Jeffrey L. Glass

Prospective comparison of openvs. laparoscopic colon surgery for carcinoma

Laparoscopy for colonic diseases began in 1990 and has established a role in benign disease. Early observations and experiences demonstrated feasibility of laparoscopic surgery for a variety of colonic disease processes, but the applicability to colonic carcinoma was unclear. METHODS: In 1990, we began a comparative study of open (OCR)vs.laparoscopic (LCR) approach to colon cancer. The study progressed 65 months, with 224 patients in OCR group and 191 patients in LCR group. Parameters studied are stage, location, length of specimen, number of lymph nodes resected, margins, postoperative course, wound complications, recurrence rates, and immediate and long-term survival. OCR were standardized by one group, and LCR were standardized by a second group. All patients undergoing LCR were given freedom to choose either OCR or LCR, and informed consent was obtained. RESULTS: Equal or greater lymph node retrieval, resections, and distal margins were evident with LCR. Benefits with LCR were shown with shorter hospitalization (5.7vs.9.7 days), less blood loss, less wound problems (1vs.14), and quicker return of bowel function. Survival, recurrence, and death rates were essentially the same. There were no trocar implants in the LCR group. CONCLUSION: After five years, this study shows that laparoscopy does no harm to the patient, offers comparable oncologic resections, and seems to be patient-friendly, with less pain, quicker return of bowel functions, shortened hospitalization, and quicker return to full activity.

Laparoscopic surgery for stage III colon cancer: Long-term follow-up

AbstractBackground: The role of laparoscopic surgery in the management of colorectal cancer is controversial. This study was undertaken to determine the oncological adequacy, in terms of margins of resection, lymph node harvest, and anastomotic and locoregional recurrence of laparoscopic colectomy in patients with stage III (node-positive) colorectal cancer. Methods: The results of laparoscopic colectomy in 50 consecutive patients with stage III colorectal cancer operated on at a single hospital between 1991 and 1998 were analyzed with respect to postoperative morbidity, mortality, and long-term survival by the Kaplan-Meier method. Methodical patient follow-up was the mainstay of the study. Results: There were 31 men (52%) and 19 women (38%) with a mean age of 67.7 years (range, 40–88). Low anterior resection was performed in 17 cases, abdominal perineal resection in five cases sigmoid colectomy in 10 cases, left hemicolectomy in six cases, right hemicolectomy in seven cases, transverse colectomy in one case, and subtotal colectomy in four cases. Conversion was necessary in three cases (6%). Major complications included one leak, one pelvic abscess, one perineal wound infection, and three anastomotic strictures early in the experience, with none in the past 4 years. One early death occurred due to massive stroke. Median length of stay was 6 days (range, 3–37). Forty-six patients were staged as CII and four as CI colon cancer. The average number of positive nodes was 5.1 (range, 3–58). The margins of resection were adequate in all patients. Follow-up ranged from 3 to 75 months (average, 29.3; median, 24). Overall cancer-related mortality was 34% (17 patients); three patients died of unrelated causes with no detectable cancer. All who died of cancer had distant disease; three of them also had pelvic recurrence. Mean time of death was 21.7 months. There were no anastomotic recurrences or trocar site implants. Overall 3- and 5-year survival was 54.5% and 38.5%, respectively; cancer-adjusted survival was 60.8% and 49.1%. Conclusions: Based on this study, laparoscopic colectomy in patients with stage III colorectal cancer is oncologically adequate. It results in a long-term outcome comparable to that of traditional open surgery and is associated with low perioperative mortality and morbidity (lower wound infection rate, lower wound recurrences at trocar sites) and a shortened length of stay.

Laparoscopic common bile duct exploration by choledochotomy : An effective and efficient method of treatment of choledocholithiasis

AbstractBackground: Management of cholelithiasis and choledocholithiasis usually requires two separate teams—the gastroenterologist/surgical endoscopist and the laparoscopic surgical team. This requires two separate procedures that potentially increase the overall morbidity and cost. Laparoscopic common bile duct exploration by choledochotomy (LCBDE-C) averts this problem with a single approach. Methods: In 1990–1991, unsuspected stones found at laparoscopy with intraoperative cholangiogram done routinely underwent postoperative ERCP. Residual stones had been found after ERCP in 16 of 22 preoperative ERCP patients and we began to seek an alternative technique. Laparoscopic common bile duct exploration by choledochotomy has achieved a high rate of success. Results: Technically successful LCBDE-C has been accomplished in 143 of 148 patients (96.6%). Retained bile duct stones have been found on postoperative cholangiogram in three patients (2.0%), all of which have been successfully removed by postoperative ERCP. Thus 140 or 148 patients had their bile duct successfully cleaned by the one-step technique alone (94.6%). Conclusions: We believe that most laparoscopic surgeons who have acquired the skills of intracorporeal suturing can be successful at laparoscopic common bile duct exploration by choledochotomy. The disadvantage of T-tube presence will likely be eliminated by future developments with intraoperative antegrade sphincterotomy-like procedures, but the ability to see both proximal and distal biliary tree with the choledochotomy in all cases seems to offer more than adequate results at this point in the evolution of the laparoscopic approach to calculus biliary tract disease.

Laparoscopic diagnosis and treatment of intestinal obstruction

Background: Intestinal obstruction is a common reason for general surgical referral. The traditional approach has been conservative management, followed by laparotomy if conservative measures are unsuccessful. However, with the advent of minimally invasive surgery, the need for laparotomy for this common problem is being challenged.Methods: From May 1991 to April 2001, 167 patients underwent laparoscopy for diagnosis and/or treatment of intestinal obstruction. Average patient age was 62 years (range, 21–98). The site of obstruction was the stomach in seven patients, small bowel in 116 patients, and colon in 44 patients.Results: Laparoscopy successfully diagnosed the site of obstruction in all patients. In addition, 154 patients (92.2%) were successfully treated laparoscopically without conversion to laparotomy. Both intraoperative and postoperative complication rates were low (3.5 and 18.6%, respectively) and compared favorably with those of published reports.Conclusions: Intestinal obstruction can be approached safely and effectively by laparoscopy with the intent not only to correctly diagnose the patient but also to render treatment.

Laparoscopic-assisted colonoscopic polypectomy

PURPOSE: The advent of laparoscopic surgery has altered the manner by which surgical specialties address pathologies of the abdominal cavity. This advance in technology has also changed colorectal surgery. One of the more common procedures of colorectal surgery is segmental resection for polyps that are large, broad based, or inaccessible for colonoscopic removal. We present a technique combining colonoscopy and laparoscopy to remove troublesome polyps without the need for segmental resections. METHODS: From May 1990 to September 1999 laparoscopicmonitored colonic polypectomies were performed in 47 patients, with a total of 60 polyps being removed. After laparoscopic mobilization of the involved segment of the colon, the proximal bowel is cross-clamped and the colonoscope passed to the involved portion of the colon. The polyp is then presented to the colonoscopist by the laparoscopist facilitating removal. The serosal surface is monitored for any indications of transluminal injury, and the area is repaired if needed. All polyps undergo immediate frozen section analysis. If the pathologic evaluation indicates malignancy then a segmental resection may be performed, otherwise the patients are decompressed and fed within a short time before discharge. RESULTS: The polyps were located most commonly in the ascending colon (18 polyps), transverse colon (12 polyps), and cecum (12 polyps). The most common histopathologic diagnosis was tubulovillous adenoma in 28 polyps followed by villous adenoma in 11 polyps. In three cases histopathologic diagnosis revealed malignancy necessitating segmental resection (1 low anterior resection and 2 right hemicolectomies), which were performed laparoscopically. Patients received a liquid diet within 6 hours, were discharged in an average of 21 hours, and returned to full activity, usually within days. The only complication presented in this group of patients was an umbilical port seroma. Virtually all patients (97 percent) behaved as if only a colonoscopy had been performed. Pain at the trocar sites was managed with acetaminophen 600 mg by mouth as needed. CONCLUSION: Laparoscopic-monitored colonoscopic polypectomy allows patients to undergo removal of colonic polyps without a segmental resection. This less invasive procedure yields recovery times similar to that of colonoscopy alone, and the potential complications of a segmental resection are avoided. All polyps are examined by frozen section, and if a malignancy is encountered, a laparoscopic resection can be performed.

Laparoscopically monitored colonoscopic polypectomy: an established form of endoluminal therapy for colorectal polyps

BackgroundBenign polyps, the most common disorders of the colon, are considered by many to be premalignant lesions. Colonoscopy is widely used to remove the majority of these polyps. However, a variety of “difficult polyps” are not accessible for colonoscopic removal because of their location and size, the tortuosity of the colon, or the complexity of the lesion (sessile vs pedunculated). In the past, a formal segmental resection usually was suggested for these difficult polyps.MethodsFor 110 patients with a median age of 73 years, a total of 149 polyps were removed as follows: 88 from the right colon, 18 from the transverse colon, 10 from the left colon, and 33 from the rectosigmoid colon. Pathologic evaluation showed adenomatous polyps in 13 patients (11.81%), hyperplastic polyps in 1 patient (0.9%), adenocarcinomas in 10 patients (9.09%), carcinoma in situ in 1 patient (0.9%), and adenomas in the remaining patients (tubulovillous, 40.18%; villous, 19.31%, and tubular, 17.77%). All the specimens were evaluated for margins and depth of resection.ResultsThe median size of the polyps was 2.30 cm (range, 0.2–6 cm). The average hospital stay was 1.14 days, with a liquid diet started 6 h postoperatively. Mild abdominal pain/trocar-site pain was the most common complaint. The patients were followed with colonoscopy 6 months postoperatively and yearly thereafter.ConclusionsA combined endoscopic–laparoscopic approach provides a valid alternative for treating difficult colonic polyps and eliminating the morbidity of a segmental resection. This approach seems to be safe and effective.

The use of bioabsorbable staple line reinforcement for circular stapler (BSG "Seamguard") in colorectal surgery: initial experience.

Of all the complications associated with colorectal surgery, the most devastating and constant, despite all techniques being performed properly is anastomotic leakage, especially in left colon and rectal resections with rates as high as 50% when the rectum is involved. In 2005, our center published the preliminary experience with the use of linear staple line reinforcement for colon surgery. The purpose of this paper is to present a series of cases using a new conformation of bioabsorbable reinforcement for circular staplers in 5 patients, 2 patients with rectal cancer, 2 patients with diverticular disease, and 1 patient with sigmoid cancer. These initial data are very promising and has encouraged us to continue using this device on further patients.

Laparoscopic-assisted endoluminal hybrid surgery: a stepping stone to NOTES.

Background Natural orifice transluminal endoscopic surgery (NOTES) is the anticipated progression of minimally invasive surgery. As it approaches, surgeons will need to develop the fundamental skills and spatial orientation needed to perform safely in this new field. The Natural Orifice Surgery Consortium for Assessment and Research has established several fundamental challenges to the safe introduction of NOTES. Our institutional experience with laparoscopic-assisted endoluminal surgery is reviewed to display the techniques and efficacy of procedures that address many of these challenges and may provide a safe transition for the general surgeon to NOTES or as an alternative to pure NOTES. Methods A retrospective review of all laparoscopic-assisted endoluminal surgeries from 1991 to 2007 was performed. Patients had been referred to the institution and selected after either unsuccessful attempts from traditional endoscopic resection of pathology by a gastroenterologist or being deemed an unfavorable candidate for traditional endoscopic resection. All procedures involved establishment of pneumoperitoneum, placement of trochar ports under laparoscopic visualization, balloon ports in gastric cases combined with endoscopy, intraluminal insufflation, coordinated resection of intraluminal pathology using both the endoscopic and laparoscopic instruments, and closure of the intraluminal port sites with intracorporeal suturing. Results A total of 175 procedures were performed from 1991 to 2007 using these techniques. These procedures varied and included laparoscopic monitored colonoscopic polypectomy, resection of gastric polyps, intraluminal cystgastrostomy, gastric ulcer resection, and foreign body removal. The average age was 55 years (range 38 to 75 y), length of operation 95 minutes (range 60 to 137 min), hospital stay 3.5 days, and 5 complications (2.8%). Of the total procedures, 18 (10.2%) patients were found to have malignancy on frozen section and preceded with a formal resection. There are no cancer recurrences to date with a mean follow up of 74 months (6 to 196 mo). Conclusions Our institutional experience with these procedures seems to be a natural transition to developing skills for NOTES procedures and displays a safe and effective approach to a wide range of intraluminal pathology. The general surgeon in practice can use this union of laparoscopy and endoscopy using current instruments and technology for safe transition into the emerging field of NOTES, or even as an alternative to pure NOTES. Mastery of intraoperative endoscopy and intraluminal surgery will be essential to this transition.

Laparoscopic Intraluminal Surgery for Gastrointestinal Malignancies

IntroductionIntraluminal surgery began with the advent of endoscopy. Endoscopic endoluminal surgery has limitations; and its failure results in conventional open or laparoscopic interventions with increased morbidity. Laparoscopy-assisted intraluminal surgery is a novel alternative to open or laparoscopic surgery for a failed endoscopic endoluminal technique, minimizing the associated complications. Endoscopic resection of early gastric and duodenal cancers is restricted by the limited view of the endoscope, insufficient number of instrument channels, and inability to have adequate margins of resection without risking perforation. These cancers potentially can be treated by laparoscopy-assisted intraluminal surgery without resorting to major gastric or duodenal resection. This procedure is relatively easy to perform and oncologically effective. We present the experience of the Texas Endosurgery Institute (TEI) in treating early gastric and duodenal cancers, including large malignant polyps and carcinoid tumors, with laparoscopy-assisted endoluminal surgery.Materials and methodsThe data for all patients with early gastric and duodenal cancers who underwent laparoscopy-assisted endoluminal surgery at TEI between 1996 and 2007 were prospectively recorded. All of the patients had been referred by the endoscopist as noncandidates for endoscopic resection. We prospectively collected data on preoperative diagnosis, operating time, estimated blood loss, postoperative complications, histopathology, and recurrence rate. All patients underwent endoluminal port placement under direct visualization after a pneumoperitoneum was established. Operations were performed in conjunction with upper endoscopy for assistance with port placement under endoluminal visualization, insufflation, and specimen retrieval. After the intraluminal portion of the operation was completed, the endoluminal port sites were closed with laparoscopic intracorporeal suturing.ResultsFrom 1996 to 2007, a total of 12 patients underwent laparoscopic endoluminal surgery. All cases were completed successfully, including 5 resections of early gastric cancer (stage I), 3 wedge resections of carcinoid tumor, 2 resections of duodenal adenocarcinoma, and 2 resections of a malignant polyp at the gastroesophagic junction; all the cases were completed with disease-free margins. No recurrence of the original pathology have been reported, and the complications were minimal.ConclusionLaparoscopic intraluminal surgery for early gastric and duodenal cancer is a feasible alternative to open conventional therapies; and it is associated with a lower incidence of incisional hernia formation and a lower infection rate.

The role of laparoscopy in the treatment of mid and low rectal cancer lesions. Is it safe and feasible

The role of Laparoscopy in Colon and Rectal disease has been criticized by many since its inception in 1990 but has become a great tool for others. Much debate has been forthcoming in the case of laparoscopic management of cancer of the colon, especially with mid and low rectal carcinoma. Evaluation of the safety and advisability of these procedures is the purpose of this study. Since 1990 thrn December 1997 we have performed 345 cases of Laparoscopic colon resection for cancer, 93 of these were tumors located in the mid and low rectum and required a LOW Anterior Resection. 88 were completed successfully with a conversion rate of 3.3% and a success rate of 96.7%. Very early in our experience a strict set of guidelines of oncological principles to dissect and extract the specimen was followed. In all cases the anastomosis has been carried out totally intracorporeally (97.8%) extracting the specimen through the rectum protected in a plastic bag in 90% of the cases. Anal dysfunction was present after transanal retrieval in 10% of the cases but was resolved within a month. Occasionally with tumors >5 cms in diameter the specimen was extracted transabdominally in a plastic bag. Lateral margins of all specimens were evaluated and compared to an open group of patients and felt to be equivalent or better. The average level of these tumors was at 11 cms. from the anal verge with a range of 4 to 15 cms. The average follow up in this group of patients is 31 months. The overall complication rate was 25% (17% Minor, 8% major complications). There was an anastomosis stricture rate of 3.2% and the leak rate was 1%. We have had no trocar site implants to date. Laparoscopic Low Anterior Resection for cancer is a feasible, safe and effective procedure in our hands, with an overall complication rate and anastomotic leak and stricture problems comparably or better to standard techniques. The advantages of Minimally Invasive procedure benefits the patient with faster recuperation, less pain and essentially a non existing wound infection rate.