Laparoscopy, Minimally Invasive Surgery, and Percutaneous Treatment of Hepatic Tumors

Laparoscopy and Minimally Invasive Surgery

The majority of abstracts on laparoscopy focused on laparoscopic surgery - including esophagomyotomy, long-term results after laparoscopic surgery for gastroesophageal reflux disease, bypass surgery for morbid obesity, the role of laparoscopic surgery in cholangitis and gallstone pancreatitis, endoscopic bile duct stone clearance during or after cholecystectomy, and complications. There were only a few controlled studies within this area.

Diagnostic Laparoscopy

Two presentations dealt with diagnostic laparoscopy. Using laparoscopy in 219 consecutive adult patients with a clinical diagnosis of appendicitis and an indication for exploration, exploration was prevented in 41 % of the female patients, but in males the clinical diagnosis was correct in 97 %. So while it is of definitive value in females, laparoscopy should only be performed in males if the appendix is also removed laparoscopically [1]. The other abstract dealt with malignancies. Adding laparoscopy with a 3.5-mm mini-laparoscope (“needle scope”) in local anesthesia and under conscious sedation in 35 patients with different malignant diseases, small metastases (on the liver or peritoneum) were detected in seven. These had not been detected with ultrasound (US), computed tomography (CT), or endoscopic ultrasonography (EUS). No complications occurred [2].

Laparoscopic Surgery

Large clinical series are now being presented within the various areas of laparoscopic surgery. New technical developments are scarce, apart from the interesting technique of hand port-assisted laparoscopic surgery in more complex procedures.

General. One abstract dealt with the important problem of trocar-related serious complications, which occur rarely, but are potentially lethal. Trocar injuries occurring in 629 patients in 1993 - 1996 and reported to the Food and Drug Administration in the USA by the manufacturers were analyzed. Two-thirds of the cases involved vascular injuries. Of the 26 deaths, 81 % resulted from vascular injury (mainly to the aorta or vena cava). Eighty-seven percent of the deaths from vascular injury involved the use of disposable trocars with safety shields, and 9 % of the instruments had a direct viewing feature. Malfunction was confirmed in only two cases. The diagnosis of bowel injury was delayed in 10 %, resulting in a mortality of 21 % within the delayed group [3].

Achalasia. One of the controversies regarding esophagomyotomy (EM) in achalasia is whether the best approach is thoracoscopic or laparoscopic. Thoracoscopic EM in 35 patients with a mean follow-up period of 40 months showed good or excellent results in 83 %, and failure in two cases (6 %). Five patients (14 %) had postoperative reflux symptoms, and three of these patients required medication [4]. In another study, after laparoscopic EM in 106 patients, ten complained of severe dysphagia or chest pain after a median of five months. Eight had complete relief after uncomplicated endoscopic pneumatic dilatation, indicating that uncut fibers in an incomplete EM are easily disrupted [5]. Finally, a decision analysis comparing three algorithms for primary treatment and for subsequent treatment when prior treatment had failed concluded that initial laparoscopic EM may achieve treatment success with fewer procedures and complications, but that pneumatic dilatation may cost less [6].

Fundoplication. The abstracts now include studies with large numbers of patients, and some have a long-term follow-up and important information on the postoperative clinical course and the rates of repeat surgery. One controlled study was presented. A randomized trial comparing laparoscopic Nissen fundoplication with maintenance proton-pump inhibition reported significantly improved esophageal sphincter pressures, pH, DeMeester symptom scores, quality of life scores, and esophageal motility in the laparoscopy group three months after treatment. Costs will be assessed after a longer follow-up period [7]. Data from a database including more than 1000 patients followed up after laparoscopic antireflux surgery (LARS) included 37 patients with morbid obesity (body mass index > 35). On follow-up assessment one year or more postoperatively, the outcomes were similar to those in nonobese patients, suggesting that morbid obesity should not be considered a contraindication to LARS [8]. LARS with 12 months follow-up in 11 patients with normal endoscopy and acid exposure times, but with a positive symptom score (“acid-sensitive esophagus”), proved to be a valid and effective treatment for these patients [9]. A follow-up of five to eight years after LARS in 171 of 291 patients showed that 88 % were satisfied or very satisfied with the outcome, while 3.5 % were not satisfied; 20.5 % had persistent bloating, and 4 - 6 % had regurgitation, heartburn, or chest pain. Mild difficulty with swallowing was experienced by 27.5 %, and 7 % required dilatation; 14 % were receiving proton-pump inhibition, but 79 % of these patients had vague symptoms unrelated to reflux disease. Two reoperations were necessary [10]. In another series including 230 patients who underwent LARS, reoperative surgery was necessary in 15 (6.5 %), in six cases because of mediastinal wrap herniation [11]. One presentation focused on the economic aspects. The total cost of laparoscopic fundoplication using a decision-analytic model was estimated to be between $5296 and $7839, depending on the estimate used, and long-term costs at five years were only moderately higher due to the success rate of the initial intervention. The study revealed potential differences between the USA and other countries with regard to procedure time and length of hospital stay - both were longer when only American studies were analyzed [12].

Laparoscopic surgery for morbid obesity. In a randomized study, 30 patients were allocated to laparoscopic surgery and 21 to open gastric bypass surgery for morbid obesity, with seven conversions in the laparoscopic group. One patient in the laparoscopic group died of malignant hyperthermia. This group required significantly less morphine postoperatively. The duration of surgery was longer in the laparoscopic group, but the hospital stay was reduced from six to four days. The paper included 13 other patients who received hand port-assisted surgery, with one conversion and a postoperative stay of five days [13]. A nonrandomized study compared hand-assisted laparoscopic bypass (35 patients operated by one surgeon) with open bypass (70 operated by two other surgeons), and reported comparable procedure times after a learning curve. Wound infections occurred in 23 % (open) and 17 % of cases (laparoscopic), and hernias in 10 % and 9 % (not significant). Four patients in the open group versus none in the laparoscopic group required reoperation [14]. In a multicenter study including 1264 cases of laparoscopic gastric bypass, leaks occurred in 23, with one mortality. Sixteen of the patients required intensive care. For surgeons with more than 130 procedures, 50 % of the leaks occurred within the first 50 procedures [15]. Laparoscopic gastric bypass in 62 carefully selected patients resulted not only in a reduction of excess weight, but also led to a significant improvement in the patients' quality of life in a two-year period following surgery [16].

Cholecystectomy and bile ducts. It has been suggested that a gasless technique may reduce the pathophysiological changes occurring during CO₂ pneumoperitoneum. In order to compare the technical and clinical problems, 52 adult patients with a body mass index (BMI) < 30 were randomly assigned to received gasless or conventional laparoscopic cholecystectomy (LC). The only differences were a significantly longer procedure time and greater difficulty in exposing Calot's triangle, while complications, conversion rates, pain, hospital stay, and return to normal functions did not differ - the gasless technique may therefore be considered when CO₂ pneumoperitoneum is contraindicated [17].

A retrospective study showed that patients with acute cholecystitis were more likely to undergo successful LC when treated by surgeons with a special interest and training in advanced laparoscopic procedures, since the conversion rate was reduced from 46 % to 20 % and the operative time and length of stay was also reduced, without an increase in the complication rate [18].

Should LC be recommended after endoscopic management of cholangitis? A study from Hong Kong including 184 patients with gallstone cholangitis, who were routinely managed endoscopically with endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES), followed by interval LC, concluded that it should - except if the surgical risk is prohibitive, since ES alone in patients who refused surgery or had an increased surgical risk was associated with a high incidence of recurrent cholangitis in that population (25 % during a 24-month follow-up), especially if the size of the sphincterotomy was small. At LC, conversion was necessary in 9.8 %, while the postoperative complication rate was only 3.6 % [19].

Should LC be routinely performed after endoscopic treatment of gallstone pancreatitis? In 34 of 118 patients who underwent primary ERCP with endoscopic sphincterotomy, laparoscopic cholecystectomy was not performed. Recurrent pancreatitis occurred in 3.7 % in the LC group, and in 5.8 % in the ES-only group (mean follow-up 22 months). After LC, one patient had a cystic duct leak. Since recurrent biliary pancreatitis after ERCP with ES is rare, it was concluded that LC should be considered if indications other than merely preventing recurrent pancreatitis are present [20]. Controlled studies are needed to address this question.

Two papers dealt with nonsurgical treatment of stones detected during LC. Using laparoscopic transcystic stenting without surgical duct clearance in 48 consecutive patients with asymptomatic common bile duct stones detected intraoperatively by routine use of operative cholangiography, all patients had their bile duct stones and stents removed at outpatient ERCP one to four weeks postoperatively. The authors argue that this laparoscopically less demanding technique ensures successful postoperative endoscopic stone clearance, and predict that expertise in the technique will be rapidly acquired once laparoscopic stent kits become commercially available [21]. Alternatively, endoscopic bile duct stone clearance can be done during or immediately after LC, as described in a two-center investigation including 57 of 2193 LCs, in which ERCP was carried out after cholecystectomy during the same session of anesthesia. ES was achieved in all cases, and stones were confirmed in 49 of 57 patients and retrieved in 46 of the 49 (94 %). Complications occurred in 7 % [22]. This principle applies only if an experienced biliary endoscopist is readily available.

Complications after LC were addressed in two papers on treatment and the subsequent quality of life, respectively. The safety and efficacy of endoscopic management of bile leaks was confirmed in an audit including 53 patients identified in an ERCP database, providing definitive treatment in 96 %. Sixteen patients required subsequent percutaneous drainage of a biloma. Early in the series, from 1992 to 1999, some patients had ES alone, but this appeared to be less effective than temporary stenting [23]. The quality of life (QOL) after bile duct injury occurring during LC has not been assessed previously. Using a QOL questionnaire sent to 106 patients treated between 1990 and 1996, all 70 responders had a significantly worse QOL compared with matched controls, although the laboratory values had normalized in 94 % and the objective outcome parameters were excellent [24], so that the psychological impact of laparoscopic bile duct injury is underestimated.

Is cholecystectomy a risk factor for subsequent pancreatic, bile duct, or ampullary cancers? This previously proposed association was tested using population-based data in the National Hospital Discharge Survey in the USA. The cholecystectomy rate increased from 203 per 100 000 before 1991 to 292 in 1996. When the period 1980 - 91 was compared with 1992 - 96, there was no increase; on the contrary, the age-adjusted incidence rates of pancreatic and bile duct cancers decreased [25].

Finally, laparoscopic transduodenal sphincteroplasty of the minor papilla was described in six patients with recurrent pancreatitis due to pancreas divisum and stenosis of the minor papilla. Secretin facilitated identification of the papilla in two cases. One patient developed pancreatitis. Four had good results, while one required endoscopic reopening of a stenotic sphincteroplasty site, and another underwent an open repeat sphincteroplasty [26].

Colorectal surgery and Crohn's disease. In 315 laparoscopic colorectal procedures, conversion was necessary in 69 (22 %). Logistic regression showed that the risk of conversion increased significantly with increasing BMI, age, and occurrence of diverticulitis. A formula presented in the abstract allows the conversion risk to be calculated for a specific patient [27]. The question of whether laparoscopic techniques favor malignant cell spread was addressed in a randomized study, in which 49 patients allocated to laparoscopically assisted or open colectomy had blood samples taken before, after, and 24 hours after surgery for detection of neoplastic cells using reverse transcriptase polymerase chain reaction (PCR) targeted to carcinoembryonic antigen (CEA) [28]. A subgroup (nine from each group) had portal blood and peritoneal fluid samples investigated as well. It was found that preoperative and perioperative dissemination occurred frequently, but the surgical approach did not seem to be a determining factor [28]. Long-term clinical follow-up is awaited.

In a nonrandomized study in which the patients underwent laparoscopic (24 patients) or open (22 patients) laparotomy for Crohn's disease, depending on the surgeons' expertise, a reduced requirement for postoperative opioids was found in the laparoscopy group, and the postoperative time with endotracheal cannulation was longer [29]. There were no data on postoperative complications. In another study, conversion was necessary in 34 % of 77 laparoscopic procedures for Crohn's disease due to adhesions (n = 3), fistulas (n = 5), and size of lesion or unclear anatomy (n = 3). Preoperative weight loss correlated with conversion [30].

References

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