Laparoscopic vs open approach for the treatment of gastroesophageal reflux in children.

BACKGROUND: The laparoscopic approach has become increasingly popular for fundoplication over the last few years; however many surgeons are skeptical about its real advantages. METHODS: We conducted a prospective comparative study of children operated on for gastroesophageal reflux (GER). Exclusion criteria included age <1 YEAR AND >14 years, previous surgery on the esophagus or stomach, and neurologic impairment. We compared two groups of patients who met the same inclusion/exclusion criteria. One group was treated via a laparotomic approach between January 1993 and December 1997; the other was treated via a laparoscopic approach between September 1998 and December 2000. A 360 degrees wrap was performed in each group. RESULTS: Group 1 (laparotomic approach) included 17 patients; mean operative time was 100 min and postoperative time was 7 days. Group 2 comprised 49 children operated on via a laparoscopic approach; mean operative time was 78 min and postoperative time was 48 hours. No major complications were encountered in either group. In postoperative period, two patients in group 1 had complications. One had a prolonged bout of gastroplegia, which required nasogastric drainage, and then recovered spontaneously after 20 days; the other had stenosis of the wrap, which required dilation. No relapses occurred during a follow-up of 6 months. Long-term follow-up data are not presented. Comparative analysis of the short-term functional results indicated that there were no differences between the two groups. CONCLUSION: This study confirms that the minimally invasive approach is safe and effective for the treatment of primary gastroesophageal reflux disease in children.

Medium-term results after cholecystectomy in patients younger than 10 years.

BACKGROUND: Gallbladder stones are a well-known and widely studied problem in children. Hematological disorders are the most common diseases that can cause cholelithiasis. However, in the last few years, the proportion of children with idiopathic cholelithiasis has increased 50%. Herein, we present a prospective study on laparoscopic cholecystectomy in a selected group of patients aged < 10 years. METHODS: Fifty-eight patients aged < 10 years underwent laparoscopic cholecystectomy for stones in the period 1992-99. The female/male ratio was 1.5, the mean age was 8 years (range, 2-10), and the mean weight was 30 kg. In all patients, parenteral nutrition, fasting state, and prolonged use of antibiotics had been suspended for > or = 6 months, and conservative treatment had been tried for > or = 12 months in the absence of symptoms of stone migration. All the patients were followed up after surgery: clinically at 1,6,12, and 36 months and by ultrasound at 1, 12, and 36 months. Liver function and hematological tests were performed in case of symptoms or if hemolytic disorders were the cause of stones. RESULTS: The mean operative time was 63 min (range, 30-120) in children undergoing cholecystectomy alone and 150 min in children undergoing associated splenectomy. There were no major complications or reoperations. Minor complications included bleeding from accessory cystic artery (n = 3) and insufflation of the omentum (n = 2). One case was converted to an open procedure due to technical problems. All the children were followed up and no complications were observed. CONCLUSION: We consider the laparoscopic approach the gold standard for cholecystectomy in children. This procedure does not have a complication rate any higher than open cholecystectomy, and patient follow-up is as good as that of open surgery. Previous abdominal surgery is not a contraindication to laparoscopy.

[Laparoscopic cholecystectomy. An analysis of the reasons for a conversion to conventional surgery in an elective surgery department]. / La colecistectomia laparoscopica. Analisi delle cause di conversione in chirurgia tradizionale in un reparto di chirurgia di elezione.

BACKGROUND: To assess which factors determined conversion to laparotomy in patients undergoing laparoscopic elective cholecystectomy. SETTING: department of General Surgery. University of Genoa. Italy. METHODS: Two hundred sixty-four consecutive laparoscopic cholecystectomies were performed in our Department. INTERVENTIONS: laparoscopic cholecystectomy was performed according to Dubois's technique. Duration of the procedure was not considered a reason for conversion. RESULTS: 121 patients showed "difficult intraoperative situations" with further conversion risk factor. Conversion to laparotomy was necessary in 11 patients (4.16%). Five patients underwent conversion in the first 50 cases (10%), while six in the last 214 (2.8%). We had to convert to open cholecystectomy only in eleven patients, despite the high rate of technical difficulties and anatomic anomalies even in cases which, in the past, represented a contraindication to this kind of technique. The use of new instruments and new surgical techniques has reduced to only factors of increased risk in those situations that in the past were considered as contraindications to laparoscopic cholecystectomy. CONCLUSIONS: Conversion to open cholecystectomy is based on the surgeon's decision and the safety should be the main consideration in performing laparoscopic cholecystectomy. The use of a careful dissection could avoid the conversion in many patients.

[Comparison of colorectal mechanical suture techniques]. / Tecniche di sutura meccanica colo-rettale a confronto.

UNLABELLED: Objective of this study is to establish which kind of stapled anastomosis is the most reliable in rectal surgery. 67 patients randomly assigned to three groups underwent low anterior resection of the rectum with end-to-end, side-to-end or double stapling anastomosis. Main outcome measures were incidence of leakage at the intraoperative check of the suture, postoperative leakage, stenosis, mortality, mean post-operative stay. Side-to-end anastomosis were followed by 4 intra-operative (19%) and one post-operative (4.7%) leakages with one case of mortality (4.7%). Four intra-operative (18.2%) and 5 post-operative (22.7%) leakages, 3 stenosis (13.6%) and one case of mortality (4.5%) were observed after double-stapling procedures. No intra- or post-operative anastomotic complications were seen after end-to-end anastomosis. Mean post-operative stay was 20, 31 and 13 days for the three methods respectively. CONCLUSIONS: In this series of colo-rectal anastomoses, the end-to-end stapling technique appears to be safer and more reliable than others.

Laparoscopic cholecystectomy and gallbladder cancer: a diagnostic and therapeutic dilemma.

The correct treatment strategy of patients with unsuspected gallbladder cancer undergoing laparoscopy, and the prevention of delayed diagnosis are current issues. We report a case of late diagnosis with umbilical metastasis and poor survival. A policy of careful inspection of the gallbladder and a cautious strategy in the case of gross alteration of its external morphology seems advisable during laparoscopic cholecystectomy. Although no agreement exists concerning the best treatment in the event of delayed diagnosis, the adopted strategy is contingent on patient status, disease stage and the possibility of performing appropriate follow-up.

The surgical approach to oesophageal achalasia.

The term "oesophageal achalasia" describes a neuropathic disorder characterized by abnormal motility of the oesophagus and incomplete or absent relaxation of the lower oesophageal sphincter. In these patients with "paroxysmal" dysphagia, barium swallow and manometric study confirm the diagnosis. In our opinion, the treatment of choice is extramucosal tardiomyotomy (Heller) which should be followed by gastric fundoplication in order to protect the mucosa and prevent gastrooesophageal reflux. We present our experience in the laparoscopic approach to Heller cardiomyotomy in children. An anterior 180 degrees hemi-fundoplication, according to Dor technique, is performed suturing the left and right oesophageal muscular margin to the gastric wrap. A manometric examination is mandatory in order to detect the complete incision of the lower oesophageal sphincter and to confirm the creation of the new-high pressure zone. This preliminary experience confirms that the laparoscopic approach can be used for the treatment of oesophageal achalasia also in children.

[An application of mini-invasive surface surgery: the thyroid]. / Un'applicazione della chirurgia mini-invasiva di superficie: la tiroide.

Since its introduction, minimally-invasive surgery has been applied to structures contained in natural cavities such as abdomen, thorax and articulations. At present, its application to surface zones (plastic surgery) gives good results. For this reason, we tried to examine thyroid area through a video-assisted access in a 32 years old woman presenting a nodule with a diameter of about 1 cm, localized in the left parahistmic thyroid area. This approach allowed a good vision of the operative field. In our opinion, this technique could be useful especially to formulate the histological diagnosis of small thyroid nodules for whom the standard surgical biopsy should be considered too invasive.

[A case of traditional appendectomy changed to laparoscopic surgery]. / Su un caso di appendicectomia tradizionale convertita a chirurgia laparoscopica.

The utility of appendectomy performed with laparoscopic procedure is at the present accepted by many surgeons, especially when there is uncertain diagnosis of appendicitis or when an ectopic position is suspected. The authors describe the case report of a 17 years old woman with a diagnosis of subacute appendicitis, in which the unsuccessful finding of the appendix made necessary conversion of traditional laparotomy approach to laparoscopic technique. This choice avoided the execution of an enlargement of laparotomy access, and allowed an easy finding of appendix. Aesthetic results at a distance are very satisfying.

Use of staplers in congenital lobar emphysema.

The authors report on a technique for the treatment of congenital lobar emphysema in a patient of 6.5 kg body weight. After left thoracotomy and vessel isolation, a section of the lobar bronchus and interlobar fissure was performed, because of incompleteness of 3/4 of its length. Metal clips were used with the stapler ENDO-GIA 30v Autosuture after tissue calibration. The authors underline the importance of the staplers, which have been widely used in adult surgery, because they reduce the risk of bacterial contamination and air leakage through the suture rims, especially in lung resective surgery.

[Diagnosis of thyroid metastasis of uveal melanoma by fine needle aspiration biopsy]. / Diagnosi di metastasi tiroidea da melanoma uveale mediante agoaspirazione con ago sottile.

The Authors report the case of intra-thyroid metastasis from uveal malignant melanoma, diagnosed by fine needle aspiration biopsy, 15 years after surgical treatment of the primary tumour. The site is very unusual as illustrated by a review of the literature, and confirms the extreme heterogeneity that sometimes the natural history of this pathology shows. The critical analysis of diagnostic reliability of the cytological techniques, proves their usefulness in the differential diagnosis of every suspicious mass.

[Gastroduodenal surgery using mechanical staplers: our experience]. / Chirurgia gastroduodenale con suturatrici meccaniche: nostra esperienza.

Results of 71 operations of the gastroduodenal tract performed with stapling devices are reported (51 for malignant diseases and 20 for benign diseases). 20 total gastrectomies, 21 Billroth II gastrectomies, 17 Roux en-Y-gastrojejunoplasty, 6 Billroth II to Roux-ex-Y-conversion and 7 palliative gastroenteroanastomosis were performed, using TA, GIA and EEA stapling instruments. The analysis of the reported data brought us to some considerations regarding the safety and versatility of mechanical viscerosynthesis, also in relation to some technical aspects.