Robotic CME in obese patients: advantage of robotic ultrasound scan for vascular dissection.

Complete mesocolic excision (CME) in right-sided colon cancers appears to confer oncological benefits compared to conventional colectomy. Identification of the superior mesenteric vein (SMV) remains challenging. We describe the novel use of intra-operative robotic ultrasound scan (rUSS) in obese patients (BMI ≥ 29). All consecutive patients having robotic CME for colon cancer between 2014 and 2017 were included in this retrospective cohort study. Data were recorded on an ethics approved prospective database and included patient demographics, clinical and oncological outcomes. Patients were divided into group 1 (BMI ≤ 28) and group 2 (BMI ≥ 29). SMV first approach was employed in all cases and SMV detection was aided using rUSS in group 2. Primary outcome was postoperative morbidity. Secondary outcomes included conversion rate, operative time and length of stay (LOS). 41 (group 1, median 66 years) were compared to 32 patients (group 2, median 63 years). There were no conversions to laparoscopy or laparotomy. Median operative times for group 2 were 30 min longer (186 vs. 216 min, p = 0.05). Overall morbidity was similar (20% vs. 19% in group 1 and 2, p = 0.26). There was no significant difference between the two groups with regard to LOS (median 7 vs. 6 days, p = 0.48), readmissions (2 vs. 5, p = 0.13), R0 resection rate (98% vs. 94%, p = 0.43) and lymph node harvest (median 31 vs. 30, p = 0.28).CME can be technically more challenging than conventional colectomy in obese patients and is associated with longer operative times. The use of rUSS in obese patients can help to identify SMV and allow safer dissection.

Emergency robotic colorectal surgery during COVID-19 pandemic: A retrospective case series study.

Objective: While interest in elective robotic surgery is growing, use in emergency setting remains limited due to challenges posed by sicker patients, advanced pathology and logistical issues. During the COVID-19 pandemic, robotic surgery could provide the benefit of having the surgeon away from the bedside and reducing the number of directly exposed medical staff. The objective of this study was to report patient outcomes and initial learning experience of emergency robotic colorectal surgery during the COVID-19 pandemic. Methods: A case series study was conducted, including patients undergoing emergency robotic colorectal surgery between February 2020 and February 2021 at Queen Alexandra Hospital in Portsmouth, UK. Patient data were collected from an ethics approved prospective database. Patient demographics, operative time, conversions and postoperative complications were recorded. In addition, readmissions, length of stay and short-term oncological outcomes were analyzed. Results: Ten patients with median age 64 y (range, 36-83 y) were included. Four patients had robotic complete mesocolic resection for obstructing cancers. Six had colorectal resections for benign disease in emergency setting. All were R0 with a mean lymph node harvest of 54 ± 13. Mean operative time was 249 ± 117 min, the median length of stay was 9.4 d (range, 5-22 d). Only one patient was given a temporary diverting ileostomy. There were no grade III/V complications and no 30-day mortality. Conclusions: Provided an experienced team and peri-operative planning, emergency robotic colorectal surgery can achieve favorable outcomes with benefits of radical lymph node dissection in oncological cases and avoidance of diverting stoma.

Perirenal perivascular epithelioid cell tumor (PEComa).

A 52-year-old woman, who is a carrier of MLH-1 mutation (HNPCC-type Lynch syndrome) with a history of colon adenocarcinoma, was diagnosed with a 26 mm lobulated contrast-capturing mass located caudally of the pancreas tail, anteromedial of the spleen and medial of the splenic colon angle. She underwent an exploratory laparotomy with resection of the tumor. Initially, this mass was presumed to be metastasis in a patient with a history of colon adenocarcinoma. However, after further histopathological and immunohistochemical examination, the mass appeared to be a rare PEComa. Only a few cases of a PEComa in this retroperitoneal perirenal location have been described.

Surgical resection of voluminous epiphrenic diverticula.

A 52-year-old male and 55-year-old female underwent surgical resection of a voluminous symptomatic epiphrenic diverticulum via a right thoracotomy. A formal myotomy of the distal esophagus was not performed. The first patient had an uncomplicated recovery whilst the other patient still suffers from an esophageal-cutaneous fistula and repetitive abscesses, treated by intravenous antibiotics and percutaneous drainage. The authors discuss the indication for resection, surgical techniques and complications.

Complication Rate after Carotid Endarterectomy Comparing Patch Angioplasty and Primary Closure.

BACKGROUND: Carotid endarterectomy (CEA) reduces the risk for stroke in patients with internal carotid artery stenosis. The optimal surgical technique remains subject of debate. Literature suggests patch angioplasty reduces complication risk. However, primary closure shortens cross-clamp times and eliminates graft-specific complications. This study aimed to assess complication rate after CEA with selective patching. METHODS: A total of 213 consecutive CEAs over a 3-year period from January 5th, 2011 to December 19th, 2013 were retrospectively analyzed. Postoperative complications were evaluated within 1 month after surgery. RESULTS: Primary closure was used in 110 operations and patch angioplasty in 103 procedures. Primary closure was performed when the carotid artery had a diameter above 5 mm, when there was a high carotid bifurcation, and when the contralateral carotid artery was occluded. After primary closure, we found 4 (3.6%) complications: 2 (1.8%) bleeding and 2 (1.8%) cranial nerve damage. After patch angioplasty 5 (4.9%) complications occurred: 1 (1.0%) bleeding, 2 (1.9%) cranial nerve damage, 1 (1.0%) cerebrovascular event, and 1 (1.0%) cerebral hyperperfusion resulting in mortality. There was no higher complication risk after primary closure (P = 0.68). Clamp time was significantly longer when using patch angioplasty (P < 0.001). CONCLUSIONS: Primary closure appears to be an equivalent closure technique compared with patch angioplasty when used in selected patients.

Patients with cardiac arrest are ventilated two times faster than guidelines recommend: an observational prehospital study using tracheal pressure measurement.

AIM: To measure ventilation rate using tracheal airway pressures in prehospitally intubated patients with and without cardiac arrest. METHODS: Prospective observational study. In 98 patients (57 with and 41 without cardiac arrest) an air-filled catheter was inserted into the endotracheal tube and connected to a custom-made portable device allowing tracheal airway pressure recording and subsequent calculation of ventilation rate. RESULTS: In manually ventilated patients with cardiac arrest 39/43 (90%) had median ventilation rates higher than 10/min (overall median 20, min 4, max 74). During mechanical ventilation, 35/38 (92%) had ventilation rates higher than 10/min. The ventilation rate in patients with cardiac arrest was higher than in patients without cardiac arrest, both for manual and mechanical ventilation. Subanalysis comparing episodes with and without compression in cardiac arrest patients showed no clinically significant difference in ventilation rate after compressions were terminated. CONCLUSION: Cardiac arrest patients were ventilated two times faster than recommended by the guidelines. Tracheal airway pressure measurement is feasible during resuscitation and may be developed further to provide real-time feedback on airway pressure and ventilation rate during resuscitation.