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BACKGROUND: Laparoscopic simultaneous resection (LSR) of primary colorectal tumors and synchronous colorectal liver metastases (sCRLM) has been recently performed. This study aimed to evaluate the postoperative outcomes after LSR and determine the risk factors for resection surface-related complications (RSRC), such as postoperative biliary fistula and liver-transection surface abscess. METHODS: Between 2009 and 2022, consecutive patients with sCRLM who underwent LSR were included. We retrospectively analyzed clinicopathological data, including intraoperative factors and postoperative outcomes. The difficulty level of all liver resections was classified according to the IWATE difficulty scoring system (DSS). We then performed univariate and multivariate analyses to identify the risk factors for RSRC. RESULTS: Of the 112 patients, 94 (83.9%) underwent partial hepatectomy and colorectal surgery. The median DSS score was 5 points (1-11), with 12 (10.7%) patients scoring ≥ 7 points. Postoperative complications were observed in 41 (36.6%) patients, of whom 16 (14.3%) experienced severe complications classified as Clavien-Dindo grade IIIa or higher. There was no postoperative mortality. The most common complication was RSRC (19 patients, 17.0%). Multivariate analysis identified American Society of Anesthesiologists (ASA) classification ≥ 3 [odds ratio (OR) 10.3, 95% confidence interval (CI) 1.37-77.8; P = 0.023], DSS score ≥ 7 points (OR 5.08, 95% CI 1.17-20.0; P = 0.030), and right-sided colectomy (OR 4.67, 95% CI 1.46-15.0; P = 0.009) as independent risk factors for RSRC. Postoperative hospital stays were significantly longer for patients with RSRC than for those without RSRC (22 days vs. 11 days; P < 0.001). CONCLUSION: Short-term outcomes of LSR for patients with sCRLM were acceptable in an experienced center. RSRC was the most common complication, and high-difficulty hepatectomy, right-sided colectomy, and ASA classification ≥ 3 were independent risk factors for RSRC.
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BACKGROUND: Iatrogenic ureteral injury is a serious complication of abdominopelvic surgery. Identifying the ureters intraoperatively is essential to avoid iatrogenic ureteral injury. Here, we developed a model that may minimize this complication. IMPACT OF INNOVATION: We applied a deep learning-based semantic segmentation algorithm to the ureter recognition task and developed a deep learning model called UreterNet. This study aimed to verify whether the ureters could be identified in videos of laparoscopic colorectal surgery. TECHNOLOGY MATERIALS AND METHODS: Semantic segmentation of the ureter area was performed using a convolutional neural network-based approach. Feature Pyramid Networks were used as the convolutional neural network architecture for semantic segmentation. Precision, recall, and the dice coefficient were used as the evaluation metrics in this study. PRELIMINARY RESULTS: We created 14,069 annotated images from 304 videos, with 9537, 2266, and 2266 images in the training, validation, and test datasets, respectively. Concerning ureter recognition performance, precision, recall, and the Dice coefficient for the test data were 0.712, 0.722, and 0.716, respectively. Regarding the real-time performance on recorded videos, it took 71 ms for UreterNet to infer all pixels corresponding to the ureter from a single still image and 143 ms to output and display the inferred results as a segmentation mask on the laparoscopic monitor. CONCLUSIONS AND FUTURE DIRECTIONS: UreterNet is a noninvasive method for identifying the ureter in videos of laparoscopic colorectal surgery and can potentially improve surgical safety. Although this could lead to the development of an image-navigated surgical system, it is necessary to verify whether UreterNet reduces the occurrence of iatrogenic ureteral injury.
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The sigmoid colon simulator was designed to accurately reproduce the anatomical layer structure and the arrangement of characteristic organs in each layer, and to have conductivity so that energy devices can be used. Dry polyester fibers were used to reproduce the layered structures, which included characteristic blood vessels, nerve sheaths, and intestinal tracts. The adhesive strength of the layers was controlled to allow realistic peeling techniques. The features of the Sigmaster are illustrated through a comparison of simulated sigmoidectomy using Sigmaster and actual surgery. We developed a laparoscopic sigmoidectomy simulator called Sigmaster. Sigmaster is a training device that closely reproduces the membrane structures of the human body and allows surgeons to experience the entire laparoscopic sigmoidectomy process.
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BACKGROUND: An unexpectedly large number of patients experienced local recurrence with transanal total mesorectal excision in Norway. This appears to be associated with cancer cell spillage during surgery. OBJECTIVE: To investigate the surgical field cytology during transanal total mesorectal excision. DESIGN: This was a prospective cohort study. SETTINGS: This study was conducted at a single center between June and December 2020. PATIENTS: Forty patients with rectal cancer underwent transanal total mesorectal excision. After irrigation of the surgical field, the water specimens were cytologically evaluated at 6 representative steps. The first sample was used as an initial control. The second, third, fourth, fifth, and sixth samples were collected after the first pursestring suture, rectotomy, the second pursestring suture, specimen resection, and anastomosis, respectively. The clinicopathological features and intraoperative complications of the patients were reviewed. MAIN OUTCOME MEASURES: The primary outcome was to evaluate the presence of cancer cells in washing cytological samples. RESULTS: Of the 40 consecutive patients enrolled in this study, 18 patients underwent neoadjuvant chemoradiotherapy. Incomplete first pursestring suture and rectal perforation were observed in 4 (10.0%) and 3 (7.5%) cases, respectively. In the first sample, 31 patients (77.5%) had malignant cells. Malignant findings were detected in 2 patients (5.0%) from the second to fifth samples. None of the sixth sample exhibited any malignant findings. LIMITATIONS: This single-center study had a small sample size. CONCLUSIONS: Cancer cells were initially detected by cytology, but only a few were observed throughout the procedure; however, cancer cells were not detected in the final surgical field. Further follow-up and novel studies are required to obtain clinically significant findings using cytology during transanal total mesorectal excision. See Video Abstract . ANLISIS CITOLGICO DEL CAMPO QUIRRGICO DURANTE LA ESCISIN TOTAL DEL MESORRECTO TRANSANAL PARA EL CNCER DE RECTO UN ESTUDIO PROSPECTIVO: ANTECEDENTES:Un número inesperadamente grande de pacientes experimentó recurrencia local con la escisión total del mesorrecto transanal en Noruega. Esto parece estar asociado con el derrame de células cancerosas durante la cirugía.OBJETIVO:Investigar la citología del campo quirúrgico durante la escisión total del mesorrecto transanal.DISEÑO:Este fue un estudio de cohorte prospectivo.ENTORNO CLINICO:Este estudio se realizó en un solo centro entre junio y diciembre de 2020.PACIENTES:Cuarenta pacientes con cáncer de recto se sometieron a escisión total del mesorrecto transanal. Después de la irrigación del campo quirúrgico, las muestras de agua se evaluaron citológicamente en seis pasos representativos. La primera muestra se utilizó como control inicial. La segunda, tercera, cuarta, quinta y sexta muestras se recolectaron después de la primera sutura en bolsa de tabaco, la rectotomía, la segunda sutura en bolsa de tabaco, la resección de la muestra y la anastomosis, respectivamente. Se revisaron las características clínico-patológicas y las complicaciones intraoperatorias de los pacientes.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue evaluar la presencia de células cancerosas en el lavado de muestras citológicas.RESULTADOS:De los 40 pacientes consecutivos inscritos en este estudio, 18 pacientes se sometieron a quimiorradioterapia neoadyuvante. Se observaron la primera sutura en bolsa de tabaco incompleta y perforación rectal en cuatro (10,0%) y tres (7,5%) casos, respectivamente. En la primera muestra, 31 (77,5%) pacientes tenían células malignas. Se detectaron hallazgos malignos en dos pacientes (5,0%) de la segunda a la quinta muestra. Ninguno de la sexta muestra demostraron hallazgos malignos.LIMITACIONES:Este estudio unicéntrico tuvo un tamaño de muestra pequeño.CONCLUSIONES:Inicialmente se detectaron células cancerosas mediante citología, pero solo se observaron unas pocas durante todo el procedimiento; sin embargo, no se detectaron células cancerosas en el campo quirúrgico final. Se requieren más seguimientos y estudios novedosos para obtener hallazgos clínicamente significativos mediante citología durante la escisión total del mesorrecto transanal. (Traducción- Dr. Francisco M. Abarca-Rendon ).
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Protectomia , Neoplasias Retais , Humanos , Neoplasias Retais/cirurgia , Neoplasias Retais/patologia , Masculino , Feminino , Estudos Prospectivos , Idoso , Pessoa de Meia-Idade , Protectomia/métodos , Cirurgia Endoscópica Transanal/métodos , Recidiva Local de Neoplasia/epidemiologia , Noruega/epidemiologia , Idoso de 80 Anos ou mais , Adulto , Terapia Neoadjuvante/métodosRESUMO
Atypical femoral fractures (AFFs) occur with minor trauma and are believed to be a potential complication of the prolonged use of antiresorptive agents, such as bisphosphonate and denosumab, for the treatment of bone metastasis. In comparison with typical femoral fractures, AFFs have a higher incidence of complications, including implant failure and delayed union or nonunion. This report describes the case of a 42-year-old woman who developed denosumab-associated AFF after denosumab therapy for bone metastasis from breast cancer. Surgical treatment with IMN was performed after open anatomical reduction. To reduce the risk of delayed union and nonunion, the autogenous bone graft obtained from the iliac crest was conducted. The radiograph taken 5 weeks after surgery showed callus formation. Full weight bearing was allowed 3 months after surgery. Six months postoperatively, radiographs and computed tomography images demonstrated bone union. Twelve months after surgery, the patient was able to walk easily without pain. For cancer patients with bone metastasis whose life expectancy may be limited, a decline in physical activity can be fatal. Consequently, it is crucial to avoid a decrease in activities of daily living brought about by delayed union or nonunion. In this regard, autogenous bone grafting is a viable and effective technique for the treatment of AFFs in patients with bone metastases.
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BACKGROUND: The precise recognition of liver vessels during liver parenchymal dissection is the crucial technique for laparoscopic liver resection (LLR). This retrospective feasibility study aimed to develop artificial intelligence (AI) models to recognize liver vessels in LLR, and to evaluate their accuracy and real-time performance. METHODS: Images from LLR videos were extracted, and the hepatic veins and Glissonean pedicles were labeled separately. Two AI models were developed to recognize liver vessels: the "2-class model" which recognized both hepatic veins and Glissonean pedicles as equivalent vessels and distinguished them from the background class, and the "3-class model" which recognized them all separately. The Feature Pyramid Network was used as a neural network architecture for both models in their semantic segmentation tasks. The models were evaluated using fivefold cross-validation tests, and the Dice coefficient (DC) was used as an evaluation metric. Ten gastroenterological surgeons also evaluated the models qualitatively through rubric. RESULTS: In total, 2421 frames from 48 video clips were extracted. The mean DC value of the 2-class model was 0.789, with a processing speed of 0.094 s. The mean DC values for the hepatic vein and the Glissonean pedicle in the 3-class model were 0.631 and 0.482, respectively. The average processing time for the 3-class model was 0.097 s. Qualitative evaluation by surgeons revealed that false-negative and false-positive ratings in the 2-class model averaged 4.40 and 3.46, respectively, on a five-point scale, while the false-negative, false-positive, and vessel differentiation ratings in the 3-class model averaged 4.36, 3.44, and 3.28, respectively, on a five-point scale. CONCLUSION: We successfully developed deep-learning models that recognize liver vessels in LLR with high accuracy and sufficient processing speed. These findings suggest the potential of a new real-time automated navigation system for LLR.
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Inteligência Artificial , Laparoscopia , Humanos , Estudos Retrospectivos , Fígado/diagnóstico por imagem , Fígado/cirurgia , Fígado/irrigação sanguínea , Hepatectomia/métodos , Laparoscopia/métodosRESUMO
BACKGROUND: In laparoscopic right hemicolectomy (RHC) for right-sided colon cancer, accurate recognition of the vascular anatomy is required for appropriate lymph node harvesting and safe operative procedures. We aimed to develop a deep learning model that enables the automatic recognition and visualization of major blood vessels in laparoscopic RHC. MATERIALS AND METHODS: This was a single-institution retrospective feasibility study. Semantic segmentation of three vessel areas, including the superior mesenteric vein (SMV), ileocolic artery (ICA), and ileocolic vein (ICV), was performed using the developed deep learning model. The Dice coefficient, recall, and precision were utilized as evaluation metrics to quantify the model performance after fivefold cross-validation. The model was further qualitatively appraised by 13 surgeons, based on a grading rubric to assess its potential for clinical application. RESULTS: In total, 2624 images were extracted from 104 laparoscopic colectomy for right-sided colon cancer videos, and the pixels corresponding to the SMV, ICA, and ICV were manually annotated and utilized as training data. SMV recognition was the most accurate, with all three evaluation metrics having values above 0.75, whereas the recognition accuracy of ICA and ICV ranged from 0.53 to 0.57 for the three evaluation metrics. Additionally, all 13 surgeons gave acceptable ratings for the possibility of clinical application in rubric-based quantitative evaluations. CONCLUSION: We developed a DL-based vessel segmentation model capable of achieving feasible identification and visualization of major blood vessels in association with RHC. This model may be used by surgeons to accomplish reliable navigation of vessel visualization.
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Neoplasias do Colo , Aprendizado Profundo , Laparoscopia , Humanos , Neoplasias do Colo/diagnóstico por imagem , Neoplasias do Colo/cirurgia , Neoplasias do Colo/irrigação sanguínea , Estudos Retrospectivos , Laparoscopia/métodos , Colectomia/métodosRESUMO
For transanal total mesorectal excision (TaTME), the indication for single-stapling technique (SST) has been expanded to include lower anastomosis, even in intersphincteric resection (ISR). We focused on the anastomotic techniques following ISR with TaTME and examined the feasibility and safety of the SST below the anorectal junction (ARJ). Data on postoperative anastomosis-related complications and anorectal function was evaluated in comparison to conventional manual hand-sewn coloanal anastomosis in ISR with TaTME. We examined patients with 3-6 cm tumors from the anal verge who underwent ISR with TaTME between January 2018 and March 2020, and whose anastomotic line was located below the ARJ. Postoperative short-term outcomes and anorectal functions were compared. We also analyzed the effects of various factors on major low anterior resection syndrome (LARS) using multivariate logistic regression analysis. In total, 87 patients-48 in the hand-sewn anastomosis group and 39 in the SST group-were included in this study. SST below the ARJ in ISR with TaTME did not exacerbate surgical outcomes, including anastomosis-related complications. The SST group had a significantly lower LARS score as compared to the hand-sewn anastomosis group, and the proportion of major LARS was significantly lower. Only hand-sewn anastomosis was identified as a statistically significant independent risk factor for major LARS. In TaTME, SST below the ARJ was safe and feasible and had a lower negative impact on postoperative anastomosis-related complications and anorectal function as compared to hand-sewn anastomosis. Thus, SST is a promising anastomotic option for patients with low-lying rectal tumors.
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Laparoscopic surgery is widely used for rectal cancer; however, this technique is challenging due to tapering of the mesorectum in the pelvis, and the forward angle of the distal rectum, which renders this part of the rectum less accessible from the abdominal cavity. Hence, concerns regarding its safety and curability have been raised, particularly for inadequate distal and circumferential resection margins. Recently, transanal total mesorectal excision (TaTME), which involves endoscopic total mesorectal excision (TME) retrogradely from the anal side, has attracted attention worldwide as a solution to these problems. TaTME is superior to the conventional laparoscopic approach for rectal cancer in terms of both oncological and functional preservations. However, a shallow learning curve caused by the unfamiliar anatomical view from the anal side can pose challenges. Therefore, an efficient educational system needs to be established. Randomized controlled trials comparing conventional laparoscopic TME with TaTME are ongoing to demonstrate the usefulness of TaTME. This article reviews changes in the surgical treatment of rectal cancer, with a focus on TaTME, and describes the indications, surgical techniques, and training curricula for TaTME.
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To prevent intraoperative organ injury, surgeons strive to identify anatomical structures as early and accurately as possible during surgery. The objective of this prospective observational study was to develop artificial intelligence (AI)-based real-time automatic organ recognition models in laparoscopic surgery and to compare its performance with that of surgeons. The time taken to recognize target anatomy between AI and both expert and novice surgeons was compared. The AI models demonstrated faster recognition of target anatomy than surgeons, especially novice surgeons. These findings suggest that AI has the potential to compensate for the skill and experience gap between surgeons.
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Cirurgia Colorretal , Procedimentos Cirúrgicos do Sistema Digestório , Laparoscopia , Humanos , Inteligência ArtificialRESUMO
Importance: Automatic surgical skill assessment with artificial intelligence (AI) is more objective than manual video review-based skill assessment and can reduce human burden. Standardization of surgical field development is an important aspect of this skill assessment. Objective: To develop a deep learning model that can recognize the standardized surgical fields in laparoscopic sigmoid colon resection and to evaluate the feasibility of automatic surgical skill assessment based on the concordance of the standardized surgical field development using the proposed deep learning model. Design, Setting, and Participants: This retrospective diagnostic study used intraoperative videos of laparoscopic colorectal surgery submitted to the Japan Society for Endoscopic Surgery between August 2016 and November 2017. Data were analyzed from April 2020 to September 2022. Interventions: Videos of surgery performed by expert surgeons with Endoscopic Surgical Skill Qualification System (ESSQS) scores higher than 75 were used to construct a deep learning model able to recognize a standardized surgical field and output its similarity to standardized surgical field development as an AI confidence score (AICS). Other videos were extracted as the validation set. Main Outcomes and Measures: Videos with scores less than or greater than 2 SDs from the mean were defined as the low- and high-score groups, respectively. The correlation between AICS and ESSQS score and the screening performance using AICS for low- and high-score groups were analyzed. Results: The sample included 650 intraoperative videos, 60 of which were used for model construction and 60 for validation. The Spearman rank correlation coefficient between the AICS and ESSQS score was 0.81. The receiver operating characteristic (ROC) curves for the screening of the low- and high-score groups were plotted, and the areas under the ROC curve for the low- and high-score group screening were 0.93 and 0.94, respectively. Conclusions and Relevance: The AICS from the developed model strongly correlated with the ESSQS score, demonstrating the model's feasibility for use as a method of automatic surgical skill assessment. The findings also suggest the feasibility of the proposed model for creating an automated screening system for surgical skills and its potential application to other types of endoscopic procedures.
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Procedimentos Cirúrgicos do Sistema Digestório , Laparoscopia , Humanos , Inteligência Artificial , Estudos Retrospectivos , Laparoscopia/métodos , Curva ROCRESUMO
BACKGROUND: Anastomotic leakage has been reported to occur when the load on the anastomotic site exceeds the resistance created by sutures, staples, and early scars. It may be possible to avoid anastomotic leakage by covering and reinforcing the anastomotic site with a biocompatible material. The aim of this study was to evaluate the safety and feasibility of a novel external reinforcement device for gastrointestinal anastomosis in an experimental model. METHODS: A single pig was used in this non-survival study, and end-to-end anastomoses were created in six small bowel loops by a single-stapling technique using a circular stapler. Three of the six anastomoses were covered with a novel external reinforcement device. Air was injected, a pressure test of each anastomosis was performed, and the bursting pressure was measured. RESULTS: Reinforcement of the anastomotic site with the device was successfully performed in all anastomoses. The bursting pressure was 76.1 ± 5.7 mmHg in the control group, and 126.8 ± 6.8 mmHg in the device group, respectively. The bursting pressure in the device group was significantly higher than that in the control group (p = 0.0006). CONCLUSIONS: The novel external reinforcement device was safe and feasible for reinforcing the anastomoses in the experimental model.
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Fístula Anastomótica , Intestino Delgado , Suínos , Animais , Fístula Anastomótica/prevenção & controle , Fístula Anastomótica/cirurgia , Anastomose Cirúrgica/métodos , Intestino Delgado/cirurgia , Grampeamento Cirúrgico/métodos , CicatrizRESUMO
BACKGROUND: To compare the short-term outcomes of patients undergoing intracorporeal anastomosis (IA) during laparoscopic colectomy to those undergoing extracorporeal anastomosis (EA). METHODS AND MATERIALS: The study was a single-centre retrospective propensity score-matched analysis conducted. Consecutive patients who underwent elective laparoscopic colectomy without the double stapling technique between January 2018 and June 2021 were investigated. The main outcome was overall postoperative complications within 30 days after the procedure. The authors also performed a sub-analysis of the postoperative results of ileocolic anastomosis and colocolic anastomosis, respectively. RESULTS: A total of 283 patients were initially extracted; after propensity score matching, there were 113 patients in each of the IA and EA groups. There were no differences in patient characteristics between the two groups. The IA group had a significantly longer operative time than the EA group (208 vs. 183 min, P =0.001). The rate of overall postoperative complications was significantly lower in the IA group ( n =18, 15.9%) than in the EA group ( n =34, 30.1%; P =0.02), especially in colocolic anastomosis after left-sided colectomy (IA: 23.8% vs. EA: 59.1%; P =0.03). Postoperative inflammatory marker levels were significantly higher in the IA group on postoperative day 1 but not on postoperative day 7. There was no difference in the postoperative lengths of hospital stay between the two groups, and no deaths occurred. CONCLUSION: The data suggest that performing IA during laparoscopic colectomy can potentially reduce the risk of postoperative complications, especially in colocolic anastomosis after left-sided colectomy.
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Neoplasias do Colo , Laparoscopia , Humanos , Estudos Retrospectivos , Pontuação de Propensão , Resultado do Tratamento , Colectomia/efeitos adversos , Colectomia/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Neoplasias do Colo/cirurgiaRESUMO
BACKGROUND: Purse-string suture in transanal total mesorectal excision is a key procedural step. The aims of this study were to develop an automatic skill assessment system for purse-string suture in transanal total mesorectal excision using deep learning and to evaluate the reliability of the score output from the proposed system. METHODS: Purse-string suturing extracted from consecutive transanal total mesorectal excision videos was manually scored using a performance rubric scale and computed into a deep learning model as training data. Deep learning-based image regression analysis was performed, and the purse-string suture skill scores predicted by the trained deep learning model (artificial intelligence score) were output as continuous variables. The outcomes of interest were the correlation, assessed using Spearman's rank correlation coefficient, between the artificial intelligence score and the manual score, purse-string suture time, and surgeon's experience. RESULTS: Forty-five videos obtained from five surgeons were evaluated. The mean(s.d.) total manual score was 9.2(2.7) points, the mean(s.d.) total artificial intelligence score was 10.2(3.9) points, and the mean(s.d.) absolute error between the artificial intelligence and manual scores was 0.42(0.39). Further, the artificial intelligence score significantly correlated with the purse-string suture time (correlation coefficient = -0.728) and surgeon's experience (P< 0.001). CONCLUSION: An automatic purse-string suture skill assessment system using deep learning-based video analysis was shown to be feasible, and the results indicated that the artificial intelligence score was reliable. This application could be expanded to other endoscopic surgeries and procedures.
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Aprendizado Profundo , Neoplasias Retais , Humanos , Inteligência Artificial , Reprodutibilidade dos Testes , SuturasRESUMO
BACKGROUND: Transanal total mesorectal excision is a promising surgical treatment for rectal cancer. However, evidence regarding the differences in outcomes between the transanal and laparoscopic total mesorectal excisions is scarce. We compared the short-term outcomes of transanal and laparoscopic total mesorectal excisions for low and middle rectal cancers. METHODS: This retrospective study included patients who underwent low anterior or intersphincteric resection for middle (5-10 cm) or low (< 5 cm) rectal cancer at the National Cancer Center Hospital East, Japan, from May 2013 to March 2020. Primary rectal adenocarcinoma was confirmed histologically. Circumferential resection margins (CRMs) of resected specimens were measured; margins ≤ 1 mm were considered positive. The operative time, blood loss, hospitalization length, postoperative readmission rate, and short-term treatment results were compared. RESULTS: Four hundred twenty-nine patients were divided into two mesorectal excision groups: transanal (n = 295) and laparoscopic (n = 134). Operative times were significantly shorter in the transanal group than in the laparoscopic group (p < 0.001). The pathological T stage and N status were not significantly different. The transanal group had significantly lower positive CRM rates (p = 0.04), and significantly lower incidence of the Clavien-Dindo grade III (p = 0.02) and IV (p = 0.03) complications. Both groups had distal margin positivity rates of 0%. CONCLUSIONS: Compared to laparoscopic, transanal total mesorectal excision for low and middle rectal cancers has lower incident postoperative complication and CRM-positivity rates, demonstrating the safety and usefulness of local curability for middle and low rectal cancers.
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Laparoscopia , Neoplasias Retais , Cirurgia Endoscópica Transanal , Humanos , Estudos Retrospectivos , Países em Desenvolvimento , Cirurgia Endoscópica Transanal/métodos , Neoplasias Retais/cirurgia , Neoplasias Retais/patologia , Laparoscopia/métodos , Reto/cirurgia , Reto/patologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: An optimal surgical approach to lateral lymph node dissection (LLND) remains controversial. With the recent popularity of transanal total mesorectal excision, a two-team procedure combining the transabdominal and transanal approaches was established as a novel approach to LLND. This study aimed to clarify the safety and feasibility of two-team LLND (2team-LLND) and compare its short-term outcomes with those of conventional transabdominal LLND (Conv-LLND). METHODS: Between April 2013 and March 2020, 463 patients diagnosed with primary locally advanced rectal cancer underwent a transanal total mesorectal excision; among them, 93 patients who underwent bilateral prophylactic LLND were included in this single-center, retrospective study. Among these patients, 50 and 43 patients underwent Conv-LLND (the Conv-LLND group) and 2team-LLND (the 2team-LLND group), respectively. The short-term outcomes, including the operation time, blood loss volume, number of complications, and number of harvested lymph nodes, were compared between the two groups. RESULTS: The intraoperative and postoperative complications in the 2team-LLND group were equivalent to those in the Conv-LLND group; furthermore, the incidence of postoperative urinary retention in the 2team-LLND group was acceptably low (9%). Compared with the Conv-LLND group, the 2team-LLND group had a significantly shorter operation time (P = 0.003), lower median blood loss (P = 0.02), and higher number of harvested lateral lymph nodes (P = 0.0005). CONCLUSION: The intraoperative and postoperative complications of 2team-LLND were comparable with those of Conv-LLND. Thus, 2team-LLND was safe and feasible for advanced lower rectal cancer. Moreover, it was superior to Conv-LLND in terms of the operation time, blood loss volume, and number of harvested lateral lymph nodes. Therefore, it can be a promising LLND approach.
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Excisão de Linfonodo , Neoplasias Retais , Humanos , Estudos Retrospectivos , Resultado do Tratamento , Excisão de Linfonodo/métodos , Linfonodos/patologia , Neoplasias Retais/cirurgia , Neoplasias Retais/patologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/patologia , Recidiva Local de Neoplasia/cirurgiaRESUMO
BACKGROUND: The preservation of autonomic nerves is the most important factor in maintaining genitourinary function in colorectal surgery; however, these nerves are not clearly recognisable, and their identification is strongly affected by the surgical ability. Therefore, this study aimed to develop a deep learning model for the semantic segmentation of autonomic nerves during laparoscopic colorectal surgery and to experimentally verify the model through intraoperative use and pathological examination. MATERIALS AND METHODS: The annotation data set comprised videos of laparoscopic colorectal surgery. The images of the hypogastric nerve (HGN) and superior hypogastric plexus (SHP) were manually annotated under a surgeon's supervision. The Dice coefficient was used to quantify the model performance after five-fold cross-validation. The model was used in actual surgeries to compare the recognition timing of the model with that of surgeons, and pathological examination was performed to confirm whether the samples labelled by the model from the colorectal branches of the HGN and SHP were nerves. RESULTS: The data set comprised 12 978 video frames of the HGN from 245 videos and 5198 frames of the SHP from 44 videos. The mean (±SD) Dice coefficients of the HGN and SHP were 0.56 (±0.03) and 0.49 (±0.07), respectively. The proposed model was used in 12 surgeries, and it recognised the right HGN earlier than the surgeons did in 50.0% of the cases, the left HGN earlier in 41.7% of the cases and the SHP earlier in 50.0% of the cases. Pathological examination confirmed that all 11 samples were nerve tissue. CONCLUSION: An approach for the deep-learning-based semantic segmentation of autonomic nerves was developed and experimentally validated. This model may facilitate intraoperative recognition during laparoscopic colorectal surgery.
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Cirurgia Colorretal , Aprendizado Profundo , Laparoscopia , Humanos , Projetos Piloto , Semântica , Vias Autônomas/cirurgia , Laparoscopia/métodosRESUMO
BACKGROUND: Currently, hand-sewn anastomosis is the standard procedure for inter-sphincteric resection (ISR); however, distal purse-string suturing during transanal total mesorectal excision (TaTME) has allowed a single-stapling technique (SST). Although it was originally intended for cases requiring anastomosis of 2â cm or more above the anorectal junction (ARJ), SST could be safely performed in ISR. The aim of this trial is to determine the superiority of SST over hand-sewn anastomosis in ISR with TaTME. METHODS: The Super SST trial is a multicentre randomized clinical trial comparing stapled and hand-sewn anastomoses in ISR with TaTME. The trial will recruit patients scheduled for TaTME with anastomosis below the ARJ, who will be allocated 1:1 to receive either hand-sewn or stapled anastomosis. The primary endpoint is anastomosis-related complications within 30 postoperative days. Secondary endpoints include all early and late complications, operating time, reoperation, mortality rate, length of postoperative hospital stay, readmission, incidence of anal pain and rectal mucosal prolapse, length of temporary stoma retention, the proportion of patients with a temporary stoma at 1 year after surgery, and anorectal function at 1 year after surgery. CONCLUSION: This trial will provide important clinical insights for new and promising anastomotic options for patients with very low rectal cancer. Registration number: UMIN000047818 (https://www.umin.ac.jp/ctr/index-j.htme).
Assuntos
Complicações Pós-Operatórias , Neoplasias Retais , Humanos , Complicações Pós-Operatórias/epidemiologia , Reto/cirurgia , Anastomose Cirúrgica/métodos , Neoplasias Retais/cirurgia , Canal Anal/cirurgia , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Multicêntricos como AssuntoRESUMO
PURPOSE: In abdominoperineal excision (APE), the advantages of the "down-to-up" approach are expected to be more obvious when performed as a two-team approach, including transperineal minimally invasive surgery (TpMIS). We investigated the efficacy of TpMIS with laparoscopic APE for lower rectal cancer. METHODS: Patients who underwent laparoscopic APE with (n = 20) or without (n = 30) TpMIS between December 2013 and April 2020 were retrospectively reviewed. Patient and tumor characteristics, intraoperative outcome, short-term outcome, and pathological findings were compared. Additional subgroup analyses were performed in technically challenging cases, including male patients, obese patients, and patients with tumors located at the anterior wall. RESULTS: There was no marked difference in the patient or tumor characteristics or short-term outcomes, including morbidity and mortality between the two groups. Pathological results were comparable, and the circumferential resection margin (CRM) positive rate was 10% in both groups. TpMIS achieved a significant reduction in operative time (p = 0.02). In a subgroup analysis, the amount of blood loss was also smaller in males (p = 0.02) and patients with a high BMI (> 25) (p = 0.005) than in others. CONCLUSION: Simultaneously performing TpMIS and laparoscopic APE is feasible owing to the favorable complication and CRM-positive rates. In terms of operative time and blood loss, TpMIS is expected to be advantageous in both easy and challenging cases.