Quality of life from a randomized trial of laparoscopic or open liver resection for colorectal liver metastases.

BACKGROUND: Most treatments for cancer cause a decline in patients' health-related quality of life (HRQoL). Limiting this decline is a universal goal for healthcare providers. Using minimally invasive instead of open surgical techniques might be one way to achieve this. The aim of this study was to compare postoperative HRQoL after open and laparoscopic liver resection. METHODS: This was a predefined substudy of an RCT comparing open with laparoscopic liver resection. Patients with colorectal liver metastases were assigned randomly to open or laparoscopic parenchyma-sparing liver resection. HRQoL was assessed with the Short Form 36 questionnaire at baseline, and 1 and 4 months after surgery. RESULTS: A total of 280 patients were randomized, of whom 273 underwent surgery (129 laparoscopic, 144 open); 682 questionnaires (83.3 per cent) were available for analysis. One month after surgery, patients in the laparoscopic surgery group reported reduced scores in two HRQoL domains (physical functioning and role physical), whereas those in the open surgery group reported reduced scores in five domains (physical functioning, role physical, bodily pain, vitality and social functioning). Four months after surgery, HRQoL scores in the laparoscopic group had returned to preoperative levels, whereas patients in the open group reported reduced scores for two domains (role physical and general health). The between-group difference was statistically significant in favour of laparoscopy for four domains after 1 month (role physical, bodily pain, vitality and social functioning) and for one domain after 4 months (role physical). CONCLUSION: Patients assigned to laparoscopic liver surgery reported better postoperative HRQoL than those assigned to open liver surgery. For role limitations caused by physical health problems, patients in the laparoscopic group reported better scores up to 4 months after surgery. Registration number: NCT01516710 ( http://www.clinicaltrials.gov).

ANTECEDENTES: La mayoría de los tratamientos para el cáncer causan una disminución de la calidad de vida relacionada con la salud (health-related quality of life, HRQoL) de los pacientes. Limitar este declive es un objetivo universal para los proveedores de atención médica. El uso de técnicas quirúrgicas mínimamente invasivas en lugar de abiertas podría ser una forma de lograrlo. El objetivo de este estudio fue comparar la HRQoL postoperatoria después de la resección hepática abierta y laparoscópica. MÉTODOS: Se trata de un subestudio predefinido de un ensayo aleatorizado y controlado que comparó la resección hepática abierta con la laparoscópica. Los pacientes con metástasis hepáticas colorrectales se asignaron aleatoriamente al grupo de resección hepática con preservación de parénquima por vía abierta o por vía laparoscópica. La HRQoL se evaluó con el cuestionario abreviado SF-36 en el momento basal y al cabo de 1 y 4 meses después de la cirugía. RESULTADOS: Un total de 280 pacientes fueron aleatorizados, de los cuales 273 se sometieron a cirugía (129 = laparoscópica, 144 = abierta) y hubo 682 cuestionarios (83%) disponibles para el análisis. Un mes después de la cirugía, los pacientes del grupo de cirugía laparoscópica presentaron puntuaciones reducidas en dos items de HRQoL (función física y rol físico), mientras que los pacientes del grupo de cirugía abierta presentaron puntuaciones reducidas en cinco items (función física, rol físico, dolor corporal, vitalidad y función social). Cuatro meses después de la cirugía, el grupo de cirugía laparoscópica había vuelto a los niveles preoperatorios de la HRQoL, mientras que los pacientes del grupo de cirugía abierta presentaron puntuaciones reducidas para dos items (función física y salud general). La diferencia entre los grupos fue estadísticamente significativa a favor de la laparoscopia para cuatro items después de un mes de la cirugía (rol físico, dolor corporal, vitalidad y función social) y para un ítem (rol físico) después de cuatro meses. CONCLUSIÓN: Los pacientes asignados a cirugía hepática laparoscópica presentaron mejor HRQoL postoperatoria que los pacientes asignados a cirugía hepática abierta. Para las limitaciones de roles causadas por problemas físicos de salud, los pacientes de cirugía laparoscópica presentaron mejores puntuaciones a los cuatro meses tras la intervención quirúrgica.

Minilaparotomy for treatment of choledocholithiasis.

BACKGROUND: Minilaparotomy has been reported to be an alternative minimally invasive option to laparoscopy. However, the quality of available data on the effectiveness of minilaparotomy to treat choledocholithiasis is poor. MATERIALS AND METHODS: Two hundred and twenty-eight patients with choledocholithiasis underwent surgical exploration of the common bile duct via minilaparotomy from 1995 to 2010. Of these, 193 patients had choledocho/cholecystolithiasis with previous ineffective attempts at endoscopic clearance and 29 patients had choledocho/cholecystolithiasis without previous attempts at endoscopic clearance. Six other patients had recurrent/residual choledocholithiasis despite ineffective attempts at endoscopic clearance. Peri-operative adverse events were analyzed in accordance with the revised Satava classification for intra-operative events while post-operative complications were graded according to the Accordion classification. RESULTS: Conversion was needed in 3.9% of procedures. The mean operative time was 86 min. Post-operative complications occurred in 6.1%, 2.2% of which were major (Accordion grade 4-6). Mortality was 0.9%. CONCLUSION: Minilaparotomy is an effective minimally invasive approach for the surgical treatment of choledocholithiasis. This approach could be considered as an alternative to the laparoscopic approach for surgical exploration of the common bile duct in patients with choledocholithiasis.

Laparoscopic liver surgery: new frontiers.

Laparoscopic liver resection (LHR) has shown classical advantages of minimally invasive surgery over open counterpart. In spite of introduction in early 1990's only few centres worldwide adapted LHR to routine practice. It was due to considerable technical challenges and uncertainty about oncologic outcomes. Surgical instrumentation and accumulation of surgical experience has largely enabled to solve many technical considerations. Intraoperative navigation options have also been improved. Consequently indications have been drastically expanded nearly reaching criteria equal to open liver resection in expert centres. Recent studies have verified oncologic integrity of LHR. However, mastering of LHR is still a quite demanding task limiting expansion of this patient friendly technique. This emphasizes the necessity of systematic training for laparoscopic liver surgery. This article reviews the state of the art of laparoscopic liver surgery lightening burning issues of research and clinical practice.

Single-centre experience of laparoscopic pancreatic surgery.

BACKGROUND: Laparoscopic resection is regarded as safe and feasible in selected patients with benign pancreatic tumours. Few data exist on laparoscopic surgery for malignant lesions and larger neoplasms in unselected patients. METHODS: The study included all patients admitted to Oslo University Hospital, Rikshospitalet, from March 1997 to March 2009 for surgery of lesions in the body and tail of the pancreas, and selected patients with lesions in the pancreatic head, who underwent surgery by a laparoscopic approach with curative intent. RESULTS: A total of 166 patients had 170 operations, including 138 pancreatic resections, 18 explorations, nine resections of peripancreatic tissue and five other therapeutic procedures. Four patients had repeat procedures. There were 53 endocrine tumours (31.0 per cent), 28 pancreatic carcinomas (16.4 per cent), five cases of metastases (2.9 per cent), 48 cystic tumours (28.1 per cent) and 37 other lesions (21.6 per cent). The total morbidity rate was 16.5 per cent. Fistula was the most common complication (10.0 per cent). Three patients needed reoperation for complications. There were three hospital deaths (1.8 per cent). Median hospital stay following surgery was 4 days. CONCLUSION: Laparoscopic resection of lesions in the body and tail of the pancreas in an unselected patient series was safe and feasible, and should be the method of choice for this patient group in specialized centres.

Evaluation of endoscopic and traditional open approaches to pheochromocytoma.

BACKGROUND: Laparoscopic adrenalectomy is an excellent alternative to open surgery, while there are doubts in regard to laparoscopic treatment of pheochromocytoma due to its unsteady intraoperative hemodynamics. The goal of the study was to define optimal surgical approach to pheochromocytoma. METHODS: A total of 99 patients with pheochromocytoma were operated from 1990 to 2002. Nine, 28, 40, and 22 patients were operated respectively through laparoscopic (group 1), thoracophrenotomic (group 2), lumbotomic (group 3), and laparotomic (group 4) approaches. Intraoperative parameters including those related with hemodynamic stability were studied. Postoperative analgesic medication, complications, and hospital stay were registered. RESULTS: Mean operative time was 132 +/- 49 min, 104 +/- 29 min, 81 +/- 30 min, and 129 +/- 40 min, respectively, in groups 1, 2, 3, and 4. Thoracophrenotomic approach had a minimal time from starting of adrenal dissection to central adrenal vein crossing on the right side and lumbotomic approach on the left side. Laparoscopy showed longest length of that period on both sides. However, we observed more stable intraoperative dynamics during laparoscopic adrenalectomy in comparison with any traditional open approaches on both sides. Mean blood loss was 178 +/- 112 ml, 410 +/- 255 ml, 314 +/- 163 ml, and 420 +/- 398 ml, respectively, in groups 1, 2, 3, and 4. Blood transfusions were required in 0%, 35.7%, 20%, and 13.6% of cases, respectively, in groups 1, 2, 3, and 4. Using laparoscopic approach resulted in significant decrease of prescription of opoids, postoperative hospital stay, and rate of postoperative complications. Among traditional approaches lumbotomy presented better postoperative results due to its less invasive nature. CONCLUSION: Laparoscopy is a method of choice to pheochromocytoma in experienced hands. Open approaches are still feasible. Among traditional approaches lumbotomy should be preferred. Thoracophrenotomy can be justified only for major tumors on the right side. Laparotomy is indicated in selected cases of extraadrenal pheochromocytoma.

Laparoscopic and open surgery for pheochromocytoma.

BACKGROUND: Laparoscopic adrenalectomy is a promising alternative to open surgery although concerns exist in regard to laparoscopic treatment of pheocromocytoma. This report compares the outcome of laparoscopic and conventional (open) resection for pheocromocytoma particular in regard to intraoperative hemodynamic stability and postoperative patient comfort. METHODS: Seven patients laparoscopically treated (1997-2000) and nine patients treated by open resection (1990-1996) at the National Hospital (Rikshospitalet), Oslo. Peroperative hemodynamic stability including need of vasoactive drugs was studied. Postoperative analgesic medication, complications and hospital stay were recorded. RESULTS: No laparoscopic resections were converted to open procedure. Patients laparoscopically treated had fewer hypertensive episodes (median 1 vs. 2) and less need of vasoactive drugs peroperatively than patients conventionally operated. There was no difference in operative time between the two groups (median 110 min vs. 125 min for adrenal pheochromocytoma and 235 vs. 210 min for paraganglioma). Postoperative need of analgesic medication (1 vs. 9 patients) and hospital stay (median 3 vs. 6 days) were significantly reduced in patients laparoscopically operated compared to patients treated by the open technique. CONCLUSION: Surgery for pheochromocytoma can be performed laparoscopically with a safety comparable to open resection. However, improved hemodynamic stability peroperatively and less need of postoperative analgesics favour the laparoscopic approach. In experienced hands the laparoscopic technique is concluded to be the method of choice also for pheocromocytoma.

Does tumor size influence the outcome of laparoscopic adrenalectomy?

BACKGROUND: Laparoscopic adrenalectomy is safe and effective for small adrenal tumors, but its role for large adrenal tumors and the influence of tumor size on the outcome of laparoscopic adrenalectomy have been questioned. PATIENTS AND METHODS: Thirty-one patients with unilateral adrenal tumors operated on between January 1997 and April 2000 were selected for this study. The indications for surgery were Conn's adenoma in 16 patients, pheochromocytoma in 7 patients, Cushing's adenoma in 4 patients, and incidental lesions in 4 patients. The patients were divided in two groups: 19 patients with tumors <3.5 cm (Group I) and 12 patients with tumors > or = 3.5 cm (Group II). The outcomes of the two groups were compared. RESULTS: None of the laparoscopic procedures was converted to open surgery. The tumor size correlated with operative time (r = 0.434; P = 0.015) and blood loss (r = 0.513; P = 0.003), with both being significantly greater for larger tumors. No patient required a blood transfusion during or after surgery. One preoperative complication occurred in Group I. There was no peroperative complication in Group II. The median postoperative hospital stay and opioid requirement did not differ significantly between the groups. One patient in Group I developed pneumonia, while no postoperative complications were recorded in Group II. CONCLUSION: Surgery for large adrenal tumors can safely be performed laparoscopically with outcomes comparable to those of surgery for small tumors.