Operative start time may impact the quality of mesorectal excision in minimally invasive rectal surgery: retrospective analysis of 137 patients.

INTRODUCTION: Timing of major elective operations is a potentially important outcome variable. This study examined the impact of operative start time (OST) on pathologic and short-term outcomes of minimally invasive rectal surgery (MIRS). METHODS: All rectal tumors patients who underwent MIRS from May 2012 to April 2016 were identified. Peroperative outcomes and the oncological quality of surgical excision were compared between patients with OST before 13.00h and after. RESULTS: A total of 137 patients were included in the study (71 Romarobot-assisted and 66 conventional laparoscopic). Ninety-nine (72%) patients were operated before 13.00h and 38 after 13.00h. The majority of cases were low/middle rectal tumors (69%). Patient's baseline characteristics were quite similar in both groups. The rate of severe complication (p=0.460) or reoperation (p=0.614) was the same. Pathologic criteria (T or N stage, number of harvested lymph nodes, and presence of any positive margin) were the same between groups except for the quality of mesorectal excision (ME) that was significantly poorer for cases beginning after 13.00h (complete 91% vs 74%; p=0.016). The OST was found to be the only parameter associated with a poor quality of ME [OR 2.55 (1.08 - 6.36)]. CONCLUSION: Perioperative outcome after MIRS does not appear to be influenced by OST. Poorer quality of ME was observed and may thus raise important questions about the timing and sequence of case scheduling.

Less Morbidity with Robot-Assisted Gastric Bypass Surgery than with Laparoscopic Surgery?

INTRODUCTION: Although several studies have compared totally robot-assisted gastric bypass (RA-GB) to laparoscopic gastric bypass (L-GB), the clinical benefit of the robotic approach remains unclear. MATERIALS AND METHODS: We compared perioperative outcomes of 82 consecutive patients undergoing RA-GB between 2013 and 2016 to 169 consecutive patients having undergone L-GB between 2009 and 2016. Secondary endpoints included duration of hospitalization, readmission rate, weight loss at 1 year, and the learning curve of RA-GB, assessed by operation times and complication rates. RESULTS: There were no statistically significant differences between groups concerning age (43.5 ± 11.2 vs. 42.2 ± 12.4 years), body mass index (42.4 ± 5.0 vs. 43.6 ± 7.2 kg/m2), or comorbidities. The rate of revision surgery was higher in L-GB group without reaching statistical significance. No statistically significant difference was observed for duration of operation (134 ± 35 vs. 135 ± 37 min), readmission rate at 90 days (4.9% vs. 8.9%), or percentage of excess weight loss at 1 year (RA-GB vs. L-GB) (76.8% ± 20.5 vs. 73.1% ± 23.5). There were fewer statistically significant complications overall in RA-GB (9.8% vs. 21.9%, p = 0.019). Median duration of hospital stay was shorter for RA-GB (3 vs. 4 days, p < 0.0001). The mean duration of operation for RA-GB decreased from 153 min in 2014 to 122 min in 2016; p = 0.004. CONCLUSION: In our experience, the robotic approach for gastric bypass was associated with fewer postoperative complications compared to traditional laparoscopic gastric bypass. Cost increment associated with RA-GB remains an important drawback that hampers its widespread.

Emergency laparoscopy: Role and implementation.

Laparoscopic surgery has emerged over the past two decades as the surgical approach of choice in the treatment of many digestive disorders. Laparoscopy has its place in the management of abdominal surgical emergencies since it provides the same benefits: less postoperative pain and shorter length of hospital stay when compared to laparotomy. However, its role in the management of abdominal emergencies has not yet been fully clarified. In this review, we focus on what has been validated concerning the role of emergency laparoscopy in the management of abdominal diseases.

Growing teratoma syndrome of the ovary presenting with liver metastasis: report of a case.

Growing teratoma syndrome (GTS) is a rare condition among patients with non-seminomatous germ cell tumors who present with enlarging metastatic masses during appropriate systemic chemotherapy in the context of normalized serum markers. This is an infrequent event in the progression of testicular tumors, and is even less common in the case of ovarian germ cell tumors. The pathogenesis of GTS is not completely understood and diagnosis can only be made with certainty after complete pathologic examination. Although histologically benign, GTS may present an enveloping growth with aggressive local expansion, which can be related to substantial morbidity and mortality. Surgery is the only recommended treatment and early recognition of this syndrome is essential as it offers hope for curative resection and avoids the use of ineffective chemotherapy. The authors present a brief review of the literature, along with the case report of a 37-year-old woman presenting GTS with liver involvement who was successfully treated by debulking surgery followed by major liver resection. This report demonstrates that complete surgical resection results in excellent disease control. More importantly, it highlights that clinicians need to be aware of the possible development of GTS when monitoring their patients with non-seminomatous germ cell tumors. These patients require coordinated care between oncologist, gynecologists, and general surgeons to obtain the best possible outcomes.

Para-aortic lymph node sampling in pancreatic head adenocarcinoma.

BACKGROUND: The significance of positive para-aortic nodes in patients with resectable pancreatic carcinoma is unclear. This study sought to evaluate the accuracy of intraoperative detection and prognostic significance of these lymph nodes in patients with resected adenocarcinoma of the pancreatic head. METHODS: From 2000 to 2010, para-aortic node sampling was performed prospectively in all patients before pancreatoduodenectomy. Frozen sections were created and nodes categorized as positive or negative for metastases. Surgeons were blinded to the frozen-section results. This was followed by standard histopathological assessment of corresponding paraffin-embedded, haematoxylin and eosin-stained material. Nodes considered uninvolved by this analysis were examined immunohistochemically for micrometastases. RESULTS: A total of 111 consecutive patients were included, with a median follow-up of 20·8 (range 1·5-126) months. The 1-, 2- and 5-year overall survival (OS) and disease-free survival (DFS) rates were 73·6, 54·0 and 24·7 per cent, and 51·8, 28·1 and 18·8 per cent respectively. Para-aortic node involvement was always associated with peripancreatic lymph node metastasis, and was detected by frozen-section analysis in 12 patients and by haematoxylin and eosin staining in 17. Sensitivity and specificity of frozen-section examination for detecting para-aortic lymph node metastases were 71 and 100 per cent respectively. Median OS for patients with and without para-aortic node involvement on frozen-section analysis was 9·7 versus 28·5 months respectively (P = 0·012), and 15·7 versus 27·2 months (P = 0·050) when assessed by haematoxylin and eosin staining. Median DFS for patients with and without para-aortic node involvement on frozen-section examination was 5·6 versus 12·9 months respectively (P = 0·041), and 8·4 versus 12·9 months (P = 0·038) for haematoxylin and eosin analysis. The presence of micrometastases in para-aortic nodes was not significantly associated with altered OS or DFS. CONCLUSION: Para-aortic node sampling with frozen-section examination detects distant lymphatic involvement reliably. It should be performed systematically. When metastases are found, they should be considered a contraindication to pancreatic resection.

Simultaneous laparoscopic resection of primary colorectal cancer and associated liver metastases: a systematic review.

As many as 25 % of colorectal cancer (CRC) patients have liver metastases at presentation. However, the optimal strategy for resectable synchronous colorectal liver metastasis remains controversial. Despite the increasing use of laparoscopy in colorectal and liver resections, combined laparoscopic resection of the primary CRC and synchronous liver metastasis is rarely performed. The potential benefits of this approach are the possibility to perform a radical operation with small incisions, earlier recovery, and reduction in costs. The aim of this study was to review the literature on feasibility and short-term results of simultaneous laparoscopic resection. We conducted a systematic search of all articles published until February 2013. Search terms included: hepatectomy [Mesh], "liver resection," laparoscopy [Mesh], hand-assisted laparoscopy [Mesh], surgical procedures, minimally invasive [Mesh], colectomy [Mesh], colorectal neoplasms [Mesh], and "colorectal resections." No randomized trials are available. All data have been reported as case reports, case series, or case-control studies. Thirty-nine minimally invasive simultaneous resections were identified in 14 different articles. There were 9 (23 %) major hepatic resections. The most performed liver resection was left lateral sectionectomy in 26 (67 %) patients. Colorectal resections included low rectal resections with total mesorectal excision, right and left hemicolectomies, and anterior resections. Despite the lack of high-quality evidence, the laparoscopic combined procedure appeared to be feasible and safe, even with major hepatectomies. Good patient selection and refined surgical technique are the keys to successful simultaneous resection. Simultaneous left lateral sectionectomy associated with colorectal resection should be routinely proposed.

Number of examined lymph nodes and nodal status assessment in pancreaticoduodenectomy for pancreatic adenocarcinoma.

BACKGROUND: The accuracy of the assessment of the nodal status in resected cephalic pancreatic adenocarcinoma (PA) depends on the number of examined lymph nodes (NELN). This study assesses the impact of the NELN on N staging and survival and propose a minimal number of examined lymph nodes (MNELN) ensuring reliability of the pN status determination. METHODS: 188 consecutive patients treated by pancreaticoduodenectomy (PD) for PA. Correlations between NELN and survivals of pN0 and pN1 groups and with the rate of pN1 patients were studied. A probability model based on the binomial law was built to estimate the MNELN able to detect pN1 patients with a sensitivity ≥ 95%. RESULTS: Overall and disease free 5-year survivals were 27.2% and 24.6% respectively. 135 patients (71.8%) were staged pN1. The median NELN was 17 (range 0-68). Overall and disease free survivals of pN1 patients were not related to NELN. The influence of NELN on survival in pN0 patients due to stage migration did not reach significance. The probability model showed that a MNELN of 16 nodes was required to detect pN1 patients with a sensitivity of 95%. CONCLUSION: A MNELN of 16 is required to assess pN status and should be considered as a quality criterion in future studies and trials on PD for PA.

Spontaneous rupture of a giant hepatic hemangioma. Sequential treatment with preoperative transcatheter arterial embolization and conservative hepatectomy.

Hemangioma is the most common benign tumor of the liver and it is often asymptomatic. Spontaneous rupture of liver hemangiomas is a rare but potentially lethal complication. Emergent hepatic resection has been the treatment of choice but carries high operative morbidity and mortality. Recently, preoperative transcatheter arterial embolization (TAE) has been used successfully for the management of bleeding ruptured liver tumors and non-operative treatment of symptomatic giant liver hemangiomas. We report a case of spontaneous rupture of a giant hepatic hemangioma that presented with thoracic and abdominal pain and shock due to hemoperitoneum. Once proper diagnosis was made the patient was successfully managed by TAE, followed by conservative hepatic resection.

Treatment of fistula-in-ano with the Surgisis(®) AFP(TM) anal fistula plug.

OBJECTIVE: Closure of the fistula tract with an anal fistula plug has been reported to provide success rates as high as 80%. The purpose of this study was to evaluate our results with this new method. METHOD: From June 2006 to September 2007, an anal fistula plug was used for the treatment of high transsphincteric fistulas. Success was defined as no residual leakage or abscess formation and closure of the external opening. RESULTS: Fifteen patients (seven women), median age 46 years (range 32-58 years), were included in the study. Three had Crohn's disease, three had an anovulvar fistula and seven had undergone previous surgical-repair attempts. Three patients expelled the prosthesis on postoperative day 2, 5 and 7, respectively, and a second plug placement was followed by expulsion again. One patient developed an abscess that was noted on postoperative day 4. The fistula tract healed in 6/15 patients (40%) after 3 months and in 8/15 (53.3%) after 7 months. The success rate in Crohn's disease was 33%. No significant difference was found between patients with or without previous surgical repair. CONCLUSION: In our experience, this simple technique provided success rates of 40% at 3 months and 53% at 7 months.

Livaditis' circular myotomy does not decrease anastomotic leak rates and induces deleterious changes in anastomotic healing.

Considering that Livaditis' myotomy is still accepted as a good method for lengthening the esophagus to allow primary repair of long-gap esophageal atresia, the aim of this experimental study was to verify if this procedure decreases the incidence of leaks in anastomoses performed under severe tension. In addition, it was verified whether the myotomy promotes any morphological or biochemical change in the healing esophageal anastomosis. Sixty small dogs were submitted to a cervicotomy and resection of an esophageal segment (8.0 - 10.0 cm) resulting in an anastomosis under severe tension. The animals were divided into two groups (control group: only anastomosis; experimental group: anastomosis plus circular myotomy in the proximal esophageal segment). The animals were sacrificed on the 14th postoperative day, submitted to autopsy, and were evaluated as to the presence of leaks. Twelve scars of each group were collected for histological, histomorphometric (evaluation of scar thickness), electrophoretic and immunoblotting studies of collagen (total collagen and types of collagen determinations). Leak rates were the same in both groups. Histologic examination showed that the scar at the anastomosis was formed by fibrous tissue, without mucosa or muscular tissue. In the myotomy animals, a decreased number of newly formed small vessels was noted in comparison to control animals, and morphometric analysis showed that in the myotomy animals the anastomotic scar was thinner than in the control animals. Biochemical analysis of scars demonstrated that myotomy promoted a decrease in the soluble collagen content in comparison with the control animals and no alteration in the content of insoluble collagen. The electrophoretic separation of the types of collagen and characterization by immunoblotting demonstrated the presence of collagen types I, III, and V, and the quantification by densitometry of the bands showed a reduction in collagen type V (present in the blood vessels) in the myotomy animals in comparison to controls. This result is in accordance with the histological observation of a decrease in newly formed blood vessels. Circular myotomy does not decrease the possibility of anastomotic leaks, in addition to promoting deleterious changes in anastomotic healing.

Primary aortoenteric fistula related to septic aortitis.

CONTEXT: Primary aortoenteric fistulas usually result from erosion of the bowel wall due to an associated abdominal aortic aneurysm. A few patients have been described with other etiologies such as pseudoaneurysm originating from septic aortitis caused by Salmonella. OBJECTIVE: To present a rare clinical case of pseudoaneurysm caused by septic aortitis that evolved into an aortoenteric fistula. CASE REPORT: A 65-year-old woman was admitted with Salmonella bacteremia that evolved to septic aortitis. An aortic pseudoaneurysm secondary to the aortitis had eroded the transition between duodenum and jejunum, and an aortoenteric fistula was formed. In the operating room, the affected aorta and intestinal area were excised and an intestine-to-intestine anastomosis was performed. The aorta was sutured and an axillofemoral bypass was carried out. In the intensive care unit, the patient had a cardiac arrest that evolved to death.