Robotic transanal minimally invasive surgery for local excision of rectal neoplasms.

BACKGROUND: Robotic transanal minimally invasive surgery (TAMIS) may be an option for rectum-preserving excision of neoplasms. Recent cadaveric studies showed improved vision, control and manoeuvrability compared with use of laparoscopic instruments. This study reports the clinical application. METHODS: Consecutive patients eligible for transanal endoscopic microsurgery (TEM) or TAMIS in three participating centres were operated on using a robotic platform and transanal glove port. Patient demographics, lesion characteristics, perioperative data, complications and follow-up of all patients were recorded prospectively. RESULTS: Sixteen patients underwent robotic TAMIS for rectal lesions with a median (range) distance from the anal verge of 8 (range 3-10) cm. The median size of the resected specimen was 5·3 (0·5-21) cm(2) . The median docking time and duration of operation were 36 (18-75) and 108 (40-180) min respectively. One conversion to regular (non-robotic) TAMIS was needed owing to difficulties accessing the rectum. Glove puncture necessitated replacement in four procedures, an unstable pneumorectum arose during one operation and one patient developed a pneumoperitoneum. One patient required catheterization for urinary retention. The median hospital stay was 1·3 (0-4) days. The additional cost of the robotic approach was approximately €1000 per procedure (excluding the capital expenditure on the robotic system and its maintenance). CONCLUSION: Robotic TAMIS is feasible in patients with rectal lesions. Potential advantages over TEM and non-robotic TAMIS will need to be balanced against the cost of the robotic system.

Preclinical cadaveric study of transanal endoscopic da Vinci® surgery.

BACKGROUND: Single-port platforms are increasingly being used for transanal surgery and may be associated with a shorter learning curve than transanal endoscopic microsurgery. However, these procedures remain technically challenging, and robotic technology could overcome some of the limitations and increase intraluminal manoeuvrability. An initial experimental experience with transanal endoscopic da Vinci(®) surgery (TEdS) using a glove port on human cadavers is reported. METHODS: After initial dry laboratory experiments, the feasibility of TEdS and ideal set-up were further evaluated in human cadavers. For transanal access a glove port was constructed on-table by using a circular anal dilator, a standard wound retractor and a surgical glove. A da Vinci(®) Si HD system was used in combination with the glove port for transanal endoscopic resections. RESULTS: It was possible to perform all necessary tasks to complete a full-thickness excision and closure of the rectal wall, with cadavers in both prone and supine positions. The stable magnified view, combined with the EndoWrist(®) technology of the robotic instruments, made every task straightforward. Intraluminal manoeuvrability could be improved further by intersecting the robotic instruments. The glove port proved to be very reliable and the inherent flexibility of the glove facilitated docking of the robotic arms in a narrow confined space. CONCLUSION: Using a reliable and universally available glove port, TEdS was feasible and a preferred set-up was determined. Further clinical trials will be necessary to assess the safety and efficacy of this technique.

Incidence of small-bowel obstruction and adhesiolysis after open colorectal and general surgery.

PURPOSE: The study contained herein was undertaken to establish the incidence of small-bowel obstruction, adhesiolysis for obstruction, and additional abdominal surgery after open colorectal and general surgery. METHODS: A retrospective cohort study was performed using patient-specific Health Care Financing Administration data to evaluate a random 5 percent sample of all Medicare patients who underwent surgery in 1993. Of these, 18,912 patients had an index abdominal procedure. Two-year follow-up data documented outcomes of hospitalizations with obstruction, adhesiolysis for obstruction, and/or additional open colorectal or general surgery. RESULTS: Within two years of incision, excision, and anastomosis of intestine (International Classification of Dis eases (ICD)-9 code 45), 14.3 percent of patients had obstructions, 2.6 percent required adhesiolysis for obstructions, and 12.9 percent underwent additional open colorectal or general surgery. After other operations of intestine (ICD code 46), 17 percent of patients had obstructions, 3.1 percent required adhesiolysis for obstructions, and 20.2 percent underwent additional open colorectal or general surgery. After operations of rectum, rectosigmoid, and perirectal tissue (ICD code 48), 15.3 percent of patients had obstructions, 5.1 percent required adhesiolysis for obstructions, and 16.4 percent underwent additional open colorectal or general surgery. After other operations on the abdominal region (ICD code 54), 12.4 percent of patients had obstructions, 2.3 percent required adhesiolysis for obstructions, and 8.8 percent underwent additional open colorectal or general surgery. CONCLUSIONS: In this retrospective study of Medicare patients, we learned that bowel obstruction, adhesiolysis for obstructions, and additional abdominal surgery occurred more often after abdominal surgery than was previously published.

Pouchitis--is it a wastebasket diagnosis?

Pouchitis is a poorly defined syndrome that is unique to patients with an ileal reservoir. During a prospective follow-up review of 215 patients who underwent ileal pouch-anal anastomosis, pouchitis was diagnosed in 30 patients (14 percent). Based on the clinical course, two distinct patterns of pouchitis were recognized: patients who experienced two or fewer episodes (Group 1-18 patients) and patients who experienced at least three episodes (Group 2-12 patients). Histopathologic review of resected colons revealed a preponderance of indeterminate colitis in patients in Group 2 (58.3 percent) compared with patients in Group 1 (0 percent). In Group 1; 88.9 percent of patients responded to therapy with metronidazole. Only 25 percent of patients in Group 2 responded to metronidazole alone. Most patients in Group 2 required sulfasalazine, topical steroids, or both. Of the 30 patients with pouchitis, four (13.3 percent) had a distinct endoscopic pattern of distal inflammation. This subset of patients with short strip pouchitis was successfully treated with topical steroid preparations. The clinical differences suggest different causes of pouchitis in these two groups.

Fluoroscopy in colonoscopy. Who is using it and why?

Use of fluoroscopy during colonoscopy has never been broadly assessed. A survey of 1,864 members of the Society of American Gastrointestinal Endoscopic Surgeons and the American Society of Colon and Rectal Surgeons was carried out to quantify the use of fluoroscopy and to elicit impressions regarding its capabilities, indications, and usefulness. After the establishment of the responding colonoscopist's training, experience, and other background data, impressions of fluoroscopy's role in many issues were obtained using a graded response system. Concluding the two-page survey were open-ended questions addressing the respondent's indications, contraindications, and rationale for using or not using fluoroscopy. Six hundred thirty-one colonoscopists responded. Seventy-five per cent never use fluoroscopy; the most frequently cited reasons were lack of need and inaccessibility of fluoroscopy. For many colonoscopists, fluoroscopy is unavailable (22%) or available outside of the usual endoscopy setting (44%). Fluoroscopy is used by 25 per cent of colonoscopists. Almost three quarters of this group have the capability of performing fluoroscopy in their colonoscopy unit. The indications for fluoroscopy varied with the frequency of its use; frequent users employ fluoroscopy to treat loops, to confirm cecal intubation, and to locate the instrument tip precisely. Infrequent users employ fluoroscopy to apply the sigmoid straightening overtube or because of prior failed colonoscopy. Impressions regarding the impact of fluoroscopy on learning, completing, and safeguarding colonoscopy were obtained. Most colonoscopists are satisfied without using fluoroscopy, although 65 per cent of nonusers believe it would improve colonoscopy performance if it were used. Ninety-two per cent of frequent users of fluoroscopy reported that they would feel significantly impaired without having the capability to perform fluoroscopy.(ABSTRACT TRUNCATED AT 250 WORDS)