Giuseppe Giraudo

Laparoscopic total mesorectal excision: a consecutive series of 100 patients.

ObjectiveTo analyze total mesorectal excision (TME) for rectal cancer by the laparoscopic approach during a prospective nonrandomized trial. Summary Background DataImproved local control and survival rates in the treatment of rectal cancer have been reported after TME. MethodsThe authors conducted a prospective consecutive series of 100 laparoscopic TMEs for low and mid-rectal tumors. All patients had a sphincter-saving procedure. Case selection, surgical technique, and clinical and oncologic results were reviewed. ResultsThe distal limit of rectal neoplasm was on average 6.1 (range 3–12) cm from the anal verge. The mean operative time was 250 (range 110–540) minutes. The conversion rate was 12%. Excluding the patient who stayed 104 days after a severe fistula and reoperation, the mean postoperative stay was 12.05 (range 5–53) days. The 30-day mortality was 2% and the overall postoperative morbidity was 36%, including 17 anastomotic leaks. Of 87 malignant cases, 70 (80.4%) had a minimum follow-up of 12 months, with a median follow-up of 45.7 (range 12–72) months. During this period 18.5% (13/70) died of cancer and 8.5% (6/70) are alive with metastatic disease. The port-site metastasis rate was 1.4% (1/70): a rectal cancer stage IV presented with a parietal recurrence at 17 months after surgery. The locoregional pelvic recurrence rate was 4.2% (3/70): three rectal cancers stage III at 19, 13, and 7 postoperative months. ConclusionsLaparoscopic TME is a feasible but technically demanding procedure (12% conversion rate). This series confirms the safety of the procedure, while oncologic results are at present comparable to the open published series with the limitation of a short follow-up period. Further studies and possibly randomized series will be necessary to evaluate long-term clinical outcome in cancer patients.

Robot-assisted vs laparoscopic adrenalectomy: a prospective randomized controlled trial

BackgroundThe aim of this study was to assess the benefits and disadvantages of robot-assisted laparoscopic surgery for disorders of the adrenal gland in terms of feasibility, safety, and length of hospitalization.MethodsTwenty consecutive patients with benign lesions of adrenal gland were randomized into two groups: Patients in the laparoscopic group underwent traditional laparoscopic adrenalectomy (LAP), whereas those in the robotic group underwent robot-assisted adrenalectomy (ROBOT) using the da Vinci robotic system.ResultsThere was no significant difference between the groups in terms of age, sex, body mass index, and size or locations of lesions. Operative times were significant longer in the ROBOT group (total operative time, 169.2 min [range, 136–215] vs 115.3 min (range, 95–155) p < 0.001. Skin-to-skin time was 107 m (range, 77–154) vs 82.1 min (range, 55–120) (p < 0.001). There were no conversions to open surgery. However, conversion to standard laparoscopic surgery was necessary in four of 10 ROBOT patients (40%; left, one right). Perioperative morbidity was higher in the ROBOT group (20% vs 0%). There was no difference in length of hospital stay. In the following ROBOT group, hospital stay was 5.7 days (range, 4–9) vs 5.4 days (range, 4–8) in the LAP group (p = NS). The total cost of the ROBOT procedure (

Laparoscopic versus open surgery for extraperitoneal rectal cancer: a prospective comparative study.

3,467) was significantly higher than that for LAP (

Roles of clinical criteria, computed tomography scan, and adrenal vein sampling in differential diagnosis of primary aldosteronism subtypes.

2,737) (p < 0.01).ConclusionLaparoscopic adrenalectomy is superior to robot-assisted adrenalectomy in terms of feasibility, morbidity, and cost.

Alterations in hepatic function during laparoscopic surgery

BackgroundThe role of laparoscopic resection (LR) in the management of extraperitoneal rectal cancer still is unclear. This study aimed to compare perioperative and long-term results of laparoscopic and open resection (OR) for low and midrectal cancer.MethodsA prospective nonrandomized trial comparing patients submitted to OR or LR for low and midrectal cancer at a single institution was conducted.ResultsThe study included 191 consecutive patients: 98 patients who underwent LR and 93 who underwent OR. The mean follow-up period was 46.3 months for LR and 49.7 months for OR. The conversion rate for LR was 18.4%. With the use of LR, the mean time for complete patient mobilization was shorter (1.7 vs 3.3 days; p < 0.001) and patients were earlier in passing flatus (2.6 vs 3.9 days; p < 0.001) and stools (3.8 vs 4.7 days; p < 0.01), and in resuming oral intake (3.4 vs 4.8 days; p < 0.001). The mean hospital stay was shorter for LR, but the difference did not reach significance (11.4 vs 13 days). Morbidity and mortality rates were similar: LR (24.4% and 1%) and OR (23.6% and 2.2%). Laparoscopic patients presented a higher rate of anastomotic fistulas (13.5% vs 5.1%) and reoperations (6.1% vs 3.2%) but the difference was statistically nonsignificant. Laparoscopic resection presented a significantly lower local recurrence rate (3.2% vs 12.6%; p < 0.05). The cumulative survival and disease-free rates at 5 years were, respectively, 80% and 65.4% after LR and 68.9% and 58.9% after OR (nonsignificant difference). Stage-by-stage comparison showed prolonged cumulative survival for stages III and IV cancer in LR (82.5% vs 40.5%; p = 0.006 and 15.8% vs 0%; p = 0.013, respectively) and a reduced rate of cancer-related death for stage III in LR (11.4% vs 51.9%; p = 0.001).ConclusionsAs compared with conventional open surgery, LR for low and midrectal cancer is characterized by a faster recovery and similar overall morbidity (but a higher rate of anastomotic leakages), and does not present any adverse oncologic effect.

Does adrenal mass size really affect safety and effectiveness of laparoscopic adrenalectomy

CONTEXT In patients with primary aldosteronism (PA), it is fundamental to distinguish between subtypes that benefit from different therapies. Computed tomography (CT) scans lack sensitivity and specificity and must be followed by adrenal venous sampling (AVS). Because AVS is not widely available, a list of clinical criteria that indicate the presence of an aldosterone-producing adenoma (APA) has been suggested. OBJECTIVE AND DESIGN The objective of the study was to test the sensitivity and specificity of the last generation CT scans, test prospectively the usefulness of clinical criteria in the diagnosis of APA, and develop a flow chart to be used when AVS is not easily available. SETTING Hypertensive patients referred to our hypertension unit were included in our study. PATIENTS Seventy-one patients with confirmed PA participated in our study. INTERVENTION All patients had a CT scan and underwent AVS. MAIN OUTCOME MEASURE Final diagnosis of APA was the main measure. RESULTS A total of 44 and 56% of patients were diagnosed as having an APA and a bilateral adrenal hyperplasia (BAH), respectively. Twenty percent of patients with PA displayed hypokalemia. CT scans displayed a sensitivity of 0.87 and a specificity of 0.71. The posture test displayed a lower sensitivity and specificity (0.64 and 0.70, respectively). The distribution grades of hypertension were not significantly different between APA and BAH. Biochemical criteria of high probability of APA displayed a sensitivity of 0.32 and a specificity of 0.95. CONCLUSIONS This study underlines the central role of AVS in the subtype diagnosis of PA. The use of the clinical criteria to distinguish between APA and BAH did not display a satisfactory diagnostic power.

Is laparoscopic adrenalectomy feasible for adrenocortical carcinoma or metastasis

AbstractBackground: Very few studies have been done on the consequences of pneumoperitoneum on hepatic function. At present, there is no consensus on the physiopathological hepatic implications of pneumoperitoneum. The purpose of this clinical study was to evaluate the effects of pneumoperitoneum on hepatic function in 52 patients treated with laparoscopic procedures. Methods: Thirty-two laparoscopic cholecystectomies and 20 nonhepatobiliary laparoscopic procedures were performed in 52 patients (12 men and 40 women) with a mean age of 44 years (range, 15–74). All patients had normal values on preoperative liver function tests. The anesthesiologic protocol was uniform, with drugs at low hepatic metabolism. The 32 cholecystectomies were randomized into 22 performed with pneumoperitoneum at 14 mmHg and 10 performed at 10 mmHg. All nonhepatobiliary laparoscopic procedures were performed with a pneumoperitoneum of 14 mmHg. The postoperative serologic levels of AST, ALT, bilirubin, and prothrombin time were measured at 6, 24, 48, and 72 h. The serologic changes were related to the procedure, the duration, and the level of pneumoperitoneum. Results: Mortality and morbidity were nil. All 52 patients had a postoperative increase in AST, ALT, bilirubin, and lengthening in prothrombin time. Slow return to normality occurred 48 or 72 h after operation. The increase of AST and ALT was statistically significant and correlated both to the level (10 versus 14 mmHg) and the duration of pneumoperitoneum. Conclusions: The duration and level of intraabdominal pressure are responsible for changes of hepatic function during laparoscopic procedures. Although no symptom appears in patients with normal hepatic function, patients with severe hepatic failure should probably not be subjected to prolonged laparoscopic procedures.

Laparoscopic cholecystectomy in cirrhosis: contraindication or privileged indication?

OBJECTIVES To evaluate the effectiveness and safety of laparoscopic adrenalectomy with regard to adrenal mass size, as well as to consider its clinical and pathologic patterns. Laparoscopy is today considered the first-choice treatment of many adrenal diseases, although its use is still controversial for large adrenal masses and incidentally found adrenal cortical carcinoma. METHODS A total of 125 patients underwent lateral transperitoneal laparoscopic adrenalectomy. The indications were either functioning or nonfunctioning adrenal masses, without any radiologic evidence of involvement of the surrounding structures. The correlation between the size and the operative times, estimated blood loss, incidence of intraoperative and postoperative complications, and length of hospital stay were studied with Pearsons correlation coefficient, Fishers exact test, and the chi-square test. The analysis of variance test was used to evaluate any possible correlation between the size and clinicopathologic features and the results. RESULTS A slight correlation was observed between the size and operative time (P = 0.004), but no correlation was observed between the size and the other parameters. Statistical analysis showed a significant correlation between the clinicopathologic patterns (nonfunctioning benign adrenal masses, Conns adenoma, Cushings adenoma, pheochromocytoma, adrenal cortical cancer, and other tumor metastasis) and the operative time (P = 0.011), but not with the other parameters. CONCLUSIONS Laparoscopic adrenalectomy is also effective and safe for large lesions. The results of our series confirms that the risk of encountering an incidental adrenal cortical cancer is significantly increased for large lesions, and therefore, in these cases, additional attention is required to observe oncologic surgical principles.

Ultrasonic Versus Standard Electric Dissection in Laparoscopic Colorectal Surgery: A Prospective Randomized Clinical Trial

To review our experience with laparoscopic adrenalectomy (LA), to evaluate the effectiveness and safety of this procedure in patients with adrenal malignancy.

Gasless laparoscopy could avoid alterations in hepatic function

Until recently, cirrhosis has been considered to be an absolute or relative contraindication of laparoscopic cholecystectomy. An evaluation of benefits and risks of laparoscopic cholecystectomy in the treatment of gall bladder lithiasis in cirrhotic patients is presented. Thirty-three consecutive laparoscopic cholecystectomies in patients with cirrhosis were performed between March 1990 and March 1997. During the same period, no open cholecystectomy was performed in patients with cirrhosis. There was no morbidity or mortality; the conversion rate was 6% (2/33). No patient received blood transfusion, and the mean hospital stay was 2.8 days. These results favorably compare with the results of open cholecystectomy. Specific advantages of laparoscopic cholecystectomy in patients with cirrhosis include the absence of wound infection and a lower rate of postoperative hepatic failure. Finally, laparoscopic surgery reduces the risk of viral contamination (the hepatitis B virus, the hepatitis C virus, or the human immunodeficiency virus) of the surgical staff.