Casandra Anderson

Short-Term Outcomes After Robotic-Assisted Total Mesorectal Excision for Rectal Cancer

BackgroundLaparoscopic total mesorectal excision for rectal cancer remains a difficult procedure with high conversion rates. We have sought to improve on some of the pitfalls of laparoscopy by using the DaVinci robotic system. Here we report our two-year experience with robotic-assisted laparoscopic surgery for primary rectal cancer.MethodsA prospectively maintained database of all rectal cancer cases starting in November 2004 was created. A series of 39 consecutive unselected patients with primary rectal cancer was analyzed. Clinical and pathologic outcomes were reviewed retrospectively.Results22 patients had low anterior, 11 intersphincteric and six abdominoperineal resections. Postoperative mortality and morbidity were % and 12.8%, respectively. The median operative time was 285 minutes (range 180–540 mins). The conversion rate was 2.6%. A total mesorectal excision with negative circumferential and distal margins was accomplished in all patients, and a median of 13 (range 7–28) lymph nodes was removed. The anastomotic leak rate was 12.1%. The median hospital stay was 4 days. There have been no local recurrences at a median follow-up of 13 months.ConclusionsRobotic-assisted surgery for rectal cancer can be carried out safely and according to oncological principles. This approach shows promising short-term outcomes and may facilitate the adoption of minimally invasive rectal surgery.

Oncologic outcomes of laparoscopic surgery for rectal cancer: A systematic review and meta-analysis of the literature

AIM To review and compare the oncologic outcomes in patients with rectal cancer undergoing laparoscopic vs. open rectal surgery. METHODS An electronic literature search was performed for trials reporting oncologic outcomes for laparoscopic rectal resections. Variables of interest were survival, recurrence rates, margin status and nodal retrieval. Trials were excluded if variables were not specifically analysed for rectal resections. A meta-analysis was performed to assess the difference in oncologic outcomes between the two treatment approaches. RESULTS Data on a total of 1403 laparoscopic (LG) and 1755 open (OG) rectal resections were gathered from 24 publications. Overall survival at 3 years (LG=76%, OG=69%) was not statistically different between the two treatment groups. The mean local recurrence rates were 7% for laparoscopic and 8% for open procedures (NS). There was no difference in radial margin positivity, 5% of patients undergoing laparoscopic surgery compared to 8% for open surgery. Laparoscopic procedures harvested a mean of 10 nodes as compared to 12 for open procedures, p=0.001. CONCLUSIONS Data gathered in this meta-analysis indicate that there are no oncologic differences between laparoscopic and open resections for treatment of primary rectal cancer.

Pilot series of robot-assisted laparoscopic subtotal gastrectomy with extended lymphadenectomy for gastric cancer.

BackgroundRobotic surgery is evolving as a therapeutic tool for thoracic and urologic applications; however, its use in gastric cancer surgery has not been extensively reported. The objective of this pilot series was to assess the feasibility of using robotic surgery in performing an extended lymphadenectomy for gastric cancer.MethodsBetween June 2005 and July 2006, seven patients (3 female, 4 male) underwent combined laparoscopic subtotal gastrectomy with omentectomy and robot-assisted extended lymphadenectomy using the da Vinci® Surgical System for early distal gastric tumors. The mean age of the patients was 64 years. Tumor staging ranged from 0 to II. Six patients had adenocarcinoma and one patient had a high-grade dysplastic adenoma.ResultsAll procedures were completed successfully without conversion. The median operating time was 420 min. There was one intraoperative complication requiring a colon resection for a devascularized segment. The median number of nodes harvested was 24 (range = 17–30). Resection margins were negative in all specimens. Patients were hospitalized a median of 4 days (range = 3–9). Thirty-day mortality was 0%. Patients resumed a solid diet a median of 4 days postoperatively. Median followup was 9 (range = 0–10) months. There have been no tumor recurrences to date.ConclusionExtended lymphadenectomy for gastric cancer using robotic surgery is safe and allows for an adequate lymph node retrieval. Our preliminary results suggest that this novel technique offers short hospital stays and low morbidity for patients undergoing surgical resection of distal gastric malignancies. Future studies will be necessary to better define the role of robotic surgery in gastric cancer treatment.

Molecular markers for gastric adenocarcinoma: an update.

Gastric cancer is the second most common cancer worldwide. Treatment of localized gastric cancer relies primarily on surgical intervention, although growing evidence suggests that the addition of chemoradiation may improve disease-free intervals and overall survival. In this regard, the current high rates of recurrence and subsequent poor survival have prompted an ever-increasing use of multimodal strategies, even for early-stage disease. However, these therapies are often limited by debilitating toxicities and varying degrees of response efficacy. As a result, pharmacogenomics, the study of specific genetic and molecular signatures that may be predictive of treatment outcomes, has gained considerable interest. For example, studies have demonstrated that the expression of enzymes involved in the metabolism or conjugation of commonly used chemotherapy agents, such as fluoropyrimidines and cisplatin, can serve as surrogate markers predictive of chemotherapy response. Polymorphisms in the genes encoding these enzymes have also been identified and may further account for altered expression patterns, resulting in varied clinical responses. Future work is necessary to further refine the list of molecular genetic markers and to identify novel markers for prognostic and predictive purposes. Technologies such as microarray analysis may be useful in identifying new molecular genetic markers, and further work may determine whether these markers can be employed to help stratify patients into different multimodal treatment regimens.

Impact of a full-time preceptor on the institutional outcome of laparoscopic colectomy

BackgroundLaparoscopic assisted colectomy (LAC) is a difficult operation with long learning curves and conversion rates inversely proportional to the surgeon’s experience. Methods to help train surgeons outside of residency or fellowship programs have been poorly analyzed. This study was undertaken to assess the impact of an experienced laparoscopic surgeon preceptor on the outcome of LAC in a single institutionMethodsIn September 2004, a fellowship-trained laparoscopic surgeon joined our department of surgery. This surgeon served as a LAC preceptor for six inexperienced staff surgeons and four surgical oncology fellows. Clinical and pathologic data from all attempted LAC for the 22 months preceding the arrival of the trained laparoscopic surgeon were compared with those for the 18 months following the recruitment.ResultsBefore the addition of the expert surgeon, 28 LAC were performed in our institution, compared with 63 during the preceptor program. These represented 59% and 95% of eligible operations for each time period, respectively (P = 0.005). Overall conversion rates before and after the preceptor’s arrival decreased from 44% to 14%, respectively (P < 0.05). The chances of conversion were strongly affected by the presence or absence of the preceptor in the operating room (7% vs. 30%, respectively, P = 0.003). Overall complication rates, hospital stay, blood loss, operative time and number of lymph nodes retrieved were not affected by the presence of the preceptor. Operations completed laparoscopically resulted in significantly lower blood loss and length of stay compared with converted ones.ConclusionsA shared departmental preceptor can positively affect the institutional outcome of laparoscopic colectomy. This model may help improve training and patient care in inexperienced centers.

Extracorporeal vs Intracorporeal Anastomosis for Laparoscopic Right Hemicolectomy: Is There a Difference?

The LEVEL-trial; Correction of inguinal hernia; Endoscopic VErsus Lichtenstein: a prospective randomised multi-centre clinical trial, was performed to evaluate the potential advantages of the Total Extraperitoneal Procedure (T.E.P.) versus the Lichtenstein-procedure. 660 patients with primary or recurrent (unior bilateral) hernias were randomised within a period of 44 months in 6 centres in the Netherlands for elective inguinal hernia repair. Follow-up was 17 months. Primary results were postoperative pain, complications, recurrence, quality of life, period until return to work and return to activities of daily life. Patients had more pain after Lichtenstein-procedure until 6 weeks postoperatively. (p = 0,01). After 1 year, there was still more pain at the incision-site. (p = 0,02) More peroperative complications were seen with TEP. (p = 0,00) This was mainly because of peroperative bleeding. Impairments of sensibility were seen with Lichtenstein-procedure up until 1 year postoperatively. (p = 0,00) Other complications were not significant. There was no difference in the number of re-operations. TEP: 11(3,3%), Lichtenstein 8(2,5%). (p = 0,5) and recurrence. TEP 10 (3,0%), Lichtenstein 7 (2,2%). (p = 0,5). 400 patients were included into a supplementary quality of life and cost efficacy analysis. Evaluation of quality of life (Euroqol) showed no significant difference between both groups. (p = 0,2) Patients had more hours of absence of work until 6 weeks postoperatively after Lichtenstein-procedure. Lichtenstein: 87 hours, TEP: 63 hours. (p = 0.00) ADL-evaluation showed an advantage for TEP. (p = 0,00). Conclusion. TEP is associated with less postoperative pain, less impairments of sensibility, faster recovery of daily activities (ADL) and quicker return to work in comparison to the Lichtenstein-procedure. The number of peroperative complications with TEP is higher. This did not result into more recurrences or re-operations. TEP is to be recommended as an efficient method for inguinal hernia repair. In this trial the Lichtenstein-procedure was not performed under local anaesthesia. Therefore it is disputable whether TEP is to be recommended in old patients and patients with a high ASA-classification. O002 Intestinal, Colorectal and Anal Disorders

Robotic Gastrectomy with Lymphadenectomy for Gastric Cancer

Minimally invasive surgical approachs to early stage gastric cancer have been employed as a means to improve postoperative outcomes in patients undergoing gastrectomy for gastric cancer. However, conventional laparoscopic techniques have not gained wide acceptance due to the inherent difficulty in performing a laparoscopic gastric lymph node dissection (D2). Although laparoscopic D2 lymphadenctomy has been described and found to be feasible by experienced laparoscopic surgeons (Uyama et al. 1999, Tanimura et al. 2006 Pugliese et al. 2006), it is technically challenging and can be associated with significant bleeding during dissection around the hepatic, celiac, and splenic arteries. With increasing evidence supporting that D2 dissections can be performed with low morbidity (Wu et al. 2006, Roukos et al. 1998 Hartgrink et al 2004), we employed robotic technology to help facilitate a minmally invasive approach to gastric lymph node dissection. This chapter will review our operative method for performing a robotic-assisted gastrectomy with lymph node dissection. In this description, advantages and disadvantages of robotic technology will be reviewed. Our short-term post-operative and oncologic outcomes will be discussed and compared with other laparoscopic and robotic series.

Robotic and Laparoscopic Assisted Subtotal Gastrectomy with Radical D2-Lymphadenectomy

Object: In colorectal cancer with liver metastasis, the only way that perfact cure is complete liver resection. Simultaneous liver and colon resection is relatedwith extent of colon surgery, volume of liver resection, patients condition, and bleeding. Laparoscopic simultaneous colon and liver resection demands advanced technical skills, optimal location of port, patient selection, and cooperation of operation team. In laparoscopic liver resection, thehandport provides palpationof liver, liver retraction, and compression of bleeding site. We demonstrate laparoscopic extended right hemicolectomy with left lateral segmentectomy of liver. Method: 28 years old male patient who suffers from transverse colon cancer with liver metastasis is admitted our institution. First of all, the operation is started with extended right hemicolectomy. Ileocolic and midcolic vessels is ligated and divided respectively. Medial to lateral dissection is proceeded. After complete dissection of right and transverse colon, handport is established in upper abdomen. Through handport colon is delivered and cut by linear cutter. By using the endosono metastatic cancer is localized. The falciform and coronary ligament is dissected by monopolar scissor and harmonic scalpel. Liver parachyme dissecrtion is commenced by ligasure. Through the handport liver is palpated and retracted by left hand. Portal veins and small ducts are coagulated by ligasure. Left hepatic vein and duct is ligated and divided by endocutter. The specimen is retrieved and ileocolic side to side anastomosis is conducted by way of handport. Result: The operation time is 345 minutes, amount of bleeding is 120 cc. There is no conversion to conventional open method. Without any complications, patient discharged postoperative 9th days. Conclusion: We did laparosopic simultaneous liver and colon resection safely and effectively. In the liver parenchyme dissection, the ligasure is used effectively without any bile leakage and bleeding. V002 Intestinal, Colorectal and Anal Disorders