Techniques in Coloproctology最新文献

Background: Level of lymph nodes dissection (LND) and inferior mesenteric artery (IMA) ligation is still matter of debate of radical resection of colorectal cancer. This study aims to compare the short-term outcome of three different surgical techniques to treat sigmoid cancer: low ligation (LL) of the IMA with D3-LND, low IMA ligation with D2-LND, and high ligation (HL) of the IMA with D3-LND.

Methods: Patients affected by sigmoid colon cancer, who underwent radical resection with three different techniques (LL and D3-LND Group A, HL and D3-LND Group B, and LL with D2 LND- Group C), were included. Operative time (min), blood loss (ml), early postoperative complications, and number of harvested lymph nodes were compared.

Results: Thirty patients per group were enrolled. The median operation time was shorter in group C (130 min, interquartile range [IQR] 120-140), compared with the 245 min (IQR 193.8-295.5) of group A and 257 min (IQR 183-345) of group B, p < 0.005. No significant differences between A and B group were observed in the median intraoperative blood loss, while group C had higher intraoperative blood loss (200 ml, IQR 200-260, p = 0.002). Anastomotic leak occurred in three patients belonging to group B. A reduced number of harvested lymph nodes was registered in Group C (14 lymph nodes, IQR 10-17), p < 0.005.

Conclusions: Both high and low tie ligation with D3-LND for sigmoid cancer can be considered safe and feasible with low rate of postoperative complications, allowing a higher number of harvested lymph nodes compared to low tie ligation with D2 lymphadenectomy.

Aim: The use of robotic surgery is increasing significantly. Specific training is fundamental to achieve high quality and better oncological outcomes. This work defines key exposure techniques in robotic total mesorectal excision (TME). Based on a modular approach, macro- and microtractions for exposure in every step of a robotic TME are identified and described. The aim is to develop a step-by-step technical guide of the exposure techniques for a robotic TME.

Methods: Twenty-five videos of robotic rectal resections performed at Champalimaud Foundation (Lisbon, Portugal) with the Da Vinci™ Xi robotic platform were examined. Robotic TME was divided into modules and steps. Modules are essential phases of the procedure. Steps are exposure moments of each module. Tractions are classified as macro- and microtractions. Macrotraction is the grasping of a structure to expose an area of dissection. Microtraction consists in the dynamic grip of tissue to optimize macrotraction in a defined area of dissection.

Results: The procedure videos reviewed showed homogeneity concerning surgical methodology. Eight modules are outlined: abdominal cavity inspection and exposure, approach to and ligation of the inferior mesenteric vessels, medial to lateral dissection of the mesocolon, lateral colon mobilization, splenic flexure takedown, proctectomy with TME, rectal transection, and anastomosis. Each module was divided into steps, with a total of 45 steps for the entire procedure. This manuscript characterizes macrotraction and microtraction fine-tuning, detailing the large-scale macrotractions and the precision of microtractions at each step.

Conclusion: Tissue exposure techniques in robotic TME are key to precise dissection. This modular guide provides a functional system to reproduce this procedure safely; the addition of the exposure techniques could serve as a training method for robotic rectal cancer surgery.

Background: Reduced-port laparoscopic surgery (RPLS) uses the minimum possible number of ports or small-sized ports in laparoscopic surgery. The combination of RPLS and natural orifice specimen extraction (NOSE) minimizes the procedural damage.

Methods: A total of 17 patients diagnosed with right colon cancer were included: 5 patients in the RPLS + NOSE group and 12 patients in the conventional laparoscopic surgery (CL) + mini-laparotomy (ML) group. We highlight the key steps of the RPLS + NOSE procedure and compare the clinicopathological characteristics and short-term postoperative outcomes of the two groups.

Results: Compared to CL + ML, RPLS + NOSE was associated with short hospitalization (8.80 ± 1.30 vs 13.75 ± 2.63, p = 0.001), faster first flatus (1.80 ± 0.45 vs 3.4 ± 0.90, p = 0.020) and less postoperative pain on the first day (2.40 ± 0.55 vs 4.25 ± 1.60, p = 0.025). Regarding operation time, intraoperative bleeding, tumor size, proximal and distal margin, number of lymph nodes harvested, number of positive lymph nodes, R0 resection, bowel movements, postoperative complications, Clavien-Dindo classification, Benz's classification and postoperative pain on day 1, day 3 and day 5, no significant difference was observed.

Conclusion: In selected patients, RPLS with D3 lymph node dissection and transvaginal specimen extraction results in fast recovery and is indicated for colon cancer patients.

Background: Treating high horseshoe anal fistula (HHAF) with the modified Halley procedure (MHP) often falls short when focusing solely on deep postanal space (DPAS) drainage. Our study underscores the significance of addressing deep posterior intersphincteric space (DPIS) drainage, prompting MHP modifications.

Methods: We studied consecutive patients with HHAF treated with either MHP or remodified-MHP (Re-MHP) at Ningbo Medical Center of Lihuili Hospital from January 2018 to December 2021. Postoperative outcomes, encompassing complications, cure rates, pain, anal incontinence, and quality of life, were retrospectively assessed.

Results: Cure rates for MHP and Re-MHP were 95.3% (41/43) and 82.1% (32/39), respectively, without statistical significance (χ² = 3.7, P = 0.08). VAS-PS, CCF-IS, and QLAF-QS scores significantly increased postsurgery and gradually decreased. Notably, Re-MHP demonstrated significantly lower VAS-PS scores during the first postoperative week, lower QLAF-QS scores on the seventh day, and more drainage secretions on the first day (P < 0.05).

Conclusion: Simultaneously enhancing DPAS and DPIS drainage in Re-MHP can enhance the cure rates of HHAF patients while preserving minimally invasive attributes.

Background: Abdominoperineal resection (APR) is the standard treatment for locally advanced distal rectal cancer (LADRC) following neoadjuvant treatment when sphincter-preserving procedures are inapplicable. However, complications such as perineal site infection, perineal hernia and postoperative ileus remain ongoing challenges. We aimed to compare the rate of postoperative ileus due to pelvic incarceration in APR patients with/without pelvic inlet closure.

Methods: LADRC patients, who underwent APR with/without pelvic inlet closure between January 2016 and September 2022 at a comprehensive cancer center were analyzed retrospectively. After laparoscopic APR, the pelvic inlet was closed with a bladder peritoneal flap. A U-shaped peritoneal flap, up to approximately 15 × 20 cm in size, was peeled off from the dome of the bladder with its base at the posterosuperior part of the bladder.

Results: Of the 80 patients included in the analysis, 27 (34%) underwent laparoscopic APR with pelvic inlet closure and 53 (66%) had no pelvic inlet closure. There was no significant difference in age, mean body mass index and American Society of Anesthesiologists score among both groups. Patients with a pelvic inlet closure had a significantly lower postoperative ileus rate because of incarceration [0 vs. 17%, n = 9/53; (P = 0.03)] and a shorter hospital stay [6.74 ± 4.21 vs. 9.00 ± 5.99 days; P = 0.03]. The rate of perineal surgical site infection (SSI) [5/27 (18.5%) vs. 14/53 (26.4%); P = 0.61) was lower in the laparoscopic APR with pelvic inlet closure group, but this was not significant.

Conclusion: Pelvic inlet closure using a bladder peritoneal flap following APR is a safe and feasible procedure associated with reduced postoperative ileus due to pelvic incarceration rates, emergent surgical interventions due to pelvic incarceration and shorter hospital stay.

Background: Splenic flexure mobilization can be technically challenging, and its oncological benefits remain uncertain. This study aims to explore the relationship between patient and clinical characteristics and splenic flexure mobilization time as well as the implications of prolonged splenic flexure mobilization duration.

Methods: This retrospective cohort study includes 105 patients who underwent laparoscopic distal colorectal cancer surgery between 2013 and 2018. The study analyzed patient characteristics, duration of surgical steps, and postoperative outcomes. Splenic flexure mobilization time was assessed using operation videos, and the impact of patient-related factors on splenic flexure mobilization complexity was examined.

Results: The study identified significant correlations of higher body mass index (BMI) (p = 0.0086), weight (p = 0.002), and height (p = 0.043) with longer splenic flexure mobilization time. Gender did not significantly influence splenic flexure mobilization duration. Splenic flexure mobilization time was correlated with the durations of other individual surgical steps (Step 1: medial-to-lateral dissection [p = 0.0013], Step 2: pelvic dissection [p = 0.067], Step 3: dissection of white line and mobilization of descending colon [p = 0.0088], Step 5: stapling, resection, extraction of the specimen, and anastomosis [p = 0.04]) and the overall operation time (p < 0.0001). A 10-min cutoff point predicts the total operation time more efficiently than other potential thresholds.

Conclusion: This research suggests that patient characteristics including BMI, weight, and height may serve as indicators for prolonged splenic flexure mobilization time in laparoscopic distal colorectal cancer surgery. Longer splenic flexure mobilization durations were correlated with extended durations of other surgical steps. A BMI-based approach to anticipate SFM duration may enhance preoperative planning, potentially aiding in surgical decision-making.

Trial registration: E-10840098-772.02-61604 2.2.2019.

Background and study aim: Local resection of early rectal cancer is being increasingly used. With invasion of the muscularis propria layer of the rectal wall, the risk of lymph node metastasis becomes too high to consider this the optimal oncological treatment. Therefore, a diagnosis of muscular invasion is important before attempting local resection; however, endoscopic and magnetic resonance imaging (MRI) images have limitations, such as overstaging (26-31%). We investigated the potential of linear endoscopic ultrasound (L-EUS) in the diagnosis of muscularis propria invasion.

Patients and methods: The study consisted of a development phase, in which linear (L)- EUS features, associated with muscular wall invasion were searched and tested, and a validation phase, during which 30 representative videos were assessed by the author F.t.B. and four experienced endosonographists without experience in rectal L-EUS.

Results: The development cohort consisted of 91 patients (2019-2023). Overall, six EUS features were found to be significantly associated with muscular wall invasion: tornado sign, blob sign, massive connection, layer split, extramural deposit, and, most importantly impaired shiftability between the lesion and muscularis propria layer. During the development phase, these findings demonstrated excellent diagnostic features (sensitivity, 94.4%; specificity, 97.9%; and overstaging, 4%). In the validation phase, the sensitivity, specificity, and overstaging by F.t.B. were 88%, 85%, and 12%, respectively. Among the four inexperienced reviewers, the percentages were 65%-71%, 46%-54%, and 33%-39%, respectively. When considering the 27 videos that were considered easy or moderately difficult to assess, only 55% were correctly interpreted by the inexperienced reviewers.

Conclusions: Linear endoscopic ultrasonography may be a valuable tool for the assessment of ingrowth into the muscularis propria in supposedly early rectal cancer, especially using its dynamic potential to assess fixation to the muscular wall by moving the lesion. However, training will be required to achieve satisfactory results.

This article presents an innovative technique for perineal wound reconstruction following extralevator abdominoperineal excision (ELAPE) in rectal cancer surgery. The authors trace the evolution of surgical methods for rectal cancer treatment, from W.E. Miles' abdominoperineal resection (APR) to T. Holm's ELAPE technique introduced in 2007. The proposed metod's primary advantage lies in its ability to completely fill the extensive deep and superficial perineal wound defect by moving two flaps from both sides of the wound and overlapping them. This approach potentially reduces postoperative complications and improves patients' quality of life following ELAPE. The authors describe the procedure in detail, including specific measurements and angles for flap creation. They also present a case study of a 52-year-old female patient with lower rectal ampulla cancer, demonstrating the practical application of this technique. This innovative reconstruction method addresses the current lack of consensus on perineal wound plastic surgery techniques following ELAPE and offers a promising solution to reduce postoperative morbidity in rectal cancer patients undergoing this procedure.