Anisakiasis is increasing worldwide, even in Europe and in the Mediterranean region due to the increased practice of raw fish consumption. Usually, a detailed food history is the key to the diagnosis. A 52-year-old woman affected by pathological obesity underwent esophagogastroduodenoscopy (EGD) for a 1-year history of epigastric pain. In the gastric fundus, an Anisakis sp. larva, was casually detected. The nematode was successfully removed with a biopsy forceps. In this case, the finding of the parasite was casual, being detected during an accurate EGD performed for a 1-year history of epigastric pain in the patient.
Heavy menstrual bleeding (HMB) or menorrhagia is the most common form of dysfunctional uterine bleeding (DUB). In spite of medical treatment for DUB, many women will eventually require a hysterectomy, which is an invasive treatment option. NovaSure ablation offers a same day non-invasive alternative to hysterectomy and hysteroscopic ablation. A 38-year-old woman presented with HMB in 2015. The attacks of HMB interrupted her lifestyle, and she refused to continue with medical treatment, which failed to resolve her symptoms. This patient was admitted to the hospital four times over 2015 due to the anemia caused by the DUB. Medroxyprogesterone acetate and oral contraceptive pills failed to control the patient’s bleeding episodes. Hysteroscopic examination of the uterine cavity showed a normal cavity, and the endometrial biopsy showed proliferative endometrium. She was counseled about NovaSure ablation as the last treatment option before hysterectomy. The NovaSure ablation procedure took 90 s, and the patient was discharged from the hospital 6 h after the procedure. At follow-up, the patient is completely amenorrheic, and she is satisfied with her results. This study demonstrated that NovaSure endometrial ablation is a safe, effective, non-invasive alternative to hysteroscopic endometrial ablation for treatment of DUB.
Aim: The marked increase in prevalence of obesity has been associated with an increase in obese patients seeking surgical treatment for refractory gastroesophageal reflux disease (GORD). The management of GORD in such patients remains contentious with no published guidelines.
Methods: A snapshot 9-item online survey was undertaken to elicit professional opinions of UK surgeons regarding the surgical management of refractory GORD in obese patients.
Results: Eighty-two percent and 51% of surgeons performed more than 10 anti-reflux procedures and more than 10 bariatric procedures per year, respectively. Nearly 80 of responders would consider laparoscopic fundoplication as the preferred option for management of refractory GORD in patients with body mass index (BMI) of 30-34.9 kg/m2. In contrast, 58% and 80% would discuss bariatric surgery as an alternative treatment option for refractory GORD in patients with BMI 35-39.9 and ≥ 40 kg/m2, respectively. Moreover, a bariatric procedure was considered the preferred option by 74% of respondents for patients with BMI ≥ 40 kg/m2 with refractory GORD, and by 58% for BMI ≥ 35 patients with refractory GORD and significant comorbidities. Eighty percent of surgeons agreed that laparoscopic Roux en-Y gastric bypass (LRYGB) was the preferred bariatric procedure for the management of obese patients with documented GORD.
Conclusion: Our survey demonstrated that amongst UK upper gastrointestinal surgeons, bariatric surgery, specifically LRYGB, was a preferred option for management of patients with a BMI ≥ 35 kg/m2 and refractory GORD. Updated national guidelines are necessary to inform consensus on the management of GORD in obese patients.
Technology keeps advancing in this era allowing surgery to become less invasive in many surgical sciences. Besides these technological advances, minimally invasive procedures such as laparoscopy and robotic assisted laparoscopy are preferred widely around the globe by both surgeons and patients. Because of the increasing demand to laparoscopy and robotic surgery, anesthetists also should adapt to these specific surgical procedures. Carbon dioxide (CO2) insufflation is applied in these procedures in order to provide working space and exposure to target organs. CO2 insufflation (pneumoperitoneum if applied intrabdominally) and positional maneuvers such as steep Trendelenburg position is used in urologic laparoscopy and robotic surgery, which have vital effects on patient’s physiology regarding cardiovascular, respiratory, renal, ocular and neurological systems. Special positions and unique surgical tools used in these procedures may hinder vital interventions such as cardiopulmonary resuscitation and open conversion. Comprehension of these pathophysiological effects and specific considerations is crucial to detect, to prevent and to manage serious complications that may occur during surgery.
Aim: A compressive orthotic brace is considered the first line therapy for patients with pectus carinatum. We designed a brace made of a non-metallic binder equipped with a balloon which can be insufflated to apply variable compression pressure to chondrogladiolar pectus carinatum. The study aimed to study the effect of this brace on patients with pectus carinatum, dynamic magnetic resonance imaging (MRI) studies were obtained.
Methods: Dynamic chest MRI studies were obtained on pectus carinatum patients fitted with the orthotic balloon brace. Patient’s vital signs and oxygen saturations were recorded.
Results: Three pediatric patients were studied with the MRI. The variable pressure balloon brace provides effective compression and correction of the pectus carinatum deformity. The compression of pectus carinatum chest did not result in changes in vital signs or oxygen saturations.
Conclusion: Dynamic MRI studies done on pectus carinatum patients showed that chest wall can be molded to a normal shape when a directional force is properly applied without changes in vital functions.
Aim: Laparoscopic wedge resection is widely accepted as the choice of treatment for gastric submucosal tumors (GST). However, tumors on the posterior wall at the esophagogastric junction (EGJ) are difficult to approach. Laparoscopic transgastric resection (LTR) is a novel technique to remove gastric tumors that are unresectable by endoscopy due to their size and location. The aim of the article is to assess the feasibility and oncological outcomes of this laparoscopic approach for intraluminal GST located in the posterior wall and near the EGJ.
Methods: A retrospective analysis of all patients with GST located at the EGJ who underwent LTR at our institution from January 2015 to February 2016 was performed.
Results: Of the 4 patients who underwent LTR, 3 were female and 1 was male, with a mean age of 74.5 years. LTR was successfully performed in all the cases. All patients received a complete resection with negative margins. Histopathologic diagnoses were gastrointestinal stromal tumor in 2 cases and leiomyoma in the other 2. Median tumor size was 3.45 cm. The mean operation time was 173 min (range 120-232 min). One patient experienced a postoperative hematemesis, but was treated conservatively. The mean postoperative stay was 8 days (range 4-15 days).
Conclusion: LTR is feasible and difficult localizations can be reached with ease. It is an appropriate alternative to laparoscopic wedge resections especially for localizations that cannot be accessed by laparoscopy such as tumors located near the EGJ.
Robot-assisted surgery is a commonly performed procedure in the recent urological approach. The scientific data that reveal the complication rates also tend to increase by the rising popularity of the robot-assisted surgeries in the treatment of urological cancers. Patient characteristics, nature of the cancer and learning curve of the surgeon are the determinant factors of the complication rates. Nevertheless, robot-assisted surgical techniques are safer with acceptable morbidity and mortality rates as compared to open surgical methods. In urology practice, robotic surgery is most commonly performed in the treatment of prostate cancer. Thus, this review subjected to reveal the commonly seen and the serious complications of robot-assisted radical prostatectomy, and their prevention and management.
This case report describes a treatment of an elderly man who had undergone pancreaticoduodenectomy (Whipple Procedure) due to bile duct cancer. Herein, we describe technical tips of endoscopic ultrasound (EUS)-guided hepaticojejunostomy EUS-HJS combined with EUS-guided antegrade stenting (EUS-AS) using novel plastic stent. First, intrahepatic bile duct was punctured using 19G fine needle aspiration needle. Next, the 0.025-inch guidewire was inserted into the biliary tract. After the guidewire was advanced into the intestine, the bile duct and the intestine wall were dilated using by balloon catheter. The covered metal stent delivery system was antegradely inserted across the stricture site, and stent placement was performed from the intestine to the bile duct. Finally, stent placement from the intrahepatic bile duct to the intestine using novel plastic stent was successfully performed without any adverse events.
Aim: Traditional methods of cervical dilatation such as Hegar rods and laminaria are associated with the damage leading to the risk of cervical incompetence or require two sessions with higher risk of infections. In this study, a new dilator based on expanding triple balloons is assessed.
Methods: Cervical dilation with the triple balloon was evaluated in 15 women with various indications. After measuring the diameter of the cervix the triple balloon was inserted and inflated for 5-7 min and thereafter measured again.
Results: This time was sufficient to achieve the diameter of 4.5-9.5 mm which allowed performing all planned procedures without any need for further dilatation except for one case with cervical stenosis.
Conclusion: Further studies are needed, but the triple dilating balloon might become the optimal dilatation method for universal use.
Aim: Intra-operative cardiac output (CO) monitoring became a standard of care in Northampton General Hospital, UK, at the end of 2013. This study aimed to assess the effectiveness of intra-operative CO monitoring with oesophageal Doppler or LiDCO for patients undergoing elective colorectal surgery for cancer within an enhanced recovery after surgery (ERAS).
Methods: Data was prospectively collected over a 5-year period (March 2010 - Feb 2015) for patients undergoing elective colorectal surgery in the practice of a single surgeon. The ERAS protocol was applied for all the patients. There were 69 patients who had intra-operative CO monitoring with oesophageal Doppler or LiDCO and 144 patients who had no intra-operative CO monitoring. Results were analysed for post-operative outcomes (morbidity, mortality, readmission within 30 days, total length of hospital stay and admission to a high level of care facility).
Results: There was no significant difference in 30-day morbidity and readmission rates between the two examined groups. Forty-six percent of patients in the intra-operative CO monitoring group were admitted to a low level of care facility (ward) in comparison to 24% of patients in the no intra-operative CO monitoring group (P = 0.01).
Conclusion: Using intra-operative CO monitoring singnificantly might reduce the need for admission to critical care. A larger cohort study is needed to further confirm these findings and account for any co-founders.
Aim: To examine the laparoscopic skill-degradation effect by investigating whether a long absence from laparoscopic surgery increases laparoscopic surgery time.
Methods: Using the Japanese Diagnosis Procedure Combination database from April 2010 to March 2012, data for patients undergoing laparoscopic nephrectomy and nephroureterectomy for malignancy were collected. To regulate the hospital volume effect, the hospitals included in the study were limited to those with hospital volumes of 12-24 per year. Laparoscopic time was assessed by multivariate linear regression analysis including interval days, age, gender, comorbidity, oncological stage, nephrectomy or nephroureterectomy, hospital academic status, and hospital volume.
Results: For intervals of ≥ 7 days (3057 cases), 8-14 days (1325 cases), 15-28 days (1424 cases), 29-56 days (711 cases), and ≤ 57 days (332 cases), the median laparoscopic times were 245, 247, 255, 265, and 260 min, respectively (P < 0.001). In multivariate analyses for laparoscopic time compared with interval of ≥ 7 days, 15-28 days, 29-56 days and ≤ 57 days were associated with slightly longer laparoscopic time (+10.5, +16.8, and +18.8 min, all P < 0.01, respectively).
Conclusion: Absence intervals of ≤ 15 days can slightly lengthen the operation time, which suggest the existence of mild degree of a skill-degradation effect in laparoscopic surgery.
Laparoscopic and robotic assisted surgeries have evolved from a limited surgical procedure to a major surgical technique during the last three decades. The indications increased incrementally. Despite its several advantages, it has some surgery and pneumoperitoneum related adverse effects and hemodynamic complications. One of them is the ischemia reperfusion injury (IRI) of the abdominal organs that can be developed secondary to pneumoperitoneum. IRI is also a risk factor for acute kidney injury in partial nephrectomy surgeries even performed via open, or laparoscopic/robotic assisted. To reduce or avoid the IRI related complications during laparoscopy and robotics, several alternative approaches were suggested including ischemic preconditioning (IPC). IPC is a phenomenon that promotes tissue tolerance to ischemia. Since it was first introduced, several studies evaluating its protective effects or mechanism of action have been published. Majority of them demonstrated its potent beneficial effects against IRI. Despite these favorable results, IPC has not yet been used in clinical settings routinely. The unknown parts of the exact mechanisms, the lack of standard protocols for its use such as the duration of clamping, the number of clamping cycles, using an early window or a late window, using local IP or remote IP, and the all remaining uncertainly about these aspects of the process might lead clinicians to be hesitant about its clinical use. In this study we discussed what we have in our hands regarding the effects of IRI and protective mechanisms of IPC, animal studies and clinical evidence of IPC, remote and local IPC, laparoscopy/robotics induced IRI, and role of laparoscopic/robotic IPC.
A 38-year-old male presented with painful obstructive jaundice. Ultrasound showed biliary dilatation and a duplicated gallbladder (DG). Magnetic resonance cholangiopancreatography (MRCP) imaging confirmed the diagnosis of DG and raised the suspicion of a stricture in the distal common bile duct. Endoscopic retrograde cholangiogram, sphincterotomy with small stone extraction, and biliary stent placement were accomplished, and the patient was transferred to our tertiary center. Given the report of a stricture, endoscopic retrograde cholangiopancreatography (ERCP) was repeated and showed no duct narrowing or persistent choledocholithiasis, but only one cystic duct and gallbladder filled. The patient subsequently underwent laparoscopic cholecystectomy using top-down technique with complete resection of both gallbladders. Postoperatively, the patient underwent another ERCP for elevated bilirubin due ampullary edema. Subsequently, his bilirubin normalized and he was discharged home on postoperative day 5. DG is a rare anatomical finding that may be associated with choledocholithiasis and cholecystitis. In this case, a combination of radiographic, endoscopic and laparoscopic procedures was utilized to resolve the patient’s clinical problem.
Aim: To summarize our experience in laparoscopic intra-peritoneal onlay mesh (IPOM) plus repair for ventral abdominal wall hernias over a 10-year period.
Methods: All patients posted for laparoscopic repair of midline lower abdominal ventral hernia on an intention to treat basis were included in the study. Patients unfit for general anesthesia, patients posted for open repair or a hybrid approach (open reduction and closure of defect followed by laparoscopic IPOM repair) were excluded. Pre-operative patient demographics were noted. Intra-operative and post-operative data was recorded and analyzed.
Results: A total of 278 patients were posted for elective laparoscopic repair of lower midline ventral hernias between January 2007 and January 2017, of which, 56.1% were para-umbilical hernias and 43.9% were incisional hernias. These included 155 female patients. The average body mass index was 27 kg/m2. Thirty-five patients were being operated for a recurrent ventral hernia. The average defect width was 1.2 cm for paraumbilical hernias and 2.2 cm for incisional hernias. The mean operating time was 55 min for para-umbilical hernias and 71 min for incisional hernias. In 13.1%, the fascia could not be sutured. There were no conversions to open surgery. Average length of hospital stay was 2.04 days with average follow-up period of 4.6 years. Overall morbidity was 7.9% with 2 recurrences. There was no mortality or mesh infection.
Conclusion: Thus, IPOM plus repair is a safe, feasible and effective technique for the treatment of ventral abdominal wall hernias.
Aim: The present study is to assess the morbidity on comparing Pfannenstiel vs. midline incision following minimally invasive radical cystectomy.
Methods: This is a retrospective comparative study from February 2004 to February 2017 and the number of patients studied was 116. Patients were divided into group A (Pfannenstiel incision) and group B (midline incision). The parameters analyzed were age, gender, co-morbidity, tobacco exposure, occupation, presentation, computed tomography findings, hydronephrosis, transurethral resection of bladder tumor report, duration of surgery (in minutes), hemoglobin drop (in gram per deciliter), need for blood transfusion (number of units), hospital stay (in days), epidural analgesia, analgesic requirement, pain score on first three postoperative days (on visual analogue scale), complications, and lymph node yield (numbers). Standard steps included cystectomy with bilateral pelvic lymph-adenectomy done either through the laparoscopic or robotic approach and specimen retrieval along with diversion through either Pfannenstiel or midline incision.
Results: Primary end points, post operative pain score (P = 0.0001), analgesic requirement (P = 0.0003), post operative wound complication (P = 0.002), length of hospital stay (P = 0.0003) all were less (statistically significant P < 0.05) for group A as compared to group B and secondary end points, duration of surgery (P = 0.0002), post operative paralytic ileus duration (P = 0.0006) were less (statistically significant P < 0.05) for group A as compared to group B. Other secondary end points, post operative hemoglobin drop (P = 0.08), the number of units of blood transfused (P = 0.189) and lymph node yield (P = 0.533) were comparable in either group (statistically insignificant P ≥ 0.05).
Conclusion: Minimally invasive (laparoscopic or robotic) radical cystectomy with an extra-corporeal diversion through Pfannenstiel incision offers an advantage of less morbidity than midline incision.
Aim: The objective of this study is to evaluate maternal and fetal outcomes following pregnancies after bariatric surgery as compared to the general population affected by obesity.
Methods: A systematic review was conducted through MEDLINE, Cochrane, and EMBASE to identify relevant studies from 2007 to 2016 with comparative data on the maternal and fetal delivery outcomes following bariatric surgery as compared to the population affected by obesity. The primary outcome analyzed was the rate of cesarean deliveries. Other outcomes included intrauterine growth restriction, small for gestational age, large for gestational age, macrosomia pregnancy-induced hypertension, gestational diabetes, assisted vaginal delivery, and preterm delivery. Statistical analysis was done using fixed-effects meta-analysis to compare the mean value of the two groups (Comprehensive Meta-Analysis Version 3.3.070 software; Biostat Inc., Englewood, NJ).
Results: Out of 549 studies, 13 were quantitatively assessed and included for meta-analysis. The need for caesarean sections in post-bariatric women was found to be significantly lower when compared to women affected by obesity [odds ratio (OR) 0.623, P < 0.001). There were also significant reduction in the incidence of LGA (OR 0.491, P < 0.001), macrosomia (OR 0.251, P < 0.001), and assisted vaginal delivery (OR 0.807, P < 0.001) in the post bariatric group of women. There was an increase in the incidence of PIH (OR 1.113, P < 0.001), SGA (OR 2.305, P < 0.001) and IUGR (OR 2.099, P < 0.001). The incidence of preterm delivery (OR 0.982, P > 0.05) and gestational diabetes (OR 1.046, P > 0.05) were similar in both groups.
Conclusion: Patients affected by obesity considering conceiving in the near future should consider bariatric surgery prior to conception to lower their risk of potentially adverse delivery outcomes.
The accurate staging of rectal cancer improves the stratification of patients for adjuvant therapy. Staging of tumor with endoluminal ultrasonography (EUS) shows a good correlation with histology (κ = 0.85; 95% confidence interval 0.76-0.95). Overall pT and pN stage accuracy of EUS was 92% and 65% respectively. The staging of local disease can be further augmented by EUS guided fine needle aspiration of extra rectal lesions lying within or outside of the mesorectum. In a systematic review of local excision after neoadjuvant therapy a total of 22 unique studies reporting on 1068 patients were analysed. At a median follow-up of 54 months, ypT0 tumours had a pooled local recurrence rate of 4% and a median disease-free survival rate of 95%. Outcomes for ≥ ypT1 tumours were much worse with pooled local recurrence and disease-free survival of 22% and 68%, respectively. In a review of 22 studies, 804 patients who underwent local excision followed by adjuvant therapy either for unfavourable histology, prohibitive comorbidity or patient choice. the pooled local recurrence was 5.8% for pT1 tumours, 13.8% for pT2 tumours and 33.7% for pT3 tumours. In addition, the response to radiotherapy may be enhanced by aspirin, metformin and statins.
The ultimate goal of rectal cancer surgery is to achieve a negative circumferential, distal resection margin and intact mesorectal excision; however, controversy remains as to what is the best approach. Based on the current evidence, open surgery remains the “gold standard”, however recent improvements in minimally invasive surgery (MIS) techniques with the introduction of robotic surgery and transanal total mesorectal excision have questioned the historical approach of open rectal dissection. A robotic system (da Vinci) overcomes many of the limitations of laparoscopic surgery. A robotic system is more like an open surgery: it gives a 3-dimensional magnified view, endowrist movements, has a shorter learning curve when compared with laparoscopic surgery, with the added advantage of an MIS procedure. However, the higher cost associated with robotic surgery has limited uptake of this approach in rectal cancer surgery in many parts of world.
Minimal invasive surgery (MIS) is an accepted modality of treatment for rectal cancer. The indications for MIS have gradually been extended to locally advanced and locally recurrent rectal cancer as a result of technological advances in instrumentation, advances in surgical techniques, increased surgeon experience, and high volume center. However, safety and feasibility of laparoscopic surgery and robotic surgery in beyond total mesorectal excision (b-TME) and extended TME (e-TME) are not well established. This review summarizes the current evidence for MIS approach for b-TME/extended resections in rectal cancer. A systematic search was carried out in PubMed. Studies available in English related to MIS approach in b-TME/e-TME in rectal cancers were identified and evaluated. This review concludes MIS is feasible with good perioperative outcomes in b-TME/e-TME in carefully selected patients. Laparoscopic surgery has considerable learning curve and should be performed by experienced surgical teams. Robotic surgery is feasible and beneficial in complex resection in pelvis. However, evidence for long-term oncological outcomes of MIS in b-TME/e-TME is low and needs to be studied further by randomized controlled trial once enough numbers are possible in institutes with high volume rate.
This is a narrative review on ano-rectal, sexual, urinary, and quality of life outcomes after transanal total mesorectal excision (TME). Little is known on this topic as only a few studies are currently available in the literature. According to these, it appears that the functional results and quality of life are not substantially impaired compared with standard TME. However more data are needed to precisely assess the outcomes of this technique.
Aim: We herein describe our initial experience of laparoscopic and endoscopic cooperative surgery (LECS) for non-ampullary duodenal epithelial neoplasms (NADENs) and reveal its clinical significance.
Methods: This study included 5 consecutive patients treated by LECS for NADENs between April 2015 and January 2016 in our hospital. For surgery, R0-resection of NADENs was accomplished by endoscopic submucosal dissection (ESD), and the mucosal defect resulting from ESD was subsequently repaired by laparoscopic seromuscular suture and endoscopic clipping. Clinical records were reviewed retrospectively.
Results: LECS was accomplished in four patients. There was a case of open conversion due to the relatively large mucosal defect resulting from ESD. In the postoperative course, no serious complications, including intra- and postoperative bleeding and delayed perforation, were noted. The duodenal stenosis occurred in the case of open conversion but was treated by repeated endoscopic balloon dilatation. Of the five lesions of NADENs, there were three adenomas and two adenocarcinomas confined in the mucosa. To date, no tumor recurrence was observed during the postoperative course.
Conclusion: LECS is a promising procedure of choice in the treatment of NADENs, facilitating early resumption of both food intake and full daily activity in the postoperative course.
Transanal total mesorectal excision (TaTME) is the newest approach for the resection of rectal cancer, according to the principles of TME. The evolution of TaTME started almost 40 years ago and is a combination of several important developments in both micro-endoscopic surgery and transanal surgery. The preliminary clinical data have revealed acceptable TME quality. Clinical trials to determine the long-term oncological results are still in process. In order to master TaTME, the surgeon should be an expert in laparoscopic rectal surgery as well as transanal microsurgery and follow a stepwise training approach. Robotic TaTME using a single-port robotic system is a promising future development.
Endoscopic retrograde cholangiopancreatography (ERCP) with stenosis stenting is the procedure of choice for treatment of malignant biliary obstruction. It has a low failure rate (< 5%-10% in cases of normal anatomy). The traditional alternative is radiological percutaneous drainage with a variable and non-negligible burden of adverse events. Interventional endoscopic ultrasound offers real-time imaging of the bilio-pancreatic district with the possibility of accessing the main biliary duct and the left hepatic duct from the duodenum or stomach. Consequently, endoscopic ultrasound-guided biliary drainage, including the rendezvous technique, choledochoduodenostomy, and/or hepatico-gastro or antegrade stenting, has become a realistic option that offers advantages of a faster and cost-saving procedure since it can be performed immediately after ERCP, thus avoiding repeated sessions and prolonged hospital stays. We describe a case of malignant obstruction of the common bile duct that was drained by creation of choledocho-duodenal anastomosis under ultrasound-guided endoscopy.
Laparoscopic rectal surgery has gained popularity over the last 20 years. Currently there are still questions surrounding the safety and efficacy of this technique as compared to the traditional open modalities. To date, despite the initial enthusiasm for laparoscopic rectal surgery this technique is yet to reach non-inferiority in trials when compared to open resection. This review article discusses the current evidence exploring the value of laparoscopic rectal surgery. It will discuss its evolution over the last 20 years, exploring all the major randomised control trials and their results. It is our belief that laparoscopic rectal surgery for malignancy is not non-inferior to conventional open surgery.
Transanal endoscopic microsurgery (TEM) has proven to be a safe and effective procedure in removal of rectal lesions and may be used in treatment of early rectal cancer in selected patients. In cases when the TEM specimen shows non-radical resection, or histological high-risk factors, completion proctectomy (CP) is warranted. It is debated when it is the best time to perform CP following TEM. It is furthermore uncertain whether CP leads to an increased risk of abdominoperineal excision. Herein, we review the available literature regarding controversial issues with early completion proctectomy following TEM.
Aim: To retrospectively evaluate the safety and efficacy of repeat thermal ablation for local progression of lung tumours after prior ablation(s).
Methods: From December 2009 to March 2017, 13 patients underwent repeat ablation (11 repeat microwave ablations and 2 repeat radiofrequency ablations) of a lung tumour (9 non-small cell lung carcinomas, 3 metastatic colorectal adenocarcinomas, 1 metastatic pelvic sarcoma) for local progression after prior ablation(s). Safety of the procedure was assessed by presence or absence of adverse events. Efficacy of the procedure was assessed by local tumour response to ablation and survival time.
Results: Repeat ablation procedures were safe, without major adverse events. Median length of hospital stay was 2 days (interquartile range 1-2). Pneumothorax was the most common complication [5 (38%) of 13 repeat ablation procedures]. There was one death within 30 days of ablation, but the cause of death and its relation to the procedure were unknown. Of the 12 patients with imaging follow-up [median follow-up 26 months (range 3-62)], 10 (83%) had complete ablation and 2 (17%) had local progression. Of all 13 patients, 8 (62%) were alive and 5 (38%) had died with a median overall survival of 43 months (95% confidence interval 36-49 months).
Conclusion: Repeat ablation in locally progressing tumours after prior ablation attempt(s) is a safe therapeutic option and often achieves local tumour control.
Aim: Recently, the transanal down-to-up rectal dissection, a new approach to improve the difficult total mesorectal excision (TME) for low-lying rectal cancer, has been popularized. This study assessed the long-term oncologic and functional outcomes after sphincter-preserving resection combined with transanal rectal dissection (TARD) under direct vision for both complete TME and preservation of the internal anal sphincter (IAS) as much as possible to clarify the clinical feasibility of this approach.
Methods: A prospective cohort study was conducted in 90 Japanese patients between April 2003 and March 2012.
Results: Abdominoperineal resection (APR) was needed in 17 patients (18.9%) including 14 salvage APRs. Local recurrences occurred in 5 sphincter-preserving resection patients (6.8%). No significant between-group differences were observed in overall survival or 5-year disease-free survival. A significant benefit of preserving the internal anal sphincter completely in sphincter-preserving resection was found on the Wexner incontinence score (P = 0.005), low anterior resection syndrome score (P = 0.002), and visual analogue scale (P = 0.047).
Conclusion: TARD, performed under direct vision for both complete TME and preservation of the IAS as much as possible in sphincter-preserving resections for low-lying rectal cancers in Japanese patients, does not negatively impact oncologic outcomes and could have the benefit of minimizing postoperative anorectal dysfunction by preserving the internal anal sphincter.
Aim: The mental demands of laparoscopic surgery create a steep learning curve for surgical trainees. Experienced surgeons informally conduct mental training prior to starting a complex laparoscopic procedure. Reconstructing haptic feedback to mentally observe surgeon-instrument-tissue interaction is considered to be acquired only with experience. An experiment was devised to implement mental training for the haptic feedback reconstruction and its effect on laparoscopic task performance was observed.
Methods: Twenty laparoscopy novice medical students with normal/corrected visual acuity and normal hearing were randomised into two groups. Both groups were asked to apply a pre-established consistent force by means of retracting a laparoscopic grasper fixed to an electronic weight scale. Studied group underwent mental training while control group conducted a laparoscopic task as a distraction exercise. Accuracy of the task performance was measured as primary outcome. Performance between dominant and non-dominant hands was the secondary outcome.
Results: Baseline assessment of both dominant and non-dominant hands between groups were similar (P > 0.05). Mental training group improved their performance (0.66 ± 0.04) vs. (1.06 ± 0.14) with dominant hand (P < 0.01) and (0.73 ± 0.04) vs. (1.10 ± 0.20) with non-dominant hand (P < 0.05), when compared with control group.
Conclusion: In a laparoscopic task performance, skill transfer is significantly accurate if mental haptic feedback reconstruction is achieved through mental training.
In colon cancer surgery, laparoscopic resection is a safer and more feasible method than open resection; however, despite its increasing popularity in recent years, laparoscopic approaches for the treatment of rectal cancer have not become a standard therapy option, due to the technical difficulties in gaining access to the deep and narrow pelvis and the steep learning curve. Multiple randomized trials found that short-term oncological outcomes and perioperative mortality and morbidity were comparable between laparoscopic and open rectal surgery, whereas comparative data between the two approaches. Comparative data between the two approaches on long-term oncological outcomes remain limited. In this review, we summarize the current status of laparoscopic surgery in rectal cancer in the light of recent studies.
Rectal cancer surgery has undergone a rapid change over the last few decades. We have come a long way from abdominoperineal resection to minimally invasive sphincter preserving techniques. Colorectal cancer screening programs made it possible to diagnose patients at earlier stages and this has led to question the necessity of radical surgery and the possibility of organ preservation. The platform most recently added to the surgical armamentarium is transanal minimally invasive surgery (TAMIS). It utilizes conventional laparoscopic tools to perform endoluminal surgery in rectum. Along with the conceptual changes in rectal cancer management, TAMIS is more frequently used for local excision of malignant rectal tumors. This review highlights the recent advances and current state of the role of TAMIS in the management of rectal cancer at various stages.
Laparoscopic surgery for rectal cancer has short-term and long-term oncological outcomes similar to those of open surgery. Conventional multiport laparoscopic surgery (CMLS) for rectal cancer requires four or five abdominal incisions for trocars, each of which could lead to complications and/or pain. Single-incision laparoscopic surgery (SILS) would reduce the incidence of such wound-related complications and achieve better cosmetic outcomes relative to CMLS. The potential advantages of SILS are less pain and more rapid recovery than achieved with CMLS. However, SILS is rarely used for rectal cancer because of the high-level technical expertise required. Reduced-port laparoscopic surgery (RPS), which involves one additional port, may bridge the technical gap between CMLS and SILS and has a less steep learning curve. RPS for rectal cancer has a short history, and its usefulness has not yet been fully established. Here, we review the present situation, challenges, and future prospects for RPS for rectal cancer.
Enhanced recovery after surgery (ERAS) protocols are gradually becoming the gold standard in the perioperative management of rectal patients. It is a multimodal and multidisciplinary approach that has the great merit to involve and empower the patient and bring him or her back to the centre of the strategy of care. If applied correctly, ERAS can improve the postoperative recovery, reduce the rate of complications and reduce the postoperative length of stay, in patients who had extensive pelvic dissection. The factors within ERAS and their application do not represent rigid schematizations but fluid concepts that may undergo substantial changes as soon as new evidence becomes available. The ERAS principles must be adapted to the specific environment and each team is expected to set up their own programme and quality control criteria. In this comprehensive review, the latest evidence and trend on enhanced recovery after rectal surgery have been critically appraised and presented.
Aim: Even though laparoscopic hepatectomy (LH) has proved to be both safe and effective in specialized centers; the restricted indications for resection in the case of benign liver lesions has resulted in poorly reported outcomes. Our aim was to describe the short and long-term results of LH to treat benign hepatic lesions, including quality of life (QoL) evaluation.
Methods: Thirty-one LHs were performed between 2007 and 2018 in 30 patients. We evaluated QoL with the SF-36 test and a body image satisfaction questionnaire by personal interview before surgical treatment and at 1 month, 3 months, 6 months and 1 year after surgery.
Results: Median age was 38 years (range 21-71) and the majority were females (68%). The most frequent etiology was hepatic adenoma in 16 patients (52%), followed by focal nodular hyperplasia (n = 4), cavernous hemangioma (n = 3), hepatic abscess (n = 3), cystadenoma (n = 5) and hepatolithiasis (n = 1). The majority of resections were minor (66%) and the conversion rate was 6.2%. Pathological examination confirmed negative margins in all patients. Postoperative mortality was nil, while morbidity was 6.2%. Median hospital stay was 4 days (range 1-32 days). In a median follow-up of 48 months (range 2-120), 2 patients experienced recurrence. QoL variables were similar between the preoperative and postoperative periods.
Conclusion: LH should be considered the main therapeutic approach for treating selected patients with benign liver lesions who require surgical resection because it presented both null mortality and low morbidity, along with rare recurrence, a good quality of life and high esthetic satisfaction.
Surgery remains the gold standard treatment for rectal cancer. All published guidelines and most protocols recommend surgery as the standard of care. However, non-surgical management of rectal cancer is increasingly gaining acceptance as it avoids extirpative surgery and a stoma. In patients who are not suitable for surgery because of advancing age or medical comorbidities, and also in a small number of patients who are stoma phobic and refuse surgery, we need to consider an alternative treatment option to bespoke surgery. External beam radiotherapy is usually offered as an alternative. However, local regrowth rate is high and contact X-ray brachytherapy (Papillon treatment) boost can be added to reduce the risk of local regrowth after external beam radiotherapy. Case selection is important to achieve the best results.
Laparoscopic surgery for the treatment of colorectal cancer has gained an enormous advantage as compared to the traditional approach in terms of patient benefits. Although it has gained popularity among surgeons, there are still some contentious issues especially in laparoscopic rectal surgery. Splenic flexure mobilization is a crucial aspect of the procedure with complex technical details thereby establishing a learning curve that cannot be easily overcome. A team of colorectal surgeons at China Medical University Hospital adopted a standardized approach to laparoscopic rectal surgery particularly simplifying the steps involved in mobilizing the splenic flexure which is deemed as one of the difficult steps in the surgery.
Aim: To evaluate our experience of radical treatment in management of liver hydatid cyst. As liver is considered the organ most frequently infected with hydatid disease.
Methods: We performed a retrospective study concerning surgical management of liver hydatid cyst at Advanced Hepato-Pancreateco-Biliary Center. Our study done from June 2011 to May 2018 on 103 patients presented with hepatic hydatid cyst.
Results: Total pericystectomy was carried out in 80 (77.67%) patients; while hepatic resection was carried out in 14 (13.59%) patients. Laparoscopic management was done in 6 (5.82%) patients (5 cases with total pericystectomy and 1 case with sub-total pericystectomy and omentoplasty). Twenty-one patients developed post-operative complications, four patients suffered from biliary leak. There was no mortality. Follow-up period ranged from 6 to 60 months with no recurrence.
Conclusion: Radical surgical procedures were safe and effective in management of hepatic hydatid cyst when it was done by experienced surgeons, with lower morbidity rates and no recurrence.
Colorectal cancer (CRC) is one of the most common solid malignancies worldwide. Although sporadic CRC represents the most common form, genetic alterations is increasingly being identified in a relevant portion of patients with CRC. Familial CRC describes an increased incidence of adenomatous polyps and CRC in first - degree relatives. Hereditary CRC is defined by the identification of deleterious mutations in known predisposing genes. Typical hereditary syndromes with predisposition to CRC include: hereditary non-polyposis colon cancer or Lynch syndrome, familial adenomatous polyposis, attenuated familial adenomatous polyposis, Peutz-Jeghers syndrome and MUTYH associated polyposis. Newly identified genetic alterations with increased risk for CRC include: PPAP, NAD, MSH3 and NTHL1. The diagnosis, surveillance and optimal surgical management of patients with hereditary predisposition to CRC warrant a good understanding of the genetic syndrome in question. Prophylactic surgery must be segregated from symptom-related procedures depending on the syndrome in question. The need for extended surgical procedures must be made in an individualized manner based on gene and gender. The patient should play an active role in the surgical decision-making. Minimally invasive access should be the preferred approach and postoperative quality of life must be seen as a primary outcome measure.
Pathologists are an integral member of the colorectal multidisciplinary team and are able to closely interact with surgeons, radiologists and oncologists to facilitate improvements in surgical quality and patient outcomes. Accurate, high quality pathology reports containing all vital prognostic information are essential to ensure the patient receives optimal treatment. These reports should also integrate feedback to all members of the multidisciplinary team on the accuracy of preoperative staging, response to preoperative treatment, and the quality of surgery. Pathologists have played a key role in improving outcomes in patients with rectal cancer by recognising the prognostic importance of an involved circumferential resection margin. In addition, pathologists have described an assessment of the surgical planes of dissection as a marker of surgical quality and thereby a means of quality control. This article will review the current best practice for the pathological assessment of anterior resections and abdominoperineal excisions for rectal cancer and ultimately look at how pathologists can influence quality control in rectal cancer surgery.
The role of aspirin in colorectal cancer prevention is currently under intense scrutiny. Low dose Aspirin effectively suppresses the cyclooxygenase-2 enzyme system, which is thought to play an important role in the pathogenesis of colorectal cancer. A number of observational studies and randomized controlled trials have supported a chemoprevention effect. In some instances, regular use of low dose aspirin has provided a nearly 20% reduction in incidence. Compliance and underutilization remain important issues however, as does the incidence of side effects - aspirin is a non-steroidal anti-inflammatory drug, and regular use of these medications carries a small but significant risk of gastrointestinal bleeding, which on occasion, can be life-threatening. These are important problems, which need wider recognition and detailed exploration before we can suggest widespread use of aspirin in primary or secondary prevention.
Transanal minimally invasive surgery is a rapidly evolving platform surgery that is facilitating the transanal approach to colorectal surgery. Over the years since its initial description, the applications have widened and now include endoluminal and extraluminal approaches to rectal and pelvic surgery. This article discusses the various applications and future direction of research evaluating this novel technique and its role in colorectal practice.
Enhanced recovery after surgery (ERAS) or fast-track surgery protocols, have been implemented across surgical fields with positive impact on outcomes. These protocols represent a standardized and evidence-based multimodal perioperative strategy founded on a series of measures aiming to attenuate the physical and psychological stress responses to surgical insults, and to potentiate the postoperative rehabilitation of patients. The successful adoption of ERAS protocols in various specialties enabled its gradual acceptance in the complex field of liver surgery. Even though many elements have been adapted especially from colorectal surgery, a few elements of ERAS protocol are unique to liver surgery. The goals of enhanced recovery can be achieved with efforts beginning at the first interaction on outpatient basis. Core elements of this multidisciplinary effort include pre-operative counseling, shortened preoperative fasting, no pre-anesthetic medication, targeted antimicrobial prophylaxis and early withdrawal, preventing and treating of postoperative nausea and vomiting, minimally invasive approaches, avoidance of postoperative nasogastric decompression, preventing hypothermia, optimal perioperative fluid management, selective use of abdominal drains, early urinary catheter removal, optimal pain control, early oral feeding and mobilization. The available evidence from recent randomized controlled studies and meta-analyses comparing ERAS programs with traditional care in liver surgery suggests that length of hospital stay is shortened without increasing morbidity, mortality or readmission rates.
Traditional open surgical technique for rectal cancer is associated with significant morbidity and impact on quality of life. Multiple structures are at risk during total mesorectal excision, which may have profound impact on sexual function, and urinary and fecal continence. In addition, having a temporary or permanent ostomy can have a significant effect on overall well-being. Patients have reported post-operative problems such as chronic wounds, poor body image, inhibited work and social function. Minimally invasive surgery (MIS) is an evolving component of colon and rectal cancer treatment that may have benefits over open surgery. The increasing role of laparoscopy for colon and rectal cancer has been associated with decreased morbidity, improved pain control, and reduced length of stay. However, laparoscopic surgery in rectal cancer remains technically difficult due to the inherent limitations of operating in the pelvis. Robotic surgery is a newer method for treating rectal cancer developed to overcome these limitations. Transanal endoscopic microsurgery and transanal MIS are techniques to achieve local excision, avoiding proctectomy in select patients, potentially improving functional outcomes. Transanal total mesorectal excision is an even newer technique to facilitate dissection of low rectal cancers. Controversy remains about equivalence in oncologic outcomes when these MIS approaches are used for rectal cancer. Even more unclear is the effect of MIS approaches on quality of life and how they compare to open surgery. This review discusses the most current evidence on the impact of various MIS techniques on quality of life after rectal cancer surgery.
Aim: To evaluate the feasibility, safety, and short-term oncological outcomes of robotic-assisted total mesorectal excision (TME) in patients with low-lying rectal cancer (≤ 5 cm from anal verge).
Methods: We enrolled 60 patients with stages I-III low-lying rectal cancer who underwent robotic-assisted TME at a single institution between July 2013 and April 2017.
Results: Of the 60 patients enrolled, 49 (81.6%) underwent preoperative concurrent chemoradiotherapy. Furthermore, among these 49 patients, 18 (36.7%) achieved a pathologic complete response. R0 resection was performed in 57 (95%) patients. Circumferential and distal resection margins were positive in 3 (5%) and 1 (1.6%) patients, respectively. The sphincter preservation rate was 93.3% (56/60). The overall complication rate was 21.7% (13/60), with an anastomotic leakage rate of 3.3% (2/60); most of these instances were mild and the patient recovered uneventfully.
Conclusion: The results demonstrate that robotic-assisted TME is safe and feasible for patients with low-lying rectal cancer.
Colorectal cancer (CRC) is a common health problem due to its high prevalence and high mortality rate. Adjuvant and neo-adjuvant strategies, chemotherapy and radiotherapy alone or in combination, have substantially improved survival and local recurrence rates. Their effectiveness remains limited due to the intrinsic build-up of resistance of cancer cells to chemotherapy drugs, dose-limiting toxicities and other major side effects. New strategies to overcome these issues are being developed, one of which is cancer nanomedicine, a rapidly developing interdisciplinary research field. The last few decades have seen a rapid growth of interest in utilising nanoparticles and nanotechnology in cancer medicine. This is mainly due to the suitable physical and chemical properties of nanoparticles for in vivo applications. Cancer nanomedicine for targeted drug delivery and imaging has been widely investigated preclinically and clinically. Nanomedicine has been considered as a novel solution to enhance CRC diagnosis and treatment, both separately and in combination using theranostic techniques. This review highlights the research, opportunities, and challenges for the development of nanoplatforms for diagnosing and treating CRC.
Laparoscopic rectal cancer surgery has widely been adopted over the past decade. With technical advances, data have shown equivalent outcomes with open surgery. In this paper, we discuss the potential complications of laparoscopic anterior resection, the need for early recognition and prompt management.