Endoscopy‐assisted transanal repair of afferent limb obstruction and long efferent limb with ileopexy after ileal J‐pouch‐anal anastomosis

Afferent limb obstruction can be a persistent complication after restorative proctocolectomy with ileal pouch‐anal anastomosis. We present a case of afferent limb obstruction complicated by a long efferent limb of the ileal pouch that we successfully treated with side‐to‐side anastomosis of the afferent and efferent limbs. The procedure involved using a transanal endoscopic stapling device assisted by transanal endoscopy with a thin intestinal video endoscope. This allowed reliable, safe visualization of the lesion from the tight pouch‐anal anastomosis and facilitated repair with an endoscopic stapling device. Because the technique was performed without enterotomy, it reduced the risks of contamination and leakage from transabdominal small bowel anastomosis. Laparotomy view also prevented of injury to the pouch itself and entrapment of the mesentery of the afferent and efferent limbs of the pouch between the stapler anvils.     

Laparoscopic low anterior resection for rectal cancer after Whitehead's hemorrhoidectomy: A case report

A 65‐year‐old man presented with bloody stool. Colonoscopy revealed a raised tumor in the rectum, above the peritoneal reflection. He underwent endoscopic mucosal resection, but the pathological findings suggested the possibility of residual cancer. We performed laparoscopic low anterior resection using a circular stapling instrument for additional curative surgery. However, we could not insert the shaft of the endoscopic circular stapler from the anus because of anal stenosis due to Whitehead's hemorrhoidectomy the patient had undergone 20 years earlier. Therefore, we planned to use a linear stapler to insert an anvil into the rectum. The cartridge‐carrying instrument was inserted from the sigmoidal side, and we performed a side‐to‐end anastomosis. The patient was discharged without anastomotic leakage or defecation disorder. We present this case because laparoscopic low anterior resection for rectal cancer with anal stenosis has not been previously reported.     

Laparoscopic diagnosis of retrograde peristalsis and intussusception in Roux‐en‐Y limb after laparoscopic gastrectomy: A case report

The cause of jejunojejunal intussusception, a rare complication after Roux‐en‐Y gastric surgery, remains unclear. Here, we present a case of retrograde jejunojejunal intussusception that occurred after laparoscopic distal gastrectomy with Roux‐en‐Y reconstruction. A 51‐year‐old woman who had undergone laparoscopic distal gastrectomy and Roux‐en‐Y reconstruction for early gastric cancer 6 years previously was admitted to our hospital with abdominal pain. Abdominal CT revealed the “target sign,” and she was diagnosed as having small bowel intussusception. Laparoscopic surgery resulted in a diagnosis of retrograde intussusception of the distal jejunum of the Roux‐en‐Y anastomosis with retrograde peristalsis in the same area. The Roux‐en‐Y anastomosis site and intussuscepted segment were resected laparoscopically. To the best of our knowledge, this is the first report of laparoscopic diagnosis of retrograde peristalsis in the distal jejunum of a Roux‐en‐Y anastomosis. Additionally, relevant published reports concerning this unusual condition are discussed.     

A memory‐shape temperature‐dependent nickel‐titanium device for colonic anastomosis in laparoscopic surgery

Minimally invasive surgery is a growing issue in medicine and is also increasingly being used for colonic surgery. With this procedure, the involved colon is dissected laparoscopically, exteriorized through a small incision and the segment containing the tumor is resected. The anastomosis is done extraperitoneally either by hand suture or with a stapler. Our study was designed to evaluate the feasibility of using a memory‐shape compression anastomosis clip (CAC) to perform colonic anastomosis in laparoscopy. Ten patients who were scheduled for laparoscopic colonic surgery entered the study. In five patients, the anastomosis was performed with the CAC and in five patients, with a stapler. To perform anastomosis with CAC, the two edges of the resected colon are placed parallel. Two 5‐mm incisions are made close to the edges, where the CAC is introduced in an open position after being cooled in ice water at 0°C, using a special applier. The applier introduces the clip which clamps the two bowel loops together, creating a small incision through the clamped walls, and then releasing the clip inside the intestine. The two 5‐mm incisions are then sutured. The clip is expelled with the stool within five to seven days after the operation, creating a perfect uniform anastomosis. Neither group had complications related to the anastomosis. Our study shows that the use of the CAC for colonic laparoscopic surgery is simple, very efficient and shortens operation time. It creates a uniform anastomosis, coming close to the no‐touch concept in surgery, may prevent infection, and is low in cost compared to the stapler.     

国产吻合器和缝合器在食管癌消化道重建术中的应用

目的评价国产吻合器和闭合器在食管癌消化道重建术中的应用价值。方法回顾性分析2005年3月2008年4月期间收治的387例食管癌手术患者的临床资料,根据不同消化道重建方式分为手工吻合组（n=172）和器械吻合组（n=215）,对两组患者吻合时间、术中出血量及术后并发症发生情况进行对比分析。结果全组无手术死亡。器械吻合组和手工吻合组术中出血量的差别无统计学意义（P〉0.05）,但前者的吻合时间、住院时间均少于后者（P〈0.05）。手工吻合组术后吻合口出血多于器械吻合组（5.2%比1.4%,P〈0.05）,发生吻合口漏亦多于器械吻合组（6.4%比2.8%,P〈0.05）。随访1.5～2年,排除失访患者后,器械吻合组吻合口狭窄发生率低于手工吻合组（4.6%比10.3%,P〈0.05）。结论国产吻合器与和缝合器用于食管癌的消化道重建安全有效,值得在基层医院推广应用。     

Three‐dimensional laparoscopy‐assisted bowel resection for cavernous hemangioma of the rectum: Report of two cases

The safety and feasibility of 3‐D laparoscopy‐assisted bowel resection were demonstrated in the management of rectal cancer. However, this procedure’s role in the management of patients with diffuse cavernous hemangioma of the rectum has not been evaluated. Here, two patients were diagnosed with diffuse cavernous hemangioma of the rectum by colonoscopy and abdominal imaging. One case underwent pull‐through transection and coloanal anastomosis in 3‐D laparoscopy‐assisted surgery. In another patient, 3‐D laparoscopy‐assisted abdominoperineal resection was performed. The operations were safely performed in both cases. The two patients recovered uneventfully, and satisfactory postoperative outcomes were demonstrated. This report shows that 3‐D laparoscopy‐assisted bowel resection may be safe and feasible for patients with diffuse cavernous hemangioma of the rectum.     

改良直肠低位双吻合技术在中低位直肠癌中的应用

【目的】探讨改良直肠低位双吻合技术在中低位直肠癌中应用的临床疗效。【方法】选取本院收治的中低位直肠癌行腹腔镜下直肠癌根治加直肠低位双吻合术患者90例,采用随机数字表法分为改良组和对照组,每组各45例。改良组采用肠-肠“端-角”吻合的改良直肠低位双吻合术,对照采用常规操作。观察两组患者手术时间、术中出血量、治疗费用,以及吻合成功率、吻合口出血、吻合口瘘、吻合口狭窄的发生率和术后6个月控便能力。【结果】改良组和对照组术中出血量和吻合成功率比较,差异无显著性(P >0.05);改良组手术时间显著低于对照组(P <0.05)。改良组和对照组吻合口出血、吻合口狭窄和术后感染发生率比较,差异无显著性(P >0.05),改良组吻合口瘘发生率显著低于对照组(P <0.05)。改良组和对照组术后6个月控便能力比较差异无显著性(P >0.05)。【结论】改良后的直肠低位双吻合方法在中低位直肠癌行腹腔镜下直肠癌根治术中应用,可有效缩短手术时间和降低吻合口瘘等并发症的发生率,值得临床推荐。     

Laparoscopy‐assisted distal gastrectomy for multiple adenocarcinomas in intrathoracic upside‐down stomach

Herein we report on a case of two adenocarcinomas arising from an upside‐down stomach in an elderly patient. An 83‐year‐old man was referred to our hospital with gastric cancer. Esophagogastroduodenoscopy showed two superficial depressed lesions in the stomach that were confirmed on biopsy as constituting a moderately differentiated tubular adenocarcinoma. CT and an upper gastrointestinal barium study revealed that the entire stomach and parts of the duodenum were located in the mediastinum. The patient underwent laparoscopy‐assisted distal gastrectomy and regional lymph node dissection with Billroth I reconstruction, followed by reduction of the migrated stomach. The hiatal defect was closed by primary suturing of the right and left crura at the anterior space of the esophagus. The patient's postoperative course was good, and follow‐up after discharge was uneventful. To the best of our knowledge, this is the first case report of multiple adenocarcinomas in an upside‐down stomach treated by laparoscopy‐assisted distal gastrectomy.     

胸腹腔镜下行食管癌切除术患者的护理配合

目的探讨胸腹腔镜辅助下行食管癌切除术患者的护理配合。方法回顾性分析2010年4月至2011年12月在大连医科大学附属第一医院手术室行胸腹腔镜辅助下食管癌切除术的12例患者的临床资料。所有患者在胸外科及普外科医生共同协助,采用超声刀和LigaSure,经胸腔镜后纵隔游离胸段食管、腹腔镜下游离胃及腹段食管、胃食管左颈吻合。结果本组12例患者手术过程顺利,无一例患者中转开胸。有1例患者中转开腹手术,术中无输血。结论手术室护士做好手术前准备,掌握手术过程与步骤,调整和准备好胸腔镜及腹腔镜器械,同时备好开胸、腹手术器械等是手术顺利进行的保证。     

The current evidence on stapled versus hand‐sewn anastomoses in the digestive tract

The innovation process and developments in technology have given surgeons new products which can improve their performance and benefit our patients. Before the era of laparoscopic surgery one of the most important applications in surgical practice was the introduction of staplers. In this article, the evidence supporting the decision whether to use a mechanical device (stapler) or to make a hand‐sewn anastomosis is presented. A sytematic review of the literature was performed. The search included published meta‐anaylses, randomized clinical trials and comparative studies. Key words for the initial search were: surgical anastomosis, stapler, hand‐sewn. There was no language restriction. The reference lists from the selected articles were also checked by the author. Literature data on main outcomes concerning the application of one or the other surgical technique have been analysed. The literature search yielded published data on various procedures in digestive surgery. Most of the available high‐quality evidence was for gastric and colorectal resections. Resection of the esophagus, use of staplers in emergency procedures and some initial reports on pancreatic surgery were also retrieved. The evidence from the literature shows that stapler anastomoses take less operative time and are more costly than hand‐sewn anastomoses. Regarding the morbidity and leaks rate the staplers give equal or better results when compared with the hand‐sewn technique. Nevertheless, proper handling of staplers and experience remain crucial issues if one wants to gain benefits when using these devices.     

Circular staplers in esophagojejunal and esophagogastric anastomoses

A report on 100 consecutive esophagoenteric anastomoses (EEA stapler) following total (esophagojejunostomy) or proximal gastrectomy (esophagogastrostomy) is presented. The following intraoperative problems occurred: insufficiency of the purse string suture [4], lumen of the esophagus too small [1], rupture of the esophageal wall [4], incomplete rings [4]. Fatal postoperative complications included two cases of insufficiency of the esophagojejunostomy, whilst the remaining six postoperative deaths were not linked to the use of the stapler (operative mortality 8%). Follow-up showed no recurrence at the stapler line, but two anastomotic strictures occurred. The EEA stapler is a helpful instrument to reduce leakage at the esophagoenteric anastomosis and, hence operative mortality after total and proximal gastrectomy.     

Laparoscopic sigmoidectomy in a case of sigmoid colon cancer with situs inversus totalis

Situs inversus totalis (SIT) is a rare anatomic anomaly in which organs in the chest and abdomen exist in a mirror image reversal of their normal positions. SIT can complicate surgical procedures, and few reports have described laparoscopic surgery for colorectal cancer in patients with SIT. Here, we report a case of successful laparoscopic surgery in a patient with SIT and sigmoid colon cancer. Laparoscopic sigmoidectomy involved colonic mobilization with high ligation of the inferior mesenteric vessels and complete mesocolic excision. The operating surgeon stood on the patient's left side, opposite the normal location for sigmoidectomy. By placing a 12‐mm trocar in the left iliac fossa and using an automatic endoscopic linear stapler, the operating surgeon was able to perform left‐handed colon resection without having to change position or move the laparoscopic monitor mid‐procedure. An automatic endoscopic linear stapler is useful for laparoscopic left‐side colon surgery in a patient with SIT.     

Laparoscopic gastrectomies for cancer: The ACOI-IHTSC national guidelines

Abstract Guidelines for laparoscopy and cancer of stomach have been outlined by several scientific societies: The main recommendation being that laparoscopy should be used only by surgeons already highly skilled in gastric surgery. The laparoscopic approach to gastric cancer surgery has become more and more frequent in most Italian centers. On behalf of the Guideline Committee of the Italian Society of Hospital Surgeons and the Italian Hi-Tech Surgical Club, a panel of experts analyzed the highest evidence of all scientific papers focusing on laparoscopic gastrectomies for cancer and published from 2003 to 2011, and drew these national guidelines. Laparoscopic gastrectomy may be considered as a safe procedure with better short-term and comparable long-term results. compared to open gastrectomy (Grade A). There is a general agreement that a laparoscopic approach to the treatment of gastric cancer should be chosen only by surgeons already highly skilled in gastric surgery and other advanced laparoscopic interventions. Furthermore, the first procedures should be carried out during a tutoring program. Diagnostic laparoscopy is strongly recommended as the first step of laparoscopic as well as laparotomic gastrectomies (Grade B). Additional randomized controlled trials (RCT) that compare and investigate the long-term oncological outcomes of laparoscopic assisted gastrectomy are required.     

直线切割吻合器在腹腔镜辅助远端胃癌根治术Roux-en-Y式吻合术中的应用

目的 探讨直线切割吻合器在腹腔镜辅助远端胃癌根治术（LDG） Roux-en-Y式吻合术中的应用效果。方法 选取2019年3月-2021年3月该院行LDG Roux-en-Y式吻合术的患者126例,按照随机数表法分为观察组（n=63）和对照组（n=63）,观察组采用直线切割吻合器实施Roux-en-Y式吻合术,对照组采用圆形吻合器实施Roux-en-Y式吻合术。统计并分析两组患者手术时间、术中出血量、清扫淋巴结数量、阳性淋巴结数量、术后恢复排气时间、首次进流食时间、拔除引流管时间和术后并发症发生率,术后3个月采用健康调查量表36 (SF-36)比较两组患者的生活质量。结果 两组患者手术时间、术中出血量、清扫淋巴结数量和阳性淋巴结数量比较,差异均无统计学意义（P> 0.05）;与对照组比较,观察组术后恢复排气时间、首次进流食时间和拔除引流管时间均较短（P <0.05）;两组患者住院总费用比较,差异无统计学意义（P> 0.05）,观察组术后住院时间明显短于对照组（P <0.05）;与对照组比较,观察组并发症发生率更低（P <0.05）;术后3个月随访,观察组S...     

Laparoscopic total gastrectomy for advanced gastric cancer in a patient with situs inversus totalis

Situs inversus totalis (SIT) is a rare congenital anomaly. Generally, laparoscopic surgery is difficult to perform in patients with SIT because of both the potential challenges associated with unexpected vascular anomalies and the lack of standardized strategy for handling such cases. This is the first report of laparoscopic total gastrectomy with lymph node dissection for advanced gastric cancer in a patient with SIT. A 79‐year‐old man with SIT was diagnosed with advanced gastric cancer. We performed laparoscopic total gastrectomy with modified D2 lymph node dissection (D2 without splenectomy) and esophagojejunal anastomosis using an overlap method involving retrocolic Roux‐en‐Y reconstruction. The total operating time was 232 min, and blood loss was 110 mL. There were no postoperative complications. In summary, laparoscopic total gastrectomy for gastric cancer can be performed safely, even in a patient with SIT.     

Current trends of laparoscopic gastrectomy for gastric cancer in Japan

Laparoscopic gastrectomy with lymph node dissection, such as laparoscopy‐assisted distal gastrectomy (LADG), is widely accepted for the treatment of early gastric cancer with a risk of lymph node metastasis. In Japan, a nationwide survey conducted by the Japan Society of Endoscopic Surgery has shown that the number of laparoscopic gastrectomies is gradually increasing. So far, the following advantages of laparoscopic surgery for the treatment of gastric cancer have been well documented: favorable clinical course after operation, pulmonary function and immune response. A retrospective multicenter study in Japan has shown that the short‐term outcomes of laparoscopic gastrectomy are beneficial and that the long‐term outcomes are the same as those for open surgery. Recently, the Gastric Cancer Surgical Study Group of the Japan Clinical Oncology Group conducted a multi‐institutional, phase II trial (JCOG0703) to evaluate the safety of LADG for clinical stage I gastric cancer. In the future, laparoscopic surgeons will need to design and implement education and training systems for standard laparoscopic procedures, evaluate clinical outcomes through multicenter randomized controlled trials and clarify the oncological aspects of laparoscopic surgery in basic studies.     

Video‐assisted thoracic surgery and jejunal reconstruction in a case of situs inversus totalis with esophageal cancer

A 78‐year‐old man with situs inversus totalis who had a previous history of distal gastrectomy for gastric cancer was referred to our hospital for treatment of esophageal cancer. He was diagnosed as cT2N0M0 and underwent video‐assisted thoracic surgery and open completion gastrectomy with jejunal reconstruction via the ante‐thoracic route. The postoperative period was uneventful except for transient palsy of the right recurrent laryngeal nerve. Based on a preoperative assessment of anatomical abnormality and an intraoperative adaptation to the mirror image of the standard procedure, video‐assisted esophagectomy was considered safe and feasible. It can be recommended for patients with esophageal cancer complicated by situs inversus totalis. This is the first case report of a patient with situs inversus totalis who underwent video‐assisted esophagectomy with jejunal reconstruction. Relevant literature is also discussed and reviewed.     

En-bloc stapling of the splenic hilum in laparoscopic splenectomy.

Vascular staplers or clips for sectioning of the splenic artery and vein are the procedure of choice in laparoscopic surgery. There are some concerns about the possible complications such as pancreatic injury, arteriovenous fistula (AVF) formation and portal or splenic vein thrombosis related to stapler usage. Hence this study was aimed to evaluate the safety and advisability of en-bloc mass stapling of the splenic hilum. A retrospective chart review was performed of 17 consecutive children undergoing laparoscopic splenectomy between June 2003 and June 2005 by a single surgeon. A routine four-trocar technique was used in all patients. Vascular isolation was achieved with an Endo-GIA (powered vascular linear stapler) without individual dissection of the splenic artery and vein. Doppler ultrasonographic evaluation was performed in order to search for a possible portal or splenic vein thrombosis and arteriovenous fistula formation in all patients one year after the operation. En-bloc stapling of the hilum was successfully performed in all children. No immediate or short-term complications related to en bloc stapling were observed. There were no arteriovenous fistula formations and splenic or portal vein thrombosis related to the previous operation with a mean follow-up of 21 months (12-36 months). En-bloc stapling can thus be safely performed in pediatric laparoscopic splenectomy with no related short-term vascular complications.     

Successful treatment of large adenoma extending close to the papilla in the duodenum by laparoscopy‐assisted pancreas‐sparing duodenectomy

A 54‐year‐old man had a 65‐mm infrapapillary, circular, and laterally spreading tubular adenoma in the distal second and proximal third parts of the duodenum. The papilla was 15 mm from the proximal margin of the tumor. Because the patient requested organ‐preserving laparoscopic surgery, we conducted laparoscopy‐assisted pancreas‐sparing duodenectomy (LAPSD). LAPSD consists of five major procedures: (i) laparoscopic wide Kocher maneuver and transection of the proximal jejunum; (ii) laparoscopic separation of the duodenum from the pancreas; (iii) creation of a small upper median laparotomy; (iv) extracorporeal completion of the segmental duodenectomy; and (v) extracorporeal intestinal reconstruction. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. Histopathological examination revealed that the circumferential margin of the specimen was negative for tumor cells. LAPSD provided a clear margin without damaging the papilla and eliminated the possibility of peritoneal or port‐site seeding of tumor cells because part of the procedure was performed extracorporeally. LAPSD is a useful alternative to pancreatoduodenectomy in patients with a large adenoma extending close to the papilla in the duodenum.     

D2 gastrectomy -- a safe operation in experienced hands

In the contemporary practice, surgery is the only potentially curative treatment available for gastric cancer. However, there is no consensus on the extent of surgical resection. Advantages of D2 gastrectomy in terms of morbidity, mortality, local recurrence and survival are confirmed in Japanese as well as some European trials. In our hospital, all patients with operable gastric cancer are treated with D2 gastrectomy along with splenectomy and distal pancreatectomy followed by jejunal pouch reconstruction. The study was undertaken to evaluate our practice in terms of postoperative morbidity and mortality. All the patients who had total gastrectomy for gastric carcinoma from January 1995 to December 2000 were included in the study. During this 6-year period, 33 patients underwent potentially curative D2 gastrectomy. Postoperative morbidity and mortality were 18 and 9%, respectively. There were no anastomotic leaks. Three (9%) patients developed dysphasia, of which two (6%) had anastomotic stricture requiring dilatation. We feel D2 gastrectomy with splenectomy and distal pancreatectomy when performed electively is a safe procedure in experienced hands. Oesophago-jejunal anastomosis can be safely performed using circular stapler.