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Chok AY, Tan IEH, Zhao Y, Chee MYM, Chen HLR, Ang KA, Au MKH, Tan EJKW. Clinical outcomes and cost comparison of laparoscopic versus open surgery in elderly colorectal cancer patients over 80 years. Int J Colorectal Dis 2023; 38:160. [PMID: 37278975 DOI: 10.1007/s00384-023-04459-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 06/07/2023]
Abstract
PURPOSE The growth of Singapore's geriatric population, coupled with the rise in colorectal cancer (CRC), has increased the number of colorectal surgeries performed on elderly patients. This study aimed to compare the clinical outcomes and costs of laparoscopic versus open elective colorectal resections in elderly CRC patients over 80 years. METHODS A retrospective cohort study using data from the American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) identified patients over 80 years undergoing elective colectomy and proctectomy between 2018 and 2021. Patient demographics, length of stay (LOS), 30-day postoperative complications, and mortality rates were analysed. Cost data in Singapore dollars were obtained from the finance database. Univariate and multivariate regression models were used to determine cost drivers. The 5-year overall survival (OS) for the entire octogenarian CRC cohort with and without postoperative complications was estimated using the Kaplan-Meier curves. RESULTS Of the 192 octogenarian CRC patients undergoing elective colorectal surgery between 2018 and 2021, 114 underwent laparoscopic resection (59.4%), while 78 underwent open surgery (40.6%). The proportion of proctectomy cases was similar between laparoscopic and open groups (24.6% vs. 23.1%, P = 0.949). Baseline characteristics, including Charlson Comorbidity Index, albumin level, and tumour staging, were comparable between both groups. Median operative duration was 52.5 min longer in the laparoscopic group (232.5 vs. 180.0 min, P < 0.001). Both groups had no significant differences in postoperative complications and 30-day and 1-year mortality rates. Median LOS was 6 days in the laparoscopic group compared to 9 days in the open group (P < 0.001). The mean total cost was 11.7% lower in the laparoscopic group (S$25,583.44 vs. S$28,970.85, P = 0.012). Proctectomy (P = 0.024), postoperative pneumonia (P < 0.001) and urinary tract infection (P < 0.001), and prolonged LOS > 6 days (P < 0.001) were factors contributing to increased costs in the entire cohort. The 5-year OS of octogenarians with minor or major postoperative complications was significantly lower than those without complications (P < 0.001). CONCLUSION Laparoscopic resection is associated with significantly reduced overall hospitalization costs and decreased LOS compared to open resection among octogenarian CRC patients, with comparable postoperative outcomes and 30-day and 1-year mortality rates. The extended operative time and higher consumables costs from laparoscopic resection were mitigated by the decrease in other inpatient hospitalization costs, including ward accommodation, daily treatment fees, investigation costs, and rehabilitation expenditures. Comprehensive perioperative care and optimised surgical approach to mitigate the impact of postoperative complications can improve survival in elderly patients undergoing CRC resection.
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Affiliation(s)
- Aik Yong Chok
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, 169608, Singapore
| | - Ivan En-Howe Tan
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Yun Zhao
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, 169608, Singapore
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Madeline Yen Min Chee
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, 169608, Singapore
| | | | - Kwok Ann Ang
- Finance, Singapore General Hospital, Singapore, 169608, Singapore
| | - Marianne Kit Har Au
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
- Finance, Singhealth Community Hospitals, Singapore, 168582, Singapore
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Chok AY, Zhao Y, Tan IEH, Au MKH, Tan EJKW. Cost-effectiveness comparison of minimally invasive, robotic and open approaches in colorectal surgery: a systematic review and bayesian network meta-analysis of randomized clinical trials. Int J Colorectal Dis 2023; 38:86. [PMID: 36988723 DOI: 10.1007/s00384-023-04361-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/30/2023]
Abstract
PURPOSE This study compares the cost-effectiveness of open, laparoscopic (LAP), laparoscopic-assisted (LAPA), hand-assisted laparoscopic (HAL), and robotic colorectal surgery using a network meta-analysis. METHODS Randomized clinical trials (RCTs) evaluating the cost-effectiveness of comparing the five different approaches in colorectal surgery were included in a literature search until September 2022. Bayesian network meta-analysis was conducted, and surface under cumulative ranking area (SUCRA) values, odds ratio (OR), and 95% credible intervals (CrIs) were reported for total costs, surgical costs, operating time, length of stay (LOS), and postoperative outcomes. Cluster analysis was performed to examine the similarity and classification of surgical approaches into homogeneous clusters. The cophenetic correlation coefficient (cc) was evaluated to identify the most cost-effective clustering method. The primary outcomes assessed were: costs-morbidity, costs-mortality, and costs-efficacy, measuring total costs against postoperative complications, mortality rate, and LOS, respectively. RESULTS 22 RCTs with 4239 patients were included. Open surgery had the lowest total costs, surgical costs, and operating time but the longest LOS and most postoperative complications. LOS was significantly decreased in LAP compared to open surgery (OR 0.67, 95% CrI 0.46-0.96). Robotic surgery resulted in the highest total costs, surgical costs, and most extended operative duration but the shortest LOS and lowest mortality. LAPA and robotic surgery were superior in the costs-morbidity analysis. HAL was associated with the worst costs-mortality profile. LAP, LAPA, and HAL were better in terms of costs-efficacy. CONCLUSION Overall, LAP and LAPA are the most cost-effective approaches for colorectal surgery in terms of overall postoperative complications, mortality, and LOS.
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Affiliation(s)
- Aik Yong Chok
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, 169856, Singapore, Singapore
| | - Yun Zhao
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, 169856, Singapore, Singapore
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Ivan En-Howe Tan
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Marianne Kit Har Au
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Emile John Kwong Wei Tan
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, 169856, Singapore, Singapore.
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Law CK, Stevenson ARL, Solomon M, Hague W, Wilson K, Simes JR, Morton RL. Healthcare Costs of Laparoscopic versus Open Surgery for Rectal Cancer Patients in the First 12 Months: A Secondary Endpoint Analysis of the Australasian Laparoscopic Cancer of the Rectum Trial (ALaCaRT). Ann Surg Oncol 2021; 29:1923-1934. [PMID: 34713371 DOI: 10.1245/s10434-021-10902-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/20/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Laparoscopic-assisted surgery for rectal cancer is widely used, however the healthcare costs are thought to be higher than for open resection. This secondary endpoint analysis of a randomized controlled trial aimed to evaluate total healthcare costs of laparoscopic-assisted surgery compared with open resection for rectal cancer over a 12-month period. METHODS Patients in the Australasian Laparoscopic Cancer of the Rectum Trial (ALaCaRT) were included in a prospective costing analysis. All healthcare use for the index surgery and hospital admission, readmissions, and follow-up care over 12 months were included. Unit costs were valued in Australian dollars (AUD$) using scheduled Medicare fees and hospital cost weights. The primary outcome was mean per patient cost. Non-parametric bootstrapping with 10,000 replications was undertaken for robustness checks. RESULTS Data from 468 patients indicated that the laparoscopic-assisted surgical procedure incurred a mean cost of AUD$4542 (standard deviation [SD] AUD$1050)-AUD$521 higher than the open procedure mean cost of AUD$4021 (SD AUD$804) due to longer operative time and involvement of more costly equipment (95% confidence interval [CI] AUD$354-AUD$692). At 12 months, the average cost for the laparoscopic-assisted and open groups was AUD$43,288 (SD AUD$40,883) and AUD$45,384 (SD AUD$38,659), respectively, due to the shorter subsequent hospital stays. No overall significant cost difference between groups was found (95% CI -AUD$9358 to AUD$5003). One-way sensitivity analyses confirmed the robustness of the results. CONCLUSION While initially higher, the costs of laparoscopic-assisted surgery for rectal cancer were similar to open resection at 12 months. Clinicians may choose a surgical approach based on clinical need. TRIAL REGISTRATION The Australasian Gastro-Intestinal Trials Group (AGITG) was the legal sponsor and trial coordination was performed by the NHMRC Clinical Trials Centre. The trial was registered with the Australian and New Zealand Clinical Trial Registry (ACTRN12609000663257).
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Affiliation(s)
- Chi Kin Law
- NHMRC Clinical Trials Centre, Medical Foundation Building, University of Sydney, Camperdown, NSW, 2050, Australia.
| | - Andrew R L Stevenson
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Department of Colon and Rectal Surgery, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,St Vincent's Private Hospital Northside, Brisbane, QLD, Australia
| | - Michael Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, University of Sydney and Sydney Local Health District, Sydney, NSW, Australia.,RPA Institute of Academic Surgery, Sydney Local Health District, Sydney, NSW, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Wendy Hague
- NHMRC Clinical Trials Centre, Medical Foundation Building, University of Sydney, Camperdown, NSW, 2050, Australia
| | - Kate Wilson
- NHMRC Clinical Trials Centre, Medical Foundation Building, University of Sydney, Camperdown, NSW, 2050, Australia
| | - John R Simes
- NHMRC Clinical Trials Centre, Medical Foundation Building, University of Sydney, Camperdown, NSW, 2050, Australia
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, Medical Foundation Building, University of Sydney, Camperdown, NSW, 2050, Australia
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4
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Reinke CE, Lim RB. Minimally Invasive Acute Care Surgery. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2021.101033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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5
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Reinke CE, Lim RB. Minimally invasive acute care surgery. Curr Probl Surg 2021; 59:101031. [DOI: 10.1016/j.cpsurg.2021.101031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 05/16/2021] [Indexed: 12/07/2022]
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Law CK, Brewer K, Brown C, Wilson K, Bailey L, Hague W, Simes JR, Stevenson A, Solomon M, Morton RL. Return to work following laparoscopic-assisted resection or open resection for rectal cancer: Findings from AlaCaRT-Australasian Laparoscopic Cancer of the Rectum Trial. Cancer Med 2021; 10:552-562. [PMID: 33280266 PMCID: PMC7877361 DOI: 10.1002/cam4.3623] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Maintaining employment for adults with cancer is important, however, little is known about the impact of surgery for rectal cancer on an individual's capacity to return to work (RTW). This study aimed to determine the impact of laparoscopic vs. open resection on RTW at 12 months. METHODS Analyses were undertaken among participants randomized in the Australian Laparoscopic Cancer of the Rectum Trial (ALaCaRT), with work status available at baseline (presurgery), and 12 months. Multivariable logistic regression, adjusted for sociodemographic and clinical characteristics estimated the effect of surgery on RTW in any capacity, or return to preoperative work status at 12 months. RESULTS About 228 of 449 (51%) surviving trial participants at 12 months completed work status questionnaires; mean age was 62 years, 66% males, 117 of these received laparoscopic resection (51%). Of 228, 120 were employed at baseline (90 full-time, 30 part-time). Overall RTW in 120 participants in paid work at baseline was 78% (84% laparoscopic, 70% open surgery). Those employed full-time were more likely to RTW at 12 months (OR, 3.55; 95% CI, 1.02-12.31). Those with distant metastases at baseline were less likely to RTW (OR, 0.07; 95% CI, <0.01-0.83). Laparoscopic surgery was associated with a higher rate of RTW but did not reach statistical significance (OR 2.88; 95% CI, 0.95-8.76). CONCLUSIONS Full-time work presurgery and the presence of metastatic disease predicts RTW status at 12 months. A laparoscopic-assisted surgical approach to rectal cancer may facilitate more patients to RTW, however, larger sample sizes are likely needed to confirm this result.
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Affiliation(s)
- Chi Kin Law
- NHMRC Clinical Trials CentreThe University of SydneyCamperdownNSWAustralia
| | - Kate Brewer
- NHMRC Clinical Trials CentreThe University of SydneyCamperdownNSWAustralia
| | - Chris Brown
- NHMRC Clinical Trials CentreThe University of SydneyCamperdownNSWAustralia
| | - Kate Wilson
- NHMRC Clinical Trials CentreThe University of SydneyCamperdownNSWAustralia
| | - Lisa Bailey
- NHMRC Clinical Trials CentreThe University of SydneyCamperdownNSWAustralia
| | - Wendy Hague
- NHMRC Clinical Trials CentreThe University of SydneyCamperdownNSWAustralia
| | - John R. Simes
- NHMRC Clinical Trials CentreThe University of SydneyCamperdownNSWAustralia
| | - Andrew Stevenson
- Faculty of Medicine and Biomedical SciencesUniversity of QueenslandHerstonQldAustralia
| | - Michael Solomon
- Institute of Academic SurgeryRoyal Prince Alfred HospitalUniversity of SydneySydneyNSWAustralia
| | - Rachael L. Morton
- NHMRC Clinical Trials CentreThe University of SydneyCamperdownNSWAustralia
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Minamikawa K, Okumura A, Kokudo N, Kono K. Regulation on introducing process of the highly difficult new medical technologies: A survey on the current status of practice guidelines in Japan and overseas. Biosci Trends 2019; 12:560-568. [PMID: 30606978 DOI: 10.5582/bst.2018.01226] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Since serious problematic cases regarding the technical safety of technically demanding operations were reported in Japan, the Ministry of Health, Labor and Welfare issued new regulations on June 10, 2016 requiring each hospital to check the status of informed consent, skill of surgery team and governance system of the surgical unit, when the highly difficult new medical technologies were introduced to a hospital. In order to firmly establish this new system for highly difficult new medical technologies, it is very important and informative to survey the current situation for guidelines and consensus regarding introduction of medical technology with special skills in Japan and overseas. Based on the survey of questionnaires, document retrieval, and expert interviews, we found that documentation related to the introduction process of highly difficult medical technologies is very rare, and the regulations were mainly issued by academic societies. Moreover, even if such documentation existed, the quality of the regulations is poor and not sufficient enough to perform surgical practice safely. Therefore, for medical practitioners, comprehensive and concrete regulations should be issued by the government or ministry to legally follow in regard to technically demanding operations. A new practice guideline was proposed by our special research group to regulate the introduction process of highly difficult new medical technologies in hospitals in Japan. This guideline, gained understanding from relevant academic societies, provided a comprehensive view on the interpretation of "high difficulty new medical technology" prescribed by the law and show the basic idea at a preliminary examination from the viewpoints of "Surgeon's requirement", "Guidance system", "Medical safety" , and "Informed consent". These efforts will contribute to the improvement of the quality of guidelines regarding "highly difficult new medical technology".
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Affiliation(s)
- Kazuo Minamikawa
- Departments of Gastrointestinal Tract Surgery, Fukushima Medical University.,Medical Research Center, Fukushima Medical University.,Special Research Group on Evaluation and Improvement of Clinical Guidelines for Introduction Process of Highly Difficult New Medical Technologies
| | - Akiko Okumura
- Special Research Group on Evaluation and Improvement of Clinical Guidelines for Introduction Process of Highly Difficult New Medical Technologies.,Department of EBM and Guidelines, Japan Council for Quality Health Care
| | - Norihiro Kokudo
- Special Research Group on Evaluation and Improvement of Clinical Guidelines for Introduction Process of Highly Difficult New Medical Technologies.,Department of Surgery, University of Tokyo
| | - Koji Kono
- Departments of Gastrointestinal Tract Surgery, Fukushima Medical University.,Special Research Group on Evaluation and Improvement of Clinical Guidelines for Introduction Process of Highly Difficult New Medical Technologies
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8
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Endoscopic full thickness resection: A surgeon's perspective. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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9
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Intracorporeal Isosceles Right Triangle-shaped Anastomosis in Totally Laparoscopic Distal Gastrectomy. Surg Laparosc Endosc Percutan Tech 2018; 28:193-201. [PMID: 29738380 DOI: 10.1097/sle.0000000000000535] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE This study aimed to evaluate the feasibility and safety of intracorporeal anastomosis with Billroth I, Billroth II, or Roux-en-Y reconstructions in totally laparoscopic distal gastrectomy. MATERIALS AND METHODS A single-institution, retrospective, cohort study including 553 patients was conducted. Intracorporeal isosceles right triangle-shaped anastomosis without slack and torsion was created using linear staplers. Billroth I was primarily used. Surgical outcomes and perioperative nutritional status were assessed. RESULTS Morbidity was 11.5%. Postoperative early complications related to anastomosis occurred in 13 patients (2.4%). Operative time and reconstruction type (Billroth I vs. others) were the only significant independent risk factors determining postoperative early and late complications, respectively. No difference was observed in postoperative changes in nutritional status across the groups, although Billroth II increased reflux esophagitis requiring medication. CONCLUSIONS Intracorporeal isosceles right triangle-shaped anastomosis using linear staplers in totally laparoscopic distal gastrectomy, in combination with our selection algorithm for type of reconstruction, is feasible and safe.
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10
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A minimally invasive approach for peritonectomy procedures and hyperthermic intraperitoneal chemotherapy (HIPEC) in limited peritoneal carcinomatosis: The American Society of Peritoneal Surface Malignancies (ASPSM) multi-institution analysis. Surg Endosc 2018; 33:854-860. [PMID: 30003349 DOI: 10.1007/s00464-018-6352-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/06/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Minimally invasive surgery is playing an increasing role in the treatment of patients with gastrointestinal and gynaecological malignancies as the data show reduced morbidity, faster recovery and similar oncological outcome when compared to open procedures. MATERIALS AND METHODS The American Society of Peritoneal Surface Malignancies (ASPSM) conducted a retrospective study to analyse peritonectomy procedures and HIPEC done via the laparoscopic route. A database with standard clinical and pathological parameters was set up and distributed amongst ASPSM members. Rate of relapse, morbidity and mortality were the primary endpoints of the study. RESULTS A total of 90 patients from 7 centres around the world were identified. Sixty percent were female. Mean age was 50 years. Peritoneal carcinomatosis from appendiceal origin was the most common diagnosis in a 64.9% of patients and colon origin was diagnosed in 16.5% of patients. Mean peritoneal cancer index (PCI) was 4.1 (0-10). Forty-one percent of patients had a bowel resection. Mean operative time was 4.7 h (2.5-8). All patients had a complete cytoreduction and HIPEC. Grade 3 and 4 morbidity was 3.0 and 6.5%, respectively. The most common reason for re-operation was an internal hernia in 2 out of 5 cases. Operative mortality and re-admission rates were 0 and 5%, respectively. Mean hospital stay was 7.4 days (1-18). At a mean follow-up of 31.6 months, 15/90 patients have a disease relapse but loco-regional relapse was identified in only five patients. CONCLUSIONS Analysis of these data suggests that minimally invasive approach for peritonectomy procedures and HIPEC is feasible, safe and should be considered as part of the armamentarium for highly selected patients with peritoneal surface malignancies with limited tumour burden, defined as PCI of 10 or less and borderline tumours as low-grade pseudomyxoma and benign multicystic mesothelioma.
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11
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Arjona-Sánchez Á, Rodríguez-Ortiz L, Rufián-Peña S, Sánchez-Hidalgo JM, Briceño-Delgado J. Laparoscopic approach in complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy by CO 2 closed system in a low grade pseudomyxoma peritonei. Cir Esp 2018; 96:656-658. [PMID: 29937297 DOI: 10.1016/j.ciresp.2018.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 11/05/2017] [Accepted: 03/12/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Álvaro Arjona-Sánchez
- Unidad de Cirugía Oncológica y Pancreática, Departamento de Cirugía, Hospital Universitario Reina Sofía, Córdoba, España; CIBERehd, IMIBIC, Hospital Universitario Reina Sofía, Córdoba, España.
| | - Lidia Rodríguez-Ortiz
- Unidad de Cirugía Oncológica y Pancreática, Departamento de Cirugía, Hospital Universitario Reina Sofía, Córdoba, España
| | - Sebastián Rufián-Peña
- Unidad de Cirugía Oncológica y Pancreática, Departamento de Cirugía, Hospital Universitario Reina Sofía, Córdoba, España; CIBERehd, IMIBIC, Hospital Universitario Reina Sofía, Córdoba, España
| | - Juan Manuel Sánchez-Hidalgo
- Unidad de Cirugía Oncológica y Pancreática, Departamento de Cirugía, Hospital Universitario Reina Sofía, Córdoba, España; CIBERehd, IMIBIC, Hospital Universitario Reina Sofía, Córdoba, España
| | - Javier Briceño-Delgado
- Unidad de Cirugía Oncológica y Pancreática, Departamento de Cirugía, Hospital Universitario Reina Sofía, Córdoba, España; CIBERehd, IMIBIC, Hospital Universitario Reina Sofía, Córdoba, España
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12
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Lianos GD, Hasemaki N, Glantzounis GK, Mitsis M, Rausei S. Assessing safety and feasibility of 'pure' laparoscopic total gastrectomy for advanced gastric cancer in the West. Review article. Int J Surg 2018; 53:275-278. [PMID: 29602017 DOI: 10.1016/j.ijsu.2018.03.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 03/23/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Gastric cancer is reported to be the fourth most common cancer and the second leading cause of cancer-related death worldwide. Minimally invasive surgical treatment for gastric cancer is a very challenging approach which offers undoubtedly important advantages. MATERIALS AND METHODS There is intense debate concerning the minimally invasive surgical approach for advanced gastric cancer especially in the Western population. A careful literature search was conducted in order to clarify the feasibility and safety of pure laparoscopic total gastrectomy in the West. RESULTS Herewith we aim to summarize the current scientific evidence assessing the feasibility and short-term outcomes of laparoscopic gastrectomy for advanced gastric cancer in the West. A lack of data from Western institutions regarding minimally invasive surgical approach for gastric cancer is yet a reality. Nevertheless, the laparoscopic procedure appears to provide satisfactory short-term oncologic outcomes and improved postoperative outcomes. CONCLUSION It is obvious that future well-conducted trials on long-term results are necessary for Western patients in order safe conclusions to be reached regarding a potential definitive 'place' for laparoscopy in the curative gastric cancer treatment.
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Affiliation(s)
- Georgios D Lianos
- Department of Surgery, University Hospital of Ioannina and University of Ioannina, Ioannina, 45110, Greece; Department of Surgery, General Hospital of Preveza, Preveza, Greece.
| | - Natasha Hasemaki
- Department of Surgery, General Hospital of Preveza, Preveza, Greece
| | - Georgios K Glantzounis
- Department of Surgery, University Hospital of Ioannina and University of Ioannina, Ioannina, 45110, Greece
| | - Michail Mitsis
- Department of Surgery, University Hospital of Ioannina and University of Ioannina, Ioannina, 45110, Greece
| | - Stefano Rausei
- Department of Surgery, University of Insubria, Varese, Italy
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Payabyab EC, Balasubramaniam S, Edgerly M, Velarde M, Merino MJ, Venkatesan AM, Leuva H, Litman T, Bates SE, Fojo T. Adrenocortical Cancer: A Molecularly Complex Disease Where Surgery Matters. Clin Cancer Res 2018; 22:4989-5000. [PMID: 27742785 DOI: 10.1158/1078-0432.ccr-16-1570] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 08/24/2016] [Indexed: 11/16/2022]
Abstract
The development of new therapies has lagged behind for rare cancers without defined therapeutic targets. Adrenocortical cancer is no exception. Mitotane, an older agent considered "adrenolytic," is used both to control symptoms in advanced disease and as adjuvant therapy after surgical resection. Molecular characterization of adrenocortical cancer has deepened our understanding of this genetically complex disease while identifying subgroups whose importance remains to be determined. Unfortunately, such studies have yet to demonstrate a therapeutic target for drug development, and to date, no targeted therapy has achieved meaningful outcomes. Consequently, first-line therapy for metastatic disease remains a combination regimen of etoposide, doxorubicin, and cisplatinum established in a randomized clinical trial. In addition to evaluating recent studies in adrenocortical cancer, we raise one critical clinical issue-the risk of peritoneal dissemination following laparoscopic resection of adrenocortical cancer. In a retrospective case series of 267 patients referred to the NCI for the treatment of recurrent or advanced adrenocortical cancer, we found extensive peritoneal dissemination in 25 of the 45 patients (55.6%) who had undergone laparoscopic resection, compared with only 7 of the 222 patients (3%) who had undergone an open resection (P < 0.0001). Although this has been debated in the literature, our data argue for an end to laparoscopic resection of adrenocortical cancers to avoid peritoneal dissemination, a complication of laparoscopy that is uniformly fatal. Clin Cancer Res; 22(20); 4989-5000. ©2016 AACR SEE ALL ARTICLES IN THIS CCR FOCUS SECTION, "ENDOCRINE CANCERS REVISING PARADIGMS".
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Affiliation(s)
- Eden C Payabyab
- Surgery Branch and Thoracic & GI Oncology Branch, NCI, NIH, Bethesda, Maryland
| | - Sanjeeve Balasubramaniam
- Division of Oncology Products 1, OHOP, CDER, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Maureen Edgerly
- Medical Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, Maryland
| | - Margarita Velarde
- Medical Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, Maryland
| | - Maria J Merino
- Laboratory of Pathology, Center for Cancer Research, NCI, NIH, Bethesda, Maryland
| | - Aradhana M Venkatesan
- Department of Diagnostic Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Harshraj Leuva
- James J. Peters Veterans Administration Medical Center, Bronx, New York
| | - Thomas Litman
- Medical Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Susan E Bates
- James J. Peters Veterans Administration Medical Center, Bronx, New York. Division of Medical Oncology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Tito Fojo
- James J. Peters Veterans Administration Medical Center, Bronx, New York. Division of Medical Oncology, Department of Medicine, Columbia University Medical Center, New York, New York.
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14
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Lin W, Lin JH, Chiu KH, Ho DR, Huang YC, Huang KT, Chen CS. Performing laparoscopic radical cystectomy is feasible for the elderly with marginal cardiopulmonary function. UROLOGICAL SCIENCE 2018. [DOI: 10.4103/uros.uros_9_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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15
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Lin JH, Chiu KH, Ho DR, Huang YC, Huang KT, Chen CS, Lin WY. Laparoscopic radical cystectomy is feasible for the elderly with marginal cardiopulmonary function. UROLOGICAL SCIENCE 2017. [DOI: 10.1016/j.urols.2017.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Rashidi L, Neighorn C, Bastawrous A. Outcome comparisons between high-volume robotic and laparoscopic surgeons in a large healthcare system. Am J Surg 2017; 213:901-905. [DOI: 10.1016/j.amjsurg.2017.03.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 03/28/2017] [Indexed: 01/24/2023]
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Hu H, Zhang K, Zhao G, Jiang Z, Huang A, Cai J, Xu A, Li H, He C, Ding K, Lu R, Ye R. Experimental use of a novel single-port gasless laparoendoscopic operative field formation device. Ann Med Surg (Lond) 2017; 13:13-19. [PMID: 28018588 PMCID: PMC5173315 DOI: 10.1016/j.amsu.2016.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 11/20/2016] [Accepted: 11/21/2016] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Traditional laparaendoscopic surgery using CO2 pneumoperitoneum is associated with complications and the existing gasless laparaendoscopic surgery has shortcomings such as poor visibility in the operation field. To overcome the disadvantages of the current lifting gasless laparaendoscopic operation platforms, we developed an inflatable device for gasless laparoscopic operation field formation (LOFF) that can be internally installed and applied in practice. METHODS We initially designed operation platforms for gasless laparaendoscopic single-port (GLESP) surgery. Subsequently, a triangular prismatic LOFF device was selected and applied successfully to GLESP cholecystectomy of five pigs. Ultimately, using pigs as a model, three surgical approaches (LOFF-assisted laparaendoscopic single-site (LOFF-LESS), LESS surgery, and traditional lifting (GLESP) were compared, and the advantages and drawbacks of inflatable devices for gasless laparoscopic operation field assessed. RESULTS The use of the LOFF device in GLESP cholecystectomy was first evaluated. The time for surgical space formation (4.4 ± 1.2 and 4.8 ± 1.0), the operating time for gallbladder removal (25.2 ± 4.8 and 25.4 ± 2.7), and the loss of blood (9.4 ± 3.1and 9.2 ± 2.4) was similar between LESS and LOFF, respectively (Table 2). In contrast these parameters were higher in GLESP (6.6 ± 1.0, 30.3 ± 4.4 and 10.1 ± 2.0, respectively. The LOFF-LESS surgery exhibited a clearer exposure of the surgical field and shorter operating time than the GLESP surgery. LESS technology showed less postoperation pain, fast recovery, and extremely high cosmetic satisfaction. CONCLUSION The LOFF device provides a safe, effective, and feasible operation platform that can be internally installed and inflated for GLESP surgery during cholescytectomy in animal models.
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Affiliation(s)
- Hai Hu
- East Hospital Affiliated with Tongji University, Shanghai, China
| | - Kai Zhang
- Medical School of Tongji University, Shanghai, China
| | - Gang Zhao
- East Hospital Affiliated with Tongji University, Shanghai, China
| | - Zhaoyan Jiang
- East Hospital Affiliated with Tongji University, Shanghai, China
| | - Anhua Huang
- East Hospital Affiliated with Tongji University, Shanghai, China
| | - Jingli Cai
- East Hospital Affiliated with Tongji University, Shanghai, China
| | - Anan Xu
- East Hospital Affiliated with Tongji University, Shanghai, China
| | - Haidong Li
- East Hospital Affiliated with Tongji University, Shanghai, China
| | - Chuanqi He
- East Hospital Affiliated with Tongji University, Shanghai, China
| | - Kan Ding
- East Hospital Affiliated with Tongji University, Shanghai, China
| | - Ruiqi Lu
- East Hospital Affiliated with Tongji University, Shanghai, China
| | - Ruiqi Ye
- East Hospital Affiliated with Tongji University, Shanghai, China
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Suda K, Man-I M, Ishida Y, Kawamura Y, Satoh S, Uyama I. Potential advantages of robotic radical gastrectomy for gastric adenocarcinoma in comparison with conventional laparoscopic approach: a single institutional retrospective comparative cohort study. Surg Endosc 2014; 29:673-85. [PMID: 25030478 DOI: 10.1007/s00464-014-3718-0] [Citation(s) in RCA: 153] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Accepted: 06/25/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND We have previously reported that laparoscopic approach improved short-term postoperative courses even for advanced gastric adenocarcinoma, but not morbidity, in comparison with open approach. The objective of this study was to determine the impact of the use of the surgical robot, da Vinci Surgical System, in minimally invasive radical gastrectomy on short-term outcomes. METHODS A single institutional retrospective cohort study was performed (UMIN000011749). Five hundred twenty-six patients who underwent radical gastrectomy were enrolled. Eighty-eight patients who agreed to uninsured use of the surgical robot underwent robotic gastrectomy, whereas the remaining 438 patients who wished for laparoscopic (lap) approach with health insurance coverage underwent conventional laparoscopic gastrectomy. RESULTS In the robotic group, morbidity (robotic vs lap 2.3 vs 11.4 %, p = 0.009) and hospital stay following surgery (robotic vs lap 14 [2-31] vs 15 [8-136] days, p = 0.021) were significantly improved, even though operative time (p = 0.003) and estimated blood loss (p = 0.026) were slightly greater. In particular, local (robotic vs lap 1.1 vs 9.8 %, p = 0.007) rather than systemic (robotic vs lap 1.1 vs 2.5 %, p = 0.376) complication rates were attenuated using the surgical robot. Multivariate analyses revealed that non-use of the surgical robot (OR 6.174 [1.454-26.224], p = 0.014), total gastrectomy (OR 4.670 [2.503-8.713], p < 0.001), and D2 lymphadenectomy (OR 2.095 [1.124-3.903], p = 0.020) were the significant independent risk factors determining postoperative complications. CONCLUSIONS The use of the surgical robot might reduce surgery-related complications, leading to further improvement in short-term postoperative courses following minimally invasive radical gastrectomy.
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Affiliation(s)
- Koichi Suda
- Division of Upper GI, Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan,
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Conditioning of the abdominal cavity reduces tumor implantation in a laparoscopic mouse model. Surg Today 2014; 44:1328-35. [PMID: 24452508 PMCID: PMC4055846 DOI: 10.1007/s00595-014-0832-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 06/04/2013] [Indexed: 01/27/2023]
Abstract
Purpose The addition of 4 % O2 and 10 % N2O to the CO2 pneumoperitoneum (PP), together with slight cooling and humidification (conditioning), contributes to reducing adhesions by preventing mesothelial damage. We investigated the effect of peritoneal damage during laparoscopy on tumor implantation. Methods In Experiment 1, different tumor cell concentrations were injected into control mice without PP and into mice with 60-min dry CO2PP (mesothelial damage). In Experiment 2, tumor cells were injected into control mice (group I) and in mice with mesothelial damage (group II). In groups III to VI, mesothelial damage was decreased by adding humidification, humidification + 10 % N2O, humidification + 10 % N2O + 4 % O2, and conditioning, respectively. Results In Experiment 1, the tumors increased with the number of cells injected and with mesothelial damage in the abdominal cavity (p = 0.018) and abdominal wall (p < 0.0001). Experiment 2 confirmed that 60 min of dry CO2PP increased the number of tumors in the abdominal cavity and wall (p = 0.026 and p = 0.003, respectively). The number of tumors was decreased in the abdominal cavity by conditioning (p = 0.030) and in the abdominal wall using humidified CO2 (p = 0.032) or conditioning (p = 0.026). Conclusions Tumor implantation was enhanced by peritoneal damage (60 min of dry CO2PP and desiccation), but this was prevented by conditioning. If confirmed in humans, conditioning would become important for oncologic surgery.
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20
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Partelli S, Maurizi A, Tamburrino D, Crippa S, Pandolfi S, Falconi M. Surgical management of pancreatic neuroendocrine neoplasms. Ann Saudi Med 2014; 34:1-5. [PMID: 24658547 PMCID: PMC6074938 DOI: 10.5144/0256-4947.2014.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Pancreatic neuroendocrine neoplasms are relatively rare entities, representing approximately 1% to 2% of all pancreatic tumors. Owing to their rarity as well as their relatively indolent natural history, treatment approaches are not yet standardized. A formal pancreatic resection is usually mandatory for large and localized sporadic pancreatic tumors or in the presence of symptoms. However, in small and asymptomatic lesions, a conservative approach consisting in a careful wait-and-see policy is going to appear as more appropriate, particularly when, to remove the lesion, an aggressive surgical procedure is required, such as pancreaticoduodenectomy or distal splenopancreatectomy, depending on the localization of the tumor. Surgery has also a significant role in locally advanced and metastatic forms. In the setting of MEN 1 syndrome or Von-Hippel Lindau disease, the tumor size and the possible symptoms should be considered in the evaluation of a proper treatment.
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Affiliation(s)
| | | | | | | | | | - Massimo Falconi
- Prof. Massimo Falconi, Department of Surgery,, Clinical Chirurgia del Pancreas,, Ospedali Riuniti,, Via Conca 71,, Torrette-Ancona 60126, Italy, T: +39 0715965781, F: +39 0712206024,
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Uyama I, Suda K, Satoh S. Laparoscopic surgery for advanced gastric cancer: current status and future perspectives. J Gastric Cancer 2013; 13:19-25. [PMID: 23610715 PMCID: PMC3627802 DOI: 10.5230/jgc.2013.13.1.19] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 03/06/2013] [Accepted: 03/06/2013] [Indexed: 12/26/2022] Open
Abstract
Laparoscopic gastrectomy has been widely accepted especially in patients with early-stage gastric cancer. However, the safety and oncologic validity of laparoscopic gastrectomy for advanced gastric cancer are still being debated. Since the late 90s', we have been engaged in developing a stable and robust methodology of laparoscopic radical gastrectomy for advanced gastric cancer, and have established laparoscopic distinctive technique for suprapancreatic lymph node dissection, namely the outermost layer-oriented medial approach. In this article, We present the development history of this method, and current status and future perspectives of laparoscopic gastrectomy for advanced gastric cancer based on our experience and a review of the literature.
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Affiliation(s)
- Ichiro Uyama
- Division of Upper Gastrointestinal Tract, Department of Surgery, Fujita Health University, Aichi, Japan
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Kang CY, Chaudhry OO, Halabi WJ, Nguyen V, Carmichael JC, Stamos MJ, Mills S. Outcomes of laparoscopic colorectal surgery: data from the Nationwide Inpatient Sample 2009. Am J Surg 2012; 204:952-7. [PMID: 23122910 DOI: 10.1016/j.amjsurg.2012.07.031] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 07/02/2012] [Accepted: 07/02/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Specific International Classification of Diseases, Ninth Revision, codes for laparoscopic procedures introduced in 2008 allow a more accurate evaluation of laparoscopic colorectal surgery. METHODS Using the Nationwide Inpatient Sample 2009, a retrospective analysis of surgical colorectal cancer and diverticulitis patients was conducted. Logistic regression was used to estimate odds ratios comparing the outcomes of laparoscopic, open, and converted surgery. RESULTS A total of 121,910 patients underwent resection for cancer and diverticulitis, 35.41% of whom underwent laparoscopic surgery. Compared with open surgery, laparoscopic surgery had lower postoperative complication rates, lower mortality, shorter hospital stays, and lower costs. Compared to open surgery, laparoscopic surgery independently decreased mortality, postoperative anastomotic leak, urinary tract infection, ileus or obstruction, pneumonia, respiratory failure, and wound infection. Converted surgery was independently associated with anastomotic leak, wound infection, ileus or obstruction, and urinary tract infection. CONCLUSIONS Laparoscopic colorectal surgery has lower postoperative complications, lower mortality, lower costs, and shorter hospital stays. Conversion had higher complications compared with laparoscopy. The use of laparoscopy should increase with efforts to minimize conversion.
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Affiliation(s)
- Celeste Y Kang
- Department of Surgery, University of California, Irvine, School of Medicine, Irvine, CA, USA
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Abstract
Gastric cancer is common worldwide. Tumor location and disease stage differ between Asian and Western countries. Western patients often have higher BMIs and comorbidities that may make laparoscopic resections challenging. Multiple trials from Asian countries demonstrate the benefits of laparoscopic gastrectomy for early gastric cancer while maintaining equivalent short-term and long-term oncologic outcomes compared with open surgery. The outcomes of laparoscopy seem to offer equivalent results to open surgery. In the United States, laparoscopic gastrectomy remains in its infancy and is somewhat controversial. This article summarizes the literature on the epidemiology, operative considerations and approaches, and outcomes for laparoscopic gastrectomy.
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Affiliation(s)
- Joseph D Phillips
- Department of Surgery, Feinberg School of Medicine, Northwestern University, East Huron Street, Galter 3-150, Chicago, IL 60611, USA
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Abstract
PURPOSE OF REVIEW The evaluation of liver histology is an important component of the diagnosis and staging of liver diseases. The most common technique employed to sample liver tissue for decades has been percutaneous liver biopsy. Although this is a relatively well tolerated technique in the early stages of liver disease, it carries a high risk of complications, particularly hemorrhage, in patients with advanced cirrhosis. Mini-laparoscopy allows macroscopic assessment and biopsy under direct vision and therefore is a well tolerated and effective technique. RECENT FINDINGS The major advantages of this technique are direct visualization of the liver surface, thereby allowing inspection for morphologic changes of cirrhosis as well as targeted biopsies, the ability to immediately treat potential complications (bleeding and bile leakage), furthermore the peritoneal cavity can be visualized to stage gastrointestinal (GI) malignancies. Additionally, 'blind' percutaneous liver biopsy fails to establish a diagnosis in about 25% of cases, largely because of sampling error. SUMMARY This technique presents the opportunity to visualize the surface of the liver and the peritoneal cavity, making it a valuable tool for liver biopsy. This review summarizes the technique of mini-laparoscopy and addresses its potential uses and limitations as a diagnostic modality.
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Laparoscopic Cytoreductive Surgery and HIPEC in Patients with Limited Pseudomyxoma Peritonei of Appendiceal Origin. Gastroenterol Res Pract 2012; 2012:981245. [PMID: 22567001 PMCID: PMC3332170 DOI: 10.1155/2012/981245] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Accepted: 02/16/2012] [Indexed: 01/02/2023] Open
Abstract
Introduction. Increasing numbers of patients with pseudomyxoma peritonei (PMP) of appendiceal origin are being evaluated with a low tumor burden. We explored a minimally invasive approach for this group of patients. Materials and Methods. We designed a protocol in which patients with a PMP diagnosis would have a diagnostic laparoscopy. If limited carcinomatosis (PCI ≤ 10) is identified, the procedure will continue laparoscopically. If extensive carcinomatosis (PCI > 10) is found, then the procedure will be converted to an open approach. Results. From December 2008 to December 2011, 19 patients had a complete cytoreduction and HIPEC: 18 of them (95%) were done laparoscopically and 1 of them (5%) was converted to an open procedure. Mean PCI was 4.2. Grade 3 morbidity was 0, and one patient (5%) experienced a grade 4 complication, needing a reoperation for an internal hernia. There were no mortalities. Mean length of hospital stay was 5.3 days. At a mean follow-up of 17 months (1–37) all 19 patients are alive and free of disease. Conclusion. This study demonstrates that cytoreductive surgery and HIPEC via the laparoscopic route is feasible and safe and should be offered to patients with limited pseudomyxoma peritonei of appendiceal origin.
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Levels of Evidence for Laparoscopic Surgery for Colorectal Cancer. J Am Coll Surg 2011; 212:269-70; author reply 270-1. [DOI: 10.1016/j.jamcollsurg.2010.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Accepted: 10/21/2010] [Indexed: 12/20/2022]
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Balasubramaniam S, Fojo T. Practical Considerations in the Evaluation and Management of Adrenocortical Cancer. Semin Oncol 2010; 37:619-26. [DOI: 10.1053/j.seminoncol.2010.10.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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