New Paradigms for Neural Monitoring in Thyroid Surgery
Hui Sun, MD, Professor, Daqi Zhang, MD, Associate Professor of Surgery, Yishen Zhao, MD, Doctor, China-Japan Union, Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical, Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, Jilin province, PR China, Paolo Carcofaro, MD, Professor of Surgery, S. Anna University Hospital, Ferrara, Italy, University of Ferrara, Ferrara, Italy, Hoon Yub Kim, MD, Associate Professor Of Surgery, Korea University College of Medicine, Seoul, Korea, Gianlorenzo Dionigi, MD, FACS, Professor of Surgery, Antonella Pino MD, Doctor, Ettore Caruso, MD, Doctor, Alessandro Pontin, MD, Doctor, University Hospital G. Martino, University of Messina, Messina, Italy, Vincenzo Pappalardo, MD, Doctor, Ospedale di Circolo di Varese, Varese, Italy, Özer Makay, MD, Professor of Surgery, Ege University Hospital, Ege University-Izmir, Turkey, Che-Wei Wu, MD, PhD, Professor of Surgery, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University Hospital, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Intraoperative neuromonitoring (IONM) in thyroid gland surgery provides real-time feedback to the endocrine surgeon regarding the electrophysiological consequences of surgical manipulation of the laryngeal nerves. The goal of monitoring modalities is to detect surgical or physiological insults to the recurrent laryngeal nerve (RLN) while they are still reversible or, in cases where prevention is not an option, to minimize the damage done to these structures during thyroidectomy. In recent decades, monitoring of the RLN has become a fundamental part of endocrine surgery. IONM is a feasible procedure in both open and endoscopic, robotic thyroidectomy. Experts in IONM have organized a working group of general, endocrine, head and neck ENT surgeons and endocrinologists (International Neural Monitoring Study Group; INMSG) to develop standards for practicing this technique in endoscopic and robotic thyroidectomy. This paper presents recent clinical and research experience with intraoperative neural monitoring for thyroid gland surgery.
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Benefits of Robotic Camera Assistance in Minimally Invasive Bariatric, Procedures: Prospective Clinical Trial Using a Joystick-Guided Camera-Holder
Sebastian W. Holländer, MD, Resident Physician, Hans Joachim Klingen, MD, Senior Physician, Visceral and Pediatric Surgery, University Hospital of the Saarland, Homburg, Germany, Sarah Hess, Diploma Ecotrophologist, Anna Merscher, MD, Assistant Physician, Hospital Bietigheim-Vaihingen, Bietigheim-Vaihingen, Germany, Dieter Birk, MD, Medical Director and Head of the Department, Matthias Glanemann, MD, Chief Physician and Head of the Department, Department of General Surgery, Vascular, Visceral and Pediatric Surgery, University Hospital of the Saarland, Homburg, Germany
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Background: While minimally invasive surgery is a growing sector in medicine, camera assistance remains a problem. Especially in bariatric surgery, the assistant holding the camera faces certain challenges. Furthermore, unless the surgeon controls the camera movement themselves, they will be challenged by an unstable image.
The aim of this study was to investigate the benefits of a robotic camera assistant (SoloAssist®, AKTORmed™ GmbH, Barbing, Germany) in bariatric surgery.
Patients and Methods: Three hundred thirty one consecutive laparoscopic bariatric procedures were performed with the assistance of a camera robot, including Roux-en-Y gastric bypass, laparoscopic gastric banding, sleeve gastrectomy, and gastroplication. Failures and aborts were documented and 6 surgeons were interviewed regarding their experiences using a questionnaire.
Results: In 18 of 331 procedures, robotic assistance was aborted and the procedure was continued manually, mostly because of a need for frequent changes of position in narrow spaces and adverse angles. Two short circuits, 4 joystick faliures and one malfunction of the control unit were reported. All of the surgeons preferred robotic to human assistance, mostly because of a steady image and the capacity for self-control. Discussion: The SoloAssist® is a reliable system for minimal invasive procedures, especially in bariatric surgery. It provides more comfortable conditions for the surgeon and their assistant by freeing one hand for other purposes. Even in narrow spaces (e.g., between a voluminous stomach and adipose liver), the robot guarantees a steady image. Slight movements of the camera can be precisely controlled, which leads to increased comfort for the surgeon.
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Near-Infrared Indocyanine Green-Enhanced Fluorescence and Evaluation of the Bowel Microperfusion During Robotic Colorectal Surgery: a Retrospective Original Paper
Alberto Mangano, MD, Robotic Surgery Research Specialist, Eduardo Fernandes, MD, PhD, FRCS, Chief Resident in General Surgery, Federico Gheza, MD, Robotic Surgery Research Specialist, Roberto Bustos, MD, Robotic Surgery Research Specialist, Liaohai Leo Chen, PhD, Visiting Research Professor, Mario Masrur, MD, FACS, Assistant Professor, Pier Cristoforo Giulianotti, MD, FACS, Lloyd Nyhus Professor of Surgery; Chief, Vice Head, Department of Surgery, University of Illinois at Chicago, Chicago, IL
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Background: Leakage of the anastomosis after colorectal surgery is a severe complication, and one of the most important causes is poor vascular supply. However, a microvascular deficit is often not detectable during surgery under white light. Near-infrared indocyanine green (ICG)-enhanced fluorescence may be useful for assessing microvascular deficits and conceivably preventing anastomotic leakage.
Objectives: This paper presents a preliminary retrospective case series on robotic colorectal surgery. The aim is to evaluate the feasibility, safety and role of near-infrared ICG-enhanced fluorescence for the intraoperative assessment of peri-anastomotic tissue vascular perfusion.
Materials and Methods: From among more than 164 robotic colorectal cases performed, we retrospectively analyzed 28 that were all performed by the same surgeon (PCG) using near-infrared ICG-enhanced fluorescence technology: 16 left colectomies (57.1%), 8 rectal resections (28.6%), 3 right colectomies (10.8%) and 1 pancolectomy (3.6%).
Results: The rates of conversion, intraoperative complications, dye allergic reaction and mortality were all 0%. In two cases (7.1%)—1 left and 1 right colectomy—the level of the anastomosis was changed intraoperatively after ICG showed ischemic tissues. Despite the application of ICG, one anastomotic leak (after left colectomy for a chronic recurrent sigmoid diverticulitis with pericolic abscess) was observed.
Conclusions: ICG technology may help to determine when to intraoperatively change the anastomotic level to a safer location. In our case series, ICG results led to a change in the level of the anastomosis in 7.1% of the cases. Despite the use of ICG, we observed one leak. This may have been related to vascularization-independent causes (e.g., infection in this case) or may reflect a need for better standardization of this ICG technology. In particular, we need a way to objectively assess the ICG signal and the related risk of leakage. More randomized, prospective, well-powered trials are needed to unveil the full potential of this innovative surgical technology.
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Clinicopathologic Features and Surgical Outcomes of Neuroendocrine Carcinoma of the Gallbladder
Nobuhisa Tanioka, MD, Chief Resident, Takehiro Okabayashi, MD, Division Manager, Kenta Sui, MD, Chief Physician, Takatsugu Matsumoto, MD, Chief Physician, Jun Iwata, MD, Head of Medical Pathology, Sojiro Morita, MD, Vice President, Yasuhiro Shimada, MD, Director, Department of Clinical Oncology, Kochi Health Sciences Center, Kochi, Japan
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Neuroendocrine carcinoma (NEC) of the gallbladder is highly aggressive and has a poor prognosis even after curative resection. The purpose of this study was to collate and analyze published data to clarify the surgical outcome of NEC of the gallbladder and the relationships between potential prognostic factors and survival after surgery. We surveyed worldwide literature from 1981 to 2018 and obtained clinicopathological data for 65 patients who had undergone surgical resection for NEC of the gallbladder. The relationships between potential prognostic factors and survival rates were examined by the Kaplan-Meier method and the log-rank test. The 1-, 3-, and 5-year disease-specific survival rates after surgery were 70.2%, 39.3%, and 29.5%, respectively. A multivariate analysis revealed that the factors that were independently associated with poor outcomes after surgery in patients with NEC of the gallbladder were older age, higher pathologic T stage, and positive lymph node metastasis. The major sites of recurrence were the liver, lung, lymph node, and local recurrence. The median time to the event for recurrence was 4.0 months. Even when curative resection was achieved, 36.9% of patients exhibited recurrence within 12 months after curative resection of gallbladder NEC. Although NEC of the gallbladder remains a rare disease worldwide, its poor prognosis, even after curative resection, demands further epidemiological and pathological studies that could lead to the development of new management strategies.
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Perioperative Use of Anti-TNFα Biological Agents in Open and Laparoscopic Surgery for Inflammatory Bowel Disease
Georgios D. Lianos, MD, MSc, PhD, Consultant General Surgeon, Konstantinos H. Katsanos, MD, PhD, Associate Professor of Gastroenterology, Georgios K. Glantzounis, MD, PhD, FEBS, Professor of Surgery, Dimitrios K. Christodoulou, MD, PhD, Professor of Gastroenterology, University of Ioannina School of Medicine, Ioannina, Greece, Maria Saridi, RN, BSc, MSc, PhD, Director of Nursing, University of Peloponnese, Corinth, Greece, Eleni Albani, MSc, PhD, Director of Nursing, TEI of Western Greece, Patras, Greece, Efstratios Koutroumpakis, MD, Gastroenterologist, University Hospital of Patras, Patras, Greece, Christos Zeglinas, MD, Gastroenterologist and Medical Advisor, AbbVie Pharmaceuticals S.A., Athens, Greece, Ioannis Papaconstantinou, MD, PhD, Professor of Surgery, University Hospital Aretaieion, Athens, Greece
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Inflammatory bowel disease (IBD) consists of two disorders: Crohn’s disease (CD) and ulcerative colitis (UC). Over the past few decades, a great body of knowledge has accumulated regarding the pathogenesis of IBD, and effective pharmaceutical agents, such as inhibitors of tumor necrosis factor (anti-TNF), have been introduced. Although these agents have dramatically improved the outcome of IBD, up to 70% of patients with CD and 10–30% of those with UC still undergo surgery within 10 years from diagnosis. Because of their young age and high recurrence rates, these patients are appropriate candidates for laparoscopic surgery as an alternative to laparotomy. Recently, considerable attention has been focused on perioperative outcomes of patients who are receiving anti-TNF agents and require surgery. The aim of this narrative review is to discuss the current evidence regarding the impact of perioperative anti-TNF treatment on post-operative complication rates with a special focus on laparoscopic surgery.
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Effects of Time to Application of Negative Pressure Therapy on Abdominal Infections After Colonic Perforation
Stefano Rausei, MD, PhD, General Surgeon, ASST Valle Olona, Gallarate, Italy, Vincenzo Pappalardo, MD, General Surgeon, Federica Galli, MD, Resident in General Surgery, Simone Giudici, MD, Resident in General Surgery, Antonio Colella, MS, Medical Student, Francesco Frattini, MD, General Surgeon, ASST Settelaghi, Varese, Italy, Luigi Boni, MD, FACS, General Surgeon, IRCCS Ca' Granda - Policlinico Hospital, University of Milan, Milan, Italy, Gianlorenzo Dionigi, MD, FACS, General Surgeon, University of Messina, Messina, Italy
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Background: Negative pressure therapy (NPT) seems to improve surgical outcomes in open abdomen (OA) management of severe intra-abdominal infections (IAIs). The aim of this study was to compare the effects of immediate vs. delayed application of NPT on outcomes in patients with IAIs after colonic perforation.
Materials and Methods: We analysed 38 patients who received NPT during OA management for IAI after colonic perforation. The endpoints were treatment duration, definitive fascial closure and in-hospital mortality. We subdivided patients according to the timing of NPT application: immediate (at the end of the first OA procedure) and delayed (at I-II revision, at III revision, and after III revision).
Results: NPT was applied immediately in 15 cases (39.5%) and was delayed in 23 (60.5%): 14 (36.8%) at I-II revision, 7 (18.4%) at III revision, and 2 (5.3%) after III revision. Immediate NPT application was associated with the best outcomes.
Conclusions: NPT should be used as soon as possible in OA management for IAIs due to colonic perforation.
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Long-term Results of Robotic Modified Belsey (Gastroesophageal Valvuloplasty) Fundoplication
Farid Gharagozloo, MD, FACS, FCCS, FACHE, Professor of Surgery, Surgeon-in-Chief, Director of Cardiothoracic Surgery, Basher Atiquzzaman, MD, Assistant Professor, Barbara Tempesta, CRNP, Nurse Practitioner, Global Robotics Institute, Florida Hospital Celebration Heath, University of Central Florida, Celebration, FL, RC Tolboom, MD, Resident in Surgery, Meanders Medical Center, Amersfoort, The Netherlands, Mark Meyer, MD, Resident in Thoracic Surgery, Stephan Gruessner, MD, Resident in Thoracic Surgery, University of Arizona Medical Center, Tucson, AZ
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Purpose: Nissen fundoplication is associated with poor long-term durability, as well as dysphasia and gas bloat. We report here the long-term results of modified Belsey fundoplication (Gastroesophageal Valvuloplasty; GEV) performed laparoscopically using a surgical robot.
Methods: Patients who underwent robotic GEV were reviewed retrospectively. Operations were performed by laparoscopy and included robotic dissection of the esophageal hiatus, primary closure of the hiatus, followed by intussusception of a 4 cm segment of the esophagus into the stomach for 270°, and suspension of the fundoplication on the hiatal closure. The results were assessed by postoperative endoscopy, contrast esophagography, a Subjective Symptom Questionnaire (SSQ), and objective Visick grading.
Results: There were 291 patients (156 male, 135 female, mean age 51±14 years). Indications were intractability (73%) and pulmonary symptoms (27%). Mean operative time was 130 minutes ± 52 minutes. Minor complications were seen in 21%. There was no mortality. Mean hospitalization was 2.8 days ± 1.7 days. Mean follow-up was 85 months ± 7 months. During this period, the mean SSQ score decreased from 8.3 ± 0.6 to 0.7± 0.2 (P < 0.05). There was no long-term dysphasia or gas bloat. Ninety-five percent of patients were Visick I and 5% were Visick II. Hiatal hernia recurred in 7 patients (2%).
Conclusions: Robotic laparoscopic modified Belsey fundoplication (GEV) is associated with excellent long-term durability, reflux control, and low rates of dysphasia and gas bloat. This procedure may represent an alternative to medical antireflux therapy and other surgical antireflux procedures such as Nissen fundoplication.
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Is Needlescopic Cholecystectomy a Safe Way to Improve Mininvasiveness and Cosmesis in Young Female Patients?
Giuseppina Talamo, MD, Resident, Francesco Sucameli, MD, Resident, Mikaela Imperatore, MD, Surgeon, Elisabetta Moggia, MD, Surgeon, Laura Dova, MD, Resident, Elisa Francone, MD, Surgeon, Costantino Eretta, MD, Surgeon, Stefano Berti, MD, Head of Department, Department of General Surgery, Sant’Andrea Hospital, La Spezia, Italy
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Introduction: Needlescopic cholecystectomy (NC) was introduced in the late 1990s. It uses a reduced trocar caliber in an otherwise standard four-port laparoscopic cholecystectomy (LC) and seeks to achieve “scarless” surgery without compromising patient safety.
Materials and Methods: Between May 2016 and November 2017, 29 patients underwent elective NC at the Department of General Surgery of Sant’Andrea Hospital (La Spezia, Italy). Inclusion criteria were female sex, age between 18 and 45 years, good performance status (ASA 1-2) and BMI lower than 25. Twenty-one patients underwent a standard 4-port technique: 12mm port in the supraumbilical area, 5mm port in the subxiphoid position, 3mm port in the mid-epigastric area and another 3 mm port in the right mid-clavicular position. In 8 patients, 3mm ports were replaced by 2mm angiocath. A Critical View of Safety (CVS) was achieved in all procedures. Intra-operative cholangiography (IOC) via the cystic duct before any transection of the structures was routinely performed in selected cases, such as those with an unclear biliary anatomy or risk factors for main-duct stones. In our institution, laparoscopic transcystic common bile duct (CBD) exploration is routinely performed in CBD lithiasis.
Results: The mean operative time was 66.79 min (range 25-120 min). IOC was performed in 12 patients (41.4%) with suspected choledocolythiasis. There was no conversion to conventional laparoscopic cholecystectomy or open cholecystectomy. The mean hospital stay was 1.48 days (1-7 days). A Clavien–Dindo IIIB complication occurred in one patient on the third postoperative day. The mean VAS pain score was 3 (0-7). Closure of the skin with primary intention was achieved in all patients. Mean return to work was 6.76 days (3-15 days) and the mean return to previous physical activity was 12.17 days (4-30 days). All of the patients completed the Scar Satisfaction Questionnaire: 26 (89.7% ) and 3 patients (10.3%) were very satisfied and satisfied, respectively.
Conclusion: Any effort to reduce invasiveness and improve cosmesis must not jeopardize safety. Our case series demonstrates that needlescopy can be safely associated with intraoperative cholangiography to recognize CBD stones. This technique offers the advantage of minor postoperative pain, better cosmesis results, early return to routine life activities and great satisfaction for the patient. Needlescopy is a valuable and safe alternative that is suitable for elective cholecystectomy in properly selected patients, such as young female patients.
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Near-Infrared Indocyanine Green-Enhanced Fluorescence and Minimally Invasive Colorectal Surgery: Review of the Literature
Alberto Mangano, MD, Robotic Surgery Research Specialist, Mario A. Masrur, MD, F.A.C.S., Assistant Professor of Surgery, Roberto Bustos, MD, Robotic Surgery Research Specialist, Liaohai Leo Chen, PhD, Research Visiting Professor, Eduardo Fernandes, MD, FRCS, Chief Administrative Surgical Resident, Pier Cristoforo Giulianotti, MD, FACS, Distinguished Lloyd Nyhus Professor of Surgery, Chief Division of General Minimally Invasive & Robotic Surgery, Vice-Head Department of Surgery, Director Robotic Surgery Fellowship Program, Associate Director UIC Health Science Simulation Consortium, Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, IL
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Background: Leakage of the anastomosis after colonic/rectal surgery is a serious complication. One of the most important causes of anastomotic leakage is impaired vascularization. A microvascular tissue deficit is very often not intraoperatively de visu detectable under white light. Near-infrared indocyanine green (ICG)-enhanced fluorescence is a cutting-edge technology that may be useful for detecting microvascular impairment and potentially preventing anastomotic leakage.
Aim: The aim of this narrative review was to evaluate the feasibility and the usefulness of intraoperative assessment of vascular anastomotic perfusion in colorectal surgery using an indocyanine green (ICG) fluorescent tracer.
Material and methods: A PubMed/MedLine, Embase, and Scopus narrative literature review was performed, in which “colorectal surgery” and “indocyanine green” were used as key words. The inclusion criteria were 1) manuscripts written in English; 2) full text is available; 3) topic related to the use of ICG fluorescence for the assessment of tissue perfusion during laparoscopic or robotic colorectal surgery; and 4) sample: adult patients, benign or malignant disease. Exclusion criteria included 1) case reports; 2) topic not related to the use of ICG fluorescence for the evaluation of tissue perfusion during laparoscopic or robotic colorectal surgery; 3) manuscripts that focused solely on other applications of ICG technology; and 4) any study type not showing original data.
Results and Critical Discussion: The intraoperative visual assessment of tissue viability under white light may lead to an underestimation of microvascular blood flow impairment. ICG can be safely used in cases of minimally invasive colonic surgery and also low anterior resections. This technology may be useful when deciding whether to intraoperatively change a previously planned resection/anastomotic level, which could decrease theoretically the occurrence of anastomotic leakage.
Conclusions: Near-infrared ICG technology is a very useful approach. Multiple preliminary studies suggest that this technique may be used to predict anastomotic leakage. However, evaluation of the ICG signal is still too subjective. Some reliable scoring/grading parameters related to the ICG signal need to be defined. Additionally, more prospective, randomized, and adequately powered studies are required to completely reveal the true potential of this surgical technological innovation.
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Technical Steps and Tips for Linear-Stapled Gastric Bypass Based on Personal Experience and the Classification of Intraoperative Complexity
Michael Korenkov, MD, Head of Department, Department of General and Visceral Surgery, Klinikum Werra-Meissner, Eschwege, Germany
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The most commonly performed Roux-en-Y gastric bypass (RYGB) procedure is difficult and has many technical variations. The individual patient’s anatomic characteristics, like an exceptionally large left liver lobe, fatty mesentery with limited mobile Roux limb, difficulty in positioning a stapler, etc., can greatly increase the technical difficulty of this procedure. Challenging situations in laparoscopic gastric bypass surgery can be classified according to the intraoperative complexity. According to this classification scheme, all patients in laparoscopic linear-stapled gastric bypass can be classified into one of four types: Type I - ideal. Surgery is straightforward, and every operative technique is relatively routine. Type II - less-than-ideal. Some minor technical difficulties may occur; some operative techniques can be more difficult than others. Type III - problematic. Difficult, with some operative techniques considerably more difficult than others. Type IV - very difficult. Every operative step is very difficult. The goal of this article is to analyze the steps of laparoscopic linear-stapled RYGB with regard to personal experience and the classification of intraoperative complexity.
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Mechanical Reinforced Terminolateral Ileo-Transverse Anastomosis: An Option After Right Hemicolectomy-A 452 Patients Study
Jordi Castellví Valls, PhD, MD, Chief of General Surgery Department, Javier Pérez Calvo, PhD, MD, Surgeon, Ana Centeno Álvarez, PhD, Resident, Verónica González Santín, PhD, Surgeon, Lorenzo Viso Pons, PhD, Head of Coloproctology Unit, Sergio Mompart García, PhD, Luis Ortiz de Zárate, PhD, Nuria Farreras Catasus, PhD, MD, Jordi Mas Jove, PhD, Vicente Fernández Trigo, PhD, MD, Domenico Sabia, PhD, Department of Colorectal Surgery, Department of Surgery, Moisés Broggi Hospital, Barcelona, Spain
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Introduction: Bowel reconstruction techniques after right hemicolectomy has currently been objective of review, due to the high rate of anastomotic leak. The aim of this study is to analyse our results of the mechanical reinforced terminolateral ileo-transverse anastomosis.
Materials and Methods: A prospective and descriptive study of a consecutive series of right colonic cancer cases that underwent right hemicolectomy. Mechanical reinforced terminolateral ileo-transverse anastomosis technique was carried out in all patients. Demographics, emergency or elective surgery, surgical management, postoperative complications, rate of anastomotic leak, need for surgical procedure after complication, average stay, and mortality were analysed.
Results: A total of 452 patients underwent surgery between 2010 and 2017. Of those, 40.6% were female and 59.4% were male. The average age and body mass index (BMI) was 72±11.3 years old, and 26±7.1, respectively. Elective surgery was carried out in 405 (89.6%) patients. Laparoscopic approach was used in 250 patients (61.7%) and 6% needed conversion. Only 41 patients (10.6%) had major complications (Clavien-Dindo III-IV). The rate of postoperative paralytic ileus reach was up to 13.9%. Reintervention was needed in five patients (1.1%) due to anastomotic leak and three (0.7%) of them from the elective surgery subgroup. There were 10 patients (2.2%) with postoperative gastrointestinal bleeding. The average stay was 8.2±2.8 days and late postoperative mortality in the first 30 days was 2%.
Conclusions: Mechanical reinforced terminolateral ileo-colic anastomosis is a safe technique with a low anastomotic leak rate. Although our results using this approach seem promising, postoperative paralytic ileus is still a high-rate complication.
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Special Use of Intraoperative Endoscopy in Sleeve Gastrectomy: A Case Report
Francesco Frattini, MD, Surgeon, Vincenzo Pappalardo, MD, Surgeon, Davide Inversini, MD, Surgeon, Matteo Lavazza, MD, Resident, Stefano Rausei, MD, PhD, Surgeon, Giulio Carcano, MD, Full Professor, Department of Surgery, Circolo Hospital and Macchi Foundation, Varese, Italy
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Sleeve gastrectomy is the most frequently performed operation for the treatment of morbid obesity. Even though sleeve gastrectomy is now widely standardized, it may still benefit from the use of certain devices and procedures such as intraoperative endoscopy. The use of an endoscope offers numerous advantages that can considerably reduce the morbidity and mortality of patients who undergo laparoscopic sleeve gastrectomy. This paper describes our experience with a case in which the information obtained by endoscopy allowed us to perform a real-time assessment of the location of two large gastric polyps to control the staple-line.
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A Surgical Case of Inferior Mesenteric Arteriovenous Malformation
Yusuke Otani, MD, Chief Resident , Takehiro Okabayashi, MD, Division Manager, Yuichi Shibuya, MD, Head Medical Director, Tatsuaki Sumiyoshi, MD, Chief Physician, Kenta Sui, MD, Chief Physician, Jun Iwata, MD, Head Medical Director, Sojiro Morita, MD, Vice President, Yasuhiro Shimada, MD , Director , Kochi Health Sciences Center, Kochi, Japan
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The treatment option for inferior mesenteric arteriovenous malformations is under debate because of the number of cases. We, herein, report about a 35-year-old man with congenital inferior mesenteric artery malformation (AVM) presenting with mucous stool and severe abdominal pain. The radical operation, after building the diverting stoma, minimized the extent of the resection. This is the first reported case where surgical management was used to control severe symptoms induced by inferior mesenteric AVM.
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Conservative Management of Chronic Anal Fissure. Results of a Case Series at 2-years Follow-up and Proposition of a New Classification
Antonio Canero, MD, PhD, Consultant General Surgeon, Carmela Rescigno, MD, General Surgeon, Francesco Giglio, MD, Consultant general surgeon, L'Azienda Ospedaliero Universitaria San Giovanni di Dio e Ruggi D'Aragona, Salerno, Italy, Vincenzo Consalvo, MD, Consultant general surgeon, Chirurgia Generale, Università degli Studi di Salerno, Salerno, Italy, Francesca D'Auria, MD, General Surgeon, Salsano Vincenzo, MD, Director of Bariatric Surgery Department, Clinique Clementvielle, Montpellier, France
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Background: Anal fissure is a common proctological condition that is usually defined as an anodermal ulcerative process starting from the posterior commissure to the dentate line. The objective of this study was to evaluate the resolution rate of anal fissure through the use of conservative management in patients grouped according to our newly proposed classification. A secondary purpose was to quantify the recurrence rates at 2-years follow-up in each group.
Methods: A retrospective analysis was carried out on patients in our general database. Diagnosis was based on symptoms, clinical observation, anal manometry and transanal ultrasounds. After application of inclusion and exclusion criteria, patients were assigned to different groups. Follow-up was carried out at 3, 6, 12 and 24 months.
Results: A total of 136 patients (54 female and 82 male) were included in the statistical analysis. At the end of the treatment period, all patients in groups 1 and 2 had a complete resolution of illness and a normal basal sphincterial tone, while those in groups 3 and 4 had a higher rate of recurrence at the 2-year follow-up.
Conclusion: Based on our series, we propose a definitive non-surgical management for all group 1 and 2 anal fissures according to our protocol. For groups 3 and 4, we recommend a primary non-surgical approach with follow-up. This was a retrospective study and further randomized controlled studies will be necessary to confirm our results.
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Management of Staple Line Leaks Following Laparoscopic Sleeve Gastrectomy for Morbid Obesity
Giuseppe Currò, MD, Associate Professor of Surgery, Department of Human Pathology in Adult and Evolutive Age ''G. Barresi'', University Hospital G. Martino, University of Messina, Messina, Italy, Iman Komaei, MD, Surgeon in Training, Claudio Lazzara, MD, Surgeon in Training, Federica Sarra, MD, Surgeon in Training, Andrea Cogliandolo, MD, Associate Professor of Surgery, Giuseppe Navarra, MD, Full Professor of Surgery, Department of Human Pathology in Adult, and Evolutive Age ''G. Barresi'', University Hospital G. Martino, University of Messina, Messina, Italy, Saverio Latteri, MD, Consulting Surgeon, Surgical Unit, Cannizzaro Hospital, Catania, Italy
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Purposes: Management of staple-line leaks following laparoscopic sleeve gastrectomy (LSG) is challenging and controversial. Guidelines for leak treatment are not standardized and often involve multidisciplinary management by surgical, medical and radiological methods. Herein we present our experience and proposed strategy for handling leaks after LSG.
Patients and methods: Retrospective data regarding LSG performed from April 2012 to October 2017 at the Surgical Oncology Division, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital "G. Martino", University of Messina, Italy, were reviewed. The management approaches and the surgical, endoscopic, and percutaneous procedures used were examined. Outcomes measured included the prevalence of gastric leaks, radiological features, related morbidities and mortalities, hospital stay and management.
Results: LSG was performed in 310 patients. Eight patients were managed for gastric leak within the 5-year period: 5 (1.6% overall prevalence) from our division, 3 referred from another hospital. All cases were successfully treated conservatively with combined CT/US-guided drainage using a locking pigtail catheter and endoscopic gastric stent positioning. Endoscopic therapy included the use of fully covered self-expanding esophageal metal stents (Hanarostent® 24 cm; M.I. Tech, Seoul, Korea) in addition to pigtail drains (Drainage Catheter Locking Pigtail 8F/21cm; Tru-Set® Ure-Sil, Skokie, IL, USA). Complete closure of the leak was achieved in all patients. The mean time from presentation to healing was 74 days ± 37.76 (SD). None of the patients underwent remedial surgery.
Conclusion: This study presents our management strategy for leak resolution in LSG patients. Based on our results, we strongly recommend the conservative and combined management of gastric leaks following LSG by endoscopic stenting and percutaneous drainage.
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Favorable Management of Low Colorectal Anastomotic Leakage with Transanal Conventional and Endoscopic Drainage (GelPOINT® Path Transanal Access Platform)
Claudio Lazzara, MD, Resident, Giuseppe Currò, MD, Associate Professor, Iman Komaei, MD, Resident, Adalberto Barbera, MD, Aggregate Professor, Giuseppe Navarra, MD, Full Professor, Surgical Oncology Division, Department of Human Pathology of Adult and Evolutive Age, University Hospital of Messina, Messina, Italy
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Objective: We describe our experience with transanal-laparoscopic treatment of anastomotic leakage.
Summary of Background Data: Anastomotic leakage leads to high mortality rates, morbidity, a complicated post-operative course and increased cost. The management of low anastomotic leakage after anterior resection of rectal cancer is not standardized.
Methods: This was a retrospective cohort study based on prospectively collected data. Among patients who underwent anterior resection for rectal cancer in our division between January 2014 and October 2017, 14 developed colorectal or colo-anal anastomotic leakage and underwent reoperation with a transanal approach. Data regarding patient demographics, reoperative outcomes, morbidity, length of hospital stay, mortality, leak closure and long-term outcomes are presented.
Results: In all patients, anastomotic healing was confirmed by radiology. No perioperative complications were detected. One patient presented anastomotic stricture after 20 months, which was successfully treated with dilatation.
Conclusions: There is little information available on the management of anastomotic leakage after anterior resection for rectal cancer. Although more studies are needed to standardize patient selection criteria and evaluate the long-term outcome of these procedures, minimally invasive transanal conventional and laparoscopic anastomotic leak repair is a feasible and safe surgical option that can often avoid the need for anastomotic takedown and stoma formation.
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Prevention of Parastomal Hernia
Ian T. MacQueen, MD, Chief Resident, David C. Chen, MD, Associate Professor of Clinical Surgery, Lichtenstein Amid Hernia Clinic, David Geffen School of Medicine at University of California, Los Angeles, Santa Monica, CA, Philipp Kirchhoff, MD, Senior Surgical Consultant, University Hospital Basel, Switzerland
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Parastomal hernia (PSH), defined as an incisional hernia at the abdominal wall defect resulting from stoma formation, is a frequent complication of enterostomy (ileostomy and jejunostomy), colostomy, and urostomy. A growing body of evidence supports the use of prophylactic mesh at the time of stoma creation to prevent the development of PSH. In particular, the use of permanent mesh has been supported in the creation of an end colostomy, and prophylactic mesh has been studied for use in other types of stoma. Permanent mesh materials used for PSH prophylaxis include polypropylene, polyester, polytetrafluoroethylene, and composite prosthetics. Despite the appeal of biologic and bioabsorbable materials in an operative field that poses a potentially higher risk of infection, there is insufficient evidence to support their use in primary PSH prevention. Two-dimensional meshes are usually cut to contain a keyhole through which the bowel passes, and may be placed in the sublay/retrorectus, intraperitoneal, or preperitoneal position. Alternative techniques include placement of a non-keyhole mesh in a position similar to that of a Sugarbaker PSH repair or use of a circular stapler fired through the abdominal wall fascia and mesh simultaneously, fixing both together. Three-dimensional mesh devices, including the Prolene® and Ultrapro® Hernia Systems (PHS/UHS) (Ethicon US, LLC, Somerville, NJ), have been studied for use in PSH prevention. Novel, specialized devices such as the Koring™ (Koring AG, Basel, Switzerland) stoma mesh have been designed specifically for primary PSH prevention. While the benefits of mesh prophylaxis have been established, further evidence is needed to identify the optimal materials and technique for PSH prevention in a variety of patients and settings. The purpose of this report is to provide an overview of the operative techniques and evidence supporting prophylaxis of parastomal hernias.
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Intracorporeal Anastomosis in Both Elective and Emergency Right Hemicolectomy: Our Experience
Simona Macina, MD, Resident, Mikaela Imperatore, MD, Surgeon, Cosimo Feleppa, MD, Surgeon, Francesco Sucameli, MD, Resident, Giuseppina Talamo, MD, Resident, Stefano Berti, MD, Head of Department, Department of General Surgery, Sant’Andrea Hospital, La Spezia, Italy
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Purpose: The aim of this study was to examine whether intracorporeal anastomosis (IA) after laparoscopic right hemicolectomy (LRH) is a safe procedure in both emergency and elective settings.
Methods: A retrospective review of all consecutive adult patients (age > 17 years) who underwent LRH from November 2014 to May 2018 at S. Andrea Hospital, La Spezia, was performed. The primary and secondary outcomes were the anastomotic leak rate and the operative time, respectively. Both IA and extracorporeal anastomosis (EA) were performed according to standardized techniques by the same team of experienced surgeons. Our findings were compared to literature data on recent studies comparing IA and EA during LRH.
Results: During the observation period, 167 patients underwent RH at our institution: IA was performed in 115. The mean age was 73.5 y. Thirty-three RH were performed in an emergency setting: 15 laparotomic procedures, 3 conversions from laparoscopic to open, 6 laparoscopic-assisted with EA, and 9 complete IA. The remaining 134 patients underwent elective RH: IA was performed in 106. The overall anastomotic leak rate in LHR IA was 2.6% (3/115), and no anastomotic leak was reported in the emergency group (0/9). The mean operative time was 180 min. In our experience, the operative time is related to the surgeon’s experience and confidence with the technique, and not to the anastomosis technique per se.
Conclusion: Consistent with the literature data, IA in LRH was associated with better outcomes than EA in both elective and emergency settings.
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The Problem of Seroma After Ventral Hernia Repair
Nathaniel Stoikes, MD, Associate Professor, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, Esra Roan, PhD , CEO/President, SOMAVAC Medical Solutions, Inc., Memphis, Tennessee, David Webb, MD, Assistant Professor, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, Guy R. Voeller, MD, Professor, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
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Seroma is a common postoperative finding after ventral hernia repair with an incidence of 20%. Often, it can be managed conservatively, but in the case of persistent or chronic seroma, reinterventions may be required. Closed drain suction has been the mainstay of seroma management for the last 40 years. Other alternative technologies have been evaluated to improve outcomes with mixed results. Because seroma is common, it is often an accepted outcome. Patient morbidity and costs to the healthcare system are underestimated, which begs for a re-evaluation of the current state of seroma management that is nearly a half-century old.
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Indocyanine Green (Icg)-Enhanced Fluorescence for Intraoperative Assessment of Bowel Microperfusion During Laparoscopic and Robotic Colorectal Surgery: The Quest for Evidence-Based Results
Alberto Mangano, MD, Robotic Surgery Research Specialist, Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, Federico Gheza, MD, Robotic Surgery Research Specialist, Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, Liaohai Leo Chen, PhD, Visiting Research Professor, Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, Eleonora Maddalena Minerva, MD, Medical Doctor, Istituto Clinico Humanitas IRCCS, Milan, Italy, Pier Cristoforo Giulianotti, MD, FACS, Vice Head Department of Surgery, Professor of Surgery: Distinguished Lloyd M. Nyhus Chair in Surgery, Chief, Division of General, Minimally, Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, IL
32/966
Anastomotic leakage is a severe complication after colonic/rectal surgery. One of the most important causes of anastomotic leakage is poor vascular supply. However, microvascular impairment at the anastomotic site is very often not detected intraoperatively by observation under white light. Indocyanine green (ICG)-enhanced fluorescence is a technology that may be useful for detecting microvascular alterations and potentially preventing anastomotic leakage. The aim of this Editorial-Minireview is to briefly and critically assess the literature evidence regarding the feasibility of using an ICG fluorescent tracer for detecting microvascular changes in the perianastomotic tissue and its potential role in preventing anastomotic leakage. We focused on minimally invasive (robotic and laparoscopic) colorectal surgery. Intraoperative ICG angiography and the quantification of ICG kinetics can be used to intraoperatively reveal the tissue-perfusion status during colorectal surgery. This may be useful for intraoperatively changing a previously planned resection/anastomotic level, and conceivably decreasing the degree of anastomotic leakage. At this stage, even though ICG technology appears to be very promising and some preliminary clinical studies have suggested that certain ICG pharmacokinetic parameters may be used to predict leakage, more reliable scoring and grading tools are needed. Furthermore, in minimally invasive colorectal surgery, more randomized prospective well-powered trials are needed to properly standardize this surgical technology.
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Video-Assisted Subcutaneous Destruction of the Sinus Tract with Vessel-Loop Drainage as Minimally-Invasive Surgical Treatment for Pilonidal Sinus Disease
Michael Korenkov, MD, Head of Department, Department of General and Visceral Surgery, Klinikum Werra-Meissner, Eschwege, Germany
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The video-assisted subcutaneous destruction of the sinus tract (VADST) is a novel, minimally-invasive technique for the treatment of pilonidal sinus disease (PSD). This is an advancement of the previously described subcutaneous destruction of the sinus tract and the removal of hairs as well as the long-term vessel-loop drainage of the wound channel (DST).
Although the first results of this operation seemed to be promising, some of my colleagues felt that the blind approach to this procedure could be its potential “weak point”. As a result of this critique, the procedure was enhanced with the subcutaneous video-assisted inspection of the natal cleft.
Throughout most steps of VADST, like the widening of pilonidal pits with mosquito and/or Pean clamps, the subcutaneous destroying of the sinus tract, lifting the skin in a natal cleft with a curette, removing the hair with a Pean clamp and a subcutaneous vessel-loop drainage, were found to be similar to DST. The new steps involve the possibility of the video-assisted control of hair vestiges and bleedings as well as the removal of hair and debris under visual control. A rigid choledochoscope from Berci (Firma Richard Wolf GmbH, Knittlingen, Germany) was used for the subcutaneous endoscopic examination of the natal cleft area. Neither gas application nor water perfusion were necessary for this step.
Three patients with simple forms of PSD, and one patient with an acute abscess formation, underwent the VADST procedure. The patients with simple forms of PSD had no adverse events during the first eight weeks postoperatively. The patient with an acute abscess formation developed a purulent inflammation that required a wide local excision with an open-wound healing.
Due to the very small number of patients in this report, we were not able to asses this technique properly. Contrary to DST, we intend to use VADST, not only for the treatment of patients with simple forms (primary pilonidal sinus without abscessed inflammation with maximal three orifices, all of them inside the navicular area), but also for the treatment of complex PSD forms.
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D3 Extended Mesenterectomy in Right Colectomy for Cancer: A Cadaver Simulation Model
Karen You, BS, Research assistant, Mahir Gachabayov, MD, PhD, Research fellow, Jela Bandovic, MD, Associate Professor of Pathology, Roberto Bergamaschi, MD, PhD, FRCS, Professor and Chief, Division of Colon and Rectal Surgery, State University of New York, Stony Brook, New York, Dejan Ignjatovic, MD, PhD, Professor of Surgery, Akershus Hospital, University of Oslo, Norway, Jens Marius Nesgaard, MD, Attending surgeon, Toensberg Hospital, University of Oslo, Norway
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Background: D3 extended mesenterectomy (D3EM) for right colon cancer has received increased attention owing to suggested improvement of oncological outcomes. The aim of this study was to evaluate the proficiency-based progression of content-valid metrics in a cadaveric model for right colectomy with D3EM.
Materials and Methods: Three expert surgeons were enrolled. Surgeon one performed the procedure robotically and surgeons two and three performed open D3EM. Proficiency-based progression was recorded for eight content-valid outcomes. The superior mesenteric vein (SMV) and artery were cannulated by independent observers to evaluate vascular tears. The specimens were analyzed for lymph node harvest by a pathologist blinded to surgical access and to the surgeon.
Results: Operating times did not differ among surgeons (50.2, 32.4 and 43.7 min). SMV tears occurred in procedures A and B only. There was no significant progression in lymph node harvest for D2 (p=0.913) and D3EM (p=0.264).
Conclusions: Cadaveric training in D3EM was associated with progression in avoidance of vascular tears with no significant changes in operating time and lymph node harvest.
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Intracorporeal Ileocolic Anastomosis in Laparoscopic Right Colectomy: A New Way to Make it Simple?
Giorgio Lisi, MD, Resident, Department of General and Pancreatic Surgery, University Hospital of Verona, Verona, Italy, Irene Gentile, MD, Medical Staff, Giuliano Barugola, MD, Medical Staff, Giacomo Ruffo, MD, Head of Department of Surgery, Roberto Rossini, MD, Medical Staff, Department of General Surgery, Sacro Cuore – Don Calabria Hospital, Negrar, Italy
32/969
Although there has been a recent increase in the use of laparoscopy in colorectal surgery, the percentage of patients who undergo surgery using entirely minimally invasive techniques is still quite low, and there are substantial differences among centers. It has been argued that the limiting factor in the use of laparoscopic procedures is not the tumor or patient characteristics, but rather the number of surgeons with adequate skills to perform an entirely laparoscopic colectomy. To address this issue, we report here our totally laparoscopic right colectomy technique, with particular focus on a new way to perform the enterotomy closure, which may simplify ileocolic anastomosis.
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Current Strategies to Prevent Iatrogenic Ureteral Injury During Colorectal Surgery
Jonathan Douissard, MD, Surgical Resident, Frederic Ris, MD, PD, Colorectal Surgery Consultant, Philippe Morel, MD, PhD, Head of the Surgery Department, Nicolas Christian Buchs, MD, PD, Colorectal Surgery Consultant, Department of Visceral Surgery, University Hospitals of Geneva, Geneva, Switzerland
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Iatrogenic ureteral injuries are a source of major concern among surgeons performing colorectal procedures. Although they are uncommon, these lesions lead to severe morbidity and long-term functional disabilities, as well as an increase in mortality, hospital stay, and cost. The laparoscopic approach has gained popularity in the field of colorectal surgery and is associated with improved global postoperative outcomes. However, it is also considered to increase the risk of ureteral injury when compared to open surgery, especially during left colonic and rectal resections.
To overcome these difficulties, surgical techniques have been improved over time through standardization of both open and laparoscopic procedures. However, these techniques are not infallible, and, in difficult cases, instrumental aids such as preoperative ureteral stenting may be used. To substitute the reduced haptic feedback in laparoscopic surgery, lighted stents have been developed. Unfortunately, prophylactic stenting, whether standard or lighted, is also associated with its own morbidity and its benefit-risk ratio remains highly controversial.
To enhance the surgeon’s visualization capabilities, augmented reality technologies have been developed. Near-infrared fluorescence and hyperspectral imaging are two promising techniques, which have been tested both in the preclinical and clinical settings. Early results show that these technologies could improve our ability to identify and protect the ureters, although technical limitations remain to be solved.
Reviewing the current literature, this article aims to evaluate pre- and intraoperative techniques to identify the ureters and potentially to avoid iatrogenic injury. In addition, future trends are explored.
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Clinical and Patient-Reported Outcomes after Absorbable Strap Fixation for Ventral Hernia Repair
Heather Bougard, MBChB, FCS(SA), Head of Clinical Unit: Surgery, Chair of the Hernia Interest Group South Africa, New Somerset Hospital & University of Cape Town, Cape Town, South Africa, Sven Bringman, MD, PhD, Associate Professor, Senior Consultant, Karolinska Institutet/Södertälje Hospital, Södertälje, Sweden, William W. Hope, MD, Associate Professor of Surgery, New Hanover Regional Medical Centre, Wilmington, North Carolina, Jay A. Redan, MD, FACS, Past President of Society of, Laparoendoscopic Surgeons, Professor of Surgery, University of Central Florida, Medical Director, Florida Hospital-Celebration Health, Celebration, Florida, Carl Doerhoff, MD, FACS, Clinical Assistant/Professor of Surgery, University of Missouri – Columbia, Surgicare of Missouri, Jefferson City, Missouri, Michal Chudy, MD, General & Laparoscopic Surgery Consultant, Ayr Hospital, Ayr, United Kingdom, Christine Romanowski, MD, Clinical Development, Peter Charles Jones, MSc, Consultant Statistician, Ethicon, Johnson & Johnson Medical Devices, Livingston, United Kingdom Statistician
Introduction: Various mesh fixation methods are employed by surgeons during ventral hernia repair. These may include tacks, straps, sutures, glue, or a combination of methods. One of these choices is an absorbable fixation device, Securestrap® (Ethicon Inc., Somerville, New Jersey), consisting of an absorbable copolymer barbed U-shaped strap with a spring-loaded deployment system.
Materials and Methods: The International Hernia Mesh Registry is a prospective multi-center registry, designed to collect longitudinal data on hernia repair methods, products, and outcomes. Patients complete the Carolinas Comfort Scale™ (CCS) (The Charlotte-Mecklenburg Hospital Authority, Charlotte, North Carolina) pre-operatively, and at one month, six months, and 12 months post-operatively. Symptomatic patients defined as responding >1 to any CCS™ question. Statistical comparison of symptom frequency was made with the McNemar test and Kaplan Meier methods to determine the recurrence rate up to 365 days.
Results: Patients were enrolled at 16 centers. Data was available on 100 of the 203 patients at six months and on 119 patients at 12 months. Demographics: mean age of 52.7 (13.2 standard deviation[ SD]); mean body mass index (BMI) of 33.2 (7.5 SD) kg/m²; 64.3% having a BMI over 30kg/m2; male patients 47.4%; 16.7% for recurrent hernias. Mesh fixation with straps alone in 48.3% of cases or straps and sutures in 51.7% of cases. Percentage of patients with symptomatic pain decreased slightly from baseline to one month (70.0 vs. 60.6, p=0.0782) and significantly from one month to six months (60.6% symptomatic vs. 23.2%; p=0.0004). From six months to twelve months, the change in percentage of symptomatic patients was not significant (23.2% vs. 28.7%; p=0.8084). Similar results were observed with symptomatic CCS™ movement limitations. Overall recurrence rate at 12 months was 4.72% (2.39%–9.22%).
Conclusion: Mesh fixation with straps with or without additional sutures is associated with significant improvements in patient-reported pain and movement limitation from baseline to six months post-operative.
31/925
28-09-2017
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AbsorbaSeal™ Vascular Closure Device: A Novel Device for Hemostasis Following Interventional Peripheral Vascular Procedures
Emily Benham, MD, Surgical Resident, Tiffany Cox, MD, Surgical Fellow, Amy Lincourt, PhD, Director of Research, B. Todd Heniford, MD, FACS, Chief, Carolinas HealthCare System, Charlotte, North Carolina, Koen Deloose, MD, Head of Vascular Surgery Department, Joren Callaert, MD, Surgeon, Marc Bosiers, MD, Surgeon, AZ Sint-Blasius Hospital, Dendermonde, Belgium
Introduction: Vascular closure devices (VCDs) are designed to achieve rapid hemostasis during percutaneous coronary and peripheral vascular procedures. Studies demonstrate that VCDs improve time to hemostasis (TTH) and time to ambulation (TTA) in comparison to standard manual compression. The available products, however, typically have 13–17 steps in their application, often require hemostatic collagen or other agents as part of the process, and can result in significant scarring at the puncture site that can impact future access. The aim of this study was to investigate the performance of a three-step, novel VCD for access site TTH, short-term and long-term histology, and a first-in-man clinical study.
Materials and Methods: This study evaluated AbsorbaSeal™ (CyndRx, LLC, Brentwood, Tennessee), a simple, three-step, VCD with bio-absorbable components. Following an institutional review board (IRB) approval, a 6-F sheath was placed directly into the porcine aorta, AbsorbaSeal™ was used to seal the puncture site, and a measure of total time of deployment (TTD) and TTH was performed, as well as histologic evaluation at 30, 60, and 180 days.
A complement activation test was performed to determine the potential for activation of the complement system as a mediator of inflammation. The test was performed by directly incubating the VCDs AbsorbaSeal™ and Angio-Seal™ (Terumo Interventional Systems, Tokyo, Japan) in human serum. Serum samples were removed after 30, 60, and 90 minutes and tested for the presence and amount of complement protein SC5b–9.
In the first in-man trial, the device was deployed in anticoagulated patients undergoing interventional vascular procedures. The TTH, estimated blood loss, patient pain scores, and procedural and follow-up complications were recorded.
Results: In the acute and chronic porcine studies, TTD averaged 25 seconds (17–29 seconds). Vascular control was immediate, yielding a TTH of effectively zero seconds. Histologic evaluation demonstrated complete endothelial coverage of the device by 30 days without evidence of bleeding, clotting, or inflammation. At 60 days, the significant mass of the device had dissolved and normal appearing collagen surrounded the devices with essentially no inflammatory response. By six months, all but one microscopic segment of one of the devices had been absorbed with normal appearing vascular endothelium, and no, or minimal, scarring appreciated. The complement test demonstrated that the AbsorbaSeal™ had similar, or lower, complement concentrations than the negative controls and significantly less than Angio-Seal™. This supported the histologic findings of minimal to no inflammation.
The VCD was deployed in 20 patients undergoing interventional vascular procedures. The mean TTH was 2.3 ± 1.5 minutes. Estimated blood loss was 11.7 mL ± 3.5 mL, and no significant hematoma was noted. Post-procedure pain scores were low, with a mean of 1.4 ± 0.8 on a 0–10 pain rating scale. There were no perioperative complications and no adverse events at follow-up. Conclusions: The AbsorbaSeal™ is safe and simple to use for vascular closure after interventional vascular procedures with favorable outcomes including a short TTH, minimal procedural blood loss, low postoperative pain scores, and no perioperative complications or adverse effects. Histologic evaluation reveals rapid device absorption and little scar formation both short- and long-term. A direct study of complement activation supports that AbsorbaSeal™ evokes a minimal inflammatory response that is significantly less than Angioseal.
31/882
18-06-2017
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Minimally-Invasive Myotomy: Percutaneous Laparoscopic Surgical Approach for Achalasia
Lavinia Alessandra Barbieri, MD, General Surgeon, Francesca Lombardo, MD, General Surgeon, Istituto Clinico Sant’Ambrogio, Milan, Italy, Piero Giovanni Bruni, MD, General Surgeon, Istituto Clinico Sant’Ambrogio, Milan, Italy, Giampiero Campanelli, PhD, Full Professor/Director, Day and Week Surgery Division, General Surgery Department, Istituto Clinico Sant’Ambrogio, Milan, Italy, Davide Bona, PhD, Professor, General Surgery Department, University of Milan, Alberto Aiolfi, MD, General Surgeon, IRCCS Policlinico San Donato, Milan, Italy, Giancarlo Micheletto, PhD, Professor, General Surgery Department, University of Milan, Marta Cavalli, MD, General Surgeon, University of Insubria, Varese, Italy
The laparoscopic approach of the upper gastrointestinal tract is considered the gold standard for the treatment of functional benign esophageal disorders since 1990. In recent years, many efforts have been made to minimize the abdominal wall’s trauma to reduce postoperative pain and to obtain a prompt return to daily activities, as well as improve cosmetic results of surgery. The progressive development of novel surgical devices has allowed for the introduction of new minimally-invasive surgical techniques. Criticism of the single-incision laparoscopic surgery includes a modification of surgical technique and an increased incidence of wound-related complications, such as infections and incisional hernia. We present our early experience using the new MiniLap® Percutaneous Surgical System (Teleflex Incorporated, Wayne, Pennsylvania) to perform a two-trocars laparoscopic percutaneous-assisted esophageal Heller myotomy. We demonstrate that the use of percutaneous instruments was not inferior in terms of clinical outcomes as compared to the standard technique, while improving cosmetic results and reducing trocar-related abdominal pain.
31/931
6-11-2017
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Over-Sewing of Staple Line in Laparoscopic Sleeve Gastrectomy: Initial Experience of a Comparative Study
Giorgio Lisi, MD, Resident, University Hospital of Verona, Verona, Italy,, Roberto Rossini, MD, Medical Staff, Irene Gentile, MD, Medical Staff, Giacomo Ruffo, MD, Head, Don Calabria Hospital, Verona, Italy
Introduction: The main drawback of laparoscopic sleeve gastrectomy (LSG) is the severity of postoperative complications. Staple line reinforcement (SLR) is strongly advocated. Recently, over-sewing has been proposed as a cost-effective and helpful method for reinforcing the staple line. The purpose of this study was to report our initial experience with LSG comparing over-sewing over the entire staple line with the upper-third staple line.
Materials and Methods: All obese patients seen at Negrar Sacro Cuore, Don Calabria Hospital were entered into our prospective database and were retrospectively evaluated. Complications (divided as major complications: leaks and bleeding; and minor complications: dysphagia, esophagitis, and reflux disease) and reoperations were recorded for all patients. Complications were graded according to the Clavien classification system.
Results: From February 2015 to March 2016, 30 patients underwent LSG. Patients were divided in two groups according to over-sewing: Group A—over-sewing over the entire staple line; and Group B upper-third over-sewing. Mean total operative time was longer in Group A—90 minutes—compared with 85 minutes in Group B. In regard to minor complications, we reported one esophagitis and two cases of dysphagia in Group B and one dysphagia in Group A. Gastroesophageal reflux was higher in Group B than in Group A (3 vs. 1, p=0.149). Three major complications were observed (10%): two bleeding and one hematoma in Group B and no major complications occurred in Group A. All major complications were conservatively treated. No leaks were reported in both groups. No mortality was observed.
Conclusions: Over-sewing of the staple line was associated with fewer leaks but no conclusions can be drawn regarding the effects of over-sewing on staple line bleedings. Before standardizing surgical techniques further, trials are necessary to improve our knowledge about over-sewing in LSG.
31/886
30-06-2017
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Right-Sided versus Left-Sided Colectomies for Cancer: Surgical Outcomes and Novel Considerations
Matteo Lavazza, MD, Consultant General Surgeon, Stefano Rausei, MD, PhD, Consultant General Surgeon, Vincenzo Pappalardo, MD, Consultant General Surgeon, Francesco Frattini, MD, Consultant General Surgeon, Domenico Iovino, MD, Resident Doctor in General Surgery, Francesca Rovera, MD, Associate Professor in General Surgery, Department of Surgery, University of Insubria, Varese, Italy, Georgios D. Lianos, MD, Consultant General Surgeon, Ioannina University Hospital, Ioannina, Greece, Gianlorenzo Dionigi, MD, FACS, Full Professor in General Surgery, University Hospital G. Martino, University of Messina, Italy, Luigi Boni, MD, FACS, Associate Professor in General Surgery, IRCCS Ca Granda, Policlinico Hospital, University of Milan, Milan, Italy
Introduction: The aim of this study is to compare short-term outcomes of right versus left colectomies performed as a form of cancer treatment.
Materials and Methods: This study includes 305 consecutive patients with adenocarcinoma treated by laparoscopic or open colectomy. Right colectomy has been compared with left colectomy. The study endpoints were the first flatus day, the first evacuation day, the first day of postoperative solid oral diet intake, and the postoperative hospital stay length.
Results: There were 140 (45.9%) right colectomies and 165 (54.1%) left colectomies performed. The cut-off values for the considered (median) endpoints were three, five, four, and eight days, respectively. The first day of postoperative solid oral diet intake and the length of postoperative hospital stay are significantly associated with the type of resection.
Conclusions: The colon cancer patients treated by right-sided colectomy assumed a solid oral diet and presented a longer postoperative hospital stay compared with the patients treated by left-sided colectomy.
31/895
24-07-2017
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Topographical Variations between Splenic Flexure and Spleen: A Study with CT Image-Based Reconstruction
Matteo Lavazza, MD, Consultant General Surgeon, University of Insubria (Varese-Como), Varese, Italy, Stefano Rausei, MD, PhD, Consultant General Surgeon, University of Insubria (Varese-Como), Varese, Italy, Vincenzo Pappalardo, MD, Consultant General Surgeon, University of Insubria (Varese-Como), Varese, Italy, Davide Inversini, MD, Resident Doctor in General Surgery, University of Insubria (Varese-Como), Varese, Italy, Monica Mangini, MD, Consultant Radiologist, Radiology Division, University of Insubria (Varese-Como), Varese, Italy, Anna Maria Ierardi, MD, Consultant Radiologist, Radiology Division, Department of Surgical Sciences and Human Morphology, University of Insubria (Varese-Como), Varese, Italy, Angkoon Anuwong, MD, Consultant General Surgeon, Police General Hospital, Siam University Pathumwan, Bangkok, Thailand, Hoon Yub Kim, MD, Consultant General Surgeon, Minimally Invasive Surgery and Robotic Surgery Center, KUMC Thyroid Center Korea University, Anam Hospital, Seoul, Korea, Gianpaolo Carrafiello, MD, Full Professor in Radiology, Università degli Studi di Milano, Postgraduation School in Radiodiagnostics, Milan, Italy, Gianlorenzo Dionigi, MD, FACS, Full Professor in General Surgery, University Hospital G. Martino, University of Messina, Messina, Italy
Introduction: An issue that is seldom seen in the literature relates the detailed relationship of the splenic flexure (SF) and the spleen—both carefully examined—with a prospective approach in patients undergoing computer tomography (CT) scan.
Materials and Methods: SF localization has been searched and examined in 120 consecutive CT scans. Several different variables (age, gender, BMI, indication of CT scan, etc.) have been considered. In cooperation with the Radiology Division, we brought to completion a dedicated topographic outline, with the purpose of providing a detailed classification for SF localization.
Results: The SF lies, in 52% of cases, in what we called the inferior (I) position, below the spleen. Other categories of our classification were anterior (A) and posterior (P) positions, which were found respectively in 42% and 8% of analyzed cases.
Considering all the variables given, we did not find any significant statistical correlation (p > 0.05). Conclusions: This study was carried out to classify types of SF in terms of its positional relationship with the spleen. We investigated 120 CT scans and classified the SF into three types, according to its localization: inferior (I), anterior (A), and posterior (P) types. A better understanding of the anatomic variability in SF may be useful for minimizing complications and performing an accurate surgical dissection.
31/896
21-07-2017
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Gastric Leaks after Sleeve Gastrectomy: Focus on Pathogenetic Factors
Francesco Frattini, MD, Consultant, Roberto Delpini, MD, General Surgery Resident, Davide Inversini, MD, Resident Doctor in General Surgery, Vincenzo Pappalardo, MD, Consultant, Stefano Rausei, MD, PhD, Consultant, Giulio Carcano, MD, Full Professor of Surgery, Department of Surgery, University of Insubria, Varese, Italy
As reported by The International Federation for the Surgery of Obesity (IFSO) worldwide survey on bariatric surgery, sleeve gastrectomy has become the second most performed bariatric/metabolic procedure in the world just after gastric bypass.
If we consider complications, despite a recent systematic review and meta-analysis that reported a substantial decrease in sleeve gastrectomy complication rates, leaks after sleeve gastrectomy still rate between 0 and 18%. Unlike the leaks of other types of gastrointestinal surgery, leaks after sleeve gastrectomy are challenging in diagnosis and treatment and can lead to sepsis, multiple organ failure, and even death.
A standardized algorithm of diagnosis and management is still lacking. Current classification of gastric leaks is based on the time of onset and clinico-pathological aspects. Nonetheless, none of the largest series in literature report the pathogenesis of gastric leaks.
Given this paucity of evidence-based data and the lack of defined guidelines, we try to examine and consider the pathogenetic factors of gastric leak to implement better treatments and predict outcomes.
31/908
16-09-2017
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Bariatric Surgery and Infertility: A Prospective Study
Vincenzo Consalvo, MD, Surgeon, Vincenzo Salsano, MD, Director, Clinique Clementville, Montpellier, France, Antonio Canero MD, PhD, Surgeon, San Giovanni di Dio e Ruggi D’Aragona, Salerno, Italy
Background: Obesity is a worldwide disease affecting 13% of the world’s adult female population. The reasons and the fetal risk are still unclear. The effect of weight loss as a result of bariatric surgery seems to induce an improvement in fertility in obese women. The main purpose of this prospective study is to demonstrate if there is an association between bariatric surgery-induced weight loss and an improvement in the fertility of women at reproductive age. Materials and Methods: From June 2013 to April 2016, all bariatric female patients from our institutes were prospectively evaluated for suitability in this study. A pool of 52 eligible patients was extracted from our database in the recruitment period. Of these, 28 underwent bariatric surgery and 24 did not. Both groups were observed for two-year follow-up. During follow-up, anthropometrics parameters, blood analysis, and comorbidities were checked and a gynaecological consultation was prescribed. Results: Fifty participants were studied. Twenty-seven successfully underwent bariatric surgery with a percentage of excess weight loss (EWL) >70% at 24 months, while 23 accepted the observation and control for 24 months as an integral part of the pre-surgical bariatric program. The contingency table analysis showed an extremely significant association (P<0.0001) between exposition (bariatric surgery) and event (pregnancy), with a relative risk (RR) = 15.33 and confidence interval (CI) 95%=2.213 to 106.26. Conclusions: Bariatric surgery improves fertility in obese women at two years’ postoperative. Every obese woman with difficulties becoming pregnant should undergo a bariatric surgery consultation. Further studies are necessary to confirm our results.
31/950
9-12-2017
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