Emanuele Lezoche

Long-term Results of Patients with pT2 Rectal Cancer Treated with Radiotherapy and Transanal Endoscopic Microsurgical Excision

AbstractAnterior resection and abdomino-perineal resection are the surgical techniques used most frequently in the treatment of rectal cancer. Local recurrence rates of 10% to 14% are described after these conventional procedures. Preoperative neoadjuvant radiotherapy reduces local failure. Because local excision techniques can be applied to treat early rectal cancer in selected patients, we evaluated the results of preoperative high-dose radiotherapy and transanal endoscopic microsurgical excision (TEM) in patients with T2 rectal cancer. All patients underwent preoperative irradiation with 5,040 cGy, divided over 5 weeks. Fourty days after completion of radiotherapy, the patients underwent complete full-thickness local excision of the rectal lesion including adjacent perirectal fat by TEM. The patients were followed for up to 8 years. Thirty-five patients, with pT2 rectal cancer as determined by pathological examination of the surgical specimen were enrolled in the present study. The tumors were responsive to preoperative radiotherapy in 82.8% of cases. No intraoperative complications and no conversion to open surgery were observed. No major complications and no mortality occurred during the 60-day postoperative period. Minor postoperative complications were observed in 5 patients (14.3%). The median follow-up of the patients was 38 months (range 24 to 96 months). One local recurrence (2.85%) was noted. The probability of surviving at 96 months after completion of treatment was 83%. Local excision by TEM combined with preoperative high-dose radiotherapy can achieve results similar to those observed after conventional surgery in patients with pT2 rectal cancer.

Magnetic resonance-cholangiopancreatography in the diagnosis of biliopancreatic diseases

BACKGROUND Magnetic resonance cholangiopancreatography (MRCP) is a new, noninvasive imaging technique for the visualization of the biliary ducts with cholangiographic images similar to those obtained with endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography. No contrast medium injection is used. The aim of this study was to assess the feasibility of MRCP versus ERCP in the diagnosis of biliary tract and pancreatic diseases. PATIENTS AND METHODS One hundred and thirty-six patients were submitted to MRCP. They were referred to MR study according to four inclusion criteria: (1) evidence or suspicion of choledocholithiasis, (2) benign or malignant bile ducts stenosis, (3) follow-up of patients submitted to biliary-enteric anastomosis, and (4) chronic pancreatitis with Wirsung duct dilatation. The MRCP was performed with a 0.5T superconducting magnet (Philips Gyroscan T5). When neoplastic disease was detected, additional images on axial planes were acquired. MRCP allowed images of diagnostic value to be obtained in all the cases. RESULTS In choledocholithiasis, MRCP showed 91.6% sensitivity, 100% specificity, and overall diagnostic accuracy 96.8%. Of 48 patients with stenotic lesions, 16 were correctly characterized as benign and 30 as malignant. Two cases of focal chronic pancreatitis were misdiagnosed as pancreatic head carcinoma. In the patients submitted to biliary-enteric anastomosis, MCRP was able to detect the dilatation of the intrahepatic ducts, the stenosis, and associated stones in all 8 positive cases. In the remaining 7 patients with mild signs of cholangitis, MCRP showed irregular aspects of the biliary tree in the main ducts. In the 11 patients with chronic pancreatitis, MCRP was able to depict the dilated Wirsung duct and the stenotic tract, although the fine details of the secondary ducts were not evaluated due to the low spatial resolution as compared with conventional films. CONCLUSIONS MRCP can be considered a technique able to completely replace diagnostic ERCP. Further studies are necessary for a better evaluation of the potential advantages and disadvantages of this technique.

A randomized, controlled, clinical study of laparoscopic vs open tension-free inguinal hernia repair

AbstractBackground: The aim of this prospective, randomized, controlled clinical study was to compare laparoscopic transabdominal preperitoneal (TAPP) hernia repair with a standard tension-free open mesh repair (open). Methods: A total of 108 low-risk patients with unilateral (primary or recurrent) or bilateral hernias were randomized to TAPP (group 1 = 52 cases) or open (group 2 = 56 cases). The outcome measures included operating time, complications, postoperative pain, return to normal activity, operating theater costs, and recurrences. Results: The mean operative time was longer for the TAPP than for the open group only in unilateral primary hernias. At rest, the median Visual Analog Scale (VAS) score was higher for group 1 than group 2 at 48 h postoperatively. Mild to discomforting pain in the inguinal region after 7 days, night pain after 30 days, and inguinal hardening after 3 months were more frequent in group 2 than group 1. No significant differences were observed in return to normal activities between the groups. One hernia recurrence was observed after 1 month in group 1. TAPP was significantly more expensive than open. Conclusions: TAPP was associated with less postoperative pain than open. The increase in operating theater costs, however, was dramatic and was not compensated by shorter time away from work. TAPP should not be adopted routinely unless its costs can be drastically reduced.

Laparoscopic treatment of gallbladder and common bile duct stones: a prospective study.

The aim of this study was to investigate prospectively the feasibility, success rate, safety, and short-term results of single-stage laparoscopic treatment of gallstones and ductal stones in 100 consecutive, unselected patients. Common bile duct (CBD) stones were diagnosed at routine intraoperative cholangiography and choledochoscopy in 100 of 950 patients with gallstones undergoing laparoscopic cholecystectomy (LC). Unsuspected CBD stones were present in 39 patients (4.1% of 950; 39% of 100); 26 patients were referred for surgery after failed endoscopic sphinctertomy (ES) performed elsewhere. Transcystic duct CBD exploration (TC-CBDE) was the procedure of choice. When it was not feasible, choledochotomy and direct CBD exploration (D-CBDE) was performed. Use of biliary drainage was liberal. A completion cholangiogram was obtained for all patients. Laparoscopic treatment of CBD stones was successful in 96 patients: after TC-CBDE in 63 and after D-CBDE in 33. Four operations were converted to open surgery (4%). Retained stones, observed in five patients, were treated by ES in two cases and by percutaneous endoscopic/fluoroscopic lithotripsy in three. Minor morbidity included biloma (n = 2), port site infection (n = 2), and subumbilical hematoma (n = 1). Major morbidity was bile leakage from the cystic duct stump in two cases due to clips or transcystic duct drainage displacement, respectively. One elderly, high risk patient died after being referred for several failed attempts of endoscopic clearance; she died from cardiogenic shock 3 days after successful laparoscopic treatment. Laparoscopic CBD exploration is feasible and safe in most patients, with short-term results that compare favorably with the results of sequential ES/LC reported in the literature.

Ultrasound-guided Laparoscopic Cryoablation of Hepatic Tumors: Preliminary Report

Abstract. The purpose of this ongoing prospective study is to evaluate the feasibility, safety, and efficacy of a total laparoscopic approach for ultrasound-guided cryoablation of primary and secondary hepatic tumors. Of 56 patients who underwent ultrasound-guided cryoablation, a total laparoscopic approach was employed in 18 (5 men, 13 women; mean age 48.6 years, range 35–77 years). Fifteen patients were included for secondary hepatic tumors and three for primary hepatic tumors. Selection criteria were the presence of three or fewer nodules, less than 40% liver volume replaced by tumor, and absence of extrahepatic disease. Altogether 28 lesions were confirmed by intraoperative laparoscopic ultrasonography and were treated; 25 by ultrasound-guided laparoscopic cryoablation and 3 by laparoscopic wedge resection. After cryoablation, surface parenchymal splits with bleeding from the frozen tissue were observed in six patients and required conversion to open surgery in two patients whose lesions were located in segment 8. No major complication and no mortality were observed. One or more minor complications occurred in nine patients; they included pleural effusion (n= 8, 44.4%), subdiaphragmatic fluid collection (n= 3, 16.6%), worsening hepatic insufficiency in a cirrhotic patient (n= 1, 5.5%), and wound infection in a patient converted to open surgery (n= 1, 5.5%). The mean hospital stay was 6.4 days (range 3–14 days). At a mean follow-up of 10.8 months (range 5–16 months) all patients are alive and 14 are disease-free, as demonstrated by normalization of tumor markers and negative magnetic resonance imaging. In carefully selected patients total laparoscopic ultrasound-guided cryoablation is feasible and safe. A longer period of follow-up is required to evaluate the efficacy of the procedure and its impact on survival.

Laparoscopic Common Bile Duct Exploration

BACKGROUND Laparoscopic common bile duct (CBD) exploration is gaining favor in the treatment of patients with gallstones and CBD stones. Our aim is to report our results with this procedure, focusing on the technical aspects. PATIENTS AND METHODS All patients with proven CBD stones undergo laparoscopic transcystic CBD exploration, preferably, or a choledochotomy if the former is not feasible. According to CBD stone load and diameter, a biliary drainage tube is positioned for postoperative biliary decompression. RESULTS Among 284 patients who underwent laparoscopic CBD exploration, 4 (1.4%) were converted to open surgery. Transcystic CBD exploration was feasible in 163 cases (58.2%), but a choledochotomy was required in 117 (41.8%). Biliary drains were positioned in 204 patients (72.8%). Minor complications included hyperamylasemia (11; 3.9%) and minor subhepatic bile collection (7; 2.5%). Major complications were bile leakage (5; 1.8%), hemoperitoneum from cystic artery bleeding (2; 0.7%), subhepatic abscess (2; 0.7%), acute pancreatitis (1; 0.3%), and jejunal perforation (1; 0.3%). Retained CBD stones in 15 patients (5.3%) were removed through the biliary drainage sinus tract (8) or after endoscopy and sphincterotomy (6). In one patient, a small stone passed spontaneously (overall success rate 94.6%). Death from a cardiovascular complication was observed in one elderly high-risk patient (0.3%). Recurrent ductal stones in 5 patients (1.8%) were treated with ERCP and endoscopic sphincterotomy. One patient with re-recurrent ductal stones underwent hepaticojejunostomy. CONCLUSIONS Laparoscopic CBD exploration during LC in unselected patients solves two problems during the same anesthesia with high success rates (94.6%), low minor (6.4%) and major (3.8%) morbidity rates, and a low mortality rate (0.3%). Standardization of the technique is mandatory to achieve high success rates.

Acid and gastrin levels after bombesin and calcium infusion in patients with incomplete antrectomy.

In 17 patients with postoperative recurrent peptic ulcer, incomplete antrectomy (I.A.) was found by endoscopic biopsies in 5. No evidence of I.A. was found in the remaining 12 patients. Gastric acid output and gastrin levels were measured in basal conditions and following a calcium I.V. infusion (4 mg/kg hr of Ca++ over 4 hr) and a bombesin (BBS) I.V. infusion (15 ng/kg min over 90 min). Basal gastrin levels were significantly different in the two groups of patients: BBS infusion augmented significantly serum gastrin levels in all patients with I.A., while BBS infusion had no significant effect on serum gastrin levels in the group of patients wihtout I.A. Acid output following BBS infusion showed a pattern similar to the pattern seen for gastrin. Calcium infusion augmented gastric acid secretion and gastrin levels in the patients with I.A.; however, the response to calcium could not clearly separate in all instances patients with I.A. from patients without I.A. It is concluded that the “BBS infusion test” may be helpful in the diagnosis of I.A. in patients with postoperative peptic ulcer.

Laparoscopic cholecystectomy and common bile duct exploration are safe for older patients

BackgroundLaparoscopic common bile duct (CBD) exploration is a well-established treatment option in dedicated centers. However, few data are available on the results in elderly patients.MethodsThe outcome after laparoscopic CBD exploration in elderly patients (age>-70 years) was compared with that in a concurrent control group of younger patients (age <70 years).ResultsThere were 77 elderly patients in group A and 207 younger patients in group B. American Society of Anesthesiology (ASA) III and IV patients and prior abdominal operations were more frequent in group A (p<0.001). Two patients from each group underwent conversion to open surgery. There was no significant difference frequency of use between the transcystic and choledochotomy approaches, although the latter tended to be more frequent in the group A because of larger stones (group A, 53.4%; group B, 37.6%). Minor and major morbidity (group A, 12%; group B, 13.6%), rate of recurrent stones (group A, 1.3%; group B, 1.9%), and mortality (group A, 1.3%; group B, 0%) were not significantly different between the two groups. The single death in group A involved a patient with acute toxic cholangitis who underwent emergency surgery after multiple failed attempts at endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy performed elsewhere. No CBD stenosis was observed at follow-up assessment.ConclusionsElective laparoscopic CBD exploration is safe and effective. It may become the standard of care in both elderly and younger patients.

Effect of bombesin on extragastric gastrin in man.

The effect of a protein test meal and a bombesin infusion on extragastric gastrin levels was studied in patients with truncal vagotomy, antrectomy, and gastroduodenostomy or gastrojejunostomy and in patients with total gastrectomy. In patients with vagotomy, antrectomy, and gastroduodenostomy and in patients with total gastrectomy the gastrin levels were raised by 33% and 35%, respectively, from basal after test meal, while during BBS infusion gastrin values decreased by 25% and 30%, respectively, from basal. In patients with vagotomy, antrectomy, and gastrojejunostomy, test meal and BBS infusion did not significantly alter basal gastrin values. It is concluded that BBS does not stimulate extragastric gastrin.

Technique and results of routine dynamic cholangiography during 528 consecutive laparoscopic cholecystectomies

With the advent of laparoscopic cholecystectomy a trend toward more extensive preoperative diagnostic study of the biliary tree by intravenous cholangiography or ERCP has been observed. However, both exams have technical limitations and are not without risk. We report our experience with 500 consecutive routine dynamic intraoperative cholangiographies during laparoscopic cholecystectomy, 97% of which were successful. No lesions from cholangiography were observed. In ten patients clips on the cystic artery appeared on intraoperative cholangiogram to be too close to the hepatic duct and were removed. Anomalies of surgical importance were discovered in 11 patients (2.3%). Unsuspected stones were found in 18 cases (3.7%) and suspected stones confirmed in 12 (2.4%). In our experience routine dynamic intraoperative cholangiography provided important information in 51 cases out of 500 (10.2%). We conclude that routine dynamic intraoperative cholangiography is extremely useful for safer laparoscopic cholecystectomy and cost containment.