Value of staging laparoscopy for multimodal therapy planning in esophago-gastric cancer.

The importance of multimodal treatment for advanced esophago-gastric cancer has contributed to the development of more accurate preoperative staging strategies. The impact of staging laparoscopy and cytology after conventional staging is evaluated in this study. Staging laparoscopy was performed in 125 patients with potentially resectable cancer of the distal esophagus or gastric cancer. Results were registered separately on a database according to the TNM classification of the International Union Against Cancer (UICC). Laparoscopy changed TNM classification in 46 cases. Explorative laparoscopy resulted in up-staging concerning the N-factor (n = 15) and M-factor (n = 28). Downstaging of the T-factor was recorded in three cases. Cytologic examination gave no additional information in our series. Our experience suggests a clear benefit of laparoscopy in staging of patients with distal esophagus or gastric malignancy. Laparoscopy is a safe and effective staging modality, avoiding unnecessary laparotomies and providing new means of directing appropriate treatment strategy.

Posterior retroperitoneoscopic adrenalectomy: a comparison between the initial experience in the invention phase and introductory phase of the new surgical technique.

BACKGROUND: Today, the posterior retroperitoneoscopic technique has become a standard procedure in adrenal surgery. The procedure allows direct access to the adrenal glands, but it seems to be difficult because of the uncommon anatomic view. This study compares the learning period of the new procedure of "posterior retroperitoneoscopic adrenalectomy" in the primary invention phase and the secondary introductory phase in a different hospital 10 years later. MATERIALS AND METHODS: The analysis included 100 posterior retroperitoneoscopic adrenalectomies (PRA) and involved 50 procedures in each center. Group A consisted of 44 patients (14 males, 30 females; age: 48.7 +/- 14.5 years) undergoing surgery between 07/1994 and 8/1996 (24 right, 26 left; 8 Cushing adenomas, 14 Conn adenomas, 11 pheochromocytomas, 7 nonfunctioning adrenocortical adenomas, 10 ACTH-dependent adrenal hyperplasias). Group B consisted of 50 patients (12 males, 38 females; mean age 59.3 +/- 10.7 years) operated between 01/2004 and 01/2006 (28 right, 22 left tumors; 5 Cushing adenomas, 12 Conn adenomas, 4 pheochromocytomas, 29 nonfunctioning adrenocortical adenomas). All PRAs were performed with the patient in the prone position with 3-4 trocars placed caudally in the region of the 11th and 12th ribs. In group A, the surgical team developed the technique of PRA themselves. Before their first PRA, the surgical team of group B was introduced to the technique by the group A surgeons and afterwards were supervised continuously. RESULTS: No serious intraoperative or postoperative complication occurred in either group. Group A experienced 7 conversions to open surgery, whereas group B had one conversion and one early reoperation due to bleeding (P = 0.03; chi(2)-test). The mean operative time was 117 +/- 41 minutes versus 83 +/- 35 minutes (group A and B respectively; P < 0.001; t-test). Estimated blood loss was similar in the two groups (47.2 +/- 46.2 ml versus 54 +/- 16.3 ml, group A versus B, respectively; P = 0.36; t-test). CONCLUSIONS: The study demonstrates the feasibility, safety, and reproducibility of the new surgical method of PRA both when it is employed in the early phase of invention, as well as when performed by surgeon-learners. After comprehensive training, the operative time and conversion rate are dramatically reduced, allowing for a short learning period.

Posterior retroperitoneoscopic adrenalectomy--results of 560 procedures in 520 patients.

BACKGROUND: The posterior retroperitoneoscopic adrenalectomy is less popular than the laparoscopic transabdominal method. Due to the direct approach to the adrenal glands, however, the posterior retroperitoneal access is easy to use and may offer advantages not available with other endoscopic procedures for adrenalectomy. METHODS: Between July 1994 and March 2006, we performed 560 adrenalectomies (right side: n = 258; left side: n = 302) by the posterior retroperitoneoscopic approach in 520 patients (200 male, 320 female; age, 10 to 83 years). Of the 520 patients, 21 suffered from Cushing's disease, 499 patients had adrenal tumors (157 Conn's adenomas, 120 pheochromocytomas [13 bilateral], 110 Cushing's adenomas [6 bilateral], and 112 other tumors). Tumor size ranged from 0.5 to 10 cm (mean, 2.9 +/- 1.7 cm). The procedures were performed with the patients in the prone position usually with 3 trocars. RESULTS: Mortality was zero. Conversions to open or laparoscopic lateral surgery were necessary in 9 patients (1.7%). Major complications occurred in 1.3% of patients, minor complications in 14.4%. Mean operating time was 67 +/- 40 min and declined significantly (P < .001) from the early procedures (106 +/- 46 min) to the later operations (40 +/- 15 min). CONCLUSIONS: The posterior retroperitoneoscopic adrenalectomy is a safe and fast procedure. In experienced hands, this method represents the ideal approach in adrenal surgery.

Partial versus total adrenalectomy by the posterior retroperitoneoscopic approach: early and long-term results of 325 consecutive procedures in primary adrenal neoplasias.

The retroperitoneoscopic approach is a standardized operative procedure for primary adrenal gland tumors. It allows direct access with a detailed view of the adrenal gland. Thereby, a clear differentiation between normal and neoplastic adrenal tissue is often possible, which permits a planned partial resection of the gland in selected cases. Between July 1994 and November 2003 325 posterior retroperitoneoscopic adrenalectomies were performed for primary benign adrenal gland tumors (106 Conn's adenomas, 83 pheochromocytomas, 76 Cushing's adenomas, 60 nonfunctioning tumors; size: 2.8 +/- 1.5 cm; site: 160 right, 165 left) in 318 patients (122 M, 196 F, age: 49.0 +/- 14.3 years). In 96 patients 100 tumors were removed by partial adrenalectomy (30 Conn's adenomas, 33 pheochromocytomas, 20 Cushing's adenomas, 17 nonfunctioning tumors; site: 61 right, 59 left) maintaining tumor-free parts of the adrenal gland. Of this group, 15 patients suffered from bilateral adrenal neoplastic diseases. During the same period, 225 total adrenalectomies (76 Conn's adenomas, 50 pheochromocytomas, 56 Cushing's adenomas, 34 nonfunctioning tumors; site: 109 right, 116 left) were performed in 224 patients. There was no mortality. Major complications were seen in 1.8%, minor complications in 14.5%. Three conversions were necessary to an open or a laparoscopic approach (2 patients and 1 patient, respectively). There are no differences between the two groups (total versus partial adrenalectomy) with regard to tumor size (2.8 +/- 1.6 cm versus 2.8 +/- 1.5 cm), operating time (80 +/- 44 minutes versus 79 +/- 42 minutes), and blood loss (33 +/- 71 ml versus 29 +/- 31 ml). In all patients with partial adrenalectomy, biochemical healing was proven. Fourteen of 15 patients with bilateral diseases had preservation of adrenocortical function. After a mean follow up of 51 months (range: 7-120 months) local recurrence or relapse of the initial diseases was noticed in 6 patients after total adrenalectomy: in 4 patients with Conn's syndrome and bilateral hyperplasia, and in 2 patients with malignant pheochromocytoma and adrenocortical carcinoma, respectively. Our data demonstrate that partial adrenalectomy is a safe procedure not only perioperatively but also in the long-term follow-up.

Endoscopic treatment of solitary, bilateral, multiple, and recurrent pheochromocytomas and paragangliomas.

Because of extensive intraoperative catecholamine release, extreme vascularization, and demanding localization, laparoscopic and retroperitoneoscopic excision of pheochromocytomas and retroperitoneal paragangliomas is challenging. In a prospective clinical study, 61 chromaffin neoplasms (52 pheochromocytomas, 9 paragangliomas) were removed endoscopically from 52 patients (30 males, 22 females; age 44.4 +/- 16.3 years) at 55 operations. Six patients showed multiple (two to five) tumors. Tumor size ranged from 1 to 7 cm (mean 3.6 +/- 1.4 cm). Twelve patients suffered from hereditary diseases. Seven patients had bilateral adrenal diseases; in three patients pheochromocytomas were removed on both sides synchronously. Four neoplasias were local recurrences (three pheochromocytomas, one paraganglioma). The laparoscopic route was chosen for six operations, and the retroperitoneoscopic technique was performed in 49 procedures. Partial adrenalectomy was performed in 19 operations (in all patients with bilateral diseases). High-dosage a-blockage with phenoxybenzamine was routinely used. There were no conversions to open surgery. Perioperative complications were minor (23%), and mortality was zero. The operating time for unilateral pheochromocytomas was 116 +/- 52 minutes (range 35-285 minutes) and depended on tumor size (<3 cm vs. > or = 3 cm; p <0.01), gender (p <0.01), and extent of resection (partial vs. complete; p <0.05). The operating time for bilateral pheochromocytomas ranged from 285 to 385 minutes, and it was 75 to 600 minutes for paragangliomas. Blood loss was 100 +/- 171 ml. Consumption of analgesics was low (mean 7 mg piritramide postoperatively). The median duration of postoperative hospitalization was 4 days. In six of seven patients with bilateral disease complete preservation of cortical function was achieved. Locoregional metastatic recurrence was found in one patient 3 years after retroperitoneoscopic adrenalectomy. Endoscopic removal of solitary, bilateral, multiple, and recurrent pheochromocytomas and retroperitoneal paragangliomas is feasible and safe but requires extensive experience in minimally invasive and endocrine surgery.