Pieter A. Seshadri

Defining a learning curve for laparoscopic colorectal resections.

PURPOSE: The purpose of this review was to define the learning curve for laparoscopic colorectal resections. METHODS: A prospectively accumulated, computerized database of all laparoscopic colorectal resections performed by three surgeons between April 1991 and March 1999 was reviewed. RESULTS: A total of 461 consecutive resections were evenly distributed among three surgeons (141, 155, and 165). Median operating time was 180 minutes for Cases 1 to 30 in each surgeons experience and declined to a steady state (150–167.5 minutes) for Cases 31 and higher. Subsequently, Cases 1 to 30 were considered “early experience,” whereas Cases 31 and higher were combined as “late experience” for statistical analysis. There were no significant differences between patients undergoing resections in the early experience and those undergoing resections in the late experience with respect to age, weight, or proportion of patients with malignancy, diverticulitis, or inflammatory bowel disease. There were greater proportions of males (42vs. 54 percent,P=0.046) and rectal resections performed (14vs. 32 percent,P=0.002) in the late experience. Trends toward declining rates of intraoperative complications (9vs. 7 percent,P=0.70) and conversion to open surgery (13.5vs. 9.7 percent,P=0.39) were observed with experience. Median operating time (180vs. 160 minutes,P<0.001) and overall length of postoperative hospital stay (6.5vs. 5 days,P<0.001) declined significantly with experience. There was no difference in the rate of postoperative complications between early and late experience (30vs. 32 percent,P=0.827). CONCLUSIONS: The learning curve for performing colorectal resections was approximately 30 procedures in this study, based on a decline in operating time, intraoperative complications, and conversion rate. Learning was also extended to clinical care because it was appreciated that patients could be discharged to their homes more quickly.

Does a laparoscopic approach to total abdominal colectomy and proctocolectomy offer advantages

BackgroundControversy exists regarding the feasibility, safety, and outcomes of laparoscopic total abdominal colectomy (LTAC) and laparoscopic total proctocolectomy (LTPC). The object of this study was to assess the outcomes of LTAC and LTPC and compare them with those of institutional open procedure used as controls.MethodsPerioperative data and surgical outcomes of patients who underwent TAC or TPC were analyzed and compared retrospectively at a single institution between 1991 and 1999.ResultsA total of 73 TACs performed during a 9-year period were evenly distributed between laparoscopic (n=37) and open (n=36) approaches. There were no significant differences between patient groups with respect to genders, age, weight, proportion of patients with inflammatory bowel disease, and the number of patients undergoing ileorectal anastomosis. The median operative time was longer with the laparoscopic method (270 vs 178 min; p=0.001), but the median length of hospital stay was significantly shorter (6 vs 9 days; p=0.001). The short-term postoperative complication rate up to 30 days from surgery was not statistically different (25% vs 44%; p=0.137), although there was a clear trend toward a reduced number of overall complications in the laparoscopic group (9 vs 24). Wound complications were significantly fewer (0% vs 19%; p=0.015) and postoperative pneumonia was nonexistent in laparoscopic patients. Long-term complications also were less common in the laparoscopic group (20% vs 64%; p=0.002), largely because of reduced incidence of impotence, incisional hernia, and ileostomy complications. Total proctocolectomy was performed laparoscopically in 15 patients and with an open procedure in 13 patients over the same period. There were no statistically significant differences between the two groups with respect to gender, age, weight, and diagnosis. Median operating time was longer for the laparoscopic patients (400 vs 235 min; p=0.001), whereas the length of hospital stay, morbidity, and mortality were not significantly different.ConclusionsThe results indicate that LTAC can be performed safely with a statistically significant reduction in wound and long-term postoperative complications, as compared with its open counterpart. Operating time is increased, but there is a marked reduction in length of hospital stay. Preliminary results demonstrate that LTPC also is technically feasible and safe, with equal morbidity, mortality, and hospital stay, as compared with open procedures. Studies with larger numbers of patients and a randomized controlled trial giving special attention to patient quality-of-life issues are needed to elucidate the real advantages of this minimally invasive technique.

Determinants of outcomes in laparoscopic colorectal surgery: a multiple regression analysis of 416 resections.

AbstractBackground: To date, most large series of laparoscopic colorectal procedures have been descriptive reports that do not account for the potentially complex interaction of outcome predictors. The purpose of this study was to identify the preoperative factors that predict operative time, conversion to open surgery, and intraoperative and postoperative complications in laparoscopic colorectal surgery. Methods: Multiple regression techniques were used to analyze 416 laparoscopic resections from a prospective database of laparoscopic colorectal procedures performed between April 1991 and April 1998. The preoperative factors considered were patient-specific (age, gender, weight) or disease-specific (diagnosis of cancer, Crohns disease, diverticulitis, fistula). Surgical experience of ≤50 cases was also considered. Finally, all resections were represented by a combination of the following five procedure components: resections of the (a) hepatic flexure, (b) splenic flexure, (c) sigmoid, and (d) rectum, or (e) a perineal dissection. Results: Patient weight, Crohns disease, and each of the five individual procedure components incrementally lengthened operative time. Conversion to open surgery was influenced by the patients weight, malignancy, and early experience of the surgeon. The risk of a postoperative complication was increased by the patients age, resection of the perineum, and the presence of a fistula. No factors significantly influenced the risk of an intraoperative complication. Conclusions: Several preoperative factors that significantly affect outcomes in laparoscopic colorectal resections have been identified. Consideration of these factors may help in case selection and estimation of operating time; they should also be valuable when patients are informed of their risk of conversion and complications.

Predicting conversion to open surgery in laparoscopic colorectal resections A simple clinical model

AbstractObjective: The objective of this study was to develop a simple model for clinical use in predicting the individual risk of conversion to open surgery in patients undergoing laparoscopic colorectal resections. Methods: A multiple logistic regression analysis of 367 laparoscopic colorectal resections completed between 1991 and 1998 was performed. The following 13 factors were considered: patient-specific factors (age, gender, weight levels less than 60 kg 60–90 kg, 90 kg or more), disease-specific factors (Crohns disease, diverticulitis, malignancy, fistula), and procedure-specific factors (resection of the hepatic flexure, splenic flexure, sigmoid, rectum, perineum, experience with less than 50 cases). A scoring system was developed on the basis of the three factors found to be predictive of the risk for conversion to open surgery: diagnosis of malignancy (odds ratio 3.23; p= 0.0037; one point), surgeon experience with 50 cases or less (odds ratio 2.26; p= 0.0363; one point), and weight level (odds ratio 3.42; p= 0.005; 60 to 90 kg, one point, 90 kg or more, two points). Results: The predicted conversion rates for the cumulative scores of 0 to 4 points were 1.1%, 3.3%, 9.8%, 25.4%, and 49.7%, respectively. No significant difference was found between predicted and actual conversion rates, indicating a good fit of the model (chi square = 1.774; p > 0.5). Conclusions: This novel scoring system is simple, accurate, and readily applicable in an office setting. It represents the large experience of one surgical group and remains to be validated by other centers.

Local recurrence and survival after laparoscopic mesorectal resection for rectal adenocarcinoma

BackgroundLaparoscopic resection for rectal cancer is controversial. Actuarial survival and local recurrence rates have not been determined.MethodsA prospective database containing 80 consecutive unselected laparoscopic resections of rectal cancers performed between November 1991 and 1999 was reviewed. Local recurrence was defined as any detectable local disease at follow-up assessment occurring either alone or in conjunction with generalized recurrence. The tumor node metastases (TNM) classification for colorectal cancers and the Kaplan-Meier method were used to determine staging and survival curves. The mesorectal excision technique was used during surgery.ResultsThe median follow-up period was 31 months for patients with stages, I, II, and III cancer, and 15.5 months for patients with stage IV cancer. The overall 5-year survival rate was 65.1% for all cancer stages and 72.1% for stages I, II, and III cancer. No trocar-site recurrence was observed. The overall local recurrence rate was 3.75% (3/80) for all cancer stages, and 4.3% (3/70) for stages I, II, and III cancer.ConclusionsThe survival and local recurrence rate for patients with rectal cancer treated by laparoscopic mesorectal excision do not differ negatively from those in the literature for open mesorectal excision. Further validation is needed.

Cimetidine in the treatment of interstitial cystitis

OBJECTIVES To assess the effect of the H2-antagonist cimetidine in the treatment of patients with interstitial cystitis (IC) refractory to other conservative therapies. METHODS A group of 9 patients previously treated conservatively for IC without success were entered in the study. They were thoroughly investigated and treated with cimetidine at the dose of 300 mg orally twice a day for 1 month. RESULTS Six of the 9 patients (66%) experienced various degrees of symptomatic relief while on the drug. Of these, 4 (44%) have noted a complete and sustained response to the medication. CONCLUSIONS The encouraging results observed in this pilot study together with the simplicity and tolerance of the treatment makes it an alternative when other options have been exhausted. Its use as a first-line monotherapy remains speculative.

Needlescopic surgery. A logical evolution from conventional laparoscopic surgery.

Background: The purpose of this study was to analyze the safety and feasibility of needlescopic surgery and to compare the short-term outcomes relative to conventional laparoscopic surgery. Methods: Needlescopic surgery patients were compared to matched cohorts of conventional laparoscopic surgery patients from the same prospective database for a variety of selected procedures. Results: A total of 101 needlescopic procedures were analyzed (30 cholecystectomy, 28 Nissen fundoplication, 12 bilateral sympathectomy, 10 splenectomy, 10 Heller myotomy, three adrenalectomy, two colon resection, two splenic cyst excision, four other). There was no significant difference between the needlescopic and conventional laparoscopic groups in conversion rates, morbidity, or mortality. A higher proportion of patients were in hospital <24 h for needlescopic splenectomies (40% vs 0%, p = 0.087), fundoplications (68% vs 42%, p = 0.107), and myotomies (90% vs 30%, p = 0.022) than for conventional laparoscopic surgery. Operative times were significantly shorter for needlescopic sympathectomy than for laparoscopic sympathectomy and Heller myotomy (p = 0.004 and 0.013, respectively), and they were equivalent for other procedures. Conclusion: Needlescopic surgery can be performed in a variety of procedures with no apparent increase in conversions, operative time, morbidity, or mortality. There is a trend toward reduced hospital stays for certain procedures. Randomized prospective trials comparing needlescopic to conventional laparoscopic surgery are still needed to confirm and/or extend our findings.

Should enteric fistulas from Crohn's disease or diverticulitis be treated laparoscopically or by open surgery?

PURPOSE: The aim of this study was to study a group of consecutive patients with enteric fistulas treated by laparoscopic surgery and to compare outcomes with a matched group of patients treated by open surgery. METHODS: The outcomes of 13 patients with Crohns disease or sigmoid diverticulitis with enteric fistulas treated laparoscopically (Group I) were compared with 13 patients matched for age, weight, gender, diagnosis, and characteristics of fistulas and treated by conventional surgery (Group II) during the same period. RESULTS: No patient died postoperatively in either group. Mean operative time was 183 minutes in Group Ivs. 154 minutes in Group II (P=0.280). No significant difference was found between Groups I and II in the number of patients with major postoperative complications (3vs. 5;P=0.462), or postoperative stay (7.6±3.6vs. 9.2±3 days;P=0.239). Conversion to open laparotomy occurred in one (7.7 percent) patient from Group I. No patient required readmission for secondary surgery in Group I, and two patients were readmitted and underwent reoperation for complications in Group II (P=0.462). CONCLUSIONS: The laparoscopic treatment of selected cases of enteric fistulas is safe. Although most good outcome trends favor the laparoscopic group, the study is inconclusive, because no statistical difference was demonstrated with regard to operative time, number of postoperative complications, readmission rate, and length of postoperative stay, most likely because of the small number of cases in each arm of the study. Study of a greater number of cases outside the learning curve of the laparoscopic surgeons would clarify this issue. Other outcomes, including cost, pain control, cosmesis, and return to activities of daily living, need to be included in the evaluation.

Early experience with laparoscopic ileal pouch-anal anastomosis for ulcerative colitis.

The purpose of this study was to describe our minimally invasive technique and outline perioperative and medium-term outcomes in patients undergoing laparoscopic ileal pouch-anal anastomosis (LIPAA) for ulcerative colitis. Data were obtained from a prospectively collected database of 13 LIPPA procedures performed for ulcerative colitis between May 1994 and November 2000. Medium-term quality-of-life follow-up was obtained by telephone interview. Eight males and five females had an LIPAA performed, all of whom had previously undergone total abdominal colectomy with ileostomy. Median operative time was 255 minutes (range, 200–398 minutes) with one conversion (8%) due to adhesions. There were no deaths or intraoperative complications; however, six patients experienced seven postoperative complications within 30 days of final closure of defunctioning ileostomy (two leaks, two wound infections, one pulmonary embolus, and two reoperations for small bowel obstruction). Median length of stay was 7 days (range, 5–13 days). Median follow-up was 24 months (range, 6–66 months). The median number of day and night bowel movements was 6.0 (range, 3–10) and 1.0 (range, 0–3), respectively, with five patients requiring medication to control frequency. None had incontinence of stool or retrograde ejaculation; however, one had occasional incontinence of gas, three had occasional nocturnal soiling, and one was impotent. Three patients (23%) had pouchitis, all treated successfully with oral antibiotics. All patients were satisfied with the outcome of their operation and all preferred their pouch to previous ileostomy. Patients reported their overall social, emotional, and physical well being to be satisfactory to excellent. Results of the SF-36, a generic quality-of-life survey, were similar to those from studies of patients following an open pelvic pouch procedure. The LIPAA is technically feasible in experienced centers. We believe that the technique is still evolving and that more time and experience is required to refine the procedure.

Laparoscopic splenic cystectomy: A case report

Congenital epidermoid splenic cysts are very rare. They are known to become symptomatic as a consequence of enlargement, hemorrhage, rupture, or infection. Recent options in the treatment of splenic cysts have included percutaneous drainage, partial splenectomy, or open splenic cystectomy. The authors present the first report of a pediatric patient with a large epidermoid cyst of the spleen treated by laparoscopic partial cyst excision and omental packing. Follow-up at 1 year confirms no recurrence. Laparoscopy provides a minimal access method of obtaining pathological confirmation of diagnosis, reduction of cyst complications, and a short hospital stay, while preserving splenic function.