Pull-through procedure as treatment for coloanal anastomotic dehiscence following laparoscopic total mesorectal excision.
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Anastomosis, Surgical↗
Biomedical subjects
M A Cuesta
Publications and source records attributed to M A Cuesta.
Preoperative radiation therapy for locally advanced rectal cancer: a comparison between two different time intervals to surgery.
BACKGROUND: Although it is now considered a standard treatment to irradiate an advanced mid or low rectal tumor before surgical total mesorectal excision (TME), the optimal time interval between radiation therapy and surgery remains controversial. MATERIALS AND METHODS: Between 1995 and 2005, patients undergoing preoperative radiation therapy and TME for locally advanced mid and low rectal tumors treated in the VU Medical Center or the Zaans Medical Center were entered into this study. All patients received identical radiation treatment in the VU Medical Center and were subsequently operated on within 2 weeks in the Zaans Medical Center (SI group) and after 6-8 weeks in the VU Medical Center (LI group). Preoperative tumor staging, operative data, postoperative complications, pathology results, and follow-up were compared. RESULTS: The SI group (N=57) underwent surgery after a median delay of 4 days and the LI group (N=51) after 45 days. Operative data and short-term morbidity were comparable for both groups. However, significantly higher numbers of complete remissions (12 vs 0%), tumor downstaging (55 vs 26%), and less lymph-node metastases (22 vs 44%) were found in the LI group. No significant differences were found regarding local control or long-term survival after a median follow-up of 34 months. CONCLUSION: Several advantages, such as complete remissions and downstaging in the LI group, do not appear to have expression in a better survival or less local recurrences after a median follow-up of 34 months. Although larger (randomized) studies will be needed for definite conclusions, this may indicate that patients can be operated on within 2 weeks after radiation therapy.
Aged↗
Reversal of Hartmann's procedure after surgery for complications of diverticular disease of the sigmoid colon is safe and possible in most patients.
BACKGROUND: Although evidence is growing that most patients who need an operation for diverticular disease of the sigmoid colon can be treated by a single-stage procedure, a two-stage procedure will still be necessary in some patients because of significant sepsis or technical difficulties. The outcomes of 65 patients who underwent secondary restoration after a Hartmann procedure for complicated diverticulitis were studied and the factors leading to complications and mortality were identified. PATIENTS AND METHODS: Of 91 patients, in a consecutive 12-year period, whose primary operation was a Hartmann procedure, 72 survived longer than 3 months after discharge. Sixty-five underwent an attempted reversal of the Hartmann procedure. The POSSUM scores were calculated in all patients as well as the morbidity and mortality rates. RESULTS: In 63 (96.9%) patients the bowel continuity could be restored with a morbidity of 38.5% and a mortality of 3.1%. The POSSUM and p-POSSUM scores adequately predicted the mortality in this series. CONCLUSION: This series shows that when surgical treatment for complicated diverticular disease of the sigmoid colon is necessary, the Hartmann procedure is still a valid indication. In a high percentage of patients the Hartmann procedure could be restored with a low mortality.
Adult↗
Effect of vaginal delivery on long-term pouch function.
BACKGROUND: The optimal method of childbirth for women with a restorative proctocolectomy (RP) has yet to be determined. Little is known about long-term ileal pouch function after vaginal delivery, especially when childbirth occurred before RP. The aim of this study was to evaluate the effect of vaginal delivery before or after RP on long-term pouch function. METHODS: All 267 women who underwent RP between January 1985 and November 2004 were invited to participate. Functional outcome was assessed by colorectal functional outcome questionnaire, and patients were asked about their pregnancies and risk factors for obstetric injury. Linear regression analysis was performed to study potential risk factors for poor pouch function. RESULTS: The response rate was 82.6 per cent. Median follow-up after pouch surgery was 7.2 (range 1.0-19.7) years. One hundred patients had at least one delivery. Fifty-two (60 per cent) of the 86 patients who attempted a vaginal delivery had an increased risk of obstetric injury according to predefined risk factors. In these patients ageing and longer follow-up were significant risk factors for impaired incontinence. CONCLUSION: Women who had RP and vaginal delivery with a high risk of obstetric injury had impaired continence with ageing and longer follow-up. Patients with RP should be informed about the considerable risk of vaginal delivery on long-term ileal pouch function.
Adult↗
Mortality after acute surgery for complications of diverticular disease of the sigmoid colon is almost exclusively due to patient related factors.
OBJECTIVE: Auditing the outcome of surgery for complicated diverticulitis of the sigmoid colon is difficult. A comparison of studies is hardly possible because risk factors both in terms of the severity of diverticulitis and patient-related risk factors are neither well described nor standardized. The purpose of this study was to define morbidity and mortality of primary surgery for acute complications of diverticular disease of the sigmoid colon and to identify the relation between risk factors and morbidity and mortality. METHODS: In a prospective computerized morbidity and mortality registration from 1990 to 2002, 114 patients, who underwent surgery on an acute or urgent base for acute complications of diverticular disease of the sigmoid colon, were identified. In all patients the POSSUM score was calculated. To audit mortality rates a POSSUM based scoring system was introduced. RESULTS: Mortality was 16.7%, and morbidity 71.1%. Higher morbidity rates were significantly related to a higher POSSUM physiological score (P = 0.012) and to older age (P < 0.001). Higher mortality rates also were significantly related to a higher POSSUM physiological score (P < 0.001) and older age (P = 0.003). Patients who died had significantly more sepsis (P < 0.001), multiple organ failure (P = 0.027), cardiac (P < 0.001) and pulmonary (P = 0.013) complications. Gender, operation indication and type of neither surgery nor surgeon had a significant relation with morbidity or mortality. CONCLUSION: Surgery for acute complications of diverticular disease of the sigmoid colon carries a high morbidity rate and a substantial mortality rate. The majority of deceased patients had severe comorbidity. Post-operative mortality and morbidity are to a large extent driven by patient related factors. Elevated physiological severity scores and a lack of peri-operative management failures express this in the majority of deceased patients.
Aged↗
Outcome of elective primary surgery for diverticular disease of the sigmoid colon: a risk analysis based on the POSSUM scoring system.
BACKGROUND: The outcome of surgery for diverticular disease of the sigmoid colon remains largely unclear. A comparison of studies is hardly possible because risk factors for diverticular disease severity and patient-related risk factors are lacking. The purpose of this study was to define morbidity and mortality of primary surgery for nonacute complications of diverticular disease of the sigmoid colon and to identify the risk factors that predict a higher morbidity and mortality. METHODS: Patients who underwent elective surgery for complications of diverticular disease of the sigmoid colon (n = 149) were identified in a prospective computerized morbidity and mortality registration. In all patients, the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) was calculated, as were the morbidity and mortality rates. Factors predicting postoperative morbidity and mortality were identified. To audit mortality figures, a POSSUM based scoring system is introduced. RESULTS: The mortality rate was 4.7% and morbidity rate was 53.7%. Significantly higher morbidity rates were correlated with a higher physiological POSSUM score (P = 0.010). Non-survivors were older (P = 0.029) and also had a higher physiological POSSUM score (P < 0.001) and operation severity POSSUM score (P < 0.001). CONCLUSION: The morbidity and mortality rates of surgery for nonacute complications of diverticular disease of the sigmoid colon are considerable. To a large extent, mortality and morbidity are driven by patient- and disease-related factors, as expressed by elevated physiological severity and operative severity scores and failures of peri-operative management in most deceased patients.
Aged↗
Impact of hospital case volume on short-term outcome after laparoscopic operation for colonic cancer.
BACKGROUND: High hospital case volume has been associated with improved outcome after open operation for colorectal malignancies. METHODS: To assess the impact of hospital case volume on short-term outcome after laparoscopic operation for colon cancer, we conducted an analysis of patients who underwent laparoscopic colon resection within the COlon Cancer Laparoscopic or Open Resection (COLOR) trial. RESULTS: A total of 536 patients with adenocarcinoma of the colon were included in the analysis. Median operating time was 240, 210 and 188 min in centers with low, medium, and high case volumes, respectively (p < 0.001). A significant difference in conversion rate was observed among low, medium, and high case volume hospitals (24% vs 24% vs 9%; p < 0.001). A higher number of lymph nodes were harvested at high case volume hospitals (p < 0.001). After operation, fewer complications (p = 0.006) and a shorter hospital stay (p < 0.001) were observed in patients treated at hospitals with high caseloads. CONCLUSIONS: Laparoscopic operation for colon cancer at hospitals with high caseloads appears to be associated with improved short-term results.
Aged↗
Robot-assisted laparoscopic aortobifemoral bypass for aortoiliac occlusive disease: early clinical experience.
BACKGROUND: Robotic technology may facilitate laparoscopic aortic reconstruction. We present our early clinical experience with laparoscopic aortobifemoral bypass, aided by two different robotic surgical systems. METHODS: Between February 2002 and April 2004, we performed eight robot-assisted laparoscopic aorto-bifemoral bypasses for aortoiliac occlusive disease. All patients were male; median age was 55 years (range: 36-64). Dissection was performed laparoscopically and the robotic system was used to construct the aortic anastomosis. RESULTS: A robot-assisted anastomosis was successfully performed in seven patients. Median operative time was 405 min (range: 260-589), with a median clamp-time of 111 min (range: 85-205). Median blood loss was 900 ml (range: 200-5800). Median anastomosis time was 74 min (range 40-110). In two patients conversion was necessary, one due to bleeding of an earlier clipped lumbar artery after completion of the anastomosis, the other because of difficulties with the laparoscopic exposure of the aorta. On post-operative day 3 one patient died unexpectedly as a result of a massive myocardial infarction. Median hospital stay was 7.5 days (range: 3-57). CONCLUSION: Our initial experience with robotic assisted laparoscopic surgery (RALS) shows it is a feasible technique for aortoiliac bypass surgery. However, laparoscopic aortoiliac surgery demands considerable experience and operative times need to be reduced before this technique can be widely implemented.
Adult↗
Operative mortality after colorectal resection in the Netherlands.
BACKGROUND: The aim of this study was to quantify factors related to operative mortality after colorectal resection in the Netherlands. METHODS: Multilevel logistic regression modelling was used. Institutional effects were calculated with and without adjustment for specific patient (age, sex, urgency of operation) and hospital (number of procedures, type of hospital) characteristics. All adult Dutch patients who underwent primary colorectal resection between 1994 and 1999 were included, except those who had (sub)total colectomy or local rectal resection. RESULTS: A total of 67 594 patients underwent colorectal resection. The in-hospital mortality rate was 7.0 per cent (elective 3.9 per cent, acute 14.3 per cent). Acute operation (odds ratio 3.89) and age (odds ratios 2.63, 5.23 and 10.13 for patients aged 50-69, 70-79 and 80 or more years respectively compared with those aged less than 50 years) had the strongest effects, followed by male sex (odds ratio 1.48) and type of hospital. There was no difference in operative mortality rate between low-, medium- and high-volume hospitals. CONCLUSION: In the Netherlands, advanced age and acute operation are by far the most important factors related to operative mortality after colorectal resection. Male sex and type of hospital have only a modest effect, and there is no discernible effect of hospital volume.
Adult↗
Laparoscopic resection of colon Cancer: consensus of the European Association of Endoscopic Surgery (EAES).
BACKGROUND: The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on the laparoscopic resection of colon cancer during the annual congress in Lisbon, Portugal, in June 2002. METHODS: A systematic review of the current literature was combined with the opinions, of experts in the field of colon cancer surgery to formulate evidence-based statements and recommendations on the laparoscopic resection of colon cancer. RESULTS: Advanced age, obesity, and previous abdominal operations are not considered absolute contraindications for laparoscopic colon cancer surgery. The most common cause for conversion is the presence of bulky or invasive tumors. Laparoscopic operation takes longer to perform than the open counterpart, but the outcome is similar in terms of specimen size and pathological examination. Immediate postoperative morbidity and mortality are comparable for laparoscopic and open colonic cancer surgery. The laparoscopically operated patients had less postoperative pain, better-preserved pulmonary function, earlier restoration of gastrointestinal function, and an earlier discharge from the hospital. The postoperative stress response is lower after laparoscopic colectomy. The incidence of port site metastases is <1%. Survival after laparoscopic resection of colon cancer appears to be at least equal to survival after open resection. The costs of laparoscopic surgery for colon cancer are higher than those for open surgery. CONCLUSION: Laparoscopic resection of colon cancer is a safe and feasible procedure that improves short-term outcome. Results regarding the long-term survival of patients enrolled in large multicenter trials will determine its role in general surgery.
Colectomy↗
Anesthesiological hazards during laparoscopic transhiatal esophageal resection: a case control study of the laparoscopic-assisted vs the conventional approach.
BACKGROUND: Interest for minimal invasive approach of esophagus resection is increasing. Today, a minimally invasive transhiatal esophagectomy is possible and is accepted widespread. Since cardiopulmonary changes during laparoscopic dissection of the mediastinum has not been studied yet we assessed the anesthesiological consequences of pneumothorax during laparoscopic mediastinal dissection. METHODS: In this case control study, 25 laparoscopically assisted transhiatal espohagus resections were compared with a control group consisting of 20 open transhiatal esophagus resections. Patient characteristics and intraoperative haemodynamic, respiratory, and ventilatory parameters were assessed. RESULTS: The laparoscopic assisted procedure was performed successfully in 12 of the 20 patients. The duration of the laparoscopic assisted procedure, compared to the open group was significantly longer (p<0.05). Intraoperative blood loss was significantly less in the laparoscopic group (p<0.05). Mediastinal dissection resulted in entry of the pleura in 84% of the open and 93% of the laparoscopic assisted procedure. Carbonedioxide pneumothorax resulted in increased end-tidal CO2)and airway pressure levels and decreased lung compliance. Airway pressure showed a significant difference between the groups (p<0.05). Hemodynamic parameters did not differ between groups significantly. There were no differences in postoperative cardiopulmonary complications. CONCLUSIONS: Laparoscopic assisted transhiatal esophagectomy is a safe procedure and has no increased risk of postoperative cardiopulmonary complications compared to thr conventional approach. The anesthesiologist and the surgeon must be aware of the potential risk of pleural injury to manage cardiopulmonary compromises and minimize complications.
Case-Control Studies↗
Laparoscopically assisted transhiatal resection for malignancies of the distal esophagus.
BACKGROUND: Resection of the esophagus remains the only curative therapy for esophageal cancer. Conventional resections are right-side thoracotomy in combination with laparotomy, gastric tube creation, and the transhiatal approach according to Orringer. This study evaluated laparoscopically assisted transhiatal esophagus resection, which offers perfect visualization of the esophagus during mediastinal dissection without the necessity of a thoracotomy. METHODS: In this study, 25 laparoscopically assisted transhiatal esophagus resections were compared with a historical control group consisting of 20 open transhiatal esophagus resections. RESULTS: Nine laparoscopically assisted resections (36%) were converted to open procedures. The operating time was longer in the laparoscopically assisted group (300 vs 257 min; p < 0.05), but laparoscopically assisted esophagus resection was associated with less blood loss (600 vs 900 ml; p < 0.05) and shorter intensive care unit stay (1 vs 2 days; p < 0.05). There were no differences in morbidity, mortality, and hospital stay. During a shorter follow-up time for the laparoscopic group (17 vs 54 months), 11 patients (44%) in the laparoscopically assisted group and 10 (50%) patients in the open group had recurrence of the disease. CONCLUSIONS: Laparoscopically assisted transhiatal esophagus resection is a safe procedure with important advantages, as compared with the open procedure, such as less blood loss and shorter intensive care unit stay. At this point, the oncologic consequences are not clear.
Aged↗
Hematological long-term results of laparoscopic splenectomy for patients with idiopathic thrombocytopenic purpura: a case control study.
BACKGROUND: Laparoscopic splenectomy (LS) for idiopathic thrombocytopenic purpura (ITP) appears, when compared to open splenectomy (OS), associated with immediate important advantages. However, in a number of patients splenectomy does not lead to an adequate response, or after initial adequate response a relapse occurs after some time. A relapse may be associated to the presence of accessory spleens and splenosis. The purpose of this study was to compare the operative outcome and the hematological results on the long term of a series of LS with a historic series of OS for the treatment of ITP. METHODS: A retrospective review was done of 50 consecutive patients who underwent LS for ITP. Patient characteristics, outcome of surgery, and hematological results were compared to a historical group of patients who underwent conventional splenectomy for ITP (n = 31). Response to splenectomy was defined in three groups: complete remission, partial remission, and no response. Grouping was based on hematological data. RESULTS: Concerning operative outcome and postoperative complications, there was a significant difference in favor of LS. Moreover, the hematological outcome of both groups showed no differences after a median period of 66 months (OS) and 35 months (LS), respectively. CONCLUSIONS: Hematological results after laparoscopic splenectomy for ITP are comparable to those after open splenectomy in both the short and the long term.
Adolescent↗
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↗
Robot-assisted versus standard videoscopic aortic replacement. A comparative study in pigs.
BACKGROUND: Reconstruction of the infrarenal aorta for aneurysms is routinely performed through laparotomy. A less invasive videoscopic approach has not gained wide acceptance due to technical difficulties. Robotic systems could potentially improve imaging of the operative field and surgeon's dexterity during videoscopic surgery and therefore might facilitate the performance of this procedure. The aim of this animal study was to compare the safety and efficacy of a robot-assisted videoscopic aortic replacement to the standard videoscopic approach. MATERIALS AND METHODS: In 10 female pigs, the infrarenal aorta was partially replaced by a 10 mm polytetrafluoroethylene (PTFE) interposition graft through a videoscopic retroperitoneal approach, using the da Vinci robot system (robot group). Ten other pigs were operated on in a similar fashion, using standard videoscopic instruments (control group). Relevant procedure times, blood loss and complications were registered. Efficacy of the anastomoses was evaluated by measuring patency and blood loss after removing the clamps. Furthermore, circumference and number of stitches were evaluated at autopsy. RESULTS: The procedure, suturing and clamping times were significantly shorter in the robot group and blood loss was less. In the control group, the inferior vena cava was injured in one pig. In two cases in the control group, haemostasis could not be established after clamp removal. At autopsy, all anastomoses in the robot group were adequate. In the control group, a stitch crossing the aortic lumen was found in two distal anastomoses and a large distance (>3 mm) between two stitches was encountered at least once in 12/20 suture lines. All 20 grafts were patent. No anastomotic narrowing was encountered. The number of stitches used for proximal and distal anastomosis was higher in the robot group. CONCLUSION: This study demonstrates the superiority of robot-assisted videoscopic aortic replacement over standard videoscopic techniques in an animal model.
Anastomosis, Surgical↗
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↗
VEGF and endostatin levels in wound fluid and plasma after breast surgery.
Angiogenesis is essential for wound repair after surgical trauma. Vascular endothelial growth factor (VEGF) and endostatin are endogenous angiogenic factors involved in the initiation and completion of angiogenesis. The aim of this study was to examine the local and systemic VEGF and endostatin profiles in patients undergoing surgery for benign and malignant breast processes. A total of 16 patients with or without cancer underwent breast surgery. Group I: eight patients with primary breast cancer underwent a simple or radical mastectomy according to Madden including dissection of axillary lymph nodes. Group II: eight healthy female-to-male transsexuals underwent subcutaneous mastectomy. VEGF and endostatin levels in plasma and wound fluid were determined. In both groups VEGF levels in wound fluid were significantly higher compared to postoperative plasma levels, whereas wound fluid endostatin levels were lower than plasma levels and decreased progressively after surgery. In both groups plasma VEGF and endostatin levels did not change significantly before and after surgery. The local VEGF increase and endostatin decrease observed immediately after surgery appears to be a physiological response to operative trauma, which can be studied more profoundly in locally generated fluid than in blood. This process did not seem to be influenced by the type of process (cancerous or non-cancerous) involved in the surgical intervention.
Breast Neoplasms↗
Nationwide decline in annual numbers of abdomino-perineal resections: effect of a successful national trial?
OBJECTIVE: Large national trials may influence surgical practice. In this study the relation between the successful national randomized trial on the management of rectal cancer (the Dutch TME trial) and national ratio of abdomino-perineal resection to low anterior resection and anastomosis was analysed. PATIENTS AND METHODS: In the study period, 1994-99, 15978 patients underwent either abdomino-perineal resection (n = 2575) or low anterior resection and anastomosis (n = 13403). The Dutch TME trial started in 1996 and a total of 1530 patients were included by 83 hospitals and 82.1% of these patients were treated from 1997 to 1999. Teaching sessions, tutor assisted surgery and quality control formed an integral and important part of the TME trial. RESULTS: Ratio of abdomino-perineal resection vs. low anterior resection was compared between period I (1994-96) and period II (1997-99). The ratio decreased from 0.19 to 0.13 between period I and II (95% CI, -0.08 to -0.04, P < 0.001). In hospital mortality rate did not change between period I and II (3.5 vs. 3.7, 95% CI, -0.08 to 0.03, P=0.385). CONCLUSION: Significant changes in surgical attitude may accompany successful national randomized trials in which investigated surgical procedures are specified, taught, and controlled. The APR ratio declined by 32% in the Netherlands during and following the Dutch TME trial, without a rise in hospital mortality rate for rectal resections.
Clinical Trials as Topic↗