Laparoscopic and open distal pancreatectomy: a comparison of outcomes.

Laparoscopic (lap) pancreatic surgery has been increasingly reported since its introduction in 1992. A retrospective analysis of consecutive patients undergoing elective lap and open distal pancreatectomy from 2002 to 2007 was performed. Univariate analysis was completed to evaluate perioperative variables. Logistic regression analysis was used to model predictors of postoperative pancreatic fistula. One hundred forty-eight subjects underwent distal pancreatectomy; 98 completed open, 44 lap, and six converted to open. There was no significant difference in the incidence of postoperative morbidity or mortality between the surgical approaches. Decreased operative time (156 vs 200 minutes, P < 0.01), blood loss (157 vs 719 mL, P < 0.01), and length of stay (5.9 vs 8.6 days, P < 0.01) were seen in the lap group. There was no significant difference in the rate of all pancreatic fistula formation (50 vs 46%, P = 0.94) or clinically significant leaks (18 vs 19%, P = 0.97) between techniques. A preoperative biopsy-proven cancer, increasing body mass index, history of pancreatitis, and male gender were significant predictors of having a pancreatic fistula. Lap and open distal pancreatectomy are performed safely at high-volume pancreatic surgery centers. This report provides ongoing support of the feasibility and safety of the lap approach with improved perioperative outcomes and equivalent pancreatic fistula rate.

Gastrointestinal symptom improvement after Roux-en-Y gastric bypass: long-term analysis.

BACKGROUND: Obese patients have a multitude of gastrointestinal symptoms that differ from their nonobese counterparts. The published data remain scant on changes in gastrointestinal symptoms among this cohort before and after Roux-en-Y gastric bypass (RYGB). The aim of this study was to quantify these symptoms and understand the changes that occur after bariatric surgery. METHODS: A total of 1724 gastrointestinal symptom surveys were prospectively administered to 763 consecutive patients who underwent laparoscopic RYGB. The patients rated each symptom on a 0-100-mm Liekert scale: 0, absence of symptoms; 33, occasional occurrence; 67, frequent occurrence; 100, continuous. The surveys were administered preoperatively and yearly thereafter. The data are presented as the mean + or - standard error of the mean. RESULTS: Of the 763 patients, 137 were black, 610 were white, and 16 were Hispanic; 83% were women and 17% were men. Their age was 40.8 + or - 0.34 years. The body mass index was 48.4 + or - 0.27 kg/m(2). The American Society of Anesthesiologists class was 2 for 31%, 3 for 68%, and 4 for 1%. Of the 763 patients, 63% underwent short-limb RYGB and 37% underwent long-limb RYGB. The preoperative symptom rating was as follows: abdominal pain, 24.3 + or - 0.7; heartburn, 41.0 + or - 0.8; acid regurgitation, 30.9 + or - 0.9; gnawing epigastric sensation, 26.5 + or - 0.9; nausea/vomiting, 18.8 + or - 0.7; borborygmus, 26.2 + or - 0.8; abdominal distension, 30.3 + or - 0.9; eructation, 28.0 + or - 0.8; increased flatus, 38.9 + or - 0.8; decreased passage of stool, 14.8 + or - 0.8; increased passage of stool, 16.4 + or - 0.7; loose stools, 22.1 + or - 0.8; hard stools, 20.5 + or - 0.9; urgent need for defecation, 23.2 + or - 0.8; incomplete evacuation, 22.2 + or - 0.8; difficulty falling asleep, 42.0 + or - 1.1; insomnia, 38.4 + or - 1; feeling rested, 60.1 + or - 1; and difficulty swallowing, 13.5 + or - 0.67. At 1, 2, 3, 4, and 5 years after RYGB, 99.5% 84.2%, 68.4%, 57.9% and 47.4% of these symptoms had improved significantly (P < .05). CONCLUSION: Laparoscopic RYGB significantly improves the gastrointestinal symptoms experienced by morbidly obese patients without adversely affecting any of the measured parameters. This improvement in symptoms proved durable in the long term.

Laparoscopic versus open approach for implantation of the peritoneal catheter during ventriculoperitoneal shunt placement.

BACKGROUND: Ventriculoperitoneal shunt (VPS) is the mainstay of therapy for hydrocephalus. The aim of this study is to compare outcomes of laparoscopic (LVPS) versus open (OVPS) techniques for placement of distal VPS catheters. METHODS: All patients undergoing new VPS placement at a tertiary care center between January 2004 and August 2007 were included. Univariate analysis was performed. Wilcoxon rank-sum, chi-square, and Fisher's exact tests were used to make comparisons between LVPS and OVPS groups. Stepwise backward logistic regression was performed to predict complications requiring operative intervention. A Kaplan-Meier estimate of the survival function was calculated for shunt survival. All data is presented as median and range unless otherwise specified. RESULTS: Five hundred thirty-five consecutive patients underwent 579 VPS (258 LVPS, 321 OVPS). Median age (52.0 years) and American Society of Anesthesiologists (ASA) score (3) were similar in LVPS and OVPS groups. Body mass index (BMI) [27.8 (17.0-64.9) kg/m(2) versus 25.9 (12.3-44.4) kg/m(2), p = 0.007], previous operations [0.8 +/- 0.9 versus 0.6 +/- 0.7, p = 0.004 (mean +/- standard deviation)], estimated blood loss (EBL) [20 (0-175) ml versus 25 (0-500) ml, p < 0.001], operating room (OR) time [37.5 (17.0-152.0) min versus 52.0 (20.0-197.0) min, p < 0.001], and length of stay (LOS) [11 (1-77) days versus 14 (1-225) days, p = 0.016] were statistically different between the LVPS and OVPS groups, respectively. LVPS abdominal complication rate of 5.8% and OVPS rate of 6.9% were similar (p = 0.611). Previous abdominal operation [odds ratio (OR) 1.673, 95% confidence interval (CI) 1.100-2.543, p = 0.016] and previous VPS (OR 1.929, 95% CI 1.147-3.243, p = 0.016) were significant predictors of complications requiring operative intervention. Kaplan-Meier analysis demonstrated no difference in survival between LVPS and OVPS groups (p = 0.538), with overall shunt survival of 86.4% at 6 months and 83.0% at 1 year. CONCLUSIONS: LVPS is associated with decreased OR time, less blood loss, and shorter LOS with no difference in complication rate when compared OVPS. The laparoscopic approach for VPS is a safe, effective, and readily reproducible alternative to the traditional open approach.

Pancreatic resection with islet cell autotransplant for the treatment of severe chronic pancreatitis.

Pancreatic resection can alleviate pain in properly selected patients with severe chronic pancreatitis (CP), although the apancreatic state causes "brittle" diabetes. Islet auto-transplantation (IAT) after resection can decrease diabetes-related morbidity. Twenty-six consecutive patients with CP who underwent 27 pancreatic resections with IAT from April 2005 to December 2007 were evaluated in this retrospective case control study. Data were collected by chart and operative note reviews and query of hospital databases. Subgroup analysis was performed on 21 cases of total pancreatectomy and six cases of pancreaticoduodenectomy (PD). Mean age was 43.8 years and 46.2 per cent of patients were female. The most common etiology of CP was alcoholism (34.6%), followed by idiopathic causes (30.8%) and pancreatic divisum (23.1%). There was no mortality and the complication rate was 56 per cent. Islet equivalents infused and islet equivalents/gram of pancreas were 82,094 and 2,739 respectively. Mean discharge insulin dose was 10.7 units/day. Mean follow-up was 6.5 months. At 6 months, 80 per cent of patients reporting had decreased or eliminated their use of narcotic medication and all total pancreatectomy patients required insulin (mean 23 units/day). In appropriately selected patients, pancreatic resection with IAT is safe and effective for the treatment of intractable pain associated with CP.