Laparoscopic surgery for ulcerative colitis

Laparoscopic techniques have revolutionized management of colorectal diseases; however, inflammatory diseases of the intestine have proven challenging because of the technical demands of their nature. Intense investigation and subsequent refinements in technique and technology have recently led to considerable advances and a clear role for laparoscopic management of Crohn's disease. and diverticulitis; laparoscopy for ulcerative colitis has not proven as promising. Laparoscopic procedures for ulcerative colitis require a significant learning curve. Although numerous experienced laparoscopic teams have documented their ability to complete them, long operative times and elevated rates of morbidity in some studies appear to counter the advantages. The question remains as to the universal application and appropriateness of these procedures in surgical management of ulcerative colitis.     

Minimal invasive surgery in female urinary incontinence: TVT-O

ObjectiveWe presented our experience in the application of Tvt-O, a surgical a new technic for SUI.MethodBetween April and December 2004, 96 patients underwent Tvt-O surgery, in Uroginecology and Vaginal Surgery Unit of the Gynecology and Obstetrics Department, Las Condes Clinic. Median age was 54 years old, weight 65 kgs. Urodinamia test: SUI II 80 cases, SUI III 4, SUI 0 in 3, and mixed urinary incontinence 9. Gynecare TVT Obturator System technique was used, Ethicon Johnson &; Johnson. It has three specific instruments: helical passers, plastic tubes fixed to mesh of prolene, and a guide for the introduction of the needle.ResultsMedia time was 7 minutes (4 to 15). Other gynecological surgery was associated in 77 (80%). Complications did not appear during the surgical act. No injury to bladder and urethra was observed. We observed in immediate postoperative period only one complication (1.04%). It was urinary retention. One complication appeared (1.04%) in remote postoperative period, corresponding polypropylene tape exposition in the anterior vaginal wall. SUI solution was obtained in 100% of patients. The medium time of observation is 6 months, 51 cases have more than 6 months of observation.DiscussionTvt-O is a surgical SUI correction technique with promissory results. Like the other types of TOT, their effectiveness will have in the long term to be evaluated.     

微侵袭手术治疗肱骨近端骨折

目的 探讨微侵袭手术治疗肱骨近端骨折的临床价值。方法 采用经肱骨鹰嘴窝上小切口多根针髓腔内固定治疗肱骨近端骨折31例。结果 31例均获随访，随访时间6—13个月，平均8．4个月。骨折均临床愈合，愈合时间6-11周，平均6.8周，随访期间无肱骨头缺血坏死征象。Con-stant Scoring System综合评分70-98分，平均86．4分。临床疗效评估：12例优，16例良，3例一般。结论 采用经肱骨鹰嘴窝上小切口多根针髓腔内固定治疗肱骨近端骨折，手术创伤小，固定牢靠，肩关节可获得早期功能锻炼，可减少并发症，是一种较理想的手术方法。     

胸椎间盘突出症微创手术治疗进展

胸椎间盘突出或胸腰段椎间盘突出是导致胸脊髓腹侧受压的重要原因之一[1]。传统的经胸或经胸膜外入路手术虽然可以达到相对满意的减压效果,但创伤大、并发症发生率高。随着手术技术的改进,经后侧入路包括经肋横突、经椎弓根和经关节突保留椎弓根等多种入路行脊髓腹侧减压越来越受到广大脊柱外科医师的认可,但仍然不能避免软组织损伤大、手术技术要求高以及对脊柱稳定性影响大等缺点[2-4]。越来越多的学者将解决问题的焦点放在内窥镜以及小切口等微创手术方面,近年来此类文献报道日趋增多。为此,我们就胸椎间盘突出症（thoracic disc her?鄄niation,TDH）的微创手术治疗进展综述如下,供广大临床医师参考。     

NOTES: new dimension of minimally invasive surgery

Natural orifice transluminal endoscopic surgery (NOTES) is an emerging experimental alternative to conventional surgery. NOTES eliminates abdominal incisions and incision‐related complications by combining endoscopic and laparoscopic techniques to diagnose and treat abdominal pathology. Since the first NOTES was reported by Kalloo et al. in 2004, significant achievements in the laboratory have occurred. Clinical use in humans has been limited, but several cases and one small clinical trial were published recently. As a further technical revolution in minimally invasive surgery, NOTES has the promising potential to be safer, less invasive, provide better cosmesis and possibly be more cost‐effective. The purpose of the present article was to review the development and current status of NOTES and highlight important advances associated with this innovative approach.     

Laparoscopic emergency and elective surgery for ulcerative colitis

Objective To analyse surgical outcomes of fulminate and medically resistant ulcerative colitis (UC) carried out laparoscopically. Method A prospective database identified 69 consecutive patients who underwent surgery for UC under the senior author over a 5‐year period to April 2006. Results Thirty‐two patients (18 male patients), median BMI 26, underwent laparoscopic subtotal colectomy (LSTC): 22 acute emergencies, 10 refractory to medical therapy and unfit for restorative proctocolectomy. All were receiving iv steroids; azathioprine (7), cyclosporin (5). The median operation time was 135 min (65–280). There was one conversion. Twenty‐nine patients have subsequently undergone completion proctectomy and W‐pouch formation [24 patients were performed laparoscopically – laparoscopic completion proctectomy (LCP)]; widespread adhesions precluded in five patients. Twenty‐six patients underwent restorative laparoscopic proctocolectomy (LRP) – one conversion. Twenty patients underwent W‐pouch reconstruction via a Pfannenstiel incision. Six J‐pouches were constructed and returned via the ileostomy site. Three underwent a laparoscopic pan‐proctocolectomy (LPPC); one conversion. Eight patients underwent open STC. The median time to normal diet was 48 h (1–7 days) for LSTC/LCP and 36 h (1–5 days) for LRP. There were two major complications following LRP, two following LSTC, one following LCP, one following LPPC and five following open surgery. Median hospital stay was 8 days (6–72) for LSTC, 7 days (6–9) for LCP and 5 days (3–45) for LRP. There were six 30‐day readmissions following laparoscopic surgery (DVT, reactive depression, ileostomy hold up (2), abdominal pain and high output ileostomy). Conclusion Laparoscopic subtotal and restorative proctocolectomies in fulminate and medically resistant UC are feasible, safe and largely predictable operations that allow for early hospital discharge. Laparoscopic colectomy facilitates subsequent proctectomy and pouch construction.     

Minimal invasive surgery in pediatric solid tumors.

BACKGROUND: There is only limited experience of using the minimally invasive surgery (MIS) technique in resecting pediatric solid tumors. In this paper, we report our experience of using the MIS technique in the management of pediatric solid tumors. METHODS: A retrospective review was undertaken on all children who had undergone MIS for their solid tumors between 1995 and 2005. RESULTS: Over a 10-year period, there were 38 patients who had undergone MIS for tumor resection. The mean age at the time of surgery was 7.5 years (range, 1 day to 15 years). There were 22 ovarian tumors, 4 sacrococcygeal tumors, 3 adrenal tumors, 3 retroperitoneal tumors, 1 kidney tumor, 1 liver mass, 1 intra-abdominal testicular tumor, and 3 intrathoracic masses. Thirty of 38 patients had undergone a successful resection using the MIS technique (78.9%). Eight patients required a conversion to the open procedure because of limited intraperitoneal space in 7 and excessive bleeding in 1. Of the 28 successfully MIS-resected intra-abdominal tumors, 18 required enlargement of the umbilical incision and 5 required an additional Pfannenstiel incision for tumor retrieval. Enlargement of the thoracic port site for specimen retrieval was required in the 2 successfully MIS-resected intrathoracic masses. The mean operation time was 171 minutes (range, 45-275). There was no postoperative complication encountered. On an average follow-up of 3.1 years, there was no recurrence observed, even in the 7 patients with malignant tumors, and all patients with successful MIS tumor excision had good cosmetic results. CONCLUSIONS: With the advance of laparoscopic instruments and techniques, a variety of pediatric solid tumors can be resected safely by the MIS technique. This has the potential benefit of a more rapid postoperative recovery and better cosmetic results. The role of the MIS technique in resecting malignant tumors is uncertain, as the number of cases in the current series is too small to draw any conclusion.     

超声引导下麦默通乳腺微创手术

麦默通(mammotome)乳腺微创手术是国内近几年用于乳腺疾病诊断和治疗的新方法,实践证明[1,2]是一种安全实用的可普及技术,但实际的应用并不广泛.以深圳市为例,全市人口逾1 200万,能开展此项技术的仅4家医院.     

Urgent surgery for ulcerative colitis: Early colectomy in 132 patients

In accordance with a policy of early colectomy for severe ulcerative colitis, urgent/emergency surgery was performed in 132 patients during the last decade. The indication for surgery was toxic megacolon (45 cases), massive hemorrhage (6 cases), and fulminating colitis not responding to medical treatment within 4 days (81 cases). The operations performed were proctocolectomy (9 cases, mostly of hemorrhage), colectomy plus ileorectal anastomosis (3 cases), and abdominal colectomy plus ileostomy plus proctostomy (CIP) (120 cases, including 45 of toxic megacolon). Secondary proctectomy (SP) was later performed in 113 CIP cases. A major distinction of this series is a colonic perforation rate of only 3% (9% in toxic megacolon). Mortality after urgent/emergency colectomy was 5.3%. Total mortality within 2 years (including SP) was 6.8%. Two of 4 patients with colonic perforation died, as did 1 patient with colonic cancer. Postoperative complications occurred in 40% of the patients after urgent/emergency colectomy, and in 52% after all surgery combined (including SP). Mortality and morbidity were higher in toxic megacolon and in patients older than 60 years. Late complications, mostly persisting perineal sinuses, were seen in 31%. We believe that the low colonic perforation rate, and the subsequent favorable mortality and morbidity, are the results of our policy of early colectomy. Also, this study lends support to the choice of abdominal colectomy plus ileostomy plus proctostomy (and subsequent secondary elective proctectomy) when urgent/emergency surgery is indicated for severe ulcerative colitis.

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Résumé Suivant une politique de colectomie précoce en cas de colite ulcéreuse grave, nous avons, au cours des 10 dernières années, opéré en urgence ou semiurgence 132 malades. Les indications opératoires ont été le mégacÔlon toxique (45 cas), l'hémorragie massive (6 cas) et la colite fulminante n'ayant pas répondu en 4 jours au traitement médical (81 cas). Les opérations réalisées ont été la proctocolectomie (9 cas, surtout pour hémorragie), la colectomie avec iléorectostomie (3 cas) et la colectomie par voie abdominale avec iléostomie et proctostomie (120 cas, y compris les 45 mégacÔlons toxiques). Une amputation ultérieure du rectum fut réalisée dans 113 de ces cas.Une première remarque s'impose pour cette série: elle ne comporte que 3% de perforations (9% pour les mégacÔlons toxiques). La mortalité après chirurgie d'urgence a été de 5.3%. La mortalité après 2 ans, y compris les amputations secondaires du rectum, a été de 6.8%. Sur 4 malades avec perforation colique, 2 sont décédés, ainsi qu'un malade atteint de cancer colique. Des complications postopératoires sont survenues chez 40% des malades après colectomie d'urgence, et chez 52% pour toute la chirurgie, y compris les amputations secondaires du rectum. La mortalité et la morbidité sont plus élevées dans le mégacÔlon toxique et chez les malades de plus de 60 ans. Nous avons eu 31% de complications tardives, surtout des fistules périnéales peristantes.Nous estimons que la rareté des perforations coliques et, en conséquence, la mortalité et la morbidité favorables résultent de notre politique de colectomie précoce. Les résultats de cette étude sont également en faveur de la colectomie abdominale avec iléostomie et proctostomie (et amputation secondaire du rectum) lorsqu'une chirurgie d'ursecondaire du rectum) lorsqu'une chirurgie d'urgence est indiquée en cas de colite ulcéreuse grave.

     

Population-based study of surgery in juvenile onset ulcerative colitis

A geographically based cohort of 37 children with ulcerative colitis has been derived by sampling from Scottish Hospital In-patient Statistics. Surgical histories were examined and analysed by actuarial methods, and the major operations performed were compared with operations for ulcerative colitis in the Lothians' Surgical Audit. Fourteen of the 37 patients had a total of 26 operations (15 major, 11 minor). Sixteen per cent had major surgery within 5 years of onset of symptoms, and the types of operation were similar to those recorded in Lothians' Surgical Audit. Operation rate was significantly lower than that for a parallel cohort of patients with Crohn's disease. With a mean follow-up of 7.4 years, seven (19 per cent) patients have a permanent stoma and there has been one death.     

腹腔镜与开腹手术治疗溃疡性结肠炎的安全性和有效性对照研究的系统评价

目的 比较溃疡性结肠炎(UC)腹腔镜手术与开腹手术的安全性和有效性.方法 外文数据库检索词:Ulcerative Colitis OR Inflammatory Bowel Disease AND Laparoscopy AND Open Surgery OR Open Procedure.中文数据库检索词:炎症性肠病OR溃疡性结肠炎AND腹腔镜AND开腹手术.检索1992年1月至2008年5月发表的相关英文或中文全文文献,检索出符合入选标准的对照研究16项共计923例患者,采用固定效应模型和随机效应模型对UC腹腔镜手术与开腹手术的安全性和有效性指标进行Meta分析.结果 与开腹手术相比,UC的腹腔镜手术明显缩短了开始进食时间(P＜0.01)和术后住院天数(P＜0.01),减少了术后总并发症发生率(P＜0.01),但延长了手术时间(P＜0.05).在肠功能恢复时间、再次手术率、腹腔脓肿、吻合口瘘、肠梗阻、切口感染、术中出血量和死亡率方面未见明显优势.中转开腹手术率为4.2%.结论 溃疡性结肠炎腹腔镜手术是安全、可行的.且术后短期恢复较快.