Learning curves for laparoscopic sigmoidectomy used to manage curable sigmoid colon cancer: single-institute, three-surgeon experience

Background  Laparoscopic surgery demands mastery of a steep learning curve. Defining a learning curve in laparoscopic surgery is useful for planning training programs or clinical trials. This study aimed to define the learning curves for laparoscopic sigmoidectomy used to manage curable sigmoid colon cancer by evaluating early surgical outcome data from three colorectal surgeons. Methods  This study analyzed data from 138 consecutive patients undergoing laparoscopic sigmoidectomy for curable sigmoid colon cancer performed by three colorectal surgeons between May 2001 and November 2006. The learning curve for each surgeon were generated using the moving average method to assess changes in operation time and cumulative sum (CUSUM) analysis to assess changes in failure rates [(failure = conversion to open surgery, major perioperative complication, or failure to harvest an adequate number of lymph nodes (<12 nodes)]. Results  Learning curves generated with the moving average method indicated that the operation time reached a steady state after 42 cases for surgeon A, 35 cases for surgeon B, and 30 cases for surgeon C. The overall open conversion rate was 2.9%. There was only one laparoscopy-related perioperative major complication (0.7%). An inadequate number of lymph nodes was harvested in 10 cases (7.2%): 6 (10.5%) for surgeon A, 1 (2.4%) for surgeon B, and 3 (7.7%) for surgeon C. Learning curves generated using CUSUM analysis based on a 90% success rate showed that adequate learning occurred after 10 cases for surgeon A, 17 cases for surgeon B, and 5 cases for surgeon C. Conclusion  Pertinent learning curves for laparoscopic sigmoidectomy used to manage curable sigmoid colon cancer can be generated using the moving average method and CUSUM analysis. These results are likely to be useful in designing laparoscopic training programs and clinical trials aimed at investigating outcomes of laparoscopic colorectal cancer surgery. Presented at the Congress of Endoscopic and Laparoscopic Surgeons of Asia 2006, Seoul, Korea, 20 October 2006     

A case of sigmoidectomy for sigmoid colon cancer with severe pulmonary arterial hypertension associated with mixed tissue connected disease: A case report

IntroductionPatients with mixed connective tissue disease (MCTD) have higher rates of pulmonary arterial hypertension (PAH) than the general population. PAH is a risk for perioperative respiratory and heart failure, and marked edema of colonic stoma after sigmoidectomy. We report a case of sigmoidectomy for sigmoid colon cancer in a patient with PAH associated with MCTD for whom perioperative treatment was planned to control pulmonary arterial pressure (PAP), and a surgical strategy to avoid complications attributable to PAH and MCTD was employed.Case presentationA 52-year-old woman with sigmoid cancer and severe PAH associated with MCTD underwent surgery. We controlled PAH by using intravenous epoprostenol. We selected open surgery without laparoscopy and Hartmann's operation. After surgery, severe perioperative complications were not detected, and the patient discharged from hospital 17 days after the operation.DiscussionDuring surgery under general anesthesia, the mortality rate of PAH is high because of heart and respiratory failure. We planned to switch the PAH treatment from an oral agent to intravenous epoprostenol only in the preoperative period, and selected open surgery. We ligated the inferior mesenteric artery (IMA) and inferior mesenteric vein (IMV) below the branch of LCA to avoid marked edema of stoma. Consequently, we could avoid severe intraoperative and postoperative complications.ConclusionsControlling PAP using epoprostenol, open surgery, stoma and the ligation level for the IMA and IMV preventing are important to avoid perioperative complications of sigmoid colon cancer complicated by severe PAH.     

Transumbilical single-incision laparoscopic surgery for sigmoid colon cancer

Background  

Transumbilical single-incision laparoscopic surgery is an emerging concept that could offer excellent cosmetic results [1]. The authors describe an index case of curatively intended resection of early-stage sigmoid colon cancer using this technique [2, 3].     

Bladder replacement with sigmoid colon for bladder cancer

From 1972 to 1989, 21 patients underwent bladder replacement with sigmoid colon after cystectomy for bladder cancer. A portion of sigmoid colon (about 15 to 20 cm) was isolated and anastomosed to the urethral stump. Then the ureters were implanted in the sigmoid colon via submucosal tunnels. There were 20 men and 1 woman, ranging in age from 24 to 71 years (average 51 years). Preoperative investigations showed that all the cases were free of metastasis. Five years survival rate was 60.7% and there was no operative mortality. There was urethral recurrence in one case and in that case postoperative histopathology revealed carcinoma in situ with tumor. All patients were able to void by themselves without any difficulty. Five patients complained mild incontinence at daytime and all patients had mild incontinence during deep sleep at night, but all of them could maintain their normal daily life like before. The major postoperative complications were: leak at the site of anastomosis (between sigmoid colon and urethra) in 6 cases, hydronephrosis in 2 cases, VUR in 2 cases and bladder stone in 1 case. The patients who underwent bladder replacement with sigmoid colon were well satisfied, because there were no external stoma and the patients could void by themselves. From now, we want to improve our operative method in order to avoid postoperative incontinence.     

腹腔镜手术对结肠癌患者腹腔脱落癌细胞及预后的影响

目的探讨腹腔镜手术对结肠癌患者腹腔脱落癌细胞和术后复发转移的影响。方法经病理诊断为结肠癌患者159例,按患者自愿的方法分成腹腔镜手术组（腹腔镜组）和开腹手术组（开腹组）。采用细胞学方法检测肿瘤切除前后腹腔脱落癌细胞,比较两组病例在肿瘤切除前后腹腔脱落肿瘤细胞阳性率、术后复发转移率和3年生存率。结果腹腔镜组与开腹组患者肿瘤切除前腹腔脱落肿瘤细胞阳性率分别为12．2％（9／74）和15．3％（13／85）,两组比较,差异无统计学意义（P=0．718）;肿瘤切除后则分别为20．3％（15／74）和30．6％（26／85）,两组比较,差异也无统计学意义（P=0．138）。术后随访4～45月,术后3年腹腔镜组与开腹组患者局部复发率分别为13．6％（8／59）和8-8％（6／68）（P=0．455）,远处转移率分别为11．9％（7／59）和17．6％（12／68）（P=0．416）,两组比较差异无统计学意义;3年生存率则分别为79．7％和80．0％（P=0．998）,差异亦无统计学意义。结论腹腔镜手术并未增加结肠癌患者术后复发转移的概率,术后3年生存率与开腹手术相当。     

Sexual and urinary dysfunction following surgery for sigmoid colon cancer

We investigated sexual and urinary dysfunction following surgery for sigmoid colon cancer. Thirteen (46.4 per cent) of the 28 male patients with a normal sexual life prior to surgery could no longer ejaculate, but all could maintain erection. With the extension of lymph node dissection, the incidence of a disappearance of ejaculation tended to increase. In particular, in patients undergoing an extended lymph node dissection, the incidence was 53.8 per cent. Urinary dysfunction occurred in 7 (10.3 per cent) of the 68 patients (37 men and 31 women), but was slight to mild. There were no significant differences between the extent of lymph node dissection and urinary dysfunction. In surgery for sigmoid colon cancer, care should be taken to preserve the hypogastric nerves.     

Sexual and urinary dysfunction following surgery for sigmoid colon cancer

We investigated sexual and urinary dysfunction following surgery for sigmoid colon cancer. Thirteen (46.4 per cent) of the 28 male patients with a normal sexual life prior to surgery could no longer ejaculate, but all could maintain erection. With the extension of lymph node dissection, the incidence of a disappearance of ejaculation tended to increase. In particular, in patients undergoing an extended lymph node dissection, the incidence was 53.8 per cent. Urinary dysfunction occurred in 7 (10.3 per cent) of the 68 patients (37 men and 31 women), but was slight to mild. There were no significant differences between the extent of lymph node dissection and urinary dysfunction. In surgery for sigmoid colon cancer, care should be taken to preserve the hypogastric nerves.     

Laparoscopic bowel resection for early colon cancer

Following the successful introduction of laparoscopic cholecystectomy, many reports confirming the feasibility of using laparoscopy for bowel resection and predicting that it would be advantageous in terms of its minimal invasiveness have been published. In the context of cancer treatment, however, the feasibility of lymphadenectomy, the risk of recurrence, and survival have emerged as major concerns. Even though mucosal cancer (Tis) can be treated by endoscopic resection (ER), when this is not possible open surgery (OS) must be performed. In patients with T1 cancer, tumors showing slight submucosal layer invasion (sm 1) can be treated in the same way as Tis (in cancer) cancers. But 5% to 10% of patients with T1 cancer have massive submucosal layer invasion (sm 2-3) with paracolic lymph node metastasis. At least partial bowel resection with paracolic lymphadenectomy is considered necessary for T1 (sm 2-3) cancers in principle. In summary, laparoscopic local excision of Tis cancers that are endoscopically unresectable and laparoscopically assisted partial resection with paracolic lymphadenectomy for T1 cancers have become accepted because local excision and partial resection with paracolic lymphnedectomy are fairly simple to perform laparoscopically. Therefore as a strategy for the treatment of early colorectal cancer (CRC), minimally invasive laparoscopic bowel resection (LBR) has been positioned between endoscopic resection (ER) and open surgery (OS). While the difficulty of performing radical lymphadenectomy is considered one of the greatest obstacles to the introduction of laparoscopic bowel resection (LBR) for the treatment of advanced colorectal cancer (CRC), early colon cancer is a good indication for laparoscopic bowel resection.     

Urogenital dysfunction after laparoscopic surgery for rectal or sigmoid colon cancer

Background/objectiveUrogenital dysfunction is a common complication after surgery for sigmoid colon or rectal cancers and may result from various causes. Herein, we evaluated urogenital dysfunction and the associated factors after laparoscopic surgery at different follow-up times.MethodsWe conducted a prospective study on 91 patients who were diagnosed with sigmoid colon and rectal cancers and underwent laparoscopic surgery during 2014–2016.Voiding and male and female sexual dysfunctions following surgery were evaluated by the International Prostate Symptom Score (IPSS), International Index of Erectile Function-5 (IIEF-5), and Female Sexual Function Index-6 (FSFI-6), respectively. Urogenital function was compared at pre-surgery and 3 and 12 months postoperatively, and factors associated with urogenital dysfunction were identified.ResultsThe overall urinary function after surgery was better when compared to that at pre-surgery; however, there was deterioration in both male and female sexual functions. The mean preoperative IPSS, IIEF-5, and FSFI-6 scores were 9.35, 12.18, and 6.09, respectively. The mean differences among IPSS, IIEF-5, and FSFI-6 at 12 months postoperatively and pre-surgery were ?3.08 (95% confidence interval [CI] ?4.77 to ?1.40), ?2.57 (95% CI -4.33 to ?0.80), and ?2.58 (95% CI -4.73 to 0.42), respectively. Multivariate analysis demonstrated that age ≤60 years (odds ratio 4.22) and postoperative complications (odds ratio 2.77) were correlated with erectile dysfunction.ConclusionVoiding function improved after laparoscopic surgery in both sigmoid colon and rectal cancer patients. However, sexual function in both male and female patients was worse. Age ≤60 years and postoperative complications were strongly associated with male sexual dysfunction.     

胃癌术中脱落癌细胞对手术用物的污染情况研究

目的探讨胃癌术中脱落癌细胞对手术用物的污染情况。方法前瞻性入组2011年4月至2012年2月间在浙江省人民医院胃肠外科行根治性手术的90例胃癌患者。术中在肿瘤标本离体时,收集5类手术用物的脱落癌细胞：A类（手术器械）,B类（术者手套）,C类（洗手护士擦器械及回收残线的纱条及手套）,D类（术中压迫止血及清洁术野的纱条、纱垫）,E类（缝合器）。对这5类手术用物分别进行细胞培养,培养出癌细胞则为阳性用物。结果31例（34．4％）患者手术用物培养出具有完整细胞膜、细胞质和细胞核的癌细胞。其中上述5类手术用物癌细胞检出率分别为12．2％（11／90）、6．7％（6／90）、22．2％（20／90）、15．6％（14／90）和3．3％（3／90）,差异有统计学意义（P=0．001）。Ⅰ、Ⅱ和Ⅲ期患者癌细胞检出率分别为10．0％（1／10）、26．5％（9／34）和45．7％（21／46）,差异有统计学意义（P=0．046）。高、中和低分化患者癌细胞检出率分别为1／8、16．7％（4／24）和44．8％（26／58）,差异有统计学意义（P=0．020）。结论胃癌根治术中,手术用物易为脱落癌细胞所污染,且随着肿瘤进展、细胞分化程度降低以及手术用物本身使用频率增高和接触范围增加,手术用物被污染的机会越大。     

腹腔镜乙状结肠癌根治术15例

目的探讨腹腔镜乙状结肠癌根治术的临床价值。方法回顾性分析2008年5月至2013年5月腹腔镜下乙状结肠癌根治术15例的临床资料。结果全组15例均在腹腔镜下完成手术,其中9例经体外行端端吻合,5例经肛门行直肠-乙状结肠端端吻合,1例行降结肠端造瘘。术后无吻合口瘘、吻合口出血等并发症发生,手术时间（192．8±33．5）min,平均186．8min,术中出血量（68．5±14．6）ml,平均59．6ml,术后住院时间（8．6±2．5）d,平均9．1d。结论腹腔镜乙状结肠癌根治术手术创伤小、术后恢复快,是治疗乙状结肠癌安全、可行的方法,但术者需有丰富的腹腔镜手术和结肠外科手术经验。     

The role of peptidases in cancer of the rectum and sigmoid colon

Increased levels of peptidases are found in some human carcinomas and may be related to invasive potential. We therefore measured the activity of four peptidases in 50 specimens of tumour and normal colonic wall from patients with a rectal or sigmoid carcinoma, and correlated this with the stage, differentiation, fixity of the tumour and presence of venous invasion, determined histologically. Since acute phase reactant proteins (APRP) may inhibit these proteolytic enzymes we have also measured serum levels of two relevant APRPs, alpha 1 acid glycoprotein (AGP) and C-reactive protein (CRP) pre-operatively. Activity of cathepsin B, cathepsin H and collagenase-like peptidase (CLP) was determined fluorimetrically and collagenase photometrically. Significantly elevated activity of cathepsin B, CLP and collagenase was found in tumour compared with normal colonic wall (median values: (nmol (mg protein)-1 min-1) Cat B 0.71 and 0.42 (P less than 0.001), CLP 25.24 and 12.25 (P less than 0.0001) and collagenase 0.49 and 0.31 (P less than 0.001). There was no correlation between the activity of these enzymes expressed as a ratio of tumour/colonic wall, and differentiation or Dukes' stage of the tumour. However, there was significant elevation of activity of cathepsin B in tumours with local spread (n = 13) compared with those with no spread (n = 37) (median values 2.76 and 1.36 respectively (P less than 0.001] and also in tumour with venous invasion (n = 24) compared with tumours without (n = 26) (median values 1.82 and 1.18 respectively (P less than 0.01]. Pre-operative serum levels of CRP were inversely correlated with the activity of CLP and cathepsin H and collagenase in the tumours (rs = 0.332, 0.359 (P less than 0.05) and 0.302 (P = 0.05) respectively). Thus certain peptidases are raised in rectal and sigmoid tumours. Activity of cathepsin B appears related to local tumour invasion. APRP may have a role in inhibiting the activity of these enzymes. These findings may have therapeutic implications.