Daniel Rosenthal

Prospective comparison of openvs. laparoscopic colon surgery for carcinoma

Laparoscopy for colonic diseases began in 1990 and has established a role in benign disease. Early observations and experiences demonstrated feasibility of laparoscopic surgery for a variety of colonic disease processes, but the applicability to colonic carcinoma was unclear. METHODS: In 1990, we began a comparative study of open (OCR)vs.laparoscopic (LCR) approach to colon cancer. The study progressed 65 months, with 224 patients in OCR group and 191 patients in LCR group. Parameters studied are stage, location, length of specimen, number of lymph nodes resected, margins, postoperative course, wound complications, recurrence rates, and immediate and long-term survival. OCR were standardized by one group, and LCR were standardized by a second group. All patients undergoing LCR were given freedom to choose either OCR or LCR, and informed consent was obtained. RESULTS: Equal or greater lymph node retrieval, resections, and distal margins were evident with LCR. Benefits with LCR were shown with shorter hospitalization (5.7vs.9.7 days), less blood loss, less wound problems (1vs.14), and quicker return of bowel function. Survival, recurrence, and death rates were essentially the same. There were no trocar implants in the LCR group. CONCLUSION: After five years, this study shows that laparoscopy does no harm to the patient, offers comparable oncologic resections, and seems to be patient-friendly, with less pain, quicker return of bowel functions, shortened hospitalization, and quicker return to full activity.

Complications of laparoscopic herniorrhaphy

SummaryAnterior inguinal hernia repair is the second-most-commonly performed abdominal operation and has been associated with low morbidity and mortality rates. The principle of laparoscopy has been applied to this surgical problem in a series of 762 patients with 841 inguinal hernias. Four types of laparoscopic repairs were conducted: (1) high ligation of the indirect inguinal hernia sac and closure of the internal ring (87 patients with 89 hernias); (2) plug and patch of the internal ring (74 patients with 87 hernias); (3) transperitoneal suture repair of the transversalis fascia to the iliopubic tract or Coopers ligament (28 patients with 30 hernias); and (4) placement of a large prosthesis over the myopectoneal orifice (563 patients with 635 hernias). These early results indicate that the overall complication rates were low, especially when a large prosthesis was used to reinforce the myopectoneal orifice. It is concluded that laparoscopic inguinal herniorrhaphy is a safe and effective procedure with which to manage this surgical problem.

Cystosarcoma phylloides in adolescent female patients

Nine cases of cystosarcoma phylloides in adolescent female patients are reported along with an additional 35 cases collected from the literature. Analysis of these 44 cases revealed 37 (84.1 percent) benign lesions, 6 (13.6 percent) malignant tumors, and 1 borderline lesion. Excision was the most common operative procedure and was performed in 35 patients. Nine patients underwent mastectomy. There were three recurrent lesions (one benign and two malignant) for a recurrence rate of 6.8 percent. Wide excision was successful in the treatment of recurrent lesions. On the basis of these data, excision is the preferred initial therapy of cystosarcoma phylloides in the adolescent patient regardless of the histologic classification of the lesion. Malignant cystosarcoma is more likely to recur than a benign lesion but a recurrence can be managed with reexcision. Sacrifice of the adolescent breast at the initial procedure is strongly discouraged.

Management of the ileocecal syndrome

Neutropenic enterocolitis, also known as typhlitis or ileocecal syndrome, is a recognized complication of the treatment of hematologic malignancies and usually is fatal. The pathologic findings consist of bowel-wall ulcerations and necrosis with bacterial or fungal invasion. These findings are usually limited to the ileum, cecum, ascending colon, and appendix. The syndrome occurs in a select patient population who generally have 1) a hematologic malignancy, 2) neutropenia, 3) thrombocytopenia, 4) a recent course of chemotherapy, and 5) a recent course of antibiotics. This syndrome also can arise spontaneously in patients with aplastic anemia or cyclic neutropenia. The clinical presentation consists of a high fever and right-sided abdominal pain with evidence of peritoneal irritation. Recommended therapy is right hemicolectomy. Experience and a critical review of the literature support this approach.

Carcinoid tumors of the appendix.

The data presented in this series support the premise that simple appendectomy is adequate therapy for appendiceal carcinoids less than 1 cm in diameter. However, little argument can be made against more radical surgery for gross lymph node metastases. When surgical margins after appendectomy are not free of tumor, additional surgery seems warranted, although in the present series there was a patient who was followed for 30 years who had residual microscopic disease in the appendiceal stump. Adequate treatment for tumors larger than 2 cm includes radical right hemicolectomy. What constitutes adequate therapy for tumors in the 1 to 2 cm range continues to be a point of controversy. From the data presented herein, it seems that appendectomy alone is sufficient except in those instances when both mesoappendiceal and subserosal lymphatic invasion is identified microscopically.

Acute cholecystitis associated with hepatic arterial infusion of floxuridine

In a 1 year period, 13 patients underwent pump implantation for liver metastasis from a primary colorectal tumor. The gallbladders were not removed at the time of pump implantation in the initial six patients. In these patients, chemotherapy consisted of floxuridine given every 2 weeks followed by a 2 week rest period and cisplatin over 1 hour by way of the side portal on day 8 of the cycle. The treatment was repeated every 28 days. All patients whose gallbladders were not removed at the time of pump implantation required reoperation for acute or chronic acalculous cholecystitis from 1 to 9 months (mean 5.4 months) after pump implantation. At operation, all patients were found to have various degrees of inflammation and fibrosis. In one patient, significant sclerosing cholangitis was documented that involved the entire intrahepatic ductal system and hepatic duct bifurcation. Cholecystectomy and operative cholangiography are recommended in all patients who undergo pump implantation for metastatic disease to the liver.

Management of a subcutaneous colostomy perforation. The role of a new synthetic skin.

Colostomy perforation is an infrequent but often diasastrous and lethal complication. In the majority of patients, the traumatic performation occurs during irrigation through the colostomy stoma. This case report reviews the clinical course of a patient with a subcutaneous colostomy perforation and the subsequent development of an extensive abscess. Aspects of the management included mobilization of the colostomy and thorough surgical debridement and drainage. In addition, the report introduces the use of the new semisynthetic biologic dressing, BioBrane®. This synthetic, semipermeable skin substitute served as a temporary dessing, provided good stability, and supported the application of a stoma appliance.

Changing trends in causalgia

The term causalgia as currently understood encompasses a wider range of post-traumatic disabilities than Mitchells original definition as burning pain. In this series, orthopedic injury replaced penetrating trauma as the most common initiating event. Injury to a peripheral nerve may be ill-defined or absent. Serious disability may arise from what appears to be a minor injury. When causalgia is recognized and appropriate therapy instituted, nearly all patients improve.

Basal cell carcinoma of the anus

SummaryTwo cases of basal cell carcinoma of the anus have been presented. In both cases, the patient had a synchronous malignant lesion. The histologic variation of basal cell carcinoma of the anus and an outline of therapy has been discussed.

Dissection and Resection Facilitated Laparoscopic Right Hemicolectomy

Laparoscopically facilitated right colectomies for benign or malignant disease can minimize the incision size and the trauma to the patient. A suitable patient is a one who after a comprehensive preoperative evaluation appears to have a lesion not involving neighboring organs, not invading the abdominal parietes, and not associated with interintestinal fistulas or abscesses. A careful history, a thorough physical examination, barium contrast studies, and enhanced computed tomography in selected patients should provide the surgeon with enough information to decide whether a patient is a suitable candidate for laparoscopic surgery.