New trends in colorectal surgery: Single port and natural orifice techniques

International Society of University Colon and Rectal Surgeons survey of surgeons' preference on rectal cancer treatment

PURPOSE

Rectal cancer treatment has a wide range of possible approaches from radical extirpative surgery to nonoperative watchful waiting following chemoradiotherapy, with or without, additional chemotherapy. Our goal was to assess the personal opinion of active practicing surgeons on rectal cancer treatment if he/she was the patient.

METHODS

A panel of the International Society of University Colon and Rectal Surgeons (ISUCRS) selected 10 questions that were included in a questionnaire that included other items including demographics. The questionnaire was distributed electronically to ISUCRS fellows and other surgeons included in our database and remained open from April 16 to 28, 2020.

RESULTS

One hundred sixty-three specialists completed the survey. The majority of surgeons (n=65, 39.9%) chose the minimally invasive (laparoscopic) surgery for their personal treatment of rectal cancer. For low-lying rectal cancer T1 and T2, the treatment choice was standard chemoradiation+local excision (n=60, 36.8%) followed by local excision±chemoradiotherapy if needed (n=55, 33.7%). In regards to locally advanced low rectal cancer T3 or greater, the preference of the responders was for laparoscopic surgery (n=65, 39.9%). We found a statistically significant relationship between surgeons' age and their preference for minimally invasive techniques demonstrating an age-based bias on senior surgeons' inclination toward open approach.

CONCLUSION

Our survey reveals an age-based preference by surgeons for minimally invasive surgical techniques as well as organ-preserving techniques for personal treatment of treating rectal cancer. Only 1/4 of specialists do adhere to the international guidelines for treating early rectal cancer.

The Extraperitoneal Approach to Left-Sided Colorectal Resections: A Human Cadaveric Study

INTRODUCTION

Technical challenges during laparoscopic and robotic anterior resection include identification of key retroperitoneal structures and obtaining clear views of the inferior mesenteric artery (IMA) pedicle and total mesorectal excision (TME) plane. Steep head-down position improves surgical exposure but is associated with cerebral oedema, high intrapulmonary pressures, and rare neurological complications. In this article we describe the key steps of an anterior resection performed via the extra-peritoneal (XP) space in the supine position.

METHODS

The technique of same-side lateral-to-medial XP dissection has been developed and refined in serial cadaveric workshops. A standard periumbilical port is inserted for initial laparoscopic exploration. Dissection is then performed in the left XP space via a 5 cm skin incision (later used as the extraction site) to allow for insertion of four (latterly three) working ports. The colon is mobilized along its lateral attachments, reflecting retroperitoneal structures down and away. The IMA pedicle is taken proximally, next to the duodenum. If required, TME dissection can be continued in the same plane. A short intraperitoneal phase is then required to complete the procedure.

RESULTS

Eight cadavers were studied (seven males; median 78 y). Four operations were performed laparoscopically and four robotically. Excellent views of the key retroperitoneal structures were achieved early in the procedure. Anatomical identification was performed sequentially for left-sided structures-psoas tendon, gonadal vessel, ureter, common iliac artery, IMA, and duodenum before ligation of the IMA pedicle. High ligation of IMA on the aorta and splenic flexure mobilization were performed in all eight procedures.

CONCLUSIONS

This novel study shows it is feasible to perform the key steps of an anterior resection using the XP space in the supine position. This will reduce the need for steep head-down positioning which may have meaningful clinical benefits. Prospective clinical studies are required to validate the technique within a patient population.

Intestinal Anastomotic Healing: What do We Know About Processes Behind Anastomotic Complications

Colorectal surgery has developed rapidly in the recent decades. Nevertheless, colorectal anastomotic leakage continues to appear postoperatively in unpleasant rates and leads to life-threatening conditions. The development of valid complication-preventing methods is inefficient in many aspects as we are still lacking knowledge about the basics of the process of anastomotic wound healing in the gastrointestinal tract. Without the proper understanding of the crucial mechanisms, research for prevention of anastomotic leakage is predestined to be unsuccessful. This review article discusses known pathophysiological mechanisms together with the most lately found processes to be further studied. The aim of the article is to facilitate the orientation in the topic, support the better understanding of known mechanisms and suggest promising possibilities and directions for further research.

Feasibility of "natural surface" epicardial mapping from the pulmonary artery for management of atrial arrhythmias

Background

The right and left pulmonary artery branches (RPA, LPA) overlie inaccessible left atrial (LA) epicardium, containing the Bachmann bundle (BB), that participate in arrhythmia pathogenesis and offer an opportunity for natural surface epicardial mapping (NSEM).

Objective

We sought to assess the feasibility of NSEM of BB and LA roof arrhythmias.

Methods

Electrogram recording, pacing, and ablation was performed in 2 swine. Subsequently, NSEM and pacing from the RPA and LPA was performed in 11 consecutive patients undergoing ablation of atrial fibrillation or flutter. Pacing entrainment and ablation of LA epicardium, from the pulmonary artery (PA), was performed in cases of atypical flutter.

Results

Swine specimens revealed no vascular disruption and LA epicardial lesions up to 7 mm in diameter and 3 mm in depth. In clinical cases, RPA mapping was performed in 11 (100%) and LPA mapping in 6 (55%) patients. Simultaneous leftward activation of the BB followed by rightward activation of the opposing LA endocardium was recorded during crista pacing. Right and left PA median signal amplitudes were 0.71 mV and 0.30 mV, respectively. Endocardial LA median distance was 9 mm to the RPA and 15.6 mm to the LPA and LA capture was successful in 7 of 8 (88%). In cases of atypical flutter, entrainment was successful in 3 of 3 (100%) and ablation was performed.

Conclusion

PA NSEM can enable safe recording and entrainment of the BB, providing otherwise inaccessible epicaridal arrhythmia measurements. The safety and efficacy of ablation from the PA requires further study.

Trans-stomal single-port laparoscopic Hartmann's reversal is an efficacious and efficient procedure: a case-controlled study

BACKGROUND

Hartman's reversal remains challenging and is associated with a widely variable success rate. In a previous study, we reported that laparoscopy may lower the mortality and morbidity rates of the procedure. The aim of the current study was to assess the operative results of single-port laparoscopic Hartmann's reversal (SP-HR) as compared to the more standard, multi-port laparoscopic variant (MP-HR).

METHODS

We performed a retrospective, non-randomized, case-controlled study of 44 consecutive patients who had SP-HR (Group A) compared to 44 patients who had MP-HR (Group B). The study was conducted in a high-volume colorectal unit in a 1200-bed university affiliated hospital, The Poissy-Saint Germain Medical Complex, France.

RESULTS

Preoperative patients' characteristics (sex, body mass index, American Society of Anesthesiologists status, prior surgery, comorbidities, colonic disease) were comparable in both groups. The conversion rate was 13.6% and 4.5% in Group A and in Group B, respectively (p = 0.084) and consisted of placement of any additional ports. Conversion to open surgery did not occur in any patient in either group (p = 1). Mean operative time was shorter in Group A than in in Group B, (105 vs. 155 min; p = 0.0133). The mortality rate was 2.2% in Group A and 0% in Group B (p = 0.3145). The overall morbidity rate was 11.4% in Group A and 18.2% in Group B (p = 0.5344). The median length of hospital stay was significantly shorter in Group than in Group B (4.8 vs. 6.8 days; p = 0.0102).

CONCLUSIONS

The SP-HR technique was found to be safe and efficient. It compares favorably with MP-HR. Moreover, indirect cost savings could be induced by the reduction in the length of hospital stay.

Laparoscopy-Assisted Natural Orifice Specimen Extraction to Treat Tumors of the Sigmoid Colon and Rectum: The Short- and Long-Term Outcomes of a Retrospective Study

Background: Few studies have assessed the short- and long-term outcomes of laparoscopically assisted natural orifice specimen extraction (NOSE) in patients with sigmoid colon and rectal tumors. We investigated the short- and long-term outcomes of patients undergoing laparoscopic-assisted NOSE for tumors of the sigmoid colon and rectum. Methods: Ninety-eight patients with sigmoid colon and rectal tumors undergoing laparoscopic-assisted NOSE were included. The tumor was classified according to its distance from the anal verge: Group 1 (15-30 cm), Group 2 (5-15 cm), and Group 3 (≤5 cm). In Group 1 patients, a laparoscopic surgical specimen collection bag was used as a special transrectal device. In Group 2 patients, transanal endoscopic microsurgery device and specimen collection bag were used. In Group 3 patients, a Lone-Star retractor was used. The demographic characteristics and intra- and postoperative outcomes were measured. Results: In Group 1, 1 patient had respiratory disease and 1 had enterocolitis as short-term postoperative complications. One patient showed intestinal obstruction as a long-term postoperative complication. In Group 2, 2 patients had an ileus, 1 had an anastomotic leak, 2 had urinary retention, and 1 had respiratory disease as short-term complications. Only one patient had a long-term complication: anastomotic stenosis. In Group 3, short-term complications were present in 3 patients: 1 had hemorrhage, 1 had urinary retention, and 1 had respiratory disease. Long-term complications included one case of anastomotic stenosis and one of intestinal obstruction. Conclusions: NOSE is safe and cosmetically and theoretically superior to conventional laparoscopy when different devices are used according to the tumor's location.

A comprehensive study of immunology repertoires in both preoperative stage and postoperative stage in patients with colorectal cancer

BACKGROUND

Colorectal cancer (CRC) is the 3rd most common cancer type in the world. The correlation between immune repertoire and prognosis of CRC has been well studied in the last decades. The diversity and stability of the immune cells can be measured by hypervariable complementarity-determining region 3 (CDR3) segments of the T-cell receptor (TCR).

METHODS

In this study, we collected five healthy controls and 19 CRC patients' peripheral blood mononuclear cells (PBMCs) in three stages, namely 1 day preoperative, 3 days' postoperative, and 7 days' postoperative, respectively. Simultaneously, we have also done the comparative analysis of these two different anesthesia methods, namely TIVA and CEGA. Sequencing of the TCR segments has been performed by multiplex PCR and high-throughput next-generation sequencing. We also analyzed the distribution of CDR3 length, highly expansion clones (HECs), TRBV, and TRBJ gene usage.

RESULTS

Our result showed a significant difference between TCR CDR3 length distribution and HEC distribution between CRC patients and healthy controls. We also found that TRBV11-2, TRBV12-1, TRBV16, TRBV3-2, TRBV4-2, TRBV4-3, TRBV5-4, TRBV6-8, TRBV7-8, TRBV7-9 and RBV11-2, TRBV12-1, TRBV16, TRBV3-2, TRBV4-2, TRBV4-3, TRBV5-4, TRBV6-8, TRBV7-8, and TRBV7-9 usages are different between CRC patients and healthy controls.

CONCLUSION

In conclusion, CRC patients were presented with different immune repertoire in comparison with healthy controls. In this study, significant difference in TRBV and TRBJ gene usage in between case and control group could provide some potential biomarker for the diagnosis and the treatment of the patients with CRC.

A Specimen Extraction Instrument Based on Braided Fiber Tube for Natural Orifice Translumenal Endoscopic Surgery

Natural orifice translumenal endoscopic surgery (NOTES) has offered significant advantages of less pain, reduced recovery time, and minimized scar after operation, demonstrating a promising development prospect. However, the large-size specimen extraction remains challenging for NOTES, due to the narrow space of the human natural orifices. To address such difficulties, a specimen extraction method that utilizes the braided fiber tube (BFT) structure with excellent retractility to accommodate and bind the bulky specimen has been proposed. Based on the theory of helical spring, the geometric model and the mechanical model of the BFT are established, and experiments have been performed to verify the accuracy of the derived mechanical model. In addition, a tensile test of using the BFT to extract large specimens via a small channel is carried out, which verifies the stable extraction performance of the proposed design. The BFT will not be damaged when extracting the specimen with a diameter less than 1.75 times of the channel diameter. A NOTES-specific specimen extraction instrument is designed according to the characteristics of NOTES, and it has three degrees-of-freedom and is able to actively capture different specimen by using a suction cup. Finally, specimen extraction experiments on NOTES multitasking platform phantom have been conducted using the prototyped instrument to validate its feasibility and effectiveness.

Isolated rectal cancer surgery: a 2007-2014 population study based on a large administrative database

Rectal resection is technically one of the most demanding laparoscopic procedures, requiring additional training and expertise of both surgeons and institutions. The literature has shown that laparoscopic procedures can be appropriate for the treatment of rectal cancer (RC), in terms of safety, outcome and efficiency, but results may not always be directly transferable to the general population. This study aimed to investigate the use of laparoscopic rectal cancer resections in a north-eastern Italian region (the Veneto) and to see how the characteristics of patients and hospitals are associated with the use of laparoscopy. This was a retrospective cohort study based on administrative data collected from 2007 to 2014 in the Veneto region (north-east Italy). In the period considered (2007-2014), 4953 rectal resections were performed for RC in Veneto hospitals, accounting for 35% of the total 14,243 surgical procedures involving the rectum, and resulting in 76,739 days in hospital [mean length of stay-post-operative (MLOS) 15.5 ± 11.1 days]. Patients were a mean 67.9 ± 11.7 years old (68 ± 12.7 for women, 67.9 ± 11 for men), while the subgroup of patients undergoing laparoscopic procedures was on average 2 years younger (66.5 ± 11.8 vs 68.8 ± 11.5; p < 0.05). The four main findings of this study are: (1) the increasing rates of laparoscopic procedures for RC resection at all the hospitals in our geographical area, rising up to 52% in 2014. This is probably related to not only to availability of better equipment but surely to a growing expertise of surgeons; (2) the esteem of proportion of laparoscopically treated RC; (3) the significant difference between the laparoscopic and open surgical approach in terms of mean length of hospital stay after RC resection, making the laparoscopic approach cost-effective generally speaking; and (4) the disparities in hospitals' use of laparoscopy by patients' age group: Laparoscopic surgery is safe also in the elderly population but it is not so widely offers in Veneto Region hospitals, and it's probably due to the lack of experience about this approach in frail/old patients.

Single-incision laparoscopic ileocecal resection using an organ retractor

INTRODUCTION

Single-incision laparoscopic surgery has been reported to be a safe and feasible technique for colorectal cancer. However, the technique needs skill due to the limitations of the device. An organ retractor is a new grasp device that has the potential to overcome these limitations.

PRESENTATION OF CASE

A 63-year-old woman with a tumor palpated in the right lower quadrant of the abdomen presented to hospital. Colonoscopy showed a type 2 mass with nearly complete stenosis, and a biopsy specimen showed well-differentiated adenocarcinoma. Single-incision laparoscopic surgery ileocecal resection was performed using an organ retractor. A 3-cm incision was placed in the umbilicus, and three conventional ports were inserted. An organ retractor was used for hepatocolic ligament resection, resection of the ileocolic vessels, and resection of the insertion of the mesentery proper. For each resection, the trailer line's tension was adjusted to provide a good operative view. The patient's postoperative course was good, and she was discharged 7days after surgery.

DISCUSSION

An organ retractor was effective for single-incision laparoscopic surgery technique not only to maintain a good operative view, but also to change trailer line tension, which enabled safe dissection.

CONCLUSION

An organ retractor could facilitate single-incision laparoscopic surgery.

Early Experience with Single-Incision Laparoscopic Total Abdominal Colectomy in Children

PURPOSE

Single-incision laparoscopic surgery for pediatric colorectal disease has been shown to be feasible and safe; however, the literature is scarce regarding the outcomes of single-incision laparoscopic total abdominal colectomy (SIL-TAC) in the pediatric population. The purpose of this pilot study was to review our initial experience and outcomes with SIL-TAC.

MATERIALS AND METHODS

A retrospective review of patients who underwent SIL-TAC from 2013 to 2015 was performed. General demographic and outcome data were analyzed.

RESULTS

Five patients were included. Indications included ulcerative colitis (n = 4) and colonic dysmotility (n = 1). The median age was 13.5 years (8.5-19.4 years) and the median body mass index (BMI) percentile was 77.4 (2.2-98). The median operative time was 182 minutes (163-244 minutes). One case was converted to an open procedure. The median postoperative self-reported pain score was 2.8 (1.2-4.5). The median time until initiation of a diet was 2 days (1-8 days). The median length of hospital stay was 5 days (3-11 days). There were no 30-day complications.

CONCLUSION

SIL-TAC is feasible and safe in children and offers improved cosmesis.

Simple, Safe, and Cost-Effective Technique for Resected Stomach Extraction in Laparoscopic Sleeve Gastrectomy

Background. Laparoscopic sleeve gastrectomy (LSG) has become a popular operation during the recent years. This procedure requires resection of 80–90% of the stomach. Extraction of gastric specimen is known to be a challenging and costly stage of the operation. In this paper, we report results of a simple and cost-effective specimen extraction technique which was applied to 137 consecutive LSG patients. Methods. Between October 2013 and October 2015, 137 laparoscopic sleeve gastrectomy surgeries were performed at Dokuz Eylul University General Surgery Department, Upper Gastrointestinal Surgery Unit. All specimens were extracted through a 15 mm trocar site without using any special device. Results. We noticed one superficial incisional surgical site infection and treated this patient with oral antibiotics. No cases of trocar site hernia were observed. Conclusion. Different techniques have been described for specimen extraction. This simple technique allows extraction of specimen safely in a short time and does not require any special device.

An endoscope with integrated transparent bioelectronics and theranostic nanoparticles for colon cancer treatment

The gastrointestinal tract is a challenging anatomical target for diagnostic and therapeutic procedures for bleeding, polyps and cancerous growths. Advanced endoscopes that combine imaging and therapies within the gastrointestinal tract provide an advantage over stand-alone diagnostic or therapeutic devices. However, current multimodal endoscopes lack the spatial resolution necessary to detect and treat small cancers and other abnormalities. Here we present a multifunctional endoscope-based interventional system that integrates transparent bioelectronics with theranostic nanoparticles, which are photoactivated within highly localized space near tumours or benign growths. These advanced electronics and nanoparticles collectively enable optical fluorescence-based mapping, electrical impedance and pH sensing, contact/temperature monitoring, radio frequency ablation and localized photo/chemotherapy, as the basis of a closed-loop solution for colon cancer treatment. In vitro, ex vivo and in vivo experiments highlight the utility of this technology for accurate detection, delineation and rapid targeted therapy of colon cancer or precancerous lesions.

Current endoscopes are limited to detection or treatment of colon cancers and growths, or resolution is too low for clinical application. Here the authors present a multimodal endoscope with theranostic nanoparticles that integrates fluorescence-based mapping, electrical impedance, pH and temperature monitoring, RF ablation and localized phototherapy or chemotherapy.

Review of single incision laparoscopic surgery in colorectal surgery

As surgical techniques continue to move towards less invasive techniques, single incision laparoscopic surgery (SILS), a hybrid between traditional multiport laparoscopy and natural orifice transluminal endoscopic surgery, was introduced to further the enhanced outcomes of multiport laparoscopy. The safety and feasibility of SILS for both benign and malignant colorectal disease has been proven. SILS provides the potential for improved cosmesis, postoperative pain, recovery time, and quality of life at the drawback of higher technical skill required. In this article, we review the history, describe the available technology and techniques, and evaluate the benefits and limitations of SILS for colorectal surgery in the published literature.