Seminars in Colon and Rectal Surgery最新文献

Endoscopic submucosal dissection (ESD) is an advanced therapeutic technique used to remove non-malignant polyps (NMP) and early cancers. Benefits include reducing unnecessary colectomies, cost, and morbidity of NMP treatment. Other roles for ESD and associated skills are likely to expand in the future, including in the non-operative management of rectal cancer. The learning curve is feasible with established training methods. Colorectal surgeons already perform routine endoscopy and manage endoscopic complications and endoscopically incurable lesions- endoluminal surgery (ELS) is a natural extension of this. Expanding technologies will only improve our ability to resect these lesions endoluminally moving forward. Collaboration with gastroenterologists and acquiring, rather than abandoning, this skillset is important and obtainable. Colorectal surgeons have the tools and professional duty to stay at the forefront of managing colorectal diseases endoscopically. Despite substantial barriers to mastering ELS, the value to our patients and profession means all colorectal surgeons should learn these techniques.

Endoscopic submucosal dissection is a challenging technique that allows en bloc removal of sessile colorectal polyps and constitutes definitive treatment for superficial T-1 cancers. To successfully complete ESD cases, the great majority of endoscopists need to acquire several new skill sets. Learning about, practicing, and becoming proficient with the advanced skills in the clinical setting is a huge challenge because of the fact that these are usually low volume cases and there may be weeks or months between cases.

Advanced endoscopic procedures require a complex skillset to remove larger, benign and early malignant lesions within the colon and rectum. These procedures require large amounts of resources and have costs associated with them. They also are associated with huge benefits to the patient and cost savings when compared to colon resection as an alternative. Maximizing reimbursement and ensuring sustainability of these techniques requires a thoughtful approach to implement into everyday practice. This manuscript explores these issues in greater depth.

Detection of colon polyps is common and is expected in 20–30 % of screening colonoscopies. As the number of colonoscopies performed increases, the detection of advanced and difficult to resect polyps will also rise. These polyps tend to be larger, greater than 2 cm, have flat morphology, and are in difficult anatomic locations behind haustral folds or at sharp flexures of the colon. Advanced endoscopic techniques such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are useful to remove these polyps. However, many polyps remain unresectable with these techniques. Combined endoscopic laparoscopic surgery (CELS) has shown to be an effective technique to facilitate safe removal of complex polyps. CELS encompasses a variety of techniques including laparoscopic assisted ESD/EMR and laparo-endoscopic full thickness excisions (FLEX). Success rate of CELS ranges from 70 to 100 %, with less than 5 % conversion to colectomy. Perioperative outcomes boast shorter hospital length of stay, with low rates of serious post-op complications when compared to colectomy. Malignancy rate after CELS in appropriately selected patients is low, ranging from 1.6 %-10 % of cases. Polyp recurrence rate after CELS is also low, usually less than 10 %. Use of CELS for early-stage cancers remains controversial but maybe adequate in appropriately selected patients. Further evaluation and long-term studies are needed to study its efficacy in cases of known cancer. The purpose of this review is to provide recommendations for use of CELS techniques, appropriate indications, describe technical tips, and review potential future applications.

Endoscopic resection (ER) is the standard of care for the management of large (≥20 mm) non-pedunculated colorectal polyps (LNPCP). Certain lesion characteristics increase the risk for incomplete ER, recurrence, harbouring submucosal invasive cancer and post ER adverse events. These include lesion location, morphology, difficult endoscopic access and prior attempts at resection. Such LNPCP are termed ‘complex’. Recognition of complexity is a crucial component of technique selection and resource allocation. Until recently, resection of complex lesions was dominated by surgery. Surgical resection of benign lesions is associated with prolonged hospital stay and post-operative recovery, stoma creation, post-operative complications and even death. Advances in ER techniques have enabled huge strides in the management of these lesions and is proven to be safer and more cost-effective than surgery.

Endoluminal surgery in colorectal surgery involves the removal of polyps/lesions using advanced colonoscopic techniques such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Prior to the adoption of these techniques in a new colorectal surgery practice, a colorectal surgeon should have some mastery of basic colonoscopy skills along with colonoscopic polypectomy. There are a variety of training options to learn endoluminal surgery including industry and institutional based courses, observation of a master endoscopist, or observational experience in Japan. Adoption of these techniques in a new practice is facilitated by knowledge of what equipment is required and the availability of trained staff. Endoluminal management of T1 colon cancers is an acceptable method of treatment and an alternative to surgical resection provided that the proper parameters are met.

The applications of computer-generated modelling in surgery are increasing and diverse. Surgeons utilise these models for preoperative planning and intraoperative guidance. In this chapter, techniques for 3D reconstruction, including volume rendering, surface rendering, and voxel-based methods are described. We are discussing advantages and limitations of these techniques, and its impact on surgical and procedure planning. The models may improve surgical accuracy and efficiency, reduce intraoperative risks and ultimately improve patient outcomes. In complex procedures, such as craniofacial surgery or organ transplantation, 3D models provide unprecedented detail, aiding surgeons in navigating critical structures. We will also discuss the role of computer-generated models in surgical simulation and training. These models offer a safe and effective environment for surgeons to hone their skills and practice intricate procedures without risk to patients.

In colorectal surgery, a promising area for minimally-invasive practice is that of natural orifice transluminal endoscopic surgery (NOTES). In this chapter, we focus on transanal total mesorectal excision (taTME), which represents the most ubiquitous application of NOTES within colorectal surgery currently. We also touch on the resurgence of natural orifice specimen extraction (NOSE) as well as other future applications of NOTES in colorectal surgery.

Biofluorescence is a physical phenomenon that has gained a multitude of clinical applications since its introduction to medicine in the 1940s. The utilisation of biofluorescence in colorectal surgery has grown from the development of the fluorophore indocyanine green (ICG) and its prior applications in assessing vascular beds in other fields of surgery. However, despite the increasing adoption of ICG in the assessment of colonic conduit perfusion, the evidence base for its utilisation remains controversial, although a range of other uses for this technology are emerging. Advances in semi-quantitative and artificial intelligence augmented platforms are providing greater objectivity in the application of biofluorescent techniques in colorectal surgery, although they are still in a largely developmental phase. Molecular-targeted biofluorescent technologies are also opening up new surgical paradigms for intraoperative real-time assessment of tumours and their locoregional spread and may in time facilitate surgeons to find equipoise in the radicality of oncologic resection.

Innovative approaches leverage cutting-edge technologies to advance the field of minimally invasive colorectal surgery. The implementation of complex endoluminal and transluminal procedures is challenging and requires extensive training. Recent technological advances not only enable improved detection of colorectal neoplasms with the support of computer science, but also enhanced surgical treatment with robotic instrumentation. Early diagnosis will revolutionize colorectal cancer treatment by avoiding surgery, as has been demonstrated in the treatment of early-stage gastric cancer using third-space endoscopy. Automated colorectal cancer screening with polyp detection and classification can change the therapeutic strategy and orient towards resection during endoscopy, including full-thickness resection, with endoscopic bimanual suturing to close the defect. Several therapeutic flexible endoscopic robotic systems are expected to provide surgery-like dexterity for endo- and transluminal approaches by enabling tissue triangulation while lowering the technical hurdles for endoscopic submucosal dissection and other highly sophisticated procedures such as endoscopic creation or revision of anastomoses. In the curvilinear anatomy of the colon and rectum, navigation assistance for improved spatio-temporal orientation will aid in the detection and documentation of lesions and facilitate their localization for excision and follow-up. Flexible robotic systems encourage surgeons as well as gastroenterologists to perform advanced intra- and transluminal resections.