Laparoscopic gastrectomy for treatment of advanced gastric cancer: preliminary experience on 38 cases.

AIM: In the last 20 years the laparoscopic surgery rapidly and successfully diffused for the treatment of benign diseases and recently also for the treatment of malignancy; newerteless, the laparoscopic gastrectomy for gastric cancer is still controversial, in relation to extreme difficulty of a radical surgical resection performing with an accurate lymphadectomy. The authors present a surgical experience of patients affected by advanced gastric cancer who underwent total or subtotal gastrectomy with videoassisted or entirely laparoscopic technique in order to evaluate the safety, feasibility, advantages and limits of this surgical approach. METHODS: between January 2002 and August 2007 we performed 40 laparoscopic procedure for advanced gastric cancer; of these, 38 (95%) patients underwent a laparoscopic gastric resection and 2 (5%) patients underwent a palliative surgical treatment (laparoscopic gastro-entero-anastomosis). In the 38 patients which underwent laparoscopic gastrectomy, the anatomical localization of cancer, ASA score, pTNM classification, type of surgical laparoscopic technique (videoassisted or entirey laparoscopic technique), mean number of lymph nodes harvested, mean operative time, rate of conversion, postoperative morbidity and mortality and rate of local recurrence at 24 mounths follow-up were retrospectively analyzed. RESULTS: Thirty-eight laparoscopic gastrectomies for gastric cancer were performed: in relation to surgical technique, 4 (10.5%) of these were video-assisted gastric resection (left subcostal minilaparotomy and extracorporeal anastomosis) and 34 (89.5%) were entirely laparoscopic gastrectomy; regarding to extension of surgical resection, there were 16 (42%) total D2 gastrectomies and 22 (58%) subtotal gastrectomies, of which 19 D2 gastrectomy and 3 D1 gastrectomy. Regarding the ASA score, 23% of patients were in ASA I, 52% in ASA II, 25% in ASA III. The mean operative time was 225 minutes (range 160-285) for total gastrectomy and 183 minutes (range 70-270) for subtotal gastrectomy. Overall, on 38 laparoscopic gastric resection, the conversion rate was 7.8% (3 patients). The number of lymph nodes harvested was 28 (range 5-53). No major intraoperative complications were observed. Overall morbidity was 31.5% (12 patients); the rate of postoperative surgical complications was 8% (3 patients). One patient (2.6%) dead for a sepsis subsequent to leak of esophagojejunal anastomosis. Mean hospital stay was 16 days for total gastrectomies and 12 days for subtotal gastrectomies. Three cases (7.9%) of cancer recurrence were observed in 3 patients (2 patiens UICC IIIa, one patient UICC IIIb) at 20th, 23th, 24th postoperative month and one case (2.6%) of peritoneal carcinosis at 18th month. No port-site metastasis were observed at 24-month follow-up. CONCLUSIONS: On the basis of this surgical preliminary experience, laparoscopic gastrectomy for malignancy resulted a technically safe surgical procedure if performed by an advanced laparoscopic surgical team, with additional benefits, time to resumption of oral intake, morbidity rate, and acceptance from patients. A radical laparoscopic gastrectomy via laparoscopic approach is advisable until UICC stage II, in patients with ASA score I-III and minimal endoabdominal adhesion. The safe and efficacy of laparoscopic treatment in locoregional limph nodes dissection is still controversial. However, long-term results of prospective and comparative trials will be necessary to show the real oncologically benefits of laparoscopic approach.

Laparoscopic approach to morbid obesity: personal experience of 250 gastric bypasses. Analysis of different techniques and results.

AIM: Severe obesity is a major health problem affecting more than 1,000,000 people in Italy, with a 95% failure rate of nonsurgical treatments. We report our over five-years experience with laparoscopic Roux-en-Y gastric bypass (LRYGBP), evaluating the postoperative course of the patients undergoing 3 different gastro-esophageal anastomosis technique: Gagner procedure (87 cases) (34.8%), the purse-string approach (93 cases) (37.2%), robotic-assisted gastric bypass (68 cases) (27.2%) and by laparoscopic hand sewn anastomosis (2 cases) (0.8%). METHODS: Between October 2000 and February 2006, we performed LRYGBP on 250 patients (77 male and 173 female aged from 16 to 65 years [mean age 43.1 years] and with an average body mass index of 51.1 kg/m(2) [35-99]). Comorbidities were: hypertension, type II diabetes, hyperlipemia, osteoarthritis, chronic restrictive pulmonary insufficiency, sleep apnea, deep venous thrombosis. RESULTS: The mean operative time was 142.3 min (80-420) with a mean hospitalization of 9.8 days (5-44). Eighteen major complications were recorded. There were no deaths. The mean percent excess body weight loss was 47.2+/-18.2% after 1 year (212 patients), 66.2+/- 19.4% after 2 years (178 patients), 78.2+/-12.4% after 3 years (139 patients), 80.6+/-11.7% after 4 years (101 patients), and 82.5+/-10.2% after 5 years (67 patients). Nearly all of the comorbidities were solved or improved. Bariatric analysis and reporting outcome system results after 5 years were excellent, good or fair in 100% of the subject evaluated. CONCLUSIONS: Although requiring the skill of an expert surgeon, LRYGBP is one of the most effective procedure available today to induce long-term weight loss, with limited nutritional risks and better prospects for improved quality of life.

Laparoscopic gastric bypass performed with the Da Vinci Intuitive Robotic System: preliminary experience.

BACKGROUND: This study aimed to analyze retrospectively the authors' preliminary experience using the Da Vinci Intuitive Robotic System for gastric bypass in managing morbid obesity, and to determine its efficacy and safety in relation to other standardized laparoscopic surgical techniques. METHODS: From October 2000 to March 2004 the authors performed 146 laparoscopic gastric bypasses, 17 of which were robot assisted using the Da Vinci Intuitive Robotic System. The last patients were 7 men and 10 women with a mean age of 44 years. The mean weight was 139 kg, and the mean body mass index (BMI) was 49.8 kg/m at first postoperative recovery. The mean excess body weight (EBW) was 131%. Follow-up assessment, performed at months 1, 3, 6, and 12, then yearly thereafter, included evaluation of the variations in BMI and the percentage of excess body weight loss (EBWL%). All the patients were informed of the risks inherent with each surgical procedure as well as the potential benefits. RESULTS: The mean operative time was 201 min (range, 90-300 min). No intraoperative complications and no conversion occurred in this series. The mean hospital stay was 9 days (range, 6-18 days). The patients in this series experienced a normal postoperative course without anastomotic complications. The mortality rate was zero. No robot-related complications were noted. The analysis of follow-up assessment at months 1, 3, 6, and 12 showed a progressive decrease in BMI and an increment of EBWL%. CONCLUSIONS: The authors' early experience with robotic surgery suggests that it is safe and could be an effective alternative to conventional laparoscopic surgery. The authors believe that robotic surgery, with its ability to restore the hand-eye coordination and three-dimensional view lost in laparoscopic surgery, could allow complex procedures to be performed with greater precision and better results.

Abdominal wall recurrences after colorectal resection for cancer: results of the Italian registry of laparoscopic colorectal surgery.

PURPOSE: The purpose of the present study was to evaluate prospectively the abdominal wall recurrence rate after laparoscopic resection for colorectal cancer, to analyze the impact of the learning curve on abdominal wall recurrence, and to assess the outcome of those patients. METHODS: The Italian Registry of Laparoscopic Colorectal Surgery database was analyzed to obtain data on cancer patients with abdominal wall recurrence, concomitant local or distant metastases, and interval between initial surgery and diagnosis of trocar site or minilaparotomy recurrences. The records of the initial procedures and the technique of specimen removal were reviewed. RESULTS: From January 1992 to July 2000, 2,583 patients (1,753 cases of carcinomas and 830 cases of benign diseases) were recorded. The malignant lesions were located on the right colon in 19 percent, the left colon in 48.8 percent, and rectum in 32.2 percent. Sixteen patients with histologic evidence of colorectal adenocarcinoma recurrences at the abdominal wall were observed (0.9 percent). Ten patients presented an advanced stage (III for 7 patients and IV for 3 patients). Eleven cases occurred during the learning curve period (the first 50 consecutive cases). The median survival time after abdominal wall recurrence diagnosis was 16 (range, 12-60) months. By July 2000 only two patients were alive. CONCLUSIONS: The results of the Italian prospective Registry of Laparoscopic Colorectal Surgery confirm that the incidence of abdominal wall recurrences is similar to that reported in open studies (<1 percent). Most abdominal wall recurrences occurred in the learning curve period, suggesting that surgical experience may play a role in the development of this outcome. The prognosis of these patients is very poor.

[Laparoscopic treatment of gastroesophageal reflux]. / Trattamento laparoscopico della malattia da reflusso gastroesofageo.

Gastroesophageal reflux disease (GERD) is a frequent illness, sometimes causing disabling symptoms and/or permanent oesophageal lesions. Etiology is multifactorial and not completely defined. Therapy is medical at first step, surgical indication is reserved to those patients with less compliance for medical therapy, unsuccessful medical therapy or reflux related complications. Different surgical techniques have been suggested for treatment of GERD, like Nissen, Rossetti or Toupet fundoplication. During the last decade laparoscopy has been proposed as a less invasive approach when surgery is indicated. From 1995 to the first months of 1999, 42 pts (28 females, 14 males, mean age 53.7 years), were operated on. Diagnosis and surgical indication were confirmed preoperatively by barium X-rays, endoscopy and 24 hrs-Ph-manometry. Hiatal hernia was demonstrated in 37 cases (88%), I or II grade esophagitis in 16 and III grade in 2; 1 patient had Barrett oesophagus. 37 pts were operated on by laparoscopic Nissen fundoplication, 5 patients had a Toupet operation. Mortality and conversion rate were 0. Complications occurred in 3 patients: 1 intraoperative pneumothorax, 1 acute cardiac ischemia in a patient with known hypertension, 1 permanent dysphagia successfully treated by endoscopic dilatation. Mean postoperative hospital stay was 6.1 days. Mean follow up was 9 months (3-48) in 100% of cases. Despite the fact that few patients were operated on by using this new less invasive approach, results are encouraging with no mortality, less morbidity and great advantages for patients.

[Surgical indications and reconstructive techniques in the treatment of chronic forms of ulcerative rectocolitis. Review of the literature]. / Indicazioni chirurgiche e tecniche ricostruttive nel trattamento delle forme croniche di rettocolite ulcerativa. Revisione dei dati della letteratura.

The authors have reviewed the literature particularly of the last decade, about surgical indications and timing in chronic ulcerative proctocolitis, also regarding the difficulties and the hazards the surgeon has to face depending on which type of chronic disease is considered. The various solutions for intestinal transit restoration have been reviewed, especially after the indications for terminal and continent ileostomy and for ileo-rectal anastomosis have been put aside, and total proctocolectomy with mucosectomy was advocated, with a special concern for assets and drawbacks of every type of ileal pouch. It is herein discussed the difference between the attitudes towards chronic active and recurrent ulcerative proctocolitis. The active form can't be cured with steroids and shows a greater risk of malignant transformation after 10-15 years of illness, insofar most cases (82%) in the long run need operation with this form that just often permits a one-stage surgery with mucosectomy, though. The commoner recurrent form is quite sensitive to steroids until these prove to be ineffective and surgery becomes mandatory (28% of cases). A two or three-stage surgery is advocated in this form with conservation of the rectum (mucosal fistula) as long as the acute phase is present, permitting only after its remission a restorative procedure with mucosectomy, which would be likely to be jeopardizing during the acute phase. The many designs of ileal reservoir do not differ indeed between each other as much in compliance as in maximum tolerable volume. The quadruple loop reservoir affords a volume approaching highly the original rectal volume, with better compliance and lesser frequency of bowel evacuations compared to other pouch designs. Some authors maintain that the functional outcome is independent of the reservoir shape. The anal continence basically depends upon the integrity of the internal sphincter, on the conservation of the anal inhibitory reflex and on the resting pressure. Muscular cuff is also mentioned with reference to anal function. Circular staplers have been employed for pouch-anal anastomosis 1-2 cm above the dentate line without mucosectomy. The stapled pouch-anal anastomosis entails a damage to the internal sphincter by some authors on the contrary a better sphincter function by others, compared to hand-sewn anastomosis with mucosectomy. Trials are needed to compare the risk of rectocolitis recurrence or malignancy after hand-sewn pouch-anal anastomosis with mucosectomy and after stapled anastomosis without mucosectomy. Postoperative complications are also herein discussed, with a special regard to pouchitis and its various aetiologic factors in early and late postoperative course.

[Ileal adenocarcinoma in Crohn's disease. A report of 2 cases]. / Adenocarcinoma ileale nel morbo di Crohn. Descrizione di 2 casi.

The incidence of intestinal adenocarcinoma in Crohn's ileal disease is reported in the literature to be higher than in the normal population. The authors report two cases of adenocarcinoma observed during the course of Crohn's ileitis and, by comparing these findings with earlier published data, highlight their characteristics. Two patients, a 53-year-old woman and a 62-year-old man, are reported as suffering from Crohn's ileitis. The woman underwent resection of the right colon with ileo-transversostomy due to stenosis twenty years earlier, whereas diagnosis in the male patient dates back to an appendicectomy 11 years earlier. Surgery, which was performed in both due to subocclusion which failed to respond to steroid therapy, showed the typical alterations of Crohn's disease. An adenocarcinoma was also found in both patients in the stenotic zone with highly dysplasic foci. The man presented a monoclonal gammopathy of an IgA-type with light lambda chains and Bence-Jones' proteinuria. Both patients are living and enjoy apparently good health respectively 2 and 6 years after surgery. The authors emphasize that the association between Crohn's ileal disease and intestinal adenocarcinoma cannot be considered casual. In the literature the relative risk is reported to be between 6 and 320 times higher, with approximately 1 out of 350 patients suffering from both diseases contemporaneously. In the series reported earlier, 2 cases of carcinoma were diagnosed in 38 Crohn's patients studied over a period of 12 years out of a total population of 114000 inhabitants, with a frequency of carcinoma of 5.13% compared to 0.3% reported in the literature. The incidence of Crohn's disease was 2.84/100000 per year.(ABSTRACT TRUNCATED AT 250 WORDS)

[Alithiasic cholecystopathies. Clinical, diagnostic and therapeutic aspects]. / Le colecistopatie alitiasiche. Inquadramento clinico, diagnostico e terapeutico

The frequency of alithiasic cholecystitis is considered and the various forms are subdivided into diffuse and localized dyskinesia. Symptomatology is described and the former are indicated as being electively medical and the latter surgical forms whether the condition is congenital or acquired. The various forms of cholecystosis are also distinguished with full documentation. Symptomatological techniques and diagnostic conclusions are illustrated for all forms and personal experience with their therapy reported.

[Our experience in the surgery of bile ducts]. / La nostra esperienza in tema di chirurgia delle vie biliari

After a brief review of modern techniques for correct diagnosis and therapy of bile duct pathology, a personal series of 955 operations (between 1-XI-1972 and 30-X-1975) is presented. The need for routine peroperative control of VBP and the usefulness of respecting the papilla where it is anatomo-functionally undamaged are stressed. Personal experience shows that the most rational methodology is after papillotomy the application of a prepapillary Kehr incision through a choledochotomy because this presents fewer complications than the transpapillary Kehr incision in calculosis or stenosis of the VBP where bile duct suture is not advisable. With regard to bilio-digestive anastomosis, indications and limitations are discussed and it is suggested that where the patient's general and local states permit, choledochojejunal anastomosis should permit, choledochojejunal anastomosis should be used, with choledocho-duodenostomy only in special cases. Cholecysto-gastro and cholecystoduodenostomy should be reserved for patients in very serious conditions.