Eduardo M. Targarona

Evaluation of quality of life after laparoscopic surgery: evidence-based guidelines of the European Association for Endoscopic Surgery

BackgroundMeasuring health-related quality of life (QoL) after surgery is essential for decision making by patients, surgeons, and payers. The aim of this consensus conference was twofold. First, it was to determine for which diseases endoscopic surgery results in better postoperative QoL than open surgery. Second, it was to recommend QoL instruments for clinical research.MethodsAn expert panel selected 12 conditions in which QoL and endoscopic surgery are important. For each condition, studies comparing endoscopic and open surgery in terms of QoL were identified. The expert panel reached consensus on the relative benefits of endoscopic surgery and recommended generic and disease-specific QoL instruments for use in clinical research.ResultsRandomized trials indicate that QoL improves earlier after endoscopic than open surgery for gastroesophageal reflux disease (GERD), cholecystolithiasis, colorectal cancer, inguinal hernia, obesity (gastric bypass), and uterine disorders that require hysterectomy. For spleen, prostate, malignant kidney, benign colorectal, and benign non-GERD esophageal diseases, evidence from nonrandomized trials supports the use of laparoscopic surgery. However, many studies failed to collect long-term results, used nonvalidated questionnaires, or measured QoL components only incompletely. The following QoL instruments can be recommended: for benign esophageal and gallbladder disease, the GIQLI or the QOLRAD together with SF-36 or the PGWB; for obesity surgery, the IWQOL-Lite with the SF-36; for colorectal cancer, the FACT-C or the EORTC QLQ-C30/CR38; for inguinal and renal surgery, the VAS for pain with the SF-36 (or the EORTC QLQ-C30 in case of malignancy); and after hysterectomy, the SF-36 together with an evaluation of urinary and sexual function.ConclusionsLaparoscopic surgery provides better postoperative QoL in many clinical situations. Researchers would improve the quality of future studies by using validated QoL instruments such as those recommended here.

Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

BackgroundAlthough laparoscopic splenectomy (LS) has become the standard approach for most splenectomy cases, some areas still remain controversial. To date, the indications that preclude laparoscopic splenectomy are not clearly defined. In view of this, the European Association for Endoscopic Surgery (EAES) has developed clinical practice guidelines for LS.MethodsAn international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. A consensus development conference using a nominal group process convened in May 2007. Its recommendations were presented at the annual EAES congress in Athens, Greece, on 5 July 2007 for discussion and further input. After a further Delphi process between the experts, the final recommendations were agreed upon.ResultsLaparoscopic splenectomy is indicated for most benign and malignant hematologic diseases independently of the patient’s age and body weight. Preoperative investigation is recommended for obtaining information on spleen size and volume as well as the presence of accessory splenic tissue. Preoperative vaccination against meningococcal, pneumococcal, and Haemophilus influenzae type B infections is recommended in elective cases. Perioperative anticoagulant prophylaxis with subcutaneous heparin should be administered to all patients and prolonged anticoagulant prophylaxis to high-risk patients. The choice of approach (supine [anterior], semilateral or lateral) is left to the surgeon’s preference and concomitant conditions. In cases of massive splenomegaly, the hand-assisted technique should be considered to avoid conversion to open surgery and to reduce complication rates. The expert panel still considered portal hypertension and major medical comorbidities as contraindications to LS.ConclusionDespite a lack of level 1 evidence, LS is a safe and advantageous procedure in experienced hands that has displaced open surgery for almost all indications. To support the clinical evidence, further randomized controlled trials on different issues are mandatory.

Can we predict immediate outcome after laparoscopic rectal surgery? Multivariate analysis of clinical, anatomic, and pathologic features after 3-dimensional reconstruction of the pelvic anatomy.

Objectives:The laparoscopic approach for colon resection is widely accepted but its definitive role in rectal tumors is controversial due to the technical difficulties associated with this procedure. Tumor size and volume, and pelvic dimensions may influence intraoperative and/or immediate outcome. This study aimed to evaluate the predictive value of anatomic and pathologic features on immediate outcome after laparoscopic rectal resection. Material and Methods:The study included a prospective series of 60 patients submitted to laparoscopic resection for rectal tumors. A preoperative computed tomography was performed in all patients. Three-dimension reconstruction of the pelvis, rectal tumor, and prostate was computed. Tumor and prostate volume and diameters were calculated, as were main pelvic diameters (subsacrum-retropubic, coccyx pubis, and promontorium coccyx), and lateral diameters, at the tumor level (3D Doctor Software package). Age, sex, body mass index (BMI), tumor height, previous radiotherapy treatment, and type of procedure (anterior resection, low anterior resection, and abdominoperineal resection) were recorded. Immediate outcome (morbidity, mortality, and stay) was also collected. Dependent variables were operative time, intraoperative difficulty, conversion, and postoperative morbidity. Univariate and multivariate analyses were performed (SPSS package). Results:The series included 36 men and 24 women, with a mean age of 72 years (range, 38–87). Surgical procedures were 10 anterior resections, 31 low anterior resections, and 19 abdominoperineal resections. Conversion rate was 9 of 60 (15%), operative time: 172 minutes (range, 90–360), morbidity: 31% and stay: 9 days (range, 6–43). Multivariate analysis showed tumor craniocaudal length was an independent predictive factor for conversion (P < 0.04, odds ratio [OR]: 1.5, confidence interval [CI]95%: 1–2.2). Pubic coccyx axis (P < 0.005) and sex (P < 0.009) showed independent values for operative time, and BMI (P < 0.02, OR: 1.2, CI 95%:1-1.5) was related to postoperative morbidity. When a subanalysis was performed in relation to sex, independent factors differed between males and females, with a predominance of anatomic and tumor measures in men. Conclusion:Local anatomy and pathologic features directly affect surgical outcome in the laparoscopic approach to the rectum. Sex, BMI, lower pelvis diameter, and tumor size are independent predictors for conversion, operative time, and morbidity. These data should be taken into account when planning this kind of procedure.

NOTES-assisted transvaginal splenectomy: the next step in the minimally invasive approach to the spleen.

Hypothesis. Natural orifice transluminal endoscopic surgery (NOTES) has marked yet another step forward in less-invasive surgical procedures. Access to solid organs located deep in the left hypochondrium can be difficult using this technique but the transvaginal approach with the patient positioned in full lateral decubitus may be an option. Material and methods. We present the case of a 60-year-old woman with a symptomatic splenic polycystic tumor. The procedure was carried out by a multidisciplinary team using a standard flexible videogastroscope and endoscopic instruments. Transvaginal visualization of the spleen and standard dissection of attachments were feasible, and splenectomy was completed using transvaginal stapling of the splenic hilum. The organ was extracted transvaginally. Results. The postoperative course was uneventful. The patient had minimal postoperative pain and minimal scars, and was discharged on the second postoperative day. Conclusions. Transvaginal access can be safely used for operative visualization, hilum transection, and spleen removal with conventional instrumentation, reducing parietal wall trauma to a minimum. The clinical, esthetic, and functional advantages require further analysis.

Minimally Invasive Treatment for Obstructive Tumors of the Left Colon: Endoluminal Self-Expanding Metal Stent and Laparoscopic Colectomy

Background: Obstruction of the left colon may be the first manifestation of colorectal cancer. Resection of the colonic segment involved and the construction of an end colostomy (Hartman’s procedure) is the most frequent treatment. Alternatives to the placement of a stoma are subtotal colectomy or intraoperative lavage of the colon and primary anastomosis, but their application depends on intraoperative findings and the availability of a skilled surgeon. The use of an expandable stent (SEMS) can enhance the feasibility of laparoscopic colectomy, avoiding the need for a colostomy and offering the advantages of a combination of two minimally invasive procedures. Study Design: Between 1997 and 2004, an SEMS was placed in 11 cases of left colonic obstruction due to cancer, the obstruction being successfully resolved in each case. Seven patients were approached by laparoscopy to attempt the definitive colectomy. We evaluated the location and pathological characteristics of the tumor, effectiveness and complications of SEMS insertion, time interval between the insertion of SEMS and laparoscopic surgery, and postoperative data. Results: The tumors were situated in the recto-sigma (1 case), sigma (3 cases) and descending colon (3 cases). Immediate relief of the obstruction was achieved in all cases after SEMS insertion of the stent, and oral diet was started at 24 h. The 7 patients were operated on an average of 8 days (range 6–14) after insertion of the stent. Conversion to open surgery was necessary in one case for reasons not related to the stent. Conclusions: Preliminary results of the combination of SEMS and elective laparoscopic surgery demonstrate that the procedure is feasible and that it presents all the clinical advantages of a minimally invasive approach. The procedure is a valid alternative to traditional major urgent surgery.

Laparoscopic surgery of the spleen: state of the art

Abstract. Introduction: Laparoscopic splenectomy (LS) offers superior visualization and access to the spleen and avoids the major laparotomy incision necessary in open splenectomy (OS). This review summarizes the current knowledge of laparoscopic techniques for splenectomy from the perspective of surgeons whose combined experience now totals 340 cases. Background and discussion: While LS has been applied across the spectrum of splenic diseases, it is most indicated in treatment of a benign hematologic condition with a normal or slightly enlarged spleen as seen in autoimmune thrombocytopenic purpura (ITP), autoimmune deficiency syndrome-related ITP, hemolytic anemia, or spherocytosis. Both anterior and lateral approaches have been used for LS. While benefits of the anterior approach include access to the splenic artery along the superior border of the pancreas within the lesser sac, thus securing vascular control early in the procedure, the lateral approach allows for improved exposure of and access to the splenic pedicle. Also, mechanics and sequence of dissection are enhanced and more intuitive to the surgeon using the lateral approach, and the tail of the pancreas is more easily identified. Potential perioperative complications of LS include hemorrhage, injury to the tail of the pancreas, and deep vein thrombosis. The most common criticisms facing LS are the potential for missed accessory spleens, longer operating time, and greater operating room costs compared to OS. However, while LS requires a longer operating time than OS, studies indicate shorter postoperative hospital stays for LS versus OS patients in comparable cases, which can, in turn, reduce the total hospital cost for the procedure. Conclusion: Although LS continues to pose certain technical challenges – such as management of the massive spleen, specimen extraction, and identification of remotely located accessory spleens – its advantages over OS in terms of faster postoperative recovery, shorter hospital stay, and equivalent or lower perioperative morbidity are now well established. Indications for LS and more laparoscopic spleen-conserving surgery are likely to broaden.

Single-Port Access: A Feasible Alternative to Conventional Laparoscopic Splenectomy

Hypothesis: The laparoscopic approach has become the gold standard for splenectomy despite the fact that the spleen is a solid organ located deep in the splenic fossa. There is currently a trend to reduce the invasiveness of minimally invasive procedures. Transabdominal or transumbilical single-incision laparoscopic (SILS) approaches are an alternative to natural orifice transluminal endoscopic surgery techniques, but no reports of their use have yet been published in relation to the spleen. Aim: To describe the SILS technique for splenectomy in 2 patients. Material and methods: Two patients were approached by SILS, a 26-year-old male diagnosed of autoimmune thrombocytopenia and a 45-year-old male with recurrent Hodgkin disease. In both cases 3 trocars (1 of 12 mm and 2 of 5 mm) were inserted through the umbilicus in one and in a left subcostal in the other, and a curved transanal endoscopic microsurgery instrument, a flexible-tip 10-mm scope, and the UltraCision were introduced. Visualization of the spleen and standard dissection of attachments were feasible, and splenectomy was completed using transumbilicus stapling of the splenic hilum. The spleen was extracted through the umbilical incision, intact in one case and after morcellation in the other. Results: The postoperative course was uneventful. Both patients had minimal postoperative pain and scarring and were discharged on the second postoperative day. Conclusions: SILS access can be safely used for operative visualization, hilum transection, and spleen removal with conventional instrumentation, reducing parietal wall trauma to a minimum. The clinical, esthetic, and functional advantages require further analysis.

Laparoscopic surgery in situs inversus: a literature review and a report of laparoscopic sigmoidectomy for diverticulitis in situs inversus

BackgroundSitus inversus (SI) is a rare autosomal recessive congenital defect in which the position of abdominal and/or thoracic organs is a “mirror image” of the normal one, in the sagittal plain. In 25% of these cases, SI is part of the Kartagener syndrome, together with bronchiectasis and chronic sinusitis.MethodsWe present a case of a patient with Kartagener syndrome and complete SI that was laparoscopically operated on for diverticulitis. We also review the published English information available on this rare condition.ResultsA review of the literature revealed another single case of laparoscopic sigmoidectomy and 27 cases of other laparoscopic interventions in the presence of SI. Those laparoscopic procedures included basic procedures such as explorations and cholecystectomies, as well as advanced procedures such as gastrectomy and gastric bypass.ConclusionThe laparoscopic approach is feasible in cases of SI, although technically more complicated because of the different position of the organs and the different laparoscopic view of the anatomy.

Predictive factors for successful laparoscopic splenectomy in immune thrombocytopenic purpura

BackgroundLaparoscopic splenectomy (LS) offers better short-term results than open surgery for the treatment of immune thrombocytopenic purpura (ITP), but long-term follow-up is required to ensure its efficacy. The remission rate after splenectomy ranges from 49 to 86% and the factors that predict a successful response to surgical management have not been clearly defined. The goal of this study was to determine the preoperative factors that predict a successful outcome following LS.MethodsFrom February 1993 to December 2003, LS was consecutively performed in a series of 119 nonselected patients diagnosed with ITP (34 men and 85 women; mean age, 41 years), and clinical results were prospectively recorded. Postoperative follow-up was based on clinical records, follow-up data provided by the referring hematologist, and a phone interview with the patient and/or relative. Univariate and multivariate analyses were performed for clinical preoperative variables to identify predictive factors of success following LS.ResultsOver a mean period of 33 months, 103 patients (84%) were available for follow-up with a remission rate of 89% (92 patients, 77 with complete remission with platelet count >150,000). Eleven patients did not respond to surgery (platelet count <50,000). Mortality during follow-up was 2.5% (two cases not related to hematological pathology and one case without response to splenectomy). Preoperative clinical variables evaluated to identify predictive factors of response to surgery were sex, age, treatment (corticoids alone or associated with Ig or chemotherapy), other immune pathology, duration of disease, and preoperative platelet count. In a subgroup of 52 patients, we also evaluated the type of autoantibodies and corticoid doses required to maintain a platelet count >50,000. Multivariate analysis showed that none of the variables evaluated could be considered as predictive factors of response to LS due to the high standard error.ConclusionLong-term clinical results show that LS is a safe and effective therapy for ITP. However, a higher number of nonresponders is needed to determine which variables predict response to LS for ITP.

La cirugía laparoscópica en España. Resultados de la encuesta nacional de la Sección de Cirugía Endoscópica de la Asociación Española de Cirujanos

Resumen Objetivo Conocer la opinion de los cirujanos miembros de la Asociacion Espanola de Cirujanos (AEC) sobre la cirugia laparoscopica (CL) y su implantacion en nuestros hospitales. Material y metodos Dos encuestas de opinion. Una remitida a todos los miembros de la AEC en abril de 2003. Incluia aspectos generales y situaciones clinicas. La otra se remitio a todos los servicios de cirugia del pais e incluia aspectos sobre dotacion e implantacion de la CL. Resultados Han contestado 106 servicios (40%) y 855 cirujanos (32,3%). Solo 209 (25%) cirujanos realizan procedimientos avanzados. El 49% de cirujanos creen que los resultados de la CL son mejores que los de la cirugia convencional y 324 (40%) creen que la CL acabara siendo una superespecialidad. La CL se considera de primera eleccion en el tratamiento de la colelitiasis (99%), reflujo gastroesofagico (RGE) (94%) y colecistitis aguda (81%). En otras afecciones como la hernia inguinal, las enfermedades del bazo, patologia benigna de colon, la obesidad y enfermedades suprarrenales se utilizaria en casos seleccionados. El cancer de colon, la apendicitis y la eventracion tienen una baja aceptacion como primera indicacion en la CL. El 59% de cirujanos considera que la CL no ha tenido el crecimiento esperado. Conclusiones La CL, en nuestro medio y para un amplio colectivo de cirujanos, es ampliamente aceptada para el tratamiento de la colelitiasis y el RGE. A pesar de que nuestros hospitales tienen medios tecnicos suficientes para realizar la CL avanzada, esta se practica por pocos cirujanos. Aspectos como la formacion en CL y la superespecializacion aun quedan por perfilar en un futuro.