Short-term and long-term outcomes of single-incision versus multi-incision laparoscopic resection for colorectal cancer: a propensity-score-matched analysis of 214 cases.

BACKGROUND: The aim of this study was to reveal the short-term and long-term outcomes of single-incision laparoscopic colorectal resection (SILC) compared with multi-incision laparoscopic colorectal resection (MILC) for colorectal cancer using propensity score matching analysis. METHODS: The study group included 235 patients who underwent SILC and 730 patients who underwent MILC for colorectal cancer between April 2009 and September 2014. The propensity score matching for age, gender, body mass index, tumor location (right-sided colon/sigmoid colon/upper rectum), lymph node dissection (D1/D2/D3), pathologic T (≤T3) stage and TNM (0-I/II/III) stage produced 107 matched pairs. The exclusion criteria for SILC were as follows: (1) tumors located at the transverse, descending colon or lower rectum, (2) stage IV tumors, synchronous or previous malignancies, (3) locally advanced tumors >T4, (4) acute obstructions or previous major abdominal surgery and (5) obese patients: BMI > 30. RESULTS: No significant differences were observed in operating time, bleeding volumes, starting time of liquid diet and length of hospital stay between the SILC and MILC groups. However, the SILC group showed less analgesic requirements (1.1 vs. 1.9 times; p = 0.0006) and shorter length of incision (2.7 vs. 4.3 cm; p = 0.0000) compared to MILC group. The overall rate of postoperative complications was similar in both groups (2.8 vs. 3.7%, p = 0.70). The 5-year overall survival rate of SILC and MILC was 100 and 95% (p = 0.125) and 5-year disease-free survival rates in stages 0-III were 97 and 94% (p = 0.189), 100 and 92% in stage II and 90 and 85% in stage III, respectively. CONCLUSIONS: This study suggests that SILC for colorectal cancer is a safe and feasible option with better cosmetic results and less pain in strictly selected patients. SILC can also produce good oncological results with similar postoperative outcomes to MILC.

Natural orifice specimen extraction using prolapsing technique in single-incision laparoscopic colorectal resections for colorectal cancers.

INTRODUCTION: It is often technically difficult to cut the lower rectum with an endoscopic linear stapler in single-incision laparoscopic colorectal resections (SILC) because some surgical devices are inserted through the same access platform. If the rectum is cut incorrectly, it may cause anastomotic leakage. We recently applied natural orifice specimen extraction (NOSE) using the prolapsing technique to overcome this technical difficulty in SILC procedures in selected patients. MATERIALS AND SURGICAL TECHNIQUE: The access platform is placed in the small umbilical incision area. SILC is performed using a surgical technique similar to the conventional laparoscopic medial-to-lateral approach. The proximal part of the tumor site is transected with laparoscopic staplers. Then, the tumor lesion and bowel are pulled out of the body through the anus by means of inversion. Next, the distal side of the bowel is cut with a stapler and the rectal stump is reinforced with sutures under direct vision. The distal side of the bowel is then pushed back into the body. NOSE with prolapsing technique is then complete. After that, the anvil is attached to the proximal part of the bowel at the umbilical incision site, and intracorporeal anastomosis is performed. DISCUSSION: NOSE with prolapsing technique was applied in 14 SILC procedures for colorectal cancer patients. All procedures were successful, and there were no anastomotic leakages in the series. This technique enabled us to perform pure SILC safely without affecting cosmesis, even in cases where we needed to cut the lower rectum.

Laparoscopic one-stage resection of right and left colon complicated diverticulitis equivalent to Hinchey stage I-II.

PURPOSE: The safety and effectiveness of laparoscopic surgery is well established for recurrent, uncomplicated diverticular disease, but not for complicated diverticular disease. Using the Hinchey classification, we compared laparoscopic colon resection (LAPH) with conventional open colon resection (OPH) for the treatment of complicated diverticulitis equivalent to Hinchey stage I-II. METHODS: In this study, the Hinchey classification (I-IV) was also adopted for right-sided diverticulitis (I'-IV'). We reviewed the clinical records of 58 patients who underwent colon resection for complicated colon diverticulitis (Hinchey stage I-IV or I'-IV') between May 1994 and December 2008. Fifty-two patients underwent colon resection for Hinchey I-II or I'-II' disease; as LAPH in 36 and as OPH in 16. Only one patient required conversion to the open procedure after laparoscopy. RESULTS: The overall complication rate was significantly higher in the OPH group (43.8%) than in the LAPH group (16.7%; P < 0.05). Wound infection was significantly more common in the OPH group (37.5%) than in the LAPH group (11.1%; P < 0.05). Hospital stay was significantly shorter in the LAPH group (P < 0.05). Hartmann procedure was performed in one patient from each group. No anastomotic leakage occurred in either group. CONCLUSION: Our findings indicate that laparoscopic surgery can be performed safely and effectively even for patients with Hinchey I-II, I'-II' colonic diverticulitis.

Single-incision laparoscopic colectomy for colon cancer: early experience with 31 cases.

BACKGROUND: Transumbilical single-port surgery has been developed with the aim to further reduce the invasiveness of conventional laparoscopy. OBJECTIVE: This study aimed to report our experience with 31 patients who were treated with transumbilical single-incision laparoscopic colectomy for colon cancer. DESIGN: This is a retrospective review of prospectively gathered data. SETTINGS: This study was conducted at the Department of Surgery of Juntendo University Urayasu Hospital between April 2009 and April 2010. Data were obtained from a prospectively maintained single-institution laparoscopic colon cancer database. PATIENTS: Thirty-one consecutively selected patients (mean BMI, 22.5 ± 2.3) were evaluated. INTERVENTIONS: All patients underwent single-incision laparoscopic colectomy for colon cancer. Two different approaches were used for single-incision laparoscopic colectomy: the trocar insertion method and the SILS port method. The trocar insertion method was adopted in 22 of 31 patients, and the SILS port method was used in 9 patients. MAIN OUTCOME MEASURES: The main measures of outcomes were intraoperative findings, postoperative course, and oncological outcomes. RESULTS: The most common procedure was sigmoid colon resection performed in 12 of 31 (39%) patients. The mean skin incision was 2.72 ± 0.79 (range, 3-5) cm. The operating time ranged from 101 to 263 (mean, 156 ± 45) minutes. The volume of bleeding ranged from 5 to 60 (mean, 27 ± 19) mL. No intraoperative complications were observed in this series. Postoperatively, there was no mortality. Wound infection was observed in 1 patient. The number of harvested lymph nodes was 18 ± 2.1, and the mean tumor-free resection margin was 11 ± 4.8 cm. CONCLUSION: Our experience indicates that single-incision laparoscopic colectomy is feasible for selected patients with colon cancer.

Comparison of two different energy-based vascular sealing systems for the hemostasis of various types of arteries: a porcine model-evaluation of LigaSure ForceTriad™.

BACKGROUND: The ForceTriad™ generator has been recently developed. This new electrosurgical generator would demonstrate improved quality and efficiency in blood vessel sealing. AIM: To compare currently available 10-mm laparoscopic electrosurgical devices with the LigaSure™ Vessel Sealing System and ForceTriad generator (Valleylab, Inc., a division of Tyco Healthcare) for use in vessel sealing. METHODS: Blood vessels of various types and diameters were harvested from alive four pigs using three instruments: LigaSure Atlas™ with LigaSure Vessel Sealing Generator (LSAt), LigaSure Atlas with ForceTriad Generator (LSAtFT), and Endoclip™ II (Autosuture, USSC; a division of Tyco Healthcare). A total of 100 arteries were processed by removal of fatty and connective tissue from the adventitia before sealing. An additional set of specimens was sealed and histopathologically analyzed after being stained with hematoxylin and eosin. RESULTS: The mean burst pressure was significantly higher with LSAtFT compared to LSAt (P < 0.01). The sealing process was significantly shorter with LSAtFT (P < 0.05). With regard to the degree of thermal injury, adventitial collagen denaturation and proximal thermal injury to the smooth muscle in the media of the vessel wall were less common with LSAtFT; however, the numbers were too small for statistical analysis. CONCLUSION: Both the LSAt and LSAtFT secured all vessel sizes to well above physiologic levels. The LSAtFT could be used more confidently in vessels up to 7 mm. Our findings indicate that LSAtFT could be a safer and more efficient instrument for advanced laparoscopic surgery.

Laparoscopic appendectomy for complicated appendicitis: a comparison with open appendectomy.

BACKGROUND: Although laparoscopic appendectomy (LA) is widely performed in many countries, LA for complicated appendicitis, which includes perforated or gangrenous appendicitis with or without localized or disseminated peritonitis, has not become a common practice yet. METHODS: We retrospectively analyzed the clinical records of 230 patients who had undergone appendectomy for complicated appendicitis: 141 had undergone LA, 84 had conventional open appendectomy (OA), and 5 patients had conversion to the open procedure after laparoscopy. The LA group (total LA) was subdivided into "early experience (early LA: cases 1-56)" and "late experience (late LA: case 57 and higher)." We defined the early LA group as the comparison group to minimize selection bias. RESULTS: Patient demographics were similar in the early LA and OA groups (P > 0.05). Wound infection was significantly more frequent in the OA group (P < 0.05). Intra-abdominal infection was equally common in these two groups. The overall rate of postoperative complications was significantly higher in the OA group (32.1%) than in the early LA group (18%; P < 0.05). This incidence was 12.8% in the total LA group. Hospital stay was significantly shorter in the early LA group (10.6 +/- 3.9 days; P < 0.05), and 8.9 +/- 3.7 days in the total LA group. CONCLUSIONS: Our findings indicate that LA is safe and useful even for the treatment of complicated appendicitis if performed by an experienced surgeon.

Protective effects of nafamostat mesilate on liver injury induced by lipopolysaccharide in rats: possible involvement of CD14 and TLR-4 downregulation on Kupffer cells.

Nafamostat mesilate (NM) is a synthetic protease inhibitor with various biological effects. To determine its effect on liver injury related to sepsis, we investigated the effects of NM on lipopolysaccharide (LPS)-induced liver injury. Wistar rats were allocated into two groups; the NM group underwent intraperitoneal NM administration 30 min before LPS administration, and the control group underwent PBS administration. Serum AST and ALT levels were significantly decreased in NM-treated rats. Reduced levels of TNF-alpha, IL-1beta, and IFN-gamma were observed after LPS administration in NM-treated rats. No significant differences were observed in IL-6 levels between the NM and the control group. In contrast, HGF levels were significantly increased only in control rats. NM treatment decreased protein and mRNA levels of TLR-4 and CD14. Our data suggest that NM treatment has protective effects against LPS-induced hepatotoxicity through downregulation of TLR4 and CD14 in liver, which decreased TNF-alpha, IL-1beta, and IFN-gammaproduction in liver.

The effect of ciprofloxacin on CD14 and toll-like receptor-4 expression on human monocytes.

CD14/toll-like receptor (TLR)-4 complex on monocytes/macrophages can bind lipopolysaccharide (LPS) and transduce the signals intracellularly. An antibacterial drug, ciprofloxacin (CIP), has been reported to modulate the inflammatory and immune responses. In the present study, we examined the effects of CIP on the LPS-induced activation of monocytes isolated from human peripheral blood mononuclear cells (PBMC). CIP suppressed the expression of CD14, TLR-4, intercellular adhesion molecule (ICAM)-1, B7.1, B7.2, and CD40 and the production of tumor necrosis factor (TNF)-alpha induced by LPS in monocytes. CIP induced the production of prostaglandin (PG)E2 and increased intracellular cyclic adenosine monophosphate (cAMP) levels. Cyclooxygenase (COX)-2 inhibitors, NS398 and indomethacin, reversed the effects of CIP on TNF-alpha production and reduced the levels of different surface antigens, whereas a protein kinase A (PKA) inhibitor, H89, did not. Therefore, CIP might regulate the TNF-alpha production induced by LPS by inhibiting the expression of LPS receptor complex, which seems to be mediated by COX-2 but not the cAMP/PKA pathway.

Beta2-adrenergic receptor stimulation inhibits LPS-induced IL-18 and IL-12 production in monocytes.

We examined the effects of beta2-adrenergic receptor (beta2-AR) agonists on monocyte-derived cytokines, interleukin (IL)-18 and IL-12 production in lipopolysaccharide (LPS)-stimulated monocytes derived from human peripheral blood mononuclear cells (PBMCs), as in vitro model of sepsis. The study found that beta2-AR agonists inhibited IL-18 and IL-12 production in monocytes, and that AR agonist activity was antagonized by the selective beta2-AR antagonist, butoxamine. The selective beta2-AR agonists salbutamol and terbutaline induced a similar inhibitory pattern of IL-18 and IL-12 production. IL-12 production induced by LPS was inhibited by anti-IL-18 Ab, but IL-18 production by LPS was not inhibited by anti-IL-12 Ab, showing that LPS induced IL-18 production without IL-12 production. Therefore, the stimulation of beta2-AR might be beneficial in the treatment of sepsis through inhibiting LPS-elicited IL-18.

Differential effect of prostaglandins E1 and E2 on lipopolysaccharide-induced adhesion molecule expression on human monocytes.

The effect of prostaglandins E1 and E2 on the 1 ng/ml lipopolysaccharide-induced expression of intercellular adhesion molecule (ICAM)-1, B7.1, B7.2, CD40 and CD40 ligand (CD40L) on monocytes was examined. Prostaglandin E1 suppressed B7.1 and CD40 expression, but prostaglandin E2 did not effect on any type of adhesion molecule expression. Both prostaglandins inhibited tumor necrosis factor (TNF)-alpha production and T-cell proliferation of lipopolysaccharide-treated human peripheral blood mononuclear cells (PBMC). Among prostaglandin E1 receptors (IP/EP1/EP2/EP3/EP4) agonists, ONO-1301, a prostanoid IP-receptor agonist, prevented B7.1 and CD40 expression. ONO-AE1-259-01 a prostanoid EP2-receptor agonist, ONO-AE1-329, a prostanoid EP4-receptor agonist, and ONO-1301 inhibited TNF-alpha production and T-cell proliferation. Moreover, anti-B7.1 and anti-CD40 Abs prevented lipopolysaccharide-induced TNF-alpha production and T-cell proliferation. Therefore, the effect of prostaglandin E1 on TNF-alpha production and T-cell proliferation might depend on the inhibition of B7.1 and CD40 expression, but that of prostaglandin E2 might be independent of adhesion molecules expression. In conclusion, the mechanism responsible for the effect of prostaglandin E1 on lipopolysaccharide-induced responses is distinct from that of prostaglandin E2.