James C. H. Wong

Endolaparoscopic Approach vs Conventional Open Surgery in the Treatment of Obstructing Left-Sided Colon Cancer: A Randomized Controlled Trial

OBJECTIVE To compare self-expanding metal stents with emergency open surgery in the treatment of obstructing left-sided colon cancer. DESIGN A randomized controlled trial. SETTING An acute care hospital. PATIENTS Adult patients with an obstructing tumor between the splenic flexure and rectosigmoid junction. MAIN OUTCOME MEASURES Successful 1-stage operation, cumulative operative time, blood loss, hospital stay, pain score, and postoperative complications. RESULTS Forty-eight patients were analyzed. Twenty-four underwent endoluminal stenting followed by laparoscopic resection and 24 underwent emergency open surgery. The 2 groups were matched for age, sex, body mass index, and disease staging. Patients in the endolaparoscopic group had significantly less cumulative blood loss and lower pain, incidence of anastomotic leak, and wound infection. Significantly more patients in the endolaparoscopic group had a successful 1-stage operation performed (16 vs 9, P = .04). None of the patients in the endolaparoscopic group had a permanent stoma compared with 6 patients in the emergency open surgery group (P = .03). CONCLUSIONS Self-expanding metal stents serve as a safe and effective bridge to subsequent laparoscopic surgery in patients with obstructing left-sided colon cancer. This endolaparoscopic approach makes a 1-stage operation more feasible, is associated with reduced incidence of stoma creation, and allows patients with malignant large-bowel obstruction to enjoy the full benefit of minimally invasive surgery. Trial Registration clinicaltrials.gov Identifier: NCT00654212.

Laparoscopic resection for rectal cancers: lessons learned from 579 cases.

Objective:The aim of this study is to evaluate the short-term outcomes and long-term survival of laparoscopic rectal cancer resection at a single institution with 579 cases over a 15-year period. Summary Background Data:The use of laparoscopic resection for colon cancer has been shown to be safe with comparable oncological outcomes. However, the role of laparoscopic resection for rectal cancer is still controversial with few studies looking into long-term outcomes. Methods:From May 1992 to April 2007, 579 patients underwent laparoscopic resection for rectosigmoid and rectal cancer. The clinical data of these patients were retrospectively reviewed from a prospectively collected database. Data evaluated includes short- and long-term results, with survival outcomes calculated using the Kaplan-Meier method. Results:Over this 15-year period, 316 patients had laparoscopic anterior resection for rectosigmoid and upper rectal cancer, 152 patients had laparoscopic sphincter-saving total mesorectal excision, 92 patients had laparoscopic abdominoperineal resection, 17 patients had laparoscopic Hartmann procedure for rectal cancer, and 2 patients had proctocolectomy. The median age of these patients was 68 years (range, 35–95). The overall early and late operative morbidity was 18.8% and 9.7%, respectively. Conversion to open surgery was required in 5.4%of patients. Anastomotic leak rate was 3.5%. The median follow-up time was 56 months (range, 8–288). Port-site recurrence occurred in 2 patients. Locoregional recurrence occurred in 7.4% of patients after curative resection. The overall 5- and 10-year survivals for rectal cancer were 70% and 45.5%, respectively. The cancer-specific 5- and 10- year survival was 76% and 56%, respectively. Conclusions:The results of this study with large number of patients over a long follow-up period suggested that laparoscopic resection for rectal cancer is safe with good long-term oncological outcomes.

Hand-assisted laparoscopic versus open right colectomy: a randomized controlled trial.

Objective:Laparoscopic colectomy has been proved to be both technically and oncologically feasible. However, the approach has been criticized for its procedural complexity and long operative time as a result of the loss of tactile feedback and absence of depth perception. The advent of hand-access devices offered a potential solution to these problems. This randomized controlled trial aims to compare hand-assisted laparoscopic colectomy (HALC) with open colectomy (OC) in the management of right-sided colonic cancer. Methods:Adult patients with nonmetastatic carcinoma of cancer or ascending colon were recruited. Patients were excluded if they presented with surgical emergencies, had synchronous tumors on work-up, or when the tumor was larger than 6.5 cm in any dimension or preoperative imaging. Recruited patients were randomized to undergo either HALC or OC by the same surgical team. Outcome measures included operative time, blood loss, postoperative pain score and analgesic requirement, length of hospital stay, postoperative complications, as well as disease recurrence and patient survival. Results:Eighty-one patients (HALC = 41, OC = 40) were successfully recruited. The 2 groups were matched for age, gender distribution, body mass index, and comorbidities. No significant difference was observed between the 2 groups in the distribution of tumors and the final histopathological staging. HALC took significantly longer than OC (110 min vs. 97.5 minutes, P = 0.003) but resulted in significantly less blood loss (35 mL vs. 50 mL, P = 0.005). Patients after HALC experienced significantly less pain, required significantly less parenteral and enteral analgesia, recovered faster, and was associated with a shorter length of stay (7 days vs. 9 days, P = 0.004). With median follow-up of 28 to 30 months, no difference was observed in terms of disease recurrence, and the 5-year survival rates remained similar (83% vs. 74%, P = 0.90). Conclusion:HALC retained the same short-term benefits of the pure laparoscopic approach. The technique is associated with a slightly increased but acceptable operative time. Aside as a useful adjunct in complex laparoscopic procedures, the hand-assisted laparoscopic technique is also a useful, if not more effective, alternative for patients with right-sided colonic cancer.

TOWARDS PAINLESS COLONOSCOPY: A RANDOMIZED CONTROLLED TRIAL ON CARBON DIOXIDE‐INSUFFLATING COLONOSCOPY

Background:  Carbon dioxide (CO2) insufflation during colonoscopy was reported to reduce pain, but data are limited. The objective of this randomized controlled trial was to assess the effect of CO2 insufflation on pain during and after colonoscopy.

Hand-assisted laparoscopic versus total laparoscopic right colectomy: a randomized controlled trial

Aim  Laparoscopic colectomy for colorectal cancer is associated with definite short‐term benefits, and is increasingly practised worldwide. The limitations of a pure laparoscopic approach include a relative lack of tactile feedback and long procedural time. Hand‐assisted laparoscopic surgery was introduced in an attempt to facilitate operation by improving the tactile sensation. To date, there is no consensus as to which approach is better. Herein we conducted a randomized controlled trial comparing hand‐assisted laparoscopic colectomy (HALC) with total laparoscopic colectomy (TLC) in the management of right‐sided colonic cancer.

Endo-Lap OR: an innovative "minimally invasive operating room" design.

BackgroundA newly constructed Endoscopic-Laparoscopic operating room (Endo-Lap OR) started to operate in our department in January 2005. A prospective study was conducted to evaluate its feasibility, efficacy, and safety, as well as the staff’s satisfaction.Patients and methodsFrom January 2005 to September 2005, all patients undergoing operation in this Endo-Lap OR were included in the study. The patient’s diagnosis, types of operating procedures, incidents of operating failure (either due to the hardware or the software of Endo-Lap OR) that led to a delay in the patient’s transfer or that extended the total operating time were recorded. In addition, questionnaires regarding staff satisfaction with the new operating room were distributed to nurses, anesthetists, and surgeons.ResultsA total of 640 cases were included in the study period, 245 cases of open surgery, 282 cases of laparoscopic surgery, 82 cases of endoscopic surgery, 17 cases of video-assisted thoracoscopic surgery, and 14 cases of combined endoscopic-laparoscopic surgery. There were no reported incidents of operating failure related to hardware or software problems. The overall staff satisfaction was excellent.ConclusionsThe integration of endoscopic and laparoscopic surgery into this newly constructed Endo-Lap OR is feasible and safe. The running of the operating room was smooth and it received a high level of acceptance and satisfaction from different staff members.

Bilateral puborectalis interposition repair of rectourethral fistula.

BACKGROUND: Rectourethral fistula is a rare but significant complication that often requires operative intervention. OBJECTIVE: A new perineal approach using the medial aspect of the puborectalis muscles as a double-breasted rotational interposition flap to repair the rectourethral fistula is hereby described. PROCEDURE: With the patient in a modified Lloyd-Davies position, a vertical midline incision from the base of the scrotum to 2 cm anterior to the anal verge is made. The dissection continues along the anterior rectal wall through the Denonvilliers fascia until the rectourethral fistula is reached. The dissection through the fused Denonvilliers fascia continues a further 1 to 2 cm above the fistula. The openings in the rectum and the urethra are then closed vertically (urethra) and horizontally (rectum) with interrupted 3/0 and 4/0 polyglactin sutures. The puborectalis muscles are then mobilized as a 1-cm strip bilaterally and released posteriorly at the level of the anorectum. The 2 strips of the puborectalis muscles are then rotated medially and superiorly along its anterior attachments, forming a double -breasted overlapping flap overlying the fistula openings. The flaps are anchored into the superior and contralateral aspect of the surgical field with the use of 2/0 polyglactin sutures. RESULTS: From November 2011 to December 2012, 4 patients underwent this procedure. No perioperative complications, including those related to the harvesting of the puborectalis muscles, were identified. Subsequent radiological studies confirmed the success of the procedure. After a median follow-up of 8 (6–18) months, 3 patients had their colostomy reversed and remained continent, whereas the last patient had a permanent ileostomy. None of the patients reported any urinary leakage through the perineum. CONCLUSIONS: The double-breasted puborectalis interposition flap is an alternative transperineal procedure in the management of rectourethral fistula. It avoids a laparotomy and is rectum sparing.

Outcomes of endoluminal stenting for distal colorectal cancer: An institutional experience

Aim:  The present article aims to review the results of the use of the self‐expanding metallic stent (SEMS) in our institution for distal colorectal tumours, defined as tumours distal to the splenic flexure.

Simultaneous laparoscopic abdominal and transanal excision for low rectal tumours

Aim:  In performing laparoscopic sphincter‐preserving total mesorectal excision, one of the technical challenges is to obtain an adequate distal mural margin of 2 cm in the case of low rectal tumours. Herein we describe a technique, known as simultaneous laparoscopic abdominal and transanal excision, where an adequate distal margin can be safely achieved at the beginning of the operation.

Minimally invasive operating suite in the 21st century: Endo‐Lap operating room

Although a number of innovative and futuristic operating room (OR) designs have been proposed, the challenge to implement the OR of the future has never been fulfilled. We believe the setting of future OR should be an integration of the entire spectrum of surgical care: from diagnostic to preoperative planning, and from intraoperative navigation to education. Besides overcoming the deficiencies of today’s OR, it should also create a platform that allows easy inclusion of upcoming innovation. The opening of the brand new, innovative operating room in the Pamela Youde Nethersole Eastern Hospital, the Endo‐Lap OR, is considered a benchmark in the territory. As minimally invasive surgery continues to flourish, we believe the concept and vision behind this Endo‐Lap OR will help to shed light on the future development of OR.