Hand-assisted laparoscopic colorectal surgery (HALS) at a community hospital: a prospective analysis of 104 consecutive cases.

BACKGROUND: We report 104 consecutive cases of hand-assisted laparoscopic (HAL) colectomy over 5 years performed by a single surgeon. METHODS: Data were gathered prospectively and include patient demographic data, diagnosis, operating time, conversion rate, length of hospital stay, and complications. Virtually all patients presenting for elective resection with benign disease and metastatic cancer were treated using HAL techniques. RESULTS: The mean age was 61 years; 48% of patients had diverticulitis; 21%, colorectal cancer; 18%, benign polyps. In addition, 55% of patients underwent sigmoid or left colectomy; 27%; right hemicolectomy; 9%, low anterior resection, and two double resections were performed. Mean operating room time was 135 minutes; in 12% of the patients conversion to open surgery became necessary, in most cases requiring only a small extension of the HAL incision. Mean and median discharge was postoperative day 4 and postoperative day 3, respectively. There was 1 death (1%) and 21% of patients had complications, 12% of them major. CONCLUSIONS: Hand-assisted laparotomy colectomy is a safe and effective procedure. The data in terms of length of hospital stay and operative time compare favorably with published data for conventional laparoscopic (CL) colectomy. Although further study is necessary, it appears that HALS confers all of the advantages of CL for colectomy, with no obvious drawbacks.

Minimal adhesions to ePTFE mesh after laparoscopic ventral incisional hernia repair: reoperative findings in 65 cases.

BACKGROUND AND OBJECTIVES: Laparoscopic ventral incisional hernia repair involves intraabdominal placement of a synthetic mesh, and the possibility of formation of severe visceral adhesions to the prosthesis is a principal concern. Little clinical information based on reoperative findings is available about adhesions to biomaterials placed intraabdominally. We conducted a multi-institutional study of adhesions to implanted expanded polytetrafluoroethylene (ePTFE) mesh at reoperation in patients who had previously undergone laparoscopic incisional hernia repair done with the same mesh implantation technique. METHODS: Nine surgeons retrospectively assessed the severity of adhesions to ePTFE mesh at reoperation in 65 patients. For each case, adhesions were assigned a score of 0 to 3, with 0 indicating no adhesions and 3 severe adhesions. RESULTS: The mean time from mesh implantation to reoperation was 420 days (range, 2-1 739 days). No adhesions were observed in 15 cases. Forty-four cases received an adhesion score of 1, and 6 cases a score of 2; no scores of 3 were assigned. Thus, 59 patients (91 %) had either no or filmy, avascular adhesions. No enterotomies occurred during adhesiolysis. CONCLUSIONS: In this large series of reoperations after laparoscopic incisional hernia repair, no or minimal formation of adhesions to implanted ePTFE mesh was observed in 91 % of cases, and no severe cohesive adhesions were found. Comparative analyses of newer materials based on clinical reoperative findings are warranted to assess the safety of intraabdominally placed meshes.

Spontaneous splenic rupture in infectious mononucleosis: a review.

Spontaneous rupture of the spleen is a rare complication of infectious mononucleosis (IM) occurring in 0.1-0.5 percent of patients with proven IM [1]. Although splenectomy has been advocated as the definitive therapy in the past, numerous recent reports have documented favorable outcomes with non-operative management. A review of the literature suggests that non-operative management can be successful if appropriate criteria, such as hemodynamic stability and transfusion requirements are applied in patient selection. We report the case of a 36 year old man with infectious mononucleosis who had a spontaneous splenic rupture and who was successfully managed by splenectomy. Based on review of the literature, an approach to management of a spontaneously ruptured spleen secondary to IM is suggested.

The diagnosis and management of adult intussusception.

BACKGROUND: While intussusception is relatively common in children, it is a rare clinical entity in adults, where the condition is almost always secondary to a definable lesion. DATA SOURCES: Thirteen cases of intussusception occurring in individuals older than 16 were encountered at our institute between 1981 and 1994. RESULTS: Presenting signs/symptoms included recurrent bowel obstruction, intermittent pain, and red blood per rectum. Correct preoperative diagnosis was made in six patients using colonoscopy, flexible sigmoidoscopy, upper gastrointestinal (GI) series and computed tomography (CT). At surgery the lead point was identified in the small intestine in eight cases, in the colon in four cases, and one small intestinal intussusception was considered idiopathic. Twelve patients underwent laparotomy and one patient was both diagnosed and treated by colonoscopy alone. CONCLUSIONS: Adult intussusception is an unusual cause of bowel obstruction. The likelihood of neoplasia, particularly in the colon as a cause, is high. Operative management is thus almost always necessary.

Laparoscopic colon and rectal surgery at a VA hospital. Analysis of the first 50 cases.

BACKGROUND: Laparoscopic techniques were utilized for all colon and rectal procedures undertaken by a single surgeon at the West Haven VA Hospital beginning in August of 1991. METHODS: All patients were entered into a registry, and data was gathered prospectively. This report comprises the first 50 patients. These patients were compared with 34 consecutive patients undergoing open operations during the same time period. RESULTS: Overall, 33 patients (66%) were completed laparoscopically. This increased to 87% after the first 20 patients. Patients undergoing laparoscopic procedures showed significant improvement over the open and converted patients in several areas. Operative blood loss was decreased. They ate sooner (3.7 days) and required less postoperative pain medication. Major complications were less common after laparoscopic operations. Average length of stay was 8.3 days, compared with 13.9 days and 14.5 days in the converted and open groups, respectively. There was no difference in the operative time between laparoscopic and open cases; time for converted cases was significantly longer. There was no difference in lymph node counts among the three groups in patients with resections for cancer. CONCLUSIONS: Laparoscopic colorectal surgery is safe and effective, although its efficacy in malignant disease is uncertain. Patients enjoy the same benefits derived from other laparoscopic procedures. Although there appears to be a longer learning curve associated with the procedure, minimally invasive techniques should become utilized more frequently for patients with colorectal disease.

Cytomegalovirus infection masquerading as an ulcerative colitis flare-up: case report and review of the literature.

We report the case of a patient with a case of cytomegalovirus (CMV) colitis, which presented as a flare-up of her ulcerative colitis. Standard treatment for the flare-up, which included intravenous corticosteroids, bowel rest, topical salicylates and ultimately colectomy were not effective. The patient did not improve until therapy with intravenous ganciclovir was initiated. There have been 26 previous reports of CMV colitis complicating inflammatory bowel disease (IBD). The diagnosis is not frequently entertained and, if not made, leads to a high rate of colectomy (67 percent) and mortality (33 percent). Appropriate antiviral therapy appears to eliminate these complications, thus a high index of suspicion for CMV superinfection in cases of IBD refractory to traditional therapy is warranted.

Molecular aspects of restitution: functions of trefoil peptides.

Healing of mucosal damage takes place in two phases: restitution of mucosal integrity and remodeling towards recreating the original glandular arrangements. These processes can be observed in several experimental rodent models: e.g., cryoprobe or NSAID-generated ulcers in the gastric or duodenal mucosa and following surgical resection of the small or large bowel. In some studies, it has been possible to detect changes in the expression of peptides, either in the reparative epithelium or adjacent to the damage, that may contribute to the healing processes. Trefoil peptides are expressed constitutively by epithelial cells in specific regions of the gastrointestinal tract, in association with mucins. Several studies have shown that trefoil peptide expression is enhanced at sites of damage in man and rat, and experimental evidence supports their active participation in the healing process. Recombinant trefoil peptides are able to enhance the rate of epithelial cell migration in vitro and are able to protect against indomethacin-induced damage in vivo, yet they do not depend upon TGF-beta for enhancing cell migration and do not appear to affect acid secretion. The mode of action of trefoil peptides appears to be receptor-mediated but is not simple. There is good evidence that there are interactions between members of the trefoil family and the EGF family that are beneficial for mucosal defense and repair. This raises the possibility that combining trefoil peptides with other growth factors or small molecules may be advantageous for treatment of ulceration.

Optimal timing and indications for cholecystectomy in cardiac transplant patients.

Cardiac transplant is performed with increasing frequency as the treatment for end-stage cardiac disease. Although cholelithiasis is more frequent in both pretransplant and posttransplant patients, no standard management approach exists. Because many such patients are cared for outside the transplant center, it is important that general surgeons develop an appropriate strategy to manage this entity. We present our experience with 11 patients from our institution who underwent cholecystectomy before or after cardiac transplantation. In addition, we have reviewed the 76 reported cases of cholecystectomy performed in precardiac or postcardiac transplant patients from centers throughout the world. Any procedure in this patient group requires critical consideration in regard to the timing and type of procedure. Pretransplant patients are well recognized cardiac risks, and posttransplant immunosuppressed patients are at considerable risk for septic complications. Six patients underwent cholecystectomy prior to heart transplant. Five were performed laparoscopically, one as an open procedure. We also report five laparoscopic cholecystectomies in patients after cardiac transplant. One patient in the pretransplant group died 7 days after surgery from an uncontrollable arrhythmia. There were no hemodynamic or septic complications in either group. Current summated experience (87 cases) indicates that the mortality rate for urgent cholecystectomy in the posttransplant group is at least 36%. Because the first presentation of gallstones in this population is often acute cholecystitis, asymptomatic calculi cannot be considered benign. Elective cholecystectomy, laparoscopic or open, is tolerated well both before and after transplant. Given these facts, it seems reasonable to recommend pretransplant screening and posttransplant surveillance for gallstones.(ABSTRACT TRUNCATED AT 250 WORDS)

Metachronous small-bowel adenocarcinoma in celiac sprue.

Celiac sprue, or nontropical sprue, is associated with an increased incidence of digestive tract malignancy. We report a patient with celiac sprue who developed two primary adenocarcinomas of the jejunum > 2 years apart. The second cancer was asymptomatic and detected by surveillance computed tomography. Small-bowel cancers are unusual, and frequency of follow-up has not been established, so that it is important to have a high index of suspicion for these malignancies in celiac patients with vague gastrointestinal symptoms.

Laparoscopic cholecystectomy: from gimmick to gold standard.

Laparoscopic cholecystectomy was first performed in 1987, and within 2 years had become widespread. Its rapid growth was due in part to a perceived reduction in postoperative morbidity and shorter convalescence than with open cholecystectomy. Although these perceptions were shared both by surgeons and the lay public, no controlled study has documented them conclusively, but now, because of its popularity, it is unlikely that such a study will ever be undertaken. Nevertheless, a wealth of information has been accumulated on open cholecystectomy, and a large body of data is being generated regarding laparoscopic cholecystectomy. We examine selected reports of both laparoscopic and open cholecystectomy in terms of incidence and outcome. Our review supports the notion that laparoscopic cholecystectomy is safe and effective, has an acceptable complication rate, and a considerably shorter convalescence. Thus, laparoscopic cholecystectomy is now the treatment of choice for symptomatic cholelithiasis, and is becoming the new gold standard against which other procedures should be judged.

Gastrin and colon cancer. Clarifying the controversy.

Controversy exists about the relationship between hypergastrinemia and colon cancer. Conflicting lines of evidence may be interpreted to support a variety of views regarding the link between the two. Although some experimental and clinical data suggest a strong correlation, other studies refute this. It is likely that the actual situation lies between these two viewpoints; the complex nature of the relationship between carcinogenesis and putative gut hormones makes a definitive answer unlikely. Nevertheless, a critical reading of the recent literature suggests that hypergastrinemia does not play a direct role in colorectal carcinogenesis. Certain subgroups of patients with elevated serum gastrin levels and tumors that possess gastrin receptors may have accelerated tumor growth. Further study of this issue is warranted to elucidate the role of the gastrointestinal hormonal milieu in colorectal neoplasia.

Colon resection.

Laparoscopic surgery has been in existence for nearly a century, yet its widespread acceptance and application in the field of general surgery is a relatively recent occurrence. With the rapid acceptance of laparoscopic cholecystectomy, surgeons have sought other procedures which would be amenable to laparoscopic approaches. This, combined with a technology boom in laparoscopic instrumentation has made possible the development of advanced laparoscopic procedures such as colectomy. It is important to emphasize that laparoscopic colon surgery is still in an evolutionary stage, and that the procedures described are being continually refined as more experience is gained, as newer instruments are developed, and as software and video applications continue to improve. Nevertheless, the goal of any surgeon performing a laparoscopic procedure should be to perform an operation identical to the one done through a large incision.

Survival after resection of carcinoma of the splenic flexure.

Nine hundred ten patients undergoing colectomy for colon cancer were studied retrospectively. Seventy-four cancers (8 percent) were located at the splenic flexure. The stage at presentation was no different between splenic flexure cancers and colon carcinomas at other sites. Although splenic flexure cancers had twice the incidence of obstruction as did other colon cancers and obstruction in the overall series adversely affected survival, there was no difference in survival between splenic flexure cancer patients and patients with other colon cancers.