Outcomes after transanal endoscopic microsurgery with intraperitoneal anastomosis.

BACKGROUND: Transanal endoscopic microsurgery has gained increasing popularity as a treatment alternative for early stage rectal neoplasms. With continued advances in technique and experience, more proximal rectal tumors are being surgically managed by using transanal endoscopic microsurgery with an intraperitoneal anastomosis. OBJECTIVE: The purpose of this study was to review the outcomes of patients who have undergone intraperitoneal anastomosis with the use of the transanal endoscopic microsurgery technique. DESIGN: A prospective, single-surgeon database documented 445 consecutive patients undergoing transanal endoscopic microsurgery from October 1, 1996 through January 1, 2012. We retrospectively reviewed information from all patients who underwent transanal endoscopic microsurgery with an intraperitoneal anastomosis in this prospective database. SETTINGS: All procedures took place in an inpatient hospital setting. PATIENTS: All patients satisfied workup criteria to undergo surgery for rectal neoplasm. INTERVENTIONS: All patients underwent transanal endoscopic microsurgery for rectal neoplasm. MAIN OUTCOME MEASURES: Size and pathology of lesion, length of procedure, hospital stay, estimated blood loss, margin status, and complications were the outcomes measured. RESULTS: Twenty-eight patients who underwent transanal endoscopic microsurgery had definitively documented intraperitoneal entry and anastomosis. Median follow-up was 12 months (range, 0.5-111 months). There were no operative mortalities. Procedure-related complications included urinary retention (11%), fever (11%), and fecal seepage (4%). Four patients (14%) had positive margins on final pathology. One patient (3%) required abdominal exploration for an anastomotic leak but did not require diversion. LIMITATIONS: Although this study analyzes prospectively collected data, it is nonetheless a retrospective analysis that can introduce bias. Because this is a single-center study with a relatively homogenous population, the results may not be generalizable. Our sample size may also be underpowered to detect clinically significant outcomes. CONCLUSIONS: Transanal endoscopic microsurgery with intraperitoneal anastomosis can be safely performed without fecal diversion by experienced surgeons.

Defining "laparoscopy" through review of technical details in JSLS.

BACKGROUND AND OBJECTIVES: The term "laparoscopy" has lost some precision in its definition due to the proliferation in techniques of access to the abdominal cavity. Currently, procedures performed with radical differences in port size, placement, and even need for an extraction incision may be characterized as "laparoscopic." However, the general public and many insurers divide procedures in the simplified categories of laparoscopic or open. Our aim was to characterize the typical laparoscopic operation through review of the technical details of a year's worth of articles in JSLS. METHODS: We assembled and analyzed a database of all articles in JSLS from 2008-2009 (4 issues starting with Volume 12, #4). For comparison, we also reviewed articles from 1 decade ago (Volume 2). All procedural details were compiled, including means of access, number and size of ports, incision length, and conversion rates. RESULTS: In the most recent year, there were 81 articles for analysis, compared to 39 in the earlier year. Few articles listed all technical details, as only 58% of reports described mode of access and 56% described the number of ports used. Access was nearly evenly divided between Hasson and Veress techniques. The average number of ports in both study periods was 4, although there was a trend toward smaller port sizes in the current year. Among those studies specifying incision length, the average was 6.1cm in both groups. CONCLUSION: The technical operative details are lacking in many reports. Based on review of published studies, most procedures are done with 4 ports, 3 of which are ≥10mm in size. Until there is greater clarity in technical description, the precise definition of laparoscopy will remain elusive.

Laparoscopic adrenalectomy for unsuspected unilateral primary adrenal lymphoma.

BACKGROUND: Rarely, a patient presents to a surgeon for evaluation of an adrenal incidentaloma where the final pathology is primary malignancy. For primary adrenal lymphoma, fewer than 100 cases have been reported in the literature. CASE REPORT: We report a case of unilateral primary adrenal aggressive B cell lymphoma discovered incidentally in a 41-year-old female. Preoperative testing demonstrated the 6-cm mass to be biochemically silent. Subsequently, the patient underwent a laparoscopic adrenalectomy. Following pathologic diagnosis of B cell lymphoma, a metastatic workup was negative, and she underwent treatment with systemic chemotherapy. She is currently disease free 6 months postoperatively. CONCLUSION: Primary adrenal lymphoma should be considered in patients with unilateral adrenal incidentaloma. We believe that adherence to guidelines of resection of incidentalomas allowed for early surgical intervention and possible cure.

Gut microbiota, tight junction protein expression, intestinal resistance, bacterial translocation and mortality following cholestasis depend on the genetic background of the host.

Failure of the intestinal barrier is a characteristic feature of cholestasis. We have previously observed higher mortality in C57BL/6J compared with A/J mice following common bile duct ligation (CBDL). We hypothesized the alteration in gut barrier function following cholestasis would vary by genetic background. Following one week of CBDL, jejunal TEER was significantly reduced in each ligated mouse compared with their sham counterparts; moreover, jejunal TEER was significantly lower in both sham and ligated C57BL/6J compared with sham and ligated A/J mice, respectively. Bacterial translocation to mesenteric lymph nodes was significantly increased in C57BL/6J mice vs. A/J mice. Four of 15 C57BL/6J mice were bacteremic; whereas, none of the 17 A/J mice were. Jejunal IFN-γ mRNA expression was significantly elevated in C57BL/6J compared with A/J mice. Western blot analysis demonstrated a significant decrease in occludin protein expression in C57BL/6J compared with A/J mice following both sham operation and CBDL. Only C57BL/6J mice demonstrated a marked decrease in ZO-1 protein expression following CBDL compared with shams. Pyrosequencing of the 16S rRNA gene in fecal samples showed a dysbiosis only in C57BL/6J mice following CBDL when compared with shams. This study provides evidence of strain differences in gut microbiota, tight junction protein expression, intestinal resistance and bacterial translocation which supports the notion of a genetic predisposition to exaggerated injury following cholestasis.

Clinical images. Massive Meckel's enterolith mimicking urachal carcinoma.

Meckel's enterolith is a rare clinical entity that may be found on imaging and at surgery, as seen in this case of a 68-year-old man presenting for esophagogastrectomy. Images are presented with differential diagnosis and treatment choices.