32. Billroth I Gastrectomy P<.05, all features Adachi Y et al, Arch Surg. 2000;135:806-810 4.5 3.9 Time to first flatus, days 7.7% 5.5% Weight loss on day 14 22.5 17.6 Post-op hospital stay, days 5.7 5.0 Time to liquid diet, days 6.2 3.3 Analgesics, times given 33.9 35.6 Serum albumin, day 7 26 4.2 Interleukin-6, day 3, U/mL 5.19 2.91 C-reactive protein, day 7, mg% 8.9 7.28 Granulocyte count, day1 8.22 6.99 Leukocyte count, day 3 11.14 9.42 Leukocyte count, day1 302 158 Blood loss, mL Open (n=53) Laparoscopic (n=49)
33. Billroth I Gastrectomy P=NS, all features Adachi Y et al, Arch Surg. 2000;135:806-810 21% 8% Complication rate 22.1 18.4 No. of lymph nodes 6.0 6.2 Proximal margin, cm 228 246 Operation time, min Open (n=53) Laparoscopic (n=49)
40. Roux-en-Y Gastric Bypass Perioperative Outcomes Nguyen NT et al, Annals of Surgery, 234(3):279-91, Sept. 2001 .02 46.1 + 20.6 32.2 + 19.8 Return to work, days <.001 17.7 + 19.1 8.4 + 8.6 Return to daily activity, days NS 5 (6.6%) 6 (7.6%) Reoperation, No. of Pts. <.001 4 (IQR 2) 3 (IQR 1) Median hospital LOS, days .03 16 (21.1%) 6 (7.6%) ICU stay, No. of Pts. <.001 395 + 284 137 + 79 Blood loss, mL <.001 195 + 41 225+40 Operative time, min P Value Open GBP (n=76) Laparoscopic GBP (n=79) Results
41. Roux-en-Y Gastric Bypass Mean % of Excess Body Weight loss * * n=60 n=45 n=29 n=56 n=44 n=25 Nguyen NT et al, Annals of Surgery, 234(3):279-91, Sept. 2001 * p<.05
44. Adjustable Silicon Gastric Banding de Wit LT et al, Annals of Surgery, 230(6);800-807, December 1999 <0.05 11.8 + 10.5 7.8 + 6 Overall hospital stay, days <0.05 15 6 Total readmissions <0.05 3.8 + 1.1 (3-7) 4.7 + 2.1 (3-10) Difficulty of procedure (1-10)(range) <0.05 7.2 (5-13) 5.9 (4-10) Days in hospital, mean (range) <0.05 76 + 20 150 + 48 Surgical time, min P Value Open ASGB (n=24) Laparoscopic ASGB (n=25) Parameter
45. Adjustable Silicon Gastric Banding All values are expressed as mean + SD P value difference before and 52 weeks after is < 0.05 de Wit LT et al, Annals of Surgery, 230(6);800-807, December 1999 NS 39.1 + 8.2 39.7 + 8.7 BMI 52 weeks after surgery (kg/m 2 ) NS 49.7 + 5.6 51.3 + 10.4 BMI before surgery (kg/m 2 ) 34.4 35 Weight loss (kg) NS 112.0 + 19.1 117.2 + 25.2 Weight 52 weeks after surgery (kg) NS 146.4 + 19.9 152.2 + 31.4 Weight before surgery (kg) P Value Open ASGB (n=24) Laparoscopic ASGB (n=25)
52. PREOP INTRAOP POSTOP ERCP Lap transcystic Lap CBD Open CBD Expectant ERCP Management Options
53. Laparoscopic CBD Exploration Fitzgibbons RJ, World J. Surg.25, 1317-1324, 2001 1 death. Shorter LOS (3.4d), lesser morbidity (5%), fewer retained stones (5%) for transcystic. 10 123, 91% success 145 99% 1231 Phillips et al 4 deaths. Morbidity 9.1%. 7 with residual stones. 137, 97.1% success 112, 68.8% success 220 - 220 Berthou et al Major complications 3.8%. 1 death. 5% retained stones. 3.2% recurrent stones on f/u 50 107 161 1975 1975 Paganini et al 2 duct injuries. 1 death. 7% morbidity 2.6% retained stones. 17%, 19% conversion 83%, 5% conversion 94% 99.5% 226 Berci et al 8% conversion. 92% success. 1 death. LOS 4.3d 37 13 50 - 50 Shuchleib et al Comment Choledo- chotomy Trans- cystic No. of pts with CBD stones No. of cholangio. No. of patients Study
54. Laparoscopic CBD Exploration Fitzgibbons RJ, World J. Surg.25, 1317-1324, 2001 Overall success rate 94%. Complication rate 10% 27 33 80 - 700 Stoker et al Overall success rate 75% 14 46 60 - 60 Khoo et al Overall success 88%. 20 conversions. 22 major & 9 minor complications. 1 death. 92 116 247 - 247 Millat et al 12% conversion. 2 deaths. 15% complication rate. 93% success 63% success 92 - 92 Gigot et al Overall success 82%. No mortality. Morbidity 10% 11 22 39 - 39 Arvidsson et al No late retained stones or stricture. 0 217 217 - 217 Giurgiu et al 15.8% complication rate. 1 death. 13% conversion. LOS 6 days. 55, 85% success 56,80% success 109 132 133 Cuschieri et al No mortality. Morbidity 7.4%. LOS 7.6 days. 101, 96% success 82,67% success 161 - 161 Drouard et al Comment Choledo- chotomy Trans- cystic No. of pts with CBD stones No. of cholangio. No. of patients Study
55.
56. “ In cases of ordinary exploratory operation for carcinoma, before having recourse to the usual large incision, the cystoscope is introduced through a very small and relatively unimportant incision, possibly made with cocaine, may reveal general metastases or a secondary nodule in the liver, thus rendering further procedures unnecessary and saving the patient a rather prolonged convalescence”. 1911 Bernheim: First laparoscopy for pancreatic cancer in the U.S.A. Bernheim B. Organoscopy: Cystoscopy of the abdominal cavity. Ann Surg 53:764-767,1911
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64. Results Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2) ___ ___ 13 (14%) 8 (9%) EQUIVOCAL 50 (56%) 49 (54%) 41 (46%) 17 (19%) UNRESECTABLE ACTUAL LAP SONO LAP CT
71. Results Rothlin,M et al;Surg Endosc (1999) 13:1065-1069 p < 0.05 p < 0.05 p < 0.06 9 days 21 days HOSPITAL STAY 0% 29% MORTALITY 7% 43% MORBIDITY LAP (n=14) OPEN (n=14)
86. Colorectal Resection Laparoscopic vs. open resection for carcinoma RHC = Right hemicolectomy; Trans = Transverse; AR = Anterior resection; Sig = Sigmoid; LAR = Low anterior resection; APR = Abdominoperineal resection Franklin ME et al, Dis Colon Rectum 1996;39:s35-s46
87. Colorectal Resection Laparoscopic vs. open resection for carcinoma Franklin ME et al, Dis Colon Rectum 1996;39:s35-s46 19.1% 13% Cumulative death and recurrence rates 5 years into the study (Stages I, II, and III) 22% 12.2% Recurrence rates 6% 0.5% Wound complications 450 150 Blood loss, mL 9 5.6 Hospitalization, days Open (n=224) Laparoscopic (n=192)
88. Colorectal Resection Laparoscopic vs. open resection for carcinoma Curet MJ et al, Surg Endosc (2000) 14: 1062-1066 1 6 4 Late death from cancer (mean follow-up 4.9 years) 12 10 11 Number of lymph nodes 32 26 26 Length of specimen (cm) 8, 100% 5, 28% 1, 5% Complications (n, %) 8 7.3 5.2 Length of stay (days) 7 5.8 4.1 Regular diet (days) 5 4.4 2.7 Clear liquids (days) 6 4 3 ICU stay (days) 683 407 284 Blood loss (mL) 242 138 210 Operating room time (min) Converted (n=7) Open (n=18) Lap (n=18) 1 1 0 Recurrence
89. Colorectal Resection Laparoscopic vs. open resection for carcinoma Santoro E et al, Hepato-Gastroenterology 1999; 46:900-904 1 1 Liver+Peritoneum+ Trocar-site or scar 4 4 Liver+ Peritoneum 5 5 Multiple sites 1 1 Regional 4 2 Liver 5 3 Single site 10 (23%) 8 (20%) Overall metastases 43 40 No. of cases (n) Open Lap. Follow-up
103. Open Versus Laparoscopic Surgery Summary X X Hepatectomy X Adjustable silicon GB X Roux-en-Y GBP X Peptic ulcer disease X X Billroth II gastrectomy X Nissen fundoplication X Paraesophageal hernia X X Esophagomyotomy X X Esophagectomy Needs additional trials No Yes Operation
104. Open Versus Laparoscopic Surgery Summary X Inguinal hernia repair X X Prostatectomy X X Colectomy for cancer X Small bowel obstruction X Splenectomy X Adrenalectomy X Palliative pancreatic ca. X X Distal pancreatectomy X Diagnostic laparoscopy / Sono pancreatic ca. X X CBDE Needs additional trials No Yes Operation