Haemodynamic effects of mechanical peritoneal retraction during laparoscopic cholecystectomy.

PURPOSE: Abdominal wall retraction (AWR) was recently proposed as an alternative for CO2 pneumoperitoneum. In this study we evaluated the cardiorespiratory effects of AWR during laparoscopic cholecystectomy. METHODS: Fifteen patients were studied during laparoscopic cholecystectomy using AWR. Monitoring included heart rate (HR), mean arterial pressure (MAP), pulse oxymetry (SpO2), end-tidal CO2 (PETCO2) minute ventilation, and peak inspiratory pressure (PIP). Using transoesophageal echocardiography, the transgastric short axis view was obtained to derive the end-diastolic area (EDA), the end-systolic area (ESA), and the ejection fraction (EF). These parameters were measured at predetermined periods: 1) five minutes after anaesthetic induction, 2) five minutes after AWR insertion, 3) 15 min after AWR insertion, and 4) after the end of surgery. RESULTS: No change in any measured parameter was observed over time in the AWR group except for an increase in MAP (P < 0.05) after AWR insertion. There were no changes in EDA, ESA and EF during the study, reflecting stable global cardiac function. In addition, no embolic episodes were observed during surgery. CONCLUSION: Our results demonstrate that the use of gasless abdominal distention for laparoscopic cholecystectomy results in a stable haemodynamic profile in healthy patients without cardiac disease, except for a brief increase in MAP after the AWR insertion. The advantages of AWR over conventional pneumoperitoneum should be confirmed in higher risk patients in a prospective, randomized study.

[Comparison of hemodynamic and ventilatory effects of pneumoperitoneum using carbon dioxide or abdominal suspension during laparoscopic cholecystectomy]. / Comparaison des effects hémodynamiques et ventilatoires d'un pneumopéritoine avec insufflation de CO2 ou par suspension abdominale lors d'une cholécystectomie par laparoscopie.

This study compares the cardio-respiratory effects of CO2 pneumoperitoneum to those of abdominal suspension (or laparolift) in laparoscopic cholecystectomy. Between september 1993 et may 1995, 31 patients participated in this non-randomized prospective trial. They consisted of 9 males et 22 females, with a mean age of 47.0 +/- 14 years. Sixteen patients were included in the CO2 group and 15 in the laparolift group. Both groups were comparable for age and gender. All patients were submitted to the same anaesthetic protocol. Repeated measurements of the respiratory and cardiovascular function were made during the intervention. End tidal CO2, minute ventilation, peak inspiratory pressure showed superior elevations in the CO2 group. And for the hemodynamic parameters, only the mean arterial pressure and cardiac frequency differed between the two groups, other hemodynamic parameters including left ventricular ejection fraction were comparable. Also, postoperatory hospital stay, OR time, per and postoperatory complications were comparable. With its stable hemodynamic and ventilatory pattern, abdominal suspension can constitute a safe and secure alternative to CO2 pneumoperitoneum in patients with respiratory dysfunction.

Common bile duct exploration: the place of laparoscopic choledochotomy.

Since laparoscopic cholecystectomy was introduced, the treatment of choledocholithiasis has been modified. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) has been performed selectively in elderly patients and in those with a strong suspicion of biliary duct stones (jaundice, demonstrated at ultrasound). Intraoperative discovery of common duct stones at cystic duct cholangiography signifies that they must be removed intraoperatively [or postoperatively by ERPC and endoscopic sphincterotomy (ES)]. As ES has a failure rate of 3-23%, laparoscopic common duct exploration emerges as the treatment of choice. Since November 1990, we have performed 59 laparoscopic common bile duct explorations. In our experience, the transcystic technique (18 patients) with choledochoscopy appears easier to perform than with fluoroscopy without choledochoscopy. Since, during our early experience, we encountered some difficulty with the transcystic technique, we elected to evaluate common duct exploration through a choledochotomy (41 patients). The main advantage of this technique is that it provides complete access to the ductal system without damage to the papilla. This procedure seems more difficult to perform than the transcystic technique and can be used when there are contraindications to the latter.

Colectomy and ileorectal anastomosis in patients with Crohn's disease.

Eighty-three patients underwent colectomy and ileorectal anastomosis for Crohn's disease of the large bowel. There were two postoperative deaths and seven anastomotic leaks. Fifty-two patients retained a functioning anastomosis with a mean follow-up of 8 years. Forty had an excellent or good functional result. The cumulative proportion of patients with a functioning ileorectal anastomosis was 77 and 63 per cent at 5 and 10 years respectively. Patients presenting with perforating Crohn's disease had a significantly increased risk of failure of the anastomosis. Perianal Crohn's disease following ileorectal anastomosis was significantly related to the need to defunction or excise the rectum.

[Abdominal rectopexy (Orr-Loygue) in rectal prolapse: celioscopic approach or conventional surgery]. / La rectopexie au promontoire (Orr-Loygue) dans le prolapsus rectal: approche coelioscopique ou chirurgie conventionnelle.

One of the treatment modalities for rectal prolapse is abdominal rectopexy, a comparison of the Orr-Loygue procedure, performed by laparotomy and by laparoscopy was done. From June 1981 and May 1993, 31 females and 3 males, with an average of age of 58.8 were operated. Twelve patients were operated by laparoscopy (group I) and 22 patients by laparotomy (group II). Two patients (16.7%) in group I were converted to a laparotomy due in one to operative hemorrhage and in the other to adhesions. Seven patients in group I and 18 in group II had had previous abdominal surgery. Average operative time was 2.56 hours and 2.25 hours for groups I and II respectively. A reduction in post operative hospital stay (5 vs 8.3 days) as well as in intramuscular analgesic requirements (5.5 vs. 14.1 doses) was observed in group I vs. group II respectively. Time to oral intake and cessation of intravenous fluids were also reduced in group I compared to group II (1.0 vs. 3.9 days and 2 vs. 5.8 days respectively). No mortality and minimal morbidity was observed in both groups. No recurrence of prolapse was noted in either group with an average of 12.6 mouths follow-up (2.8 to 17 months). We concluded that rectopexy by laparoscopy is technically feasible and has undeniable advantages over laparotomy.

[Total colectomy and ileorectal anastomosis in Crohn's colitis. Functional results and recurrence factors (83 cases)]. / Colectomie totale et anastomose iléo-rectale dans la colite de Crohn. Résultats fonctionnels et facteurs de récidive (83 cas).

Eighty-three consecutive patients (38 men, 45 women) underwent colectomy and ileorectal anastomosis (IRA) for Crohn's colitis between 1960 and 1988. The mean age at the time of IRA was 28.5 years after a mean interval of four years from diagnosis. At the time of IRA, 31 patients had proctitis, while 25 had perianal disease. Two patients died postoperatively. Postoperative complications appeared in 21 cases (25.3%) including 7 anastomotic leaks (13.2%). Leakage did not imply IRA compromise and the diverting ileostomy did not decrease the risk of preservation of the ileorectal anastomosis. With a mean follow-up of 8 years after IRA, among the 81 surviving patients, it was necessary to retain the stomy in five, 24 required exclusion or excision of their IRA (10 defunctioning ileostomies, 14 proctectomies) and 52 still had a functioning IRA at follow-up (64.2%). Among the 43 recurrences (53%), 21 underwent reoperation. The mean interval between IRA and recurrence was 2.2 years. The cumulative rate of recurrence reached 47% at 5 years and 57% at 10 years. Fifty percent of the patients still had a functioning IRA and were satisfied. Preoperative ileal lesions affected the functional results of the IRA and the recurrence rate. Development of ileal, rectal or anal disease after IRA significantly increased the risk of exclusion of the rectum but did not require suppression of anal function. Patients under 30 years of age or patients suffering for more than 5 years had poorer functional results and more frequent reoperations at 5 years. Rectal preservation after IRA may be proposed with success to patients with a healthy rectum or with minimal or moderate proctitis, even if there is perianal disease that could be safely treated before IRA. In this last setting, the patient has to be informed of the risk of rectal preservation and the possible risk of requiring ulterior proctectomy.

Survival of breast-cancer patients with previous or subsequent neoplasms.

The authors reviewed retrospectively 1510 patients with breast cancer operated on between 1960 and 1980. They compared 1353 patients who had an isolated breast cancer (group 1) with 157 patients who also had breast cancer but had other cancers either previously or subsequently (group 2). The mean age of patients in group 2 was 2 years more than that of patients in group 1. Group 2 patients had fewer T3 tumours, more T1 tumours (TNM classification), a lower incidence of lymph-node involvement and clinically less advanced tumours than group 1 patients. Hormonal status, histologic type of tumour and surgical and adjuvant treatment were identical in both groups. The 10-year survival rate (considering death from breast cancer) was 54.6% in group 1 versus 78.1% in group 2. The overall survival rate (considering death from breast cancer or from the other cancer) was 54.1% in group 1 versus 64.5% in group 2. Survival was also better in group 2 for each clinical stage. The authors conclude that patients who have another cancer before or after the development of their breast cancer have a better survival rate than those who have isolated breast cancer with no previous or subsequent neoplasms.

Excision of the rectum with colonic J pouch-anal anastomosis for adenocarcinoma of the low and mid rectum.

The results of rectal excision with colonic pouch-anal anastomosis are reviewed from a series of 162 patients covering 7 years. All patients have been operated upon in the same institution and consecutively. The follow-up is now sufficient to allow an accurate evaluation of the outcome of the patients. The main goal of this study was to provide a detailed report of the functional results. Continence was satisfactory in 96% of the patients, with either a perfect continence or minor troubles that would not have been detectable other than by a rigorous questioning. The mean number of bowel movements was 2 per 24 hours. Fragmentation of the defecation and urgency were absent. Twenty-five per cent of the patients had to elicit the evacuation of the reservoir with a suppository or an enema. Improvement of function yielded by a reservoir over straight colo-anal and low colo-rectal anastomoses are significant and, as suggested by manometric studies, are directly related to the restoration of a reservoir function.

Comparative clinical results of ileal-pouch anal anastomosis and ileorectal anastomosis in ulcerative colitis.

The aim of the study was to compare the results of ileal-pouch anal anastomosis (IAA) and total abdominal colectomy with ileorectal anastomosis (IRA) in the treatment of ulcerative colitis. The number of patients included in the comparative trial was 104 (IAA) and 197 (IRA), respectively. No clear advantage of IRA over IAA was seen: postoperative mortality and morbidity were about the same; functional results as shown by the frequency of stools and daytime continence were virtually equal. A factor favoring IAA was, among others, recurrence of proctitis after IRA which is more difficult to treat than the pouchitis occurring after IAA and is associated with a higher rate of secondary permanent end ileostomy; besides, IRA entails the risk of cancer developing in the rectal stump, while at the same time it is difficult to follow up these patients closely enough. IRA is indicated only if the diagnosis of ulcerative colitis is in doubt; if the patient is more than 60 years of age; and if IAA proves technically too difficult, IAA is usually preferable, however, if there is any doubt as to whether the patient is suffering from ulcerative colitis or Crohn's disease, ileorectostomy is preferred which does not preclude IAA at a later date in case of need.