Pull-through procedure as treatment for coloanal anastomotic dehiscence following laparoscopic total mesorectal excision.
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Anastomosis, Surgical↗
Biomedical subjects
C Sietses
Publications and source records attributed to C Sietses.
Systemic and peritoneal angiogenic response after laparoscopic or conventional colon resection in cancer patients: a prospective, randomized trial.
PURPOSE: Angiogenesis is essential for wound healing. Vascular endothelial growth factor and endostatin are both endogenous angiogenic factors thought to be involved in the initiation and termination of angiogenesis. The aim of this study was to assess the local and systemic angiogenic profile in patients undergoing laparoscopic or open surgery for colon cancer. METHODS: Patients with primary colon carcinoma were prospectively randomized to curative laparoscopic (n = 12) or conventional (n = 14) resection. Vascular endothelial growth factor and endostatin levels in serum and wound fluid were investigated. RESULTS: In both groups vascular endothelial growth factor levels in wound fluid were significantly higher than postoperative serum levels, whereas endostatin levels in wound fluid were lower than serum levels and decreased progressively after surgery. The vascular endothelial growth factor levels in wound fluid measured at Day 4 were significantly higher in the laparoscopy group than in the laparotomy patients. CONCLUSIONS: Wound healing is associated with a strong local increase in pro-angiogenic factors and a decrease in antiangiogenic factors. The investigation of locally produced factors offered greater insight into the process of angiogenesis during wound healing than could be acquired from the circulation.
Aged↗
Systemic and peritoneal inflammatory response after laparoscopic or conventional colon resection in cancer patients: a prospective, randomized trial.
PURPOSE: This study was designed to evaluate differences in both the peritoneal and systemic immune response after laparoscopic and conventional surgical approaches. METHODS: Patients with a primary carcinoma were prospectively randomized to curative laparoscopic (n = 12) or conventional (n = 14) colon resection. The proinflammatory cytokines interleukin-6, interleukin-8, and tumor necrosis factor-alpha were measured in the peritoneal drain fluid and in the serum. C-reactive protein and leukocyte counts and the differences in leukocyte subpopulations and expression of human leukocyte antigen-DR on monocytes were measured perioperatively. RESULTS: Significantly higher levels of proinflammatory cytokine were found in the peritoneal drain fluid than in the circulation after both procedures. Serum interleukin-6 and interleukin-8 levels were significantly lower 2 hours after laparoscopic surgery than with the conventional procedure. Postoperative cellular immune counts and human leukocyte antigen-DR expression normalized earlier after the laparoscopic approach. CONCLUSIONS: The systemic proinflammatory concentrations after both surgical approaches represent only a small fragment of what is generated in the peritoneal drain fluid. Even if the immediate levels of proinflammatory cytokines in the serum are significantly lower in the laparoscopic group, the same cytokines locally produced showed no differences, which suggests that the two intra-abdominal approaches are equally traumatic. No differences in cellular response were observed between the groups.
Aged↗
Randomized clinical trial of the effect of open versus laproscopically assisted colectomy on systemic immunity in patients with colorectal cancer.
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Colectomy↗
The influence of CO2 versus helium insufflation or the abdominal wall lifting technique on the systemic immune response.
BACKGROUND: Both laparoscopic and conventional surgery result in activation of the systemic immune response; however, the influence of the laparoscopic approach, using CO2 insufflation, is significantly less. Little is known about the influence of alternative methods for performing laparoscopy, such as helium insufflation and the abdominal wall lifting technique (AWLT), and the systemic immune response. METHODS: Thirty-three patients scheduled for elective cholecystectomy were randomly assigned to undergo laparoscopy using either CO2 or helium for abdominal insufflation or laparoscopy using only the AWLT. The postoperative inflammatory response was assessed by measuring the white blood cell count, C-reactive protein (CRP) and interleukin-6 (IL-6). The postoperative immune response was assessed by measuring monocyte HLA-DR expression. RESULTS: CRP levels were significantly higher 1 day after helium insufflation when compared with CO2 insufflation; however, no differences were observed 2 days after surgery. The AWLT resulted in significantly higher levels of CRP both 1 and 2 days after surgery when compared with either CO2 or helium insufflation. A small increase in postoperative IL-6 levels was observed in all groups, but no significant differences were seen between the groups. After both helium insufflation and AWLT a significant decrease in HLA-DR expression was observed, in contrast to the CO2 group. CONCLUSION: Carbon dioxide used for abdominal insufflation seems to limit the postoperative inflammatory response and to preserve parameters reflecting the immune status. These findings may be of importance in determining the preferred method of laparoscopy in oncologic surgery.
Abdominal Muscles↗
Randomized clinical trial of the effect of open versus laparoscopically assisted colectomy on systemic immunity in patients with colorectal cancer (Br J Surg 2001; 88: 801-7).
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Colectomy↗
Ultrasonic energy vs monopolar electrosurgery in laparoscopic cholecystectomy: influence on the postoperative systemic immune response.
BACKGROUND: The influence of surgical operations on the systemic immune response is proportional to the degree of trauma. Ultrasonic surgery can dissect structures and divide vessels by the effect produced by vibrations in the tissues. It is believed to be less traumatic than the more commonly used monopolar electrosurgery. This randomized study compares the systemic immune response after laparoscopic cholecystectomy performed using either ultrasonic energy or monopolar electrosurgery. METHODS: Eighteen patients scheduled for elective laparoscopic cholecystectomy were randomly assigned to treatment using either a harmonic scalpel and clips or monopolar electrosurgery and clips. Postoperative inflammatory response was assessed via changes in the white blood cell count and levels of C-reactive protein. Postoperative immune function was assessed by measuring monocyte HLA-DR expression. RESULTS: Both the harmonic scalpel and the use of monopolar electrosurgery resulted in activation of the systemic immune response. No significant differences between the two groups were observed. CONCLUSION: The harmonic scalpel and monopolar electrosurgery are equally traumatic in terms of activation of the systemic immune response.
C-Reactive Protein↗
Laparoscopic elective treatment of diverticular disease. A comparison between laparoscopic-assisted and resection-facilitated techniques.
BACKGROUND: Because of the presence of significant inflammatory reaction, elective surgical laparoscopic-assisted treatment of complicated diverticular disease can be difficult, leading to a high conversion and complication rate. Laparoscopic alternatives to this assisted approach consist of the hand-assisted method and the more conventional facilitated laparoscopic sigmoid resection. Facilitated laparoscopic sigmoid resection implies laparoscopic mobilization of the sigmoid as much as possible and splenic flexure when called for. Through a Pfannenstiel incision, the difficult steps of the operation-such as the dissection of the inflammatory process and taking down the fistula, but also resection and manual anastomosis-can be performed. In this study, we compare the operating time, conversion rate, complications, and costs of both assisted and resection-facilitated techniques. METHODS: We compared two consecutive series of 35 patients with diverticular disease who underwent a sigmoid resection by laparoscopy. Both groups were comparable in terms of age, gender, and kind of complicated diverticular disease. RESULTS: The operating time, conversion rate, and costs were all less in the laparoscopic-facilitated group. The fact that there were no conversions in this group is the most important finding of this study. Not only was it possible to convert from the assisted laparoscopic approach to laparotomy (five patients of 35), it was also possible to convert from the assisted to the facilitated form (seven of 35 patients). CONCLUSIONS: Laparoscopic-facilitated sigmoid resection is a feasible intervention for all forms of complicated diverticular disease and yields marked reductions in operating time, conversion rate, and operative and general costs.
Aged↗
Laparoscopic surgery preserves monocyte-mediated tumor cell killing in contrast to the conventional approach.
BACKGROUND: Experimental animal research shows that immunologic defenses against tumor cells are disturbed by surgical trauma, resulting in an increased rate of tumor implantation and the growth of subsequent metastases. Minimally invasive surgery is associated with a preservation of postoperative immunologic functions and, in animal models, with decreased tumor growth. The objective was to study the influence of several surgical procedures, approached conventionally and laparoscopically, on interleukin-6 (IL-6) and monocyte-mediated cytotoxicity (MMC). METHODS: Five groups of five patients each were included in this prospective study: laparoscopic cholecystectomy (minor trauma) group, Nissen fundoplication (laparoscopic and conventional as moderate trauma) groups, and sigmoid colectomy (laparoscopic and conventional as major trauma) groups. Preoperatively, 1 and 4 days after surgery, IL-6 and MMC against SW948 colon cancer cell line were determined. RESULTS: The IL-6 levels differed significantly between the three laparoscopic procedures (p = 0.004) and increased according to the degree of trauma. There was no significant difference in MMC between the three laparoscopic procedures. However, MMC was suppressed after conventional procedures and preserved after laparoscopic procedures (p = 0.001). There was no correlation between IL-6 levels and changes in MMC. CONCLUSIONS: More extensive laparoscopic procedures induce increased levels of IL-6, reflecting higher levels of trauma. Conventional surgical procedures result in depressed MMC in the postoperative period. After laparoscopic procedures, MMC is preserved. These findings may be of importance in preventing implantation and growth of cancer cells spread by surgical manipulation.
Adult↗
Laparoscopic treatment of large paraesophageal hernias: both excision of the sac and gastropexy are imperative for adequate surgical treatment.
BACKGROUND: We set out to evaluate the results of the laparoscopic treatment of large paraesophageal hernias in 22 patients. METHODS: Between 1993 and 1998, we operated on 22 consecutive patients. Preoperative assessment consisted of endoscopy, barium esophagogram, 24-h pH testing, manometry, and gastric emptying times. RESULTS: In the first three patients, the sac was not excised and gastropexy was not performed. Because of recurrences, we decided to change the technique in an attempt to avoid further complications. During middle- to long-term follow-up, only three recurrences were seen in the subsequent 19 patients. There were no deaths in this series. CONCLUSIONS: Laparoscopic treatment of large paraesophageal hernias is feasible. Because recurrences may occur after successful laparoscopic treatment, both resection of the sac and some form of gastropexy are imperative.
Adult↗
The influence of laparoscopic surgery on postoperative polymorphonuclear leukocyte function.
BACKGROUND: Laparoscopic surgery is thought to result in a better preservation of patients' immunological defenses. Polymorphonuclear leukocytes (PMN) are the most important effector cells in the elimination of pathogenic microorganisms. Because little is known about their function after laparoscopic surgery, we studied PMN phagocytosis, antigen expression, and oxygen radical production. METHODS: In this study, 17 patients scheduled for Nissen fundoplication were randomly assigned to undergo either a laparoscopic or conventional procedure. To study phagocytic capacity, PMN were incubated with fluorescein isothiocyanate (FITC)-labeled Staphylococcus aureus. Plasma opsonic capacity was measured by comparing PMN phagocytosis in the presence of patients' own plasma with phagocytosis in the presence of control plasma. Cellular activation was measured by the expression of various cell surface markers and by assessment of PMA-stimulated oxidative burst. RESULTS: Phagocytosis by PMN in the presence of patients' plasma was significantly lower 2 h after the conventional operation. No decrease in phagocytosis was observed when control plasma was used, indicating a decreased opsonic capacity of plasma after conventional surgery. No changes were observed after laparoscopic surgery. Furthermore, CD11b expression was significantly lower after the laparoscopic approach, indicating a blunted cellular activation. A significantly lower PMA-stimulated oxidative burst further confirmed the tempered stimulation after laparoscopic surgery. CONCLUSIONS: Laparoscopic surgery results in a preservation of the plasma opsonic capacity, and thereby the ability of PMN to phagocytose bacteria. Moreover, the postoperative cellular activation is reduced. The preserved phagocytosis and the blunted activation may prevent the development of postoperative infectious complications.
Adult↗
Bactericidal/permeability-increasing protein preserves leukocyte functions after major liver resection.
OBJECTIVE: To analyze postoperative leukocyte functions in patients undergoing hemihepatectomy, and to assess the effect of treatment with the endotoxin-neutralizing agent bactericidal/permeability-increasing protein (rBPI21). SUMMARY BACKGROUND DATA: Extensive liver resection is associated with a high incidence of infectious complications. Because elimination of pathogenic microorganisms occurs mainly by leukocytes, this increased rate of infections is most likely due to an impaired function of these cells. Endotoxin, translocated from the gut into the systemic circulation as a result of increased gut permeability and reduced hepatic clearance function after major liver resection, may play an important role in the impairment of posthepatectomy leukocyte function. METHODS: To investigate whether hemihepatectomy results in impaired leukocyte functions and to determine the role of endotoxin in this process, leukocyte oxidative burst and leukocyte antigen expression were studied in three groups of patients: patients undergoing a hemihepatectomy and receiving rBPI21 treatment, patients undergoing hemihepatectomy and receiving placebo, and as an extra control group patients undergoing other major abdominal surgeries. Blood samples were collected before surgery, 2 hours after surgery, and at days 1, 2, 5, and 7. Phorbol myristate acetate-stimulated oxidative burst was measured using dihydrorhodamine, and leukocyte surface expression of the antigens CD11b, CD16, and CD14 was investigated by indirect immunofluorescence. Both oxidative burst and membrane surface expression were quantified by flow cytometry. An indication of the antiendotoxin effect of rBPI21 treatment was provided by assessment of plasma lipopolysaccharide binding protein (LBP) levels by enzyme-linked immunosorbent assay. RESULTS: The oxidative burst in the hemihepatectomized patients receiving placebo and the controls increased 2 hours after surgery, whereas it decreased in the rBPI21-treated patients, resulting in significant differences between the groups. On day 1, neutrophil CD11b expression and monocyte CD14 expression in the rBPI21-treated patients and controls were significantly lower than in the placebo group. At 2 hours, CD16 expression in the placebo-treated patients was significantly higher than in the rBPI21-treated patients and controls. On day 5 and day 7, plasma LBP levels were significantly higher in the placebo-treated patients compared with the rBPI21-treated patients. CONCLUSIONS: The results of this study show that patients undergoing major liver resection have an increased activation of leukocytes compared with those undergoing other major abdominal surgery. This enhanced activation may contribute to the increased risk of infection in these patients. Administration of the endotoxin-neutralizing agent rBPI21 to hemihepatectomy patients was shown to reduce plasma LBP levels, to preserve leukocyte functions partially, and to reduce leukocyte activation to the level of other, nonhepatic abdominal surgery.
Acute-Phase Proteins↗
Laparoscopic techniques preserve immune function during and after surgery.
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C-Reactive Protein↗
Immunological consequences of laparoscopic surgery, speculations on the cause and clinical implications.
BACKGROUND: Immune suppression is an established consequence of surgical stress and trauma. Postoperative changes in the systemic immune system are proportional to the degree of surgical trauma and subsequent immune suppression may be implicated in the development of infectious complications and tumor metastasis formation. Laparoscopic surgery reduces the magnitude of the operative trauma and is thought to preserve postoperative immunological defenses. METHODS: Relevant literature concerning postoperative immune functions and laparoscopic surgery was reviewed and clinical implications are discussed. RESULTS: The influence of laparoscopic surgery on the postoperative systemic immune response is significantly less after laparoscopic cholecystectomy than with the conventional approach. Few immunological data are available concerning more advanced laparoscopic procedures. Various animal model studies of postoperative septic complications and tumor growth show that the postoperative preservation of the systemic immune response after laparoscopic surgery can have enormous clinical advantages. CONCLUSION: Laparoscopic surgery preserves the postoperative immunological defenses. In the future, this may imply a lower number of infections, less local recurrence and even fewer distant metastases. Prospective randomized studies are necessary to see whether these suspected advantages can be demonstrated in clinical practice.
Cholecystectomy, Laparoscopic↗
Laparoscopic surgery in the treatment of colonic polyps.
BACKGROUND: Benign colonic polyps that are impossible to remove with the aid of the flexible colonoscope because of their size or location must be removed surgically. METHODS: Twenty patients with colonic adenomatous polyps that could not be resected by colonoscopy because of size or difficult location (n = 18) or polyps in combination with diverticulitis (n = 2) underwent polyp removal through a small 'assisted' incision in the abdominal wall using a standard 'dissection-facilitated' laparoscopic approach to the affected colonic segment. RESULTS: In six patients the polyp was removed through a colotomy, in three through a limited resection (two ileocaecal and one limited sigmoid resection) and in 11 through a standard colectomy (four right hemicolectomy, one left hemicolectomy, four sigmoid and two anterior resections) because of suspicion of cancer. In only one patient could the polyp not be found during laparoscopy, resulting in a second conventional surgical intervention. In four patients carcinoma was diagnosed in the specimen. CONCLUSION: Precise preoperative localization of the polyp and the use of dissection-facilitated laparoscopic colonic surgery make laparoscopic removal of benign colonic polyps an alternative to an open procedure.
Aged↗
A prospective randomized study of the systemic immune response after laparoscopic and conventional Nissen fundoplication.
BACKGROUND: Laparoscopic techniques are thought to reduce the postoperative immunologic and metabolic changes of conventional operations. Until now, the only clinical data available were obtained from patients operated on for symptomatic gallstones; moreover, few studies were randomized. This randomized prospective study compares the systemic immune response after laparoscopic and conventional Nissen fundoplication. METHODS: Seventeen patients scheduled for Nissen fundoplication were randomly assigned to undergo either a laparoscopic or a conventional procedure. Postoperative inflammatory response was assessed by measuring the white blood cell count, C-reactive protein, and soluble tumor necrosis factor receptors p55 and p75. Postoperative immune function was assessed by measuring monocyte HLA-DR expression and the stress response was assessed by measuring plasma cortisol concentrations. RESULTS: Laparoscopic surgery resulted in significantly lower plasma CRP levels 1 day after surgery. Both approaches resulted in a significant decrease in HLA-DR expression within 2 hours after surgery. After the laparoscopic approach, postoperative expression was restored to preoperative values within 1 day after surgery. However, after conventional surgery HLA-DR expression remained suppressed and did not return to preoperative values until the fourth postoperative day. No significant differences between the 2 procedures were observed in white cell blood count, sTNFr-p55 and p75, nor in postoperative cortisol levels. CONCLUSIONS: Although both laparoscopic and conventional Nissen fundoplication result in an activation of the systemic immune response, this study suggests that this response could be less after the laparoscopic approach. The differences found may reflect a lower risk for postoperative infective complications.
Adult↗
Laparoscopic versus conventional Nissen fundoplication: the influence on plasma insulin-like growth factor-I and insulin-like growth factor binding protein-3.
BACKGROUND: Conventional surgery is known to influence postoperative insulin-like growth factor-I (IGF-I) levels and to increase protein breakdown. Recent animal data described that laparoscopic surgery, in contrast to conventional surgery, maintains postoperative IGF-I levels, suggesting a reduced postoperative catabolic response. AIM: The aim of this study was to demonstrate differences in the postoperative catabolic response between laparoscopic and conventional surgery. METHODS: Seventeen patients scheduled for Nissen fundoplication were randomly assigned to undergo either a laparoscopic or a conventional procedure. The catabolic response was assessed by measuring total IGF-I and insulin-like growth factor binding protein-3 (IGFBP-3). RESULTS: IGF-I levels decreased significantly 4 days after both types of surgery. IGFBP-3 decreased more rapidly after conventional surgery than after the laparoscopic technique; however, the differences between the groups were not significant. CONCLUSION: In contrast to animal data, no differences in plasma IGF-I or IGFBP-3 were seen in patients undergoing laparoscopic or conventional Nissen fundoplication.
Adult↗
Elective laparoscopic-assisted sigmoid resection for diverticular disease.
BACKGROUND: Although the laparoscopic-assisted approach to colorectal cancer remains controversial, its use for benign diseases can have important advantages. The purpose of this study is to determine the feasibility of this approach for the treatment of elective diverticular disease and to identify preoperative and perioperative factors which can help to select the best procedure for each patient: either assisted laparoscopic resection (ALR) or dissection-facilitated laparoscopic resection (DLR). METHODS: From November 1991 to the present, we conducted a prospective study of 41 patients approached electively for diverticular disease. RESULTS: Twenty-nine patients underwent an ALR, seven were approached by DLR, and another five patients were converted to laparotomy (15%). Morbidity was 17.5% and there was no mortality in this series. The mean hospital stay after operation was 6.5 days. CONCLUSIONS: Because of the complexity of this inflammatory process, choice of either an assisted or a more invasive laparoscopic facilitated approach is necessary. The decision is based on the technical difficulty as determined by data collected both preoperatively and during laparoscopy.
Colon, Sigmoid↗