David Hazzan

Laparoscopic cholecystectomy in octogenarians

Background: This study aimed to assess the outcome of laparoscopic cholecystectomy (LC) in patients 80 years old or older. Methods: All consecutive patients 80 years old or older who underwent LC for symptomatic gallstone disease were evaluated. Data analysis included patients’ age, gender, indication for surgery, comorbid condition, American Society of Anesthesiology (ASA) score, preoperative endoscopic retrograde cholangio pancreatography (ERCP), intraoperative cholangiogram, operative time, conversion to open surgery, morbidity, mortality, and length of stay. Results: In this study, 67 patients (31 men and 36 women) with a mean age of 84 years (range, 80–90 years) were evaluated. Of these 67 patients, 38 (57%) underwent surgery for complicated diseases including acute cholecystitis in 15 patients (22%), gallstone pancreatitis in 17 patients (25%), cholangitis in 3 patients (4.5%), and obstructive jaundice in 3 patients (4.5%). A total of 38 patients (57%) had a preoperative ASA of 3 or 4; 23 (34%) had a preoperative ERCP; and 6 (9%) had intraoperative cholangiogram. The mean operative time was 94 ± 20 min. Five patients (7.4%) underwent conversion to open surgery because of unclear anatomy. Complications occurred in 12 patients (18%) including pulmonary edema in 3 patients, myocardial infarction in 1 patient, atelectasis in 2 patients, common bile duct injury in 1 patient, urinary tract infection in 2 patients, wound infection in 2 patients, and intraabdominal infected hematoma in 1 patient. The mean length of stay was 5.3 days. There was no mortality. Conclusions: In octogenarians LC is safe and associated with acceptable morbidity and mortality. Therefore, it should be considered for this age group. The relatively high incidence of complicated gallstone disease in this age group may be decreased if surgery is offered to them at earlier stage of the disease, leading to further decrease in perioperative morbidity.

Laparoscopic donor nephrectomy

BackgroundSeveral large series of laparoscopic donor nephrectomy (LDN) have been published, largely focusing on immediate results and short-term complications. The aim of this study was to examine the results of LDN and collect medium-term and long-term donor followup.MethodsWe examined the results of two surgeons who performed 500 consecutive LDNs from 1996 to 2005. Prospective databases were reviewed for both donors and recipients to record demographics, medical history, intraoperative events, and complications. Patients were followed between 1 month and 9 years after surgery to assess for delayed complications, especially hypertension, renal insufficiency, incisional hernia, bowel obstruction, and chronic pain.ResultsLeft kidneys were procured in 86.2% of cases. Mean operative time was 3.5 h, and warm ischemia time averaged 3.4 min. Hand-assistance was used in 13.8%, and conversion rate was 1.8%. Intraoperative complication rate was 5.8% and was predominantly bleeding (93.1%). Most (86.2%) of the operative complications occurred during the initial 150 cases of a surgeon, compared with 10.3% in the subsequent 150 cases (p = 0.003). Operative time decreased by 87 min after the initial 150 cases (p < 0.001). Immediate graft survival was 97.5%. Delayed graft function occurred in 3.0% of recipients, and acute tubular necrosis occurred in 7.0%. Thirty-day donor complication rate was 9.8%. Mean donor creatinine was 1.24 on the first postoperative day, 1.27 at 2 weeks, and 1.24 at 1 year. At a mean followup of 32.8 months, long-term donor complications consisted of 11 cases of hypertension, 9 cases of prolonged pain or paresthesia, 2 incisional hernias, 1 small bowel obstruction requiring laparoscopic lysis of adhesions, and 1 hydrocele requiring repair.ConclusionsLDN can be performed with acceptable immediate morbidity and excellent graft function. Operative time and complications decreased significantly after a surgeon performed 150 cases. Long-term complications were uncommon but included a likely underestimated incidence of hypertension.

The First Decade of a Laparoscopic Donor Nephrectomy Program: Effect of Surgeon and Institution Experience with 512 Cases from 1996 to 2006

BACKGROUND Although the procedure is generally safe, significant morbidity and even mortality have occurred after laparoscopic donor nephrectomy (LDN). The learning curves for both surgeons and institutions with LDN have not been well delineated, and longterm donor data are not well reported. STUDY DESIGN A retrospective study of the initial 512 patients undergoing LDN performed at Mount Sinai Medical Center between October 1996 and March 2006 was performed. Intraoperative and immediate postoperative surgical outcomes were reviewed. Univariate analysis and multivariate logistic regressions were performed to identify predictors of outcomes, including the experience level of individual surgeons and of the institution. Longitudinal followup data of donor patients between 1 month and 9 years were obtained. RESULTS Mean donor age was 39.2 years, and 54.6% of patients were women. Left kidneys were procured in 84.0%. Operative time averaged 215.2 minutes, and warm ischemia time, 166.6 seconds. The conversion rate was 1.4%, and hand-assistance was used in 49.9%. The intraoperative complication rate was 5.5%, 30-day complication rate 9.4%, and 1.4% of patients required reoperation. Immediate graft survival was 97.1%, acute tubular necrosis occurred in 8.5%, and delayed graft function in 3.7%. At a mean followup of 37.2 months, delayed donor complications were infrequent, but included chronic pain, hypertension, incisional hernia, and small bowel obstruction. Although individual surgeons and our institution gained experience, operative and warm ischemia times decreased significantly, but complication rates were unchanged. CONCLUSIONS Although a learning curve was discovered for operative time and warm ischemia time, excellent results can be achieved during the early experience of both surgeons and institutions with LDN, and maintained over time. Younger, female, and nonobese donors were associated with fewer complications. Longterm donor morbidity is uncommon, but mandates better followup.

A review of laparoscopic paraesophageal hernia repair

ZusammenfassungGRUNDLAGEN: Bei der Therapie der paraösophagealen Hernien (PEH) hat die laparoskopische Technik die offenen Operationen verdrängt. Gewisse Aspekte der operativen Therapie haben sich, unabhängig von der Methodik, bewährt. Andere wiederum werden weiterhin kontrovers diskutiert. METHODIK: Literaturanalyse. ERGEBNISSE: Die chirurgische Therapie der paraösophagealen Hernien (PEH) stellt den goldenen Standard bei symptomatischen Patienten dar. Bei asymptomatischen Patienten jedoch bleibt die Rolle der Chirurgie weiterhin unklar. In der Literatur liegen keine auf Evidenz basierenden Daten vor, die die Notwendigkeit einer routinemäßigen Durchführung einer Antirefluxmaßnahme bestätigen. Die Verwendung von Kunststoffnetzen bei großen Gewebedefekten wird in der Literatur sowohl empfohlen als auch als unnotwendig dargestellt. Die vorliegenden Daten bringen keine Klarheit darüber, ob die möglichen Vorteile oder das Risiko der Kunststoffnetz-bedingten Komplikationen überwiegen. Die Inzidenz und die klinische Signifikanz der Rezidive der PEH nach laparoskopischen Operationen sind unklar. Die publizierte Rezidivrate rangiert zwischen 0 und 42%. SCHLUSSFOLGERUNGEN: Die laparoskopische Therapie der paraösophagealen Hernien stellt unbestritten eine anspruchsvolle Technik dar, welche jedoch bei exakter Durchführung exzellente Resultate ergeben kann.SummaryBACKGROUND: Laparoscopic repair of paraesophageal hernias (PEH) is replacing the open approach. Regardless of the technique, certain aspects of the repair have proven to be beneficial while others remain controversial. METHODS: Review of the literature. RESULTS: Surgical correction of paraesophageal hernias (PEH) is the gold standard for symptomatic patients, the role of surgery in asymptomatic patients is less clear. There is not good evidence-based data to support the routine addition of an antireflux procedure. Prosthetic repair of large defects has been both advocated and condemned in the literature. Conflicting data make it unclear whether the potential benefits outweigh the risk of mesh-related complications. The incidence and clinical significance of PEH recurrence after laparoscopic repair remain undefined. The recurrence rate in the literature after laparoscopic PEH repair ranges from 0 to 42%. CONCLUSIONS: Laparoscopic paraesophageal hernia repair is a challenging procedure, but with meticulous technique, provides excellent results.

Midterm outcomes of sleeve gastrectomy in the elderly.

BACKGROUND The increase in life expectancy presents health systems with a growing challenge in the form of elderly obesity. Bariatric surgery has been shown to be a safe and effective treatment for obesity with reduction of excess weight and improvement in obesity-related co-morbidities. However, only recently have surgeons begun performing these operations on elderly patients on a larger scale, making data regarding mid- and long-term outcomes scarce. The objective of this study was to evaluate the safety and midterm efficacy of laparoscopic sleeve gastrectomy (LSG) in patients aged ≥60 years. METHODS All patients aged ≥60 years who underwent LSG between 2008 and 2014 and achieved ≥24-month follow-up were retrospectively reviewed. Demographic characteristics and perioperative data were analyzed. Weight loss parameters and co-morbidity resolution rates were compared with preoperative data. RESULTS In total 55 patients aged ≥60 years underwent LSG. Mean patient age was 63.9 ± 3.2 years (range, 60-75.2), and mean preoperative body mass index was 43 ± 6.0 kg/m2. Perioperative morbidity included 5 cases of hemorrhage necessitating operative exploration, 2 cases of reduced hemoglobin levels treated with blood transfusion, and 1 case of portal vein thrombosis managed with anticoagulation. There were no mortalities. Mean follow-up time was 48.6 (range, 25.6-94.5) months. Mean percentage of excess weight loss was 66.4 ± 19.7, 67.5 ±1 6.4, 61.4 ± 18.3, 66.7 ± 25.6, 50.7 ± 21.4 at 12, 24, 36, 37 to 60, and 61 to 96 months, respectively. Statistically significant improvement of type 2 diabetes, hypertension, and dyslipidemia were observed at the latest follow-up (P < .01). CONCLUSION LSG offers an effective treatment of obesity and its co-morbidities in patients aged ≥60 years, albeit with a high perioperative bleeding rate at our center; efficacy is maintained for at least 4.5 years.

Correction to: Long-Term (over 10 Years) Retrospective Follow-up of Laparoscopic Adjustable Gastric Banding

In the original article the spelling of author Naama Kafri was incorrect.

Insulinoma of Tail of Pancreas

Insulinomas are generally benign tumors ideally suited to laparoscopic resection. Surgical management has changed over the years. Small benign tumors of the endocrine pancreas, including insulinomas, can be enucleated if their location is separate from the main pancreatic duct. Those over 2 cm and those close to the main pancreatic duct are generally treated by resection of the distal pancreas. Such a resection may be done as a spleen-preserving operation, or may include splenectomy. This chapter explores options in surgical treatment of a 2-cm insulinoma.