Laparoscopic vs conventional Nissen fundoplication

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

Cellular and humoral inflammatory response after laparoscopic and conventional colorectal resections

Background: Surgical trauma and anesthesia are known to cause transient postoperative suppression of the immune system. In randomized controlled trials, it has been shown that laparoscopic colorectal resections have short-term benefits not observed with conventional colorectal resections. We hypothesized that these benefits were due to the reduction in surgical trauma, leading to a diminished cytokine response and less depression of cell-mediated immunity after laparoscopy. Methods: In a prospective randomized trial, colorectal cancer patients without evidence of metastatic disease underwent either laparoscopic (n = 20) or conventional (n = 20) tumor resection. Postoperative immune function was assessed by measuring the white blood cell (WBC) count, the CD4+ and CD8+ lymphocytes, the CD4+/CD8+/ratio, and the HLA-DR expression of CD14+ monocytes. In addition, the production of interleukin-6 (IL = 6) and TNF-a were measured after ex vivo stimulation of mononuclear blood cells with lipopolysaccharide (LPS) and compared to the plasma levels of these cytokines. Postoperative mean levels of the immunologic parameters for the two groups were calculated and compared using the Mann-Whitney U test. Results: Preoperatively, there were no differences between the two groups in terms of patient characteristics or immunologic parameters. Although the postoperative peak concentrations of white blood cells were significant lower in the laparoscopic group than the conventional group (p < 0.05), there were no differences between the two groups in the subpopulation of lymphocytes (CD4+, CD8+). HLA-DR expression of CD14+ monocytes was lower in the conventional group on the 4th postoperative day (p < 0.05). The laparoscopic group showed higher values in cytokine production of mononuclear blood cells after LPS stimulation. Postoperative plasma peak concentrations of IL-6 and TNF-a were lower after laparoscopic resection. Conclusion: Postoperative cell-mediated immunity was better preserved after laparoscopic than after conventional colorectal resection. Cellular cytokine production was preserved only in the laparoscopic group, while cytokine plasma levels were significantly higher in the conventional group. These findings may have important implications for the use of laparoscopic colorectal resection, especially in patients with malignant disease. apd: 3 April 2001     

Laparoscopic surgery preserves monocyte-mediated tumor cell killing in contrast to the conventional approach

Background: Experimental animal research shows that immunologic defenses against tumor cells are disturbed by surgical trauma, resulting in an increased rate of tumor implantation and the growth of subsequent metastases. Minimally invasive surgery is associated with a preservation of postoperative immunologic functions and, in animal models, with decreased tumor growth. The objective was to study the influence of several surgical procedures, approached conventionally and laparoscopically, on interleukin-6 (IL-6) and monocyte-mediated cytotoxicity (MMC). Methods: Five groups of five patients each were included in this prospective study: laparoscopic cholecystectomy (minor trauma) group, Nissen fundoplication (laparoscopic and conventional as moderate trauma) groups, and sigmoid colectomy (laparoscopic and conventional as major trauma) groups. Preoperatively, 1 and 4 days after surgery, IL-6 and MMC against SW948 colon cancer cell line were determined. Results: The IL-6 levels differed significantly between the three laparoscopic procedures (p= 0.004) and increased according to the degree of trauma. There was no significant difference in MMC between the three laparoscopic procedures. However, MMC was suppressed after conventional procedures and preserved after laparoscopic procedures (p= 0.001). There was no correlation between IL-6 levels and changes in MMC. Conclusions: More extensive laparoscopic procedures induce increased levels of IL-6, reflecting higher levels of trauma. Conventional surgical procedures result in depressed MMC in the postoperative period. After laparoscopic procedures, MMC is preserved. These findings may be of importance in preventing implantation and growth of cancer cells spread by surgical manipulation. Received: 10 December 1998/Accepted: 25 March 1999     

Immune response after laparoscopic and conventional Nissen fundoplication.

OBJECTIVE: To compare the changes in the immune responses of patients undergoing laparoscopic or conventional Nissen fundoplication. DESIGN: Prospective randomised clinical study. SETTING: University hospital, Finland. SUBJECTS: 20 patients undergoing Nissen fundoplication for symptomatic erosive oesophagitis. INTERVENTION: Laparoscopic Nissen fundoplication (n = 10) or conventional open Nissen fundoplication (n = 10). MAIN OUTCOME MEASURES: Leucocyte and differential counts; percentages of lymphocyte subpopulations (CD3, CD4, CD8, CD16 and CD20 positive lymphocytes); and monocytes (CD 14); phytohemagglutinin, concanavalin A and pokeweed mitogen-induced and unstimulated proliferation of separated lymphocytes; plasma interleukin-6 (IL-6), serum C-reactive protein (CRP), albumin, and cortisol concentrations; and group II phospholipase A2 (PLA2) activity. RESULTS: Laparoscopic fundoplication was associated with less tissue damage (IL-6, and CRP concentrations) than the conventional open operation. However, although there were pronounced changes in immune responses over time, there were no differences between the groups. CONCLUSION: Laparoscopic fundoplication seemed to cause less tissue damage than the conventional open operation, but this difference was not reflected in patients' immune responses.     

Advantages of laparoscopic resection for ileocolic Crohn’s disease

BACKGROUND: Laparoscopic colorectal procedures are considered to be technically challenging, and there is a lack of consensus regarding the magnitude of their benefits. The laparoscopic approach is generally held to be more expensive. Using a model of a single procedure performed for a single indication (ileocolic resection for Crohn's disease [CD]), we set out to demonstrate the feasibility of this procedure by determining the conversion rate, documenting the patient benefits, and performing a formal cost analysis. METHODS: Consecutive cases of laparoscopic ileocolic resection for CD were identified (LAP). Case-match methodology identified a series of open laparotomy controls (OPEN) that were matched for five potential confounding criteria: age, gender, diagnosis, type of resection, and date of operation. Pre-, intra-, and postoperative details were gathered. Medical resource utilization was tracked using a standardized database, and all costs were reported in 1999 dollars. RESULTS: The conversion rate was 5.9%. Resolution of ileus occurred more rapidly in the LAP than in the OPEN group. The time to clears in the LAP group was a median of 0 days (range, 0-4) vs 3.0 days (range, 2-8) in the OPEN group (p = 0.0001). Time to regular diet was 2.0 days (range, 1-6) in the LAP group vs 5.0 days (range, 3-12) in the OPEN group (p = 0.0001). Length of hospital stay was significantly reduced in the LAP group (4.0 days [range, 2-8], vs 7.0 days [range, 3-14], p = 0.0001). The LAP group had significantly lower direct costs ($8684 vs $11,373) and indirect costs ($1358 vs $2349) than the OPEN group (p < 0.001). This resulted in total costs of $9895 for LAP vs $13,268 for OPEN (p < 0.001). CONCLUSION: Laparoscopic ileocolic resection for CD is feasible. There are significant postoperative benefits in terms of resolution of ileus, narcotic use, and hospital stay. This approach translates into cost savings of >$3300 for laparoscopic patients.     

A prospective randomized study of the systemic immune response after laparoscopic and conventional Nissen fundoplication.

BACKGROUND: Laparoscopic techniques are thought to reduce the postoperative immunologic and metabolic changes of conventional operations. Until now, the only clinical data available were obtained from patients operated on for symptomatic gallstones; moreover, few studies were randomized. This randomized prospective study compares the systemic immune response after laparoscopic and conventional Nissen fundoplication. METHODS: Seventeen patients scheduled for Nissen fundoplication were randomly assigned to undergo either a laparoscopic or a conventional procedure. Postoperative inflammatory response was assessed by measuring the white blood cell count, C-reactive protein, and soluble tumor necrosis factor receptors p55 and p75. Postoperative immune function was assessed by measuring monocyte HLA-DR expression and the stress response was assessed by measuring plasma cortisol concentrations. RESULTS: Laparoscopic surgery resulted in significantly lower plasma CRP levels 1 day after surgery. Both approaches resulted in a significant decrease in HLA-DR expression within 2 hours after surgery. After the laparoscopic approach, postoperative expression was restored to preoperative values within 1 day after surgery. However, after conventional surgery HLA-DR expression remained suppressed and did not return to preoperative values until the fourth postoperative day. No significant differences between the 2 procedures were observed in white cell blood count, sTNFr-p55 and p75, nor in postoperative cortisol levels. CONCLUSIONS: Although both laparoscopic and conventional Nissen fundoplication result in an activation of the systemic immune response, this study suggests that this response could be less after the laparoscopic approach. The differences found may reflect a lower risk for postoperative infective complications.     

Short- and long-term results after laparoscopic vs conventional colon resection in a tumor-bearing small animal model

BACKGROUND: We designed a study to evaluate the short- and long-term outcome of laparoscopic vs conventional colonic resection in a tumor-bearing small animal model. METHODS: We operated on male BD X rats (260-300 g), performing either laparoscopic (n = 9) or open colon resection (n = 9) in order to evaluate stress and immunological response to laparoscopic vs conventional colon resection. A third group (n = 9) underwent anesthesia only. Immediately before and after surgery, as well as at 1, 7, and 21 days postoperatively, a sample of 1 ml blood was taken from the retrobulbar venous plexus. Stress (corticosterone) and immune parameters (neopterine and IL-1 beta, IL-6) and body weight as a parameter of postoperative recovery were measured to identify short-term alterations. Long-term changes were evaluated in terms of survival time and at autopsy by measuring the tumor weight and the number of tumor infiltrated nodules (histology). RESULTS: The analysis of variance (ANOVA) showed significant differences between the three groups over a period of 1 week (p < 0.001 for corticosterone, p = 0.009 for neopterine, p = 0.04 for IL-1 beta, p = 0.024 for IL-6). Additionally, significant differences by t-test were found between the laparoscopic (minor alteration) and conventional (major alteration) group regarding corticosterone (p = 0.0015), neopterine (p = 0.0024), IL 1-beta (p = 0.033), and IL-6 (p = 0.015) at the end of the operation. One week after the operation, the body weight was different depending on the type of operative procedure: 7 days postoperatively the rats lost 8% of their body weight after open surgery but only 4.3% after laparoscopic surgery. After anesthesia only, body weight increased by approximately 4.8%. The medium survival time for the lap group was 44 days, whereas it was 44.1 days for the conventional group and 46 days for the anesthesia group (ANOVA p = 0.625). The number of nodules was 13.5 in the laparoscopic group 10.5 in the open group, and 7.4 in the anesthesia group, (ANOVA p = 0.119). The tumor weight was 6.8 g in the laparoscopic group, 6.4 g in the open group, and 5.04 g in the anesthesia group (ANOVA p = 0.874). CONCLUSION: In a tumor-bearing small animal model, laparoscopic colon resection alters the stress and immune system less than open colon resection. This observation has no implications for the long-term results as measured by survival time and at autopsy. Therefore, laparoscopic colon resection has a short-term benefit and has no negative effect on long-term results compared to conventional operative procedures.     

Extended transmediastinal dissection: an alternative to gastroplasty for short esophagus

HYPOTHESIS: The significance of short esophagus and its impact on failure after laparoscopic Nissen fundoplication are unknown. Although patients with severe esophageal shortening that requires Collis gastroplasty comprise a small percentage of patients undergoing fundoplication, we hypothesize that patients with moderate esophageal shortening requiring extended mediastinal dissection make up a larger subgroup and that extended laparoscopic mediastinal dissection is a good treatment strategy for such patients. DESIGN AND SETTING: Retrospective comparative analysis in an academic and private practice-based tertiary referral center. PATIENTS: A total of 205 patients underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease or paraesophageal hernias over 4 years. Outcomes in patients requiring either a type I (<5 cm) or type II (>5 cm) mediastinal dissection were compared. INTERVENTIONS: Laparoscopic Nissen fundoplication with or without extended mediastinal dissection and esophageal physiology testing. MAIN OUTCOME MEASURES: Symptom assessments, operative reports, and outcomes were prospectively recorded on standardized data sheets. Postoperative symptom assessment and esophageal physiology testing were performed. RESULTS: A total of 133 (65%) of the 205 patients underwent type I dissection, and 72 (35%) of the 205 patients underwent type II dissection. Failure occurred in 15 (11%) of 133 patients and 6 (10%) of 72 patients, respectively. The presence of a large hiatal or paraesophageal hernia predicted the need for type II dissection. CONCLUSIONS: No difference was seen in failure rates between patients who required a type II dissection and those who did not. This finding suggests that aggressive application of laparoscopic transmediastinal dissection to obtain adequate esophageal length may reduce fundoplication failure in patients with esophageal shortening and provide a success rate similar to that of patients with normal esophageal length. More liberal application of Collis gastroplasty in these patients is not warranted.     

Immediate postoperative complications after a laparoscopic partial posterior fundoplication. Early laparoscopic reoperation

AIM OF THE STUDY: The immediate postoperative course of laparoscopic partial posterior fundoplication can be complicated by severe dysphagia or paraesophageal hernia. The aim of this study was to describe the technical causes of these complications. PATIENTS AND METHOD: Four patients, operated for gastroesophageal reflux disease by laparoscopic partial posterior fundoplication, developed severe dysphagia (n = 2) or paraesophageal hernia (n = 2) during the immediate postoperative period. A barium swallow examination visualized the complication in both cases of dysphagia and in 1 case of paraesophageal hernia. The correct diagnosis was established by CT scan in the other case of paraesophageal hernia. Reoperations were performed by laparoscopy, 3 days (n = 2) or 6 days (n = 2) postoperatively. RESULTS: Dysphagia was due to compression of the esophagus against the hiatus by the fundoplication. A new and looser fundoplication was easily performed. Dysphagia was no longer present postoperatively. The two patients were symptom-free after 6 and 12 months of follow-up, respectively. In the cases of paraesophageal hernia, the bottoms of the crura were torn. In the patient reoperated 3 days postoperatively, the procedure was easily performed, the postoperative course was uneventful and the patient was symptom-free after a follow-up of 20 months. In the patient reoperated 6 days postoperatively, the upper part of the stomach had moved into the left pleural cavity, the procedure was difficult due to inflammation and thickening of the gastric wall, and the postoperative course was uneventful, but reflux recurred 18 months later. CONCLUSION: When severe dysphagia or paraesophageal hernia occurs during the immediate postoperative course of laparoscopic partial posterior fundoplication, reoperation, possibly by laparoscopy, identifies and cures the technical defects. Based on our experience, we suggest that surgical cure of paraesophageal hernia is easier when performed during the immediate postoperative period.     

Impact of surgery on immunologic function: comparison between minimally invasive techniques and conventional laparotomy for surgical resection of colorectal tumors

Background

Surgical trauma suppresses host immune function, potentially creating an environment vulnerable to tumor cell growth. This study compared immune function after laparoscopy, minilaparotomy, and conventional colorectal tumor resections.

Methods

Seventy-one patients underwent surgery (20 laparoscopy, 21 minilaparotomy, and 30 conventional). Blood samples were taken before surgery and at 3 hours, 24 hours, and 5 days after surgery. White blood cell constitution was determined using monoclonal antibodies. Levels of TH1 cytokines interferon-γ, tumor necrosis factor-α, and interleukin (IL)-2 and TH2 cytokines IL-10, -4, and -6 were measured in plasma and from supernatants of activated peripheral blood mononuclear cells.

Results

At 5 days after surgery, lymphocyte counts remained low in the conventional and minilaparotomy groups (P = .001 and P = .008) but had resolved in laparoscopic patients. Three-hour postoperative serum IL-6 concentrations were lower in laparoscopic than in conventional patients (P = .028). Production of TH1 cytokines 3 hours after surgery were significantly increased in laparoscopic patients (interferon-γ P = .018, tumor necrosis factor-α P = .011, and IL-2 P = .037).

Conclusions

TH1 lymphocyte function is improved transiently and immune homeostasis restored earlier in patients undergoing laparoscopic colorectal cancer resection, which may influence disease recurrence.     

Anterior partial fundoplication for gastroesophageal reflux disease

Background This study examined the effect of anterior partial fundoplication on reflux symptoms and dysphagia in gastroesophageal reflux disease.Patients and methods Perioperative results in 249 patients were evaluated retrospectively for 93 conventional and prospectively for 156 laparoscopic procedures. The patients were followed up by standardized questionnaire. Median clinical follow-up period was 9 months (range 6–44) after laparoscopic and 88 months (range 15–194) following partial open fundoplication.Results The median operating time was 58 and 115 min for laparoscopic and open partial fundoplication. Intraoperative complications were rare (1%) for both approaches. After introduction of the laparoscopic procedure the morbidity rate was reduced (mean 3.2% vs. 1.3%) at a shorter postoperative hospital stay (10 vs. 5 days). No reflux symptoms were found in 71.4% patients after conventional and in 69% after laparoscopic partial fundoplication, dysphagia did not develop in 86% and 85%, respectively, and 66% and 82% received no medications. Among the patients with reflux symptoms 6.5% and 0.9% underwent revision surgery. Satisfaction with the surgical outcome was expressed by 78% and 85% of patients, respectively.Conclusions Anterior partial fundoplication achieves effective medium- and long-term control of reflux symptoms. Technically easy to perform and associated with few complications, the procedure is superior to fundoplication with respect to the development of postoperative dysphagia and therefore represents a viable alternative to fundoplication.     

Serum interleukin-6 and C reactive protein responses in patients after laparoscopic or conventional cholecystectomy.

OBJECTIVE--To investigate the acute phase inflammatory response to surgical trauma after laparoscopic and conventional cholecystectomy. DESIGN--Prospective open study. SETTING--University Hospital in The Netherlands. SUBJECTS--21 patients with symptomatic cholelithiasis admitted for elective cholecystectomy who had had no previous upper abdominal operations. INTERVENTIONS--12 patients underwent conventional, and 9 patients laparoscopic, cholecystectomy. Circulating interleukin-6 (IL-6) and C reactive protein concentrations were measured 6, 12, 24 and 48 hours after operation. MAIN OUTCOME MEASURE--Changes in IL-6 and C reactive protein concentrations, and comparison of operative blood loss and length of stay in hospital. RESULTS--Those treated by laparoscopic cholecystectomy lost significantly less blood (median 60 compared to 100 ml) and spent significantly fewer days in hospital (median 2 compared with 7 days), (p < 0.01 in each case). The only changes in circulating IL-6 concentrations were seen in patients over the age of 60 years who underwent conventional cholecystectomy. There were significant differences in C reactive protein concentrations between the two operations at both 24 and 48 hours after the operation (p < 0.01 in each case). CONCLUSION: We conclude that laparoscopic cholecystectomy reduces the acute phase inflammatory response compared with the conventional operation; there seems to be no relevant correlation between plasma concentrations of IL-6 and C reactive protein; the presence of IL-6 does not affect the response of C reactive protein to trauma; and the response of IL-6 to trauma is age dependent.     

Laparoscopic esophagotomy without diverticular resection for treating epiphrenic diverticulum in hypertonic lower esophageal sphincter]

INTRODUCTION: As a rule, epiphrenic diverticulum occurs in combination with most diverse forms of dysfunction in the lower esophageal sphincter (LES) and/or in the esophagus itself. The main symptoms are dysphagia, pain, and regurgitation. The operation consists in myotomy, diverticulum resection, and partial fundoplication via abdominal or thoracic approach using conventional or minimally invasive technique. The main risk is postoperative suture dehiscence after diverticular resection. The present study was therefore undertaken to establish whether the operation succeeds in risk patients even without resection of the diverticulum. PATIENTS AND METHODS: In the period from 1998 to 2001, six patients were investigated preoperatively by means of esophageal manometry, endoscopy, and radiological barium swallow. The four risk patients underwent only myotomy of the LES, if appropriate, in combination with laparoscopic partial fundoplication. Resection of the diverticulum by thoracoscopy or with conventional thoracic technique was also performed in the two patients with normal risk. RESULTS: Three of the four risk patients showed normal postoperative courses after laparoscopic myotomy and rapidly became free of symptoms and were able to eat normally. One patient died perioperatively of pulmonary complications. After thoracic diverticulum resection, both patients developed postoperative suture dehiscence with a complicated course. Altogether, freedom from symptoms with regard to dysphagia and regurgitation could be attained in five out of six patients over a follow-up period of 6 to 25 months. CONCLUSION: In patients with epiphrenic diverticulum and disorder of LES function, myotomy alone without resection of the diverticulum may be sufficient to relieve or eliminate symptoms. Laparoscopy and the combination with partial fundoplication are the preferred techniques. In our opinion, this method must be considered in order to reduce the surgical risk in multimorbid and elderly patients.     

Does means of access affect the incidence of small bowel obstruction and ventral hernia after bowel resection? Laparoscopy versus laparotomy

BACKGROUND: Laparotomy for bowel resection is causally related to the development of small bowel obstruction (SBO) and ventral hernia, with incidences approaching 12% to 15% each. This report attempts to define the incidence of these access-related complications in a large group of patients undergoing laparoscopic-assisted bowel resection (LABR) and open bowel operation (OPEN). STUDY DESIGN: A retrospective cohort of 716 consecutive patients undergoing either LABR (n = 211) or OPEN (n = 505) procedures between January 1995 and July 2000 was identified and selected from a prospective registry. RESULTS: Index LABR (n = 211) and OPEN (n = 505) cases included segmental colectomy in 146 LABR and 408 OPEN patients; subtotal colectomy with or without stoma in 18 LABR and 6 OPEN patients; ileocolectomy in 37 LABR and 85 OPEN patients; and small bowel resection in 10 LABR and 6 OPEN patients. The mean followup periods in the LABR and OPEN groups were 2.71 years and 2.42 years, respectively.The incidence of wound hernia was significantly higher in OPEN cases (n = 65) compared with LABR (n = 5) (p < 0.05). The incidence of surgical repair of ventral hernia was also significantly higher in the OPEN group (28) compared with LABR (4) (p < 0.05). Postoperative SBO requiring hospitalization with conservative management occurred significantly less frequently in LABR patients (n = 4) compared with OPEN patients (n = 31) (p = 0.016). The need for surgical release of SBO was similar between the OPEN and LABR groups (n = 4 versus n = 11). The overall reoperation rate for these two complications was two times higher in the OPEN group than in the LABR group (7.7% versus 3.8%). CONCLUSIONS: The data demonstrate that laparoscopic access for bowel operation significantly reduces the incidence of ventral hernia and SBO rates compared with laparotomy. This reduces the need for readmission to the hospital and additional surgical procedures, providing a potential source of decreased morbidity. It should be considered as a means of cost savings associated with laparoscopic bowel operations.     

Incidence of small bowel obstruction after laparoscopic and open colon resection

Background

Small bowel obstruction (SBO) is responsible for more than 1 billion dollars in health care costs yearly in the United States. We sought to evaluate whether laparoscopic colorectal surgery resulted in a decreased incidence of SBO within the first year of surgical resection compared with open surgery.

Methods

From January 2003 to December 2008, 339 patients underwent open (open colorectal resection [OPEN]) colorectal resection and 448 patients underwent laparoscopic (laparoscopic colorectal resection [LAP]) colorectal resection. Hospital admissions up to 1 year after the initial resection identified patients admitted for the management of SBO, ileus, or nausea and vomiting.

Results

During the 1st year after surgery, 6 patients in the OPEN group developed SBO, and 5 patients in the LAP group developed SBO. The overall frequency of SBO for the OPEN group was 1.8% and 1.1% for the LAP group (P < .5461).

Conclusions

Although advantages such as quicker postoperative recovery and decreased hospital stay have been attributed to laparoscopic surgery, no difference in the incidence of SBO within the 1st year of surgery was found compared with open colorectal surgery.     

Laparoscopic fundoplication for gastroesophageal reflux disease: retrospective study of functional results in 243 patients

STUDY AIM: The aim of this retrospective study was to evaluate the 38 month-results of laparoscopic fundoplication for gastroesophageal reflux disease (GERD). PATIENTS AND METHODS: Two hundred forty three consecutive patients were operated laparoscopically. The surgical procedures were complete fundoplication with division of short vessels (Nissen: 80 patients), without division of short vessels (Nissen-Rossetti: 68 patients) or partial fundoplication of 270 degrees (Toupet: 95 patients). The mean follow-up was 38 months. Functional results were evaluated in 225 patients (92.5%) using a questionnaire with visual analog scales. RESULTS: The morbidity rate was 5%, higher after Nissen procedure (6.5%). With a follow-up of 3 months: a dysphagia coted 5/10, a gas bloat syndrome coted 4/10 and colon distension present in 61% of patients, were significantly more frequent after Nissen procedure. GERD recurred early in 4.5% of patients. With a follow-up of 38 months: dysphagia rate (coted 1/10) was significantly higher after Nissen. Dysphagia still persisted in 8 patients (9%) after Nissen. Colon distension and flatulence were more present after Nissen fundoplication. GERD recurrence rate was 12%. Pyrosis was significantly higher after Toupet fundoplication. Continuous medical treatment was necessary in 19 patients (8%). The satisfaction of patients was coted 7.5/10 without difference between to the three types of fundoplication. CONCLUSION: The total laparoscopic fundoplication for GERD seems to be a safe and efficient operation. This procedure proves to be more effective than partial fundoplicature but with a grater morbidity. Whatever the type of fundoplicature, the satisfaction of patients was good.     

Comparison of surgical stress between laparoscopic and open colonic resections

BACKGROUND: The magnitude of surgical trauma after laparoscopic and open colonic resection was evaluated by examining postoperative serum values of interleukin-6 (IL-6), IL-10, C-reactive protein (CRP), and granulocyte elastase (GE) for further evidence of the benefit realized with minimally invasive approaches in colonic surgery. METHODS: Altogether, 42 patients with Crohn's disease (n = 20) or colon carcinomas/adenomas (n = 22) were matched by age, gender, body mass index (BMI), and Crohn's Disease Activity Index for either a laparoscopic (n = 21) or an open colonic resection (n = 21). In both groups the postoperative serum levels of IL-6, IL-10, C-RP, and granulocyte elastase were determined, as indicators of surgical stress. RESULTS: Laparoscopic and open colonic resection caused a significant increase in serum IL-6, IL-10, CRP, and granulocyte elastase levels. The comparison between laparoscopic and open colonic resections, however, showed significantly lower serum IL-6, IL-10, CRP, and granulocyte elastase levels after laparoscopic colonic resection, which was most evident for IL-6 and granulocyte elastase. CONCLUSIONS: Our study demonstrated that IL-6 and granulocyte elastase may be appropriated particularly to monitor surgical stress. By using these parameters, we found a significant reduction in surgical trauma after laparoscopic surgery, was compared with the open procedure. This supports the clinical findings of a clear benefit for patients undergoing laparoscopic colonic surgery.     

Laparoscopic Nissen fundoplication: two-year comprehensive follow-up of a technique of minimal paraesophageal dissection.

OBJECTIVE: To provide a comprehensive follow-up of 381 patients after laparoscopic Nissen fundoplication (LNF) using a technique of minimal paraesophageal dissection. METHODS: Patients underwent a 24-hour pH recording, esophageal manometry, and symptom score assessment for six symptoms of gastroesophageal reflux disease preoperatively. To date, 260 patients have undergone repeat studies at 6 months and 108 patients at 2 years. RESULTS: LNF was associated with a significant (p < 0.0001) increase in the lower esophageal sphincter (LES) pressure and a significant (p < 0.0001) drop in duration of acid reflux in 24 hours and symptom score 6 and 24 months after surgery when compared to preoperative values. Twelve patients (3%) have experienced recurrence of reflux symptoms, 8 presenting in the first 6 months and 4 by the second year after surgery, but only 1 has required repeat surgery. The incidence of clinical dysphagia was found to be 1.3% of the patient group. CONCLUSIONS: LNF remains an effective antireflux procedure at 2 years. Most recurrences occur early, and there is no significant deterioration in the high-pressure zone at the LES, the percentage reflux in 24 hours, or symptom control between 6 months and 2 years after surgery, suggesting that the long-term results should be satisfactory.     

腹腔镜肝癌切除术对患者术后临床康复和体液免疫影响的临床对照研究

目的探讨腹腔镜与开腹肝癌切除术对患者临床康复和体液免疫功能的影响。方法选取2010年1月至2012年6月期间徐州医学院附属医院、江苏省肿瘤医院及南京中医药大学第二附属医院行腹腔镜及开腹肝癌左外叶切除术患者44例,其中腹腔镜组22例,常规开腹组22例。采用ELISA法测定患者术前1 d以及术后第l天和第5天外周血中IgG、IgA、IgM、C3、C4、C反应蛋白（CRP）、IL-2、IL-6及TNF-α水平的变化,同时比较2组患者的手术时间、术中出血量、住院时间及并发症发生情况。结果腹腔镜组患者术后镇痛剂使用时间为（1.9±0.8）d,首次进食时间为（2.2±0.5）d,住院时间为（6.3±1.3）d,均短于开腹组（P〈0.05）,但2组间的手术时间、术中失血量、并发症发生率及死亡率差异均无统计学意义（P〉0.05）。与术前相比,术后第1天2组患者的C3、C4、lgA、IgG、lgM和IL-2均明显降低（P〈0.05）,CRP、IL-6及TNF-α均明显升高（P〈0.05）;开腹组患者术后第l天的C3、C4、lgA、IgG、lgM和IL-2的下降幅度较腹腔镜组更明显（P〈0.05）。术后第5天,腹腔镜组患者的C3、C4、lgA、IgG、lgM及IL-2水平上升和CRP、IL-6及TNF-α水平下降并均接近术前水平;而开腹组患者的C3、C4、lgA、IgG、lgM及IL-2仍低于术前水平（P〈0.05）,CRP、IL-6及TNF-α仍仍高于术前水平（P〈0.05）。结论腹腔镜肝癌切除术后患者的恢复较快,且对患者机体体液免疫功能的影响小于开腹肝癌切除术。     

Laparoscopic treatment of large hiatal hernias using a prosthesis. Report of ten cases

OBJECTIVE: To evaluate prospectively the laparoscopic surgery for giant hiatal hernias treated by fundoplication and hiatal prosthesis. PATIENTS AND METHODS: Ten patients were included in this study. Surgical technic included the dissection of oesophageal hiatus, the sac excision and the dissection of the abdominal oesophagus to obtain a physiological length. The decision criterion for a prosthesis was the hiatus oesophagus diameter of 5 cm or more. The crura were closed and the hiatus was reinforce by a prosthesis of 15 x 15 cm. All patients underwent a fundoplication whether partial or complete. RESULTS: Eight patients had a type III hernia, and 2 had a type II. The mean size for the hiatus was 6.5 cm (5.5-8). Eight patients underwent a total fundoplicature and 2 a partial one. The prosthesis was made of polypropylene in 5 cases. Average operating time was 182 min (78-240). One patient had postoperative morbidity, with gastroplagia which resolved. There was no mortality. Mean hospitalisation duration was 7.7 days (5-12). No one case of recurrence have been noticed after a mean follow-up of 24 months (8-40). CONCLUSION: It appears that the large size hiatal hernia (more than 5 cm) can be treated with good results by using a prosthesis during laparoscopic fundoplication.