Laparoscopic and Open Distal Pancreatic Resection for Benign Pancreatic Disease

The aim of the study is to provide comparisons of the perioperative outcomes between open and laparoscopic distal pancreatic resection (DPR) for benign pancreatic disease. From 2002 and 2005, there were 28 patients (16 open, 12 laparoscopic) with a mean age of 52 who had presumptive diagnoses of benign pancreatic lesions. Pathology was neuroendocrine tumor (nine and five), mucinous cystic neoplasm (three and three), symptomatic pancreatic pseudocyst (two and two), and others (two and two). The mean operative time was 278 vs 212 min (p = 0.05), the estimated blood lost was 609 vs 193 ml (p = 0.01), and the success rate of preoperative intent for splenic preservation was 17 vs 62% (p = 0.08) in the open and laparoscopic groups, respectively. Two patients (16%) were converted to an open procedure. There was no perioperative mortality. The mean hospital stay and total perioperative morbidity were 10.6 vs 6.2 days (p = 0.001) and nine vs two events (p = 0.03) in the open and laparoscopic groups, respectively. Ten of 12 patients (83%) with laparoscopic DPR had adequate oral intake within 72 h post operatively in contrast to 2 of 16 (12.5%) patients in the open DPR group (p = 0.0001). Laparoscopic DPR is technically feasible, safe, and associated with less perioperative morbidity and a shorter hospital stay than open DPR. In centers with the appropriate expertise, laparoscopic DPR should be considered the procedure of choice for putative benign lesions of the pancreatic body and tail. Presented at the AHPBA Spring Meeting, Miami Beach, FL March 9–12, 2006 (oral presentation)     

Laparoscopic Bowel Resection in the Setting of Metastatic Colorectal Cancer

Background This study aimed to review the outcomes of laparoscopic colorectal resection for patients with stage IV colorectal cancer. Methods From the prospectively collected database for patients who underwent surgery for colorectal cancer in our institution, those with stage IV colorectal cancer who underwent elective resection of tumor during the period from January 2000 to June 2006 were included. The outcomes of those with laparoscopic resection were reviewed and comparison was made between patients with laparoscopic and open resection. Results A total of 200 patients (127 men) with median age of 69 years (range: 25–91 years) were included, and 77 underwent laparoscopic resection. Conversion was required in ten patients (13.0%) and all except one conversion were due to fixed or bulky tumors. There was no operative mortality in the laparoscopic group. The complication rate was 14% and the median postoperative hospital stay was 7 days. When patients with laparoscopic resection were compared with those with open operations, there was no difference in age, gender, comorbidity, or tumor size between the two groups. However, the complication rate was significantly lower in those with laparoscopic resection (14% versus 32%, P = 0.007) and the median hospital stay was significantly shorter (7 days versus 8 days, P = 0.005).The operative mortalities and the survivals were similar in the two groups. Conclusions Colorectal resection can be performed safely in patients with stage IV colorectal cancer. The operative outcomes in terms of complication rate and hospital stay compare favorably with patients with open resection. Presented in the Scientific Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons on 18–22 April 2007 in Las Vegas, Nevada, USA.     

Laparoscopic Versus Open Ileo-Colonic Resection in Crohn’s Disease: Short- and Long-Term Results from a Prospective Longitudinal Study

Possible relations between surgical approaches, frequency, and severity of Crohn’s disease recurrence after ileo-colonic resection is unknown. We aimed to assess perioperative outcomes and postsurgical complications of laparoscopic versus standard open surgery and to detect differences between the two groups in endoscopical recurrence and patients’ satisfaction. Twenty-eight consecutive patients undergoing elective ileo-colonic resection by either laparoscopic approach (n = 15) or conventional open surgery (n = 13) were prospectively enrolled. No mortality or major intraoperative complications were observed in both groups. Significant differences between groups were the median operating time found shorter in the open group than in the laparoscopic group (p = 0.003), the higher dosage of pain killers needed in the open group (p = 0.05), the passage of flatus and\or stool after surgery found faster in group A (p = 0.004) and the shorter recovery period in the laparoscopic group (p = 0.007). Colonoscopy was performed in 27 patients. The frequency and pattern of recurrence did not differ between the two groups (p = 0.63). Patients’ satisfaction was significantly in favor of laparoscopy. Present findings support the feasibility and advantages in the short-term of laparoscopic ileo-colonic resection in patients with Crohn’s disease. No differences were observed in terms of frequency, time of onset, and severity of recurrence in a 1-year follow-up.     

Laparoscopic Surgery for Patients with Crohn’s Colitis: A Case-matched Study

Introduction The purpose of this study was to compare short and long-term outcomes of laparoscopic colectomy with open colectomy in patients with Crohn’s disease confined to the colon. Materials and Methods We reviewed all patients undergoing laparoscopic colectomy for Crohn’s disease at our institution between 1994 and 2005. Laparoscopic colectomies were matched to open colectomies by patient age, gender, American Society of Anesthesiologists score, type, and year of surgery. We excluded patients with concomitant small bowel disease. Results Twenty-seven laparoscopic cases were matched with 27 open cases. There were seven conversions (26%). There was no mortality. Median operative times were significantly longer after laparoscopic colectomy (240 vs 150 min, P < 0.01), and estimated blood loss was comparable (325 vs 350 ml, P = 0.4). Postoperative complications were similar. Laparoscopic colectomies had shorter median length of stay (5 vs 6 days, P = 0.07) and median time to first bowel movement (3 vs 4 days, P = 0.4). When overall length of stay included 30-day readmissions, the difference in favor of laparoscopy became statistically significant (P = 0.02). Recurrent disease requiring surgery was decreased after laparoscopy, although median follow-up was significantly shorter. Conclusion Laparoscopic colectomy is a safe and acceptable option for patients with Crohn’s colitis. Longer follow-up is needed to accurately establish recurrence rates.     

The Evolving Role of Laparoscopy in Colonic Diverticular Disease: A Systematic Review

Background

A PubMed search of the biomedical literature was carried out to systematically review the role of laparoscopy in colonic diverticular disease. All original reports comparing elective laparoscopic, hand-assisted, and open colon resection for diverticular disease of the colon, as well as original reports evaluating outcomes after laparoscopic lavage for acute diverticulitis, were considered. Of the 21 articles chosen for final review, nine evaluated laparoscopic versus open elective resection, six compared hand-assisted colon resection versus conventional laparoscopic resection, and six considered laparoscopic lavage. Five were randomized controlled trials.

Results

Elective laparoscopic colon resection for diverticular disease is associated with increased operative time, decreased postoperative pain, fewer postoperative complications, less paralytic ileus, and shorter hospital stay compared to open colectomy. Laparoscopic lavage and drainage appears to be a safe and effective therapy for selected patients with complicated diverticulitis.

Conclusions

Elective laparoscopic colectomy for diverticular disease is associated with decreased postoperative morbidity compared to open colectomy, leading to shorter hospital stay and fewer costs. Laparoscopic lavage has an increasing but poorly defined role in complicated diverticulitis.     

A Prospective Evaluation of Laparoscopic Versus Open Left Lateral Hepatic Sectionectomy

Background Left lateral sectionectomy is one of the most commonly performed laparoscopic liver resections, but limited clinical data are actually available to support the advantage of laparoscopic versus open-liver surgery. The present study compared the short-term outcomes of laparoscopic versus open surgery in a case-matched analysis. Materials and Methods Surgical outcome of 20 patients who underwent left lateral sectionectomy by laparoscopic approach (LHR group) from September 2005 to January 2007 were compared in a case-control analysis with those of 20 patients who underwent open left lateral sectionectomy (OHR group). Both groups were similar for: tumor size, preoperative laboratory data, presence of cirrhosis, and histology of the lesion. Surgical procedures were performed in both groups combining the ultrasonic dissector and the ultrasonic coagulating cutter without portal clamping. Results Compared with OHR, the LHR group had a decreased blood loss (165 mL versus 214 mL, P = 0.001), and earlier postoperative recovery (4.5 versus 5.8 days, P = 0.003). There were no significant differences in terms of surgical margin and operative time. Morbidity was comparable between the two groups, but two cases of postoperative ascites were recorded in two cirrhotic patients in the OHR. Major complications were not observed in either groups. Conclusions Laparoscopic resection results in reduced operative blood loss and earlier recovery with oncologic clearance and operative time comparable with open surgery. Laparoscopic liver surgery may be considered the approach of choice for tumors located in the left hepatic lobe.     

Outcome for Patients Treated with Laparoscopic Versus Open Resection of Hepatocellular Carcinoma: Case-Matched Analysis

Introduction  This is a case-matched analysis of patients undergoing laparoscopic versus open hepatectomy for hepatocellular carcinoma (HCC), with specific regard to margin status and survival. Methods   Laparoscopic cases were matched with open controls by cirrhosis and tumor size (within 10%). Data were evaluated by logistic regression using the generalized estimating equation method. Mixed linear regression models were used to assess operative duration in the groups. Overall and disease-free survival were compared using a Cox proportional frailty model. Results   Twenty laparoscopic cases were matched to 56 open resections. Thirty patients (39%) developed recurrence and 13 patients (17%) died, including one (1.3%) death within 30 days. There were no significant differences in age, gender, cirrhosis or tumor size. Paired univariate and multivariate analyses showed cases of laparoscopic resection had similar rates of transfusion and positive margins compared with open resection. Operative duration was similar in laparoscopic (mean 161 ± 37 min) and open (mean 165 ± 53 min) groups. The adjusted odds of length of stay ≥ 6 days was significantly lower in patients with laparoscopic resection [odds ratio (OR) = 0.07, 95% confidence interval (CI) = 0.02–0.27]. Both unadjusted and adjusted analyses showed no significant association between type of resection and overall or disease-free survival. Discussion   Neither margin status, nor recurrence, nor survival was significantly different between the two cohorts. Laparoscopic resection for malignancy is safe, with a similar operative time as open hepatectomy. If tumor location is amenable, laparoscopic resection for HCC is a reasonable alternative to open resection with the added benefits of improved cosmesis and sooner discharge home.     

高龄患者腹腔镜结直肠切除术安全性的研究

目的:评价为高龄患者行腹腔镜结直肠切除术的安全性及可行性。方法:回顾分析2003年8月至2008年8月我院择期行结直肠切除术中大于等于70岁高龄患者的临床资料。比较同期56例腹腔镜结直肠切除术和52例开腹手术患者的一般情况、疾病分类、手术指标、术后恢复情况和治疗效果。患者平均年龄开腹组74岁,腹腔镜组73岁。两组患者术前合并症、美国麻醉师协会术前危险度评分、疾病类型均无显著差异。结果:平均手术时间开腹组192min,腹腔镜组187min,P=0.616。开腹组术中平均出血218ml,腹腔镜组约86ml,P=0.000。腹腔镜组1例中转开腹。两组均无死亡病例。肠功能恢复时间开腹组5d,腹腔镜组3d,P=0.000。进流食时间开腹组5d,腹腔镜组4d,P=0.026。平均住院时间开腹组22d,腹腔镜组18d,P=0.000。术后心肺并发症发生率开腹组26.9%,腹腔镜组10.7%,P=0.030。结论:为高龄患者行腹腔镜结直肠切除术安全可行,可减少患者术中出血量,降低术后心肺并发症的发生率,加快术后胃肠功能恢复,缩短住院时间等。     

Laparoscopic Versus Open Multivisceral Resection for Primary Colorectal Cancer: Comparison of Perioperative Outcomes

Background

The role of laparoscopic surgery for locally advanced colorectal cancer invading or adhering to neighboring organs is controversial. This study evaluated the safety and feasibility of laparoscopic multivisceral resection for colorectal cancer.

Methods

This study included 126 patients who underwent multivisceral resection for primary colorectal cancer invading or adhering to neighboring organs or structures between July 2005 and November 2012 at our institution. Perioperative outcomes were compared between laparoscopic and open resections.

Results

Laparoscopic and open multivisceral resections were performed in 60 and 66 patients, respectively. Conversion to open surgery occurred in 6.7 % of patients. The median operative time was significantly longer (271 vs. 227 min), but the median blood loss was significantly less (40 vs. 205 mL), in the laparoscopic compared with the open group. The R0 resection rate of the primary tumor (95 vs. 98.5 %), number of lymph nodes harvested (18 vs. 18), and postoperative complications (28 vs. 24 %) were comparable between the groups. The median length of hospital stay was significantly shorter (13.5 vs. 18 days) in the laparoscopic compared with the open group.

Conclusions

Laparoscopic multivisceral resection for colorectal cancer invading or adhering to neighboring organs is safe and feasible in selected patients.     

Laparoscopic colorectal resection: a safe option for elderly patients

BACKGROUND: Open colorectal surgery in the elderly has been associated with higher morbidity and mortality rates. The favorable short-term outcomes of laparosocopic colorectal resection might reduce the morbidity in elderly patients. This study compares results of elderly patients (aged 70 and above) who underwent laparoscopic colorectal resection with those having open surgery. STUDY DESIGN: Consecutive patients aged 70 and above who had elective colorectal resection from June 2000 to December 2001 were included. Data concerning demographics, diseases, details of operations, and postoperative events were collected prospectively. Comparisons between results of laparoscopic surgery and open surgery were made. RESULTS: Sixty-five patients had laparoscopic colectomy and 89 had open surgery during the study period. Median ages were 77 years and 75 years in the open and laparoscopic groups, respectively. Presence of premorbid medical conditions, American Society of Anesthesiology score, and incidence of previous surgery were similar in the two groups. Median operative time was longer (180 minutes versus 135 minutes, p < 0.001), but blood loss was less (100 mL versus 200 mL, p = 0.001) in the laparoscopic group. Conversion to open surgery occurred in eight patients. One patient died in the laparoscopic group and five died in the open group. Laparoscopic resection was associated with earlier return of bowel function (3 days versus 4 days, p = 0.004), earlier resumption of solid diet (3 days versus 5 days, p < 0.001), shorter hospital stay (7 days versus 9 days, p = 0.001), and less cardiopulmonary morbidity (7.7% versus 22.4%, p = 0.033) when compared with open colorectal resection. CONCLUSIONS: Laparoscopic colorectal resection is a safe option for elderly patients and is associated with more favorable short-term outcomes in terms of earlier return of bowel function, earlier resumption of diet, and shorter hospital stay. It is also associated with less cardiopulmonary morbidity, which is an important complication after colorectal surgery in the elderly.     

Resection Versus Laparoscopic Radiofrequency Thermal Ablation Of Solitary Colorectal Liver Metastasis

Purpose  There is scant data in the literature regarding radiofrequency thermal ablation (RFA) versus resection of colorectal liver metastases. The aim of this study is to compare the clinical profile and survival of patients with solitary colorectal liver metastasis undergoing resection versus laparoscopic RFA. Methods  Between 1996 and 2007, 158 patients underwent RFA (n = 68) and open liver resection (n = 90) of solitary liver metastasis from colorectal cancer. Patients were evaluated in a multidisciplinary fashion and allocated to a treatment type. Data were collected prospectively for the RFA patients and retrospectively for the resection patients. Results  Although the groups were matched for age, gender, chemotherapy exposure and tumor size, RFA patients tended to have a higher ASA score and presence of extra-hepatic disease (EHD) at the time of treatment. The main indication for referral to RFA included technical reasons (n = 25), patient comorbidities (n = 24), extra-hepatic disease (n = 10) and patient decision (n = 9). There were no peri-operative mortalities in either group. The complication rate was 2.9% (n = 2) for RFA and 31.1% (n = 28) for resection. The overall Kaplan–Meier median actuarial survival from the date of surgery was 24 months for RFA patients with EHD, 34 months for RFA patients without EHD and 57 months for resection patients (p < 0.0001). The 5-year actual survival was 30% for RFA patients and 40% for resection patients (p = 0.35). Conclusions  This study shows that, although patients in both groups had a solitary liver metastasis, other factors including medical comorbidities, technically challenging tumor locations and extra-hepatic disease were different, prompting selection of therapy. With a simultaneous ablation program, higher risk patients have been channeled to RFA, leaving a highly selected group of patients for resection with a very favorable survival. RFA still achieved long-term survival in patients who were otherwise not candidates for resection.     

Laparoscopic vs. Open Resection of Noninvasive Intraductal Pancreatic Mucinous Neoplasms

Required resection margins for noninvasive intraductal papillary mucinous neoplasms (IPMNs) are a controversial issue. Over a 10-year period we have resected IPMNs from the entire pancreatic gland with minimally invasive techniques and compared our survival and complication rates with open controls to see if any difference in resection margins and outcomes could be observed. Data were collected retrospectively, including our first cases of advanced laparoscopic resections. Five-year Kaplan–Meier curves were calculated and statistical analysis was performed using the log rank and Student’s T test for continuous variables. Chi square and Fisher’s exact tests were used for analyzing categorical variables. From March 1997 to Febuary 2006, we operated on 22 patients with noninvasive IPMNs, of which 9 (41%) were operated on laparoscopically and 13 (59%) using open techniques. Three patients underwent laparoscopic duodenopancreatectomy, compared to five in the open group. All resection margins were negative, but two patients required total pancreatectomy, both of which were performed laparoscopically. One of these was converted to open (11%) because of difficulty in reconstructing the biliary anastomosis. The overall complication rates were 56% for the laparoscopic group and 85% for the open group. Twenty-two percent of the laparoscopic group required reoperation and 11% required percutaneous drainage, compared to 15 and 23% in the open group, respectively. All patients are alive after a mean of 20 months (range = 2–43) in the laparoscopic group and 37 months (range = 1–121) in the open one (p > 0.05). Laparoscopic resection of noninvasive IPMNs of the entire pancreatic gland has similar complication and survival rates as open procedures. As a result, the laparoscopic approach is appropriate for noninvasive IPMNs of the entire pancreatic gland; however, larger cohorts are needed to see if any approach has superior outcomes. Because of these favorable results, studies are currently underway to see if the minimally invasive approach is also appropriate for invasive IPMNs.     

Correlation of surgical trainee performance on laparoscopic versus endoscopic simulation

Both laparoscopy and endoscopy are image-based procedures, which are less intuitive than traditional open surgery and require extensive training to reach adequate proficiency. Currently, there is lack of understanding as to how the skills in one image-based procedure translate to another, such as endoscopy to laparoscopy and vice versa. The aim of our study was to explore the relationship between endoscopic and laparoscopic skills using a Fundamentals of Laparoscopic Surgery (FLS) trainer, a traditional virtual reality endoscopic trainer and a “desk-top” endoscopic physical simulator. Senior surgical residents from across Canada participating in an advanced laparoscopic foregut training course were enrolled in the study. Participants were assessed performing the FLS laparoscopic suturing task, the Endobubble 2 task (Simbionix, GI Mentor), and a forward viewing peg transfer on the novel Basics in Endoscopic Skills Training Box (BEST Box). There was significant correlation between the participant’s skill in simulated laparoscopic suturing and simulated endoscopic skill using the BEST box (Pearson coefficient (r) was 0.551 (p = 0.033) and the coefficient of determination (r2) was 0.304). There was a trend towards correlation between laparoscopic suturing time and Endobubble 2 score, but this did not reach statistical significance (r = 0.458, p = 0.086; r2 = 0.210). Performance in the two physical simulators, laparoscopic suturing and simulated flexible endoscopy using the BEST box, showed a correlation. This study adds to the growing body of evidence that laparoscopic and endoscopic skills are complementary and has the potential to impact simulation training involving both skill sets.     

Comparison of Outcome of Open and Laparoscopic Resection for Stage II and Stage III Rectal Cancer

Background  Laparoscopic resection for advanced rectal cancer has not been widely accepted, and there are only few studies with survival data. This study aimed to compare the survival of patients who underwent laparoscopic and open resection for stage II and III rectal cancer. Materials and Methods  Consecutive patients (open resection: n = 310; laparoscopic resection: n = 111) who underwent curative resection for stage II and III rectal cancer from June 2000 to December 2006 were included. The operative details, postoperative complications, postoperative outcomes, and survival data were collected prospectively. Comparison was made between patients who had laparoscopic and open surgery. Results  The age, gender, medical morbidity, types of operation, and American Society of Anesthesiologists (ASA) status were similar between the two groups. There was also no difference in the mortality, morbidity, and pathological staging. Laparoscopic resection was associated with significantly less blood loss and shorter hospital stay. With the median follow-up of 34 months, there was no difference in local recurrence rates. The 5-year actuarial survivals were 71.1% and 59.3% in the laparoscopic and open groups, respectively (P = .029). In the multivariate analysis, laparoscopic resection was one of the independent significant factors associated with better survival (P = .03, hazards ratio: 0.558, 95% confidence interval: 0.339–0.969). Other independent poor prognostic factors included lymph node metastasis, poor differentiation, perineural invasion, presence of postoperative complications, and no chemotherapy. Conclusions  Laparoscopic resection for locally advanced rectal cancer is associated with more favorable overall survival when compared with open resection.     

Laparoscopic vs open resection of pancreatic endocrine neoplasms: single institution’s experience over 14 years

Background Laparoscopic resection of benign pancreatic endocrine neoplasms (PENs) has become the standard of care for tumors in the pancreatic tail. Over a 14-year period, we have resected both benign and malignant tumors of the entire pancreas laparoscopically and compared our survival and complication rates with open controls. Materials and methods We collected our data retrospectively and reviewed our outcomes with an actuarial 5-year survival according to Kaplan–Meier. Patients who underwent minimally invasive techniques were compared to patients who were approached with open techniques. Results From April 1992 to September 2006, we operated on 31 patients for PENs: 13 (42%) were operated on using open techniques and 18 (58%) laparoscopically, and conversion occurred in one patient (6%). In the laparoscopic group, eight (47%) tumors were malignant compared to six (43%) in the open group. Operative times averaged 188 min for the minimally invasive approach and 305 min for the open approach (p = 0.02). Length of stay was 25 days (range 8–82) for the laparoscopic group compared to 20 days (range 6–63; p > 0.05). Overall morbidity and fistula rates ranged from 67 to 24% in the laparoscopic group to 69 to 38% in the open group (p > 0.05). There were no postoperative mortalities. The average follow-up was 63 months for the open group and 33 months for the laparoscopic group. The overall actuarial survival rates were both 90% at 5 years. Conclusions Laparoscopic resection of benign and malignant PENs has similar overall complication and 5-year survival rates as the open technique; however, the laparoscopic approach is associated with shorter operative times.     

Hospital Discharge in the Day Following Open Roux-en-Y Gastric Bypass: Is it Feasible and Safe?

Background  Roux-en-Y gastric bypass (RYGBP) either laparoscopic or open has been increasingly employed in the treatment of patients with morbid obesity. Laparoscopic approach is believed to be superior over open approach in terms of shorter hospital stay and easier recovery. We aimed to assess feasibility and safety of open RYGBP with short stay in comparison with laparoscopic RYGBP. Methods  One hundred and ninety consecutive patients were assigned to open (n = 103) or laparoscopic (n = 87) RYGBP. The first 20 patients of the laparoscopic arm were excluded due to procedure learning curve. Patients were treated by a multidisciplinary team focused on successfully RYGBP with short stay (1 day). Results  Short stay was reached by 90% of patients operated with open approach and 81% by laparoscopy (P = 0.070). Discharge in the second day was reached by 97% of patients in both groups. Procedure length [(median (IQR)] was faster for open RYGBP [103 (70–180 min) vs. 169 (105–248 min); P < 0.0001]. Thirty-day readmission rate was similar between groups (3% vs. 7%; P = 0.266). There was no death in either group. Conclusion  Short stay (1 day) following open gastric bypass was a feasible and safe procedure. This approach might have economic impact and might increase patient acceptance for open RYGBP.     

A comparison of laparoscopic and abdominal sacral colpopexy: objective outcome and perioperative differences

The purpose of this study was to compare anatomic and perioperative outcomes following laparoscopic sacral colpopexy (LSC) and abdominal sacral colpopexy (ASC). The hypothesis is that the laparoscopic technique has similar anatomic outcomes as compared with the open technique. A retrospective comparative chart review was conducted consisting of 43 patients who underwent laparoscopic sacral colpopexy and 41 patients who underwent abdominal sacral colpopexy. Demographics were comparable between groups except mean follow-up time (LSC = 7.4 months, ASC = 10.6 months). Mean improvement at the apex was similar between the two groups. Hospital stay in hours was shorter for the LSC group (mean/median = 35.4/30.9) than the ASC group (mean/median = 63.3/54.1, p < 0.001). Mean operative time was similar (LSC = 183, ASC = 168 min, p = NS) and complication rates were comparable between the groups. Patients undergoing laparoscopic and abdominal sacral colpopexy have comparable anatomical outcomes and operative times. Laparoscopy affords a shorter hospital stay.     

National Trends and Outcomes for the Surgical Therapy of Ileocolonic Crohn’s Disease: A Population-Based Analysis of Laparoscopic vs. Open Approaches

Purpose  The laparoscopic approach to Crohn’s disease has demonstrated benefits in several small series. We sought to examine its use and outcomes on a national level. Methods  All admissions with a diagnosis of Crohn’s disease requiring bowel resection were selected from the 2000–2004 Nationwide Inpatient Sample. Regression analyses were used to compare outcome measures and identify independent predictors of undergoing laparoscopy. Results  Of 396,911 patients admitted for Crohn’s disease, 49,609 (12%) required surgical treatment. They were predominately Caucasian (64%), female (54%), and with ileocolic disease (72%). Most had private insurance (71%) and had surgery in urban hospitals (91%). Laparoscopic resection was performed in 2,826 cases (6%) and was associated with lower complications (8% vs. 16%), shorter length of stay (6 vs. 9 days), lower charges ($27,575 vs. $38,713), and mortality (0.2% vs. 0.9%, all P < 0.01). Open surgery was used more often for fistulas (8% vs. 1%) and when ostomies were required (12% vs. 7%). Independent predictors of laparoscopic resection were age <35 [odds ratio (OR) = 2.4], female gender (OR = 1.4), admission to a teaching hospital (OR = 1.2), ileocecal location (OR = 1.5), and lower disease stage (OR = 1.1, all P < 0.05). Ethnic category, insurance status, and type of admission (elective vs. non-elective) were not associated with operative method (P > 0.05). Conclusions  A variety of patient- and system-related factors influence the utilization of laparoscopy in Crohn’s disease. Laparoscopic resection is associated with excellent short-term outcomes compared to open surgery. “The views expressed in the article (book, speech, etc.) are those of the author(s) and do not reflect the official policy of the Department of the Army, the Department of Defense or the US Government.” “The investigators have adhered to the policies for protection of human subjects as prescribed in 45 CFR 46.”     

Laparoscopic vs. open liver resection for malignant liver disease. A systematic review

IntroductionSince the introduction of minimally invasive techniques, there is little agreement about use of laparoscopic surgery for malignant liver lesions as compared to open resection. We aim to analyse all available data comparing both these groups.MethodsAll the studies that compared laparoscopic and open liver resections for malignant lesions were searched on various databases. Data were collected and analysed in Review Manager RevMan (version 5.0).ResultsThere were total of 10 studies (n = 700) that compared laparoscopic (296/700) and open (404/700) hepatic resections for malignant lesions. Laparoscopic group was associated with reduced number of patients requiring blood transfusion [Odds ratio 0.35 CI 0.20, 0.60 P<0.001 HG 0.85], decreased number of positive resection margin [Odds ratio 0.34 CI 0.16, P0.006 HG 0.73] and decrease in overall complication rate [Odds ratio 0.43, CI 0.26, 0.73 P0.002 HG 0.22]. Laparoscopic group was associated with less operative blood loss [WMD 162.6 ml CI ?261.79, 73.45 P<0.001] and reduced hospital stay [WMD 4.28 days CI ?6.33, ?2.23 P<0.001]; however, there was significant heterogeneity [HG <0.001] between the studies for these parameters.ConclusionThe laparoscopic group was associated with reduce overall complication rate, positive resection margins and number of patients requiring blood transfusion. There is still need for level I and II data to compare laparoscopic versus open hepatic resection in malignant lesions.     

Laparoscopic common bile duct exploration in patients with previous abdominal biliary tract operations

A history of abdominal biliary tract surgery has been identified as a relative contraindication for laparoscopic common bile duct exploration (LCBDE), and there are very few reports about laparoscopic procedures in patients with a history of abdominal biliary tract surgery. We retrospectively reviewed the clinical outcomes of 227 consecutive patients with previous abdominal biliary tract operations at our institution between December 2013 and June 2019. A total of 110 consecutive patients underwent LCBDE, and 117 consecutive patients underwent open common bile duct exploration (OCBDE). Patient demographics and perioperative variables were compared between the two groups. The LCBDE group performed significantly better than the OCBDE group with respect to estimated blood loss [30 (5–700) vs. 50 (10–1800) ml; p = 0.041], remnant common bile duct (CBD) stones (17 vs. 28%; p = 0.050), postoperative hospital stay [7 (3–78) vs. 8.5 (4.5–74) days; p = 0.041], and time to oral intake [2.5 (1–7) vs. 3 (2–24) days; p = 0.015]. There were no significant differences in the operation time [170 (60–480) vs. 180 (41–330) minutes; p = 0.067]. A total of 19 patients (17%) in the LCBDE group were converted to open surgery. According to Clavien’s classification of complications, the LCBDE group had significantly fewer postoperative complications than the OCBDE group (40 vs. 57; p = 0.045). There was no mortality in either group. Multiple previous operations (≥ 2 times), a history of open surgery, and previous biliary tract surgery (including bile duct or gallbladder + bile duct other than cholecystectomy alone) were risk factors for postoperative adhesion (p = 0.000, p = 0.000, and p = 0.000, respectively). LCBDE is ultimately the least invasive, safest, and the most effective treatment option for patients with previous abdominal biliary tract operations and is especially suitable for those with a history of cholecystectomy, few previous operations (< 2 times), or a history of laparoscopic surgery.