Michael Ka-Wah Li

Laparoscopic resection for rectal cancers: lessons learned from 579 cases.

Objective:The aim of this study is to evaluate the short-term outcomes and long-term survival of laparoscopic rectal cancer resection at a single institution with 579 cases over a 15-year period. Summary Background Data:The use of laparoscopic resection for colon cancer has been shown to be safe with comparable oncological outcomes. However, the role of laparoscopic resection for rectal cancer is still controversial with few studies looking into long-term outcomes. Methods:From May 1992 to April 2007, 579 patients underwent laparoscopic resection for rectosigmoid and rectal cancer. The clinical data of these patients were retrospectively reviewed from a prospectively collected database. Data evaluated includes short- and long-term results, with survival outcomes calculated using the Kaplan-Meier method. Results:Over this 15-year period, 316 patients had laparoscopic anterior resection for rectosigmoid and upper rectal cancer, 152 patients had laparoscopic sphincter-saving total mesorectal excision, 92 patients had laparoscopic abdominoperineal resection, 17 patients had laparoscopic Hartmann procedure for rectal cancer, and 2 patients had proctocolectomy. The median age of these patients was 68 years (range, 35–95). The overall early and late operative morbidity was 18.8% and 9.7%, respectively. Conversion to open surgery was required in 5.4%of patients. Anastomotic leak rate was 3.5%. The median follow-up time was 56 months (range, 8–288). Port-site recurrence occurred in 2 patients. Locoregional recurrence occurred in 7.4% of patients after curative resection. The overall 5- and 10-year survivals for rectal cancer were 70% and 45.5%, respectively. The cancer-specific 5- and 10- year survival was 76% and 56%, respectively. Conclusions:The results of this study with large number of patients over a long follow-up period suggested that laparoscopic resection for rectal cancer is safe with good long-term oncological outcomes.

Double-blind, randomized trial comparing Harmonic Scalpel hemorrhoidectomy, bipolar scissors hemorrhoidectomy, and scissors excision: Ligation technique

AbstractPURPOSE: The aim of this study was to compare the outcome of patients receiving hemorrhoidectomy using Harmonic Scalpel™, bipolar scissors, and the conventional scissors excision–ligation technique. METHODS: Eighty-six patients with irreducible prolapsing piles were randomly assigned to receive 1) Milligan-Morgan hemorrhoidectomy using scissors excision–ligation technique or 2) bipolar scissors hemorrhoidectomy and Harmonic Scalpel™ hemorrhoidectomy. Neither the patient nor the independent assessor were aware of the technique used at operation. Patients were followed up at 4 and 12 weeks after operation. The measured outcomes included 1) operation time; 2) blood loss; 3) postoperative hospital stay; 4) pain score; 5) pain expectation score; 6) date of first bowel movement; 7) number of pethidine injections; 8) number of dologesic tablets taken; 9) time off work or normal activity; 10) wound healing; 11) satisfaction score; and 12) postoperative complications, including anal stenosis and fecal or flatus incontinence. RESULTS: There was no difference among the three groups in the operation time, hospital stay, pain expectation score, day of first bowel movement, number of dologesic tablets taken, time off work or normal activity, wound healing, and satisfaction score. The complication rate also did not differ in the three groups. Both Harmonic Scalpel™ hemorrhoidectomy and bipolar scissors hemorrhoidectomy were superior to Milligan-Morgan hemorrhoidectomy in terms of reduced blood loss. Harmonic Scalpel™ hemorrhoidectomy had the best pain score when compared with bipolar scissors hemorrhoidectomy and Milligan-Morgan hemorrhoidectomy, and patients required significantly less pethidine injection after Harmonic Scalpel™ hemorrhoidectomy than after Milligan-Morgan hemorrhoidectomy. Although the time required to return to work or normal activity remained similar, patients after Harmonic Scalpel™ hemorrhoidectomy had the best satisfaction score among the three groups. CONCLUSION: The study shows that Harmonic Scalpel™ hemorrhoidectomy is as good as bipolar scissors hemorrhoidectomy in terms of reduced blood loss but is superior because it is associated with less postoperative pain and hence, better patient satisfaction. However, these observed benefits are small, and the time off work or normal activity remains similar.

Routine use of laparoscopic repair for perforated peptic ulcer

Laparoscopic repair of perforated peptic ulcer was reported in 1990 but has not gained wide acceptance. The aim of this study was to evaluate the safety and efficacy of laparoscopic repair for perforated peptic ulcer in routine clinical practice.

a Double-blind, Randomized Trial Comparing Ligasuretm and Harmonic Scalpeltm Hemorrhoidectomy

PURPOSEThe major problem after hemorrhoidectomy is postoperative pain. New techniques have been evolved to circumvent this problem. The present study was conducted to compare the outcomes of LigasureTM hemorrhoidectomy and Harmonic ScalpelTM hemorrhoidectomy.METHODSThis study was a double-blind, randomized controlled trial. Patients with Grade 3 and 4 hemorrhoids admitted for hemorrhoidectomy were selected and randomized into two groups: 1) LigasureTM hemorrhoidectomy or 2) Harmonic ScalpelTM hemorrhoidectomy. The primary outcomes measured were the analgesic requirement and the postoperative pain score (assessed by an independent assessor). Secondary outcome criteria included the operating time, blood loss, hospital stay, patient satisfaction score, and early and late complications.RESULTSForty-nine patients were randomized into two groups (LigaSureT 24, Harmonic ScalpelT 25). Two patients were lost to follow-up, leaving 47 patients (LigaSureT 24, Harmonic ScalpelT 23) available for final analysis. The age and gender distribution were comparable. The postoperative pain score (median 2.6 vs. 4.8, P < 0.001) and postoperative oral analgesic (Dologesicreg) requirement (median 5 vs. 13, P = 0.001) were significantly less in the LigaSureT group. The operating time (median 11 vs. 18 minutes, P < 0.001) was significantly less in the LigaSureT group. The hospital stay, patient satisfaction score, percentage of patients requiring pethidine injection, percentage of patients with first bowel movement on or before the first postoperative day, and complication rates were similar between the two groups.CONCLUSIONSLigasureTM hemorrhoidectomy reduces the postoperative pain and operating time compared to the Harmonic ScalpelTM hemorrhoidectomy. It is a safe, effective procedure for treating Grade 3 and 4 hemorrhoids

Prospective evaluation of laparoscopic total mesorectal excision with colonic J-pouch reconstruction for mid and low rectal cancers

Results of laparoscopic sphincter‐preserving total mesorectal excision and colonic J‐pouch reconstruction are few. The aim of this study was to examine outcomes after this procedure.

Laparoscopy and its current role in the management of colorectal disease.

Objective  To evaluate the current place of laparoscopy in the management of colorectal disease.

Laparoscopy versus open left lateral segmentectomy for recurrent pyogenic cholangitis

Background:Recurrent pyogenic cholangitis (RPC) is a common disease in Southeast Asia. Its classical presentation is repeated attacks of cholangitis with multiple recurrences of bile duct stones. The stones are commonly located in the left lateral segments (2 and 3) and therefore complete clearance is difficult to achieve by either endoscopic retrograde cholangiopancreatography or surgical exploration of the common bile duct. The definitive treatment usually involves resection of the stone-harboring segments. The recent advent in laparoscopic surgery has shown that hand-assisted laparoscopic segmentectomy is a safe and feasible, alternative. This study aimed to compare hand-assisted laparoscopic segmentectomy with open segmentectomy in patients with recurrent, RPC.Methods:This study retrospectively reviewed a prospectively maintained database of both open and laparoscopic treatments for RPC in a single center between 1994 and 2004. During this period, patients with RPC and left intrahepatic (segments 2 and 3) ductal stones not amendable to endoscopic treatment were recruited for analysis. Patients with concomitant gallbladder stones and common bile duct stones were offered left lateral segmentectomy with cholecystectomy and exploration of the common bile duct. Selected patients would have choledochoduodenostomy drainage during the same operation. The operations were performed via either the hand-assisted laparoscopic approach or the open approach using an ultrasonic surgical aspirator. The two cohorts were compared with respect to perioperative parameters to determine whether there would be any advantage in attempting hand-assisted laparoscopic segmentectomy.Results:During the study period from 1994 to 2004, 17 patients underwent left lateral segmentectomy for RPC. Of the 17 patients, 10 had hand-assisted laparoscopic resections, and 7 underwent open resections. All open resections were performed before 1999. Despite the small number of patients and potential type 2 error, there were no differences in age, sex distribution, number of cholangitic attacks, sessions of endoscopic retrograde cholangiopancreatography before surgery, or number of previous operation between the two groups. The median operating time was shorter in the open group (232.5 vs 150 min; p = 0.007), whereas the median blood loss was similar (350 vs 400 ml; p = 0.551). The median postoperative stay was 8 days for hand-assisted laparoscopic group versus 14 days for the open group. This difference was statistically significant (p = 0.019). There was one open conversion in the hand-assisted laparoscopic group because of intraoperative bleeding from the left hepatic vein. Postoperative complication rates were lower in hand-assisted laparoscopic group, but the difference was not statistically significant (20% vs 57%; p = 126). The intramuscular pethidine requirement again was less in hand-assisted laparoscopic group (0 vs 600 mg; p = 0.002). There was no operative mortality in either group of patients. No recurrent cholangitis was noted in either groups during the median follow-up period of more than 3 years.Conclusion:This study not only confirmed the feasibility of hand-assisted laparoscopic segmentectomy for recurrent pyogenic cholangitis, but also showed that this treatment approach is associated with less pain and shorter hospital stay. However, hand-assisted laparoscopic segmentectomy is a lengthier operation and technically more challenging. Nevertheless, the authors believe that with more experience and further improvement of ancillary technology, this procedure can become a standard treatment for recurrent pyogenic cholangitis in selected cases.

Laparoscopic abdominoperineal resection revisited: are there any health–related benefits? A comparative study

BackgroundLaparoscopic colectomy is associated with less overall morbidity and improved survival for patients with colonic cancers. There are unfortunately limited clinical reports on laparoscopic abdominoperineal resection. We therefore designed this study to compare laparoscopic abdominoperineal resection with conventional open surgery, with emphasis on health–related issues from the patients’ perspective in order to justify its role in the management of low rectal or anal canal tumours.MethodsWe carried out a non–randomized, prospective comparative study on a cohort of patients who underwent either laparoscopic or open abdominoperineal resection between March 1994 and December 2003. Patient demographics, tumour characteristics, operative morbidity and mortality, as well as overall survival were considered. The standard endpoints of last follow–up date and deaths were used. Data was analyzed according to intention–to–treat principle.ResultsA total of 102 patients were recruited: 31 patients underwent conventional open abdominoperineal resection (OAPR) and 71 patients were treated laparoscopically. Patient demographics, median follow–up period, as well as tumour characteristics were similar between groups. The median operating time was similar among groups (145 min in laparoscopic group vs. 156 min in open group; p=0.62). Patients in the laparoscopic group had significantly less blood loss (p=0.01) and fewer requirements for blood transfusion (p=0.01). Despite similar overall morbidity, the laparoscopic group had a reduced incidence of abdominal wound infections (p=0.01) and chest infections (p=0.01). Overall survival was significantly better in the laparoscopic group (p=0.01).ConclusionsLaparoscopic abdominoperineal resection confers definite health–related benefits the over open approach in terms of reduced septic complications and fewer requirements for blood transfusion. It should be considered the procedure of choice for patients with low rectal or anal canal tumour in whom sphincter excision proved inevitable.

Hand-assisted laparoscopic segmentectomy in recurrent pyogenic cholangitis

Recurrent pyogenic cholangitis (RPC) is a prevalent disease in Southeast Asia and presents a unique challenge to both gastroenterologist and hepatobiliary surgeon. Despite rapid development in endoscopic instrumentation and skill maturation, it is still difficult to clear those pigmented stones lodged in the intrahepatic ducts. The alternative approach to stones through the percutaneous transhepatic route can offer access for repeated ductal dilatation and lithotripsy. However, recurrence is still commonly seen. Resection of the atrophic stone-harboring segment has proven to be an effective treatment option associated with the lowest recurrence rate. Compared to the other technique, it is the only treatment that can potentially offer a cure. The complication rate is higher because of existing bacterial colonization and access trauma. With the accumulation of laparoscopic experience and improved instrumentation, laparoscopic liver resection is demonstrated to be safe and feasible for either benign or malignant conditions. This article reviews a single-center experience of hand-assisted laparoscopic segmentectomy (HALS) in patients with RPC.

Laparoscopic choledochoduodenostomy: an effective drainage procedure for recurrent pyogenic cholangitis.

Background: This article reports the technical aspects of laparoscopic choledochoduodenostomy (LCD) in patients with recurrent pyogenic cholangitis (RPC) and the perioperative results are also evaluated. This is a retrospective review of a prospectively maintained database. Methods: Twelve patients diagnosed to have RPC with the absence of intrahepatic stricture were selected for LCD during the period from 1995 to 2002. The majority of our patients had repeated attacks of cholangitis and had already undergone multiple sessions of endoscopic and operative lithotripsy. The LCD was performed using a five-port approach with the patient lying in the supine position. The stones were first cleared through the longitudinal supraduodenal choledochotomy followed by construction of a side-to-side diamond-shaped anastomosis of at least 15 mm between the bile duct and the first part of the duodenum using 2/0 monocryl in the single-layer method. Results: During the period from 1995 to 2002, 12 patients with RPC underwent LCD. There were 3 male and 9 female patients with a mean age of 62 (40–77). The median operation time was 137.5 min (90–270) and the median postoperative stay was 7.5 days (5–20). All cases were successful using the laparoscopic approach. Average analgesic requirement post operation was 126 mg (50–200 mg) intramuscular pethidine. There was one postoperative bile leak, and this complication was settled by conservative measures. Upon a mean follow-up of 37.6 months (6–91), there was no recurrent attack of cholangitis or any evidence of sump syndrome in this group of patients. Conclusion: LCD is a safe and effective drainage procedure for patients with RPC. Complications are uncommon and postoperative results are promising.