Laparoscopic vs open resection of gastric stromal tumors.

BACKGROUND: Gastric stromal tumors are rare neoplasms that may be benign or malignant. Given that malignant gastric stromal tumors rarely involve lymph nodes and require excision with negative margins, they appear amendable to laparoscopic excision. There are few reports of laparoscopic resection, and no comparisons have been done between laparoscopic and open surgery. This study compares the relative efficacy of the two approaches. METHODS: Between May 1994 and December 2000, 33 patients underwent 35 operations for gastric stromal tumors. Laparoscopic resections were performed in 21 patients; open resections were done in 12 patients. The medical records of the patients were reviewed retrospectively with regard to operating time, blood loss, length of stay, and clinical course. RESULTS: Patient demographics, tumor characteristics (mean tumor size, benign vs malignant), and presenting symptoms were similar for both groups. In the laparoscopic group, 15 wedge resections; three partial gastrectomies, and three transgastric needlescopic enucleations were performed. In the open group, six wedge resections, four antrectomies, and two partial proximal gastrectomies were performed. There were no significant differences in mean operative time (169 vs 160 min), mean estimated blood loss (106 vs 129 cc), or perioperative complication rate (9.5% vs 8.3%) between the laparoscopic and open groups, respectively. The mean length of stay was significantly less (p<0.05) in the laparoscopic group (3.8 vs 6.2 days). Average follow-up was 1.5 years. One patient in each group has died due to metastatic disease. There have been no trocar site recurrences. CONCLUSIONS: Laparoscopic resection of gastric stromal tumors is safe and appropriate. Tumor size, operating time, and estimated blood loss were equivalent to the open approach, and there was a statistically shorter hospital stay in the laparoscopic group.

Blunt traumatic rupture of the thoracic aorta: a report of an unusual mechanism of injury.

Classic teaching suggests that blunt thoracic aortic rupture (BTAR) results from high-speed deceleration injury mechanisms. Our recent experience with a patient who sustained fatal aortic rupture resulting from a low-speed crushing injury emphasizes the importance of maintaining a high index of suspicion for BTAR, even in patients with "low-risk" injury mechanisms. Several potential pathophysiologic mechanisms of BTAR are discussed.

Breast conservation: trends in a major southern metropolitan area compared with surrounding rural counties.

Despite randomized prospective studies and National Institutes of Health recommendations, surgeons especially in the southern United States have been slow to adopt breast conservation surgery (BCS). Data were analyzed regarding 3,349 cases of stage 0, I, and II breast cancer (1991-1998) from Charlotte-Mecklenburg County, NC; 1057 cases from six surrounding rural counties (1995-1997); and 90,398 cases (1995) from the National Cancer Data Base. During 1995 through 1997 Charlotte-Mecklenburg County had statistically significantly higher rates of BCS compared with six surrounding rural counties for stage I (59% and 42% respectively, P = 0.001) and stage II (37% and 19%, respectively, P = 0.001) breast cancer. The BCS rates in Charlotte-Mecklenburg County (1991-1998) showed the following: Stage 0 rate increased from 17 per cent in 1991 to 78 per cent in 1998 (P = 0.001), stage I rate increased from 31 per cent in 1991 to 65 per cent in 1998 (P = 0.001), and stage II rate increased from 18 per cent in 1991 to 42 per cent in 1998 (P = 0.001). BCS rates for early-stage breast cancer in Charlotte-Mecklenburg County have increased over the last 8 years and now equal national rates; however, patients in surrounding rural counties are not receiving BCS as frequently. There is a need for more widespread education of surgeons, other health care providers, and the general public to increase the use of BCS.

Strategies for laparoscopic diagnosis of malignancy.

Accurate cancer diagnosis and staging are crucial to the determination of an efficacious treatment plan for localized and advanced malignancy. The physician must differentiate patients with potentially resectable, localized disease from those with advanced and/or distant disease. The diagnostic and staging modalities currently available are expensive and often inaccurate. This can result in the nonoperative management of potentially resectable malignancies or, more commonly, in an underestimation of the preoperative cancer stage with intraoperative evidence of advanced/metastatic disease. The combination of laparoscopy and laparoscopic ultrasonography can be used to help diagnose and stage malignancies and select patients for either curative or palliative procedures.

Laparoscopic splenectomy for malignant diseases.

A variety of malignant diseases involving the spleen, both primary and metastatic, may require splenectomy for diagnosis or therapeutic reasons. The role of minimally invasive surgery in the management of malignant diseases involving the spleen is not well defined because of a lack of reported experience with laparoscopic splenectomy in this group. A reluctance to perform laparoscopic splenectomy in these patients may be explained by the technical and oncological challenges that often accompany malignant splenic diseases such as splenomegaly, perisplenitis, hilar lymphadenopathy, and fear of splenic disruption and tumor spillage. In our experience, the adoption of a lateral technique and the use of hand-assisted devices has allowed for the successful completion of laparoscopic splenectomy for malignant hematologic diseases including spleens up to 28 cm in length and greater than 3 kg morcellated weight. Laparoscopic splenectomy reliably alleviates the symptoms related to splenomegaly and reverses the hematologic abnormalities of hypersplenism. Although laparoscopic splenectomy for malignant diseases is feasible, the role of minimally invasive surgery in the staging of Hodgkin's lymphoma remains undetermined.