Standardized technique for single-docking robotic rectal surgery.

AIM: The aim of this technical note is to describe our standardized technique for rectal surgery using a single-docking totally robotic approach. METHOD: The data related to patients who underwent single-docking robotic rectal surgery were analysed for the feasibility of this approach. RESULTS: This technique was used in 124 consecutive patients who underwent rectal resection since July 2013. Male to female ratio of patients was 2:1 while median age was 67 years (range 24-92). The median operating time was 240 min (range 105-456), whilst blood loss was 10 ml (range 0-200). There was no evidence of intra-operative complications or conversions to either a laparoscopic or an open procedure. The median length of stay was 7 days (range 3-48). CONCLUSION: A single-docking technique for robotic rectal surgery is safe and feasible. It can be considered as standard approach for pelvic robotic surgery.

Prevention of deleterious effects of reperfusion injury using one-week high-dose allopurinol.

Allopurinol has been widely used to reduce the severity of the reperfusion injury. However, conflicting data have been reported regarding the dosage, the duration of the timing, and the administrative regimen of the drug. The aim of this study was, therefore, to evaluate the effects of short versus long periods of allopurinol pretreatment on the anastomotic healing of intestines, directly after being subjected to ischemia-reperfusion (IR) stress. Furthermore, the effects of an allopurinol pretreatment on the survival rate following IR stress, was also assessed. One hundred thirty-seven male Wistar rats with a median weight of 235 (range, 180-275) g used in the study. In group I (control group, N = 20) superior mesenteric artery (SMA) and collateral vessels were isolated but not occluded. In group II, the profound IR group (PIR, N = 42), the SMA was occluded immediately distal to the aorta with collateral interruption using an atraumatic arterial clip for 30 min. In group III [two days of allopurinol (ALL) pretreatment group, 2ALL, N = 38], allopurinol (100 mg/kg body wt) was given intraperitoneally on a daily basis for two days prior to the experiment. In group IV (seven days of allopurinol pretreatment group, 7ALL, N = 37), the same pretreatment and the allopurinol schedule was performed for seven days before surgery. All animals underwent 3 cm of ileal resection and primary anastomosis, 10 cm proximal to ileocecal valve. Within each group, animals were anesthetized either on the third or seventh postoperative days. Abdominal wound healing, intraabdominal adhesions, anastomotic complications, anastomotic bursting pressure measurements, and bursting site were recorded as were the histopathologic evaluation. No rats in group I, 20 rats in group II, 18 rats in group III, and 7 rats in group IV died (P = 0.0003). Anastomotic dehiscence was found in one of 20 group I, in 11 of 22 in group II, in 9 of 20 in group III, and in 3 of 30 in group IV (P = 0.0003). On the third and seventh days, the median bursting pressures of the anastomosis were determined: 42 and 235 mm Hg in group I, 17 and 105 mm in Hg in group II, 22 and 183 mm Hg in group III, and 36 and 214 mm Hg in group IV (P < 0.0001). The burst occurred at the anastomoses in all animals tested on the third postoperative day, one in group I, six in group II, four in group III and one in group IV on the seventh postoperative day (P < 0.01). All deleterious effects of reperfusion injury on intestinal anastomosis healing, including survival rates and the histopathological parameters, were significantly prevented by seven days, but not two days, of high-dose allopurinol pretreatment.

Evaluation of peripheral vascular system disorders in vascular symptom--free Behçet's disease.

Vascular involvement in Behçet's disease has been reported in 7-40% of patients in the literature and nearly 8% of these will have serious vascular complications during follow-up. So far, little information is available on the extent of vascular involvement in patients with Behçet's disease who are free of vascular symptoms. The study comprised 34 individuals with Behçet's disease who were free of vascular symptoms and 47 healthy volunteers. Both groups underwent non-invasive peripheral vascular examination consisting of Doppler, photoplethysmography, and segmental pressure measurements and determination of ankle-brachial pressure and femoro-brachial pressure indices. Venous insufficiency was detected in 22 of 68 lower extremities examined in the Behçet's disease group and in ten of 94 in the controls (P < 0.001). The number of extremities with an ankle-brachial pressure index of less than 1.00 for both the anterior and posterior tibial arteries, was significantly higher in the Behçet's disease group (P < 0.001). The femoro-brachial pressure index was significantly higher in the controls than in the Behçet's disease group (1.32 versus 1.23 for the right leg, P < 0.05; 1.31 versus 1.22 for the left leg, P < 0.03). Vascular symptom-free patients with Behçet's disease seem to have a high incidence of peripheral vascular involvement compared with healthy controls.

The risk factors in central venous catheter-related thrombosis.

Catheter-related venous thrombosis is one of the most important complications of central venous catheters. The aim of this prospective study was to assess the risk factors that may be important in the development of catheter-related thrombosis. Multiple lumen (n = 20) and single lumen (n = 24) polyurethane catheters were inserted to the subclavian vein by the infraclavicular approach in 44 consecutive patients. All variables that may be significant for the development of thrombosis related to the patient, the catheter, the insertion technique and the solution administered through the line were recorded. Eighteen of 44 patients (40%) were found to have venous thrombosis. Two factors were found to correlate significantly with the development of central venous catheter-related thrombosis, namely the number of vein punctures (one vs two punctures, P < 0.01) and the composition of solution (fluid replacement vs total parenteral nutrition, P = 0.01).

The diagnostic value of colour Doppler ultrasound in central venous catheter related thrombosis.

AIM: This prospective study was performed to establish the correlation between colour Doppler ultrasound (US) observations and venography in detecting catheter-related thrombosis. METHOD: Forty-four patients with subclavian venous catheters were studied. The sensitivity and specificity of colour Doppler US was determined for the diagnosis of central venous thrombosis and compared with contrast venography. Criteria considered to show the presence of catheter-related thrombosis included visualization of thrombus (T), absence of spontaneous flow (S), absence of phasicity of flow with respiration (P), incompressibility of the vein with probe pressure (C) and visualization of increased venous collaterals (V). RESULTS: Analysing each variable separately, P had the highest sensitivity (94%) and S had the highest specificity (100%). The best combinations for diagnosis were T+P, P+S, and T+P+S with a sensitivity of 94% and specificity of 88%. Overall diagnostic value of colour Doppler US had a sensitivity of 94% and specificity of 96%. CONCLUSION: Colour Doppler US is a reliable method for detecting central venous catheter-related thrombosis, especially if several parameters are evaluated in combination.

Potential disadvantages of post-operative adjuvant radiotherapy after anterior resection for rectal cancer: a pilot study of sphincter function, rectal capacity and clinical outcome.

The aim of this study was to try to gauge the functional effect of post-operative adjuvant radiotherapy after potentially curative anterior resection for carcinoma of the rectum. Anorectal function was studied both in the laboratory and clinically in 59 patients, a median of 12 months (range 6-96) after operation. Nine patients received post-operative radiotherapy and 50 matched patients were treated by surgery alone. Though maximum resting anal pressures and maximum squeeze pressures were similar in the two groups of patients, the length and pressure profile of the anal sphincter were both markedly abnormal after radiotherapy. The capacity and compliance of the neorectum were diminished significantly after radiotherapy (maximum tolerated volume 53 ml vs 110 ml after surgery alone, P = 0.008, compliance 1.5 ml/cm H2O vs 3.7 ml/cm H2O after surgery alone, p = 0.018) and the amount of distension of the neorectum required to produced maximum inhibition of the anal sphincter during the rectoanal inhibitory reflex was also significantly diminished after radiotherapy (P = 0.005). Clinical anorectal function was worse among patients who had received radiotherapy, a greater proportion of whom experienced both urgency of defaecation and varying degrees of incontinence. Major faecal leakage necessitating the use of a pad was recorded in 3 of the 59 patients after radiotherapy (one of whom required a permanent colostomy), but in only 5 of 50 patients after surgery alone.

The endothelium-derived relaxing factor-mediated acetylcholine response of the arterial perfusion pressure after cold storage of the isolated rabbit kidney.

The vasodilatation induced by acetylcholine (ACh) in a rabbit isolated perfused kidney was abolished when the tissue was exposed to cold ischemia for 72 h in Euro-Collins (EC) solution. This vasodilatation is due to the release of endothelium-derived relaxing factor (EDRF) from renal vasculature as evidenced by the attenuation following methylene blue pretreatment. When kidneys were preserved in EC solution containing UK 38485, a thromboxane synthase inhibitor, or nicardipine, a calcium channel blocker, ACh-induced vasodilatation persisted after 72 h of cold ischemia. These results were taken as evidence of tissue protective activity of UK 38485 and nicardipine and have promising implications for cadaveric kidney transplantation.

Predictive value of colour Doppler ultrasonography in detecting failure of vascular access grafts.

The predictive role of colour Doppler ultrasonography in determining the initial success and long-term patency of polytetrafluoroethylene (PTFE) vascular access grafts for haemodialysis was investigated. Two groups of patients were studied. The upper extremities of 21 patients in the control group were assessed by clinical examination only; those of 17 in a second group (Doppler group) were also assessed by ultrasonography before and after operation. Straight PTFE vascular access grafts were used between the brachial artery and axillary vein in all patients. The median preoperative brachial artery flow rate was significantly lower in patients who later developed graft thrombosis (66 versus 87 ml/min, P < 0.01), as was the median postoperative graft flow rate (480 versus 800 ml/min, P < 0.001). Routine preoperative and postoperative colour Doppler ultrasonography is recommended for every patient in whom a vascular access graft is planned.

Stricture at the pouch-anal anastomosis after restorative proctocolectomy.

PURPOSE: The aim of this study was to determine what factors may be responsible for the development of a stricture at the pouch-anal anastomosis after restorative proctocolectomy. METHODS: A consecutive series of 115 patients was studied retrospectively a median of 34 months (range, 4-100 months) after operation or ileostomy closure. The procedure failed in 11 patients (9.6 percent) who subsequently had to have a permanent ileostomy. Another two patients were excluded from the analysis, one of whom was awaiting ileostomy closure, whereas the other had a stricture due to a desmoid tumor. Of the remaining 102 patients, 39 (38 percent) developed an ileoanal anastomotic stricture, which was severe and persistent in 16 percent. RESULTS: The results were analyzed with the aid of multivariate logistic regression analysis. Factors which predisposed significantly to the development of an ileoanal anastomotic stricture were 1) use of the 25-mm (small) diameter stapling gun (P = 0.05), 3) use of a defunctioning ileostomy (P = 0.03), and 4) anastomotic dehiscence and pelvic sepsis (P = 0.03). The single patient whose operation failed because of a stricture had also developed pelvic sepsis associated with an anastomotic dehiscence. CONCLUSIONS: The eventual clinical, functional outcome after dilation of a stricture in the 39 patients who developed a stricture was as good as the outcome in the 63 patients who did not a develop stricture.

Use of polyglycolic acid mesh with a new double pursestring technique in renal trauma: an experimental study.

Repair of major kidney lacerations with conventional techniques is extremely difficult and 'through and through' suturing is associated with further loss of viable tissue because it promotes scarring. In this study, we investigate the haemostatic and viable parenchyma salvaging effect of an alternative, new wrapping technique in an experimental renal trauma model. This resulted in immediate haemostasis in all 25 animals, while the same injury caused excessive haemorrhage with 50 per cent mortality in eight untreated controls. This technique differs from other wrapping methods because no additional suturing for the application of PAM or haemostasis is required. It is an easy, rapid procedure which decreases the operating time and may allow successful repair in major lacerations of the kidney.

Use of autologous fibrin glue in the treatment of splenic trauma: an experimental study.

There is little doubt that preserving the spleen will contribute to a much more favourable outcome in patients undergoing splenic surgery, as a result of avoiding the well known risks of splenectomy. Among many operative methods described for splenic salvage, application of autologous fibrin glue (AFG) is particularly promising because of its unique characteristics. The use of AFG has been evaluated and its efficacy and tissue compatibility assessed in the treatment of splenic trauma in 15 partially splenectomized New Zealand White rabbits. The application of the AFG to the resected splenic surface achieved complete haemostasis in all animals. The animals were divided into four groups and were killed at varying intervals ranging from 24 h to 10 weeks. During re-exploration there was no evidence of recurrent bleeding and histopathological examination revealed progressive absorption of the AFG with a minimal inflammatory response. It is concluded that AFG is an effective haemostatic agent with good systemic and local compatibility and can be used in splenic salvage, which thereby avoids the use of non-autologous products with their risks of disease transmission.