M. Trías

Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bileduct calculi in high-risk patients

BACKGROUND Morbidity and mortality after surgical treatment of bileduct stones increase with age and associated diseases. A proposed alternative therapy is endoscopic sphincterotomy (ES) with the gallbladder left in situ, and we elected to compare this option with standard open surgery in high-risk patients. METHODS 98 patients (mean age 80 years) with symptoms likely to be due to bileduct stones or a recent episode of biliary pancreatitis were randomised to be treated either by open cholecystectomy with operative cholangiography and (if necessary) bileduct exploration (n=48) or by endoscopic sphincterotomy alone (n=50). FINDINGS The procedure was accomplished successfully in 94% of the surgery group and 88% of the ES group, and there were no significant differences in immediate morbidity (23% vs 16%) or mortality (4% vs 6%). During mean follow-up of 17 months biliary symptoms recurred in three surgical patients, none of whom underwent repeat surgery, and in 10 ES patients, seven of whom had biliary surgery. By multivariate regression analysis endoscopic sphincterotomy was an independent predictor of recurrent biliary symptoms (odds ratio 6.9; 95% Cl 1.46 to 32.54). INTERPRETATION In elderly or high-risk patients, surgery is preferable to endoscopic sphincterotomy with the gallbladder left in situ as a definitive treatment for bileduct stones or non-severe biliary pancreatitis.

Apolipoprotein E polymorphism and gallstones

BACKGROUND & AIMS Apolipoprotein (apo) E is a genetically polymorphic protein influencing lipoprotein metabolism and the risk of both atherosclerosis and Alzheimers disease. As opposed to common apo E3, apo E2 decreases and apo E4 increases hepatic lipoprotein uptake; hence, apo E4 could promote gallstone formation by increasing hepatic and biliary cholesterol concentrations. This study was designed to evaluate whether apo E polymorphism is related to gallstone risk. METHODS apo E phenotype was determined in subjects older than 40 years of age (160 with and 125 without gallstones) and in 61 patients with cholesterol gallstones who underwent cholecystectomy. Bile composition, nucleation time, and gallstone features were analyzed in surgical patients. RESULTS The E4/3 phenotype was enriched in both patients with gallstones and those who underwent cholecystectomy, with significantly (P < 0.006) higher epsilon 4 allele frequencies than in gallstone-free subjects (odds ratio, 2.67 [95% confidence limits, 1.23-5.93] and 3.62 [95% confidence limits, 1.49-8.91], respectively); women, but not men, accounted for these differences. The prevalence of the epsilon 4 allele increased with age in patients with gallstones, whereas the opposite occurred in gallstone-free subjects. Biliary lipid and gallstone cholesterol content tended to increase in the sequence E4 > E3 > E2 in patients who underwent cholecystectomy. CONCLUSIONS Carrying the apo E4 isoform is a genetic risk factor for cholelithiasis in humans, thus adding another adverse effect of apo E polymorphism on health.

Cancer dissemination during laparoscopic surgery: tubes, gas, and cells.

Abstract. Port-site metastasis has been an unexpected finding after laparoscopic surgery in gastrointestinal cancer patients. No clear explanation exists for this phenomenom. The aims of this study were to evaluate the dissemination pattern in an experimental model of hepatocarcinoma in the rat and summarize current knowledge about the risks and the results of experimental studies on cancer dissemination during laparoscopic surgery. NDA-induced hepatocarcinoma was obtained in Sprague-Dawley rats. Tumors were manipulated during laparoscopy (group 1,n= 11) or laparotomy (group 2, n= 12). A Medline review of all experimental studies about the risk of cancer dissemination during laparoscopic surgery was undertaken. Both models were associated with implants in parietal wounds [1/11 in group 1 (9%) vs. 1/12 in group 2 (8%), p= NS]. Analysis of the current literature confirms that laparoscopy is associated with abdominal cell mobilization, and cells can be recovered in trocars, filtered exhaust gas, and instruments. Postoperative immunosuppression, the biologic aggressiveness of the tumor, and the gas used for laparoscopy also influence tumoral growth. Port-site metastases are secondary to multiple factors, including the technical skill of the surgeon, the biologic properties of the tumors, and local environmental aspects. Undoubtedly, laparoscopy can help disseminate aggressive tumors and should be reserved for diagnostic and staging procedures or for treatment of low-grade malignant tumors. Therapeutic resection, especially of colon cancer, should be restricted to prospective and randomized trials until there are enough hard data to rule out the clinical importance of this potentially severe complication.

Laparoscopic surgery for splenic disorders

Abstract. Laparoscopic splenectomy (LS) has recently been gaining acceptance as an alternative to open splenectomy. However, several aspects, such as learning curve, residual splenic function, and management of large spleens, remain controversial. In this paper we present the analysis of technical details and immediate and late outcome of a consecutive series of 64 cases of splenic disorders approached by laparoscopy. Between Feb-1993 and April-1997, 64 patients with a wide range of splenic disorders were treated by laparoscopy, and prospectively recorded. Age, body mass index, operative time, number of trocars, perioperative transfusion, spleen weight, conversion rate, mode of spleen retrieval (bag or accessory incision), postoperative analgesia, stay and morbidity were analyzed. Late failures after LS were reevaluated with 99mTc-heat-damaged red blood cells scintigraphy and CT. LS was performed in 61 patients, and two cases with splenic cyst and one splenic artery aneurysm received a laparoscopic partial cystectomy and aneurysmectomy. LS was performed through an anterior approach in 12 patients and laterally in 49. Conversion rate was 6.5%. Accessory spleens were found in 7 patients (7/61, 11.5%). Morbidity was 16%. There was no correlation between the weight of the spleen, platelet count or obesity with operative time. A lateral approach was associated with a decrease in operative time (p < 0.002), postoperative stay (p < 0.001), transfusion (p < 0.04) and number of trocars (p < 0.001). Operative time was significantly longer in large spleens (>1000 gr) (p < 0.001). However, there were no differences in transfusion rate, stay, morbidity or conversion rate. After a follow up of 12 m, 10 patients revealed a low platelet count. Scintigraphy showed residual splenic tissue in 3 (ITP). A wide range of splenic disorders can be treated by laparoscopy, including enlarged spleens. This technique should be continually audited, but initial results reflect the approachs safety and advantages provided that great technical care is taken and an exhaustive search for accessory spleens is conducted.

Peritoneal response to a septic challenge. Comparison between open laparotomy, pneumoperitoneum laparoscopy, and wall lift laparoscopy.

AbstractBackground: Laparoscopic surgery has a lower incidence of surgical infection than open surgery. Differential factors that may modify the bacterial biology and explain this finding to some extent include CO2 atmosphere, less desiccation of intraabdominal structures, fewer temperature changes, and a better preserved peritoneal and systemic immune response. Previous data suggest that the immune response and acute phase response are better preserved after laparoscopy. Therefore, we designed a study to evaluate the early peritoneal response to sepsis in an experimental peritonitis model comparing open surgery with CO2 and abdominal wall lift laparoscopy. Methods: The study subjects comprised 360 mice distributed into the following four groups: group 1, n= 72 (controls); group 2, n= 96 (open surgery), 2–3 cm laparotomy, with abdominal cavity exposed to the air for 30 min; group 3, n= 96, CO2 laparoscopy (5 mmHg pneumoperitoneum) for 30 min; group 4, n= 96, wall lift laparoscopy for 30 min. Intraabdominal contamination in the four groups was induced with 1 ml of E. coli suspension (1 × 104 CFU/ml) 10 min before abdomen closure. Peritoneal fluid and blood samples were obtained 1.5, 3, 24, and 72 h after surgery, and TNF, IL-1, and IL-6 were measured (via ELISA), as well as quantitative culture. Results: The number of CFU (colony-forming units) obtained in peritoneal fluid and positive blood culture rates were significantly lower in the laparoscopic groups than in the open group. IL-1 peritoneal levels were significantly lower after 24 h and 72 h in the laparoscopy groups. IL-6 levels decreased sharply in the laparoscopy groups at 24 h and 72 h. There were no differences between the two types of laparoscopy models (CO2 and wall lift). Conclusions: Peritoneal response to sepsis is better preserved after laparoscopy than after open surgery. CO2 does not seem to influence bacterial growth. According to these findings, laparoscopy entails less local trauma and better preserved intraabdominal conditions.

Laparoscopic splenectomy: an evolving technique

AbstractBackground: The success of laparoscopic cholecystectomy has favored the application of this technique in abdominal surgery. Laparoscopic splenectomy (LS) suffers from several technical problems for mobilization and manipulation of a solid organ. Lateral approach has been proposed as an alternative to the anterior approach which facilitates LS. The aim of this paper is to compare the results of LS using and anterior or lateral approach. Methods: Between February 1993 and May 1995, 27 LS were performed (group I, Ant-LS, n: 10; group II, Lat-SL, n: 17). LS was indicated in 19 patients for treatment of an idiopathic purpura, for spherocytosis in four; for AIDS-related thrombocytopenia in two; and for autoimmune anemia and leucopenia in two. Gallstones were associated in two cases and an ovarian cyst in another. Results: LS was completed in 8 patients of group I (80%) and 17 of group II (100%). Operative time (236±21 min vs 159±71 min p<0.003), number of trocars (4.5±0.5 vs 4±0.5, p<0.02), transfusion requirements (60 vs 17%, p<0.04) and mean stay (6.5±3.6 days vs 4±2 days, p<0.05) were significantly lower in the group of LS with a lateral approach. Conclusions: The lateral approach significantly facilitates the performance of LS compared with the anterior approach.

Laparoscopic resection of a retroperitoneal cystic lymphangioma

The success of laparoscopic cholecystectomy has expanded the scope of laparoscopic procedures and resection of retroperitoneal organs and selected cystic intraadominal masses have been performed by minimally invasive surgical techniques. We report the case of a 45-year-old that presented a retroperitoneal cystic lymphangioma that was successfully excised by a laparoscopic approach. Laparoscopic surgical techniques should be considered for treatment of selected cystic lesions of intrabdominal or retroperitoneal origin.

Mirizzi's syndrome : Diagnostic and therapeutic controversies in the laparoscopic era

AbstractBackground: Mirizzis syndrome (MS) is an unusual cause of obstructive jaundice. It can mimic bile duct cancer, and the role of laparoscopic surgery is not well defined. The aim of this paper is to report five cases and describe the pitfalls encountered in its diagnosis and treatment with a laparoscopic approach. Methods: From January 1992 to January 1996, five cases of MS out of 560 patients with gallstones prospectively treated and recorded were found (0.9%). Results: There were two men and three women, (mean age: 54 years [30–93]). In one case diagnosis of bile duct carcinoma was established but surgery revealed MS. Four cases were approached by laparoscopy, but all of them were converted: in two, due to a distorted anatomy, in a third due in the difficulty of visualizing the distal end of the bile duct, and in the last case due to the impossibility of retrieving the stones. All were treated with a cholecochorrhaphy over a T tube, except one, in which a hepaticojejunostomy was performed. Morbidity and mortality were nil, and they remain asymptomatic after a mean follow-up of 19 months (3–36). Conclusions: MS constitutes an important laparoscopic challenge, both to clearance of duct stones and to the proper reconstruction of the biliary duct. A prudent policy is to perform a dissection trial and convert if local conditions are not clear for an experienced laparoscopic surgeon.

Laparoscopic sleeve gastrectomy in patients over 60 years: impact of age on weight loss and co-morbidity improvement

BACKGROUND Advanced age has traditionally been considered a relative contraindication to bariatric surgery due to increased perioperative risk and less weight loss. However, it is now being reconsidered in older patients after encouraging results in recent series and the increasing life expectancy. We compared operative and postoperative outcomes of laparoscopic sleeve gastrectomy in patients over 60 years with outcomes in younger patients. We also, analyzed the effect of bariatric surgery on improvement and resolution of co-morbidities in the older group. METHODS From November 2008 to November 2013, 130 patients underwent laparoscopic sleeve gastrectomy. Of these, 28 patients (21.5%) were 60 years or older. Outcomes in terms of perioperative complications, short-term and medium-term weight loss, remission or improvement of co-morbidities and medication requirements were extracted from our prospective database. RESULTS Short-term mortality was 0% and 30-day complication rate was similar in both groups (17.9% versus 17.6% according to Clavien-Dindo classification). At 12 months postsurgery, older patients had lost 49% percent of excess weight compared to 60% in the younger group (P = 0.012). At 2 years, the results were 45% versus 60%, respectively, with P = 0.015. At least 1 major co-morbidity improved in 65.2% of older patients. Before surgery, the older group took an average of 4.3 medications compared to 2.7 at 1 year after surgery (P<0.001). CONCLUSION Laparoscopic sleeve gastrectomy is a safe and effective treatment for morbid obesity in people over 60 years, although younger patients show greater weight loss. Daily medication requirements and co-morbidities decrease significantly in older patients after this procedure.

Unsuspected carcinoma of the gallbladder

Laparoscopic cholecystectomy is the treatment of choice for gallstones. A formal contraindication is gallbladder cancer. However, in a great number of cases, this is a previously unsuspected intraoperative finding, and sometimes its first appearance is in acute cholecystitis. We present the case of 67-year-old woman, which presented an unsuspected carcinoma of the gallbladder that developed abdominal wall implants at the umbilical and left hypocondrium site. The success of LC favors the observation of cases similar to that described in this article. Surgeons who operate using laparoscopic techniques should bear this possibility in mind and practice an extemporaneous biopsy at the slightest suspicion of malignancy, and, if it is confirmed, the operation should be continued as an open one.