Rizk N

The use of diagnostic laparoscopy supported by laparoscopic ultrasonography in the assessment of pancreatic cancer

AbstractBackground: Pancreatic resection with curative intent is possible in a select minority of patients with carcinomas of the pancreatic head. Diagnostic laparoscopy supported by laparoscopic ultrasonography combines the proven benefits of staging laparoscopy with high-resolution intraoperative ultrasound, thus allowing the surgeon to perform a detailed assessment of the pancreatic cancer. Methods: In a prospective study of 26 patients with obstructive jaundice from a carcinoma of the head of the pancreas, the curative resectability of tumors was assessed by ultrasound (26 cases), computerized tomography (26 cases), endoscopic ultrasound (16 cases), and a combination of diagnostic laparoscopy and laparoscopic ultrasound (26 cases). Results: The findings of ultrasound and computerized tomography were comparable: 50% of patients were excluded from curative resection. Endoscopic ultrasound provided precise information on the primary tumors. The accuracy of the combined diagnostic laparoscopy and laparoscopic ultrasound, when compared with ultrasound, computerized tomography, and endoscopic ultrasound, was better with respect to minute peritoneal or hepatic metastasis: 80.7% (or a further 30.7%) of patients did not qualify for curative resection. Conclusions: Diagnostic laparoscopy supported by laparoscopic ultrasonography enables detection of previously unsuspected metastases; thus, needless laparotomy can be avoided. It should therefore be considered the first step in any potentially curative surgical procedure.

The effect of the learning curve on the outcome of laparoscopic treatment for gastroesophageal reflux.

The laparoscopic treatment for gastroesophageal reflux (GR) by partial (PF) or total (TF) fundoplication is the current surgical treatment of choice after failure of appropriate medical treatment. The overall results with fundoplication include the initial learning period, during which the rate of complications, conversions, and duration of surgery and hospitalization are assumed to be greater. The aim of this study was to compare the results of laparoscopic treatment for GR in three groups of consecutive patients to determine the effect of the learning period on outcome. One hundred and fifty-six patients (88 men and 68 women) with an average age of 52.3 years (range, 18-78) were included. Surgery was indicated for failure or early relapse after the end of medical treatment or a symptomatic sliding hernia. The preoperative workup (endoscopy, barium meal, or esophageal pH monitoring) was governed by the clinical picture. The choice between TF and PF was based on the results of pH monitoring. Three groups of patients were chronologically defined. The parameters that were examined were the type of preoperative exploration, the type of fundoplication, the operative technique, the conversion rate, the mortality and morbidity rates, the duration of surgery and hospitalization, and the results at short- and medium-term follow-up. The three groups were comparable with respect to patient characteristics and the nature of their GR. All patients had an endoscopy, 91% had a barium meal, 77.5% underwent esophageal manometry, and 67% had pH monitoring. One hundred and thirty-six patients had a TF and 20 had a PF. Rossetti type TF became the reference procedure (67% in group III) and closure of the diaphragmatic crura was performed systematically in group III (100%). The duration of surgery was significantly reduced between groups I and groups II and III (140, 100, 80 minutes, respectively). The rate of conversion, due to a variety of causes, decreased from 9.8% to 3.8%, and then to 0%. The average duration of hospitalization decreased from 5.8 to 4.2 days (p = 0.01). There was no mortality and the morbidity rate decreased from 15% to 3.8%, and then to 0%. There were seven cases of relapse (4.6%), five in group I (10%) and two in group II (4%), with no cases in group III, although the follow-up in group III was shorter. There is an effect of the learning curve on the outcome of treatment for GR, and this must be taken into account in the training of surgeons (training within experienced departments and guidance during their initial interventions) and also in publications to allow a more accurate comparison of this technique with other treatments for GR.

Thromboembolism in laparoscopic surgery: risk factors and preventive measures.

The aim of this study was to assess the risk of clinical thromboembolism in laparoscopic digestive surgery. From June 1992 to June 1997, 2,384 consecutive patients were studied. All received perioperative prophylaxis with low-molecular-weight heparin (LMWH), which was continued until full mobility was regained. Eight cases (0.33%) of deep venous thrombosis were noted, but there were no cases of pulmonary embolus. In six cases (five cholecystectomies with reverse Trendelenburg position and one inguinal hernia repair), release of the pneumoperitoneum took longer than 2 hours, and in two cases (one rectopexy and one sigmoid colectomy for diverticulitis), longer than 3 hours. In six of the eight cases, the diagnosis of DVT was made after LMWH had been ceased and the patient had been discharged. All cases were diagnosed before the 10th postoperative day. Pneumoperitoneum is felt to predispose to deep venous thrombosis. Long operations and reverse Trendelenburg position are further potentiating factors. Thromboprophylaxis for laparoscopy should be the same as for conventional surgery, i.e., tailored to individual risk and continued for a minimum of 7 to 10 days. We also recommend using graduated compression stockings, maintaining a relatively low insufflation pressure, keeping use of the reverse Trendelenberg position to a minimum, and intermittently releasing the pneumoperitoneum in longer procedures.

Quality of life after laparoscopic gastric banding: Prospective study (152 cases) with a follow-up of 2 years.

To evaluate influence of laparoscopic gastric banding (LGB) on quality of life (QOL) in patients with morbid obesity. Laparoscopic adjustable gastric banding is a popular bariatric operation in Europe. The objectives of surgical therapy in patients with morbid obesity are reduction of body weight, and a positive influence on the obesity-related comorbidity as well the concomitant psychologic and social restrictions of these patients. In a prospective clinical trial, development of the individual patient QOL was analyzed, after LGB in patients with morbid obesity. From October 1999 to January 2001, 152 patients [119 women, 33 men, mean age 38.4 y (range 24 to 62), mean body mass index 44.3 (range 38 to 63)] underwent evaluation for LGB according the following protocol: history of obesity; concise counseling of patients and relative on nonsurgical treatment alternatives, risk of surgery, psychologic testing, questionnaire for eating habits, necessity of lifestyle change after surgery; medical evaluation including endocrinologic and nutritionist work-up, upper GI endoscopy, evaluation of QOL using the Gastro Intestinal Quality of Life Index (GIQLI). Decision for surgery was a multidisciplinay consensus. This group was follow-up at least 2 years, focusing on weight loss and QOL. Mean operative time was 82 minutes; mean hospital stay was 2.3 days and the mean follow-up period was 34 months. The BMI dropped from 44.3 to 29.6 kg/m2 and all comorbid conditions improved markedly: diabetes melitus resolved in 71% of the patients, hypertension in 33%, and sleep apnea in 90%. However, 26 patients (17%) had late complications requiring reoperation. Preoperative global GIQLI score was 95 (range 56 to 140), significant different of the healthy volonteers score (120) (70 to 140) P<0.001. Correlated with weight loss (percentage loss of overweight and BMI), the global score of the group increased to 100 at 3 months, 104 at 6, 111 at 1 year to reach 119 at 2 years which is no significant different of healthy patients. Analyzing the subscale, physical condition, emotional status, and social integration increased significantly (P<0.001) from preoperative to end of follow-up. Digestive symptoms were not modified. In case of failure of the procedure (10.5%) global Giqli score is not modified. Patients who have required successfull revisional surgery for late complications (6.5%) have an excellent QOL outcome that are not different from the whole group. Together with a satisfactory reduction of the excess overweight, laparoscopic gastric banding may lead in a carefully selected population of patients with morbid obesity to a significant improvment of patient QOL, in at least 2 years follow-up.

A comparison of laparoscopic ultrasound versus cholangiography in the evaluation of the biliary tree during laparoscopic cholecystectomy.

OBJECTIVE This study assessed the effectiveness of laparoscopic ultrasound in detecting main biliary duct stones. METHODS From November 1994 to August 1998, 600 patients treated by laparoscopic cholecystectomy were included in a prospective study, to compare intraoperative cholangiography and laparoscopic ultrasound. The biliary tree was successively explored by these two methods in the routine detection of common bile duct stones. RESULTS The feasibility of laparoscopic ultrasound was 100%. Cholangiography was performed only in 498 cases (83%). The time taken for laparoscopic ultrasound examination was significantly shorter (10.2 vs 17.9 min, P=0.0001). In this study, common bile duct stones were found in 54 cases (9%). For their detection, results were comparable to laparoscopic ultrasound and intraoperative cholangiography. For laparoscopic ultrasound, sensitivity was 80% and specificity 99%; and for cholangiography 75 and 98% respectively. Both examinations combined had a 100% sensitivity and specificity. Laparoscopic ultrasound failed to recognize the intrapancreatic part of the common bile duct in 78 cases (13%) and did not show anatomical anomalies detected by cholangiography. It did however detect other unsuspected intra-abdominal pathologies. CONCLUSIONS Laparoscopic ultrasound is safe, repeatable, and non-invasive, but a considerable learning curve is necessary to optimize its efficacy. Comparison of relative cost must be undertaken.

Inguinal hernia repair

SummaryIn a prospective randomized trial comparing a totally pre-peritoneal (TPP) laparoscopic approach and the Stoppa procedure (open), 100 patients with inguinal hernias (Nyhus IIIA, IIIB, IV) were followed over a 3-year period. Both groups were epidemiologically comparable. In the laparoscopic group, operating time was significantly longer (p=0.01) but hospital stay (3.2 vs 7.3 days) and delay in return to work (17 vs 35 days) were significantly reduced (p=0.01). Post operative comfort (less pain) was better (p=0.001) after laparoscopy. In this group, morbidity was also reduced (4% vs 20%, p=0.02). The mean follow up was 605 days and 93% of the patients were reviewed at three years. There were three (6%) recurrences after TPP, especially at the beginning of the surgeons learning curve versus one for the Stoppa procedure (ns). For bilateral hernias, the authors suggest the use of a large prosthesis rather than two small ones to minimise the likelihood of recurrence. In the conditions described the laparoscopic (TPP) approach to inguinal hernia treatment appears to have the same long-term recurrence rate as the open (Stoppa) procedure, but confers a real advantage in the early post operative period.

Traitement vidéolaparoscopique des traumatismes spléniques. Etude de cinq cas

Background When splenic trauma does not require an emergency splenectomy in order to achieve hemostasis, the current policy is either observation under close surveillance, with transfusions if necessary, or conservative surgical procedure through laparotomy. Videolaparoscopic approach has the advantage of achieving in the same procedure, complete evacuation of the hemoperitoneum, full investigation of the abdominal cavity and repair of the damaged spleen.

Existe-t-il des facteurs prédictifs de succès dans le traitement de l'obésité morbide par anneau périgastrique modulable ? Étude prospective

Background. – Surgical treatment of morbid obesity by perigastric adjustable banding give at mid term follow up, contrasted results which associate succes, failure and intermediate situations. Aims. – The objective of this work was to prospectively validate predicting items that would predict success in the surgical treatment of morbid obesity by adjustable gastric banding. Material and methods. – Eighty patients with morbid obesity have been treated with adjustable gastric banding. Seventy one women, and nine men with a mean age of 37.8 years (20–59) with a mean follow up of 17 months (12–52). They have been classified in three groups: success, failure, and intermediate results. Uni- and multivariate analysis was performed on six criterions: age, sex, professional activity, metabolic disorders, lengh of obesity and body mass index (BMI). Results. – Concerning age, sex, professional activity, metabolic disorders, and lengh of obesity, there was no difference between the three groups. However, a BMI more than 50 kg/m2 has a strong predictive value. Patients called super obese: BMI >50 has a high rate of failure (64%) even the weight loss is ofen important in absolute value, but the BMI a the follow up remain high and more than 40. In this situation: gastric banding does not seem a good treatment because it does not protect these patients against the lethal risk of their comorbidities. Conclusion. – In this study, there is not a specific candidate « profile » to a successful treatment of morbid obesity by adjustable gastric banding. Meanwhile the initial BMI appear to be a predictive factor of success or failure. In the case of patients with high BMI >50 (super obese) Gastric banding did not seen to be a good treatment and an other technical approach (gastric by pass) must be discuss.

Influence de l'apprentissage et de l'expérience dans le traitement laparoscopique du reflux gastro-œsophagien

Learning curve and experience in laparoscopic treatment of gastroesophageal reflux disease. Study aim: Laparoscopic treatment of gastroesophageal reflux disease (GERD) by partial (PF) or total (TF) fundoplication is the most appropriate surgical treatment after failure of medical treatment. The aim of this study was to compare the results of the same series in three consecutive periods in order to determine the effects of the learning curve and experience on the technique and outcome. Patients and methods: From January 1993 to January 1998, 150 patients (84 men and 66 women) with a mean age of 52.2 years (18 to 78) were included. Three groups of 49, 50 and 51 patients were chronologically defined. The comparison was established on the following criteria: the operative technique; the conversion rate; the mortality and morbidity rate; the duration of surgery and hospitalization and the results with short and medium follow-up. Results: The three groups were comparable with respect to patients and GERD characteristics. One hundred and thirty two patients had a TF and 18 had a PF. Rossettis type TF became the reference procedure (80,3% in group III) and closure of the diaphragmatic crura was performed systematically in group III (100%). The duration of surgery was significantly reduced between group I and the two other groups (138, 100, 80min). The rate of conversion decreased from 10,2% to 4% and then 0%. The average duration of hospitalization decreased from 5.8 to 4.2 days (p=0.01). There was no mortality and the morbidity rate decreased from 14,3% to 4% and then 0%. Seven cases of recurrence occurred(4.6%), 5 in group I (10,2%), 2 in group II (4%), and 0 in group III, (with a shorter follow-up). Conclusion: The effect of the learning curve has to be taken into account in the training of surgeons (within experienced departments, with «guidance» during initial interventions) and also in the evaluation of results, in order to allow a more accurate comparison between the different treatments for GERD.

Groin hernias — four year results of two randomised prospective studies comparing the Shouldice operation and the Stoppa procedure using a totally pre-peritoneal laparoscopic approach (461 patients)

SummaryThe aim of this study is to estimate, at a mean follow up period of 1464 days (4 years), the incidence of hernial recurrence after initial treatment by a laparoscopic approach (using a totally pre-peritoneal route-TPP) as compared with the Shouldice operation, and that of Stoppa. The patients were submitted to rigorous controls of inclusion and exclusion and were divided into two controlled studies. The operations were reviewed at one month, six months, one year and every year thereafter. The follow-up rate was 100% at one month, 90% at six months, 95% at one year, 92% at two years, 84% at three years, 79% at four years and 61% at five years. The incidence of early recurrence (one year) seems to be higher in the laparoscopic group (2.2%) as compared with the two other techniques (Shouldice 1.2% and Stoppa 0%) though this is not significant. At three years, the recurrence rate is comparable (not significant) in the three groups: 3.6% for laparoscopy, 5.1% for Shouldice, 5.2% for Stoppa. At four years, the incidence of recurrence was lower (not significant) for the laparoscopic approach 7.4% and for the two other techniques 12.5% and 10.5% respectively. Analysis of the factors for recurrence in the laparoscopic approach (TPP) made clear the determining role of the experience of the operator and of the size of the prosthesis which was used.