Giovanna Sgarzini

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.

Influence of blunt needles on surgical glove perforation and safety for the surgeon

BACKGROUND Round-tipped blunt needle (BN) may decrease the risk of needlestick injuries and hand contamination. We prospectively determined the incidence of glove perforations in emergency abdominal procedures and the efficacy of BN in increasing the safety for surgeons. METHODS Two hundred patients were randomized to undergo closure of the abdominal fascia using sharp needle (SN) or BN. Gloves were tested at the end of the procedure. RESULTS Surgeons had 14 needlestick injuries and 76 perforations recorded in 69 pair of gloves. Sharp needles were responsible for all injuries and 58 (76%) perforations (P < 0.00004 and P < 0.00001, respectively). This difference was still higher when considering the perforations related to the abdominal fascia closure (BN 7% versus SN 50%; P < 0.0006). CONCLUSION The risk of glove perforation is sevenfold greater if SN are used. Blunt needles reduce sharp injuries and improve safety for surgeons.

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.

Management of abdominal aortic prosthetic graft infection requiring emergent treatment

The purpose of this study was to investigate mortality and morbidity rates and long-term outcome of patients who underwent emergency treatment of abdominal aortic prosthetic graft infection. Between January 1984 and December 1993, 18 men aged fifty-nine ±sixteen years were operated on as an emergency for an acute life-threatening complication of aortic prosthetic graft infection. The grafts had been implanted for abdominal aortic aneurysm in 9 patients and aortoiliac occlusive disease in 9, from one to one hundred seventy months previously. Five (28%) patients presented with a hemorrhagic shock due to a fistula between the vascular reconstruction and the small bowel (4 patients) or the right ureter (1 patient) and 13 (72%) had generalized sepsis. The grafts were always radically explanted. Extraanatomic revascularization procedures included 6 axillopopliteal and 12 axillofemoral bypass grafts. Operative mortality was 39% (7 patients), and 3 (9%) limbs were amputated within thirty days. Two (11%) patients died after seven and twelve months, respectively, of septic complications, and 1 (5%) patient died after six months from an unrelated cause. Eight (73%) patients are still alive at a mean follow-up of fifty ±thirty-four months, but in 3 the extraanatomic bypass was removed for infection and 5 major amputations were performed. Two-year survival and limb salvage rates were 44% and 50%, respectively. Aortic prosthetic graft infections that require emergent treatment continue to demon strate high early and late mortality and limb loss rates despite aggressive intervention and limb salvage procedures. Newer methods of managing these complications should continue to be investigated.

Carotid endarterectomy in young adults: Is it a worthwhile procedure?

PURPOSE The aim of the study was to investigate surgical indication and long-term outcome of carotid endarterectomy (CE) in young adults. METHODS Between 1973 and 1990, 1693 patients underwent CE. Forty-nine patients (group T) 35 to 45 years of age who had carotid artery stenosis greater than 70%, formed the basis for the analysis. They were compared with two additional groups of patients older than 45 years of age selected from the entire series. Group 2 was randomly chosen to determine differences in risk factors, associated diseases, operative indications, preoperative findings, and outcome. Group 3 was matched with patients in group 1 for sex, risk factors, associated diseases, preoperative findings, and operative indications to assess the importance of age in determining the short- and long-term outcome of CE. RESULTS Postoperative mortality, cerebrovascular accidents, and cardiac complications in patients of group 1 (2%, 2%, and 2%, respectively) were similar to those of the other groups (p = NS). During the follow-up (76.7 +/- 3.6 months; range, 1 to 120 months) the incidence of strokes and transient ischemic attacks in group 1 was lower than in group 2 (p < 0.05) but similar to group 3 (p = NS). Ten-year disease-free intervals were 75.7%, 58.7%, and 77.6%, respectively, for groups 1, 2, and 3. Mortality rate unrelated to cerebrovascular disease was similar between group 1 and group 3 (p = NS) but was higher in group 1 than in group 2 (p < 0.02). Ten-year survival rates were 46.1%, 71.7%, and 55.5%, respectively, for groups 1, 2, and 3. CONCLUSIONS CE in patients younger than 45 years of age is a safe procedure with low operative risks and good disease-free intervals. However, life expectancy is poor because of the high incidence of deaths resulting from complications of atherosclerosis.

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

Feasibility of Colonic and Gastric Standard Laparoscopic Procedures With a Single Skin Incision Approach

W e read with great interest the article by Leroy et al about their innovative singleaccess laparoscopic sigmoidectomy for diverticulitis. The rationale for this minimally invasive procedure is the improved cosmetic results; the potential decrease in morbidity related to visceral and vascular injuries during trocar placement; and the lower risk of postoperative wound infection, hernia formation, and pain. By using technical innovations like umbilical, multichannel, single-port, magnetic anchoring; roticulated graspers; and intraluminal assistance for traction, they performed a sigmoidectomy for diverticulitis via a 2-cm single skin incision. However, because of the difficulty in performing full mesenteric dissections, they consider this procedure unsuitable for oncologic resections. We share the authors’ enthusiasm for this innovative technique, but we believe that its promising benefits can also be achieved with a single 4-cm periumbilical skin incision and 3 adjacent trocars inserted through separated fascial sites; conventional instruments; and traction stitches. Using this technique, in the last 6 months we were able to reproduce the standard laparoscopic procedures in performing 12 (8 left and 4 right) colonic resections for cancer, 4 distal gastrectomies for benign (n=2) and malignant (2 D1-resections) diseases, and 1 left hepatic sectionectomy for a recurrent giant cyst. Mortality and morbidity were nil, but 1 left colectomy was converted for bleeding. In conclusion, we think that the singleincision laparoscopic approach is also safe and feasible for gastric and colonic cancer, even if its clinical advantages over standard laparoscopy should be demonstrated by future studies.

Hollow viscus injuries: predictors of outcome and role of diagnostic delay

Introduction Hollow viscus injuries (HVIs) are uncommon but potentially catastrophic conditions with high mortality and morbidity rates. The aim of this study was to analyze our 16-year experience with patients undergoing surgery for blunt or penetrating bowel trauma to identify prognostic factors with particular attention to the influence of diagnostic delay on outcome. Methods From our multicenter trauma registry, we selected 169 consecutive patients with an HVI, enrolled from 2000 to 2016. Preoperative, intraoperative, and postoperative data were analyzed to assess determinants of mortality, morbidity, and length of stay by univariate and multivariate analysis models. Results Overall mortality and morbidity rates were 15.9% and 36.1%, respectively. The mean length of hospital stay was 23±7 days. Morbidity was independently related to an increase of white blood cells (P=0.01), and to delay of treatment >6 hours (P=0.033), while Injury Severity Score (ISS) (P=0.01), presence of shock (P=0.01), and a low diastolic arterial pressure registered at emergency room admission (P=0.02) significantly affected postoperative mortality. Conclusion There is evidence that patients with clinical signs of shock, low diastolic pressure at admission, and high ISS are at increased risk of postoperative mortality. Leukocytosis and delayed treatment (>6 hours) were independent predictors of postoperative morbidity. More effort should be made to increase the preoperative detection rate of HVI and reduce the delay of treatment.