Minia Hellan

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.

Totally Robotic Low Anterior Resection with Total Mesorectal Excision and Splenic Flexure Mobilization

Some limitations of conventional laparoscopy have been overcome by the enhanced dexterity of the robotic da Vinci system, and its use in gastrointestinal procedures is evolving. However, difficulties accessing multiple quadrants of the abdomen with the first robotic system led to a rather slow introduction of the da Vinci into the field of abdominal surgery compared with its success with urologic and cardiac procedures. The new da Vinci S HD system offers improved range of motion that allows for easier access to a wider surgical field. The authors developed a new “one-step” setup to perform a low anterior resection with total mesorectal excision and splenic flexure mobilization for rectal cancer using a completely robotic approach. This technical report describes all the major aspects for successful performance of this complex minimally invasive procedure.

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.

The impact of lymph node number on survival in patients with lymph node-negative pancreatic cancer.

Objectives: The role of lymph node (LN) dissection for pancreatic cancer remains uncertain, and guidelines for a minimum LN number have not been established. We hypothesized that LN number in node-negative (N0) pancreatic cancer influences survival. Methods: The Surveillance, Epidemiology, and End Results database was queried for patients undergoing resection for N0 pancreatic adenocarcinoma between 1988 and 2003. Lymph node number was categorized as 1-10, 11-20, and >20. Results: In a cohort of 1915 patients, the median LN number was 7 (range 1-57); 1365 (71%) patients had <11 LN. Survival was significantly better in the 11 to 20 compared with the 1-10 group (median, 20 vs 15 months, respectively, P < 0.0001); no difference was observed between the 11-20 and >20 groups (median, 20 vs 23 months, respectively, P = 0.14). Multivariate analysis demonstrated the prognostic significance of LN number for determining overall survival (hazard ratio 0.98, 95% confidence interval: 0.97-0.99; P<0.0001). Conclusions: Pancreatic cancer lymphadenectomy with examination of >10 LN is associated with improved survival in N0 disease and should be considered a benchmark for adequacy of surgery and/or pathology. Currently, only a minority of patients are assessed by this measure. The variation in LN number may be indicative of diverse surgical technique and/or pathologic analysis and warrants further investigation.

Robotic-assisted placement of a hepatic artery infusion catheter for regional chemotherapy

Hepatic arterial infusion chemotherapy can be of value to patients with metastatic liver disease from colorectal cancer. Arterial infusion therapy requires surgical placement of a catheter into the gastroduodenal artery connected to a subcutaneous infusion pump or port, a procedure involving major abdominal surgery. Placement of chemotherapy infusion catheters by conventional laparoscopic techniques has been described, but is a technically challenging procedure. The purpose of this report is to introduce a new, minimally invasive approach for hepatic artery catheter placement using the DaVinci robotic system with the potential to minimize surgical trauma, pain, and hospital stay, and to render this minimal access procedure more feasible and widely applicable.

Diagnosis and Therapy of Primary Hypertrophic Pyloric Stenosis in Adults: Case Report and Review of Literature

Adult idiopathic hypertrophic pyloric stenosis (AIHPS) is a misleading anatomic and radio-clinical entity of unknown etiology. Only about 200 cases have been reported in the literature. It is a benign disease resulting from hypertrophy of the circular fibers of the pyloric canal. Despite the recent progress in radiography and endoscopy, it is very hard to define hypertrophic stenosis in adults. Differentiation of primary from secondary pyloric stenosis is frequently a task of the pathologist rather than the surgeon. The main therapy is surgical, although endoscopic dilatation has been tried. There remains controversy over the best surgical approach. A case is reported of a 48-year-old male patient with AIHPS who was subjected to distal gastrectomy. This paper discusses the possible causes of the disorder, the recommended diagnostic steps, and the different surgical approaches.

Senescence-Associated Gene YPEL3 Is Downregulated in Human Colon Tumors

BackgroundPrevious work has demonstrated YPEL3 to be a growth-suppressive protein that acts through a pathway of cellular senescence. We set out to determine whether human colon tumors demonstrated downregulation of YPEL3.MethodsWe collected colon tumor samples with matched normal control samples and analyzed them for YPEL3 gene expression by reverse transcriptase–polymerase chain reaction and CpG hypermethylation of the YPEL3 promoter by base-specific polymerase chain reaction analysis. Colon cancer cell lines (Caco-2 and HCT116−/− p53) were used to assess YPEL3 gene expression after treatment with 5-azadeoxycytidine or trichostatin A.ResultsReverse transcriptase–polymerase chain reaction analysis demonstrated a decrease in YPEL3 expression in tumor samples when compared to their patient-matched normal tissue. We determined that DNA methylation of the YPEL3 promoter CpG island does not play a role in YPEL3 regulation in human colon tumors or colon cancer cells lines, consistent with the inability of 5-azadeoxycytidine treatment to induce YPEL3 expression in colon cancer cell lines. In contrast, colon cell line results suggest that histone acetylation may play a role in YPEL3 regulation in colon cancer.ConclusionsYPEL3 is preferentially downregulated in human colon adenocarcinomas. DNA hypermethylation does not appear to be the mechanism of YPEL3 downregulation in this subset of collected patient samples or in colon cell lines. Histone acetylation may be a relevant epigenetic modulator of YPEL3 in colon adenocarcinomas. Future investigation of YPEL3 and its role in colon cancer signaling and development may lead to increased understanding and alternative treatment options for this disease.

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

Comparison of complication and conversion rates between robotic-assisted and laparoscopic rectal resection for rectal cancer: which patients and providers could benefit most from robotic-assisted surgery?

Abstract Aims: To compare (1) complication and (2) conversion rates to open surgery (OS) from laparoscopic surgery (LS) and robotic-assisted surgery (RA) for rectal cancer patients who underwent rectal resection. (3) To identify patient, physician, and hospital predictors of conversion. Materials and methods: A US-based database study was conducted utilizing the 2012–2014 Premier Healthcare Data, including rectal cancer patients ≥18 with rectal resection. ICD-9-CM diagnosis and procedural codes were utilized to identify surgical approaches, conversions to OS, and surgical complications. Propensity score matching on patient, surgeon, and hospital level characteristics was used to create comparable groups of RA\LS patients (n = 533 per group). Predictors of conversion from LS and RA to OS were identified with stepwise logistic regression in the unmatched sample. Results: Post-match results suggested comparable perioperative complication rates (RA 29% vs LS 29%; p = .7784); whereas conversion rates to OS were 12% for RA vs 29% for LS (p < .0001). Colorectal surgeons (RA 9% vs LS 23%), general surgeons (RA 13% vs LS 35%), and smaller bed-size hospitals (RA 14% vs LS 33%) have reduced conversion rates for RA vs LS (p < .0001). Statistically significant predictors of conversion included LS, non-colorectal surgeon, and smaller bed-size hospitals. Limitations: Retrospective observational study limitations apply. Analysis of the hospital administrative database was subject to the data captured in the database and the accuracy of coding. Propensity score matching limitations apply. RA and LS groups were balanced with respect to measured patient, surgeon, and hospital characteristics. Conclusions: Compared to LS, RA offers a higher probability of completing a successful minimally invasive surgery for rectal cancer patients undergoing rectal resection without exacerbating complications. Male, obese, or moderately-to-severely ill patients had higher conversion rates. While colorectal surgeons had lower conversion rates from RA than LS, the reduction was magnified for general surgeons and smaller bed-size hospitals.

Novel technique of robotic extralevator abdominoperineal resection with gracilis flap closure

The purpose of this paper is to introduce a robotic assisted approach to extralevator abdominoperineal excision in the modified Lloyd‐Davis position with reconstruction of the perineum using pedicled gracilis flaps, and to discuss outcomes in a cohort of six patients.