Which is the Optimal Method of Reconstruction After Laparoscopic Right Hemicolectomy, the Intracorporeal or Extracorporeal Anastomosis Technique?

Introduction: The laparoscopic approach to right colectomy is gradually gaining a leading role in the surgical treatment of right colonic diseases. However, not all aspects of the procedure are standardized and the method of reconstruction of the digestive tract is still under debate. The present study critically evaluates the extracorporeal (EA) and intracorporeal (IA) techniques used for creation of the ileocolic anastomosis during a laparoscopic right colectomy. Material and Method: The EA and IA anastomotic techniques are described in detail. The peri operative data of a cohort of consecutive patients operated by our surgical team was retrospectively recorded and analyzed regarding type of anastomosis, the path for transition from EA to IA and the incidence of postoperative complications. Furthermore, an analysis of randomized clinical trials, reviews and meta-analyses that provided a comparative evaluation of EA versus IA was performed to provide a more in-depth integration of our own data into the literature. Results: EA was used at the beginning of our experience but was later replaced by IA which became the favorite anastomotic technique. There was no anastomotic fistula recorded in the EA or IA groups but in our cohort IA was unexpectedly associated with higher incidence of peritoneal drainage, prolonged ileus, surgical site infections, anastomotic bleeding and chyloperitoneum. However, IA allows better visualization of the ileal and colonic stumps, avoids twisting of the anastomosis, prevents extraction-related tearing of the mesocolon and reduces the risk of post operative hernia. Data from the literature also shows that IA is generally associated with earlier postoperative return of bowel function, less morbidity and less postoperative pain. Conclusions: Based on this study and the data currently present in the literature it can not be concluded that IA should be considered as the standard of care for laparoscopic right colectomy. The decision for an EA or IA anastomosis ultimately belongs to the surgeon and is influenced by his surgical skill and experience. The results of ongoing randomized controlled trials on large group of patients may bring more clarity on this issue in the future.

The Value of Staging Laparoscopy for Optimal Multidisciplinary Treatment in Patients with Gastric Cancer.

Introduction: Despite improvements in the conventional preoperative tools used for staging of gastric cancer, their accuracy still needs to be improved. Laparoscopy has the potential to visualize and characterize the tumor, the peritoneal cavity and the lymph nodes and thus to better select patients for the optimal treatment strategy. Material and Method: Patients with gastric cancer staged initially with contrast enhanced computer tomography and endoscopic ultrasound were also evaluated by laparoscopy and laparoscopic ultrasound in a distinct preoperative staging procedure. The perioperative data was recorded in a prospective database and was used to decide within the multidisciplinary team the optimal treatment protocol for each patient. The database was retrospectively reviewed for this study. Results: Among the 20 CT-scan M0 patients analyzed, peritoneal carcinomatosis was detected in 15% of the cases. In other 15% of patients laparoscopy upstaged the tumor and directed the patient towards neoadjuvant chemotherapy. Laparoscopic guided percutaneous core biopsies settled the definitive diagnosis in 3 further cases. In total, laparoscopic staging brought important information in 65% of cases and changed the treatment plan in 30% of patients. Conclusions: In the era of neoadjuvant chemotherapy, laparoscopy has the potential to overcome some of the limitations of the conventional staging methods and offers additional informations which finally change the treatment plan in as much as a third of patients with gastric cancer.

Is there a correlation between peripheral blood expression of angiogenic transcriptional factors/receptors and colorectal cancer?

PURPOSE: The aim of this study was to evaluate whether there is a correlation between peripheral blood expression of angiogenic transcriptional factors/receptors and colorectal cancer (CRC). METHODS: Eighty six blood samples collected from patients with CRC (N=42), adenomas and/or hyperplastic polyps(AP, N=30) and individuals without colon pathology (control group/CTR, N=14) were used for this study. Twelve transcription factors and receptors were assessed by qRT-PCR in a case-control study. The molecules with a minimum of 30% differences in gene expression for CRC and AP compared to CTR were then analyzed separately for each sample. Gene expression was evaluated relatively to the CTR after normalization to the large ribosomal protein PO (RPLPO) housekeeping gene, and the differential expression between studied groups was assessed by ANOVA. RESULTS: Seven out of 12 genes presented differences in expression between 10-29% in CRC and/or AP compared to CTR. Considering the selection criteria, we further individually evaluated the levels of expression of 5 genes that had a minimum of 30% expression in the case-control study. Our data showed a significant up-regulation of platelet derived growth factor (PDGF) C in the blood of the patients with CRC compared to CTR (p=0.007). Likewise, clusterin (CLU) was significantly up-regulated both in CRC and AP groups compared to healthy subjects (p=0.01). For VEGFR1, PDGFRA and TGFB1 we didn't find significantly differential expression between any of the studied groups, even if increased levels were observed in both CRC and AP vs CTR. CONCLUSIONS: The results of our study indicated that increased blood level of PDGFC mRNA was associated with the presence of CRC (p=0.007). Additionally, high levels of circulating CLU mRNA were observed in both malignant and benign colorectal pathologies.

Non-invasive laparoscopic detection of small tumors of the digestive tract using inductive sensors of proximity.

The precise location of gastric and colorectal tumors is of paramount importance for the oncological surgeon as it dictates the limits of resection and the extent of lymphadenectomy. However, this task proves sometimes to be very challenging, especially in the laparoscopic setting when the tumors are small, have a soft texture, and do not invade the serosa. In this view, our research team has developed a new instrument adapted to minimally-invasive surgery, and manipulated solely by the operating surgeon which has the potential to locate precisely tumors of the digestive tract. It consists of an inductive proximity sensor and an electronic block encapsulated into an autoclavable stainless-steel cage that works in tandem with an endoscopic hemostatic clip whose structure was modified to increase detectability. By scanning the serosal side of the colon or stomach, the instrument is capable to accurately pinpoint the location of the clip placed previously during diagnostic endoscopy on the normal bowel mucosa, adjacent to the tumor. In the current in-vivo experiments performed on large animals, the modified clips were transported without difficulties to the point of interest and attached to the mucosa of the bowel. Using a laparoscopic approach, the detection rate of this system reached 65% when the sensor scanned the bowel at a speed of 0.3 cm/s, and applying slight pressure on the serosa. This value increased to 95% when the sensor was guided directly on the point of clip attachment. The detection rate dropped sharply when the scanning speed exceeded 1 cm/s and when the sensor-clip distance exceeded the cut-off value of 3 mm. In conclusion, the proposed detection system demonstrated its potential to offer a swift and convenient solution for the digestive laparoscopic surgeons, however its detection range still needs to be improved to render it useful for the clinical setting.

Laparoscopic compatible device incorporating inductive proximity sensors for precise detection of gastric and colorectal small tumors.

The accurate localization of small tumors of the digestive tract is of paramount importance in surgical oncology because it dictates the limits of resection and the extent of lymph node dissection. In this view, we have designed and fabricated a highly efficient sensing laparoscopic instrument focused on precise non-invasive extralumenal intraoperative detection of small colorectal or gastric tumors. The equipment is fully adapted for laparoscopic surgery and consists of an inductive proximity sensor encapsulated into a watertight stainless-steel case that is connected to an electronic functional block dimensionally scaled-down by the desired form and size for optimal surgical manipulation. The sensor-case unit and the electronic block are coupled together using a modular system which allows disconnection of the latter and sterilization by autoclavation of the former, followed by swift plugging of the electronic block just before surgery in a sterile-controlled environment. The instrument works in tandem with a modified endoscopic hemostatic clip which is attached endoscopically, before surgery, in the mucosa proximal and distal to the tumor. By scanning the serosal side of the digestive organ during the laparoscopic surgical procedure, the detector senses the modified clip and thus pinpoints to the location of the tumor. Additional engineering of the standard endoscopic hemostatic clips by coating them with various combinations of metallic alloys of Cu and Zn was necessary to improve the detection range and sensitivity without compromising on their functionality. The clips were also covered with nanometric layers of Au to ensure their biocompatibility. The ex-vivo dry-lab experiments showed a satisfactory detection distance which was later confirmed in ex-vivo wet-lab experiments on animal organs and human surgical specimens.

Ultrasound-guided bone lesions biopsies - a systematic review.

AIMS: Ultrasound (US) is a highly valuable imagistic tool used to guide numerous interventional procedures. The US guided bone lesions biopsy has not yet received a consensus or a guideline. We aimed to evaluate the evidence to support the US role in guiding bone lesions biopsies. MATERIAL AND METHODS: A computer literature search of PubMed was conducted using the keywords "ultrasound" and "bone biopsy", in order to detect relevant studies regarding the aim of our analysis. Records were screened for eligible studies and data were extracted and analyzed. RESULTS: We included 23 studies (n=610 patients) in the final analysis. The specificity and diagnostic yield of US guided biopsy were very good (between 78-100%), depending on the type and dimensions of the bone lesions. The type of the biopsy - aspiration or cutting - influenced theresults. The studies which included larger groups showed a better  performance for cutting needles (83.3-100% vs 50-80.5% for aspiration). The size of the bone lesion influences the diagnostic yield of the US guided bone biopsy. Most of the studies reported nil post-procedural complications. CONCLUSION: Core needle biopsy provided better diagnostic yield compared to fine needle aspiration. The number of the passages of the cutting needle biopsies in order to achieve the best diagnostic yield wasthree. Further studies are needed in order to standardize US-guided bone lesions biopsy and increase its role in the diagnosis algorithm of the bone lesions.

Value of hepatic elastography and Doppler indexes for predictions of esophageal varices in liver cirrhosis.

AIMS: Non-invasive methods are required to diagnose presence and grading of esophageal varices in patients with hepatic cirrhosis and in this respect we have evaluated the role of transient elastography and abdominal ultrasound parameters. MATERIAL AND METHODS: Cirrhotic patients were prospectively evaluated by transient elastography and Doppler ultrasound for diagnosis of presence and grading of esophageal varices, the results being compared with the findings of the esophagogastroduodenoscopy. RESULTS: Sixty patients with hepatic cirrhosis were analysed. The parameters that reached statistical significance for diagnosis of esophageal varices were: liver stiffness (LSM) > 15 kPa, hemodynamic liver index (PVr1) >/= 0.66, portal vascular resistance (PVR) > 17.66 and splenoportal index (SPI) > 4.77. The only parameter that reached statistical power for the diagnosis of large esophageal varices was LSM at a cut-off value of 28.8 kPa. CONCLUSIONS: Assessment of LSM in patients with liver cirrhosis can predict both the presence of esophageal varices and of large esophageal varices. The PVr1, PVR and SPI Doppler indexes can be used to diagnose the presence of esophageal varices but have no role in the prediction of large esophageal varices. Further studies are required to confirm these results and offer a stronger clinical significance.

Pleural ultrasonography. Pictorial essay.

Pleural ultrasonography (US) represents nowadays a useful diagnostic tool in the management of pleural diseases. Detection and evaluation of pleural effusions, pneumothorax and pleural-based lesions can be performed with US, which has the advantages of wide availability, low cost, absence of radiation exposure, and portability. It is the best method for guiding interventional procedures in the pleural space. It has also limitations, due to the interposition of bony parts of the thorax, subcutaneous emphysema and inability to visualize the mediastinal pleura. US of the thorax is an operator dependent technique demanding an experienced operator in order to obtain reliable results. This pictorial essay presents various ultrasound findings of the diseases which concern the pleura.

Non-invasive ultrasound-based diagnosis and staging of esophageal varices in liver cirrhosis. A systematic review of the literature published in the third millenium.

INTRODUCTION: Endoscopic surveilance of esophageal varices in patients with liver cirrhosis is expensive for the health system and uncomfortable for the patients. Recently, non-invasive ultrasound-based parameters seem to offer valuable informations about the status of esophaeal varices and thus challenge the need for repetitive endoscopic monitoring. MATERIAL AND METHOD: We have performed a systematic review of the literature published in PubMed from January 2000 until March 2012 over the role of ultrasound-based parameters on the evaluation of esophageal varices in patients with liver cirrhosis. RESULTS: Eleven papers studied the role of gray-scale and Doppler ultrasound and two further studies analyzed the relationship between liver stiffness and staging of esophageal varices. The parameters that proved to be valuable for diagnosis of esophageal varices and reached statistcal significance were: diameter of the spleen > 15 cm, congestion index of the portal vein > 0.154 cm x sec, portal hipertensive index > 2.08, liver stiffness > 43.97kPa, portal vein diameter > 13 mm, renal artery resistance index >/= 0.7 and development of new porto-systemic collaterals. Other parameters such as: pattern of hepatic venous waveforms or flow parameters of the hepatic or splenic veins did not reach statistical significance. CONCLUSIONS: Altough esophagogastroduodenoscopy remains the golden standard, there are some ultrasound-based parameters which, used within complex algorithms, may represent a viable alternative for the diagnosis and surveilance of esophageal varices in patients with liver cirrhosis.