Search

Background: Several serious complications are associated with the lithotomy position, including well-leg compartment syndrome and peroneal nerve paralysis. The aims of this study were to identify risk factors for the intraoperative elevation of lower leg pressure and to evaluate the effectiveness of monitoring external pressure during surgery for preventing these complications. Methods: The study included 106 patients with a diagnosis of sigmoid colon or rectal cancer who underwent elective laparoscopic surgery between June 2019 and December 2020. We divided the posterior side of the lower leg into four parts (upper outside, upper inside, lower outside, lower inside) and recorded the peak pressure applied to each area at hourly intervals during surgery (called "regular points") and when the operating position was changed (e.g., by head-tilt or leg elevation; called "points after change in position"). When the pressure was observed to be higher than 50 mmHg, we adjusted the position of the leg and re-recorded the data. Data on postoperative leg-associated complications were also collected. Results: The pressure was measured at a total of 1125 points (regular, n = 620; after change of position, n = 505). The external pressure on the upper outer side of the right leg (median, 36 mmHg) was higher than that on any other area of the lower leg. The pressure increase to more than 50 mmHg was observed not only during the change of position (27.5%) but also during regular points (22.4%). Bodyweight, strong leg elevation, and low head position were identified as factors associated with increased external pressure. There have been no compression-related complications in 534 cases at our institution since the introduction of intraoperative pressure monitoring. Conclusions: Several risk factors associated with increased external pressure on the lower leg were identified. Intraoperative pressure monitoring might help reduction of pressure-related complications, needing further and larger prospective data collections. [ABSTRACT FROM AUTHOR]

Background: Peroral endoscopic myotomy (POEM) is standard treatment for achalasia. Gastroesophageal reflux disease (GERD) after POEM has been an important challenge since the early days of POEM implementation. The esophagogastric junction anti-reflux barrier consists of internal lower esophageal sphincter (LES) (i.e., intrinsic muscles of distal esophagus with sling fibers) and external LES (crural diaphragm and phrenoesophageal ligament anchors the distal esophagus to the crural diaphragm). During conventional POEM, the entire internal LES is unintentionally dissected. Preservation of the sling fiber may reduce post-POEM GERD, but its safety and effectiveness have been unclear. In this study, we investigated the safety and effectiveness of sling fiber preservation POEM (SP-POEM) for reducing severe post-procedural erosive esophagitis. Methods: We analyzed data of 236 patients who underwent POEM; of these, 203 patients underwent posterior myotomy without (Group 1) or with attempted (Group 2) sling fiber preservation. Group 1 (N = 79; sling fiber excision, N = 68) and Group 2 (N = 90; sling fiber preservation, N = 81) were compared. Post-procedural erosive esophagitis (Los Angeles classification) were assessed and the area (direction and length) of mucosal break was also investigated. The gastroesophageal flap valve was evaluated by Hill's classification. Results: Severe erosive esophagitis exceeding grade C (Los Angeles classification) occurred in 44.1% of patients (30/68) in Group 1 and in 18.5% of patients (15/81) in Group 2. In mapping of erosive esophagitis, mucosal breaks appeared widely in all directions in Group 1; they tended to be limited in Group 2 (especially in the 2 o'clock direction). Assessment using the Hill's classification showed that the gastroesophageal flap valve was preserved after SP-POEM. Conclusion: SP-POEM is safe and effective, with a success rate of 90%. The rate of severe erosive esophagitis can be decreased by preserving sling fibers. [ABSTRACT FROM AUTHOR]

Background: Complete mesocolic excision with central vascular ligation is a standard advanced technique for achieving favorable long-term oncological outcomes in colon cancer surgery. Clinical evidence abounds demonstrating the safety of high ligation of the inferior mesenteric artery (IMA) for sigmoid colon cancer but is scarce for descending colon cancer. A major concern is the blood supply to the remnant distal sigmoid colon, especially for cases with a long sigmoid colon. We sought to clarify the safety and feasibility of high ligation of the IMA in surgery for descending colon cancer using indocyanine green (ICG) fluorescence imaging. Methods: In this prospective single-center pilot study, we examined 20 patients with descending colon cancer who underwent laparoscopic colectomy between April 2018 and September 2019. Following full mobilization and division of the proximal colonic mesentery, we temporarily clamped the root of the IMA and performed ICG fluorescence imaging of the blood flow to the sigmoid colon. The postoperative anastomosis-related complications (primary endpoint) and length of viable remnant colon, and the number of lymph nodes retrieved (secondary endpoints) were evaluated and compared with historical controls who underwent conventional IMA-preserving surgery (n = 20). Results: Blood flow reached 40 (17–66) cm retrograde from the peritoneal reflection, even after IMA clamping. Accordingly, IMA high ligation was performed in all cases. No anastomotic anastomosis-related complications occurred in each group. Retrieved total lymph nodes were higher in number in the ICG-guided group than in the conventional group (p = 0.035). Specifically, more principal nodes were retrieved in the ICG-guided group, compared with the conventional group (p = 0.023). However, the distal margin was not as long compared with the conventional group. Conclusion: We demonstrated the safety and feasibility of high ligation of the IMA for descending colon cancer without sacrificing additional distal colon using fluorescence evaluation of blood flow in the remnant colon. [ABSTRACT FROM AUTHOR]

Background: In abdominoperineal resection (APR) in male patients with rectal cancer, high margin involvement and urethral injury have been reported to result from difficulty in dissecting the anterior anorectum. Recently, the efficacy of an endoscopic down-to-up rectal dissection was reported. Here, we present a safe and simple technique for anterior dissection using a simultaneous laparoscopic and transperineal endoscopic approach.Methods: We perform transperineal APR (TpAPR) using both the laparoscopic and transperineal approach (a 2-team approach). Anterior dissection commences just behind the superficial transverse perineal muscle. Next, the striated muscle complex surrounding the rectum (levator ani and puborectalis muscle) is divided. At this point, it is difficult to identify the dissection plane between the membranous urethra and anterior rectum; thus, dissection along the lateral aspect of neurovascular bundle from the lateral to anterior side with the assistance of the laparoscopic team is helpful in identifying the posterior surface of the prostate. Once the prostate is identified, it is relatively easy to divide the rectourethralis muscles. The key steps of our procedure are shown in the video.Results: Between April 2016 and July 2019, we performed 14 TpAPR procedures in male patients with rectal cancer without distant metastasis. Extended surgery was performed in 8 patients, including pelvic sidewall dissection and combined resection of adjacent organs. Median operative time was 453 min and median blood loss was 46 g. There was 1 (7.1%) circumferential-positive case, but no cases of urethral injury or rectal perforation.Conclusions: The 2-team TpAPR procedure is beneficial for appropriate dissection of the anterior side during APR surgery. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic abdominoperineal resection (APR) for low rectal cancer (LRC) is performed worldwide. However, APR involves technical difficulties and often causes intractable perineal complications. Therefore, a novel and secure technique during APR is required to overcome these critical issues. Although the usefulness of the endoscopic trans-anal approach has been documented, no series of the endoscopic trans-perineal approach during laparoscopic APR for LRC has been reported.Methods: Trans-perineal minimally invasive surgery (TpMIS) has been used during laparoscopic APR in our institution since April 2014. TpMIS is defined as an endoscopic trans-perineal approach using a single-port device and laparoscopic instruments. In this study, we retrospectively evaluated 50 consecutive patients with LRC who underwent laparoscopic APR at our institution from February 2011 to June 2017 and compared the outcomes of the patients who underwent TpMIS [trans-perineal APR (TpAPR) group, n = 21] versus the conventional trans-perineal approach (conventional group, n = 29). We investigated our experiences with TpMIS in detail and evaluated the safety and utility of TpMIS for patients with LRC. Moreover, major features and difficulties of TpMIS were examined from a surgical viewpoint.Results: Intraoperative blood loss (median (range) 55 (10-600) vs. 120 (20-1650) ml) and severe perineal wound infection (Clavien-Dindo grade 3, 0 vs. 5 cases) were significantly lower in the TpAPR than conventional group. TpMIS led to a shortened hospital stay (median (range), 14 (10-74) vs. 23 (10-84) days), and neither mortality nor conversion to open surgery occurred in the TpAPR group.Conclusions: Magnified visualization via endoscopy provided more accurate dissection and less blood loss during surgery. Minimal skin incisions enabled a reduction in postoperative perineal complications, and consequently shortened the hospital stay. TpMIS during laparoscopic APR is safe and beneficial for patients with LRC. [ABSTRACT FROM AUTHOR]

Background: Fluorescence technology with indocyanine green (ICG) provides a real-time assessment of intestinal perfusion. However, a subjective evaluation of fluorescence intensity based on the surgeon's visual judgement is a major limitation. This study evaluated the quantitative assessment of ICG fluorescence imaging in determining the transection line of the proximal colon during laparoscopic colorectal surgery.Methods: This is a retrospective analysis of a prospectively maintained database of 112 patients who underwent laparoscopic surgery for left-sided colorectal cancers. After distal transection of the bowel, the specimen was extracted extracorporeally and then the proximal colon was divided within the well-perfused area based on the ICG fluorescence imaging. We evaluated whether quantitative assessment of intestinal perfusion by measuring ICG intensity could predict postoperative outcomes: F max, T max, T 1/2, and Slope were calculated.Results: Anastomotic leakage (AL) occurred in 5 cases (4.5%). Based on the fluorescence imaging, the surgical team opted for further proximal change of the transection line up to an "adequate" fluorescent portion in 18 cases (16.1%). Among the 18 patients, AL occurred in 4 patients (4/18: 22.2%), whereas it occurred in only 1 case (1/94: 1.0%) in the good perfusion patients who did not need proximal change of the transection line. The F max of the AL group was less than 52.0 in all 5 cases (5/5), whereas that of the non-AL group was in only 8 cases (8/107): with an F max cutoff value of 52.0, the sensitivity and specificity for the prediction of AL were 100 and 92.5%, respectively. Regarding postoperative bowel movement recovery, the T max of the early flatus group or early defecation group was significantly lower than that of the late flatus group or late defecation group, respectively.Conclusions: ICG fluorescence imaging is useful for assessing anastomotic perfusion in colorectal surgery, which can result in more precise operative decisions tailored for an individual patient. [ABSTRACT FROM AUTHOR]

Background: Decreased blood perfusion is an important risk factor for postoperative anastomotic leakage (AL). Fluorescence imaging with indocyanine green (ICG) provides a real-time assessment of intestinal perfusion. This study evaluated the utility of ICG fluorescence imaging in determining the transection line of the proximal colon during laparoscopic colorectal surgery with double stapling technique (DST) anastomosis.Methods: This was a prospective single-institution study of 68 patients with left-sided colorectal cancers who underwent laparoscopic colorectal surgery between August 2013 and December 2014. After distal transection of the bowel, the specimen was extracted extracorporeally and then the mesentery was divided along the planned transection line determined by the surgeons' judgement under normal q. After ICG was injected intravenously, intestinal perfusion of the proximal colon was assessed in the fluorescent imaging mode. Intestinal perfusion was examined in relation to the patient-, tumor- and surgery-related variables using univariate and multivariate analyses.Results: ICG fluorescence imaging showed that intestinal perfusion was present at 3 mm (median) distal to the initially planned transection line. ICG fluorescence imaging resulted in a proximal change of the transection line by more than 5 mm in 18 patients (26.5 %) and, particularly, by more than 50 mm in 3 patients (4.4 %), compared with the initially planned transection line. Univariate analysis revealed that diabetes mellitus, anticoagulation therapy, preoperative chemotherapy and operative time were significantly associated with poor intestinal perfusion. Multivariate analysis identified anticoagulation therapy (P = 0.021) and preoperative chemotherapy (P = 0.019) as independent risk factors for poor intestinal perfusion. Three patients (4.5 %) with a change of transection line developed AL.Conclusions: ICG fluorescence imaging is useful for determining the transection line in laparoscopic colorectal surgery with DST anastomosis. Anticoagulation therapy and preoperative chemotherapy are important risk factors for poor intestinal perfusion. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic rectal surgery involving rectal transection and anastomosis with stapling devices is technically difficult. The aim of this study was to evaluate the risk factors for anastomotic leakage (AL) after laparoscopic low anterior resection (LAR) with double-stapling technique (DST) anastomosis. Methods: This was a retrospective single-institution study of 154 rectal cancer patients who underwent laparoscopic LAR with DST anastomosis between June 2005 and August 2013. Patient-, tumor-, and surgery-related variables were examined by univariate and multivariate analyses. The outcome of interest was clinical AL. Results: The overall AL rate was 12.3 % (19/154). In univariate analysis, tumor size ( P = 0.001), operative time ( P = 0.049), intraoperative bleeding ( P = 0.037), lateral lymph node dissection ( P = 0.009), multiple firings of the linear stapler ( P = 0.041), and precompression before stapler firings ( P = 0.008) were significantly associated with AL. Multivariate analysis identified tumor size (odds ratio [OR] 4.01; 95 % confidence interval [CI] 1.25-12.89; P = 0.02) and precompression before stapler firings (OR 4.58; CI 1.22-17.20; P = 0.024) as independent risk factors for AL. In particular, precompression before stapler firing tended to reduce the AL occurring in early postoperative period. Conclusions: Using appropriate techniques, laparoscopic LAR with DST anastomosis can be performed safely without increasing the risk of AL. Important risk factors for AL were tumor size and precompression before stapler firings. [ABSTRACT FROM AUTHOR]

Background: One prerequisite for the safe stapling of anastomoses is the formation of perfectly aligned B-shaped staples. Using an animal model, this study investigated whether precompression enhances secure staple formation. Methods: A 45-mm linear stapler with a blue cartridge (staple leg length, 3.5 mm) was used on three portions each of six porcine stomachs (cardia, center, and pylorus). Staple shape and height were examined according to the precompression time (0, 1, or 5 min) before firing. The shape was classified as optimal or suboptimal, and the heights of the staples were measured individually. The completeness of the proximal staple lines also was compared with the distal lines. Results: The optimal staple rate in the 5-min group (52.7%) was significantly higher than in the 1-min group (28.7%; p < 0.001) or the 0-min group (17.1%; p = 0.002). The optimal staple rate in the 5-min group for the cardiac portion (mean wall thickness, 2.7 mm) reached 98.9%. However, this rate was less than 50% in the center (5.3 mm) and pylorus (4.2 mm) portions regardless of the precompression time. Compared with the root side, the top side of the cartridge had a lower optimal rate (45.3 vs. 18.7%; p < 0.001). A high correlation of completeness was observed between the distal and proximal sides of the stump. Conclusions: When a linear stapling device is used, proper staple formation is correlated with intestinal wall thickness, and a sufficient amount of precompression time is effective for gaining the secure staple formation. [ABSTRACT FROM AUTHOR]

Background: Recently, the efficiency of transanal minimally invasive surgery (TAMIS) for rectal cancer has been demonstrated (Velthuis et al. in Surg Endosc 28:3494-3499, 2014; Fernandez-Hevia in Ann Surg 261:221-227, 2015; Atallah et al. in Tech Coloproctol 18:473-480, 2014). We present our procedure of TAMIS for extralevator abdominoperineal excision (ELAPE) (Holm et al. in Br J Surg 94:232-238, 2007).Methods: The patient had a rectal cancer located 4 cm from the anal verge with suspected invasion of the levator ani (cT4bN0M0). A skin incision was made around the tightly closed anus, and a GelPOINT device was placed. The fat tissue of the ischioanal fossa was divided until the levator ani muscle was widely exposed. Anterior dissection was performed just behind the transverse perineal muscle, and the arms of the puborectalis sling were identified at 1 and 11 o'clock. The levator muscle was divided from the posterior to bilateral sides, and dissection was entered into the mesorectal plane. Posterior dissection was performed until the sacral promontory was reached. Bilateral pelvic splanchnic nerves were identified at the 5 and 7 o'clock positions, and special care was taken to preserve them. At the anterior side, the arms of the puborectalis sling and perineal body were divided. Special care should be taken to avoid inadvertent injury to the anterior tissues (urethra or prostate) because the dissection tends to go toward the anterior-lateral side of the prostate in this approach. Once the dissection plane behind the prostate was established, it was easy to dissect the mesorectum circumferentially while preserving the pelvic autonomic nerves. Vascular division, mobilization of left colon and stoma creation were performed laparoscopically.Results: This approach provides better exposure of the surgical field, especially at the anterior side, compared with the conventional perineal approach of ELAPE. Since January 2014, we have performed seven cases using this procedure. There was no conversion to the conventional approach, and no major complication was encountered.Conclusion: TAMIS is a promising approach for the perineal phase of ELAPE. [ABSTRACT FROM AUTHOR]

A correction to the article "Risk Factors for Anastomotic Leakage After Laparoscopic Low Anterior Resection With DST Anastomosis," which appeared in the July 10, 2014 online issue of the periodical, is presented.

Although laparoscopic surgery is one of the treatment options for colorectal cancer, certain technical problems remain unresolved for the radical dissection of regional lymph nodes (LNs), which is essential to improve treatment outcome. We present a safe procedure for laparoscopic right hemicolectomy to dissect the regional LNs along the superior mesenteric vein (SMV). The key characteristic of our procedure is that all right and middle colic vessels are cut along the surgical trunk using only a medial approach. First, the pedicle of ileocolic vessels is identified and the mesocolon is dissected between the pedicle and the periphery of the SMV to expose the second portion of the duodenum. The ileocolic vessels are then cut at their roots. The ascending mesocolon is separated from the retroperitoneal tissues, duodenum, and pancreatic head up to the hepatocolic ligament cranially. The important detail in this procedure is the wide separation between the pancreatic head and the transverse mesocolon. This procedure uncovers the course of the right colic artery, veins, and the gastrocolic trunk. The right colic artery and veins can then be safely cut at their roots. For an extended right hemicolectomy, the middle colic vessels can easily be identified below the lower edge of the pancreas and cut at their roots. We performed curative resections in this manner for 16 consecutive patients with advanced right-sided colon cancer without any serious intraoperative complications. The median number of retrieved lymph nodes was 31 (range = 9-57). The median operative time and intraoperative blood loss were 274 min (range = 147-431 min) and 45 g (range = 0-120 g), respectively. The postoperative course of all patients was uneventful. Four of 16 patients had node-positive disease. With a median follow-up period of 272 days, all patients are alive without recurrence. We consider this a safe method for radical LN dissection during laparoscopic right hemicolectomy. Electronic supplementary material The online version of this article (doi:10.1007/s00464-007-9305-x) contains supplementary material, which is available to authorized users. [ABSTRACT FROM AUTHOR]