Seminars in laparoscopic surgery最新文献

Endoscopic techniques for esophagectomy are disparate. The aim of this article is to describe the main surgical endoscopic techniques applied to esophagectomy and to report their results. In most published series, the benefit in terms of postoperative morbidity cannot be demonstrated. This reflects the fact that postoperative morbidity after esophagectomy is related not only with the type of surgical approach but also with other factors related to the patient's status. Finally, the lack of long-term follow-up in most series does not permit to draw conclusion about the relevance of endoscopic esophagectomy. Contrary to other advanced surgical endoscopic procedures, endoscopic esophagectomy has not yet been convincing.

Endogastric surgery is a branch of minimally invasive surgery that combines flexible endoscopy and laparoscopy. By placing trocars directly into the stomach, quite a number of procedures may be performed. Leiomyomas and other benign gastric tumors are readily removed, and in Asia early gastric cancers are removed with these techniques. Large pancreatic pseudocysts abutting the posterior wall of the stomach may be drained through the stomach using an endogastric approach. Lastly, intragastric bleeding in areas not reachable with a conventional endoscope may be approached with an endogastric approach. Although the indications for these procedures are-in general-rare, they are not difficult to perform, and outcomes have been superb.

Until now, for treatment of morbid obesity in the long term, surgery remained as the final option. For 40 years, surgeons looked at the best procedure. Among the restrictive procedures (gastroplasty), the laparoscopic adjustable silicone banding is the least invasive surgical treatment of morbid obesity. Between October 1992 and January 1998, we performed this procedure on 652 patients. Median body mass index was 45 (range, 35-65). Median hospital stay was 3 days (range, 2-10 days). The mean operative time was 80 minutes (range, 40-240 minutes). Four patients (0.6%) presented early complications: bleeding (1 patient), gastric perforation (2 patients), and pneumonia (1 patient). Forty-seven (7.2%) patients presented late complications and needed to be reoperated. There is one case of mortality. Loss of mass body weight was 62% in 2 years. According to these results, laparoscopic adjustable silicone gastric banding seems to be a safe and efficient technique.

The impressive breakthrough in laparoscopic surgery has pushed surgeons to perform gastric resection through such an approach. Laparoscopy reduces the surgical stress and the postoperative pain and has a positive impact on the rehabilitation time, the hospital stay, and return to work and social activities. Laparoscopic partial gastrectomy for benign diseases and for palliation has been accepted as an effective surgical option: they are reproducible operations performed worldwide at a more and more rapid pace. Laparoscopic gastric resections and laparoscopically assisted gastric resections for malignancy deserve a word of caution. Nevertheless, the investigators report their series of laparoscopic subtotal and distal gastrectomies for cancer with medium and long-term results comparable with those of open surgery. Furthermore, new and less invasive surgical options have been recently introduced. Full and partial thickness local resections may be accomplished through intragastric procedures, for treatment of small benign tumors and early stage gastric cancer.

Palliation of advanced esophageal cancer continues to be a challenge to clinicians. Self expanding metal stents have been used in the esophagus for palliation of advanced esophageal cancer since 1983. They are relatively easy to insert by practicing endoscopists and have low rates of early complications. Delayed complications necessitating reintervention can arise in as many as a third of patients. The majority of stents are placed under sedation using endoscopy and fluoroscopy. Once deployed, they expand in the esophagus causing pressure necrosis on the wall of the esophagus. Several stents are available on the market with newer designs continuing to emerge. Choice of stent seems random among clinicians. Stents have been used for the management of esophageal obstruction including cervical esophageal obstruction and obstruction at the esophagogastric junction, tracheopulmonary fistulae, and mediastinal esophageal compression. Complications include chest pain, deployment and expansion problems, stent migration, tumor overgrowth and ingrowth, gastroesophageal reflux, and stent-related hemorrhage. Despite their high cost, stenting produce better palliation and some cost savings in comparison to conventional methods of palliation. Combination therapy using stenting followed by chemo/radio therapy may increase quality survival.

Large hiatal or paraesophageal hernias constitute between 5% and 10% of all hiatal hernias. This hernia is a potential threatening complication, and a timely operative correction should be performed in all patients with an acceptable risk. Based on the lessons learned from conventional approach, laparoscopic treatment has confirmed the initial good results with all advantages of laparoscopic surgery. Reduction of the hernia, excision of the sac, and approximation of the hiatus followed by selective use of an antireflux procedure and some form of gastropexy constitute the operative steps to obtain optimal postoperative results.

Gastric outlet obstruction continues to be an indication for drainage despite the common use of powerful proton pump inhibitors. Minimal invasive surgery techniques now play a significant role in the treatment of this pathology. Complicated peptic ulcer disease and cancer are the two most common causes. To accomplish drainage, advanced laparoscopic techniques are required. A variety of procedures are possible, and these are discussed in detail in this report. The advantages of the laparoscopic approach have been realized in this group of patients.