Short term Outcomes of Routine Exposure Versus non Exposure of the Recurrent Laryngeal Nerve During Thyroidectomy for Benign Thyroid Diseases.

Aims: To evaluate the outcomes of the exposure versus non-exposure of the RLN during thyroidectomy for benign thyroid diseases. Materials and methods: A prospective study for patients who underwent thyroidectomy for benign diseases. They were classified into two groups, group 1 (the exposed group) and group 2 (the non-exposed group) of the RLN. History, examination, laboratory and radiological investigations as well as intra and post-operative details were recorded. Results: 97 patients were included in the study, group 1 (63 patients) while group 2 (34 patients). The median age of both groups was 40 (for group 1) and 42 (for group 2) respectively. There was no significant difference regarding the gender of the patients (P = 0.089) and the type of surgery (P = 0.234). The duration of surgery as well as the amount of intraoperative blood loss were equal with no significant difference (P = 0.791) (P = 0.225). Hematoma was detected in three patients in the exposed group while RLN injury was detected in 5 patients in total (2 in group 1 and 3 in group 2) without any significant difference. There was significant hypocalcemia in favor of the non-exposed group (P = 0.001). Regarding the postoperative hospital stay, there was no significant difference between both groups (P = 0.720). Conclusions: Exposure versus non-exposure of the RLN is still considered a matter of debate but precautions during dissection are a very useful maneuver. Meanwhile, it is better to expose the nerve with meticulous dissection and preservation of the parathyroid gland vascularity.

Efficacy and Feasibility of Complete Mesocolic Excision with Central Vascular Ligation in Complicated Colorectal Cancer.

Complete mesocolic excision (CME) with central vascular ligation (CVL) involves sharp dissection through the embryological planes. However, it may be associated with high mortalities and morbidities especially in colorectal emergencies. This study aimed to investigate the outcomes of CME with CVL in complicated colorectal cancers (CRCs). This was a retrospective study of emergency CRC resection in a tertiary center between March 2016 and November 2018. A total of 46 patients, with a mean age of 51 years, underwent an emergency colectomy for cancer (males, 26 [56.5%]; females, 20 [43.5%]). CME with CVL was performed for all patients. The mean operative time and blood loss were 188 min and 397 mL, respectively. Only five (10.8%) patients presented with burst abdomen, whereas only three (6.5%) presented with anastomotic leakage. The mean length of vascular tie was 8.7 cm, and the mean number of harvested lymph nodes (LNs) was 21.2. Emergency CME with CVL is a safe and feasible technique when performed by a colorectal surgeon and will result in obtaining a superior specimen with a large number of LNs.

Optimal Complete Rectum Mobilization Focused on the Anatomy of the Pelvic Fascia and Autonomic Nerves: 30 Years of Experience at Severance Hospital.

The primary goal of surgery for rectal cancer is to achieve an oncologically safe resection, i.e., a radical resection with a sufficient safe margin. Total mesorectal excision has been introduced for radical surgery of rectal cancer and has yielded greatly improved oncologic outcomes in terms of local recurrence and cancer-specific survival. Along with oncologic outcomes, functional outcomes, such as voiding and sexual function, have also been emphasized in patients undergoing rectal cancer surgery to improve quality of life. Intraoperative nerve damage or combined excision is the primary reason for sexual and urinary dysfunction. In the past, these forms of damage could be attributed to the lack of anatomical knowledge and poor visualization of the pelvic autonomic nerve. With the adoption of minimally invasive surgery, visualization of nerve structure and meticulous dissection for the mesorectum are now possible. As the leading hospital employing this technique, we have adopted minimally invasive platforms (laparoscopy, robot-assisted surgery) in the field of rectal cancer surgery and standardized this technique globally. Here, we review a standardized technique for rectal cancer surgery based on our experience at Severance Hospital, suggest some practical technical tips, and discuss a couple of debatable issues in this field.

Characteristics of Patients Presented With Metastases During or After Completion of Chemoradiation Therapy for Locally Advanced Rectal Cancer: A Case Series.

PURPOSE: Locally advanced rectal cancer (LARC) is managed by chemoradiotherapy (CRT), followed by surgery. Herein we reported patients with metastases during or after CRT. METHODS: Data of patients with LARC who received CRT from 2008 to 2017 were reviewed. Patients with metastases after CRT were included. Those with metastatic tumors at the initial diagnosis were excluded. RESULTS: Fourteen patients (1.3%) of 1,092 who received CRT presented with metastases. Magnetic resonance circumferential resection margin (mrCRM) and mesorectal lymph nodes (LNs) were positive in 12 patients (85.7%). Meanwhile, magnetic resonance extramural vascular invasion (mrEMVI) was positive in 10 patients (71.4%). Magnetic resonance tumor regression grade (mrTRG) 4 and mrTRG5 was detected in 5 and 1 patient respectively. Ten patients (71.4%) underwent combined surgery and 3 (21.4%) received palliative chemotherapy. CONCLUSION: Patients with metastases after CRT showed a higher rate of positive mrCRM, mrEMVI, mesorectal LNs, and poor tumor response. Further studies with a large number of patients are necessary for better survival outcomes in LARC.

Does the timing of protective ileostomy closure post-low anterior resection have an impact on the outcome? A retrospective study.

BACKGROUND: The optimal timing for ileostomy closure remains controversial, most of the surgeons are closing ileostomy after two to three months, although ileostomy closure considered a simple procedure, it can cause significant morbidity; this study aims to clarify any relation between the post-closure complications rate and the time from its creation to the repair. METHOD: From January 2010 to December 2017, data retrieved for a 405 patients who had protective ileostomy closure after rectal cancer surgery, our sample has been enrolled into two arms, the first arm includes whose ileostomies closed at or before three months, and the second arm involved whose ileostomies closed after three months from the index surgery, statistical analysis was performed and compared in both arms, RESULT: The overall post-closure complications in our hospital was 23.7%, there was no significant difference between the overall complications rate for both early and late closure groups (26.8% and 22.7%) respectively (P = 0.499), The majority of the complications were intestinal obstruction, and superficial surgical site infection, there was no significant association between the interval to ileostomy reversal and the intestinal obstruction although it was higher in the late closure group, in the other hand the surgical site infection complication found to be significantly higher in the early closure group than the late closure group (15.4% Vs 5.1%) with (P = 0.002). CONCLUSION: The duration between the creation of protective ileostomy and its reversal was not a significant independent predictor of post-closure complications rate.

Assessment and management of low anterior resection syndrome after sphincter preserving surgery for rectal cancer.

Many patients develop a variety of bowel dysfunction after sphincter preserving surgeries (SPS) for rectal cancer. The bowel dysfunction usually manifests in the form of low anterior resection syndrome (LARS), which has a negative impact on the patients' quality of life. This study reviewed the LARS after SPS, its mechanism, risk factors, diagnosis, prevention, and treatment based on previously published studies. Adequate history taking, physical examination of the patients, using validated questionnaires and other diagnostic tools are important for assessment of LARS severity. Treatment of LARS should be tailored to each patient. Multimodal therapy is usually needed for patients with major LARS with acceptable results. The treatment includes conservative management in the form of medical, pelvic floor rehabilitation and transanal irrigation and invasive procedures including neuromodulation. If this treatment failed, fecal diversion may be needed. In conclusion, Initial meticulous dissection with preservation of nerves and creation of a neorectal reservoir during anastomosis and proper Kegel exercise of the anal sphincter can minimize the occurrence of LARS. Pre-treatment counseling is an essential step for patients who have risk factors for developing LARS.