Technique of sentinel lymph node biopsy and lymphatic mapping during laparoscopic colon resection for cancer.

BACKGROUND: The utility of lymph node mapping to improve staging in colon cancer is still under evaluation. Laparoscopic colectomy for colon cancer has been validated in multi-centric trials. This study assessed the feasibility and technical aspects of lymph node mapping in laparoscopic colectomy for colon cancer. METHODS: A total of 42 patients with histologically proven colon cancer were studied from January 2006 to September 2007. Exclusion criteria were: advanced disease (clinical stage III), rectal cancer, previous colon resection and contraindication to laparoscopy. Lymph-nodal status was assessed preoperatively by computed tomography (CT) scan and intra-operatively with the aid of laparoscopic ultrasound. Before resection, 2-3 ml of Patent Blue V dye was injected sub-serosally around the tumour. Coloured lymph nodes were marked as sentinel (SN) with metal clips or suture and laparoscopic colectomy with lymphadenectomy completed as normal. In case of failure of the intra-operative procedure, an ex vivo SN biopsy was performed on the colectomy specimen after resection. RESULTS: A total number of 904 lymph nodes were examined, with a median number of 22 lymph nodes harvested per patient. The SN detection rate was 100%, an ex vivo lymph node mapping was necessary in four patients. Eleven (26.2%) patients had lymph-nodal metastases and in five (45.5%) of these patients, SN was the only positive lymph node. There were two (18.2%) false-negative SN. In three cases (7.1%) with aberrant lymphatic drainage, lymphadenectomy was extended. The accuracy of SN mapping was 95.2% and negative predictive value was 93.9%. CONCLUSIONS: Laparoscopic lymphatic mapping and SN removal is feasible in laparoscopic colectomy for colon cancer. The ex vivo technique is useful as a salvage technique in case of failure of the intra-operative procedure. Prospective studies are justified to determine the real accuracy and false-negative rate of the technique.

Induced abdominal compartment syndrome increases intracranial pressure in neurotrauma patients: a prospective study.

OBJECTIVE: To evaluate the effect of a stepwise increase in intra-abdominal pressure (IAP) on intracranial pressure (ICP) and to further define the pressure transmission characteristics of different body compartments. DESIGN: A prospective, nonrandomized study. SETTING: A multidisciplinary intensive care unit at a university medical center. PATIENTS: Fifteen patients with moderate-to-severe head injury. INTERVENTIONS: All patients were studied after the initial stabilization and resolution of intracranial hypertension. Measurements were carried out before and 20 mins after IAP was increased by positioning a soft, 15-L water bag on the patient's abdomen. MEASUREMENTS AND MAIN RESULTS: Placing weights upon the abdomen generated a significant increase in IAP, which rose from 4.7 +/- 2.9 to 15.5 +/- 4.1 mm Hg (p <.001). The rise in IAP caused concomitant and rapid increases in central venous pressure (from 6.2 +/- 2.4 to 10.4 +/- 2.9 mm Hg; p <.001), internal jugular pressure (from 11.9 +/- 3.2 to 14.3 +/- 2.4 mm Hg; p <.001), and ICP (from 12.0 +/- 4.2 to 15.5 +/- 4.4 mm Hg; p <.001). Thoracic transmural pressure, calculated as the difference between central venous pressure and esophageal pressure, remained constant during the protocol. Respiratory system compliance decreased from 58.9 +/- 9.8 to 44.9 +/- 9.4 mL/cm H2O (p <.001) in all patients because of decreased chest wall compliance. The mean arterial pressure increased from 94 +/- 11 to 100 +/- 13 mm Hg (p <.01), which allowed the maintenance of a stable cerebral perfusion pressure (82.4 +/- 10.3 vs. 84.7 +/- 11.5 mm Hg; p = NS) despite the ICP increase. CONCLUSIONS: Increased IAP causes a significant rise in ICP in head trauma patients. This effect seems to be the result of an increase in intrathoracic pressure, which causes a functional obstruction to cerebral venous outflow. Routine assessment of IAP may help clinicians to identify remediable causes of increased ICP. Caution should be used when applying laparoscopic techniques in neurotrauma patients.

Laparoscopic treatment of epiphrenic diverticula.

BACKGROUND AND PURPOSE: Epiphrenic diverticula are a rare disease probably caused by long-standing impairment of esophageal motor activity. Symptomatic disease, which may worsen clinically during follow-up even to severe symptoms, is usually considered an indication for surgical treatment. Surgery for epiphrenic diverticula consists of diverticulectomy, which traditionally is performed through a left thoracotomy; a myotomy and partial fundoplication are generally included in order to treat the underlying motor disorder and to prevent or correct reflux. The same principles of surgical treatment can be achieved through the laparoscopic transhiatal approach. The aim of this paper is to describe the technique and the results of laparoscopic diverticulectomy combined with esophageal myotomy and antireflux wrap to treat epiphrenic diverticula of the esophagus. PATIENTS AND METHODS: From January 1994 through May 2001, 11 patients underwent laparoscopic transhiatal diverticulectomy, esophageal myotomy, and partial fundoplication at our institution. RESULTS: In all patients, the operation was completed through the minimally invasive access. The postoperative course was complicated in one patient (9%), who had a leak from the staple line, which was repaired through a thoracotomy. At follow-up, this patient had persistence of a small pouch at the diverticuletomy site. However, he was asymptomatic. All other patients were free of symptoms and without recurrence. CONCLUSION: Laparoscopy offers good access to the distal esophagus and the inferior mediastinum. Removal of the diverticulum, treatment of the motor disorder, and prevention of postoperative reflux can all be obtained through this approach. The immediate postoperative and long-term results are satisfactory.

[The role of echo-endoscopy in the staging of squamous-cell carcinoma of the esophagus. The correlation between the surgical and anatomicopathological findings]. / Ruolo dell'ecoendoscopia nella stadiazione del carcinoma squamoso dell'esofago. Correlazione con i reperti operatori ed anatomopatologici.

BACKGROUND: Endoscopic ultrasonography (EUS) is a relatively new diagnostic method to assess the extent and the depth of infiltration of esophageal carcinoma. METHODS: From October 1990, 100 patients affected by esophageal squamous cell carcinoma underwent preoperative evaluation with endoscopic ultrasonography, 85 of whom were operated on. The first 23 patients underwent endosonography with an Olympus GF-EUM2 with a 7.5 MHz echo-probe; the remaining 77 patients underwent EUS with an Olympus GF-EUM3 with a 7.5-12 MHz echo-probe. RESULTS: In 33 cases (33%), the procedure was not completed because of the impossibility of passing through the neoplastic stenosis. The depth of infiltration was correctly defined by EUS in 73 of 85 patients (86%) compared with 47% of Computed Tomography (CT) (p < 0.05). Overestimation occurred in 6 patients (7%), whereas underestimation occurred in 6 cases (7%). Lymph-node involvement was correctly classified by EUS in 50 of 57 patients (88%) compared with 39% of CT. CONCLUSIONS: EUS provides a high degree of accuracy in assessing both T and N parameters in staging esophageal cancer. The major problem of the method is still the frequent impossibility of passing through a neoplastic stenosis.