Seminars in Colon and Rectal Surgery最新文献

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.

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.

The shift from open to endoscopic surgeries, including laparoscopic and robot-assisted surgeries, has enabled the storage of a large number of high-quality intraoperative videos. Endoscopic surgery is highly compatible with artificial intelligence (AI), especially deep-learning-based computer vision, as it provides easy access to videos that form the basis of image analysis. Following the self-learning process, wherein surgeons gain an understanding of surgery by repeatedly watching intraoperative videos, numerous efforts have been made to build AI models for surgery using AI input and analyzing a vast amount of information from intraoperative videos. However, whether AI's understanding of surgery increases sufficiently and becomes useful in daily surgical practice remains unclear. Therefore, this review aims to discuss the current status and future challenges of using AI in surgery, particularly in laparoscopic colorectal surgery, and to explore aspects such as surgical phase or step recognition, navigation and surgical automation, and surgical skill assessment.

Recent advancements in artificial intelligence (AI) have had a profound impact on the field of gastrointestinal endoscopy, particularly in the realm of colonoscopy. Recent studies have shown excellent performance of AI models in both computer-aided detection (CADe) and computer-aided diagnosis (CADx) of polyps. Moreover, AI has shown promising results in other aspects of colonoscopy such as prediction of depth of tumor invasion, colonoscopy quality assurance, and AI applications in inflammatory bowel disease.

In this review, we summarize the recent literature on the application of AI in colonoscopy, and review the limitations and challenges of existing AI technologies and future directions for this field.

The incidence of colorectal anastomotic leaks is approximately 5–19 % of cases, posing a threat to intestinal continuity, particularly if the leak arises after a low or ultra-low colorectal anastomosis. A Turnbull–Cutait procedure can be a salvage option for such patients and they may be eligible if they are adequate redo pelvic surgery candidates, who are motivated to regain intestinal continuity, and who have good continence and anal function at baseline. The first stage of the procedure is colonic mobilization and pull-through after perineal division at the top of the anorectal complex and mucosectomy. A diverting loop ileostomy is utilized. The second stage is amputation of the excess colon and creation of a hand-sewn colo-anal anastomosis, typically performed 7 days later. Outcomes after a Turnbull–Cutait procedure are reasonable based on a series from specialized centers with 80–90 % of patients having a complete Turnbull–Cutait and reversal of the diverting ileostomy. Low anterior resection syndrome is common. In the long-term, studies show that just over half of patients will remain stoma free at 5 years; fecal incontinence is the main reason for failure and return to a stoma. The prospect of a Turnbull–Cutait can be kept in mind when addressing an anastomotic leak in appropriate patients; this may allow for surgical decision-making that makes it feasible to utilize a Turnbull–Cutait in the future.