Validation of modular endoscopic medial maxillectomies for inverted papilloma of the maxillary sinus.

BACKGROUND: Treatment of inverted papilloma of the maxillary sinus (IPMS) has a lower success rate compared to other IPs. As such, its correct management generally needs trans-nasal endoscopic medial maxillectomy (EMMs) for adequate resection. The aim of this manuscript is to describe outcomes and major prognostic factors of a cohort of patients with IPMS who were treated with EMM. METHODOLOGY: In this multicentric study, patients affected with IPMS and treated with EMMs were included. The site of origin of the IPMS were studied as well as the type of EMM performed. The histological features (IP vs dysplasia), type of mucosal resection (total vs. pedicle oriented), and post-operative complications were analyzed. RESULTS: 310 patients were included (212 primary and 98 recurrent cases). After a mean follow-up of 45.4 months, 15 patients experienced recurrence (4.8%) due to the application of EMMs tailored to the surgical insertion point. Dysplasia was significantly associated with a higher risk of recurrence. The rates of early and late complications were 11.6% and 11.9%, respectively. CONCLUSIONS: IPMS resection via tailored EMM is associated with excellent disease control, thus excluding the systematic use of extended EMMs, which can however be justified in case of dysplastic IPMS given its significant impact on recurrence.

Economic Studies Reinforce Efforts to Safeguard Specialty Crops in the United States.

Pathogen-tested foundation plant stocks are the cornerstone of sustainable specialty crop production. They provide the propagative units that are used to produce clean planting materials, which are essential as the first-line management option of diseases caused by graft-transmissible pathogens such as viruses, viroids, bacteria, and phytoplasmas. In the United States, efforts to produce, maintain, and distribute pathogen-tested propagative material of specialty crops are spearheaded by centers of the National Clean Plant Network (NCPN). Agricultural economists collaborated with plant pathologists, extension educators, specialty crop growers, and regulators to investigate the impacts of select diseases caused by graft-transmissible pathogens and to estimate the return on investments in NCPN centers. Economic studies have proven valuable to the NCPN in (i) incentivizing the use of clean planting material derived from pathogen-tested foundation plant stocks; (ii) documenting benefits of clean plant centers, which can outweigh operating costs by 10:1 to 150:1; (iii) aiding the development of disease management solutions that are not only ecologically driven but also profit maximizing; and (iv) disseminating integrated disease management recommendations that resonate with growers. Together, economic studies have reinforced efforts to safeguard specialty crops in the United States through the production and use of clean planting material.

Envisioning the future of colorectal surgery: preclinical assessment and detailed description of an endoluminal robotic system (ColubrisMX ELS).

BACKGROUND: The EndoLuminal Surgical System (ELS) is an emerging non-linear robotic system specifically designed for transanal surgery that allows for excision of colorectal neoplasia and luminal defect closure. METHODS: An evaluation of ELS was conducted by a single surgeon in a preclinical setting at the EndoSurgical Center of Florida in Orlando, between October 1st, 2020 and December 31st, 2020, using porcine colon as a model. Mock lesions measured 2.5 to 3.5 cm were excised partial-thickness. Specimen quality and excision time was assessed and evaluated. RESULTS: Twenty consecutive robotic transanal minimally invasive surgery (TAMIS) operations utilizing the ELS system were successfully performed without fragmentation. The mean and standard deviation procedure time for all 20 cases was 18.41 ± 14.15 min. The latter 10 cases were completed in substantially less time, suggesting that ELS requires at least 10 preclinical cases for a surgeon to become familiar with the technology. A second task, namely suture closure of the partial-thickness defect, was performed in 9 of the 20 cases. Mean time and standard deviation for this task measured 27.89 ± 10.07 min. There were no adverse events. CONCLUSIONS: ELS was successful in performing the tasks of partial-thickness disc excision and closure in a preclinical evaluation. Further study is necessary to determine its clinical applicability.

Initial clinical experience with a powered circular stapler for colorectal anastomosis.

BACKGROUND: The Echelon circular™ powered stapler (ECP stapler) obviates the need for manual firing of conventional circular staplers during the construction of a colorectal anastomosis, but has not been evaluated clinically. The aim of this study was to perform a clinical evaluation of this stapler. METHODS: A retrospective review of the initial clinical experience of a single surgeon using the ECP stapler for left-sided colorectal anastomosis construction during elective colorectal resections for benign and malignant disease was conducted by analyzing results from a prospectively maintained study database. Additionally, four attending colorectal and/or general surgeons who had performed ≥ 5 colorectal operations with the ECP stapler were invited to complete an anonymous online survey to subjectively assess the user experience with the device. Statistical analysis was conducted using Microsoft Excel Version 15.33. RESULTS: Seventeen patients underwent left-sided anastomotic reconstruction using the ECP stapler. All donuts (proximal and distal) were intact. Anastomotic integrity was evaluated using the air-leak test utilizing flexible video sigmoidoscopy. No leaks were observed, although one patient (5.9%) developed a postoperative pelvic abscess. The anonymous survey was completed by all four surgeons. Subjective evaluation of the ECP stapler suggests that the overall stapling quality, overall device ease-of-use, and the overall perception of anastomotic quality as above average when compared to manual 'end-to-end anastomosis' (EEA) stapling devices. CONCLUSIONS: In an initial clinical evaluation of the ECP stapler, the safety and ease-of-use of the device appears to be satisfactory. Powered stapling and the design of '3D stapling' may provide advantages over manual systems, and may improve the construction quality of left-sided colorectal anastomosis.

Assessment of the Versius surgical robotic system for dual-field synchronous transanal total mesorectal excision (taTME) in a preclinical model: will tomorrow's surgical robots promise newfound options?

BACKGROUND: The aim of this study was to evaluate the feasibility of the Versius surgical robotic system for transanal total mesorectal excision (taTME) in a preclinical setting. METHODS: Dry laboratory and cadaveric sessions were first conducted for three experienced colorectal surgeons in order to gain familiarity with the modular surgical system and the robotic workstation. After introduction, the system was configured to allow for synchronous, totally robotic taTME in a cadaver. RESULTS: Using the modular robotic system, one surgeon performed the abdominal portion of the operation, including colonic mobilization and vascular pedicle ligation while simultaneously a second surgeon performed the transanal portion of the operation to the point of rendezvous at the peritoneal reflection, where the operation was completed cooperatively. The operation was successfully completed in 195 min demonstrating preclinical feasibility of this unique approach with an emerging robotic system. CONCLUSIONS: This is the first preclinical assessment of the Versius surgical robotic system for taTME. The ability to work simultaneously carries the theoretical advantage of reducing surgical time and thereby reducing overall operative costs. It may also allow surgeons to maintain focus on critical parts of the operation by halving the fatigue associated with long, complex cases such as taTME.

Robotic-assisted stereotactic real-time navigation: initial clinical experience and feasibility for rectal cancer surgery.

BACKGROUND: Real-time stereotactic navigation for transanal total mesorectal excision has been demonstrated to be feasible in small pilot series using laparoscopic techniques. The possibility of real-time stereotactic navigation coupled with robotics has not been previously explored in a clinical setting. METHODS: After pre-clinical assessment, and configuration of a robotic-assisted navigational system, two patients with locally advanced rectal cancer were selected for enrollment into a pilot study designed to assess the feasibility of navigation coupled with the robotic da Vinci Xi platform via TilePro interface. In one case, fluorescence-guided surgery was also used as an adjunct for structure localization, with local administration of indocyanine green into the ureters and at the tumor site. RESULTS: Each operation was successfully completed with a robotic-assisted approach; image-guided navigation provided computed accuracy of ± 4.5 to 4.6 mm. The principle limitation encountered was navigation signal dropout due to temporary loss of direct line-of-sight with the navigational system's infrared camera. Subjectively, the aid of navigation assisted the operating surgeon in identifying critical anatomical planes. The combination of fluorescence with image-guided surgery further augmented the surgeon's perception of the operative field. CONCLUSIONS: The combination of stereotactic navigation and robotic surgery is feasible, although some limitations and technical challenges were observed. For complex surgery, the addition of navigation to robotics can improve surgical precision. This will likely represent the next step in the evolution of robotics and in the development of digital surgery.

Direct target NOTES: prospective applications for next generation robotic platforms.

BACKGROUND: A new era in surgical robotics has centered on alternative access to anatomic targets and next generation designs include flexible, single-port systems which follow circuitous rather than straight pathways. Such systems maintain a small footprint and could be utilized for specialized operations based on direct organ target natural orifice transluminal endoscopic surgery (NOTES), of which transanal total mesorectal excision (taTME) is an important derivative. METHODS: During two sessions, four direct target NOTES operations were conducted on a cadaveric model using a flexible robotic system to demonstrate proof-of-concept of the application of a next generation robotic system to specific types of NOTES operations, all of which required removal of a direct target organ through natural orifice access. These four operations were (a) robotic taTME, (b) robotic transvaginal hysterectomy in conjunction with (c) robotic transvaginal salpingo-oophorectomy, and in an ex vivo model, (d) trans-cecal appendectomy. RESULTS: Feasibility was demonstrated in all cases using the Flex® Robotic System with Colorectal Drive. During taTME, the platform excursion was 17 cm along a non-linear path; operative time was 57 min for the transanal portion of the dissection. Robotic transvaginal hysterectomy was successfully completed in 78 min with transvaginal extraction of the uterus, although laparoscopic assistance was required. Robotic transvaginal unilateral salpingo-oophorectomy with transvaginal extraction of the ovary and fallopian tube was performed without laparoscopic assistance in 13.5 min. In an ex vivo model, a robotic trans-cecal appendectomy was also successfully performed for the purpose of demonstrating proof-of-concept only; this was completed in 24 min. CONCLUSIONS: A flexible robotic system has the potential to access anatomy along circuitous paths, making it a suitable platform for direct target NOTES. The conceptual operations posed could be considered suitable for next generation robotics once the technology is optimized, and after further preclinical validation.

#colorectalsurgery.

BACKGROUND: The use of social media platforms among healthcare professionals is increasing. A Twitter social media campaign promoting the hashtag #colorectalsurgery was launched with the aim of providing a specialty-specific forum to collate discussions and science relevant to an engaged, global community of coloproctologists. This article reviews initial experiences of the early adoption, engagement and utilization of this pilot initiative. METHODS: The hashtag #colorectalsurgery was promoted via the online microblogging service Twitter across a 180-day interval. Data on all tweets containing the #colorectalsurgery hashtag were analysed using online analytical tools. Data included total number of tweets, number of views, and user engagement since registration and launch of the campaign. Content of tweet and user demographic analysis was undertaken. RESULTS: The number of tweets using #colorectalsurgery grew rapidly following the launch on 24 April 2016; #colorectalsurgery was used in 15 708 tweets, which resulted in 65 398 696 impressions and involved 1863 individual Twitter accounts. Increased volumes of #colorectalsurgery tweets were noted in association with the timing of three major international colorectal surgical conferences, and geographical trends were noted. Some 88·4 per cent of all posts were by male users. The top 25 users by volume of #colorectalsurgery tweets had considerable influence and posted 8023 tweets (51·1 per cent). CONCLUSION: Online global communities formed via healthcare-related hashtags, such as #colorectalsurgery, unify social media posts, scientists, surgeons and authors who have an interest in coloproctology. Furthermore, they facilitate greater connectivity among geographically separate users.

Operative vectors, anatomic distortion, fluid dynamics and the inherent effects of pneumatic insufflation encountered during transanal total mesorectal excision.

BACKGROUND: Transanal total mesorectal excision (taTME) is an altogether different approach to rectal cancer surgery, and the effects of carbon dioxide (CO2) on this dissection remain poorly described. METHODS: This article critically examines the effect of carbon dioxide insufflation and the workspace it creates during the process of taTME. The unique aspects of insulation with this approach are governed by the laws of physics, especially the principles of fluid dynamics, an area that remains poorly described for laparoscopy and not at all described for taTME. RESULTS: A summary of established factors which affect the operative field of the taTME surgeon is delineated and further explored. In addition, new concepts regarding gas delivery, such as insufflation vectors, anatomic distortion, hyper-dissection, and workspace volume rate of change as a function of taTME dissection time, are addressed. Collectively, these factors pose important challenges which increase case complexity and are thus essential for taTME trainers and trainees alike to understand. CONCLUSIONS: Although an invisible gas, CO2 insufflation with taTME produces markedly visible effects which are imposed upon the operative field. This can result in anatomic distortion and misperception of operative planes. Thus, practicing taTME surgeons should be cognizant of these effects.

Surgery beyond the visible light spectrum: theoretical and applied methods for localization of the male urethra during transanal total mesorectal excision.

The risk of urethral injury during transanal total mesorectal excision (taTME) is delineated, and potential risk factors for iatrogenic transection are reviewed. A variety of applied and theoretical techniques can be used by surgeons to diminish the risk of injury in males undergoing this operation. Many of the approaches utilize non-optic media and wavelengths beyond the visible light spectrum which can enhance the surgeon's frame of reference. The aim of the present study was to assess the techniques and theoretical approaches to urethral localization during taTME. Future directions in surgical imaging are also discussed, including the use of organic dyes, quantum dots, and carbon nanotubes; collectively, technology that could someday provide surgeons with an ability to identify anatomic structures prone to injury.

Adrenocortical carcinoma: patterns of care and role of adjuvant radiation therapy-a population-based study and review of the literature.

PURPOSE: We reviewed the experience of a tertiary cancer centre in the management of adrenocortical carcinoma (acc) treated over 40 years. We also searched the literature for guidelines related to the treatment of acc and for evidence for adjuvant radiation therapy (rt). METHODS: In a retrospective chart review, acc patients treated between January 1974 and December 2013 were identified, and patient demographics and tumour characteristics were extracted. Outcomes data, including dates and sites of failure, vital status, and cause of death, were collected. Overall survival was estimated using the Kaplan- Meier method. A medline search using PubMed, Ovid, and embase was used to review the literature about the role of rt and any available management guidelines for acc. RESULTS: Of 81 patients identified during the chart review, 39 had confirmed acc. In 32 patients, surgical resection was performed, including in 2 patients with M1 disease. Of those 32 patients, 16 received adjuvant systemic treatment (mitotane or concurrent chemoradiation). Only 6 patients received adjuvant rt, of whom 3 are still alive (2 living with distant failure). At a median follow-up of 3.8 years, 28 patients had died (72%), 10 were living (26%), and 1 had been lost to follow-up. Of the 22 patients for whom failure data were available, 2 experienced local failure, and the rest, distant failure. CONCLUSIONS: The current data are insufficient to make treatment recommendations. Use of collaborative databases and consensus about diagnostic and therapeutic guidelines are warranted for better identification of optimum management. Adjuvant rt could be a reasonable option for R1 disease, but further research is needed.

Transanal total mesorectal excision for rectal cancer: early outcomes in 50 consecutive patients.

AIM: Minimally invasive approaches to proctectomy for rectal cancer have not been widely adopted due to inherent technical challenges. A modification of traditional transabdominal mobilization, termed transanal total mesorectal excision (TaTME), has the potential to improve access to the distal rectum. The aim of the current study is to assess outcomes following TaTME for rectal cancer. METHOD: This is a retrospective analysis of a prospectively maintained database of consecutive patients who underwent TaTME for rectal cancer at a single institution. The study period was from 1 March 2012 to 31 July 2015. RESULTS: During the study period 50 patients underwent TaTME. The median tumour distance from the anal verge was 4.4 (3.0-5.5) cm. The rate of conversion from a planned minimally invasive approach was 2.2%. The median operative time was 267.0 (227.0-331.0) min. The median lymph node yield was 18.0 (12.0-23.8), the macroscopic quality assessment of the resected specimen was incomplete in 2% and the circumferential resection margin positivity rate was 4%. Intra-operative morbidity occurred in 6% and the 30 day morbidity rate was 36%. The median length of stay was 4.5 (4.0-8.0) days. The median follow-up was 15.1 (7.0-23.2) months; two patients have developed a local recurrence and eight patients have developed distant recurrence. CONCLUSION: These data suggest that TaTME for rectal cancer is feasible with an acceptable pathological outcome and morbidity profile. Further data on functional and long-term survival outcomes are required.

The iLappSurgery taTME app: a modern adjunct to the teaching of surgical techniques.

Application-based technology has emerged as a method of modern information communication, and this has been applied towards surgical training and education. It allows surgeons the ability to obtain portable and instant access to information that is otherwise difficult to deliver. The iLappSurgery Foundation has recently launched the transanal total mesorectal excision educational application (taTME app) which provides a useful adjunct, especially for surgeons interested in mastery of the taTME technique and its principles. The article provides a detailed review of the application, which has achieved a large user-base since its debut in June, 2016.

Critical concepts and important anatomic landmarks encountered during transanal total mesorectal excision (taTME): toward the mastery of a new operation for rectal cancer surgery.

Over the past 3 years, colorectal surgeons have begun to adapt the technique of transanal total mesorectal excision. As international experience has been quickly forged, an improved recognition of the pitfalls and the practical details of this disruptive technique have been realized. The purpose of this technical note was to express the various nuances of transanal total mesorectal excision as learned during the course of its clinical application and international teaching, so as to rapidly communicate and share important insights with other surgeons who are in the early adoption phase of this approach. The technical points specific to transanal total mesorectal excision are addressed herein. When correctly applied, these will likely improve the quality of surgery and decrease morbidity attributable to inexperience with the transanal approach to total mesorectal excision.

Transanal hemorrhoidal dearterialization (THD): a safe procedure for the anticoagulated patient?

BACKGROUND: Approximately one in five persons living in the USA is maintained on oral anticoagulation. It has typically been recommended that anticoagulation be withheld prior to hemorrhoidal procedures. Transanal hemorrhoidal dearterialization (THD) is a minimally invasive treatment for symptomatic hemorrhoids, and outcomes with patients on anticoagulation who have undergone this procedure have not been previously reported. Here, we report our preliminary results of patients who underwent THD while on anticoagulation. METHODS: During a 53-month period (February 2009-July 2015), patients with symptomatic hemorrhoids refractory to medical management who underwent surgical treatment with THD were retrospectively reviewed. The subset of patients who underwent THD while anticoagulated was compared to a cohort of patient who were not taking anticoagulation and who otherwise demonstrated normal coagulation profiles and who did not have a known predisposition to bleeding or inherited coagulopathy. The primary study endpoint was to assess postoperative bleeding in patients who were maintained on anticoagulation before and after surgery. RESULTS: During the 53-month study period, 106 patients underwent the THD procedure for symptomatic hemorrhoids. Of these, seventy patients underwent THD without anticoagulation therapy, while 36 patients underwent THD while taking one or more oral anticoagulants. The postoperative morbidity between the two cohorts was similar, and specifically there was no statistical difference in the rate of postoperative hemorrhage (19.4 vs. 15.7 %; odds ratio 1.295, 95 % CI 0.455-3.688, p = 0.785). No patient, in either cohort, required re-intervention for any reason during the study period. Patients who underwent THD while on anticoagulation were less likely to have recurrent hemorrhoidal disease during the study's 6-month median follow-up period (2.8 vs. 7.1 %, p = 0.049). CONCLUSIONS: These preliminary data reveal that THD can be performed on anticoagulated patients without cessation of oral agents without increasing morbidity from postoperative bleeding.

Natural-orifice transluminal endoscopic surgery.

BACKGROUND: Natural-orifice transluminal endoscopic surgery (NOTES) represents one of the most significant innovations in surgery to emerge since the advent of laparoscopy. A decade of progress with this approach has now been catalogued, and yet its clinical application remains controversial. METHODS: A PubMed search was carried out for articles describing NOTES in both the preclinical and the clinical setting. Public perceptions and expert opinion regarding NOTES in the published literature were analysed carefully. RESULTS: Two hundred relevant articles on NOTES were studied and the outcomes reviewed. A division between direct- and indirect-target NOTES was established. The areas with the most promising clinical application included direct-target NOTES, such as transanal total mesorectal excision and peroral endoscopic myotomy. The clinical experience with distant-target NOTES, such as for appendicectomy and cholecystectomy, showed feasibility; however, NOTES-specific morbidity was introduced and this represents an important limitation. CONCLUSION: NOTES experimentation in the preclinical setting has increased substantially. There has also been a significant increase in the application of NOTES in humans in the past decade. Enthusiasm for NOTES should be tempered by the risk of incurring NOTES-specific morbidity. Surgeons should carefully consider patient preferences regarding this new minimally invasive option, as opinions are not unanimously supportive of NOTES. As technical limitations are overcome, the clinical application of NOTES is predicted to increase. It is paramount that, when this complex technique is performed on humans, it is applied judiciously by appropriately trained experts with outcomes recorded in a registry.

Image-guided real-time navigation for transanal total mesorectal excision: a pilot study.

BACKGROUND: Frameless stereotaxy for real-time, image-guided surgery has been most utilized for neurological and orthopedic surgery. Recently, our center has reported the application of real-time navigation for transanal total mesorectal excision. METHODS: During a 5-month period (June 2013-October 2013), three male patients underwent transanal minimally invasive surgery for total mesorectal excision with image-guided real-time navigation during the transanal portion of the operation. This was completed using a frameless stereotactic navigational system as shown in a demonstration video. Male patients with anterior, locally advanced rectal cancer were selected for enrollment into the pilot study. RESULTS: Three male patients (mean age 69) underwent transanal total mesorectal excision with stereotactic navigation during a 5-month study period. Mean operative time was 402 min, and there were no intra-operative complications recorded. The mean distance from anal verge of the tumor was 6.3 cm (range 4-8 cm). The navigational accuracy was computed to be ±3.69 mm (range ±3.20 to ±4.02 mm). The average navigation setup time was 47 min, not including scan time. The surgical specimens were found to have completely intact mesorectal envelopes (Quirke 3) in all cases. All margins, including radial and distal margins, were negative. Mean postoperative length of stay was 5 days. At a median of 18-month follow-up, there was no evidence of locoregional recurrence or distant metastatic disease. CONCLUSION: This is the first pilot series to report the use of frameless stereotactic navigation for TAMIS-TME. Stereotactic navigation for transanal total mesorectal excision is shown to be feasible, and may aid in providing colorectal surgeons with the ability to better perform safe, high-quality surgery in select cases.