The original Ivor Lewis two stage esophagectomy revisited in the era of minimally invasive surgery.

BACKGROUND: Esophagectomy has high cardiac and pulmonary complication rates that can reach 43% and 58% respectively. The original Ivor Lewis esophagectomy was a two-stage procedure. We revisited this procedure using a hybrid minimally-invasive approach. METHODS: Thirty-five consecutive patients with esophageal cancer were operated on over an eight-year period. The first stage used laparoscopic mobilization of the stomach, while the second stage used open thoracotomy. Six patients were aborted due to unresectable disease. RESULTS: Twenty-nine patients were studied. The mean operative times for stage-one and stage-two were 108 ±â€¯18 and 226 ±â€¯63 min respectively. All patients were extubated in the operating room. One (3.4%) patients had cardiac complication and one (3.4%) patient had pulmonary complication. CONCLUSION: Metachronous hybrid two-stage esophagectomy was associated with a low rate of cardio-pulmonary complications. It may be considered as an alternative to the one-stage esophagectomy, especially in low-volume centers, to decrease these high-risk cardio-pulmonary complications.

The impact of robotic cholecystectomy on private practice in a community teaching hospital.

BACKGROUND: Recently, through aggressive marketing, robotic cholecystectomy has been gaining popularity. The purpose of this study was to evaluate the impact of this technology on private practice and hospital cost and volume. METHODS: From November 2012 to April 2014, all elective cholecystectomies were evaluated for procedure type, operative time (OR), insurance type and payment, hospital length of stay, and volume. Data were analyzed using the Chi-square test, Student t test and the Mann-Whitney U test. RESULTS: Of 338 patients, 246 had complete financial records. Of these patients, 84.1% (207) patients were female with mean age of 45.4 ± 17.1 years. Patients were divided into 2 groups; group 1: 220(89.4%) patients had laparoscopic cholecystectomy (LC) and group 2: 26(10.6%) patients had robotic cholecystectomy (RC). The mean direct cost was higher in the robotic group $2,704.08 ± 308.40 vs $1,712.51 ± 379.50; P < .0001. The median gross margin; however, was not statically different (RC: $1,593.00 (Interquartile range $3,936) vs LC: $1,726.00 (Interquartile range $1,480); P = .85). Both case time and OR were higher in the robotic group; case time (RC: 121 ± 15.4 vs LC: 98.4 ± 27.5 minutes, P < .0001); OR (RC: 86.6 ± 14.3 vs LC: 63.9 ± 25.9 minutes, P < .0001). There was no appreciable change over time in either surgeon or hospital volume. CONCLUSIONS: There was a statistically significant increase in direct cost in RC vs. LC but not in margin. There was no impact in private practice on the number of cases being done robotically, nor there was an increase in hospital volume. This analysis did not include the purchase cost or maintenance of the robot.

Laparoscopic versus conventional live donor nephrectomy: experience in a community transplant program.

Fifty-nine consecutive patients underwent live donor nephrectomy for transplantation. Twenty-nine patients (Group I) had open kidney procurement, and 30 patients (Group II) had laparoscopic procurement. The mean operative time in Group I was 2:30 hours (range 1:55-2:59), whereas in Group II it was 3:01 hours (1:54-5:21). All kidneys functioned immediately after transplantation. The average warm ischemia time was not calculated in Group I; it was 3.9 minutes (2-15) in Group II. Intraoperative complications occurred in two patients in Group II. One patient had bleeding from an accessory renal artery. The second patient had a tear in the splenic capsule. No ureteral complications occurred in either group. Postoperatively one patient in Group I developed incisional hernia, one developed pneumothorax, and two developed atelectasis. In Group II one patient developed pancreatitis, one developed flank ecchymosis, and two had suprapubic wound hematomas. Using the laparoscopic approach the hospital stay decreased from 4.1 to 1.27 days (69%) (P < 0.001) and return to work decreased from 28.4 to 14.8 days (49%) (P < 0.01). Live donation increased by 67 per cent. We conclude that the laparoscopic procurement of kidneys for transplantation compares well with the open method. It offers several advantages that may increase the living donor pool.

Should needle localization breast biopsy give way to the new technology; the advanced breast biopsy instrumentation.

Between July 1995 and June 1997, 114 consecutive women underwent 118 breast biopsies for nonpalpable lesions. A limited procedure room and local anesthesia were used in 96.5 per cent of patients. Intravenous access was not established in 95 per cent of patients. Oral diazepam was given to 51 per cent of patients. Needle localization technique was used with a success rate of 97.5 per cent and average operative time of 18 minutes. Breast carcinoma was found in 29 (24.6 per cent) biopsies. A review of 99 of the 118 mammograms showed only 45 per cent of the lesions being amenable to the new technology, the advanced breast biopsy instrumentation. Advantages of the needle localization include short operative time; supine position for the patient; easy access to control bleeding; ability to choose a cosmetic site for the skin incision; minimal tissue removal before reaching the lesion; ability to maintain a sterile field; and applicability to almost any mammographic lesion identified, whether single or multiple. Disadvantages include the need for a separate procedure to place the wire and potential of missing the lesion in 2.5 per cent, requiring additional surgery.

Management of choledocholithiasis in the era of laparoscopic surgery.

Laparoscopic biliary surgery is changing the management of choledocholithiasis. Between November 1989 and December 1998, 2834 cholecystectomies were performed at two institutions. Choledocholithiasis was suspected in 420 patients on the basis of elevated preoperative laboratory and ultrasound criteria [bilirubin, alkaline phosphatase, serum glutamic-oxaloacetic transaminase, serum glutamate pyruvate transaminase, and common bile duct (CBD) size]. One hundred seventeen patients had preoperative endoscopic retrograde cholangiopancreatography (ERCP) because of persistent elevation in their enzymes beyond 24 to 48 hours or as an emergency. Laparoscopic intraoperative cholangiogram was attempted in 329 patients whose enzymes fell rapidly within the first 24 to 48 hours or had a failed ERCP. Eighty-one of the 329 were found to have stones. Seventy-three had laparoscopic attempt to clear the CBD, with success in 62 patients (85%). This included 41 transcystic duct and 21 direct CBD exploration. Eight patients had post-operative ERCP for retained stones. Six (0.25%) were in patients with normal preoperative enzymes. We conclude that choledocholithiasis can be suspected with preoperative laboratory and ultrasound criteria. By waiting 24 to 48 hours (except in an emergency), a good number of CBD stones will pass. With increases in laparoscopic experience, laparoscopic removal of CBD stones may replace preoperative ERCP. The small number of cases of retained or missed stones that occur with the use of selective cholangiography can be easily handled with postoperative ERCP.

Laparoscopic anterior lumbar fusion.

PURPOSE: To assess the feasibility and complications of the laparoscopic approach to anterior lumbar fusion and to evaluate the ability of metoclopramide in conjunction with preoperative bowel preparation and early oral feeding to decrease postoperative ileus and reduce the length of hospital stay. PATIENTS AND METHODS: Laparoscopic anterior lumbar fusion was performed on 30 patients with persistent back pain between September 1997 and March 1999. All patients received metoclopramide 10 mg intravenously preoperatively and every 6 hours postoperatively, then 10 mg orally every 8 hours for 7 days. An experienced laparoscopic surgeon exposed the disc space, and lumbar fusion was performed by a neurosurgeon or an orthopedic surgeon. RESULTS: One procedure in an obese patient was converted to open surgery. The average operating time for the remaining patients was 2 hours 23 minutes. The average estimated blood loss was 75 mL. The only intraoperative complication was a trocar injury to the bladder. The average hospital stay was 2.3 days. CONCLUSION: In properly selected patients, laparoscopic anterior lumbar fusion with metoclopramide, preoperative bowel preparation, and early oral feeding results in a short hospital stay and yields better cosmetic results than traditional surgery.

Laparoscopic live donor nephrectomy at a community hospital.

Recently, laparoscopic harvesting of kidneys from live donors has been reported by major university centers. As a community transplant center, we adopted a multidisciplinary cooperative approach, including a full-time transplant surgeon, a laparoscopic general surgeon, and a urologist with laparoscopic experience, in order to perform our first successful laparoscopic live donor nephrectomy in December 1998. The operative time was 234 minutes, and the warm ischemia time was 2 minutes. No intraoperative or postoperative complications occurred. The length of the renal artery was 2.4 cm, the renal vein was 3.0 cm, and the ureter was 10.0 cm. The donor was discharged home the next day and returned to work within 14 days. The transplanted kidney functioned immediately. The recipient serum creatinine concentration dropped from 9.3 mg/dL preoperatively to 3.4 mg/dL within 24 hours and to 1.3 mg/dL on the third day.

Laparoscopic repair of paraesophageal hiatal hernia.

Twenty-seven patients underwent consecutive elective laparoscopic repair of paraesophageal hiatal hernia between October 1992 and June 1997. There were 24 females and 3 males. The average age was 68 years (range, 46-86) and average weight was 173 pounds (range, 122-243 lb.). Presenting symptoms were: postprandial epigastric pain or pressure in 19 patients, postprandial dyspnea in 7 patients, anemia in 5 patients, postprandial vomiting of food in 5 patients, and 1 patient had postprandial palpitation. Heartburn was present in 9 patients. Five patients had a history of symptoms of intermittent volvulus. History of hiatal hernia was present in 19 patients ranging from 6 months to 38 years in duration. The operative procedure included a laparoscopic reduction of the herniated stomach, excision of the hernia sac, and closure of the diaphragmatic defect with placement of mesh graft. Anterior gastropexy was performed on all patients except two who had a Nissen fundoplication due to severe reflux symptoms. Seven patients had laparoscopic cholecystectomy at the same time and one patient had an excision of a small benign gastric leiomyoma of the fundus. The average operative time was 2:54 hours (range, 1:35-4:05 hrs.). The average hospital stay was 3.8 days (range, 2-8 days). One patient had a postoperative stroke and recovered quickly. Follow-up of 1 to 56 months showed no recurrence of the hernia. Two patients complained of some epigastric pain and six patients had occasional mild reflux that was easily controlled medically. Laparoscopic repair of paraesophageal hernia is a safe procedure with a short hospital stay and recovery time. Using mesh graft decreases the risk of developing an iatrogenic parahiatal hernia. The addition of Nissen fundoplication is not necessary unless the patient has objective findings of reflux.

Cholangiography for evaluation of the proximal biliary ducts in laparoscopic cholecystectomy.

Visualization of the entire biliary tree can be difficult in some patients undergoing cholangiography during laparoscopic cholecystectomy. A simple technique was developed for these patients, utilizing the laparoscope under fluoroscopic guidance, in order to visualize the proximal biliary ducts.

Laparoscopic training in residency program.

The use of laparoscopy in general surgery has provided surgeons with a new approach to multiple procedures. New techniques are being developed daily. Laparoscopic training for surgical residents must be incorporated into their curriculum. To decrease the risks of training residents on patients and to decrease operative time, a program of videoscopic "bench" training exercises, to improve eye-hand coordination, was instituted for junior residents. Between July and September 1995, nine surgical residents participated in this proficiency videoscopic study. At the end of the study, there was a statistically significant improvement in the residents performance by an average of 37% (P = 0.0109). This program proved to be both effective and economical. It can be reproduced and easily incorporated into any surgical residency program.

The effect of drains in laparoscopic cholecystectomy.

A prospective controlled randomized study was performed on 100 patients undergoing elective laparoscopic cholecystectomy to evaluate the benefit of routine drainage in simple uncomplicated procedures. The 100 patients were randomized into two groups. Group 1 patients (n = 50) had a drain placed through the epigastric trocar site. The drain was removed before their discharge unless bile or blood was present. Group 2 patients (n = 50) did not have a drain placed. Eleven patients in group 2 (no drain) (22%) were discharged on the same day of surgery (within 8 h), and the remaining 89 patients in both groups were discharged the day after surgery (within 23 h). There were no wound infections or postoperative fever in either group. There were minor but not statistically significant differences between the two groups in postoperative severity and duration of abdominal pain, shoulder pain, and nausea. Furthermore, the two groups were similar in respect to postoperative recovery time and return to work.

The use of absorbable clips in laparoscopic cholecystectomy.

A prospective randomized controlled study was conducted to evaluate the use of absorbable clips in elective laparoscopic cholecystectomy. Fifty consecutive patients, 36 females and 14 males, were randomized into two groups. Group 1 patients had metal clips, and group 2 patients had absorbable clips applied on the cystic duct and cystic artery. These patients were followed for 3 months postoperatively. There was no difference between the two groups with regard to operative time, hospital stay, and postoperative complications. The absorbable clips were as effective as the metal clips in providing hemostasis and securing on the cystic duct stump.

Timing of laparoscopic cholecystectomy in acute cholecystitis.

Laparoscopic cholecystectomy was performed in 467 patients between November 1989 and April 1991. Fifty-four patients (12%) had acute inflammatory changes. These were divided into three different groups: group 1-13 patients who admitted having an attack of right upper quadrant pain within 24-48 h of their scheduled elective laparoscopic cholecystectomy; group 2-23 patients who had a history of acute cholecystitis treated 4-6 weeks before their elective laparoscopic cholecystectomy; group 3-18 patients who were admitted to the hospital and were diagnosed with acute cholecystitis; they had laparoscopic cholecystectomy performed in the same admission. All patients had a successful laparoscopic removal of their gallbladder except 2 in group 3 who had to be converted to an open procedure. Analysis of the operative time, complications, and hospital stay showed that after adequate experience is gained in performing laparoscopic cholecystectomy, acute cholecystitis is not a contraindication. The procedure is faster and safer if performed in the first 24-48 h of the onset of the symptoms. Different technical maneuvers are needed due to the nature of the disease.

Multifocal musculoskeletal cystic tuberculosis without systemic manifestations.

A case of multifocal cystic tuberculosis is presented, affecting the clavicle and the iliac bones with considerable soft tissue involvement. It was found in a 34-year-old male, an immigrant from Yemen. The extensive cystic nature of both lesions and the lack of systemic manifestations despite multifocal disease are unusual.

Laparoscopic appendectomy for acute appendicitis: is there really any benefit?

Laparoscopic appendectomy is emerging as a popular treatment modality for acute appendicitis. Although claims have been made to potential superiority over traditional appendectomy, comparisons of operative difficulty, hospital stay, hospital costs, complication rates, postoperative pain, and convalescence have not been well studied. Two hundred consecutive patients presenting with signs and symptoms of acute appendicitis underwent appendectomy. Traditional appendectomy was employed in 101 patients, while 99 underwent laparoscopy. Successful laparoscopic appendectomy was possible in 89 patients who were compared with the 101 patients with traditional appendectomy. There were two pregnant patients with appendicitis in each group. The incidence of acute appendicitis was 72 per cent for traditional appendectomy and 74 per cent for laparoscopic appendectomy. Operating time was significantly longer with laparoscopic appendectomy (60.1 vs 45.4 minutes, P = 0.0001). This was reflected in higher (although not significant) hospital costs ($8,683 vs $6,213). Post-op hospital stay was shorter for laparoscopic appendectomy (2.7 vs 3.8 days, P = 0.001). Complication rates were no different between the two groups. Post-op pain, as evaluated by a patient grading scale, was less for laparoscopic appendectomies up to the third post-op week (P = 0.003). The amount of IM pain medication was greater with traditional appendectomy (P = 0.009). Convalescence was significantly shorter with laparoscopic appendectomy as measured by: 1) return to normal household activity (7.8 vs 13.2 days, P = 0.016), 2) returned ability to exercise (19.7 vs 29.0 days, P = 0.009), 3) patient feeling well enough to return to work (14.1 vs 19.2 days, P = 0.032), and 4) actual return to work (15.4 vs 20.5 days, P = 0.038).(ABSTRACT TRUNCATED AT 250 WORDS)

Does routine cystic duct cholangiogram during laparoscopic cholecystectomy prevent common bile duct injury?

Between November 1989 and September 1992, the author performed 1,000 laparoscopic cholecystectomies. Three common bile duct injuries occurred (0.3%). Selective cystic duct cholangiograms were performed for diagnosis and management of common bile duct stones. A total of 102 cholangiograms (10%) were done. Only eight of these cholangiograms were done for anatomical verification in the face of severe chronic or acute cholecystitis. Five were cystic duct cholangiograms, resulting in two common bile duct injuries. To avoid the problem of common bile duct injury in cases of obscure anatomy where clarification was needed, a cholecystocholangiogram was done for duct identification in three subsequent cases without event. The third common bile duct injury occurred early in the learning experience without benefit of the cholangiogram.

The role of endoscopic retrograde cholangio-pancreaticrogram in laparoscopic cholecystectomy.

Four hundred and fifty-nine patients were studied to evaluate the role of diagnostic and therapeutic endoscopic retrograde cholangio-pancreaticrogram (ERCP) in their management before laparoscopic cholecystectomy (LC) when choledocholithiasis is suspected. Using bilirubin, liver function tests (LFTs) (alkaline phosphatase, SGOT, SGPT) and findings on ultrasound of a dilated common bile duct (CBD), 37 patients (8.1%) were suspected of having concomitant common bile duct stones preoperatively. These patients were subjected to the following diagnostic and therapeutic procedures: 25 ERCPs, 20 laparoscopic cholangiograms, and three extracorporeal shock wave lithotripsies. Preoperative ERCP was done on 19 patients, intraoperative ERCP-sphincterotomy was done on one patient, and postoperative ERCP-sphincterotomy was done on five patients. Fifteen laparoscopic cholangiograms were done as primary tests and five after preoperative ERCP. Sixteen patients (3.5%) had stones in their CBD. Four patients had their laparoscopic cholecystectomy cancelled, and one patient had laparoscopic common duct exploration that was converted to an open procedure. Three groups were identified: group I, patients with a high index of suspicion, included elevated bilirubin with elevation of all three LFTs, or normal bilirubin with elevation of all three LFTs with or without dilated CBD. Seventy-five per cent of this group had CBD stones. Group II, patients with a low index of suspicion, included normal bilirubin and normal CBD by ultrasound with elevation of the alkaline phosphatase alone or elevation of two of the three LFTs. Six per cent of this group had CBD stones. Group III, patients with no index of suspicion, were patients with normal preoperative laboratory test results and CBD. Two patients (0.47%) in this group had elevated LFTs postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

Infected hepatic Echinococcus cyst presenting as recurrent Escherichia coli empyema.

An 81-year-old man, previously a shepherd in Italy, presented with recurrent Escherichia coli empyema over an 8-month period. His empyema was caused by an infected, nonviable hepatic Echinococcus cyst that eroded the diaphragm and led to intermittent spillage and pleural seeding. This case demonstrates that when dealing with Escherichia coli empyema, a subdiaphragmatic source ought to be suspected, and among immigrants from areas with prevalent hydatid disease, infected hepatic Echinococcus cyst might rarely be the cause.

Laparoscopic cholecystectomy: morbidity and mortality in a community teaching institution.

From November 1989 to December 1990, 474 elective laparoscopic cholecystectomies were performed. This study analyzes the first year's experience with regard to complications, postoperative response in terms of pain and nausea, and time back to activity and work. There were 369 females and 105 males in the group. The average age was 51.5 years. Of these, 394 were discharged within 23 h and 80 required admission postoperatively. Of the group requiring hospitalization, there were 10 (2.1%) major complications, 37 (7.8%) minor complications, 14 (3.0%) aborted laparoscopic cholecystectomies, and 19 (4.0%) others. Major complications occurred early in the surgeon's experience, all but two within the surgeons' first 25 cases. Patients in the short stay group were followed-up with a phone questionnaire. In this group, most patients experienced minimal abdominal pain following surgery, with an average score of 2.4 (SD = 1.38) on a scale of 1 (absent) to 5 (extreme). At home, 48.6% of patients experienced some form of postoperative discomfort. Of these, 38.2% experienced abdominal pain, 18.7% shoulder pain, and 32.7% nausea. The average postoperative time to resume normal daily activity was 7.9 days (SD = 8.2) and to return to work was 11.6 days (SD = 9.9).