Endoscopic photodynamic therapy for obstructing esophageal cancer: 77 cases over a 2-year period

rid="id="<e5>Correspondence to:</e5> J. D. Luketich, 200 Lothrop Street, C-800, Presbyterian Hospital, Pittsburgh, PA 15213, USA Background: Photodynamic therapy (PDT) is an alternative treatment option for the palliation of obstructive esophageal cancer. We report our experience with PDT for patients presenting with inoperable, obstructing, or bleeding esophageal cancer. Methods: Seventy-seven patients with inoperable, obstructing esophageal cancer were treated with PDT from November 1996 to July 1998. Photofrin (1.5–2.0 mg/kg) was administered, followed by endoscopic light treatment (630 nm red dye laser) at 48 h. Dysphagia score (1 for no dysphagia to 5 for complete obstruction), dysphagia-free interval, and patient survival were assessed. Results: Seventy-seven patients underwent 125 PDT courses. The mean dysphagia score at 4 weeks after PDT in 90.8% of the patients improved from 3.2 ± 0.7 to 1.9 ± 0.8 (p < 0.05). PDT adequately controlled bleeding in all six patients who had bleeding. The most common complications after the 125 PDT courses were esophageal stricture (4.8%), Candida esophagitis (3.2%), symptomatic pleural effusion (3.2%), and sunburn (10.0%). Twenty-nine patients (38%) required more than one PDT course, and seven patients required placement of an expandable metal stent for recurrent dysphagia. The mean dysphagia-free interval was 80.3 ± 58.2 days. The median survival was 5.9 months. Conclusions: Photodynamic therapy is a safe and effective treatment for the palliation of obstructing and bleeding esophagus cancer. Received: 8 May 1999/Accepted: 24 September 1999/Online publication: 15 May 2000     

Thoracoscopic partial pericardiectomy in the diagnosis and management of pericardial effusion

Background: An effort was made to present our experience with thoracoscopy in the diagnosis and management of pericardial effusions. Methods: Twenty-two partial pericardiectomies were performed with the thoracoscopic approach in patients with pericardial effusions, the etiology of which was uremic (n= 7), neoplastic (n= 8), idiopathic (n= 5), septicemia (n= 1), and postpericardiotomy (n= 1). All cases had grade III-IV/IV radiological cardiomegaly and ultrasonographic confirmation of the effusion. We found hemodynamic compromise in 17 patients. The operation, requiring the insertion of three trocars, enabled us to remove a large part (approximately 6 × 10 cm) of the left anterolateral side of the pericardium and aspirate the effusion contents for diagnostic and therapeutic purposes. Results: In five cases we found coexisting pleural effusions. The pericardial effusion had a mean volume of 817 ml, which was serous in 11 cases, hematic in six, serohematic in four, and purulent in one. Cytology of the pericardial effusion was positive for neoplasia in four cases (one pulmonary neoplasia, two breast carcinomas, and one lymphoma). We observed conversion to grade I/IV cardiomegaly in 16 cases and a return to normality in the other six, with the absence of ultrasonographic effusion in all cases. There was no recurrence during the mean follow-up period of 20.5 months (range: 2–47). Conclusions: The thoracoscopic management of pericardial effusions is a simple and effective technique that allows us to create a large pericardial window that drains the effusion definitively, determines its etiology, and explores and treats coexisting pleural lesions, all without recurrences. Received: 30 May 1996/Accepted: 27 August 1996     

Laparoscopic cholecystectomy and time-course changes in renal function

Background: Recently, the retraction method has been used to reduce intraabdominal pressure (IAP) during laparoscopic surgery. The purpose of this study was to determine the serial changes in renal function during laparoscopic cholecystectomy (LC) using the retraction method. Methods: Urine output, effective renal plasma flow (ERPF), and glomerular filtration rate (GFR) were measured serially in seven patients who underwent LC with 12 mmHg pneumoperitoneum (High-IAP group) and five who underwent LC using the retraction method with 4 mmHg pneumoperitoneum (Low-IAP group). Results: Urine output, ERPF, and GFR were decreased during pneumoperitoneum in the High-IAP group, whereas no significant changes in any of these parameters were observed in the Low-IAP group. Conclusions: Our findings demonstrate that reduction of IAP to 4 mmHg using the retraction method prevents the transient renal dysfunction caused by prolonged 12 mmHg pneumoperitoneum during LC, suggesting that the retraction method reduces the risk of perioperative renal dysfunction during laparoscopic surgery. Received: 26 March 1996/Accepted: 27 July 1996     

Laparoscopic fundoplication in infants and children

Background: Laparoscopic fundoplication is a new method for treating gastroesophageal reflux in children. We present 160 children with gastroesophageal reflux treated by laparoscopic fundoplication. Methods: Patients underwent either a laparoscopic Nissen or Toupet fundoplication. Many patients also required gastrostomies and gastric outlet procedures. Results: Twelve patients (7.5%) were converted to open fundoplication. Laparoscopic gastrostomies were placed in 112 patients (75.7%) and laparoscopic gastric outlet procedures in 62 patients (41.9%). Feedings were initiated by postoperative day 2 in 126 children (85.7%). Sixty-four percent were discharged by postoperative day 3. Complications occurred in 11 of 148 fundoplications (7.4%), in nine of 112 gastrostomies (8.0%), and in three of 62 gastric outlet procedures (4.8%). One patient died as a result of a surgical error in placing a gastrostomy (0.7%). Conclusion: Laparoscopic fundoplication appears to foster a more rapid recovery and decreased hospital stay while maintaining complication rates similar to or better than open fundoplication. Received: 22 March 1996/Accepted: 12 June 1996     

Results of the routine use of a modified endoprosthesis to drain the common bile duct after laparoscopic choledochotomy

Background: One hundred eighty-one patients were submitted to laparoscopic common bile duct exploration. Methods: A transcystic approach was used in 147 patients, choledochotomy in 14, and both in 20. The indications to perform a choledochotomy included stones larger than 20 mm, stones proximal to the cystic duct entrance, and cases in which the transcystic duct approach proved impossible or unsuccessful. Results: The common bile duct was drained by a T-tube in four patients, by laparoscopic sphincterotomy in one, by laparoscopic choledochoduodenostomy in one, and by a 10 Fr endoprosthesis in 28. The stent placement was technically feasible in all patients but one. The biliary drainage was adequate. Mean hospital stay was 2.1 days. Complication was limited to one umbilical infection and one self-limited biliary leak. Conclusions: The procedure proved to be technically simple, safe, and efficient, and resulted in a low morbidity rate and short hospital stay. Received: 29 March 1996/Accepted: 12 June 1996     

Changing management of gallstone disease during pregnancy

Background: Symptomatic gallstones may be problematic during pregnancy. The advisability of laparoscopic cholecystectomy (LC) is uncertain. The objective of this study is to define the natural history of gallstone disease during pregnancy and evaluate the safety of LC during pregnancy. Methods: Review of medical records of all pregnant patients with gallstone disease at the University of California, San Francisco, from 1980 to 1996. Results: Of approximately 29,750 deliveries, 47 (0.16%) patients were treated for gallstone disease, including biliary colic in 33, acute cholecystitis in 12, and pancreatitis in two. Conservative treatment was attempted in all patients but failed in 17 (36%) cases. Two patients required combined preterm Cesarean-section cholecystectomy and 10 required surgery in the early postpartum period for persistent symptoms. Seventeen patients required cholecystectomy during pregnancy for biliary colic (10), acute cholecystitis (six), and pancreatitis (one). Three patients were treated with open cholecystectomy. Fourteen patients underwent LC at a mean gestational age of 18.6 weeks, mean OR time of 74 min, and mean length of stay of 1.2 days. Hasson cannulation was utilized in 11 patients. Reduced-pressure pneumoperitoneum (6–10 mmHg) was used in seven patients. Prophylactic tocolytics were used in seven patients, with transient postoperative preterm labor observed in one. There were no open conversions, preterm deliveries, fetal loss, teratogenicity, or maternal morbidity. Conclusions: In past years, symptomatic gallstones during pregnancy were managed conservatively or with open cholecystectomy. LC is a feasible and safe method for treating severely symptomatic patients. Received: 3 April 1997/Accepted: 5 July 1997     

Laparoscopic management of ovarian tumors

Background: Laparoscopy can be used with minimal operative morbidity to evaluate adnexal masses. We report our experience with the endoscopic approach to the diagnosis and treatment of ovarian tumors. In particular, we describe 11 patients who incidentally underwent laparoscopy and in whom the ovarian masses were found to be malignant. Methods: Between September 1994 and September 1996, 292 patients with 316 ovarian tumors were treated laparoscopically in the Department of Obstetrics–Gynaecology, University of Ulm. We assessed vaginal ultrasonography, clinical assessment, the tumor marker CA 12-5, and the intraoperative low-power magnification for their value in predicting the final diagnosis in all laparoscopically treated ovarian tumors. Results: From a total of 292 patients with ovarian tumors, 11 were diagnosed, intraoperatively or after final histologic examination, as having a malignant or borderline ovarian tumor. All applied pre- and intraoperative diagnostic procedures were by themselves too unreliable to exclude early stages of ovarian carcinoma exactly. Conclusions: On the basis of the present findings, we are tempted to conclude that laparoscopic surgery is justified in the management of ovarian tumors. Even with an accurate preoperative selection of suitable patients for laparoscopic surgery, the presence of an undetected ovarian carcinoma cannot be entirely excluded. Received: 23 September 1997/Accepted: 4 December 1997     

A cost-effective thoracoscopic treatment strategy for pediatric spontaneous pneumothorax

Background: Recent data suggest that children have a higher incidence of recurrence than adults after nonoperative treatment of primary spontaneous pneumothorax (PSP). Video-assisted thoracoscopic surgery (VATS) allows efficacious therapy with significantly less morbidity. We attempt to define the most cost-effective clinically efficacious strategy using VATS to manage pediatric PSP. Methods: We retrospectively reviewed all admissions to a tertiary care children's hospital for PSP between January 1, 1991 and June 30, 1996. Results: Fifteen children had 29 primary or recurrent PSPs. Mean patient age was 14.8 ± 1.1 years, boy–girl ratio 4:1, median body mass index 18 (normal, 20–25), and 67% of pneumothoraces left sided. All patients were managed initially nonoperatively: 14 with tube thoracostomy drainage and 1 with oxygen alone. Of the children initially managed nonoperatively, 57% had a recurrent pneumothorax, and 50% of these patients eventually developed contralateral pneumothoraces. Nonoperative treatment for recurrence resulted in a 75% second recurrence rate. In contrast, eight children who underwent operative management had a 9% incidence of recurrence. The total for charges accrued in treating 29 pneumothoraces in these 15 patients was approximately $315,000. In the same population, the estimated charges for initial nonoperative therapy followed by bilateral thoracoscopy after a single recurrence would be $230,000. Conclusions: A cost-effective treatment strategy for pediatric primary spontaneous pneumothorax is tube thoracostomy at first presentation, followed by VATS with thoracoscopic bleb resection and pleurodesis for patients who experience recurrent pneumothorax. Received: 15 May 1998/Accepted: 15 January 1999     

Laparoscopic cholecystectomy in 1994

Background: In 1996, laparoscopic cholecystectomy is the gold standard for symptomatic cholelithiasis. The results of this operation as published so far include data on the learning curve of the method. The aim of this study is to evaluate the results of laparoscopic cholecystectomy when performed by a large number of surgeons during the year 1994, not taking into account the beginning years in which the technique was being used. Methods: This study has been carried out prospectively and anonymously among members of SFCERO. All the patients who underwent a cholecystectomy started laparoscopically during 1994 have been included. Results: Some 4,624 cholecystectomies were performed by 150 surgeons. There were 3,310 females (42.5 ± 19.8 years old) and 1,314 males (56.3 ± 1.61 years old). The conversion rate was 6.9%: 320 operations had to be converted into laparotomy (group II) while 4,261 were performed entirely by laparoscopy (group I). Morbidity was 5% (N= 230)—4.7% in group I (N= 203) and 8.4% in group II (N= 27). Mortality was 0.2% (N= 9)—namely four intraabdominal complications (three cases of peritonitis and one biliary reoperation), two cardiac failures, and one brain infarction. The causes of death were not specified in two patients. Conclusions: These results show that morbidity and mortality have not changed dramatically since the beginnings of this technique, whereas the frequency of common bile duct (CBD) injuries has decreased. However, the conversion rate has increased slightly. These results make it possible to calculate the risk of conversion and postoperative complication according to the age of the patient and the biliary symptoms. Received: 25 January 1996/Accepted: 10 April 1996     

Laparoscopic bilateral adrenalectomy following failed hypophysectomy

Background: Laparoscopic adrenalectomy has recently been shown to be a safe and effective means of treating adrenal pathology with much lower morbidity than the traditional approach. The majority of reports in the literature involve removal of adrenal tumors. Although open bilateral adrenalectomy has been utilized for persistent Cushing's syndrome following attempted hypophysectomy, there is little data available describing the application of laparoscopic adrenal surgery to this problem. Methods: Four patients with persistent Cushing's syndrome after attempted treatment with hypophysectomy underwent laparoscopic bilateral adrenalectomy at our institution. One procedure was done transabdominally in the supine position. Three procedures were done transabdominally using sequential lateral decubitus positions. Results: All procedures were completed laparoscopically. The mean operative time was 4.6 h (range 3.9–5.25). Repositioning and reprepping the patients resulted in a slight increase in operative time, but visualization was improved using the lateral decubitus position. Average blood loss: 156 cc (range 50–300). One patient required early reoperation for bleeding from the left adrenal bed, which was controlled laparoscopically. Three patients were eating the following day and were discharged on postoperative days 1, 2, and 5. The fourth patient remained hospitalized for 18 days due to problems unrelated to surgery. After a mean follow-up of 10 months, all patients have done well and have no clinical or biochemical evidence of recurrent disease. Conclusion: Our clinical experience indicates that laparoscopic bilateral adrenalectomy is a viable treatment option for Cushing's syndrome following failed hypophysectomy. Received: 29 March 1996/Accepted: 12 June 1996     

Does laparoscopy increase bacteremia and endotoxemia in a peritonitis model?

Background: Laparoscopy is increasingly used in patients with intraabdominal bacterial infection although pneumoperitoneum may increase bacteremia by elevated intraabdominal pressure. Methods: The influence of laparotomy and laparoscopy on bacteremia, endotoxemia, and postoperative abscess formation was investigated in a rat model. Rats received intraperitoneally a standardized fecal inoculum and underwent laparotomy (n= 20), or laparoscopy (n= 20), or no further manipulation in the control group (n= 20). Results: Bacteremia and endotoxemia were higher after laparotomy and laparoscopy compared to the control group (p= 0.01) 1 h after intervention. One hour after intervention, aerobic and anaerobic bacterial species were detected in the laparotomy group while only anaerobic bacteria were found in the other two groups. Although bacteremia and endotoxemia did not differ among the three groups after 1 week, the mean number of intraperitoneal abscesses was significantly higher (p < 0.05) after laparotomy (n= 10) compared with laparoscopy (n= 6) and control group (n= 5). Conclusion: Laparoscopy does not increase bacteremia and intraperitoneal abscess formation compared to laparotomy in an animal model of peritonitis. Received: 28 May 1996/Accepted: 25 July 1996     

Port site electrosurgical (diathermy) burns during surgical laparoscopy

Background: Direct and capacitive coupling of diathermy current have been reported as causes of occult injury during surgical laparoscopy. Methods: In order to determine the incidence of electrosurgical injury adjacent to metal and plastic cannulas, skin biopsies at 19 port sites used for monopolar electrosurgery were analyzed for coagulative necrosis. Prior to surgery the cannulas were randomized to either metal or plastic. Results: Coagulative necrosis was observed at nine electrosurgery port sites compared to only one control (χ²= 4.872; df= 1; 0.05 > p > 0.02). Plastic cannulas afforded no greater protection from skin burns than metal cannulas. Conclusions: Burns may be the result of direct or capacitive coupling to metal cannulas or capacitive coupling to the skin edge across plastic cannulas. The potential exists for burns to other tissues also in close proximity to a cannula used for electrosurgery. Received: 12 August 1996/Accepted 26 November 1996     

Preemptive analgesia in the laparoscopic patient

Background: One hundred consecutive laparoscopic patients were prospectively followed in the Post-anesthesia Recovery Unit (PAR) in a community hospital. Methods: Data was collected regarding (1) intraoperative administration of ketorolac, (2) instillation of local anesthesia into the wound, and (3) requirements for analgesic administration in the PAR. Those patients receiving both forms of preemptive analgesia required less narcotic administration in the PAR. The results were highly significant. Results: Based on these data and the observance of markedly reduced pain in patients during the early postoperative period, an institutional plan of care was developed which has resulted in the virtual elimination of the need to administer narcotics to patients undergoing routine laparoscopic surgical procedures. Conclusions: The resultant plan of care, which includes preemptive analgesia, rapid ambulation, early feeding, and routine timed administration of non-narcotic pain medications, is presented. Data is also presented which demonstrates a more rapid discharge of patients from the hospital. Received: 5 April 1996/Accepted 2 November 1996     

Laparoscopic splenectomy

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     

Laparoscopic interval appendectomy for periappendicular abscess

Background: Laparoscopic appendectomy was first described in the early 1980s and is currently widely used for the treatment of acute appendicitis. The application of laparoscopic techniques to interval appendectomy and the value of this procedure as compared to open elective interval appendectomy remains uncertain. Therefore, we set out to assess the usefulness of interval laparoscopic appendectomy following periappendicular abscess. Methods: This study analyzes the data for 10 patients who underwent interval laparoscopic appendectomy 8–10 weeks following documented periappendicular abscess in the period between January 1996 and June 1998. Results: Laparoscopic appendectomy was completed successfully in all 10 patients. Nine patients were discharged 1 day after the operation; one patient was discharged on the evening of the operative day. There were no complications and no wound infections. Conclusion: We conclude that the laparoscopic approach is the preferable treatment for interval appendectomy. It is associated with minimal or no morbidity and a very short hospital stay. Received: 13 May 1999/Accepted: 9 December 1999/Online publication: 12 July 2000     

A stratified intraoperative surgical strategy is mandatory during laparoscopic common bile duct exploration for common bile duct stones

Background: Open exploration and endoscopic sphincterotomy (ES) remain the preferred treatment of common bile duct stones (CBDS). The recent spread of laparoscopy has worsened the dilemna of choosing between surgical and endoscopic treatment of CBDS. The aim of this study was to critically evaluate the results of our preliminary experience with laparoscopic common bile duct exploration (CBDE) for CBDS. Methods: Ninety-two consecutive patients were prospectively submitted to laparoscopic CBDE. Surgical strategy included an initial transcystic approach or laparoscopic choledochotomy. Failure of stone clearance was managed by conversion to open CBDE or by postoperative ES. Electrohydraulic lithotripsy and papillary balloon dilatation were selectively used. Stone clearance was assessed by choledochoscopy and control cholangiography. Results: The overall laparoscopic stone clearance in this series was 84% (transcystic route 63% and choledochotomy 93%). Conversion to laparotomy was mandatory in 12% of the patients because of incomplete stone clearance and in 5% because of intraoperative complications. Postoperative ES was required in 4% of the patients, giving an overall surgical success rate of 96%. When indicated (small and limited number of stones located below the cysticocholedochal junction, with a dilated and patent cystic duct) the transcystic route had the lower success rate, the higher complication rate, and the shorter operative time and postoperative hospital stay. When indicated (accessible and dilated common bile duct over 7 mm), laparoscopic choledochotomy had the higher success rate, the lower complication rate, the longer operative time, and the longer postoperative hospital stay, which is related to associated external biliary drainage. The hospital mortality included two high-risk patients (2%) and the complications rate was 15%. Conclusions: Laparoscopic CBDE is safe in selected patients. A stratified intraoperative surgical strategy is mandatory in deciding between a transcystic route and choledochotomy with specific indications for each approach. When feasible, laparoscopic choledochotomy is more efficient and safe than the transcystic route, but it is associated with a longer postoperative hospital stay, which is due to external biliary drainage. Received: 7 May 1996/Accepted: 19 November 1996     

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     

Acute cholecystitis

Background: Most of the literature dealing with the surgical management of acute cholecystitis bases patient selection on pathological diagnosis, either exclusively or using it as a major selection criteria or as a confirmation of diagnosis. The purpose of this study was to examine the correlation between preoperative clinical findings, intraoperative gross findings, and postoperative pathological findings. Methods: A retrospective review of 493 consecutive laparoscopic cholecystectomies performed by a single surgeon (RJF) in a single institution was done. Four different sets of criteria were used to define four groups of patients as having acute cholecystitis: (1) preoperative acute cholecystitis based on defined criteria (PA); (2) intraoperative gross findings of acute or subacute cholecystitis based on surgeon assessment of inflammation (IA); (3) initial pathological evaluation by a staff pathologist (IP); and (4) expert pathological (EP) review using strictly defined histological criteria. Results: Of 41 patients, 40 (97.6%) were classified as having acute cholecystitis by IA, 21 (51.2%) by IP, and 17 (41.5%) by EP. Of the 75 patients classified as having acute cholecystitis by IA, 40 (53.0%) were classified acute by PA, 34 (45.0%) by IP, and 17 (22.7%) by EP. Of the 72 IP patients, 34 (47.2%) were classified as acute by IA, 15 (20.8%) by EP, and 24 (33.3%) were PA. Of the 32 EP patients, 21 (65.6%) were classified as acute by IA, 14 (43.8%) by IP, and 18 (56.3%) were PA. Conclusion: The correlation between the pathological diagnosis and intraoperative findings is poor. Preoperative clinical findings of acute cholecystitis are highly reliable for predicting intraoperative gross findings. However, intraoperative findings of acute cholecystitis are commonly found in the absence of preoperative clinical signs. Recommendations for surgical therapy should be based on studies which use either operative findings or the preoperative clinical findings as the basis for patient selection. Received: 29 March 1996/Accepted: 12 June 1996