Complications and Quality of Life Following Urinary Diversion After Cystectomy

Objective:

The aim of this review is to outline specific surgical complications, metabolic consequences and quality of life (QOL) following urinary diversion in patients undergoing radical cystectomy.

Methods:

Based on a comprehensive literature search (MEDLINE) the published knowledge on urinary diversion was examined regarding the research question with an emphasis on contemporary cystectomy series.

Results:

Despite the fact, that urinary diversion is commonplace in these days and the existing literature is rather extensive, the vast majority of assumptions are based on low level evidence (retrospective, single-institutional case series with small sample sizes and short-term followup). There are few randomized trials in this field.Early and late surgical complications following radical cystectomy have decreased over the past three decades for both incontinent and continent diversion, but are still significant. While metabolic disturbances are common after continent forms of urinary diversion, the problems can be minimized in most cases. Most reports testify that QOL is high after cystectomy irrespective of type of urinary diversion although urinary and sexual problems are common.

Conclusion:

Careful patient selection, strict adherence to proper surgical technique and appropriate life-long follow-up are of paramount importance in the successful management of patients undergoing radical cystectomy for bladder cancer.     

New Laparoscopic Double-Stapling Technique

Background Laparoscopic surgery for colon cancer has been shown by several randomized, controlled trials to be an acceptable alternative to open surgery; however, laparoscopic rectal surgery has not been evaluated in a randomized trial. One of the most serious problems associated with laparoscopic rectal surgery are bowel clamping, irrigation, and transection of the rectum, and laparoscopic rectal surgery has not been as reliable as open rectal surgery. Materials and Methods We present our new technique, the laparoscopic double-stapling technique, which eliminates these problems. This technique uses curved Doyen forceps introduced through the wound just above pubis symphysis for clamping the rectal wall at the anal side of the tumor. An endolinear stapler (length 60 mm) is inserted through the same wound, applied at the rectal wall parallel and caudal to the Doyen forceps, and transects the rectum under pneumoperitoneum. We used this technique for eight cases of rectal surgery. Results and Discussion The laparoscopic double-stapling technique provided secure bowel clamping and rectal irrigation. The number of cartridges used in laparoscopic double-stapling technique cases was not more than 2, with an average of 1.6 per patient. None of the laparoscopic double-stapling technique cases experienced major complications. Conclusion We consider that many cases of rectal cancer that are suitable for laparoscopic low anterior resection can undergo laparoscopic surgery by using this technique, which will improve the quality of rectal surgery. Presented at the meeting of the Japan Society for Endoscopic Surgery, Kyoto, Japan, December 5 to 7, 2006.     

Laparoscopic partial cystectomy with mucosal stripping of extraluminal duodenal duplication cysts

Duodenal duplication cysts are rare congenital anomalies.Duodenal duplication should be considered in the differential diagnosis of patients who present with abdominal symptoms with cystic structures neighboring the duodenum.Here,we present an 8-year-old girl with a duodenal duplication cyst treated with partial cystectomy with mucosal stripping performed laparoscopically.Laparoscopic surgery can be considered as a treatment option for duodenal duplication cysts,especially in extraluminal locations.     

Laparoscopic segmental colectomy for colonic lymphangiomas: A definitive,minimally invasive surgical option

Colonic lymphangioma is an unusual benign malformation. We herein describe two cases. A 36-year-old woman was admitted with one year of intermittent abdominal pain; colonoscopy, abdominopelvic computed tomography and endoscopic ultrasonography (EUS) revealed enlarged cystic masses at the ascending colon. In another 40-year-old man, colonoscopy and EUS revealed an asymptomatic lobulated cystic mass with four small sessile polyps at the sigmoid colon. Both patients underwent laparoscopic segmental colectomy. Both masses were histologically confirmed as cystic lymphangiomas, and the patients were discharged without complications. The management of colonic lymphangioma depends on the individual situation; close surveillance or endoscopic therapy may be appropriate for asymptomatic lesions smaller than 2.5 cm in diameter. Surgical intervention can be considered for larger lesions or in patients who develop complication risks. Laparoscopic segmental colon resection may be recommended to excise relatively large submucosal lesions because it is a definitive, minimally invasive intervention with a fast postoperative recovery.     

Laparoscopic liver resection for malignancy: A review of the literature

AIM: To review the published literature about laparoscopic liver resection for malignancy.METHODS: A PubMed search was performed for original published studies until June 2013 and original series containing at least 30 patients were reviewed.RESULTS: All forms of hepatic resections have been described ranging from simple wedge resections to extended right or left hepatectomies. The usual approach is pure laparoscopic, but hand-assisted, as well as robotic approaches have been described. Most studies showed comparable results to open resection in terms of operative blood loss, postoperative morbidity and mortality. Many of them showed decreased postoperative pain, shorter hospital stays, and even lower costs. Oncological results including resection margin status and long-term survival were not inferior to open resection.CONCLUSION: In the hands of experienced surgeons, laparoscopic liver resection for malignant lesions is safe and offers some short-term advantages over open resection. Oncologically, similar survival rates have been observed in patients treated with the laparoscopic approach when compared to their open resection counterparts.     

Laparoscopic Surgery in Rectal Cancer: A Prospective Analysis of Patient Survival and Outcomes

Purpose The role of laparoscopic resection in the management of rectal cancer is still controversial. We prospectively evaluated patient survival and outcomes in patients undergoing laparoscopic rectal resection for rectal cancer at a single institution. Methods From November 1999 to November 2005, 107 patients with rectal cancer were treated by laparoscopy. Exclusion criteria were: metastatic disease, advanced disease with invasion of adjacent structures, clinical or radiologic involvement of the external anal sphincter, previous colonic resection, synchronous colonic adenocarcinoma, and contraindications to laparoscopy. All patients were followed prospectively for survival and complications. Survival was calculated by the Kaplan-Meier method. Results A laparoscopic sphincter-saving procedure was performed in 104 patients, 2 patients had a laparoscopic Miles operation, and 1 underwent a laparoscopic Hartmann’s procedure. Mean operating time was 278 (range, 135–430) minutes. Conversion to open surgery was required in 20 of 107 patients (18.7 percent). Overall morbidity was 27 percent, anastomotic leakage occurred in 14 of 104 patients (13.5 percent). There was no postoperative mortality. A mean of 18 (range, 1–49) lymph nodes was removed. Mean distance of distal margin from tumor was 2.6 (range, 0.5–10) cm; in two patients there was microscopic invasion of the distal margin. Mean hospital stay was nine (range, 4–43) days. Mean follow-up was 35.8 months. There was local recurrence in 1 of 107 patients (0.95 percent); there were no port site metastases. Actuarial five-year and disease-free survival rates are 81.4 and 79.8 percent, respectively. Conclusions Laparoscopic rectal surgery is feasible and oncologically radical but also technically demanding (conversion rate, 18.7 percent), time-consuming (mean operating time, 278 minutes), and associated with specific intraoperative complications. At present, the technique should only be performed in specialist centers by teams experienced in laparoscopic surgery. Presented at the meeting of The Society for Surgery of the Alimentary Tract, Los Angeles, California, May 20 to 24, 2006.     

Comparison of Laparoscopic <Emphasis Type="Italic">vs.</Emphasis> Open Access Surgery in Patients with Rectal Cancer: A Prospective Analysis

Purpose Laparoscopic surgery of colon cancer has been accepted to be oncologically adequate compared with open resection. However, the situation in rectal cancer remains unclear, because anatomy and complex surgical procedures might specifically influence the long-term outcome. This study was designed to analyze perioperative and long-term outcome of patients with rectal cancer after laparoscopic vs. open access surgery. Methods A total of 389 patients (1998–2005) were prospectively analyzed; 114 patients had laparoscopic beginning, and 25 patients had conversion and were separately analyzed. Eighty-nine patients remained in the laparoscopic group and 275 had open access surgery. Results Both groups were comparable regarding age, gender, tumor localization, stage, and complications. Differences were found in harvested lymph nodes (laparoscopic 13.5/open access 16.9; P = 0.001) and hospitalization (15.1/18.7 days; P = 0.037). Local recurrence rate and metachronous metastasis were comparable. In patients with deep anterior resection with total mesenteric excision, favorable long-term survival in the laparoscopic group was found (P = 0.035, log-rank). Conclusions Minimally invasive surgery is equivalent in the treatment of rectal cancer and shows advantages of shorter hospitalization and faster recovery. Especially in patients with low rectal cancer, minimally invasive surgery with exact preparation of the total mesenteric excision seems to be favorable compared with open access surgery.     

Laparoscopic transduodenal local resection of periampullary neuroendocrine tumor: A case report

Studies on laparoscopic transduodenal local resection have not been readily available.Only three cases have been reported in the English-language literature.We describe herein a case of 25-year-old woman with periampullary neuroendocrine tumor(NET).Endoscopic ultrasonography revealed a duodenal papilla mass originated from the submucosa and close to the ampulla.The periampullary tumor was successfully managed with laparoscopic transduodenal local resection without any procedure-related complications.Pathological examination showed a NET(Grade 2)with negative margin.The patient was followed up for six months without signs of recurrence.This case suggests that laparoscopic transduodenal local resection is a feasible procedure in selected patients with periampullary tumor.     

Laparoscopic pylorus preserving pancreaticoduodenectomy in paediatric age for solid pseudopapillary neoplasm of head of the pancreas – Case report

Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare tumour commonly seen in young women without significant clinical features. SPN is usually a lowgrade malignant neoplasm which warrants resection. Recurrence and metastasis is seen rarely after complete resection. Pancreaticoduodenectomy is indicated for SPN situated in head of the pancreas which is generally performed by open approach. Laparoscopic pancreaticoduodenectomy (LPD) is difficult to perform for this condition because of smaller size of pancreatic and hepatic ducts more so in paediatric population. We report a case of 12 years old girl having SPN arising from head of the pancreas. She underwent laparoscopic pylorus preserving pancreaticoduodenectomy. Post-operative period was uneventful. Histological examination of resected specimen confirmed diagnosis of SPN. At 6 months follow up, she was doing well without any recurrence. To best of our knowledge, no case of LPD in paediatric patients is reported in literature available to us.     

Selective Endoscopic Retrograde Pancreatography (Selective ERP) Using a Radifocus Gllidewire–A New Technique for a Diagnostic Pancreatogram

Abstract: We have developed a new method called the “Selective Endoscopic Retrograde Pancreatograpy (Selective ERP)” which uses a Radifocus guidewire to obtain a more precise pancreatogram than a standard ERP. The deep cannulation of a catheter guided by a Radifocus guidewire following standard ERP was easily and rapidly accomplished and precise pancreatograms were successfully obtained. The Selective ERP was very useful not only for obtaining detailed pancreatograms beyond severe stenosis of the main pancreatic duct in ductal cell carcinoma of the pancreas but also in revealing whether mucinous cystadenoma/cystadenocarcinoma communicated with the pancreatic duct or not. In the case of a mucin producing pancreatic tumor, Selective ERP successfully enabled us to obtain a whole pancreatogram and the location and extent of a tumor that standard ERP often fails to reveal because of an abundant accumulation of mucin in the duct. A Selective ERP is a simple and useful method for diagnosing pancreatic tumors and can provide precise and whole pancreatograms. We recommend Selective ERP as it enables us to obtain more complete diagnostic pancreatograms following standard ERP.     

Robot-Assisted <Emphasis Type="Italic">vs</Emphasis>. Conventional Laparoscopic Rectopexy for Rectal Prolapse: A Comparative Study on Costs and Time

Purpose Laparoscopic rectopexy has become one of the most advocated treatments for full-thickness rectal prolapse, offering good functional results compared with open surgery and resulting in less postoperative pain and faster convalescence. However, laparoscopic rectopexy can be technically demanding. Once having mastered dexterity, with robotic assistance, laparoscopic rectopexy can be performed faster. Moreover, it shortens the learning curve in simple laparoscopic tasks. This may lead to faster and safer laparoscopic surgery. Robot-assisted rectopexy has been proven safe and feasible; however, until now, no study has been performed comparing costs and time consumption in conventional laparoscopic rectopexy vs. robot-assisted rectopexy. Methods Our first 14 cases of robot-assisted laparoscopic rectopexy were reviewed and compared with 19 patients who underwent conventional laparoscopic rectopexy in the same period. Results Robot-assisted laparoscopic rectopexy did not show more complications. However, the average operating time was 39 minutes longer, and costs were €557.29 (or: $745.09) higher. Conclusion Robot-assisted laparoscopic rectopexy is a safe and feasible procedure but results in increased time and higher costs than conventional laparoscopy.     

A New Variant of Erythrocyte Pyruvate Kinase – PK ‘Maebashi’

A new case of erythrocyte pyruvate kinase deficiency was described. – A 9-year-old male patient was hospitalized because of anaemia, jaundice and splenomegaly. Diagnosis was made primarily on the basis of the erythrocyte enzyme studies. Because the pyruvate kinase of this patient demonstrated certain different characteristics from the other variants described previously, it was tentatively designated PK ‘Maebashi’.     

Interleukin-6, C-Reactive Protein,and Expression of Human Leukocyte Antigen-DR on Peripheral Blood Mononuclear Cells in Patients After Laparoscopic <Emphasis Type="Italic">vs.</Emphasis> Conventional Bowel Resection

PURPOSE: The aim of the study was to investigate the effect of surgical trauma in terms of approach (laparoscopic vs. conventional surgery) and extent of bowel resection (ileocolic resection vs. colectomy) on interleukin-6 level, C-reactive protein level, and expression of human leukocyte antigen-DR on peripheral blood mononuclear cells. Second, the length of the incision was correlated with the inflammatory response. METHODS: Thirty-four patients were analyzed as part of a randomized trial comparing laparoscopically assisted vs. open bowel resection for Crohns disease, ulcerative colitis, and familial adenomatous polyposis. C-reactive protein levels and expression of human leukocyte antigen-DR on peripheral blood mononuclear cells were measured preoperatively and one day after surgery. Interleukin-6 was measured preoperatively and on Days 1 and 7 postoperatively. RESULTS: Four of the 34 patients were excluded because of blood transfusion after surgery. One day postoperatively, the interleukin-6 level peaked significantly within the laparoscopic and conventional group. There was no significant difference between the conventional and laparoscopic groups at Day 1 postoperatively. At Day 7 postoperatively, interleukin-6 levels were similar in both groups and returned to baseline levels. There was a higher C-reactive protein level in the conventional group one day after surgery than in the laparoscopic group, although the difference was not significant. Preoperative and postoperative human leukocyte antigen-DR expression on monocytes and postoperative percentage of lymphocytes expressing human leukocyte antigen-DR did not differ between the conventional and laparoscopic groups. No differences in immune response with respect to the measured parameters were noticed in patients with a large or small bowel resection segment or in patients with a small (8 cm) or large (>8 cm) incision. CONCLUSIONS: These data suggest that surgical trauma did not significantly affect the immune status of patients with respect to the measured parameters in terms of either the approach or the extent of bowel resection.     

Experience with Laparoscopic Appendectomy —The Technique and Our Views of its Indications—

Abstract: Since June, 1991 a laparoscopic appendectomy (LA) was performed on eleven patients with suspected appendicitis which could not be confirmed by the conventional diagnostic methods. The patients included 7 males and 4 females, with a mean age of 27, 9, ranging from 16 to 46 years. No postoperative complications were encountered. The laparoscopic diagnoses included gangrenous appendicitis in 2, suppurative appendicitis in 2, catarrhal appendicitis in 4, salpingitis in 2 and an appendiceal mass in one patient (Case 7). Histopathological diagnoses were phlegmonous appendicitis in 3, mucinous cystadenoma in one and catarrhal appendicitis in 7 patients. Two cases of salpingitis and a case with ovarian bleeding were treated conservatively after incidental laparoscopic removal of the appendix. Case 7 was histopathologically diagnosed as having mucinous cystadenoma. The patients’postoperative hospital stay was from 5 to 8 days, with an average of 6.9 days. All patients had been given the permission to be discharged by the third POD but they stayed longer because of benefits given by the health insurance system very specific to Japan. LA in our clinic has so far been limited to selected patients in whom the diagnosis of appendicitis could not been confirmed and laparoscopic examination was indicated, mainly due to manpower problems involving surgeons, anesthetists and operating room nurses. However, LA provides not only benefits for patients but also several merits for surgeons including better exposure of the operating field in most cases when compared with an open appendectomy. We feel, therefore, that the indications for LA might be extended more widely, probably to most cases of appendicitis.     

Postoperative Urinary Retention After Primary Colorectal Cancer Resection <Emphasis Type="Italic">via</Emphasis> Laparotomy: A Prospective Study of 2,355 Consecutive Patients

Purpose The risk factors for postoperative urinary retention after colorectal carcinoma surgery can be clearly defined. This study was designed to determine risk factors for postoperative urinary retention after colorectal cancer surgery. Methods A total of 2,355 consecutive patients with colorectal cancer who underwent open resection for colorectal cancer during a four-year period were included. The association between dependent and independent variables (including 19 clinicopathologic and surgical factors) was analyzed by using the chi-squared test or Fisher’s exact test, as appropriate. The significant variables in the univariate analyses were included in multivariate analysis. Results The overall prevalence of postoperative urinary retention was 5.5 percent (colon cancer, 1.7 percent; rectal cancer, 9.1 percent, P < 0.0001). Multivariate analysis showed an independent association between postoperative urinary retention and age, lung disease, tumor location, operation duration, and additional pelvic procedure. Of the 121 patients with postoperative urinary retention, urine catheterization was required in 42 patients one month postoperatively. Discriminate analysis showed that gender, American Society of Anesthesiologists’ score, tumor location, presence of drainage, and pelvic infection were best able to discriminate between prolonged (>1 month) and transient urinary dysfunction. Conclusions Older patients, lung disease, rectal cancer, longer operation duration, and additional pelvic procedure were at greater risk. There is a time-dependent change in postoperative urinary dysfunction. Male gender, American Society of Anesthesiologists’ score of 2 or 3, rectal tumor, surgical drain, and pelvic infection can identify patients at risk for prolonged urinary dysfunction.     

A Case-Control Study of Laparoscopic Right Hemicolectomy <Emphasis Type="Italic">vs.</Emphasis> Open Right Hemicolectomy

PURPOSE The purpose of our study was to examine all laparoscopic right hemicolectomies performed for cancer in our unit and to compare them with a case-control series of open right hemicolectomies, with emphasis on long-term survival.METHODS In a retrospective case-control series of right hemicolectomies, those done laparoscopically were compared with an age-matched and stage-matched series of patients who underwent open surgery. Survival was analyzed with the Kaplan-Meier method.RESULTS Ninety-nine patients were included in the study, 33 laparoscopic and 66 open. Mean age 69.7 years. Dukes staging was the same between the two groups and mean follow-up period was 65.7 months. There were six laparoscopic conversions. The number of days patients were kept nil by mouth was significantly less in the laparoscopic cohort, with a mean of 2.4 days vs. a mean of 3.65 days (P = 0.005, Mann-Whitney U test). The number of days during which patients required parenteral opiates was significantly less in the laparoscopic cohort, with a mean number of days of 2.5, in contrast to 4.5 days in the open group (P = 0.008, Mann-Whitney U test). When overall survival was compared between the open and laparoscopic groups, no difference was found, with a mean overall survival of 40 months in the laparoscopic cohort and 39.4 months in the open cohort (P = 0.348, log-rank test).CONCLUSION Laparoscopic right hemicolectomy for cancer does not compromise long-term survival and affords the advantage of a shorter period of postoperative ileus and decreased analgesia requirements.     

State of the Art – How I manage coagulopathy in cardiac surgery patients

Over 35 000 cardiac operations using cardiopulmonary bypass are performed annually in the UK. Post‐operative bleeding is a common cause of morbidity. Although there have been improvements in surgical techniques, recent publications still show post‐operative blood loss to be significant, with allogeneic blood product usage as high as 50%. Despite greater understanding of the mechanisms of the coagulopathy encountered during cardiac surgery the development of treatment options has been slow. There has been a realization of the inadequacy of fresh frozen plasma to correct the coagulopathy in this setting, leading to greater off‐label use of specific factor concentrates to stop bleeding, e.g., prothrombin complex concentrates and fibrinogen concentrates. Recent trials using factor XIII and IX concentrates have not been successful. This article will review preventative measures to reduce post‐operative bleeding and the current management of bleeding with such factor concentrates and, in most cases, the limited evidence supporting their widespread use.