Juan Santiago Azagra

Laparoscopic Liver Resection for Malignant Liver Tumors: Preliminary Results of a Multicenter European Study

ObjectiveTo assess the feasibility, safety, and outcome of laparoscopic liver resection for malignant liver tumors. Summary Background DataThe precise role of laparoscopy in resection of liver malignancies (hepatocellular carcinoma [HCC] and liver metastases) remains controversial despite an increasing number of publications reporting laparoscopic resection of benign liver tumors. MethodsA retrospective study was performed in 11 surgical centers in Europe regarding their experience with laparoscopic resection of liver malignancies. Detailed questionnaires were sent to each surgeon focusing on patient characteristics, clinical data, type and characteristics of the tumor, technical details of the operation, and early and late clinical outcome. All patients had radiologic investigations at follow-up to exclude disease recurrence. ResultsFrom February 1994 to December 2000, 37 patients with malignant liver tumors were included in this study. Ten patients had HCC, including 9 with cirrhotic liver, and 27 patients had liver metastases. The mean tumor size was 3.3 cm, and 89% of the tumors were located in the left lobe or in the anterior segments of the right liver. Liver procedures included 12 wedge resections, 9 segmentectomies, 14 bisegmentectomies (including 13 left lateral segmentectomies), and 2 major hepatectomies. The transfusion rate, the use of pedicular clamping, the conversion rate (13.5% in the whole series), and the complication rate were significantly greater in patients with HCC. There were no deaths. Postoperative complications occurred in eight patients (22%). The surgical margin was less than 1 cm in 30% of the patients. During a mean follow-up of 14 months, the 2-year disease-free survival was 44% for patients with HCC and 53% for patients having hepatic metastases from colorectal cancer. No port-site metastases were observed during follow-up. ConclusionsIn patients with small malignant tumors, located in the left lateral segments or in the anterior segments of the right liver, laparoscopic resection is feasible and safe. The complication rate is low, except in patients with HCC on cirrhotic liver. By using laparoscopic ultrasound, a 1-cm free surgical margin should be routinely obtained. The late outcome needs to be evaluated in expert centers.

Laparoscopic anatomical (hepatic) left lateral segmentectomy : technical aspects

Laparoscopic liver surgery is a tremendous challenge. The authors report a left liver lobectomy and removal by a total laparoscopic approach. Anatomical left lateral laparoscopic segmentectomy was performed on a woman who had a symptomatic hepatic adenoma. The patient was discharged after an uncomplicated postoperative recovery; the hospital stay and convalescence period were very short. The cosmetic result was good.

Laparoscopic liver resection of benign liver tumors: Results of a multicenter European experience

Objective: The objective of this study was to assess the feasibility, safety, and outcome of laparoscopic liver resection for benign liver tumors in a multicenter setting. Background: Despite restrictive, tailored indications for resection in benign liver tumors, an increasing number of articles have been published concerning laparoscopic liver resection of these tumors. Methods: A retrospective study was performed in 18 surgical centres in Europe regarding their experience with laparoscopic resection of benign liver tumors. Detailed standardized questionnaires were used that focused on patients characteristics, clinical data, type and characteristics of the tumor, technical details of the operation, and early and late clinical outcome. Results: From March 1992 to September 2000, 87 patients suffering from benign liver tumor were included in this study: 48 patients with focal nodular hyperplasia (55%), 17 patients with liver cell adenoma (21%), 13 patients with hemangioma (15%), 3 patients with hamartoma (3%), 3 patients with hydatid liver cysts (3%), 2 patients with adult polycystic liver disease (APLD) (2%), and 1 patient with liver cystadenoma (1%). The mean size of the tumor was 6 cm, and 95% of the tumors were located in the left liver lobe or in the anterior segments of the right liver. Liver procedures included 38 wedge resections, 25 segmentectomies, 21 bisegmentectomies (including 20 left lateral segmentectomies), and 3 major hepatectomies. There were 9 conversions to an open approach (10%) due to bleeding in 45% of the patients. Five patients (6%) received autologous blood transfusion. There was no postoperative mortality, and the postoperative complication rate was low (5%). The mean postoperative hospital stay was 5 days (range, 2–13 days). At a mean follow-up of 13 months (median, 10 months; range, 2–58 months), all patients are alive without disease recurrence, except for the 2 patients with APLD. Conclusions: Laparoscopic resection of benign liver tumors is feasible and safe for selected patients with small tumors located in the left lateral segments or in the anterior segments of the right liver. Despite the use of a laparoscopic approach, selective indications for resection of benign liver tumors should remain unchanged. When performed by expert liver and laparoscopic surgeons in selected patients and tumors, laparoscopic resection of benign liver tumor is a promising technique.

Minimally invasive surgery for gastric cancer

AbstractBackground: The use of laparoscopic surgery in the treatment of gastric cancer has not yet met with widespread acceptance; thus, it should be regarded as still in the developmental phase. Nevertheless, the laparoscopic approach appears to have some valuable advantages for the management of gastric cancer patients, and it can be expected to have a dramatic impact on public health expenditures. Herein we present the results of our experience with laparoscopic and laparoscopy-assisted gastrectomies for cancer, and we discuss the role of these procedures in current surgical practice. Methods: Between June 1993 and November 1997, we performed a total of 13 laparoscopic procedures on 13 patients affected with gastric carcinoma. There were eight male and five female patients with a mean age of 65.4 years (range, 42–78). All patients were staged preoperatively with US and CT scan and required to sign a formal consent. Results: Altogether we performed nine D1 laparoscopic total gastrectomies, seven of which were done with a laparoscopy-assisted approach; three D2 laparoscopy-assisted total gastrectomies, associated in one case with a distal pancreasectomy; and one laparoscopy-assisted distal gastrectomy performed on a morbid obese patient. The preliminary laparoscopic staging allowed for a better definition of tumor extension and identification of undetected hepatic metastases in two patients. The mean duration of the intervention was 240 min. Blood losses were as high as 300 cc on average. We recorded one major intraoperative complication, consisting of an inadvertent injury to the proper hepatic artery, which was successfully repaired by the same laparoscopic route. The postoperative course was uneventful in all patients but one, who died of acute hepatic failure on day 6. At a mean follow-up of 27.5 months, 11 patients are still alive. Two of them have hepatic metastases and nine are disease-free. Conclusions: Although they remain challenging procedures, laparoscopic gastrectomies appear to be oncologically adequate. We believe that a pure laparoscopic approach should be reserved for low-stage lesions (N0, up to T2), while a combined approach is preferable for locally advanced cancer (N1 or higher, T3 or higher). Much work still needs to be done to establish the optimal strategy in both open and laparoscopic surgery, but laparoscopy can be a valuable tool in the decision-making process for patients affected with gastric malignancies.

Laparoscopic gastric reduction surgery. Preliminary results of a randomized, prospective trial of laparoscopic vs open vertical banded gastroplasty.

AbstractBackground: The purpose of the current study was to present the preliminary results of a randomized prospective trial comparing laparoscopic and open vertical banded gastroplasty (Mason’s procedure). Methods: From April 1995 to April 1996, 68 patients (9 men and 59 women, mean age, 36 years; ranges, 17–60 years) affected from morbid obesity (mean body weight, 123 kg; range, 89–188 kg; mean body mass index (BMI), 43 kg/m2; range, 37–66 kg/m2) were enrolled in a prospective trial and randomly assigned to a laparoscopic (group A) or open (group B) Mason’s gastroplasty. There was no statistically significant difference between the two groups in terms of patient epidemiologic data. The significance level among the data was assessed by means of Fisher’s exact test. Results: The success of laparoscopic gastroplasty was 88.2% (30/34). The intervention was significantly longer in the laparoscopic group (150 min vs. 60 min; p= 0.001). No mortality was recorded in the overall population. Intraoperative complications included only one case of gastric bleeding in group A (2.9% vs. 0%; p value not significant [NS]). Early major complications ranged as high as 6.6% and 7.8%, respectively, in groups A and B (p= NS), and included one case of peritonitis and one case of pneumonia in group A, and two cases of peritonitis and one pulmonary embolism in group B. Early minor postoperative complications consisted of wound infections only, observed in one group A patient (3.3%) and four group B patients (10.8%, p= 0.04). At longer follow-up, incisional hernias occurred in 15.8% (6/38) of patients surgically treated with a conventional approach compared with none among those successfully surgically treated with laparoscopic accesss (p= 0.04). No statistically significant difference was observed between the two groups regarding the efficacy of the procedure, in terms of decrease in percentage of excess body weight, mean body weight, or mean BMI. Conclusions: The preliminary results of current study show that the laparoscopic Mason procedure is a time-consuming and technically demanding operation, as effective as its traditional counterpart, but carrying a statistically significant decrease in the incidence of wound infections and incisional hernias.

Laparoscopic Roux-en-Y gastric bypass versus laparoscopic vertical banded gastroplasty: results of a 2-year follow-up study.

BackgroundThe world’s epidemic of obesity is responsible for the development of bariatric surgery in recent decades. The number of gastrointestinal surgeries performed annually for severe obesity (BMI > 40 kg/m2) in the United States has increased from about 16,000 in the early 1990s to about 103,000 in 2003. The surgical techniques can be classified as restrictive, malabsorptive, or mixed procedures. This article presents the results for 2 years of bariatric surgery in the authors’ minimally invasive center and analyzes the results of the most used surgical techniques with regard to eating habits.MethodsBetween January 2002 and January 2004, the authors attempted operations for morbid obesity in 110 consecutive patients adequately selected by a multidisciplinary obesity unit. This represented 43% of all consultations for morbidly obese patients. The patients were classified as sweet eaters or non–sweet eaters. All sweet eaters underwent gastric bypass. The procedures included 70 Roux-en-Y gastric bypasses, 39 Mason’s vertical banded gastroplasties, and 1 combination of vertical gastroplasty with an antireflux procedure. Revision procedures were excluded.ResultsThe mean age of the patients was 41.36 years (range, 23–67 years), and 72.3% were female. The mean preoperative body mass index was 44.78 kg/m2 (range, 34.75–70.16 kg/m2). The mean operating time was longer for gastric bypass than for the Mason procedure. Three patients required conversion to an open procedure (2.7%). The two operative techniques had the same efficacy in weight reduction. Early complications developed in 11 patients (10%), and late complications occurred in 9 patients (8.1%). The postoperative length of hospital stay averaged 4.4 days (range, 1–47 days; median, 4 days), and was longer in the gastric bypass group. The mortality rate was zero. Data were available 2 years after surgery for 101 of the 110 patients (91%). Most comorbid conditions resolved by 1 year after surgery regardless of the type of operation used.ConclusionWith zero mortality and low morbidity, bariatric surgery performed for adequately selected patients is the most effective therapeutic intervention for weight loss and subsequent amelioration or resolution of comorbidities. The patient’s eating habits before surgery play an important role in the choice of the operative technique used.

Is There a Place for Laparoscopy in Management of Postcholecystectomy Biliary Injuries

Abstract. Despite its minimal invasiveness, laparoscopic cholecystectomy (LC) carries unquestionably higher morbidity and mortality rates when compared with the open counterpart (OC). Among the iatrogenic injuries, biliary tract lesions are the most clinically relevant because of their potential for patients disability and long-term sequelae. No universal agreement exists for classifying these lesions, but numerous authors have advocated a distinction between bile leaks and bile injuries. Even if not entirely correct, bile leaks refer to fistulas from minor ducts in continuity with the major ductal system or from accessory ducts (as the duct of Luschka). Biliary injuries are major complications consisting of leaks, strictures, transection, or ligation of major bile ducts. While bile leaks are typically treated by percutaneous and/or endoscopic drainage and stenting, biliary injuries often require a combined radiology-assisted and endoscopic approach or even conventional surgery. The role of laparoscopy in the management algorithm of biliary lesions is still anecdotal. To date, a total of 25 cases of laparoscopic drainage of post-cholecystectomy bilomas have been reported in the literature, whereas there is no mention of laparoscopic primary repair of biliary injuries detected at or after cholecystectomy. The main reasons depend on the excellent results achieved by the ancillary techniques; the emergency settings that accompany more complex biliary lesions; the technical challenges posed by the presence of inflammation, collections, and obscured anatomy; and the potential for malpractice litigation. However, a sound laparoscopic technique and a strict adherence to basic surgical tenets are crucial in order to avoid the incidence of iatrogenic biliary injuries and reduce their still unknown impact on long-term patient disability.

Percutaneous and Reduced-Port Roux-en-Y Gastric Bypass: Technical Aspects

The well-known advantages of minimally invasive surgery, such as improved surgical vision and precision, less postoperative pain, faster recovery, shorter hospital stay, and reduced parietal complications, are particularly important in bariatric surgery. Patient acceptance and cosmetic results have also been widely demonstrated. The introduction of single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery, which are aimed at maximizing the benefits of laparoscopy, have generated considerable interest. Unfortunately, the current learning curve and acquisition of specific materials limit the spread of these techniques. The feasibility is well demonstrated but standardization, safety, and long-term results need additional assessment. In addition, there are higher hospital costs and an increased rate of port-site hernia compared with standard laparoscopic surgery, especially for single-incision laparoscopic cholecystectomy. In this context, reduced-port surgery (RPS) with classic laparoscopic triangulation could represent a new target, with no concerns related to procedural safety and surgical outcomes and no additional skills and equipment required. We have already demonstrated the standardization, reproducibility, and safety of RPS in other bariatric procedures. In addition, RPS can lead to better outcomes and avoid potential complications (eg, port-site hernia) that are more deleterious and difficult to manage in these patients. The purpose of this study is to describe our technique of laparoscopic Roux-en-Y gastric bypass (LRYGB) using RPS with percutaneous instrumentation, define the technical details, and analyze the short-term outcomes.

Erratum: Laparoscopic liver resection of benign liver tumors

B. Descottes, D. Glineur, F. Lachachi, D. Valleix, J. Paineau, A. Hamy, M. Morino, H. Bismuth, D. Castaing, E. Savier, P. Honore, O. Detry, M. Legrand, J. S. Azagra, M. Goergen, M. Ceuterick, J. Marescaux, D. Mutter, B. de Hemptinne, R. Troisi, J. Weerts, B. Dallemagne, C. Jehaes, M. Gelin, V. Donckier, R. Aerts, B. Topal, C. Bertrand, B. Mansvelt, L. Van Krunckelsven, D. Herman, M. Kint, E. Totte, R. Schockmel, J. F. Gigot

Use of upper gastrointestinal studies after gastric bypass

After reading the interesting article ‘‘Predictive value of upper gastrointestinal studies versus clinical signs for gastrointestinal leaks after laparoscopic gastric bypass’’ by Madan [1] et al., we want to contribute our opinion about the use of routine imaging tests (RIT) after laparoscopic Roux-en-Y gastric bypass (LRYGB). The efficiency of upper gastrointestinal (UGI) studies relies mainly on radiologist experience; besides, it is well known that computed tomography (CT) scanning has a better sensitivity and specificity [2] than UGI studies for detection of leaks. Therefore we consider that in the case of clinical suspicions of any complications after LRYGB, a CT scan with isotonic oral contrast must be requested and UGI studies should be limited only to patients with a weight over the CT scanner limit (most frequently 180 kg). In the last few years, surgeons have acquired great experience in bariatric surgery, which has been translated into a significant decrease in leak rates [3], such that the most experienced bariatric surgeons show leak rates under 1%. For this reason, we do not support the routine use of any RIT after LRYGB, but to perform them when patient’s clinical signs and symptoms require us to do so.