Is laparoscopic single-stage biliopancreatic diversion with duodenal switch safe in super morbidly obese patients?

BackgroundIt has been hypothesized that the morbidity and mortality of laparoscopic biliopancreatic diversion with duodenal switch (BPD-DS) are likely to increase with increasing body mass index (BMI), especially with BMI>50 kg/m². Therefore, a 2-stage approach to this procedure has been advocated in super morbidly obese patients. The authors hypothesized that a BMI≥50 kg/m² does not significantly influence the morbidity and mortality perioperatively associated with this procedure.MethodsA retrospective analysis of all patients who underwent laparoscopic BPD-DS between January 2009 and September 2011 was performed. The patients were divided into 2 groups: patients with BMI<50 kg/m² and those with BMI>50 kg/m². Patient characteristics, perioperative variables, 30-day outcomes, and complications were analyzed and compared.ResultsA total of 226 patients underwent laparoscopic BPD-DS. Mean patient age was 44.9 years (range: 20–72 yr). Male to female ratio was 59 to 170 patients (75% versus 25%), respectively. Mean BMI was 50.2 kg/m² (range: 37.2–68.8 kg/m²). A total of 127 patients had a BMI<50 kg/m² (Group 1), and 99 patients had a BMI≥50 kg/m² (Group 2). The length of procedure in Groups 1 and 2 was 296 minutes and 287 minutes, respectively (P = .25). The rate of conversion to open BPD-DS was 1.5% in Group 1 and 3% in Group 2 (P = .65). Two leaks occurred in Group 1; no patient in Group 2 developed this complication. One patient in Group 2 developed pulmonary embolism. The rates of all other complications resulting in a longer length of stay were 11% in Group 1 and 8% in Group 2 (P = .50). The 30-day reoperation rate was 3% in Group 1 and 1% in Group 2 (P = .39). The mean length of stay was 3.97 days for Group 1 and 3.67 days for Group 2 (P = .34). No mortality occurred in this series.ConclusionIn the present study, BMI≥50 kg/m² did not increase intraoperative or postoperative complications at 30 days after laparoscopic PBD-DS. No significant differences were noted between patients with BMI≥50 kg/m² and patients with BMI<50 kg/m². A single-stage laparoscopic BPD-DS procedure can be safely offered to the super morbidly obese patients.     

Is the laparoscopic approach appropriate for porcelain gallbladder?

Contrary to the fears raised in surgical publications of the 1950's and 60's, the prognosis of porcelain gallbladder is not automatically associated with an increased risk of gallbladder carcinoma. Two recent cohort studies have allowed a better definition of the appropriate therapeutic attitude for a patient with a calcified gallbladder. In cases of "true" porcelain gallbladder, i.e., the presence of complete transmural calcification of the entire gallbladder wall, indications for cholecystectomy are based on biliary symptoms, all the more so since choledocholithiasis is often associated with porcelain gallbladder. In the case of partial calcification of the gallbladder, i.e., focal plaques of calcification involving the mucosa, prophylatic operative treatment is indicated. In these cases, the incidence of malignancy is markedly increased (14 times that of a control population). Cholecystectomy can still be performed laparascopically as long as the rules for prevention of peritoneal dissemination of tumor cells are scrupulously observed--the gallbladder should not be opened nor bile spilled, the specimen should be placed in a bag for removal through the abdominal wall, the pneumoperitoneum should be evacuated with the trocars still in place and the specimen should be opened and examined after removal with immediate frozen section pathologic exam if there is any question of tumor.     

Is laparoscopic antireflux surgery safe and effective in obese patients?

Background  

It is not clear whether obesity has any negative impact on the results of laparoscopic antireflux surgery (LARS). In this prospective study we investigated the effect of body mass index (BMI) on the surgical outcome of LARS.     

Is laparoscopic colectomy as cost beneficial as open colectomy?

Background: Laparoscopic colectomy has yet to gain widespread acceptance in cost‐conscious health‐care institutions. The aim of the present study was to define the cost–benefit relationship of laparoscopic versus open colectomy. Methods: Thirty‐two consecutive patients undergoing elective laparoscopic colectomy (LC) by a single colorectal surgeon between August 2004 and September 2005 were reviewed. Cases were matched with a historical cohort undergoing elective open colectomy (OC) between June 2003 and July 2004. Demography, perioperative data, histopathology and cost were compared. Results: Both groups had similar demographics. Most resections (90.6%) were for cancer. Operative time was significantly longer for LC compared to OC (180 min vs 110 min, P < 0.001). Four patients (12.5%) in the LC group required conversion. LC patients, however, had lower median pain scores (3, 2 and 1 vs 6, 4 and 2 at 24, 48 and 72 h postoperatively, P < 0.001), faster resolution of ileus (3 vs 4 days, P < 0.001) and earlier discharge (6 vs 9 days, P < 0.001) compared to the OC group. As a result, overall hospital cost for both procedures was not significantly different (US$7943 vs US$7253, P = 0.41). Conclusion: Laparoscopic colectomy is as cost‐beneficial in the short term as open colectomy.     

Is the laparoscopic Palomo procedure for pediatric varicocele safe and effective?

Background Varicocele is a rare disorder in children that can lead to testicular atrophy and infertility; therefore, radical treatment is frequently required. Whatever treatment is chosen, postoperative complications are fairly common (hydrocele, recurrence, persistence, and testicular atrophy). Laparoscopic varicocelectomy (the laparoscopic Palomo procedure) is one of the surgical options that has recently gained popularity. The aim of this study is to assess the safety and effectiveness of laparoscopic Palomo varicocelectomy by describing a series of patients operated on during a 9 year period at the Royal Hospital for Sick Children in Edinburgh. Methods This is a retrospective unicentric study including patients operated on between June 1995 and June 2004. All patients preoperatively underwent ultrasound scan of the testicles (color Doppler) and the abdomen. Indications for surgery included symptoms, high-grade varicocele (grade II and III), and testicular atrophy. Pneumoperitoneum was created using carbon dioxide insufflation with intraabdominal pressure up to 12 mmHg. Three 5 mm ports were inserted. The first port was inserted just below the umbilicus (telescope) under direct vision, and the others were inserted at the left flank and in the suprapubic region. All the enlarged spermatic and vas vessels were ligated or clipped. Outcomes and possible intraoperative, postoperative, or long-term complications are described. Results Forty-one patients were included in the study. Ninety percent of symptomatic patients improved significantly postoperatively, and 62% of patients with preoperative testicular atrophy showed postoperative catch-up growth of the involved testis. Nevertheless, hydrocele represents the most frequent postoperative complication in this series of patients. Approximately 15% of the patients required some sort of further surgical intervention (12% because of postoperative hydrocele occurrence). Conclusions The laparoscopic Palomo procedure is a safe and effective surgical option for the treatment of pediatric varicocele, although it carries a fairly high risk of postoperative hydrocele. Postoperative hydrocele seems to be related to some sort of lymphatic obstruction, therefore lymphatic sparing procedures that can be accomplished laparoscopically should be reconsidered. Nevertheless, their feasibility and effectiveness need to be more carefully assessed.     

Is laparoscopic approach for pancreatic insulinomas safe? Results of a systematic review and meta-analysis

Background

No consensus exists as to whether laparoscopic treatment for pancreatic insulinomas (PIs) is safe and feasible. The aim of this meta-analysis was to assess the feasibility, safety, and potential benefits of laparoscopic approach (LA) for PIs. The abovementioned approach is also compared with open surgery.

Methods

A systematic literature search (MEDLINE, EMBASE, Cochrane Library, Science Citation Index, and Ovid journals) was performed to identify relevant articles. Articles that compare the use of LA and open approach to treat PI published on or before April 30, 2013, were included in the meta-analysis. The evaluated end points were operative outcomes, postoperative recovery, and postoperative complications.

Results

Seven observational clinical studies that recruited a total of 452 patients were included. The rates of conversion from LA to open surgery ranged from 0%–41.3%. The meta-analysis revealed that LA for PIs is associated with reduced length of hospital stay (weighted mean difference, −5.64; 95% confidence interval [CI], −7.11 to −4.16; P < 0.00001). No significant difference was observed between LA and open surgery in terms of operation time (weighted mean difference, 2.57; 95% CI, −10.91 to 16.05; P = 0.71), postoperative mortality, overall morbidity (odds ratio [OR], 0.64; 95% CI, 0.35–1.17; P = 0.14], incidence of pancreatic fistula (OR, 0.86; 95% CI, 0.51–1.44; P = 0.56), and recurrence of hyperglycemia (OR, 1.81; 95% CI, 0.41–7.95; P = 0.43).

Conclusions

Laparoscopic treatment for PIs is a safe and feasible approach associated with reduction in length of hospital stay and comparable rates of postoperative complications in relation with open surgery.     

Is laparoscopic approach to lumbar spine fusion worthwhile?

BACKGROUND: Laparoscopic lumbar spine fusion has been recently described. The aim of this study is to evaluate the safety and efficacy of this procedure for single- and multiple-level degenerative disc disease. METHODS: Twenty-four consecutive laparoscopic interbody lumbar fusions were evaluated prospectively (18 single-level were compared with 6 multiple-level procedures). Results of the laparoscopic multiple-level procedures were further compared with 12 open multiple-level operations. RESULTS: Twenty procedures were completed laparoscopically. The conversions were related to iliac vein lacerations (3 cases) and a mesenteric tear. Single-level cases had lower morbidity (22% versus 83%), shorter hospital stay (2 versus 10 days), and higher fusion rate (88% versus 50%) than multiple-level procedures. Overall results in the latter group were worse than in the matched open group. CONCLUSIONS: Laparoscopic single-level fusion (L5-S1) is safe and carries the benefits of minimal access surgery. Morbidity after multiple level approach is high, and this procedure cannot be advocated at this time.     

Does a laparoscopic approach to total abdominal colectomy and proctocolectomy offer advantages?

BACKGROUND: Controversy exists regarding the feasibility, safety, and outcomes of laparoscopic total abdominal colectomy (LTAC) and laparoscopic total proctocolectomy (LTPC). The object of this study was to assess the outcomes of LTAC and LTPC and compare them with those of institutional open procedure used as controls. METHODS: Perioperative data and surgical outcomes of patients who underwent TAC or TPC were analyzed and compared retrospectively at a single institution between 1991 and 1999. RESULTS: A total of 73 TACs performed during a 9-year period were evenly distributed between laparoscopic (n = 37) and open (n = 36) approaches. There were no significant differences between patient groups with respect to genders, age, weight, proportion of patients with inflammatory bowel disease, and the number of patients undergoing ileorectal anastomosis. The median operative time was longer with the laparoscopic method (270 vs 178 min; p = 0.001), but the median length of hospital stay was significantly shorter (6 vs 9 days; p = 0.001). The short-term postoperative complication rate up to 30 days from surgery was not statistically different (25% vs 44%; p = 0.137), although there was a clear trend toward a reduced number of overall complications in the laparoscopic group (9 vs 24). Wound complications were significantly fewer (0% vs 19%; p = 0.015) and postoperative pneumonia was nonexistent in laparoscopic patients. Long-term complications also were less common in the laparoscopic group (20% vs 64%; p = 0.002), largely because of reduced incidence of impotence, incisional hernia, and ileostomy complications. Total proctocolectomy was performed laparoscopically in 15 patients and with an open procedure in 13 patients over the same period. There were no statistically significant differences between the two groups with respect to gender, age, weight, and diagnosis. Median operating time was longer for the laparoscopic patients (400 vs 235 min; p = 0.001), whereas the length of hospital stay, morbidity, and mortality were not significantly different. CONCLUSIONS: The results indicate that LTAC can be performed safely with a statistically significant reduction in wound and long-term postoperative complications, as compared with its open counterpart. Operating time is increased, but there is a marked reduction in length of hospital stay. Preliminary results demonstrate that LTPC also is technically feasible and safe, with equal morbidity, mortality, and hospital stay, as compared with open procedures. Studies with larger numbers of patients and a randomized controlled trial giving special attention to patient quality-of-life issues are needed to elucidate the real advantages of this minimally invasive technique.     

Total abdominal colectomy for severe ulcerative colitis: does the laparoscopic approach really have benefit?

Background

It is still unknown to what extent the reported morbidity and recovery benefits of laparoscopic total abdominal colectomy (TAC) for severe ulcerative colitis (UC) are associated with patient selection bias. This study aimed to evaluate whether laparoscopic TAC has any advantages over open surgery after control for perioperative confounding factors.

Methods

Patients undergoing TAC for UC during 2006–2010 were identified. Demographics, disease characteristics, and perioperative outcomes were compared between laparoscopic and open TAC. Postoperative recovery and 30-day complications were further assessed by covariate-adjusted multivariate regression models. The outcomes of different laparoscopic techniques were compared. A subgroup analysis including surgeons who routinely used both laparoscopic and open techniques was also performed.

Results

Of the 412 eligible patients, the 197 patients undergoing laparoscopic TAC were significantly younger and had a decreased Charlson Comorbidity Index and ASA score, increased hemoglobin and serum albumin levels, and a smaller proportion of extensive colitis and urgent cases. Unadjusted analyses showed that intraoperative morbidity, postoperative mortality, and rates for readmission and reoperation were similar. Laparoscopic TAC was associated with a longer operative time but a decrease in blood loss, overall morbidity, ileus, and thromboembolism, as well as a faster return to bowel function and a shorter hospital stay. After covariate adjustments, laparoscopic surgery remained associated with a reduction in the time to stoma function, incidence of postoperative ileus, and hospital stay compared with open TAC. The rates of postoperative morbidity, readmission, and reoperation did not differ regardless whether the conventional multitrocar technique, hand-assisted procedure, or single-incision technique was used. Laparoscopic TAC among surgeons using both open and laparoscopic techniques was associated with recovery benefits similar to those observed in the overall study population.

Conclusion

The data suggest that laparoscopic TAC retains recovery advantages over open surgery even after adjustments for confounders.     

Is laparoscopic subtotal colectomy better than open subtotal colectomy in children?

Purpose: The role of laparoscopic colectomy is not defined clearly. The aim of this study was to compare clinical outcomes of laparoscopic versus open subtotal colectomy in children with inflammatory bowel disease. Methods: Eight consecutive patients undergoing laparoscopic subtotal colectomy were compared with 10 consecutive patients undergoing open subtotal colectomy. All patients were refractory to medical management on immunosuppressive regimens. Operating time, length of postoperative stay and intravenous narcotic use, time to return of intestinal function, and perioperative complications were compared between the groups. Results: Operating times were significantly longer in the laparoscopic group (mean laparoscopic, 4 hours 40 minutes v mean open 2 hours 25 minutes; P [lt ] .01). There was no difference between the 2 groups in length of postoperative intravenous narcotics or hospital stay. Ileostomy output occurred earlier (mean laparoscopic, 2.5 days v mean open 3.8 days; P = .01), and there was a trend toward earlier oral intake in the laparoscopic group. A total of 6 complications occurred in 4 patients in the laparoscopic group compared with 5 complications in 5 patients in the open group. Conclusions: Perioperative clinical outcomes, including complication rates, are similar with laparoscopic and open subtotal colectomy. Laparoscopic subtotal colectomy can be performed safely in children with improved cosmesis.     

Is it safe to reuse disposable laparoscopic trocars?rid=""

BACKGROUND: The reuse of disposable laparoscopic instruments carries a risk of transmitting infectious diseases such as hepatitis and HIV. We evaluated the safety of reusing disposable trocars by studying the chances of their harboring infectious viruses after resterilization in an in vitro setting. METHODS: Disposable laparoscopic trocars were exposed to horse blood contaminated with high or low viral concentrations of herpes simplex virus type 1 (HSV1) and attenuated polio virus type 1 at room temperature for 2 h. HSV1 was chosen as the surrogate for lipid viruses that include hepatitis B and HIV virus; polio virus represented the nonlipid viruses that cause infections in immunocompromised patients and are more resistant to sterilization. The trocars were subsequently cleaned and resterilized by low-temperature steam and formaldehyde at 80 degrees C for 3 h. Viral cultures were then repeated after sterilization. RESULTS: A cytopathic effect (CPE) was demonstrated at both concentrations for HSV1 in all trocars before but not after sterilization. For the polio virus, CPE was evident in 50% of the trocars (two of four) exposed to high viral concentration after sterilization. CONCLUSION: Disposable trocars are difficult to resterilize and may harbor infectious viruses after their initial use. Therefore, the reuse of disposable trocars in laparoscopic surgery cannot be recommended.     

Is laparoscopic cholecystectomy safe for acute cholecystitis in the presence of ventriculo-peritoneal shunt?

Introduction

In patients with ventriculo-peritoneal shunts, laparoscopic procedures were previously contraindicated for the potential risks of elevating intra-cranial pressure resulting from increased intra-abdominal pressure and shunt malfunction/infection.

Presentation of case

Here we present a case of a patient with ventriculo-peritoneal shunt who successfully and uneventfully underwent laparoscopic cholecystectomy for acute cholecystitis without any shunt manipulation or intra-cranial pressure monitoring.

Discussion

Several methods have been suggested to decrease the risks of increased intra-cranial pressure during laparoscopic cholecystectomy in patients with ventriculo-peritoneal shunts, but have not been routinely used.

Conclusion

Standard technique laparoscopic cholecystectomy can be safely used to manage patients with VP shunts presenting with acute gall bladder disease.     

Is the laparoscopic approach reasonable in cases of splenomegaly?

Laparoscopic splenectomy in cases of splenomegaly has been shown to be feasible in experienced hands, even though the size of the spleen increases the operative time and difficulty. Laparoscopic splenectomy for splenomegaly offers the same advantages as for patients with smaller spleens: a shorter hospital stay and a faster recovery. Recent experience has shown that hand-assisted laparoscopic surgery makes the surgical maneuvers during laparoscopic splenectomy in cases of splenomegaly considerably easier while preserving the advantages of a purely laparoscopic approach. This technique may facilitate and broaden the application of laparoscopy for splenectomy in patients with enlarged spleens.