CC BY
13
Научни трудове на Съюза на учените в България-Пловдив, серия Г.Медицина, фармация и дентална медицина т. XVIII. ISSN 1311-9427. Научна сесия „Медицина и дентална медицина", 5 - 6 ноември 2015. Scientific works of the Union of Scientists in Bulgaria-Plovdiv, series G. Medicine, Pharmacy and Dental medicine, Vol. XVIII, ISSN 1311-9427 Medicine and Dental medicine Session, 5-6 November 2015.
GUIDELINES AND RECOMMENDATIONS FOR LAPAROSCOPIC TREATMENT OF ACUTE ABDOMEN IN THE FIRST DECADE OF
21ST CENTURY.
B. Sakakushev, B. Atanasov University of Medicine/University Hospital"Saint George", Plovdiv
First Clinic of Surgery
НАСОКИ И ПРЕПОРЪКИ ЗА ЛАПАРОСКОПСКО ЛЕЧЕНИЕ НА ОСТРИЯ ХИРУРГИЧЕН КОРЕМ ПРЕЗ ПЪРВАТА ДЕКАДА НА 21 ВЕК.
Б. Сакакушев, Б. Атанасов..
Медицински Университет/УМБАЛ „Свети Георги" Пловдив Първа Клиника по Хирургия
The development of new instruments and the refinement of established techniques will lead to the expansion of minimally invasive surgery to new areas of interest for general surgeons. However, one must realize - and accept, that minimally invasive surgery only represents a different technique that offers an alternative to open surgery. The indication for surgery are similar for both minimally invasive surgery and open surgery.. .It is important for all general surgeons to keep up with this trend and become an integral part of the revolution in medicine that the advent of minimally surgery has wrought/1/.
Acute appendicitis
The diagnosis of acute appendicitis includes clinical exam, US to , CT in equivocal cases, to reduce negative appendectomy rate (NAR) and missed perforations . Alvarado score (with a cutoff of 4) for diagnosis and for stratification of candidates to CT scan /2/.
Laparoscopic appendectomy/LA/ is gold standard in pre-menopausal women; age > 65 years improved clinical outcomes (in terms of length of stay (LOS), mortality and overall morbidity) compared with OA ; obese (BMI >30) and feasible in men, even if advantages over OA in the latter group are not demonstrated /3,4,5,6/. Complicated appendicitis can be approached laparoscopically by experienced surgeons with significant advantages, comprehending lower overall complications, readmission rate, SBO rate, infections of the surgical and faster recovery/7,8,9/. Higher rates of conversion affect patients with >5 days of symptoms, >20000 WBC count, > 45 years males, ruptured appendicitis on CT scan (10).
Colonic malignant obstruction
Emergency laparoscopic right colectomy for malignant obstruction is rarely reported and not supported by literature/11/.Colonic stenting for obstructing neoplasm offers advantages over emergency surgery in terms of increase in successful primary anastomosis, reduction of stoma creation, infections and overall morbidities. If emergency surgery is proposed through laparotomy, colon stenting is followed by laparoscopy in a minority of cases reported/12,13/.
Iatrogenic perforations
Early recognition of perforation during diagnostic or therapeutic endoscopy allows immediate repair of the defect endoscopically if feasible. For those non recognised immediately
or failed to repair, emergency surgery is mandatory and may be approached laparoscopically. The options include a laparoscopic lavage and drainage, eventual defunctioning stoma, or a segmental resection with or without primary anastomosis/14/.
Inflammatory bowel disease
In the emergency setting, compared to open surgery, laparoscopy offers limited advantages in terms of overall morbidity, in the treatment of both ulcerative colitis and Crohn's disease of the colon.Based on the evidence of case-matched studies with few cases in each series, a limited advantage in terms of overall morbidity may be observed/15/..
Acute diverticulitis
Hinchey I and II, when septic despite medical therapy, are indicated for percutaneous drainage when feasible (16). When successfully performed laparoscopic lavage and drainage does not always necessitate a future elective colonic resection (17,18). Advantages advocated by the supporters of this technique are avoidance of a large laparotomy and derivative procedures, thus, reducing their consequent complications, reduction of postoperative pain and the subsequent use of analgesic, lowering of surgical site infections, potential reduction of the rate of incisional hernias, amelioration in postoperative disability. In all other cases colonic resection is indicated, which may be performed laparoscopically, depending on the general conditions of the patient and on the skill of the operator where primary anastomosis protected by a loop ileostomy seems more effective than Hartmann's procedure in terms of stoma reversal rate (19,20). With no difference in mortality or morbidity, laparoscopic approach resulted a predictor of routine discharge and decreased length of stay, although cost analysis revealed substantial equivalence between groups/21/.
Acute pancreatitis
In moderate biliary pancreatitis, LA must be performed after stabilizing the patient in the same hospitalization/22,23,24 /. In severe pancreatitis При тежкия билиарен панкреатит, LA must be postponed until regress of inflammatory syndrome and clinical recovery /25/.
Besides cases with emergency ERCP, in choleocholithiasis, stones are derived either by preoperative ERCP or during the cholecystectomy /26,27/. Necrectomy in necrotizing pancreatitis with poly-organ insufficiency, without medical treatment response are indicative for step approach by needle aspiration or if needed mini-invasive retroperitoneal debridement. Open surgery follows mini-invasive failure. /28,29/. Abdominal compartment syndrome requires laparostomy.
Perforated Peptic Ulcer
Up to today, there is no unanimous agreement about which group of patients might benefit from a laparoscopic approach of PPU. Several studies suggest that Boey's shock score on admission, ASA III-V (severe comorbidities), and duration of symptomatology, are the most reliable parameters for selecting patientsq while other principles of selection are: MPI, age >70 years, APACHE II and surgeon's skill in miniinvasive surgery/30/. There is is growing evidence that high risk surgical patients can benefit from a period of resuscitation ("damage control") before surgical intervention to minimize the insult on physiology and get early control on sepsis/31/. NOM management should be carefully considered in selected patients, knowing that evidence is weak for its efficacy and risk may be high if disease symptoms does not resolve/32/.The choice of perforation closure technique depends on lesion characteristics: if margins are edematous, friable,and/or difficult to mobilize, repair can be limited to an omental patch, eventually associated with one or more sealant devices; when the margins can be easily brought together, without tension, direct suturing can be sufficient with or without omentoplasty/33,34/. A recent Danish study demostred that laparoscopy was associated with lower risk of reoperation than laparotomy or a converted procedure. However, the quality is limited because there was a risk of bias, including confounding by indication/35/. Recent reports confirm a decrease in the incidence of complications (abdominal wall complications, prolonged postoperative ileus, pulmonary infection, and mortality rate) with laparoscopic surgery compared to open surgery. The operative times are longer for laparoscopy however, progressive and constant reduction of operative times 108
over the past 10 years has been seen, probably due to an improvement in the surgeon's skill, better technology, and better organization of the surgical teams. The hospital stay has been shown to be more favorable for the laparoscopic approach compared to traditional surgery in Siu et al. but not in Lau and Bertleff et al. The meta-analysis of Sanabria (updated in 2012) and Stravos (2013) conclude that laparoscopic surgery could be the first therapeutic after considering other variables such as surgeon's experience, costs and availability/36/.Variables that measure the experience of surgeons with laparoscopic repair must be introduced and assessed. One of the advantages of laparoscopic surgery is less postoperative pain (LE 1a), but earlier data about pain (within 24 h postoperatively) did not show any difference, probably because of peritoneal inflammation.On the other hand, a greater incidence of intra-abdominal fluid collection (due mostly to leakage at the suture site) has been reported. However, none of these differences are statistically significant.
Adhesive small bowel obstruction
Laparoscopic treatment of adhesive small bowel obstruction can be successfully and safely accomplished. Selection of patients and preoperative planning is the key for a safe and successful laparoscopic surgery for ASBO. When feasible, laparoscopic adhesiolisis is associated with a quicker functional recovery and a reduced LOS, with at least similar morbidity and mortality than open surgery/37/. The use of laparoscopy in the setting of ASBO as a diagnostic tool only is not advised. No differences between Oxford GL 2009 and 2011No subtantial new data from recent literature
Gynecological disorders
The 2010 recommendations state that when gynecologic disorders like adnnexial torsion, ecotopic pregnancy, endometriosis ,PID follicular bleeding are the suspected cause of abdominal pain, diagnostic laparoscopy (DL) should follow conventional diagnostic investigations, especially US and if needed, a laparoscopic treatment of the disease should be performed . Close cooperation with the gynecologist is strongly recommended. Both recommendations are confirmed.
Nonspecific acute abdominal pain
NSAP is defined as acute abdominal pain that lasts less than 7 days and for which the diagnosis remains uncertain after baseline examination and diagnostic tests and not requiring urgent procedure. Laparoscopy is feasable also in high risk patients(morbidity 0-8% mortality 0% ), because it improves % diagnosis, reduces hospital stay and reduces % laparotomies and rate of postoperative adhesions/38/.
AMI / ACUTE MESENTERIC ISCHEMIA /
The gold standard for the diagnosis according with the consensus statement of SICE and latest literature articles is multidetector CT Angiography (CTA) with sensibility of 93.3% and specificity of 95.9%/39/.Laparotomy could be useful to confirm cases of AMI without signs of SMA (superior mesenteric artery) occlusion at CTA /40/.In AMI when there aren't conditions for rapid CTA performing or when a previous CTA had been not conclusive laparoscopy can reduce the number of unnecessary laparotomies overall in elderly critically ill patients. Literature underlines that the first treatment of AMI is bowel revascularization (The second step is the reassessment of bowel viability. If possible the time of 20 or 30 minutes after revascularization should be spent before decision making about bowel /41/.If no vascular surgeon is available, resection of obvious necrotic bowel should be performed and after the abdomen closure the patient should be transported to a vascular surgical center .
PENETRATING ABDOMINAL TRAUMA
In stable penetrating abdominal trauma laparoscopy may be useful in patients with documented or equivocal penetration of the anterior fascia. Stable blunt trauma patients with suspected Intraabdominal injury and equivocal findings on imaging studies or even in patients with negative studies, but with high clinical likehood for intraabdominal injury*unclear abdomen* to exclude relevant injury. The use of laparoscopy in selected trauma patients, especially after penetrating abdominal trauma, is associated with decreased negative laparotomy rate, decreased
109
morbidity, shortened hospital stay and increased cost-effectiveness. The use of laparoscopy for trauma should be attempted only after a proper laparoscopic learning curve skills, by surgeons with appropriate both open and laparoscopic surgical skills. Laparoscopy has an highly effective diagnostic value and potential therapeutic value for diaphragmatic injuries repair, in patients sustaining left upper quadrant thoraco-abdominal injuries. After penetrating abdominal trauma laparoscopy may have diagnostic and eventually therapeutic purpose in hemodynamically stable patients with documented or suspected peritoneal penetration. Laparoscopy should be considered in hemodynamically stable blunt trauma patients with suspected intra-abdominal hollow viscus injuries on imaging and peritoneal findings or in patients with negative imaging but with high clinical suspicion of intra-abdominal hollow viscus injury (''unclear abdomen'').
These guidelines have been developed to help surgeons with their decisions in the very difficult situation of emergency surgery... a need to discuss and share experience, using the same language.
Reference
1. H.S. Himal: Minimally invasive (laparoscopic) surgery. The future of general surgery. Surg Endosc 2002; 16: 1647-52)
2. Shogilev DJ, Duus N, Odom SR, Shapiro NI. Diagnosing appendicitis: evidence-based review of the diagnostic approach in 2014. West J Emerg Med. 2014 Nov;15(7):859-71.
3. Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev. 2010 Oct 6;(10):CD001546.
4. Ward NT, Ramamoorthy SL, Chang DC, Parsons JK. Laparoscopic appendectomy is safer than open appendectomy in an elderly population. JSLS. 2014 Jul;18(3).
5. Ciarrocchi A(1), Amicucci G(1).Laparoscopic versus open appendectomy in obese patients: A meta-analysis of prospective and retrospective studies. J Minim Access Surg. 2014 Jan;10(1):4-9.
6. Tzovaras G, Baloyiannis I, Kouritas V, Symeonidis D, Spyridakis M, Poultsidi A, Tepetes K, Zacharoulis D. Laparoscopic versus open appendectomy in men: a prospective randomized trial. Surg Endosc. 2010;24(12):2987-92
7. Wang CC, Tu CC, Wang PC, Lin HC, Wei PL. Outcome comparison between laparoscopic and open appendectomy: evidence from a nationwide population-based study. PLoS One. 2013 Jul 12;8(7):e68662.
8. Yeh CC, Wu SC, Liao CC, Su LT, Hsieh CH, Li TC. Laparoscopic appendectomy for acute appendicitis is more favorable for patients with comorbidities, the elderly, and those with complicated appendicitis: a nationwide populationbased study. Surg Endosc 2011; 25: 2932-2942
9. Isaksson K, Montgomery A, Moberg AC, Andersson R, Tingstedt B. Long-term follow-up for adhesive small bowel obstruction after open versus laparoscopic surgery for suspected appendicitis. Ann Surg. 2014 Jun;259(6):1173-7.
10. Gupta N, Machado-Aranda D, Bennett K, Mittal VK. Identification of preoperative risk factors associated with the conversion of laparoscopic to open appendectomies. Int Surg. 2013 Oct-Dec;98(4):334-9.
11. Li JC, Hon SS, Ng SS, et al. Emergency laparoscopic-assisted right hemicolectomy: can we achieve outcomes similar to elective operation? J Laparoendosc Adv Surg Tech A. 2011 Oct;21(8):701-4. doi: 10.1089/lap.2011.0039. Epub 2011 Aug 22.
12. Huang X, Lv B, Zhang S, Meng L. Preoperative colonic stents versus emergency surgery for acute left-sided malignant colonic obstruction: a meta-analysis. J Gastrointest Surg. 2014;18:584-91
13. Sabbagh C, Browet F, Diouf M, et al. Is stenting as a "bridge to surgery" an oncologically safe strategy for the management of acute, left-sided, malignant, colonic obstruction? A comparative study with a propensity score analysis. Ann Surg. 2013 Jul;258:107-15
14. Bleier JI, Moon V, Feingold D, Whelan RL, Arnell T, Sonoda T, Milsom JW, Lee SW.
Initial repair of iatrogenic colon perforation using laparoscopic methods. Surg Endosc 2008; 22: 646-649
15. Marcello PW, Milsom JW, Wong SK, Brady K, Goormastic M, Fazio VW. Laparoscopic total colectomy for acute colitis: a case-control study. Dis Colon Rectum 2001; 44: 1441-1445
16. Toorenvliet BR, Swank H, Schoones JW, Hamming JF, Bemelman WA. Laparoscopic peritoneal lavage for perforated colonic diverticulitis: a systematic review. Colorectal Dis 2010;12(9):862-7
17. Sorrentino M, Brizzolari M, Scarpa E, et al. Laparoscopic peritoneal lavage for perforated colonic diverticulitis: a definitive treatment? Retrospective analysis of 63 cases. Tech Coloproctol. 2015 Feb;19(2):105-10.
18. Cirocchi R, Trastulli S, Vettoretto N, et al. Laparoscopic peritoneal lavage: a definitive treatment for diverticular peritonitis or a «bridge» to elective laparoscopic sigmoidectomy?: a systematic review. Medicine (Baltimore). 2015 Jan;94(1):e334. doi: 10.1097/ MD.0000000000000334
19. Binda GA, Karas JR, Serventi A, et al. Study Group on Diverticulitis. Primary anastomosis vs non-restorative resection for perforated diverticulitis with peritonitis: a prematurely terminated randomized controlled trial. Colorectal Dis. 2012 Nov;14(11):1403-10
20. Oberkofler CE, Rickenbacher A, Raptis DA, et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann's procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg. 2012 Nov;256(5):819-26; discussion 826-7
21. Rea JD, Herzig DO, Diggs BS, Cone MM, Lu KC. Use and outcomes of emergent laparoscopic resection for acute diverticulitis. Am J Surg 2012; 203: 639-643
22. Aboulian A, Chan T, Yaghoubian A et al. Early cholecystectomy safely decreases hospital stay in patients with mild gallstone pancreatitis: a randomized prospective study.Ann Surg. 2010 Apr;251(4):615-9
23. Kimura Y, Takada T, Kawarada Y et al. JPN Guidelines for the management of acute pancreatitis: treatment of gallstone-induced acute pancreatitis.J Hepatobiliary Pancreat Surg. 2006;13(1):56-60.
24. Taylor E, Wong C. The optimal timing of laparoscopic cholecystectomy in mild gallstone pancreatitis.Am Surg. 2004 Nov;70(11):971-5
25. Nebiker CA, Frey DM, Hamel CT et al. Early versus delayed cholecystectomy in patients with biliary acute pancreatitis.Surgery. 2009 Mar;145(3):260-4
26. Sinha R.Early laparoscopic cholecystectomy in acute biliary pancreatitis: the optimal choice?HPB (Oxford). 2008;10(5):332-5
27. Cameron DR, Goodman AJ. Delayed cholecystectomy for gallstone pancreatitis: readmissions and outcomes.Ann R Coll Surg Engl. 2004 Sep;86(5):358-62
28. Horvath K, Freeny P, Escallon J et al. Safety and efficacy of video-assisted retroperitoneal debridement for infected pancreatic collections: a multicenter, prospective, single-arm phase 2 study.Arch Surg. 2010 Sep;145(9):817-25
29. van Santvoort HC, Besselink MG, Bakker OJ et al. A step-up approach or open necrosectomy for necrotizing pancreatitis.N Engl J Med. 2010 Apr 22;362(16):1491-502
30. M0ller MH, Engebjerg MC, Adamsen S, Bendix J, Thomsen RWThe Peptic Ulcer Perforation (PULP) score: a predictor of mortality following peptic ulcer perforation. A cohort study. Acta Anaesthesiol Scand., 2012 May;56(5):655-62
31. Weber DG, Bendinelli C, Balogh ZJ Damage control surgery for abdominal emergencies.. Br J Surg. 2014 Jan;101(1):e109-18. doi: 10.1002/bjs.9360. Epub 2013 Nov 25.
32. Kenneth Thorsen & Jon Arne S0reide & Kjetil S0reide. What Is the Best Predictor of Mortality in Perforated Peptic Ulcer Disease? A Population-Based, Multivariable RegressionAnalysis Including Three Clinical Scoring Systems. J Gastrointest Surg (2014) 18:1261-1268
33. Lee CW, Sarosi GA Jr. Emergency ulcer surgery. Surg Clin North Am 2011; 91: 10011013.
34. Madhumita Mukhopadhyay & Chirantan Banerjee &Sabyasachi Sarkar & Debabrata Roy & Quazi M Rahman: Comparative Study Between Omentopexy and Omental Plugging in Treatment of Giant Peptic Perforation Indian J Surg (September-October 2011) 73(5):341-345
35. Wilhelmsen M, M0ller MH, Rosenstock S. Surgical complications after open and laparoscopic surgery for perforated peptic ulcer in a nationwide cohort. Br J Surg. 2015 Mar;102(4):382-7. doi: 10.1002/bjs.9753
36. Sanabria AE, Morales CH, Villegas MI. Laparoscopic repair for perforated peptic ulcer disease.The Cochrane Library 2005, Issue 4-Updated:2012
37. SallinenV., Wikstrom H., Victorzon M et alt. Laparoscopic versus open adhesiolysis for small bowell obstruction - a multicenter prospective randomized controlled trial. Surg Endoscopy 2014, 28, 65-73
38. Morino M., Pellegrino L., Castagna E et alt. Acute nonspecific abdominal pain. A randomized controlled trial comparing laparoscopy versus clinical observation
39. TshombaY, et al. Diagnostic laparoscopy for early detection ofacute mesenteric ischaemia in patients with aortic dissection. Eur J Vasc Endovasc Surg. 2012 Jun;43(6):690-7.
40. Acosta S.(2014). Surgical management of peritonitis secondary to acute superior mesenteric artery occlusion. World J Gastroenterol. 2014 Aug 7;20(29):9936-41.
41. Wyers MC, Acute mesenteric ischemia: diagnostic approach and surgical treatment. Semin Vasc Surg. 2010 Mar;23(1):9-20.
