A robotic system (da Vinci® Surgical System, Intuitive Surgical Inc., Sunnyvale, CA, USA) has technical advantages over conventional laparoscopic surgery because it increases the precision and accuracy of anatomical dissection. The present study aimed to compare the short-term outcomes between robot-assisted intersphincteric resection (ISR) and laparoscopic ISR for distal rectal cancer.
Methods
Patients who underwent robot- or laparoscopy-assisted ISR for rectal cancer between March 2008 and July 2011 were included in this retrospective comparative study. Perioperative and postoperative data, including complications and early functional outcomes, were analyzed between the two groups. Functional outcomes were evaluated using the Wexner scoring system, the International Prostate Symptom Score, and the 5-item version of the International Index of Erectile Function.
Results
A total of 40 patients underwent robot-assisted and 40 underwent laparoscopic ISR. The mean operative time was significantly longer in the robotic group than in the laparoscopic group (235.5 vs. 185.4 min; p < 0.001). Transabdominal ISR, in which intersphincteric dissection is completed in the pelvic cavity, was performed more with robotic assistance than with laparoscopic surgery (8 vs. 2 cases; p = 0.043). No difference was observed between groups regarding postoperative morbidity and pathological outcomes. The robot-assisted group showed a trend toward less postoperative blood loss and early recovery of functional outcomes.
Conclusion
Robot-assisted surgery was safe and effective for ISR of distal rectal cancer and showed surgical outcomes similar to those of the latest laparoscopic ISR. The favorable results of the robot-assisted ISR included reduced adaptation time, alleviated difficulty of perineal phase, and early recovery of functional outcomes in this analysis of short-term clinical outcomes. 相似文献
Most previous studies of intersphincteric resection (ISR) adopted a two-stage procedure involving abdominal and transanal approaches. We performed completely abdominal ISR via open and a robot-assisted (RA) approaches as treatments for lower rectal cancer (LRC). The RA approach might enable deep dissection and facilitate ISR in patients with restrictive pelvic anatomy.
Methods
A consecutive cohort of 222 LRC patients who underwent completely abdominal ISR (RA ISR, n = 108; open ISR, n = 114) was enrolled prospectively, and their short-term outcomes were evaluated.
Results
In a multivariate analysis, ISR was performed more frequently in the RA than in the open group (82.6 vs. 67.9 %, p = 0.008). The number of harvested lymph nodes was >12 in both groups. A positive distal resection margin was not observed in either group, and a positive circumferential resection margin was found in one patient in the RA group. Overall morbidity did not differ between the groups. Moderate to severe sexual dysfunction occurred 2.7-fold more frequently in the open group (p = 0.023) among male patients ≤65 years. Mean Wexner’s fecal incontinence scores at postoperative months 6 and 12 were greater in the open group than in the RA group (p < 0.05).
Conclusions
Completely abdominal ISR may be feasible in the treatment of LRC, based on a short-term study. Furthermore, RA ISR had equivalent oncological outcomes and slightly improved functional recovery relative to open ISR. 相似文献
The Aim of this study is to evaluate the feasibility and analyze the functional outcome of laparoscopic intersphincteric resection (LISR) in ultra-low rectal cancer. The preservation of anal function following curative operations for low rectal cancer is becoming increasingly important. Laparoscopic intersphincteric resection of the rectum is the utmost sphincter saving operation for rectal cancer. The rectum is laparoscopically resected along with the internal anal sphincter, providing an adequate distal margin for even the ultra-low tumours of the rectum.
Methods
Between 2008 and 2012, nine patients, 2 with a T3 tumour that received preoperative chemoradiotherapy and 7 patients with a non-fixed T2 rectal adenocarcinoma, underwent LISR by a single surgeon. Preoperative tumour staging included endorectal ultrasonography (ERUS) and pelvic MRI. Patients with multiple distant metastases, tumour invasion into adjacent organs and invasion into the external anal sphincter and/or levator ani, were excluded from LISR. Covering ileostomy in seven patients was reversed with a satisfactory functional outcome in each case.
Results
All patients underwent LISR with curative intent. There was no postoperative mortality. Complications included anal stenosis, prolapse of the neorectum and pelvic hematoma. The overall quality of life and functional outcome were deemed satisfactory.
Conclusion
In selected patients, intersphincteric rectal resection may provide an acceptable functional outcome for ultra-low rectal cancer patients, without a permanent stoma. 相似文献
To assess oncologic outcome of patients treated by conservative radical surgery for tumors below 5 cm from the anal verge.
Summary background data
Standard surgical treatment of low rectal cancer below 5 cm from the anal verge is abdominoperineal resection.
Methods
From 1990 to 2003, patients with a nonfixed rectal carcinoma at 4.5 cm or less from the anal verge and without external sphincter infiltration underwent conservative surgery. Surgery included total mesorectal excision with intersphincteric resection, that is, removal of the internal sphincter, to achieve adequate distal margin. Patients with T3 disease or internal sphincter infiltration received preoperative radiotherapy.
Results
Ninety-two patients with a tumor at 3 cm (range 1.5?C4.5) from the anal verge underwent conservative surgery. There was no mortality and morbidity was 27%. The rate of complete microscopic resection (R0) was 89%, with 98% negative distal margin and 89% negative circumferential margin. In 58 patients with a follow-up of more than 24 months, the rate of local recurrence was 2%, and the 5-year overall survival and disease-free survival were 81% and 70%, respectively.
Conclusion
The technique of intersphincteric resection allows us to achieve conservative surgery in patients with a tumor close to or in the anal canal without compromising local control and survival. The distance of tumor from the anal verge is no longer a limit for sphincter-saving resection. 相似文献
This retrospective study investigates the safety of neoadjuvant chemotherapy with oxaliplatin capecitabine (CapeOx), followed by laparoscopic surgery, for lower rectal cancer, and its efficacy in preserving the sphincter.
Methods
Ten patients with diagnosed lower rectal cancer received three or four cycles of neoadjuvant CapeOx chemotherapy, prior to undergoing low anterior resection or intersphincteric resection, with total mesorectal excision. The primary outcomes were R0 resection and the rate of sphincter preservation.
Results
Nine patients completed CapeOx as scheduled and a partial response was achieved in four; thus, the overall response rate was 40% (n = 4/10). After surgical intervention, 80% of tumors displayed downstaging. Postoperative anastomosis leakage developed in one patient. The distance from the anal verge to the tumor increased by 60% (median 1.5 cm) after CapeOx treatment. The anal sphincter was preserved in all patients and all pathological distal and radial margins were negative (R0 resections). A pathological complete response was achieved in one patient.
Conclusions
Neoadjuvant CapeOx chemotherapy is a promising approach, because it extended the distance from the anus to the tumor. Subsequent laparoscopic intervention for advanced lower rectal cancer could allow for safe preservation of the sphincter.
Laparoscopic sleeve gastrectomy (LSG) is becoming one of the most common bariatric surgeries performed worldwide. Leak or stenosis following LSG can lead to major morbidity. We aim to evaluate whether the routine use of intraoperative endoscopy (IOE) can reduce these complications.
Methods
All cases of LSG between 2009 and 2015 were reviewed. In all cases, we place the 32 Fr endoscope once we are done with the greater curvature dissection. We perform an IOE at the end of surgery. If IOE shows stenosis, the over-sewing sutures are removed and the IOE is repeated.
Results
During the study period, 310 LSG were performed (97.4 % were primary LSG cases). The study population included 213 (68.7 %) females. The average age for our cohort was 34.9 years (range 25–63 years), the average BMI was BMI 45 kg/M2 (range 35–65 kg/M2), and the average weight was 120 kg (89–180 kg). The average length of stay was 2.2 days [1, 2, 3, 4, 5, 6, 7]. Our clinical leak rate was 0.3 % (1/310). Our leak rate in primary LSG was 0 % (0/302), and in revisional LSG was 12.5 % (1/8). All IOE leak tests were negative and the only patient with leak had negative radiographic studies as well. In contrast, IOE showed stenosis in 10 LSG cases (3.2 %), which resolved after removing over-sewing sutures. Our clinical stenosis after LSG was 0 %.
Conclusion
Routine use of IOE in LSG has led to a change in the operative strategy and could be one of the reasons behind the acceptable leak and stenosis in this series of laparoscopic sleeve gastrectomy.
Robotic intersphincteric resection (ISR) has been introduced for sphincter-preservation in the treatment of low rectal cancer. However, many patients experience anorectal symptoms and defecatory dysfunction after ISR. This study aims to evaluate the anorectal complications that develop after ISR.
Methods
The medical records of 108 patients who underwent robotic ISR at Taipei Medical University Hospital, Taipei, Taiwan between December 2011 and June 2016 were retrospectively reviewed. Photographic records of perineal conditions were documented at the following time intervals after surgery: 1 day, 2 weeks, 1, 2, 3 and 6 months. Clinical outcomes and treatment results were analysed.
Results
Eighty-five patients (78.7%) developed edematous hemorrhoids after surgery. These subsided at a median of 56 days after operation (range 23–89 days). Forty-six patients (42.6%) were found to have anal stenosis requiring anal dilatation. Sixteen patients (14.8%) had neorectal mucosal prolapse, which was noted to occur at an average of 98 days after surgery (range 41–162 days). Multivariate analysis showed that the occurrence of edematous hemorrhoids was associated with operating time (P?=?0.043), and male gender was a significant risk factor for anal stenosis (P?=?0.007).
Conclusions
This is the first study reporting on the clinical outcomes of anorectal status after robotic ISR. Further studies are needed to assess the long-term effects of these anorectal complications.
As an anus-preserving surgery for very low rectal cancer, intersphincteric resection (ISR), has advanced markedly over the last 20 years. We investigated long-term oncologic, functional, and quality of life (QOL) outcomes after ISR with or without partial external sphincter resection (PESR).
Methods
A series of 199 patients underwent curative ISR with or without PESR between 2000 and 2008, with 49 receiving preoperative chemoradiotherapy (CRT group) and 150 undergoing surgery first (surgery group). Overall survival (OS), disease-free survival (DFS), and local relapse-free survival (LFS) rates were calculated using Kaplan–Meier methods. Functional outcomes were assessed using the Wexner incontinence score. QOL was investigated using the Short-Form 36 questionnaire (SF-36) and modified fecal incontinence quality of life (mFIQL) scale.
Results
After a median follow-up of 78 months (range 12–164 months), estimated 7-year OS, DFS, and LFS rates were 78, 67, and 80 %, respectively. LFS was better in the CRT group than in the surgery group (p = 0.045). Patients with PESR or positive circumferential resection margins showed significantly worse survival. The median Wexner incontinence score at >5 years was 8 in the surgery group and 10 in the CRT group (p = 0.01). QOL was improved in all physical and mental subscales of the SF-36 at >5 years. Although the mFIQL showed a relatively good score in all groups at >5 years, a significant difference existed between the CRT and surgery groups (p = 0.008).
Conclusions
With long-term follow-up, oncologic, functional, and QOL results after ISR appear acceptable, although CRT is associated with disturbance. 相似文献
The goal of this study was to evaluate the short-term outcomes of robotic-assisted lateral lymph node dissection for patients with advanced lower rectal cancer.
Methods
Between 2012 and 2013, 50 consecutive patients underwent robotic-assisted lateral lymph node dissection for rectal cancer in Shizuoka Cancer Center Hospital. Perioperative outcomes including operative time, operative blood loss, length of stay, postoperative complications, and histopathological data were collected prospectively.
Results
Median patient age was 62 years (range 36–74 years). Operative procedures included low anterior resections (n = 27), intersphincteric resections (n = 16), and abdominoperineal resections (n = 7). Bilateral lymph node dissection was performed in 44 patients. The median operative time was 476 min (range 320–683 min), and the median time required for lateral lymph node dissection was 165 min (range 85–257 min). The median blood loss was 27 mL (range 5–690 mL). There were no cases of open surgery or laparoscopic conversion. The median duration of postoperative hospital stay was 8 days (range 6–13 days). Clavien–Dindo classification Grade III–IV complications occurred in only one patient (2.0 %). There were no cases of anastomotic leak. There was no perioperative mortality. The median number of harvested lateral lymph nodes was 19 (range 5–47).
Conclusions
Robotic-assisted lateral lymph node dissection is a safe, feasible, and useful approach for patients with advanced lower rectal cancer.
To compare the time-course change in the postoperative anorectal function between laparoscopic intersphincteric resection (ISR) and low anterior resection (LAR).
Methods
This is a single-institution observational study. We evaluated the time-course change in the anorectal function using functional questionnaires before and at 6, 12, and 24 months after laparoscopic ISR or LAR.
Results
Sixty-two patients answered the functional questionnaires (28 in the ISR group and 34 in the LAR group). In the ISR group, the Wexner scores at 6, 12, and 24 months postoperatively were significantly higher than preoperatively. Importantly, the Wexner score at 24 months postoperatively was significantly lower than that at 6 months postoperatively. The low GIFO scores at 6 and 12 months postoperatively tended to be recovered to some extent at 24 months postoperatively. In the LAR group, Wexner score at 6 months postoperatively was significantly higher than that preoperatively. Notably, the Wexner score at 12 months postoperatively was recovered to almost the same as that preoperatively. The GIFO scores at 12 months postoperatively were mostly recovered to the same levels as those preoperatively.
Conclusions
Laparoscopic ISR exhibits different time-course changes in the anorectal function from laparoscopic LAR.
Details of postoperative damage to anal sphincter tonus following sphincter-preserving operation for rectal cancer remain unclear.
Methods
Postoperative anal tonus was measured using 3-dimensional (3D) vector manometry in 56 patients. Anal length with pressure from any direction was defined as total length (TL). Length with circular pressure (LCP), which is only measurable using 3D manometry, was also evaluated.
Results
In operations associated with low anastomosis, both TL and LCP at rest were significantly shortened when compared with control (high interior resection [HAR]). In particular, degraded LCP at rest was obvious. Anal lengths in squeezing state were preserved except in cases with intersphincteric resection (ISR). Postoperative incontinence score inversely correlated with functional anal length at rest.
Conclusions
Although the sphincter muscles are mechanically preserved, function of the internal sphincter and subsequent defecatory function can be degraded in cases with operative procedures including surgical maneuvers at the pelvic floor. 相似文献
Pelvic organ prolapse (POP) is a common condition for which approximately 200,000 US women annually undergo surgical repair [Am J Obstet Gynecol 188:108–115, 2003]. After surgical correction, persistent or new lower urinary tract symptoms (LUTS) can be present. We provide guidance on the current tools to predict, counsel, and subsequently handle postoperative LUTS. The current literature is reviewed regarding LUTS diagnosis and management in the setting of prolapse surgery with an emphasis on newer developments in this area.
Recent Findings
1.
More severe stages of prolapse are positively correlated with obstructive symptoms [Am J Obstet Gynecol 185:1332–1337, 2001], but not with other LUTS [Adv Urol 2013:5673753, 2013, Eur J Obstet Gynecol Reprod Biol 177:141–145, 2014, Am J Obstet Gynecol 199:683, 2008, Int Urogynecol J 21:1143–1149, 2010].
2.
One-week ambulatory pessary trial is an effective way to approximate postoperative results—one study correctly predicted persistent urgency and frequency in addition to occult stress urinary incontinence in 20% of study population [Obstet Gynecol Int 2012:392027, 2012].
3.
No preoperative overactive bladder (OAB) symptom was the best predictor for the absence of de novo OAB symptoms postoperatively [Int Urogynecol J 21:1143–1149, 2010].
4.
Urge incontinence patients respond favorably to sacral neuromodulation [Neurourol Urodyn 26: 29–35, 2007], botulinum toxin, and anticholinergic therapy [Res Rep Urol 8:113–122, 2016 , N Engl J Med, 367:1803–1813, 2012].
5.
Primary bladder outlet obstruction (BOO) can be treated effectively with alpha antagonists or anticholinergics, timed voiding, and pelvic physiotherapy as first-line therapy.
Summary
Counseling regarding postoperative LUTS is key when planning POP surgery. A thorough understanding of patient history is crucial to successful repair. Patients with significant preoperative symptoms, history of neurologic disease, pelvic floor dysfunction, bladder neck obstruction, or higher stages of anterior wall prolapse may be higher risk for postoperative LUTS. UDS with or without reduction and an ambulatory pessary trial can help prognosticate. Patients will likely maintain a positive therapeutic relationship postoperatively for LUTS if counseled preoperatively.
Postoperative internal hernia (IH) is a potentially life-threatening acute protrusion of viscus through an iatrogenic mesenteric defect. In our retrospective study of 1943 consecutive gastric cancer (GC) patients who had undergone surgery, the incidence of IH after laparoscopic total gastrectomy (LTG) was 4.9%.1 This high incidence seems to be caused by decreased adhesion formation after LTG. There is no consensus regarding orifice management during robotic total gastrectomy (RTG). We therefore developed a new procedure for IH prevention during RTG.
Methods
We performed RTG with antecolic Roux-en-Y reconstruction using the da Vinci S system (Intuitive, Sunnyvale, CA). We chose an intracorporeal side-to-side esophagojejunostomy (overlap method).2 First, mesenteric defect of jejunojejunostomy was closed under direct vision following retrieval of the stomach. Second, the esophagus hiatus and Petersen’s defect were closed under laparoscopic vision using robotic suture.3 Finally, the duodenal stump and the Roux limb were fixed to prevent torsion of the Roux limb.
Results
We performed this procedure on five patients between May and October 2017. The median duration of surgery was 395 min (range, 319–442 min), median bleeding was 60 ml (range, 35–140 ml). There were no anastomosis-related complications higher than Clavien-Dindo grade II in any patients.4 Although the follow-up period is less than 1 year, no IH after RTG has been observed in any patients.
Conclusion
Regarding short-term surgical outcomes, this procedure is recommended for GC patients who undergo RTG. However, more long-term follow-up for patients who have undergone RTG with closure of all mesenteric defects is required.
Nipple inversion is a relatively common problem in adolescent and adult women; however, most present surgical treatments are prone to injure the lactiferous ducts and impair the breast feeding function. A nipple retractor was developed by us in 2003 to correct nipple inversion to avoid lactiferous duct injury. The details and a 10-year evaluation of this technique were introduced in this paper.
Methods
The nipple retractor was made from the hollow end of single-use syringe, then eight holes were punctured for sutures crossing the base, and the height of retractor depended on the sizes of nipple-areola complex and breast volume. Two sutures were made to cross beneath the base of the nipple to elevate the nipple, and the hollow retractor was placed on the areola with the nipple and four ends of the sutures in the center, sutures then passed the prefabricated holes on the retractor base and were fixed with knots and suitable tension. The retractor was worn for 3–6 months and then could be removed.
Results
A total of 257 nipples in 136 patients with nipple inversion (unilateral: 15 patients; bilateral: 121 patients) received this operation from Jan 2003 to Dec 2012, among which 233 nipples were successfully corrected (90.7 %), and 24 nipples reoccurred in 2 years. The effective rates of grade I and grade II inversions were significantly higher than that of grade III (P < 0.01). Thirty-two patients with 56 treated nipples underwent labor and breastfeeding, and all the nipples were functional. The complications included fistula after suture removal (19 nipples, 7.4 %), breaking of suture (8 nipples, 3.1 %), erosion of nipple (28 nipples, 10.9 %), and chronic pain (10 nipples, 3.4 %), and all these complications were properly managed.
Conclusion
The nipple retractor technique is a feasible, effective, and safe method for correction of grade I and grade II nipple inversions, and could also be indicated for primary correction of grade III inversion. Its most significant advantage is that lactiferous duct injury can be avoided and the breast feeding function preserved.
Level of Evidence V
Nipple inversion is a common malformation in adolescent and adult women, which can be present unilaterally or bilaterally. It was generally initiated from the adolescent period and could be caused by primary hypogenesis of smooth muscle and supporting tissue of the nipple-areola complex or hypoplasia of lactiferous ducts [1] . Some other secondary factors such as chronic infection, tumor, and previous surgery could contribute to the fibrosis, and some of them were believed to be congenital and hereditary [2, 3]. Since the openings of lactiferous ducts are immersed, inversion might cause reoccurring infection and breast feeding difficulty, and the appearance of the breast would be affected as well, which would impact patients’ psychological health.
Nipple inversion can be clinically divided into three categories according to Han et al.’s grading rules. In grade I, the nipple is easily pulled out manually and maintains its projection quite well. In grade II, the nipples can be pulled out but cannot maintain projection and tend to go back again. In grade III, the nipple can hardly be pulled out manually. [4] The images of three grades of nipple inversion are present in Fig. 1.
Fig. 1 Three categories of nipple inversion grade I inverted nipple(a), grade II inverted nipple(b), grade III inverted nipple(c)
Surgical interventions are the most effective treatments at present; however, injury to lactiferous ducts is inevitable in most surgical techniques [1, 5, 6, 7, 8, 9, 10]. Some conservative nonoperative techniques have been developed in the last several years, such as a self-retraction and suction device, but only mild cases of grade I are indicated. Several suspension and retraction devices have been reported in recent years [10, 11], and the effect was acceptable, but long-term results were not reported.To simplify the operation procedures and diminish the possibility of lactiferous duct injury, we developed a nipple retractor, which was made from a single-use syringe, to correct nipple inversion from 2003. The details of procedures and techniques are introduced in this paper, as well as a 10-year retrospective analysis.
Laparoscopic sphincter saving rectal resection for low rectal cancer is hampered by narrow pelvis and limitations of current stapling devices [1]. The APPEAR (Anterior Perineal PlanE for Ultra-low Anterior Resection of the Rectum) was proposed by Williams et al. [2, 3] as an alternative to the abdominal-perineal resection to perform very low rectal resection and anastomosis through a perineal wound. We adapted the original technique to the laparoscopic approach, avoiding any other abdominal incision.
Methods
Between December 2011 and April 2012, five patients (2 females; median age 72 years (range 60–78)) with rectal cancer not involving the sphincters underwent laparoscopic total mesorectal excision (TME) with APPEAR. Mean distance of the tumor from anal verge was 3.2 ± 1.1 cm (range 2–5).
Results
All of the procedures were completed laparoscopically. All of the anastomoses were stapled, and a protective stoma was always constructed. The surgical specimens were retrieved from the perineal wound, and the stoma performed through one of the port sites, without any further abdominal incision. Mean operative time was 333 ± 47 min (range 295–405), postoperative stay 12 ± 5 days (range 6–17). Perineal wound infection was observed in three patients, two of whom also had anastomotic fistula, and was treated conservatively with prolonged suction drainage. Histological examination showed three pT3N+, one T2N0, and one complete response after neoadjuvant radiochemotherapy, with a mean distal clear margin of 1.27 ± 0.5 cm (range 0.5–1.7). After a median follow-up of 9 months (range 8–12), one stoma reversal has been performed and the patient is fully continent.
Conclusions
Our experience shows the feasibility of the APPEAR technique with laparoscopic TME, without any other abdominal incision. This technique offers advantage over the limitations of current laparoscopic stapling devices and their scanty maneuverability in the pelvis, allowing resection and anastomosis under direct vision, with adequate distal clearance, while sparing the anal sphincters. 相似文献
Laparoscopic surgery has been reported to be one of the approaches for total mesorectal excision (TME) in rectal cancer surgery. Intersphincteric resection (ISR) has been reported as a promising method for sphincter-preserving operation in selected patients with very low rectal cancer.
Methods
From July 2005 to December 2008, 35 patients with very low rectal cancer underwent laparoscopic TME with ISR. The results were compared retrospectively with those of previous open TME with ISR.
Results
Conversion to open surgery was necessary in one (3%) patient. The median operation time was 293 min and median estimated blood loss was 40 ml. The pelvic plexus was completely preserved in 32 patients. There was no mortality. Postoperative complications occurred in three (9%) patients. The median length of postoperative hospital stay was 17 days. Macroscopic complete mesorectal excision was achieved in all cases. Complete resection (R0) was achieved in 34 patients. Clinical lymph node stage, operation time, and blood loss were significantly different between the laparoscopic group and open group, but the differences of other factors were not statistically significant.
Conclusions
Laparoscopic TME with ISR is technically feasible and a safe alternative to laparotomy with favorable short-term postoperative outcomes. 相似文献
Laparoscopic surgery for rectal cancer has been considered more demanding than laparoscopic colectomy due to its technical difficulties.
Objective
The aim of this study was to show safety and feasibility of laparoscopic low anterior resection for lower rectal cancer reconstructed by double-stapling technique (DST).
Methods
The present study reviewed 159 patients with rectal cancer undergoing laparoscopic anterior resection reconstructed by DST. They were subdivided into two groups: 98 patients with upper rectal cancer located between 75 and 150 mm from the anal verge (group A) and 61 with lower rectal cancer located within 75 mm from the anal verge (group B). Short-term results and pathological findings were compared between the two groups.
Results
There was no conversion in both groups. Operating time and intraoperative blood loss were similar in the two groups. No mortality occurred in either group. Overall morbidity rate was 10.2% in group A and 11.5% in group B (p = 0.798). Anastomotic leak rate was similar in the two groups (2.0% in group A versus 3.3% in group B; p = 0.638). Pathological examination of resected specimen showed no involvement of distal resection margin or circumferential resection margin in both groups.
Conclusions
The present study shows that laparoscopic surgery is safe and feasible for lower rectal cancer in a very select group of patients. 相似文献
The posterior retroperitoneoscopic adrenalec tomy has several advantages compared with the transperitoneal approach such as a shorter and more direct route to the target organ, no breach of the intraperitoneal space, and no required retraction of the adjacent organs. It also is a safe procedure with a short learning curve.1–5 This report presents a challenging case of an extra-adrenal paraganglioma located in the aorto-caval space and managed using the retroperitoneal approach.
Methods
A 39-year-old man was placed in the prone jackknife position, and three incisions were made in the right posterior abdominal wall for placement of the laparoscopic ports. The retroperitoneal space was entered with diathermy and blunt finger dissection, and retropneumoperitoneum was achieved with carbon dioxide insufflation pressure up to 18 mmHg. After identification of the right kidney and vessels, the tumor was meticulously dissected and excised with an energy device. The specimen was removed using a laparoscopic specimen retrieval bag, and the port sites were closed in layers.
Results
The operative time was 130 min, and the total blood loss was 30 ml. The tumor was diagnosed as a moderately differentiated extra-adrenal paraganglioma. The Von Hippel-Lindau gene mutation was detected using next-generation sequencing.
Conclusions
The posterior retroperitoneoscopic approach is a safe, feasible, and effective method for excising an extra-adrenal paraganglioma even in the aorto-caval space. The authors suggest that this procedure is a useful surgical option for treatment of an aorto-caval paraganglioma for selected patients and by experienced surgeons.
Our objective was to evaluate the quality of surgery regarding application of the robotic approach to perform D3 lymph node dissection over the inferior mesenteric artery (IMA) with preservation of the left colic artery (LCA) and autonomic nerves for the treatment of distal rectal cancer, which has not been reported before, although it has been successfully performed by some surgeons laparoscopically.
Methods
Patients with distal rectal cancer posing risk factors for anastomotic leakage were recruited and underwent the present robotic procedure, which was standardized and presented in the attached video file. Patients’ surgical outcomes were prospectively evaluated.
Results
A total of 26 patients with distal rectal cancer were operated on via the present robotic approach. The number of cleared lymph nodes was 26.1 ± 7.2 (range 10–44). The operation time was 307.3 ± 74.1 min (including docking time). The blood loss was 190.5 ± 225.8 ml. Anastomotic leakage occurred in one (1/16, 6 %) patient without preoperative chemoradiation therapy, and wound infection of port sites was detected in two (2/26, 7.6 %) patients. The patients had quick convalescence, as evaluated by the recovery of flatus passage (48.0 ± 12.0 h), hospitalization (14.6 ± 4.8 days), and degree of postoperative pain (2.5 ± 0.5, visual analog scale). The median duration for indwelling urine Foley catheter was 6.0 days (range 3.0–28). The voiding function after removal of the urine Foley catheter was good (International Prostate Score Symptom [IPSS] 0–7) in 22 (84.6 %) patients, fair (IPSS 8–14) in three (11.5 %), and poor (IPSS 15–35) in one (3.8 %). The median time of return to partial activity, full activity, and work was 2.0, 4.0, and 6.0 weeks, respectively.
Conclusions
By using the three-armed Da Vinci® robotic system in our clinical setting, quality surgery of the D3 lymph node dissection around the IMA with preservation of the LCA and autonomic nerves, in which the adequacy of lymph node harvest and the security of blood supply over distal colon were juggled, can be achieved for patients with distal rectal cancer posing risk factors of anastomotic failure. 相似文献
Colorectal carcinoids are described as low-grade malignancy in the WHO classification. However, the survival is equally poor between carcinoids and adenocarcinomas if the tumors have lymph node metastasis or distant metastasis.
Patients and methods
We reviewed 17 patients with rectal carcinoid, who underwent surgical resection with lymph node dissection at our institution between March 2005 and November 2007. Our criteria for surgical resection were: tumor size of 10 mm or larger and positive resection margin or the presence of lymphovascular invasion in lesions to which endoscopic or surgical local treatment was carried out.
Results
Lymph node metastases were present in 12 patients. Three of them were with tumors less than 10 mm in size, of whom two patients had lymphovascular invasion. In eight out of the 12 with lymph node metastases, preoperative computed tomography (CT) identified lymph nodes of 5 mm or larger in size.
Conclusions
The present study demonstrated that rectal carcinoids with lymph node metastasis are common. Previously reported risk factors of lymph node metastasis in rectal carcinoid such as tumor size >?=?10 mm and lymphovascular invasion are useful in predicting lymph node metastasis. In addition, lymph nodes 5 mm or larger in size identified on preoperative CT suggest the presence of metastasis. 相似文献
