Is the laparoscopic adrenalectomy for pheochromocytoma the best treatment?

BACKGROUND: Laparoscopic adrenalectomy has become the gold standard for removing adrenal masses, but several authors still debate the role of laparoscopic adrenalectomy in pheochromocytoma. The purpose of this study was to evaluate the short- and long-term outcomes of laparoscopic versus open adrenalectomy for pheochromocytomas and to compare the feasibility and safety of laparoscopic adrenalectomy for neoplasms that are smaller than 6 cm versus those that are larger than 6 cm. METHODS: From January 1990 to December 2005, the same team in our department carried out 221 adrenalectomies in 211 patients. A total of 64 of these patients underwent 71 adrenalectomies for pheochromocytoma, 24 patients (37%) had open adrenalectomy, and 40 patients (63%) had laparoscopic adrenalectomy. Sex, age, side and size of lesion, operating time, duration of hospital stay, need for intensive care, intraoperative blood pressure variations, blood loss, postoperative analgesia, return to oral nutrition, and complications were compared among groups. RESULTS: An advantage of laparoscopic adrenalectomy over open adrenalectomy was observed in mean operating time, hospital stay, need for intensive care, intraoperative hypertension, intraoperative blood loss, postoperative analgesia, and return to oral nutrition (P 6 cm) in laparoscopic adrenalectomy showed that none of the variables differed significantly, except for intraoperative blood loss, which was greater for the larger neoplasms (P = .007). CONCLUSIONS: Laparoscopic adrenalectomy, when performed by experienced laparoscopic surgeons, is preferable to open adrenalectomy for the majority of pheochromocytomas, and as long as there is no evidence of invasion of surrounding structures, tumor size does not appear to have a profound effect on surgical outcome.     

A retrospective wound review of standard four-port laparoscopic cholecystectomy: Is there need for single-port laparoscopic surgery?

Background  

This study was designed to assess the satisfaction or otherwise of a proportion of the U.K. population who have undergone standard four-port laparoscopic cholecystectomy within the past 18 months. The results should indicate whether there is potential demand for a new, improved approach to surgery.     

Open transumbilical pyloromyotomy: is it more painful than the laparoscopic approach?

Background

Open transumbilical pyloromyotomy (UMBP) and laparoscopic pyloromyotomy (LAP) have been compared on different outcomes, but postoperative pain as a primary end point had never been assessed. The aim of this study was to compare the use of analgesia in UMBP and LAP patients.

Methods

Infants with hypertrophic pyloric stenosis treated by UMBP in 2008-2009 were matched with LAP-treated infants. Demographics, type and use of analgesia, and length of stay were recorded. Statistical analysis was performed using the Fisher exact test.

Results

Each group contained 19 patients (N = 38) with comparable demographics and no comorbid condition. Bupivacaine was injected intraoperatively in all UMBP and 89% of LAP infants. There was a trend toward increased acetaminophen use in LAP infants (79% vs 58%, P = .61) in the recovery room. There was no difference in opiates use (3 UMBP vs 1 LAP, P = .60). In the ward, more UMBP patients received acetaminophen (78% vs 53%, P = .03). This difference was significant. Mean postoperative length of stay was similar in both groups.

Conclusion

Our study suggests that UMBP infants might experience more postoperative pain in the ward, without any impact on various outcomes. A prospective study with a larger sample size should be undertaken to verify these findings.     

Is the use of a bougie necessary for laparoscopic Nissen fundoplication?

HYPOTHESIS: Esophageal intubation with a bougie during laparoscopic Nissen fundoplication (LNF) is commonly used to prevent an excessively tight wrap. However, a bougie may cause intraoperative gastric and esophageal perforations. We hypothesized that LNF is safe and effective when performed without a bougie. DESIGN: Retrospective review of 102 consecutive patients who underwent LNF without a bougie. SETTING: Tertiary care university hospital. PATIENTS: All patients presented with symptoms of reflux disease. Mean (+/- SD) percentage of time with pH of less than 4 was 12.6% +/- 9.4%. Mean DeMeester score was 47.8. Mean (+/- SD) resting lower esophageal sphincter pressure was 15.0 +/- 9.4 mm Hg. Mean (+/- SD) distal esophageal amplitude was 69.4 +/- 39.2 mm Hg. INTERVENTION: During LNF, we obtained 2 to 3 cm of intra-abdominal esophagus, divided all short gastric vessels, reapproximated the crura, and performed a loose 360 degrees fundoplication without a bougie. MAIN OUTCOME MEASURES: Postoperative rates of dysphagia, gas bloat, and recurrent reflux. RESULTS: In the early postoperative period, 50 patients (49.0%) complained of mild, 11 (10.8%) of moderate, and 7 (6.9%) of severe dysphagia. Average (+/- SD) duration of early dysphagia was 4.6 +/- 2.1 weeks. Dysphagia resolved in 61 (89.7%) of 68 patients within 6 weeks. Late resolution of dysphagia was noted in 4 (5.8%) patients. Three patients were successfully treated with esophageal dilatations. Persistent dysphagia was found in 1 patient. Thirty patients (29.4%) had transient gas bloat. Mild persistent reflux, requiring daily medication, was noted in 5 (4.9%) patients. CONCLUSIONS: Performance of LNF without a bougie offers a safe and effective therapy for gastroesophageal reflux disease. While avoiding the potential risks for gastric and esophageal injury, it may provide low rates of long-term postoperative dysphagia and reflux recurrence.     

The vomiting infant: pyloric stenosis

Infantile hypertrophic pyloric stenosis is the commonest reason to perform an intra-abdominal operation on a young infant. It is thus an important condition for the trainee surgeon to understand. It illustrates many important lessons in diagnosis, preoperative preparation, operative skill and postoperative management and how to apply them to infants and babies to achieve the excellent outcome that is expected with minimal morbidity.     

The vomiting infant: pyloric stenosis

Infantile hypertrophic pyloric stenosis is the commonest reason to perform an intra-abdominal operation on a young infant. It is thus an important condition for the trainee surgeon to understand. It illustrates many important lessons in diagnosis, pre-operative preparation, operative skill and post-operative management and how to apply them to infants and babies to achieve the excellent outcome that is expected with minimal morbidity.     

A new technical variant for extramucosal pyloromyotomy: the Tan-Bianchi operation moves to the right

Background

Since its first publication in 1986, the Tan-Bianchi procedure for treatment of infantile hypertrophic pyloric stenosis has displayed a growing consensus among pediatric surgeons. However, in up to 30% of cases, the supraumbilical skin fold incision does not allow a comfortable access. Delivery through this route, a large pyloric tumor into the wound to perform a pyloromyotomy, can be fairly difficult and time consuming and may damage the gastric or duodenal serosa by tearing. Other technical variants have been proposed to overcome these limitations, but some are more complicated, some are demanding, and some others can worsen the final cosmetic result.

Methods

The authors present a personal modification to the Tan-Bianchi procedure that they have successfully applied in the last 25 cases of infantile hypertrophic pyloric stenosis. A right semicircular umbilical skin fold incision is performed. The anterior rectus abdominis muscle (RAM) sheath is incised vertically all around the umbilicus, the muscle is laterally displaced, and its posterior sheath and the peritoneal cavity entered in the same line. Because all incisions lay in the same axis, the abdominal cavity is largely opened by 2 retractors without the need for excessive increased traction as it often happens with the supraumbilical approach.

Results

This technical variant was particularly useful to deliver a very large hypertrophic pyloric muscle into the wound. There were no complications and excellent cosmetic results were obtained in all patients.

Conclusions

These observations suggest that a right semicircular umbilical skin fold incision is an attractive alternative for pyloromyotomy mostly when facing with a large pyloric tumor.     

Surgical practice for infantile hypertrophic pyloric stenosis in the United Kingdom and Ireland--a survey of members of the British Association of Paediatric Surgeons

Purpose

Operative strategy and antibiotic policy in treating infantile hypertrophic pyloric stenosis (IHPS) may vary widely. This study surveys current practice in the United Kingdom and Ireland among members of the British Association of Paediatric Surgeons.

Methods

The study used postal and email survey of consultant pediatric surgeons.

Results

One hundred five questionnaires were distributed, and 94 replies (90% response) were received. Umbilical pyloromyotomy is performed exclusively by 57 surgeons. Fourteen surgeons (15%) use laparoscopy, whereas 5 (randomized trial in progress) use the umbilical or laparoscopic route. Eight reported that the umbilical or classical right upper quadrant (RUQ) incision is undertaken at their institution according to surgeon's preference. Ten surgeons only deploy an RUQ incision. Antibiotic practice showed that 40 (70%) using the umbilical incision prescribe prophylactic therapy, whereas only 6 adopting other operative techniques (RUQ incision or laparoscopy) found this policy beneficial. More than 50% surveyed do not routinely recommend antibiotics.

Conclusion

Umbilical pyloromyotomy is used by most pediatric surgeons in the United Kingdom and Ireland. Laparoscopy is increasingly popular in minimally invasive centers. The RUQ incision is used by a minority of surgeons. Antibiotic prophylaxis was common with the umbilical incision only. The superior cosmetic results offered by umbilical pyloromyotomy and laparoscopy are a benchmark for surgeons currently providing contemporary care for babies with IHPS.     

Treatment of infantile hypertrophic pyloric stenosis in a district general hospital: a review of 160 cases

Background: Ramstedt’s pyloromyotomy has long been the standard operation for the treatment of infantile hypertrophic pyloric stenosis. Controversy exists over whether this procedure can be performed safely in the district general hospital setting or whether it should be restricted to specialist pediatric units only.Methods: Retrospective analysis was performed on the medical records of a series of 160 infants treated by Ramstedt’s pyloromyotomy by 2 surgeons in a district general hospital over 16 years.Results: There was no perioperative mortality. Oral feeding was achieved by 24 hours in 76% of infants, and there was persistent vomiting in only 3.8%. Wound discharge was encountered in 4.4% and confirmed wound infection in 1.3%. Wound dehiscence occurred in 1.9% of infants. Inadvertent mucosal perforation occurred in 19% of cases, although all cases were recognized and repaired at once with no apparent ill effects. These results are comparable with those reported from specialist pediatric units and from pediatric surgeons working within general surgical units.Conclusions: Infantile hypertrophic pyloric stenosis can be treated safely in a district general hospital when care is provided by appropriately trained surgical, anesthetic, and pediatric staff.     

Surgical technique of laparoscopic pyloromyotomy for infantile hypertrophic pyloric stenosis

We report herein a new method of performing laparoscopic pyloromyotomy for infantile hypertrophic pyloric stenosis, using refined surgical techniques. The pyloric tumor was immobilized by grasping the first portion of the duodenum and the anterior wall of the stomach, and electrocoagulation was used prior to incising the pyloric tumor to minimize bleeding during the procedure. Although this technique has been applied in only two patients so far, we present the details herein. We believe that with technical and instrumental refinements, the speed and safety of laparoscopic pyloromyotomy will improve and it will become an alternative to open surgery in pediatric patients.     

Evaluation of surgical approaches to pyloromyotomy: a single-center experience

Background

This study was conducted to evaluate the outcome of various approaches to pyloromyotomy: supraumbilical (SU), right upper quadrant (RUQ), and laparoscopic (LP).

Methods

Single-center retrospective review from 1998 to 2005 with institutional review board approval, evaluating 192 pyloromyotomies based on surgical approach: RUQ (119), SU (64), and LP (9). Patient demographics, acid-base/electrolyte status on presentation, mean operative time, postoperative length of stay, and complications were evaluated.

Results

Patient demographics, acid-base/electrolyte status, and mean operative time were not significantly different. The median length of stay was 34, 29, and 24.5 hours for SU, RUQ, and LP, respectively (P = .479). The frequency of duodenal/gastric perforations in the SU, RUQ, and LP groups were 1, 4, and 1, respectively. The LP perforation was not recognized intraoperatively, resulting in sepsis and multiorgan failure. One patient in the SU group had a late adhesive bowel obstruction requiring laparotomy and bowel resection. Wound infection rates did not differ significantly between groups (SU, 4; RUQ, 2; LP, 1; P = .113).

Conclusion

Pyloromyotomy is associated with a low complication rate. Cosmetically, SU is superior to the RUQ approach. The added benefits of being able to examine the integrity of the duodenal mucosa intraoperatively and its short learning curve may make SU a safer alternative to LP for surgeons who are still practicing the RUQ approach.     

Comparison between umbilical and transverse right upper abdominal incision for pyloromyotomy

Background

Besides laparoscopic pyloromyotomy, the operation for pyloric stenosis has been performed using 2 standard open surgical exposures: the right upper quadrant (RUQ) incision and the semi-circumumbilical (UMB) incision. The aim of this study was to compare the morbidity and cosmetic results of both open exposures.

Methods

Between 1990 and 1995, we performed 104 pyloromyotomies through a RUQ incision. These operations were retrospectively compared with 133 UMB incisions performed between 1995 and 1999.

Results

There were no significant differences between the 2 groups regarding age at presentation, sex, and preoperative status. Only a significantly higher percentage of patients with a metabolic alkalosis before surgery was found in the UMB group, but this did not affect morbidity rate. The groups did not differ significantly with respect to mucosal perforations (P = .95), wound infections (P = .53), inadequate pyloromyotomies (P = .42), or other complications. The mean operating time was slightly longer in the UMB group (P < .025). The UMB approach produced a better cosmetic result, with an almost invisible scar.

Conclusions

This study has shown that the UMB approach has equal intra- and postoperative complication rates as compared with the RUQ approach. The main advantage of the UMB approach is that it produces an excellent long-term cosmetic result.