Evaluation of the robotic approach concerning pitfalls in rectal surgery.

INTRODUCTION: The feasibility and advantages of robotic rectal surgery (RRS) in comparison to conventional open or laparoscopic rectal resections have been postulated in several reports. But well-known challenges and pitfalls of minimal invasive rectal surgery have not been evaluated by a prospective, multicenter setting so far. Aim of this study was to analyze the perioperative outcome of patients following RRS especially in regard to the pitfalls such as obesity, male patients and low tumors by a European multicenter setting. METHODS: This prospective study included 348 patients undergoing robotic surgery due to rectal cancer in six major European centers. Clinicopathological parameters, morbidity, perioperative recovery and short-term outcome were analyzed. RESULTS: A total of 283 restorative surgeries and 65 abdominoperineal resections were carried out. The conversion rate was 4.3%, mean blood loss was 191 ml, and mean operative time was 315 min. Postoperative complications with a Clavien-Dindo score >2 were observed in 13.5%. Obesity and low rectal tumors showed no significant higher rates of major complications or impaired oncological parameters. Male patients had significant higher rates of major complications and anastomotic leakage (p = 0.048 and p = 0.007, respectively). DISCUSSION: RRS is a promising tool for improvement of rectal resections. The well-known pitfalls of minimal-invasive rectal surgery like obesity and low tumors were sufficiently managed by RRS. However, RRS showed significantly higher rates of major complications and anastomotic leakage in male patients, which has to be evaluated by future randomized trials.

Sacral nerve stimulation lead implantation in partial sacral agenesis using intra-operative computerized tomography.

AIM: Sacral nerve stimulation (SNS) lead implantation is a straightforward procedure for individuals with intact spinal vertebrae. When sacral anomalies are present, however, the anatomical and radiological reference points used for the accurate placement of the electrode may be absent or difficult to identify. METHOD: We describe an innovative surgical procedure of percutaneous nerve evaluation for SNS in a patient with faecal incontinence secondary to a congenital imperforate anus and partial sacral agenesis using a surgical imaging platform (O-arm system) under neurophysiological control. RESULTS: Using intra-operative CT and neuronavigation, the insertion point at the skin was identified. The lead was introduced into the right-sided S3 foramen and placed at the correct depth. An appropriate motor response was obtained after stimulation and neurophysiological control confirmed that the right S3 root was being stimulated. CONCLUSION: Our experience showed that O-arm guided navigation can be used to overcome the difficulty of SNS lead placement in patients with partial sacral agenesis who have faecal incontinence.

Impact of reduction mammoplasty on the quality of life of obese patients suffering from symptomatic macromastia: A descriptive cohort study.

BACKGROUND: Although reduction mammoplasty (RM) is an effective and efficient treatment for symptomatic macromastia, overweight and obese patients who request this treatment are frequently rejected because of selection criteria based on the body mass index. Scientific evidence is inconclusive regarding the increased postoperative complications in obese patients undergoing RM, and there is a lack of adequately designed studies examining the impact of RM on the quality of life of this group of patients. PATIENTS AND METHODS: A descriptive cohort study was performed on 37 consecutive obese patients (body mass index > 30 kg/m(2)) undergoing bilateral RM for symptomatic macromastia. Short Form SF-36 quality-of-life questionnaires were completed at interviews a week before surgery and 6 and 18 months after surgery. In addition, 37 women of matching ages, who were companions of patients hospitalized at our short-stay surgery unit, were used as a control group for comparison. Significant differences between repeated measurements on a single sample were assessed using the Wilcoxon signed-rank test. To evaluate these changes, we used effect size by computing Hedges' g corrected. RESULTS: The preoperative SF-36 physical component score was significantly lower than the control group's score (40 vs. 53, p < 0.001). There was no significant difference in the mental component score (45 vs. 49, p = 0.210). Postoperative SF-36 scores were increased with a normalizing effect, as 18 months after surgery only the body pain domain scored lower than the control group scores. CONCLUSIONS: According to our results, obese women with symptomatic macromastia undergoing RM exhibited increased quality of life, and this improvement was maintained over time. THERAPY: Level III Evidence.

[Role of bacteriobilia in postoperative complications]. / Papel de la bacteriobilia en las complicaciones postoperatorias.

OBJECTIVE: At present there is a controversy regarding the impact of positive bile cultures on morbidity and mortality rates, and on the incidence of readmissions in patients with biliar disease. The aim of this study was to evaluate the role of bacteriobilia in postoperatory infections, mortality or readmissions in these patients. METHODS: The information was obtained from all patients with bile cultures admitted to Hospital Universitario Marqués de Valdecilla (Santander, Spain) from January to December 2011. Clinical, epidemiological and microbiological data and laboratory findings were analyzed. The patients were followed for two years. RESULTS: One hundred and fifty-two patients (65% men) were included. Mean age was 67 years (SD= 15 years). The most frequent diagnoses were acute cholecystitis (79%) and cholangitis (8%). Laparoscopic cholecystectomy was performed in 42% of patients, open cholecystectomy in 45% and percutaneous cholecystostomy in 8%. Bacteriobilia was present in 83 patients (55%). The most frecuent microorganisms isolated were Escherichia coli (31%), Enterococcus faecium (13%) and Klebsiella pneumoniae (13%). The initial antimicrobial agent was a carbapenem in 62 patients (44%) and piperacillin-tazobactam in 28 (18%). There were 39 postoperative infections (26%), 21 readmissions (14%) and 17 patients died during admission (11%). The presence of microorganisms in bile cultures was not a statistically significant predictor of neither complications nor readmissions. CONCLUSIONS: Intra-operative bile cultures would allow guide early appropriate antibiotic treatment use in case of infection, or empiric antimicrobial therapy, however there was no correlation between bacteriobilia and postoperative infections, length of stay, mortality or readmissions.

Short- and mid-term outcomes of robotic-assisted total mesorectal excision for the treatment of rectal cancer. Our experience after 198 consecutive cases.

BACKGROUND: Robot-assisted total mesorectal excision is a safe alternative for rectal cancer treatment. Nevertheless, substantial data is still missing. Our aim was to assess the perioperative and oncological outcomes of the routine use of the robotic-assisted approach for rectal cancer treatment. PATIENTS AND METHODS: 198 Consecutive robotic rectal resections were performed between January 2011 and April 2015 in patients with stage I-IV disease. We prospectively evaluated peri and postoperative data, pathological findings and mid-term oncological outcomes. RESULTS: 36 Abdominoperineal Amputations, 28 High Anterior Resections, 131 Low Anterior Resections and 3 Hartmann operations were performed. Mean age, ASA, BMI and distance form anal verge were respectively 67.5 years, ASA II, 26.95 kg/m(2) and 5.9 cm. 71.2% Patients received neoadjuvant therapy. Mean OR time was 294 minutes. Conversion occurred in 4.5%. Mean postoperative stay was 8 days. 36 Patients required blood transfusion with a mean of 162 ml. Complications Clavien III-IV were 12.1%. 8 complete responses were observed, 50 UICC class I, 84 class II, 51 class III and 13 class IV. Mean lymph node harvested were 11.7. Mean distal margin was 3.3 cm. 11 Circumferential margins were affected in UICC class III-IV patients. Postoperative mortality was 0.5%. Local recurrence was observed in 5% patients. Median follow-up was 27.6 months. LIMITATIONS: Single institution descriptive study. CONCLUSIONS: The routine use of robotic assisted laparoscopic surgery may help to achieve lower conversion rates with lower ventral hernia rates and similar oncological outcomes using a minimally invasive approach in a non-selected group of patients with non-selected rectal tumours.

Echinococcosis: A 15-year epidemiological, clinical and outcome overview.

OBJECTIVE: To analyze the epidemiological and clinical characteristics and mortality of patients with cystic echinococcosis (CE) in northern Spain. PATIENTS AND METHODS: A retrospective study of the medical records of patients diagnosed with CE and hospitalized from 1997 to 2011 in a University Hospital. RESULTS: A total of 76 patients (44 men) were diagnosed with CE. The mean age was 57.8 years (SD: 19.1 years; range: 14.9-92.7). The yearly average incidence was 1.08 cases/100,000 inhabitants. The highest incidence was registered in patients aged 70-79 years (22.7% of all cases). Liver was the main organ involved (92.1%), followed by lung (6.6%) and peritoneum (1.3%). Fifty-five patients (72%) received treatment: 2 (3.6%) medical treatment with albendazole, 27 (49%) surgical treatment, 3 (5.4%) medical treatment combined with cyst drainage, and 23 (42%) combined medical and surgical treatment. Eight patients had a recurrence. Twenty-four (31.2%) patients died. No patient's death was attributed directly to hydatidosis, though mortality was significantly higher in the untreated vs. the treated patient group (57% vs. 22%, p=0.003). CONCLUSIONS: Hydatidosis treatment and diagnostic approaches remain heterogeneous. The liver continues being the main organ affected. Mortality was higher in patients who did not receive treatment. However, this result might have been influenced by other factors, mainly age.

Preclinical cadaveric study of transanal robotic proctectomy with total mesorectal excision combined with laparoscopic assistance.

BACKGROUND: Anterior resection with total mesorectal excision (TME) is the standard method of rectal cancer resection. However, this procedure remains technically difficult. A robotic transanal approach could overcome some of these limitations. An initial laboratory experience with robotic transanal TME using a new designed port on human cadavers is reported. METHODS: The feasibility of robotic transanal TME and ideal set-up were evaluated in human cadavers. For the da Vinci Si HD system transanal access and total mesorectal excision, a specifically designed port was used. RESULTS: It was possible to complete a proctectomy with transanal total mesorectal excision. The port proved to be very reliable and facilitated docking of the robotic arms. CONCLUSION: Using the robotic technology and a specifically designed port for robotic transanal access, TME was shown to be feasible and one specific preferred set-up was determined. Further clinical trials will be necessary to assess the safety and efficacy of this technique.

Initial results of robot-assisted Ivor-Lewis oesophagectomy with intrathoracic hand-sewn anastomosis in the prone position.

BACKGROUND: There is scanty experience concerning robot-assisted Ivor-Lewis oesophagectomy, so every new experience is helpful. METHODS: We describe the techniques and short-term results of Ivor-Lewis oesophagectomy using a laparoscopic approach and robot-assisted thoracoscopy, and an observational study of prospective surveillance of the first 14 patients treated for oesophageal cancer. A gastric tube was created laparoscopically. Oesophagectomy was performed through a robot-assisted thoracoscopy followed by hand-sewn intrathoracic anastomosis. RESULTS: There were no conversion cases. Mortality was zero. Six patients had a major complication. There were no cases of respiratory complication or recurrent laryngeal nerve palsy. Three patients had a radiological fistula (21.4%), successfully treated by endoscopic stenting, and one (7.1%) had an anastomosis leak needing reoperation. There were two cases of chylothorax (14.3%). CONCLUSIONS: Our initial results suggest that the reported technique is safe and satisfies the oncological principles. It provides the advantages of minimally invasive surgery by overcoming some limitations of conventional thoracoscopy.

Obesity-dependent metabolic signatures associated with nonalcoholic fatty liver disease progression.

Our understanding of the mechanisms by which nonalcoholic fatty liver disease (NAFLD) progresses from simple steatosis to steatohepatitis (NASH) is still very limited. Despite the growing number of studies linking the disease with altered serum metabolite levels, an obstacle to the development of metabolome-based NAFLD predictors has been the lack of large cohort data from biopsy-proven patients matched for key metabolic features such as obesity. We studied 467 biopsied individuals with normal liver histology (n=90) or diagnosed with NAFLD (steatosis, n=246; NASH, n=131), randomly divided into estimation (80% of all patients) and validation (20% of all patients) groups. Qualitative determinations of 540 serum metabolite variables were performed using ultraperformance liquid chromatography coupled to mass spectrometry (UPLC-MS). The metabolic profile was dependent on patient body-mass index (BMI), suggesting that the NAFLD pathogenesis mechanism may be quite different depending on an individual's level of obesity. A BMI-stratified multivariate model based on the NAFLD serum metabolic profile was used to separate patients with and without NASH. The area under the receiver operating characteristic curve was 0.87 in the estimation and 0.85 in the validation group. The cutoff (0.54) corresponding to maximum average diagnostic accuracy (0.82) predicted NASH with a sensitivity of 0.71 and a specificity of 0.92 (negative/positive predictive values=0.82/0.84). The present data, indicating that a BMI-dependent serum metabolic profile may be able to reliably distinguish NASH from steatosis patients, have significant implications for the development of NASH biomarkers and potential novel targets for therapeutic intervention.

Traumatic neuroma of extrahepatic bile ducts after orthotopic liver transplantation.

Traumatic neuromas (TN) of the biliary tree causing strictures have only occasionally been described after liver transplantation. Herein, we have reported 15 cases of TN that were detected between 1 and 17 months after transplantation (median: 4 months) during surgery for obstructive jaundice (12 cases), after alterations of liver function tests (two cases), or incidentally discovered after retransplantation (n = 1) we resected the lesion and the biliary anastomosis. Pathological examination and immunostaining for S-100 protein were performed to study the nerve fascicles. After a median follow-up time of 64 months (range = 0-127), 10 patients are alive without any complication related to the previous biliary TN. We propose the following classification: type I: TN originating from and located in the main biliary tract wall, and type II: TN arising from the surrounding tissues next to the main biliary tract. We conclude that TN are not uncommon after liver transplantation and that they are sometimes symptomatic, causing a biliary stricture that requires surgical treatment. We propose a classification to help patient selection for surgery. In our opinion, resection of the TN is the operation of choice, together with resection of the involved biliary tract in type I TN.

Absence of port-site metastases following staging laparoscopy for gastric carcinoma.

BACKGROUND: port-site metastases (PSM) have been reported following oncological laparoscopic surgery. However, their frequency after laparoscopic examination in gastric cancer has not been well established. MATERIAL AND METHODS: prospective follow-up of 41 patients having had a staging laparoscopy and a follow-up longer than 12 months. Mean age was 65 years (29-89). After staging, an open gastrectomy was performed in 33 cases. Mean follow-up was 21.4 (12-66) months. PSM was defined as a node in the former port-site wound with adenocarcinoma histology at biopsy. RESULTS: no patient showed clinical signs of PSM or port-site recurrence, even in advanced stages. We had no morbidity or postoperative mortality attributable to laparoscopic manoeuvres, and no need for laparotomy in cases without a gastrectomy indication. CONCLUSIONS: our results suggest that staging laparoscopy is a safe procedure in gastric carcinoma, as it is not associated with PSM after even considerable follow-up, and has a very low complication rate.

A novel mutation in the E-cadherin gene in the first family with hereditary diffuse gastric cancer reported in Spain.

AIMS: Mutations of the E-cadherin gene (CDH1) result in dominantly inherited hereditary diffuse gastric cancer (HDGC). We report a study in the first family diagnosed with HDGC in Spain, examining the presence of mutations in the CDH1 gene. METHODS: The presence of mutations was studied by direct sequencing of all CDH1 exons. Immunohistochemical analysis with specific antibodies was used to detect the expression of E-cadherin in normal and tumour tissue. RESULTS: A novel 1610delC mutation in exon 11 has been found in a Spanish family diagnosed with HDGC. This mutation generates a premature stop codon at position 1667 giving rise to a truncated protein that lacks the transmembrane and beta-catenin-binding domains. The presence of a 1610delC germline mutation was confirmed in three family members diagnosed with diffuse gastric cancer, and also in six asymptomatic members. Of note, the diffuse gastric cancer coexisted with a gastric lymphoma in the proband. Furthermore, immunohistochemical analyses of tumour tissue showed the complete absence of E-cadherin in the proband, revealing a second genetic hit at the CDH1 locus. CONCLUSIONS: We have identified a HDGC family in Spain that carries a novel germline truncating mutation in the CDH1 gene.

Do current indications for surgery of primary gastric lymphoma exist?

OBJECTIVE: To analyze the results of our series in order to assess whether surgical excision is still a valid therapeutic option in case the patient needs surgery. Secondarily, to analyze Helicobacter pylori infection rate. PATIENTS AND METHOD: A retrospective study of 69 consecutive patients having stage IE-IIE primary gastric lymphoma; of these, 65 were treated by gastrectomy between 1974 and 1999. Mean age: 62.6 years (28-85). New staining of paraffin-embedded samples from the surgical specimen were carried out (hematoxiline-eosine, Giemsa, immunohistochemistry) and reviewed. The histological classification was performed according to Isaacson's criteria. The statistical analysis was done by Chi-squared and Fisher's exact tests, as well as Kaplan-Meier and Log-Rank tests. RESULTS: Mortality was 9.2%. There were non-fatal complications in 10.8%. Helicobacter pylori was identified in 62.7%. Seven patients (11.9%) suffered a relapse. The 5-year survival probability was 87%. The statistical analysis did not show any influences of Ann Arbor stage, gastric wall invasion, Helicobacter pylori infection, histological type, or margin resection involvement on survival. CONCLUSIONS: Surgical excision provides a high rate of complete remissions and excellent long-term survival with acceptable mortality. Therefore it appears to be a valid treatment in case of emergency surgery, incidental finding, or lack of histological diagnosis.

Prognostic value of flow cytometry in surgically treated primary gastric lymphoma.

AIM: To investigate whether flow cytometry could help to define the optimal therapeutic strategy of primary gastric lymphomas. MATERIAL AND METHOD: Retrospective study of 46 patients having primary gastric lymphoma--according to Dawson criteria--in Ann Arbor stage IE and IIE, who were surgically treated. From selected paraffin-embedded tissue blocks of the tumor, DNA content was studied by flow cytometry (FC). Other pathological tumor features were analysed by hematoxiline-eosine and Giemsa stains as well as immunohistochemical study; any possible influence on postoperative survival was investigated through statistical analysis. RESULTS: The DNA ploidy pattern was diploid in 40 cases (87%) and aneuploid (hyperdiploid) in 6 (13%). Postoperative survival probability (PSP) was 62.7% at 5 years. Statistical analysis showed significant prognostic value for Ann Arbor classification--with higher PSP for stage IE (p = 0.009)--and FC parameters: diploid tumors had higher PSP than aneuploid tumors. Also tumors having S-phase (p = 0.044) or G2-M phase values (p = 0.023) under the respective mean values had higher PSP. No influence on PSP was found for wall invasion, Helicobacter pylori infection, Isaacson's histologic type or resection margin involvement. No significant relationship was appreciated between Isaacson's histologic type and DNA ploidy patterns. CONCLUSION: FC could be useful in assessing gastric lymphoma prognosis.