Giuseppe Borzellino

Laparoscopy for abdominal emergencies: evidence-based guidelines of the European Association for Endoscopic Surgery.

Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment. A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain. Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen. Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results.

LAPAROSCOPIC CHOLECYSTECTOMY FOR SEVERE ACUTE CHOLECYSTITIS. A META-ANALYSIS OF RESULTS

ObjectiveThe aim of this review was to evaluate surgical outcomes of laparoscopic cholecystectomy for gangrenous and empyematous acute cholecystitis defined as severe acute cholecystitis.BackgroundIt is not known to what extent surgical outcomes of laparoscopic cholecystectomy for severe acute cholecystitis differ from those for the nonsevere acute form, making it questionable whether urgent laparoscopic cholecystectomy is the best approach even in severe acute cases.MethodsLiterature searches were conducted to identify: (1) comparative studies which reported laparoscopic surgical outcomes separately for severe acute and nonsevere acute cholecystitis; (2) studies comparing such an approach with open cholecystectomy, subtotal laparoscopic cholecystectomy or cholecystostomy in severe acute cholecystitis. Results were pooled by standard meta-analytic techniques.ResultsSeven studies with a total of 1,408 patients undergoing laparoscopic cholecystectomy were found. The risks of conversion (RR 3.2, 95% CI 2.5 to 4.2) and overall postoperative complications (RR 1.6, 95% CI 1.2–2.2) were significantly higher in severe acute cholecystitis with respect to the nonsevere acute forms. However, no difference was detected as regards to local postoperative complications. No studies comparing open cholecystectomy or cholecystostomy with urgent laparoscopy were found.ConclusionA lower feasibility of laparoscopic cholecystectomy has been found for severe cholecystitis. A lower threshold of conversion is recommended since this may allow to reduce local postoperative complications. Literature data lack valuable comparative studies with other treatment modalities, which therefore need to be investigated.

Laparoscopic approach to postoperative adhesive obstruction

BackgroundSome authors have assessed the feasibility of laparoscopy in the treatment of postoperative adhesive obstruction, but conclusions about its effectiveness are related to different selection criteria used for surgery. This paper reports on our experience in laparoscopic adhesiolysis and analyses the results on the basis of the selection criteria used.MethodsFrom January 1993 to December 2001, 65 patients were submitted to laparoscopic adhesiolysis for small bowel obstruction according to specific selection criteria. Of the 65 patients, 40 were admitted for acute obstruction and 25 for chronic or recurrent transit disturbances. Correlation between historical and clinical data and the results of surgical treatment were statistically analyzed.ResultsThe procedure was completed by laparoscopy in 52 patients (conversion rate: 20%). Mean postoperative stay was 4.4 days with a 12.3% morbidity and no mortality. Recurrence rate was 15.4%; a single correlation was found between recurrence and age.ConclusionsLaparoscopic adhesiolysis in the treatment of small bowel obstructions seems to be effective; further studies are required to define selection criteria for surgery and confirm real advantages in terms of recurrences.

Perianal Paget's disease: presentation of six cases and literature review

PurposeExtramammary Paget’s disease (EMPD) is frequently associated with adnexal or visceral synchronous or metachronous malignancies. Our purpose was to evaluate, retrospectively, the results obtained in six cases of EMPD and to review the literature.MethodsSix patients with the perianal Paget’s disease had been treated in our division between March 1996 and December 2006. In three cases, the disease was confined in the epidermis; in one case, there was a microinvasion of the dermis, while in another one the dermis was infiltrated. The last case was associated to a low rectal adenocarcinoma. All patients underwent wide perianal excision and reconstruction with skin graft. We performed a transanal resection of the rectal adenocarcinoma. A review of the literature from 1990 to 2008 revealed 193 cases of perianal EMPD, 112 were intraepithelial/intradermal while 81 were associated with malignancies. Anorectal adenocarcinoma was already existing in two cases, synchronous in 48, and subsequent to diagnosis in 11.ResultsIn three cases, the disease recurred locally, but no patient developed metastatic spread. Five patients survived and are free of disease. The review of the literature allows a clear identification of the primitive EMPD and the form associated to anorectal adenocarcinoma and little information about cases associated with synchronous adnexal adenocarcinoma. The Paget’s disease can relapse after radical surgery and has a capacity of metastatic spread.ConclusionsUp to now, no clear guidelines have been established for the diagnosis of EMPD. The association with synchronous or metachronous carcinomas imposes a long-term follow-up with frequent clinical, radiological, and endoscopical controls.

Treatment for Retrieved Common Bile Duct Stones During Laparoscopic Cholecystectomy: The Rendezvous Technique

OBJECTIVE To determine the feasibility and efficacy of the laparoscopic intraoperative rendezvous technique for common bile duct stones (CBDS). DESIGN Case series. SETTING Verona University Hospital, Verona, Italy. PATIENTS A total of 110 patients were enrolled in the study; 47 had biliary colic; 39, acute cholecystitis; 19, acute biliary pancreatitis; and 5, acute biliary pancreatitis with associated acute cholecystitis. INTERVENTIONS In all patients, CBDS diagnosis was reached by intraoperative cholangiography. Intraoperative endoscopy with rendezvous performed during laparascopic cholecystectomy for confirmed CBDS; for such a procedure, a transcystic guide wire was positioned into the duodenum. Intraoperative endoscopy with rendezvous was performed for retrieved CBDS during a laparoscopic cholecystectomy. MAIN OUTCOME MEASURES Laparoscopic rendezvous feasibility, morbidity, postprocedure pancreatitis, and mortality. RESULTS The laparoscopic rendezvous proved to be feasible in 95.5% (105 of 110 patients). The rendezvous failed in 3 cases of successfully performed laparoscopic cholecystectomy, and a conversion of the laparoscopy was needed in 2 cases of successful rendezvous. Two major complications and 2 cases of bleeding were registered after sphincterotomy was successfully performed with rendezvous, and severe acute pancreatitis complicated a traditional sphincterotomy performed after a failed rendezvous. CONCLUSIONS Rendezvous is a feasible option for treatment of CBDS; it allows one to perform only 1 stage of treatment, even in acute cases such as cholecystitis and pancreatitis. Positioning of the guide wire may allow reduced complications secondary to papilla cannulation but not those of the endoscopic sphincterotomy.

Treatment of Gallstone Pancreatitis: Six-year Experience in a Single Center

Acute pancreatitis (AP) is a complicated disease in 20% to 25% of cases and carries a mortality of 8% to 15%. Etiologically, the most frequent form is acute biliary pancreatitis. Treatment of such an entity is still controversial, but minimally invasive techniques undoubtedly play an important role. We retrospectively analyze our cases of AP observed from January 1992 to May 1998. Etiology was biliary in 95/125 (76%) cases. In 90 cases we evaluated the patient within a few hours of the onset of symptoms. According to the Ranson criteria, we observed a mild form in 74/90 (82.2%) cases and a severe form in 16/90 (17.8%) cases. Our standard policy was to perform urgent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy followed by elective laparoscopic cholecystectomy. In particular clinical settings, other modalities of treatment were employed, such as percutaneous cholecystostomy and percutaneous drainage of fluid collections. Successful ERCP was performed in 86/90 cases (95.5%). The procedure was performed in an emergency setting (within 48 hours) in 62/90 cases (68.9%). Whenever the patient was a candidate for surgery, cholecystectomy was performed, laparoscopically in 67/90 cases (74.4%) and via laparotomy in 7/90 cases (7.8%). In only two cases was pancreatic necrosectomy necessary. Globally, we observed a low procedure-related morbility (6.7%) and no mortality. In the setting of acute biliary pancreatitis, regardless of the severity of the attack, an urgent ERCP endoscopic sphincterotomy followed by laparoscopic cholecystectomy is safe and could enable succesful management of the patient. Associated morbidity and mortality were low. In addition, when indicated, it is possible to treat a great number of concomitant complications with percutaneous ultrasoundguided drainage. Acute pancreatitis (AP) is a disease that has a by no means negligible social impact, with an incidence of approximately ten cases/100,000 population/year [1]. The mild forms, which account for some 75% to 80% of cases [2–4] may benefit from simple conservative treatment, whereas the severe forms, i.e. those characterized by the occurrence of local complications and/or multiorgan impairment [2], make up the remaining 20% to 25% of cases [3, 5]. The overall mortality rate is 8%–15% [3, 6–8]. Etiologically, the most frequent form of AP is acute biliary pancreatitis (ABP), the incidence of which in published reports ranges from 16% to 70% [1] with values mainly somewhere in the region of 60% to 70% [8–11]. There is also evidence that up to one-third of cases of AP defined as “idiopathic” in actual fact are due to the presence of microlithiasis or bile crystals [12–14]. In our experience, a biliary etiology was clearly established in 76% of AP cases treated in our department [15]. The development and increasing refinement of minimally invasive surgery make it possible today to treat biliary lithiasis effectively. Therefore, our policy when dealing with a patient with ABP is to perform emergency endoscopic retrograde cholangiopancreatography (ERCP) combined in principle with an endoscopic sphincterotomy (ES) of the papilla, regardless of the severity of the clinical picture. Then, once the acute episode has been resolved, we perform a laparoscopic cholecystectomy (LC) [15]. Radiological intervention techniques afford effective treatment for a number of the complications of AP. For the purposes of assessing the soundness of this treatment strategy we reassessed our ABP patient series. Materials and Methods Over the period from January 1992 to May 1998 we treated 125 cases of AP in our department (Table 1). The AP diagnosis was based on the presence of abdominal pain typically associated with amylasemia 5N (n.v. 120 IU/L). A radiological pattern of altered pancreatic gland was also required. A biliary etiology was found in 76% of cases (95/125). The diagnosis of ABP was based on the following criteria: ● Medical history: existing evidence of gallstone disease, history of biliary-type colic, absence of alcohol abuse, dyslipidemia, etc.; ● Indicative laboratory tests; alkaline phosphatase 300 IU/L, alanine aminotransferase 100 IU/L, total bilirubin 25 mmol/L; ● Liver ultrasonography: lithiasis, microlithiasis or bile sludge in the gallbladder, dilation of the main biliary tract and stones in the common bile duct (CBD); these findings may be present in various combinations; ● ERCP: direct imaging of the papilla and indirect imaging of the CBD. In 5/95 cases, the patients were referred to our department from another hospital after deterioration of their general condition Correspondence to: F. Ricci, M.D., e-mail: chirurgia.urgenza@univr.it within a mean period of 7 days of onset of symptoms (range: 4 to 11 days). Because of the severity of the clinical picture (sepsis), all these patients were submitted to pancreatic necrosectomy, cholecystectomy, placement of a Kehr-type bile duct drain, and placement of multiple abdominal drains. Two deaths occurred in this subgroup of patients, and those patients were excluded from our analysis of the data. In the other 90 cases we examined the patients within a few hours of onset of symptoms. The mean age of these patients was 62.1 years (range: 24 to 86) and in 25 cases (27.8%) the age was 70 years; the M:F ratio was 1.2:1. At entry, all patients underwent abdominal ultrasonography (US) and, in selected cases, abdominal computed tomography (CT). In all cases US showed alterations of the pancreatic gland (i.e. pancreatic edema or pancreatic/peripancreatic fluid collection). When fluid collections were observed, abdominal CT was performed. All patients were evaluated prognostically according to the Ranson criteria. On this basis, mild AP was observed in 74/90 cases (82.2%) (Ranson scores 1–2) and severe AP in 16/90 (17.8%) (Ranson scores 3). Further details of the Ranson classification are provided in Table 2. Fifty-two patients belonged to American Society of Anesthesiologists (ASA) Class I, 30 to ASA Class II, 5 to ASA Class III and 3 to ASA Class IV. In all cases in which there was a strong suspicion that the AP was of biliary origin, or in which such etiology had been established on the basis of the above-mentioned criteria, the patient was put on a minimally invasive treatment protocol involving emergency ERCP (within 48 hours) combined with ES and, once the acute episode had been resolved, LC. It also proved possible to treat concomitant diseases (acute cholecystitis) and local complications of AP (intraabdominal fluid collections, pseudocysts) with minimally invasive procedures (US-guided percutaneous drainage). Results Endoscopic retrograde cholangiopancreatography was successful at the first attempt in 80/90 cases (88.9% of patients). In 10 patients (8 of whom were emergency cases), ERCP was unsuccessful owing to substantial duodenal and/or papillary edema of such a degree as to prevent cannulation of the bile duct (8 cases), to location of the papilla at the base of a duodenal diverticulum (1 case), and to respiratory insufficiency during the procedure (1 case). In 6/8 cases of duodenal edema, the maneuver was repeated successfully after a mean period of 8 days (range: 6 to 12 days) after the first attempt. In all, ERCP was performed successfully in 86/90 cases (95.5%). In the remaining 4 cases, all with a mild prognosis, the patient refused to repeat the ERCP and the AP resolved rapidly with medical therapy alone (2 of these 4 patients were subsequently submitted to LC and to intraoperative cholangiography, which, however, yielded negative findings). As regards the timing, emergency ERCP was performed in 70/90 cases (77.7%) and was successful in 62 cases. Therefore, 68.9% of the patients (62/90) successfully underwent ERCP ES within 48 hours of onset of symptoms and the emergency procedure proved feasible in our experience in 88.5% of cases (62/70). In the remaining 20 cases the procedure was attempted after 48 hours, proving successful in 18 patients (90% success rate), and in 15 of these 20 cases (75%) ERCP was performed within 72 hours of entry into the hospital (deferred emergency ERCP). Table 3 gives the ERCP feasibility data. The ERCP findings of lithiasis or microlithiasis of the CBD in 59 cases (CBDS) and of bile sludge and/or thick bile in 20 cases, sometimes associated with dilation of the CBD (CBDD) or with edema of the papilla (in 35 and 21 cases, respectively), confirmed the biliary etiology of the AP in all patients. Further ERCP data are provided in Table 4. Endoscopic sphincterotomy was performed in 84/86 cases (97.6%). In one case, the papilla was pre-cut. Endoscopic extraction of the stones using a Dormia basket was necessary in 40 cases (46.5%), and mechanical lithotripsy was accomplished in 5 cases (5.8%). In 9 patients (10.4%), a nasobiliary probe was introduced. The ES-related morbidity was 6%, representing 5 cases of bleeding of the papilla, which was mild and stopped with no need for blood transfusion. In 4 of 5 cases bleeding was observed in mild forms of ABP. In no case did we observe worsening of ABP due to ES. The mortality was 0%. In 4 of 90 patients (4.4%) with clinical evidence of cholangitis associated with AP (temperature 38.5°C, poor general condiTable 1. Etiology and mortality in the acute pancreatitis (AP) cases observed. AP etiology No. of cases % Of total AP No. of deaths % Mortality per etiology % Mortality of total AP Biliary 95 76 2 2.1 1.6 Alcoholic 15 12 1 6.6 0.8 Papillary disease 9 7.2 — — — Postoperative 3 2.4 1 33.3 0.8 Metabolic 2 1.6 1 50 0.8 Infectious 1 0.8 — — — Total 125 100 5 — 4 Table 2. Correlation between Ranson scores and number of mild and severe cases of acute biliary pancreatitis (ABP) observed, together with respective mortality rates.

Minimally invasive treatment of acute biliary pancreatitis.

AbstractBackground: Stones of the common bile duct are the most important factor in acute pancreatitis (AP). Endolaparoscopic surgery plays a well-recognized role in the treatment of this pathology. Methods: From January 1992 to December 1995 we observed 62 cases of acute biliary pancreatitis (ABP). In 57 cases (= 93.4%) we proposed a minimally invasive treatment, based on performance of endoscopic retrograde cholangiopancreatography (ERCP) combined with endoscopic sphincterotomy (ES) and then of laparoscopic cholecystectomy (LC). Results: ERCP was attempted in emergency in 40/57 cases and successfully done in 34 cases. An ES was performed in all but two cases. In 51 patients we performed LC. The overall morbidity was 8.9% with no mortality. Conclusions: In the case of ABP early treatment can achieve the restoration of patency of the papilla, reducing the risk of associated cholangitis and the development of pancreatic necrosis. The cholecystectomy prevents the risk of relapse of ABP.

Laparoscopic hepatic resection

BackgroundAlthough laparoscopy in general surgery is increasingly being performed, only recently has liver surgery been performed with laparoscopy. We critically review our experience with laparoscopic liver resections.MethodsFrom January 2000 to April 2004, we performed laparoscopic hepatic resection in 16 patients with 18 hepatic lesions. Nine lesions were benign in seven patients (five hydatid cysts, three hemangiomas, and one simple cyst), five were malignant in five patients (five hepatocarcinoma), and four patients had an uncertain preoperative diagnosis (one suspected hemangioma and three suspected adenomas). The mean lesion size was 5.2 cm (range, 1–12). Twelve lesions were located in the left lobe, three were in segment VI, one was in segment V, one was in segment IV, and one was in the subcapsular part of segment VIII.ResultsThe conversion rate was 6.2%; intraoperative bleeding requiring blood transfusions occurred in two patients. Mean operative time was 120 min. Mean hospital stay was 4 days (range, 2–7). There were no major postoperative complications and no mortality.ConclusionsHepatic resection with laparoscopy is feasible in malignant and benign hepatic lesions located in the left lobe and anterior inferior right lobe segments (IV, V, and VI). Results are similar to those of the open surgical technique in carefully selected cases, although studies with large numbers of patients are necessary to drawn definite conclusions.

Predictive factors for the diagnosis of severe acute cholecystitis in an emergency setting

BackgroundThe aim of this study was to assess predictive factors for the diagnosis of severe acute cholecystitis.MethodsThe medical records of 295 patients with pathologically confirmed acute cholecystitis were reviewed. Patients were divided, based on pathology findings, into a group with nonsevere acute cholecystitis and a group with severe acute cholecystitis. Preoperative data were compared by univariate and multivariate analyses. Therefore, diagnostic values were assessed based on the statistically significant predictive factors. The same approach was attempted for differential diagnosis between gangrenous and phlegmonous cholecystitis.ResultsAmong ten variables found to be significantly different at univariate analysis, four were found to be independent predictive factors of severe acute cholecystitis: fever, distension of the gallbladder, wall edema, and preoperative adverse events. Common bile duct stones were confirmed as a protective factor. Leukocyte count, cardiovascular diseases, age, gender, and diabetes were not found to be significant predictive factors of severe acute cholecystitis. No differences were found in any of the preoperative data by comparing phlegmonous and gangrenous cholecystitis.ConclusionSevere acute cholecystitis may be differentiated preoperatively from nonsevere acute cholecystitis based on clinical and US data, and predictive diagnostic values may be estimated according to the number of observed predictive factors. No differences were found when comparing phlegmonous and gangrenous cholecystitis.

EFFICACY AND TOXICITY OF VINORELBINE-CARBOPLATIN COMBINATION IN THE TREATMENT OF ADVANCED ADENOCARCINOMA OR LARGE-CELL CARCINOMA OF THE LUNG

Aims and background The aim of the study was to assess the activity and toxicity of the vinorelbine-carboplatin combination in advanced adenocarcinoma or large-cell carcinoma of the lung. The new vinca derivative, vinorelbine, shows promising activity when combined with cisplatin, but toxicity of the combination is substantial. Methods Accordingly, we substituted carboplatin for cisplatin in the combination in order to improve the therapeutic index. From March 1992 to March 1994, 55 untreated patients with undifferentiated unresectable or metastatic adenocarcinoma or large-cell carcinoma of the lung were recruited. The treatment consisted of a course of carboplatin (300 mg/m2) and vinorelbine (25 mg/m2) repeated every 4 weeks. The only grade 3 toxicity observed was 16 cases of grade 3 vomiting and 2 cases of grade 3 stomatitis. Results The positive response rate was 40% (partial response, 22 patients). In conclusion, the vinorelbine-carboplatin combination may be regarded as an active, safe regimen for the palliative treatment of advanced adenocarcinoma or large-cell carcinoma of the lung.