Cystic trophoblastic tumor - The effect of chemotherapy in metastatic testicular germ cell tumor to retroperitoneal lymph nodes.

Cystic trophoblastic tumor is an uncommon lesion which is occasionally seen after chemotherapy in metastatic retroperitoneal lymph nodes in patients with testicular germ cell tumor. The tumor cell clusters show cystic change lined by single to multiple layers of cells with abundant dense eosinophilic vacuolated cytoplasm, large pleomorphic vesicular nuclei with smudged chromatin, and prominent nucleoli. It is important to identify this lesion as its prognosis is similar to a teratoma and does not require any additional chemotherapy.

Rectal Dissection Simulator for da Vinci Surgery: Details of Simulator Manufacturing With Evidence of Construct, Face, and Content Validity.

BACKGROUND: Apprenticeship in training new surgical skills is problematic, because it involves human subjects. To date there are limited inanimate trainers for rectal surgery. OBJECTIVE: The purpose of this article is to present manufacturing details accompanied by evidence of construct, face, and content validity for a robotic rectal dissection simulation. DESIGN: Residents versus experts were recruited and tested on performing simulated total mesorectal excision. Time for each dissection was recorded. Effectiveness of retraction to achieve adequate exposure was scored on a dichotomous yes-or-no scale. Number of critical errors was counted. Dissection quality was tested using a visual 7-point Likert scale. The times and scores were then compared to assess construct validity. Two scorer results were used to show interobserver agreement. A 5-point Likert scale questionnaire was administered to each participant inquiring about basic demographics, surgical experience, and opinion of the simulator. Survey data relevant to the determination of face validity (realism and ease of use) and content validity (appropriateness and usefulness) were then analyzed. SETTINGS: The study was conducted at a single teaching institution. SUBJECTS: Residents and trained surgeons were included. INTERVENTION: The study intervention included total mesorectal excision on an inanimate model. MAIN OUTCOME MEASURES: Metrics confirming or refuting that the model can distinguish between novices and experts were measured. RESULTS: A total of 19 residents and 9 experts were recruited. The residents versus experts comparison featured average completion times of 31.3 versus 10.3 minutes, percentage achieving adequate exposure of 5.3% versus 88.9%, number of errors of 31.9 versus 3.9, and dissection quality scores of 1.8 versus 5.2. Interobserver correlations of R = 0.977 or better confirmed interobserver agreement. Overall average scores were 4.2 of 5.0 for face validation and 4.5 of 5.0 for content validation. LIMITATIONS: The use of a da Vinci microblade instead of hook electrocautery was a study limitation. CONCLUSIONS: The pelvic model showed evidence of construct validity, because all of the measured performance indicators accurately differentiated the 2 groups studied. Furthermore, study participants provided evidence for the simulator's face and content validity. These results justify proceeding to the next stage of validation, which consists of evaluating predictive and concurrent validity. See Video Abstract at http://links.lww.com/DCR/A551.

Usefulness of Statins for Prevention of Venous Thromboembolism.

Venous thromboembolism (VTE), including deep venous thrombosis and pulmonary embolism, is common with an annual incidence of 1 to 5 per 1,000, resulting in major morbidity, mortality, and increased health care costs. It is more common in the elderly, obese, those with cancer, those undergoing surgery, and those with previous VTE. Strategy to reduce its occurrence has important public health implications. Pleotropic effects of statins may have beneficial effects on a number of potential targets associated with VTE. Statins have excellent safety profile and seem to be associated with beneficial effects in VTE in case-control studies, large observational studies, meta-analyses, and a randomized trial. In conclusion, after critically reviewing the clinical data supporting statin use in the prevention of VTE, we presented clinical recommendations for the use of statins in reducing VTE occurrence, especially in high-risk situations.

The Impact of Obesity on the Perioperative, Clinicopathologic, and Oncologic Outcomes of Robot Assisted Total Mesorectal Excision for Rectal Cancer.

PURPOSE: To analyze the feasibility and outcomes of robotic rectal cancer surgery in obese patients. METHODS: From 2005 to 2012, 101 consecutive rectal cancers operated robotically were enrolled in a prospective database. Patients were stratified into obese (BMI ≥ 30 kg/m2) and non-obese (BMI < 30 kg/m2) groups. Operative, perioperative parameters, and pathologic outcomes were compared. Data were analyzed using SPSS 22.0, while statistical significance was defined as a p value ≤ .05. RESULTS: There were 33 obese patients (mean BMI 33.8 kg/m2). Patients were comparable regarding gender, T stage, and type of operation. Operative time and blood loss were higher in the obese group; only operative time was statistically significant. The conversion rate, length of stay, and anastomotic leak rates were similar. Circumferential margin positivity and lymph node yield were comparable. Disease free and overall survivals at 3 years were 75.8% versus 80.9% and 84.8% versus 92.6%, respectively for obese and non-obese subgroups. CONCLUSIONS: Robotic surgery for curative treatment of rectal cancer in the obese is safe and feasible. BMI does not influence conversion rates, length of stay, postoperative complications, and quality of the specimen or survival when the robotic platform is used.

Robotic Colorectal Surgery for Neoplasia.

Robotic colorectal surgery has become increasingly prevalent, with several reported benefits for surgeons and patients alike. Although its use is well-supported for pelvic surgery, there is less evidence that it is beneficial for abdominal surgery. There are several technical limitations of robotic surgery, and newer generations of robot platforms have addressed these, which may lead to increased use in the near future. In general, robotic surgery is more beneficial for surgeons than it is for patients.

Robotic Site Adjusted Levator Transection for Carcinoma of the Rectum: A Modification of the Existing Cylindrical Abdominoperineal Resection for Eccentrically Located Tumors.

BACKGROUND: Today, extralevator abdominoperineal resection is the standard of care for low rectal cancers with sphincter involvement or location precluding anastomosis. This procedure, while effective from an oncologic point of view, is morbid, with a high incidence of wound complications and genitourinary, and sexual dysfunction. We present a modification of this procedure via a robotic approach, which maintains the radicality while reducing the soft tissue loss and potentially the morbidity. METHODS: Over a 2-year period, five patients (four men and one woman) with eccentric low rectal cancers following neoadjuvant chemoradiation underwent a robot-assisted modified abdominoperineal resection with wide levator transection on the tumor side and conservative levator division on the opposite side. These patients were prospectively followed. Perioperative outcomes, pathologic specimen measures, wound-related problems, and local and systemic recurrences were documented and analyzed. RESULTS: All procedures were successfully completed without conversion. Average body mass index was 32 kg/m2. The mean operative time and blood loss were 370 min and 130 ml, respectively. All specimens had an intact mesorectal envelope with no tumor perforations, and the mean lymph node yield was 16. There were no urinary complications or perineal wound infections. At a median follow-up of 14 months, all patients remain disease-free. CONCLUSIONS: Modified robotic cylindrical abdominoperineal resection with site adjusted levator transection for rectal cancer is an oncologically sound operation in eccentrically located tumors. It maintains the radicality of conventional extralevator abdominoperineal resection, while also reducing the soft tissue loss and thereby potentially the morbidity.

Endoscopic control of enterocutaneous fistula by dual intussuscepting stent technique.

INTRODUCTION: Large high-output enterocutaneous fistulas pose great difficulties, especially in the setting of recent surgery and compromised skin integrity. METHODS: This video demonstrates a new technique of endoscopic control of enterocutaneous fistula by using two covered overlapping stents. In brief, the two stents are each inserted endoscopically, one proximal, and the other distal to the fistula with 2 cm of each stent protruding cutaneously. Following this, the proximal stent is crimped and intussuscepted into the distal stent with an adequate overlap. A prolene suture is passed through the anterior wall of both stents to prevent migration. The two stents used were evolution esophageal stents-10 cm long, fully covered, double-flared with non-flared and flared diameters being 20 and 25 mm, respectively (product number EVO-FC-20-25-10-E, Cook Medical, Bloomington, IN, USA). RESULTS: The patient featured in this video developed a high-output enterocutaneous fistula proximal to a loop ileostomy, which was created following a small bowel leak after a curative surgery for bladder cancer. Using the technique featured in this video (schematic depicted in Fig. 1), the patient was nutritionally optimized with oral feeds from albumin of 0.9-3.4 g/dl within 2 months despite prior failure to achieve nutrition optimization and adequate skin protection with combination of oral and/or parenteral nutrition. Three months after stenting, following nutritional optimization and improvement of skin coverage, definitive procedure consisted of uncomplicated fistula resection with primary stapled side-to-side functional end-to-end anastomosis. The stents were not completely incorporated into the mucosa and were rather easily pulled through the residual fistula opening just prior to the surgery. Only minimal fibrosis was noted and less than 20 cm of involved small bowel needed to be resected. Had the fistula have closed completely, the options would have included (1) proceeding to bowel resection with removal of the stents regardless of closure, or (2) cutting the securing prolene stitch and observation. Considering the placement of the stents in mid-small bowel, their endoscopic retrieval would have been difficult unless they were to migrate into the colon. CONCLUSIONS: Although a prior attempt at managing an enterocutaneous fistula with a stent deployed through a colostomy site was previously reported [1], there is no published account of bridging an enterocutaneous fistula with overlapping endoscopic stents through the fistula itself. This video serves as a proof of concept for temporizing enterocutaneous fistulas with endoscopic stenting.

Robot-Assisted Abdominoperineal Resection: Clinical, Pathologic, and Oncologic Outcomes.

BACKGROUND: The extralevator approach to abdominoperineal resection is associated with a decreased incidence of rectal perforation and circumferential resection margin positivity translating to lower recurrence rates. The abdominoperineal resection, as such, is an operation associated with poorer outcomes in comparison with low anterior resections, and any improvements in short-term outcomes are likely to be related to surgical technique. Robot assistance in extralevator abdominoperineal resection has shown improvement in these pathologic outcomes. Because these are surrogate markers for local recurrence and disease-free survival, long-term survival data are needed to assess the efficacy of this robot-assisted technique, exclusively in a dedicated abdominoperineal resection cohort. OBJECTIVE: We assessed the perioperative, pathologic, and oncologic outcomes of the robot-assisted extralevator abdominoperineal resection for rectal cancer. DESIGN: This study was a review of a prospective database of patients over a 5-year period. SETTING: Procedures were performed in the colorectal division of a tertiary hospital from April 2007 to July 2012. PATIENTS: Patients with rectal cancer were operated on robotically. Indications for abdominoperineal resection were low rectal cancers invading the sphincter complex or location in the anal canal precluding anastomosis. INTERVENTIONS: All patients received a robot-assisted extralevator abdominoperineal resection. MAIN OUTCOME MEASURES: Operative and perioperative measures, pathologic outcomes, and disease-free survival and overall survival were documented and assessed. RESULTS: Twenty-two patients (15 men) with a mean age of 65.5 years and mean BMI of 28.6 kg/m underwent robotic abdominoperineal resection. Circumferential resection margin was positive in 13.6%. There was 1 tumor/rectal perforation. At a mean follow-up of 33.9 months, overall survival was 81.8% with a disease-free survival of 72.7%. Local recurrence was 4.5%. LIMITATIONS: This was a single-institution study with no comparative open or laparoscopic group. CONCLUSION: Robot-assisted abdominoperineal resection is safe, feasible, and oncologically sound with short-term and long-term outcomes comparable to open and laparoscopic surgery.

Sacral nerve stimulation in the treatment of bowel dysfunction from imperforate anus: A case report.

INTRODUCTION: Bowel dysfunction (fecal incontinence and constipation) presents in over 50% of patients after treatment of congenital anal malformations. Sacral nerve stimulation (SNS) for the treatment of fecal incontinence improves function in the majority of patients. We present a case report of the treatment of bowel dysfunction with sacral nerve stimulation in a patient with a history of an imperforate anus. PRESENTATION OF CASE: A twenty year-old female with a history of imperforate anus at birth, repaired during infancy with anorectoplasty, presented with fecal incontinence and constipation. Since childhood, she had been suffering from intermittent constipation with worsening fecal incontinence in early adulthood. Examination revealed mild anal stenosis and mucosal prolapse. Endoanal ultrasound demonstrated intact internal and external sphincter with low resting and squeeze pressures on anal manometry. Flexible sigmoidoscopy was normal. The patient underwent permanent sacral nerve stimulation with a primary goal of improvement in continence and, secondarily, for the alleviation of intermittent chronic constipation. DISCUSSION: At 15 month follow-up, the patient had improvement in fecal incontinence (CCIS of 14 pre-SNS to 1 post-SNS), constipation (CCCS of 28 pre-SNS to 20 post-SNS), and quality of life (FIQOL improved in lifestyle (3.7), coping/behavior (3.4), self perception (3.9), and social embarrassment (4.5). CONCLUSION: Sacral nerve stimulation for the treatment of bowel dysfunction in adults secondary to imperforate anus can be performed safely and with good results.

Robot-assisted approach to a retrorectal lesion in an obese female.

BACKGROUND: Often detected incidentally, retrorectal tumors frequently require resection secondary to possibility of malignancy, development of infection, and localized growth with compression. The surgical approach is summarized to abdominal, posterior or a combination, depending on the location of the retrorectal mass and its relationship to the pelvic sidewall. Laparoscopic transabdominal resection of retrorectal tumors has shown safety and efficacy. Robot technology offers a stable platform with superb optics, and endo-wristed instruments that can facilitate dissection in the narrow pelvis. We present the emerging new technique of robot-assisted minimally invasive approach to a retrorectal mass in an obese female. METHODS: An obese 35-year-old female, body mass index (BMI) 41 kg/m2, with an incidental 2 cm cystic retrorectal lesion involving the pelvic sidewall was taken to the operating room for a robot-assisted minimally invasive resection of the mass. RESULTS: Total operative time was 2 hours and 30 minutes, and total robotic dissection at 70 minutes. The patient was discharged on postoperative day 2. Final pathology revealed a benign Mullerian type cyst, 2.2 cm in greatest dimension. CONCLUSIONS: Robot-assisted minimally invasive resection of a retrorectal mass is safe and feasible. This method can be particularly useful in the narrow pelvis and with obese patients.

Combining all forces: abdominoperineal resection in an obese male.

BACKGROUND: In patients with rectal cancer, pelvic dissection is challenging. A complete total mesorectal excision (TME) is particularly difficult in a narrow and long pelvis often encountered in males. This difficulty is compounded in the obese. In addition to the open approach being morbid, laparoscopy has often proven difficult secondary to rigid instruments along with a steep learning curve. Robot assistance offers an advantage, however limitations are observed in abdominal colon dissection outside of the pelvis. As these individual modalities have their disadvantages, they each can contribute unique aspects in a combined or a hybrid approach to rectal tumors. Therefore, a multi-modal, combined approach, involving hand assist, laparoscopic, and robotic assistance, to a 5-cm tumor at the anal verge was applied to an abdominoperineal resection in an obese, male patient. METHODS: An obese 58-year-old male, BMI of 36 kg/m2, with a 5-cm anal canal squamous cell carcinoma which recurred after Nigro protocol treatment, underwent a multi-modal abdominoperineal resection. RESULTS: The approach to recurrent anal cancer is as that for rectal cancer. Hence, a hand port was placed to assist in colon mobilization, visceral mesenteric dissection, and to facilitate the laparoscopic division of the inferior mesenteric artery (IMA) at its origin. The robot was used for deep pelvic dissection and TME. The levators were divided in the perineal phase. A complete mesorectal excision was achieved and a cylindrical specimen was extracted. CONCLUSIONS: An abdominoperineal resection with a multi-modal approach (hand assist, laparoscopic, and robotic) is safe and effective in resection of low rectal cancers especially in the narrow, obese, and male pelvis.

Oncologic and Clinicopathologic Outcomes of Robot-Assisted Total Mesorectal Excision for Rectal Cancer.

BACKGROUND: Minimally invasive rectal cancer surgery is challenging and technically difficult. Robotic technology offers a stable surgical platform with magnified 3-dimensional vision and endowristed instruments, which may facilitate the minimally invasive procedure. Data on short-term and long-term outcomes indicate results comparable to laparoscopic and open surgery. OBJECTIVE: We assessed the perioperative, clinicopathologic, and oncologic outcomes of robotic surgery for rectal cancer. DESIGN: This study was a review of a prospective database of patients over a 7-year period. SETTINGS: Procedures took place in the colorectal division at a tertiary hospital. PATIENTS: From August 2005 to October 2012, 101 patients with rectal cancer were operated on using the robotic approach. Rectal cancers were defined as tumors within 15 cm from the anal verge. INTERVENTIONS: Patients received either a totally robotic or a hybrid laparoscopic-robotic operation with rectal dissection performed robotically. MAIN OUTCOME MEASURES: Operative and perioperative data, pathologic outcomes, and disease-free and overall survival were examined. RESULTS: There were 63 men (62.4%) and 38 women (37.6%) in the study; the mean age was 61.5 years. Mid rectal and low rectal cancers composed 74.2% of cases. Preoperative chemoradiation was given to 74.3% of patients. Four conversions to open surgery occurred. Circumferential margin positivity was 5%, and median lymph node yield was 15. At a mean follow-up of 34.9 months, the disease-free survival was 79.2% and overall survival 90.1%. The mean cost of robotic surgery was $22,640 versus $18,330 for the hand-assisted laparoscopic approach (p = 0.005). LIMITATIONS: This was a single-institution study with no head-to-head comparative group. CONCLUSIONS: Robotic surgery for rectal cancer extirpation is safe and feasible. It has a low conversion rate, satisfies all measures of pathologic adequacy, and offers acceptable oncologic outcomes. Robotic surgery is significantly more expensive than hand-assisted laparoscopic surgery. The absence of randomized data limits recommending it as the standard of care at present.