Colonic stenting for malignant large bowel obstruction is safe and effective: a single-surgeon experience.

INTRODUCTION: Self-expanding metal stents (SEMS) can be used as a bridge to surgery (BTS) or for palliation in the treatment of malignant large bowel obstruction. This case series evaluates the short-term outcomes of SEMS and success rates over time. METHODS: A total of 75 consecutive patients who underwent colonic stenting for malignant colonic obstruction over a period of six years were included. This time period was subdivided into two equal parts for analysis. The procedure was carried out by a single surgeon from a tertiary institution in Singapore. RESULTS: Technical success was reported in 93.3% of cases and clinical success in 81.3% of cases, with better success rates in the second half of the study (89.2% vs. 73.7%; p < 0.05). There were seven cases of inadequate decompression and two cases of colonic perforation. The median duration from stent insertion to surgery was ten days, and the median postoperative length of stay was six days. CONCLUSION: SEMS are a safe and effective way of relieving malignant large bowel obstruction, including those that are proximal. The improvement in success over time reflects the importance of having an experienced endoscopist carry out the procedure to ensure optimum success rates.

Initial experience of laparoscopic right hemicolectomy with complete mesocolic excision in Singapore: a case series.

INTRODUCTION: Laparoscopic colorectal surgery is increasingly performed worldwide due to its multiple advantages over traditional open surgery. In the surgical treatment of right-sided colonic tumours, the latest technique is laparoscopic right hemicolectomy with complete mesocolic excision (lapCME), which aims to lower the rate of local recurrence and maximise survival as compared to standard laparoscopic right hemicolectomy (lapS). METHODS: We conducted a retrospective analysis of our initial experience with lapCME in Singapore General Hospital between 2012 and 2015. All procedures were performed by a single surgeon. RESULTS: Nine patients underwent lapCME and 16 patients underwent lapS. Indication for lapCME was cancer in the right colon. None of the patients required conversion to open surgery, and all were discharged well. The number of lymph nodes resected in the lapCME group was significantly greater than in the lapS group (29 ± 15 vs. 19 ± 6; p = 0.02) during the study period, and the mean operation time was significantly longer for lapCME (237 ± 50 minutes vs. 156 ± 46 minutes; p = 0.0005). There were no statistically significant differences in terms of demographics, tumour stage, time taken for bowel to open postoperatively, time taken for patient to resume a solid diet postoperatively and length of hospital stay. Two patients who underwent lapS were re-admitted for intra-abdominal collections - one patient required radiology-guided drainage, while the other patient was managed conservatively. CONCLUSION: Our initial experience with lapCME confirms the feasibility and safety of the procedure.

Universal suprapubic approach for complete mesocolic excision and central vascular ligation using the da Vinci Xi® system: from cadaveric models to clinical cases.

There has been little enthusiasm for performing robotic colectomy for colon cancer in recent years due to multiple factors, one being that the previous robotic systems such as the da Vinci Si® (dVSi) were poorly designed for multi-quadrant surgery. The new da Vinci Xi® (dVXi) system enables colectomy with central mesocolic excision to be performed easily in a single docking procedure. We developed a universal port placement strategy to allow right and left hemicolectomies to be performed via a suprapubic approach and a Pfannensteil extraction site. This proof of concept paper describes the development and subsequent clinical application of this setup. After extensive training on the dVXi system concepts in collaboration with clinical development engineers, we developed a port placement strategy which was tested and adapted after performing experimental surgery in three cadaveric models. Subsequently our port placement was used for two clinical cases of suprapubic right and left hemicolectomy. With some modifications of port placements after the initial cadaveric colectomies, we have developed a potentially universal suprapubic port placement strategy for robotic colectomy with complete mesocolic excision and central vascular ligation using the dVXi robotic system. This port placement strategy was applied successfully in our first two clinical cases. Based on our cadaveric laboratory as well as our initial clinical application, the suprapubic port placement strategy for the dVXi system with its improved features over the dVSi can feasibly perform right and left hemicolectomy with complete mesocolic excision and central vascular ligation. Further studies will be required to establish efficacy as well as safety profile of these procedures.

The number of retrieved lymph nodes needed for accurate staging differs based on the presence of preoperative chemoradiation for rectal cancer.

The aim of this study is to investigate if retrieval of 12 lymph nodes (LNs) is sufficient to avoid stage migration as well as to evaluate the prognostic impact of insufficient LN retrieval in different treatment settings of rectal cancer, particularly in the case of preoperative chemoradiotherapy (pCRT).The data of all patients with biopsy proven rectal adenocarcinoma who underwent curative surgery between January 2005 and December 2012 were analyzed. Univariate and multivariate analyses for oncologic outcomes were performed in LN metastasis or no LN metastasis (LN-) group. Subgroup analyses were performed according to whether a patient had received pCRT.A total of 1825 patients were enrolled into the study. The maximal Chi-square method revealed the minimum number of harvested LNs required to be 12. Univariate and multivariate analyses found LNs ≥ 12 to be an independent prognostic factor for both overall survival (OS) (hazard ratio [HR] = 0.5, 95% confidence intervals [CIs]: 0.3-0.8; P = 0.002) and disease-free survival (DFS) (HR = 0.6, 95% CI: 0.4-0.7; P < 0.001) in the LN- group. In the LN- group, LNs ≥ 12 continued to be a significant prognostic factor both for OS and DFS in the subgroup of patients who did not undergo pCRT. However, in the subgroup of the LN- patients who underwent pCRT, LN ≥ 8 was significant for DFS and OS.Retrieval of LNs ≥ 12 and LNs ≥ 8 should be achieved to obtain accurate staging and optimal treatment for the non-pCRT and pCRT groups in rectal cancer, respectively.

Toxic haemorrhagic colitis: a rare presentation of eosinophilic colitis.

Eosinophilic colitis is a rare condition that usually presents with non specific abdominal symptoms. Very uncommonly it presents with an acute surgical emergency such as peritonitis or haemorrhage. We present a rare presentation of eosinophilic colitis with toxic hemorrhagic colitis and ischaemic bowel requiring laparotomy and bowel resection.

Critical analysis of mucin and signet ring cell as prognostic factors in an Asian population of 2,764 sporadic colorectal cancers.

INTRODUCTION: Conflicting data on the clinicopathological characteristics as well as prognosis and survival of signet ring cell (SRC) and mucinous adenocarcinomas (MA) of the colorectum persist. METHODS: Consecutive patients (2,764) with sporadic colorectal cancer from 1999 to 2005 were evaluated. The clinicopathological characteristics of these patients were reviewed. Univariate analysis was performed, and survival curves were constructed using the Kaplan-Meier method. Multivariate analysis assessed independent prognostic factors. RESULTS: The incidence of MA and SRC is 6% and 1.1%, respectively. MA and SRC tend to occur in patients aged