Abstract


Background: Minimally Invasive Colorectal Surgery (MICS) is continually evolving. The recognition of the anus as a natural orifice to perform MICS has contributed to the development of a new philosophy of treatment called TransAnal Minimally Invasive Surgery (TAMIS). Transanal total mesorectal excision (TaTME) is one of the most common forms of TAMIS. Other indications include benign diseases and early malignant rectal adenocarcinoma. This report presents the author’s experience with TAMIS as a multi-purpose operation.
Patients and Methods: Between January 2015 and May 2019, 36 patients underwent TAMIS for benign and early malignant diseases (group 1) and 30 patients underwent TaTME (group 2). The mean ± SD age was 60.2 ± 13.9 years (range 28-84) (group 1) and 63.7 ± 8.6 years (47-87) (group 2). The mean ± SD BMI was 26.7 ± 5.2 kg/m2 (19.3-42.9) (group 1) and 25.7 ± 5.9 kg/m2 (17.3-50.7) (group 2). The conditions in group 1 consisted of anastomotic leakage (n=20), benign rectal stenosis (2), anastomotic exploration with lavage and drainage (2), salvage of abdominal dissection (1), rectal ulcus (1), rectal intussusception (1), and removal of early malignant rectal polyps (9). The conditions in group 2 consisted of TaTME associated with single-incision abdominal laparoscopy (19) and conventional abdominal laparoscopy (11).
Results: In group 1, the mean operative time was 38.2 ± 19.2 min (range 20-89) for immediate anastomotic leak repair, 90.2 ± 30.4 min (41-120) for early leak repair, 85 ± 67.4 min (30-180) for late leak repair, 45-163 min for rectal stenosis, 25-30 min for pelvic lavage and drainage, 180 min for difficult pelvic dissection, 57 min for rectal ulcus, 127 min for rectal intussusception, and 84.3 ± 28.0 min (50-131) for early malignant rectal polyps. In group 2, the mean operative time was 197.1 ± 63.3 min (96-399). The mean operative bleeding was 14.3 ± 24.7 ml (0-100) in group 1 and 57.0 ± 102.5 ml (0-450) in group 2. In group 1, the mean hospital stay was 11.6 ± 7.2 days (5-27) for immediate leak, 20.7 ± 14.7 days (6-42) for early leak, 2.6 ± 1.6 days (1-5) for late leak, 2-5 days for rectal stenosis, 4-7 days for pelvic lavage and drainage, 17 days for difficult pelvic dissection, 2 days for rectal ulcus, 1 day for rectal intussusception, and 1.3 ± 0.4 days (1-2) for early malignant rectal polyps. In group 2, the mean hospital stay was 11.4 ± 10.0 days (3-49). The early complication rate was 27.7% in group 1 and 40% in group 2. The late complication rate was 8.3% in group 1 and 10% in group 2.
Conclusions: TAMIS is an innovative technique that may be considered for the treatment of benign diseases like anastomotic complications, benign rectal stenosis, anastomotic explorations with lavage and drainage, rectal ulcus, and rectal intussusception. It can be used to search for a good plane of dissection, which cannot be found through the abdominal anterior approach. It can also be adopted for removal of early malignant rectal polyps and for TaTME. The technique described here allows the surgeons to work under ergonomic conditions, with completely reusable materials, and with a magnified view of the operative field, allowing intraluminal surgical sutures.

Abstract


The number of bariatric surgical procedures performed worldwide increases every year and has recently exceeded 685,000. Over 50% of these are laparoscopic sleeve gastrectomy (SG), and Roux-en-Y gastric bypass accounts for an additional 30%. Bariatric/metabolic surgery seeks to achieve not only weight loss and the remission of comorbidities, such as diabetes mellitus type II, arterial hypertension, sleep apnea, risk of cancer, non-alcoholic liver steatosis, etc., but also improvements in the patient’s quality of life. SG is mainly a restrictive procedure consisting of the resection and removal of a major part of the stomach, which has an additional impact on hormones such as Ghrelin and Glucagon-like Peptide 1. The first part of this article focuses on patient preparation before a bariatric procedure with mandatory and additional examinations to decrease the patient’s risk. Next, the surgical technique itself, including positioning of the patient, positioning of the trocars and related tips and tricks, and the postoperative course are described. The second part discusses the outcomes of SG, including weight loss, remission of comorbidities and quality of life. Further possible acute complications of SG such as leaks, bleeding or stenoses as well as long-term complications (reflux, weight regain and malnutrition) and respective treatments are also described. In conclusion, SG is an effective procedure for weight loss with a low risk for the patient to develop malnutrition. In terms of post-operative care, regular check-ups are vital to ensure a positive outcome as well as for the early detection of possible issues. Reflux and weight regain are common issues with SG in a long-term follow-up; thus, patients should be selected carefully for this procedure.

Abstract


Introduction: This report describes the techniques and outcomes of robot-assisted distal gastrectomy (RDG) for gastric carcinoma using an oval-shaped port device.
Materials and Methods: A total of 15 patients underwent RDG with lymphadenectomy using the E‧Z Access™/LAP-PROTECTOR™ oval-type device (Hakko Co., Ltd., Tokyo, Japan) performed by a single surgeon between 2018 and 2019. This device was introduced to the umbilicus under two settings, depending on the patient’s figure. A horizontal setting (n=7) was used to reduce the number of trocar skin incisions in thin patients by placing a scope trocar and assist port within the E‧Z Access™. The vertical setting (n=8) was used for large and obese patients, enabling the endoscope position to move 50mm toward the cephalad side by rotating the device 180° to improve the surgical view of the suprapancreatic area (“dual port position” using the E‧Z Access™ oval-type device). The intracorporeal Billroth-I anastomosis or Roux-en-Y method was used for reconstruction. The short-term patient outcomes were determined to assess the safety and feasibility of our procedures.
Results: The E‧Z Access™ oval-type device was useful for maintaining an optimal surgical field and reducing the number of skin incisions and the level of surgeon stress. Furthermore, its removal cap and wound protector allowed for an airtight seal, umbilical wound protection, and smooth specimen removal and re-pneumoperitoneum. R0 resection was accomplished in all cases without the need for conversion to open or conventional laparoscopic surgery. The median operating time was 323 (range, 245–590) minutes, and the median blood loss was 5ml. The median number of retrieved lymph nodes was 30. Neither major postoperative complication, including umbilical skin damage, nor postoperative mortality, was observed. The mean length of the hospitalization was 12.5 days.
Conclusions: Our robotic approach using an oval-shaped port device for gastric cancer patients is feasible in terms of patient safety and curability.

Abstract


Enteric fistulas are among the most dreaded surgical complications. Controlling fistula effluent and protecting the surrounding tissue is a difficult long-term endeavor that can consume significant clinical resources. This article describes novel, one-piece compressible isolation devices that can be used to manage the body surface around an enteric fistula, stoma, or drain tube to seal and protect the patient from effluent. The described devices and methods are the result of an innovative partnership between an abdominal reconstructive surgeon and a Certified Wound Ostomy Nurse (CWON) to deliver improved patient outcomes.

Abstract


Introduction: The prognosis of pancreatic ductal adenocarcinoma has been associated with several factors. The aim of the present study was to correlate tumor-related factors and pathological findings with disease-free survival (DFS) and overall survival (OS) in patients undergoing pancreaticoduodenectomy. Material and methods: From a prospectively maintained database, we reviewed 89 pancreatic ductal adenocarcinomas in patients who underwent pancreaticoduodenectomy from 2010 to 2014. The impact of histopathologic or tumor-related data, including a lymph node ratio greater than 15% (LNR15), on survival was analyzed. Results: Univariate analysis of DFS and OS showed that vascular resection, pT, pN, LNR15, microvascular, lymphatic, and perineural invasion, and R1 resection influenced survival. Only LNR15, perineural invasion and R1 resection were independent predictors for both DFS (HR 6.39, p = 0.011; HR 8.53, p = 0.003; HR 9.68, p = 0.002, respectively) and OS (HR 4.21, p = 0.039; HR 5.41, p = 0.020; HR 4.41, p = 0.036, respectively). Conclusions: This study demonstrates that LNR15, perineural invasion and R1 resection are independently associated with DFS and OS.