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1.
Laparoscopic splenectomy for ITP 总被引:6,自引:0,他引:6
R. L. Friedman M. J. Fallas B. J. Carroll J. R. Hiatt E. H. Phillips 《Surgical endoscopy》1996,10(10):991-995
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 相似文献
2.
Trias M Targarona EM Espert JJ Cerdan G Bombuy E Vidal O Artigas V 《Surgical endoscopy》2000,14(6):556-560
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 相似文献
3.
Splenectomy for idiopathic thrombocytopenic purpura 总被引:1,自引:0,他引:1
A. Marassi A. Vignali W. Zuliani E. Biguzzi C. Bergamo L. Gianotti V. Di Carlo 《Surgical endoscopy》1999,13(1):17-20
Background: This study aimed to compare the safety, efficacy, and clinical benefits of laparoscopic splenectomy (LS) to open splenectomy
(OS) in patients with idiopathic thrombocytopenic purpura (ITP).
Methods: The results from 14 consecutive patients who underwent LS for ITP were reviewed and compared with the results from patients
who underwent OS for the same disease. Demographics, concomitant disease on admission, and platelet counts were evaluated,
as were details of the surgical procedure, postoperative physiologic status, and hospital stay.
Results: Mean operative time was 88.3 min for OS and 146.4 min in LS group (p < 0.05). The conversion rate to open splenectomy was 7.1. Therapeutic response to splenectomy was 92.8% in the LS group and
86.6% in the OS group. Bowel canalization, return to liquid diet, and length of hospital stay were all significantly delayed
in the OS group as compared with those who underwent LS (p= 0.01, p= 0.02, p= 0.005, respectively). In the OS group the morbidity rate was 13.3%, whereas in the LS group it was 7.1%.
Conclusions: Laparoscopic splenectomy represents a valid alternative to conventional splenectomy in the treatment of ITP.
Received: 10 October 1997/Accepted: 11 March 1998 相似文献
4.
Donini A Baccarani U Terrosu G Corno V Ermacora A Pasqualucci A Bresadola F 《Surgical endoscopy》1999,13(12):1220-1225
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 相似文献
5.
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 相似文献
6.
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 相似文献
7.
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 相似文献
8.
Laparoscopic closure of perforated duodenal ulcer 总被引:4,自引:2,他引:2
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 相似文献
9.
S. S. Rothenberg D. Bratton G. Larsen R. Deterding H. Milgrom S. Brugman M. Boguniewicz S. Copenhaver C. White J. Wagener L. Fan J. Chang T. Stathos 《Surgical endoscopy》1997,11(11):1088-1090
Background: The relationship between severe reactive airway disease (RAD) and gastroesophageal reflux disease (GERD) has been noted but
the relationship is poorly understood. This study reports our experience with laparoscopic fundoplication and it's effect
on the pulmonary status of children with severe steroid-dependent reactive airway disease.
Methods: Fifty-six patients with severe steroid-dependent RAD and medically refractory GERD underwent laparoscopic Nissen fundoplications.
Mean age was 7 years and mean weight was 20 kg. All patients had the procedure completed successfully laparoscopically with
an average operative time of 62 min. Average hospital stay was 1.6 days.
Results: Forty-eight of 56 patients noted significant improvement in their respiratory symptoms in the first week. Fifty of 56 patients
have been weaned off their oral steroids and four others have had a greater than 50% decrease in their dose. Sixteen patients
had a documented increase in their FEV1 in the initial postoperative period (avg. 26%).
Conclusion: Patients with steroid-dependent RAD and GERD refractory to medical management show improvement in their respiratory status
following fundoplication and the majority can be weaned off of their oral steroids. Laparoscopic techniques allow this procedure
to be performed safely even in this high-risk group of patients.
Received: 25 March 1997/Accepted: 5 July 1997 相似文献
10.
Laparoscopic common bile duct exploration by choledochotomy 总被引:2,自引:2,他引:0
Background: Management of cholelithiasis and choledocholithiasis usually requires two separate teams—the gastroenterologist/surgical
endoscopist and the laparoscopic surgical team. This requires two separate procedures that potentially increase the overall
morbidity and cost. Laparoscopic common bile duct exploration by choledochotomy (LCBDE-C) averts this problem with a single
approach.
Methods: In 1990–1991, unsuspected stones found at laparoscopy with intraoperative cholangiogram done routinely underwent postoperative
ERCP. Residual stones had been found after ERCP in 16 of 22 preoperative ERCP patients and we began to seek an alternative
technique. Laparoscopic common bile duct exploration by choledochotomy has achieved a high rate of success.
Results: Technically successful LCBDE-C has been accomplished in 143 of 148 patients (96.6%). Retained bile duct stones have been
found on postoperative cholangiogram in three patients (2.0%), all of which have been successfully removed by postoperative
ERCP. Thus 140 or 148 patients had their bile duct successfully cleaned by the one-step technique alone (94.6%).
Conclusions: We believe that most laparoscopic surgeons who have acquired the skills of intracorporeal suturing can be successful at laparoscopic
common bile duct exploration by choledochotomy. The disadvantage of T-tube presence will likely be eliminated by future developments
with intraoperative antegrade sphincterotomy-like procedures, but the ability to see both proximal and distal biliary tree
with the choledochotomy in all cases seems to offer more than adequate results at this point in the evolution of the laparoscopic
approach to calculus biliary tract disease.
Received: 3 April 1997/Accepted: 18 September 1997 相似文献
11.
Laparoscopic cholecystectomy and interventional endoscopy for gallstone complications during pregnancy 总被引:6,自引:3,他引:3
Sungler P Heinerman PM Steiner H Waclawiczek HW Holzinger J Mayer F Heuberger A Boeckl O 《Surgical endoscopy》2000,14(3):267-271
Background: Symptomatic or complicated gallstone disease is the most common reason for nongynecological operations during pregnancy.
Gallstones are present in 12% of all pregnancies, and more than one-third of patients fail medical treatment and therefore
require surgical endoscopy or laparoscopy. Gallstone pancreatitis and jaundice during pregnancy is associated with a high
recurrence rate, exposing both fetus and mother to an increased risk of morbidity and mortality.
Methods: During a 4-year period, all pregnant patients (n= 37) with symptomatic or complicated gallstone disease were studied prospectively at the Landeskrankenhaus in Salzburg, Austria.
Five patients had an endoscopic retrograde cholangiopancreatogram (ERCP) for biliary pancreatitis or jaundice; two of these
underwent subsequent laparoscopic cholecystectomy. Another seven patients required laparoscopic cholecystectomy for severe
pain or cholecystitis; all were in their 13th–32nd gestational week. Access was established by Veress needle in all cases.
Insufflation pressure was 8–10 mmHg, and mean operative time was 62 min.
Results: All patients delivered full-term, healthy babies. There were no postendoscopic or postoperative complications. All patients
enjoyed full relief from their symptoms; there were no recurrences of pancreatitis or jaundice.
Conclusions: The combination of ERCP and laparoscopic cholecystectomy offers a safe and effective option for the definitive treatment
of complicated gallstone disease and intractable pain during pregnancy, and there is sufficient access for the combined treatment
to be employed.
Received: 7 September 1998/Accepted: 2 June 1999 相似文献
12.
The outcome of unretrieved gallstones in the peritoneal cavity during laparoscopic cholecystectomy 总被引:5,自引:0,他引:5
Background: Gallbladder perforation during laparoscopic cholecystectomy (LC) with spillage of bile and gallstones occurs in a substantial
number of patients (up to 40%). Most surgeons believe that free intraperitoneal stones are not a justification for conversion
to laparotomy even if a large number of stones are left in situ. There are, however, a number of reports demonstrating that, on occasion, these unretrieved gallstones may cause infection
or abscess, inflammation, fibrosis, adhesions, cutaneous sinuses, small bowel obstruction, or generalized septicemia. The
aim of this study was to determine the outcome of unretrieved gallstones in the peritoneal cavity after gallbladder perforation
during LC.
Methods: In a 7-year period between 1989 and 1996, prospective data were maintained on 856 patients who underwent LCs by a single
surgeon (R.J.F.). Of the 856 patients, 165 (16%) had gallbladder perforations resulting in lost gallstones in the peritoneal
cavity. A concerted attempt was made to remove the lost stones using a variety of extraction devices. Of these 165 patients,
106 (64%) were available for follow-up through mail (76%) and by telephone (24%). The mean age of these patients was 64.9
years (range, 18 to 98 years), and the mean follow-up was 44.8 months (range 4.9 to 92.3 months).
Results: Of the 106 patients with unretrieved gallstones, we identified four patients with short-term complications and one patient
with a long-term complication. The first patient with a short-term complication had pyrexia for 10 days postoperatively. Diagnostic
evaluation, which included computed tomography (CT) scan, failed to reveal any abnormality. The patient was treated conservatively
with a course of oral antibiotics. In the second patient, cellulitis developed at a drain site after its removal, which resolved
with oral antibiotics. The third patient acquired an umbilical wound abscess, which drained spontaneously, requiring no treatment.
A sterile subphrenic collection developed in the fourth patient 1 month postoperatively, which was treated with percutaneous
drainage under CT guidance. The only long-term complication was spontaneous erosion of a gallstone from the back of a patient
with a questionable history of inflammatory bowel disease 8 months postoperatively. All of the patients made complete recoveries.
Conclusions: In most patients, unretrieved gallstones are of no consequence, but complications occur occasionally. It is therefore advisable
to retrieve as many gallstones as possible during LC short of converting to a laparotomy.
Received: 21 July 1998/Accepted 12 February 1999 相似文献
13.
Comparison of results after transanal endoscopic microsurgery and radical resection for T1 carcinoma of the rectum 总被引:25,自引:3,他引:22
Background: We compared the results of transanal endoscopic microsurgery and radical surgery in patients with T1 carcinomas of the rectum.
Methods: We performed a retrospective study (1985–96) to compare the results obtained in 103 patients with T1 rectal carcinomas (low-risk
T1, n= 80; high-risk T1; n= 23) undergoing transanal endoscopic microsurgery and radical surgical therapy.
Results: The complication rate in patients undergoing local excision was 3.4% (two of 58); it was 18% (eight of 45) in the group treated
with radical surgery. Two of 45 patients (3.8%) died after radical resection; there were no deaths after local excision. With
regard to the actuarial 5-year survival rate, no difference was observed in the group with low-risk T1 carcinoma between patients
treated with local excision (79%) and those who had radical resection (81%) (p= 0.72). In patients with high-risk T1 carcinoma, lymph node metastases were identified in four of 11 patients undergoing
radical resection (36%). Four of 12 patients with high-risk T1 carcinoma treated by local excision developed recurrences,
whereas none of the patients undergoing primary radical surgery had a recurrence.
Conclusions: Transanal endoscopic microsurgery for the treatment of low-risk T1 carcinomas is associated with a significantly lower complication
rate than radical surgical therapy. There is no difference in 5-year survival between local and radical surgical therapy in
patients with low-risk T1 carcinoma.
Received: 23 May 1997/Accepted: 18 December 1997 相似文献
14.
Short-term outcome of laparoscopic paraesophageal hernia repair 总被引:5,自引:0,他引:5
T. R. Huntington 《Surgical endoscopy》1997,11(9):894-898
Background: The purpose of this study is to determine the morbidity, mortality, and short-term outcomes associated with laparoscopic
paraesophageal hernia repair (LPHR).
Methods: A series of 58 consecutive LPHRs performed by the author were reviewed with an average 1-year follow-up. Morbidity and mortality
rates were compared with historical series of open repairs. Anatomy and technical considerations pertinent to LPHR were reviewed.
Results: There were no procedure-related or perioperative deaths in this series of patients undergoing LPHR. Four major complications
occurred (7%), two of which required reoperation, all in urgently repaired patients. One patient required conversion to laparotomy
(1.7%). Based on symptoms, there were no reherniations. No patients had long-term dysphagia worse than preoperatively. Preoperative
symptoms of chest pain, esophageal obstruction, hemorrhage, and reflux were resolved in all patients.
Conclusions: LPHR is safe, effective, and compares favorably to historical series of open paraesophageal hernia repair.
Received: 24 July 1996/Accepted: 20 November 1996 相似文献
15.
Bile duct injury after laparoscopic cholecystectomy 总被引:27,自引:3,他引:27
Background: Forty series reporting experience with laparoscopic cholecystectomy in the United States from 1989 to 1995 were reviewed.
A total of 114,005 cases were analyzed and 561 major bile duct injuries (0.50%) and 401 bile leaks from the cystic duct or
liver bed (0.38%) were recorded. Intraoperative cholangiography (IOC) was attempted in 41.5% of the laparoscopic cholecystectomies
and was successful in 82.7%. In major bile duct injuries, the common bile duct/common hepatic duct were the most frequently
injured (61.1%) and only 1.4% of the patients had complete transection.
Methods: When reported, most of the bile duct injuries were managed surgically with a biliary-enteric anastomosis (41.8%) or via laparotomy
and t-tube or stent placement (27.5%). The long-term success rate could not be determined because of the small number of series
reporting this information. The management for bile leaks usually consisted of a drainage procedure (55.3%) performed endoscopically,
percutaneously, or operatively.
Results: The morbidity for laparoscopic cholecystectomy, excluding bile duct injuries or leaks, was 5.4% and the overall mortality
was 0.06%. It was also noted that the conversion rate to an open procedure was 2.16%.
Conclusions: It is concluded based on this review of laparoscopic cholecystectomies that the morbidity and mortality rates are similar
to open surgery. In addition, the rate of bile duct injuries and leaks is higher than in open cholecystectomy. Furthermore,
bile duct injuries can be minimized by lateral retraction of the gallbladder neck and careful dissection of Calot's triangle,
the cystic duct–gallbladder junction, and the cystic duct–common bile duct junction.
Received: 24 September 1996/Accepted: 28 July 1997 相似文献
16.
Laparoscopic treatment of large paraesophageal hernias 总被引:6,自引:4,他引:2
van der Peet DL Klinkenberg-Knol EC Alonso Poza A Sietses C Eijsbouts QA Cuesta MA 《Surgical endoscopy》2000,14(11):1015-1018
Background: We set out to evaluate the results of the laparoscopic treatment of large paraesophageal hernias in 22 patients.
Methods: Between 1993 and 1998, we operated on 22 consecutive patients. Preoperative assessment consisted of endoscopy, barium esophagogram,
24-h pH testing, manometry, and gastric emptying times.
Results: In the first three patients, the sac was not excised and gastropexy was not performed. Because of recurrences, we decided
to change the technique in an attempt to avoid further complications. During middle- to long-term follow-up, only three recurrences
were seen in the subsequent 19 patients. There were no deaths in this series.
Conclusions: Laparoscopic treatment of large paraesophageal hernias is feasible. Because recurrences may occur after successful laparoscopic
treatment, both resection of the sac and some form of gastropexy are imperative.
Received: 22 March 2000/Accepted: 30 April 2000/Online publication: 20 September 2000 相似文献
17.
Background: This prospective study was conducted to evaluate the accuracy and the therapeutic relevance of staging laparoscopy.
Methods: Between June 1993 and February 1997 staging laparoscopy was performed in 389 patients with various neoplasms. Additionally,
144 selected patients of this group were examined with laparoscopic ultrasound using a semiflexible ultrasound probe (7.5
MHz).
Results: Compared to conventional imaging methods, laparoscopy and laparoscopic ultrasound improved the accuracy of staging in 158
of 389 patients (41%). Statistical subgroup analysis of 131 patients with gastric cancer showed that the accuracy of staging
laparoscopy in the detection of distant metastases (68%) was significantly higher (p < 0.01) than that of ultrasound (63%) or computed tomography (58%). In the whole group, laparoscopy alone disclosed intraabdominal
tumor dissemination or nonresectable disease in 111 patients. Laparoscopic ultrasound displayed additional metastases—i.e.,
liver metastases (n = 9), M1 lymph nodes (n = 15), or nonresectable tumors (n = 6) in 30 patients. Although metastastic disease
was suggested by preoperative imaging, benign lesions were found in five patients with laparoscopy and in a further 12 patients
with ultrasonography. The findings of staging laparoscopy changed the treatment strategy in 45% of the patients. Conversion
to open surgery was necessary in 5% of the cases, and complications related to laparoscopy occured in 4% of the patients.
Conclusions: Laparoscopy with laparoscopic ultrasound improves the staging of gastrointestinal tumors and has a significant impact on
a stage-adapted surgical therapy.
Received: 3 April 1997/Accepted: 26 September 1997 相似文献
18.
Early laparoscopic cholecystectomy for acute cholecystitis 总被引:4,自引:0,他引:4
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 相似文献
19.
Background: Endoscopic placement of biliary stents is an effective initial treatment for jaundice and cholangitis caused by common bile
duct (CBD) strictures secondary to chronic pancreatitis; however, the role of endoscopic treatment for long-term management
of these strictures is less clear. In 1992, we designed a protocol of balloon dilatation and stenting for ≥12 months. This
study evaluates endoscopic therapy as a definitive long-term treatment for these strictures. We have treated 25 patients with
this protocol.
Methods: All patients had an endoscopic sphincterotomy, balloon dilatation of the stricture, and then placement of a polyethylene
stent (7–11.5 F). Stents were exchanged at 3–4-month intervals to avoid the complications of clogging and cholangitis. We
were particularly interested in how many patients would achieve resolution of the stricture and tolerate removal of the stent.
Results: The length of the CBD strictures ranged from 8 to 40 mm. Within days of stenting, all patients achieved relief of jaundice
and cholestasis. Complications consisted of six episodes of cholangitis and nine episodes of pancreatitis. There were no deaths.
Twenty of the 25 patients are now stent-free after an average stenting period of 13 months (range, 3–28). To date, there has
been no recurrence of stricture, for a mean of 32 months. Three patients still have stents in place, and two patients required
operation—one for persistent stricture and recurrent cholangitis after 8 months of stenting, and one for a mass in the head
of the pancreas that was thought to be cancer.
Conclusions: Our results indicate that these strictures will respond and dilate after a course of stenting in 80% of patients, with an
acceptable morbidity. Although these are medium-term results at 32 months, we would expect most recurrences within the 1st
year following stent removal. In some cases, stenting is necessary for >12 months. Thus, the data suggest that endoscopic
stenting provides definitive treatment in most patients with CBD stricture due to chronic pancreatitis and may be considered
a viable alternative to standard surgical bypass.
Received: 18 May 1999/Accepted: 24 September 1999 相似文献
20.
J. Kuriansky M. Ben Chaim D. Rosin J. Haik O. Zmora P. Saavedra M. Shabtai A. Ayalon 《Surgical endoscopy》1998,12(6):898-900
Laparoscopic splenectomy (LS) is effective and technically feasible for treating various hematological diseases, especially
idiopathic thrombocytopenic purpura (ITP). An anterior approach to the vascular pedicle is usually described. However, in
this approach to the splenic hilum, the dissection of the splenic artery is often difficult. A total of 13 patients with ITP
underwent elective laparoscopic splenectomy. We utilized a laparoscopic posterolateral approach involving dissection of the
suspensory ligaments at the lower pole, then dissection and division of the posterolateral attachments, followed by the dissection
and ligation of all splenic branches near the splenic parenchyma. This procedure was completed in 11 of our 13 patients and
converted to open surgery in the other two patients. Mean operative time was 3 h; mean postoperative stay was 3 days. No blood
transfusion was required, and no complications were noted in the postoperative period. The posterolateral approach provides
better visualization and control of branches of the splenic vein and artery in the splenic hilum. It also permits visualization
and control of surgical hemorrhage through the operating ports.
Received: 24 January 1997/Accepted: 28 October 1997 相似文献