Karl A. Zucker

Laparoscopic guided cholecystectomy

Cholecystectomy remains the most effective form of therapy for patients with symptomatic cholelithiasis. An alternative method of gallbladder removal, laparoscopic guided cholecystectomy, was attempted in 100 patients. Five patients required conversion of the laparoscopic procedure to an open laparotomy for the following reasons: discovery of a pancreatic malignancy in one patient, extensive adhesions in one, presence of an aberrant accessory right hepatic duct in one, common hepatic duct injury in one, and avulsion of the cystic duct in one. Both ductal injuries occurred during the early phase of the clinical program. In those patients undergoing laparoscopic cholecystectomy, 93 were discharged within 24 hours of surgery and 94 returned to normal activity within 1 week. Laparoscopic guided cholecystectomy appears to offer a number of advantages in patient care as well as a significant reduction in health care expenses for gallbladder disease. Appropriate training in laparoscopic surgery is necessary in order to avoid operative complications.

Laparoscopic cholangiography. Results and indications.

One hundred sixty-five operative cholangiograms were attempted in 364 patients who underwent laparoscopic cholecystectomy (45%). Laparoscopie cholangiography was successful in 150 of 165 attempts (91%). Eighty-nine per cent of studies were normal (134/150) and 11% were abnormal (16/150). All 134 patients with normal cholangiograms remained asymptomatic (false-negative rate, 0%). False-positive studies occurred in 3 of 150 (2%) total cholangiograms and 3 of 12 (25%) abnormal cholangiograms consistent with choledocholithiasis. A total of 16 of 364 patients had proven common bile duct stones (4.4%). Eight of the sixteen stones were removed by preoperative endoscopie retrograde cholangiopancreatography/sphincterotomy. Five of sixteen stones were found at cholangiography, four of which were unsuspected (4/150, 2.6%). Retained common duct stones were found in 3 of 214 patients not undergoing cholangiography (1.4%). No complications or deaths occurred that were due to cholangiography. One biliary injury occurred (1/364, 0.3%), in a patient with aberrant anatomy who did not undergo cholangiography. Laparoscopie cholangiography is a safe technique with a success rate greater than 90%. Routine cholangiography is presently recommended for prevention of biliary injury, detection of stones in the cystic and common ducts, and for training purposes, especially during the learning phase of laparoscopie cholecystectomy.

Laparoscopically assisted colon resection for colon carcinoma: perioperative results and long-term outcome.

AbstractBackground: The role of laparoscopic colon resection in the management of colon cancer is unclear. The aims of this study were to compare perioperative results and long-term outcomes in patients randomized to either open (O) or laparoscopically assisted (LA) colon resection for colon cancer. Methods: A prospective randomized trial comparing O to LA colon resection was conducted from January 1993 to November 1995. Preoperative workup, intraoperative results, complications, length of stay, pathologic findings, and long-term outcomes were compared between the two groups. Statistical analysis was performed with t-test. Follow-up periods ranged from 3.5 to 6.3 years (mean, 4.9 years). Results: No port-site or abdominal wall recurrences were noted in any patients. Conclusions: These results suggest that laparoscopically assisted colon resection for malignant disease can be performed safely, with morbidity, mortality, and en bloc resections comparable with those of open laparotomy. Long-term (5-year) follow-up assessment shows similar outcomes in both groups of patients, demonstrating definite perioperative advantages with LA surgery and no perioperative or long-term disadvantages.

The Baltimore experience with laparoscopic management of acute cholecystitis

Laparoscopic cholecystectomy has rapidly emerged as a popular alternative to traditional laparotomy and cholecystectomy. Acute cholecystitis has been considered to be a relative or absolute contraindication to laparoscopic surgery. After gaining extensive experience in laparoscopic biliary tract surgery, this procedure was attempted in 15 patients with acute cholecystitis. All patients were operated on within 72 hours of admission. In five patients, the laparoscopic procedure was converted to an open laparotomy; in one patient, a localized abscess was found, and in the other four patients, extensive inflammation and edema precluded a safe dissection of the vascular and ductal structures. Laparoscopic cholangiography was performed in 14 patients and proved valuable in demonstrating the ductal anatomy. Patients were discharged an average of 2.7 days after the laparoscopic procedure. Laparoscopic cholecystectomy may be safely performed by experienced surgeons in patients with acute cholecystitis. To ensure a low complication rate, a low threshold for converting the procedure to an open laparotomy must be maintained if the ductal and vascular anatomy cannot be safely demonstrated.

Laparoscopic management of acute cholecystitis

The role of laparoscopic surgery in patients presenting with acute cholecystitis remains controversial. From September 1989 through August 1992, a total of 720 patients underwent cholecystectomy. Ninety-six were unplanned admissions with a clinical diagnosis of acute cholecystitis. Laparoscopic surgery was attempted in 83 patients. Thirteen individuals were not offered laparoscopy because of the surgeons inexperience. Twenty-two (27%) patients required the laparoscopic procedure converted to an open laparotomy. The mean postoperative hospital stay for patients undergoing laparoscopic cholecystectomy was 3.3 days versus 6.8 days for the laparotomy group. There was no mortality and no bile duct or major vascular injuries in either group. The overall operative morbidity rate was 16.9%. Laparoscopic cholecystectomy appears to be a safe and beneficial option in selected patients with acute cholecystitis. A low threshold for conversion to laparotomy appeared to be an important factor in maintaining a low incidence of operative complications. Several modifications to the technique of laparoscopic cholecystectomy have evolved over the 3-year study period and are described.

Laparoscopic-assisted colon resection

The popularity and success of laparoscopic biliary tract surgery have persuaded surgeons to explore other applications for rigid endoscopic surgery. From July 1990 to February 1993 a total of 65 patients (mean age 57 years; range 41–82) underwent attempted laparoscopic colon resection. Indications for surgical intervention included cancer (39), adenomatous polyps (14), diverticulosis (10), stricture (1), and foreign-body perforation (1). A laparoscopic-assisted technique whereby the specimen was removed and the anastomosis was completed outside of the abdomen was used in all patients. A dilated umbilical opening was used for right-sided lesions and a left-lower-quadrant muscle-splitting incision for descending and sigmoid colon resections.Two patients required conversion to open laparotomy. There were no deaths and only four complications (pneumonia 1, urinary tract infection 1, prolonged ileus 1, and subfascial abscess 1). The mean postoperative stay was 4.4 days (range 3–8 days) and the average interval for return to normal activity was 8 days.Laparoscopic-assisted colon resection appears to be a safe and beneficial option for many patients with pathologic disorders of the large intestine. Future clinical trials are needed to fully determine the appropriateness of this procedure in patients with localized malignancies.

Successful treatment of esophageal achalasia with laparoscopic Heller myotomy and Toupet fundoplication

BACKGROUND Recently, investigators have reported the use of endoscopic myotomy in the treatment of esophageal achalasia. As with the open operation, considerable disagreement exists regarding the appropriate length of the myotomy and the need for a concomitant antireflux procedure. METHODS Patients presenting with symptomatic achalasia between 1993 and 1997 were included in this prospective study. Preoperative studies included barium upper gastrointestinal study, endoscopy, and esophageal manometry. Laparoscopic myotomy was completed in all 20 patients; 18 had concomitant Toupet fundoplication. RESULTS Operative times ranged from 95 to 345 minutes (mean 216). Blood loss ranged from 50 to 300 cc (mean 100 cc). There were 7 minor complications (5 mucosal injuries repaired laparoscopically, 1 bile leak and 1 splenic capsular tear). Nine patients began a liquid diet on the first day postoperatively; 19 were tolerating liquids by postoperative day 3. Hospital stay ranged from 2 to 20 days (mean 5). Eighteen patients had complete relief of dysphagia, with less than one reflux episode per month. One individual continues to have mild persistent solid food dysphagia. Another patient initially did well but subsequently developed mild recurrent dysphagia and reflux. One patient required laparoscopic take-down of the wrap because of recurrent dysphagia and now has no problems swallowing, but does complain of mild reflux. Two other patients also have mild reflux, 1 of whom did not undergo fundoplication. CONCLUSIONS Laparoscopic Heller myotomy can be performed safely with excellent results in patients with achalasia. Adding a partial fundoplication appears to help control postoperative symptoms of reflux. This procedure should be considered the procedure of choice in patients with symptomatic esophageal achalasia.

Laparoscopic cholecystectomy and common bile duct stones : the utility of planned perioperative endoscopic retrograde cholangiography and sphincterotomy : experience with 63 patients

ObjectivePlanned perioperative endoscopic retrograde cholangiography (ERC) and sphincterotomy (ES) for suspected or proven common bile duct stones (CBDS) has been attempted in 63 of 540 consecutive patients undergoing laparoscopic cholecystectomy (LC). Experience with this intervention has been studied with respect to accuracy, efficacy, and safety. Summary Background DataThe optimal management of CBDSs in the era of LC is not defined. Methods exist for the laparoscopic manipulation of the common bile duct; however, experience is limited. Until surgeons become comfortable with this more demanding technique, ERG and ES will have a prominent role in the perioperative management of CBDSs. MethodsA preoperative group (n = 41) included all candidates for LC with historical, biochemical, or radiologic evidence of CBDSs. A postoperative LC group (n = 22) included patients with stones diagnosed by intraoperative cholangiogram (IOC) (n = 6) or with signs or symptoms of retained, but unproven, CBDSs (n = 16). ResultsThirty-six (88%) of the preoperative attempts were successful. Stones were identified in 18 cases and ES and duct clearance were achieved in all 18. In the postoperative group, ERC was successful in 21 (95%) cases. Calculi were demonstrated in 5 of 6 patients with a positive IOC and 6 of 16 with clinically suspected retained stones. ES and duct clearance were achieved in all 11 patients with documented CBDSs. Overall, ERC was accomplished in 90% of cases. Stones were identified in 51% of cases and all stones were cleared by ES. Morbidity was confined to four cases of self-limited pancreatitis (6%). There were no deaths. ConclusionsThe perioperative management of CBDSs is an appealing approach for patients anticipating the benefits of LC, at least until the laparoscopic manipulation of the common bile duct becomes a more widely accepted technique.

The increasing prevalence of acalculous cholecystitis in outpatients. Results of a 7-year study.

Acute acalculous cholecystitis (AAC) is a disease that causes high rates of morbidity such as those traditionally observed in the critically ill. Recently we noted an increase in the de novo presentation of outpatients with this disease. Our aim was to characterize this disease in outpatients, identify risk factors, and assess clinical outcome. Therefore a 7-year review of the Yale experience with AAC was undertaken. Forty-seven patients were identified. Seventy-seven per cent (36 of 47 patients) developed AAC at home without evidence of acute illness or trauma, while 23% (11 of 47 patients) developed the disease while hospitalized. Significant vascular disease was observed in 72% of outpatients. A 38% morbidity rate and 6% mortality rate were observed. We conclude that AAC occurs commonly in elderly male outpatients with vascular disease and that these patients incur significant morbidity in association with this condition. AAC should be suspected and prompt surgical management instituted when these patients present with an acute right upper quadrant inflammatory process.

Successful management of severe gastroesophageal reflux disease with laparoscopic nissen fundoplication

BACKGROUND Nissen fundoplication has been shown to be superior to medical treatment in the management of severe or complicated gastroesophageal reflux disease (GERD). Rapid advances in minimally invasive surgical technique and recognition of the advantages of reduced incision-related morbidity have fostered application of laparoscopic techniques to antireflux surgery. A prospective evaluation of 70 patients undergoing laparoscopic Nissen fundoplication for severe GERD was undertaken. PATIENTS AND METHODS Rigid selection criteria for laparoscopic Nissen fundoplication included severe or refractory disease with documentation of abnormal esophageal acid exposure by 24-hour pH probe monitoring, documentation of a mechanically defective lower esophageal sphincter by esophageal manometry, and absence of severe esophageal and/or gastric motility disorders. RESULTS Sixty-eight of 70 patients were completed laparoscopically with an intraoperative morbidity rate of 9%. Major postoperative complications occurred in 3 patients (4%) and included deep venous thrombosis (n = 1), delayed gastric leak (n = 1), and trocar site hernia (n = 1). The average hospital stay was 3.0 days, and the average time to return to normal activity was 7.0 days. All patients experienced relief of symptoms of reflux with mean follow-up of 7.7 months. Transient, mild dysphagia was experienced by 37% of patients, and persistent, severe dysphagia by 7%. The mean increase in lower esophageal sphincter pressure was 16.2 mm Hg. The total and intra-abdominal sphincter lengths increased an average of 1.5 and 1.4 cm, respectively. CONCLUSIONS These preliminary data suggest that laparoscopic Nissen fundoplication can be performed by experienced laparoscopic surgeons with excellent symptomatic and physiologic results and a morbidity rate comparable to conventional open antireflux procedures. Rigid patient selection criteria will help identify the patients most likely to benefit from reconstruction of a mechanically defective lower esophageal sphincter. Adherence to established operative principles for Nissen fundoplication will reduce the incidence of significant postfundoplication symptoms.