Laparoscopic distal pancreatectomy for benign or borderline malignant pancreatic tumors.

BACKGROUND/AIMS: Laparoscopic distal pancreatectomy (LDP) for benign conditions is increasingly performed. But, there are few limited studies about the outcomes of the laparoscopic surgery compared with open surgery. The aim of this study was to evaluate the clinical outcomes of LDP and compare it to that of open distal pancreatectomy (ODP). MATERIALS AND METHODS: From July 2007 to February 2012, 60 consecutive patients (41 LDP patients and 19 ODP patients) who underwent elective distal pancreatectomy with an apparent diagnosis of benign or borderline malignant tumor were recruited into the current study. RESULTS: There were no significant differences in operation time, transfusion, intravenous patient-controlled analgesia (IV-PCA) duration, pancreatic fistula, mortality, and recurrence between the two groups. Compared to ODP, LDP had lower blood loss (272.7±134.8 vs. 476.9±140.8 ml; p=0.002), shorter time to first flatus (2.4±0.5 vs. 4.0±1.5 days; p=0.003), earlier time to oral intake (3.4±1.6 vs. 5.4±1.9 days; p=0.013), and shorter postoperative hospital stay (9.4±6.9 vs. 17.0±6.7 days; p=0.043). CONCLUSION: LDP is a safe procedure and should be considered as a standard treatment option for benign or borderline malignant pancreatic tumors.

Clinical outcomes compared between laparoscopic and open appendectomy in pregnant women.

BACKGROUND: Despite the initial absolute or relative contraindication of laparoscopic surgery during pregnancy, in the last decade, laparoscopic appendectomy (LA) has been performed in pregnant women. But few studies compare the outcomes of LA compared with open appendectomy (OA). We investigated clinical outcomes to evaluate the safety and efficacy of LA compared with OA in pregnant women. METHODS: We recruited consecutive pregnant patients with a diagnosis of acute appendicitis who were undergoing LA or OA between May 2007 and August 2011 into the study. RESULTS: Sixty-one patients (22 LA and 39 OA) enrolled in our study. There were no significant differences in duration of surgery, postoperative complication rate and obstetric and fetal outcomes, including incidence of preterm labour, delivery type, gestation age at delivery, birth weight and APGAR scores between the 2 groups. However, the LA group had shorter time to first flatus (2.4 ± 0.4 d v. 4.0 ± 1.7 d, p = 0.034), earlier time to oral intake (2.3 ± 1.6 d v. 4.1 ± 1.9 d, p = 0.023) and shorter postoperative hospital stay (4.2 ± 2.9 d v. 6.9 ± 3.7 d, p = 0.043) than the OA group. CONCLUSION: Laparoscopic appendectomy is a clinically safe and effective procedure in all trimesters of pregnancy and should be considered as a standard treatment alternative to OA. Further evaluation including prospective randomized clinical trials comparing LA with OA are needed to confirm our results.

CONTEXTE: Malgré une contre-indication initiale absolue ou relative de l'opération laparoscopique durant la grossesse au cours de la dernière décennie, on a eu recours à l'appendicectomie laparoscopique (AL) chez des femmes enceintes. Mais peu d'études ont comparé les résultats de l'AL à ceux de l'appendicectomie ouverte (AO). Nous avons analysé les résultats cliniques pour comparer l'innocuité et l'efficacité de l'AL à celles de l'AO chez les femmes enceintes. MÉTHODES: Pour la présente étude, nous avons recruté des patientes enceintes consécutives porteuses d'un diagnostic d'appendicite aiguë qui ont dû subir une AL ou une AO entre mai 2007 et août 2011. RÉSULTANTS: Soixante-et-une patientes (22 soumises à l'AL et 39 à l'AO) ont été inscrites à notre étude. Nous n'avons noté aucune différence significative pour ce qui est de la durée de l'intervention chirurgicale, du taux de complications postopératoires et des résultats obstétricaux et fœtaux, y compris l'incidence du travail prématuré, le type d'accouchement, l'âge gestationnel et le poids à la naissance et les indices d'APGAR entre les 2 groupes. Toutefois, le groupe soumis à l'AL a moins tardé à présenter des flatuosités (2,4 ± 0,4 j c. 4,0 ± 1,7 j, p = 0,034), a commencé à s'alimenter par la bouche plus tôt (2,3 ± 1,6 j c. 4,1 ± 1,9 j, p = 0,023) et a connu un séjour hospitalier postopératoire plus bref (4,2 ± 2,9 j c. 6,9 ± 3,7 j, p = 0,043) comparativement au groupe soumis à l'AO. CONCLUSIONS: L'appendicectomie laparoscopique est une intervention sécuritaire et efficace au plan clinique durant les 3 trimestres de la grossesse, et il faut l'envisager comme solution de rechange thérapeutique standard à l'AO. Il faudra une évaluation plus approfondie pour confirmer nos résultats, y compris au moyen d'essais cliniques randomisés prospectifs comparant l'AL à l'AO.

Conventional Linear versus Purse-string Skin Closure after Loop Ileostomy Reversal: Comparison of Wound Infection Rates and Operative Outcomes.

PURPOSE: Wound infection after an ileostomy reversal is a common problem. To reduce wound-related complications, purse-string skin closure was introduced as an alternative to conventional linear skin closure. This study is designed to compare wound infection rates and operative outcomes between linear and purse-string skin closure after a loop ileostomy reversal. METHODS: Between December 2002 and October 2010, a total of 48 consecutive patients undergoing a loop ileostomy reversal were enrolled. Outcomes were compared between linear skin closure (group L, n = 30) and purse string closure (group P, n = 18). The operative technique for linear skin closure consisted of an elliptical incision around the stoma, with mobilization, and anastomosis of the ileum. The rectus fascia was repaired with interrupted sutures. Skin closure was performed with vertical mattress interrupted sutures. Purse-string skin closure consisted of a circumstomal incision around the ileostomy using the same procedures as used for the ileum. Fascial closure was identical to linear closure, but the circumstomal skin incision was approximated using a purse-string subcuticular suture (2-0 Polysorb). RESULTS: Between group L and P, there were no differences of age, gender, body mass index, and American Society of Anesthesiologists (ASA) scores. Original indication for ileostomy was 23 cases of malignancy (76.7%) in group L, and 13 cases of malignancy (77.2%) in group P. The median time duration from ileostomy to reversal was 4.0 months (range, 0.6 to 55.7 months) in group L and 4.1 months (range, 2.2 to 43.9 months) in group P. The median operative time was 103 minutes (range, 45 to 260 minutes) in group L and 100 minutes (range, 30 to 185 minutes) in group P. The median hospital stay was 11 days (range, 5 to 4 days) in group L and 7 days (range, 4 to 14 days) in group P (P < 0.001). Wound infection was found in 5 cases (16.7%) in group L and in one case (5.6%) in group L (P = 0.26). CONCLUSION: Based on this study, purse-string skin closure after a loop ileostomy reversal showed comparable outcomes, in terms of wound infection rates, to those of linear skin closure. Thus, purse-string skin closure could be a good alternative to the conventional linear closure.

Liver function alterations after laparoscopy-assisted gastrectomy for gastric cancer and its clinical significance.

AIM: To evaluate the factors associated with liver function alterations after laparoscopy-assisted gastrectomy (LAG) for gastric cancer. METHODS: We collected the data of gastrectomy patients with gastric cancer and divided them into 2 groups: open gastrectomy (OG) and LAG. We also collected the data of patients with colon cancer to evaluate the effect of liver manipulations during surgery on liver function alterations. Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin, and alkaline phosphatase were measured on the preoperative day and postoperative day 1 (POD1), POD3, POD5, and POD7. RESULTS: No changes in liver function were observed after the operation in patients with colon cancer (n = 121). However, in gastric cancer patients (n = 215), AST and ALT levels increased until POD5 compared to those in colon cancer patients and these findings were observed both in the LAG and OG without a significant difference except at POD1. The mean hepatic enzyme levels at POD1 in the LAG group were significantly higher than those in the OG group (P = 0.047 for AST and P = 0.039 for ALT). The factors associated with elevated ALT on POD1 in patients with gastric cancer were body mass index (P < 0.001), operation time (P < 0.001), intraoperative hepatic injury (P = 0.048), and ligation of an aberrant left hepatic artery (P = 0.052) but not type of operation (OG vs LAG, P = 0.094). CONCLUSION: We conclude that the liver function alteration after LAG may have been caused by direct liver manipulation or aberrant hepatic artery ligation rather than the CO2 pneumoperitoneum.

Management and outcome of gastrointestinal stromal tumors of the duodenum.

BACKGROUND: Duodenal gastrointestinal stromal tumors (GISTs) are uncommon and relatively small subset of GISTs whose optimal surgical procedure has not been well defined. We conducted this study to present the surgical experience in our institution and to analyze the postoperative outcome of duodenal GISTs. METHODS: A retrospective clinicopathologic analysis was performed for nine duodenal GIST patients who underwent surgery from May 2001 to April 2009. The median follow-up period was 22 months (range: 13-61 months). RESULTS: A total of nine patients (six males/three females) with a median age of 52 years (range: 45-73 years) were treated. The most common presentation was abdominal pain (45%), and the second portion of duodenum (45%) was most common dominant site. All of the patients underwent limited resection: there were seven wedge resections with primary closures (five open/two laparoscopic) and two segmental resections with end-to-end duodenojejunostomies. The median tumor size was 3.5 cm (range: 1.9-5.5 cm), and the mitotic count was less than fivemitoses/50 high power fields (HPF) in all cases. None patients had neoadjuvant or adjuvant therapy. All of the patients were alive and disease-free. CONCLUSION: We obtained excellent disease-free survival following limited resection with clear margins. Limited resection should be considered a treatment option for duodenal GIST.

Transvaginal endoscopic appendectomy.

Since Kalloo and colleagues first reported the feasibility and safety of a peroral transgastric approach in the porcine model in 2004, various groups have reported more complex natural orifice transluminal endoscopic surgery (NOTES) procedures, such as the cholecystectomy, splenectomy and liver biopsy, in the porcine model. Natural orifice access to the abdominal cavity, such as transgastric, transvesical, transcolonic, and transvaginal, has been described. Although a novel, minimally invasive approach to the abdominal cavity is a peroral endoscopic transgastric approach, there are still some challenging issues, such as the risk of infection and leakage, and the method of gastric closure. Hybrid-NOTES is an ideal first step in humans. Human hybrid transvaginal access has been used for years by many surgeons for diagnostic and therapeutic purposes. Here, we report a transvaginal flexible endoscopic appendectomy, with a 5-mm umbilical port using ultrasonic scissors in a 74-year-old woman with acute appendicitis.

Laparoscopic repair of paraduodenal hernia: comparison with conventional open repair.

Paraduodenal hernia is a congenital internal hernia caused by abnormal retroperitoneal fixation of the intestinal mesentery. The management of paraduodenal hernia consists of reduction of the herniated intestine and repair of the defect. Recently, laparoscopic surgery has been increasingly performed in abdominal procedures. To evaluate the feasibility and efficacy of laparoscopic repair of paraduodenal hernia, we present our experience in 2 cases of laparoscopic repair, compared with 3 other cases treated with conventional open repair; all 5 cases were successfully treated. All patients had symptoms of intestinal obstruction and were diagnosed by preoperative abdominal computed tomography. Two cases were right-sided hernias, and 3 cases were left sided. Among them, 2 patients with left-sided paraduodenal hernia underwent laparoscopic reduction (LR group) of the herniated small bowel, and the other 3 cases underwent open reduction (OR group). In the LR group, the duration of hospital stay, time to first flatus, and time to first intake of a soft diet were shorter than in the OR group. Thus, with an accurate preoperative diagnosis of paraduodenal hernia, laparoscopic surgery may be a feasible and efficient procedure, with good postoperative outcomes.