NATIONAL HARBOR, Md. (EGMN) –Advanced age need not be an impediment to laparoscopic surgery for colon resection or paraesophageal hernia.

Two retrospective studies presented at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons found that octogenarians not only tolerated laparoscopic surgery, but came through both colorectal surgery and paraesophageal hernia repair with excellent outcomes.

A shortened hospital stay is one of the biggest benefits the elderly can reap from a laparoscopic procedure, said Dr. Steven Wexner, chair of the colorectal surgery department at the Cleveland Clinic, Weston, Florida.

“Leaving the hospital sooner is beneficial to older patients because it lessens their chances of a hospital-acquired infection, fall, or psychological changes,” said Dr. Wexner, lead author on one of the studies. “Unless there is a specific contraindication, these older patients [who need colorectal surgery] should be offered a laparoscopic procedure.”

Dr. Wexner and his colleague, Dr. Rodrigo Pinto, examined outcomes in 83 laparoscopic and 116 open colorectal resections among a group of 199 octogenarians. All the operations were elective; there were no urgent or emergent cases included in the review.

The patients’ mean age was 84 years, and their mean American Society of Anesthesiologists class was 2.7. Cancer was the most common diagnosis, occurring in 86% of the open surgery group and 89% of the laparoscopic surgery group. Diverticular disease was present in 9% of the open group and 8% of the laparoscopic group. The remainder of the patients had other disorders.

The patients underwent a variety of surgical procedures including right, sigmoid, and transverse colectomy; sigmoid colectomy; low anterior resection; abdomino-perineal resection; left hemicolectomy; and proctacolectomy. Stomas were constructed in 47% of the open group and 10% of the laparoscopic group.

The mean operative time was not significantly different between the groups. However, the laparoscopic group lost significantly less blood than the open group (mean 100 vs. 200 mL), required significantly fewer intraoperative transfusions (3 vs. 19), and had a significantly shorter incision length (mean 9 vs. 23 cm).

There were no significant differences in the incidence of minor surgical complications or wound infection. There was one partial small bowel obstruction in each group.

The overall rate of major surgical complications was 5% in each group. Three patients in each group required reoperation. The rate of medical complications was lower – but not significantly lower – in the laparoscopic group compared with the open group (25% vs. 39%). There was no significant difference in mortality.

The overall morbidity rate was 49% for open surgery and 30% for laparoscopic surgery, a significant difference. Patients who underwent laparoscopic surgery left the hospital a mean of 2 days earlier than did open surgery patients (6 vs. 8 days).

The open conversion rate was 25% (21 cases). The converted cases had a longer mean operative time than those completed laparoscopically (197 vs. 156 minutes), greater mean blood loss (220 vs. 129 mL), more surgical complications (96% vs. 5%), and more postsurgical medical complications (79% vs. 21%). All the differences were significant.

Overall, however, “laparoscopic colorectal resection was very safe and effective for these patients,” Dr. Wexner said.

Dr. Heidi Fitzgerald of Dartmouth-Hitchcock Medical Center, Lebanon, N.H., reported on a series of 59 elderly patients (age 80 or older) who underwent paraesophageal hernia repair. Based on her findings of a low mortality rate (2 patients) and an 86% rate of symptom resolution, she and her colleagues recommended elective laparoscopic repair for octogenarians rather than watchful waiting.

The decision to repair electively or not is a controversial one, Dr. Fitzgerald said. “The major concern with paraesophageal hernias is their 10%-30% risk of complications, including hemorrhage, volvulus, strangulation, and perforation,” she said. Mortality rates in untreated patients undergoing emergent surgery have ranged from 5.4% to 26% in various studies. The only study to examine the issue in the very elderly found a 16% mortality rate associated with emergent repair, compared with a 2.5% rate in elective repair in patients 80 years and older.

The mean age of Dr. Fitzgerald’s patients was 86 years, and 76% were women. Most (86%) had an elective repair; the other 14% were emergent. All repairs were completed laparoscopically.

Key operative steps included reduction of the hernia sac and its contents, dissection of the right and left crus, and excision of the hernia sac. The crural junction was exposed to create a generous retroesophageal window, with a high esophageal dissection to ensure adequate intra-abdominal esophageal length. Crural closures were accomplished with suture alone, pledgets, biologic mesh, or a combination. Most patients also underwent an antireflux procedure – either Nissen or Toupet fundoplication – with or without gastroplexy at the surgeon’s discretion.

Patients presented with a variety of symptoms, including postpranidal fullness (64%), regurgitation (46%), anemia (44%), dysphagia (40%), gastroesophageal reflux (37%), and respiratory compromise (32%).

“It’s important to note that all the emergent patients were admitted with symptoms of gastric outlet obstruction, unremitting nausea, and vomiting. All were treated with nasogastric tube decompression and taken to the operating room on a semiurgent basis during the same hospital admission,” Dr. Fitzgerald said.

The mean operating time was 193 minutes. Five intraoperative complications occurred. They included three pneumothoraces, which were treated in the recovery unit with needle decompression, an esophageal perforation that was recognized and repaired intraoperatively, and an esophageal perforation that was noted on postoperative day 2 and required a reoperation.

Major complications occurred in 21 patients (36%) over the 30-day postoperative period. They included two cardiac arrhythmias; four cases of dysphagia, three of which required dilation; one empyema and one aspiration pneumonia that required admission to the intensive care unit; and four cases of anemia that required transfusion.

Two patients died in the hospital after surgery. One patient had an esophageal leak that was repaired, but resulted in a fatal sepsis. One patient needed a reoperation for bleeding and subsequently developed renal and cardiac failure; the family elected to withdraw life support.

Dr. Fitzgerald had complete 1-month follow-up data on 86% of the patients (51). Thirty-nine percent of the patients (23) reported complete symptom resolution, and 47% (28) reported partial resolution.

“This was a small sample size, but despite this, we feel that laparoscopic paraesophageal hernia repair can be performed safely with minimal perioperative morbidity in octogenarians. We now advocate this approach as opposed to watchful waiting in this subset of symptomatic patients.”

Dr. Pinto and Dr. Fitzgerald had no conflicts of interest to disclose. Dr. Wexner disclosed relationships with numerous medical equipment companies, including some that manufacture laparoscopic surgical instruments.

Copyright (c) 2009 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

马里兰州国家港湾 (EGMN)——不必因患者高龄而放弃行腹腔镜下结肠切除术或食管裂孔疝修补术的机会。

 

美国胃肠内镜外科医师学会(Society of American Gastrointestinal and Endoscopic Surgeons)年会上公布的两项回顾性研究发现，80多岁的老人不仅可耐受腹腔镜手术，而且经过直结肠手术和食管裂孔疝修补术治疗后转归极佳。

 

住院时间缩短是这些老年人在腹腔镜手术后获得的最大收益之一，佛罗里达温斯顿克利夫兰诊所直结肠外科主任Steven Wexner博士说。

 

 “鉴于出院较早会减少年长者发生院内获得性感染、跌倒或心理变化的几率，故出院较早对老年人有助益。”其中一项研究的第一作者Wexner说，“在无特殊禁忌证的情况下，对这些需要行直结肠手术的年长患者均应进行腹腔镜手术。”

 

Wexner博士及其同事Rodrigo Pinto博士对199位80多岁老年患者的转归进行检查，其中包括83例腹腔镜直结肠切除术和116例开腹直结肠手术。所有手术均为择期手术；综述中未包括紧急或急诊手术病例。

 

这些患者的平均为84岁，其美国麻醉医师学会(American Society of Anesthesiologists)的平均分级为2.7级。诊断以癌症居多，开腹手术组癌症患者占86%，腹腔镜手术组占89%。憩室病在开腹手术组中占9%，而在腹腔镜手术组占8%。余者患有其他疾病。

 

这些患者进行了多种手术，其中包括右乙状结肠和横结肠切除术；乙状结肠切除术；低位前切除术；腹膜切除术；左半结肠切除术以及直结肠切除术。开腹手术组和腹腔镜手术组分别有47%和10%行造口术。

 

平均手术时间无明显的组间差异。但腹腔镜手术组失血量显著少于开腹手术组(平均值：100 ml对200 ml)，术中所需的输液次数明显偏少(3 对19)，且切口长度亦显著缩短(平均值：9 cm对 23 cm)。

 

轻微手术并发症或伤口感染的发生率无显著的组间差异，各组均有1例部分小肠梗阻。

 

两组总的严重手术并发症发生率均为5%。各组均有3例需要再手术的病例。腹腔镜手术组内科并发症的发生率低于开腹手术组，但无统计学意义(25% 对 39%)。病死率无显著的组间差异。

 

开腹手术组总患病率为49%，而腹腔镜手术组为30%，具有统计学差异。行腹腔镜手术的患者出院时间较行开腹手术者平均提前2天(6天 对 8 天)。

 

有25%(21例)患者转为开腹手术。这类患者与完成腹腔镜手术者相比，其平均手术时间延长(197 min 对 156 min)，平均失血量增加(220 ml对 129 ml)，手术并发症较多(96% 对 5%)，且术后内科并发症亦较多(79% 对 21%)。所有的差异均有统计学意义。

 

但总体上，“对这类患者行腹腔镜直结肠切除术非常安全且有效，”Wexner博士说。

 

黎巴嫩新罕布什尔州Dartmouth-Hitchcock医学中心的Heidi Fitzgerald博士报告了59例行食管裂孔疝修补术的老年患者(年龄≥80岁)的预后情况。其研究发现，这些患者的病死率较低(2例患者)，症状缓解率为86%，她及其同事据此建议对80多岁的老人应行择期腹腔镜修补术而非静观其变。

 

在决定行择期修补术抑或非择期手术方面仍存有争议，Fitzgerald博士指出。“对食管裂孔疝患者的主要顾虑为其并发症风险达10%~30%，其中包括出血、肠扭转、绞窄及穿孔，”她说。在各种类型的研究中，那些未接受治疗的患者行急诊手术的病死率为5.4% ~26%。惟一一项在高龄患者中探讨此问题的研究发现，年龄≥80岁的患者行急诊修补术的病死率为16%，而行择期手术为2.5%。

 

Fitzgerald博士的患者平均年龄为86岁，女性占76%。大多数(86%)行择期修补术；其他14%为急诊手术。所有的修补术均在腹腔镜下完成。

 

关键手术步骤包括疝囊及其内容物复位、左脚和右脚的分离及疝囊的切除。暴露左脚和右脚连接处，形成一个足够大的食管后窗，高位分离食管，确保腹腔内有足够长度的食管。单用缝线、外科纱布、生物补片或这几项联用关闭左右脚。大多数患者还进行抗反流术——Nissen或Toupet胃底折叠术，同时由医生判定是否行胃固定术。

 

患者表现出了多种症状，其中包括餐后饱腹感(64%)，反流(46%)、贫血(44%)、吞咽困难(40%)、胃食管返流(37%)以及呼吸功能受损(32%)。

 

 “应注意，所有急诊患者均因胃流出道梗阻、持续的恶心和呕吐而入院。所有患者均接受了鼻胃管减压术治疗，并在入院治疗的同一时期行半紧急手术，”Fitzgerald博士说。

 

平均手术时间为193 min。发生了5例术中并发症，包括3例气胸和2例食管穿孔，对发生气胸的病例在康复室内行针头穿刺减压术进行治疗，而在气管穿孔的病例中，1例在术中被发现并进行了修补，1例在术后第2天发现并需要再手术。

 

在术后30天中有21例患者(36%)发生了严重并发症，其中包括2例心律失常、4例吞咽困难(有3例需要扩张治疗)、1例脓胸和1例吸入性肺炎(均需送入重症监护室)以及4例贫血(需输血)。

 

2例患者术后死于医院。1例由于修补术后发生食管瘘而引发致死性脓毒血症；1例因出血而需再手术，随后发生肾脏和心脏衰竭；家属决定停止生命支持治疗。

 

Fitzgerald博士拥有了86% (51例)的患者1个月随访的完整数据。有39%的患者(23)报告症状完全缓解，而47%(28)报告部分缓解。

 

 “这项研究的样本量很小，尽管如此，我们仍认为腹腔镜食管裂孔疝修补术可以在80多岁的老年患者中安全完成，围手术期合并症极少。我们现在提倡这种术式，反对对有这类症状的患者采取静观其变的态度。”

 

Pinto博士和 Fitzgerald博士无利益冲突可供披露。Wexner博士披露与许多医疗器械公司有关系，其中包括生产腹腔镜手术器械的公司。

 

 

爱思唯尔  版权所有