R. Campagnacci

Long-term results of laparoscopic versus open resections for rectal cancer for 124 unselected patients

Background: Controversy continues to surround laparoscopic rectal resection for malignancy. A longer follow-up period is required to evaluate the long-term efficacy of the procedure and its impact on survival. Furthermore, no data from ongoing randomized controlled trials are yet available. The aims of this study were to compare long-term outcomes for unselected patients undergoing either laparoscopic or open rectal resection for cancer. Methods: A series of 124 unselected consecutive patients with rectal cancer, who underwent surgery by the same surgical team, have been included in this study. Patients with T1N0 tumors underwent local excision, and emergency cases were excluded from the study. Written consent was submitted by each patient, and inclusion in either group (laparoscopic or open) was left to the patient’s choice. The laparoscopic approach was chosen by 81 patients, and 43 patients chose open surgery. All the patients underwent preoperative radiotherapy (5,040 cGy), performed in selected cases with chemotherapy (for patients younger than 70 years). The following parameters were compared between the two groups: length of the surgical specimen, clearance of the margins of the specimen, number of lymph nodes identified, local recurrence rate, incidence of distant metastases, and survival probability analysis. The mean follow-up period for both groups was 43.8 months (range, l–9 years). Results: We performed 60 laparoscopic and 27 open anterior resections, as well as 21 laparoscopic and 16 open abdomino perineal resections, respectively. No mortality occurred in either group. The mean length of the resected specimens was 24.3 cm in the laparoscopic group and 23.8 cm in the open group (p = 0.47). The mean tumor-free margin was 3.0 cm in the laparoscopic group and 2.8 cm in the open group (p = 0.57), and the mean number of lymph nodes identified was 10.3 in the laparoscopic group and 9.8 in the open group (p = 0.63). Of the 124 patients, 86 (52 laparoscopic and 34 open) were included in out study. We excluded patients who underwent a palliative resection (6 laparoscopic and 6 open patients) or conversion to open surgery (n = 10) and patients who had undergone surgery in the past year (n = 16). One laparoscopic patient was lost to follow-up evaluation, whereas three laparoscopic patients and one open patient died of causes not related to cancer. No wound recurrence was observed. The local recurrence rate after laparoscopic resection was 20.8%, as compared with 16.6% after open resection (p = 0.687). Distant metastases occurred in 18.2% of the patients in the laparoscopic group, as compared with 21.2% in the open group (p = 0.528). Cumulative survival probability was 0.709 after laparoscopic resection after LR and 0.606 after open resection (p = 0.162), whereas for Dukes’ stages A, B, and C in the laparoscopic group versus the open group, it was 0.875 vs 0.889 (p = 0.392), 0.722 vs 0.584 (p = 0.199), and 0.500 vs 0.417 (p = 0.320), respectively. At this writing 20 laparoscopic patients (62.5%) and 20 open patients (60.6%) are disease free (p = 0.623). Conclusions: Oncologic surgical principles were respected. Long-term outcome after laparoscopic resection of rectal cancer was comparable with that after conventional resection. We should wait to draw conclusive scientific statements until the completion of ongoing international radomized controlled trials.

Laparoscopic vs open hemicolectomy for colon cancer

BackgroundThe role of laparoscopic resection in the management of colon cancer is still a subject of debate. In this clinical study, we compared the perioperative results and long-term outcome for two unselected groups of patients undergoing either laparoscopic or open hemicolectomy for colon cancer.MethodsThis prospective nonrandomized study was based on a series of 248 consecutive patients operated on by the same surgical team using the same type of surgical technique for right (RHC) and left (LHC) hemicolectomy, excluding segmental resections; the only difference was the type of access, which was either laparoscopic or open. The choice of type of access was left up to the patient after he or she had read the informed consent form. Operative time, length of stay, complications, and long-term outcome for the two groups were compared. Follow-up time ranged between 12 and 92 months (mean, 42).ResultsBetween March 1992 and January 2000, 140 patients underwent a laparoscopic hemicolectomy (55 RHC and 86 LHC); at the same time, 107 patients (44 RHC and 63 LHC) were treated via an open approach. There were no conversions to open surgery in the laparoscopic RHC group, but six patients (7%) in the laparoscopic LHC group were converted. The mean operative time for laparoscopic surgery was significantly longer than the time for open surgery (190 vs 140 min for RHC, 240 vs 190 min for LHC); however, with increasing experience, this time decreased significantly. The mean hospital stay for the patients who underwent laparoscopic procedures was significantly shorter in both the RHC and the LHC groups (9.2 vs 13.2 days for RHC, 10.0 vs 13.2 days for LHC). No statistically significant difference between the two laparoscopic and open groups was observed for the major complication rate (1.9% vs 2.3% for RHC, 7.5% vs 6.3% for LHC). The patient in the laparoscopic RHC group were lost to follow-up. The local recurrence rate was lower after laparoscopic surgery in both arms (5.4% vs 9% for RHC, 1.5% vs 7.5% for LHC), but the differences were not statistically significant. Two port site recurrences were observed in the laparoscopic groups, one after RHC (2.7%) and one after LHC (1.5%). Metachronous metastases rates were similar for the two groups (16.2% vs 15.1% for RHC, 4.4% vs 5.7% for LHC). Cumulative survival probability at 48 months after laparoscopic RHC was 0.865, as compared to 0.818 after open surgery, and 0.971 after laparoscopic LHC, as compared to 0.887 after open surgery.ConclusionThese results suggest that laparoscopic hemicolectomy for colonic cancer can be performed safely, with morbidity, mortality, and long-term results comparable to those of open surgery.

Laparoscopic colorectal resection for endometriosis

BackgroundThe rectosigmoid colon is affected by deep pelvic endometriosis in 3–37% of cases. In the past, treatment of the affected gastrointestinal tract generally required conversion to conventional surgery. We describe our experience with complete laparoscopic management of deep pelvic endometriosis with bowel involvement.MethodsFrom March 1995 to March 2003, 29 consecutive patients with endometriosis requiring laparoscopic intervention were evaluated. In seven patients (24%) colorectal involvement was identified prior to the operation. A low anterior resection was performed in four patients (57%) and a sigmoid resection in three (43%). In all cases, colonoscopy showed a normal mucosa. In all cases, treatment consisted of resection of the bowel involved together with the excision of all other implants. Data analysis included age, previous abdominal operations, previous history of endometriosis, operative time, conversion rate, complications, length of stay, and pain relief.ResultsThere were seven patients with colorectal involvement whose median age was 32.8 years (range, 28–40), with a history of previous abdominal operation in two (28%). Preoperative symptoms were as follow: dysmenorrea in four patients (57%), dyspareunia in four (57%), pelvic pain in seven (100%), rectal bleeding in one (14%), and tenesmus in five (71%). Mean operative time was 190 min (range, 165–230). Length of stay was 8.3 days (range, 7–11). There were no anastomotic leak and no major postoperative complication. One patient had temporary urinary retention. At a median follow-up of 38.7 months (range, 1–84), complete relief of pelvic symptoms was achieved in five patients (71%), and there was improvement in one patient. In one patient complaining of persistent pain, a new colonic implant was diagnosed two years after the surgery requiring reoperation.ConclusionsThe results show that provided that the surgeon is highly skilled in laparoscopy, laparoscopic resection of deep pelvic endometriosis with rectosigmoid involvement is feasible and effective in nearly all patients.

Hepatic resections by means of electrothermal bipolar vessel device (EBVS) LigaSure V: early experience

BackgroundMany techniques and devices are available for performing liver resection, such as clamp crushing, Cavitron Ultrasonic Surgical Aspirator (CUSA), Hydrojet and dissecting sealer, ultrasonic shears, and, more recently, electrothermal bipolar vessel sealing system (EBVS). In this prospective trial we sought to evaluate the impact of EBVS on hepatic resections.MethodsFrom March 2004 to December 2005, 24 patients from our consecutive liver resection series were enrolled in the present study. There were 17 males and 7 females with a mean age of 59.6 years (range = 41–80) who had colonic cancer metastases (18), hepatocarcinoma (3), angioma (2), and intrahepatic lithisasis (1). Patients were prospectively randomized to undergo liver resection via EBVS LigaSure V (12 patients, group A) or ultrasonic shears harmonic scalpel (HS) (12 patients, group B). Hepatic procedures did not differ significantly between the two groups and were as follows: right hepatectomy (2), left hepatectomy (1), bisegmentectomy (14), and segmentectomy (7).ResultsThere was no mortality in either group. The mean operative time was 136.7 min (range = 90–210) in group A and 187.9 min (range = 130–360) in group B. The Pringle maneuver was done in five patients in group A [mean time = 11.4 min (range = 6–12)] and in four patients in group B [mean time = 16 min (range = 9–26)]. The mean blood loss, total bile salts, and hemoglobin concentration from drained fluid on the second postoperative day were 205.8 vs. 506.7 ml, 0.6 vs. 1.1 mmol/L, and 1.0 vs. 2.1 g/L (p < 0.05) for groups A and B, respectively. Mean postoperative hospital stay was 6.1 vs. 7.8 days. In group B a patient who underwent right hepatectomy for colon cancer metastases had transient hepatic failure. No patients received blood transfusions in group A, while two or more blood units were administered in two cases in group B.ConclusionsIn the present study EBVS proved to be safe and effective for liver resection. By means of this device, statistically significant benefits concerning blood loss, total bile salts, and hemoglobin postoperative leakage were found.

Long-term results of laparoscopic versus open colorectal resections for cancer in 235 patients with a minimum follow-up of 5 years

BackgroundLaparoscopic resection for cure of colorectal cancer is controversial. More investigations on long-term results are required. This study aimed to compare the long-term outcome with a minimum follow-up of 5 years between laparoscopic or open approach for the treatment of colo-rectal cancer.MethodsThe treatment modality (laparoscopic or open) was related to the patients (pts) choice. The following parameters between the two groups (laparoscopic and open) were assessed: wound recurrences rate, local recurrences rate, incidence of distant metastases and survival probability analysis.ResultsWe report the long term outcome of 149 pts with colon cancer of which 85 treated by Laparoscopic Surgery (LS) and 64 by Open Surgery (OS) and of 86 patients with rectal cancer of which 52 treated by LS and 34 by OS. In the pts with colonic cancer, mean follow-up was 82.8 months. No Statistically Significant Difference (SSD) was observed in the local recurrences rate (3.5% after LS and 6.2% after OS) and in the incidence of distant metastases (10.5% after LS and 10.9% after OS). Cumulative survival probability in LS was 0.882 as compared to 0.859 after OS. In the pts with rectal cancer, mean follow-up was 78.5 months. No SSD was observed in the local recurrences rate (19.2% after LS and 17.6% after OS) and in the incidence of distant metastases (15.3% after LS and 20.5% after OS). Cumulative survival probability in LS was 0.711 as compared to 0.617 after OS. We report an interesting data about the time of recurrences between LS and OS: the recurrences were delayed after LS, both after colonic (22.6 months vs 6.5) and rectal (25.7 months vs 13.0) resections, respectively.ConclusionWe suppose that laparoscopic surgery in the treatment of colo-rectal cancer is quite safe. However, further investigation is needed.

Results of laparoscopic vs open resections for colon cancer in patients with a minimum follow-up of 3 years.

Background: Laparoscopic resection for colon cancer is still a controversial procedure, the major cause of concern being the lack of long-term results. The aims of this study was to compare long-term outcome in unselected patients undergoing either laparoscopic (LH) or open hemicolectomy (OH) for colonic cancer. Methods: From March 1992 to August 1997, 197 elective patients were included in this prospective nonrandomized study. The patients were operated on by the same surgical team following the same type of surgical technique for both right and left hemicolectomy, excluding segmental resections; the only difference was the type of access, which was either laparoscopic or open. Each patient gave a written consent, and the allocation to each group (laparoscopic or open) was done on the basis of the patients choice. The long-term outcomes of the two groups were compared. Follow-up for both groups ranged from 36 to 96 months (mean, 48.9). Results: In all, 149 (74 LH, 75 OH) of 197 patients were studied, excluding palliative resections, conversions to open surgery, perioperative deaths, and deaths not related to cancer. Only two patients in the laparoscopic group were lost to follow-up. The local recurrence after LH was 1.3% vs 2.7% after OH (p = 0.105). Metachronous metastases rates were similar for the two groups (10.8% for LH and 10.7% for OH). Cumulative survival probability (CSP) in the LH group vs the OH group was 0.892 vs 0.867 (p = 0.513), respectively. CSP for Dukes stage B and C in the LH group vs the OH group was 0.910 vs 0.895 (p = 0.506) and 0.800 vs 0.734 (p = 0.544) respectively. Sixty-four LH patients (86.5%) and 65 OH patients (86.7%) are disease-free. Conclusion: In our series of patients, no statistically significant difference was found between the two groups in terms of long-term survival rate.

Perioperative results of 214 laparoscopic adrenalectomies by anterior transperitoneal approach

BackgroundThe present study attempts to evaluate the perioperative results of the anterior approached laparoscopic adrenalectomy (LA) in a large cohort of patients, and report the advantages and disadvantages of this route.Methods204 patients, 125 female and 79 male with a mean age 52.8 years (range, 19–75 years), underwent LA by the anterior transperitoneal approach from 1994 to 2005 in our institution. There were 100 right and 114 left LAs. Ten patients underwent bilateral LA. Associated surgical procedures were performed in 17 cases. During the same period 47 LAs had been performed by different approaches (flank and submesocolic).ResultsMean operative time was 80 minutes for right (40–150), 109 minutes for left (64–300) and 194 minutes for bilateral adrenalectomy. Intraoperative major complications were observed in six patients. Mortality occurred in one diabetic patient who was converted to open surgery because of a colonic perforation and subsequently developed a Candida sepsis in the postoperative course. The mean size of lesion removed was 6.2 cm (1.5–12 cm). Oral intake started within 24 hours and the mean hospital stay was 2.5 days (1–8 days). Histology results were as follows: nonsecreting adenoma 65, Cushing’s adenoma 58, Conn’s adenoma 53, pheochromocytoma 24, metastases 9, myelolipoma 3, adrenogenital syndrome 1, carcinoma 1.ConclusionsLA by anterior transperitoneal approach is safe and effective in our experience, despite the inherent limitation that this was not a prospective randomized study. The main advantage of this route is early ligature of the adrenal vein on both sides, enabling the performance of associated surgical procedures and bilateral adrenalectomy.

Laparoscopic Common Bile Duct Exploration

BACKGROUND Laparoscopic common bile duct (CBD) exploration is gaining favor in the treatment of patients with gallstones and CBD stones. Our aim is to report our results with this procedure, focusing on the technical aspects. PATIENTS AND METHODS All patients with proven CBD stones undergo laparoscopic transcystic CBD exploration, preferably, or a choledochotomy if the former is not feasible. According to CBD stone load and diameter, a biliary drainage tube is positioned for postoperative biliary decompression. RESULTS Among 284 patients who underwent laparoscopic CBD exploration, 4 (1.4%) were converted to open surgery. Transcystic CBD exploration was feasible in 163 cases (58.2%), but a choledochotomy was required in 117 (41.8%). Biliary drains were positioned in 204 patients (72.8%). Minor complications included hyperamylasemia (11; 3.9%) and minor subhepatic bile collection (7; 2.5%). Major complications were bile leakage (5; 1.8%), hemoperitoneum from cystic artery bleeding (2; 0.7%), subhepatic abscess (2; 0.7%), acute pancreatitis (1; 0.3%), and jejunal perforation (1; 0.3%). Retained CBD stones in 15 patients (5.3%) were removed through the biliary drainage sinus tract (8) or after endoscopy and sphincterotomy (6). In one patient, a small stone passed spontaneously (overall success rate 94.6%). Death from a cardiovascular complication was observed in one elderly high-risk patient (0.3%). Recurrent ductal stones in 5 patients (1.8%) were treated with ERCP and endoscopic sphincterotomy. One patient with re-recurrent ductal stones underwent hepaticojejunostomy. CONCLUSIONS Laparoscopic CBD exploration during LC in unselected patients solves two problems during the same anesthesia with high success rates (94.6%), low minor (6.4%) and major (3.8%) morbidity rates, and a low mortality rate (0.3%). Standardization of the technique is mandatory to achieve high success rates.

The learning curve in laparoscopic adrenalectomy.

Background: Laparoscopic adrenalectomy (LA) is the procedure of choice for surgical management of most adrenal tumors. LA learning curve (LC) varies among surgeons and may be influenced by factors depending on surgeon, patient, and lesion peculiarities. The aim of this study was to evaluate the LC by multi-dimensional analysis. Methods: Between August 1994 and August 2005, 241 LA were performed in our department. Data were prospectively collected. The pre-operative variables evaluated were patient-related (age, gender, body mass index, co-morbidities) and disease-related (histology, size, and side of lesion). Level of experience of surgical team and surgical approach (anterior, flank, submesocolic routes) were evaluated as well. Flank approached and bilateral procedures were excluded, while submesocolic LA, were collected separately. Operating time (OpT), conversion rate (CR), intra-operative and post-operative complications were evaluated. Patient, surgeon, and procedure-related factors involved in LC were investigated by a multi-factorial logistic regression analysis. Results: Body mass index, side, size, histology, technology improvement, and experience of surgical team, evaluated through the progressive series of surgical procedures, were independent predictors of CR and OpT. The CR for right adrenalectomy was 3% (3 cases) compared to 4.2% for left side (6 cases). The submesocolic approach significantly influenced OpT, but not CR. Mean OpT for right and left LA was 83 and 109 min, respectively. Based on surgical experience increase, the OpT and CR flattened their curves, roughly at 30 and 40 procedures for right and left LA, respectively. Post-operative complications did not change considerably throughout the series. Readmission rate within 30 days was negligible. Conclusions: Manifold factors may affect LC and outcome in LA. Their knowledge may support teaching activities as well as reducing conversion and complication rates.

Laparoscopic cholecystectomy and common bile duct exploration are safe for older patients

BackgroundLaparoscopic common bile duct (CBD) exploration is a well-established treatment option in dedicated centers. However, few data are available on the results in elderly patients.MethodsThe outcome after laparoscopic CBD exploration in elderly patients (age>-70 years) was compared with that in a concurrent control group of younger patients (age <70 years).ResultsThere were 77 elderly patients in group A and 207 younger patients in group B. American Society of Anesthesiology (ASA) III and IV patients and prior abdominal operations were more frequent in group A (p<0.001). Two patients from each group underwent conversion to open surgery. There was no significant difference frequency of use between the transcystic and choledochotomy approaches, although the latter tended to be more frequent in the group A because of larger stones (group A, 53.4%; group B, 37.6%). Minor and major morbidity (group A, 12%; group B, 13.6%), rate of recurrent stones (group A, 1.3%; group B, 1.9%), and mortality (group A, 1.3%; group B, 0%) were not significantly different between the two groups. The single death in group A involved a patient with acute toxic cholangitis who underwent emergency surgery after multiple failed attempts at endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy performed elsewhere. No CBD stenosis was observed at follow-up assessment.ConclusionsElective laparoscopic CBD exploration is safe and effective. It may become the standard of care in both elderly and younger patients.