Virtual Reality for Preoperative Planning in Complex Surgical Oncology: A Single-Center Experience.

INTRODUCTION: Virtual reality models (VRM) are three-dimensional (3D) simulations of two-dimensional (2D) images, creating a more accurate mental representation of patient-specific anatomy. METHODS: Patients were retrospectively identified who underwent complex oncologic resections whose operations differed from preoperative plans between April 2018 and April 2019. Virtual reality modeling was performed based on preoperative 2D images to assess feasibility of use of this technology to create models. Preoperative plans made based upon 2D imaging versus VRM were compared to the final operations performed. Once the use of VRM to create preoperative plans was deemed feasible, individuals undergoing complex oncologic resections whose operative plans were difficult to define preoperatively were enrolled prospectively from July 2019 to December 2021. Preoperative plans made based upon 2D imaging and VRM by both the operating surgeon and a consulting surgeon were compared to the operation performed. Confidence in each operative plan was also measured. RESULTS: Twenty patients were identified, seven retrospective and 13 prospective, with tumors of the liver, pancreas, retroperitoneum, stomach, and soft tissue. Retrospectively, VRM were unable to be created in one patient due to a poor quality 2D image; the remainder (86%) were successfully able to be created and examined. Virtual reality modeling more clearly defined the extent of resection in 50% of successful cases. Prospectively, all VRM were successfully performed. The concordance of the operative plan with VRM was higher than with 2D imaging (92% versus 54% for the operating surgeon and 69% versus 23% for the consulting surgeon). Confidence in the operative plan after VRM compared to 2D imaging also increased for both surgeons (by 15% and 8% for the operating and consulting surgeons, respectively). CONCLUSIONS: Virtual reality modeling is feasible and may improve preoperative planning compared to 2D imaging. Further investigation is warranted.

Safety and efficacy of synchronous robotic surgery for colorectal cancer with liver metastases.

Timing of resection and treatment of colorectal cancer (CRC) with liver metastases varies based on patient characteristics and center protocols. Concerns of increased morbidity and mortality (M&M) related to anesthetic time and blood loss have limited widespread adaptation of synchronous colorectal and liver resections. Furthermore, technical challenges have made minimally invasive synchronous resections less common. We present our series of synchronous robotic surgery for CRC with liver metastases. Retrospective review of prospectively collected data of patients with stage IV CRC with liver metastases treated at a tertiary center from February 2013 to June 2014. Patients who underwent synchronous robotic surgery for CRC with liver metastasis(es) were included and selected by a multidisciplinary cancer committee. Data included patient demographics, disease stage, OR time, EBL, and complications. All resections were performed robotically by the same well-experienced surgeons. A radiologist was present for intraoperative ultrasound. Liver treatment was performed first in consideration of intraoperative bleeding risk. Sixty-six patients with Stage IV CRC were seen at the tertiary center during the study period. Six patients met inclusion criteria (2 male, 4 female). Mean age was 59.3 years and mean BMI was 23.46. Mean of 2.25 liver segments were resected and mean of 1.75 liver segments were ablated. Four patients underwent metastatectomy; three with concurrent microwave ablation. One patient had ablation without resection and another had no identifiable lesion on ultrasound. The colonic resections included 3 low anterior resections, 2 abdominal perineal resections (APR), and 1 right hemicolectomy. Mean operative time was 401 min (349-506 min) with mean EBL of 316 mL (150-1000 mL). No conversions to an open approach occurred. Median length of stay (LOS) was 4.5 days (3-10 days). Complications included delayed wound healing after an APR and a delayed rectal anastomotic failure after ileostomy reversal. There was no 30-day mortality. At a mean follow-up of 19 months, one death occurred at 26 months and the remaining patients had documented metastatic disease. Synchronous resection for metastatic CRC carries risks. We report our series of synchronous robotic surgery for CRC with liver metastases. The robotic approach contributed to low blood loss, appropriate LOS, and no 30-day mortality. Morbidity experienced was consistent with the procedures and not related to the robotic technique. This series supports the potential benefits of synchronous resection from a technical standpoint. Further data are required to determine treatment and survival benefits. Limitations include small number and retrospective review of data.

Stricture dilation after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: In surgical treatment of morbid obesity, maintaining a restrictive anastomosis is key to long-range success. However, laparoscopic Roux-en-Y gastric bypass (LRYGB) may result in gastrojejunal (GJ) stricture, requiring treatment in up to 27% of patients. METHODS: This is a retrospective review of the outcome of 223 consecutive LRYGB patients. Patients developing stricture received standard endoscopic balloon dilation by the same surgeon. Stricture and nonstricture groups were compared for excess body weight loss (EBWL) at 1, 3, 6, and 12 months. RESULTS: GJ stricture requiring dilation occurred in 38 patients (17%). After dilation all patients were relieved of stricture symptoms and none required revision. By 12 months, patients with stricture had an EBWL of 86% compared with nonstrictured patients at 75%. CONCLUSION: Endoscopic balloon dilation is a safe and effective treatment option for GJ stricture. Improved weight loss occurred for patients with stricture requiring dilation.

Roux-en-Y gastric bypass leak complications.

HYPOTHESIS: Enteric leakage is a significant complication of the Roux-en-Y gastric bypass (RYGB) procedure that can be treated successfully. DESIGN: Retrospective study of 400 consecutive RYGB patients from 1999-2002. SETTING: Community hospital with a university surgical residency. PATIENTS: Hospital records of 400 morbidly obese patients who underwent gastric bypass surgery were reviewed. MAIN OUTCOME MEASURES: Time of discovery of leak, location of leak, treatment, hospital stay, and mortality. RESULTS: Twenty-one patients (5.25%) developed leaks. The mean body mass index (calculated as weight in kilograms divided by the square of height in meters) was 54.2. Thirteen patients were noted to develop a leak at the gastrojejunal anastomosis, with an average time to diagnosis of 7.0 days. Five of these patients underwent reexploration, and 8 were successfully treated with percutaneous drainage alone. Four patients developed leaks at the jejunojejunal anastomosis (mean time to diagnosis, 2.0 days). All of these patients required exploration, and 2 patients died. Four patients were noted to have leaks in other areas (average time to diagnosis, 3.5 days). Two patients were treated with drainage, and 2 underwent exploration. The average hospital stay of all patients was 33 days. CONCLUSIONS: Enteric leakage is a significant complication of the RYGB. Patients who are suspected of having an enteric leak because of signs of sepsis or hemodynamic instability require emergent exploration. Leaks that are more insidious may be treated successfully with percutaneous drainage. Aggressive exploration of patients who appear to be septic, and percutaneous drainage of insidiously developing leaks may decrease patients' morbidity and mortality.

Body composition analysis in bariatric surgery: use of air displacement plethysmograph.

Body weight, body mass index (BMI), and percent excess weight loss are used to assess patient outcomes after bariatric surgery; however, they provide little insight into the true nature of the patient's weight loss. Body composition measurements monitor fat versus lean mass losses to permit interventions to reduce or avoid lean body mass loss after bariatric surgery. A retrospective review of patients who underwent bariatric surgery between 2002 and 2008 was performed. Patients underwent body composition testing via air displacement plethysmography before and after surgery (6 and 12 months). Body composition changes were assessed and compared with the BMI. Results include 330 patients (54 male, 276 female). Average preoperative weight was 139 kg, BMI was 50 kg/m(2), fat percentage was 55 per cent, and lean mass percent was 45 per cent. Twelve months after surgery average weight was 90 kg, mean BMI was 32 kg/m(2), fat percentage was 38 per cent, and lean mass percent was 62 per cent. Body composition measurements help monitor fat losses versus lean mass gains after bariatric surgery. This may give a better assessment of the patient's health and metabolic state than either BMI or excess weight loss and permits intervention if weight loss results in lean mass losses.

Perinatal management of gastroschisis: analysis of a newly established clinical pathway.

PURPOSE: The authors developed a clinical pathway for optimal management after antenatal diagnosis of gastroschisis. This is the outcomes analysis of our first 30 consecutive patients. METHOD: Antenatal counseling was provided for all families with in-utero diagnosis of gastroschisis. Bowel dilatation, thickness, motility, amniotic fluid volume, and fetal development were followed by ultrasonography every 4 weeks. Babies were delivered by cesarean section between 36 and 38 weeks gestation if the lungs were mature or earlier for bowel complications. Gastroschisis repair was scheduled 90 minutes after birth. Primary repair was attempted in all through the abdominal wall defect without an additional incision, resulting in an umbilicus with no abdominal scar. RESULTS: Primary repair was achieved in 83%. Babies needed assisted ventilation for 3 days, reached full feeds by 19 days, and were discharged by 24 days (all medians). There were 3 (10%) deaths, all after staged repair. CONCLUSIONS: Our new protocol of both scheduled elective cesarean section and early gastroschisis repair resulted in a higher proportion of primary repair, shorter duration of mechanical ventilation, earlier full feeds, and shorter length of stay. There was no increase in mortality or morbidity. The primary-repair babies had no mortality and had excellent cosmesis.