Pub Date : 2024-09-13DOI: 10.1097/dcr.0000000000003354
Sergey K Efetov,Arina K Rychkova,Yaroslav P Krasnov
BACKGROUNDLaparoscopic approaches and robot-assisted operations are used for colorectal cancer surgery because of their minimal invasiveness.1 However, changes in intra-abdominal pressure during laparoscopy can lead to cardiovascular complications in compromised patients;2 obesity and intraabdominal adhesions may further interfere with laparoscopic procedures. The retroperitoneal approach may facilitate minimally invasive surgery, even in patients with comorbidities. The technique for high ligation of the inferior mesenteric artery has been described in left colonic surgeries.3 However, complete termination of the blood supply through this artery may lead to a higher frequency of anastomotic leakage.4.IMPACT OF INNOVATIONWe present a novel retroperitoneal approach for D3-lymph node dissection with low ligation of the inferior mesenteric artery and preservation of the left colic artery. This method can reduce the duration of laparoscopic procedures for compromised patients and meet the standards for extended lymph node dissection with tumor-specific mesocolic excision.5,6.TECHNOLOGY MATERIALS AND METHODSThe procedure started with the installation of a paraumbilical optical trocar to introduce a 30-degree optical system. The SILS™ Port (Covidien, Medtronic) was inserted into the retroperitoneal space via a 4-cm incision, made 2 cm below and parallel to the anterior superior iliac spine in the left flank under the control of the optical system. The horizontal aspect of the duodenum served as the cranial landmark during interfascial dissection, with the dissection proceeding in a cranial and medial direction. During the dissection, the left ureter was the primary landmark, passing medial to the gonadal vessels and Gerota's fascia.The aorta was exposed medially and the inferior mesenteric artery was identified. The inferior mesenteric artery was skeletonized from its origin until the branching of the left colic artery and the sigmoid artery. The left colic artery was skeletonized until the passage of the inferior mesenteric vein, and the apical lymphatic nodes with mesocolic tissue were mobilized and excised. The inferior mesenteric artery was cut below the left colic artery.The final step was performed laparoscopically. The parietal fascia along Toldt's line was cut laterally to complete the mesocolon excision. The parietal fascia was cut along the right side of the aorta to free the mesocolonic medial border. The sigmoid mesocolon was dissected at the proximal and distal resection margins.Following mobilization, the colon was cut 10 cm distal to the tumor margin using a linear stapler. The specimen was then extracted using an SILS incision. The sigmorectal anastomosis was made. Atypical hepatic resection was performed using two additional trocars.PRELIMINARY RESULTSThe incidence of pain syndrome in the early postoperative period was low. Blood loss reached 100 mL. The duration of the surgery was 300 min. The retroperitoneal step took 63 min. Metasta
{"title":"Retroperitoneal Approach to D3-Lymph Node Dissection With Left Colic Artery Preservation in the Treatment of Sigmoid Cancer.","authors":"Sergey K Efetov,Arina K Rychkova,Yaroslav P Krasnov","doi":"10.1097/dcr.0000000000003354","DOIUrl":"https://doi.org/10.1097/dcr.0000000000003354","url":null,"abstract":"BACKGROUNDLaparoscopic approaches and robot-assisted operations are used for colorectal cancer surgery because of their minimal invasiveness.1 However, changes in intra-abdominal pressure during laparoscopy can lead to cardiovascular complications in compromised patients;2 obesity and intraabdominal adhesions may further interfere with laparoscopic procedures. The retroperitoneal approach may facilitate minimally invasive surgery, even in patients with comorbidities. The technique for high ligation of the inferior mesenteric artery has been described in left colonic surgeries.3 However, complete termination of the blood supply through this artery may lead to a higher frequency of anastomotic leakage.4.IMPACT OF INNOVATIONWe present a novel retroperitoneal approach for D3-lymph node dissection with low ligation of the inferior mesenteric artery and preservation of the left colic artery. This method can reduce the duration of laparoscopic procedures for compromised patients and meet the standards for extended lymph node dissection with tumor-specific mesocolic excision.5,6.TECHNOLOGY MATERIALS AND METHODSThe procedure started with the installation of a paraumbilical optical trocar to introduce a 30-degree optical system. The SILS™ Port (Covidien, Medtronic) was inserted into the retroperitoneal space via a 4-cm incision, made 2 cm below and parallel to the anterior superior iliac spine in the left flank under the control of the optical system. The horizontal aspect of the duodenum served as the cranial landmark during interfascial dissection, with the dissection proceeding in a cranial and medial direction. During the dissection, the left ureter was the primary landmark, passing medial to the gonadal vessels and Gerota's fascia.The aorta was exposed medially and the inferior mesenteric artery was identified. The inferior mesenteric artery was skeletonized from its origin until the branching of the left colic artery and the sigmoid artery. The left colic artery was skeletonized until the passage of the inferior mesenteric vein, and the apical lymphatic nodes with mesocolic tissue were mobilized and excised. The inferior mesenteric artery was cut below the left colic artery.The final step was performed laparoscopically. The parietal fascia along Toldt's line was cut laterally to complete the mesocolon excision. The parietal fascia was cut along the right side of the aorta to free the mesocolonic medial border. The sigmoid mesocolon was dissected at the proximal and distal resection margins.Following mobilization, the colon was cut 10 cm distal to the tumor margin using a linear stapler. The specimen was then extracted using an SILS incision. The sigmorectal anastomosis was made. Atypical hepatic resection was performed using two additional trocars.PRELIMINARY RESULTSThe incidence of pain syndrome in the early postoperative period was low. Blood loss reached 100 mL. The duration of the surgery was 300 min. The retroperitoneal step took 63 min. Metasta","PeriodicalId":11299,"journal":{"name":"Diseases of the Colon & Rectum","volume":null,"pages":null},"PeriodicalIF":3.9,"publicationDate":"2024-09-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142259740","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-12DOI: 10.1097/dcr.0000000000003482
Kamil Erozkan,Olga Lavryk,Emre Gorgun
BACKGROUNDSubmucosal dissection using the da Vinci SP® system (Intuitive Surgical, Sunnyvale, CA, USA) is an emerging approach for treating premalignant lesions in the colon and rectum. The endoluminal space is tight and small, and during the procedure, this tight space is accessed by the 40 mm GelPOINT® Path transanal platform (Applied Medical, Rancho Santa Margarita, CA, USA). Most of the trocar space is occupied by the 25 mm port of the da Vinci SP® system. There is limited space for an additional trocar, and the full mobility of this trocar is restricted; hence there is a need for an effective suction irrigator during these procedures. Although the da Vinci SP® system has four instrument capabilities, it does not have a suction irrigation instrument. To address this issue, we tested a Remotely Operated Suction Irrigation System (ROSI™) (VTI, Nashua, NH, USA) in three patients undergoing da Vinci SP® submucosal dissection.IMPACT OF INNOVATIONThe impact of innovation is the evaluation of a flexible suction irrigator during endorobotic submucosal dissection (ERSD), addressing space constraints and enhancing surgical precision.TECHNOLOGY MATERIALS AND METHODSThis was a single-center retrospective observational study involving three patients who underwent ERSD, between February 2023 and May 2023. ROSI™ was used selectively for rectal lesions.PRELIMINARY RESULTSThe first patient was a 67-year-old male with a 30 mm tubulovillous adenoma found in the rectum at 4 cm. The second patient was a 49-year-old female, referred after a screening colonoscopy, with a 40 mm rectal mass 12 cm from the anal verge. A biopsy revealed a tubular adenoma without dysplasia. The last patient was a 66-year-old male with a 25 mm tubulovillous adenoma with a focal high-grade dysplasia at 10 cm. There was no evidence of invasive carcinoma or lymph node metastasis on MRI in any of the patients. The patients were placed in a modified lithotomy position, and the GelPOINT® Path was inserted. A silk suture was attached at the proximal end of ROSI™ to facilitate tubing manipulation. ROSI™ was freely passed into the endoluminal space through the gel using a surgical clamp. Any bleeding during the operation was aspirated and irrigated using ROSI™ with the assistance of bipolar forceps. All surgeries were completed without complications and the patients were discharged on the same day.CONCLUSION AND FUTURE DIRECTIONSROSI™ is a flexible foot pedal-controlled suction irrigator that can facilitate da Vinci SP® submucosal dissection. The flexibility and controllability of ROSI in the surgeon's hand may qualify it as an essential tool for performing ERSD and possibly other TAMIS procedures.
{"title":"Using Remotely Operated Suction Irrigation System in da Vinci SP Submucosal Dissection.","authors":"Kamil Erozkan,Olga Lavryk,Emre Gorgun","doi":"10.1097/dcr.0000000000003482","DOIUrl":"https://doi.org/10.1097/dcr.0000000000003482","url":null,"abstract":"BACKGROUNDSubmucosal dissection using the da Vinci SP® system (Intuitive Surgical, Sunnyvale, CA, USA) is an emerging approach for treating premalignant lesions in the colon and rectum. The endoluminal space is tight and small, and during the procedure, this tight space is accessed by the 40 mm GelPOINT® Path transanal platform (Applied Medical, Rancho Santa Margarita, CA, USA). Most of the trocar space is occupied by the 25 mm port of the da Vinci SP® system. There is limited space for an additional trocar, and the full mobility of this trocar is restricted; hence there is a need for an effective suction irrigator during these procedures. Although the da Vinci SP® system has four instrument capabilities, it does not have a suction irrigation instrument. To address this issue, we tested a Remotely Operated Suction Irrigation System (ROSI™) (VTI, Nashua, NH, USA) in three patients undergoing da Vinci SP® submucosal dissection.IMPACT OF INNOVATIONThe impact of innovation is the evaluation of a flexible suction irrigator during endorobotic submucosal dissection (ERSD), addressing space constraints and enhancing surgical precision.TECHNOLOGY MATERIALS AND METHODSThis was a single-center retrospective observational study involving three patients who underwent ERSD, between February 2023 and May 2023. ROSI™ was used selectively for rectal lesions.PRELIMINARY RESULTSThe first patient was a 67-year-old male with a 30 mm tubulovillous adenoma found in the rectum at 4 cm. The second patient was a 49-year-old female, referred after a screening colonoscopy, with a 40 mm rectal mass 12 cm from the anal verge. A biopsy revealed a tubular adenoma without dysplasia. The last patient was a 66-year-old male with a 25 mm tubulovillous adenoma with a focal high-grade dysplasia at 10 cm. There was no evidence of invasive carcinoma or lymph node metastasis on MRI in any of the patients. The patients were placed in a modified lithotomy position, and the GelPOINT® Path was inserted. A silk suture was attached at the proximal end of ROSI™ to facilitate tubing manipulation. ROSI™ was freely passed into the endoluminal space through the gel using a surgical clamp. Any bleeding during the operation was aspirated and irrigated using ROSI™ with the assistance of bipolar forceps. All surgeries were completed without complications and the patients were discharged on the same day.CONCLUSION AND FUTURE DIRECTIONSROSI™ is a flexible foot pedal-controlled suction irrigator that can facilitate da Vinci SP® submucosal dissection. The flexibility and controllability of ROSI in the surgeon's hand may qualify it as an essential tool for performing ERSD and possibly other TAMIS procedures.","PeriodicalId":11299,"journal":{"name":"Diseases of the Colon & Rectum","volume":null,"pages":null},"PeriodicalIF":3.9,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142201227","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-12DOI: 10.1097/dcr.0000000000003526
Michael J Klingler,Kamil Erozkan,Ali Alipouriani,Joshua Sommovilla,Emre Gorgun
BACKGROUNDEndoscopic submucosal dissection for advanced colon lesions is typically performed with specialized and costly endoscopic knives, potentially limiting accessibility and increasing procedural cost. Alternatively, the tip of an endoscopic snare, which is inexpensive and universally available, has demonstrated safe and efficient use in gastric lesions but lacks sufficient data for use in colon lesions.OBJECTIVEThis study aimed to assess patient outcomes following endoscopic submucosal dissection of advanced colon lesions using the endoscopic snare tip.DESIGNA retrospective review of a prospectively maintained database at a single tertiary care center was conducted.SETTINGSThis study was conducted at a single tertiary care center.PATIENTSAdult patients with colon lesions that were not amenable to snare polypectomy were evaluated for endoscopic submucosal dissection. Snare tip resection was performed in select patients with lesions that lifted adequately after submucosal injection. Patients who underwent hybrid resections with endoscopic mucosal dissection were excluded.MAIN OUTCOME MEASURESEn bloc resection rates, operative time, perioperative complications, and short-term outcomes such as length of stay and lesion recurrence on follow-up colonoscopy were evaluated.RESULTSA total of 121 patients underwent snare tip endoscopic submucosal dissection, with a mean lesion size of 28.8 ± 9.84 mm. Most procedures were performed in the endoscopy suite (81.8%). The en bloc resection rate was 81.8% with an average procedure time of 37.1 ± 29.8 min. There were two perforations (1.70%), one of which was managed operatively. Recurrence occurred in 6 patients (7.89%) at the time of follow-up colonoscopy.LIMITATIONSThis study was retrospective, conducted by two skilled endoscopists with experience in endoscopic resection, and had short-term follow up.CONCLUSIONSSnare tip endoscopic submucosal dissection for advanced colon lesions demonstrates satisfactory short-term outcomes, suggesting its potential as a safe and accessible alternative to specialized knives, thereby possibly enhancing adoption of endoscopic resection and improving patient accessibility. See Video Abstract.
{"title":"Use of Snare Tip Endoscopic Submucosal Dissection in the Endoluminal Management of Complex Colon Lesions.","authors":"Michael J Klingler,Kamil Erozkan,Ali Alipouriani,Joshua Sommovilla,Emre Gorgun","doi":"10.1097/dcr.0000000000003526","DOIUrl":"https://doi.org/10.1097/dcr.0000000000003526","url":null,"abstract":"BACKGROUNDEndoscopic submucosal dissection for advanced colon lesions is typically performed with specialized and costly endoscopic knives, potentially limiting accessibility and increasing procedural cost. Alternatively, the tip of an endoscopic snare, which is inexpensive and universally available, has demonstrated safe and efficient use in gastric lesions but lacks sufficient data for use in colon lesions.OBJECTIVEThis study aimed to assess patient outcomes following endoscopic submucosal dissection of advanced colon lesions using the endoscopic snare tip.DESIGNA retrospective review of a prospectively maintained database at a single tertiary care center was conducted.SETTINGSThis study was conducted at a single tertiary care center.PATIENTSAdult patients with colon lesions that were not amenable to snare polypectomy were evaluated for endoscopic submucosal dissection. Snare tip resection was performed in select patients with lesions that lifted adequately after submucosal injection. Patients who underwent hybrid resections with endoscopic mucosal dissection were excluded.MAIN OUTCOME MEASURESEn bloc resection rates, operative time, perioperative complications, and short-term outcomes such as length of stay and lesion recurrence on follow-up colonoscopy were evaluated.RESULTSA total of 121 patients underwent snare tip endoscopic submucosal dissection, with a mean lesion size of 28.8 ± 9.84 mm. Most procedures were performed in the endoscopy suite (81.8%). The en bloc resection rate was 81.8% with an average procedure time of 37.1 ± 29.8 min. There were two perforations (1.70%), one of which was managed operatively. Recurrence occurred in 6 patients (7.89%) at the time of follow-up colonoscopy.LIMITATIONSThis study was retrospective, conducted by two skilled endoscopists with experience in endoscopic resection, and had short-term follow up.CONCLUSIONSSnare tip endoscopic submucosal dissection for advanced colon lesions demonstrates satisfactory short-term outcomes, suggesting its potential as a safe and accessible alternative to specialized knives, thereby possibly enhancing adoption of endoscopic resection and improving patient accessibility. See Video Abstract.","PeriodicalId":11299,"journal":{"name":"Diseases of the Colon & Rectum","volume":null,"pages":null},"PeriodicalIF":3.9,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142201226","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-12DOI: 10.1097/dcr.0000000000003518
Thomas L Sutton,Ranish K Patel,Katherine M Watson,Ivy H Gardner,Daniel O Herzig,V Liana Tsikitis,Emerson Y Chen,Skye C Mayo
BACKGROUNDSynchronous colorectal liver metastases may be managed with primary-first, simultaneous, or liver-first resection. Relative oncologic outcomes based upon treatment sequencing are understudied.OBJECTIVEThis study aimed to assess oncologic survival outcomes in patients with synchronous colorectal liver metastases managed with each of the three treatment strategies, with respect to early or delayed removal of the primary tumor.DESIGNRetrospective analysis of prospectively maintained database, with 1:1 propensity-matching of relevant clinicopathologic variables comparing liver-first to primary-first/simultaneous approaches.SETTINGSSingle-institution, tertiary cancer center.PATIENTSPatients undergoing curative-intent hepatectomy for synchronous colorectal liver metastases from 2003-2019.MAIN OUTCOME MEASURESOverall and recurrence-free survival.RESULTSOf 151 patients, 23% (n = 35) had liver-first and 77% (n = 116; primary-first = 93 and simultaneous = 23) had primary-first/simultaneous approaches. Median follow-up was 45 months. Recurrence-free survival was worse for liver-first versus primary-first/simultaneous groups (median 12 versus 16 months, p = 0.02), driven by three-year extrahepatic recurrence-free survival of 19%, 58%, and 50% for liver-first, primary-first, and simultaneous groups, respectively. Three-year overall survival was not significantly different at 86%, 79%, and 86%, respectively. Oncologic outcomes did not significantly differ between primary-first and simultaneous groups (all p > 0.4). Matching yielded 34 clinicopathologically similar patients per group (liver-first = 34, primary-first = 28/simultaneous = 6). The liver-first approach was associated with shorter recurrence-free survival (median 12 versus 23 months, p = 0.004), driven by extrahepatic recurrence-free survival (3-year: 20% versus 55%, p = 0.04). Overall survival was not significantly different at 3-years (79% versus 80%, p = 0.95) or 5-years (59% versus 59%, p > 0.99).LIMITATIONSThis study has a retrospective design and limited sample size.CONCLUSIONSA liver-first approach is associated with worse recurrence free-survival compared to primary-first or simultaneous resection, driven by extrahepatic recurrence. Prospective study of whether oncologic risk is associated with leaving the primary in situ is needed. Multidisciplinary treatment sequencing and enhanced postoperative surveillance for patients receiving liver-first resection is recommended. See Video Abstract.
{"title":"Liver-First Resection in Patients With Synchronous Colorectal Liver Metastases Is Associated with Inferior Recurrence-Free Survival: Reconsidering the Importance of the Primary Cancer.","authors":"Thomas L Sutton,Ranish K Patel,Katherine M Watson,Ivy H Gardner,Daniel O Herzig,V Liana Tsikitis,Emerson Y Chen,Skye C Mayo","doi":"10.1097/dcr.0000000000003518","DOIUrl":"https://doi.org/10.1097/dcr.0000000000003518","url":null,"abstract":"BACKGROUNDSynchronous colorectal liver metastases may be managed with primary-first, simultaneous, or liver-first resection. Relative oncologic outcomes based upon treatment sequencing are understudied.OBJECTIVEThis study aimed to assess oncologic survival outcomes in patients with synchronous colorectal liver metastases managed with each of the three treatment strategies, with respect to early or delayed removal of the primary tumor.DESIGNRetrospective analysis of prospectively maintained database, with 1:1 propensity-matching of relevant clinicopathologic variables comparing liver-first to primary-first/simultaneous approaches.SETTINGSSingle-institution, tertiary cancer center.PATIENTSPatients undergoing curative-intent hepatectomy for synchronous colorectal liver metastases from 2003-2019.MAIN OUTCOME MEASURESOverall and recurrence-free survival.RESULTSOf 151 patients, 23% (n = 35) had liver-first and 77% (n = 116; primary-first = 93 and simultaneous = 23) had primary-first/simultaneous approaches. Median follow-up was 45 months. Recurrence-free survival was worse for liver-first versus primary-first/simultaneous groups (median 12 versus 16 months, p = 0.02), driven by three-year extrahepatic recurrence-free survival of 19%, 58%, and 50% for liver-first, primary-first, and simultaneous groups, respectively. Three-year overall survival was not significantly different at 86%, 79%, and 86%, respectively. Oncologic outcomes did not significantly differ between primary-first and simultaneous groups (all p > 0.4). Matching yielded 34 clinicopathologically similar patients per group (liver-first = 34, primary-first = 28/simultaneous = 6). The liver-first approach was associated with shorter recurrence-free survival (median 12 versus 23 months, p = 0.004), driven by extrahepatic recurrence-free survival (3-year: 20% versus 55%, p = 0.04). Overall survival was not significantly different at 3-years (79% versus 80%, p = 0.95) or 5-years (59% versus 59%, p > 0.99).LIMITATIONSThis study has a retrospective design and limited sample size.CONCLUSIONSA liver-first approach is associated with worse recurrence free-survival compared to primary-first or simultaneous resection, driven by extrahepatic recurrence. Prospective study of whether oncologic risk is associated with leaving the primary in situ is needed. Multidisciplinary treatment sequencing and enhanced postoperative surveillance for patients receiving liver-first resection is recommended. See Video Abstract.","PeriodicalId":11299,"journal":{"name":"Diseases of the Colon & Rectum","volume":null,"pages":null},"PeriodicalIF":3.9,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142201223","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-12DOI: 10.1097/dcr.0000000000003287
Dae Hee Pyo,Seijong Kim,Misol Do,Jung Wook Huh
BACKGROUNDLaparoscopic surgery offers several advantages, but it can be challenging to perform in confined spaces, such as the narrow and deep pelvis, due to poor vision and instrument collisions. Conventional laparoscopic instruments are rigid and straight, which can restrict optimal access to the target organ. Although the use of robotic surgical platforms with flexible wrists has significantly reduced movement restrictions and surgeon fatigue, their high cost remains a barrier to widespread adoption.IMPACT OF INNOVATIONRecent technological advancements in laparoscopic instruments have led to the development of an articulating flexible hand-held device that enables greater dexterity and easier access to difficult anatomical locations. This technology has the potential to improve surgical outcomes by using multiple degrees of freedom to perform complex surgical procedures with greater precision.TECHNOLOGY, MATERIALS, AND METHODSThe ArtiSential® product line comprises over 30 end-effectors, such as scissors, hooks, and graspers. The benefits of this device are evident throughout the total mesorectal excision, especially when approaching the left lateral side of the mesorectum (the side opposite the surgeon) or the deepest part of the pelvis around the levator ani muscle. The Samsung Medical Center Institutional Review Board approved this study (2022-01-174).PRELIMINARY RESULTSA 79-year-old male with rectal cancer located 9 cm from the anal verge underwent an laparoscopic ultralow anterior resection using ArtiSential®. There were no intraoperative complications. The pathologic results showed that the tumor was at pT3N0 stage. The patient was discharged without any complications.CONCLUSION AND FUTURE DIRECTIONSThe articulating device can be effectively used for laparoscopic surgery, but has some challenges related to the bulky handpiece and learning curve. A multicenter prospective cohort study to compare the outcomes of articulating laparoscopic surgery and robotic surgery for patients with rectal cancer is oncoing (clinicaltrials.gov number: NCT05566249).
{"title":"Laparoscopic Ultralow Anterior Resection Using a New Articulating Device.","authors":"Dae Hee Pyo,Seijong Kim,Misol Do,Jung Wook Huh","doi":"10.1097/dcr.0000000000003287","DOIUrl":"https://doi.org/10.1097/dcr.0000000000003287","url":null,"abstract":"BACKGROUNDLaparoscopic surgery offers several advantages, but it can be challenging to perform in confined spaces, such as the narrow and deep pelvis, due to poor vision and instrument collisions. Conventional laparoscopic instruments are rigid and straight, which can restrict optimal access to the target organ. Although the use of robotic surgical platforms with flexible wrists has significantly reduced movement restrictions and surgeon fatigue, their high cost remains a barrier to widespread adoption.IMPACT OF INNOVATIONRecent technological advancements in laparoscopic instruments have led to the development of an articulating flexible hand-held device that enables greater dexterity and easier access to difficult anatomical locations. This technology has the potential to improve surgical outcomes by using multiple degrees of freedom to perform complex surgical procedures with greater precision.TECHNOLOGY, MATERIALS, AND METHODSThe ArtiSential® product line comprises over 30 end-effectors, such as scissors, hooks, and graspers. The benefits of this device are evident throughout the total mesorectal excision, especially when approaching the left lateral side of the mesorectum (the side opposite the surgeon) or the deepest part of the pelvis around the levator ani muscle. The Samsung Medical Center Institutional Review Board approved this study (2022-01-174).PRELIMINARY RESULTSA 79-year-old male with rectal cancer located 9 cm from the anal verge underwent an laparoscopic ultralow anterior resection using ArtiSential®. There were no intraoperative complications. The pathologic results showed that the tumor was at pT3N0 stage. The patient was discharged without any complications.CONCLUSION AND FUTURE DIRECTIONSThe articulating device can be effectively used for laparoscopic surgery, but has some challenges related to the bulky handpiece and learning curve. A multicenter prospective cohort study to compare the outcomes of articulating laparoscopic surgery and robotic surgery for patients with rectal cancer is oncoing (clinicaltrials.gov number: NCT05566249).","PeriodicalId":11299,"journal":{"name":"Diseases of the Colon & Rectum","volume":null,"pages":null},"PeriodicalIF":3.9,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142201225","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
BACKGROUNDAnastomotic stenosis after pull-through surgery remains a challenge in the management of Hirschsprung disease. Based on the management of esophageal stenosis, we evaluated the efficacy of combined radial incision and steroid injection for the treatment of refractory colorectal anastomotic stenosis after pull-through.IMPACT OF INNOVATIONCombined radial incision and steroid injection is an alternative conservative treatment of refractory anastomotic stenosis after pull-though for Hirschsprung disease, avoiding a potential complicated redo pull-though surgery.TECHNOLOGY MATERIALS AND METHODSWe included patients with recto-sigmoid Hirschsprung disease that developed a refractory anastomotic stenosis after a laparoscopic-assisted Swenson pull-through at Robert-Debré Children University Hospital, Paris, France. Refractory stenosis was defined as obstructive symptoms associated with an anastomotic stenosis upon rectal exam without improvement after serial anal dilatations. Under general anesthesia, an injection of 10mg delayed-action steroid per quadrant was combined with a radial incision of the stenosis using monopolar cautery.PRELIMINARY RESULTSCombined radial incision and steroid injection was performed in 4 children, for either early or late refractory stenosis. This resulted in improvement of refractory anastomotic stenosis, avoiding a redo pull-through in 75% of patients. One child presented with transient improvement after combined radial incision and steroid injection but developed recurrent stenosis despite additional combined radial incision and steroid injection and redo pull-through. The median follow-up was 29 months.CONCLUSION AND FUTURE DIRECTIONSWe observed a clinical improvement in all the patients after combined radial incision and steroid injection. Steroids injection should be considered as a potential alternative therapy for anastomotic stenosis.
{"title":"Combined Radial Incision and Steroid Injection for Refractory Colorectal Stenosis After Pull-Through Surgery in Hirschsprung Disease: An Innovative Conservative Treatment.","authors":"Margaux Langeron,Louise Montalva,Alexis Mosca,Liza Ali,Pierre Pardessus,Arnaud Bonnard","doi":"10.1097/dcr.0000000000003362","DOIUrl":"https://doi.org/10.1097/dcr.0000000000003362","url":null,"abstract":"BACKGROUNDAnastomotic stenosis after pull-through surgery remains a challenge in the management of Hirschsprung disease. Based on the management of esophageal stenosis, we evaluated the efficacy of combined radial incision and steroid injection for the treatment of refractory colorectal anastomotic stenosis after pull-through.IMPACT OF INNOVATIONCombined radial incision and steroid injection is an alternative conservative treatment of refractory anastomotic stenosis after pull-though for Hirschsprung disease, avoiding a potential complicated redo pull-though surgery.TECHNOLOGY MATERIALS AND METHODSWe included patients with recto-sigmoid Hirschsprung disease that developed a refractory anastomotic stenosis after a laparoscopic-assisted Swenson pull-through at Robert-Debré Children University Hospital, Paris, France. Refractory stenosis was defined as obstructive symptoms associated with an anastomotic stenosis upon rectal exam without improvement after serial anal dilatations. Under general anesthesia, an injection of 10mg delayed-action steroid per quadrant was combined with a radial incision of the stenosis using monopolar cautery.PRELIMINARY RESULTSCombined radial incision and steroid injection was performed in 4 children, for either early or late refractory stenosis. This resulted in improvement of refractory anastomotic stenosis, avoiding a redo pull-through in 75% of patients. One child presented with transient improvement after combined radial incision and steroid injection but developed recurrent stenosis despite additional combined radial incision and steroid injection and redo pull-through. The median follow-up was 29 months.CONCLUSION AND FUTURE DIRECTIONSWe observed a clinical improvement in all the patients after combined radial incision and steroid injection. Steroids injection should be considered as a potential alternative therapy for anastomotic stenosis.","PeriodicalId":11299,"journal":{"name":"Diseases of the Colon & Rectum","volume":null,"pages":null},"PeriodicalIF":3.9,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142201224","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
BACKGROUNDThe use of programmed death-1 blockade has a significant therapeutic effect in patients with Mismatch Repair-Deficient/Microsatellite Instability-High metastatic colorectal cancer. However, data on preoperative single-agent programmed death-1 blockade are rare.OBJECTIVEThis study aims to evaluate the effectiveness and safety of preoperative programmed death-1 blockade as a conversion strategy in patients with locally advanced and resectable metastatic Mismatch Repair-Deficient/Microsatellite Instability-High colorectal cancer.DESIGNThis is a retrospective observational study.SETTINGSThis study was conducted at a high-volume tertiary referral cancer center in China.PATIENTSTwenty-four patients of consecutive cases since 2020-2022 with Mismatch Repair-Deficient/Microsatellite Instability-High colorectal cancer who received preoperative single-agent programmed death-1 blockade were retrospectively reviewed. These patients had either bulking tumor scheduled for multivisceral resection, a strong desire for organ preservation, or potentially resectable metastatic lesions.MAIN OUTCOME MEASURESPathological complete response, clinical complete response, toxicity, R0 resection rate, and complications were evaluated.RESULTSPatients tolerated preoperative immunotherapy well. The R0 resection rate was 95.2% and the pathological complete response rate was 47.6%. Three patients (12.5%) were evaluated as clinical complete response and then underwent "watch and wait". One half of the cT4b patients were spared multivisceral resection, while 60% (3/5) achieved pathological complete response. All three patients with liver metastases obtained CR of all liver lesions after programmed death-1 blockade treatment. Grade III postoperative complications occurred in two patients.LIMITATIONSThe limitations of this study are as follows: retrospective study, small sample size, and short follow-up.CONCLUSIONSPreoperative anti-programmed death-1 therapy alone as a conversion strategy in initially resected difficult dMMR/MSI-H colorectal cancer can achieve a high tumor complete response. The use of immuno-preoperative therapy in patients with T4b colon cancer or low rectal cancer can reduce multivisceral resection and achieve high organ function preservation. See Video Abstract.
{"title":"Neoadjuvant Immunotherapy Alone for Patients With Locally Advanced and Resectable Metastatic Colorectal Cancer of dMMR/MSI-H Status.","authors":"Yingjie Li,Luxin Tan,Nan Chen,Xinzhi Liu,Fei Liang,Yunfeng Yao,Xiaoyan Zhang,Aiwen Wu","doi":"10.1097/dcr.0000000000003290","DOIUrl":"https://doi.org/10.1097/dcr.0000000000003290","url":null,"abstract":"BACKGROUNDThe use of programmed death-1 blockade has a significant therapeutic effect in patients with Mismatch Repair-Deficient/Microsatellite Instability-High metastatic colorectal cancer. However, data on preoperative single-agent programmed death-1 blockade are rare.OBJECTIVEThis study aims to evaluate the effectiveness and safety of preoperative programmed death-1 blockade as a conversion strategy in patients with locally advanced and resectable metastatic Mismatch Repair-Deficient/Microsatellite Instability-High colorectal cancer.DESIGNThis is a retrospective observational study.SETTINGSThis study was conducted at a high-volume tertiary referral cancer center in China.PATIENTSTwenty-four patients of consecutive cases since 2020-2022 with Mismatch Repair-Deficient/Microsatellite Instability-High colorectal cancer who received preoperative single-agent programmed death-1 blockade were retrospectively reviewed. These patients had either bulking tumor scheduled for multivisceral resection, a strong desire for organ preservation, or potentially resectable metastatic lesions.MAIN OUTCOME MEASURESPathological complete response, clinical complete response, toxicity, R0 resection rate, and complications were evaluated.RESULTSPatients tolerated preoperative immunotherapy well. The R0 resection rate was 95.2% and the pathological complete response rate was 47.6%. Three patients (12.5%) were evaluated as clinical complete response and then underwent \"watch and wait\". One half of the cT4b patients were spared multivisceral resection, while 60% (3/5) achieved pathological complete response. All three patients with liver metastases obtained CR of all liver lesions after programmed death-1 blockade treatment. Grade III postoperative complications occurred in two patients.LIMITATIONSThe limitations of this study are as follows: retrospective study, small sample size, and short follow-up.CONCLUSIONSPreoperative anti-programmed death-1 therapy alone as a conversion strategy in initially resected difficult dMMR/MSI-H colorectal cancer can achieve a high tumor complete response. The use of immuno-preoperative therapy in patients with T4b colon cancer or low rectal cancer can reduce multivisceral resection and achieve high organ function preservation. See Video Abstract.","PeriodicalId":11299,"journal":{"name":"Diseases of the Colon & Rectum","volume":null,"pages":null},"PeriodicalIF":3.9,"publicationDate":"2024-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142201229","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
BACKGROUNDTotal neoadjuvant therapy in treatment of stage II-III rectal cancer involves administration of either induction or consolidation chemotherapy with chemoradiation before surgery. Total neoadjuvant therapy is associated with increased complete response rate, which is defined as the proportion of patients who either had pathological complete response after surgery or sustained clinical complete response at least for a year under surveillance.OBJECTIVETo identify the predictors of complete response to total neoadjuvant therapy and compare different diagnostic tools in predicting complete response.DESIGNRetrospective cohort study.SETTINGSA single tertiary-care center.PATIENTSStage II-III rectal cancer patients who were diagnosed between January 2015 and December 2021.INTERVENTIONTotal neoadjuvant therapy.MAIN OUTCOME MEASURESComplete response rate, predictors of complete response, sensitivity and specificity of sigmoidoscopy and MRI in predicting complete response.RESULTSOne hundred nineteen patients (mean age 56 [±11.3] years, 47 [39.5%] female, 100 [84%] stage III rectal cancer were included. Median tumor size was 5.1 (4-6.5) cm, 63 (52.9%) were low rectal tumors. Twenty-one (17.6%) patients had extramural vascular invasion, 62 (52.1%) had elevated carcinoembryonic antigen at baseline. One hundred eight (90.8%) patients received consolidation chemotherapy. After total neoadjuvant therapy, 88 (73.9%) out of 119 patients underwent surgery, of whom 20 (22.7%) had pathological complete response. Thirty-one (26.1%) patients underwent watch-and-wait, of whom 24 (77.4%) had sustained clinical complete response. Overall complete response rate was 37%. Low rectal tumors (OR 2.6 [95% CI, 1.1-5.9], p = 0.02) and absence of EMVI [OR 5.4 (95% CI, 1.2-25.1), p = 0.01] were predictors of complete response. In predicting complete response, sigmoidoscopy was more sensitive (76.0% vs. 62.5%) and specific (72.5% vs. 69.2%) than MRI. The specificity further increased when 2 techniques were combined (82.5%).LIMITATIONSRetrospective study.CONCLUSIONSComplete response rate after total neoadjuvant therapy was 37%. Low rectal tumors and absence of extramural vascular invasion were predictors of complete response. Sigmoidoscopy was better in predicting incomplete response, whereas combination (MRI and sigmoidoscopy) was better in predicting complete response.
{"title":"What Predicts Complete Response to Total Neoadjuvant Therapy in Locally Advanced Rectal Cancer?","authors":"Sumeyye Yilmaz,David Liska,Madison Conces,Naz Tursun,Doua Elamin,Ilker Ozgur,Marianna Maspero,David Rosen,Alok Khorana,Ehsan Balagamwala,Sudha Amarnath,Michael Valente,Scott R Steele,Smitha Krishnamurthi,Emre Gorgun","doi":"10.1097/dcr.0000000000003395","DOIUrl":"https://doi.org/10.1097/dcr.0000000000003395","url":null,"abstract":"BACKGROUNDTotal neoadjuvant therapy in treatment of stage II-III rectal cancer involves administration of either induction or consolidation chemotherapy with chemoradiation before surgery. Total neoadjuvant therapy is associated with increased complete response rate, which is defined as the proportion of patients who either had pathological complete response after surgery or sustained clinical complete response at least for a year under surveillance.OBJECTIVETo identify the predictors of complete response to total neoadjuvant therapy and compare different diagnostic tools in predicting complete response.DESIGNRetrospective cohort study.SETTINGSA single tertiary-care center.PATIENTSStage II-III rectal cancer patients who were diagnosed between January 2015 and December 2021.INTERVENTIONTotal neoadjuvant therapy.MAIN OUTCOME MEASURESComplete response rate, predictors of complete response, sensitivity and specificity of sigmoidoscopy and MRI in predicting complete response.RESULTSOne hundred nineteen patients (mean age 56 [±11.3] years, 47 [39.5%] female, 100 [84%] stage III rectal cancer were included. Median tumor size was 5.1 (4-6.5) cm, 63 (52.9%) were low rectal tumors. Twenty-one (17.6%) patients had extramural vascular invasion, 62 (52.1%) had elevated carcinoembryonic antigen at baseline. One hundred eight (90.8%) patients received consolidation chemotherapy. After total neoadjuvant therapy, 88 (73.9%) out of 119 patients underwent surgery, of whom 20 (22.7%) had pathological complete response. Thirty-one (26.1%) patients underwent watch-and-wait, of whom 24 (77.4%) had sustained clinical complete response. Overall complete response rate was 37%. Low rectal tumors (OR 2.6 [95% CI, 1.1-5.9], p = 0.02) and absence of EMVI [OR 5.4 (95% CI, 1.2-25.1), p = 0.01] were predictors of complete response. In predicting complete response, sigmoidoscopy was more sensitive (76.0% vs. 62.5%) and specific (72.5% vs. 69.2%) than MRI. The specificity further increased when 2 techniques were combined (82.5%).LIMITATIONSRetrospective study.CONCLUSIONSComplete response rate after total neoadjuvant therapy was 37%. Low rectal tumors and absence of extramural vascular invasion were predictors of complete response. Sigmoidoscopy was better in predicting incomplete response, whereas combination (MRI and sigmoidoscopy) was better in predicting complete response.","PeriodicalId":11299,"journal":{"name":"Diseases of the Colon & Rectum","volume":null,"pages":null},"PeriodicalIF":3.9,"publicationDate":"2024-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142201232","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-11DOI: 10.1097/dcr.0000000000003537
Bo Liu,Song Zhao
{"title":"No Matter Whether the Cat Is Black Or White, As Long As It Catches Mice.","authors":"Bo Liu,Song Zhao","doi":"10.1097/dcr.0000000000003537","DOIUrl":"https://doi.org/10.1097/dcr.0000000000003537","url":null,"abstract":"","PeriodicalId":11299,"journal":{"name":"Diseases of the Colon & Rectum","volume":null,"pages":null},"PeriodicalIF":3.9,"publicationDate":"2024-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142201231","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-11DOI: 10.1097/dcr.0000000000003415
Kevin Ma,Luay Ailabouni
{"title":"Malone Antegrade Continence Enema Procedure in the Management of Chronic Constipation.","authors":"Kevin Ma,Luay Ailabouni","doi":"10.1097/dcr.0000000000003415","DOIUrl":"https://doi.org/10.1097/dcr.0000000000003415","url":null,"abstract":"","PeriodicalId":11299,"journal":{"name":"Diseases of the Colon & Rectum","volume":null,"pages":null},"PeriodicalIF":3.9,"publicationDate":"2024-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142201228","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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