Tehnica “Rendez-vous” in abordul laparo-endoscopic al litiazei colecistocoledociene

F. Turcu

Publicatia : Chirurgia vol.95, nr.5, pag:463-467; 2000

Rezumat

In articol este prezentata tehnica abordului laparo-endoscopic simultan al litiazei colecistocoledociene prin asa numita tehnica “rendez-vous”.

Aceasta tehnica consta intr-o colecistectomie laparoscopica standard cu colangiografe intraoperatorie si sfincterotomie endoscoica pe fir ghid trecut transcistic, daca calea biliara este locuita de calculi.

In 1999 noua pacienti cu litiaza veziculara si suspiciune de litiaza coledociana au fost programati pentru abord laparo-endoscopic simultan.  La toti cei 4 cu colangiografie intraoperatorie pozitiva s-a reusit dezobstructia coledocului prin tehnica “rendez-vous”.  Nu s-au consemnat complicatii postoperatorii.

Tehnica este fezabila, elimina explorarile endoscopice retrograde inutile, reduce morbiditatea specifica endoscopiei si durata spitalizarii postoperatorii.

Abstract

The laparo-endoscopic approach to cholecysto-choledocholithiasis.

The “Rendez-vous” technique.

A combined method of endoscopic sphincterotomy (ES) with common bile duct (CBD) stone extraction and laparoscopic cholecystectomy under general anesthesia for a single-session treatment of patients with colecysto-choledocholithiasis is described.

The so called “Rendez-vous” technique consists in: standard laparoscopic cholecystectomy with intraoperative cholangiography followed by ES if common bile duct stones are detected.  The sphincterotome is driven across the papilla through a wire guide inserted by transcystic route.

Nine patients were scheduled for “rendez-vous” approach. At intraoperative cholangiography 4 have had CBD stones.  Endoscopic sphincterotomy and CBD clearance were successful in all patients.  No complication was encountered.  Mean postoperative hospital stay was 5 days.

The laparo-endoscopic “rendez-vous” approach is feasible, it reduces the number of unnecessary ERCP examinations, it lowers the morbidity related with endoscopic sphincterotomy and shortens the hospital stay.

Introducere

Modalitatea optima de rezolvare a litiazei colecistocoledociene ramine inca controversata in literatura de specialitate.  Optiunile posibile sunt: chirurgia clasica, abordul secvential endoscopic si laparoscopic sau abordul integral laparoscopic. In functie de dotarea tehnica si experienta, chirurgii prefera una sau alta dintre metode.

In ultima vreme se contureaza o noua alternativa, anume: abordul simultan laparo-endoscopic prin tehnica “rendez-vous”.

Tehnica

Dispozitivul operator este cel pentru colecistectomia laparoscopica.  Pacientul este asezat in decubit dorsal pe o masa operatorie radiotransparenta.  Aparatul de radiologie mobil (Siremobil 2000) este indispensabil.

Se incepe operatia laparoscopica conform timpilor standardizati. Dupa disectia completa a triunghiului Calot, la nevoie cu desprinderea infundibulului vezicular din patul hepatic pentru a conferi o mai mare mobilitate ductului cisitc, se trateaza artera cistica si se pune un clip pe coletul vezicular.

Se sectioneaza partial canalul cistic sub clip si se introduce un cateter de colangiografie, al carui lumen trebuie sa permita trecerea unui fir ghid de 0.035 inch.  Cateterul este asigurat cu un clip care este strins foarte lejer.

Se efectueaza colangiografia intraoperatorie.  Daca aceasta este pozitiva pentru litiaza, este solicitat endoscopistul pentru tehnica “rendez-vous”.  Acesta trebuie sa aprecieze mai intii daca extractia calculilor este fezabila pe aceasta cale (dependenta in principal de dimensiunea acestora si de posibilitatile de litotritie).

Troliul de endoscopie ca si monitorul radiologic sunt situate linga capul pacientului, la stinga mesei operatorii.

Introducerea duodenoscopului pina in fata papilei Vater se face in principal sub controlul laparoscopului.  Datorita presiunii intaabdominale stomacul nu poate fi insuflat, de altfel acest lucru nici nu este de dorit intru-cit ar deranja manevrele laparoscopice prin micsorarea camerei de lucru.

Anestezistul trebuie avertizat la inceputul manevrei pentru a urmari ca nu cumva sonda de intubatie orotraheala sa se deplaseze.

Se urmareste progresia fibroscopului in lungul mari curburi pina la pilor, cind, prin miscarea clasica de “insurubare” in sens orar, virful aparatului este plasat in fata papilei.  Din punct de vedere practic endoscopistul rasuceste duodenoscopul 1800, asezindu-se cu spatele la bolnav.

Chirurgul trece un fir ghid (TMT-35-260, Wilson-Cook) prin cateterul transcistic, in coledoc si apoi transpapilar in duoden, unde este prins de endoscopist cu o sonda de polipectomie si extras prin canalul de lucru al duodenoscopului (fig. 1).

Figura 1. Trecerea firului ghid transcistic

Se introduce pe firul ghid sfincterotomul (Cotton canulatome II, Wilson-Cook) si se executa o sfincterotomie larga (corelata cu dimensiunile coledocului), utilizind curentul de taiere (fig. 2).  Se extrag sfincterotomul si firul ghid si se dragheaza calea biliara principala cu sonda Dormia, pina la evacuarea completa a calculilor.

Dupa colangiografia de control se extrage cateterul transcistic, se clipeaza ductul cistic si se sectioneaza.  Colecistectomia laparoscopica continua conform timpilor standardizati.

In dimineata primei zile postoperator se solicita o amilazemie, care daca este in limite normale permite reluarea alimentatiei.  In absenta complicatiilor, externarea se face ca dupa o colecistectomie laparoscopica obisnuita.

Figura 2.  Sfincterotomie pe fir ghid

Experienta clinica

In perioada martie-decembrie 1999 noua pacienti cu litiaza veziculara si cu suspiciune de litiaza coledociana au fost programati pentru tehnica “rendez-vous”.  La cinci dintre ei colangiografia intraoperatorie a fost normala, timpul endoscopic nefiind necesar.

La trei pacienti abordul laparo-endoscopic dupa tehnica descrisa a fost incununat de succes, extragindu-se cite un calcul in doua cazuri si 12 calculi intr-un caz.

La ultimul pacient firul ghid nu a putut fi trecut in duoden datorita inclavarii calculului in ampula Vater.  Sa facut papilotomie pe calcul cu “knife papilotom”. Injectind ser fiziologic pe cateterul transcistic, calculul a fost expulzat.

Nu s-a inregistrat nici o complicatie legata de efectuarea colangiografiei intraoperatorii.

Canularea duodenului cu fibroscopul nu a ridicat probleme deosebite. Sfincterotomiile endoscopice au fost facile si nu au generat incidente, inclusiv la un caz cu papila situata intr-un diverticul de fereastra duodenala..

Insuflarea duodenului cu aer a fost minima si timpii operatori laparoscopici nu au fost afectati.

Nici unul dintre pacienti nu a prezentat reactie pancreatica clinica sau biochimica.

Fiind primele cazuri abordate in acest fel, externarile s-au facut intre 2 si 7 zile de la operatie, cu o medie de 5 zile.

Discutii

O data cu larga raspindire a tehnicilor laparoscopice, abordul deschis al litiazei colecistocoledociene este in declin.  Totusi el ramine prima optiune in centrele cu o experienta redusa in abordul miniinvaziv al litiazei de cale biliara principala.

Abordul integral laparoscopic al litiazei colecistocoledociene este o tehnica utilizata tot mai frecvent.  Din punct de vedere teoretic ar putea deveni standardul de aur, dar are dezavantajul de a fi foarte pretentioasa din punct de vedere tehnic, ca atare accesibila putinor specialisti.

Imbinarea chirurgiei laparoscopice cu explorarea endoscopica a cailor biliare este o solutie de compromis foarte pertinenta.

Un punct slab al metodei este riscul ca poate suma teoretic complicatiile a doua tehnici diferite.  Oricum nu exista studii randomizate care sa demonstreze inferioritatea sau superioritatea abordului combinat, in raport cu abordul integral laparoscopic.

Traumatizarea fizica si psihica de doua ori a pacientului este si ea criticabila.

In cazul in care dezobstructia endoscopica a caii biliare principale, tentata dupa colecistectomia laparoscopica, esueaza, pacientul va fi supus unei noi interventii chirurgicale pe cale deschisa.

Deoarece nu exista criterii clinice, de laborator si investigatii imagistice curente (ecografie, colangiografie i.v.) care sa prezica cu acuratete prezenta litiazei in calea biliara principala, intre 40% si 60% din colangiografiile retrograde sunt negative, atunci cind explorarea endoscopica are loc inaintea operatiei laparoscopice.

Abordul simultan laparo-endoscopic incearca sa raspunda acestor critici.  Din punct de vedere tehnic exista patru variante:

·Tehnica “rendez-vous” (cea pe care am descris-o) (1-3).

·Sub aceiasi anestezie se face initial explorarea endoscopica diagnostica sau/si terapeutica urmata de colecistectomia laparoscopica. Dezavantaje: nu elimina posibilele colangiografii negative si poate ingreuna timpul laparoscopic ca urmare a insuflarii intestinului cu aer (4).

·La sfirsitul colecistectomiei laparoscopice se face dezobstructia endoscopica a coledocului.  Aceasta varianta nu scuteste endoscopistul de dificultati la canularea papilei (5,6).

·Sfincterotomia laparoscopica transcistica (anterograda) efectuata sub control endoscopic, promovata de De Paula (7-9), nu prezinta avantaje fata de tehnica “rendez-vous”.

Avantajele tratamentului litiazei colecistocoledociene prin tehnnica “rendez-vous” sunt:

·Bolnavul este supus unui singur stres anestezico-operator.

·Elimina explorarile endoscopice inutile.

·Reduce morbiditatea specifica endoscopiei, prin faptul ca elimina dificultatile in canularea papilei.

·Exclude riscul unei reinterventii in caz de esec al dezobstructiei endoscopice, rezolvarea litiazei coledociene efectuindu-se in acelasi timp operator pe cale laparoscopica sau deschisa.

·Scurteaza mult durata de spitalizare.

Singurul dezavantaj poate consta in dificultatea sincronizarii programului echipei operatori cu echipa endoscopica.

Marea majoritate a bolnavilor cu litiaza veziculara si suspiciune de litiaza coledociana se preteaza la abordul prin tehnica “rendez-vous”. Asocierea unei papilooddite stenozante impune sfincterotomia endoscopica.  Colangiografia retrograda poate fi solicitata si pentru identificarea anatomiei cailor biliare, atunci cind colangiografia intraoperatorie a esuat.

Contraindicatiile abordului laparo-endoscopic simultan al CBP sunt: insuficienta hepatorenala, angiocolita acuta severa, pancreatita acuta biliara severa, stenozele hepato-coledociene asociate si calculii de dimensiuni foarte mari.

Tabelul I

Autor

Nr.

conversii

hiper-amilazemie

complicatii

decese

spitalizare

p.o.

Cavina (1)

16

0

1

1

1

4

Basso(2)

54

0

0

3

1

3.3

Cox(3)

13

2

0

3

0

3

DePalma(4)

15

0

0

0

0

3

Meyer(6)

44

0

0

0

0

4.6

De Paula(7)

22

0

2

0

0

1.4

Curet(9)

6

0

3

0

0

2.9

In ceea ce priveste rezultatele din literatura de specialitate (tabelul I), ele sunt greu de sistematizat, deoarece sfincterotomie endoscopica peroperatorie nu este inca standardizata, nici ca moment si nici in ceea ce priveste utilizarea de rutina a firului ghid.

Concluzii

Numarul mic de cazuri nu permite formularea unor concluzii fundamentate stiintific.  Aceasta experienta personala imi permite insa sa afirm ca temerile legate de dificultatea explorarii endoscopice a caii biliare principale la un bolnav in decubit dorsal si intubat orotraheal nu sunt justificate.  Tehnica este relativ facila si poate fi aplicata de rutina de catre chirurgii care au competenta de endoscopie, sau colaboreaza cu un endoscopist avizat.

BIBLIOGRAFIE

1.CAVINIA E., FRANCESCHI M., SIDOTI F., et al. Laparo-endoscopic “Rendezvous”: a new technique in the choledocholithiasis treatment.  Hepato-Gastroenterology 1998; 45:1430-1435

2.BASSO N., PIZZUTO G., SURGO D., et al. Laparoscopic cholecystectomy and intraoperative endoscopic sphincterotomy in the treatment of cholecysto-choledocholithiasis. Gastrointest Endosc 1999; 50(4):532-535

3.COX M.R., WILSON T.G., TOOULI J.  Peroperative endoscopic sphincterotomy during laparoscopic cholecystectomy for choledocholithiasis. Br J Surg. 1995; 82:257-259

4.DePALMA G., ANGRISANI L., LORENZO M., et al. Laparoscopic cholecystectomy, intraoperative endoscopic sphincterotomy , and common bile duct stones extraction for management of patients with cholcystocholedocholithiasis. Surg Endosc 1996; 10:649-652

5.MEYER C., LE J.V., ROHR S., et al. Management of common bile duct stones by laparoscopic cholecystectomy and endoscopic sphincterotomy: pre-, per-, or postoperative sphincterotomy? Dig Surg 1999; 16:26-31

6.MEYER C., LE J.V., ROHR S., et al. Management of common bile duct stones in a single operation combining laparoscopic cholecystectomy and perioperative endoscopic sphincterotomy. Surg Endosc 1999; 13(9):874-877

7.De PAULA A.L., HASHIBA K., BUFATTO M., et al. Laparoscopic antegrade sphincterotomy. Surg Laparosc Endosc 1993; 3:157-160

8.De PAULA A.L., HASHIBA K., BUFATTO M. Laparoscopic management of choledocholithiasis. Surg Endosc 1994; 8:1399-1403

9.CURET M.J., PITCHER D.E., MARTIN D.T., ZUCKER K.A.:  Laparoscopic antegrade sphincterotomy. Ann. Surg. 1995; 221:149

...

Thymectomy by thoracoscopic approach in myasthenia gravis

I. Popescu1, V. Tomulescu1, V. Ion2, and D. Tulbure3

1Department of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Sos. Fundeni 253, Sector 2, 72434, Bucharest, Romania

2Department of Neurology, Fundeni Clinical Institute, Sos. Fundeni 253, Sector 2, 72434, Bucharest, Romania

3Department of Anesthesia and Intensive Care, Fundeni Clinical Institute, Sos. Fundeni 253, Sector 2, 72434, Bucharest, Romania

Received: 4 July 2001; Accepted: 4 October 2001; Online publication: 31 December 2001

Abstract

Background: A series of 25 thoracoscopic thymectomies performed in the Department of General Surgery and Liver Transplantation of the Fundeni Clinical Institute between April 1999 and April 2000 is analyzed. Methods: Thoroscopic thymectomies were performed on 4 male patients (16%) and 21 female patients (84%), aged between 8 and 60 years. Results: The mean operative time was 90 (±15) min. There were no conversions to open thymectomy. Mortality was nil, and morbidity consisted of one minor postoperative right pneumothorax probably related to a injury to right mediastinal pleura that was not observed intraoperatively. Hospital stay ranged from 2 to 4 days, with a mean of 2.28 days. The patients were transferred to the neurological department and they were usually discharged after 1 more day. Conclusions: Postoperatively, all patients had clinical improvement of their disease both in symptoms and medication requirements, but a longer follow-up is necessary. The results are edifying regarding the very low morbidity, the lack of mortality, the acceptance of the patients, and the short hospitalization.

Keywords: Thoracoscopic approach, Thymectomy, Myasthenia gravis

Correspondence to: I. Popescu — Email: fundenip@com.pcnet.ro

 

 

Myasthenia gravis (MG) is a heterogeneous disorder with a protean, clinical, pathologic, and immunobiological picture [2 ] Until 1960, the pathogenesis of MG was unknown, although the thymus gland was determined to be involved by empiric observations of the beneficial effect of thymectomy. The autoimmune origin of the disease was suggested for the first time by Simpson [22], but Almon and colleagues [1 ] were the first to demonstrate circulating antibodies to acetylcholine receptor (AchR) sites of the neuromuscular junction. Elevated antibody levels are found in approximately 90% of patients and are roughly correlated with the clinical severity of the disease [2]. As Williams and Lenon [23 ] showed, the thymus is evidently implicated in the production of not only these end-plate antibodies but also striated muscle antibodies through some aberration in its normal function.

Today it is considered that the necessary and effective treatment of MG must include both mixed immunosuppression and surgery [1, 2, 22, 23]. Since the first case reported by Schumacher and Roth [21 ], the role of thymectomy in MG treatment has been well established. The main study demonstrating -the benefit of thymectomy in MG was that of Buckingham and associates [3], who compared the clinical course of patients after thymectomy with a computer-matched cohort receiving medical therapy.

After the success of laparoscopy in abdominal surgery, the miniinvasive access opened new possibilities in thoracic surgery. The principle of lessening the morbidity of a surgical procedure by minimizing the access trauma necessary to accomplish the desired operation was successfully applied to a wide variety of thoracic diseases. In 1992, Landrenau et al. [13] and Lewis et al. [14] and in 1993, Hazelrigg et al. [8], and Naunheim and Andrus [18 ] reported their experience using the miniinvasive approach [video-assisted thoracoscopic surgery (VATS)] on some mediastinal lesions. Yimm et al. [24], Mack et al. [15], and Mineo et al. [16], were the the first to report series of thoracoscopic thymectomies and their results.

Materials and methods

Between June 1989 and April 1999, in the Department of General Surgery and Liver Transplantation of Fundeni Clinical Institute, 64 thymectomies were performed using the transsternal approach. The first thoracoscopic thymectomy (VATS) was performed in April 1999 by Popescu and colleagues. Since April 1999, all patients with nonthymomatous MG or with stage I thymoma [tumor less than 4 cm with no signs of invasiveness on computed tomography (CT)] have undergone the thoracoscopic approach, and patients with thymoma stage II or III have undergone the transsternal approach.Between April 1999 and April 2000, the thoracoscopic approach was used on 25 patients, whereas 5 patients with tumor larger than 4 cm or with signs of invasiveness on CT were assigned to open thymectomy. All patients were previously treated in the neurological department of the Fundeni Clinical Institute for at least 3 months. The diagnosis of MG was based on clinical signs and one or more of the following: response to edrophonium chloride, results of electromyography, and the presence of circulating antibodies against the AchR. A myasthenia deficiency score (MDS), proposed in 1975 by V. Ion and A. Cinca [9 ], was calculated in correlation with a striate muscular effort test. The maximal myasthenia deficit is 50 points according to this score; the striate muscles of the head represent 20 points and the spinal innervated muscles 30 points. The MDS was reduced to less than 10 points by medical treatment before surgery.

The medical treatment consists of anticholinesterase drugs, steroids, and immunosupression. Patients with severe symptoms, considered at risk for postoperative respiratory failure, underwent plasma exchange prior to operation (three cases, 12%).

For the clinical assessment of disease severity, a modified Osserman classification was used:

  • Class 1 (1)ocular myasthenia only
  • Class 2 (IIa)mild generalized myasthenia with ocular involvement
  • Class 3 (IIb)moderately severe generalized myasthenia with ocular involvement and mild bulbar symptoms
  • Class 4 (III and IV)acute severe myasthenia developing over a period of weeks or months with severe bulbar symptoms and late-onset severe myasthenia with severe bulbar involvement and gradual development from classes I and II

Our standard procedure was not to operate on patients in modified Osserman class 1 (I). Twelve patients (48%) in modified Osserman class 2 (IIa), 12 patients (48%) in modified Osserman class 3 (Il), and 1 patient (4%) in modified Osserman class 4 have been operated on.

The timing of surgery was determined in consultation with the neurologist. Preoperative diagnostic tests included spirometry and CT scan in all patients. Anticholinesterase drugs and steroid treatment were given as needed before and after the surgical procedure.

Surgical technique

Thymectomy was performed with the patient under general anesthesia with double-lumen tube placement and lying in a 30° off-centre position. A left thoracic approach was used in all cases. Three flexible trocars were inserted into the left hemithorax.

The operator stays on the left side of the patient in a cephalad position to the cameraman. The monitor is on the right side of the patient. The first trocar (12–44 mm) is placed through the fifth or sixth intercostal space, between the middle and posterior axillar lines. Pleural cavity exploration is facilitated by the selective right bronchus intubation, which allows the left lung to collapse. The pulmonary collapse may also be facilitated by gas insufflations at a maximum of 5 mmHg pressure for 5 min. The second and third trocars (12–14 and 5–7 mm, respectively) are placed through the third intercostal space on the anterior axilary line and through the fourth or fifth intercostal spaces on the midclavicule line. After a careful pleural cavity exploration, we spot the anterior mediastinum. There are two important anatomical marks for the anterior mediastinum: the phrenic nerve and the internal thoracic artery.

The incision of the mediastinal pleura and the dissection of the thymus begin anterior to the left phrenic nerve and continue into the entire thyrmic compartment. The cranial limit of the dissection, at the level of the mediastinal pleura, is the internal thoracic artery. The thymectomy represents the emptying of the lymphatic and fat tissue in the thymus compartment.

The use of the ultrascision scalpel (Harmonic Scalpel Ultrascision; Ethicon Endo-Surgery) facilitates the dissection, decreases the time of the intervention, and avoids the risks of the electrocoagulation in this area. The anterior, retrosternal dissection is the easiest part of the intervention. It starts from the pericardial plane and ends at the inferior neck limit. The posterior dissection also begins anterior to the phrenic nerve and continues posterior and inferior in the pericardial plane, overtaking the median line, to the right of the thymus gland. All anterior mediastinal tissue including the pericardial fat at the pericardiophrenic angle is included in the en bloc resection.

During the posterior dissection, the pericardium, the aortic arch, the left brachiocephalic vein, and the superior vena cava are visualized and cleaned of all fat tissue. The most difficult area to dissect is between the superior vena cava and the left brachiocephalic vein. At the superior pole, the dissection is performed in the anterior carotidal plane to the internal thoracic artery level. The left superior horn may occasionally pass behind, instead of in front of the brahiocephalic vein. The thymectomy ends with the identification of the superior part of the gland, the thireothymic ligament section, and freeing of the superior horns from the surrounding tissue. Cervical skin transillumination is the indication that the cervical limit of the dissection has been reached.

During the operation, we can visualize the superior, lateral, or medial arterial thymic pedicles. They are clipped and cut or ultrasonically coagulated. Dissection of the thymic veins is very important. The veins are very short and enter directly into the left brachiocephalic vein. Tearing out such a pedicle may cause a hemorrhage, which is very difficult to correct thoracoscopically. During the operation, the lung is periodically reventilated, and bronchial secretions are aspirated to reduce the risk of postoperative atelectasis. Thymus extraction is quite easily done by enlarging the hole of the second trocar port (the anterior one) and bagging the piece before extracting it.

The operation ends with the thymic cavity inspection, which can detect possible remnant tissue. Finally, we wash the cavity with warm saline. At the end of the operation we place two drains in the pleural cavity through the inferior trocar ports.

The therapeutic effect of thymectomy was established by comparing the preoperative clinical status with the status recorded every 3 months postoperatively. All patients have been followed from 6 to l8 months. Postoperative clinical status was rated based on changes in both symptoms and medication requirements.

Because of the need for universally accepted classifications and grading systems, we analyzed our series results retrospectively using the recommendations of the Thymectomy Task Force of Myasthenia Gravls Foundation in America (MGFA)[10].

Results

Four male patients (16%) and 21 female patients (84%), aged 8–60 years, underwent a thoracoscopic thymectomy. Using the MGFA [10] clinical classification (Table 1 ) prior to operation there were 8 patients (32%) in class IIa, 4 patients (15%) in class IIb, 7 patients (28%) in class IIIa, 5 patients (20%) in class IIIb, and 1 patients (4%) in class IVa.

Surgical results

There was no conversion to open thymectomy. No patients had phrenic or recurrent nerve injury, and no patients developed atelectasis or pneumonia postoperatively. The mean operative time was 90±15 min. All patients were extubated within 1 h after operation.

In one patient (4%) with organized pachipleural adhesions, pleuralisis was extremely difficult and time-consuming. Bleeding at the level of the trocar port occurred in two cases (8%); in one of these cases ligature of the intercostal artery was necessary. There was one minor postoperative right pneumothorax that was probably related to a right mediastinal pleural lesion that was not observed intraoperatively.

On average, postoperative hospital stay was 2 days in the general surgery department, and then the patients were transferred for 1 day to the neurological department. Hospital stay in the surgical department ranged from 2 to 4 days, with a mean of 2.28 days.

Clinical results

Regarding the MGFA MG therapy status (Table 2) [10 ], prior to operation all patients received prednisone (PR) therapy, 23 patients (92%) were on cholinesterase inhibitors therapy (CH) and 20 patients (80%) had been on lmmunosuppression therapy other than prednisone In two cases (8%) plasma exchange therapy, acute [PE(a)] (for exacerbations or preoperatively) was needed.

Postoperative MGFA MG therapy status at 3 months showed that 22 patients (88%) were on PR therapy, 17 patients (68%) were on CH therapy, and no patient needed IM or PE therapy. Postoperative MGFA MG therapy status at 6 months showed that 18 (72%) of patients were on PR therapy, 16 patients (64%) were on CH therapy, and 1 patient needed IM therapy.

The quantitative MG score for disease severity (QMG score; Table 3) [10] was calculated prior to operation (Fig. 1) and every 3 months after. The MGFA post intervention status [10 ] cannot be calculated because the minimum interval for follow-up is recommended to be 1 year, and the most recent followup of 19 patients (76%) occurred less then 1 year since surgery.

Pathologic examination of the specimens revealed the following: 3 patients (12%) had normal thymus, 5 patients (20%) had thymic hyperplasia,11 patients (44%) had thymic involution, and 6 patients (24%) had thymoma. The pathological examination in the thymoma cases showed a lymphoepitelial thymoma with lobular disposition in 4 cases (16%), malignant lymphoepitelial thymoma with calcification in 1 case (4%), and timolipoma in 1 case (1%). By the classification of Masaoka and colleagues all thymomas were stage I. The patient with malignant thymoma first underwent chemotherapy and then radiotherapy.

Discussion

The major issues for a surgeon who has an interest in thymectomy are related to patient selection and surgical technique. Regarding patient selection, in cooperation with the neurological department of our hospital, we decided to operate only on patients with generalized MG. We did not operate on patients with ocular symptoms alone, modified Osserman class 1 (I), although it is well-known that more than 30% of these patients will develop generalized MG [2, 5 ]. We also decided to operate on patients with late-onset MG only If the patients are younger than 70 years old and/or they have thymomatous MG. All patients were medically treated until the MDS was reduced at least to 10 points (QMG score at least 13 points). Figure 1 presents the evolution of QMG score from the highest values until operation and at 3 and 6 months.

Throughout the years, many approaches have been described, such as the transcervical approach [6, 7] the transsternal approach [12], the mixed transcervical and transsternal approach (the so called maximal thymectomy [4, 11] and the minimally invasive thoracoscopic approach (VATS)[15, 17, 24 ]. The maximal thymectomy is certainly the most radical and effective thymectomy, but in well-selected cases the results of transsternal thymectomy are similar to those obtained using the cervical or thoracoscopic approach and near to those obtained using the mixed approach, such as maximal thymectomy [15, 24].

Like the cervical approach, the thoracoscopic approach is associated with minimal thoracic trauma, low postoperative morbidity, short hospitalization time, and, most important, a high patient compliance at surgery compared with the transsternal approach[24 ]. The thoracoscopic approach has the advantages of the microinvasive surgery, with a good view and a simple technique, especially for a team well trained in advanced laparoscopic procedures. The instruments are not crowded on a single port and the monitor allows the entire surgical team to visualize the operation. Thoracoscopy permits very early recovery, with rapid reintegration into the working process. Long-term complaints after videothoracoscopy are rare.

We started using the thoracoscopic approach in 1999 after achieving significant experience in open thymectomy [20] and advanced laparoscopic procedures (splenectomy, colorectal, and hepatic laparoscopic surgery).

Yim and colleagues [24 ] first proposed a right-sided approach for VATS thymectomy and recommended this approach for several reasons: (1) identification of the vena cava is a land mark for easier dissection of innominate vein, (2) the confluence of the innominate veins is easier to dissect using a right approach, and (3) ergonomically it is easier for right-hand surgeons to dissect the thymus from inferior horns to upper horns in a right approach.

As Minneo and associates [17 ], we believe that thymectomy can be performed from either side. We believe that the dissection maneuvers are safer from the left because the superior vena cava lies outside of the surgical field, thus reducing the risk of an incidental lesion to this vessel, and dissection of the right part of the thymus is easier from the left approach than dissection of the left part of the thymus from the right approach.

In all instances, every effort was made to remove all thymic tissue as completely as possible by clearing the innominate vein and anterior pericardium from all resident mediastinal fat. We believe this is easier to perform using a left-side approach since, most of the mediastinal fat is located on the left part of anterior mediastinum. The use of a 30° scope (Karl Storz endoscope) significantly helps in these areas.

Opening of the right pleural cavity is not an accident. On the contrary, if the intention to remove all all thymic tissue as completely as possible calls for the resection of the entire right costomediastinal sinus (sparing the right phrenic nerve, of course), we perform this procedure and finish the operation with bilateral thoracic drainage. This has happened in two cases with thymomatous myasthenia.

We have not performed a pneumomediastinum to facilitate thymectomy, as have Minneo and colleagues [16], but we have seen that insufflation upto 5 mmHg facilitates pulmonary collapse, making mediastinal dissection easier.

Our surgical results, with no mortality and major morbidity are similar to those of Mack and colleagues [15] and Minneo and associates [17] and they compare favorably with 33% morbidity reported by Bulkley and colleagues[4] with transsternal thymectomy and with 9.52% in our historical series [20].

The mean duration of the disease until the patient underwent surgery in our series was 28.8 months, which compares favorably with the mean duration of 42.2 month in our historical series [20 ]. This indicates that the thoracoscopic approach has a high patient compliance at surgery because of its superior cosmetic results, with the same medical results.

Follow-up at 3 and 6 months showed a slow decrease in QMG score (normal in MG thymus surgery), but this was a good result considering the reduction of medical requirements.

The patient that needed an IM treatment had malignant thymoma, and at 6 months the QMG score was still high. CT scan has not shown any remnant thymus tissue. Reevaluation of the patient has shown multiple bone metastases and chemotherapy has started. In our series, the thoracoscopic thymectomy indications were for thymus dysplasia and stage I thymoma. We do not believe that the method is indicated in stage II or III thymoma, even; if technically possible [19], because the risk of major complications or incomplete resection is very high.

Postoperatively, all patients had clinical improvement in both symptoms and medication requirements, but the follow-up period is too short for conclusions. Larger series and longer follow-up are necessary to make definite conclusions. The results have to be analyzed using standardized methods. The guidelines of the Thymectomy Task Force of the M6FA [10 ] might be used to analyze and compare the results of thoracoscopic thymectomy versus other approaches. Our results are certainly conclusive regarding the very low morbidity, the lack of mortality, the acceptance of the patients, and the short hospitalization time.

References

1. Almon RR, Andrew AG, Appel SH (1974) Serum globulin in myasthenia gravis: inhibition of L-bulgaroton to acetylcholine receptors. Science J 186:55 [PubMed]

2. Beekman R, Kuks JB, Oosterhuis HJ (1997) Myasthenia gravis: diagnosis and follow-up of 100 consecutive patients. J Neurol 244:112-118 [PubMed]

3. Buckingham JM, Howard Jr FM, Bernatz PE (1976) The value of thymectomy in myasthenia gravis: a computer-assisted matched study. Ann Surg 184:453-458 [PubMed]

4. Bulkley GB, Bass KN, Stephenson GR, Diener-West M, George S, Reilly PA, Baker RR, Drachman DB (1997) Extended cervicomediastinal thymectomy in the integrated management of myasthenia gravis. Ann Surg 226:324-335 [PubMed]

5. Busch C, Machens A, Pichlmeier U, Emskotter T, Izbicki J (1996) Long-term outcome and quality of life after thymectomy for myasthenia gravis Ann Surg 224:226-231 [PubMed]

6. Calhoun RF, Ritter JH, Guthrie TJ, et al. (1999) Results of transcervical thymectomy for myasthenia gravis in 100 consecutive patients. Ann Surg 4:555-561 [PubMed]

7. Crile Jr G (1964) Thymectomy through the neck. Surgery 59:313-315 [PubMed]

8. Hazelrigg SR, Mack MJ, Landrenau RJ (1993) Videoassisted thoracic surgery for mediastinal disease. Chest Surg Clin North Am 3:283-291 [PubMed]

9. Ion V, Cinca A (1981) Miastenia gravis. Tratat de neurologie, sub redactia C. Arseni, Ed Medicala :1109-1189 [PubMed]

10. Jaretzki A, Barohn RJ, Etstoff RM, et al. (2000) Myasthenia gravis: recommendation for clinical research standards. Ann Thorac Surg 70:327-334 [PubMed]

11. Jaretzky III A, Bethea M, Wolff M, Olarte M, Lovelace RE, Penn AS, Rowland L (1977) A rational approach to total thymectomy in the treatment of myasthenia gravis. Ann Thorac Surg 24:120-130 [PubMed]

12. Kreel I, Osserman K, Genkins G, Kark AE (1967) Role of thymectomy in management of myasthenia gravis. Ann Surg 165:111-117 [PubMed]

13. Landrenau RJ, Dowling RD, Castillo WM, Ferson PF (1992) Thoracoscopic resection of an anterior mediastinal tumor. Ann Thorac Surg 54:142-144 [PubMed]

14. Lewis RJ, Caccavale RJ, Sisler GE (1992) Imaged thoracoscopic surgery: a new thoracic technique for resection of mediastinal cysts. Ann Thorac Surg 53:38-44 [PubMed]

15. Mack JM, Landrenau RJ, Yim AP, Hazelrigg SR, Scrugs GR (1996) Results of video-assisted thymectomy in patients with myasthenia gravis. J Thorac Cardiovasc Surg 112:1352-1360 [PubMed]

16. Mineo TC, Pompeo E, Ambrogi V, Sabato AF, Bernardi G, Casciani CU (1996) Adjuvant pneumomediastinum in thoracoscopic thymectomy for myasthenia gravis. Ann Thorac Surg 62:1210-1212 [PubMed]

17. Mineo TC, Pompeo E, Lerut TE, Bemardi G, Coosemans W, Nofroni I (2000) Thoracoscopic thymectomy in autoimmune myasthenia: results of left side approach. Ann thorac Surg 70:327-334 [PubMed]

18. Naunheim KS, Andrus CH (1993) Thoracoscopic drainage and resection of giant mediastinal cysts. Ann Thorac Surg 55:156-162 [PubMed]

19. Noda M, Matsumaray , Handa M, Tanita T, Fujimura S (1997) Video-assisted thoracoscopic surgery of bilateral dissemination of invasive thymoma: report of a case. Kyobu Geka 50:886-889 [PubMed]

20. Popescu I, Ion V, Tulbure D, Brasoveanu V, Hrehoret D, Popescu C (1998) Rolul timectomiei in tratamentul miasteniei gravis—experienta pe 42 de cazuri. J Chir Toracica 3:131-135 [PubMed]

21. Schumacher ED, Roth J (1912) Thymectomie bei cenem Fall von Morbus Basedowii mit Myasthenie. Mitt Gregzeb D Med Chir 25:746 [PubMed]

22. Simpson JA (1981) The thymus in the pathogenesis and treatment of myasthenia gravis. In: E Satoyoshi (ed) Myasthenia gravis pathogenesis and treatment. Univ of Tokyo Press, Tokyo, pp 301-307

23. Williams CL, Lennon VA (1986) Thymic B lymphocyte clones from patients with myasthenia gravis secrete monoclonal striational antibodies reacting with myosin, alpha actinin or actin. J Exp Med 164:1043 [PubMed]

24. Yim AP, Kay RLC, Ho JKS (1995) Video-assisted thoracoscopic thymectomy for myasthenia gravis. Chest 108:1440-1443 [PubMed]

...

Tratamentul combinat laparoscopic si endoscopic al litiazei colecistocoledociene

F. Turcu

Publicatia: Chirurgia

Rezumat

Combinarea endoscopiei cu laparoscopia prezerva caracterul miniinvaziv al tratamentului la bolnavii cu litiaza colecistocoledociana.  In studiul prezentat am incercat sa evaluam care este modalitatea optima de asociere a celor 2 tehnici terapeutice. Metoda: In baza intentiei de a trata miniinvaziv, au fost selectati 89 de pacienti cu suspiciune de litiaza colecistocoledociana. Ei au fost impartiti in 3 loturi in functie de momentul in care s-a apelat la endoscopie: preoperator (Lotul A: 38 cazuri), postoperator (Lotul B: 35 cazuri) sau peroperator (Lotul C: 16 cazuri).  Rezultate: S-a constatat o proportie semnificativ mai mare de cazuri rezolvate integral miniinvaziv (94%) si o medie a spitalizarii mai scurta (8,6±3,7 zile) in cazul lotului C. Concluzii:  Modalitatea optima de asociere a endoscopiei cu laparoscopia in tratamentul litiazei colecistocoledociene este abordul simultan conform tehnicii „redez-vous”.


Abstract

Combined laparoscopic and endoscopic treatment of gallbladder and bile duct stones.

In the present study we have tried to find what is the best time for endoscopy in the treatment of gallstones associated with common bile duct stones.  Method: We have selected on the intention to treat 89 patients suspected of cholecysto-choledocholithiasis.  There have been 38 cases with preoperative endoscopy (Group A), 35 cases with postoperative endoscopy (Group B) and 16 cases with perioperative endoscopy (Group C).  Results: In group C it has been a significant higher proportion of successfully treated cases (94%) and a lower hospital stay (8,6±3,7 days).  Conclusions: Combining the endoscopy and laparoscopy in the same operation (“rendez-vous” technique) is the best approach for treating cholecysto-choledocholithiasis.


INTRODUCERE

Standardul din chirurgia clasica pentru tratamentul litiazei colecistocoledociene: colecistectomie plus coledocolitotomie, nu poate fi reprodus pe cale laparoscopica decit in centrele cu performante ridicate. Rezultatele bune nu sunt reproductibile inca in conditii clinice obisnuite.

O alternativa pentru prezervarea caracterului miniinvaziv al tratamentului este asocierea chirurgiei cu endoscopia.  Intrucit rezultatele bune ale abordului endoscopic sunt reproductibile, aceasta strategie este preferata de majoritatea chirurgilor laparoscopisti.

Exista trei atitudini vis-a-vis de posibila asociere a endoscopiei cu laparoscopia:

1.     Abordul secvential  in ordinea: endoscopie – laparoscopie:

2.     Abordul secvential in ordinea: laparoscopie – endoscopie:

3.     Abordul simultan laparoendoscopic:

Obiectivul acestui studiu este de a pune in evidenta care dintre cei trei algoritmi de tratare a litiazei colecistocoledociene este mai bun.

Dupa parcurgerea literaturii de specialitate am formulat urmatoarea ipoteza de lucru:

„Abordul simultan laparoendoscopic (prin tehnica „rendez-vous”) al litiazei colecistocoledociene este superior abordului secvential.”

MATERIAL SI METODA

Studiul clinic s-a desfasurat intr-o maniera prospectiva, in perioada    1 ianuarie 1995 – 30 iunie 2001, in clinica Chirurgie Generala a Spitalului Cl. de Urgenta „Sfantul Ioan” – Bucuresti.

Au fost selectati toti pacientii cu suspiciune de litiaza colecistocoledociana la care s-a intentionat rezolvarea patologiei prin abord miniinvaziv, in perioada: 1 ianuarie 1995 – 31 decembrie 2000.

Suspiciunea preoperatorie de litiaza de CBP s-a bazat pe criterii clinice: icter, pencreatita acuta, colica coledociana, pe testele de colestaza (fosfataza alcalina, bilirubinemie), pe semnele indirecte (dilatatie de cai biliare) sau directe (imagine hiperecogena cu con de umbra la nivelul CBP)  decelate la ecografie.

Pentru confirmare s-a apelat la colangiografia retrograda endoscopica sau la colangiografia intraoperatorie transcistica. Nu au fost utilizate colangiografia intravenoasa, examenul computer tomograf sau rezonanata magnetica nucleara.

Suspiciunea intraoperatorie de litiaza de CBP s-a bazat pe aspectul macroscopic al canalului cistic (calibru larg, lipsa de permeabilitate) si al coledocului (dilatat), precum si pe prezenta microlitiaziei veziculare.  Confirmarea a fost obtinuta prin colangiografie intraoperatorie transcistica, sau prin explorarea palpatorie si chirurgicala a CBP dupa conversie.

Suspiciunea postoperatorie de litiaza de CBP s-a bazat pe criterii clinice: icter, pancreatita acuta, colica coledociana, pe testele de colestaza si pe ecografie.

Confirmarea a fost obtinuta prin colangiografie retrograda endoscopica sau in urma explorarii chirurgicale clasice.

Toate manevrele endoscopice au fost efectuate de catre autorul lucrarii.  In functie de accesoriile disponibile au fost utilizate diferite tehnici pentru sfincterotomie: tehnica standard, tehnica pe fir ghid, tehnica „rendez-vous”, sau tehnica „precut” cu papilotomul „knife”.

Operatiile (laparoscopice sau / si clasice) au fost efectuate de un numar de 14 chirurgi, medici specialisti sau primari, cu grade diferite de experienta laparoscopica.  Tehnica utilizata a fost cea descrisa de Redic [1].

Atunci cind litiaza coledociana a fost operata pe cale deschisa, operatiile au fost terminate de principiu cu un drenaj biliar extern si mai rar cu anastomoze biliodigestive.

Parametrii urmariti au fost preluati din baza de date computerizata a clinicii, din foile de observatie (inclusiv reinternarile) si din condica de operatii.

Toate datele au fost contabilizate pe baza „intentiei de a trata” miniinvaziv bolnavul.  Pacientii au fost selectati pentru studiu, chiar daca, in urma unui esec al metodei endoscopice sau a celei laparoscopice, s-a recurs in final la operatia deschisa.

Pacientii au fost urmariti postoperator pina la 30 iunie 2001.

Toate informatiile obtinute au fost arhivate cu ajutorul programului Excel 6.0, ale carui functii statistice au fost utilizate pentru prelucrarea datelor.

Cazurile au fost impartite in trei loturi, functie de momentul in care   s-a apelat la abordul endoscopic:

·        Lotul A : pacienti cu suspiciune preoperatorie de litiaza de CBP care au fost abordati secvential, initial prin endoscopie ulterior prin laparoscopie;

·        Lotul B : pacienti cu suspiciune intra sau postoperaatorie de litiaza de CBP, care au fost convertiti sau abordati intr-un timp ulterior pe cale endoscopica;

·        Lotul C : pacienti cu suspiciune preoperatorie de litiaza de CBP,  care au fost programati pentru abordul simultan laparoendoscopic prin tehnica „rendez-vous”.

Principalii parametrii tinta urmariti, cei care masoara efectul aplicarii celor trei algoritmi in tratamentul litiazei colecistocoledociene, sunt: ponderea cazurilor rezolvate miniinvaziv,  morbiditatea si mortalitatea cumulata a celor doua tehnici, durata de spitalizare.

Cele trei loturi au fost apoi comparate intre ele, doua cite doua, pentru a vedea care algoritm de rezolvare a litiazei colecistocoledociene este mai bun.

Semnificatia statistica  a diferentelor observate intre valori medii, proportii, distributii, a fost testata cu testul „t” (pentru caracteristici cantitative) si cu testul χ2 (pentru caracteristici calitative).  Diferentele au fost considerate semnificative din punct de vedere statistic cind valoarea lui „p” a fost mai mica sau egala cu 0,05.

Definim unii termeni folositi in lucrare, pentru a nu genera confuzii.

Intelegem prin Conversie de necesitate situatia in care chirurgul este obligat sa treaca la operatia deschisa ca urmare a unor incidente / accidente intraoperatorii ce nu pot fi rezolvate pe cale laparoscopica.

Conversiile impuse de prezenta litiazei coledociene au fost considerate deliberate, intrucit abordul integral laparoscopic nu l-am practicat in clinica decit in mod exceptional.

La complicatiile postoperatorii am contabilizat atit complicatiile abordului endoscopic al CBP, cit si complicatiile interventiei chirurgicale, indiferent de modul ei de finalizare: laparoscopic sau deschis.

Complicatiile abordului endoscopic au fost definite, conform criteriilor lui Cotton [2].

Reinterventia este operatia desfasurata pe cale deschisa sau laparoscopica, impusa de manifestarile clinice ale unor complicatii secundare colecistectomiei laparoscopice sau abordului endoscopic al CBP.  Eventratiile nu au fost contabilizate ca reinterventii.

REZULTATE

Care sunt caracteristicile loturilor studiate ?

Pe durata acestui studiu, au intrunit criteriile de selectie un numar de 89 pacienti. La toti acesti bolnavi intentia chirurgului a fost de a-i trata prin mijloace miniinvazive.

In functie de algoritmul de rezolvare a litiazei colecistocoledociene, pentru care a optat operatorul, 38 de cazuri s-au incadrat in Lotul A, 35 in Lotul B si 16 in Lotul C.

Perioada de urmarire postoperatorie a fost in medie de 34 ± 20 luni (valoarea mediana = 34 luni), cu extreme 6 – 74 luni.

In tabelul I sunt redate comparativ acele caracteristicii care definesc materialul analizat.

Tabelul I – Caracteristicile loturilor studiate.

Lotul A

Lotul B

Lotul C

Virsta medie (ani)

53±16

54±13

55±15

Mediana virstei (ani)

54

55

54

Raport  barbati/femei

1/2

1/3

1/2

Risc ASA IV sau V

0%

0%

0%

Litiaza de CBP

45%

80%

56%

Colecistita ac.

26%

48%

19%

Pancreatita ac.

21%

0%

19%

Angiocolita

2,6%

0%

0%

Ciroza hepatica

8%

0%

0%

DISCUTII

Comparind intre ele, doua cite doua, cele trei loturi, constatam ca nu exista diferente semnificative din punct de vedere statistic pentru media si mediana virstei, repartitia pe sexe a cazurilor, sau incidenta cazurilor cu risc mare anestezico-chirurgical (ASA IV si V).

Din acest punct de vedere putem considera ca loturile sunt comparabile, caracteristicile amintite neinfluentind diferentele constatate intre parametrii tinta.

In ceea ce priveste incidenta litiazei de cale biliara pricipala, exista o  diferenta semnificativa intre Lotul A si Lotul B (p < 0,01).  Acest lucru este explicat de specificul fiecarui algoritm.

In Lotul A, la toti bolnavii cu suspiciune clinica, biochimica sau ecografica de litiaza coledociana, s-a facut o depistare preoperatorie activa prin colangiografie retrograda endoscopica. Cum specificitatea parametrilor mai sus amintiti este mica, un numar insemnat de pacienti nu aveau litiaza de CBP.

In Lotul B, colangiografia retrograda endoscopica a fost solicitata in general la cazurile cu colangiografie intraoperatorie pozitiva (explorare cu specificitate mare).

Intre loturile A si C nu exista diferente semnificative in aceasta privinta, explicabil prin faptul ca in ambele loturi selectia pacientilor s-a facut pe criterii preoperatorii.

Desi datorita criteriilor diferite de selectie ne-am astepta sa existe diferente semnificative statistic intre loturile B si C, acest lucru nu s-a inregistrat .  Explicatia probabila este numarul mic de pacienti analizati.

Colecistita acuta, fiind o urgenta chirurgicala, nu permite de obicei un interval de timp preoperator suficient pentru depistarea litiazei de CBP si planificarea unei manevre endoscopice.  Aceasta este explicatia pentru proportia semnificativ mai mare a proceselor inflamatorii acute in Lotul B comparativ cu Lotul A respectiv Lotul C.

Asa cum era de asteptat, diferentele inregistrate intre loturile A si C, pentru aceasta patologie, nu au semnificatie statistica.

Pancreatita acuta este o afectiune care ridica suspiciunea de litiaza coledociana, in plus ea impune temporizarea interventiei chirurgicale, ceea lasa suficient timp pentru investigatii suplimentare si programarea unei manevre endoscopice.  Acest lucru explica de ce incidenta acestei afectiuni este semnificativ mai mica in Lotul B comparativ cu Lotul A si Lotul C      (p < 0,01).

Explorarea endoscopica in urgenta a cailor biliare la pacientii cu pancreatita acuta si bilirubinemie peste 3 mg/dl, nu este o atitudine impartasita de toti chirurgii din clinica.  De aceea nu exista diferente semnificative statistic intre incidenta pancreatitei acute in loturile A si C.

Nu sunt diferente semnificative din punct de vedere statistic intre cele trei loturi in ceea ce priveste proportia angiocolitelor acute si a cirozei hepatice.

Mai trebuie mentionat ca 9 bolnavi din lotul B aveau un drenaj biliar extern transcistic, pozitionat in timpul colecistectomiei laparoscopice, cu scopul de a reduce presiunea in CBP pina la rezolvarea endoscopica a litiazei coledociene.

Care dintre cei trei algoritmi de tratament miniinvaziv al litiazei colecistocoledociene este mai bun ?

In Tabelul II sunt redati principalii parametri urmariti, parametrii care definesc eficienta algoritmului aplicat (clearance endoscopic, indicele de conversie al laparoscopiilor, proportia cazurilor rezolvate miniinvaziv, media spitalizarii), precum si cei care reflecta siguranta metodei (morbiditate, mortalitate).

Tabelul II – Principalii parametri urmariti

Lotul A

Lotul B

Lotul C

Clearance endoscopic

70%

87%

89%

Laparoscopii convertite

2,2%

4,3%

0,6%

Rezolvate miniinvaziv

66%

51%

94%

Media spitalizarii (zile)

14,8±7,7

17,9±8,9

8,6±3,7

Mediana spitalizarii (zile)

13,5

15

7,5

Morbiditate endoscopie

2,6%

0%

0%

Morbiditate chirurgie

5,2%

14%

0%

Morbiditate cumulata

7,8%

14%

0%

Mortalitate

2,6%

2,8%

0%

DISCUTII

Daca privim la valoarea absoluta a cifrelor, clearanceul endoscopic (proportia reusitelor din totalul tentativelor de dezobstructie endoscopica a CBP) este mai mic in cazul abordului secvential endoscopie – laparoscopie.  Acest lucru ar putea fi explicat prin faptul ca in algoritmul invers (laparoscopie – endoscopie) exista o selectie a cazurilor, in sensul ca operatorul prefera sa converteasca acele cazuri care par a fi dificile pentru endoscopist.

Analizind insa din punct de vedere statistic aceste diferente constatam ca ele nu au nici o semnificatie, intrucit p > 0,05 in fiecare caz.  Rezultatul este normal, deoarece posibilitatile de litotritie (principalul factor care influenteaza clearanceul), au fost aceleasi in fiecare din cele trei algoritme studiate.

Analizind statistic datele referitoare la proportia conversiilor in cele trei loturi constatam o diferenta semnificativa intre loturile B si C (p < 0,01), nu si  intre loturile A si B, desi „p calculat” are valoarea 0,06 fiind foarte aproape de pragul de 0,05. Nici intre loturile A si C diferenta nu este semnificativa din punct de vedere statistic.

Aceste rezultate in defavoarea lotului B le atribuim numarului semnificativ mai mare de colecistite acute din acest grup. Conversiile numeroase se datoreaza in mare parte procesului inflamator acut vezicular, aderentele pericolecistice nepermitind evidentierea canalului cistic in 7 cazuri.

In ceea ce priveste proportia conversiilor inregistrate in lotul A, care este asemanatoare cu cea inregistrata in clinica pentru colecistite cronice (2,4%), ea dovedeste ca rezolvarea endoscopica a litiazei coledociene nu garanteaza reusita operatiei laparoscopice.

Limitele abordului endoscopic al CBP pe de o parte si limitele abordului laparoscopic in colecistectomie pe de alta parte fac improbabila rezolvarea intr-o proportie de 100% pe cale miniinvaziva a litiazei colecistocoledociene, indiferent de algoritmul ales.

Analizind insa proportia cazurilor rezolvate miniinvaziv in cele trei loturi, remarcam ca abord laparoendoscopic simultan prin tehnica „rendez-vous” este cel mai eficient, diferentele fiind semnificative statistic atit in cazul comparatiei cu lotul A (p < 0,05), cit si in cazul comparatiei cu lotul B (p < 0,01).

Desi algoritmul endoscopie – laparoscopie pare mai eficient decit algoritmul laparoscopie – endoscopie, diferentele constatate nu au semnificatie statistica.

In lotul A, din cele 6 cazuri in care timpul endoscopic a fost urmat de chirurgie deschisa, doua ar fi putut beneficia de abordul simultan laparoendoscopic prin tehnica „rendez-vous”.

Analiza retrospectiva a motivelor de conversie din lotul B si a cauzelor de reinterventie, ne-a facut sa concluzionam ca cel putin patru pacienti ar fi beneficiat de abordul laparoendoscopic simultan prin tehnica „rendez-vous”.

In lotul C un singur bolnav a necesitat conversie, datorita litiazei de CBP de mari dimensiuni.

Aceasta eficienta crescuta a abordului laparoendoscopic simultan este cel mai sugestiv evidentiata de diferentele mari intre mediile perioadelor  de spitalizare consemnate in cele trei loturi.

Lotul C are o medie a duratei de spitalizare mai scurta cu 6 zile fata de lotul A (p < 0,001) si cu 9 zile fata de lotul B (p < 0,001). Intre loturile A si B diferentele consemnate in durata medie de spitalizare sunt nesemnificative.

La aceste diferente mari au contribuit trei factori:

·Proportia semnificativ mai mare de cazuri rezolvate miniinvaziv in lotul C.

·Eliminarea in lotul C a  intervalului de timp scurs intre cele doua interventii.

·Prelungirea spitalizarii ca urmare a morbiditatii mai mari consemnate in cazul abordului secvential (loturile A si B).

In lotul A s-au scurs in medie 3,3 ± 3,3 zile intre manevra endoscopica si interventia chirurgicala.

In lotul B acest interval de timp nu a putut fi determinat deoarce o parte din bolnavi au fost convertiti (nu li s-a facut endoscopie), altii au fost externati si au revenit pentru manifestari tardive ale litiazei restante.  In linii mari acest interval de timp a fost mai lung decit in cazul algoritmului endoscopie – laparoscopie.

Spre deosebire de celelalte doua loturi, in lotul C morbiditatea a fost nula.  Desi diferentele nu sunt semnificative statistic nici cind analizam morbiditatea globala a fiecarui algoritm, nici cind analizam morbiditatea imputabila endoscopiei respectiv interventiei chirurgicale, nu poate fi negat ca aceste complicatii au contribuit si ele la prelungirea duratei de spitalizare.

In lotul A a fost consemnate 3 complicatii, dintre care prima ar fi putut fi prevenita prin  tehnica „rendez-vous”:

·O hemoragie digestiva superioara la un pacient la care nu s-a reusit injectarea CBP cu substanta de contrast si la care s-a incercat o papilosfincterotomie pentru accesul in coledoc, manevra si ea esuata.  Desi in timpul operatiei deschise nu a fost necesar un gest specific pentru hemostaza (hemoragia se oprise spontan), coledocolitotomia urmata de drenaj biliar extern Kehr a prelungit spitalizarea la 29 de zile, mult peste medie.

·Un hemoperitoneu postoperator la un pacient la care colecistectomia laparoscopica fusese convertita (spitalizare 22 zile).

·Un bolnav cu ciroza hepatica a prezentat dupa colecistectomia laparoscopica convertita o hemoragie digestiva superioara si insuficienta hepatica urmate de deces (spitalizare 7 zile).

Fara a o incadra in complicatiile operatorii, mentionam un caz de litiaza coledociana restanta rezolvata endoscopic; era vorba de un pacient cu impietruire de CBP, motiv pentru care initial nu s-a tentat dezobstructia endoscopica optindu-se pentru operatia deschisa (spitalizare 40 zile).

In lotul B au fost consemnate 5 complicatii postoperatorii dintre care primele 3 ar fi putut fi prevenite prin tehnica „rendez-vous”:

·O pancreatita acuta postoperatorie ca urmare a inclavarii in ampula Vater a unui calcul restant (spitalizare 11 zile).

·O fistula biliara externa consecutiva deplasarii drenajului biliar transcistic.  Acesta fusese pozitionat in timpul colecistectomiei laparoscopice pentru o litiaza coledociana, care urma sa fie rezolvata endoscopic. Papilosfincterotomia si extractia endoscopica de calcul au rezolvat complicatia (spitalizare 10 zile).

·Un coleperitoneu consecutiv deraparii de clipuri de pe bontul cistic, la o bolnava ce prezenta o litiaza coledociana ce nu a fost recunoscuta.  Cazul a fost rezolvat printr-o reinterventie combinata, endoscopica si laparoscopica (spitalizare 18 zile).

·Un coleperitoneu la o pacienta la care incertitudinea dezobstructiei prin coledocolitotomie laparoscopica a impus conversia, explorarea instrumentala a CBP si drenajul biliar extern Kehr.  Dehiscenta coledocorafiei (efectuata calsic) a impus reinterventia chirurgicala.  Dupa o suita de complicatii septice bolnava a decedat (spitalizare 26 zile).

·O leziune de CBP produsa dupa conversia operatiei laparoscopice, motivata de existentei unei fistule biliobiliare (spitalizare 20 zile).

Si in acest lot au existat doua cazuri de litiaza coledociana restanta dupa operatia clasica, ambele situatii fiind rezolvate prin abord endoscopic.

In ceea ce priveste decesele, s-au inregistrat cite un caz in lotul A respectiv lotul B.  Aceste diferente inregistrate in fatalitatea celor trei loturi nu au semnificatie statistica.

Aruncind o privire de ansamblu asupra datelor analizate mai sus constatam ca intre primele doua algoritme diferentele constatate privind rezultatele urmarite nu au semnificatie statistica si ca ele sunt explicate de caracteristicile loturilor studiate (mai multe cazuri dificile pentru endoscopist in lotul A si mai multe cazuri dificile pentru chirurg in lotul B).

Aparent o proportie mai mare de bolnavi sunt rezolvati miniinvaziv in cazul primului algoritm, cu o morbiditate mai mica si o durata de spitalizare mai scurta.

Optiunea pentru unul din cele doua algoritme va depinde in ultima instanta de facilitatea accesului la un serviciu de endoscopie si de urgenta patologiei chirurgicale.

Al treilea algoritm este superior fata de algoritmele precedente prin proportia mare a cazurilor rezolvate miniinvaziv si prin media scazuta a duratelor de spitalizare.

Desi diferentele in favoarea acestui algoritm, in ceea ce priveste morbiditatea, sunt justificate de reducerea manevrelor asupra papilei Vater, ele nu au avut semnificatie statistica.

Desigur un punct slab al studiului prezentat este numarul mic de pacienti din lotul C.  Este evidenta   necesitatea continuarii studiului pina la acumularea unui numar mai mare de pacienti tratati prin abord laparoendoscopic simultan, conform tehnicii „rendez-vous”.

Rezultatele noastre se incadreaza insa intre cele publicate in literatura de specialitate (tabelul III), care confirma morbiditatea si mortalitatea redusa a acestui algoritm terapeutic.  De aceea este de dorit ca toti pacientii cu suspiciune preoperatorie de litiaza de cale biliara principala sa fie programati pentru un astfel de abord combinat.

Tabelul III – Abordul laparoendoscopic prin tehnica „rendez-vous”

Autor

Nr. Cazuri*

Reusite

Conversii

Morbiditate

Decese

Filauro [3]

21

90%

10%

0%

0%

Cavina [4]

16

100%

0%

6%

6%

Basso [5]

54

87%

0%

6%

2%

Morino[6]

32

86%

9%

6%

0%

Gagner [7]

90

87%

0%

3%

0%

Tatulli [8]

45

95%

5%

0%

0%

Iodice [9]

52

94%

2%

0%

0%

Studiul prezent

9

88%

11%

0%

0%

* numar cazuri cu litiaza de CBP

In experienta noastra nu am constatat prelungirea excesiva a timpului operator (intre 40 si 60 minute), datorata in principal aspectelor organizatorice [3]. Existenta duodenoscopului si a accesoriilor de endoscopie in dotarea blocului operator a facilitat aceasta maniera terapeutica.  Timpul endoscopic a durat in medie 20 de minute.

Pacientii cu litiaza asimptomatica de CBP (in general de mici dimensiuni), diagnosticata la colangiografia intraoperatorie, in lipsa coordonarii cu echipa endoscopica, vor beneficia de abordul endoscopic postoperator.

CONCLUZII

1.       Algoritmul optim de tratare a pacientilor cu suspiciune preoperatorie de litiaza colecistocoledociana este abordul laparoendoscopic simultan conform tehnicii „rendez-vous”.

Acest lucru este evidentiat de proportia semnificativ mai mare a cazurilor rezolvate miniinvaziv si de durata de spitalizare mult scurtata.

2.       Pentru a constata daca intradevar morbiditatea si mortalitatea sunt mai reduse in cazul acestui algoritm, trebuie continuat studiul pina la acumularea unui numar mai mare de pacienti tratati prin tehnica „rendez-vous”.

3.       Este necesara incadrarea preoperatorie  a pacientilor in grupa de risc pentru litiaza coledociana, apelind la anamneza, explorari biochimice si imagistice.

4.       Diagnosticul de litiaza coledociana se va stabili pe baza colangiografiei intraoperatorii, efectuata sistematic la acesti pacienti.

5.   Prezenta echipamentului de endoscopie la blocul operator si anuntarea in prealabil a endoscopistului, faciliteaza rezolvarea litiazei colecistocoledociene prin tehnica „rendez-vous”.

6.       Litiaza asimptomatica de CBP, diagnosticata „intimplator” la colangiografia intraoperatorie, va beneficia de abord endoscopic postoperator.

BIBLIOGRAFIE

1.REDDICK E.J., OLSEN D.O., SPAW A., et al. Safe performance of difficult laparoscopic cholecystectomies. Am J Surg 161:377-381; 1991

2.COTTON P.B., LEHMAN G., VENNES J.A. et al.  Endoscopic sphincterotomy complications and their management; an attempt at consensus. Gastrointest Endosc 37: 383-393; 1991

3.FILAURO M., COMES P., De CONCA V., et al. Combined laparoendoscopic approach for biliary lithiasis treatment. Hepato-Gastroenterology 47:922-926; 2000

4.CAVINIA E., FRANCESCHI M., SIDOTI F., et al. Laparo-endoscopic “Rendezvous”: a new technique in the choledocholithiasis treatment.  Hepato-Gastroenterology 45:1430-1435; 1998

5.BASSO N., PIZZUTO G., SURGO D., et al. Laparoscopic cholecystectomy and intraoperative endoscopic sphincterotomy in the treatment of cholecysto-choledocholithiasis. Gastrointest Endosc 50:532-535; 1999

6.BARACCHI F., ROSSO E., MORINO M., et al. Combined endoscopic-laparoscopic technique in patients with gallbladder and bile duct stones.  In Postgraduate Course II – Complicated gallbladder and common bile duct disease.  9th International Congress of EAES; 2001

7.GAGNER M., POMP A., DESLANDRES E., et al.  Intraoperative ERCP with retrograde guided sphincterotomy by transcystic catheter during laparoscopic cholecystectomy: a 5-year clinical study [abstract].  Surg Endosc 10: 190; 1996

8.TATULLI F., CUTTITTA A.  Laparoendoscopic approach to treatment of common bile duct stones. J Laparoendosc Adv Surg Tech A 10:315-317; 2000

9.IODICE G., GIARDIELLO C., FRANCICA G., et al.  Single-step treatment of gallbladder and bile duct stones: a combined endoscopic-laparoscopic technique. Gastrointest Endosc 53: 336-338; 2001

...

Tratamentul miniinvaziv al herniilor

A.Zarei, F.Turcu  (Email: florin.turcu@net4u.ro)

publicatia: Medicina Moderna vol.5, nr.9, pag:440-442; 1998

Chirurgia laparoscopica a abordat si patologia peretelui abdominal pe plan mondial inregistrindu-se o experienta de 8 ani, tehnica patrunzind si la noi in tara in urma cu 4 ani in mai multe centre universitare.

Fiind o tehnicã a cãrei rezultate necesitã o evaluare pe o duratã lungã  în timp ( peste 10 ani) pe de o parte, iar pe da alta parte find un procedeu mai laborios decit cel clasic, tratametul laparoscopic al herniilor inghinale nu s-a impus încã, aºa cum s-a întâmplat cu colecistectomia sau fundoplicaturile laparoscopice.

Lucrarea prezentata analizeaza experienta initiala a clinicii chirurgicale a spitalului Sf.Ioan cu acest procedeu.S/N:

Material si metoda

Studiul se deruleaza pe primii trei ani (octombrie 1994 – septembrie 1997) de experienta in abordarea herniilor pe cale laparoscopica.  Cei 110 pacienti operati au fost chemaþi la control la o lunã, la 3 luni ºi apoi anual, timpul de urmãrire variind între 48 ºi 12 luni cu o medie de 31 ± 10 luni. Au fost cosemnate tipurile de hernie operate utilizind clasificarea Nyhus pentru a evalua marimea defectului parietal, au fost urmarite incidentele si complicatiile survenite intraoperator sau postoperator si bineinteles recidivele.

Rezultate

Au fost efectuate 113 interventii laparoscopice pentru hernie, reprezentând 13% din totalul herniilor operate în secþie in acelasi interval de timp.  În total au fost operate 128 hernii (13 pacienti prezentau hernii bilaterale,  2 aveau hernii femurale asociate, iar 3 au revenit pentru apariþia unei hernii pe partea controlateralã).

Lotul laparoscopic  (98 bãrbaþi, 12 femei, vârsta medie 52±14 ,extreme 19 ºi 77 ani) reflectã în mare cazuistica secþiei.

Varietatea herniilor operate este redatã în tabelul I, din cele 128 hernii 9% (12) fiind recidivate. Dorim sã subliniem cã 45% din hernii s-au constituit prin defecte mari  parietale sau/ºi erau recidive (tipurile III ºi IV Nyhus).

Tabelul I- Varietatea herniilor operate

Tipul herniilor

Numãr

Hernii inginale

124

– oblice externe în canal

74

– inghinoscrotale / labiale

13

– directe

22

-“în pantalon”

15

Hernii Spigel

2

Hernii femurale

2

TOTAL

128

De principiu s-a preferat abordul extraperitoneal (93% din 113 operaþii). Opt operaþii au fost efectuate transperitoneal:

– cei trei pacienþi cu recidivã pe partea controlateralã

– un pacient cu recidivã dupã un procedeu Stoppa;

– în 2 cazuri a fost opþiunea chirurgului pentru acest procedeu;

– cele 2 hernii Spiegel.

Au fost puse 121 de proteze pe cale laparoscopicã (28 din polipropilenã, 21 din poliester, 72 din poliester colagenat). Herniile Spiegel au fost rezolvate prin sutura defectului parietal, iar  herniile inghinale asociate cu hernii femurale au fost acoperite cu o singurã protezã.

În primele 20 de operaþii laparoscopice s-au înregistrat trei conversii la operaþia clasicã (2,5% din 113).  În 2 cazuri cu hernii inghinoscrotale pe partea dreaptã ºi apendicectomie în antecedente, efracþia peritoneului produsã la nivelul cicatricii de laparotomie a dus la pensarea camerei de lucru ºi la imposibilitatea disecþiei sacului herniar.  Herniile au fost rezolvate prin pocedeul Lichtenstein.  În alt caz adipozitatea excesivã a pacientului ºi dimensiunile mari ale herniei inghinoscrotale au impus iniþial conversia la tehnica transperitonealã, iar în cele din urmã efectuarea procedeului Wantz pe cale deschisã.

Alte dificultãþi tehnice întâlnite:

·pneumoperitoneu care a necesitat introducerea unui ac Veress: de 8 ori;

·efracþia peritoneului la abordarea spaþiului preperitoneal: de 2 ori;

·teaca posterioarã a muºchiului drept abdominal coborând pânã în zona herniarã: de 2 ori;

·chiste de cordon: de 2 ori;

·luxare testiculului preperitoneal: o datã;

·nu sau  consemnat incidente hemoragice importante.

Alte soluþii tehnice utilizate:

·Ancorarea protezei la perete cu ajutorul acului Reverdin: de 21 ori pentru protezele din poliester necolagenate;

·Secþionarea sacului de hernie inghinoscrotalã ºi abandonarea lui în canal: de 6 ori;

·Utilizarea unui trocar suplimentar (al III lea): de 10 ori;

·Conversia la sfârºitul operaþiei la abordul transperitoneal: de 3 ori pentru a sutura o breºã peritonealã ºi o datã pentru o chistectomie ovarianã.

La cura herniei au fost asociate: o curã a unei hernii a liniei albe,  o orhectomie laparoscopicã pentru testicul ectopic, o chistectomie laparoscopicã pentru un chist ovarian.

S-au înregistrat 4 hematoame colectate în scrot, toate dupã disecþia laborioasã a unor hernii inghinoscrotale.  Douã dintre ele (unul complicând conversia la procedeul Wantz) au necesitat incizie pentru drenaj. Celelalte au fost puncþionate.

A fost consemnatã o nevralgie tranzitorie pe traiectul nervului ilioinghinal, la un pacient la care peritoneul a fost închis prin agrafare la sfârºitul procedeului transperitoneal.

O pacientã cu fibrom uterin submucos a prezentat o metroragie importantã la 3 zile postoperator ºi a necesitat histerectomie totalã.  S-a constituit o supuraþie postoperatorie ce a drenat ºi prin vagin ºi prin plaga de laparotomie, dar proteza din polipropilen monofilament a fost incorporatã în cele din urmã.

S-au înregistrat 2 recidive imediate (48 ore).  În primul caz s-a reintervenit laparoscopic ºi s-a constatat cã sacul de hernie inginoscrotalã nu fusese redus complet.  Atunci când pacientul s-a mobilizat testiculul a coborât în scrot, iar funiculul spermatic a antrenat în canal, pe sub poartã, sacul de hernie.  A  fost foarte greu de dezlipit proteza de pe peretele muscular datoritã adezivitãþii date de colagen.  S- a completat disecþia sacului ºi s-a poziþionat o nouã protezã.

În cel de al doilea caz (o hernie directã de mici dimensiuni care nu a ridicat nici un fel de probleme tehnice) s-a reintervenit clasic ºi s-a constatat absenþa protezei din zona herniarã.  Rememorând filmul evenimentelor am constatat cã la sfârºitul operaþiei laparoscopice nu s-a urmãrit expansionarea peritoneului, iar o necoordonare cu echipa anestezicã a fãcut ca pacientul sã rãmânã curarizat ºi în Trendelenburg mai multe minute.  Probabil în acest rãstimp partea medialã a protezei “a cãzut” dezvelind traiectul herniar.

S-au înregistrat ºi 2 recidive la 3 luni ºi la 6 luni.  În ambele cazuri plasa a fost antrenatã în traiectul unei hernii directe de mari dimensiuni la care fascia transversalis nu a fost suturatã.  Primul pacient s-a adresat  unui alt serviciu chirurgical.  Cel de al doilea a refuzat reintervenþia dar a rãmas în evidenþa chirurgului care l-a operat.  Acest pacient prezenta o hernie inginala directã bilateralã ºi testicul ectopic stâng.  Pe partea pe care s-a fãcut orhectomia s-a pus o protezã de polipropilen, iar în partea cealaltã o protezã de poliester fixatã la peretele abdomial la nivelul marginii superioare.  Pe aceastã parte, pe sub marginea inferioarã a protezei, s-a produs recidiva.

Discutii

În prezent trei procedee clasice sunt practicate pe scarã largã: Bassini, Shouldice ºi Mc Vay. Între acestea procedeul Shouldice este creditat cu cele mai bune rezultate, având o ratã a recurenþelor în jur de 1% pentru herniile primare.  Pentru chirurgii care nu sunt specializaþi însã în acest procedeu rata recidivelor este de 4-8%.

Având în vedere tendinþa demograficã de îmbãtrânire a populaþiei ºi faptul cã tehnicile clasice se bazeazã pe troficitatea þesuturilor, este de aºteptat o incidenþa crescutã a recidivelor la mai mult de 10 ani de la operaþia primarã.  Statisticile naþionale aratã cã anual 10-15% din curele herniare sunt efectuate pentru hernii recidivate.

Procedeelor clasice li se reproºeazã pe lângã rata mare a recurenþelor ºi durerea importantã generatã de tensiunea din plagã, care determinã perioade de convalescenþã ce depãºesc 6 sãptãmâni.

Un progres in cura herniilor a fost introducerea conceptului de reparare a defectului parietal fara tensiune, ceea ce presupune utilizarea materialelor protetice.

Shulman analizând experienþa a 5 operatori specializaþi în procedeul Lichtenstein (grupând 3019 hernii inghinale) constatã o ratã a recurenþelor între   0 ºi 0,7%.  Grupând 22300 operaþii efectuate de 70 chirurgi care nu aveau un interes deosebit în acest domeniu, constatã aceeaºi ratã a recidivelor.

Concluzia este cã procedeul Lichtenstein este simplu, sigur, eficient ºi are rezultate reproductibile. Dacã luãm în considerare faptul cã este efectuat sub anestezie localã, cã se preteazã foarte bine la chirurgia de o singurã zi, ºi cã 90% dintre pacienþi se intorc la lucru în primele 2 sãptãmâini ar putea fi considerat un “gold standard” al chirurgiei herniare.

Pentru a se impune chirurgia laparoscopica trebuie sa ofere rate de recidiva asemanatoare dar cu o morbiditate si o convalescenta reduse fata de procedeul Lichtenstein.

În prezent trei procedee tehnice sunt practicate curent pe cale laparoscopicã: pozitionarea protezei intraperitoneal (TIP), pozitionarea protezei preperitoneala pe cale transperitoneala (TTP) si pozitionarea protezei preperitoneal pe cale extraperitoneala.(TEP). Phillips realizeaza un studiu multicentric totalizind  hernii operate si analizeaza morbiditatea si rata recidivelor (vezi tabelul II).

Tabelul II – morbiditatea si rata recidivelor dupa cura laparoscopica a herniilor

TIP

TTP

TEP

Total

Nr.

345

1994

578

2917

Recidive

5%

1%

0%

1%

Morbiditate

14%

7%

10%

8%

Morbiditatea in experienta noastra a fost de 5%, mai mica decit in literatura de specilitate explicabil prin faptul ca anumite complicatii minore precum infectiile urinare sau enfizemul subcutan nu au fost consemnate in foaia de observatie.

Rata recidivelor de 2,4% (3 din 124 hernii finalizate laparoscopic) este relativ mare faþã de datele din literaturã. Trebuie avut însã în vedere cã raportorii aveau o bogatã experienþã în abordul transperitoneal în momentul când au optat pentru tehnica extraperitonealã. În statistica noastrã toate recidivele sunt defecte de tehnicã înregistrate în perioada de asimilare a tehnicii laparoscopice.

De altfel tehnicii extraperitoneale i se imputa faptul ca are o curbã de învãþare mai lungã, apreciata la 30 de operatii, ceea ce face ca necesitatea de a converti la abordul transperitoneal sau la cel deschis sa fie de 4-8% în perioada de asimilare. Nici unul din operatorii din clinica nu avea o experienta personala care sa depaseasca acest preg.

Din punct de vedere conceptual insa tehnica extraperitoneala este cea mai bunã (respectã principiile procedeului Stoppa) ºi este îmbrãþiºatã de tot mai mulþi chirurgi. Ea prezintã urmãtoarele avantaje:

·     peritoneul nu este deschis,

·     proteza nu are contact cu viscerele intraabdominale,

·     protezle au dimensiuni mari (>10×12 cm) ºi nu necesitã fixare,

·     poate fi efectuatã sub rahianestezie ºi în tehnica “gasless”.

Concluzii

Rezultatele obtinute in clinica in perioada de asimilare a metodei pot fi considreate bune si incurajatoare si pentru alte colective ce au intentia de a aborda laparoscopic aceasta patologie.

Întrucât în hernioplastiile laparoscopice recidivele se datoreazã unor greºeli de tehnicã, ca ºi în chirurgia clasicã, este mai importantã experienþa chirurgului decât procedeul tehnic.

BIBLIOGRAFIE

1.  ANGELESCU N., BURCOS T., JITEA N et al. Rezultate preliminare dupa cura laparoscopica pe cale transperitoneala a primelor 50 hernii inghinale.  Chirurgia 1995; 3:1-6.

2.  LIEM M.S.L., van STEENSEL C.J., BOELHOUWER R.U. et al. The learning curve for totally extraperitoneal laparoscopic inguinal hernia repair. Am J Surg 1996; 171: 281.

3.  NYHUS L.  A classifcation of groin hernia in “Inguinal hernia, advances or controversies?” edited by M. ARREGUI and R. NAGAN  Radcliffe Medical Press, New York 1994, p.99

4.  PHILLIPS E.H., ARREGUI M., CARROLL B.J. et al. Incidence of complications following laparoscopic hernioplasty Surg Endosc 1995; 9: 16-21

5.  PHILLIPS E.H., ROSENTHAL R., FALLAS M. et al. Reasons for early recurrence following laparoscopic hernioplasty Surg Endosc 1995; 9: 140-145

6.  POPP L.W: Endoscopic patch repair of inguinal hernia in a female patient. Surg Endosc 1990; 4: 10-12.

7.  PUIA C. Cura laparoscopica a herniilor inghinale in “Chirurgia laparoscopica” sub redactia lui Duca S. Ed. Dacia Cluj-Napoca, 1997 p. 253 – 262

8.  SCHULMAN AG, AMID PK, LICHTENSTEIN IL : The safety of mesh repair for primary inguinal hernias : Results of 3019  operations from five diverse surgical sources.   Am Surg 1992; 58: 255-257

9.  SCHULTZ L., GRABER J., PIETRAFITTA J. :Laser laparoscopic herniorhaphy a clinical trial.  Preliminary result J Laparoendosc Surg 1990; 1: 41-45

...

VIDEO ASSISTED THYROIDECTOMY

Dr. C. Bradea – First Surgical Clinic, „St. Spiridon” Hospital Iaşi, „Gr.T. Popa” University of Medicine and Pharmacy Iaşi

Jurnalul de Chirurgie, Iaşi, 2009, Vol. 5, Nr. 1 [ISSN 1584 – 9341]

rezumatul video al interventiei

VIDEO ASSISTED THYROIDECTOMY (Abstract): Video assisted techniques were documented by M. Gagner (1996 – video assisted parathyroidectomy), Henry (1999), Shimizu (1999), Ohgami (2000), Miccoli (2000 – video assisted parathyroidectomy and thyroidectomy). The advantage of this kind of surgery: aesthetics i.e. trying to make only small scars on the neck. Our first case of video assisted thyroidectomy was a female 50 years of age, with multinodular goiter, nodules of 2-3 cm in each lobe, admitted in our clinic in December 2008. History of the disease: 9 years; treatment: hormones pills. The refractive thyroid goiter became surgical in the last four years. The intervention was delayed because of pulmonary tuberculosis the patient suffered from. The video assited technique is inspired from Websurg site (Miccoli technique, 2007), modified by the author. We started with general anesthesia, patient lying, without hiper extension of the neck. The skin incision was on midline of the neck, 15 mm long, horizontal, at 2 cm above the inferior limit of the neck, with electric scalpel. By this skin incision we entered the thyroid space gland with classical instruments; then we introduce a 10 mm, 0 degree telescope, together with a 5 mm Ligasure grasp. After coagulation and section with Ligasure, the superior thyroid pedicle, the right thyroid lobe was dissected all around. Finally, we extracted the right thyroid lobe and then we severed with Ligasure the inferior right thyroid pedicle. The same procedure was used on the left side; it needn’t any drainage; the closure was anatomically tipical. The evolution was uneventful. The histopathological exam result was chronical Hashimoto thyroiditis. Conclusions: Video assisted thyroidectomy can be considered feasible and safe and allows for an excellent cosmetic result and has possible new promising indications such as prophylactic thyroidectomy. Not all patients are eligible for this procedure, but in selected cases it can be a valid option for the surgical treatment of thyroid diseases.

KEY WORDS: VIDEO ASSISTED SURGERY, VIDEOSCOPIC SURGERY SKILL, SELECTED PATIENTS.

Correspondence to: Costel Bradea, MD, PhD; Assoc. Professor of Surgery, First Surgical Clinic, „St. Spiridon” Hospital Iaşi, Independenţei Street No. 1, 700111, Iaşi, Romania; e-mail:costelbradea@yahoo.com

BACKGROUND

From Kocher neck incision, along years, the surgeons tried to make smaller and smaller incisions because, in general, the patients are females. The aesthetic result of the operation has always been an important aspect for them. The first video assisted surgical techniques started with M. Gagner who made the first a parathyroidectomy, in 1996. Then, other authors, Henry, Miccoli, Oghami, Shimizu, stated that videoresection of nodular goiters is feasible with good results on selected patients (without gigantic goiters).

CASE REPORT

A 50 year old female with multinodular goiter, with nodules of 2-3 cm at echography, in both thyroid lobes was admitted in our clinic. The hystory of the disease was of 9 years with medical treatment;in the last 4 years the goiter was refractive to the hormonal pills. The surgical intervention was delayed because of a pulmonary tuberculossis, treated in a clinic of pulmonary diseases. The general cardio-pulmonary and endocrine status was normal before the surgical intervention. Our source of inspiration was Miccoli’s technique, 2007, modified by the author, for video-assisted thyroidectomy. We started with the patient lying, without neck hyperextension; general anesthesia is used. The incision at the skin was made by electric scalpel, 15 mm long, horizontal, at midline of the neck, at 2 cm above the inferior line of the neck. We entered by this incision with classical instruments the thyroid region; then we introduced a 10 mm 0 degree rigid telescop together with a 5 mm Ligasure device by the same incision. We dissected and transected with Ligasure device the superior right thyroid pedicle. Then we dissected all around the right lobe The right thyroid lobe was extracted; by the same incision the inferior pedicle also with Ligasure is resected. On the left side, the same procedure was applied; no drainage was used; the incision was inclosed in layers. The evolution was uneventful. The histopathological exam result was chronical Hashimoto thyroiditis.

DISSCUSION

The thyroid gland begins to form on 17-th day of embryologic development between the first and second pharyngeal pouch, like an epithelial cord which penetrates the floor of the oral cavity and reaches the anterior side of trachea. The thyroid gland consists of two lobes joined by an isthmus; it normally weights 20 grams; each lobe is of 2/3/5 cm. It is covered by strap muscles (sternothyroid and sterno-hioid). The recurrent nerves lie in the trachea-esphageal grooves. The arterial supply is from inferior and superior thyroid arteries, branches of external carotid and thyrocervical trunk.There are three thyroid veins: superior, middle and inferior whom drains in the internal jugular vein. The lymphatic drainage of the thyroid gland is extensive. It consists of the central compartment (periglandular space) and a lateral one which are separated by the carotid sheet.

A number of details must be clarified before to start a video-operate: the size of thyroid gland, the adherences after a previous operation or in our case of thyroiditis. During the operation we mustn’t disrupt the capsule (the nodules are often suspected for a carcinoma). Small papillary carcinomas have been resected by this technique for two years (low risk carcinomas) with encouraging oncologic results [1]. The patient must have a normal thyroid gland function at the time of the operation. The position of pacient is supine with or without neck hyperextension. The incision must be made in an avascular zone,in a bloodless plane, with a electrocautery protected blade. Any bleeding is embaressing and can block the operation. The retractions are very gentle on strap muscles and thyroid tissues. A 5 mm, 30 degrees telescope is ideal. Dissections are made with 2 mm atraumatic instruments. An aspirator-spatula is very important for direct washing and aspiration the smoke. The first vessel to be ligated is middle thyroid vein with 3 mm vascular clips, ultrasonic scalpel or Ligasure device. The tip of the electric scalpel must be carefully checked because a high temperature can damage the larynx and the recurrent laryngeal nerves. The inferior part of the thyroid gland is severed after it has been pulled out. No drainage is necessary. The wound is closed with absorbable sutures.

Complication rates are not high in video-thyroidectomy; is a safe operation with an acceptable time, following a short learning curve [1]. Video assisted total thyroidectomy is feasible with good oncologic and cosmetic results [2]. Large multinodular goiters are not eligible for minimal invasive surgery. The presence of lymph nodes and high risk carcinomas are a contra-indication for video resection [1]. It is possible to make prophylactic thyroidectomy to persons with Multiple Endocrine Neoplasia [3]. Total thyroidectomy for Multifocal Micropapillary Cancer is, also, feasible by video surgery [4]. The utilization of new devices for dissection, coagulation and division (harmonic, Ligasure) instead of the conventional technique as it ensures a dry field and a shorter operation time [5].

CONCLUSION

Video assisted thyroidectomy can be considered feasible and safe and allows for an excellent cosmetic result and has possible new promising indications such as prophylactic thyroidectomy. Not all patients are eligible for this procedure, but in selected cases it can be a valid option for the surgical treatment of thyroid diseases.

REFERENCES

1. Miccoli P. Minimally invasive video-asisted thyroidectomy. WeBSurg’s World University, 2004-2007.

2. Ghorayeb BY. Minimally invasive video assisted thyroidectomy. Otolaringology Houston on line magazine.

3. Skinner MA, Moley JA, Dilley WG, Owzar K, Debenedetti MK, Wells SA Jr. Prophylactic thyroidectomy in multiple endocrine neoplasia type 2A. The New England Journal of Medicine. 2005; 353(11): 1105-1113.

4. American Thyroid Association. Total or near total thyroidectomy in patients with multifocal micropapillary cancer. Cancer/Oncology. 04oct2008.

5. United States National Institute of Health. Govern trials. Harmonic FOCUS versus Conventional Technique in Total Thyroidectomy for Benign Thyroid Dissease.

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