Robotic total mesorectal excision for the treatment of rectal cancer

Robotic techniques have been developed to facilitate endoscopic surgery and to overcome its disadvantages. Thus, we performed robotic total mesorectal excison (TME) in a patient with rectal cancer, using the da Vinci^® Surgical System. To our knowledge, this is the first robotic low anterior resection, based on standard TME principles, with pelvic autonomic nerve preservation. In conclusion, this robotic system is an excellent instrument for performing the standard TME procedure in rectal cancer patients.     

Serum cystatin C for estimation of residual renal function in children on peritoneal dialysis

Residual renal function (RRF) is an important parameter in the management of patients on chronic dialysis. The aim of this cross-sectional study was to determine the efficacy of serum cystatin C (CysC) for RRF estimation in 20 children (16 boys, 4 girls; median age 13.4 years) undergoing peritoneal dialysis (PD). For studies of correlation with serum CysC, the average of creatinine clearance rate (C_cr) and urea clearance rate (C_urea), Kt/V_urea, and weekly C_cr were evaluated as parameters reflecting RRF. The serum CysC level was found to be negatively correlated with urine volume (r = −0.717, P < 0.001), average of C_cr and C_urea(r = −0.851, P < 0.001), total and renal weekly C_cr (r = −0.795, P < 0.001; r = −0.845, P < 0.001, respectively), and renal Kt/V_urea (r = −0.793, P < 0.001) and positively correlated with peritoneal weekly C_cr (r = 0.738, P < 0.001) and peritoneal Kt/V_urea (r = 0.785, P < 0.001). There was no significant association with total Kt/V_urea (r = −0.335, P = 0.148). In non-anuric group of patients, serum CysC had no link to peritoneal Kt/V_urea (r = 0.573, P = 0.066), but was negatively correlated with renal Kt/V_urea (r = −0.609, P = 0.047). In the multiple regression analysis, renal Kt/V_urea significantly contributed to log CysC concentration rather than peritoneal Kt/V_urea. The results of this study suggest that serum CysC could be an appropriate marker for RRF, independent of total and peritoneal Kt/V_urea.     

Comparison of metacarpal plating methods

PURPOSE: Most metacarpal fractures are stable and can be treated with nonsurgical stabilization. However, some metacarpal fractures are treated with open reduction and internal fixation because of an open fracture, instability, or multiple fractures. Newer plate designs have emerged that allow a shorter plate and screw construct. We sought to determine the relative strength of 3 different methods of metacarpal plating for unstable fractures. METHODS: We tested our hypothesis in a transverse metacarpal fracture model using fourth-generation, biomechanical testing grade composite sawbones (Sawbones; Pacific Research Laboratories, Vashon, WA). The metacarpals were divided into 3 groups of 15 bones. Group 1 was plated with a standard 6-hole, 2.3-mm plate with 6 nonlocking bicortical screws in standard AO fashion. Group 2 was plated with a 6-hole, double-row, 3-dimensional (3D) plate with 3 nonlocking screws on either side of the fracture aiming for convergence of the screws. Group 3 was plated with a 2.4-mm plate using 6 nonlocking screws and standard AO technique. The metacarpals were then tested to failure in cantilever bending mode. RESULTS: All constructs broke through the bone. No plate failure or screw pullout was seen. Group 1 had a load to failure of 264 N +/- 14. Group 2 had a load to failure of 302 N +/- 17. Group 3 had a load to failure of 274 N +/- 20. The load to failure was highest in group 2 (3D plate). All differences were statistically significant. CONCLUSIONS: All 3 methods produced a strong construct. The load to failure was highest in group 2 (3D plate). Double-row plates with converging screws provide adequate or superior strength of fixation when compared with standard plate constructs.     

Feasibility of Single-Stage Laparoscopic Resection After Placement of a Self-Expandable Metallic Stent for Obstructive Left Colorectal Cancer

BACKGROUND: The present study investigated the feasibility of a single-stage operation consisting of self-expandable metallic stent (SEMS) placement followed by laparoscopic surgery for obstructive left colorectal cancer. METHODS: From July 2002 to March 2007, 17 consecutive patients with primary obstructive left colorectal cancer underwent SEMS placement followed by laparoscopic surgery. Data were collected retrospectively regarding clinicopathological findings, SEMS placement, operative procedures, and perioperative outcomes. Technical success was defined as successful stent deployment across the obstructive lesion, and clinical success as the possibility of performing a single-stage operation without creating a stoma. RESULTS: In the laparoscopic group, the technical success rate was 100% (17/17) and there was no morbidity associated with SEMS placement. The median interval to laparoscopic surgery was 7 (range, 2-11) days, and the procedures included 11 anterior resections, 3 left hemicolectomies, 2 Hartmann's procedures, and 1 subtotal colectomy. All procedures were completed laparoscopically without conversion to open surgery. The median operating time was 178 (range, 93-377) minutes, and the median estimated blood loss was 100 (range, 50-400) ml with no cases requiring intraoperative transfusions. The clinical success rate was 82.4% (14/17), and there was no surgical morbidity other than two patients in whom chyloperitoneum and ileus were controlled by using conservative management. The median postoperative hospital stay was 9 (range, 7-49) days. CONCLUSIONS: A single-stage operation consisting of SEMS placement followed by laparoscopic surgery seems to be a feasible and safe treatment option for obstructive left colorectal cancer.     

Endoscopic Evaluation of the Quality of the Anastomosis After Esophagectomy with Gastric Tube Reconstruction

BACKGROUND: The morbidity and mortality of anastomotic complications after esophagectomy have gradually decreased in recent years. However, swallowing difficulties and reflux continue to burden patients jeopardizing their quality of life. In the present study we performed endoscopic evaluation of the outcomes of esophagogastrostomy by analyzing the presence of anastomotic stenosis and reflux esophagitis. METHODS: A retrospective analysis was carried out on 74 patients who underwent esophagogastrostomy after esophagectomy by one surgeon between January 1995 and December 2004. Fifty-three patients had an endoscopic examination during follow-up (29 +/- 23.6 months, range = 5-111 months). Reflux esophagitis and stenosis at the anastomostic site were analyzed according to the surgical technique used and the location of the esophagogastrostomy. RESULTS: The mean age at the time of repair was 60.3 +/- 8.87 (range = 39-81) years. Cervical anastomosis was performed in 26 patients and intrathoracic anastomosis in 27 patients. No significant statistical difference in the frequency of anastomotic stenosis was observed between the two groups (p = 0.829); reflux esophagitis was noted in three patients in the cervical anastomosis group and in 14 patients in the intrathoracic anastomosis group (p = 0.041). For all patients, 23 received a hand-sewn esophagogastric anastomosis and 30 a circular stapled one. There was no significant statistical difference in anastomotic stenosis (p = 0.689) and reflux esophagitis (p = 0.879) in comparisons between the two groups. CONCLUSION: Cervical anastomosis resulted in a better outcome for esophagogastrostomy by lowering the risk of reflux esophagitis; this outcome might improve the patient's quality of life.     

Factors Influencing Pathologic Results after Total Mesorectal Excision for Rectal Cancer: Analysis of Consecutive 100 Cases

Background The aim of this study was to analyze clinical and anatomical factors affecting the pathologic quality of the resected specimen after total mesorectal excision (TME) for rectal cancer. Methods A total of 100 patients who underwent TME for mid or low rectal cancer were evaluated prospectively. MRI pelvimetry data (transverse diameter, obstetric conjugate, interspinous distance, sacrum length, and sacrum depth) were analyzed as anatomically affecting factors to postoperative specimen quality. Sex, body mass index (BMI), type of surgery, tumor size, and tumor distance from the anal verge were analyzed as clinically affecting factors. The gross judgment of resected specimen, circumferential resection margin and the number of harvested lymph nodes were used to access postoperative specimen quality. Results The univariate and multivariate analysis showed that narrow obstetric conjugate and shorter interspinous distance were related to the inadequate quality of the mesorectum in the specimen (P = 0.022, P = 0.030). Interspinous distance was a predicting factor of a positive circumferential resection margin (P = 0.007). There were no clinical factors affecting the inadequate quality of the mesorectum or positive circumferential resection margin. Moreover, there were no clinico-anatomical factors affecting the number of harvested lymph nodes after TME. Conclusion Narrow obstetric conjugate and shorter interspinous distance were factors leading to poor postoperative specimen quality. Rectal cancer patients with narrow obstetric conjugate or shorter interspinous distance should be considered as high-risk patients with regard to specimen quality, which is in turn related to oncological outcome.     

Successful colonoscopic decompression of colon after development of an early postoperative obstruction at the stapled anastomosis after an anterior colectomy and early chemotherapy: a case report

A case report describing the successful colonoscopic decompression and catheter drainage of an early postoperative large bowel obstruction caused by swelling at the stapled anastomosis after the initiation of chemotherapy. Our case illustrates that colonoscopy can be successful in managing early postoperative bowel obstruction secondary to swelling at the stapled colonic anastomosis.     

Long-term results of the Cox-Maze III procedure for persistent atrial fibrillation associated with rheumatic mitral valve disease: 10-year experience.

OBJECTIVE: We evaluated the long-term results of the Cox-Maze III procedure (CM-III) for persistent atrial fibrillation (AF) associated with rheumatic mitral valve (MV) disease. METHODS: We analyzed 127 patients who underwent the CM-III combined with a rheumatic MV procedure between 1994 and 2004. In-hospital mortalities were excluded from the study. RESULTS: There were 10 late deaths and the mean follow-up duration was 7.1+/-2.8 years (range, 13 months to 11.5 years). Normal sinus rhythm was restored in 88.2% (112/127) after the CM-III. Right atrial contractility was demonstrable in 100% (112/112) and left atrial contractility in 68.8% (77/112) of the patients restored to sinus rhythm. Fifteen patients never regained sinus rhythm after the CM-III (AF treatment failure). Permanent pacemakers were implanted in 4.7% (6/127) of the patients during the follow-up. Late recurrence of AF developed in 34 of 112 patients at 44+/-27 months postoperatively, and sinus rhythm was restored in 29 of 34 patients by administration of an antiarrhythmic medication. Independent risk factors for late AF recurrence were longer duration of AF (>60 months) (odds ratio (OR)=2.758, p=0.025), increased left atrial size (OR=1.113, p=0.004). Freedom from AF recurrence was 93% at 1-year, 82% at 3 years, 71% at 5 years, and 63% at 7 years. Risk factors for AF treatment failure were longer duration of AF (>60 months) (p<0.001) and increased patient age (p=0.030). A higher prevalence of significant late tricuspid regurgitation was observed in patients with AF treatment failure and those with late AF recurrence. CONCLUSIONS: The CM-III for persistent AF associated with rheumatic MV disease demonstrated a progressively decreased cure rate during the follow-up period. Early surgical therapy, aggressive left atrial reduction, and correction of tricuspid regurgitation at the time of surgery may increase the long-term success rate.