Short-term outcomes in robot-assisted compared to laparoscopic colon cancer resections: a systematic review and meta-analysis.

BACKGROUND: Robot-assisted surgery is increasingly adopted in colorectal surgery. However, evidence for the implementation of robot-assisted surgery for colon cancer is sparse. This study aims to evaluate the short-term outcomes of robot-assisted colon surgery (RCS) for cancer compared to laparoscopic colon surgery (LCS). METHODS: Embase, MEDLINE, and Cochrane Library were searched between January 1, 2005 and October 2, 2020. Randomized clinical trials and observational studies were included. Non-original literature was excluded. Primary endpoints were anastomotic leakage rate, conversion to open surgery, operative time, and length of hospital stay. Secondary endpoints were surgical efficacy and postoperative morbidity. We evaluated risk of bias using RoB2 and ROBINS-I quality assessment tools. We performed a pooled analysis of primary and secondary endpoints. Heterogeneity was assessed by I2, and possible causes were explored by sensitivity- and meta-regression analyses. Publication bias was evaluated by Funnel plots and Eggers linear regression test. The level of evidence was assessed by GRADE. RESULTS: Twenty studies enrolling 13,799 patients (RCS 1740 (12.6%) and LCS 12,059 (87.4%) were included in the meta-analysis that demonstrated RCS was superior regarding: anastomotic leakage (odds ratio (OR) = 0.54, 95% CI [0.32, 0.94]), conversion (OR = 0.31, 95% CI [0.23, 0.41]), overall complication rate (OR = 0.85, 95% CI [0.73, 1.00]) and time to regular diet (MD = - 0.29, 95% CI [- 0.56, 0.02]). LCS proved to have a shortened operative time compared to RCS (MD = 42.99, 95% CI [28.37, 57.60]). Level of evidence was very low according to GRADE. CONCLUSION: RCS showed advantages in colonic cancer surgery regarding surgical efficacy and morbidity compared to LCS despite a predominant inclusion of non-RCT with serious risk of bias assessment and a very low level of evidence.

Improved perioperative outcomes and reduced inflammatory stress response in malignant robot-assisted colorectal resections: a retrospective cohort study of 298 patients.

BACKGROUND: Robot-assisted surgery is increasingly implemented for the resection of colorectal cancer, although the scientific evidence for adopting this technique is still limited. This study's main objective was to compare short-term complication rates, oncological outcomes, and the inflammatory stress response after colorectal resection for cancer performed laparoscopic or robot-assisted. METHODS: We conducted a retrospective cohort study comparing the robot-assisted approach to laparoscopic surgery for elective malignant colorectal neoplasm. Certified colorectal and da Vinci ® robotic surgeons performed resections at a Danish tertiary colorectal high volume center from May 2017 to March 2019. We analyzed the two surgical groups using uni- and multivariate regression analyses to detect differences in intra- and postoperative clinical outcomes and the inflammatory stress response. RESULTS: Two hundred and ninety-eight patients were enrolled in the study. Significant differences favoring robot-assisted surgery was demonstrated for; length of hospital stay (4 days, interquartile range (4, 5) versus 5 days, interquartile range (4-7), p < 0.001), and intraoperative blood loss (50 mL, interquartile range (20-100) versus 100 mL, interquartile range (50-150), p < 0.001) compared to laparoscopic surgery. The inflammatory stress response was significantly higher after laparoscopic compared to robot-assisted surgery reflected by an increase in C-reactive protein concentration (exponentiated coefficient = 1.23, 95% confidence interval (1.06-1.46), p = 0.008). No differences between the two groups were found concerning mortality, microradical resection rate, conversion to open surgery, and surgical or medical short-term complication rates. CONCLUSION: Robot-assisted surgery is feasible and can be safely implemented for colorectal resections. The robot-assisted approach, when compared to laparoscopic surgery, was associated with improved intra- and postoperative outcomes. Extensive prospective studies are needed to determine the short- and long-term outcomes of robotic surgery for colorectal cancer.

Systemic inflammatory response in robot-assisted and laparoscopic surgery for colon cancer (SIRIRALS): study protocol of a randomized controlled trial.

BACKGROUND: Robot-assisted surgery is being increasingly adopted in treating colorectal cancer, and the transition from laparoscopic surgery to robot-assisted surgery is a trend. The evidence of the benefits of robot-assisted surgery is sparse. However, findings are associated with improved patient-related outcomes and overall morbidity rates compared to laparoscopic surgery. This induction is unclear, considering both surgical modalities are characterized as minimally invasive. This study aims to evaluate the systemic and peritoneal inflammatory stress response induced by robot-assisted surgery compared with laparoscopic surgery for elective colon cancer resections in a prospective, randomized controlled clinical trial. METHODS: This study is a single-centre randomized controlled superiority trial with 50 colon cancer participants. The primary endpoint is the level of systemic inflammatory response expressed as serum C-reactive protein (CRP) and interleukin 6 (IL-6) levels between postoperative days one and three. Secondary endpoints include (i) levels of systemic inflammation in serum expressed by a panel of inflammatory and pro-inflammatory cytokines measured during the first three postoperative days, (ii) postoperative surgical and medical complications (30 days) according to Clavien-Dindo classification and Comprehensive Complication Index, (iii) intraoperative blood loss, (iv) conversion rate to open surgery, (v) length of surgery, (vi) operative time, (vii) the number of harvested lymph nodes, and (viii) length of hospital stay. The exploratory endpoints are (i) levels of peritoneal inflammatory response in peritoneal fluid expressed by inflammatory and pro-inflammatory cytokines between postoperative day one and three, (ii) patient-reported health-related quality of recovery-15 (QoR-15), (iii) 30 days mortality rate, (iv) heart rate variability and (v) gene transcript (mRNA) analysis. DISCUSSION: To our knowledge, this is the first clinical randomized controlled trial to clarify the inflammatory stress response induced by robot-assisted or laparoscopic surgery for colon cancer resections. Trial registration This trial is registered at Clinicaltrials.gov (Identifier: NCT04687384) on December, 29, 2020, Regional committee on health research ethics, Region of Southern Denmark (N75709) and Data Protection Agency, Hospital Sønderjylland, University Hospital of Southern Denmark (N20/46179).

Consequences of parenteral iron-dextran loading investigated in minipigs. A new model of transfusional iron overload.

Patients with blood transfusion-dependent anemias develop transfusional iron overload (TIO), which may cause cardiosiderosis. In patients with an ineffective erythropoiesis, such as thalassemia major, common transfusion regimes aim at suppression of erythropoiesis and of enteral iron loading. Recent data suggest that maintaining residual, ineffective erythropoiesis may protect from cardiosiderosis. We investigated the common consequences of TIO, including cardiosiderosis, in a minipig model of iron overload with normal erythropoiesis. TIO was mimicked by long-term, weekly iron-dextran injections. Iron-dextran loading for around one year induced very high liver iron concentrations, but extrahepatic iron loading, and iron-induced toxicities were mild and did not include fibrosis. Iron deposits were primarily in reticuloendothelial cells, and parenchymal cardiac iron loading was mild. Compared to non-thalassemic patients with TIO, comparable cardiosiderosis in minipigs required about 4-fold greater body iron loads. It is suggested that this resistance against extrahepatic iron loading and toxicity in minipigs may at least in part be explained by a protective effect of the normal erythropoiesis, and additionally by a larger total iron storage capacity of RES than in patients with TIO. Parenteral iron-dextran loading of minipigs is a promising and feasible large-animal model of iron overload, that may mimic TIO in non-thalassemic patients.

Peritoneal Flap Hernioplasty for Reconstruction of Large Ventral Hernias: Long-Term Outcome in 251 Patients.

BACKGROUND: Repair of large ventral hernias is challenging when primary fascial closure cannot be achieved. The peritoneal flap hernioplasty, a modification of the Rives-Stoppa retromuscular mesh repair, addresses this problem by using the hernial sac to bridge the fascial gap and isolate the mesh from both the intraperitoneal contents and the subcutaneous space. It is applicable to both midline and transverse hernias. We report the results from our institution using this repair based on a retrospective review of 251 cases. METHODS: Patients undergoing peritoneal flap hernioplasty repair from January 1, 2010-December 31, 2014 were identified from the Lothian Surgical Audit system, a prospectively maintained computer database of all surgical procedures in the Edinburgh region of southeast Scotland. Patient demographics, clinical presentation, location of the hernia and surgical treatment were obtained from the hospital case-notes. Follow-up consisted of a clinical consultation 3 months postoperatively and a retrospective review of patient files completed December 2018. Patients presenting signs of complications were assessed during a clinical review. RESULTS: Two hundred and fifty-one patients underwent incisional hernia repair, 68.1% in the midline and 31.9% arising through transverse incisions. Forty-three of these (17%) were recurrences referred from other centers. Mean BMI was 32.1 kg/m2 (range 20-59.4 kg/m2). Mean defect width was 9.2 ± 4.2 cm (range 2.5-24.2 cm). Mean mesh size was 752 cm2 (range 150-1760 cm2). Some form of abdominoplasty was performed in 59% of cases. Mean postoperative stay was 6.3 days (range 1-33 days). Mean follow-up time was 75 months (range 44-104 months). Fifty-three patients (21.1%) developed postoperative complications. Three (1.2%) developed superficial skin necrosis and 27 (10.8%) a superficial wound infection, but none developed deep mesh infection. Twelve (4.8%) developed symptomatic seroma and 11 (4.4%) a hematoma requiring surgical intervention. Seven (2.8%) patients developed recurrence within the follow-up period. CONCLUSION: Peritoneal flap hernioplasty is an excellent and versatile method for reconstruction of large ventral hernias arising in both midline and transverse incisions. The technique is safe and associated with few complications and a very low recurrence rate.

Increased Insulin Secretion and Glucose Effectiveness in Obese Patients with Type 2 Diabetes following Bariatric Surgery.

Background: ß-cell dysfunction and insulin resistance are the main mechanisms causing glucose intolerance in type 2 diabetes (T2D). Bariatric surgeries, i.e., sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), are procedures both known to induce weight loss, increase insulin action, and enhance ß-cell function, but hepatic insulin extraction and glucose effectiveness may also play a role. Methods: To determine the contribution of these regulators on glucose tolerance after bariatric surgery, an oral glucose tolerance test (OGTT) was performed before and 2 months after surgery in 9 RYGB and 7 SG subjects. Eight healthy subjects served as metabolic controls. Plasma glucose, insulin, C-peptide, GLP-1, and GIP were measured during each OGTT. Insulin sensitivity and secretion, glucose effectiveness, and glucose rate of appearance were determined via oral minimal models. Results: RYGB and SG resulted in similar weight reductions (13%, RYGB (p < 0.01); 14%, SG (p < 0.05)). Two months after surgery, insulin secretion (p < 0.05) and glucose effectiveness both improved equally in the two groups (11%, RYGB (p < 0.01); 8%, SG (p > 0.05)), whereas insulin sensitivity remained virtually unaltered. Bariatric surgery resulted in a comparable increase in the GLP-1 response during the OGTT, whereas GIP concentrations remained unaltered. Following surgery, oral glucose intake resulted in a comparable increase in hepatic insulin extraction, the response in both RYGB and SG patients significantly exceeding the response observed in the control subjects. Conclusions: These results demonstrate that the early improvement in glucose tolerance in obese T2D after RYGB and SG surgeries is attributable mainly to increased insulin secretion and glucose effectiveness, while insulin sensitivity seems to play only a minor role. This trial is registered with NCT02713555.

Metabolic syndrome in women with previous gestational diabetes.

To evaluate the incidence and timing of the diagnosis of metabolic syndrome in a cohort of Danish women after a pregnancy with gestational diabetes (GDM) to estimate the optimum time for preventative actions in relation to metabolic syndrome (MetS). In this follow-up study, 435 women were included from a consecutive cohort with prior history of GDM. Data on dyslipidemia, hypertension and other cardiovascular disorders (CVD) were extracted from the electronic patient journal. Any antidiabetic, cardiovascular and cholesterol-lowering medicine was ascertained in the national prescription database. Similarly, any blood test taken was evaluated. We defined a patient having MetS if the criteria of the WHO based definition of diabetes or impaired glucose regulation were met. Further, we added as alternative for glucose intolerance, a glycosylated hemoglobin (HbA1c) > 44 mmol/mol or the former level ≥ 6.5%. Further, dyslipidemia, lipid lowering medications, BMI > 30 kg/m2 or antihypertensive treatment were used. For MetS outcome, diagnosis or medication for CVD was registered. All women were followed for median 5.7 years (range 0; 9). The incidence of MetS was 28%. Thirteen percent of these qualified already within one year after pregnancy for the diagnosis of MetS. Postpartum MetS was detected after a median of 3 years (range 0; 7 years); further, 36 (8%) had been diagnosed with manifest diabetes after pregnancy. The diagnosis of postpartum MetS was strongly associated with the prevalence of manifest diabetes. Six years after pregnancy the rate of metabolic syndrome was more than tripled (25 vs. 89%, no DM vs manifest DM, RR: 6.7; 95% CI 2.7-17, p < 0.001). At 40 years the MetS rate nearly tripled if manifest DM was diagnosed (26 vs. 78%, no DM vs. manifest DM, RR: 3.3, 95% CI 1.8-6, p < 0.001). We found that GDM and later on manifest DM in women increase the risk of metabolic syndrome. There seems to be a window of opportunity before the early thirties where it would be especially beneficial to begin preventive efforts in women with GDM.

Insulin sensitivity and body composition in cirrhosis: changes after TIPS.

Insertion of a transjugular intrahepatic porto-systemic shunt (TIPS) increases body cell mass (BCM) in patients with liver cirrhosis. The responsible mechanism is unidentified, but may involve changes in insulin sensitivity and glucose metabolism. Eleven patients with liver cirrhosis were examined before and 6 mo after a TIPS procedure with bioimpedance analyses, 2-h oral glucose tolerance tests, and two-step hyperinsulinemic euglycemic clamp with tracer-determined endogenous glucose production. After TIPS, BCM increased by 4.8 kg [confidence interval (CI): 2.7-7.3]. Fasting (f)-insulin increased from 123 +/- 81 to 193 +/- 124 pmol/l (P = 0.03), whereas f-glucose was unchanged (6.0 +/- 0.8 vs. 6.2 +/- 1.0 mmol/l). Glucose and insulin oral glucose tolerance test area under the curve increased by 14% (CI: 7-22%) and 53% (CI: 14-90%), respectively, P < 0.05. The C-peptide-to-insulin ratio decreased by 21% (CI: 8-35%, P = 0.01). Insulin sensitivity based on glucose infusion rate (4.69 +/- 1.82 vs. 4.85 +/- 2.37 mg.kg(-1).min(-1)) and glucose tracer-based rate of disappearance were unchanged (5.01 +/- 1.61 vs. 4.97 +/- 2.13 mg.kg(-1).min(-1)). Despite a further increase in peripheral hyperinsulinemia, f-endogenous glucose production did not change between study days (2.01 +/- 0.42 vs. 2.42 +/- 0.58 mg.kg(-1).min(-1)) and was suppressed equally by insulin (1.1 +/- 0.1 vs. 1.0 +/- 0.1 mg.kg(-1).min(-1)). Insulin clearance, growth hormone, cortisol, and glucagon levels were unchanged. BCM improvement did not correlate with the measured variables. After TIPS, BCM rose, despite enhanced hyperinsulinemia and aggravated glucose intolerance, but unchanged peripheral and hepatic insulin sensitivity. This apparent discrepancy may be ascribed to shunt-related decreased insulin exposure to the liver cells. However, the anabolic effect of TIPS seems not to be related to improvements in insulin sensitivity and remains mechanistically unexplained.

[Radiology diagnostics and treatment of acute cholecystitis].

Acute cholecystitis (AC) is mainly caused by stones in the gall bladder. Although cholescintigraphy has the highest sensitivity (97%) and specificity (94%) for AC, ultrasound is the most commonly used technique in confirming the diagnosis. Laparoscopic cholecystectomy is the recom-mended treatment of choice; however, in high-risk patients percutaneous gall bladder drainage is an attractive alter-native approach to avoid lesions to the common bile duct. To avoid serious bleeding incidences, it is imperative to pause anticoagulation therapy prior to gall bladder drainage.

[Treatment of acute cholecystitis in a third-trimester pregnant women]. / Behandling af akut kolecystitis hos gravide i tredje trimester.

This case report describes a 35-year-old female with acute cholecystitis 36 weeks into her pregnancy. Laparoscopic cholecystectomy was assessed not to be possible. An ultrasonic guided percutaneous transhepatic gall bladder drainage was performed resulting in immediate pain relief. The patient was discharged two days later, and the drain sat in place until a caesarian section was per--formed. A post-surgery cholangiography demonstrated stones in the gall bladder but no stones in the common bile duct. An uneventful laparoscopic cholecystectomy was carried out three months after surgery. The case report demonstrates that percutaneous transhepatic gall bladder drainage is a safe procedure to be considered in women with cholecystitis in which cholecystectomy is not possible or assumed to be associated with an unacceptable high risk.

Impaired hepatic counterregulatory response to insulin-induced hypoglycemia in hepatic denervated pigs.

OBJECTIVE: The liver reacts to hypoglycemia by increasing its glucose output. This response is assumed to depend both on glucose sensing at the liver and the brain, as well as efferent impulses from the brain to the liver. We tested the importance of this signaling pathway by studying the hepatic response to insulin-induced hypoglycemia in hepatic complete denervated pigs. MATERIALS/METHODS: Two weeks prior to the metabolic study, 36-kg pigs underwent either total hepatic denervation (DN; n = 12) or sham operation (sham; n = 12). On the metabolic study day, measurements were performed at baseline conditions and during a hypoglycemic hyperinsulinemic (5 mU/kg/min) clamp. Endogenous insulin and glucagon secretions were inhibited by somatostatin, and glucagon was replaced at baseline levels. Endogenous glucose production (EGP) and glucose utilization (Rd) were determined by [3-3H] glucose infusion. RESULTS: Baseline plasma concentrations of glucose, insulin, EGP and Rd did not differ significantly between the two groups of animals. During insulin infusion, the plasma glucose concentration was clamped at ~3 mmol/L in both groups of animals resulting in an increase in plasma concentrations of epinephrine and norepinephrine in sham pigs (both P < 0.05), while this effect was abolished in DN pigs. While insulin action (P = 0.09) and glucose utilization (P = 0.44) were similar, EGP was markedly decreased in the DN pigs (P < 0.05). CONCLUSION: The findings indicate a blunted hepatic counterregulatory response to hypoglycemia following complete hepatic denervation. This implies that intact neural impulses to and from the liver are necessary to maintain the increase in EGP that protects the organism against hypoglycemia.

[Frequency of recanalization after vasectomy. Experiences from 2.563 sterilizations]. / Frekvensen af rekanalisering ved vasektomi. Erfaringer fra 2.563 sterilisationer.

INTRODUCTION: Vasectomy is a simple and common operation used worldwide for contraception. The present study sought to determine the rate of recanalisation after vasectomy and whether it is associated with the level of surgical experience. MATERIAL AND METHODS: Altogether 2563 vasectomies were conducted from 1 January 1997 to 1 January 2001. Postoperative semen analysis was performed in all subjects to ensure sterility. RESULTS: Seventy-nine per cent of patients submitted a semen sample for analysis. Fifteen per cent of the samples contained sperm. These subjects were asked to provide additional samples until azoospermia was diagnosed. Out of the 2563 vasectomies, 36 patients were reoperated, thus yielding a calculated incidence of recanalisation of 1.4%. The rate of recanalisation could not be associated with the level of experience by the operating surgeon. DISCUSSION: Vasectomy is a safe surgical procedure that can be performed with a low rate of failure by surgeons with limited surgical experience. Our results indicate that intermittent appearance of sperm can occur early after vasectomy. Consequently, reoperation should be performed on a conservative basis and solely in subjects in whom repeated semen analysis has failed to provide evidence of azoospermia.

[Jejunal diverticulitis as the cause of acute abdomen].

We present two patients with jejunal diverticulitis. Diverticula in jejunum and ileum are very rare, occurring with an incidence of 0.07-2% in the gastrointestinal tract. They are often associated with unspecific symptoms as intermittent abdominal pain, nausea and diarrhoea. The treatment of mild diverticular disease is intravenous fluids and antibiotics. If there is an occurrence of peritonitis as a complication of jejunal diverticulitis, laparatomy may be indicated. Both of the patients received a conservative treatment with intravenous fluids and antibiotics with good response.