Early laparoscopy to help diagnose acute non-specific abdominal pain.
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Abdomen, Acute↗
Biomedical subjects
C M Schlachta
Publications and source records attributed to C M Schlachta.
Should enteric fistulas from Crohn's disease or diverticulitis be treated laparoscopically or by open surgery? A matched cohort study.
PURPOSE: The aim of this study was to study a group of consecutive patients with enteric fistulas treated by laparoscopic surgery and to compare outcomes with a matched group of patients treated by open surgery. METHODS: The outcomes of 13 patients with Crohn's disease or sigmoid diverticulitis with enteric fistulas treated laparoscopically (Group I) were compared with 13 patients matched for age, weight, gender, diagnosis, and characteristics of fistulas and treated by conventional surgery (Group II) during the same period. RESULTS: No patient died postoperatively in either group. Mean operative time was 183 minutes in Group I vs. 154 minutes in Group II (P = 0.280). No significant difference was found between Groups I and II in the number of patients with major postoperative complications (3 vs. 5; P = 0.462), or postoperative stay (7.6 +/- 3.6 vs. 9.2 +/- 3 days; P = 0.239). Conversion to open laparotomy occurred in one (7.7 percent) patient from Group I. No patient required readmission for secondary surgery in Group I, and two patients were readmitted and underwent reoperation for complications in Group II (P = 0.462). CONCLUSIONS: The laparoscopic treatment of selected cases of enteric fistulas is safe. Although most good outcome trends favor the laparoscopic group, the study is inconclusive, because no statistical difference was demonstrated with regard to operative time, number of postoperative complications, readmission rate, and length of postoperative stay, most likely because of the small number of cases in each arm of the study. Study of a greater number of cases outside the learning curve of the laparoscopic surgeons would clarify this issue. Other outcomes, including cost, pain control, cosmesis, and return to activities of daily living, need to be included in the evaluation.
Adult↗
Determinants of outcomes in laparoscopic colorectal surgery: a multiple regression analysis of 416 resections.
BACKGROUND: To date, most large series of laparoscopic colorectal procedures have been descriptive reports that do not account for the potentially complex interaction of outcome predictors. The purpose of this study was to identify the preoperative factors that predict operative time, conversion to open surgery, and intraoperative and postoperative complications in laparoscopic colorectal surgery. METHODS: Multiple regression techniques were used to analyze 416 laparoscopic resections from a prospective database of laparoscopic colorectal procedures performed between April 1991 and April 1998. The preoperative factors considered were patient-specific (age, gender, weight) or disease-specific (diagnosis of cancer, Crohn's disease, diverticulitis, fistula). Surgical experience of < or =50 cases was also considered. Finally, all resections were represented by a combination of the following five procedure components: resections of the (a) hepatic flexure, (b) splenic flexure, (c) sigmoid, and (d) rectum, or (e) a perineal dissection. RESULTS: Patient weight, Crohn's disease, and each of the five individual procedure components incrementally lengthened operative time. Conversion to open surgery was influenced by the patient's weight, malignancy, and early experience of the surgeon. The risk of a postoperative complication was increased by the patient's age, resection of the perineum, and the presence of a fistula. No factors significantly influenced the risk of an intraoperative complication. CONCLUSIONS: Several preoperative factors that significantly affect outcomes in laparoscopic colorectal resections have been identified. Consideration of these factors may help in case selection and estimation of operating time; they should also be valuable when patients are informed of their risk of conversion and complications.
Adolescent↗
Predicting conversion to open surgery in laparoscopic colorectal resections. A simple clinical model.
OBJECTIVE: The objective of this study was to develop a simple model for clinical use in predicting the individual risk of conversion to open surgery in patients undergoing laparoscopic colorectal resections. METHODS: A multiple logistic regression analysis of 367 laparoscopic colorectal resections completed between 1991 and 1998 was performed. The following 13 factors were considered: patient-specific factors (age, gender, weight levels less than 60 kg 60-90 kg, 90 kg or more), disease-specific factors (Crohn's disease, diverticulitis, malignancy, fistula), and procedure-specific factors (resection of the hepatic flexure, splenic flexure, sigmoid, rectum, perineum, experience with less than 50 cases). A scoring system was developed on the basis of the three factors found to be predictive of the risk for conversion to open surgery: diagnosis of malignancy (odds ratio 3.23; p = 0.0037; one point), surgeon experience with 50 cases or less (odds ratio 2.26; p = 0.0363; one point), and weight level (odds ratio 3.42; p = 0.005; 60 to 90 kg, one point, 90 kg or more, two points). RESULTS: The predicted conversion rates for the cumulative scores of 0 to 4 points were 1.1%, 3.3%, 9.8%, 25.4%, and 49.7%, respectively. No significant difference was found between predicted and actual conversion rates, indicating a good fit of the model (chi square = 1.774; p > 0.5). CONCLUSIONS: This novel scoring system is simple, accurate, and readily applicable in an office setting. It represents the large experience of one surgical group and remains to be validated by other centers.
Adult↗
Liver hematoma after laparoscopic nissen fundoplication: a case report and review of retraction injuries.
Laparoscopic fundoplication is a safe and effective alternative to long-term medical therapy in select patients with gastroesophageal reflux disease. Among the technical challenges of laparoscopic fundoplication, retraction of the left lobe of liver can cause significant morbidity. Intraoperative complications from retraction injuries have been reported in the literature, but postoperative complications arising from liver retraction have not been published. The authors present a case of a symptomatic liver hematoma requiring hospital readmission for diagnosis and pain control and a review of retraction injuries.
Female↗
Technique for laparoscopic partial splenectomy.
Splenic preservation and conservative management are now accepted norms when dealing with splenic pathologic conditions. This case report describes the technique of laparoscopic partial splenectomy for an undiagnosed splenic lesion. A thorough understanding of splenic anatomy permits laparoscopic partial splenectomy with the resultant benefits, including a decreased risk of postsplenectomy sepsis, short hospital stay, and superior cosmesis. The success and relative ease of performing this procedure will pave the way for its future use in other selective cases involving splenic pathology.
Adult↗
Needlescopic decapsulation of a splenic epithelial cyst.
As technology advances, the techniques of laparoscopic surgery are being refined and their application is expanding to include many disease processes and organs. The new-generation laparoscopic instruments are becoming smaller (less than 5 mm). Expected advantages include improvements in cosmesis and patient satisfaction, and decreased postoperative analgesic requirements. Non-neoplastic cysts of the spleen are rare, and their management has evolved from total open splenectomy to laparoscopic cyst decapsulation. A 22-year-old woman with a symptomatic 10-cm epithelial cyst was treated by splenic decapsulation with needlescopic instruments (3 mm or smaller). Three trocars were used: one 12-mm umbilical and two 3-mm subcostal ports. The cyst was punctured by a Veress needle, and after drainage of straw-coloured fluid, circumferential decapsulation with 5-mm laparoscopic shears through the umbilical port site was done. The patient was discharged within 24 hours, having had a single intramuscular injection of meperidine and an excellent cosmetic result.
Adult↗
Laparoscopic sigmoid resection for acute and chronic diverticulitis. An outcomes comparison with laparoscopic resection for nondiverticular disease.
BACKGROUND: Sigmoid diverticulitis is a common benign condition; however, cases of acute and chronic diverticulitis may be difficult for the surgeon to treat. We designed a study to compare the outcomes of patients who undergo laparoscopic resections for sigmoid diverticulitis with those who have similar resections for other indications. METHODS: From a prospectively accumulated database of 397 consecutive laparoscopic colorectal procedures performed by three surgeons, we reviewed the outcomes of 178 patients who underwent laparoscopic sigmoid resections with primary anastomosis. RESULTS: Laparoscopic sigmoid colectomies or anterior resections were performed in 22 patients with acute diverticulitis (AD), 70 patients with chronic diverticulitis (CD), and 86 patients with nondiverticular disease (ND). Patients with ND were significantly older than those with AD or CD (67 +/- 14 year versus 55 +/- 13 year, 55 +/- 12 year, p < 0.05). Conversion to open surgery was required in three AD patients (14%), three CD patients (4%), and 17 ND patients (20%) (chi2 = 8.23, p = 0.016). In cases completed laparoscopically, there was no significant difference in median operative time (AD, 165 min; CD, 150 min; ND, 165 min), proportion of patients with intraoperative complications (AD, one; CD, six; ND, one), or postoperative complications (AD, four; CD, 13; ND, 11). The occurrence of a postoperative complication significantly prolonged median time to full diet (4 days vs 3 days, p < 0.001) and discharge (9 days vs 5 days, p < 0.001) but not return to normal activity (16 days vs 15 days). CONCLUSIONS: In this study, patients who underwent laparoscopic sigmoid colectomies and anterior resections had similar outcomes regardless of diagnosis. This finding substantiates our view that laparoscopic resections for diverticulitis can be performed safely and with the same benefits as resections for other indications.
Acute Disease↗
Laparoscopic splenectomy for hematologic malignancies.
BACKGROUND: Patients with hematologic malignancy (HM) tend to have large spleens. The purpose of this study was to compare the outcomes of laparoscopic splenectomy for patients with HM to those with benign disease (BD). METHODS: A review was conducted of a prospectively accumulated database of 64 consecutive, unselected laparoscopic splenectomies performed by two surgeons between March 1992 and August 1997. RESULTS: Of 14 patients with HM (7 lymphoma, 6 leukemia, 1 myeloid metaplasia), three required conversion to open splenectomy (21%). In the remaining 11 patients, two had postoperation complications (18%), including one death from sepsis (9%). Of 50 patients with BD (36 idiopathic thrombocytopenic purpura [ITP], 5 spherocytosis, 4 hemolytic anemia, and 5 others), three were converted to open surgery (6%). Complications developed in 5 (11%) of the remaining 47 patients. No deaths occurred. All patients who had spleens larger than 27 cm in diameter required conversion. Patients undergoing laparoscopic splenectomy for HM were older (54 +/- 16 years vs. 36 +/- 18 years; p = 0.002), had larger spleens (median 17.0 cm vs. 11.0 cm; p < 0.001), and had lower preoperation hemoglobin levels (113 +/- 30 g/L vs. 132 +/- 23 g/L; p = 0.03) than patients with BD. The HM group required longer operation time (239 +/- 73 min vs. 180 +/- 61 min; p < 0.01), but showed no differences with respect to operation blood loss (median, 100 vs. 165 mL), requirement for transfusion (median, 0.0 vs. 0.0 units), and length of hospital stay (median 3.0 vs. 3.0 days). CONCLUSIONS: Although patients with HM had larger spleens and required longer operation time for laparoscopic splenectomy, surgical outcomes were equivalent. The laparoscopic approach should be preferred, even for patients with HM. The only limitation appears to be splenic size greater than 27 cm.
Adult↗
Laparoscopic resection does not adversely affect early survival curves in patients undergoing surgery for colorectal adenocarcinoma.
OBJECTIVE: To determine the survival curves for laparoscopic resection (LR) of colorectal cancer. SUMMARY BACKGROUND DATA: Laparoscopic resection for cure of colorectal cancer is controversial, and survival curves have not been determined. METHODS: A prospective database of 177 consecutive LRs of colorectal cancers performed between November 1991 and 1997 was reviewed. The TNM classification (stage 0, I, II, III, and IV) for colorectal cancers and the Kaplan-Meier method were used to determine survival curves. RESULTS: Of the 177 patients, 5 were excluded for not having adenocarcinomas. Twenty-five patients (14.5%) had conversion to open surgery; most of these patients had rectal cancer or tumor invasion to adjacent organs. Twelve patients were lost to follow-up. All 135 remaining patients had follow-up. Overall, 28 deaths occurred during the follow-up period, 15 of which were cancer-related. The median follow-up was 24 months for patients with stage I, II, and III disease and 9 months for patients with stage IV disease. Observed 2-year survival rates were 100% stage I, 88.7% stage II, 80.6% stage III, and 28.6% stage IV. Survival rates at 4 years were 100% stage I, 79.5% stage II, 53.7% stage III, and 0% stage IV. No trocar site recurrence was observed. CONCLUSIONS: Early survival curves for patients with colorectal cancer who underwent LR do not differ negatively from historical controls for conventional surgery. Further validation is needed.
Adenocarcinoma↗
Evaluating laparoscopic skills.
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Clinical Competence↗
Technique for laparoscopic gastric surgery.
As technology and surgeon experience expand, laparoscopic surgery is playing a larger role in the treatment of gastric conditions. We present our technical approach to various laparoscopic gastric resections and outline our preliminary results. Contrary to the majority of publications on laparoscopic gastric resection, we believe gastric mobilization should be carried out by incising the avascular plane between the greater omentum and transverse colon. This gives easy access to the origin of the left gastric artery and permits an acceptable D1 oncologic resection. For small lesions, tumor localization and resection margins should be mapped with the aid of routine intraoperative endoscopy. Nine patients underwent formal gastric resections, six of which were done for malignancy. Median time to discharge and length of follow-up were 4.5 days (range 3-10) and 25 months (range 24-35), respectively. One patient died postoperatively, and the remaining five patients operated for malignancy are alive and well with no evidence of recurrent disease or port site metastases.
Adenocarcinoma↗
Simplified laparoscopic approach to "second-look" laparotomy: a review.
Acute mesenteric vascular accidents are being diagnosed more commonly as a consequence of an aging population and often result in emergency bowel resection for ischemia. Because predicting postoperative intestinal viability remains difficult, second-look laparotomy has been advocated to improve outcomes. Recently, laparoscopy has emerged as an alternative to laparotomy for the diagnosis and treatment of ongoing postoperative ischemia. A review of the literature since 1994 reveals that, to date, 19 procedures have been reported to prevent 13 (68%) unnecessary laparotomies. We describe our laparoscopic second- look technique and review the literature. Second-look laparoscopy has been shown repeatedly to be a safe alternative to laparotomy. It is simple and reduces negative second-look laparotomy in critically ill patients.
Aged↗
Splenic artery embolization before laparoscopic splenectomy. An update.
BACKGROUND: This study assessed preoperative splenic artery embolization before laparoscopic splenectomy. METHODS: Preoperative splenic artery embolization was used in 26 of 54 patients (48%) undergoing laparoscopic splenectomy. Between 1992 and 1994, this procedure was used in all patients with spleens shorter than 20 cm (group I), except the first two (18/20). An anterior surgical approach was used. After 1994 (group II), embolization was not used for these patients (0/26), and a lateral surgical approach was used. Throughout the study period, all patients with spleens longer than 20 cm had embolization (8/8). RESULTS: Five complications occurred, three related to the use of small-particle embolic material (microspheres, gelatin foam powder). In group I, the conversion rate was lower than that of most current series, largely because of embolization. In group II, similar results were obtained because of experience and a better surgical approach (i.e., lateral). CONCLUSIONS: Preoperative splenic artery embolization is not necessary for spleens shorter than 20 cm. Increased experience and mostly the lateral surgical approach have permitted a shorter operation and a low conversion rate (4%) similar to the rate achieved with embolization and the anterior approach in the initial stages of the study. Embolization is used for 20- to 30-cm spleens. The conversion rate is higher (17%), and blood replacement is required frequently (83%). Despite embolization, laparoscopic splenectomy for spleens longer than 30 cm is futile at this time (100% conversion).
Angiography↗
Surgery for peptic strictures.
Benign peptic stricture of the esophagus is a complex disorder which results from persistent gastroesophageal reflux. Its successful management depends on an accurate preoperative evaluation of the stricture and the patient. Surgical management of peptic strictures can be quite effective in relieving the symptoms and halting the pathologic gastroesophageal reflux that accompanies this disorder. This article reviews the general principles of evaluation and surgical treatment of benign peptic esophageal strictures.
Barrett Esophagus↗
Operative treatment of malignancy.
The overall prognosis of patients afflicted with cancer of the esophagus is dismal and has not changed greatly over the last few decades. Improvements have largely been due to better perioperative care rather than new surgical techniques. There remain, about the optimal treatment of these patients, and these differences are summarized in this article. The principal elements required to make an appropriate surgical decision also are outlined. Until new markers for early detection and effective systematic therapy emerge, improvement is likely to occur only in subsets of patients referred early and treated in an environment that guarantees low operative mortality.
Esophageal Neoplasms↗
Human antiglioma monoclonal antibodies from patients with astrocytic tumors.
The current management of malignant gliomas is unsatisfactory compared to that of other solid tumors; the expected median survival period is less than 1 year with the patient undergoing conventional surgery, radiotherapy, and chemotherapy treatment. Immunological reagents could be a useful adjunct. Human monoclonal antibodies derived from patients with astrocytic tumors might recognize subtle antigenic specificities that would differ from those recognized by xenogeneic (murine) systems. Five hybridomas, designated as BT27/1A2, BT27/2A3, BT32/A6, BT34/A5, and BT54/B8, were produced from the fusion of peripheral blood lymphocytes of four patients with astrocytic tumors to the human myeloma-like cell line TM-H2-SP2. This cell line has a 46, XX karyotype and is negative for hypoxanthine guanine phosphoribosyltransferase. All five human monoclonal antibodies produced 2.4 to 44 micrograms/ml of immunoglobulin M, had a similar but not identical pattern of reactivity against a panel of human tumor cell lines, and failed to react with normal human astrocytes. Labeling of four neuroectodermal tumor explant cultures by BT27/2A3 was demonstrated by flow cytometry. Karyotyping of three of the five hybridomas demonstrated that two were pseudodiploid (2-3n) and one hypodiploid (less than 2n). The monoclonality of the hybridomas was evaluated by Southern blot analysis of JH gene rearrangements, revealing two types of rearrangements for each hybridoma, both consistent with monoclonality. Preliminary antigen characterization indicated that at least four of the five human monoclonal antibodies were directed to cell-surface glycolipids.
Adolescent↗
Correcting reflux laparoscopically.
Most operations in the abdominal cavity and chest can be performed using minimally invasive techniques. As yet it has not been determined which laparoscopic procedures are preferable to the same operations done through conventional laparotomy. However, most surgeons who have completed the learning curves of these procedures believe that most minimally invasive techniques will be scientifically recognized soon. The evolution, validation and justification of advanced laparoscopic surgical methods seem inevitable. Most believe that the trend towards procedures that minimize or eliminate the trauma of surgery while adhering to accepted surgical principles is irreversible. The functional results of laparoscopic antireflux surgery in the seven years since its inception have been virtually identical to the success curves generated with open fundoplication in past years. Furthermore, overall patient outcomes with laparoscopic procedures have been superior to outcomes with the traditional approach. Success is determined by patient selection and operative technique. Patient evaluation should include esophagogastroduodenoscopy, barium swallow, 24 h pH study and esophageal motility study. Gastric emptying also should be evaluated. Patients who have abnormal propulsion in the esophagus should not receive a complete fundoplication (Nissen) because it adds a factor of obstruction. Dor or Toupet procedures are adequate alternatives. Prokinetic agents, dilation or pyloroplasty are used for pyloric obstruction ranging from little to more severe. Correcting reflux laparoscopically is more difficult in patients with obesity, peptic strictures, paraesophageal hernias, short esophagus, or a history of previous upper abdominal or antireflux surgery.
Gastroesophageal Reflux↗