Surgical Technology International
35th Edition
Contains 55 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
456 pages
Nov 2019 - ISSN:1090-3941
1 year Institutional Subscription
both electronic and print versions
Colorectal Surgery
Right Colectomy with Extended D3 Mesenterectomy: Anterior and Posterior to the Mesenteric Vessels
Jens Marius Nesgaard, MD, Consultant Surgeon, Vestfold Hospital Trust, Tonsberg, Norway, Bojan V. Stimec, MD, PhD, Professor, Faculty of Medicine, University of Geneva, Geneva, Switzerland , Arne O. Bakka, MD, PhD, Professor and Consultant Surgeon, Akershus University Hospital, Lorenskog, Norway, Institute of Clinical Medicine, University of Oslo, Oslo, Norway, Bjørn Edwin, MD, PhD, Professor and Consultant Surgeon, Interventional Centre, Oslo University Hospital-Rikshospitale, Institute Of Clinicalmedicine University Of Oslo, Oslo, Norway, Dejan Ignjatovic, MD, PhD, Professor and Consultant Surgeon, Akershus University Hospital, University Of Oslo, Lorenskog, Norway, Institute Of Clinicalmedicine, University Of Oslo, Oslo, Norway, Roberto Bergamaschi, MD, PhD, Professor and Chief Colorectal Surgeon, New York Medical College, Westchester Medical Center, Valhalla, NY
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Background: In right colectomy for cancer, complete mesocolic excision and D3 lymphadenectomy each leave behind lymphatic tissue anterior and posterior to the superior mesenteric vein (SMV) and artery (SMA). In this article, we present D3 extended mesenterectomy: a surgical technique that excises the lymphatic tissue en bloc with the right colectomy specimen.
Material and Methods: A 3D map of the mesentery of the right colon was reconstructed from staging CT-angiogram scans. The surgical technique of right colectomy with D3 extended mesenterectomy consisted of eight steps: 1) reveal the SMV and SMA; 2) isolate the ileocolic artery; 3) isolate the middle colic artery; 4) resolve the anterior mesenteric flap; 5) specimen de-vascularization; 6) colectomy; 7) resolve the posterior mesenteric flap; and 8) anastomosis.
Results: One-hundred-seventy-six patients (77 men) 66 years of age were operated upon from February 2011 to January 2017. There were 169 adenocarcinomas: 16.0% Stage I, 49.1% Stage II, 33.7% Stage III, 1.2% Stage IV. Tumor locations were 50.6% cecum, 41.5% ascending colon, 4.5% hepatic flexure, and 2.3% transverse colon. Mean operating time was 200 minutes, blood loss 273 ml, and length of stay 7.9 days. There were 9 anastomotic leakages and 15 reoperations. One patient underwent small bowel resection due to SMA tear. There was no postoperative mortality. The mean number of lymph nodes per specimen (40.9) was comprised of 27.1 in the D2 volume and 13.8 in the D3 volume. The mean number of metastatic lymph nodes was 1.2 in the D2 volume and 0.13 in D3. There were 7 patients with lymph node metastasis in D3, 2 of whom had node metastasis solely within D3.
Conclusion: This study shows that 1.2% of patients would have been incorrectly diagnosed as Stage II if extended D3 mesenterectomy had not been performed. Similarly, lymph node metastases would have been left behind in 4.1% of patients if extended D3 mesenterectomy had not been performed.
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Repair of Parastomal Hernia with Component Separation at Reversal of Loop Ileostomy. A technical note
Hanjoo Lee, MD, Surgery Resident, Mahir Gachabayov, MD, PhD, Research Scholar, Agon Kajmolli, MD, Surgery Resident, Roberto Bergamaschi, MD, PhD, FRCS, FASCRS, FACS, Professor and Chief, Westchester Medical Center, New York Medical College, Valhalla, NY, George Angelos, MD, FACS, Attending Colorectal Surgeon, Sanford Health, Sioux Falls, SD
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Aim: The aim of this technical note is to describe a surgical technique to repair parastomal hernias with component separation and mesh at reversal of loop ileostomy.
Background: Stage III rectal cancer patients who have completed neoadjuvant chemoradiation will undergo low anterior resection with loop ileostomy. Following completion of adjuvant chemotherapy, the ileostomy will be reversed after an average of five to six months. A minority of patients presenting with an obstructed rectal cancer may undergo laparoscopic loop ileostomy prior to commencing neoadjuvant chemoradiation, resulting in a longer ileostomy time.
Technique: Loop ileostomy reversal consists of five steps: mobilization of the stoma, side-to-side anastomosis, component separation, placement of biologic mesh, and purse-string skin closure.
Conclusion: The surgical technique described here, consisting of component separation and mesh at loop ileostomy reversal, is effective for repairing parastomal hernia.
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Double-barreled Wet Colostomy Versus Separate Urinary and Fecal Diversion in Patients Undergoing Total Pelvic Exenteration: A Cohort Meta-analysis
Mahir Gachabayov, MD, PhD, Research Scholar, Hanjoo Lee, MD, Surgery Resident, Xiang Da Dong, MD, FACS, Clinical Associate Professor of Surgery, Nikathan Swah Kumar, Medical Student, Roberto Bergamaschi, MD, PhD, FRCS, FASCRS, FACS, Professor and Chief, Westchester Medical Center, New York Medical College, Valhalla, NY, Department of Surgery, Faculty of Preventive, Medicine, Clinic of Colorectal and Minimally, Invasive Surgery, Sechenov First Moscow State, Medical University, Moscow, Russia, Inna Tulina, MD, PhD, Associate Professor of Surgery, Petr Tsarkov, MD, PhD, FASCRS(Hon), Professor of Surgery, Sechenov First Moscow State, Medical University, Moscow, Russia
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Background: The aim of this meta-analysis was to determine whether double-barreled wet colostomy (DBWC) provides similar urinary tract infection rates as separate urinary and fecal diversion (SUFD) in patients undergoing pelvic exenteration.
Methods: The MEDLINE, PubMed, Cochrane Library, and Scopus databases were systematically searched by two independent researchers. The primary endpoint was the urinary tract infection rate. The Mantel-Haenszel method with odds ratios with 95% confidence intervals (OR (95%CI)) was used as an effect measure for dichotomous variables. A random-effects model was used for the meta-analysis. Statistical heterogeneity among effect estimates was evaluated using I2 and Tau2.
Results: Three observational studies that included a total of 257 patients (159 DBWC; 98 SUFD) were included after 14 potentially eligible records were screened. Pooled urinary tract infection rates were 1.9% (3/159) in DBWC and 6.1% (6/98) in SUFD. This difference was not statistically significant [OR (95%CI) = 0.27 (0.06, 1.19); p=0.08] with low among-study heterogeneity (I2=0%).
Conclusions: This meta-analysis did not find a significant difference in urinary tract infection rates between DBWC and SUFD in patients undergoing total pelvic exenteration. Further clinical studies will be required to further understand the pros and cons of these procedures.
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Does Immediate Colon Surgery Within Two Hours Predict a Negative Postoperative Outcome? A Prospective Cohort Study
Samantha McKenzie Olszewski Stancu, MD, Florin Iordache, MD, PhD, Bucharest Emergency Hospital, Bucharest, Romania
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Background: The aim of this study was to evaluate whether immediate surgery within 2 hours is a prognostic factor for adverse postoperative outcomes.
Methods: This was a prospective observational study that included all consecutive patients who underwent emergency and elective colon resection at a tertiary-level hospital for malignant or benign conditions over a 13-month period. Postoperative outcomes included morbidity, mortality, reoperation, readmission and length of stay. The statistical analysis included both univariate and multivariate tests, with statistical significance set at p<0.05.
Results: Over a 13-month period, 300 colon resections were performed. Twenty-five cases (8.3%) underwent emergency operations within 2 hours of admission. Immediate surgery was associated with worse postoperative outcomes including higher mortality and reoperation rates: 40% versus 5.8% (p <0.0001, OR: 10.79, 95% CI: 4.18-27.79) and 20% versus 6.9% (p=0.02, OR: 3.36, 95% CI: 1.19-9.97), respectively. Postoperative outcomes were also worse in operations for malignant tumors (OR: 6.97, 95% CI: 2.82-17.60, p< 0.0001).
Conclusion: Immediate colon surgery within 2 hours is a negative predictor for morbidity and mortality.
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p-Value: Villain or Scapegoat?
EDITORIAL
Mahir Gachabayov, MD, PhD, New York Medical College, Westchester Medical Center, Valhalla, NY, Abraham Fingerhut, MD, PhD, Professor of Surgery, Medical University of Graz, Graz, Austria
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T≤2N0 TRG1-2 in Post-Chemoradiation Therapy MRI: What can it Predict?
Caio Sergio Rizkallah Nahas, MD, PhD, Assistant Professor, Sergio Carlos Nahas, MD, PhD, Leonardo Bustamante-Lopez, MD, PhD, Assistant Professor, Carlos Frederico Sparapan Marques, MD, PhD, Assistant Professor , Cinthia Ortega, MD, PhD, Assistant Professor, Rodrigo Azambuja, MD, Assistant Professor, Ulysses Ribeiro Jr., MD, PhD, Assistant Professor, Guilherme Cutait Cotti, MD, Assistant Professor, Antonio Rocco Imperiale, MD, Assistant Professor, Ivan Cecconello, MD, PhD, Instituto do Câncer do Estado de São Paulo , Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Universidade de São Paulo, São Paulo, Brazil
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Background: Total mesorectal excision is the standard radical operation after neoadjuvant chemoradiotherapy for patients with middle/low locally advanced rectal cancer. However, it carries significant rates of morbidity, sexual/urinary dysfunction, fecal impairment and permanent stoma. The ability to identify patients with a complete or nearly-complete response could help steer patients to less-invasive surgery or a watch-and-wait strategy.
Objective: To assess the ability to predict good responders and a favorable prognosis among rectal cancer patients by post-chemoradiation therapy MRI.
Patients: Consecutive patients stage T3-4N0M0 or T(any)N+M0 located within 10cm from the anal verge were enrolled. Patients were staged and re-staged 8.8 weeks after the completion of chemoradiation by digital exam, colonoscopy, pelvic-MRI, and thorax and abdominal CT scans. All patients underwent total mesorectal excision with curative intent.
Results: Of the total 309 patients, 275 were eligible, and 199 (72.4%) of these were stage III. Restaging-MRI identified 59 (21.4%) T≤2N0/TRG1-2. Specimen pathologic evaluation revealed 43 (15.6%) patients with a complete pathologic response.
Estimates of the accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of MRIyT≤2N0/TRG1-2 for the identification of ypT0N0 were 79.7%, 84.5%, 53.5%, 39%, and 90.7%, respectively. Estimates for the identification of ypN0 were 48.4%, 27.8%, 92%, 88.1%, and 48.4%, respectively. In a multivariate analysis, the only pre-CRT/MRI variables that were associated with an increased risk of lymph node involvement at the specimen were N+ (OR=2.22) and extramural vascular invasion (OR=2.28). MRI yT≤2N0/TRG1-2 patients showed improved estimated 5-year disease-free survival, but no difference in estimated 5-year survival.
Conclusion: Although MRIyT≤2N0/TRG1-2 cannot predict all cases of a complete pathologic response, it can effectively predict a low rate of lymph node involvement and a better prognosis in patients who undergo total mesorectal excision.
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