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The objective of this prospective study was to compare the results of total (TG) versus subtotal (SG) gastrectomy in patients with adenocarcinoma of the lower two-thirds of the stomach.Two hundred and twenty-seven patients underwent curative operation. Preoperative nutritional assessment, postoperative tumor stage, postoperative morbidity/mortality, five-year survival, postgastrectomy dietary intake and nutritional sequelae were recorded in all patients.Postoperative mortality rate was 2.8% in the TG group and 1.1% in the SG group. The number of reoperations, anastomotic dehiscence rate and the length of postoperative stay were higher in the TG group. Five-year survival was closely related to lymph node involvement and gastric wall invasion. The extent of gastric resection did not influence survival when patients were matched for cancer stage. In the SG group, no recurrence in the gastric stump was observed. SG group showed a higher dietary energy intake than the TG group (p0.01). This might explain the ability of the SG group to increase body weight more than the TG group (p0.01). Only the TG group needed a monthly parenteral vitamin B12 supplements starting 36 months after surgery.The results suggest that SG should be considered the treatment of choice of the gastric adenocarcinoma when a cancer-free proximal resection margin can be guaranteed.

Background: Laparoscopic distal pancreatectomy (LDP) has been recently proposed as the procedure of choice for lesions of the pancreatic body and tail in experienced centres. The purpose of this study is to assess the potential advantages of LDP in a consecutive series of 100 patients. Methods: Propensity score matching was used to identify patients for comparison between LDP and control open group. Match criteria were: age, gender, ASA score, BMI, lesion site and size, and malignancy. All patients were treated according to an early feeding recovery policy. Primary endpoint was postoperative morbidity rate. Secondary endpoints were operative time, blood transfusion, length of hospital stay (LOS), hospital costs, and quality of life. Results: Thirty patients of the LDP group had pancreatic adenocarcinoma. Conversion to open surgery was necessary in 23 patients. Mean operative time was 29min shorter in the open group (p=0.002). No significant difference between groups was found in blood transfusion rate and postoperative morbidity rate. LDP was associated with an early postoperative rehabilitation and a shorter LOS in uneventful patients. Economic analysis showed € 775 extra cost per patient of the LDP group. General health perception and vitality were better in the LDP group onemonth after surgery. Conclusion: Laparoscopic distal pancreatectomy improved short-term postoperative recovery and quality of life in a consecutive series of both cancer and non-cancer patients. Despite the extra cost, thelaparoscopic approach should be considered the first option in patients undergoing distal pancreatectomy.

Background: High hospital volume improves outcomes after pancreatic resection. The aim of this study was to assess if practice and outcomes differed between high- and low-volume centers across which chief surgeons shared a similar training and mentoring. Methods: Data on patients undergoing standard pancreatic resections (2010-2013) at 7 Italian hospitals were collected. Chiefs of pancreatic surgery at each hospital had received the same training, with the same mentor. Two centers were high-volume referral hospitals for pancreatic disease, while 5 were low-volume hospitals. Results: A total of 856 patients were included, with median annual volume of resections 82 at high-volume referral hospitals and 11 at low-volume hospitals. Patients at low-volume hospitals were older, had more comorbidities, and were more often referred from the emergency room. Intraoperative techniques and reconstruction methods were similar. Comparable rates of major postoperative complications (18 vs. 22%; p = 0.236) and pancreatic fistula (29 vs. 32%; p = 0.287) were achieved in both groups, with no significant increases in failure to rescue from grade B-C fistula (6.2 vs. 15.0%; p = 0.108) and mortality (2.4 vs. 4.1%; p = 0.233) in low-volume hospitals. Postoperative length of stay was shorter in high-volume referral hospitals (10 vs. 15 days; p < 0.001). Conclusion: Similar postoperative outcomes can be achieved across high- and low-volume centers where chief surgeons shared a similar training and mentoring. However, multidisciplinary postoperative provision more often associated with high-volume centers may also affect outcomes.

Purpose: To evaluate the impact of laparoscopy compared to open surgery on long-term outcomes in a large series of patients who participated in a randomized controlled trial comparing short-term results of laparoscopic (LPS) versus open colorectal resection. Methods: This is a retrospective review of a prospective database including 662 patients with colorectal disease (526, 79 % cancer patients) who were randomly assigned to LPS or open colorectal resection and followed every 6 months by office visits. The primary endpoint of the study was long-term morbidity. Secondary outcomes included 10-year overall, cancer-specific, and disease-free survivals. All patients were analyzed on an intention-to-treat basis. Results: Fifty-eight (8.8 %) patients were lost to follow-up. Median follow-up was 131 (IQR 78–153) months in the LPS group and 126 (IQR 52–152) months in the open group (p = 0.121). Overall, long-term morbidity rate was 11.8 % (36/309) in the LPS versus 12.6 % (37/295) in the open group (p = 0.770). Incisional hernia rate was 5.8 % (18/309) in the LPS group versus 8.1 % (24/295) in the open group (p = 0.264). Adhesion-related small-bowel obstruction occurred in five (1.6 %) patients in the LPS versus four (1.4 %) patients in the open group (p = 1.000). In 497 cancer patients, 10-year overall survival was 45.3 % in the LPS group and 40.9 % in the open group (p = 0.160). No difference was found in cancer-specific and disease-free survivals, also when patients were stratified according to cancer stage. Conclusion: In this series, LPS colorectal resection was not associated with a lower long-term morbidity rate when compared to open surgery. Overall, cancer-specific and disease-free survivals were similar in cancer patients who were treated with LPS and open surgeries.

OBJECTIVE: The primary goal of this study was to clarify whether a laparoscopic (LPS) approach could be considered the dominant strategy in patients undergoing right colectomy. SUMMARY BACKGROUND DATA: Because few nonrandomized or small sized studies have been carried out so far, definitive conclusions about the role of LPS right colectomy cannot be drawn. METHODS: Two hundred twenty-six patients, candidates for right colectomy, were randomly assigned to LPS (n = 113) or open (n = 113) resection. The postoperative care protocol was the same for both groups. Trained members of the surgical staff who were not involved in the study registered postoperative morbidity. Follow-up was carried out for 30 days after hospital discharge. The following costs were calculated: surgical instruments, operative room occupation, routine care, postoperative morbidity, and hospitalization. RESULTS: Conversion rate in the LPS group was 2.6% (3 of 113). Operative time (in minutes) was longer in the LPS group (131 vs. 112, P = 0.01). Postoperative morbidity rate was 18.6% in the open group and 13.3% in the LPS group (P = 0.31). Postoperative stay was one day longer in the open group (P = 0.002). No difference was found in postoperative quality of life. The additional operative charge in the LPS group was €980 per patient randomized (€821 for surgical instruments and €159 for longer operative time). The savings in the LPS group was €390 per patient randomized (€144 for shorter length of hospital stay and €246 for the lower cost of postoperative morbidity). The net balance resulted in a €590 extra charge per patient randomly allocated to the LPS group. CONCLUSION: LPS slightly improved postoperative recovery. This translated into a savings that covered only 40% of the extra operative charge. Therefore, open right colectomy could be still considered an effective procedure.

This study aimed to compare the safety, efficacy, and clinical benefits of laparoscopic splenectomy (LS) to open splenectomy (OS) in patients with idiopathic thrombocytopenic purpura (ITP).The results from 14 consecutive patients who underwent LS for ITP were reviewed and compared with the results from patients who underwent OS for the same disease. Demographics, concomitant disease on admission, and platelet counts were evaluated, as were details of the surgical procedure, postoperative physiologic status, and hospital stay.Mean operative time was 88.3 min for OS and 146.4 min in LS group (p0.05). The conversion rate to open splenectomy was 7.1. Therapeutic response to splenectomy was 92.8% in the LS group and 86.6% in the OS group. Bowel canalization, return to liquid diet, and length of hospital stay were all significantly delayed in the OS group as compared with those who underwent LS (p = 0.01, p = 0.02, p = 0.005, respectively). In the OS group the morbidity rate was 13.3%, whereas in the LS group it was 7.1%.Laparoscopic splenectomy represents a valid alternative to conventional splenectomy in the treatment of ITP.

56 patients with large CBD or intrahepatic stones underwent endoscopic and/or percutaneous treatment followed by extracorporeal shock wave lithotripsy. Percutaneous access to the biliary tract was chosen when an endoscopic approach was not possible (hepaticojejunostomy in 5 patients, 1 juxtapapillary diverticulum and I inflammatory bile duct stricture). Visualization of stones was achieved radiologically in 32 patients and by ultrasound in 24. The procedure was successful in 47 of 56 treated patients (83.9%). Clearance of the biliary tract was obtained in 25 cases (53%), whereas in 22 cases (47%) complete clearing of biliary tract was obtained only after endoscopic extraction of fragments (17 cases) or percutaneous (5 cases). The median number of shock waves in each session was 1725 (range 300–3166), which were applied during one (n=30), two (n=22) or three sessions (n=4). The only complications were 1 case of symptomatic hyperamylasemia and 3 cases of macrohematuria. In conclusion, extracorporeal lithotripsy combined with endoscopic and/or percutaneous treatment is a real alternative to surgery for difficult stones.

Background The main aim of this study was to compare short-term results and long-term outcomes of patients undergoing laparoscopic versus open left colonic resection. Methods Between February 2000 and December 2004, all adult patients undergoing elective left colonic resection were assessed for eligibility to the study. The protocol for postoperative care was the same in both groups. Cost–benefit analysis was based on hospital costs. Quality of life, long-term morbidity and 5-year survival were also evaluated. Results Some 268 patients undergoing left colonic resection were assigned randomly to the laparoscopic (n = 134) or open (n = 134) approach. The short-term morbidity rate was 20·1 per cent in the open group and 11·9 per cent in the laparoscopic group (P = 0·094). Hospital stay was longer in the open group (8·7 versus 7·0 days for the laparoscopic approach; P = 0·002). Cost–benefit analysis showed an additional cost of €66 per patient randomly allocated to the laparoscopic group. Quality of life was significantly improved in the laparoscopic group 6 months after surgery, but no difference was found subsequently. The long-term morbidity rate was 11·9 per cent in the open group and 7·5 per cent in the laparoscopic group (P = 0·413). The 5-year survival rate of patients with cancer was 66 and 72 per cent for open and laparoscopic groups respectively (P = 0·321). Conclusion Laparoscopic left colonic resection resulted in an earlier recovery after surgery. As cost–benefit analysis and long-term follow-up showed similar results, the laparoscopic approach should be preferred to open surgery. Registration number: NCT00894725 (http://clinicaltrials.gov).

PURPOSE: The purpose of this study was to evaluate the impact of laparoscopic colorectal resection on short-term postoperative outcome in elderly patients. METHODS: A series of 535 patients with colorectal disease who had been randomly assigned to laparoscopic (n=268) or open (n=267) resection was analyzed. A total of 201 patients (37.6 percent) were elderly (aged 70 years or older) and 334 patients (62.4 percent) were younger than aged 70 years. Follow-up for postoperative morbidity was performed for 30 days after hospital discharge. RESULTS: Elderly patients had a higher American Society of Anesthesiologists score compared with younger patients in both the laparoscopic and open groups (P=0.0001). In the open group, elderly patients had higher morbidity rate (37.5 vs. 23.9 percent; P=0.02) and longer length of hospital stay (13 vs. 10.6; P=0.007) compared with younger patients. In the laparoscopic group, morbidity rate (20.2 vs. 15.1 percent) and length of hospital stay (9.5 vs. 9.1) were similar in elderly and younger patients. In elderly patients, the laparoscopy-reduced morbidity rate (20.2 vs. 37.5 percent; P=0.01) and length of hospital stay (9.5 vs. 13; P=0.001) compared to the open approach. In younger patients, the advantages of the laparoscopic approach on morbidity rate (15.1 vs. 23.9 percent; P=0.06) and length of stay (9.1 vs. 10.6; P=0.004) were less pronounced. CONCLUSIONS: Laparoscopy improved short-term postoperative outcome more in elderly than in younger patients. Advanced age was associated with higher morbidity and longer length of stay only in patients who underwent open colorectal surgery.

PURPOSE: This study was designed to evaluate the impact of laparoscopic rectal resection on short-term postoperative morbidity and costs. METHODS: A total of 168 patients with rectal cancer were randomly assigned to laparoscopic (n = 83) or open (n = 85) resection. Outcome parameters were: postoperative morbidity, length of hospital stay, quality of life, long-term survival, and local recurrences. The mean follow-up period was 53.6 months. Cost-benefit analysis was based on hospital costs. RESULTS: Operative time was 53 minutes longer in the laparoscopic group (P < 0.0001). Postoperative morbidity rate was 28.9 percent in the laparoscopic vs. 40 percent in the open group (P = 0.18). The mean length of hospital stay was 10 (4.9) days in the laparoscopic group and 13.6 (10) days in the open group (P = 0.004). Local recurrence rate and five-year survival were similar in both groups; however, the limited number of patients does not allow firm conclusions. Quality of life was better in the laparoscopic group only in the first year after surgery (P < 0.0001). The additional charge in the laparoscopic group was $1,748 per patient randomized ($1,194 the result of surgical instruments and $554 the result of longer operative time). The saving in the laparoscopic group was $1,396 per patient randomized ($647 the result of shorter length of hospital stay and $749 the result of the lower cost of postoperative complications). The net balance resulted in $351 extra cost per patient randomly allocated to the laparoscopic group. CONCLUSIONS: Short-term postoperative morbidity was similar in the two groups. Laparoscopic resection reduced length of hospital stay, improved first-year quality of life, and slightly increased hospital costs.

PURPOSE: This study was designed to evaluate long-term complications, quality of life, and survival rate in a series of colorectal cancer patients randomized to laparoscopic or open surgery. METHODS: A total of 391 patients with colorectal cancer were randomly assigned to laparoscopic (n = 190) or open (n = 201) resection. Long-term follow-up was performed every six months by office visits. Quality of life was assessed at 12, 24, and 48 months after surgery by a modified version of Short Form 36 Health Survey questionnaire. All patients were analyzed on an intention-to-treat basis. RESULTS: Eight (4.2 percent) laparoscopic group patients needed conversion to open surgery. Overall long-term morbidity rate was 6.8 percent (13/190) in the laparoscopic vs. 14.9 percent (30/201) in the open group (P = 0.018). Overall quality of life was significantly better in the laparoscopic group in the first 12 months after surgery, whereas at 24 months, patients of the laparoscopic group reported a significant advantage only in social functioning. No difference was found in both overall and disease-free survival rates by comparing laparoscopic vs. open group. CONCLUSIONS: Laparoscopic colorectal resection was associated with a lower incidence of long-term complications and a better quality of life in the first 12 months after surgery compared with open surgery. No difference between groups was found in overall and disease-free survival rates

Background Data: Studies comparing the costs of colorectal resection by laparoscopic (LPS) and open approaches are small sized or not randomized. The main purpose of this study is to compare the hospital costs of LPS and open colorectal surgery in a large series of randomized patients. Methods: A total of 517 patients with colorectal disease were randomly assigned to LPS (n = 258) or open (n = 259) resection. The following costs were calculated: surgical instruments, operative room (OR) occupation, routine care, postoperative morbidity, and length of hospital stay (LOS). Follow-up for postoperative morbidity was carried out for 30 days after hospital discharge. Results: Operative time was 37 minutes longer in the LPS group. Overall morbidity rate was 18.2% (47 of 258) in the LPS versus 34.7% (90 of 259) in the open group (P = 0.0005). The mean LOS was 9.9 (2.6) days in the LPS group and 12.4 (3.9) days in the open group (P < 0.0001). The additional OR charge in the LPS group was €1171 per patient randomized (€864 due to surgical instruments and €307 due to longer time). The saving in the LPS group was €1046 per patient randomized (€401 due to shorter LOS and €645 due to the lower cost of postoperative complications). The net balance resulted in €125 extra cost per patient allocated to the LPS group. Conclusions: The present cost-benefit analysis showed a slight additional cost in the LPS group. The better postoperative short-term outcome in patients receiving LPS had a key role to nearly balance the operative room charges due to laparoscopy. Copyright © 2005 by Lippincott Williams & Wilkins.

PURPOSE: The aim of this study was to evaluate whether laparoscopic colorectal surgery can modify the risk factors for the occurrence of postoperative morbidity. METHODS: A total of 384 consecutive patients with colorectal disease were randomized to laparoscopic resection (n = 190) or open resection (n = 194). On admission, demographics, comorbidity, and nutritional status were recorded. Operative variables, patient outcome, and length of stay were also recorded. Postoperative complications were registered by four members of staff not involved in the study. RESULTS: The overall morbidity rate was 27.1 percent, with the rate in the laparoscopic group (18.7 percent) being less than that in the open group (31.5 percent; P = 0.003). Patients who underwent laparoscopic resection had a faster recovery of bowel function (P = 0.0001) and a shorter length of stay (P = 0.0001). In the whole cohort of patients, multi variate analysis identified open surgery (P = 0.003), duration of surgery (P = 0.01), and homologous blood transfusion (P = 0.01) as risk factors for postoperative morbidity. In the open group, blood loss (P = 0.01), homologous blood transfusion (P = 0.01), duration of surgery (P = 0.009), weight loss (P = 0.06), and age (P = 0.08) were related to postoperative morbidity. In the laparoscopic group the only risk factor identified was duration of surgery (P = 0.005). CONCLUSION: In the laparoscopic group, both postoperative morbidity and length of stay were significantly reduced and most risk factors for postoperative morbidity disappeared

This study was designed to compare metabolic and functional results after laparoscopic and open colorectal resection. Seventy-nine patients were randomly assigned to laparoscopic (n = 40) or open (n = 39) colorectal resection. Before and after operation, the following parameters were determined: respiratory function (spirography and blood gas); serum level of cortisol, lactate, and C-reactive protein; total lymphocyte count; and CD4 and CD8 lymphocyte subsets. Intraoperative core temperature was measured by a bladder probe. Postoperative pain and analgesic consumption were also monitored. Mild operative hypothermia, a trend to postoperative reduction of total lymphocyte count, and significant impairment of respiratory function early after surgery were found in both groups. Laparoscopy showed a higher CD4/CD8 ratio (P= 0.01) on postoperative Day 1 and a faster return of C-reactive protein to preoperative values (P= 0.01) than in the open colorectal resection group. Morphine consumption in the first 48 hours after surgery was lower in the laparoscopic than in the open group (P= 0.02). Laparoscopy was associated with a less pronounced immunosuppression and inflammatory response and a lower consumption of analgesic drugs than open surgery. Moreover, our data did not show any additional detrimental effect of laparoscopy on either operative core temperature or early postoperative respiratory function.

We studied the nutritional status and the prevalence of malabsorption in 12 patients one to three years after total gastrectomy (TG) for gastric neoplasm. The Roux-en Y technique was used for reconstruction. A correct dietary regimen according to the recommended daily allowance was suggested and patients were seen quarterly on an out patient basis. The nutritional status was evaluated by measuring serum albumin levels, total iron binding capacity, cholinesterase, area muscular circumference, triceps skinfold and delayed hypersensitivity response. Work-up studies for the small intestine included: stool fat, D-xylose and glucose tolerance tests, Schilling test (phase II and III), serum iron levels, serum vitamin B12 levels and biopsy of the jejunum. Malnutrition, defined as the occurrence of two or more abnormal nutritional parameters, was observed in one patient; glucose and D-xylose tolerance tests were normal in all. A mild degree of steatorrhea was observed in four patients. The second phase of the Schilling test was abnormal in eight patients, but urinary excretion of vitamin B12 increased in three of four patients after use of antibiotics. Low serum vitamin B12 levels were common after the twentieth postoperative month. Serum iron levels were initially low and returned to normal six months after TG. All patients had normal jejunal histologic findings. These data indicate that malnutrition after TG is not common if an adequate dietary intake is maintained. Malabsorption, possibly due to bacterial overgrowth, is not a major clinical problem.

We studied dietary intake and nutritional status of 23 patients for 6 months after total gastrectomy with Roux-en-Y reconstruction. At discharge, patients were instructed to keep to recommended dietary allowances (RDA) and to record food intake on a specific form twice weekly. Nutritional follow-up was performed monthly and consisted of a computerized determination of food intake and of a nutritional assessment. The average daily energy intake was 6.10 MJ (1457.9 kcal) in the first postoperative month and 8.87 MJ (2118.4 kcal) in the sixth (P less than 0.0005). In the first monthly follow-up no patient reached RDA. By the sixth month mean daily calorie intake was greater than or equal to RDA in 14 patients (group A), while 9 patients (group B) did not reach RDA. A significant increase in body weight, serum albumin, total iron binding capacity and arm muscular circumference was observed in group A, while a significant decrease in body weight and arm muscular circumference was noted in group B. Moreover, of the seven patients who showed weight loss at 6 months only one was group A. These data indicate that malnutrition is not an inevitable consequence of total gastrectomy and can be prevented by an adequate calorie intake. A close relationship between dietary intake and postoperative nutritional parameters was observed. In gastrectomized patients a strict nutritional follow-up is very important to obtain an adequate dietary intake.