Laparoscopic Sleeve Gastrectomy for Adolescents Under 18 Years Old with Severe Obesity.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is a widely accepted stand-alone bariatric operation. Data on adolescent patients undergoing LSG are limited. The aim of this study was to demonstrate that LSG is safe and effective for patients strictly under 18 years old with severe obesity. METHODS: Prospectively collected data from consecutive patients undergoing LSG were retrospectively analyzed. Patients with more than 1-year follow-up were included in the analysis for weight loss and comorbidity evaluation. Quality of life (QoL) was evaluated using the Short-Form 36 questionnaire. RESULTS: Eighty-four patients under 18 years old (range: 15-17 years) underwent LSG. Median weight was 128 kg and median body mass index (BMI) 43.7 kg/m2. Median duration of surgery was 68.5 min. One major complication was recorded: a patient developed severe pneumonia that necessitated ventilatory support in intensive care unit and intravenous antibiotic treatment. Mortality was null. Median length of hospital stay was 4 days. Six, 12, and 24 months after LSG, median BMI decreased significantly to 34.3, 29.8, and 28.8 kg/m2, respectively (p < 0.001), with a mean percentage of total body weight loss of 29.1% at 2 years. Obesity-related comorbidities improved at 1 year, while all SF-36 scale scores of QoL assessment improved significantly. CONCLUSION: This study suggests that LSG is safe and effective for patients under 18 years old, resulting in significant weight loss, comorbidity remission, and QoL improvement. Careful patient selection after adequate risk versus benefit evaluation by an expert multidisciplinary team is essential.

Single incision laparoscopic cholecystectomy: for what benefit?

BACKGROUND: A single-incision laparoscopic cholecystectomy (SILC) was developed to improve outcomes as compared with the four-port classic laparoscopic cholecystectomy (CLC). Any potential benefits associated with a SILC have been suggested by previous studies reporting few patients with different surgical techniques. The aim of this study was to describe the experience with a standardized SILC as compared with CLC. METHODS: From June 2010 to January 2012, 40 patients underwent a SILC [median age: 47.5 years (25-92)] and operative and peri-operative data were prospectively collected. Over the same period, 37 patients underwent a CLC. A 10-point visual analogue scale (VAS) was used for qualitative data. The costs of SILC and CLC were also compared. RESULTS: For those patients undergoing a SILC the median operating time was 70 min (24-110). There were no conversions. An additional trocar was necessary in 16 patients. Four patients developed post-operative complications. The median immediate post-operative pain score was 5 (0-10). The median quality of life and cosmetic satisfaction at the initial post-operative visit were 10 (6-10) and 10 (5-10), respectively (VAS). Although the surgical results of both groups were similar, post-operative complications were exclusively reported in the SILC group (two incisional hernias). CONCLUSION: Standardization of SILC is possible but associated with an important rate of additional trocar placement and a disturbing rate of incisional hernias.

Routine single-port sleeve gastrectomy: a study of 60 consecutive patients.

BACKGROUND: Single-port surgery has been developed for many digestive procedures, such as cholecystectomy and colectomy. Our objective was to present our preliminary results for laparoscopic single-port sleeve gastrectomy (SPSG), performed in our department for the treatment of morbid obesity, at Antoine Beclere Hospital and Paris XI University. METHODS: From July 2010 to February 2011, all patients evaluated by our multidisciplinary team for morbid obesity and eligible for sleeve gastrectomy underwent SPSG. The data were collected prospectively. RESULTS: Sixty consecutive patients underwent SPSG. The median age was 40.1 years; 6 patients were men and 48 were white. The median body mass index was 46.5 kg/m(2). The co-morbidities included diabetes in 12, essential hypertension in 31, sleep apnea in 39, dyslipidemia in 33, and coronary artery disease in 9. Of the 60 patients, 9 had previously undergone laparotomy and 5 had undergone bariatric surgery. The median operating time was 86 minutes. All procedures were achieved laparoscopically, with 10 patients requiring a second trocar and 3 patients 2 additional trocars. No conversion to open surgery was required. One leak was reported, and 1 patient experienced cubital nerve compression. The median hospital stay was 4 days. During a median follow-up of 8 months, most preoperative co-morbidities resolved, and the Bariatric Analysis and Reporting Outcome System score for care efficacy was 6.8 of 9. CONCLUSION: SPSG is feasible in routine bariatric surgery. The results for weight loss and co-morbidity resolution seem to be equivalent to those with "multiple port" laparoscopy. New instruments and specific training are required. We believe that this technique is a natural evolution of minimally invasive surgery requiring additional investigation in prospective studies.

Laparoscopic liver resection with selective prior vascular control.

BACKGROUND: Selective control of vascular inflow can reduce blood loss and transfusion rates and may be particularly efficient in laparoscopic liver resection (LLR). The aim of this study was to evaluate the efficacy of selective prior vascular control (PVC) in patients undergoing laparoscopic or open liver resections (OLR). METHODS: Between 1999 and 2008, 52 patients underwent LLR with PVC with prospective data collection and were compared with patients undergoing OLR with PVC. RESULTS: There was no difference in the operative time between the 2 groups. Blood loss and transfusion rates were lower in patients who underwent LLR (367 vs 589 mL, P = .001; 3.8% vs 17.3%, P = .05, respectively). Morbidity did not differ significantly between the 2 groups. Hospital stay was longer in the OLR group (11.0 vs 7.4 days, P = .001). CONCLUSIONS: PVC during LLR was feasible and improved intraoperative and postoperative results. Selective PVC should be obtained in LLR whenever possible.

Laparoscopic resection for hepatocellular carcinoma: a matched-pair comparative study.

BACKGROUND: Only a few series have demonstrated the safety of laparoscopic resection for hepatocellular carcinoma (HCC) and the benefits of this approach. Moreover, these studies reported mostly minor and nonanatomic hepatic resections. This report describes the results of a pair-matched comparative study between open and laparoscopic liver resections for HCC in a series of essentially anatomic resections. METHODS: Patients were retrospectively matched in pairs for the following criteria: sex, age, American Society of Anesthesiology (ASA) score, severity of liver disease, tumor size, and type of resection. A total of 42 patients undergoing laparoscopy were compared with patients undergoing laparotomy during the same period. Surgeons from the authors' department not trained in laparoscopy performed open resections. Operative, postoperative, and oncologic outcomes were compared. RESULTS: The mean duration of surgery was similar in the two groups. Significantly less bleeding was observed in the laparoscopic group (364.3 vs. 723.7 ml; p < 0.0001). Transfusion was required for four patients (9.5%) in the laparoscopic group and seven patients (16.7%) in the open surgery group (p = 0.51). Postoperative ascites was less frequent after laparoscopic resections (7.1 vs. 26.1%; p = 0.03). General morbidity was similar in the two groups (9.5 vs. 11.9%; p = 1.00). The mean hospital stay was significantly shorter for the patients undergoing laparoscopy (6.7 vs. 9.6 days; p < 0.0001). The surgical margin and local recurrence adjacent to the liver stump were not affected by laparoscopy. The overall postoperative survival rates in the laparoscopic group were 93.1% at 1 year, 74.4% at 3 years, and 59.5% at 5 years and, respectively, 81.8, 73, and 47.4% in the open surgery group (p = 0.25). The postoperative disease-free survival rates in the laparoscopic group were at 81.6% at 1 year, 60.9% at 3 years, and 45.6% at 5 years, respectively, 70.2, 54.3, and 37.2% in the open surgery group (p = 0.29). CONCLUSIONS: Laparoscopic resection of HCC for selected patients gave a better postoperative outcome without oncologic consequences. Prospective trials are required to confirm these results.

Laparoscopic left hepatectomy with prior vascular control.

BACKGROUND: Laparoscopic major resections remain a challenge for liver surgeons. This video illustrates, step by step, our laparoscopic technique for left hepatectomy. METHODS: The control of vascular inflow and outflow as well as the division of the left hepatic duct were carried out extraparenchymally before liver transection. Between 2002 and 2008, 11 left hepatectomies were performed by laparoscopy: 7 for liver tumor and 4 for localized Caroli's disease. RESULTS: Mean duration of surgery was 248 +/- 25 min. Mean operative blood loss was 129 +/- 42 ml. Intraoperative blood transfusion or conversion to laparotomy were never required. One postoperative biliary collection occurred and was drained percutaneously. None of the patients died. Mean hospital stay was 7.6 +/- 2.2 days. CONCLUSIONS: This technique has proved to be safe and easily reproducible.

Laparoscopic versus open right hepatectomy: a comparative study.

BACKGROUND: The safety of laparoscopic major liver resections is still uncertain. The aim of this study was to compare our results for laparoscopic right hepatectomy (LRH) with those for open right hepatectomy (ORH). METHODS: Patients undergoing LRH were compared with retrospectively selected patients from our ORH database. The 2 groups were well matched for sex, age, American Society of Anesthesiologists score, body mass index, liver disease, and tumor size. Surgical and postsurgical outcomes were compared. RESULTS: Seventy-two patients were analyzed: 22 in the LRH group and 50 in the ORH group. Operating time was similar. Blood loss was significantly less in laparoscopic resections (P = .038). Specific morbidity rates were not different, general morbidity was lower after laparoscopy (P = .04), and the severity of postsurgical complications was not different. Mean hospital stay was significantly shorter after laparoscopy (P = .009). COMMENTS: Laparoscopy improved surgical and postsurgical outcomes for ORH in selected patients. This is the first comparative study to demonstrate an advantage of laparoscopy for a major liver resection. Prospective randomized studies with a greater number of cases are needed to confirm the role of laparoscopy in major liver resections.

Laparoscopic left hepatectomy with intraoperative biliary exploration for hepatolithiasis.

Major liver resections remain a challenge for liver surgeons. This video illustrates, step by step, a totally laparoscopic technique for left hepatectomy with intraoperative exploration of the remaining biliary tree in a patient with unilateral hepatolithiasis.

Laparoscopic right hepatectomy with selective vascular exclusion.

INTRODUCTION: Laparoscopic right hepatectomy remains a challenge for liver surgeons. This video illustrates, step by step, a standardized technique for laparoscopic right hepatectomy with selective vascular exclusion. METHODS: The main steps of this totally laparoscopic technique are: extraparenchymal control of vascular inflow, extraparenchymal division of the right hepatic duct, complete mobilization of the right liver, control and division of the right hepatic vein, and parenchymal transection. RESULTS: The duration of surgery was 280 min, and the blood loss was 100 ml. The postoperative period was uneventful, and the length of stay was 7 days. CONCLUSION: This technique has been proven to be safe and easily reproducible in hands of surgeons with expertise in both liver and laparoscopic surgery.

[Intestinal and systemic endotoxaemia after laparotomic or laparoscopic cholecystectomy]. / Permeabilità intestinale ed endotossiemia sistemica dopo colecistectomia laparotomica o laparoscopica.

Since laparoscopic cholecystectomy (LC) is widely recognised as being a "mild" or minimally invasive kind surgery, the aim of this prospective non-randomised study was to investigate the effect of intestinal manipulation on intestinal permeability and endotoxaemia in patients undergoing elective cholecystectomy, comparing the laparoscopic and laparotomic approaches. The intestine is susceptible to operations at remote locations, and the barrier function is altered during intestinal manipulation, leading to bacterial or endotoxin translocation into the systemic circulation. Fifty-three patients undergoing elective cholecystectomy were divided into two groups on the basis of laparotomic (n = 27) or laparoscopic (n = 26) approach. Intestinal permeability was measured preoperatively, and on day 1 and day 3 after surgery using the lactulose/mannitol absorption test. Serial venous samples were taken at 0, 30, 60, 90, 120 and 180 minutes, and at 12, 24 and 48 hours after surgery, for endotoxin measurement using the chromogenic limulus amoebocyte lysate assay. Intestinal permeability was significantly increased on day 1 [0.106 +/- 0.0005 (mean +/- S.E.M.)] in the laparotomic group compared to the preoperative level (0.019 +/- 0.005, p < 0.05) and to the laparoscopic group on day 1 (0.019 +/- 0.005, p < 0.05) which showed no change in comparison with the preoperative level. A significantly higher concentration of systemic endotoxin was detected intraoperatively in the laparotomic group of patients in comparison with the laparoscopic group (p < 0.05). There was significant positive correlation between systemic endotoxaemia and intestinal permeability (rs = 0.958; p = 0.001). An increase in intestinal permeability and degree of systemic endotoxaemia are observed during laparotomic cholecystectomy. This suggets that intestinal manipulation may impair the mucosal barrier function of the gut and contribute to the systemic inflammatory response seen in open cholecystectomy.

Recurrence rates after abdominal surgery for complete rectal prolapse: a multicenter pooled analysis of 643 individual patient data.

PURPOSE: This study was designed to determine what impact surgical technique, means of access, and method of rectopexy have on recurrence rates following abdominal surgery for full-thickness rectal prolapse. METHODS: Consecutive individual patient data on age, gender, surgical technique (mobilization-only, mobilization-resection-pexy, or mobilization-pexy), means of access (open or laparoscopic), rectopexy method (suture or mesh), follow-up length, and recurrences were collected from 15 centers performing abdominal surgery for full-thickness rectal prolapse between 1979 and 2001. Recurrence was defined as the presence of full-thickness rectal prolapse after abdominal surgery. Chi-squared test and Cox proportional hazards regression analysis were used to assess statistical heterogeneity. Recurrence-free curves were generated and compared using the Kaplan-Meier method and log-rank test, respectively. RESULTS: Abdominal surgery consisted of mobilization-only (n = 46), mobilization-resection-pexy (n = 130), or mobilization-pexy (n = 467). There were 643 patients. After excluding center 8, there was homogeneity on recurrence rates among the centers with recurrences (n = 8) for age (hazards ratio, 0.6; 95 percent confidence interval, 0.2-1.7; P = 0.405), gender (hazards ratio, 0.6; 95 percent confidence interval, 0.1-2.3; P = 0.519), and center (hazards ratio, 0.3; 95 percent confidence interval, 0.1-1.5; P = 0.142). However, there was heterogeneity between centers with (n = 8) and without recurrences (n = 6) for gender (P = 0.0003), surgical technique (P < 0.0001), means of access (P = 0.01), and rectopexy method (P < 0.0001). The median length of follow-up of individual centers varied from 4 to 127 months (P < 0.0001). There were 38 recurrences at a median follow-up of 43 (range, 1-235) months. The pooled one-, five-, and ten-year recurrence rates were 1.06, 6.61, and 28.9 percent, respectively. Age, gender, surgical technique, means of access, and rectopexy method had no impact on recurrence rates. CONCLUSIONS: Although this study is likely underpowered, the impact of mobilization-only on recurrence rates was similar to that of other surgical techniques.

Spontaneous hematoma of the mesocolon.

Spontaneous hematoma of the mesocolon is a rare condition, mainly due to the rupture of a colic artery aneurysm. The authors report on two cases of spontaneous hematoma of the mesocolon and examine the relevant literature. The clinical presentation in our patients was, as indicated in the literature, non-specific, with the occurrence of acute abdomen (case 1) or mild abdominal pain (case 2). Only diagnostic imaging (contrast-enhanced CT scan) is capable of yielding an accurate diagnosis, specifying the size and location of the hematoma. A palpable mass or hemoperitoneum due to rupture should be regarded as late signs of presentation. Early diagnosis is of the utmost importance in order to avoid the by no means negligible mortality reported in such instances or ischaemic bowel wall complications.