Intracorporeal antimesenteric ancillary trocar: an anastomotic technique facilitating natural orifice specimen extraction in left-sided colorectal surgery.

AIM: Natural orifice specimen extraction (NOSE) in left-sided colorectal surgery requires application of the circular stapler anvil to the proximal bowel without exteriorization through an additional abdominal incision. We describe an intracorporeal method to secure the stapler anvil, termed the intracorporeal antimesenteric ancillary trocar (IAAT) technique. METHOD: The ancillary trocar is attached to the stapler anvil before introduction into the abdominal cavity through the anal or vaginal orifice. The colon is incised before the trocar spike is brought out through the antimesenteric surface 3-4 cm within the cut edge. A linear stapler is used to seal the bowel end. The ancillary trocar is detached and retrieved via the NOSE conduit. Following the NOSE procedure, a side-to-end colorectal anastomosis is performed with the transanal circular stapler. RESULTS: Ten consecutive patients underwent elective left-sided colorectal resection with IAAT for NOSE (seven transanal, three transvaginal) from January to June 2023. Median age and body mass index were 66 (range 47-74) years and 24.3 (range 17.9-30.8) kg/m2 respectively. Two (20%) patients underwent sigmoid colectomy for sigmoid volvulus while eight (80%) underwent anterior resection for colorectal cancer. Median operating time, operative blood loss and postoperative length of hospital stay were 170 (range 140-240) min, 20 (range 10-40) mL and 1 (range 1-3) day respectively. There were no postoperative complications, readmissions or reoperations. Median follow-up duration was 3 (range 1-6) months. CONCLUSION: The IAAT double-stapling side-to-end anastomotic technique is safe and feasible for patients undergoing left-sided colorectal resection with NOSE, resulting in good outcomes.

Segmental bowel resection for rectal endometriosis using the da Vinci SP.

OBJECTIVE: The da Vinci SP Surgical System (SP) received regulatory approval for use in gynecological surgeries in Japan in 2023. Given the advantages of the precision of a robot, less pain, and the cosmesis of single-port surgery, the da Vinci SP is expected to be further used for minimally invasive surgeries. To the best of our knowledge, this is the first report of the use of SP for the treatment of rectal endometriosis with segmental bowel resection. SETTING: An urban general hospital. Stepwise demonstration of the technique with narrated video footage. PARTICIPANTS: The patient was a 46-year-old woman presented with chronic pelvic pain, pain on defecation and constipation. Magnetic resonance imaging showed uterine large fibroid, left ovarian endometrioma, and 38mm of rectal endometriosis, with complete cul-de-sac obliteration. INTERVENTIONS: We made a 30-mm vertical incision at the umbilicus, then placed the access port, and inserted three articulating instruments and a camera. An assistant port was placed in the right lower quadrant for using the linear stapler. The surgical steps were completely identical to conventional multiport laparoscopic robotic surgery. This suggests that conventional laparoscopic or robotic skills are highly transferrable to SP. SP offer several advantages, including high-resolution three-dimensional visualization, articulating instruments, and improved dexterity and range of motion. In addition, the umbilical access port was particularly useful for proximal bowel resection, specimen retrieval, and anvil positioning during bowel resection. The total operative time was 216 minutes. The estimated blood loss was 100 ml without any complications. The uterine weight was 800 g. The postoperative course was uneventful, with no perioperative complications, including no postoperative bladder dysfunction or low anterior resection syndrome [1, 2]. CONCLUSION: The use of SP with the access port for segmental bowel resection for rectal endometriosis is technically safe and feasible, with good cosmesis and less pain.

Double stapling technique versus hemi-double stapling technique for esophagojejunostomy with OrVil™ after laparoscopic total gastrectomy: a single-blind, randomized clinical trial.

BACKGROUND: The transorally inserted anvil (OrVil™) is frequently selected for esophagojejunostomy after laparoscopic total gastrectomy (LTG) because of its versatility. During anastomosis with OrVil™, the double stapling technique (DST) or hemi-double stapling technique (HDST) can be selected by overlapping the linear stapler and the circular stapler. However, no studies have reported the differences between the methods and their clinical significance. METHODS: A randomized controlled clinical trial with a parallel assignment and single-blind outcomes assessment analysis was conducted. Patients with gastric cancer eligible for LTG who met the selection criteria were randomized. Preoperative characteristics and perioperative and postoperative outcomes were compared between the DST and HDST. The primary endpoint was an anastomosis-related complication, and the secondary endpoints were perioperative outcomes and postoperative complications, excluding anastomosis-related complications. RESULTS: Thirty patients with gastric cancer were eligible and randomized. LTG and esophagojejunostomy were successfully performed in all patients, without conversion to laparotomy. Preoperative characteristics, excluding preoperative chemotherapy, were not significantly different between the two groups. One anastomotic leakage of Clavien-Dindo classification grade ≥ IIIa was observed in the DST, although no significant difference was found between the two groups (6.6% vs. 0%, P = 0.30). In the HDST, one case of anastomotic stricture required endoscopic balloon dilation. No significant differences were found in operative time, whereas the anastomosis time was significantly shorter in the HDST than in the DST (47.5 ± 15.8 vs. 38.2 ± 8.8 min, P = 0.028). Except for anastomosis-related complications, postoperative complications (P = 0.282) and postoperative hospital stay for the DST and HDST were not significantly different. CONCLUSIONS: No superiority was found between the DST and HDST with OrVil™ in esophagojejunostomy of LTG for gastric cancer with respect to postoperative complications, whereas the HDST may be preferable in terms of the simplicity of the surgical technique.

Time required for indocyanine green fluorescence emission for evaluating bowel perfusion in left-sided colon and rectal cancer surgery.

BACKGROUND: Indocyanine green fluorescence imaging (ICG-FI) has been reported to be useful in reducing the incidence of anastomotic leakage (AL) in colectomy. This study aimed to investigate the correlation between the required time for ICG fluorescence emission and AL in left-sided colon and rectal cancer surgery using the double-stapling technique (DST) anastomosis. METHODS: This retrospective study included 217 patients with colorectal cancer who underwent left-sided colon and rectal surgery using ICG-FI-based perfusion assessment at our department between November 2018 and July 2022. We recorded the time required to achieve maximum fluorescence emission after ICG systemic injection and assessed its correlation with the occurrence of AL. RESULTS: Among 217 patients, AL occurred in 21 patients (9.7%). The median time from ICG administration to maximum fluorescence emission was 32 s (range 25-58 s) in the AL group and 28 s (range 10-45 s) in the non-AL group (p < 0.001). The cut-off value for the presence of AL obtained from the ROC curve was 31 s. In 58 patients with a required time for ICG fluorescence of 31 s or longer, the following risk factors for AL were identified: low preoperative albumin [3.4 mg/dl (range 2.6-4.4) vs. 3.9 mg/dl (range 2.6-4.9), p = 0.016], absence of preoperative mechanical bowel preparation (53.8% vs. 91.1%, p = 0.005), obstructive tumor (61.5% vs. 17.8%, p = 0.004), and larger tumor diameter [65 mm (range 40-90) vs. 35 mm (range 4.0-100), p < 0.001]. CONCLUSION: The time required for ICG fluorescence emission was associated with AL.

Efficacy of the polyglycolic acid sheet for preventing anastomotic leakage in double-stapling technique anastomosis for left-sided colon or rectal cancer surgery: a propensity score-matched study.

BACKGROUND: To prevent anastomotic leakage in patients with left-sided colorectal cancer who underwent double-stapling technique (DST) anastomosis, we investigated a new method: DST anastomosis with a polyglycolic acid (PGA) sheet. This procedure has been shown to have the potential to decrease the rate of anastomotic leakage. However, due to the small number of cases enrolled in our previous study, it was not possible to compare the outcomes of the new and conventional procedures. The aim of this study was to evaluate the effect of the PGA sheet on preventing anastomotic leakage in patients with left-sided colorectal cancer who underwent DST anastomosis by retrospectively comparing the anastomotic leakage rate between the PGA sheet and conventional groups. METHODS: A total of 356 patients with left-sided colorectal cancer who underwent DST anastomosis during surgery at Osaka City University Hospital between January 2016 and April 2022 were enrolled in this study. Propensity score matching was performed to reduce the confounding effects secondary to imbalances in the use of PGA sheets. RESULTS: The PGA sheet was used in 43 cases (PGA sheet group) and it was not used in 313 cases (conventional group). After propensity score matching, the incidence of anastomotic leakage in the PGA sheet group was significantly lower than that in the conventional group. CONCLUSION: DST anastomosis with PGA sheet, which is easy to perform, contributes to the reduction of anastomotic leakage rate by increasing the strength of the anastomotic site.

Impact of a circular powered stapler on preventing anastomotic leakage in patients with left-sided colorectal cancer: a retrospective study.

BACKGROUND: The powered circular stapler, which was developed with the aim of providing reliable and reproducible anastomosis, provides complete anastomosis, resulting in a reduced risk of anastomotic leakage. The aim of this study was to compare the incidence of anastomotic leakage between a conventional manual circular stapler (MCS) and the ECHELON CIRCULAR™ Powered Stapler (ECPS) in patients with left-sided colorectal cancer who underwent anastomosis with the double stapling technique. METHODS: A total of 187 patients with left-sided colorectal cancer who underwent anastomosis with the double stapling technique with a conventional MCS or the ECPS during surgery at Osaka City University Hospital between January 2016 and July 2022 were enrolled in this study. RESULTS: The incidence of anastomotic leakage in the ECPS group was significantly lower than that in the MCS group (4.4% versus 14.3%, p = 0.048). Furthermore, even after propensity score matching, an association was found between the use of the ECPS and a reduced incidence of anastomotic leakage. CONCLUSION: The ECPS has the potential to help reduce the rate of anastomotic leakage in left-sided colorectal surgery.

The use of single-stapling techniques reduces anastomotic complications in minimal-invasive rectal surgery.

BACKGROUND: Leakage of rectal anastomoses is one of the most important and feared complications in colorectal surgery. Apart from patient-specific risk factors, technical aspects may influence the occurrence of anastomotic complications. This study investigated whether using single-stapling techniques (SST) instead of the double-stapling technique (DST) for minimal-invasive rectal anastomosis is associated with a lower rate of anastomotic complications. METHODS: A retrospective review of 272 patients who received a minimally invasive stapled rectal anastomosis (3-16 cm from the anal verge) at our institution from 2015 to 2020 was performed. In 131 patients, rectal anastomosis was created by SST (SST group), while 141 patients received a rectal anastomosis with crossing stapler lines (DST group). The impact of the anastomotic technique on patient outcomes was determined by uni- and multivariate analyses. RESULTS: Overall anastomotic leakage rate was 6%. Patients with SST anastomoses had a lower leakage rate than patients with DST anastomoses (3% vs. 9% in the DST group, p = 0.045). The rate of anastomotic stenosis was lower in the SST group than in the DST group (1% vs. 6%, p = 0.037). Overall morbidity and mortality did not differ between the two groups. Multivariate analysis showed that single-stapling techniques significantly reduce the risk of anastomotic leakage (OR 3.5 [1.0-11.5], p = 0.043). CONCLUSION: The use of SST for rectal anastomosis may help to reduce anastomotic complications. This finding should be confirmed by a randomized controlled trial.

Feasibility of augmented rectangle technique in laparoscopic distal gastrectomy: comparison with hemi-double stapling technique in a single-center retrospective cohort study.

PURPOSE: Augmented rectangle technique (ART) anastomosis is a totally intracorporeal anastomosis of laparoscopic distal gastrectomy (LDG), Billroth I (B1) reconstruction for gastric cancer, which secures a wide anastomotic stoma. Since the conventional extracorporeal hemi-double stapling technique (HD) may have a narrow anastomotic stoma, our aim of this study was to evaluate the feasibility and usefulness of ART anastomosis by comparing the surgical outcomes with HD anastomosis. METHODS: Clinical data of 89 patients undergoing LDG with B1 reconstruction were retrospectively collected. Patients were divided into ART group (n = 40) and HD group (n = 49). Surgical outcomes including short-term outcomes, postoperative endoscopic findings, and nutritional factors 1 year after surgery were compared between the groups. RESULTS: Baseline characteristics were similar between the groups. In terms of short-term outcomes, blood loss was less (11.5 mL vs 40 mL, P = 0.011) and postoperative hospital stay was shorter (10 days vs 12 days, P = 0.022) in the ART group. In terms of endoscopic findings, residual food was less (P = 0.032) in the ART group. In terms of nutritional factors, percent decrease of visceral fat area (- 27.6% vs - 40.5%, P = 0.049) and subcutaneous fat area (- 25.7% vs - 39.3%, P = 0.050) 1 year after surgery attenuated in the ART group. CONCLUSIONS: ART anastomosis is superior in perioperative course such as postoperative hospital stay. Moreover, a better nutritional recovery is expected by securing a wide anastomotic stoma leading to a favorable food passage.

A novel colorectal anastomotic method in natural orifice specimen extraction surgery for colorectal cancer.

PURPOSE: We introduced a novel colorectal anastomotic technique, double-angle anastomosis combined with the double stapling technique (DAA-DST), to simplify the anastomosis step during natural orifice specimen extraction surgery (NOSES) and compared its safety and effectiveness with purse string anastomosis combined with the double stapling technique (PSA-DST). METHODS: Between January 2018 and March 2021, 63 patients with colorectal cancer underwent NOSES with DAA-DST or PSA-DST. We compared the perioperative and oncological outcomes between the groups. RESULTS: There were no significant differences in the operation time, blood loss, time to first passage of flatus and excrement or hospital stay duration between PSA-DST and DAA-DST groups. The overall postoperative complication rates were similar (DAA-DST vs PSA-DST, 21.2% vs 26.7%, p = 0.78), including the rate of anastomotic leakage (6.1% vs 10%, p = 0.91). The rate of successful DAA-DST was higher than that of PSA-DST (100% vs 93.3%). The DAA-DST group had a lower rate of positive drain fluid culture than the PSA-DST group (18.2% vs 26.7% p = 0.61). Recurrence (3.01% vs 6.67%, p = 0.93) and metastasis rates (6.06% vs 6.67%, p = 0.98) were similar between the groups. CONCLUSION: DAA-DST is a safe and effective procedure and can simplify the procedure of NOSES.

Postoperative morbidity and quality of life between totally laparoscopic total gastrectomy and laparoscopy-assisted total gastrectomy: a propensity-score matched analysis.

BACKGROUND: This study aimed to evaluate the surgical outcome and quality of life (QoL) of totally laparoscopic total gastrectomy (TLTG) compared with laparoscopy-assisted total gastrectomy (LATG) in patients with clinical stage I gastric cancer. METHODS: From 2012 to 2018, EGC patients who underwent TLTG (n = 223), including the first case with intracorporeal hemi-double stapling, were matched to those who underwent LATG (n = 114) with extracorporeal circular stapling, using 2:1 propensity score matching (PSM). Prospectively collected morbidity was compared between the TLTG and LATG groups in conjunction with the learning curve. The European Organization for Research and Treatment of Cancer (EORTC) QoL questionnaires QLQ-C30, STO22, and OG25 were prospectively surveyed during postoperative 1 year for patient subgroups. RESULTS: After PSM, grade I pulmonary complication rate was lower in the TLTG group (n = 213) than in the LATG group (n = 111) (0.5% vs. 5.4%, P = 0.007). Other complications were not different between the groups. The learning curve of TLTG was overcome at the 26th case in terms of the comprehensive complication index. The TLTG group after learning curve showed lower grade I pulmonary complication rate than the matched LATG group (0.5% vs. 4.7%, P = 0.024). Regarding postoperative QoL, the TLTG group (n = 63) revealed less dysphagia (P = 0.028), pain (P = 0.028), eating restriction (P = 0.006), eating (P = 0.004), odynophagia (P = 0.023) than the LATG group (n = 21). Multivariate analyses for each QoL item demonstrated that TLTG was the only common independent factor for better QoL. CONCLUSIONS: TLTG reduced grade I pulmonary complications and provided better QoL in dysphagia, pain, eating, odynophagia than LATG for patients with clinical stage I gastric cancer.

Effect of different reinforcement methods on anastomotic leakage prevention after laparoscopic double anastomosis.

BACKGROUND AND OBJECTIVES: To investigate the effects of different suture reinforcement methods for anastomotic leakage and other postoperative complications after the use of a laparoscopic double stapling technique (DST). METHODS: We collected the data of 124 patients who underwent laparoscopic radical resection of colorectal cancer from July 2017 to September 2018 at our institution. Patients were divided into three groups according to the suture reinforcement methods: intermittent, continuous suture reinforcement, and non-reinforcement (n = 41, 41, and 42, respectively). One-way analysis of variance, χ2 , Fisher's exact, and nonparametric tests were used for statistical analysis. RESULTS: Among the 124 patients, there were no statistically significant differences in operation times, intraoperative blood loss, postoperative hospital stays and recovery of bowel movement. Nine patients were diagnosed with anastomotic leakage (AL). The incidences of serious AL in the intermittent and continuous suture reinforcement groups were lower than that in the control group, with lower reoperation rate, shorter average lengths of stay and lower treatment costs of two experimental groups. CONCLUSION: Intermittent and continuous sutures after laparoscopic DST is effective, safe, and feasible on anastomotic leakage prevention. These procedures could be popularized in rectal surgery on patients with high risk of AL.

Predicting the level of difficulty of the double-stapling technique in laparoscopic total mesorectal excision.

BACKGROUND: The transection of rectum and fashioning of anastomosis is a crucial step in laparoscopic total mesorectal excision (TME) and the double-stapling technique (DST) is often employed. This study aimed to evaluate the factors that were associated with difficult DST. METHOD: Cases of laparoscopic TME were retrospectively reviewed. The clinico-anatomical parameters were retrieved from a prospectively maintained database. In addition, pelvic dimensions were taken by reviewing the magnetic resonance imaging scan. The number of stapler cartridges used for intracorporeal transection of rectum was used as a surrogate for the level of difficulty of DST and its relationship with various parameters were evaluated. RESULTS: There were a total of 121 consecutive cases analyzed. The mean number of stapler cartridges used was 2.1 ± 0.7. Pelvic inlet (p = 0.002) and tumor height (p = 0.015) were predictors of the number of cartridges used, R2 = 0.366. A model was developed to predict the likelihood of transecting the rectum with two or less stapler cartridges, which included the following parameters: gender, pelvic inlet, interspinous distance, intertuberous distance, and tumor height. The predicted probability also correlated with overall operation time (p = 0.009) and anastomotic leakage (p = 0.023). CONCLUSION: The difficulty of DST was associated with patient's clinico-anatomical factors. Surgeons can consider other feasible alternatives, like transanal anastomosis, when a technically challenging DST is anticipated.

Ligating the rectum with cable tie facilitates rectum transection in laparoscopic anterior resection of rectal cancer.

PURPOSE: Proper transection of the distal rectum is important for reconstruction of bowel continuity in rectal cancer surgery. In this study, we introduced a modified technique for ligation of the distal rectum, and investigated its safety and efficiency to facilitate the rectum transection. METHODS: After complete mobilization and transection of the mesorectum, a cable tie was carefully positioned distal to the tumor, followed by washout and transecting the rectum with a linear stapler. From September 2017 to June 2018, consecutive 67 mid-low rectal cancer patients with laparoscopic anterior resection underwent this technique. Clinical data of these patients, including number of firings, pathological and operative variables, and postoperative outcomes, were compared with those of 132 consecutive patients who underwent traditional surgery from January 2016 to August 2017. RESULTS: Compared with the traditional method, cable tie ligation significantly reduced the number of firings (1.1 ± 0.32 vs. 1.3 ± 0.52, p < 0.001). A very high ratio of one firing transection of rectum was observed in the cable tie group (94.0% vs. 68.9%, p < 0.001), even in patients with tumor at or below the peritoneal reflection (90.2% vs. 54.4%, p < 0.001), in male patients (95.5% vs. 65.8%, p < 0.001), and in obese patients (93.8% vs. 64.9%, p = 0.005). The mean distal margin was longer in the cable tie group (3.19 ± 1.77 cm vs. 2.54 ± 1.36 cm, p = 0.005), with no positive distal margin observed. The operation time, quality of mesorectum, and morbidity between two groups were comparable. Two leaks (3.0%) in the cable tie group were observed, similar to 3.8% in the control. CONCLUSIONS: Ligation of the rectum with a cable tie reduces the number of cartridges, and increases the rate of one stapler firing for rectal transection, even in those difficult cases like male, overweight, and low rectal cancer patients. It is also useful for occlusion of the rectum before washout. It is safe, feasible, and worthwhile for popularization. TRIAL REGISTRATION: Registered at ClinicalTrial.gov, number NCT03570684.

Risk and early predictive factors of anastomotic leakage in laparoscopic low anterior resection for rectal cancer.

BACKGROUND: In recent years, laparoscopic surgery has been widely used for rectal cancer. In laparoscopic rectal surgery, a double-stapling technique (DST) anastomosis using a stapling device is considered a relatively difficult procedure. Postoperative anastomotic leakage (AL) is a major complication related to patients' quality of life and prognosis. METHODS: This study was a retrospective, single-institution study of 101 rectal cancer patients who underwent laparoscopic low anterior resection (LAR) with DST anastomosis (excluding simultaneous resection of other organs and construction of protective diverting stoma) between February 2008 and November 2017 at the Gifu University Graduate School of Medicine. This study aimed to identify risk and early predictive factors of AL. RESULTS: Among 101 patients, symptomatic AL occurred in 13 patients (12.9%), of whom 10 were male and 3 were female. Their median BMI was 22.7 kg/m2 (range, 17.9-26.4 kg/m2). Among the pre- and intraoperative factors, AL was significantly associated with tumor location (lower rectum), distance from the anal verge (< 6 cm), intraoperative blood loss (≥ 50 ml), and the number of linear staples (≥ 2) in univariate analysis. In multivariate analysis, only intraoperative blood loss (≥ 50 ml, odds ratio [OR] 4.59; 95% confidence interval [CI] 1.04-19.52; p = 0.045) was identified as an independent risk factor for AL. Among the postoperative factors, AL was significantly associated with tachycardia-POD1 (≥ 100 bpm), CRP-POD3 (≥ 15 mg/dl), fever on postoperative day (fever-POD) 3 (≥ 38 °C), and first defecation day after surgery (< POD3) in univariate analysis. In multivariate analysis, fever-POD3 (≥ 38 °C, OR 30.97; 95% CI 4.68-311.22; p = 0.0003) and first defecation day after surgery (< POD3, OR 5.82; 95% CI 1.34-31.30; p = 0.019) were identified as early predictive factors for AL. CONCLUSION: In this study, intraoperative blood loss was an indicator of difficulty in a transection and anastomosing procedure, and fever-POD3 and early first defecation day after surgery were independent early predictive factors for AL. Careful surgery using an appropriate technique and standardized procedures with minimal bleeding and careful postoperative management paying attention to fever and defecation may prevent the onset and severity of AL.

Male sex and history of ischemic heart disease are major risk factors for anastomotic leakage after laparoscopic anterior resection in patients with rectal cancer.

BACKGROUND: Anastomotic leakage (AL) is the most serious and common complication of surgery for rectal cancer, and associated risk factors remain unknown despite developments in laparoscopic surgery. The present study aimed to determine risk factors for AL after laparoscopic anterior resection (AR) of rectal cancer. METHODS: This retrospective cohort study extracted information from a prospective database of all consecutive colorectal resections that proceeded at Nippon Medical School Hospital between January 2011 and December 2015 (n = 865). We identified 154 patients with rectal cancer treated by elective laparoscopic AR with anastomosis using primary double-stapling. Clinical variables and comorbidity, habits, and surgery-related variables were assessed by univariate and multivariate analyses to determine preoperative risk factors for clinical AL. RESULTS: The overall rate of clinical AL was 11.7% (18 of 154 patients), and 5 (27.8%) of 18 patients required revised laparotomy. Data from males were analyzed because AL occurred only in males. Univariate analysis of male patients (n = 100) significantly associated preoperative creatinine values (p = 0.03) and a history of ischemic heart disease (IHD) (p = 0.012) with AL. The frequency of AL tended to increase (p = 0.06) when patients had low AR (p = 0.06) and transanal drainage. Having AL significantly prolonged hospital stays compared with patients without leakage (36.2 vs. 11.1 days; p <  0.01). Multivariate analysis identified a history of IHD (odds ratio [OR], 4.73; 95% confidence interval [CI], 1.27-17.5; p = 0.025] as an independent risk factor for AL. CONCLUSIONS: Male sex and a history of IHD are possible risk factors for AL after elective laparoscopic rectal cancer surgery.

Impact of transanal drainage tube on anastomotic leakage after laparoscopic low anterior resection.

BACKGROUND: Although a few reports have suggested transanal drainage tube (TDT) can reduce the pressure in the anastomotic portion, it remains unclear whether TDT can prevent anastomotic leakage (AL). In addition, little is known about the relationship between AL and daily fecal volume through TDT. This study investigated the role of TDT for the prevention of AL following laparoscopic low anterior resection (LAR). METHODS: This is a retrospective analysis of a prospectively maintained database of 201 rectal cancer patients who underwent laparoscopic LAR. The relationship between AL and daily fecal volume through TDT was examined. RESULTS: AL occurred in 25 patients. Based on the TDT grouping, AL occurred in 10.7% (19/178) of the TDT group, whereas it occurred in 26.1% (6/23) of the non-TDT group (P = 0.046). In the 178 patients with TDT placement, the daily fecal volumes on postoperative days (PODs) 2-5 were significantly higher compared with those on POD 1 (P < 0.05). The daily fecal volume was observed to be gradually increasing until POD 3 or 4 (median, 25 or 23 ml/day, respectively) and then significantly decreasing on POD 5 (10 ml/day) (P < 0.05). The AL rate of the patients whose daily fecal volume exceeded 100 ml/day in two or more days was significantly higher than that of those in 0 or 1 day (26.9 vs. 7.9%; P < 0.01). CONCLUSIONS: TDT could be efficient to prevent AL following laparoscopic LAR. Postoperative fecal volume may be a reliable predictor of AL.

Evaluation of intestinal perfusion by ICG fluorescence imaging in laparoscopic colorectal surgery with DST anastomosis.

BACKGROUND: Decreased blood perfusion is an important risk factor for postoperative anastomotic leakage (AL). Fluorescence imaging with indocyanine green (ICG) provides a real-time assessment of intestinal perfusion. This study evaluated the utility of ICG fluorescence imaging in determining the transection line of the proximal colon during laparoscopic colorectal surgery with double stapling technique (DST) anastomosis. METHODS: This was a prospective single-institution study of 68 patients with left-sided colorectal cancers who underwent laparoscopic colorectal surgery between August 2013 and December 2014. After distal transection of the bowel, the specimen was extracted extracorporeally and then the mesentery was divided along the planned transection line determined by the surgeons' judgement under normal q. After ICG was injected intravenously, intestinal perfusion of the proximal colon was assessed in the fluorescent imaging mode. Intestinal perfusion was examined in relation to the patient-, tumor- and surgery-related variables using univariate and multivariate analyses. RESULTS: ICG fluorescence imaging showed that intestinal perfusion was present at 3 mm (median) distal to the initially planned transection line. ICG fluorescence imaging resulted in a proximal change of the transection line by more than 5 mm in 18 patients (26.5 %) and, particularly, by more than 50 mm in 3 patients (4.4 %), compared with the initially planned transection line. Univariate analysis revealed that diabetes mellitus, anticoagulation therapy, preoperative chemotherapy and operative time were significantly associated with poor intestinal perfusion. Multivariate analysis identified anticoagulation therapy (P = 0.021) and preoperative chemotherapy (P = 0.019) as independent risk factors for poor intestinal perfusion. Three patients (4.5 %) with a change of transection line developed AL. CONCLUSIONS: ICG fluorescence imaging is useful for determining the transection line in laparoscopic colorectal surgery with DST anastomosis. Anticoagulation therapy and preoperative chemotherapy are important risk factors for poor intestinal perfusion.

ICG fluorescence imaging for quantitative evaluation of colonic perfusion in laparoscopic colorectal surgery.

BACKGROUND: Fluorescence technology with indocyanine green (ICG) provides a real-time assessment of intestinal perfusion. However, a subjective evaluation of fluorescence intensity based on the surgeon's visual judgement is a major limitation. This study evaluated the quantitative assessment of ICG fluorescence imaging in determining the transection line of the proximal colon during laparoscopic colorectal surgery. METHODS: This is a retrospective analysis of a prospectively maintained database of 112 patients who underwent laparoscopic surgery for left-sided colorectal cancers. After distal transection of the bowel, the specimen was extracted extracorporeally and then the proximal colon was divided within the well-perfused area based on the ICG fluorescence imaging. We evaluated whether quantitative assessment of intestinal perfusion by measuring ICG intensity could predict postoperative outcomes: F max, T max, T 1/2, and Slope were calculated. RESULTS: Anastomotic leakage (AL) occurred in 5 cases (4.5%). Based on the fluorescence imaging, the surgical team opted for further proximal change of the transection line up to an "adequate" fluorescent portion in 18 cases (16.1%). Among the 18 patients, AL occurred in 4 patients (4/18: 22.2%), whereas it occurred in only 1 case (1/94: 1.0%) in the good perfusion patients who did not need proximal change of the transection line. The F max of the AL group was less than 52.0 in all 5 cases (5/5), whereas that of the non-AL group was in only 8 cases (8/107): with an F max cutoff value of 52.0, the sensitivity and specificity for the prediction of AL were 100 and 92.5%, respectively. Regarding postoperative bowel movement recovery, the T max of the early flatus group or early defecation group was significantly lower than that of the late flatus group or late defecation group, respectively. CONCLUSIONS: ICG fluorescence imaging is useful for assessing anastomotic perfusion in colorectal surgery, which can result in more precise operative decisions tailored for an individual patient.

The intentional oblique transection double stapling technique in anterior resection for rectal cancer.

The double stapling technique (DST) is an intestinal reconstruction technique that has been widely adopted in anterior resection (AR) for rectal cancer. However, anastomotic leakage (AL) after the operation remains a major concern for colorectal surgeons. The sharp-angled corner of the remnant rectum that is often created by the ordinary DST can be a risk factor for AL. We have developed a new method of performing intentional oblique transection DST (IOT-DST). Using this technique, the anal side of the rectum is intentionally obliquely transected with linear staplers, and the area of the sharp-angled edge is totally punched out with a circular stapler. Between September 2015 and March 2016, we used the IOT-DST technique in the treatment of 15 consecutive rectal cancer patients and experienced no anastomosis-related complications, including leakage and stenosis. IOT-DST is easy to use and less stressful to perform than other techniques. IOT-DST has the potential to become the standard technique for AR in rectal cancer surgery.

Transanal Inspection and Management of Low Colorectal Anastomosis Performed With a New Technique: the TICRANT Study.

BACKGROUND: Anastomotic leakage is one of the most serious complications after rectal cancer surgery. METHOD: A prospective multicenter interventional study to assess a newly described technique of creating the colorectal and coloanal anastomosis. The primary outcome was to access the safety and efficacy of this technique in the reduction of anastomotic leak. RESULT: Fifty-three patients with rectal cancer who underwent low or ultra-low anterior resection were included in the study. There were 35 males and 18 females, with a median age of 68 years (range = 49-89 years). The median tumor distance from the anal verge was 8 cm (range = 4-12 cm), and the median body mass index was 24 kg/m2 (range = 20-35 kg/m2). Thirty patients underwent open, 16 laparoscopic, and 7 robotic surgeries. Multiple firing (2-charges) was required in 30 patients to obtain a complete rectal division. Forty-five patients had colorectal anastomosis, and 8 patients had coloanal anastomosis. The protective ileostomy was created in 40 patients at the time of initial surgery. There was no mortality in the first 30 days postoperatively, and only 10 (19%) patients developed complications. There were 3 anastomotic leakages (6%); 2 of them were subclinical with ileostomy created at initial operation and both were treated conservatively with transanal drainage and intravenous antibiotics. One patient required reoperation and ileostomy. The median length of hospital stay was 10 days (range = 4-20 days). CONCLUSION: Our technique is a safe and efficient method of creation of colorectal anastomosis. It is also a universal method that can be used in open, laparoscopic, and robotic surgeries.