Laparoscopic-assisted abdominoperineal resection in the prone position

With the introduction of laparoscopic-assisted abdominoperineal resection (LAPR), the traditional Lloyd-Davies position with the Mayo two-team combined approach is being adapted. The Lloyd-Davies position allows two teams of surgeons to work simultaneously, minimizing operating time. The conditions required for laparoscopy restrict a simultaneous procedure. Since LAPR is typically performed as a two-stage procedure, we introduce an alternative position which facilitates the perineal dissection. We review the results and technique of LAPR in the prone position in three patients who were suitable candidates for this procedure. Three patients underwent LAPR. No operative or postoperative complications were encountered and the procedures were in keeping with oncologic principles of resection. Total anesthesia times were less than 3.5 h for these initial patients. No hemodynamic problems were encountered due to the choice of patient positioning. The prone jackknife position greatly increases visualization of deep structures, reduces blood loss, enhances dissection, and reduces the technical demands of the laparoscopic portion of the procedure. Received: 23 October 1995/Accepted: 5 August 1996     

Video-assisted thoracoscopic surgery in the management of loculated empyema

Background: Fibropurulent empyema (stage II of Light) does not respond to antibiotic therapy and simple drainage. If the condition is inadequately treated, restrictive pulmonary deficit develops, necessitating thoracotomy and decortication. We report our experience with the videoscopic management of stage II and limited stage III disease. Methods: Ten consecutive patients underwent videoscopic debridement of fibropurulent empyema; three of them required removal of limited visceral and parietal rind. Results: The mean operating time was 42 ± 8.1 min. Postoperative pyrexia and leucocytosis settled within 4.2 ± 2.1 days and 13.1 ± 3.2 days, respectively. Intercostal chest tubes were removed by 4.5 ± 1.0 days. The mean fall in hematocrit following surgery was 4.9%. Parenteral analgesics were required for 1.0 ± 0.5 days and oral analgesics for 3 ± 1.6 days. The mean postoperative stay was 11 ± 8.1 days. No patient required any further intervention. Conclusions: Videoscopic debridement of empyema produces excellent results, with minimal patient morbidity and a short hospital stay. We recommend it as the preferred method for first-line management of fibropurulent (stage II) empyema. Received: 10 December 1998/Accepted: 13 May 1999     

Is laparoscopic resection of colorectal polyps beneficial?

Background: We set out to compare the results of laparoscopic and open resections of colorectal polyps. Methods: Forty-five consecutive patients who underwent operation by a single surgeon for endoscopically irretrievable colonic polyps between April 1992 and March 1996 were classified into the following two groups: group I, laparoscopic procedures for colonic polyps (n= 23); and group II, open procedures for colonic polyps (n= 22). Results: No significant differences were seen between the groups relative to age [71.7 ± 10.7 versus 70.6 ± 13.7 years], gender [male:female = 10:13 versus 13:9], history of previous abdominal operation (eight of 23 [34.8%] versus 10 of 22 [45.5%]), type of pathology (villous: seven of 23 [30.4%] versus four of 22 [18.1%], tubulovillous: nine of 23 [39.1%] versus six of 22 [27.2%], tubular: three of 23 [13.0%] versus seven of 22 [31.8%]), size of polyps (2.6 ± 1.7 cm versus 2.7 ± 1.5 cm), or type of procedures (right hemicolectomy: 15 of 23 [65.2%] versus 11 of 22 [50%], sigmoid colectomy: five of 23 [21.7%] versus six of 22 [27.3%], left hemicolectomy: two of 23 [8.7%] versus two of 22 [9.1%]). There was no mortality and no difference in the incidence of postoperative complications (four of 23 [17.4%] versus seven of 22 [31.8%]), blood loss (167 cc versus 243 cc), number of retrieved lymph nodes (7.1 ± 5 versus 6.6 ± 4), incidence of carcinoma in polyps (two of 23 [13.0%] versus four of 22 [18.2%]), or medical cost ($22,840 versus $18,420), respectively, between the two groups. There were statistically significant differences in length of ileus (3.5 ± 1.0 days versus 5.5 ± 1.8 days), postoperative pain (2.3 ± 1.4 versus 3.7 ± 1.9 on postoperative day 1 [patient pain rating scale 1–10]), length of hospital stay (6.5 ± 2.0 days versus 9.4 ± 2.7 days), and return to normal activity (5.2 ± 4.2 weeks versus 9.3 ± 12.1 weeks) in group I compared to group II, respectively. However, patients in group II had a longer mean specimen length (18.5 ± 6.4 cm versus 29.1 ± 22.7 cm) and a shorter mean operative time (177.6 ± 52.7 min versus 143 ± 51.4 min) than patients in group I. Conclusions: Laparoscopic colectomy for colonic polyps has definite advantages over traditional open surgery, including less postoperative pain, earlier return of bowel function, and earlier return to normal activity. Conversely, its disadvantages include longer operative time and a shorter specimen. Received: 27 January 1997/Accepted: 2 February 1998     

Production and systemic absorption of toxic byproducts of tissue combustion during laparoscopic surgery

Background: Among the potential hazards of laparoscopic surgery using electrocautery is the intraperitoneal release and subsequent absorption of byproducts of tissue combustion. In a porcine model of laparoscopic surgery with smoke production, our aims were to assess (1) the relationship between levels of intraperitoneal carbon monoxide (CO) and systemic carboxyhemoglobin (COHb) and methemoglobin (MetHb), and (2) intraperitoneal concentrations of other noxious gases, including hydrogen cyanide (HCN), acrylonitrile (Acr), and benzene (Bzn). Methods: Seven pigs underwent laparoscopic resection of three hepatic wedges using monopolar electrocautery in a CO₂ pneumoperitoneum. Sequential arterial samples were drawn to measure [COHb] and [MetHb] perioperatively, while gaseous intraabdominal [CO], [HCN], [Acr], and [Bzn] were assayed intraoperatively. Results: The mean ± SEM duration of operation was 90 ± 2 min, and electrocautery was used for 68 ± 4 min. Intraabdominal [CO] rose from 0 to 814 ± 200 ppm (p < 0.01) while [COHb] increased from 2.9 ± 0.1% to 3.5 ± 0.1% (p < 0.001). Systemic [MetHb] remained unchanged intra- and postoperatively, ranging from 0.3 to 0.7%. Intraperitoneal [HCN] rose from 0 to 5.7 ± 0.7 ppm (p < 0.001). [Acr], however, did not change significantly from preoperative values, ranging from 0 to 1.6 ± 1.0 ppm, and [Bzn] was undetectable. Conclusions: Laparoscopic tissue combustion increases intraabdominal [CO] to ``hazardous' levels leading to minimal, yet significant, elevations of [COHb]. Systemic [MetHb] and intraabdominal [HCN], [Acr], and [Bzn] are not elevated to toxic levels. Production of intraperitoneal smoke during laparoscopic electrosurgery therefore may not pose a significant threat to the patient. Received: 3 April 1997/Accepted: 22 May 1997     

Is laparoscopic sonography a reliable and sensitive procedure for staging colorectal cancer?

Background: Laparoscopic colectomy has developed rapidly with the explosion of technology. In most cases, laparoscopic resection is performed for colorectal cancer. Intraoperative staging during laparoscopic procedure is limited. Laparoscopic ultrasonography (LUS) represents the only real alternative to manual palpation during laparoscopic surgery. Methods: We evaluated the diagnostic accuracy of LUS in comparison with preoperative staging and laparoscopy in 33 patients with colorectal cancer. Preoperative staging included abdominal US, CT, and endoscopic US (for rectal cancer). Laparoscopy and LUS were performed in all cases. Pre- and intraoperative staging were related to definitive histology. Staging was done according to the TNM classification. Results: LUS obtained good results in the evaluation of hepatic metastases, with a sensitivity of 100% versus 62.5% and 75% by preoperative diagnostic means and laparoscopy, respectively. Nodal metastases were diagnosed with a sensitivity of 94% versus 18% with preoperative staging and 6% with laparoscopy, but the method had a low specificity (53%). The therapeutic program was changed thanks to laparoscopy and LUS in 11 cases (33%). In four cases (12%), the planned therapeutic approach was changed after LUS alone. Conclusions: The results obtained in this study demonstrate that LUS is an accurate and highly sensitive procedure in staging colorectal cancer, providing a useful and reliable diagnostic tool complementary to laparoscopy. Received: 2 May 1997/Accepted: 11 February 1998     

Evaluating results of laparoscopic surgery for esophageal achalasia

Background: Extramucosal myotomy of the lower esophagus and cardia, combined with anterior fundoplication, is, in our opinion, the procedure of choice to treat stage I–III esophageal achalasia. Methods: After a successful experience with open surgery in over 280 patients, from January 1992 through February 1997, 61 patients underwent laparoscopic Heller-Dor for stage I–III achalasia. Conversion to laparotomy was done in three cases. All procedures were performed under intraoperative endoscopic control. Intraoperative complications were seven mucosal tears, which were sutured laparoscopically in five cases. The sole postoperative complication was bleeding from an acute gastric ulcer (conservative treatment). Results: Follow-up consisted of clinical and radiographic study 1 month after surgery, and endoscopy and manometry within 1 year. After a mean follow-up (F.U.) of 21 months (1–62), clinical results range from excellent to good in 98.2%. One patient (1.7%) complaining of recurrent dysphagia improved after endoscopic dilation. Esophageal diameter reduced from 52 to 27 mm. LES pressure reduced from 30.3 ± 12.4 to 10.7 ± 3.5 mmHg (basal) and from 14.8 ± 9.3 to 2.9 ± 2.1 mmHg (residual). Conclusions: Laparoscopic Heller-Dor operation is feasible, safe, and effective. Special care should be taken in patients with previous endoscopic dilations. Received: 3 April 1997/Accepted: 28 July 1997     

Laparoscopic closure of perforated duodenal ulcer

Background: Medical treatment of peptic ulcer is highly successful, and the eradication of Helicobacter pylori (H. pylori) reduces ulcer recurrence. However, the incidence of perforated duodenal ulcer and its associated mortality have not been reduced by modern methods of therapy. Laparoscopic simple closure and omental plug by suturing, fibrin glue, and stapler have been successful. Methods: Over a 1-year period (1996–97), 21 patients with perforated duodenal ulcer were operated on in our hospital by laparoscopic simple closure and omental patch. The mean age was 36.4 ± 11.8 years (range, 18–61). Twenty patients were male (93.7%). The mean duration of pain was 9.1 ± 11.7 hs (range, 2–48). Three patients had a previous history of duodenal ulcer (14.3%), and another three (14.3%) patients had a history of nonsteroidal antiinflammatory drug (NSAID) intake. Erect chest radiograph showed that 19 patients had air under the diaphragm (90.5%). Sixteen patients (76.2%) had frank pus in the abdomen, and five patients had a minimal peritoneal reaction (23.8%). Results: The mean operative time was 71.6 ± 24.6 mins (range, 40–120), and the mean hospital stay was 5.2 ± 1.6 days (range, 3–9). The mean time to resume oral fluids was 3.1 ± 0.8 days (range, 2–4). Only one patient was reoperated due to leakage identified by gastrographin swallow. Conclusions: This procedure is safe and efficient; however, further study of its long-term effectiveness and comparability to existing therapy is still needed. Received: 28 May 1998/Accepted: 17 November 1998     

Endoscopic photodynamic therapy for obstructing esophageal cancer: 77 cases over a 2-year period

rid="id="<e5>Correspondence to:</e5> J. D. Luketich, 200 Lothrop Street, C-800, Presbyterian Hospital, Pittsburgh, PA 15213, USA Background: Photodynamic therapy (PDT) is an alternative treatment option for the palliation of obstructive esophageal cancer. We report our experience with PDT for patients presenting with inoperable, obstructing, or bleeding esophageal cancer. Methods: Seventy-seven patients with inoperable, obstructing esophageal cancer were treated with PDT from November 1996 to July 1998. Photofrin (1.5–2.0 mg/kg) was administered, followed by endoscopic light treatment (630 nm red dye laser) at 48 h. Dysphagia score (1 for no dysphagia to 5 for complete obstruction), dysphagia-free interval, and patient survival were assessed. Results: Seventy-seven patients underwent 125 PDT courses. The mean dysphagia score at 4 weeks after PDT in 90.8% of the patients improved from 3.2 ± 0.7 to 1.9 ± 0.8 (p < 0.05). PDT adequately controlled bleeding in all six patients who had bleeding. The most common complications after the 125 PDT courses were esophageal stricture (4.8%), Candida esophagitis (3.2%), symptomatic pleural effusion (3.2%), and sunburn (10.0%). Twenty-nine patients (38%) required more than one PDT course, and seven patients required placement of an expandable metal stent for recurrent dysphagia. The mean dysphagia-free interval was 80.3 ± 58.2 days. The median survival was 5.9 months. Conclusions: Photodynamic therapy is a safe and effective treatment for the palliation of obstructing and bleeding esophagus cancer. Received: 8 May 1999/Accepted: 24 September 1999/Online publication: 15 May 2000     

Accuracy of endorectal ultrasound after preoperative radiochemotherapy in locally advanced rectal cancer

Objectives: Factors limiting the accuracy of endorectal ultrasound in staging, locally advanced primary rectal cancer after preoperative neoadjuvant radiochemotherapy (RCT) were evaluated. Methods: Patients (n= 84) with initial locally advanced rectal cancer (uT3/uT4) undergoing R0 resection were investigated after preoperative treatment that combined radiotherapy up to 45 Gy with two cycles of chemotherapy (5-FU and leucovorin on d 1–5 and 22–28). At 4 to 6 weeks after completion of RCT and before tumor resection, preoperative endoluminal ultrasound was performed. Results: The accuracy to predict the depth of tumor infiltration (T-category) was found to correlate with downstaging. The T-category was correctly staged before surgery in 15 of the 51 responders (29%) and in 27 of 33 nonresponders (82%), whereas misinterpretation occurred in 36 of the responders (71%) and in 6 of the nonresponders (18%) (p < 0.001). Neither tumor distance from anal verge nor tumor location correlated with the staging accuracy. Lymph node involvement was correctly assessed in 48 patients (57%). Wall invasion was correctly ascertained in 42 patients (50%), with under estimation in 11 patients (13%) and overestimation in 31 patients (37%). Conclusions: After radiochemotherapy, endosonography does not provide a satisfactory accuracy for preoperative staging of rectal cancer. New interpretation and diagnostic criteria are needed for the prediction of treatment response. Received: 28 February 1999/Accepted: 2 April 1999     

Circumferential resection margin involvement after laparoscopic abdominoperineal excision for rectal cancer

Aim This study aimed to evaluate circumferential resection margin (CRM) involvement in patients with rectal adenocarcinoma after laparoscopic abdominoperineal excision (APR). Method Prospectively collected data were analyzed on consecutive patients who underwent laparoscopic APR for histologically proven rectal cancer following neoadjuvant chemotherapy, from 1998 to 2006. Patients with no sphincter involvement were not included and underwent intersphincteric resection with coloanal anastomosis. CRM involvement was defined as ≤ 2 mm using a standardized pathology protocol. Data were presented as mean ± SD or as median (range). Results Seventy‐four patients (60 ± 14 years of age; body mass index = 29.7 ± 7.9 kg/m²) underwent laparoscopic APR. The distance of the tumour from the anal verge was 3.1 ± 0.93 cm. All patients had sphincter involvement. The operative time was 180 ± 73 min, and estimated blood loss was 269 ± 149 ml. There were no conversions and no postoperative mortality. The adverse event rate was 11%. There were two reoperations and three readmissions. Seventy‐one patients had a T3 tumour and three patients had a T4 tumour. The median tumour size was 3.1 (range, 0–10) × 3 (range, 0–8.5) × 2 (range, 0–3.6) cm, and 26 (range, 3–41) lymph nodes were harvested. The median CRM was 7 (range, 1–11) mm. This was localized at the waist of the specimen in 12 (16.2%) of patients. Adjuvant therapy was given to 92% and 97% of patients with an involved and an uninvolved CRM, respectively. At 50 ± 27 months of follow up of 73 patients, 12 had CRM involvement and had a significantly decreased cancer‐specific survival (log rank test, P = 0.002). Conclusion Laparoscopic APR resulted in CRM involvement in 16.2% of patients with rectal cancer.     

The use of intraoperative ultrasound in laparoscopic adrenal surgery

Background: Laparoscopic adrenalectomy has been shown to be a safe and effective therapy for benign adrenal lesions. We review our experience with this procedure, including the use of laparoscopic ultrasound. Methods: We retrospectively reviewed our experience with 36 patients who underwent resection of 42 adrenal glands. Data gathered included preoperative evaluation and diagnosis, operative time, blood loss, complications, and follow-up status. Laparoscopic ultrasound was used to guide dissection and characterize a variety of adrenal lesions. Results: Thirty-five of 36 patients underwent successful laparoscopic adrenalectomy. There was one conversion to the open procedure in a patient with bilateral adrenal metastases from an endometrial cancer. For the bilateral laparoscopic procedure, the operative time averaged 262 mins, blood loss was 160 cc, and hospital stay was 3.0 days. For unilateral cases, operative time averaged 193 min, blood loss was 108 cc, and hospitalization was 1.1 days. Six patients experienced perioperative complications, most of which were minor and transient. Laparoscopic ultrasound was useful to define anatomy and to identify the adrenal vein, especially on the left side. Conclusions: Laparoscopic adrenalectomy is the procedure of choice for benign adrenal disease. Laparoscopic ultrasound is useful to localize and aid in the dissection of the left adrenal vein. Received: 24 December 1998/Accepted: 12 February 1999     

Mesh configurations in laparoscopic extraperitoneal herniorrhaphy

Background: Laparoscopic total extraperitoneal (TEP) hernia repair utilizes slit mesh that is placed around the spermatic cord to secure the prosthesis and prevent recurrence. Because of concern that encircling of the cord might increase pain and morbidity, we compared patients with mesh repairs using encircled and nonencircled techniques. Methods: The 191 male patients who underwent bilateral TEP repairs were divided into three groups. In 100 consecutive patients (group A), the slit mesh was closed around both spermatic cords; in 56 patients (group B), the slit mesh was tucked under the spermatic cords but not closed; in 35 consecutive patients (group C), the slit was closed around one cord and tucked under the other, in a randomized fashion. Results: The groups had similar operative times (A: 83 ± 25 min; B: 79 ± 21; C; 77 ± 24), use of pain medication (A: 2.7 ± 2.5 days; B: 2.4 ± 1.9; C: 3.1 ± 2.4), and recovery before return to work (A: 7.9 ± 7.0 days; B: 8.2 ± 6.1; C: 6.7 ± 4.8). The incidence of indirect hernias was similar in all groups. Complication rate was 20% in A, 20% in B, and 14% in C (p= NS). Chronic pain was more frequent in A (A: 6, B: 0, p= 0.06). In group C, fluid collections were more common on the closed side (closed: 3, tucked: 0; p= 0.08). There were no recurrences in any group. Conclusions: Closing the slit around the spermatic cord in laparoscopic inguinal hernia repair is not essential for prevention of early recurrence. Fluid collections tended to be more frequent when the mesh was closed around the cord, and chronic pain was more frequent in the group with closed mesh bilaterally. Received: 3 April 1997/Accepted: 3 July 1997     

Clinical and radiologic assessment of laparoscopic paraesophageal hernia repair

Background: Unlike sliding hiatal hernias, paraesophageal hiatal hernias (PEH) present a risk of catastrophic complications and should be repaired. To assess laparoscopic repair of PEH, we prospectively evaluated the outcome of 38 consecutive patients with type II (20 patients) or III (18 patients) PEH treated laparoscopically. Methods: With the use of 5 or 6 ports, laparoscopic PEH reduction and repair was attempted. One patient (3%) was converted to an open procedure. In the first 12 patients, the hiatus was closed using varying techniques including the placement of prothestic mesh in 6 patients, and the hernia sac was not routinely excised. In the next 25 patients, the hernia sac always was excised and the hiatus routinely sutured posteriorly to the esophagus. Twenty-nine patients also underwent either a Nissen (n= 27) or Toupet (n= 2) fundoplication, which is now performed routinely. Sutured anterior gastropexy was performed selectively in 10 of the first 20 patients, then routinely, using T-fasteners in the last 17 patients. Barium swallow studies were performed on all patients at 3 to 5 months postoperatively. Results: Mean ± standard error of the mean (SEM) age was 67 ± 2 year (range, 39–92 years; 11 men, 27 women), and the American Society of Anesthesia (ASA) score was 2.5 ± 0.1. The operating time was 195 ± 10 min: 244 ± 15 min in the first 12 patients and 170 ± 11 min in the last 25 patients (p < 0.001). There were three (8%) intraoperation complications, which were treated without sequelae, and four (11%) grade II postoperation morbidities. Median discharge was 3 days, and return to full activity was 14 days. Two patients (5%) died of cardiovascular disease after discharge. Barium swallow revealed 2/35 (6%) PEH recurrences (1 reoperated), 3 (9%) intrathoracic wraps, and 3 (9%) small sliding hiatal hernias. At follow-up of 1 year or more, 6/28 (21%) patients noted mild symptoms of reflux or bloating, but only 1 patient (4%) required medication for these symptoms. Conclusions: Laparoscopic PEH repair offers a reasonable alternative to traditional surgery, especially for high-risk patients. Rapid recovery is achieved with acceptable morbidity and early outcome. Barium x-rays revealed hiatal abnormalities in a significant fraction of patients, many of whom were asymptomatic. Longer follow-up will be required to determine the ideal strategy for management of these patients. Received: 4 April 1998/Accepted: 9 December 1998     

Laparoscopic extraperitoneal inguinal hernia repair with spinal anesthesia and nitrous oxide insufflation

Background: Laparoscopic repair of inguinal hernia is traditionally performed under general anesthesia mainly because of the adverse effects that carbon dioxide pneumoperitoneum has on awake patients. Since a mandatory use of general anesthesia for all hernia repairs is questionable, the feasibility of laparoscopic extraperitoneal herniorraphy using spinal anesthesia combined with nitrous oxide insufflation was investigated. Methods: Over a 4-month period, February to May 1998, we performed 35 consecutive total extraperitoneal inguinal hernia procedures (24 unilateral, 11 bilateral) using spinal anesthesia and nitrous oxide extraperitoneal gas. Data on operative findings, self-reported operative and postoperative pain and discomfort (visual analog pain scale), procedure-related hemodynamics, and complications were collected prospectively. Results: All 35 procedures were completed laparoscopically without the need to convert to general anesthesia. Mean operative time was 39 ± 7 min for unilateral hernia and 65 ± 10 min for bilateral hernia. Incidental peritoneal tears occurred in 22 patients (63%) resulting in nitrous oxide pneumoperitoneum, which was well tolerated. The patients remained hemodynamically stable throughout the procedure, and operative conditions and visibility were excellent. Complications at a mean of 4 months after the procedure included seven uninfected seromas (20%), three patients with transient testicular pain, and one (3%) recurrence. Conclusions: Laparoscopic total extraperitoneal hernia repair can be safely and comfortably performed using spinal anesthesia with extraperitoneal nitrous oxide insufflation gas. This method provides a good alternative to general anesthesia. Received: 17 February 1999/Accepted: 1 July 1999     

First results of laparoscopic gastrostomy

Background: Laparoscopic gastrostomy as an alternative to open gastrostomy was introduced with various technical variants 5 years ago. However, long-term results of these new methods are still lacking. Methods: From 4/1993 to 2/1996, laparoscopic gastrostomies were performed on 42 patients (50.9 ± 15.6 [24–71] years) with esophageal stenosis in locally advanced hypopharyngeal (17 patients) or oropharyngeal (nine patients) carcinoma, incurable esophageal carcinoma (13 patients) and cerebral dyspagia (three patients). Operating time was 38 ± 11 min [15–65 min]. Procedure-related mortality was 0%. Major complications occurred in 2/42 (4.7%) patients; minor complications were found in 4/42 (9.4%) patients. During a total usage time of 427 months, 14 stoma infections occurred (0.11 infections/100 days). Conclusion: Laparoscopic gastrostomy allows a safe, fast, and cheap reestablishment of enteral nutrition. The procedure is minimally invasive and can also be performed under local anesthesia. It has become our method of choice in patients with malignant, nonresectable subtotal stenosis of the hypopharynx or esophagus. Received: 5 March 1996/Accepted: 31 July 1996     

Prevalence of gastroesophageal reflux after laparoscopic Heller myotomy

Background: There is still some controversy over the need for antireflux procedures with Heller myotomy in the treatment of achalasia. This study was undertaken in an effort to clarify this question. Methods: To determine whether Heller myotomy alone would cause significant gastroesophageal reflux (GER), we studied 16 patients who had undergone laparoscopic Heller myotomy without concomitant antireflux procedures. Patients were asked to return for esophageal manometry and 24-h pH studies after giving informed consent for the Institutional Review Board (IRB)-approved study at a median follow-up time of 8.3 months (range, 3–51). Results are expressed as the mean ± SEM. Results: Fourteen of the 16 patients reported good to excellent relief of dysphagia after myotomy. They were subsequently studied with a 24-h pH probe and esophageal manometry. These 14 patients had a significant fall in lower esophageal sphincter (LES) pressure from 41.4 ± 4.2 mmHg to 14.2 ± 1.3 mmHg, after the myotomy (p < 0.01, Student's t-test). The two patients who reported more dysphagia postoperatively had LES pressures of 20 and 25 mmHg, respectively. Two of 14 patients had DeMeester scores of >22 (scores = 61.8, 29.4), while only one patient had a pathologic total time of reflux (percent time of reflux, 8%). The mean percent time of reflux in the other 13 patients was 1.9 ± 0.6% (range, 0.1–4%), and the mean DeMeester score was 11.7 ± 4.6 (range, 0.48–19.7). Conclusions: Laparoscopic Heller myotomy is effective for the relief of dysphagia in achalasia if the myotomy lowers the LES pressure to <17 mmHg. If performed without dissection of the entire esophagus, the laparoscopic Heller myotomy does not create significant GER in the postoperative period. Clearance of acid refluxate from the aperistaltic esophagus is an important component of the pathologic gastroesophageal reflux disease (GERD) seen after Heller myotomy for achalasia. Furthermore, GERD symptoms do not correlate with objective measurement of GE reflux in patients with achalasia. Objective measurement of GERD with 24 h pH probes may be indicated to identify those patients with pathologic acid reflux who need additional medical treatment. Received: 12 May 1998/Accepted: 15 December 1998     

腹腔镜提肛肌外腹会阴联合切除术治疗低位直肠癌的临床应用

目的:探讨腹腔镜提肛肌外腹会阴联合切除术(laparoscopic extralevator abdominoperineal excision,LELAPE)治疗低位直肠癌的临床效果。方法:回顾分析2011年6月至2013年1月为15例低位直肠癌患者行LELAPE的临床资料。结果:手术均顺利完成,手术时间平均(258.8±52.1)min,术中出血量平均(130±48.4)ml,术中未发生医源性肠管穿孔,切除标本为"柱状",无"外科腰"。术后下床活动时间平均(35.1±12.5)h,肠功能恢复时间平均(60.6±24.5)h,会阴部引流管拔除时间平均(6.2±1.5)d,会阴部切口拆线时间平均(15.6±2.52)d,术后平均住院(12.1±3.4)d;术后未发生排尿障碍及勃起障碍;1例发生会阴部切口延迟愈合,1例发生不全肠梗阻,经对症治疗后痊愈出院。无死亡病例。患者均获随访,随访1～19个月,无复发及死亡病例。结论:LELAPE可降低标本环周切缘阳性率及术中标本穿孔率,改善预后,未增加并发症发生率及会阴部创伤,为术者提供了良好的手术视野。LELAPE治疗低位直肠癌是安全、可行、理想的术式。     

One-year follow-up after laparoscopic Heller-Dor operation for esophageal achalasia

Background: The Heller-Dor operation has recently been proposed for the treatment of esophageal achalasia even via a laparoscopic approach. Methods: To measure the medium-term effectiveness of this new minimally invasive technique, an evaluation of pre- and postoperative symptoms, esophagogram, endoscopic findings, esophageal manometry, and pH monitoring was prospectively designed in 43 patients with primary esophageal achalasia. The mean clinical follow-up for all the patients is 12 months (range 3–43), while the mean radiological follow-up is 11 months (range 1–23). Endoscopic data 1 year after surgery are currently available for 27 patients (63%), whereas a 12-month (range 1–26) functional follow-up (including manometric and pH-monitoring studies of the esophagus) is currently available for 35 patients (81.4%). Results: No dysphagia was reported in 38 cases (88.4%); two (4.6%) complained of occasional swallowing discomfort which regressed spontaneously; two (4.6%) had persistent dysphagia which regressed with pneumatic dilatation. One patient (2.8%) reported mild occasional dysphagia after a 1-year asymptomatic period. Preoperatively, esophagograms showed an average maximum diameter of 40.6 ± 9.1 mm which decreased to 24.1 ± 6.0 mm after operation. Mean lower esophageal sphincter (LES) resting and residual pressures decreased significantly from 28.6 ± 10.7 mmHg to 8.8 ± 4.1 mmHg and from 17.0 ± 9.7 mmHg to 4.7 ± 4.0 mmHg, respectively (p < 0.0001). These effects on esophageal diameter and LES function seem to persist over time. The complete absence of any peristaltic contractions recorded preoperatively in all cases remained unchanged after surgery in all but four patients. However, this rare recovery of peristalsis proved to be transient, and patients revealed a manometric impairment of their esophageal body function, but without complaining of dysphagia. Twenty-four-hour pH monitoring showed abnormal gastroesophageal reflux episodes in two (5.7%) of the 35 patients who were monitored: one was asymptomatic; the other had heartburn and endoscopically demonstrated grade II esophagitis. Conclusions: Laparoscopic Heller-Dor operation achieves excellent medium-term results which, together with the already-demonstrated advantages of a minimal surgical trauma and rapid convalescence, validate the use of such a minimally invasive approach to treat patients with primary achalasia of the esophagus. Received: 19 March 1996/Accepted: 15 May 1996     

Simultaneous laparoscopic biliary and retrocolic gastric bypass in patients with unresectable carcinoma of the pancreas

Background: A substantial number of patients with unresectable pancreatic cancer eventually develop biliary or gastric outlet obstruction. In some cases, they present initially with both complications. These conditions contribute markedly to their discomfort and certainly justify palliative intervention. The purpose of this study was to examine the feasibility and safety of simultaneous laparoscopic biliary and gastric bypass in patients with unresectable carcinoma of the pancreas. Methods: Between August 1995 and July 1998, simultaneous laparoscopic biliary and retrocolic gastric bypass was performed successfully in 12 consecutive patients with unresectable carcinoma of the pancreas. There were eight men and four women. Their median age was 72 years (range, 50–82). In all patients, the indications for gastrointestinal bypass were gastric outlet obstruction and obstructive jaundice. The following parameters were evaluated for each patient: procedure-related morbidity and mortality, operative time, length of hospital stay, overall survival, and ability to sustain oral nutrition during the survival period. Results: All procedures were completed laparoscopically. The mean operative time was 89 ± 29.56 min. There were no intraoperative complications. Postoperative morbidity consisted of wound infection in two patients and pneumonia in one patient. One patient died of multiorgan failure on postoperative day 2. The mean hospital stay was 6.4 ± 1.5 days (range, 5–17). The mean survival time until death from underlying disease was 85 ± 32.46 days (range, 31–260). None of the patients had recurrent jaundice, and all of them were able to maintain oral nutrition. Conclusion: Simultaneous laparoscopic biliary and retrocolic gastric bypass is a safe and effective technique for the treatment of biliary and gastroduodenal obstruction in patients with unresectable pancreatic cancer. Received: 17 December 1998/Accepted: 13 May 1999     

Postoperative complications of laparoscopic-assisted colectomy

Background: This study was performed to prospectively assess the complications of 118 consecutive patients who underwent laparoscopic assisted colorectal resections. Methods: The variables included were: indication for surgery, type of resection, duration of operation, duration of postoperative ileus, length of hospital stay, port-site recurrence, and complications in relation to the laparoscopic technique. Results: 118 Laparoscopic-assisted procedures were performed between July 1992 and October 1995. Surgical indications were: 106 patients for colonic malignancy, six for diverticulitis, two for Crohn's disease, two for benign polyps, one for endometriosis, and one for ischemic colitis. Fifteen patients required conversion to open techniques for completion of the operations (12.7%). The mean operating time was 168.8 min. The amount of operative blood loss was 98 ml. The mean time for passing flatus was 36 ± 16 h. Mean postoperative stay was 5.4 (range 3–13) days. Eight patients (6.8%) sustained complications: four unrelated to laparoscopy (three wound infection, one anastomotic leak); and four complications related to the laparoscopic approach: one small-bowel obstruction, one trocar injury, one rotation of the anastomosis, and one misdiagnosed synchronous adenocarcinoma. Conclusions: We suggest that with the development of improved technical devices and more experience, the indications for laparoscopic colectomy should continue to expand. The low incidence of infectious complications suggests an important role for the laparoscopic approach to colorectal surgery. Received: 25 March 1996/Accepted: 8 July 1996