Manuel Trias

Energy Sources for Laparoscopic Colectomy: A Prospective Randomized Comparison of Conventional Electrosurgery, Bipolar Computer-Controlled Electrosurgery and Ultrasonic Dissection. Operative Outcome and Costs Analysis

The development of operative laparoscopic surgery is linked to advances in ancillary surgical instrumentation. Ultrasonic energy devices avoid the use of electricity and provide effective control of small to medium-sized vessels. Bipolar computercontrolled electrosurgical technology eliminates the disadvantages of electrical energy, and a mechanical blade adds a cutting action. This instrument can provide effective hemostasis of large vessels up to 7 mm. Such devices significantly increase the cost of laparoscopic procedures, however, and the amount of evidence-based information on this topic is surprisingly scarce. This study compared the effectiveness of three different energy sources on the laparoscopic performance of a left colectomy. The trial included 38 nonselected patients with a disease of the colon requiring an elective segmental left-sided colon resection. Patients were preoperatively randomized into three groups. Group I had electrosurgery; vascular dissection was performed entirely with an electrosurgery generator, and vessels were controlled with clips. Group II underwent computer-controlled bipolar electrosurgery; vascular and mesocolon section was completed by using the 10-mm Ligasure device alone. In group III, 5-mm ultrasonic shears (Harmonic Scalpel) were used for bowel dissection, vascular pedicle dissection, and mesocolon transection. The mesenteric vessel pedicle was controlled with an endostapler. Demographics (age, sex, body mass index, comorbidity, previous surgery and diagnoses requiring surgery) were recorded, as were surgical details (operative time, conversion, blood loss), additional disposable instruments (number of trocars, EndoGIA charges, and clip appliers), and clinical outcome. Intraoperative economic costs were also evaluated. End points of the trial were operative time and intraoperative blood loss, and an intention-to-treat principle was followed. The three groups were well matched for demographic and pathologic features. Surgical time was significantly longer in patients operated on with conventional electrosurgery vs the Harmonic Scalpel or computed-based bipolar energy devices. This finding correlated with a significant reduction in intraoperative blood loss. Conversion to other endoscopic techniques was more frequent in Group I; however, conversion to open surgery was similar in all three groups. No intraoperative accident related to the use of the specific device was observed in any group. Immediate outcome was similar in the three groups, without differences in morbidity, mortality, or hospital stay. Analysis of operative costs showed no significant differences between the three groups. High-energy power sources specifically adapted for endoscopic surgery reduce operative time and blood loss and may be considered cost-effective when left colectomy is used as a model.

Acute Phase is the Only Significantly Reduced Component of the Injury Response after Laparoscopic Cholecystectomy

AbstractThe objective demonstration of improved postoperative recovery suggests that the surgical injury response induced by the laparoscopic approach is less intense than that after open surgery. Twenty-five patients diagnosed as having noncomplicated gallstones were studied prospectively. They were operated by laparoscopy (group I, n = 12) or open surgery (group II, n = 13). Analgesia requirements (p < 0.026) and postoperative stay (p < 0.001) were significantly less in group I. Cholecystectomy performed by either technical options induced a significant increase over basal values of glucose, lactate, white blood cell count, prolactin, ACTH, cortisol, interleukin 6, C-reactive protein, and PCO2. Both surgical procedures induced a significant reduction of total proteins, albumin, prealbumin, free fatty acids hemoglobin, hematocrit, and pH. There were no differences between the levels of growth hormone, insulin, glucagon, or PO2 during any of the periods studied. Comparison of the results of the two cholecystectomy techniques showed that laparoscopic cholecystectomy induced a significantly less intense acute-phase response (area under the curve) of interleukin 6 (17 ± 17 versus 47 ± 26 pg/ml × hr × 102; p < 0.003), C-reactive protein (16 ± 12 versus 35 ± 16 mg/dl × hr × 10;np < 0.004), and prealbumin (16 ± 2.7 versus 13.8 ± 2.3 mg/dl × hr × 102; p < 0.05). The surgical injury response after laparoscopic cholecystectomy is similar to that after open cholecystectomy, but the acute-phase response component is less intense. This finding may be a consequence of the reduced size of the operative wound with laparoscopic cholecystectomy.

Endorectal ultrasonography in the follow-up of rectal cancer. Is it a better way to detect early local recurrence?

Abstract. After curative surgery for rectal cancer, diverse protocols are used in order to detect early possible local recurrence. Our objective was to compare the results obtained by the endorectal ultrasonography (EUS) with other means of assessment. From 1988 to 1995, 140 patients have undergone curative surgery for rectal cancer. The pathological and sonographic lesions were evaluated according to the TNM classification. In 21 patients a local recurrence was diagnosed: 5 of those 21 were corresponding to T 3 – 4, N 0 and 16 to T 2 – 4, N 1 stage. All 21 showed evidence of local recurrence by EUS examination, 14 by digital rectal examination, 16 by colonoscopy, 18 by computed tomography, and the carcinoembryonic antigen level was high in 13 cases. In 12 patient who were asymptomatic EUS was positive in 12, digital rectal examination in 5, computer tomography in 9, colonoscopy in 8, and the CEA was increased in 4. Re-resection was possible in 15 cases, 6 with curative approach and 9 palliative. These findings suggest that EUS in care accurate in the early detection of local recurrence compared to other means of assessment review of the. The limited number of patients studies. Main form of assessment required further evaluation.Résumé. Après un traitement chirurgical curatif dun cancer du rectum, divers protocoles sont utilisés dans le but de détecter le plus précocément possible une récidive. Le but de cette étude est de comparer les résultats obtenus par léchographie endo-rectale (EUS) avec ceux obtenus par dautres méthodes. Entre 1988 et 1995, 140 patients ont subi une résection curative dun cancer du rectum. Les lésions pathologiques et échographiques ont étéévaluées sur la base de la classification TNM. Chez 21 patients, une récidive locale a été diagnostiquée: 5 de ces 21 correspondaient à une stade T 3 – 4, N 0 et 16 à un stade de T 2 – 4, N 1. Les 21 patients présentaient des évidences de récidive locale à léchographie; 14 à lexamen digital, 16 à la colonoscopie, 18 au CT-Scan et 13 présentaient une élévation du taux dantigène carcinoembryonnaire. Chez 12 patients asymptomatiques, léchographie était positive à 12 reprises, le toucher rectal à 5 reprises, le CT-Scan chez 9, la colonoscopie chez 8, et un taux élevé de CEA chez 4. Une re-résection a été possible chez 15 patients 6 fois dans un but curatif et 9 fois dans un but palliatif. Ces constatations suggèrent que léchographie endo-anale est plus précise dans la détection précoce des récidives locales en comparaison aux autres techniques dévaluation. En raison du nombre limité de patients inclus dans cette étude, cet examen nécessite une évaluation plus extensive.

Endorectal ultrasonography in the follow-up of rectal cancer Is it a better way of to detect early local recurrence?

Abstract. After curative surgery for rectal cancer, diverse protocols are used in order to detect early possible local recurrence. Our objective was to compare the results obtained by the endorectal ultrasonography (EUS) with other means of assessment. From 1988 to 1995, 140 patients have undergone curative surgery for rectal cancer. The pathological and sonographic lesions were evaluated according to the TNM classification. In 21 patients a local recurrence was diagnosed: 5 of those 21 were corresponding to T 3 – 4, N 0 and 16 to T 2 – 4, N 1 stage. All 21 showed evidence of local recurrence by EUS examination, 14 by digital rectal examination, 16 by colonoscopy, 18 by computed tomography, and the carcinoembryonic antigen level was high in 13 cases. In 12 patient who were asymptomatic EUS was positive in 12, digital rectal examination in 5, computer tomography in 9, colonoscopy in 8, and the CEA was increased in 4. Re-resection was possible in 15 cases, 6 with curative approach and 9 palliative. These findings suggest that EUS in care accurate in the early detection of local recurrence compared to other means of assessment review of the. The limited number of patients studies. Main form of assessment required further evaluation.Résumé. Après un traitement chirurgical curatif dun cancer du rectum, divers protocoles sont utilisés dans le but de détecter le plus précocément possible une récidive. Le but de cette étude est de comparer les résultats obtenus par léchographie endo-rectale (EUS) avec ceux obtenus par dautres méthodes. Entre 1988 et 1995, 140 patients ont subi une résection curative dun cancer du rectum. Les lésions pathologiques et échographiques ont étéévaluées sur la base de la classification TNM. Chez 21 patients, une récidive locale a été diagnostiquée: 5 de ces 21 correspondaient à une stade T 3 – 4, N 0 et 16 à un stade de T 2 – 4, N 1. Les 21 patients présentaient des évidences de récidive locale à léchographie; 14 à lexamen digital, 16 à la colonoscopie, 18 au CT-Scan et 13 présentaient une élévation du taux dantigène carcinoembryonnaire. Chez 12 patients asymptomatiques, léchographie était positive à 12 reprises, le toucher rectal à 5 reprises, le CT-Scan chez 9, la colonoscopie chez 8, et un taux élevé de CEA chez 4. Une re-résection a été possible chez 15 patients 6 fois dans un but curatif et 9 fois dans un but palliatif. Ces constatations suggèrent que léchographie endo-anale est plus précise dans la détection précoce des récidives locales en comparaison aux autres techniques dévaluation. En raison du nombre limité de patients inclus dans cette étude, cet examen nécessite une évaluation plus extensive.

Endorectal ultrasonography in the follow-up of rectal cancer

Abstract. After curative surgery for rectal cancer, diverse protocols are used in order to detect early possible local recurrence. Our objective was to compare the results obtained by the endorectal ultrasonography (EUS) with other means of assessment. From 1988 to 1995, 140 patients have undergone curative surgery for rectal cancer. The pathological and sonographic lesions were evaluated according to the TNM classification. In 21 patients a local recurrence was diagnosed: 5 of those 21 were corresponding to T 3 – 4, N 0 and 16 to T 2 – 4, N 1 stage. All 21 showed evidence of local recurrence by EUS examination, 14 by digital rectal examination, 16 by colonoscopy, 18 by computed tomography, and the carcinoembryonic antigen level was high in 13 cases. In 12 patient who were asymptomatic EUS was positive in 12, digital rectal examination in 5, computer tomography in 9, colonoscopy in 8, and the CEA was increased in 4. Re-resection was possible in 15 cases, 6 with curative approach and 9 palliative. These findings suggest that EUS in care accurate in the early detection of local recurrence compared to other means of assessment review of the. The limited number of patients studies. Main form of assessment required further evaluation.Résumé. Après un traitement chirurgical curatif dun cancer du rectum, divers protocoles sont utilisés dans le but de détecter le plus précocément possible une récidive. Le but de cette étude est de comparer les résultats obtenus par léchographie endo-rectale (EUS) avec ceux obtenus par dautres méthodes. Entre 1988 et 1995, 140 patients ont subi une résection curative dun cancer du rectum. Les lésions pathologiques et échographiques ont étéévaluées sur la base de la classification TNM. Chez 21 patients, une récidive locale a été diagnostiquée: 5 de ces 21 correspondaient à une stade T 3 – 4, N 0 et 16 à un stade de T 2 – 4, N 1. Les 21 patients présentaient des évidences de récidive locale à léchographie; 14 à lexamen digital, 16 à la colonoscopie, 18 au CT-Scan et 13 présentaient une élévation du taux dantigène carcinoembryonnaire. Chez 12 patients asymptomatiques, léchographie était positive à 12 reprises, le toucher rectal à 5 reprises, le CT-Scan chez 9, la colonoscopie chez 8, et un taux élevé de CEA chez 4. Une re-résection a été possible chez 15 patients 6 fois dans un but curatif et 9 fois dans un but palliatif. Ces constatations suggèrent que léchographie endo-anale est plus précise dans la détection précoce des récidives locales en comparaison aux autres techniques dévaluation. En raison du nombre limité de patients inclus dans cette étude, cet examen nécessite une évaluation plus extensive.

Spleen: Hematological Disorders

The great advances in minimally invasive surgery (MIS) that have been made over the last two decades did also benefit patients suffering from hematological disease. It should be kept in mind that patients requiring splenectomy are usually elderly and frail, so a less invasive approach to their treatment may be an advantage. Laparoscopic splenectomy (LS) is mainly indicated for hematological disorders that are not associated with splenomegaly, such as idiopathic thrombocytopenic purpura (ITP) (Bellows and Sweeney, Expert Rev Med Devices 3:95–104, 2006; Park et al. Langenbecks J Surg 386:230–239, 2001; Habermalz et al. Surg Endosc 22(4):821–848, 2008). Intra-abdominal manipulation of bulky organs during laparoscopic surgery is technically challenging, and retrieval of the specimen may be difficult. Splenomegaly was initially considered a contraindication for LS. Many hematological diseases associated with an enlarged spleen are malignant conditions and were traditionally a domain for open splenectomy with its associated increased morbidity. Improvements and refinement of LS techniques have resulted in the ability to remove an enlarged spleen using a laparoscopic approach and preserving all the advantages of a minimally invasive approach (Weiss et al. Surg Innov 12:23–29, 2005; Nicholson et al. Surg Endosc 12:73–75, 1998; Terrosu et al. Surg Endosc 16:103–107, 2002; Todd et al. Am Surg 67:854–858, 2001; Kercher et al. Am J Surg 183:192–196, 2002; Patel et al. Ann Surg 238:235–240, 2003; Mahon and Rhodes Ann R Coll Surg Engl 85:248–251, 2003; Kaban et al. Surg Endosc 18:1340–1343, 2004; Targarona et al. Semin Laparosc Surg 11:185–190, 2004). However, a large spleen is associated with considerable technical demands. In addition, operative time is longer and the conversion rate higher than in the case of a normal-sized spleen. We describe our experience with laparoscopic splenectomy and how our technique evolved over the last few years.

Laparoscopic Approach for Treatment of a Posttraumatic Diaphragmatic Hernia

The laparoscopic approach for treatment of hiatal sliding or paraesophageal hernias is currently a widely accepted technique. We present a case of posttraumatic diaphragmatic hernia that was repaired by a laparoscopic approach using a stapled synthetic mesh. A 45-year-old male who suffered a blunt thoracic trauma 4 years earlier was diagnosed as having a posttraumatic diaphragmatic hernia. Laparoscopic exploration observed a defect in the central area of the left diaphragm. The defect measured 5 cm in diameter. A polypropylene mesh (10 × 8 cm) was fixed to the diaphragm with two rows of staples. The patient was discharged 72 h after surgery. A laparoscopic approach offers functional and cosmetic advantages in the treatment of diaphragmatic hernias.