) in 461 consecutive patients undergoing LC in order to evaluate the theoretical benefits of ultrasonic dissection and the possible reduction in intraoperative bile duct injuries (BDIs) and postoperative complications. Patients were divided in two groups: in group 1 (HS; 331 patients) the operation was performed by Ultracision (including coagulation–division of cystic duct and artery); in group 2 (LOOP; 130 patients) the cystic duct, after coagulation–division by harmonic scissors, was further secured with an endo-loop. Both groups were further divided into two subgroups: expert and surgeon-in-training. The following categories of data were collected and analyzed: individual patient data, indication for laparoscopic cholecystectomy, surgical procedure data (associated procedures, intraoperative cholangiography, intraoperative complications, length of surgery, and conversion to open), and postoperative course data (postoperative morbidity, postoperative mortality, reinterventions, and postoperative hospital stay). Furthermore, biliary complications were analyzed as a single parameter comparing the incidence within groups and subgroups. Cumulative complications (intraoperative and postoperative) were also analyzed as a single parameter comparing their incidence in the series of each surgeon within the surgeon-in-training subgroup to the average results of the expert subgroup. Finally, length of surgery, postoperative complication rate, and length of postoperative hospital stay within subgroups were analyzed to evaluate the learning curve. Results: Overall conversion rate was 0.87%. The mean operating time was 76.8 min (median, 70 min) in group 1 and 97.5 min (median 90 min) in group 2. BDI occurred in 1 case (0.32%) in the surgeon-in-training subgroup. Overall BDI rate was 0.22% (1/461). The overall incidence of postoperative bile leak was 2.7% (9 patients of subgroup 1 and 1 patient of subgroup 2). Clinical observation with spontaneous resolution occurred in 4 patients, and in 1 case the management consisted in an endoscopic biliary drainage; surgery was requested in the remaining cases. A laparoscopic approach was successfully attempted in all cases. Overall morbidity rate was 8.76% in group 1 and 13.84% in group 2. Rates of major complications, overall biliary complication, and postoperative bile leaks within the expert and surgeon-in-training subgroup differ significantly (p = 0.026, p = 0.03, and p = 0.049, respectively). There was 1 death (0.22%) due to sepsis that resulted from a small bowel injury by trocar insertion. Mean postoperative stay was 4.28 days for group 1 and 5.05 days for group 2. Conclusion: No significant difference was found in both patient groups regarding postoperative mortality and complications, biliary complications, and especially cystic duct leaks. A retrospective comparison of literature data showed that use of ultrasonic dissection during LC seems to reduce the risk of BDI. Nevertheless, a learning curve in the use of ultrasonic-activated devices is required: a significant differences in postoperative major complications and biliary complications between the expert and the surgeon-in-training subgroups was shown. Furthermore, ultrasonic scissors misuse may cause bowel injuries in patients with severe adhesions, and this could represent a possible limitation for surgical safety.

Laparoscopic treatment of blunt splenic injuries: initial experience with 11 patients.

BackgroundNonoperative treatment of splenic injuries is the current standard of care for hemodynamically stable patients. However, uncertainty exists about its efficacy for patients with major polytrauma, a high Injury Severity Score (ISS), a high grade of splenic injury, a low Glasgow Coma Score (GCS), and important hemoperitoneum. In these cases, the videolaparoscopic approach could allow full abdominal cavity investigation, hemoperitoneum evacuation with autotransfusion, and spleen removal or repair.MethodsThis study investigated 11 hemodynamically stable patients with severe politrauma who underwent emergency laparoscopy. The mean ISS was 29.0 ± 3.9, and the mean GCS was 12.1 ± 1.6. A laparoscopic splenectomy was performed for six patients, whereas splenic hemostasis was achieved for five patients, involving one electrocoagulation, one polar resection, and three polyglycolic mesh wrappings.ResultsThe average length of the operation was 121.4 ± 41.6 min. There were two complications (18.2%), with one conversion to open surgery (9.1%), and no mortality.ConclusionsLaparoscopy is a safe, feasible, and effective procedure for evaluation and treatment of hemodynamically stable patients with splenic injuries for whom nonoperative treatment is controversial.

Laparoscopic Gastric Resections

The impressive breakthrough in laparoscopic surgery has pushed surgeons to perform gastric resection through such an approach. Laparoscopy reduces the surgical stress and the postoperative pain and has a positive impact on the rehabilitation time, the hospital stay, and return to work and social activities. Laparoscopic partial gastrectomy for benign diseases and for palliation has been accepted as an effective surgical option: they are reproducible operations performed worldwide at a more and more rapid pace. Laparoscopic gastric resections and laparoscopically assisted gastric resections for malignancy deserve a word of caution. Nevertheless, the investigators report their series of laparoscopic subtotal and distal gastrectomies for cancer with medium and long-term results comparable with those of open surgery. Furthermore, new and less invasive surgical options have been recently introduced. Full and partial thickness local resections may be accomplished through intragastric procedures, for treatment of small benign tumors and early stage gastric cancer. Copyright

Combining ultrasonic dissection and the Storz operation rectoscope

Background: Transanal endoscopic microsurgery (TEM) allows a precise, full-thickness resection of rectal tumors anywhere within the rectum. Unfortunately, the standard TEM technique needs complex and rather expensive equipment, demands high skill, and is attended by bleeding and oozing that may be challenging. A modified TEM procedure combining the new Storz operation rectoscope and ultrasonic dissection has been developed to overcome the limitations of the original technique. Methods: The Storz operation rectoscope features a 5-mm telescope combined with a single-monitor display. Standard laparoscopic instruments and the LCSC5 Ultracision Maniple are used for dissection and coagulation. Full-thickness resection is performed most often. Closure of the defect is accomplished by interrupted 3-0 polydoxanone sutures secured by extracorporeal slipknots. Results: Altogether, 18 TEMs have been performed according to the modified technique: 9 for malignant and 9 for benign lesions. The median operating time was 92.5 min for resection of malignant lesions and 40 min for resection of benign lesions. Two postoperative complications occurred: a bleeding and a partial dehiscence. The median follow-up periods were 35 months for malignant disease and 19.5 months for benign disease. No recurrence was observed. Conclusion: For tumors located up to 15 cm from the anal verge, TEM with the Storz rectoscope and ultrasonic dissection is indicated. Despite the complication described, coagulation is optimal and ultrasonic scissors allow working in a fairly bloodless field. The overall costs of the equipment are significantly lower.

Laparoscopic gastrectomies for cancer: The ACOI-IHTSC national guidelines

Abstract Guidelines for laparoscopy and cancer of stomach have been outlined by several scientific societies: The main recommendation being that laparoscopy should be used only by surgeons already highly skilled in gastric surgery. The laparoscopic approach to gastric cancer surgery has become more and more frequent in most Italian centers. On behalf of the Guideline Committee of the Italian Society of Hospital Surgeons and the Italian Hi-Tech Surgical Club, a panel of experts analyzed the highest evidence of all scientific papers focusing on laparoscopic gastrectomies for cancer and published from 2003 to 2011, and drew these national guidelines. Laparoscopic gastrectomy may be considered as a safe procedure with better short-term and comparable long-term results. compared to open gastrectomy (Grade A). There is a general agreement that a laparoscopic approach to the treatment of gastric cancer should be chosen only by surgeons already highly skilled in gastric surgery and other advanced laparoscopic interventions. Furthermore, the first procedures should be carried out during a tutoring program. Diagnostic laparoscopy is strongly recommended as the first step of laparoscopic as well as laparotomic gastrectomies (Grade B). Additional randomized controlled trials (RCT) that compare and investigate the long-term oncological outcomes of laparoscopic assisted gastrectomy are required.

Transoral Extraction of a Laparoscopically Resected Large Gastric GIST

Although natural orifice specimen extraction is now widely performed, there have been no reports of transoral extraction following laparoscopic gastric resection. This report describes the first transoral specimen extraction in a patient with a gastrointestinal stromal tumor (GIST) of the lesser curvature of the stomach. The clinical data of a patient with a large gastric GIST were reviewed. Totally laparoscopic resection of the gastric lesser curvature was performed using four trocars. The specimen, put in a retrieval bag, was withdrawn via the transgastric and esophageal route. Reconstruction of the stomach was performed using the intracorporeal technique. The procedure was successfully accomplished without intraoperative and postoperative complications. In conclusion, transoral specimen extraction after laparoscopic gastric resection is a safe and feasible operative procedure for selected patients with a large benign gastric tumor.

Laparoscopy can be very effective in reducing mortality rate for caustic ingestion in suicide attempt.

We read with great interest the article by Chou et al. [1] about the predictive factors of postoperative mortality in patients with gastrointestinal corrosive injuries who undergo emergency esophagogastrectomy. The experience of the Taiwan group is impressive, with more than 500 patients admitted with caustic injuries and more than 70 patients operated on in a 10-year period. Their indications for emergency surgery were (1) presence of peritoneal signs or free air, (2) grade 3 corrosive injuries in EGD, (3) intractable acid-base imbalance after medical resuscitation, (4) indications of shock upon arrival at the emergency department, and (5) presence of gross hematuria. Their postoperative mortality rate was 42.3%, similar to that observed in several series from around the world. We agree with Chou et al.’s indications for emergency surgery; however, since 1995, we have included diagnostic laparoscopy in the preoperative workup of these patients. It helps us to detect a very early serosal involvement and to explore the lesser sac for the presence of posterior gastric wall perforations and pancreas damage, and explore the mediastinum for the presence of free fluid. Moreover, with laparoscopy we can perform a minimally invasive esophagogastrectomy and reduce the surgical trauma. Between 1998 and 2006, we performed a totally laparoscopic emergency esophagogastrectomy in 6 patients (2 males and 4 females; mean age = 38.5 ± 14.7 years, range = 18-56 years) who attempted suicide by caustic ingestion. All patients were operated on between 6 and 10 h after emergency admission, after fluid resuscitation, acid-base imbalance correction, EGD, bronchoscopy and CT. No clinical or CT signs of peritoneal irritation or free air were evident. Prior to the diagnostic laparoscopy, indications for surgery were grade 3 corrosive injuries at EGD in four cases, shock upon arrival in one case, and abdominal free fluid in one case. At laparoscopy, we detected a serosal involvement with abdominal free fluid in all patients, a posterior gastric wall perforation in two patients, and free fluid in the mediastinum in two patients. The totally laparoscopic emergency esophagogastrectomy was performed with four trocars placed in a rhombus shape. Total gastrectomy was performed, dividing the gastrocolic ligament and short gastric vessels using harmonic scissors (Ultracision , Ethicon Endo-Surgery, Cincinnati, OH). The duodenum was transected with a linear stapler (blue cartridge) and the left gastric artery was transected with a vascular stapler (white cartridge). The hiatus was opened wide and the esophagus was dissected free with the Ultracision scissors using the intravagal technique to spear both pleuras. The esophageal dissection was completed through a left neck incision, the specimen was retrieved, and an esophagostomy was performed. A feeding jejunostomy was carried out using a balloon catheter (Fig. 1). The mean operative time was 218 ± 28 min and blood loss was minimal in four patients and 200 and 300 cc in the remaining two cases. All patients survived; mean ICU stay was 7 ± 3 days and mean hospital stay was 28 ± 15 days. In two young patients intestinal continuity was restored C. G. Huscher (&) Department of Health Sciences, Division of Surgery, Veneziale Hospital, Molise University, Via Sant Ippolito, Isernia, Italy e-mail: c.huscher@tiscali.it

Techniques and technology evolution of rectal cancer surgery: a history of more than a hundred years

Abstract History of rectal cancer surgery has shown a continuous evolution of techniques and technologies over the years, with the aim of improving both oncological outcomes and patients quality of life. Progress in rectal cancer surgery depended on a better comprehension of the disease and its behavior, and also, it was strictly linked to advances in technologies and amazing surgical intuitions by some surgeons who pioneered in rectal surgery, and this marked a breakthrough in the surgical treatment of rectal cancer. Rectal surgery with radical intent was first performed by Miles in 1907 and the procedure he developed, abdomino-perineal resection, became a gold standard for many years. In the following years and over the last century other procedures were introduced which became new gold standards: Hartmanns procedure, anterior rectal resection, total mesorectal excision (TME); the last one, developed by Heald in 1982, is the present gold standard treatment of rectal cancer. At the same time, new technologies were developed and introduced into the clinical practice, which enhanced results of surgery and even made possible performing new operations: leg-rests, stapling devices, instruments, appliances and platforms for laparoscopic surgery and transanal rectal surgery. In more recent years the transanal approach to TME has been introduced, which might improve oncologic results of surgery of the rectum. Ongoing randomized studies, future systematic reviews and metanalyses will show whether the transanal approach to TME will become a new gold standard.