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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.
Percutaneous renal access remains the cornerstone initial step in varied clinical settings. For obtaining the best surgical outcome and minimizing patient morbidity, an appropriate access to the target calyx is needed. Though the site of entry depends upon anatomy of pelvicalyceal system and indication for access, a proper technique should be used for gaining access and at the same time minimizing the associated complications. This article describes our technique of gaining access to the pelvicalyceal system and subsequent percutaneous nephrostomy placement in a stepwise manner.
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.
Lumbar disc herniation (LDH) is a common disease characterized by leg pain, numbness, and low back pain, which are also encountered in peripheral nerve and paralumbar spine disease. This study describes other diseases with symptoms similar to LDH. Patients with paralumbar spine diseases such as superior cluneal nerve entrapment neuropathy (NEN), gluteus medius muscle pain, piriformis syndrome, and sacroiliac joint pain experience lowback, buttock, and leg pain. Peripheral nerve diseases of the leg including lateral femoral cutaneous NEN, common and superficial peroneal NEN, and tarsal tunnel syndrome also cause leg symptoms. These diseases can produce intermittent claudication, thought to be specific to lumbar spine disease, and can be misdiagnosed as LDH. They are rather common and can be treated less invasively. As a misdiagnosis may result in failed back-surgery syndrome, it is important to differentiate between LDH and the diseases described here.
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.
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.
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.
Experienced surgeons have reported excellent results for laparoscopic Nissen fundoplication to treat gastroesophageal reflux disease (GERD). Others, however, associate this operation with unacceptable rates of morbidity, mortality and inferior outcomes. Results are certainly linked to an appropriate patient selection, work up, technical details and follow-up. This review focuses on the proper preoperative workup, patient selection, surgical technique, and follow-up for a successful laparoscopic Nissen fundoplication. Certainty of the diagnosis of GERD and the esophageal physiology is essential. An extensive dissection of the esophagus and crus in the abdomen and mediastinum, an adequate hiatoplasty, and a short-floppy fundoplication are important technical points. New onset or persistent symptoms after the operation must be carefully studied. Excellent outcomes may be reproducible if a proper preoperative workup, patient selection, surgical technique and follow-up are rigorously observed.
Aim: Full-endoscopic posterior cervical foraminotomy (FPCF) has been utilized to treat cervical lateral disc herniation and provided good surgical outcomes. The authors examined the superiority of FPCF in patients with spondylotic foraminal stenosis.
Methods: Fifty-nine cases of FPCF were evaluated. Of the 59 patients, 34 had lateral disc herniation (group H) and 25 had spondylotic foraminal stenosis (group S). Operative time, complications, length of hospital stay, visual analog pain scale scores of neck and arm pain, and the amount of facet joint resection were compared between the groups.
Results: The mean operative times were 96 min (group H) and 100 min (group S). The lengths of hospital stay were 3.0 days and 3.9 days, respectively. No significant differences were observed in pre-operative neck and arm pain between the groups. Average neck pain at the final follow-up was significantly less severe in group H (2.9) than in group S (12). However, postoperative arm pain was the same after surgery in both groups (14). In both groups, 52% of the facet joint was resected.
Conclusion: The surgical outcome of FPCF in patients with spondylotic foraminal stenosis is equivalent to that in patients with lateral disc herniation.
Aim: Rectal prolapse in children is a common condition in infancy and early childhood that usually responds to conservative measures. Surgery is reserved only for resistant cases that fail to respond to conservative measures. This study was designed to evaluate the efficacy of 3-point fixation concept (retrorectal dissection, rectopexy to presacral fascia of the sacral promontory and sigmoidopexy onto the anterior abdominal wall) in treatment of complete rectal prolapse in children using laparoscopy.
Methods: This prospective study was conducted on 12 children with persistent complete rectal prolapse who failed to respond to adequate conservative measures from July 2015 to July 2016. The technical details of the procedure are described. Patients were followed up for at least 6 months and were assessed clinically and radiologically for continence and constipation using the appropriate scoring systems.
Results: Twelve patients were included, 8 females and 4 males, laparoscopic rectopexy and sigmoidopexy were done for all cases. The mean duration for surgery was 58.42 min. No intraoperative complications recorded. One case (8.3%) had partial thickness recurrence and 1 case had skin stitch sinus. No postoperative constipation nor incontinence was observed.
Conclusion: The laparoscopic rectopexy and sigmoidopexy is an effective approach for the treatment of refractory complete rectal prolapse in children. The 3-point fixation proved efficient in controlling rectal prolapse in children with minimal complications.
Aim: Mesh is commonly utilized in the laparoscopic repair of sports hernias. A hybrid mesh was recently released containing a single light weight layer of macroporous, polypropylene mesh between layers of biologic mesh. Having an extensive experience with laparoscopic and sports hernia repairs, a small sample of hybrid mesh was trialed.
Methods: From April 2015 to August 2016, 16 male patients with sports hernias were consented for hybrid mesh repair. A prospective data base was developed and patients were followed at 1 week, 4 weeks and 4 months after surgery.
Results: Ages ranged from 18 years to 43 years (average 22.9 years). Operative times ranged from 25 min to 75 min (average 42.5 min). All were athletes playing basketball, soccer, baseball, football and track. There were no operative problems. Two patients developed post-operative seromas requiring radiologic drainage. All patients completed a post-operative therapy program and all have returned to their sport without problems.
Conclusion: There is not one type of mesh repair that has been proven to be the most effective treatment for sports hernias. Continued follow up as well as a more structured study will be necessary to prove if hybrid mesh has long term effectiveness for the laparoscopic treatment of sports hernias. The initial study has promising findings.
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.
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.
Non-small cell lung cancer (NSCLC) is one of the leading causes of cancer-related deaths in the world. Therefore, there is a need to intensify treatments of these tumors. Because stage I NSCLC is a nonmetastatic disease, local therapies are indicated, among which surgery is the most commonly deployed strategy. Pulmonary wedge/sublobar resection is therefore discussed in comparison to stereotactic body radiation therapy for stage I lung cancer. Review of retrospective and prospective clinical trials reveal similar outcomes for both strategies, while a multicenter randomized prospective study comparing the efficacy of both therapies is on-going. Because the results of pulmonary wedge/sublobar resection may depend on tumor size, tumor-distance from surgical margin, tumor size-to-margin distance ratio, and margin cytology, prospective studies to evaluate the clinical implications of these factors, so as to inform patient prognostication, are recommended.
Aim: Percutaneous endoscopic lumbar laminectomy or laminotomy (PELL) is a minimally invasive surgical technique to treat lumbar canal stenosis. The procedure is undertaken using a single port endoscope, as with percutaneous endoscopic lumbar discectomy (PED). PED has become popular with spinal surgeons in Japan as a suitable surgery for lumbar disc herniation patients. Because PED has the powerful advantage of structural preservation, it allows for short hospital stays and early recovery of the patient. PELL and PED are conceptually very similar, in that they are both minimally invasive. PELL is not as popular as PED, however. The aim of the current study was to explore the reasons why.
Methods: The current study reports the early experiences of surgeons at this institution in using the PELL technique, and its limitations.
Results: The goal of PELL is total flavectomy and decompression of the bony structure. Currently, there are difficulties and limitations in achieving decompression using PELL with small tools.
Conclusion: PELL requires much more skill than PED and the learning curve is not steep. PELL is minimally invasive for the patient, but further developments of the endoscope or procedures are required to achieve widespread use.
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.
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: Posterolateral percutaneous endoscopic discectomy (PLPED) is commonly performed under local anesthesia, but patients and surgeons are concerned about intraoperative uncontrolled pain. The purpose of this study was to evaluate the safety of the PLPED under general anesthesia with free-running electromyography (EMG) monitoring.
Methods: The clinical outcomes of consecutive 48 cases of lumbar disc herniation (LDH) were evaluated by numeric rating scale (NRS) score and MacNab's criteria. Hospital stay and time to ambulation and return to work were also assessed.
Results: NRS score for the affected leg significantly improved from 6.4 to 0.9 immediately after the operation. MacNab's criteria were 91.5% for a follow-up period of 13.5 months. Although no serious complication occurred, 3 patients (6.3%) had transient paresis that completely disappeared by 3 months. No recurrences were observed during the follow-up period.
Conclusion: PLPED combined with EMG monitoring under general anesthesia is a safe and efficacious procedure for the treatment of LDH.
Aim: To evaluate the application of laminectomy using the interlaminar approach (ILA) for percutaneous endoscopic lumbar discectomy (PELD).
Methods: Minimal laminectomy using the ILA for PELD was performed in 13 patients with lumbar disc herniation (LDH). The width of the interlaminar space, shape of the caudal margin of the upper vertebral laminae (CM-UVL), LDH size, and caudal migration grade were radiologically evaluated. Ten LDHs were removed via the shoulder of the corresponding nerve root, and three via the axilla of the corresponding nerve root and dural sac. Bone status was evaluated preoperatively and postoperatively using two- and three-dimensional computed tomography.
Results: All patients (mean age 46.3 years) underwent PELD at a single spinal level, mostly at L5/S1. Compared with a previous study without laminectomy, the mean operative duration (57.5 min) and operative outcome, evaluated using the modified Japanese Orthopaedic Association and Numerical Rating Scale scores, were similar; no complications were observed. However, the width of the interlaminar space was significantly narrower, and eight cases revealeda narrow interlaminar space (width < 20 mm and/or lost concave shape of CM-UVL).
Conclusion: Minimal laminectomy using the ILA for PELD is feasible for treating LDH with the narrow space and highly migrated LDH.
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.
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.
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.
Aim: This study proposed the robot-assisted laparoscopic simple prostatectomy (RASP) as safe and reliable surgical option for the treatment of men with prostate size > 80 mL. It was aimed to evaluate preoperative and postoperative results in RASP using a surgical variation to the standard technique: the temporary bilateral internal iliac arteries clamping.
Methods: This study analyzed 18 patients underwent RASP with temporary clamping of bilateral internal iliac arteries. Procedures were performed by two surgeons in two different hospitals using the same surgical technique. Preoperative and postoperative data were collected and statistically analyzed.
Results: The temporary clamping duration was less than 12 min during each adenoma's enucleation. Despite the vascular control, the median operating time was similar to RASP performed without iliac clamping. The results showed minimal blood loss, a median catheter duration of 5 days, a median duration of postoperative continuous catheter irrigation of 41 h, and short hospitalization (3.2 days). A significant corellation was observed between the estimated blood loss and the duration of irrigation.
Conclusion: RASP performed with bilateral vascular control, combined with the known benefits of minimally invasive surgery resulted in bleeding reduction. The minimal blood loss further reduces catheter duration, decreases continuous catheter irrigation and patient's hospitalization duration.
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.
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.
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-abdominal collection or abscess (IAA) is a dreaded complication post open or laparoscopic appendectomy for perforated appendicitis. There have been many discussions on the role of laparoscopic irrigation during laparoscopic appendectomy for perforated appendix but not its role for patients who subsequently developed IAA post-surgery.
Methods: All patients who developed clinical symptoms and radiological evidence of IAA of more than 5 cm × 5 cm post appendectomy from January 2014 to May 2016 were subjected to delayed laparoscopic suction (DLS) of the IAA. Days to resolution of fever and improvement of symptoms post the DLS were recorded. Complications during DLS like bowel injury, bleeding and conversion to open surgery were documented and analysed. Patients were followed up for 1 month to a year to look for potential adhesive intestinal obstruction.
Results: Seven patients who met the criteria of large IAA were subjected to DLS at post-operative day 3 to day 5 post appendectomy. Six of the cases were post laparoscopic appendectomy and one case was post open appendectomy from another institution. Ports were inserted via the same sites as used during the first surgery. Turbid intraperitoneal fluid and abscesses were laparoscopically sucked without irrigation. There was no bowel injury, bleeding or conversion in any of the cases. All patients were afebrile within 24 h post procedure and their associated symptoms improved significantly. All patients were discharged within three days of DLS and have not returned with adhesive obstruction.
Conclusion: Early recognition of IAA is important and early attempt at DLS resulted in better outcome of patients and lesser hospital stay. DLS is a safe and feasible technique.
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: Cardiac surgery, as with other surgical specialties, has moved toward minimally invasive procedures. Currently, since the cardiopulmonary bypass machine remains necessary for most cardiac surgery procedures, efforts have focused on decreasing surgical trauma by limiting vascular access sites and any unnecessary dissection. This study presents the authors' approach for less invasive valve surgery, which aimed to avoid a conventional midline sternotomy and reducing the length of incision.
Methods: For patients with aortic valve involvement, parasternal approach was the primary choice. A longitudinal 5-6 cm incision was made one fingerbreadth lateral to the sternal border. The 3rd rib was cut at the chondrosternal junction and bent into the right pleural cavity. After either central aortic or peripheral cannulation, all procedures were completed under surgeon's direct vision and conventional instruments. The rib was reduced into position with a wire to offer stability and eliminate postoperative chest deformity.
Results: The authors' experience of more than 500 cases with the minimally invasive approach showed that bypass time and ischemic time for parasternal valve surgery were compatible with to a full-sternotomy approach. In this series, postoperative ventilation time, blood product consumption and overall mortality were reduced.
Conclusion: Reviewing the parasternal aortic valve series of more than 500 cases, parasternal approach is safe, effective, and reproducible. The surgical trauma and blood product consumption were minimized with this approach. Multiple valve procedures and ablation for atrial fibrillation are also feasible. Stable sternoclavicular joints could facilitate early and aggressive activity of upper extremities for improved postoperative recovery. This approach could be a good alternative option in aortic or multiple valve surgical procedures.
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.
Idiopathic and Chagas' disease achalasia are characterized by absent or partial lower esophageal sphincter relaxation, absence of peristaltic esophageal contraction, food retenction in the esophagus and esophageal dilatation. The most frequent symptoms are dysphagia, regurgitation, heartburn, weight loss and non-cardiac chest pain. The diagnosis is made by radiologic examination and esophageal manometry, which is considered the most accurate exam to characterized achalasia. In both diseases there is destruction of the esophageal myenteric plexus. Despite similarities in clinical and manometric presentation there is evidence of greater loss of inhibitory neurons of the myenteric plexus in idiopathic achalasia, whereas in Chagas' disease there is a loss of both excitatory and inhibitory neurons. Such differences, though do not affect patients' clinical presentation, and hence treatment options should be the same for both diseases.
Aim: The need for an antireflux procedure after myotomy is no longer as controversial as it used to be. However, the choice of the best fundoplication after myotomy is still controversial. The authors present the results of laparoscopic myotomies associated with postero-latero-anterior fundoplications (Heller-Pinotti).
Methods: Medical records and endoscopic findings were reviewed for achalasia patients that had submitted to the procedure following 5 years of follow-up.
Results: In total, 445 patients were enrolled: 39 (8.7%) presented erosive esophagitis, the Los Angeles classification being A-21, B-12, C-2 and D-4 (2 with peptic substenosis and 2 Barret); 41 (9.2%) patients had dysphagia, 4 needed reinterventions; 49 (11%) presented a migration of the fundoplication wrap to the thorax due to hiatal hernia, this was correlated with a higher risk of present erosive esophagitis (P = 0.047) and dysphagia (P < 0.001).
Conclusion: Laparoscopy myotomy postero-latero-anterior fundoplication (Heller-Pinotti) produces a good long-term outcome for dealing with dysphagia and in terms of reflux prevention.
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: 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.
Oesophageal and gastroesophageal junction (GEJ) malignancy is the fastest growing cancer in the Western population. This together with the deadly nature of the disease has attracted increased attention from doctors and researchers alike. The increasing incidence has been primarily attributed to the increase in rates of obesity that in turn causes increased gastroesophageal reflux disease leading to Barrett's oesophagus and eventually adenocarcinoma of the oesophagus especially at the GEJ. We discuss the epidemiology, risk factors and the management of GEJ tumours.
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.
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: 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.
The incidence of adenocarcinoma of esophagogastric junction (AEG) has been increased continuously in the past decades, especially in western countries. Siewert type II is regard as the true AEG because of its location, however, the treatment for Siewert type II AEG has not reached a consensus in the academic. According to published studies nowadays, this commentary will introduce the surgical strategies and put forward suggestions for Siewert type II AEG in several aspects as follows: (1) optimal surgical approach; (2) optimal extent of lymph node dissection; (3) reconstruction methods. With the development of minimally invasive surgery, many experienced surgeons perform esophagogastrostomy via transhiatal approach. Moreover, many details during the surgery still need further research by cooperation between different departments and even countries.
Aim: Single-incision laparoscopic hernia repair (SILHR) is a popular technique, especially in female children, as it reduces the number of incisions while achieving a better cosmetic outcome. However, intracorporeal suturing and knotting remains a major obstacle during SILHR and it requires a relatively long learning curve. Conversely, extracorporeal suturing and knotting is straightforward, though it has several drawbacks. The purpose of this report is to describe a simple technique for SILHR in female children.
Methods: Between May 2014 and December 2016, 100 girls with 120 hernias of the Canal of Nuck (34 with right-side inguinal hernia, 46 with left-side hernia, and 20 with bilateral hernia) underwent SILHR. The opened internal inguinal ring was closed using a complete purse string suture fashioned by epidural needle with intracorporeal knot tying. The main outcomes were feasibility, operative time, complications and cosmetic outcome.
Results: The mean age was 2.0 ± 2.2 years, and the mean operative time was 8.0 ± 2.2 min for unilateral hernia repair and 16.0 ± 4.3 min for bilateral cases. All cases were completed laparoscopically without intraoperative complications. During follow-up, there were no recurrences and umbilical scars were almost invisible.
Conclusion: This simplified technique is feasible, quick, achieves better cosmetic results in female children, and avoids the drawbacks of extracorporeal knotting.
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: Laparoscopic pancreatic surgery is a minimally invasive technique that has been widely applied only in the past decade. The purpose of this study was to evaluate its safety and assess whether laparoscopic distal pancreatectomy (LDP) is cost-effective compared with open distal pancreatectomy (ODP).
Methods: The medical records of patients treated for left-sided pancreatic lesions were retrospectively analysed, and the analysis of costs for hospital stay, operative time, and equipment were analysed. Twelve patients underwent LDP, while 12 patients underwent ODP.
Results: The two groups were homogeneous according to age, ASA score, BMI, and distribution of pathological findings. Both the size of the specimen (5.33 ± 3.2 vs. 5.58 ± 2.57 cm) and the number of removed lymph nodes (10.5 ± 4.3 vs. 12.1 ± 3.1) did not differ. Although LDP required a longer operative time (197.5 ± 33.7 vs. 122.5 ± 35.4 min), intraoperative bleeding, postoperative pain intensity (measured by VAS scale) and hospital stay were significantly reduced.
Conclusion: The mini-invasive approach offers several advantages compared with open surgery, including a significant reduction of blood loss and postoperative pain, and an earlier recovery. The global costs of laparoscopic surgery should be carefully re-evaluated, considering the saving that arises from these advantages.
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.
Aim: Transhiatal esophagectomy is a therapeuthic option for the treatment of end-stage achalasia that avoids the complications of a thoracotomy. This technique; however, is still linked to some degree of morbimortality especially due to pleuromediastinal complications. Esophageal mucosectomy and endomuscular pull-through could avoid these complications.This study aims to evaluate the short and long-term outcomes of esophageal mucosectomy and endomuscular pull-through in a series of patients with advanced megaesophagus.
Methods: We retrospectively studied 115 patients with end-stage achalasia that underwent esophageal mucosectomy and endomuscular pull-through. Digestive tract reconstruction was accomplished most times using the stomachthourgh the muscular tunnel. Outcomes were evaluated in a short and long-term follow-up based on clinical, endoscopic and tomographic evaluation.
Results: Anastomotic leak or stenosis was present in 27%. Pleural efusion was noticed in 11% and pneumonia in 9%. Mortality was 1.7%. Long-term follow-up (over 10 years) was possible in 42 patients. Excellent and good clinical results were obtained in 83% of the patients.
Conclusion: Esophageal mucosectomy and endomuscular pull-through is a valuable procedure for the treatment of end-stage achalasia. It shows a low rate of complications and good outcomes at long-term follow-up.
Aim: The advent of minimally invasive abdominal and thoracic surgeries has led to a meaningful reduction in complication and mortality rates among patients undergoing esophagectomy, especially when used for the treatment of benign diseases such as megaesophagus.
Methods: Two hundred thirty-one patients, 152 (65.8%) men and 79 (34.2%) women, with a mean age of 52.46 (19-80) years, were treated for advanced megaesophagus between September 1996 and October 2016. Two hundred ten patients (90.91%) had chagasic megaesophagus and 21 patients (9.09%) had idiopathic megaesophagus.
Results: Immediate complications were observed in 37 patients (16.01%): hemopneumothorax in 22 cases (9.52%), gastric stasis in 11 (4.76%), cervical fistula in 11 (4.76%), dysphonia in 18 (7.8%), and mediastinitis in 1 case (0.43%). Two patients (0.86%) died: 1 patient with a pacemaker died of cardiorespiratory arrest on postoperative day 12 and the other patient died of mediastinitis on day 28. Our standardized protocol includes nutritional and pulmonary outpatient care.
Conclusion: With a standardized multidisciplinary protocol and a team adequately trained in laparoscopy, minimally invasive esophagectomy is an excellent option for the treatment of advanced megaesophagus. The technique is easily standardized and reproducible, and provides excellent postoperative outcomes.
Aim: This study aimed to document the use of percutaneous endoscopic cervical laminectomy (PECL) and the treatment results.
Methods: Eleven patients with a limited cervical spinal canal stenosis were indicated for the surgery. Under general anesthesia, the interlaminar space between the affected vertebrae was approached from 5 mm outside the midline. Laminectomy was performed using a 2.5-mm or 3.5-mm high speed drill, and an endoscope. Subsequently, the bilateral yellow ligament was removed and sufficient decompression of the dural sac was confirmed. Surgery was completed after the placement of an indwelling drain. Pre- and postoperative statuses were evaluated using the modified Japanese Orthopedic Association (mJOA) score.
Results: The mean operation time was 87.1 min, and no complications were observed. During the mean follow-up period of 16.6 months, the mJOA score improved significantly from 10.9 ± 0.7 to 14.3 ± 1.3 (P = 0.0000002).
Conclusion: PECL is a minimally invasive surgical technique for cervical posterior decompression. This is a useful procedure, although it is technically demanding, and must be carefully performed under strict indication by a surgeon with sufficient experience of endoscopic techniques.
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: 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.
Achalasia is a primary esophageal disorderth variable causes, with an incidence between 0.03 to 1/100,000 people, and prevalence of approximately 10/100,000, with no difference between gender. It is more frequent in South and Central America, where Chagas disease is endemic. There are several methods to treat achalasia including endoscopic and surgical procedures, however, all of these methods are palliative. This article discusses 2 different endoscopic methods to treat advanced megaesophagus in Chagas disease, pneumatic balloon dilatation (PBD), and peroral endoscopic myotomy (POEM). Although varying between studies, PBD has an average symptom relief in 93% of patients in 6 months and 44% in 6 years. Some risk factors for failure of PBD are: younger age, male gender, a wider esophagus, poor emptying on post-treatment barium esophagogram and Eckardt scale < 3 before the treatment. Despite relatively short-term follow-up of an average of 3 years, POEM has excellent results. The clinical success achieved in 98 % with the Eckardt score decreased from 6.9 preoperatively to 0.77. Regarding sigmoid-shaped esophagus, only a few papers have been published on POEM. The largest population was 32 patients with a follow-up of 2 years. There was an efficacy of 96%, with the Eckardt scale decreasing from 7.8 to 1.4. In conclusion, PBD, is still widely used mainly due to its availability, especially in patients with a higher surgical risk and in patients who already had a Heller myotomy who persist or develop dysphagia. POEM has already demonstrated excellent results, but it requires advanced technical skills and Long-term results and randomized clinical trials are needed to validate the use of POEM in routine clinical practice.
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.
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.
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.
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.
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.
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.
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.
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.
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: The purpose of this study was to evaluate the clinical feasibility and efficacy of the intracorporeal hemi-hand-sewn (IC-HHS) technique for Billroth-I gastroduodenostomy in comparison with extracorporeal total hand-sewn (EC-THS) anastomosis. We also examined the size of resected specimens in each procedure.
Methods: The number of enrolled cases of EC-THS and IC-HHS anastomosis groups were 85 and 110 cases, respectively. Perioperative data and the measured sizes of resected specimens were analyzed.
Results: Operation time in the IC-HHS group was significantly longer than the EC-THS group (234.8 min vs. 275.0 min, P < 0.01), whereas intraoperative blood loss was less in the IC-HHS group (48.4 mL vs. 25.4 mL, P = 0.03). There were no procedure-related complications in the IC-HHS group. The greater curvature of the EC-THS group was significantly shorter than the IC-HHS group (214.6 mm vs. 228.7 mm, P < 0.01). There was no correlation between body mass index (BMI) and the length of the greater curvature in the IC-HHS group (r = 0.07, P = 0.47), but in the EC-THS group, the length of the greater curvature tends to shorten as BMI increases (r = -0.45, P < 0.01).
Conclusion: IC-HHS technique for Billroth-I gastroduodenostomy revealed feasible with acceptable operation time and postoperative outcome. Another advantage of total laparoscopic distal gastrectomy that intracorporeal transection can facilitate is to ensure an adequate proximal margin, especially in obese middle gastric cancer patients.
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.
Laparoscopic Heller's myotomy is the most common surgical procedure to treat achalasia. It is the most accepted therapy for non-advanced stages of the disease. In the setting of advanced disease with marked esophageal dilatation or sigmoid-shaped esophagus the ideal surgical procedure is debatable. Esophagectomy is believed by several authors to be the operation of choice in these cases. Others; however, opt for less invasive alternatives. Laparoscopic Heller's myotomy has been shown to be a safe and resourceful alternative in end-stage achalasia as well.
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.
Transanal total mesorectal excision (TaTME) is the latest in a long list of developments in the surgical treatment of low rectal cancer. This article describes the evolution of the technique, a brief summation of the technical procedure, the current literature into its results, and the possible future direction that it might take. It is the authors' opinion that TaTME will form another technique within the modern colorectal surgeon's armament.
Several reconstruction techniques are possible after totally laparoscopic distal radical gastrectomy. An optimal technique of digestive tract reconstruction after distal gastrectomy has not yet been established. The ideal reconstruction should be not only for doctors but also for patients. Alimentary intake, satisfactory nutritional status and easy performing should be all considered. The aim of the study was to describe the different Billroth-I reconstruction techniques that can be proposed after totally laparoscopic distal radical gastrectomy.
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.
Aim: Current financial and work hour constraints make proctored on-site laparoscopic simulation training challenging. An independent learning approach utilizing proficiency-based training is a potential solution. The purpose of this study was to determine if an independent approach using a portable, laparoscopic training device within one's home environment could effectively train novices in laparoscopic procedural skills.
Methods: After baseline testing, laparoscopic novices (n = 16) were randomized to one of two study groups. The on-site group (n = 7) received unlimited access to the workplace laparoscopic trainers and the home group (n = 9) received portable laparoscopic trainers for home. Both groups underwent self-directed, proficiency-based training for three months then were retested. Results were compared with parametric and non-parametric statistical tests.
Results: Baseline characteristics were similar between groups. The practice rate (56%) and practice time (range, 0.18 to 2.6 h) were poor in both groups during the training period. At post-test, the number of participants who demonstrated an improvement (86% on-site, 78% home) on the peg task was not different between groups. The successful completion of the suturing task post-test had significantly improved compared with pre-test in both groups (71% vs. 29% on-site; 44% vs. 22% home, P < 0.001). Although the majority of participants reported it was difficult to practice on a regular basis (86% on-site, 89% home), 56% of the home group participants agreed that the at-home trainer was a helpful teaching modality.
Conclusion: Learning of laparoscopic skills by novice trainees can be augmented by an independent learning approach using either home or on-site laparoscopic trainers. Although over half the candidates found it was useful to have the training device at home, none of the participants practiced more than an hour or two in the three month training period. Thus, the solution to conducting training does not lie in merely providing home training, but rather to understand the work-related stressors and reconfigure jobs.
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.
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.
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.
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.
Interstitial cystitis, also called painful bladder syndrome, is a chronic condition causing bladder pain and sometimes pelvic pain. The exact cause of interstitial cystitis is not known. Often, signs and symptoms are hard to elucidate and no single treatment works for everyone. We report two cases of patients affected by interstitial cystitis treated with endovesical instillation of platelets rich fibrin (PRF). PRF is an autologous component that promotes angiogenesis, tissue growth and repair. This report presents the safety and the efficacy of PRF instillations in controlling clinical symptoms and restoring quality of life.
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.
Aim: To report the initial monocentric experience of totally laparoscopic total gastrectomy, assessing its feasibility and safety, especially relating to the challenging step of esophago-jejunal (E-J) reconstruction.
Methods: All consecutive patients, underwent laparoscopic total gastrectomy for gastric cancer with curative intent, between January 2017 and June 2018 at our institution, were considered. Data of the selected patients was retrieved from a prospectively collected database. Short and long term outcomes were analyzed.
Results: Ten patients underwent totally laparoscopic total gastrectomy with D2 lymphadenectomy and 4 of these had received preoperative chemotherapy; Two patients also received the lymphadenectomy of the station 10. E-J reconstruction consisted of hemi-double stapling technique with transorally inserted anvil in 1 case, side-to-side overlap anastomosis in 5 cases and end-to-side anastomosis in 4 cases. One patient experienced intraoperative complications needing conversion to laparotomy. Seven patients experienced postoperative complications, three of these were severe according to Dindo-Clavien classification. All the specimens had free proximal resection margins with R0 resection in all the cases. Average postoperative length of hospital stay was 10 days and no patients died during hospitalization. Median overall survival and disease-free survival were 15.5 and 12.5 months respectively.
Conclusion: Totally laparoscopic total gastrectomy is a feasible and safe option in the treatment of gastric cancer. The choice about the type of E-J reconstruction should be based on the single patient's features and on the dexterity of the surgeon who should be able to perform more than one option for a tailored approach.
Minimally-invasive liver resection (MILR) is a promising approach and has become a standard therapy option for a variety of indications, including liver tumors, in adults. Although minimally-invasive techniques are common practices in children, the usage and literature regarding MILR in children is scarce. In this article, we give an update on the current literature, share some of our own experience and give a future outlook of the potential benefits and shortcomings regarding MILR in children.
Laparoscopic liver resection is technically challenging compared to open liver surgery and has a steep learning curve. Tumors located in the posterior sector, centrally, in proximity of major vascular pedicles or in a background of liver cirrhosis are surgically more complex with a higher risk of blood loss. There is emerging consensus about indications for laparoscopic liver resection. While laparoscopic approach is considered standard for left lateral sectionectomy and minor laparoscopic liver resections in antero-lateral segments, with increasing experience, major resections, parenchyma sparing resections and even donor hepatectomies are being performed laparoscopically with good outcomes. Laparoscopic liver surgery is feasible and safe for well selected patients by well-trained surgeons with short-term advantages and non-inferior long-term oncologic outcomes.
The laparoscopic gastrectomy (LG) with D2 lymph node dissection (LND) for advanced gastric cancer (AGC) have been widely done. However, the applicability to more advanced disease is still under debate. Actually, there are a lot of technical demands against D2 LND for AGC, e.g., total omentectomy, splenic hilar node dissection, and the management for bulky lymph nodes, etc. Recently, extensive research has been gradually performed in the field of LG for AGC and demonstrated that LG for AGC is a safe and feasible procedure with better short-term outcomes compared with open gastrectomy. Also, large-scaled phase III trials are ongoing, and their long-term outcomes are awaited the publication in the near future. LG with D2 LND by expert surgeons under the cautious indications could be acceptable treatment for locally AGC. On the other hand, we should keep searching for solutions to the technical or oncological issues, and long-term outcome of phase III study should be warranted for standard treatment. Robotic surgery, LG following neoadjuvant chemotherapy, or conversion therapy using LG for several stage IV patients may help us clear the technical hurdles, and may show survival advantages in the future.
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.
Aim: To investigate the short-term outcomes of laparoscopic colorectal resection compared with open surgery in psychiatric patients with colorectal cancer.
Methods: The authors retrospectively reviewed the medical records of 31 consecutive patients who underwent open surgery (OS) or laparoscopic surgery (LS) for colorectal cancer between April 2013 and September 2015. All patients were involuntarily admitted to the hospital, because of anosodiaphoria. The clinicopathological characteristics, intraoperative outcomes, and postoperative data of the two groups were analyzed. Categorical data were compared using the χ2 test or Fisher exact test, as appropriate. Continuous variables were compared using the Student t test or Mann-Whitney U test, as appropriate. Statistical analyses were performed using the statistical software program, SPSS, version 22 (SPSS Japan, Tokyo). P-values < 0.05 were considered statistically significant.
Results: Sixteenpatients underwent LS, and 15 underwent OS. Blood loss was lower in the LS group than in the OS group (P = 0.001). LS was associated with the earlier resumption of psychiatric drug treatment (P < 0.001) and a shorter hospital stay (P = 0.021) compared with OS.
Conclusion: Laparoscopic colorectal surgery is safe for psychiatric patients. The main advantages of LS include a shorter washout period and reduced hospital stay.
The number of robotic gastrectomy (RG) cases is increasing, especially in East Asia. The da Vinci Surgical System for RG allows surgeons to perform meticulous procedures using articulated devices and provides potential advantages over laparoscopic gastrectomy (LG). Meta-analyses including a large number of retrospective studies comparing RG and LG revealed only a limited advantage for RG over LG, such as lower blood loss, and the obvious disadvantage of longer operation times and higher medical cost. Specifically, a multicenter, prospective, single-arm study performed in Japan showed favorable short-term outcomes of RG over LG, while a non-randomized controlled trial in Korea showed similar postoperative complication rates for RG and LG, although the medical costs were significantly higher in RG. A well-designed randomized controlled trial is thus necessary to establish robust evidence comparing the two surgeries. In addition, further development of surgical robotics is expected for RG to be accepted more widely.
Aim: It is unclear whether elderly patients with advanced gastric cancer can benefit from laparoscopic gastrectomy. This study aimed to compare the surgical and early postoperative outcomes of laparoscopic distal gastrectomy with those of open distal gastrectomy for advanced gastric cancer in elderly patients aged 75 years or older.
Methods: We retrospectively examined all elderly patients who underwent laparoscopic distal gastrectomy or open distal gastrectomy from October 2010 to October 2017 using prospectively collected data. Operative results, hospital courses, and survival rates were compared between the two groups.
Results: Distal gastrectomy was performed in 60 patients, laparoscopically in 20 and through open surgery in 40. The laparoscopic group had significantly lesser intraoperative blood loss (100 mL vs. 300 mL; P < 0.001) and shorter mean postoperative hospital stays (12 days vs. 23 days; P < 0.001). The overall 3-year survival rate was 50.1% in the laparoscopic group and 41.7% in the open group (P = 0.531).
Conclusion: Laparoscopic distal gastrectomy led to a faster return to a full diet and a shorter postoperative hospital stay in our study, and it was well tolerated by elderly patients with advanced gastric cancer.
Ablative techniques (AT) offer a combination of nephron-sparing and minimally invasive approaches. AT include different options and cryoablation (CA) and radiofrequency ablation (RFA) have been relatively safe and traditionally can be either performed laparoscopically or percutaneously. CA and RFA have emerged as a leading option for renal ablation, and compared with surgical techniques they offer benefits in preserving renal function with fewer complications, shorter hospitalization times, and allow for quicker convalescence. A mature dataset exists at this time, with intermediate and long-term follow up data available. Generally, laparoscopic access was the first technique used in the past, and typically for anterior and lateral mass. Afterwards, with the improvements in imaging and percutaneous techniques, laparoscopic approaches are progressively decreased and currently limited in few lesions and in relation with the surgeon's and center's experience. Nevertheless, laparoscopic CA and RFA could be useful techniques and currently, recommendations as a first-line therapy are made at this time in limited populations, including elderly patients, patients with multiple comorbidities, and those with imperative indications of a nephron sparing surgery. As more data emerge on oncologic efficacy, and technical experience continue to improve, the application of AT will likely be extended in future treatment guidelines and laparoscopic approaches will be a valid option in the era of tailored therapy.
Aim: Minimally invasive techniques for esophagectomy decrease cardiopulmonary complications and guarantee better quality of life (QoL) compared to open techniques, without compromising oncological radicality. This retrospective study compares the short-term and QoL outcomes of hybrid Ivor Lewis (HIL) and totally minimally invasive Ivor Lewis (TMIIL).
Methods: Patients with cancer of the distal esophagus and esophagogastric junction were included into (HIL) and (TMIIL) groups in the period January 2017-July 2018. General features, intraoperative and postoperative results were analyzed. The surgical radicality and number of resected nodes were also evaluated. QoL was determined preoperatively and at 7 and 90 days postoperatively with EORTC QLQ-C30 questionnaire.
Results: General features were similar in the TMIIL and HIL groups, which contained 13 and 14 patients, respectively. Median intervention duration was 360 min (range: 240-420) for TMIIL and 330 min (range: 240-400) for HIL (P = 0.0647). Median blood losses were similar for TMIIL and HIL at 100 mL (range: 50-400) and 175 mL (range: 50-350), respectively (P = 0.0831); pulmonary complications were 15% and 14% (P = 1) and leaks were 7% and 14% (P = 1) for TMIIL and HIL, respectively.
Conclusion: Our experience suggests that TMIIL esophagectomy appears to give results similar to HIL and positively influences the QoL within 90 days after surgery. Duration of surgery and anastomotic leaks are the key elements influencing the learning curve. Randomized controlled trials are necessary to confirm the good results obtained and to give recommendations to avoid a high rate of complications during the learning curve for this difficult technique.
The presence of hydronephrosis usually signifies the presence of significant urinary tract obstruction, more commonly at the level of the ureter, and occasionally at the bladder outlet in cases of bilateral hydronephrosis. Unilateral hydronephrosis is most commonly caused by a ureteric stone or stricture, and rarely caused by neoplasm. Metastatic disease to the urinary bladder is rare and usually presents with hematuria, and we report the first case of hydronephrosis resulting from a metastatic esophageal cancer to the bladder.
Aim: Recurrent laryngeal nerve paralysis (RLNP) after esophageal cancer surgery, especially on the left, is a major clinical challenge. We believe that the use of intra-operative neural monitoring can help us to learn and identify surgical maneuvers that can cause RLNP, so as to improve the postoperative course for patients. Thus, the aim of this study was to determine the causes of RLNP and to devise a preventive surgical technique.
Methods: Radical esophageal cancer surgery was performed with intra-operative neural monitoring at our institution from July 2015 to January 2019. The cause(s) of RLNP was investigated by video analysis, which enabled a preventive technique to be developed and introduced. Short-term surgical outcomes of the modified and conventional surgical methods were compared.
Results: RLNP occurred in 10/57 (17.5%) of cases. The causes of paralysis were traction (n = 5), compression (n = 3), thermal injury (n = 1), and compression in cervical procedure (n = 1). Subsequently, 20 surgeries were performed between February and December 2019 using the modified technique and there was only one case (5%) of RLNP.
Conclusion: The main causes of RLNP are compression and traction. Our modified technique for esophageal cancer surgery substantially decreases the incidence of RLNP post-operatively.
Aim: The use of robotic-assisted laparoscopy seems fully adapted to pelvic surgery. However, few studies focus on robotic-assisted abdominoperineal resection (RAAPR). The aim of this study was to assess the feasibility, short-term postoperative outcomes, and pathological results of RAAPR. In addition, we provide a detailed description of the operative procedure and a brief review of the current literature.
Methods: Between January 2013 and April 2018, we performed a total of 428 robotic surgeries, including 294 colorectal resections (68.7%). Data were prospectively collected and included demographics, intraoperative findings, postoperative outcomes, and pathological data. For this study, we included the first 20 consecutive RAAPRs performed with the four-arm da Vinci Si surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA).
Results: Twenty patients (nine men) with a mean age of 68 years and a mean BMI of 24.5 ± 5.0 kg/m2 underwent RAAPR for low rectal adenocarcinoma (80%) or squamous cell carcinoma of the anal canal. Sixteen (80%) patients underwent preoperative pelvic radiotherapy and eight (40%) had a history of previous abdominal surgery. Mean operative duration was 218 ± 52 min. There was no conversion to open surgery. Mortality, reoperation, and morbidity rate were 5%, 25%, and 60%, respectively. Three (15%) patients presented perineal complications. Mean length of hospital stay was 20 days. Three (15%) patients had pT4 tumor. Mesorectal excision was considered complete in 90%. On average, 16.5 ± 7.2 lymph nodes were retrieved.
Conclusion: RAAPR is feasible, with acceptable pathologic and short-term outcomes. The current literature does not demonstrate significant differences between robotic and laparoscopic APR. Indeed, we cannot justify its use in routine on the basis on the available evidence.
The incidence of esophagogastric junction (EGJ) cancer is increasing in the world. EGJ cancer is traditionally classified by the Siewert classification, despite its limitations. The definition and classification of EGJ cancer is a controversial topic. Thus, the best available strategy for the surgical treatment of EGJ cancer remains controversial. This chapter reviews a minimally invasive approaches for EGJ cancer. Most operations for EGJ cancer that are performed by open surgery can be performed minimally invasively. A minimally invasive transthoracic approach (Ivor-Lewis or McKeown esophagectomy) is the optimal surgical approach for Siewert type I cancer. Mediastinoscope-assisted transhiatal esophagectomy, which was recently reported, may be a suitable surgical option, especially for frail patients with Siewert type I cancer. Generally, laparoscopic total or proximal gastrectomy is regarded as the standard for surgerical method for Siewert type III cancer, while both laparoscopic gastrectomy (with lower esophagectomy) or a minimally invasive Ivor-Lewis approach are recommended for Siewert type II cancer. Minimally invasive surgery (MIS) has the potential to shorten the length of hospitalization, reduce the risk of postoperative pulmonary complications, and improve quality of life with a similar margin status, nodal harvest, and survival rate to open techniques. However, as the existing literature is still limited, the choice of surgical method should be judged by the experienced surgeons, especially in MIS. This review reveals that further large clinical stuidies are need to deepen our understanding of MIS for EGJ cancer.
Cross-sectional imaging shows a limited diagnostic accuracy for the histological discrimination of small renal masses (SRM). In this scenario, a renal tumor biopsy is a safe, feasible and effective diagnostic tool that can guide treatment strategy by providing the histological characterization of a SRM. Although nephron-sparing surgery is still considered the gold standard treatment for patients with SRM, more and more evidence suggests that active surveillance (AS) is a reasonable alternative option, especially in old and comorbid patients. Indeed, owing to the relatively slow growth and favorable biology of SRM, AS followed up by, if necessary, a delayed intervention provides an optimal oncological outcome with low rates of systemic progression or death.
This chapter is devoted towards analyzing the progress and barriers to the development of artificial intelligence (AI) and medical robotics in minimally-invasive surgery. The less invasive the surgical intervention and the further the surgeon is from the operating table, the greater the roles of decision support systems (AI) and performance of specific tasks (by medical robots).
Aim: The overall incidence of adenocarcinoma is on the rise, mainly in the western population. Minimally invasive thoracolaparoscopic esophagectomy for adenocarcinoma of gastroesophageal junction tumors is being adopted worldwide, albeit with a slower pace. This study is to share our experience and technical modifications over two decades.
Methods: This a retrospective data from 2009-2018 at a single center, including all the 143 cases of thora-colaparoscopic Ivor Lewis esophagectomies performed. There were no exclusions. The study objectives were to evaluate postoperative recovery, complications, and pathological completeness.
Results: In 11 years, we have performed 532 cases of minimally invasive esophagectomies for both malignant and benign etiologies. Out of which 143 cases were of Ivor Lewis esophagectomy. The mean age of patients was 64.4 ± 10.86 years, and male to female ratio is 3:1. Out of these cases, 139 (97.20%) were performed for malignancy and 4 (2.79%) for benign cases, which include peptic stricture, sigmoid esophagus. The mean operative time is 457.97 ± 79.35 min. The mean blood loss was 138.08 ± 29.3mL. Out of these cases, the hand-sewn anastomosis was performed in 72 (50.34%), circular stapler anastomosis in 46 (32.16%) and, linear stapled anastomosis in 25 (17.48%). The mean lymph node retrieval rate was 22.68 ± 9.49 nodes. The average ICU stay in the postoperative period was 4.68 ± 3.95 days, and overall hospital stay was 13.48 ± 7.43 days. Among malignant cases (139), adenocarcinoma in 121 (87.05%), squamous cell carcinoma in 18 (12.94%). Among these cases T2, lesions in 56 (40.28%), T3 lesions in 77 (55.39%), T4 lesions in 6 (4.31%) The overall complication rate was 12.58% (pneumonia- 8.39%, RLN injury in 1.39%, anastomotic leak in 2.09%, chyle leak in 0.69%, anastomotic stricture in 12.58%). 3 (2.09%) cases had re-intervention in the form of combined endoscopic procedures (stenting) and re-thoracoscopic lavage in 3. Overall 30-day mortality in 1 case (0.69%).
Conclusion: Thoracolaparoscopic esophagectomy with intrathoracic Ivor Lewis anastomosis is an excellent option for selected patients, in experienced hands.
Endo-bronchial tumors are sporadic in the pediatric population. Pneumonectomy is rarely indicated and best to be avoided if possible due to the morbidity it may cause. In children, preserving as much of the lung parenchymal tissue as possible is crucial and maintaining the integrity of the "still maturing" chest wall may reduce the risk of developing scoliosis and chest deformities in the future. The integration of minimally invasive surgical techniques and parenchymal sparing procedures rep-resents the best possible outcome for these patients. Of course, oncological principles should be re-spected when such a procedure is performed. We present the first report in the literature of a "left" upper lobe sleeve resection in an 8 year old patient via a single port video-assisted thoracoscopic surgery technique.
Gastric cancer remains one of the most frequent cancers worldwide. Currently the only potentially curative treatment is surgery, often in combination with perioperative chemotherapy. Gastric cancer surgery is associated with significant morbidity. However, over the last few decades several potential advances have been introduced to improve the treatment for gastric cancer patients. Introduction of laparoscopic gastric cancer surgery has shown promising results and therefore gained popularity worldwide. This review describes an overview of laparoscopic gastrectomy for gastric cancer patients. In general, the introduction of laparoscopic surgery has shown improvement in the short-term outcomes of gastric cancer treatment. Laparoscopic approach for gastric cancer is feasible, safe and should be performed in experienced high volume centres. However, results from randomised trials in advanced gastric cancer are awaited to further determine the effect of a laparoscopic gastrectomy on oncological and long-term outcomes.
The incidence of renal cell carcinoma is rising and its represents the 2%, 3% of all cancers. The increased use of ultrasonography, contrast enhanced ultrasonography, computed tomography and magnetic resonance imaging have resulted in incidentally detected small renal masses (SRMs). SRMs represent a heterogeneous group of tumors that included metastatic lesions, benign, malignant, and cystic lesions. With the increase number of renal incidentalomas, we have seen an increase in therapeutic choices (surgery, ablation therapies and active surveillance). The role of imaging has progressively grown over the decades and became currently a cornerstone that is needed to perform diagnosis, treatment and follow-up of SRMs after ablation treatment. Hence, in this review, we critically assess recent literature on the role of imaging in the context of ablation management of SRMs with a focus on the diagnosis and follow-up protocol.
The current obesity pandemic has a clear impact on quality of life and health resource utilization; hence it has become a significant global health concern. Multiple obesity-related comorbidities such as gastroesophageal reflux disease (GERD) are frequently observed among this patient population. GERD is a complex disease with multiple elements contributing to the failure of the anti-reflux barrier. If left untreated, the excessive reflux of gastric contents into the esophagus can give rise to multiple complications such as esophagitis, strictures, metaplasia, and cancer. When surgical treatment of GERD is indicated in an obese patient, adequate preoperative evaluation and treatment are critical to achieve durable resolution of symptoms attributed to GERD as well as other obesity related comorbidities. To maximize the potential for a positive outcome, when suitable, gastric bypass surgery rather than sleeve gastrectomy or fundoplication should be strongly considered in the obese patient with GERD.
The surgical management of rectal cancers located in the distal rectum presents a unique challenge for surgeons as it is anatomically unfavorable and technically difficult to access. Over the course of the 20th century, novel techniques contributed to the improvement of rectal cancer management and led to improved quality of life for patients following surgical resection. In this article, we explore the background of rectal surgery techniques, which have progressed from abdominal perineal resection to transanal abdominal transanal proctosigmoidectomy, transanal total mesorectal excision (taTME), and ultimately minimally invasive transanal sphincter preserving techniques utilizing single port robotic technology (SPr taTME). In the first clinical experience with the DaVinci SP robot in the United States, we are finding many advantages of this new platform in transanal surgery. The SP offers superior image quality with 3D view, wristed instruments facilitating ergonomics, and superior surgical precision.
One anastomosis gastric bypass (OAGB) is a popular bariatric procedure, but controversies remain regarding biliary reflux and the potential risk of cancer. Esophagojejunostomy (EJ) in rats is a validated and reproducible model for the development of metaplasia [Barett's esophagus (BE)] and esophageal adenocarcinoma (EA) with a minimal exposure of 12 to 20 weeks. We are analyzing the risks of BE and EA in an OAGB rat model and comparing these with the EJ rat model. The purpose of this study is to describe our OAGB and EJ techniques in rats that we used to evaluate biliary reflux and share our experience with scientists and the bariatric community. These operations are short and simple procedures with acceptable morbidity.
We developed a method for mediastinoscopic esophagectomy via a bilateral transcervical and transhiatal approach under pneumomediastinum as a less-invasive radical operation. The right recurrent nerve is first identified using an open approach, and the right cervical paraesophageal lymph nodes and part of the right recurrent nerve lymph nodes are dissected, after which pneumomediastinum is initiated. The upper thoracic paraesophageal lymph nodes and right recurrent nerve lymph nodes are dissected along the right vagus nerve. The dorsal side of the esophagus is dissected along the visceral sheath taking care to avoid thoracic duct injury and is then dissected along the vascular sheath in front of the descending aorta. The esophagus is dissected from the trachea at the caudal side of the aortic arch, and then dissected along the ventral side of the left main bronchus, reaching the pulmonary artery. Finally, the right recurrent nerve lymph nodes around the right subclavian artery are completely retrieved. The left cervical approach is almost the same as that via the right side. The dorsal side of the esophagus is almost dissected along the visceral sheath with a right transcervical approach. The subaortic arch to the left tracheobronchial lymph nodes are dissected using the crossover technique. These lymph nodes are easily dissected by cutting the left and ventral side of the lymph nodes because the caudal side is already dissected in the right transcervical approach. A bilateral (especially right trans-cervico-pneumomediastinal) approach is useful for bilateral upper mediastinal lymph node dissection and esophagectomy.
Sentinel lymph node biopsy is currently the standard of care for axillary staging in early breast cancer patients with no clinical or radiological evidence of axillary lymph node involvement. Novel techniques studied in recent years include the use indocyanine green (ICG) fluorescence imaging, which was reported in a recent network meta-analysis to be comparable to standard dual modality in terms of false negative as well as detection rate. However, there have been no standardized operative methods leading to the underutilization of this modality in clinical practice. In addition, technical limitations such as the difficulty in tracing ICG flow in obese patients further restrict the use of ICG fluorescence in sentinel lymph node biopsy. In this article, we describe in detail the use of the endoscopic-assisted ICG technique in performing sentinel lymph node biopsy, which addresses limitations associated with conventional use of ICG fluorescence imaging. The technical novelty of this technique lies in the fact that it has not been previously described in the literature and it allows for the identification of sentinel lymph nodes with minimal incision and tissue disruption as well.
Robotic-assisted abdominal surgery was introduced with the aim of overcoming the drawbacks of the conventional laparoscopic approach. The present narrative review focuses on the comparison between laparoscopic and robotic-assisted approaches for right colectomy (RC) regarding short- and long-term outcomes, costs, and learning curve. The main technical aspects related to the use of robotic assistance for this specific procedure are further discussed. Minimally invasive RC is considered technically challenging due to the particularities of the right and middle colic vascular anatomy. Robotic RC is not yet widespread due to its high cost and longer operating time. However, its use may result in advantages regarding short-term clinical outcomes, and it facilitates the acquisition of basic surgical skills by speeding up the learning curve of minimally invasive colorectal surgery.
Thoracoscopic surgeries have witnessed tremendous and prompt recent development, especially in the field of uniportal video assisted thoracoscopic surgery (VATS) surgery. It is now possible to perform the most complex surgeries through this technique, which is of great benefit to the patient by significantly reducing the level of postoperative pain and complications of surgery. As surgeons gain experience in this field, their confidence and ability to push the limits and develop technologies are increasing. Performing uniportal VATS surgeries in children is a significant challenge for the surgeon due to the limited size of the thoracic cavity and the difficulty of the instrumentation. Here, we report the first case in the literature (as far as we know) of a uniportal Subxiphoid VATS lobectomy in a 2.5-year-old child. In conclusion, Subxiphoid uniportal VATS lobectomy is feasible in pediatric patients and may have some benefits over the intercostal approach.
Heart transplant is the primary treatment for end-stage heart failure; however, morbid obesity limits candidacy. Bariatric surgery performed in patients with advanced heart failure improves eligibility for heart transplantation. This is the first report of an intra-aortic balloon pump used during laparoscopic sleeve gastrectomy. A patient with morbid obesity and non-ischemic cardiomyopathy was referred for weight loss surgery prior to evaluation for heart transplantation. An intra-aortic balloon pump was placed for aggressive diuresis and cardiovascular support during laparoscopic sleeve gastrectomy. The patient did not suffer any complications or require readmission. The use of an intra-aortic balloon pump as a mechanical circulatory system provided a safe laparoscopic sleeve gastrectomy in a patient with advanced heart failure.
The present article is a historical review intended to trace the most important phases in the development of robotic surgical technology, with a special focus on colorectal surgery. The initial section considers the origin and some etymological aspects of the word "robot". Then, a historical overview traces the development of robotic technology in industry and its implementation within the operating theatres. Finally, the first publications concerning robot-assisted colon and rectal surgery are reported together with a brief state of the art about this issue.
A 67-year-old man complained of the sudden onset of disabling pain in his right leg. He had already undergone full-endoscopic lumbar discectomy, interlaminar (FELD-IL) approach twice for lumbar disc herniation (LDH) at the L4/5 level. MRI showed recurrence of LDH at L4/5 level. Intradural masses were also suspected at the L4 vertebral level. Discography at the L4/5 disc showed contrast medium leakage from the disc to the subarachnoid space. Operation was performed and fragments of the herniated disc were carefully removed under a surgical microscope. The ventral dura mater could be seen adhering to the L4/5 disc. This report is the first documentation of intradural LDH after FELD-IL. Although FELD is less invasive than previous procedures, adhesion between dura mater and surrounding tissues may occur. It is most important to apply discography to confirm the presence of a hole between the intradural space and the disc.
Minimally-invasive conventional up-to-down laparoscopic approach is a widespread alternative for rectal cancer resection. Its potential benefits towards open surgery have been shown to rely, however, at secondary clinical outcomes, and its oncological non-inferiority compared with the traditional open approach has not been demonstrated yet. In this scenario, robotic-assisted minimally-invasive rectal resection has gained increasing popularity and promising expectancies. This narrative review aims to assemble the most updated evidence available and to discuss the future perspectives and challenges for this emergent surgical tool. The main benefit over conventional laparoscopy appears to be a reduction of conversion rates to open surgery, whereas the oncologic and functional outcomes seem similar than the other alternatives. Increased costs are the main limitation of the widespread of robotic technology. Low quality of the current evidence is remarkable.
Surgical treatment for non-achalasia primary esophageal motility disorders is reserved for few situations. Proper selection of patients brings good outcomes with low morbidity, which makes surgical therapy an adequate therapeutic option. High resolution manometry reclassifies esophageal motility disorders. Interestingly, literature is scarce on surgical therapy for this new classification with per oral endoscopic myotomy as the leading treatment.
Gynaecomastia is a benign clinical condition that can occur in men of all ages, attributed by the proliferation of glandular tissue. Most patients are asymptomatic while symptoms ranging from mild discomfort to severe pain can present in patients with gynaecomastia. In addition to these, this condition may affect the psychological well-being of patients leading to a need for further treatment. Medical treatment of primary gynaecomastia in the form of anti-oestrogen therapy has not been proven to be effective and there is no consensus regarding the drug of choice or optimal duration of treatment. Surgical treatment is usually the standard treatment in primary gynaecomastia. There have been various techniques described in the literature with the aim of restoring a pleasant chest shape with limited scar on incision. Most of the techniques however involve the use of a peri-areolar or a Wise pattern incision, which can be obvious, especially in patients with a tendency to scar badly. The authors describe a novel approach, whereby a single-port endoscopic subcutaneous mastectomy using the three-dimensional endoscopic system with incision placed along the anterior axillary line was performed for a patient with gynaecomastia and thereby conferring excellent aesthetic outcomes.
Aim: To analyze the series in literature of pure robotic surgery.
Methods: A complete review of the literature was performed to identify papers with data concerning robotic synchronous treatment of colorectal liver metastases.
Results: Three papers demonstrate the feasibility of this kind of synchronous treatment.
Conclusion: Robotic synchronous treatment of primary tumor and colorectal liver metastasis is feasible and safe.
Even though robotic-assisted surgery is increasingly used for resection of non-small cell lung cancer (NSCLC), data on long-term oncologic outcomes of robotic surgery are still not well defined. The primary endpoint of this review is to analyse the long-term results of robotic lobectomy in NSCLC patients. A systematic research was performed using the PubMed database. Articles published from January 2008 to January 2019 were included. We excluded studies that did not provide results for the long-term outcomes of robotic lobectomy, studies that had fewer than 50 cases and ones that focused on results of sub-lobar resections. Therefore, ten eligible studies were included in this analysis. In total, 2873 patients, with a mean age ranging between 66 and 68 years, who underwent robotic lobectomy for NSCLC, were analysed. Most patients (81%) had early-stage disease. The five-year overall survival for stage I disease fluctuated between 77% and 100%. The five-year disease-free survival was reported to be near 73%. We can conclude that robotic assisted lobectomy is an effective minimally-invasive procedure for lung resection. The current literature shows that robotic lobectomy is associated with long-term survival and lasting disease-free survival, equivalent to those reached by video-assisted thoracic surgery and open approach.
Aim: Currently, there is a paucity of data comparing robotic to traditional video-assisted thoracic surgery stapling devices and the effects on perioperative outcomes during robotic anatomic lung resection. We sought to investigate our institutional experience with patients undergoing robotic anatomic lung resection stratified by the type of stapler used over a contemporary period.
Methods: We performed a retrospective review of a prospectively maintained thoracic surgery database and evaluated all patients who underwent robotic anatomic lung resection between January 2015 and December 2018. Patients were grouped based on the type of stapler used during surgery and preoperative characteristics and intraoperative and postoperative outcomes were compared.
Results: In total, 634 lung resections occurred during the study period. Of those, 236 met inclusion criteria, and 49 cases (20.8%) fully utilized the robotic stapler. We found no clinically significant difference in preoperative or intraoperative characteristics between groups, except operative time was longer in the robot stapler group. This was likely related to surgeon learning curve. There were no differences between groups in postoperative outcomes or complications.
Conclusion: We found equivalent rates of complications, prolonged air leak, and chest tube duration between the two groups. Based on our data, we recommend that surgeons use the stapling device with which they are most confident.
Transanal total mesorectal excision (TaTME) is widely performed for the resection of rectal cancer around the world. However, due to lower body mass index and a lack of necessity, TaTMEs have not been accepted in East Asia as generally as in Western countries. In East Asia, conventional laparoscopic surgeries have been performed with lower rates of open conversions and robotic surgery has been considered as an acceptable option for patients with narrow pelvis. This review article discusses TaTMEs from an East Asian perspective.
Aim: Rates of clinically relevant postoperative morbidity after transanal endoscopic microsurgery (TEM) are low. For this reason, there are few descriptions in the literature on the management of these complications. Because of this lack of information, their importance may be either underestimated or overestimated (in the latter case, leading to overtreatment). The present article reports the frequency of the occurrence of postoperative surgical complications after TEM and describes various approaches to their management.
Methods: An observational study was carried out with prospective data collection and retrospective analysis from June 2004 to June 2019, including all patients undergoing TEM for rectal tumors. All postoperative complications were recorded using the Clavien-Dindo classification (Cl-D), as well as preoperative, surgical, postoperative, and pathological variables.
Results: During the study period, 778 patients underwent TEM, of whom 716 met the inclusion criteria. Postoperative morbidity was 22.1% (158/716). Clinically relevant morbidity (Cl-D > II) was 5% (36/716). The most frequent complication was rectal bleeding, occurring in 115/716 (16.1%) patients; 85 of these 115 (73.9%) patients were grade I Cl-D. Urinary complications were rare (30/716, 4.2%). Similarly, infectious complications of perianal and pelvic abscesses appeared in 7/716 (1%) patients, two of whom required colostomy.
Conclusion: Clinically relevant complications after TEM are rare. For this reason, experience of these complications is limited. Here, we propose a management protocol to ensure that these complications are neither underestimated nor subjected to excessively aggressive or unnecessary treatment.
We present an alternative didactic approach to the esophagogastric junction through an active liver retraction with a laparoscopic palpator. We believe this didactic approach is not necessarily carried by a well-trained team. However, it is a minor modification of the standard operation that has advantages on surgical training in academic centers.
Aim: Transforaminal percutaneous endoscopic lumbar discectomy (TF-PELD) is usually performed under local anesthesia because the patient should be conscious to prevent nerve root injury. However, some patients cannot tolerate intraoperative pain and require intravenous analgesia, or must be converted to surgery under general anesthesia (GA). If PELD under GA can be performed safely, it is more convenient and comfortable for both the patient and surgeon.
Methods: A total of 49 cases (mean age, 53 years) were examined. PELD was performed under GA with free-run electromyography (f-EMG) monitoring. Clinical outcomes were assessed according to the visual analogue scale score (VAS) and the Oswestry disability index (ODI). All patients were monitored with f-EMG.
Results: VAS decreased from 7.7 to 1.1 and ODI from 62.3% to 20.5%. A true-positive was observed in one of 27 TF-PELD cases. Care during the procedure is necessary to avoid the risk of severe neurological injury. A false-negative was observed in one of 22 interlaminar (IL)-PELD cases. This patient complained of aggravated numbness for 6 months after surgery. False-positives were recorded in 2 cases of IL-PELD with a train wave just after removal of the herniated discs.
Conclusion: F-EMG monitoring during PELD under GA was useful to identify nerve root damage. TF-PELD under GA requires f-EMG to ensure safety. On the contrary, IL-PELD does not necessitate f-EMG.
For robotic thoracic surgical patients, minimizing pulmonary complications is the key to decreasing morbidity. Once the pain is controlled, the morbidity associated with thoracic surgery is decreased. Consequently, control of pain is the core requirement in robotic thoracic surgical patients. Appropriate pain control depends on a multifaceted program that is based on an understanding of the pathophysiology of pain. A multifaceted pain control program after robotic surgery needs to address local and systemic pain pathways. This review outlines such a multifaceted program with the use of subpleural catheters for prolonged ambulatory infusion of local anesthetic for 10 days, nonsteroidal anti-inflammatory agents, and measured use of narcotic analgesics.
Aim: We report our four-arm robotic bronchial sleeve anatomical lung resection technique and its early results.
Methods: We retrospectively collected all the four-arm robotic sleeve anatomical lung resections we performed in our institution from February 2014 to August 2019. We reported the results as a series of cases.
Results: During that period, 582 robotic procedures were performed by a single surgeon, of which 486 were major anatomical lung resections. From this group, 10 patients (2%) underwent bronchial sleeve resections. All patients were treated on the right lung. Neither conversion nor major events occurred during surgery. The first bronchial sleeve was performed for Patient 219. The mean length of procedure was 164 (± 43) min. One patient died during hospitalization due to a non-related complication (gastric massive bleeding). Three patients had no complications. Six had minor complications (Clavien Dindo Grade 2) resulting in prolonged length of stay. The mean length of stay was 10 (± 5.7) days. No bronchial fistula occurred. All resection margins were R0.
Conclusion: Four-arm robotic bronchial sleeve is a feasible and safe procedure. Telemanipulation surgery offers excellent technical conditions to ensure a hand-sewed anastomosis and R0 resection. The technical principle and dissection are the same as those of open surgery. Patient selection and mastering of the telemanipulation device are mandatory to perform these complex and rare procedures.
The evolution of video technology and instrumentation have revolutionised the way lung resections are performed without compromising outcomes. In a new thoracic surgery setup, we have adopted the uniportal video assisted thoracoscopic surgery (U-VATS) technique for lung resections in most of our cases. A retrospective review of operative records from July 2017 till June 2019 in Hospital Kuala Lumpur (HKL) for all thoracic surgeries was done. Patients were divided into two groups: those that underwent U-VATS surgery in the first and second year as part of the learning curve. The operative time, blood loss, lymph node yield, duration of drain placement, and length of hospital stay were compared between the groups. The most common indication for U-VATS surgery was malignant lung tumors (21%) followed by ruptured bullae (20%) and empyema thoracis (15%). The average time taken for lobectomies performed for non-small cell lung cancer was 201 min. U-VATS decortication caused the most amount of blood loss with an average of 350 mL, followed by aspergilloma at 315 mL and bronchoplasty at 250 mL. The rest of the procedures had < 150 mL of blood loss. There was no significant difference in the parameters compared between procedures in the two groups.No mortality was seen.The learning curve of U-VATS was used as a guide to gradually increase the complexity of cases performed in a pyramidal manner. U-VATS is an alternative and promising minimal access approach in thoracic surgery that can be safely performed in Malaysia.
Aim: The incidence of adenocarcinoma among lung cancer patients has increased in recent years. We identified the factors affecting lymph node status in patients with primary lung adenocarcinoma who underwent minimally-invasive anatomic resection.
Methods: We retrospectively analyzed the medical records of primary lung adenocarcinoma patients who underwent minimally-invasive anatomic lung resections and mediastinal lymph node dissection between January 2012 and December 2017. We evaluated lymph node positivity and nodal status in each T and histologic subgroup, tumoral prognostic characteristics, minimally-invasive surgical methods and resection type.
Results: Of 473 patients who underwent anatomic resection for lung cancer between January 2012 and December 2017, 274 underwent minimally-invasive anatomic lung resections for primary lung cancer, 158 adenocarcinoma patients were analyzed in this study. Nodal status and number of positive lymph nodes were similar in the stages T1, T2, T3. Lymphovascular invasion (n : 78) and micropapillary predominance tended to be significant predisposing factors for lymph node metastasis. Mean dissected lymph node number was significantly higher in patients who underwent Robot-assisted thoracoscopic surgery compared to Video-assisted thoracoscopic surgery (P < 0.05), and in those who underwent lobectomy compared to segmentectomy (P < 0.05).
Conclusion: We were unable to demonstrate a relationship between T stage and N status. Factors contributing to unexpected N positivity were tumor characteristics that could not be identified in the preoperative period. We recommend performing systematic mediastinal lymph node dissection regardless of the size and histopathologic type of adenocarcinoma. In our study, robotic surgery and lobectomy operation showed superiority in dissecting more lymph nodes.
Aim: After bariatric surgery, a variety of complaints may arise. Identification of the causes of such symptoms is often challenging due to the postoperatively modified anatomy. While standard examinations with upper endoscopy and upper gastrointestinal series might miss the three-dimensional anatomic nature of the problem, quantitative three-dimensional computed tomography volumetry (3D-CT) of the upper gastrointestinal tract offers a novel, adjunctive examination, revealing the detailed anatomy. The aim of this study was to analyse the clinical value of 3D-CT in post-bariatric patients.
Methods: Prospective data of 279 patients, who underwent 3D-CT due to complications after different bariatric procedures, were retrospectively analysed. Directly before examination, the surgical-modified stomach was distended with an effervescent-powder. CT images were 3D-reconstructed and, further, gastric volume was calculated.
Results: In total, 279 patients were examined. Time between surgery and examination was significantly different between Roux-en-Y gastric bypass (n = 168) (54.3 ± 38.6 months) and sleeve gastrectomy (n = 78) (27.8 ± 21.7 months) (P = 0.0001). Others, less numerous, but included procedures were one-anastomosis/mini gastric bypass (n = 11), and dated procedures, such as the vertical banded gastrostomy. The examination allowed calculation of the gastric volume, and the 3D-reconstructions depicted accurately the pivotable anatomic details of the modified upper gastrointestinal tract with 360° view. As a robust result, patients with a higher gastric volume showed more weight regain after sleeve gastrectomy.
Conclusion: 3D-CT is easy-to-perform and facilitates identification of the post-surgical three-dimensional gastric anatomy. It represents a valuable additional diagnostic tool in post-bariatric patients with post-procedural complications. 3D-CT might be an important preoperative tool prior to revisional surgery. In addition, this is the only exact and reproducible calculation of the gastric volume.
Aim: We aimed to evaluate the feasibility of single-port laparoscopic myomectomy in the virgin womb.
Methods: A retrospective chart review of 31 consecutive cases between November 2017 and October 2019 performed by a single surgeon was performed.
Results: The mean age of patient was 50.10 ± 7.79 years old. The mean BMI was 23.55 ± 4.36 kg/m2. The mean number of myoma in single patient was 3.84 ± 2.45 pieces. The mean maximum diameter of myoma in single patient was 11.24 ± 3.27 cm. The mean operation time was 182.32 ± 52.39 min. The mean blood loss was 231.77 ± 238.90 mL. The Visual Analogue Score (VAS) of pain when immediately arriving at the ward after operation was 2.32 ± 1.60. The VAS after 24 h dropped to 1.23 ± 1.43. In total, 119 myomas were removed in our study. There were 15 (48.4%) women with more than four myomas. Fifteen (48.4%) women had more than two myomas that were > 5 cm. There were 58 (48.74%) intramural myomas, with mean diameter of 6.72 ± 4.41 cm. Fifty-two (43.70%) subserous type myoma were removed with mean diameter 2.58 ± 3.35 cm. Posterior myoma accounted for five (4.20%) pieces with mean diameter of 9.30 ± 4.49 cm. The broad ligament type myoma accounted for four pieces (3.36%), and the mean diameter was 3.74 ± 1.87 cm. There were 51 (42.9%) myomas > 5 cm in diameter. Among the different types of myoma, there were 36 (62.1%) intramural type and 6 (11.5%) subserous type, and all posterior and broad ligament type were > 5 cm in diameter. The blood loss and operation time showed no relationship to myoma number. There were differences in blood loss (P = 0.0359) and operation time (P = 0.0537) based on the maximum diameter of myoma. No learning curve was noted in the cumulative sum control chart analysis of the 31 consecutive cases.
Conclusion: In our 31 consecutive cases, the operation time, blood loss, and postoperative VAS score were all comparable to the previously published literature for single-port laparoscopic myomectomy. It is feasible for virgin women with symptomatic myoma to receive single-port laparoscopic myomectomy.
Aim: Bariatric surgery is an effective treatment for morbid obesity that has inevitable complications including postoperative bleeding and staple-line leakage. Erythrocyte sedimentation rate (ESR) can be a clinical indicator for prediction of leakage.
Methods: This retrospective cohort study was done on 1999 patients who underwent sleeve gastrectomy in Erfan Niyayesh Hospital, Tehran, Iran. ESR levels of patients were evaluated in cases which had postoperative leak. Statistical analyses were performed using SPSS software.
Results: Among the 2350 patients, 50 subjects experienced gastric leak (2.12%). ESR mean was 73.1 mm/h for cases, statistically significantly higher in patients with leakage compared to the control group. In addition, ESR serum level mean was 31.34 mm/h for control groups. Other variables including C-reactive protein and platelet count were not statistically significant.
Conclusion: Higher ESR serum level can be seen in various conditions, and, in obese patients who undergo bariatric surgery, it can be a reliable predictor for postoperative gastric leak complication.
Aim: Thoracic sympathectomy is indicated in patients with upper extremity hyperhidrosis. The success of dorsal thoracic sympathectomy is judged by the rates of relief of hyperhidrosis, recurrence, and compensatory hyperhidrosis. We studied robotic selective sympathectomy (RSS) directed at the division of the preganglionic and postganglionic rami without interruption of the sympathetic chain.
Methods: During RSS, the preganglionic and postganglionic sympathetic fibers and communicating rami to intercostal nerves 2, 3, and 4 are divided. The sympathetic chain is left intact.
Results: Forty-seven patients underwent RSS. RSS was performed in a staged fashion with the more symptomatic side first, followed by the contralateral side after at least four weeks. Mean operative time was 67 ± 13 min for unilateral RSS. There was no conversion to thoracotomy. The mean increase in ipsilateral palmar temperature was 1.2 ± 0.3 °C. Median hospital stay was three days (range 1-4 days). Complications included transient heart block after sympathectomy on the second side in 1/47 (2%) and transient partial Horner's syndrome which resolved in two weeks in 1/47 (2%). There was no permanent Horner's syndrome. Relief of hyperhidrosis was seen in 98% of patients. At a mean follow up of 28 ± 6 months, 46/47 (98%) patients were free of sustained compensatory hyperhidrosis.
Conclusion: RSS is associated with excellent relief of hyperhidrosis and the lowest reported rate of compensatory hyperhidrosis.
Transanal minimally invasive surgery (TAMIS) is a surgical technique which allows the local excision of rectal benign tumors and early stage cancers measuring up to 4 cm and lying within 6-8 cm from the anal verge. It is performed by means of a disposable transanal platform and conventional laparoscopic instruments, proving to be effective and easily available. Hence, TAMIS soon became a valid alternative to other transanal resective procedures, especially transanal endoscopic microsurgery, and rapidly spread. Moreover, soon after its introduction, TAMIS started to be performed also using robotic technologies, but no clear advantages were found to date. This review is intended to provide a general overview on TAMIS, with a special focus on its association with robotic systems and the perspectives of this approach.
Bariatric surgeries have proven to be an effective treatment for morbid obesity to reduce the excess body weight of the individuals. Besides weight loss and improvement in metabolic parameters, bariatric surgery procedures can also cause some complications. One of the most common complications observed after bariatric surgery is vitamin deficiencies. Vitamin deficiencies occur due to malabsorptive surgery in patients with absorption disorder and restrictive surgery in patients with inadequate intake. These deficiencies may be accompanied by systematic and neurological findings. Therefore, regular follow-up of patients after bariatric surgery is crucial. If any vitamin deficiency is detected in the patient clinically or biochemically, it is recommended to eliminate this deficiency through supplementation.
Total mesorectal excision (TME) is accepted as the standard technique in rectal surgery. In recent years, significant attention has been focused on transanal TME (taTME) as a promising approach for rectal cancer. However, this approach can involve an inherent risk of male urethral injury, because there is no clear anatomical border between the rectal muscularis propria and rectourethral muscle. We used a lighted urethral stent to identify the urethra during taTME for 6 patients with distal rectal cancer. In five of six cases, an infrared-detecting camera could detect a red fluorescent signal from the lighted urethral stent during the anterior dissection of the rectum, which helped us to determine the correct dissection line. A lighted urethral stent is a useful tool that helps visualize the urethra during taTME and improves taTME applicability in clinical practice.
The surgical approach for lobectomy has changed over time with recent data demonstrating that the majority are performed using a minimally invasive approach. While the use of the robotic platform for pulmonary resection has been shown to have acceptable clinical outcomes, cost and quality of life need to be considered when starting a robotic lobectomy program. In this review, we evaluate the literature on cost of robotic lobectomy and quality of life. The results suggest that early experience in a robotic lobectomy program may be associated with relatively higher index hospital costs when compared to video-assisted thoracoscopic surgery; however, with increased experience and volume, the difference may no longer be of significance. When compared with thoracotomy, the cost is comparable if not less costly and may even be profitable for the hospital. Quality of life appears to be acceptable in the early experience of robotic lobectomy.
Obesity is a growing epidemic affecting more than one third of the United States' population. It has detrimental effects on an individual's health and is associated with myriad negative outcomes including increased mortality. It also poses a substantial financial burden on the healthcare system. Weight loss surgery is an effective way of treating obesity with tremendous positive outcomes. Most patients who undergo bariatric surgery lose a significant amount of weight, reverse most of their comorbidities, and enjoy an improved quality of life. However, fewer than one percent of patients eligible for bariatric surgery actually undergo treatment. Furthermore, there exists a considerable gender disparity, with women comprising 80% of those patients who undergo bariatric surgery, despite equal obesity rates across genders. Many barriers exist between obese patients and weight loss surgery including misconceptions among patients and primary care providers regarding the perceived risk of surgery. This is in addition to numerous other psychosocial and cultural factors that may have contributed to and precipitated the existing gender imbalance. This review aims to highlight barriers to patients undergoing bariatric surgery and examine factors leading to the gender disparity that exists.
Aim: We report our experience in minimally invasive thoracic robot-assisted surgery in children, and a current analysis is carried out on this topic.
Methods: Observational, prospective, and longitudinal studies were performed for children with thoracic pathology treated with robotic surgery, from March 2015 to April 2019. We used the "da Vinci surgical system" (Intuitive Surgical, Inc., Sunnyvale, CA. USA). Registered variables included demographic data, diagnosis, surgery, total time, time of console surgery, bleeding, hemotransfusions, conversions, complications, postoperative (PO) stay, and follow-up. Measures of central tendency were used. Research Ethics Committee of Hospital approved the study. We conducted a detailed non-systematic review of previous publications of children undergoing thoracic robotic surgery.
Results: We treated 11 children, with average age of 5.7 years and weight of 21.3 kg. Diagnosis were: congenital cystic adenomatoid malformation, intralobar sequestration, diaphragmatic paralysis, diaphragmatic eventration, mediastinal teratoma, Ewing's tumor of the fourth left rib, and pulmonary tuberculosis. Surgeries performed were: four lobectomies, four diaphragmatic plications, two tumor resections, and a case of pleural and lung biopsies. The average of console surgery time was 166.45 min, PO stay was 3.6 days, and follow-up was 24.7 months. Conversions and PO complications were 9.1%, and there were no intraoperative complications and mortality. Currently, the number of children treated with thoracic robot-assisted surgery has barely reached 100 cases.
Conclusion: Our results are encouraging, although our experience is limited to a few cases. Robotic surgery for the treatment of thoracic pathology is feasible and safe, and has advantages. To date, very few patients have been treated, and few pediatric surgeons worldwide have applied thoracic robotic surgery in children.
Aim: Laparoscopic anterior esophageal myotomy with a Dor anterior fundoplication is the most commonly performed surgical myotomy procedure. A lateral esophageal myotomy without an antireflux procedure performed through a left thoracotomy has been associated with the lowest rate of postoperative gastroesophageal reflux and the highest rate for relief of dysphagia. The surgical robot allows for the lateral myotomy procedure to be performed by laparoscopy rather than thoracotomy. We studied our experience with Robotic Lateral Heller Myotomy Without Fundoplication (RLHM) for achalasia.
Methods: A retrospective review was conducted of the patients with achalasia who underwent RLHM. All patients completed a subjective dysphagia score questionnaire, received an Eckardt Score, and underwent manometry and pH testing preoperatively, as well as at 6 and 12 months following the myotomy procedure.
Results: Forty-eight patients underwent RLHM. The median operating room time was 85 min (range 60-132 min). There was no conversion to a laparotomy. Median hospitalization was 2 days (range 2-3 days). There were no mucosal perforations, complications, or deaths. Following RLHM, the Lower Esophageal pressure decreased from 35 mmHg (range 18-120 mmHg) to 13.2 mmHg (range 9.8-16.6 mmHg) (P < 0.0001). The length of the Lower Esophageal high-pressure xone decreased from 5.5 cm (range 4-9 cm) to 2.2 cm (range 1.5-2.8 cm) (P < 0.0001). Two patients (2/48) (4.2%) had pathologic gastroesophageal reflux. The median acid exposure in all patients was 0.4% (range 0%-17.8%), and the median Demeester score was 7.5 (range 2-125). The Eckardt score decreased from 6.3 ± 1.8 to 0.8 ± 1.8 at 1 month (P < 0.0001), and 0.8 ± 1.1 at 12 months (P < 0.0001).
Conclusion: RLHM is associated with excellent relief of dysphagia and a low incidence of new gastroesophageal reflux.
Locally advanced non-small cell lung cancer (NSCLC) has historically been defined as Stage III by the IASCLC staging. While the workup for these patients has been standardized, the treatment algorithms remain unclear. The use of neoadjuvant chemotherapy, radiotherapy, and now immunotherapy still awaits results in terms of optimal regimen. Surgery for local disease control is routinely used and this group of patients have historically been treated with open thoracotomy for resection. Only in the last 10-20 years have minimally invasive surgical methods been applied for treatment. Video-assisted and robotic-assisted thoracoscopic surgery have retrospectively been shown to be safe and effective with equivalent or better perioperative outcomes, long-term overall and disease-free survival, mediastinal lymph node staging to open thoracotomy, and the ability to operate on patients who are too sick for thoracotomy. This review shows that minimally invasive surgery for treatment of locally advanced NSCLC disease should now be routinely offered to patients as the initial surgical method of resection.
Obesity is an expanding threat globally. Several surgical procedures have been developed to achieve the best outcomes in obesity. One of them is laparoscopic sleeve gastrectomy that was first applied in 1999 to initiate weight loss in overweight patients. Laparoscopic sleeve gastrectomy is a restrictive bariatric technique consisting of subtotal partial vertical gastrectomy with the preservation of the pylorus, and a gastric tube is created as a continuation of the esophagus along the lesser curvature with the resection of the fundus, corpus, and antrum. Although this technique is routinely-applied all over the world, the technical details are still controversial. This review aims to define the tips and tricks for the sleeve gastrectomy technique and discuss the controversial subjects in this technique.
Aim: The purpose of this study is to investigate the efficacy of surgical management in ovarian endometrioma for early disease control and long-term fertility preservation in adolescents and women of very young age. A history of cyclic pains in adolescents is highly associated with endometriosis. Sonography enables the diagnosis of small endometriomas 1-2 cm in diameter. Although it is obvious that the risk of damage to normal ovarian tissue is diminished when operating and removing a 2 cm endometrioma, it is not approved since there are currently no tools available to identify at-risk patients. Additionally, performing laparoscopic surgery with 5 mm instruments in patients with small endometriomas will likely cause more harm than benefit.
Methods: A literature review was performed using key words for endometrioma surgery, in vitro fertilization (IVF), implantation rate, pregnancy rate and adolescents. The pros and cons of surgical removal prior to assisted reproductive therapy (ART), outcomes of endometrioma surgical treatment before IVF, and current recommendations for endometrioma removal were investigated.
Results: The total patient population from articles supporting removal of endometrioma before assisted reproductive therapy and evidence against were 30,741 and 9983 respectively. However, the only study reporting a statistically significant result found an 8.2% implantation rate for the surgical removal group vs. 12% in the direct-to-IVF group, and 14.9% pregnancy rate in the surgical removal group vs. 24.9% in the direct-to-IVF group. Damage to ovarian reserve and function due to surgery is exacerbated by large cyst size, stripping of the pseudocapsule and older age. Larger endometrioma, ablation of the endometrioma base and younger age are associated with higher recurrence rate.
Conclusion: The patient's age, in addition to the size and type of endometrioma, can direct and indicate the timing of surgical management. Bilateral endometriomas and those larger than 7 cm are associated with more damage to ovarian reserve due to disease and surgery, as compared with unilateral lesions and those smaller than 7 cm. High-risk adolescents and very young women seeking fertility treatment can thus benefit from an early diagnosis of endometrioma. Treatment by trans vaginal hydro-laparoscopy of selected cases can probably be suggested for the treatment of small endometriomas, since 5fr instruments are used following microsurgery principles. Therefore, an early diagnosis of endometrioma, especially in young patients, must be encouraged, improved and standardized, through stepwise clinical reasoning and diagnostic testing.
More and more data are available on the benefits of minimally invasive thoracic surgery compared to open thoracic surgery in the curative treatment of early-stage non-small cell lung cancer. However, results are conflicting, especially when video-assisted thoracoscopic surgery (VATS) is compared to robotic-assisted thoracoscopic surgery (RATS) for lobectomy. Our goal is to report the main results of recent systematic reviews and meta-analyses comparing RATS, VATS, and open surgery for lobectomy. Using PubMed database, we selected systematic reviews and meta-analyses, which compared the short-term outcomes of patients treated by RATS, VATS, or open surgery for lobectomy. In all but one of the systematic reviews, robotic lobectomy allowed similar short-term outcomes as VATS lobectomy and better short-term outcomes than open surgery. One meta-analysis by O'Sullivan et al. found that robotic lobectomy was associated with fewer adverse events (P < 0.00001) and lower 30-day mortality (P = 0.001), compared to VATS lobectomy. Robotic lobectomy could be a valid alternative to VATS and open lobectomy. Short-term outcomes do not appear to be different between VATS and RATS cohorts, except in one recent meta-analysis, which reported the superiority of RATS compared to VATS. Without cost analysis and randomized controlled trials with long-term outcomes, no strong conclusions can be drawn.
Nodal upstaging takes place when unsuspected lymph node metastases are detected by pathological evaluation, after surgical treatment for non-small cell lung cancer. In early stages non-small cell lung cancer, nodal upstaging amounts to 4.8%-24.6%, depending on several factors, such as accuracy of preoperative staging, localisation and size of tumour and number of lymph nodes removed. Nodal upstaging is considered a surrogate of the completeness of thoracic oncologic surgery; for this reason, various studies focus on the evaluation of its rate in the different surgical approaches used to treat lung cancer. In this analysis, a high percentage of upstaging is observed in robotic surgery, having similar values to open surgery results, usually considered the gold standard in terms of oncologic radicality. In fact, thanks to its features, robotic surgery allows carrying out a thorough lymphadenectomy in the most comfortable manner, ensuring an excellent vision and manoeuvrability of the instruments even in the most remote areas of the thorax. According to these results, robotic surgery constitutes a safe and radical surgical option, showing encouraging results on the efficacy of lymphadenectomy and, consequently, on its the long-term outcomes.
The incidence of bariatric surgery is increasing exponentially. The number of bariatric surgeries performed in the United States has significantly increased in the past decades. Complications of bariatric surgery can present days to years postoperatively. Advances in endoscopic procedures and technology has made it possible to address many complications endoscopically. We describe the most common complications after bariatric surgery and the endoscopic treatment options available to date.
Transanal surgery has evolved significantly in the past few decades. With the technological advancements of endoscopic systems, minimally invasive approaches in transanal surgeries are quickly increasing in popularity. Transanal endoscopic microsurgery was developed initially with subsequent transanal minimally invasive surgery (TAMIS) being introduced as an alternative in 2009. Over the past decade, more and more papers have been published on TAMIS, regarding the management of benign/malignant rectal lesions as well as repair of anastomotic leaks, anastomotic strictures, rectovaginal/rectourethral fistula, etc. This review details the progress of transanal surgery and the use of TAMIS in different scenarios.
Esophageal cancer persists as one of the most common causes of cancer-related death and 5-year survival remains poor at 20%. Surgical resection is the gold standard for treatment and cure, and the development of minimally invasive surgery has increased the popularity of robotic-assisted minimally-invasive esophagectomy. The benefits described include less morbidity and greater patient satisfaction compared to open techniques. Nevertheless, institution capabilities and surgeon experience are strong determinants of whether a robotic program will be adopted for oncologic esophageal care. Thus, we review the available literature regarding the history of esophagectomy, evolution to minimally invasive approaches, the introduction of robotic-assisted esophagectomy including its respective outcomes in comparison to open and minimally invasive approaches, and future directions.
The recent improvement in surgical techniques for non-small cell lung cancer enables evident better results in term of postoperative recovery with lower adverse events. Even though the interest in minimally invasive procedures has increased, more subjective advantages are not always so apparent in the literature. There is indeed a growing interest in the daily life of patients including their management of physical and emotional pain, the perception of quality of life, and pulmonary function recovery. This review aims to highlight the advantages of minimal invasive surgery on pain, quality of life, and functional pulmonary recovery after lobectomy alone for early stage non-small cell lung cancer. Minimal invasive techniques or limited sparing open techniques offer better results in term of postoperative pain than open non-sparing techniques, allowing a lighter analgesia protocol. However, these clear benefits seem to disappear in the mid-term postoperative period. Studies suggest that minimal invasive surgery is non-inferior to thoracotomy in terms of quality of life, and seems to give patients at least a better vision of their health, but larger-scale studies are needed to demonstrate its superiority. Data show clear advantages in the postoperative pulmonary function recovery for minimal invasive surgery compared to that of open procedures, although sparing and anterior incisions can show equivalence. That benefit does not seem to persist in the mid and long term. Nevertheless, the posterolateral thoracotomy appears to have the worse effect on the loss of pulmonary function.
Aim: The advantages and feasibility of video-assisted thoracoscopic surgery (VATS) in the surgical management of early resectable thymoma and thymic hyperplasia have largely been described and adopted in many thoracic surgery units. In order to allow for resection of all immunogenic thymic cells in patients with myasthenia gravis, surgical removal of the whole thymus gland including perithymic and pericardiophrenic fatty tissue becomes imperative. It is also important to achieve radical resection and excision in cases of thymoma.
Methods: Numerous technical variations of VATS thymectomy have been reported in literature. In this study, the surgical technique of a minimally invasive, extended thymectomy through a bilateral approach is illustrated with key features highlighted.
Results: In our experience, no conversion to the open transternal approach, surgical mortality or major complications were observed; the median length of hospital stay was 3 days.
Conclusion: Bilateral video-assisted extended thymectomy is an effective, safe and well-tolerated approach, with surgical benefits and clinical outcomes similar to other thoracoscopic techniques.
Total mesorectal excision remains the gold standard for surgical treatment for rectal cancer to achieve excellent oncological outcomes. The transanal approach to the mesorectum was introduced to complement conventional surgery so that technical difficulties related to the distal rectal dissection could be overcome. Since its introduction, interest in transanal mesorectal excision has been growing and it appears that the benefits are maximal in patients with mid-low rectal cancer where anatomical and pathological factors present the greatest challenges. Current evidence demonstrates this approach is safe and feasible, with an acceptable morbidity profile, but with specific complications related to the technique. Oncological and functional data seem comparable to the conventional approaches, but most of the results come from small studies with short-term endpoints. Robotics, when available, might potentially overcome the difficulty of distal rectal dissection with a shorter learning curve compared to the transanal approach, but with higher costs. The aim of this review is to critically evaluate the available literature concerning transanal total mesorectal excision so that we can better define its role in the management of rectal cancer.
Advanced heart failure (HF) prevalence is increasing and ranges between 1% and 10% of the overall HF population, due to the growing number of patients with HF and their better treatment and survival in the last 20 years. The best treatment for these patients is represented by heart transplantation, which, unfortunately, is only available for a minority of them. A significant portion of patients with advanced HF has concomitant severe mitral regurgitation, which acts as a driving force in inducing and maintaining this end-stage condition in a vicious cycle. Percutaneous mitral valve repair with MitraClip is a treatment option to stop this vicious cycle, providing safer outcomes and clinical benefits in some of these patients. Preliminary clinical observations show a possible selective role for percutaneous mitral valve treatment with MitraClip as a bridge to transplantation, candidacy or recovery. Further evidence will be necessary to confirm these preliminary data and support this new treatment framework of patients with advanced HF.
Aim: Esophagectomy is associated with several post-operative complications (50%-70%) due to surgical trauma. Minimally invasive techniques have therefore been applied to decrease mortality and morbidity. Robot-assisted minimally-invasive esophagectomy (RAMIE) was developed to overcome the drawbacks of the thoraco-laparoscopic approach. The objective of this systematic review is to report some recent experiences and to compare RAMIE with other approaches to esophagectomy, focusing on technical and oncological aspects.
Methods: Pubmed, Embase and Scopus databases were searched for "robot-assisted esophagectomy", "minimally invasive esophagectomy" and "robotic esophagectomy" in January 2020. The study was focused on original papers on totally endoscopic RAMIE in the English language. No statistical procedures (meta-analysis) were performed.
Results: Three hundred and twenty studies were identified across the database and after screening and reviewing, 14 were included for final analysis. The overall 90-day post-operative mortality after trans-thoracic esophagectomy ranged from 0% to 9% and did not differ between approaches. Post-operative complications ranged between 24% and 60.9%: respiratory (6.25% to 65%), cardiac (0.8% to 32%), anastomotic leak (3.1% and 37.5%) and vocal cord palsy (9.1%-35%) were the most frequent. The evidence for long-term outcomes is weak, with no significant differences in overall survival, disease-free survival and recurrence identified in comparison with other approaches. The selected papers showed that RAMIE had comparable outcomes between the open and thoraco-laparoscopic approaches within a multimodal treatment pathway.
Conclusion: RAMIE also seems to be associated with better lymph node dissection, nerve sparing and quality of life, but larger studies are needed to obtain more evidence.
Thymectomy is an effective treatment option for the management of myasthenia gravis, as demonstrated by a recent multicenter randomized clinical trial. Complete removal of all thymic tissue, including ectopic foci, increases the chance of achieving a remission or a substantial improvement of the disease; therefore, extended transsternal thymectomy was long considered the procedure of choice. Over the years, several minimally invasive approaches have been proposed, with the aim to reduce perioperative morbidity and to improve aesthetics; however, concerns exist that through such approaches, it may not be possible to achieve a complete resection. Robotic thymectomy seems to overcome many of the limitations associated with other minimally invasive approaches. The available evidence suggests that robotic thymectomy for myasthenia gravis is a safe procedure, and that long-term neurological outcomes are satisfactory.
Transcatheter mitral valve implantation provides an off-pump treatment option for mitral valve regurgitation, especially for secondary mitral regurgitation. It offers an opportunity for the treatment of a large cohort of patients not referred for conventional surgery. One of the biggest challenges is the development of a valved stent that suits the complex anatomy of the native mitral valve. Furthermore, secure anchorage of the device is difficult in the mitral area without clearly defined structures. In the last few years, various new self-expanding nitinol valved stents for transapical implantation in the beating heart have been developed. Different design iterations were conducted to improve fixation and overall stent performance. The risk of paravalvular leakage was decreased and reproducibility enhanced. This article reviews the major achievements in the development process of our apically fixed mitral valved stent over the last few years, with prototypes that provide secure stent deployment, high reproducibility and low paravalvular leakage rates.
The steady increase in bariatric surgery has led to room for innovation. Endoscopy has become an important tool for evaluation, diagnosis, management of complications, and even for primary bariatric interventions. Leaks are the most feared complication and new endoscopic therapies have been developed such as septotomy, double-pigtail stents, and endoscopic vacuum therapy. Additionally, primary bariatric endoscopic procedures are gaining popularity and the new procedures include intragastric balloons, stoma reduction, aspiration therapy, among others. The altered anatomy and reoperation increase the risk of complications after bariatric surgery, especially when managing conditions like achalasia, gastroparesis, and cholelithiasis. Per-oral endoscopic myotomy, per-oral pyloromyotomy, and endoscopic ultrasound-guided transgastric endoscopic retrograde cholangiopancreatography provide a less invasive approach to address these conditions. This narrative review article intends to expose current endoscopic therapies for the management of primary bariatric procedures, complications and related conditions.
As the obesity epidemic continues to grow, the need for effective management strategies is more important than ever. There are several medical, endoscopic, and surgical management options available. The last decade has seen a rise in endoscopic bariatric interventions. These minimally invasive therapies can be used for patients who do not qualify or are unwilling to undergo bariatric surgery. Currently, there is limited formal training in bariatric endoscopy. In this commentary, we discuss our experience in establishing a center for bariatric endoscopy at a large academic medical center.
Surgical resection is treatment of choice for early stage non-small cell lung cancer, even though 20%-30% of patients do not undergo surgery. Compared to conventional fractionated radiotherapy, stereotactic body radiotherapy (SBRT) has demonstrated excellent local control (LC) and overall survival (OS). Central and ultra-central lesions present higher toxicity rates after SBRT because of their proximity to mediastinal structures. Dose escalation studies have documented that 10-12 Gy per fraction is the maximal tolerable dose with acceptable rates of treatment adverse events and survival. Peripheral lesions can be safely treated with high radiotherapy dose (biologically equivalent dose of ≥ 150 Gy) and a different SBRT dose schedule has showed comparable results with LC rates > 90% and OS comparable to surgical resection. Elderly patients, defined as 75 years or older, are a subgroup of patients who may benefit the most from SBRT, as they have higher morbidity and mortality risks because of comorbidities and decreased lung function. At present, there are no randomized studies comparing SBRT with surgery for patients who are potential candidates for surgical removal. Retrospective studies and systematic reviews have showed encouraging results in terms of cancer-specific survival and LC.
Aim: We have recently standardized upper mediastinal lymph node dissection (UMLND) based on microanatomical concepts in minimally invasive esophagectomy using a 4K ultra-high-definition (HD) system. In this study, the aim was to investigate the outcomes of microanatomy-based standardization using 4K ultra-HD for UMLND with the main focus on thoracoscopic operative time.
Methods: We have performed more than 500 cases of thoracoscopic esophagectomy in the prone position as minimally invasive esophagectomy. After about 400 cases of thoracoscopic esophagectomy in the prone position, we established the microanatomy-based standardization of UMLND using a 4K ultra-HD system. Two groups were analyzed: a pre-standardization group (n = 100) and a post-standardization group (n = 100). Furthermore, the change in our thoracoscopic operative time for all cases was analyzed using the moving average method.
Results: In the post-standardization group, the rate of surgeries performed by operators with less than 20 years' experience was significantly higher (P < 0.001). There were no significant differences in the number of mediastinal lymph nodes dissected, intraoperative blood loss and total postoperative morbidity rates between the two groups. The rate of recurrent laryngeal nerve palsy decreased to less than half (19.8% to 9.6%) (P = 0.061) and the thoracoscopic operative time decreased [232.0 (202.8-264.0) min to 209.0 (176.0-235.0) min] significantly (P < 0.001) after standardization. The moving average showed a marked decrease of thoracoscopic operative time during the standardization phase.
Conclusion: Microanatomy-based standardization enabled quicker and more precise UMLD despite an increase in the number of surgeries performed by less experienced operators.
Much effort has been made to improve outcomes and/or minimize the invasiveness of esophagectomy for thoracic esophageal cancer. This has led to the evolution from open esophagectomy to thoracoscopic minimally invasive esophagectomy (MIE), and from MIE to robot-assisted minimally invasive esophagectomy (RAMIE). RAMIE is being applied clinically to overcome the limitations of MIE. In this article, we review the trends in the evolution from thoracoscopic MIE to RAMIE. It has now been demonstrated that RAMIE is both safe and feasible, and may decrease morbidity and mortality rates associated with esophagectomy and improve oncological outcomes. On the other hand, there are still many problems that need to be solved.
Thoracic sympathectomy is used for the palliation of hyperhidrosis. However, significant controversies surround the optimal surgical approach and the extent of sympathectomy. The determinants of success in the surgical palliation of hyperhidrosis are the postoperative rate of anhidrosis, recurrence of symptoms, and rate of compensatory hyperhidrosis. This paper attempts to shed light on the controversies by examining the historic background, clearly defining the anatomic considerations, and outlining the various surgical approaches culminating with robotic selective dorsal thoracic sympathectomy.