Alterations in the immune system and tumor growth in laparoscopy

Laparoscopy-assisted pancreaticoduodenectomy as minimally invasive surgery for periampullary tumors: a comparison of short-term clinical outcomes of laparoscopy-assisted pancreaticoduodenectomy and open pancreaticoduodenectomy

BACKGROUND

Few reports have described laparoscopy-assisted pancreaticoduodenectomy (LAPD) as an alternative to the conventional open approach for periampullary tumors. The safety and feasibility of this procedure remain to be determined. In this study, we compared the short-term clinical outcomes of LAPD with those of open pancreaticoduodenectomy (OPD).

METHODS

A retrospective review of patients who had undergone pancreaticoduodenectomy for periampullary tumors between June and December 2014 was conducted. Patient demographic data and their pathological and short-term clinical parameters were compared between the LAPD and OPD groups.

RESULTS

Fifty-two patients were included in the study: 18 had undergone LAPD and 34 had undergone OPD. The mean operation time was longer for LAPD than for OPD (531.1 vs. 383.2 min, P < 0.001). The estimated blood loss, rate of blood transfusion, surgical resection margin status, and number of lymph nodes retrieved were similar in both groups. Overall morbidity and the incidence of pancreatic fistula did not differ significantly between the two groups. However, the mean length of hospital stay was significantly shorter in the LAPD group (12.6 vs. 18.6 days, P = 0.001).

CONCLUSION

LAPD is a technically safe and feasible alternative treatment for periampullary tumors, with short-term clinical outcomes equivalent to those of OPD, with a shorter hospital stay.

Systemic inflammatory response after laparoscopic and conventional colectomy for cancer: a matched case-control study

BACKGROUND

Studies dealing with laparoscopic colectomy for cancer have reached conflicting results in regards to various inflammatory cytokines. Most of them have not examined potential differences with the open procedures at later postoperative days, when the immunologic advantage of laparoscopic surgery would be more demanding to demonstrate (for earlier administration of adjuvant treatment). The aim of this work is to detect differences of proinflammatory cytokines between conventional and laparoscopic colectomy for cancer.

PATIENTS AND METHODS

30 patients who underwent laparoscopic colectomy were age, sex, and preoperative stage-matched with 30 patients treated by open surgery. C-reactive protein (CRP), interleukin (IL)-1, -6, and -8, and interferon (IFN)-γ serum levels were measured preoperatively, at 24 h, and at the 7th postoperative day (POD).

RESULTS

CRP and IL-6 postoperative values (24 h and 7th POD) were significantly higher than baseline for both groups (p = 0.001), but the respective values at the 7th POD were less than at 24 h (p = 0.001). IL-1 and -8 levels did not show any differences between assessment timepoints. A higher IFN-γ measurement was demonstrated at 24 h compared with baseline for the laparoscopic group only (p = 0.03). This difference was not maintained at the 7th POD. IFN-γ levels at 24 h and the 7th POD were significantly less for the open compared with the laparoscopic group of patients (p = 0.001). No correlation was revealed between measured serum values and age, sex, tumor location, or stage.

CONCLUSIONS

This matched case-control study verifies the already reported lack of differences regarding IL-1. Controversy still exists on likely IL-6 differences. The inadequately studied IL-8 does not seem to play an important role in immunologic differences. The immunologically beneficial IFN-γ, produced by the principal effectors of cell-mediated immunity Th1 cells, seems to have a more active presence following laparoscopic colectomy, potentially contributing to an immunologic "advantage" by counteracting "harmful" cytokines, such as IL-1.

Laparoscopic colectomy for colon cancer: comparable to conventional oncologic surgery?

As a result of the obvious benefits of laparoscopic cholecystectomy, minimally invasive techniques have been applied to more complex gastrointestinal procedures, including colorectal resections. The goal in adapting laparoscopic techniques for colorectal surgery is to offer an operation that results in less pain, shorter hospital stay, more rapid return to normal activities, and improved cosmesis compared with conventional operation. The challenge has been to show that this can be done safely and efficiently and that for cancer patients there is no detrimental oncologic effect. The major issues that have been and continue to be addressed are (1) whether an adequate resection can be performed laparoscopically, (2) whether there is a high rate of wound or port site recurrence following these operations, and (3) whether, by using these techniques, we are trading short-term benefits for a poor long-term oncologic outcome. To answer these fundamental questions, several prospective randomized trials have been conducted and several more are under way. The results of these trials indicate that, in terms of cancer outcome, there is no difference in overall survival, disease-free survival, and wound recurrences in patients treated using laparoscopic techniques compared with conventional operation. In addition, there are short-term benefits associated with the use of these techniques. It can now be said that from an oncologic standpoint, in experienced hands, laparoscopic colectomy for curable colon cancer is equivalent to conventional therapy, and it is superior to conventional operation regarding short-term outcomes. Laparoscopic colectomy for colon cancer should be offered to appropriately selected patients.

Robotic resection of intraductal neoplasm of the pancreas

BACKGROUND

Minimally invasive techniques have been revolutionary and provide clinical evidence of decreased morbidity and comparable efficacy to traditional open surgery. Computer-assisted surgical devices have recently been approved for general surgical use.

AIM

The aim of this study was to report the first known case of pancreatic resection with the use of a computer-assisted, or robotic, surgical device in Latin America.

PATIENT AND METHODS

A 37-year-old female with a previous history of radical mastectomy for bilateral breast cancer due to a BRCA2 mutation presented with an acute pancreatitis episode. Radiologic investigation disclosed an intraductal pancreatic neoplasm located in the neck of the pancreas with atrophy of the body and tail. The main pancreatic duct was enlarged. The surgical decision was to perform a laparoscopic subtotal pancreatectomy, using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA). Five trocars were used. Pancreatic transection was achieved with vascular endoscopic stapler. The surgical specimen was removed without an additional incision.

RESULTS

Operative time was 240 minutes. Blood loss was minimal, and the patient did not receive a transfusion. The recovery was uneventful, and the patient was discharged on postoperative day 4.

CONCLUSIONS

The subtotal laparoscopic pancreatic resection can safely be performed. The da Vinci robotic system allowed for technical refinements of laparoscopic pancreatic resection. Robotic assistance improved the dissection and control of major blood vessels due to three-dimensional visualization of the operative field and instruments with wrist-type end-effectors.

Laparoscopic pancreaticoduodenectomy: technique and outcomes

BACKGROUND

We describe our experience with laparoscopic pancreaticoduodenectomy, including 5-year actuarial survival rates.

STUDY DESIGN

This is a retrospective study of selected patients who underwent laparoscopic pancreaticoduodenectomy at a single center between 1998 and 2006. We have described the salient features of our technique and followup protocol. Patient characteristics, histologic variety of the tumor, resection margins, morbidity, mortality, and actuarial survival rates were studied.

RESULTS

The procedure could be completed laparoscopically with tumor-free margins in all patients, including patients with ampullary carcinoma (n = 24), pancreatic cystadenocarcinoma (n = 4), pancreatic head adenocarcinoma (n = 9), low common bile duct cancer (n = 3), and two patients with chronic pancreatitis with a suspicious mass lesion in the head of pancreas. Mean age of patients was 61 years (range 28 to 70 years). There was a single perioperative mortality. Overall followup rate was 95.1%, with two patients lost to followup at 22 and 36 months. Among the survivors, two patients have metastatic disease and local recurrence developed in one patient. Five-year actuarial survival rates for all patients with malignancy, ampullary adenocarcinoma, pancreatic cystadenocarcinoma, pancreatic head adenocarcinoma, and common bile duct adenocarcinoma are 32%, 30.7%, 33.3%, 19.1%, and 50%, respectively. Presence of microscopic lymph node involvement is associated with poor survival, although operations in the setting of chronic pancreatitis resulted in increased morbidity.

CONCLUSIONS

Laparoscopic pancreaticoduodenectomy can be performed with safety and good results in properly selected patients. Localized malignant lesions, irrespective of histopathology, are particularly amenable to this approach.

Laparoscopic bowel injury in an animal model: monocyte migration and apoptosis

BACKGROUND

Unrecognized laparoscopic bowel injury has a delayed and covert presentation. Differences in monocyte migration and apoptosis between laparoscopic and open bowel injury were determined.

METHODS

For this study, 24 rabbits were divided into laparoscopic (n = 9) and open surgical (n = 9) bowel injury groups and a control group (n = 6) without bowel injury. Bowel injury was created using monopolar electrocautery. The animals were killed 1 day, 1 week, and 2 weeks after surgery. Monocyte migration assay was performed across a modified Boyden chamber. Apoptosis was assessed by DNA fluorescent stain H-33342.

RESULTS

In laparoscopy, monocyte apoptosis was decreased (p < 0.001), and migration was increased (p < 0.05), as compared with the open group. Apoptosis increased over time in both study groups, and was higher than in the control group (p < 0.001). Migration was decreased in both study groups as compared with the control group (p < 0.05)

CONCLUSIONS

These results suggest decreased immune system priming with laparoscopic bowel injury, which may contribute to the masking of relevant signs and symptoms of peritonitis.

Laparoscopic-type environment enhances mesothelial cell fibrinolytic activity in vitro via a down-regulation of plasminogen activator inhibitor-1 activity

BACKGROUND

Fewer intraperitoneal adhesions have been observed after laparoscopic surgery compared with conventional techniques. The aim of this study is to assess the effect of the pneumoperitoneum on mesothelial cell fibrinolytic activity by use of an in vitro model.

METHODS

Human peritoneal mesothelial cells were seeded onto 24-well plates and incubated in carbon dioxide or helium at 5 mm Hg for 4 hours or standard culture conditions. Supernatant was removed for analysis at 0, 24, 48, and 72 hours after gas incubation and analyzed for plasminogen activator activity, total tissue plasminogen activator (tPA), and total plasminogen activator inhibitor-1 (PAI-1) concentrations by use of an enzyme-linked immunosorbent assay. The effect of different insufflation pressures (0, 7, and 14 mm Hg) was also examined.

RESULTS

Enhanced plasminogen activator activity was observed at 48 hours and 72 hours from cells exposed to CO(2) (P<.04 each) and helium (P<.05 each) compared with control. This was associated with a decrease in PAI-1 concentrations at 48 and 72 hours in both the CO(2) and helium groups compared with control (P<.03 each, CO(2) vs control; and P<.04 each, helium vs control). No changes in tPA levels were observed. Changes in insufflation pressures did not affect plasminogen activator activity.

CONCLUSIONS

These results suggest that incubation of human mesothelial cells with both CO(2) and helium in the absence of oxygen enhances mesothelial cell fibrinolytic activity because of a reduction in PAI-1 concentrations. These changes may participate in the observed reduction in adhesions after laparoscopic surgery relative to open surgery.

The effects of staging laparoscopy on trocar site and peritoneal recurrence of pancreatic cancer

BACKGROUND

Staging laparoscopy (SL) has been used to assess resectability of patients with pancreatic cancer. It has lead to increased resectability rates and decreased morbidity. However, experimental data suggests that laparoscopy and peritoneal insufflation can promote tumor growth and potential recurrence. Few clinical data exist to allow assessment of whether these theoretical concerns translate into clinical problems. The purpose of this study was to determine if SL increases the incidence of trocar-site and peritoneal recurrence of pancreatic cancer.

METHODS

A retrospective review of all patients evaluated for pancreatic cancer from 1996 to 2001, inclusive, was included in this study. Patients were divided into five groups: nonoperative management (NM), SL followed by resection (SL-R), SL without resection (SL-NR), exploratory laparotomy with resection (EL-R), and exploratory laparotomy without resection (EL-NR). Patient records were assessed for postoperative occurrence of carcinomatosis and/or malignant ascites, trocar- or incisional-site recurrence, use of postoperative chemotherapy or radiation therapy, and survival.

RESULTS

A total of 235 patients were included. Peritoneal progression of disease: NM 15.9%, SL 24.2%, EL 31.6% ( p = 0.03). Trocar/incisional recurrence: SL 3.0%, EL 3.9% ( p = NS). Use of chemotherapy/radiotherapy: NM 29.4%, SL-R 76.5%, SL-NR 62.5%, EL-R 69.6%, EL-NR 41.5%. Median survival (months): NM 3; SL-R 15, EL-R 10 ( p = NS); SL-NR 6, EL-NR 5 ( p = NS).

CONCLUSION

SL does not increase the occurrence of trocar-site disease or peritoneal disease progression of pancreatic cancer. Patients who are found not to be resectable by SL are more likely to receive postoperative treatment. However, this does not appear to affect survival greatly. Nevertheless, avoidance of nontherapeutic laparotomy is worthwhile in these patients.

Minimally invasive pancreatic surgery

Robotic surgery remains in its infancy, and little experience has been reported, as surgeons carefully explore the application of this type of technology to diseases of the pancreas. While challenging and controversial, Dr. Zollinger would most likely support the ongoing research in the techniques of pancreatic surgery that can lead only to an improvement in the outcomes of our patients.

The role of laparoscopy in the multimodality treatment of colorectal cancer

Ten years after the first reports of laparoscopic techniques in colorectal surgery the precise role for these approaches in future colorectal practice as still to be defined. However, it seems most unlikely that the application is going to disappear. Laparoscopic colectomy is undoubtedly a complex. time-consuming procedure and it is clear that the technique is intolerant of difficult cases and will likely remain thus. Therefore. the potential advantages of laparoscopy do not as yet appear to be attainable across the board in colorectal resection. Such generalized advantage may, however, be tantalizingly close. Although many studies have failed to show major benefits for laparoscopy in terms of postoperative recovery, it must be remembered that most of these have been of insufficient statistical power to settle the issue. What is clear to all involved in the field is that very many patients do gain major benefit from the minimally invasive approach. The challenge for the future lies in developing the technology to such a point that these benefits for patients are more reproducible. The requirement for a significant abdominal incision to deliver an intact specimen represents a significant hurdle in this regard. The importance of pathological staging for colorectal cancer at present mandates retrieval of an intact specimen. It is of course possible that radiological staging may develop to such a point that surgeons need only remove the lesion with minimal attention to lymphadenectomy. Alternatively, new adjuvant therapies may arrive that, by virtue of increased efficacy and low side-effect profiles, may be applicable to all but the earliest lesions. Finally, increasing health awareness and application of screening programs may lead to a preponderance of large polyps and preinvasive lesions for which a more limited resection may be appropriate. Obviously these scenarios remain almost entirely speculative. However, the trend towards less invasive local therapy for colorectal cancer seems inexorable, and we firmly believe that laparoscopy will come to play an increasing role. Finally, we suggest that the oncological safety of laparoscopy is of less concern than was the case some years ago. The specter of port-site metastasis, once so alarming, has faded. It is now apparent from all of the larger scale studies that port-site metastases are not a significant issue in the presence of adequate training and laparoscopic skills. Almost without exception, the accumulating evidence seems to point to equivalence in terms of disease-specific recurrence and survival between patients treated using conventional and laparoscopic techniques. We foresee these findings being confirmed by the North American and European trials.