Hollow viscus injuries: predictors of outcome and role of diagnostic delay.

INTRODUCTION: Hollow viscus injuries (HVIs) are uncommon but potentially catastrophic conditions with high mortality and morbidity rates. The aim of this study was to analyze our 16-year experience with patients undergoing surgery for blunt or penetrating bowel trauma to identify prognostic factors with particular attention to the influence of diagnostic delay on outcome. METHODS: From our multicenter trauma registry, we selected 169 consecutive patients with an HVI, enrolled from 2000 to 2016. Preoperative, intraoperative, and postoperative data were analyzed to assess determinants of mortality, morbidity, and length of stay by univariate and multivariate analysis models. RESULTS: Overall mortality and morbidity rates were 15.9% and 36.1%, respectively. The mean length of hospital stay was 23±7 days. Morbidity was independently related to an increase of white blood cells (P=0.01), and to delay of treatment >6 hours (P=0.033), while Injury Severity Score (ISS) (P=0.01), presence of shock (P=0.01), and a low diastolic arterial pressure registered at emergency room admission (P=0.02) significantly affected postoperative mortality. CONCLUSION: There is evidence that patients with clinical signs of shock, low diastolic pressure at admission, and high ISS are at increased risk of postoperative mortality. Leukocytosis and delayed treatment (>6 hours) were independent predictors of postoperative morbidity. More effort should be made to increase the preoperative detection rate of HVI and reduce the delay of treatment.

Transoral extraction of a laparoscopically resected large gastric GIST.

Although natural orifice specimen extraction is now widely performed, there have been no reports of transoral extraction following laparoscopic gastric resection. This report describes the first transoral specimen extraction in a patient with a gastrointestinal stromal tumor (GIST) of the lesser curvature of the stomach. The clinical data of a patient with a large gastric GIST were reviewed. Totally laparoscopic resection of the gastric lesser curvature was performed using four trocars. The specimen, put in a retrieval bag, was withdrawn via the transgastric and esophageal route. Reconstruction of the stomach was performed using the intracorporeal technique. The procedure was successfully accomplished without intraoperative and postoperative complications. In conclusion, transoral specimen extraction after laparoscopic gastric resection is a safe and feasible operative procedure for selected patients with a large benign gastric tumor.

Single-access laparoscopic "lavage" for purulent diverticulitis in a 96-year-old patient: how to reduce surgical trauma and standardize surgical technique.

INTRODUCTION: Recently, laparoscopic lavage emerged as an effective alternative for patients with perforated diverticulitis with purulent peritonitis. CASE REPORT: A 96-year-old woman, diagnosed with Hinchey 3 diverticulitis after a computed tomography scan, was operated on with a single-access "lavage" to reduce surgical trauma and to avoid stoma. METHODS: The procedure was performed under general anesthesia. Tracheal intubation, nasogastric tube, and urethral catheterization were mandatory. The patient was in a modified Lloyd-Davis position, with the table tilted in Trendelenburg position, left side up. Surgeons were on the right side. INSTRUMENTATION: The procedure was performed using a surgical technique similar to standard laparoscopy with traditional laparoscopic instruments. SURGICAL STEPS: The surgical procedure involved single-incision laparoscopic surgery (Covidien, Mansfield, MA) insertion, small bowel dissection, abscess opening, and peritoneal washing. RESULTS: The procedure was completed in 75 minutes with an estimated blood loss of 120 mL. The patient was kept in the intensive care unit for 1 day. She was on postoperative analgesia for 2 days and was discharged from the hospital on postoperative day 5. The patient was able to drink on day 1 and eat on day 3 after flatus.

Pharyngolaryngo-esophagectomy with laparoscopic gastric pull-up: a reappraisal for the pharyngoesophageal junction cancer.

BACKGROUND: Surgical treatment of advanced hypopharyngeal tumors is still a surgical challenge. We report a case of a hypopharyngeal tumor treated with a pharyngolaryngo-esophagectomy (PLE) and laparoscopic gastric tubulization and interposition. METHODS: A 56-year-old man presented with a relapsing hypopharynx carcinoma, after primary chemoradiation therapy. Preoperative workup showed a stage IV cancer with esophageal invasion and multiple cervical lymph node metastases. Surgical treatment consisted of a cervical phase, with larynx, pharynx, and esophagus dissection, radical lymph node dissection, homolateral hemithyroidectomy and definitive tracheostomy, and an abdominal phase with a 4-trocar laparoscopy. The gastrocolic ligament was opened, and short gastric and left gastric vessels were divided preserving an accessory left hepatic artery. Gastric tailoring was carried out with 45-mm linear staplers. The hiatus was opened and the esophagus dissected free with Ultracision (Ethicon Endo-Surgery, Cincinnati, OH) to the tracheal bifurcation. The upper esophagus was bluntly mobilized by finger and sponge stick dissection. The gastric tube was pulled up, and the anastomosis between the stomach and the tongue base was performed with a 2-layer interrupted hand-sewn technique. RESULTS: Total operative time was 390 min (abdominal time 180 min). Estimated blood loss was 400 cc. The number of dissected cervical lymph nodes was 32. Oral feeding was started after 10 days, and the patient was discharged after 14 days. Stage of disease was pT4N1M0 G3 R0. CONCLUSIONS: Laparoscopic surgery allows a minimally invasive gastric tailoring and tubulization and transhiatal esophageal dissection and represents a valuable alternative for intestinal reconstruction after PLE. CT scan showing a large hypopharynx carcinoma involving cervical lymph nodes and cervical esophagus.

Image-guided robotic radiosurgery (CyberKnife) for pancreatic insulinoma: is laparoscopy becoming old?

Insulinomas constitute about 25% of endocrine pancreatic tumors. Laparoscopic surgery is the treatment of choice. However, pancreas-related complications rate is very high, even in experienced hands, ranging up to 37%. Alternative procedures such as embolization with trisacryl have not been accepted by the surgical community. Image-guided robotic radiosurgery or stereotactic radiosurgery (CyberKnife) is a minimally invasive procedure delivering large doses of ionizing radiation to a well-defined target. CyberKnife radiosurgery is successfully used in brain cancer, lung cancer, prostate cancer, liver metastases, kidney cancer, and pancreatic cancer. The authors present the first case to their knowledge of a benign functioning insulinoma successfully treated by a CyberKnife technique with a 3-year follow-up.

Standard laparoscopic versus single-incision laparoscopic colectomy for cancer: early results of a randomized prospective study.

BACKGROUND: Standard laparoscopic colectomy (SLC) for cancer is a safe, feasible, and oncologically effective procedure with better short-term and similar long-term results of open colectomy. Conversely, owing to technical difficulties in colonic resection and full mesenteric dissection, single-incision laparoscopic colectomy (SILC) has been considered unsuitable for oncologic purposes. We compared the technical feasibility and early clinical outcomes of SLC and SILC for cancer. METHODS: In this prospective randomized clinical trial, 16 (50%) patients underwent SLC (10 left and 6 right) and 16 (50%) patients underwent SILC (8 left and 8 right). RESULTS: Demographics, preoperative data, and characteristics of the tumor were similar. The mean number of resected lymph nodes was 16 ± 5 in the SLC and 18 ± 6 in the SILC group (P = NS). Surgical time was 124 ± 8 minutes and 147 ± 5 minutes, respectively (P = NS). Surgical mortality was nil and the major morbidity rate was 6.3% in both groups. CONCLUSIONS: SILC for cancer is a technically feasible and safe oncologic procedure with short-term results similar to those obtained with a traditional laparoscopic approach.

Laparoscopic left nephrectomy with "en bloc" distal splenopancreatectomy.

BACKGROUND: Multiorgan resection for cancer is considered a demanding laparoscopic procedure. We report a laparoscopic radical nephrectomy and distal splenopancreatectomy for a locally advanced kidney tumor. METHODS: A 67-year-old woman presented with left flank pain and hematuria. CT scan showed a left kidney upper pole large mass with direct extension to spleen and pancreatic tail, but not metastases. With the patient on the right flank, three 10-mm trocars were placed forming an isosceles triangle in the left subcostal arch. Entering the lesser sac, splenic vessels were separately divided between clips. The pancreatic tail was dissected free and divided with Ultracision. The left renal vein was dissected free, and the aorta was exposed to perform the lymphadenectomy. Superior mesenteric artery and left renal vein and artery were isolated, and renal vessels were separately divided with a vascular stapler. The left kidney was mobilized. The specimen was inserted in a bag and retrieved transvaginally through a posterior colpotomy. RESULTS: Total operation time was 210 minutes. Estimated blood loss was 250 mL. The patient was discharged after 7 days. Final stage of disease was pT4N0M0 G2 R0 renal cell carcinoma. The patient came back 6 years later presenting a ductal adenocarcinoma of pancreatic head. At the second look laparoscopy, very few adhesions were found in right upper quadrant, and the posterior colpotomy scar was very small. The patient died 1 year after Whipple operation. CONCLUSIONS: Oncologic rules of an "en bloc" resection can be respected also with a laparoscopic approach.

Totally laparoscopic total and subtotal gastrectomy with extended lymph node dissection for early and advanced gastric cancer: early and long-term results of a 100-patient series.

BACKGROUND: Controversies exist about feasibility and oncologic effectiveness of laparoscopic gastrectomies with extended lymphadenectomy for advanced gastric cancer. The aim of our study was to determine if long-term results of these laparoscopic procedures may justify their use as an alternative to open surgery also in advanced gastric cancer. METHODS: We performed a retrospective review of 100 patients after laparoscopic surgery for gastric cancer. RESULTS: Tumor stage (S) was SIA in 21 patients, SIB in 20, SII in 17, SIIIA in 17, SIIIB in 5, and SIV in 20. Eleven total and 89 subtotal R0 gastrectomies were performed. The mean number of dissected lymph nodes was 35 +/- 18. The conversion rate was 3%. Surgical mortality and major morbidity were 6% and 13%, respectively. Overall and disease-free 5-year survival rates were 59% and 57%, respectively. CONCLUSIONS: Laparoscopic gastrectomy with extended lymphadenectomy for early and advanced gastric cancer is feasible, safe, and oncologically effective. Long-term survival rates are similar to those observed after open surgery.

Laparoscopic versus open subtotal gastrectomy for distal gastric cancer: five-year results of a randomized prospective trial.

OBJECTIVE: The aim of this study was to compare technical feasibility and both early and 5-year clinical outcomes of laparoscopic-assisted and open radical subtotal gastrectomy for distal gastric cancer. SUMMARY BACKGROUND DATA: The role of laparoscopic surgery in the treatment of gastric cancer has not yet been defined, and many doubts remain about the ability to satisfy all the oncologic criteria met during conventional, open surgery. METHODS: This study was designed as a prospective, randomized clinical trial with a total of 59 patients. Twenty-nine (49.1%) patients were randomized to undergo open subtotal gastrectomy (OG), while 30 (50.9%) patients were randomized to the laparoscopic group (LG). Demographics, ASA status, pTNM stage, histologic type of the tumor, number of resected lymph nodes, postoperative complications, and 5-year overall and disease-free survival rates were studied to assess outcome differences between the groups. RESULTS: The demographics, preoperative data, and characteristics of the tumor were similar. The mean number of resected lymph nodes was 33.4 +/- 17.4 in the OG group and 30.0 +/- 14.9 in the LG (P = not significant). Operative mortality rates were 6.7% (2 patients) in the OG and 3.3% (1 patient) in the LG (P = not significant); morbidity rates were 27.6% and 26.7%, respectively (P = not significant). Five-year overall and disease-free survival rates were 55.7% and 54.8% and 58.9% and 57.3% in the OG and the LG, respectively (P = not significant). CONCLUSIONS: Laparoscopic radical subtotal gastrectomy for distal gastric cancer is a feasible and safe oncologic procedure with short- and long-term results similar to those obtained with an open approach. Additional benefits for the LG were reduced blood loss, shorter time to resumption of oral intake, and earlier discharge from hospital.

Videolaparoscopic total and subtotal gastrectomy with extended lymph node dissection for gastric cancer.

BACKGROUND: Laparoscopic surgery has been used in the treatment of early gastric cancer with low mortality and morbidity and improvement in patient's quality of life. The purpose of the current study was to determine if these advantages persist after radical laparoscopic treatment of more advanced gastric cancer. METHODS: A retrospective review of 44 patients after laparoscopic surgery for gastric cancer was performed. RESULTS: Tumor stage was IA in 8 patients, IB in 12, II in 9, IIIA in 6, IIIB in 1, and IV in 8. Eight total and 36 subtotal R0 gastrectomies were performed (12 D(1) and 32 D(2)). The mean number of dissected lymph nodes was 38.1 +/- 21.5. Conversion rate was 7%. Operative mortality and morbidity were 7% and 12%, respectively. Three-year survival was 75%. CONCLUSIONS: Laparoscopic radical total or subtotal gastrectomy with extended lymphadenectomy for gastric cancer is a feasible, safe, and oncologically effective procedure.