Are major laparoscopic pancreatic resections worthwhile? A prospective study of 32 patients in a single institution.

BACKGROUND: Laparoscopic surgery has been used increasingly as a less invasive alternative to conventional open surgery. Recently, laparoscopic therapy for pancreatic diseases has made significant strides. The current investigation studied pancreatic resection by laparoscopy. The objective of this study was to assess the feasibility, safety, and outcome of laparoscopic pancreatic major resection for benign and malignant lesions of the pancreas. METHODS: A prospective study of laparoscopic pancreatic resections was undertaken in patients with benign and malignant lesions of the pancreas. Over an 8-year period, 32 patients underwent laparoscopic pancreatic major resection: 21 left pancreatectomies (1 performed using a retroperitoneal approach), and 11 pancreatoduodenectomies (10 Whipple procedures and 1 total pancreatectomy). All the operations were performed in a single institution. RESULTS: The operations were performed without serious complications. Only one left pancreatectomy was converted to laparotomy because of massive splenic bleeding, and one Whipple procedure was converted because of adhesion to the portal vein. In four of the Whipple operations, the resection was performed completely laparoscopically, and the reconstruction was done via a small midline incision. There was no operative mortality. In 16 patients of the left pancreatectomy group, the spleen was preserved. The mean blood loss was 150 and 162 ml; and the mean operating time was 154 and 284 min, respectively, for the left pancreatectomy and the Whipple procedure. Postoperative complications occurred for five patients after left pancreatectomy and for three patients after the Whipple procedure. Two patients needed surgical reexploration after left pancreatectomy because of intraperitoneal haemorrhage and eventration of the extraction site. Two patients underwent reoperation after the Whipple procedure: one because of intraabdominal bleeding and the other because of small bowel obstruction. The mean hospital stay was 10.8 days after left the pancreatectomy and 13.6 days after the whipple procedure. CONCLUSION: Laparoscopic left pancreatectomy for benign and malignant lesions is feasible, safe, and beneficial. We believe that pancreatoduodenectomy should be performed only in selected cases and by a highly skilled laparoscopic surgeon. If there is any doubt, an open resection should be performed.

Laparoscopic and open gastric resections for malignant lesions: a prospective comparative study.

BACKGROUND: Whereas laparoscopy for benign diseases provides clear advantages over traditional surgery, the benefits of laparoscopic gastric resection for malignant diseases are less clear. The objectives of this study were to compare prospectively the clinical outcomes between completely laparoscopic and open total and partial gastrectomies for malignant diseases and to assess whether laparoscopic gastrectomies obtain adequate margins and follow oncologic principles. METHODS: Between April 1995 and March 2004, a prospective comparative study was performed comparing eight patients who underwent laparoscopic total gastrectomy with 11 patients who underwent open total gastrectomy, and 16 patients who underwent laparoscopic partial gastrectomy with 17 who patients underwent open partial gastrectomy. Stage, extent of lymphadenectomy, and long-term follow-up were examined. The intraoperative and postoperative details of the two groups were compared. RESULTS: The laparoscopic group patients had fewer intraoperative complications while the operative time was similar to that of the open group. Both ambulation and hospital stay were significantly shorter in the laparoscopic groups than in the open groups. The short-term morbidity was lower in the laparoscopic groups and there were no cases of death, whereas one case of postoperative death occurred after an open total gastrectomy. There was no need to convert to open surgery. The number of lymph nodes obtained in the laparoscopic and open procedures was not significantly different. In addition, all resected margins were tumor free in the laparoscopic group, whereas tumor involvement was presented in the margin of one specimen in the open group. CONCLUSIONS: The totally laparoscopic approach to total and partial gastrectomies had good results and was proven to be a feasible and safe procedure. In addition, the laparoscopic procedures are superior to open surgeries in terms of faster postoperative recovery, shorter hospital stay, and better cosmetic outcomes. A totally laparoscopic approach for early and advanced gastric cancer can obtain adequate margins and follow oncologic principles.

Laparoscopic surgery: A pioneer's point of view.

For a surgeon who performed some of the first laparoscopic cholecystectomies, laparoscopic surgery is undoubtedly the main revolution in the last decade of this century. It is impossible not to be fascinated by the extraordinary changes introduced in our profession in less than 10 years. However, looking back in history, one realizes that laparoscopy is but one of those leaps forward that have always punctuated the evolution of our profession. Since the last century we have witnessed the advent of painless surgery, infectionless surgery, reconstructive surgery, microsurgery, surgery under extracorporeal circulation, organ replacement, and so on. We are in the time of scarless surgery, with no lengthy postoperative handicap. Maybe tomorrow will see surgery performed by remote-controlled robots and surgery at the molecule level. The laparoscopic revolution is particularly important because for the first time surgery no longer involves any physical contact between the surgeon's hand and the patient. Let us hope that this will not lead to total absence of a human relationship in the surgical operation. To avoid this possibility we must remain resolutely involved in the development of laparoscopic surgery; we must keep our minds open to the future advances of science and technology and integrate them in our operative procedures.

Advances in laparoscopic surgery.

After a brief account of the origins of laparoscopy and of its development into an interventional technique thanks to technical improvement, the author gives a dynamic state of the art in laparoscopic surgery, beginning with a description of his original classification method for laparoscopic procedures according to their level of use. Before tackling the highly controversial issue of laparoscopic surgery for cancer, he reviews in detail the various operations successfully performed by laparoscopy for the treatment of nonmalignant abdominal disorders and acute syndromes, all the while checking their results against those obtained with their open counterparts. As the various procedures are described, the interest of the laparoscopic approach becomes clearly visible, based on the excellent view of the operative field that allows diagnostic accuracy, thus avoiding unnecessary operations, and precise dissection with minimal damage. However, the laparoscopic approach is highly dependent on the surgeon's proficiency, itself depending on experience and therefore on the frequency of occurrence of the disorder, and on the progress in and availability of adequate equipments. The last chapter looks into the future of this ever-expanding approach and defines two great trends in its evolution, one accessible to the individual surgeon, the gradual adaptation of open procedures into laparoscopic ones, the other at the institutional level, in view of the huge financial support involved if high technologies are to be systematically integrated in this new surgery. What will the future be like?

[Functional results of the laparoscopic treatment of gastroesophageal reflux (followup greater than 2 years)]. / Résultats fonctionnels du traitement laparoscopique du reflux gastro-oesophagien (recul supérieur à 2 ans).

STUDY AIM: The of this study was to evaluate functional results in 70 patients operated on for gastroesophageal reflux disease with a follow-up > 2 years, by means of a questionnaire sent to them. PATIENTS AND METHODS: Functional results were evaluated in the 60 patients who answered the questionnaire. The fundoplication (Nissen = 27, Nissen-Rosseti = 21, Toupet (n = 12) was laparoscopically performed with a mean follow-up of 3.4 years (range: 2-6.6 years). A circular wrap (either Nissen or Nissen-Rossetti) had been systematically performed except in patients who had an esophageal motility disorder, who had a partial wrap according to Toupet. RESULTS: Three patients experienced recurrent symptoms of reflux (failure rate: 5%). Thirteen patients had mild dysphagia, requiring modification of the oral intake in two cases. No patient required dilatation. Fifty patients complained of postoperative side effects: flatulence (n = 40), meteorism (n = 24), abdominal pain (n = 16), diarrhea (n = 12), impossibility either to vomit (n = 16) or to belch (n = 20). Ten patients were symptom free and had neither symptoms of reflux nor side effects. Despite undesirable side effects, 46 patients (78%) were very satisfied with the operation, six (10%) were satisfied and five (8%) were disappointed. CONCLUSION: Recurrent symptoms of reflux were rarely observed (5%) but postoperative side effects were frequent (67%). Side effects when present provide less discomfort than reflux itself. Patients must be aware of it prior to surgery. These results should be confirmed by further assessments.

[Laparoscopic fundoplication for gastroesophageal reflux. Apropos of our first 123 patients]. / Fundoplicature par laparoscopie pour reflux gastro-oesophagien. A propos des 123 premiers patients.

From July 1991 to March 1997, 123 patients underwent laparoscopic fundoplication. Surgical indications were as follows: either failure of medical therapy, or early recurrence of symptoms after interruption of medical treatment in young patients or large hiatal hernia associated with symptoms of reflux and/or symptoms of mediastinal compression. The type of the wrap was tailored to the preoperative manometry: circumferential fundoplication was achieved in patients with normal esophageal motility, and partial wrap in patients with altered motility. Short gastric vessels were not routinely divided. One hundred and eleven circumferential fundoplications were performed: 52 with division of short gastric vessels and 49 without, whereas there were 22 partial wraps. In 4 cases, it was necessary to switch to open surgery (conversion rate: 3.2%): 2 enlarged left liver lobes, one esophageal tear and one splenic injury. Six postoperative complications were observed (morbidity rate: 4.8%), one of whom was severe and led to the patient's death due to necrosis of the fundus. After a mean follow-up of 1.7 +/- 1.4 years, 4 patients have transient recurrent reflux, 3 patients have had annoying dysphagia requiring balloon dilatation in one case and reoperation in two cases. Four patients experienced a late thoracic migration: in one case after a violent physical effort, requiring urgent reoperation; in the other three cases, the migration remained asymptomatic. The pH- and manometric study performed in 41 consecutive patients before and after surgery allows objective evaluation of the results.

[Ileocaecal tuberculosis. Apropos of a case]. / La tuberculose iléo-caecale. A propos d'une observation.

The authors report a case of ileocaecal tuberculosis in a 27-year-old man with no particular risk factor for this disease. The initial diagnosis was terminal ileitis discovered at appendicectomy. The diagnosis of ileal tuberculosis was suspected in the presence of giant cell follicles on ileal biopsies, and was confirmed by the presence of AFB in the gastric intubation fluid. This patient presented known atypical pulmonary images for several years, which had never been investigated in more detail. A favourable course was observed in response to triple-agent, then double-agent antibiotic therapy. This case illustrates the fact that ileal tuberculosis still exists today, and that it does not exclusively affect "high-risk" patients.

[Digestive surgery using the celioscopic route. Prospects for the future]. / La chirurgie digestive par voie coelioscopique. Perspectives d'avenir.

Digestive surgery through the laparoscopic approach started to develop in March 1987 when the first laparoscopic cholecystectomy was performed. Thanks to the quick success achieved by the pioneers, most of the surgeons soon became aware of the advantages of the method. In the history of surgery, very few procedures have been fortunate enough to cause such a radical and sudden change in each surgeon's daily practice. Over a period of eight years, all the major procedures in digestive surgery have been performed through the laparoscopic approach ; it is now time to evaluate them. Only laparoscopic cholecystectomy has satisfied all the requirements for official approval, thus becoming the gold standard for the treatment of gallbladder lithiasis. However, the use of laparoscopy in the treatment of digestive diseases has already led to a number of major achievements, which makes it possible to outline its prospects. It will develop along two main lines, the first one being gradual transformation of open surgical procedures into laparoscopic procedures through adaptation of operative manoeuvres and design of new instruments. Any surgeon can achieve this transformation provided that he gets specific training. The second line of development will be the integration of high technologies into operative procedures. But this can only be achieved by multidisciplinary institutes endowed with huge financial resources. Patients derive such benefit from laparoscopic surgery that its practise has now reached the point of no-return. Laparoscopic surgery is part of the general evolution towards treatments involving less and less adverse side-effects. It is no doubt the surgery of the future.

[Treatment of esophageal fistulas after gastrectomy. Apropos of 4 cases]. / Traitement des fistules oesophagiennes après gastrectomie. A propos de 4 observations.

The authors report 4 cases of esophageal fistula following a total gastrectomy. One patient died after a reoperation for a subphrenic abscess, another just before a coloplasty 3 months after an esophageal exclusion. Two patients have been successfully treated by an operation which comprised the removal of the fistula and an intra-thoracic esophago-jejunal anastomosis. This procedure, albeit risked, is probably a better option than the esophageal exclusion usually recommended, particularly in the patients with a malignant disease who have a short life expectancy.

Management of bile duct stones in the era of laparoscopic cholecystectomy.

The introduction of laparoscopic cholecystectomy has resulted in increased options for the management of bile duct stones and has stimulated a fundamental reappraisal of the situation before the laparoscopic era. This article reviews the natural history of bile duct stones and details the different ways in which they may now be treated. New areas of controversy are highlighted and the need for further studies is emphasized.

Conversions and complications of laparoscopic cholecystectomy. Results of a survey conducted by the French Society of Endoscopic Surgery and Interventional Radiology.

During 1991, 41 surgeons of the French Society of Endoscopic Surgery and Operative Radiology (SFCERO) performed 3,673 cholecystectome of which 2,955 were laparoscopic. Data for those patients in whom a conversion to laparotomy was necessary or a complication occurred were collected by a retrospective multicenter survey. Conversion was performed in 142 patients (4.8%): in 106 this was due to pathology in the subhepatic space; in 36 it was because of a complication related to the laparoscopy. There were 101 postoperative complications (morbidity 3.4%): 59 biliary and 42 non biliary complications and six deaths (mortality 0.2%). There were 18 bile duct injuries, one of which led to the death of the patient. Excluding conversions to laparotomy, these figures are comparable to those for open cholecystectomy. These results define the limits and advantages of laparoscopic cholecystectomy. Conversion to laparotomy remains a wise option in cases of technical difficulty or doubtful biliary anatomy.

Laparoscopic cholecystectomy: the European experience.

Laparoscopic cholecystectomy, initially performed in France in 1987, has rapidly spread to other European countries, the United States, and elsewhere. Of the techniques that have evolved, the "French" technique, in which the surgeon stands between the patient's legs, and the "American" technique, in which the surgeon stands on the patient's left side, are the most commonly used. In the former technique, the liver is retracted via the mid-clavicular cannula and the infundibulum of the gallbladder via the anterior axillary port. In the latter technique, the liver is retracted by axial traction on the gallbladder through the anterior axillary cannula and the infundibulum through the mid-clavicular cannula. This position may increase the risk of bile duct injury. The technique selected for operative cholangiography should be adapted to the problem at hand. Cystic duct cholangiography shows ductal calculi more reliably due to better filling of the common bile duct; direct puncture of the gallbladder is safer when the biliary anatomy is unclear. A number of European studies confirm the safety of laparoscopic cholecystectomy. Mortality rates vary between 0% and 0.1%, and duct injury rates range between 0.2% and 0.6%. Conversion, which is done in 3% to 8% of cases, may be necessary in the case of uncontrollable hemorrhage, bile duct injury unsuitable for laparoscopic repair, or if the gallbladder is densely scarred (scleroatrophic). It can also be done for safety reasons, when the anatomy is unclear. Complications include bile collections due to accessory duct or cystic duct stump leaks or less commonly to common duct injury. The average postoperative stay is longer in Europe (3.2 days) than in the United States. A decision tree is presented for the management of common bile duct stones. In general, preoperatively identified ductal stones are removed by endoscopic sphincterotomy, which is then followed by laparoscopic cholecystectomy to remove the source of the calculi. The techniques of laparoscopic choledochotomy and transcystic exploration for the removal of stones in the common bile duct are only beginning to be used, but they may well prove to be the most popular procedures. Results with these procedures will need to be evaluated against those obtained with endoscopic sphincterotomy.

Laparoscopic cholecystectomy: an analysis of 777 cases.

Born in secret in 1987 and developed in an atmosphere of scepticism throughout 1988, laparoscopic cholecystectomy triumphed in 1989 and 1990, causing a veritable revolution in the world of general surgery. The 777 consecutive cases that are reported in this chapter reflect the spirit of these various periods. From conservatively restrictive, our indications widened to include 90% of gallstone cases. For us the sclero-atrophic gallbladder still constitutes the greatest endoscopic challenge and should be reserved for the most experienced operators. The rates for mortality (0.1%) and complications (3.3%), which include three common bile duct injuries (0.4%), are comparable to, if not better than, those for traditional cholecystectomy. The quality of recovery is markedly better: near absence of pain, short hospitalization, return to normal physical activity within 10 days, rapid return to work and preservation of the abdominal musculature in sportspeople. These advantages are unavailable to the 5.5% of patients for whom an intraoperative conversion to an open procedure is necessary. Their recovery is that of traditional cholecystectomy, which itself is far from being poor. The large multicentre studies, such as those carried out in France and Belgium recently, reporting 3708 cases, have reached identical conclusions. Laparoscopic cholecystectomy is set to become the gold standard for treatment of gallstones and is the first step towards surgical techniques of the 21st century which will be performed within the musculocutaneous envelope of the intact human body.

Laparoscopic cholecystectomy: the state of the art. A report on 700 consecutive cases.

Born in secret in 1987, developed in an atmosphere of skepticism and even hostility throughout 1988, the laparoscopic cholecystectomy triumphed in 1989-90 and caused a veritable revolution in the world of general surgery. The 700 consecutive cases that we report here reflect the spirit of these various periods. From prudently restrictive, our indications widened to include 90% of all patients with gallbladder lithiasis. Sclero-atrophic gallbladders constitute the greatest challenge for endoscopic maneuvers. This group of patients should be treated by the most experienced operators only. The figures for mortality (0.1%) and complications (3%) are very comparable and even better than those for traditional cholecystectomy. The quality of recovery is infinitely better; there is absence of pain, a short period of hospitalization, return to normal physical activity within 10 days, rapid return to work, and total preservation of the abdominal muscles for participation in sports activities. All these advantages are assets of the laparoscopic cholecystectomy which are not available to the 6% of patients for whom an intra-operative conversion to open surgery is necessary. These patients recover within the conditions of a traditional cholecystectomy which are far from being poor. The large multicenter studies, such as those carried out in France and Belgium recently involving 3,708 patients, arrive at identical conclusions. The laparoscopic cholecystectomy is on its way to becoming the gold standard of treatment for gallbladder lithiasis. It is the first successful step towards surgical techniques of the 21st century which will be carried out inside the musculo-cutaneous envelope of the unopened human body.

A new biodegradable elastin-fibrin material; its use in urological, digestive and cardiovascular surgery.

A new original artificial connective matrix mainly made of elastin and fibrin-like product is used to reinforce damaged tissues and to close and restore a loss of substance in several domains of surgery: all sites in the digestive system and urinary tract; besides, it can substitute for the pericardium in iterative heart operations. In all cases, the original tissue is restored ad integrum while the biodegradable material disappears completely, without any complications.