Hubert Scheidbach

Laparoscopic resection of sigmoid diverticulitis

AbstractBackground: In the large bowel, resection of the sigmoid colon is the most commonly performed laparoscopic intervention because large bowel lesions often are located in this part of the bowel and the procedure technically is the most favorable one. A number of publications involving case series or the results of highly experienced individual surgeons already have confirmed the feasibility of laparoscopic resection in cases of diverticulitis. The aim of the present prospective multicentric investigation was to check the results obtained by a large number of surgeons performing laparoscopic resection of the sigmoid colon for diverticulitis in various stages of severity. Results: Between January 8, 1995 and January 1, 1998, the Laparoscopic Colorectal Surgery Study Group recruited 1,118 patients to the prospective multicenter study. Diverticulitis of the sigmoid colon, which accounted for 304 cases, was the most common indication for laparoscopic intervention. In most of these patients undergoing laparoscopic surgery (81.9%), the diverticulitis manifested as acute phlegmonous peridiverticulitis, recurrent attacks of inflammation, or stenosis. Complicated forms of diverticulitis in Hinchey stages I to IV and late complications of chronic diverticular disease with fistula formation and bleeding accounted for only 18.1% of the cases. For the overall group, the conversion rate was 7.2%. Patients with less severe diverticulitis (i.e., those presenting with peridiverticulitis, stenosis, or recurrent attacks of inflammation) had a conversion rate of 4.8% and the rate for complicated cases was 18.2%. Regarding laparoscopically completed interventions, 3 of 282 patients died (1.1%). In the group of patients with peridiverticulitis, stenosis, or recurrent attacks of inflammation the overall complication rate was 14.8%. The group with perforated diverticulitis in Hinchey stages I to IV or those with fistula and bleeding, the corresponding rate was 28.9%, and after conversion it was 31.8%. Conclusions: Laparoscopic colorectal interventions in sigmoid diverticulitis are, for the most part, carried out as elective procedures for peridiverticulitis, stenosis, or recurrent attacks of inflammation. The conversion, complication, and mortality rates associated with these interventions are acceptable. Laparoscopic procedures in Hinchey stages I to IV sigmoid diverticulitis and in the presence of fistula and bleeding are more likely to be associated with complications, and should be carried out only by highly experienced laparoscopic surgeons.

Early results of a prospective multicenter study on 500 consecutive cases of laparoscopic colorectal surgery

AbstractBackground: Prospective randomized multicenter studies comparing laparoscopic with open colorectal surgery are not yet available. Reliable data from prospective multicenter studies involving consecutive patients are also lacking. On the basis of the personal caseloads of specialized surgeons or of retrospective analyses, it is difficult to judge the true effectiveness of this new technique. This study aims to investigate the results of laparoscopic colorectal surgery in consecutive patients operated on by unselected surgeons. Methods: This observational study was begun August 1, 1995, in the German-speaking part of Europe (Germany and Austria) and 43 centers initially agreed to participate. All consecutive cases were documented. All data were rendered anonymous. Analysis was performed on an intention-to-treat basis. The study committee was blinded to the participating center. Results: By the end of the 1st year, 500 patients (M:F ratio 0.83, mean age 62.9 years) had been treated by 18 centers; 269 operations were performed for benign indications and 231 for cancer (palliative and curative). Most operations were done on the distal colon or rectum. An anastomosis was performed in 84%, with an overall leakage rate of 5.3% (colon 3.6% and rectum 11.8%), which required surgical reintervention in 1.7%. The mean operating time was 176 min and showed a decreasing tendency over the period under study. The conversion rate was 7.0% and the overall complication rate 21.4%. The reoperation rate was 6.6%; the most common cause was bleeding. There was one ureteral lesion (0.2%), but urinary tract infections were fairly common (4.8%). A postoperative pneumonia was diagnosed in 1.6% of the cases. No thromboembolic complications were reported. The 30-day mortality rate was 1.4% and overall hospital mortality 1.8%. Conclusions: Laparoscopic colorectal operations are still rare (about 1% of all colorectal operations in Germany). Laparoscopic procedures are more common on the left colon and rectum than on the right colon. The surgical complication rate is acceptable, comparable with rates reported by others for open surgery. Cardiopulmonary and thromboembolic complications were rarely seen. Mortality and surgical morbidity rates do not differ significantly among participating centers. A learning curve, reflected by a shortening of the operating time and a somewhat lower conversion rate, was observed over the observation period.

Prospective multicenter study of the quality of oncologic resections in patients undergoing laparoscopic colorectal surgery for cancer

PURPOSE: Laparoscopic colorectal surgery for cancer is currently under discussion. Results of large, randomized studies will not be available for a number of years yet. This study analyses the results of such resections in consecutive patients operated on by unselected surgeons. METHODS: A prospective, observational, multicenter study was initiated on August 1, 1995, in the German-speaking countries of Europe. One year after initiation of the study, findings are presented with respect to the quality of oncologic resections. RESULTS: Of 500 operations, 231 (46 percent) were performed for cancer, 167 (33 percent) with a curative intent. The most common curative resections were as follows: 63 anterior rectum resections (38 percent), 51 sigmoid resections (30 percent), and 27 abdominoperineal resections (16 percent). Segmental resections were performed in 20 patients (12 percent). Intraoperative tumor spillage was reported in 2 percent. Mean number of lymph nodes harvested was 13 (confidence interval, 5–95 percent; range, 11.5–14.6) and positive lymph nodes harvested was 2.2 (confidence interval, 5–95 percent; range, 0.9–3.4). Significant differences were noted between participating centers in terms of number of lymph nodes resected (P<0.0001). Distal and proximal resection margins were tumorfree in every case. Lateral margins were tumor-free when examined. In the case of 63 curative anterior resections, the mean distal resection margin was 39 (confidence interval, 5–95 percent; range, 33–45) mm, and in 8 of these resections, it was less than 20 mm. Mean blood loss was 344 (confidence interval, 5–95 percent; 292–396) ml, and 21 percent of patients received blood transfusions. CONCLUSIONS: These data document that the average quality of laparoscopic colorectal procedures for cancer is satisfactory but differs among surgeons.

Percutaneous endoscopic gastrostomy/jejunostomy (PEG/PEJ) for decompression in the upper gastrointestinal tract. Initial experience with palliative treatment of gastrointestinal obstruction in terminally ill patients with advanced carcinomas.

AbstractBackground: Signs of gastrointestinal obstruction, with intractable vomiting and an inability to take oral food, are common symptoms in terminally ill cancer patients with advanced primary tumors or peritoneal carcinomatosis. The application of percutaneous endoscopic gastrostomy or jejunostomy (PEG/PEJ) instead of the usual nasoenteral tube is a simple method of achieving permanent decompression in the upper gastrointestinal tract. The goals of this study, in addition to establishing indications and outcome, were to identify specific aspects of tube placement and to determine the incidence of complications. Method: Over a period of 3 years, a total of 24 consecutive patients (mean age, 64 years; range, 37–83 years) underwent either a PEG (17/71%) or a PEJ (seven/29%). Results: In all patients, PEG/PEJ obviated the need for the nasoenteral tube. A total of 22 patients (92%) were enabled to take liquids orally, and 20 (83%) were discharged to home care. With the exception of a single spontaneous dislodgement of the PEG tube, no major complications were observed. Conclusion: We believe that PEG/PEJ represents an effective, minimally invasive, and cost-effective method for gastrointestinal decompression in patients with advanced incurable cancer.

Conversion in Laparoscopic Colorectal Cancer Surgery: Impact on Short- and Long-Term Outcome

INTRODUCTION Despite the well-documented safety and effectiveness of laparoscopic colorectal surgery in curative intention, the role of conversion and its impact on short- and long-term outcome after resection of a carcinoma are unclear and continue to give rise to controversial discussion. METHODS Within the framework of a prospective, multicenter observational study (Laparoscopic Colorectal Surgery Study Group), into which a total of 5,863 patients from 69 hospitals were recruited over a period of 10 years, a subgroup of all patients who had undergone curative resection was analyzed with regard to the effects of conversion. RESULTS Of the 1409 patients who had undergone curative resection for colorectal carcinoma, conversion had to be performed in 80 (5.7%) cases for the most diverse reasons. The duration of surgery (median: 183 vs. 241 minutes; P<.001) was significantly longer in the conversion group. Perioperatively, significant disadvantages were noted in converted patients in terms of intraoperative blood loss (median: 243 vs. 573 mL, P<.001), need for perioperative blood transfusion (10.8% vs. 33.8%; P<.001), and resumption of bowel movement (median: after 3 vs. 4 days; P<.001). With regard to postoperative morbidity, significant disadvantages were observed in converted patients, in particular in terms of specific surgical complications, including a higher rate of anastomotic insufficiency (5.0% vs. 13.8%; P=.003) and a higher reoperation rate (4.9% vs. 15.0%; P=.001). In the long term, conversion was associated with lower overall survival, but not with poorer disease-free survival. CONCLUSION Significantly higher postoperative morbidity was observed in patients after conversion, in particular in terms of specific surgical complications. In addition, conversion is associated with overall lower survival but not with poorer disease-free survival.

Laparoscopically assisted reversal of Hartmann procedure.

Introduction Restoration of intestinal continuity following Hartmann procedure is an operation associated with a lengthy stay in hospital, protracted convalescence, and a high morbidity rate. With the aim of using the advantages of minimally invasive surgery, such as rapid mobilization, less postoperative pain, early restoration of bowel function, and a rapid return to a normal diet, and reduced morbidity, the laparoscopic modality was employed. The objective of the present study was to investigate the usefulness of laparoscopic restoration of intestinal continuity following Hartmann procedure. Method A total of 71 patients who, in the period between 1995 and 2005 within the framework of the prospective multicenter study “Laparoscopic Colorectal Surgery Study Group,” underwent a laparoscopically assisted restoration of bowel continuity following Hartmann procedure, were investigated. Results In 62 patients (87%), the laparoscopic procedure was completed as planned, whereas 9 cases had to be converted to open surgery—mostly on account of massive intra-abdominal adhesions. The 39 male (55%) and 32 female (45%) patients had an average body mass index of 25 (range, 19 to 38), a height of 168 cm (range, 150 to 190 cm), and a weight of 72 kg (range, 49 to 103 kg). Mean operating time was 164 min (range, 60 to 410 min) and the intraoperative blood loss 196 mL (range, 10 to 1000 mL). Five patients (7%) received packed red cells. In all, 85.9% of the procedures (n=61) were free of complications. The most common intraoperative complications were injuries to the bowel and problems with the anastomosis (dehiscence, difficult stapling), each occurring in 5.6% of the cases (n=4). Intraoperative lesions to the ureters (0%), the bladder (n=1/1.4%), and blood vessels (n=1/1.4%) played a numerically subordinate role. Purely parenteral nutrition was applied up to the third postoperative day (range, 0 to seventh postoperative day). In those patients who were able to take a liquid meal on the third postoperative day (range, first to eighth postoperative day), enteral nutrition was initiated on the fifth postoperative day (range, second to tenth postoperative day). On average, bowel movements were restored on the fourth postoperative day (range, second to ninth postoperative day). Patients in whom a bladder catheter was placed for the operation had it removed on the third postoperative day (range, first to twelfth postoperative day) and had normal urination thereafter. In Hartmann procedure, patients without such a catheter, normal urination was possible from postoperative day 1 onward (range, 0 to second postoperative day). Postoperative complications included hematomas/abscesses (n=3/4.2%), transit disorders (n=2/2.8%), surgery-requiring ileus (n=2/2.8%), cardiopulmonary complications (n=1/1.4%), and surgery-requiring hemorrhage (n=1/1.4%), with other complications accounting for 4.2% (n=3). The median hospital stay was 11 days (range, 5 to 35 d); the mortality rate was 1.4% (n=1). Conclusions Reversal of Hartmann procedure employing the laparoscopic modality is compatible with acceptable morbidity and mortality rates. The elevated conversion rate is a reflection of the fact that the operation is technically demanding.

Laparoscopy for Rectal Carcinoma: Abdominoperineal Excision

The enthusiasm for laparoscopic procedures in the field of visceral and colorectal surgery, in particular, has increased. Potential advantages include a reduction in pain as a result of less trauma, improved postoperative immune function, the earlier reestablishment of postoperative intestinal transit, shorter hospitalization, improved cosmesis, and reduced formation of intra-abdominal adhesions. In contrast to treatment for benign conditions, laparoscopic surgery with curative intent for malignancy is still controversial. In particular, compliance with the required criteria of oncologic radicality (extent of lymph node dissection, prevention of intraoperative tumor cell dissemination, assurance of acceptable margins of clearance) and thus, the achievement of long-term results identical with those results obtained after laparotomy, are considerations that have repeatedly been questioned. However, a number of published reports have confirmed that all the criteria for oncologic radicality in colorectal surgery can be met. An additional advantage of laparoscopic abdominoperineal excision is that it avoids a number of general problems associated with laparoscopic colorectal surgery. However, despite this encouraging information, a general recommendation for the use of laparoscopic abdominoperineal excision can be made only when definitive long-term results are available. Against this background, we discuss the questions of oncologic radicality and long-term outcome on the basis of currently available published data and our own results.

Laparoskopische Resektion beim kolorektalen Karzinom – aktueller Stand und Perspektiven

Die laparoskopische Resektion des kolorektalen Karzinoms in kurativer Absicht hat bis heute im chirurgischen Alltag einen nur begrenzten Stellenwert. Dies zeigt die «Qualitätssicherungsstudie Kolorektales Karzinom». Dennoch gibt es inzwischen einige prospektiv randomisierte Vergleichsstudien, deren Auswertungen für die offene und die laparoskopische Resektion vergleichbare onkologischen Ergebnisse nachweisen konnten. Das rezidivfreie Überleben hängt dabei neben dem Tumorstadium von der operativen Erfahrung und Sorgfalt des Einzelnen ab und ist unabhängig von der Art des operativen Zugangs, wenn vorgegebene Standards eingehalten werden. Die Patienten profitieren von den allgemeinen Vorteilen des laparoskopischen Eingriffs im unmittelbar postoperativen Verlauf.

Laparoscopic-assisted colon anastomosis using the Valtrac® ring

PURPOSE: For deep colon anastomoses in laparoscopic surgery, the mainstay is the circular stapler. Theoretically, however, such anastomoses can also be constructed with the aid of the Valtrac® ring. The aim of the present study was to investigate the feasibility of this approach. METHODS: In this approved animal study nine pigs weighing 15 to 20 kg were operated on under general anesthesia. After intracorporeal preparation, the colon was divided at the level of the entry to the pelvis. To fix the proximal half of the Valtrac® ring, the proximal limb of the colon was exteriorizedvia a minilaparotomy. After replacing this part of the colon—now bearing the Valtrac® ring—in the abdominal cavity and reestablishment of pneumoperitoneum, the ring was fixed to the applicator inserted transanally into the abdominal cavity. After placement of the distal half of the ring in the rectal limb and extracorporeal knotting of the pursestring suture previously placed with the aid of the laparoscopic pursestring clamp, the two halves of the Valtrac® ring were reliably closed with the help of the applicator. RESULTS: Eight of nine animals survived. One animal died on the fourth postoperative day as a result of an anastomotic insufficiency. At follow-up examination in the fifth postoperative week, none of the surviving eight animals showed any signs of prior anastomotic insufficiency. CONCLUSION: This animal study has shown that using the newly developed applicator system, the Valtrac® ring can be just as readily employed as the circular stapler for creation of a colonic anastomosis below the level of the promontorium.

Ergebnisse der laparoskopischen kolorektalen Chirurgie

Laparoscopic operative techniques may be of advantage to the patient undergoing colorectal surgery. Of fundamental importance, however, is the careful selection of suitable patients and indications. Even with indications of the colorectum, the many benefits of the minimally invasive approach may be fully effective. Overall morbidity associated with the laparoscopic modality is lower than with conventional surgery. There is a clear relationship between operative experience, conversion rate, and the complication rate achieved (learning curve). Laparoscopic colorectal procedures can also be performed in the elderly patient, in whom – provided the indication has been properly established – the minimally invasive modality is of particular benefit. More recent studies on the topic of laparoscopic colorectal surgery focus, in contrast to earlier studies, less on the feasibility and safety of the technique but more on the criteria of quality of treatment. Surgical treatment of diverticulitis of the sigmoid colon has benefited from the introduction of laparoscopic procedures. In general, laparoscopic procedures here should be restricted to less developed stages. Rectal prolapse is considered to be an ideal indication for a laparoscopic procedure. The use of such interventions to treat colorectal carcinoma, however, continues to be controversial. In the case of low tumour stages located at a favourable site, and provided that the monitoring of the patient be carried out under the more stringent requirements demanded by prospective study protocols, there would appear to be no objection, on the basis of current data, to the use of a laparoscopic procedure. Whether the use of the laparoscopic modality can reduce costs has not been unequivocally established at present, but is considered to be highly likely.