Laparoscopic splenectomy for ITP

Background: A comparison of safety, efficacy, and cost of laparoscopic splenectomy (LS) vs open splenectomy (OS) for idiopathic thrombocytopenic purpura (ITP) was performed. Methods: The records of 49 consecutive patients who underwent splenectomy for ITP (31 LS and 18 OS) at a large metropolitan teaching hospital between 3/91 and 8/95 were reviewed. Morbidity, mortality, hospital stay, operative time, blood loss, time to oral fluid intake, direct costs, and operating room (OR) costs were analyzed. Results: Age, sex, comorbidity, and spleen size were similar in both groups. LS was successful in 94% of patients in whom it was attempted. Operative times showed a learning curve for LS, with average times for the last ten cases (94 ± 35 min) significantly shorter than for the first ten (p= 0.01) and also shorter than for OS (103 ± 45 min). Postsurgical hospital stay was 2.9 ± 1.3 days for LS and 6.9 ± 3.0 days for OS (p < 0.001). Patients tolerated an oral diet 1.2 ± 0.5 days after LS and 3.2 + 0.7 days after OS (p < 0.001). Direct hospital cost was $5,509 ± 3,636 for LS and $9,031 ± 12,752 for OS. In the LS group, six patients (21%) had accessory spleens identified and removed, compared with two patients (11%) in the OS group. Platelet counts did not respond in two (7%) patients in the LS group, but no accessory spleens were identified by nuclear scan. One major complication occurred in the LS group. There were no cases of splenosis or mortality in either group. Conclusions: LS is a safe and effective treatment for ITP, with significantly shorter postoperative hospital stay than OS. Received: 26 March 1996/Accepted: 11 May 1996     

Laparoscopic splenectomy

Background: The purpose of this study was to evaluate the outcome of patients undergoing laparoscopic splenectomy (LS) at the University of California, San Francisco. Methods: The medical records of the initial 52 unselected patients undergoing LS were reviewed and compared to 28 concurrently treated open splenectomy patients (OS). Results: Patients did not differ with regard to age, gender, body, or splenic weights. The operative time was longer in the LS patients (mean 196 vs 156 min), but the length of stay and duration of ileus were shorter in the LS group. For adult patients admitted exclusively for splenectomy, operative times did not differ between LS and OS and total hospital cost was less in the LS group (mean $8,939 vs $14,022). Six patients required conversion to OS, four occurring in the first 11 patients treated (overall conversion rate of 11%). Three patients died from complications related to their underlying disease. Two other major complications occurred. Complication rates and transfusion requirements did not differ between OS and LS patients. Conclusions: Laparoscopic splenectomy is a safe and effective alternative to open splenectomy for treatment of hematologic diseases in patients of all ages. Received: 16 April 1996/Accepted: 5 July 1996     

Laparoscopic vs open splenectomy in the management of hematologic diseases

Background: Laparoscopic splenectomy (LS) is becoming the gold standard in the treatment of several splenic diseases. Shorter postoperative stay and more rapid return to full activity are the primary advantages of LS. Methods: Prospective data collection of 44 consecutive LS (group 1) and comparison with a historical control group of 56 consecutive open splenectomies (OS) (group 2) were performed for hematologic diseases. Results: The LS patients started earlier on an oral diet (p < 0.0001) and left the hospital sooner (p < 0.0002) than OS patients. Less blood transfusion (p < 0.004) and pain medication (p < 0.0001) was required by LS patients. They also had fewer postoperative complications (p < 0.03). Compared by diagnosis, patients with laparoscopic idiopathic thrombocytopenic purpura or Hodgkin's disease started to eat earlier (p < 0.0001) and left the hospital sooner (p < 0.01). Multivariate analysis showed that time to oral diet and postoperative stay was related to operative technique and age. Morbidity and pain medications were related, respectively, to transfusion requirements and type of surgical approach. Conclusions: Used to manage hematologic diseases, LS is feasible, effective, and safe. It offers several advantages over the open approach. The type of surgical approach seems to be the crucial factor in determining the length of the postoperative course. Received: 16 July 1998/Accepted: 20 January 1999     

Impact of hematological diagnosis on early and late outcome after laparoscopic splenectomyrid=""

Background: Laparoscopic splenectomy (LS) is now regarded as the treatment of choice for autoimmune thrombopenia (ITP). However, there have been few reports describing the application of LS to other splenic diseases, such as malignant entities and conditions associated with splenomegaly. Hematological diseases have specific clinical features that can influence immediate outcome after LS. Although the long-term effects of LS are unknown, a risk of splenosis has been suggested. Therefore, we designed a study to analyze the impact of primary hematological disease on immediate and late outcome in a prospective series of LS patients. Methods: We performed a prospective analysis of 111 LS done between February 1993 and March 1999. The patients were classified by hematological indications into the following four groups: (a) group 1, low platelet count. This group was further subdivided into group 1A, idiopathic thrombocytopenic purpura (ITP) (n= 48) and group 1B, HIV-related ITP (n= 8); (b) group 2, anemia. This group was further subdivided into group 2A, autoimmune hemolytic anemia (n= 8), and group 2B, spherocytosis (n= 11); (c) group 3, malignancy (n= 28); and (d) group 4, others (n= 8). Immediate outcomes were recorded prospectively. Hematological status and late complications were reviewed after a mean follow-up of 24 ± 18 months. Results: There were no significant differences between the groups in terms of conversion, transfusion requirements, and morbidity, although transfusion and morbidity were slightly higher in group 3. However, hospital stay was significantly longer in groups 3 and 4 than in groups 1 and 2. Long-term follow-up showed satisfactory hematological results in ≥75% of patients (group 1A, 82%; group 1B, 88%; group 2A, 88%; group 2B, 100%; group 3, 75%; group 4, 88%). Overall, late morbidity was 8.3% and mortality was 6.2%, mainly due to deaths in group 4 (six of 22 patients). Conclusion: LS is a safe and reproducible procedure for most hematological indications, with a similar immediate outcome for benign diseases and a long-term hematological response comparable to the standard results that have been observed in open series. Received: 1 April 1999/Accepted: 22 November 1999/Online publication: 8 May 2000     

Conversion factors for laparoscopic splenectomy for immune thrombocytopenic purpura

Background: Since 1994, 27 patients at our institution have undergone laparoscopic splenectomy for immune thrombocytopenic purpura (ITP). Laparoscopic splenectomy was completed in 22 of these patients. We sought to identify factors that precluded successful laparoscopic splenectomy in the remaining 5 patients. Methods: Retrospective review of 27 patients with ITP undergoing laparoscopic splenectomy was performed at Duke University Medical Center from August, 1994 to September, 1997. Results: Laparoscopic splenectomy was performed in 16 women and 11 men with a mean age of 47.2 years. Five (18%) of these procedures were converted to open splenectomy. There was no significant difference in age, ASA score, gender, weight, height, or splenic size between the converted and laparoscopic groups. However, preoperative and postoperative platelet counts were significantly higher in the laparoscopic group than in the converted group (p < 0.001). Operative times also were significantly longer for the laparoscopic group than for the converted group (p < 0.001). Adherent adjacent structures, associated comorbidities, and technical errors prohibited laparoscopic completion in five patients. Technical errors with subsequent bleeding required conversion in two patients. A thickened greater omentum blanketing the splenic capsule and a densely adherent pancreatic tail extending well into the splenic hilum prevented laparoscopic completion in two patients. Increased peak airway pressures greater than 60 mmHg after pneumoperitoneum necessitated conversion in the remaining patient, who had a previous history of pulmonary insufficiency. Regardless of surgical approach, all patients achieved a therapeutic response after splenectomy. Splenectomies completed laparoscopically resulted in a significantly shorter length of hospital stay (p < 0.01). Conclusions: Densely adherent adjacent structures, technical errors, and cardiopulmonary instability may preclude successful completion of laparoscopic splenectomies. Thorough preoperative evaluation with an emphasis on the cardiopulmonary system may elicit a cohort of individuals with ITP who are unlikely to undergo laparoscopic splenectomy successfully. This cohort also may include individuals with preoperative platelet counts less than 35,000 mm⁻³. Received: 15 April 1998/Received: 15 January 1999     

Laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP)

Background: Laparoscopic splenectomy (LS) has rapidly become the preferred surgical treatment for idiopathic thrombocytopenic purpura (ITP), but its long-term efficacy for this disorder is unproved. This report documents the author's 5-year experience with, and long-term follow-up of, LS for ITP. Methods: Between September 1992 and September 1997, 30 patients with clinical ITP and intractable thrombocytopenia were referred as surgical candidates. Two of them (7%) were converted to open, and the other 28 underwent successful LS. The operative approach evolved from a supine lithotomy to right lateral decubitus position, and the harmonic scalpel became the primary dissection tool in the later part of the study. Results: The 28 successful LS patients constituted the study group. Accessory spleens were identified and resected in six patients (21%). Surgical times and blood loss averaged 2.4 h and 170 cc, respectively. The typical hospital stay was 2 days. Initial reversal of thrombocytopenia and ultimate cessation of oral steroids was achieved in 25 of 28 patients (89%). There were no deaths, but two patients had major complications (bleeding and pneumonia). All but two patients experienced a return to full activity and/or employment by 3 weeks post-LS. In the three cases that failed LS, none had residual splenic tissue on subsequent radionuclide scan. Long-term follow-up (2–60 months) was obtained in 22 of 28 patients (79%). The only death (at 13 months) resulted from oncologic disease. Twenty-one patients had lasting clinical remission of ITP. A positive preoperative response to oral steroids was the best predictor of success. Conclusions: This 5-year experience with LS supports its use for the surgical treatment of ITP. The procedure is safe and efficacious, resulting in brief hospitalization, minimal recovery time, and excellent long-term results. Received: 11 October 1998/Accepted: 19 February 1999     

Laparoscopic management of accessory spleens in immune thrombocytopenic purpura

Background: A disparity exists between the incidence of accessory spleens reported in the open (15–30%) versus the laparoscopic (0–12%) literature. This disparity implies that a percentage of laparoscopic patients will require a reoperation for accessory splenectomy. We present our experience with the laparoscopic management of accessory spleens discovered after primary splenectomy for idiopathic thrombocytopenic purpura (ITP). Methods: Seventeen patients who underwent primary splenectomy for ITP were reviewed (1 open, 16 laparoscopic). In the laparoscopic group, the incidence of accessory spleens was 3 in 16 (19%). In 1 of these 3 patients, the accessory spleen was found and removed at the initial operation, whereas in 2 of the 16 patients (13%), the accessory spleens were missed. A third patient, whose initial operation was open, presented with recurrent thrombocytopenia after primary splenectomy. After recurrent thrombocytopenia developed, radio nuclide spleen scans were performed showing accessory spleens in all three patients. These three patients underwent accessory splenectomy using a four-port laparoscopic approach. Results: Laparoscopic accessory splenectomy was successfully performed in all three patients. Location of accessory spleens correlated with the spleen scan in each case. Mean operation time was 180 min. There were no conversions to open surgery and no complications. All patients were discharged from the hospital on postoperation day 1. The three patients had a good clinical response and were weaned effectively from their steroid medications. Conclusions: Patients undergoing a laparoscopic splenectomy for chronic ITP have a higher probability of requiring a reoperation for a missed accessory spleen. To minimize missing an accessory spleen, a systematic search should be made at the beginning of the laparoscopic operation. We have found that preoperation imaging with heat-treated erythrocyte scans is valuable for locating accessory spleens before reoperation. When reoperation for accessory splenectomy is necessary, a laparoscopic approach is safe and effective. Received: 22 July 1998/Accepted: 13 October 1998     

Port site tumor recurrence rates in a murine model of laparoscopic splenectomy decreased with increased experiencerid=""id=""Presented at the sixth International Congress of the European Association of Endoscopic Surgery (E.A.E.S.), Rome, Italy, 5 June 1998

Background: The etiology of port site tumor recurrences following laparoscopic surgery for cancer remains unknown. A recent study from our laboratory using a murine splenic tumor model suggests that it is poor surgical technique (i.e., crushing of the tumor) rather than the CO₂ pneumoperitoneum that is responsible for these tumors. However, in that experiment, no intraabdominal procedure was carried out. We subsequently performed a preliminary study in which we compared the rate of port site tumor recurrences after laparoscopic-assisted splenectomy (LAS) vs open splenectomy (OS) using the murine splenic tumor model. In this study, we found significantly more port and incisional tumors after laparoscopic splenectomy. The reasons for this finding are unclear. Further analysis of the data showed that the incidence of port tumors in the LAS group decreased dramatically from the first to the second trial, suggesting that the experience of the surgeon may play a role. The purpose of the current study was to carry out further trials to determine if the lower rate of port tumor recurrence in the laparoscopic group will persist with increased surgical experience. Methods: Splenic tumors were established in female Balb/C mice (n= 128) via a subcapsular injection of a 0.1-cc suspension containing 10⁵ C-26 colon adenocarcinoma cells via a left flank incision at the initial procedure. Seven days later, the animals with isolated splenic tumors (95%) were randomized to one of two groups—open splenectomy (OS) or laparoscopic-assisted splenectomy (LAS). Three ports were placed in similar locations in all animals. The OS mice underwent an open splenectomy via a subcostal incision and anesthesia for 20 min. The LAS mice underwent laparoscopic mobilization of the spleen using a three-port technique, followed by an extracorporeal splenectomy via a subcostal incision. Seven days after splenectomy, the mice were killed and inspected for abdominal wall tumor implants. The experiment was carried out in four separate trials. Results: When the results of the four trials were combined, there was no significant difference in the incidence of animals with at least one port tumor recurrence between the OS vs the LAS group (25% vs 35.2%; p= 0.30, power = 0.91). However, the overall incidence of port site tumors (number of ports with tumors/total number of ports for each group) was significantly higher in the laparoscopic-assisted group than in the open group (18.5% vs 9.5%; p= 0.03). It was noted that the incidence of port tumor recurrence (PTR) in the LAS group dropped significantly from the first to the latter three trials (second, third, and fourth trials combined) (36.1% vs 13.5%; p < 0.006) while it did not change significantly in the OS group. In the latter three trials, there was no significant difference in the number of animals with PTR between the LAS and the OS group (13.5% vs 9.8%; p= 0.43). Conclusions: Overall, there was no significant difference between the OS and the LAS groups in number of animals with port tumor recurrence or subcostal wound tumor recurrence. However, there were more port tumors in the laparoscopic-assisted group. The reasons for these findings are unclear. The laparoscopic mobilization was quite difficult; it required excessive splenic manipulation, which may have liberated tumor cells from the primary lesion and facilitated port tumor formation. With increased experience, less manipulation was required to complete the mobilization. Of note, the incidence of port tumors in the LAS group decreased significantly from the first to the subsequent three trials; therefore, it is possible that surgical technique is a factor in port tumor formation. The CO₂ pneumoperitoneum may also be a factor, but this seems less likely. Received: 10 September 1999/Accepted: 4 April 2000/Online publication: 9 August 2000     

Laparoscopic vs open colectomy for sigmoid diverticulitis

Background: The aim of this prospective comparative study was to assess the outcome of laparoscopic and open colectomy for sigmoid diverticulitis in patients aged ≥75 years. Methods: From January 1993 to December 1998, all patients 75 years of age and older undergoing an elective colectomy for sigmoid diverticulitis were included in the study. The patients were divided into the following two groups: group 1 (n= 22) consisted of patients who underwent a laparoscopic procedure; group 2 (n= 24) consisted of patients who underwent an open procedure. Results: In group 1, there were 12 women and 10 men with a mean age of 77.2 years (range, 75–82); in group 2, there were 14 women and 10 men with a mean age of 78 years (range, 76–84) (p= 0.37). There was no difference between the groups in ASA classification. The operative time was shorter in group 2 (136 vs 234 mins). The postoperative period during which parenteral analgesics were required (5.4 vs 8.2 days, p= 0.001), postoperative morbidity (18% vs 50%, p= 0.02), postoperative length of hospital stay (13.1 vs 20.2 days, p= 0.003), and the inpatient rehabilitation (6 vs 15 patients, p= 0.01) were significantly shorter for group 1 than for group 2. There were no perioperative deaths. The conversion rate was 9% in group 1. Conclusion: The data from the present study suggest that laparoscopic colectomy for sigmoid diverticulitis can be applied safely to older patients with fewer complication, less pain, shorter hospital stay, and a more rapid return to preoperative activity levels than that seen with open colorectal resection. Received: 22 November 2000/Accepted: 22 February 2000/Online publication: 7 September 2000     

Laparoscopic gastro- and hepaticojejunostomy for palliation of pancreatic cancer

Background: Most patients presenting with pancreatic cancer are irresectable at the time the diagnosis is made. Therefore, they are in need of palliative treatment that can guarantee minimal morbidity, mortality, and hospital stay. To address this need, we designed a study to test the feasibility of laparoscopic gastroenterostomy and hepaticojejunostomy and to compare their results with those achieved with open techniques. Methods: We performed a case control study of a new concept in laparoscopic palliation based on the findings of preoperative imaging and diagnostic laparoscopy. Laparoscopic side-to-side gastroenterostomy and end-to-side hepaticojejunostomy (Roux-en-Y) were done in irresectable cases. Of 14 patients who underwent laparoscopic palliation, three had a laparoscopic double bypass, seven had a gastroenterostomy, and four underwent staging laparoscopy only. The results were compared with a population of 14 matched patients who had conventional palliative procedures. Results: Postoperative morbidity was 7% vs 43% for laparoscopic and open palliation, respectively (p < 0.05). There were no mortalities in the laparoscopic group, as compared to 29% in the group who had open bypass surgery (p < 0.05). Postoperative hospital stay averaged 9 days in the laparoscopic group and 21 days in the open group (p < 0.06). Operating time tended to be shorter in the laparoscopic group (p < 0.25). Morphine derivatives were necessary for a significantly shorter period after laparoscopic surgery (p < 0.03). Conclusions: Our preliminary experience strongly suggests that laparoscopic palliation can reduce the three major drawbacks of open bypass surgery—i.e., high morbidity, high mortality, and long hospital stay. Received: 24 February 1999/Accepted: 13 May 1999     

Laparoscopic splenectomy in children

To determine the safety and efficiacy of laparoscopic splenectomy (LS) in children, a retrospective review of our preliminary experience using LS was compared to results in patients who previously underwent open splenectomy (OS). From July 1993 to January 1995, we performed eight LS procedures in six children with hereditary spherocytosis (HS) and two with immune thrombocytopenic purpura (ITP). Laparoscopic cholecystectomy was simultaneously done in one case with HS. There were 4 males and 4 females who ranged in age from 5 to 15 years—an average age of 8.8 years. Two cases in the early series required a counterincision because of bleeding. Eleven patients who previously underwent OS in our department were used to compare demographics, operative courses, and surgical outcomes. The ages, genders, diseases, body weights, and spleen weights were comparable between LS group and OS groups. The operative time for the LS group was statistically longer than for the OS group (226±24 min vs 101±8 min, P<0.001). The estimated blood loss in the LS group was similar to that of the OS group (100±39 ml vs 73±11 ml, P=0.97). There were no peri- or postoperative complications in two groups. The postoperative hospital stay of LS group was statistically shorter than that of the OS (6.8±0.6 days vs 10.4±0.5 days, P<0.001). LS provided better cosmesis and minimized trauma in children over OS. LS appears to be a safe and effective procedure in children, and is useful in the management of pediatric patients with HS or ITP.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, Florida, USA, 11–14 March 1995     

Hematological long-term results of laparoscopic splenectomy for patients with idiopathic thrombocytopenic purpura: a case control study

Background Laparoscopic splenectomy (LS) for idiopathic thrombocytopenic purpura (ITP) appears, when compared to open splenectomy (OS), associated with immediate important advantages. However, in a number of patients splenectomy does not lead to an adequate response, or after initial adequate response a relapse occurs after some time. A relapse may be associated to the presence of accessory spleens and splenosis. The purpose of this study was to compare the operative outcome and the hematological results on the long term of a series of LS with a historic series of OS for the treatment of ITP.Methods A retrospective review was done of 50 consecutive patients who underwent LS for ITP. Patient characteristics, outcome of surgery, and hematological results were compared to a historical group of patients who underwent conventional splenectomy for ITP (n = 31). Response to splenectomy was defined in three groups: complete remission, partial remission, and no response. Grouping was based on hematological data.Results Concerning operative outcome and postoperative complications, there was a significant difference in favor of LS. Moreover, the hematological outcome of both groups showed no differences after a median period of 66 months (OS) and 35 months (LS), respectively.Conclusions Hematological results after laparoscopic splenectomy for ITP are comparable to those after open splenectomy in both the short and the long term.     

Laparoscopic splenectomy for treatment of patients with idiopathic thrombocytopenic purpura

BACKGROUND: Laparoscopic splenectomy (LS) is one of the advanced laparoscopic procedures that benefit most from minimally invasive surgery. This study was undertaken to compare the operating time, blood loss, length of hospital stay, and platelet count response for patients with idiopathic thrombocytopenic purpura (ITP) undergoing open splenectomy (OS) versus LS. METHODS: We performed OS in 20 cases before 1992 and LS in 14 cases after 1993 for the treatment of ITP. RESULTS: The operating time was significantly shorter for OS than for LS (126 +/- 52 min versus 203 +/- 83 min, p < 0.01). Blood loss was less for OS than for LS (321 +/- 264 ml versus 524 +/- 648 ml, p = 0.287). None of the patients who underwent LS were converted to open surgery. Accessory spleens were found in four OS patients (20.0%) and four LS patients (28.6%). The postoperative hospital stay was significantly longer for OS patients than for LS patients (15.2 +/- 5.8 days versus 8.9 +/- 2.9 days, p < 0.0005). No significant difference was noted in the long-term results of splenectomy. CONCLUSIONS: Compared with OS, LS required more operating time, had the potential to cause greater blood loss, had a comparable incidence of accessory spleen and response rate, and appeared to shorten the postoperative stay.     

Laparoscopic versus open splenectomy in children

BACKGROUND: The authors have reviewed their initial experience with laparoscopic splenectomy (LS) to identify the indications, success rate, and complications associated with this procedure compared with a series of children undergoing open splenectomy (OS) during the same time period. METHODS: The records of 51 children who underwent splenectomy from 1993 through 1998 were reviewed retrospectively. RESULTS: Thirty-five patients aged 1 to 17 years (mean, 9.4 years) underwent LS for the following indications: ITP (n = 20), sickle cell disease or thalassemia (n = 6), hereditary spherocytosis (n = 5), other hematologic disorders (n = 4). Seventeen patients aged 2 to 17 years (mean, 11.8 years) underwent OS during the same time period for ITP (n = 4), sickle cell disease or thalassemia (n = 4), hereditary spherocytosis (n = 5), and other indications (n = 4). Concomitant cholecystectomy was performed in 4 of 35 LS and 4 of 17 OS. Accessory spleens were identified in 10 of 35 LS and 2 of 17 OS cases. Eleven spleens were enlarged in the LS group, and 8 were enlarged in the OS group. One LS required conversion to an open procedure because the spleen did not fit in the bag. No other cases were converted. Median estimated blood loss was 50 mL for both the LS and OS groups. The only intraoperative complication in the LS group was a splenic capsular tear, which had no effect on the successful laparoscopic removal of the spleen. No patient in either group required a blood transfusion. The LS patients had a shorter length of hospital stay (1.8 +/- 1 versus 4.0 +/- 1 day, P = .0001). Total hospital charges were not significantly different. Follow-up ranged from 6 to 40 months. One LS patient died 47 days postoperatively from unrelated causes. Two LS patients had recurrent ITP; accessory spleens were found in one and resected laparoscopically. CONCLUSION: LS in children can be performed safely with a low conversion rate (2.9%) and is associated with a shorter hospital stay and comparable total hospital cost when compared with OS.     

Open versus laparoscopic splenectomy for idiopathic thrombocytopenic purpura: clinical and economic analysis

BACKGROUND: Since 1991, laparoscopic splenectomy (LS) has gained acceptance in the treatment of hematologic disorders, including idiopathic thrombocytopenic purpura (ITP). Several studies suggest that LS provides benefits over open splenectomy (OS). However, study design flaws hinder formal technology assessment. METHODS: We retrospectively reviewed medical and administrative records of patients who underwent splenectomy for ITP between January 1995 and December 2000 to compare clinical and economic outcomes associated with LS and OS. RESULTS: Eighty-six patients were identified; 42 underwent an attempted LS and 44 had OS. Preoperative patient characteristics were similar between groups. Mean operative and anesthesia times for LS and OS were 167 and 201 minutes and 119 and 151 minutes, respectively (P <.001). Overall transfusion and postoperative complication rates were similar between groups. On average, LS patients required 1.2 fewer days of parenteral analgesia and were able to tolerate a general diet 1.7 days earlier. Mean postoperative stay was 2 days lower for LS patients and mean total direct costs did not differ by surgical method (US dollars 8134 vs US dollars 8200). CONCLUSIONS: This observational study shows that LS is safe and offers advantages over OS: less postoperative pain, earlier general diet tolerance, and shorter hospital stay. These benefits are obtained at no significant additional cost.     

Laparoscopically assisted distal gastrectomy for early gastric cancer

Background: The purpose of this study was to compare clinical outcomes between laparoscopically assisted and open distal gastrectomy for early gastric cancer. Methods: The records of 21 patients who underwent laparoscopically assisted distal gastrectomy (LG) for preoperative diagnosis of intramucosal gastric carcinoma between January 1996 and August 1998 were reviewed and compared with those of 31 open distal gastrectomy patients during the same period. Results: Age, gender, and size and histologic differentiation of the lesions were matched. Those located at the body of the stomach (p= 0.011) and those macroscopically depressed (p= 0.049) were subjected more frequently to open surgery. Laparoscopically assisted gastrectomy required significantly longer operative time (p < 0.001) with less extensive lymph node dissection (p < 0.001). However, time to start of walking (p= 0.032), time to flatus (p= 0.002), duration of postoperative fever (p= 0.027), and postoperative hospital stay (p= 0.001) were significantly shorter in the LG group, and this group had a lower white blood cell count on the first postoperative day (p= 0.010). Blood loss and time to oral intake were comparable between the groups. Complications included one conversion to open surgery, one leakage, and one stenosis in the LG group, and two leakages and an atelectasis in the OG group. Conclusions: Although LG requires longer surgical time, this retrospective study suggests that it is superior to open surgery in terms of faster postoperative recoveries, shorter hospital stays, and cosmetic outcomes. Received: 25 December 1998/Accepted: 15 July 1999     

A comparison of laparoscopic Nissen fundoplication and Rossetti's modification in 239 patients

Background: Laparoscopic Nissen fundoplication and the Rossetti modification represent two different surgical approaches to resolving gastroesophageal reflux disease (GERD). Concerns have arisen that the Rossetti modification results in increased postoperative dysphagia. In this study, we compared a group of patients who underwent a laparoscopic Nissen fundoplication with a group who had undergone the Rossetti modification to determine if there was a significant difference in postoperative dysphagia. Additionally, we wanted to confirm that the Nissen procedure performed laparoscopically could resolve GERD as successfully as the Rossetti modification, with no difference in operative complications. Methods: We prospectively collected data on 101 patients who underwent laparoscopic Nissen fundoplication and compared outcomes with those of 138 patients who had undergone the laparoscopic Rossetti modification in a previous series. Results: All patients experienced resolution of reflux symptoms. No statistically significant differences were found between the groups in terms of intraoperative or postoperative complications, conversions to open procedure, or length of hospitalization. Paradoxically, there was a significant difference in operating time between the Rossetti and the Nissen groups (70.6 min vs 45.6 min, p= 0.006). Postoperative dysphagia requiring dilation was significantly higher in the Rossetti group (21.7% vs 8.9%, p= 0.008). However, there was a significantly higher percentage of patients in the Rossetti group who had had esophagitis preoperatively (95.7% vs 86.1%, p= 0.009), although the proportion of patients having Barrett's esophagus was higher in the Nissen group (9.4% vs 24.8%, p= 0.001). Conclusions: Both approaches resolved reflux symptoms without significant differences in complications, conversions, or length of stay. Preoperative differences between groups, as well as the method of sequentially comparing the two different procedures, prevent us from attributing greater postoperative dysphagia in the Rossetti group solely to the choice of surgical approach. Prospective randomized studies are needed to control for variables, such as surgical team experience and patient differences. Online publication: 17 April 2000     

Early laparoscopic cholecystectomy for acute cholecystitis

Background: The timing of laparoscopic cholecystectomy for acute cholecystitis remains controversial. Methods: One hundred ninety-four patients with acute cholecystitis were reviewed. The conversion rates for the various number of days of symptoms before surgery were analyzed. The conversion rate dramatically increased from 3.6% for those patients with 4 days of symptoms to 26% for those patients with 5 days of symptoms. The mean number of days of symptoms prior to surgery in those patients who underwent successful laparoscopic cholecystectomy was 4.1 as compared to 8.0 in those patients who required open cholecystectomy (p < 0.0001). Based on this data the patients were divided into two groups. Group 1 consisted of 109 patients who underwent laparoscopic cholecystectomy within 4 days of onset of symptoms and group 2 consisted of 85 patients who underwent laparoscopic cholecystectomy after more than 4 days following onset of symptoms. Results: The conversion rate from laparoscopic to open cholecystectomy was 15%. The conversion rate for group 1 was 1.8% as compared to 31.7% for group 2 (p < 0.0001). Indications for conversion were inability to identify the anatomy secondary to inflammatory adhesions (68%), cholecystoduodenal fistula (18%), and bleeding (14%). The major complication rate for group 1 was 2.7% as compared to 13% for group 2 (p= 0.007). The mortality rate for all patients with attempted laparoscopic cholecystectomy for acute cholecystitis was 1.5%. The average procedure time for group 1 was 100 ± 37 min vs 120 ± 55 min in group 2. The average number of postoperative hospital days in group 1 was 5.5 ± 2.7 days as compared to 10.8 ± 2.7 days in group 2. Conclusions: We advocate early laparoscopic cholecystectomy within 4 days of onset of symptoms to decrease major complications and conversion rates. This decreased conversion rate results in decreased length of procedure and hospital stay. Received: 28 March 1996/Accepted: 12 September 1996     

Laparoscopic vs conventional Nissen fundoplication

Background: Laparoscopic Nissen fundoplication has gained wide acceptance among surgeons, but the results of the laparoscopic procedure have not been compared to the results of an open fundoplication in a randomized study. Methods: Some 110 consecutive patients with prolonged symptoms of grade II–IV esophagitis were randomized, 55 to laparoscopic (LAP) and 55 to an open (OPEN) Nissen fundoplication. Postoperative recovery, complications, and outcome at 3- and 12-month follow-up were compared in the two groups. Results: Five LAP operations were converted to open laparotomy due to esophageal perforation (two), technical difficulties (two), and bleeding (one). In the OPEN group (two) patients underwent splenectomy. There was no mortality. The mean hospital stay was 3.2 days in the LAP group and 6.4 in the OPEN group. Dysphagia and gas bloating were the most common complaints 3 months after the operation in both groups. These symptoms had disappeared at the 12-month follow-up examination. All patients in the LAP group and 86% in the OPEN group were satisfied with the result. Conclusions: Laparoscopic Nissen fundoplication is a safe and feasible procedure. Complications are few and functional results are good if not better than those of conventional open surgery. Received: 15 May 1996/Accepted: 10 September 1996     

Splenectomy for hematologic disease. Mini-invasive versus traditional technique]

BACKGROUND: This study aimed to compare the safety, efficacy and clinical benefits of laparoscopic splenectomy (LS) to open splenectomy (OS) in patients with hematologic disorders. METHODS: EXPERIMENTAL DESIGN: prospective study; SETTING: II Department of Surgery, Santa Maria Nuova Hospital, Reggio Emilia and III Department of Surgery, Santo Spirito Hospital Pescara; PATIENTS: 48 consecutive adult patients underwent splenectomy; 30 patients under-went LS and 18 OS. Perioperative characteristics, outcomes, complications and costs were comparatively analyzed. RESULTS: Mean age was 35.3 years in the LS group, and 40.8 in the OS group. Mean spleen size was 11.7 cm in the LS group and 15.2 cm in the OS group. Accessory spleens were found in 5 patients in the LS group and in 4 patients in the OS group; 4 conversions to laparotomy occurred in the LS group. A total of 4 complications occurred in 3 patients of the LS; 9 complications occurred in 5 patients of OS group. Mean surgical time was 141.5 minutes for LS and 89.7 minutes for OS (p<0.005). Mean postsurgical stay was 5.8 days in the LS group and 8.5 days in the OS group (p<0.005). Response rates were similar in both groups. CONCLUSIONS: LS is comparable to OS in terms of efficacy and safety and it is associated with a shorter hospital stay. LS should become the technique of choice for treatment of intractable benign hematologic disease.