Effects of age after laparoscopic right colectomy for cancer: Are there any specific outcomes?

BACKGROUND: Laparoscopic approach in colorectal surgery has demonstrated to give advantages in terms of postoperative outcomes, particularly in high-risk patients. The aim was to assess the impact of patients' age on the short-term outcomes after laparoscopic right colectomy for cancer. METHODS: From January 2004 to September 2014, all patients who underwent laparoscopic right colectomy for cancer in a single institution were divided into four groups (A: <64 years; B: 65-74 years; C: 75-84 years; D ≥85 years). Risk factors for postoperative complications were determined on multivariable analysis. RESULTS: Laparoscopic right colectomy was performed in 507 patients, including 171 (33.7%) in A, 168 (33.1%) in B, 131 (25.8) in C and 37 (7.4%) in D. Patients in Group C and Group D had higher ASA score (p<0.0001) and presented more frequently with anaemia (20.6% and 29.7%, p=0.001). Stages III and IV were more frequently encountered in groups C and D. Overall morbidity was 27.5% without any difference in the four groups (24.5%, 29.1%, 7.5% and 18.4% respectively, p=0.58). The rate of minor complications (such as wound infection or postoperative ileus) was higher in Group D compared to other groups (p=0.05). The only independent variable correlated with postoperative morbidity was intraoperative blood transfusion (OR 2.82; CI 95% 1.05-4.59, p<0.0001). CONCLUSIONS: The present series suggests that patient's age did not significantly jeopardize the postoperative outcomes after laparoscopic right colectomy for cancer.

Management of postoperative bleeding after laparoscopic left colectomy.

BACKGROUND: Lower gastrointestinal bleeding after left colectomy is an uncommon complication that can lead to critical situation. Diagnostic and therapeutic manoeuvres should be performed in emergency with step-by-step strategy in order to avoid reoperation. This study aims to identify bleeding risks factors and describe a management strategy. METHODS: This is a retrospective study of patients who underwent left colectomy with primary anastomosis, from May 2004 to December 2013. We studied their demographic characteristics, surgical procedures and postoperative courses, more specifically hemorrhagic complications, management of bleeding and outcomes. RESULTS: Hemorrhagic anastomotic complication occurred in 47 of the 729 (6.4 %) patients after left colectomy. Neither anticoagulant nor antiaggregant treatment was associated with postoperative bleeding. Among the 47 patients with bleeding, endoscopy was performed in 37 (78.7 %). At the time of endoscopy, the bleeding was spontaneously stopped in nine (24.3 %). Therapeutic strategy used clips in 10 (27.0 %) cases, mucosal sclerosis in 11 (29.7 %) and both in 7 (18.9 %) cases. Four (8.5 %) patients required blood transfusion for treatment of this gastrointestinal bleeding. Five (10.6 %) patients with bleeding were reoperated in this group because early endoscopy showed associated anastomotic leakage. Based on a multivariate analysis, stapled anastomosis and diverticular disease were independent factors associated with anastomotic bleeding. CONCLUSIONS: Postoperative anastomotic bleeding is not so uncommon after left colectomy. This complication should be particularly dreaded in patients who underwent stapled colorectal anastomosis for diverticular disease. With the use of clip or mucosal sclerosis, early endoscopy is a safe and efficient treatment.

A critical appraisal of laparoscopic pancreatic enucleations: right-sided procedures (Pancreatic Head, Uncus) are not mini-invasive surgery.

Laparoscopic pancreatic enucleation is increasingly performed worldwide. Few small-sized series show encouraging results, especially after enucleations performed for lesions located in the left part of the pancreas. The outcome of laparoscopic pancreatic enucleations was retrospectively evaluated by the analysis of prospectively collected parameters. Results of right-sided (head/uncus) and left-sided (neck/body/tail) enucleations were compared. From 1997 to 2010, 25 patients underwent laparoscopic pancreatic enucleation. The conversion rate was 12%, mean operating time was 158 minutes, and mean blood loss was 106 mL. Morbidity was 56% and the rate of pancreatic fistula 32%. Outcome differed between patients undergoing right-sided and left-sided enucleations, the operative time being 178 versus 132 minutes, morbidity 64% versus 45%, and median hospital stay 26 versus 9 days, respectively. Pancreatic enucleation is feasible by laparoscopy, with a high success rate and no mortality but significant morbidity. Laparoscopy seems to be of no use in right-sided procedures. Pancreatic fistula is still the main cause of long-lasting morbidity.

Laparoscopic minor pancreatic resections (enucleations/atypical resections). A long-term appraisal of a supposed mini-invasive approach.

INTRODUCTION: A few retrospective, small, often multicentric studies show encouraging results of laparoscopic minor pancreatic surgery, but do not allow for an evaluation of feasibility and effectiveness. AIM: Evaluation of the results of laparoscopic minor pancreatic resections (LMPR), including atypical resections and enucleations. MATERIAL AND METHODS: The outcome of all consecutive patients undergoing LMPR in a tertiary care university hospital specializing in the laparoscopic approach to solid organs (I.M.M., Paris - France) was retrospectively evaluated by the analysis of operating time, blood loss, conversion, morbidity, stay and late outcome. RESULTS: Thirty-three patients underwent LMPR (29 enucleations and 4 atypical resections) for various diseases. The conversion rate was 21%, mean operating time 189 min, and mean blood loss 133 ml. Morbidity was 60%; 10 patients (30%) presented a pancreatic fistula. Pancreatic fistula was independent of type of resection, technique of pancreas section, management of enucleated surface and somatostatin administration. Median stay for enucleations was 18 days. Mean follow-up was 61 months. CONCLUSIONS: Laparoscopic pancreatic enucleation is feasible and safe, with no mortality, no lengthening of operating time and a high success rate. Conversely, it does not imply a reduction in complications or hospital stay at the present state of the art.

Fatores preditivos de morbidade nas ressecções pancreáticas esquerdas / Predictive factors of morbidity in distal pancreatic resections

OBJETIVO: Avaliar a morbidade pós-operatória e investigar a existência de seus fatores preditivos. MÉTODOS: O estudo foi realizado de forma retrospectiva, a partir de uma base de dados mantida de forma prospectiva. De 1994 a 2008, 100 pacientes consecutivos foram submetidos à ressecções pancreaticas esquerdas. A principal variável de interesse foi a morbidade pós-operatória, tendo diversas outras características da população sido registradas simultaneamente. Posteriormente, para a análise de fatores preditivos de morbidade pós-operatória o subgrupo de pacientes que foi submetido aos procedimentos de pancreatectomia distal com preservação do baço (n=65) foi analisado separadamente quanto à relevância das diferentes técnicas de secção do parênquima pancreático, assim como, outros possíveis fatores preditivos à ocorrência de morbidade pós-operatória. RESULTADOS: Considerando-se juntamente todas as ressecções pancreáticas esquerdas realizadas, a ocorrência de complicações globais, de complicações relevantes e graves foi 55%, 42% e 20%, respectivamente. Os fatores que se mostraram preditivos à ocorrência de morbidade pós-operatória após pancreatectomia distal com preservação do baço foram a técnica de secção do parênquima pancreático, idade, índice de massa corporal e a realização de operação abdominal concomitante. CONCLUSÃO: A morbidade associada às ressecções pancreáticas, à esquerda dos vasos mesentéricos superiores, foi importante. De acordo com a estratificação adotada baseada na gravidade das complicações, alguns fatores preditivos foram identificados. Estudos futuros com coortes maiores de pacientes são necessários para confirmar tais resultados.

OBJECTIVE: To evaluate the postoperative morbidity of distal pancreatic resections and to investigate its predictive factors. METHODS: The study was conducted retrospectively from a prospectively database maintained. From 1994 to 2008, 100 consecutive patients underwent left pancreatic resections. The primary variable of interest was postoperative morbidity, and various other characteristics of the population were simultaneously recorded. Later, for the analysis of predictors of postoperative morbidity, the subgroup of patients who underwent distal pancreatectomy with spleen preservation (n = 65) was separately analyzed with regards to the different techniques of section of the pancreatic parenchyma, as well as to other possible predictors of postoperative morbidity. RESULTS: Considering all left pancreatic resections performed, the occurrence of overall, relevant and serious complications was 55%, 42% and 20%, respectively. The factors predictive of postoperative morbidity after distal pancreatectomy with spleen preservation were the technique employed for section of the pancreatic parenchyma, age, body mass index and the performance of concomitant abdominal operations. CONCLUSION: The morbidity associated with pancreatic resections to the left of the superior mesenteric vessels was high. According to the stratification adopted based on the severity of complications, some predictive factors have been identified. Future studies with larger cohorts of patients are needed to confirm these results.

Predictive factors of morbidity in distal pancreatic resections.

OBJECTIVE: To evaluate the postoperative morbidity of distal pancreatic resections and to investigate its predictive factors. METHODS: The study was conducted retrospectively from a prospectively database maintained. From 1994 to 2008, 100 consecutive patients underwent left pancreatic resections. The primary variable of interest was postoperative morbidity, and various other characteristics of the population were simultaneously recorded. Later, for the analysis of predictors of postoperative morbidity, the subgroup of patients who underwent distal pancreatectomy with spleen preservation (n = 65) was separately analyzed with regards to the different techniques of section of the pancreatic parenchyma, as well as to other possible predictors of postoperative morbidity. RESULTS: Considering all left pancreatic resections performed, the occurrence of overall, relevant and serious complications was 55%, 42% and 20%, respectively. The factors predictive of postoperative morbidity after distal pancreatectomy with spleen preservation were the technique employed for section of the pancreatic parenchyma, age, body mass index and the performance of concomitant abdominal operations. CONCLUSION: The morbidity associated with pancreatic resections to the left of the superior mesenteric vessels was high. According to the stratification adopted based on the severity of complications, some predictive factors have been identified. Future studies with larger cohorts of patients are needed to confirm these results.

Totally laparoscopic right hepatectomy.

BACKGROUND: Since the first laparoscopic cholecystectomy was performed in 1987, the surgical applications of laparoscopy have grown to involve most areas of general surgery. Until recently, however, major liver surgery remained outside of the scope of minimally invasive surgery. Building on advances in laparoscopic equipment, techniques, and ongoing experience in hepatic surgery, major liver resection has been performed laparoscopically in some select centers. At our institute, a safe and standardized approach to minimally invasive major hepatectomy has been developed. This article illustrates the relevant technical maneuvers in the performance of a totally laparoscopic right hepatectomy. Common pitfalls and areas of concern are discussed. METHODS: A detailed description of a standardized procedure is presented. The technique was developed from a single-institution experience of 41 laparoscopic right hepatectomies performed in a tertiary care referral center for laparoscopic digestive surgery. The prevention of bleeding and gas embolism are discussed. CONCLUSIONS: The laparoscopic right hepatectomy is feasible and safe if the appropriate expertise and equipment are available. In selected patients, this new approach can be proposed by a surgeon experienced in laparoscopic and hepatic surgery as an alternative to conventional open liver resection.

Pre-operative predictive factors of early recurrence after resection of adenocarcinoma of the esophagus and cardia.

OBJECTIVES: To determine pre-operative predictive factors of early recurrence in patients with esophageal and cardial adenocarcinoma. PATIENTS AND METHODS: We retrospectively analyzed consecutive patients who underwent resection for esophageal and cardial adenocarcinoma in our institution between October 1992 and October 2001. Patient files were studied and classified according to the occurrence of early recurrence (within one year) (group A) and patients without recurrence (group B). Pre-operative clinical, biological and radiological parameters were recorded. Both groups were compared in univariate and multivariate analysis. RESULTS: One hundred patients underwent surgical resection. Tumor was located in lower esophagus in 71 cases and at the cardia in 29 cases. R0 resection was feasible in 95 cases. Hospital mortality was 2%. Survival rate at 3 years was 56%. Recurrence before 1 year occurred in 28 patients (group A) and not in 72 (group B). In univariate analysis, younger age (P=0.01), dysphagia (P=0.04) and percentage of weight loss (P<0.0004) were significantly different between both groups. Weight loss more than 10% was observed in 2 patients of group B, and in 9 patients of group A. In multivariate analysis, weight loss more than 10% was the only pre-operative factor associated with early recurrence (P=0.018). CONCLUSION: Important weight loss could be a pre-operative predictive factor of early recurrence after resection of esophageal and cardial adenocarcinoma and surgery as first line treatment could be avoided in these patients.