Kevin Kwok-Kay Yau

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.

Risk of Deep Vein Thrombosis Following Laparoscopic Rectosigmoid Cancer Resection in Chinese Patients

OBJECTIVE The aim of this study was to evaluate the incidence of postoperative deep vein thrombosis (DVT) in Chinese patients who underwent laparoscopic resection of rectal or sigmoid cancer in the absence of thromboprophylaxis. METHODS Patients with adenocarcinoma of the sigmoid colon or rectum scheduled for laparoscopic resection were recruited. Neither chemoprophylaxis nor mechanical methods against DVT were employed. They were scheduled to have routine duplex ultrasound of both lower limbs perioperatively. RESULTS In a 12-month period, 50 patients were recruited. Postoperative DVT occurred in 19 (38%) patients. None needed anticoagulation. Complete resolution of the thrombus was noted in 10 (53%) patients 12 weeks after operation, and in six patients 36 weeks after operation. Female sex was identified as being associated with a higher incidence of DVT. Age, smoking, preoperative neoadjuvant chemoirradiation, preoperative metastasis, duration of operation, conversion and postoperative complications did not appear to be risk factors for DVT. CONCLUSION The incidence of asymptomatic calf vein DVT is relatively high after laparoscopic resection for rectosigmoid cancers in the Chinese population. However, complete resolution occurred without the use of anticoagulant therapy in the majority of cases. It is thus difficult to advocate the routine use of anticoagulant prophylaxis.

Combined single-port and endoluminal technique for laparoscopic anterior resection.

Objective To determine the technical feasibility and clinical outcomes of laparoscopic anterior resection using combined single-port and endoluminal technique. Methods A single port was placed at the umbilicus. Sigmoid colon was retracted using transabdominal sutures. After adequate mobilization, the colon was stapled distal to the lesion using noncutting endostapler, and the rectum was opened distal to the staple line. The transanal endoscopic operation device was placed transanally and the anvil of a circular stapler was then delivered through the device into the peritoneal cavity. The anvil was placed intraluminally through a colotomy made proximal to the lesion; after this, the colon was transected above the colotomy site. The specimen was next delivered transanally through the transanal endoscopic operation device. Finally, the rectum was closed with endostapler and intracorporeal side-to-end colorectal anastomosis was constructed using the circular stapler. Results This technique was attempted in an 80-year-old woman with a 3 cm sessile polyp in the distal sigmoid. Laparoscopic anterior resection was arranged as the polyp was not amenable to endoscopic removal. The operative time was 150 minutes. There was no intraoperative complication. The patient was discharged on postoperative day 6, with a maximum pain score of 3. Conclusions Laparoscopic anterior resection using this combined single-port and endoluminal technique is feasible for small lesions in the sigmoid colon or upper rectum. The technique avoids multiple trocar incisions and a minilaparotomy for specimen retrieval.

Laparoscopic omentoplasty for metastatic breast cancer: Laparoscopic omentoplasty

Classical teaching for managing metastatic breast cancer is always palliation, to provide patients the best quality of life with minimum side-effects. Extensive surgery is no longer curative for this group of patients. However, uncontrolled chest wall disease sometimes causes severe and debilitating symptoms, including pain, ulceration, malodour and discharge. The psychological aspects of these symptoms are also considerable and keep reminding patients of the disease progression. We believe that palliative surgery can still be justified in a minority of patients who are fit for surgery and are not likely to die within a short period of time. Herein we report a case of metastatic breast cancer, which was successfully treated by wide local excision with wound coverage by laparoscopic omentoplasty.

Laparoscopic management of ingested foreign body with transluminal migration

A 26-year-old man with good past health was admitted after swallowing a toothpick 2 days earlier. He complained of progressive epigastric pain with no fever. The physical examination found no surgical emphysema over his neck and chest wall. The abdomen was soft with mild epigastric tenderness. White cell count was mildly elevated to 10.8 10∧9/L. There was no free gas under the diaphragm on erect chest X-ray, and no dilated bowel shadows on abdominal X-ray. No foreign body was noted on both X-rays. Upper endoscopy revealed a 3-mm clean base ulcer at the anterior wall of the first part of the duodenum, but no foreign body was found. Contrast computed tomography (CT) scan of the abdomen and pelvis showed mild diffuse wall thickening in the fourth part of the duodenum, with a small amount of adjacent fluid and fat stranding. However, no pneumoperitoneum or radio-opaque foreign body was seen. The patient was discharged with a course of antibiotics and proton-pump inhibitor. A follow-up CT scan was performed 6 weeks later and revealed a 5.4-cm linear hyperdensity in the left upper abdomen, which we suspected was the previously-ingested toothpick. The upper part of it appeared to be close to the fourth part of the duodenum and the inferior border of the pancreatic body. There was minimal ascites in the pelvis, without rimenhancing collection or pneumoperitoneum (Fig. 1). The patient was asymptomatic, with no abdominal pain or fever. After discussing the pros and cons of surgery versus conservative management with the patient, he requested to have the toothpick removed by surgery. Laparoscopy was performed approximately 7 weeks after the ingestion of the toothpick. Intraoperative upper endoscopy was done, and showed no foreign body or erosion down to the thirdto-fourth part of the duodenum. Laparoscopy revealed a small amount of turbid fluid in the lesser sac only; the small and large bowels appeared unremarkable. Splenic flexure was taken down, and the tail of the pancreas was reflected medially up to the body part; however, no foreign body was seen. Duodenal-jejunal flexure was mobilized, revealing some scarring and mild oedema along the paraduodenal fossa. It was then divided with a Harmonic scalpel, and the toothpick was eventually discovered. No pus or small bowel content was observed. The toothpick was removed, and the tissue was approximated with an absorbable stitch and reinforced with tissue glue. The operative time was 1 h and 45 min. Blood loss was minimal. Postoperative recovery was uneventful, and the patient was discharged on postoperative day 2 with a 1-week antibiotic treatment.

Vacuum-assisted excision for benign breast lesions

The vacuum-assisted breast biopsy (VABB) system was first developed in 1995. It was initially designed as a diagnostic tool to obtain a sufficient amount of breast specimen to provide a more accurate diagnosis compared with conventional core biopsy. In 2002, the Food and Drug Administration approved the use of the VABB system for the therapeutic purpose of benign lesions, as could provide complete removal of lesions under real-time ultrasonic guidance. Many studies have evaluated the use of the VABB system, and the authors of those studies have concluded that using the VABB system in resecting breast fibroadenoma with a small incision is feasible and safe, and yields a high patient satisfaction rate of up to 97 per cent. It can be performed under local anaesthesia in outpatient settings. The complete removal of breast fibroadenoma using the VABB system was found to have only minimal complications. Lesions up to 2.5–3 cm can be completely removed with minimal or no scarring. The use of an 8-gauge needle is recommended for nodules > 1 cm in size. During the procedure, lesions must be removed as completely as possible to prevent growth, and extra samples should be obtained in different directions to ensure complete removal. Incomplete excision is attributed to the limitation of the use of the VABB system in the excision of benign breast lesions. Fine et al. reported that 97 per cent of women in their study demonstrated complete removal of the imaged mass immediately after biopsy. However, 27 per cent had a residual mass during a follow-up ultrasound 6 months later. They suggested several possibilities for this issue, which included the use of local anaesthesia, which might blur the operative field and contribute to a visual challenge when the mass became smaller during the procedure, bleeding during the procedure and that the mass was not completely removed and became enlarged over the ensuing months. Nevertheless, the rate of successful initial complete removal of a lesion varies widely, from 22 to 100 per cent, although most studies report rates of 75–100 per cent. Follow-up rates without recurrence are 62–98 per cent. These variations might be explained by the use of different gauge devices and different methods for assessing the completeness of removal, including clinical, radiological and histological assessments. The reported complication rate of this procedure ranges 0 to 9 per cent, with a mean of 2.5 cent. Haematoma is the most frequent post-procedure complication; others include subcutaneous bleeding, skin defects and pneumothorax. Most complications are of mild-to-moderate severity. Careful ultrasonic monitoring throughout the whole procedure is mandatory to avoid skin tear. Usually, subcutaneous bleeding can be controlled by direct compression, and crepe bandage for 24 h is recommended to diminish bruising. In conclusion, the vacuum assisted excision of breast lesions using the VABB system is a feasible and safe procedure. Careful real-time ultrasonic monitoring is mandatory to avoid complications.

Squamous cell carcinoma of the breast presenting as an abscess

Pure squamous cell carcinoma of the breast is a rare form of metaplastic breast carcinomas. We report a case who presented with a breast abscess. Diagnosis was only made after wide local excision. The patient subsequently had a sentinel lymph node biopsy and is currently receiving radiation therapy. Squamous cell carcinoma of the breast is a rare tumour with limited evidence on its optimal treatment.