Impact of diagnostic laparoscopy on the management of chronic pelvic pain

Background Diagnostic laparoscopy is a useful tool, especially when there is no definite anatomical abnormality visible on imaging modalities. We assess the role and clinical impact of diagnostic laparoscopy in the management of women with chronic pelvic pain. Methods Clinical data of 3,068 cases of diagnostic laparoscopy performed for chronic pelvic pain from June 1994 to August 2005 were analyzed. We compared the diagnoses after diagnostic laparoscopy and those after pelvic examination and imaging modalities such as ultrasound or computed tomography (CT), and we then checked the final pathologic diagnoses after operation. Results Pelvic endometriosis was the most common (60.2%) laparoscopic finding in patients with chronic pelvic pain in this study, followed by normal pelvic findings (21.2%) and pelvic congestion (13.0%). Diagnostic laparoscopy had an influence on correcting previous plans based on imaging modalities in 42.7% of patients such as discarding unnecessary procedures or introducing new diagnostic or therapeutic plans. There were 3 cases of major complications requiring immediate correction. Conclusions Diagnostic laparoscopy is a useful diagnostic tool for of women with chronic pelvic pain and can be used as a guideline for individualized treatment.     

The accuracy of diagnostic laparoscopy in trauma patients: a prospective, controlled study

BACKGROUND: Numerous studies advocate the use of diagnostic laparoscopy (DL) for abdominal trauma, but none have documented its ability to diagnose specific injuries. This study tests the hypothesis that DL can accurately identify all significant intra-abdominal injuries in trauma patients. METHODS: Of trauma patients requiring laparotomy for presumed injuries, 47 underwent DL followed by laparotomy. Injuries noted at laparoscopy were compared with those found at laparotomy. RESULTS: Of these, 14 patients had no significant injuries necessitating operative intervention noted at laparoscopy and celiotomy. The remaining 33 patients harbored 93 significant injuries at laparotomy, of which only 57.0% were found by DL. DL possessed poor sensitivity (<50%) for injuries to hollow viscera. Despite DL's poor performance in finding specific injuries, it possessed excellent sensitivity (96.2%), and specificity (100%) for determining the need for therapeutic celiotomy. CONCLUSIONS: DL offers no clear advantage over diagnostic peritoneal lavage and computed tomography in blunt trauma. Its utility lies in assessment of the need for laparotomy in patients with penetrating wounds. Currently, DL cannot consistently identify all abdominal injuries, disqualifying it as a therapeutic tool in abdominal trauma.     

Palliative surgery for far-advanced gastric cancer: a retrospective study on 305 consecutive patients

Few reports of the Western countries have investigated the value of palliative surgery for stomach cancer. The aim of this study was to evaluate the results of palliative surgery in a large series of patients affected by gastric carcinoma, consecutively treated by the same surgical team. The hospital records of 305 patients affected by gastric cancer who did not undergo surgical treatment or who underwent a palliative surgical procedure at our unit between 1981 and 1995 were reviewed. Univariate and multivariate analyses were used to calculate the 5-year survival probabilities with respect to the following variables: demographic data, tumor location and gross appearance, spread of the disease, histological type according to P. Lauren, and type of treatment. Multivariate logistic regression analysis showed that resectional surgery and tumor spread limited to local sites were independently associated with better survival. The study indicates that even though there are host-related factors that govern survival in far-advanced stomach cancer, the type of surgery can have a significant effect on prognosis; resectional surgery should be undertaken whenever possible in such patients.     

Impact of laparoscopy on the management of adrenal diseases. A retrospective study of 220 patients

OBJECTIVE: Soon after its introduction in 1992, laparoscopic adrenalectomy became the gold standard in the surgical management of most adrenal tumors. The aim of this study was to assess the influence of laparoscopy on surgical indications. PATIENTS AND METHODS: Between 1994 and 2003, 220 adrenalectomies were performed, 179 among them by a laparoscopic approach. There were 137 females and 83 males. The mean age was 53 years (range 15-83 years). RESULTS: The indications of adrenalectomy were: Cushing syndrome 18%, pheochromocytoma 31%, Conn syndrome 16%, incidentaloma 21%, and malignant tumours 13%. Laparoscopic approach was performed in 81% of the cases and the conversion rate was 11%. There were 3 postoperative deaths (2 after laparoscopy). The mean hospital stay was 7.6 days in the laparoscopic group, and 13.6 days in the open surgery group. CONCLUSIONS: This study is consistent with the findings of the literature supporting that there are no indications for the open procedure in case of small benign lesions. The video-asisted adrenalectomy had not changed the management of the adrenal incidentaloma. Today, the laparoscopic approach seems to be adapted also for malignant disease.     

FDG-PET improves management of patients with colorectal liver metastases allocated for local treatment: a consecutive prospective study.

BACKGROUND AND AIM: Colorectal cancer is a common cancer in the Nordic countries and 50% of the patients develop liver metastases. Liver resection may result in long term survival. Proper staging is therefore essential and CT is the standard imaging modality. We examined whether additional FDG-PET improves therapeutic management of patients with colorectal liver metastases. PATIENTS AND METHODS: Fifty-four consecutive patients were enrolled. Each patient had a treatment plan made based on our standard evaluation. The patients then had a PET scan and the treatment plan was re-evaluated, taking these results into account. RESULTS: In 76% of the cases, PET did not change the treatment plan due to complete concordance with CT. In another 19% of the cases, the plan was altered due to finding of more liver lesions by PET than by CT (four patients), fewer or no liver lesions (three patients), and extrahepatic lesions not visible on CT (three patients). In 5% of the cases, non-concordance between PET and CT did not change the therapeutic plan. CONCLUSION: Pre-treatment FDG-PET, used supplementary to CT, improved the treatment plan in one fifth of the patients with colorectal liver metastases.     

The utility of diagnostic laparoscopy for abdominal disorders. Audit of 120 patients.

We audited our recent experience with diagnostic laparoscopy performed over a 30-month period on 131 consecutive patients. Laparoscopy was 100% accurate in the diagnosis or exclusion of intra-abdominal malignant neoplasms, and future care decisions were affected by this information. Laparoscopy in the evaluation of chronic abdominal pain yielded positive findings in 47% of cases. The majority of referrals (73%) for the investigation of chronic abdominal pain came from the medical services, whereas the majority of referrals (72%) for the investigation of cancer originated from surgeons. Laparoscopy in the setting of acute abdominal pain yielded useful information that affected patient outcomes in 71% of cases. There were no serious complications in this series. Laparoscopy is a safe and useful diagnostic tool, especially for the diagnosis, staging, or exclusion of cancer.     

Laparoscopic gastric banding: a minimally invasive surgical treatment for morbid obesity: prospective study of 500 consecutive patients

OBJECTIVE: To evaluate early and late morbidity of laparoscopic adjustable gastric banding for morbid obesity and to assess the efficacy of this procedure by analyzing its results. SUMMARY BACKGROUND DATA: Laparoscopic adjustable gastric banding is considered the least invasive surgical option for morbid obesity. It is effective, with an average loss of 50% of excessive weight after 2 years of follow-up. It is potentially reversible and safe; major morbidity is low and there is no mortality. METHODS: Between April 1997 and June 2001, 500 patients underwent laparoscopic surgery for morbid obesity with application of an adjustable gastric band. There were 438 women and 62 men (sex ratio = 0.14) with a mean age of 40.4 years. Preoperative mean body weight was 120.7 kg and mean body mass index (BMI) was 44.3 kg. m. RESULTS: Mean operative time was 105 minutes, 84 minutes during the last 300 operations. Mean hospital stay was 4.5 days. There were no deaths. There were 12 conversions (2.4%), 2 during the last 300 operations. Fifty-two patients (10.4%) had complications requiring an abdominal reoperation. Forty-nine underwent a reoperation for minor complications: slippage (n = 43, incisional hernias (n = 3), and reconnection of the catheter (n = 3). Three patients underwent a reoperation for major complications: gastroesophageal perforation (n = 2) and gastric necrosis (n = 1). Seven patients had pulmonary complications and 36 patients experienced minor problems related to the access port. At 1-, 2-, and 3-year follow-up, mean BMI decreased from 44.3 kg. m to 34.2, 32.8, and 31.9, respectively, and mean excess weight loss reached 42.8%, 52%, and 54.8%. CONCLUSIONS: Laparoscopic adjustable gastric banding is a beneficial operation in terms of excessive weight loss, with an acceptably low complication rate. It can noticeably improve the quality of life in obese patients. Half of the excess body weight can be effortlessly lost within 2 years.     

Curative surgery for gastric cancer: Study of 166 consecutive patients

From January 1980 to December 1991 we operated on 295 patients with a gastric carcinoma. In 166 cases (56.3%) surgery was performed with curative intent. In 93 patients (56%) a subtotal gastrectomy was performed, and in 73 cases (44%) a total gastrectomy. In all the cases a D-2 type lymphadenectomy was used. The global morbidity rate was 23%, and in-hospital mortality was 3.6%. The morbidity and mortality rates of these two operations were statistically different. Global 5-year survival estimate for the whole series is 61.3%. Univariate and multivariate analysis according to T and N (TNM classification), the number of positive nodes resected, and the relation of positive per resected nodes, revealed statistically different outcomes. This kind of quantitative classification allowed identification of high risk groups irrespective of site of nodal involvement. Tumors classified as intestinal or diffuse type by the Lauren classification had similar survival curves and 5-year survival estimates (p=0.834). By univariate and multivariate analysis this classification did not reveal a prognostic value in this group of patients. In our opinion, tumor penetration and lymph node involvement are at present the most reliable prognostic factors available.

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Resumen En el período enero 1980 a diciembre 1991 se operaron 295 pacientes con carcinoma gástrico. En 166 (56.3%), la cirugía fue realizada con intención curativa; en 93 (56%) se realizó gastrectomía subtotal y en 73 (44%) gastrectomía total. En la totalidad de los casos se realizó linfadenectomía D-2. La mortalidad global fue 23% y la mortalidad hospitalaria 3.6%. Las tasas de mortalidad y morbilidad de estas dos operaciones aparecieron significativamente diferentes. La sobrevida global a cinco años estimada para la totalidad de la serie es de 61.3%. Los análisis uni y multivariables de acuerdo con la clasificación TNM, el número de ganglios positivos resecados y la relación positivos/resecados revelaron resultados estadísticamente diferentes. Este tipo de clasificación cuantitativa permitió la identificación de Grupos de alto riesgo independientes del lugar de la invasión ganglionar. Los tumores clasificados como intestinales o difusos (clasificación de Lauren), registraron similares curvas de sobrevida y de sobrevida estimada a cinco años (P=0.834). Mediante el análisis univariable y multivariable esta clasificación no demostró tener valor pronóstico en nuestro Grupo de pacientes. En nuestra opinión, el grado de penetración del tumor y la invasión ganglionar son los factores de pronóstico más confiables.

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Résumé Entre Janvier 1980 et Décembre 1991, nous avons opéré 295 patients ayant un cancer gastrique. Chez 166 (56.3%), l'exérèse a été jugée curative. Chez 93 (56%) des cas, il s'agissait d'une gastrectomie subtotale alors que dans 73 (44%) cas, une gastrectomie totale a été pratiquée. Dans tous les cas une lymphadénectomie du type D-2 lui a été associée. La morbidité globale a été de 23% et la mortalité hospitalière de 3.6%. La morbidité et la mortalité des deux types d'intervention différaient de façon statistiquement significative. La survie à 5 ans de la série en entier a été de 61.3%. Une analyse uni et multifactorielle a pu mettre en évidence une différence statistiquement significative en ce qui concerne la survie par rapport à la classification T-N (TNM), le nombre de ganglions réséqués et le nombre de ganglions envahis/nombre de ganglions enlevés. Cette analyse a permis d'identifier les malades à haut risque, indépendamment du site de l'envahissement lymphatique. La courbe de survie et la survie estimée à 5 ans étaient identiques selon que la tumeur a été classée intestinale ou diffuse selon Lauren. Cette classification n'a pas, pourtant, de valeur pronostique d'après les analyses uni et multifactorielle. A notre avis, la pénétration tumorale et le degré d'envahissement lymphatique sont les deux facteurs pronostiques les plus constants.

     

Outpatient laparoscopic cholecystectomy. A prospective study with 100 consecutive patients

One hundred patients with cholelithiasis were included in a prospective consecutive follow-up study to evaluate laparoscopic cholecystectomy in a day surgical setting. The median operating time was 70 min. In 96% of the patients, it was possible to perform peroperative cholangiography. The median time off work was 7 days and the median time to full recovery was 14 days. Five patients were admitted due to weakness/nausea. Six patients were admitted due to conversion to open surgery or choledocholithiasis. Eighty-nine patients were treated in ambulatory surgery. We conclude that laparoscopic outpatient cholecystectomy can be performed safely with a low unplanned admission rate.     

A prospective analysis of staging laparoscopy in patients with primary and secondary hepatobiliary malignancies

Laparoscopy and laparoscopic ultrasound are used widely in cancer staging and are perceived to prevent unnecessary open exploration in many patients. The aim of this study was to analyze the impact of staging laparoscopy in improving resectability in patients with primary and secondary hepatobiliary malignancies. Over a 10-month period (November 1, 1997 to August 31, 1998), 186 patients with primary and secondary hepatobiliary cancers were submitted to operation for potentially curative resection. One hundred four patients staged laparoscopically (LAP) before laparotomy were compared prospectively to 82 patients undergoing exploration without laparoscopy (NO LAP). Assignment to each group was not random but was based on surgeon practice. Demographic data, diagnoses, the extent of preoperative evaluation, and the percentage of patients resected were similar in the two groups. Laparoscopy identified 26 (67%) of 39 patients with unresectable disease. In the NO LAP group, 28 patients (34%) had unresectable disease discovered at laparotomy. In patients with unresectable disease and submitted to biopsy only, the operating times were similar in the two groups (LAP 83 ±22 minutes vs. NO LAP 91 ±33 minutes; P = 0.4). However, laparoscopic staging significantly reduced the length of hospital stay (LAP 2.2 ±2 days vs. NO LAP 8.5 ±8.6 days; P = 0.006). Likewise, total hospital charges, normalized to 100 in the NO LAP patients, were significantly lower in the LAP group (LAP 54 ±42 vs. NO LAP 100 ±84; P = 0.02). Staging laparoscopy identified the majority of patients with unresectable hepatobiliary malignancies, significantly improved resectability, and reduced the number of days in the hospital and the total charges. The yield of laparoscopy was greatest for detecting peritoneal metastases (9 of 10), additional hepatic tumors (10 of 12), and unsuspected advanced cirrhosis (5 of 5) but often failed to identify nonresectability because of lymph node metastases, vascular involvement, or extensive biliary involvement. Eighty-three percent of patients subjected to laparotomy after laparoscopy underwent a potentially curative resection compared to 66% of those who were not staged laparoscopically. Supported in part by grants R01 CA76416 (Dr. Fong) and R01CA/DK80982 (Dr. Fong) from the National Institutes of Health. Presented at the Fortieth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Fla., May 16–19, 1999.     

Bedside diagnostic laparoscopy for critically ill patients: a retrospective study of 62 patients

Background

Bedside diagnostic laparoscopy has an important role of diagnosing acute abdomen in critically ill patients hospitalized in the intensive care unit (ICU). Delayed diagnosis of intraabdominal pathology increases the morbidity and mortality rates for these patients, whose clinical signs often are absent due to analgesic medication and sedation.

Methods

In this retrospective study performed from January 2007 to December 2009, 62 consecutive ICU patients whose blood test results showed them to be hemodynamically unstable underwent bedside diagnostic laparoscopy. The inclusion criteria specified clinically suspected acute cholecystitis, unknown sepsis, acidosis with a high level of lactate, elevated lab tests (white blood cell count, bilirubin, lactic dehydrogenase, creatine phosphokinase, gamma glutamyl transferase [??GT]), and acute anemia with suspected intraabdominal bleeding. The major contraindications to bedside diagnostic laparoscopy were coagulopathy, endocranic hypertension, and heart failure. Patients with a clear indication for an open surgical procedure were excluded from the study.

Results

Of the 62 patients who underwent bedside diagnostic laparoscopy, 43 (69.3?%) had positive findings and 29 (46.7?%) had acute acalculous cholecystitis. The mean operation time was 38 min, and no procedure-related deaths occurred. The procedure was performed for postsurgery patients, especially after cardiac operations, and for trauma or septic patients. Respiratory and hemodynamic parameters were monitored before, during, and after the procedure.

Conclusions

As a minimally invasive procedure, bedside diagnostic laparoscopy can be performed in the ICU for hemodynamically unstable patients. It is safe procedure with high diagnostic accuracy for acute intraabdominal conditions that avoids negative laparotomies for unstable patients. The bedside diagnostic laparoscopy procedure is not performed widely, and prospective studies are needed to better evaluate outcome and advantages for critically ill patients.     

预防性镇痛在胃癌根治术中应用价值的前瞻性研究

目的 探讨预防性镇痛方案在胃癌患者行胃癌根治术中的应用价值.方法 选取2012年7月至2013年6月第四军医大学西京消化病医院行胃癌根治术的161例患者行前瞻性随机研究.采用随机、单盲对照法,通过随机数字表法将入组患者分为预防性镇痛组和对照组.两组患者行胃癌根治术,包括传统胃大部分切除联合毕Ⅱ式吻合术,或全胃切除联合食管空肠吻合术,术后均经空肠营养管给予肠内营养.预防性镇痛组开腹前给予地塞米松10 mg和帕瑞昔布200 mg静脉注射,开腹前、入腹后、关腹时在腹壁切口周围浸润注射0.5％罗哌卡因7～8 mL,术后连续3d口服塞来昔布.对照组仅在术后给予静脉留置管泵注入镇痛剂.记录2组患者视觉模拟评分(VAS)、术后每天下床活动时间＞8h的患者例数、术后肛门排气时间、术后排便时间、住院时间.正态分布的计量资料采用x±s表示,组间比较采用t检验和重复测量方差分析;偏态分布数据和等级资料采用秩和检验;计数资料采用四格表x2检验.结果 筛选出符合研究条件的患者161例,分为预防性镇痛组(87例)和对照组(74例).预防性镇痛组患者术后第1、2、3天VAS评分分别为(2.8±0.6)分、(2.6±0.4)分、(1.8±0.4)分,对照组患者分别为(5.3±0.5)分、(4.2±0.6)分、(2.4±0.3)分,两组比较,差异有统计学意义(F=4.25,P＜0.05).预防性镇痛组患者术后第1、2、3天每天下床活动时间＞8h的例数分别为8、17、20例,对照组分别为0、3、11例,两组比较,差异有统计学意义(x2=7.60,10.26,3.16,P＜0.05).预防性镇痛组患者术后肛门排气时间、术后排便时间和术后住院时间分别为(51 ±24)h、(61 ±24)h、(5.5 ±3.0)d,对照组分别为(71 ±23)h、(83±30)h、(6.3±2.1)d,两组比较,差异有统计学意义(t=5.32,5.04,0.17,P＜0.05).两组患者术后均顺利康复,未出现呼吸抑制和切口感染等并发症及药物不良反应.结论 胃癌患者施行胃癌根治术围术期采用预防性镇痛方案,可减轻患者术后疼痛,促进患者肠道功能恢复,加速患者术后康复.临床试验注册在中国临床试验注册中心注册,注册号为ChiCTR-TRC-11001440.     

Minimally invasive single-vessel coronary artery bypass with the internal thoracic artery and early postoperative angiography: midterm results of a prospective study in 120 consecutive patients

BACKGROUND: This prospective study was undertaken to determine the role of the minimally invasive direct coronary artery bypass with early postoperative angiography and midterm follow-up in 120 consecutive patients with single-vessel coronary artery disease. METHODS: Minimal access (6 to 10 cm), without complete sternotomy and no cardiopulmonary bypass, was used. The lesions were located at the proximal left anterior descending coronary artery in 95% of the patients. Routine coronary angiography was performed before discharge. RESULTS: Postoperative angiography was performed in 104 (90.4%) of those 115 patients who had coronary revascularization concluded by the mini-access method. The internal thoracic artery patency rate was 98.1% (95.2% grade A). Two (1.7%) patients presented with perioperative myocardial infarction, which led to the single in-hospital death (0.8%). Of the remaining 119 patients, 113 (95.0%) were asymptomatic. The event-free probability was 94.9% and the actuarial survival was 98.3% with 42 months of follow-up. CONCLUSIONS: For selected patients with single-vessel coronary artery disease and no major myocardial dysfunction, minimally invasive direct coronary artery bypass is a safe operation and a less invasive alternative to conventional coronary artery bypass grafting.     

胸腹腔镜联合食管癌切除术后颈部残胃闭锁端瘘的诊治经验

目的分析胸腹腔镜联合食管癌切除术后颈部残胃闭锁端瘘的临床特点,总结治疗经验,探讨个体化治疗方法。 方法2014年9月至2015年8月期间,山东大学齐鲁医院胸外科同一手术团队共行胸腹腔镜联合食管癌切除术77例,收集术后发生颈部残胃闭锁端瘘患者的临床资料,进行回顾性分析。 结果共有3例(3.9%)患者发生颈部残胃闭锁端瘘,残胃闭锁端瘘的发生时间分别为术后第4、4、6天,临床表现主要为颈部切口红、肿、压痛、皮下积气及脓液溢出。3例患者均经保守治疗痊愈出院,治愈时间分别为9、13、35 d。 结论胸腹腔镜联合食管癌切除术后颈部残胃闭锁端瘘的发生率较高,局部处理应根据瘘发生时间、瘘口大小和局限程度等给予个体化治疗,以促进瘘口愈合。     

胃切除方式对胃中部癌患者预后的影响

目的探讨胃切除方式对胃中部癌患者预后的影响。方法回顾性分析1998年1月至2005年12月间福建医科大学附属协和医院收治的222例胃中部癌患者的临床资料,其中行开腹远端胃大部切除术66例（DG组）,行开腹全胃切除术患者156例（TG组）,比较两组患者术后5年的生存率。结果DG组和TG组术后5年生存率分别为63．9％和49．8％,差异具有统计学意义（P〈0．05）。但相比之下,TG组患者肿瘤更大、分期更晚、肿瘤位于小弯侧者居多（均P〈0．01）。按TNM分期进行分层预后分析显示,相同病期的两组患者术后5年生存率的差异均无统计学意义（均P〉0．05）。无论是以4cm、5cm还是6cm作为近切缘截点,不同近切缘距离患者5年生存率的差异均无统计学意义（均P〉0．05）。多因素预后分析显示,浸润深度、淋巴结转移和TNM分期是独立预后影响因素（均P〈0．05）;而胃切除方式并不是独立预后因素（P〉0．05）。结论胃中部癌患者如果能够达到根治手术的要求,其预后不受胃切除方式的影响,行远端胃大部切除术是可行的。     

淋巴结隐匿性微转移对肺癌预后影响的前瞻性研究

目的　探讨肺癌纵隔淋巴结隐匿性微转移的诊断方法并评价其预后意义。方法　应用逆转录聚合酶链反应法 (RT PCR) ,对 5 8例非小细胞肺癌手术后病理检查阴性 (pN0 )的 2 4 2组纵隔淋巴结进行淋巴结中MUC1基因mRNA表达的再检测 ,诊断纵隔淋巴结隐匿性微转移。对病人进行随访 ,应用Ka plan Meier法计算生存率 ,Log Rank检验比较生存差别。 结果　 16例病人的 2 3组纵隔淋巴结中检测到MUC1基因mRNA表达 ,诊断为纵隔淋巴结隐匿性微转移 ,常规病理检查的漏诊率为 2 7 6 % (16 /5 8例 )。病人的TNM分期由IA～IIB 期上调为IIIA 期。纵隔淋巴结隐匿性微转移组 3年生存率为 4 3 7% ,无转移组的 3年生存率为 73 8%。两组差异有显著统计学意义 (P <0 0 5 )。结论　应用RT PCR法检测纵隔淋巴结中MUC1基因mRNA的表达 ,可以诊断纵隔淋巴结隐匿性微转移 ,提高肺癌TNM分期的准确性 ;纵隔淋巴结隐匿性微转移与部分pN0 病人预后不良有关。