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1.
Am Surg ; 85(10): 1194-1197, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657323

RESUMO

Minimally invasive approaches to total abdominal colectomy (TAC) in ulcerative colitis (UC) patients include straight laparoscopy (SL), hand-assisted laparoscopic surgery (HALS), and robotics. In this study, short-term outcomes of patients undergoing SL and HALS TAC were compared. Prospectively collected data on UC patients undergoing TAC were tabulated. The study cohort included 36 (27%) patients in the SL group and 95 (73%) patients in the HALS group. The groups were comparable in terms of preoperative characteristics and demographics. The mean operative time was 151 (range, 73-225) minutes in the SL group versus 164 (range, 103-295) minutes in the HALS group (P = 0.09). Total 48-hour IV morphine use was 30 (range, 0-186) mg in the SL group compared with 56 (0-275) mg in the HALS group (P < 0.01). Although overall morbidity was comparable between the groups, Clavien-Dindo Class III complications did not occur in any of the SL group patients versus 11 (11%) of the HALS group patients (P = 0.03). The postoperative length of stay was 3 (3-21) days in the SL group versus 5 (3-15) days in the HALS group (P < 0.01). Compared with HALS, SL is associated with lower postoperative narcotic use and hospital length of stay in UC patients undergoing TAC.


Assuntos
Colectomia/métodos , Colite Ulcerativa/cirurgia , Estética , Ileostomia , Laparoscopia/métodos , Adolescente , Adulto , Idoso , Analgésicos Opioides/administração & dosagem , Criança , Pré-Escolar , Colectomia/efeitos adversos , Colectomia/estatística & dados numéricos , Feminino , Laparoscopia Assistida com a Mão/efeitos adversos , Laparoscopia Assistida com a Mão/métodos , Laparoscopia Assistida com a Mão/estatística & dados numéricos , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/estatística & dados numéricos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Morfina/administração & dosagem , Duração da Cirurgia , Complicações Pós-Operatórias , Estudos Prospectivos , Estomas Cirúrgicos , Resultado do Tratamento , Adulto Jovem
2.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(10): 920-925, 2019 Oct 25.
Artigo em Chinês | MEDLINE | ID: mdl-31630487

RESUMO

The theory of membrane surgery actually holds the same concepts as that of traditional cancer surgery, which believes that tumor spread is regarded as an isotropic process but the tumor is confined by the block of the membrane. Therefore, the radical resection can be achieved by complete mesentery excision along the membrane plane. The surgical practice derived from these conceptions is extended excision and lays emphasis on tumor-free margins. But the theory is controversial in the view of the existence of mesorectal fascial envelope and the feasibility of complete excision of mesorectum along the "holy plane". Based on ontogenetic anatomy, the compartment theory suggeststhat tumor spread is not isotropic, and it is locally confined within the ontogenetic compartment derived from a common primordium for a relatively long phase during their natural course. Local tumor is suppressed by the boundary instead of fascia. The anatomical territory developing from each anlage primordium may be separated morphologically. Consequently, ontogenetic compartment theory states that optimal local control of cancer is achieved by whole compartment resection, irrespective of margin width. The compartment model of tumor spread provides explanations for total mesorectal excision (TME) which excises the complete rectum compartment including the rectum and its surrounding vascular and ligamentous mesenteries. The compartment theory may set up the new principles for surgical tumor treatment, namely the resection of the tumor bearing compartment rather than target organ.


Assuntos
Mesentério/patologia , Mesentério/cirurgia , Protectomia/métodos , Neoplasias Retais/patologia , Neoplasias Retais/cirurgia , Colectomia/métodos , Colectomia/normas , Fáscia/patologia , Humanos , Margens de Excisão , Mesocolo/patologia , Mesocolo/cirurgia , Invasividade Neoplásica , Metástase Neoplásica , Protectomia/normas , Reto/anatomia & histologia , Reto/patologia
3.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(10): 943-948, 2019 Oct 25.
Artigo em Chinês | MEDLINE | ID: mdl-31630491

RESUMO

The neurovascular bundle (NVB) starts at the lateral angle of the seminal vesicle (the initial part), passes posterolateral of the prostate gland (the main part), and ends at the cavernous body of the penis (the cavernous part). In low rectal surgery, different transabdominal and transanal perspectives result in different NVB injury risks. In the perspective of transabdominal operation, the separation between the initial part of NVB and Denonvilliers fascia and the anatomical variation of the two lateral sides of Denonvilliers fascia increases the risk of NVB injury, and conformation separation may take into account the convenience of separationand the protection of NVB. In the perspective of transanal operation, when separating the main part with NVB and mesorectum, the perspective of the transanal, unidirection traction and excessive dissection increase the risk of NVB main exposure. Clear anatomical identification helps the protection of NVB in the transanal operation. At present, the medical evidence on the difference of NVB injury in different perspectives of transabdominal and transanal approach is still in need of relevant clinical researches.


Assuntos
Mesentério/cirurgia , Protectomia/métodos , Neoplasias Retais/cirurgia , Reto/cirurgia , Colectomia/métodos , Dissecação , Fáscia/anatomia & histologia , Humanos , Masculino , Mesentério/anatomia & histologia , Mesentério/irrigação sanguínea , Mesentério/inervação , Neoplasias Retais/patologia , Reto/anatomia & histologia , Reto/irrigação sanguínea , Reto/inervação
4.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(10): 949-954, 2019 Oct 25.
Artigo em Chinês | MEDLINE | ID: mdl-31630492

RESUMO

Objective: To perform an anatomical observation on the extension of the mesocolon to the mesorectum and the continuity of the fasciae lining the abdomen and pelvis, in order to clarify the appropriate surgical plane of total mesorectal excision. Methods: This is an descriptive study. The operation videos of 61 cases (28 males, 33 females, median age of 61) were collected. All the patients underwent laparoscopic colorectal surgery from January 2018 to December 2018 in Yangpu Hospital, including low anterior resection for rectal cancer in 25 cases, left hemicolectomy for descending colon cancer in 15 cases, and subtotal resection of the colon for intractable constipation in 21 cases. Among these 21 constipation patients, 8 received additional modified Duhamel surgeries. Gross anatomy was performed on 24 adult cadavers provided by Department of Anatomy, Shanghai Jiaotong University School of Medicine, including 23 formalin-fixed and 1 fresh cadaver (12 males, 12 females). Sixty-one patients and 24 cadavers had no previous abdominal or pelvic surgical history. The anatomy and extension of fasciae related to descending colon, sigmoid colon and rectum, especially the morphology of Toldt fascia, and the continuities of mesocolon and mesorectum were observed carefully. The distribution characteristics of the fasciae and anatomical landmarks during laparoscopic surgery were recorded and described. Results: The anatomical study on 24 cadavers showed that visceral fascia was the densest connective tissue in the pelvic, posterolateral to the rectum, and stretched as a hammock to lift all pelvic organs. Among 61 patients undergoing laparoscopic surgery, 36 (59.0%) needed to free the left colon during operation, and Toldt fascia in the descending colon segment presented as potential, avascular and extensible loose connective tissue plane between the mesocolon and posterior Gerota fascia; 33 (54.1%) needed to free the rectum during operation, and Toldt fascia extended downward to pelvis as loose connective tissue between the fascia propria of the rectum and visceral fascia; the fascia propria of the rectum exposed completely in 32 (32/33, 97.0%) cases, which ran downward and fused with visceral fascia at the level of the fourth sacral vertebra. The anatomy of 24 cadavers also showed that fascia propria of the rectum fused with visceral fascia at the level of Waldeyer fascia. The fusion line of these two fasciae was supposed to be the extension of Waldeyer fascia. There were two avascular planes behind the rectum: one between the fascia propria of the rectum and visceral fascia, and the other between the visceral fascia and parietal fascia. In 8 constipation cases undergoing laparoscopic subtotal colon resection plus modified Duhamel operation, both mesocolon and mesorectum needed to be mobilized. It was obvious that the mesocolon of descending colon extended and became the mesocolon of sigmoid colon, and ran further into the pelvic and became the mesorectum. The colon fascia of descending colon served as the natural boundary of mesocolon extended downward as the fascia of sigmoid colon and the fascia propria of the rectum, respectively. Toldt fascia locating between mesocolon of descending colon and Gerota fascia extended to pelvis as the 'presacral space' between the fascia propria of the rectum and visceral fascia. Gerota fascia in descending colon segment extended as urogenital fascia in sigmoid colon segment and visceral fascia in the pelvis, respectively. In the cadaver anatomy study, the visceral fascia served as a corridor carrying the hypogastric nerve, and ureter was observed in 23 (23/24, 95.8%) cases. The visceral fascia passed from posterior to anterior lateral of rectum, fusing with Denonvilliers fascia in a fan shape. The pelvic plexus located exactly external to the junction of visceral fascia and Denonvilliers fascia. Pelvic splanchnic nerves went through the parietal fascia toward to the inferolateral of the pelvic plexus. Conclusion: Fascia propria of the rectum and the visceral pelvic fascia are two independent layers of fascia, and the TME surgical plane is between the fascia propria of the rectum and visceral pelvic fascia instead of between the visceral and the parietal pelvic fascia.


Assuntos
Fáscia/anatomia & histologia , Mesentério/anatomia & histologia , Pelve/anatomia & histologia , Protectomia/métodos , Neoplasias Retais/cirurgia , Reto/anatomia & histologia , Abdome/anatomia & histologia , Cadáver , Colectomia/métodos , Feminino , Humanos , Laparoscopia , Masculino , Mesocolo/anatomia & histologia , Pessoa de Meia-Idade
5.
Rev Col Bras Cir ; 46(4): e20192171, 2019.
Artigo em Português, Inglês | MEDLINE | ID: mdl-31644719

RESUMO

OBJECTIVE: to evaluate the influence of the splenic flexure mobilization for the main surgical outcomes of patients submitted to resection of sigmoid and rectal cancer. METHODS: we searched the MEDLINE, Cochrane Central Register of Controlled Trials and LILACS, using the terms "splenic flexure mobilization", "colorectal surgery", "rectal cancer", "anterior resection", "sigmoid colon cancer", and "sigmoid resection". The main outcome was anastomotic dehiscence. Other outcomes analyzed were mortality, bleeding, infection and general complications. We estimated the effect sizes by grouping data from six case-control studies (1,433 patients) published until January 2018. RESULTS: our meta-analysis showed that patients undergoing complete mobilization of the splenic flexure had a higher risk of anastomotic dehiscence (RR=2.27, 95%CI: 1.22-4.23) compared with those not submitted to this procedure. There was no difference between the groups in terms of mortality, bleeding, infection and general complications. CONCLUSION: splenic flexure mobilization is associated with a higher risk of anastomotic dehiscence in resections of sigmoid and rectal cancer. This surgical maneuver should be used with caution in the surgical management of sigmoid or rectal cancers.


Assuntos
Colectomia/métodos , Protectomia/métodos , Neoplasias Retais/cirurgia , Neoplasias do Colo Sigmoide/cirurgia , Colectomia/efeitos adversos , Humanos , Complicações Pós-Operatórias , Protectomia/efeitos adversos , Resultado do Tratamento
6.
Khirurgiia (Mosk) ; (8. Vyp. 2): 54-59, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31502594

RESUMO

This article deal with method of multimodal, opioid-free anesthesia for colorectal surgery in the perioperative period. AIM: To improve the quality of treatment for patients with colorectal cancer using non-opioid anesthesia and analgesia in the perioperative period. MATERIAL AND METHODS: The study included 47 patients who underwent laparoscopic colon surgery. This anesthesia method consists of epidural anesthesia with sevoflurane during surgery end epidural analgesia after surgery. We describe the method of non-opioid anesthesia technics during colorectal surgery. The pain syndrome was evaluated at various time intervals. Harvard standard for monitoring during anesthesia is presented. RESULTS: Opioid-free anesthesia is safety method for colorectal surgery. It was also possible to reduce the incidence of postoperative nausea and vomiting, pain, intestinal paresis, the duration of hospitalization, and rise quality of medical care for patient with colorectal cancer.


Assuntos
Analgesia Epidural , Anestésicos Inalatórios/administração & dosagem , Colectomia/métodos , Neoplasias Colorretais/cirurgia , Sevoflurano/administração & dosagem , Humanos , Laparoscopia , Período Perioperatório , Resultado do Tratamento
7.
Khirurgiia (Mosk) ; (8. Vyp. 2): 65-69, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31502596

RESUMO

Laparoscopic colon resections are currently becoming a standart method of surgical treatment of colon cancer. Long-term oncologic outcomes of such procedures are shown to be non-inferior to outcomes of traditional open surgery, while short-term results and morbidity profile are more favourable. The current direction of colon mini-invasive surgery development is to make procedures more easily tolerable by patients, using less traumatic methods and operative approaches. The article contains a review of one of such methods, which allows less traumatic performance of laparoscopic right hemicolectomy - an intracorporeal ileotransversoanastomosis. The current evidence concerning safety and efficacy are reviewed, when authors' own data are also brought to support implementation of this method into routine practice.


Assuntos
Colectomia/métodos , Colo Transverso/cirurgia , Neoplasias do Colo/cirurgia , Íleo/cirurgia , Anastomose Cirúrgica/métodos , Humanos , Laparoscopia , Resultado do Tratamento
8.
Zhonghua Zhong Liu Za Zhi ; 41(9): 654-658, 2019 Sep 23.
Artigo em Chinês | MEDLINE | ID: mdl-31550854

RESUMO

Objective: This study aims to explore the clinical value of fusion indocyanine green fluorescence imaging (FIGFI) in total laparoscopic radical resection for right colon cancer. Methods: From October, 2018 to December, 2018, 15 patients who underwent total laparoscopic radical resection for right colon cancer using FIGFI in Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College were retrospectively enrolled in this study. Data regarding surgical outcomes, postoperative recovery, pathological outcomes and complications were collected and analyzed. Results: All patients successfully underwent total laparoscopic radical resection for right colon cancer using FIGFI. 1 patients (6.7%) received extended resection of bowel due to poor blood supply after mesentery excision. The average operation time was 133.7 minutes and intraoperative blood loss was 26.7 ml. The average time to ground activities, fluid diet intake, first flatus and postoperative hospitalization were 19.1 h, 11.7 h, 32.5 h and 5.0 d, respectively. The average length of tumor was 4.5 cm. The average proximal and distal resection margins were 14.9 cm and 12.1 cm, respectively. The average number of lymph nodes retrieved was 29.3 per patient. Only one patient suffered from incisional fat liquefaction after surgery and was managed effectively by regular dressing change. No severe complications such as indocyanine green allergy, anastomotic stenosis, anastomotic leakage, abdominal bleeding, bowel obstruction, pulmonary infection, and abdominal infection occurred in any patients. Conclusions: FIGFI is helpful to judge the blood supply of intestinal segments and anastomotic stoma in total laparoscopic radical resection for right colon cancer quickly. It is a safe and feasible technique with satisfactory short-term effect.


Assuntos
Anastomose Cirúrgica/métodos , Colectomia/métodos , Colo/irrigação sanguínea , Neoplasias do Colo/cirurgia , Corantes/administração & dosagem , Verde de Indocianina/administração & dosagem , Imagem Óptica/métodos , Fístula Anastomótica/prevenção & controle , Colo/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Estudos de Viabilidade , Humanos , Laparoscopia/métodos , Estudos Retrospectivos , Resultado do Tratamento
10.
Am Surg ; 85(7): 695-699, 2019 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-31405410

RESUMO

SSI is a leading cause of morbidity and increases health-care cost after colorectal operations. It is a key hospital-level patient safety indicator. Previous literature has identified perioperative risk factors associated with SSI and interventions to decrease rate of infection. The purpose of this study was to evaluate the impact of blowhole closure on the rate of superficial and deep SSI. The ACS-NSQIP database was queried for patients undergoing colectomy at the University of Kentucky from 2013 to 2016. Retrospective chart review was performed to gather demographic data and perioperative variables. Wounds left open and packed were excluded. Rates of postoperative SSI were measured between the groups. One thousand eighty-three patients undergoing elective and emergent colectomy were reviewed. Nine hundred and forty-five had closed incision and 138 had blowhole closure. Patient characteristics between the groups were well matched. Patients with a blowhole closure were more likely to have an open procedure (P = 0.037) and a higher wound class (P < 0.001). The rate of superficial and deep SSI was 9.1 per cent in patients with a closed incision and 5.1 per cent in patients with blowhole closure (P = 0.142). With adjustment for approach and wound class, blowhole closure decreased the incidence of SSI (P = 0.04). There was no significant difference in morbidity or mortality. Patients undergoing elective and emergent colectomy had decreased incidence of SSI when blowhole closure was used. Given that it does not increase resource usage and its technical ease, blowhole closure should become the standard method of surgical wound closure.


Assuntos
Colectomia/métodos , Infecção da Ferida Cirúrgica/prevenção & controle , Adolescente , Adulto , Idoso , Colectomia/efeitos adversos , Comorbidade , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Infecção da Ferida Cirúrgica/epidemiologia , Adulto Jovem
12.
Khirurgiia (Mosk) ; (8): 29-35, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31464271

RESUMO

OBJECTIVE: To compare short- and long-term outcomes of treatment in patients with colon cancer undergoing laparoscopic and open surgery. MATERIAL AND METHODS: There were 281 patients with colon cancer. All patients underwent open (n=144, 51.2%) or laparoscopic (n=137, 48.8%) procedures. Short- and long-term outcomes of treatment were compared in both groups. RESULTS: There were no significant differences in sex, age, body mass index, location of tumors and tumor differentiation grade in both groups. Conversion was required in 10 (7.2%) cases. The median of duration of surgery was greater for laparoscopic procedures (150 min vs. 130 min; p<0.001). Intraoperative blood loss was significantly less in laparoscopic surgery (100 ml vs. 300 ml; p=0.001). Postoperative mortality was similar (3.5% vs. 2.5%; p=0.5) while incidence of postoperative complications was significantly lower after laparoscopic interventions (13.1% vs. 22.2%; p=0.04). There was earlier recovery of the gastrointestinal tract after laparoscopic procedures (2.1±0.9 days vs. 3.6±1.5 days, respectively; p<0.001). The postoperative hospital-stay was significantly less in the 2nd group (p<0.001). Two-year disease -free and overall survival was similar in both groups. CONCLUSION: Laparoscopic interventions for colon cancer are followed by similar overall and disease-free 2-year survival and better early outcomes.


Assuntos
Colectomia , Neoplasias do Colo/cirurgia , Colectomia/efeitos adversos , Colectomia/métodos , Colectomia/mortalidade , Humanos , Laparoscopia , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
15.
Lancet ; 394(10201): 840-848, 2019 09 07.
Artigo em Inglês | MEDLINE | ID: mdl-31402112

RESUMO

BACKGROUND: Decreased surgical site infections (SSIs) and morbidity have been reported with mechanical and oral antibiotic bowel preparation (MOABP) compared with no bowel preparation (NBP) in colonic surgery. Several societies have recommended routine use of MOABP in patients undergoing colon resection on the basis of these data. Our aim was to investigate this recommendation in a prospective randomised context. METHODS: In this multicentre, parallel, single-blinded trial, patients undergoing colon resection were randomly assigned (1:1) to either MOABP or NBP in four hospitals in Finland, using a web-based randomisation technique. Randomly varying block sizes (four, six, and eight) were used for randomisation, and stratification was done according to centre. The recruiters, treating physicians, operating surgeons, data collectors, and analysts were masked to the allocated treatment. Key exclusion criteria were need for emergency surgery; bowel obstruction; colonoscopy planned during surgery; allergy to polyethylene glycol, neomycin, or metronidazole; and age younger than 18 years or older than 95 years. Study nurses opened numbered opaque envelopes containing the patient allocated group, and instructed the patients according to the allocation group to either prepare the bowel, or not prepare the bowel. Patients allocated to MOABP prepared their bowel by drinking 2 L of polyethylene glycol and 1 L of clear fluid before 6 pm on the day before surgery and took 2 g of neomycin orally at 7 pm and 2 g of metronidazole orally at 11 pm the day before surgery. The primary outcome was SSI within 30 days after surgery, analysed in the modified intention-to-treat population (all patients who were randomly allocated to and underwent elective colon resection with an anastomosis) along with safety analyses. The trial is registered with ClinicalTrials.gov, NCT02652637, and EudraCT, 2015-004559-38, and is closed to new participants. FINDINGS: Between March 17, 2016, and Aug 20, 2018, 738 patients were assessed for eligibility. Of the 417 patients who were randomised (209 to MOABP and 208 to NBP), 13 in the MOABP group and eight in the NBP were excluded before undergoing colonic resection; therefore, the modified intention-to-treat analysis included 396 patients (196 for MOABP and 200 for NBP). SSI was detected in 13 (7%) of 196 patients randomised to MOABP, and in 21 (11%) of 200 patients randomised to NBP (odds ratio 1·65, 95% CI 0·80-3·40; p=0·17). Anastomotic dehiscence was reported in 7 (4%) of 196 patients in the MOABP group and in 8 (4%) of 200 in the NBP group, and reoperations were necessary in 16 (8%) of 196 compared with 13 (7%) of 200 patients. Two patients died in the NBP group and none in the MOABP group within 30 days. INTERPRETATION: MOABP does not reduce SSIs or the overall morbidity of colon surgery compared with NBP. We therefore propose that the current recommendations of using MOABP for colectomies to reduce SSIs or morbidity should be reconsidered. FUNDING: Vatsatautien Tutkimussäätiö Foundation, Mary and Georg Ehrnrooth's Foundation, and Helsinki University Hospital research funds.


Assuntos
Antibacterianos/administração & dosagem , Cefuroxima/administração & dosagem , Colectomia/métodos , Metronidazol/administração & dosagem , Cuidados Pré-Operatórios/métodos , Infecção da Ferida Cirúrgica/prevenção & controle , Administração Intravenosa , Idoso , Catárticos/administração & dosagem , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polietilenoglicóis/administração & dosagem , Estudos Prospectivos , Método Simples-Cego
16.
Medicine (Baltimore) ; 98(29): e16377, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31335687

RESUMO

RATIONALE: Small intestine stromal tumors (SISTs) are a type of gastrointestinal stromal tumor (GIST) that has an insidious onset. Natural orifice specimen extraction (NOSE) surgery has been gradually developed for the treatment of colorectal, stomach, small intestine, hepatobiliary, and gynecological tumors because of its safety and feasibility. This case study explored the possibility of applying the NOSE method for the treatment of SIST. PATIENT CONCERNS: A 59-year-old male patient was admitted to the hospital after having an irregular abdominal mass for >1 month that was detected by a medical examination. Thoracic and abdominopelvic enhanced computer tomography revealed irregular masses on the left side of the abdominal cavity. DIAGNOSIS: Sist. INTERVENTIONS: Nose (laparoscopic resection of intestinal stromal tumors with transrectal extract specimen and no abdominal auxiliary incision) surgery was performed. OUTCOMES: The patient underwent operation successfully and recuperates well with no complications. LESSONS: Nose surgery is minimally invasive, results in patient recuperation with no complications, and is considered to be feasible for SIST treatment.


Assuntos
Colectomia/métodos , Tumores do Estroma Gastrointestinal , Neoplasias Intestinais , Laparoscopia/métodos , Cirurgia Endoscópica por Orifício Natural/métodos , Tumores do Estroma Gastrointestinal/patologia , Tumores do Estroma Gastrointestinal/fisiopatologia , Tumores do Estroma Gastrointestinal/cirurgia , Humanos , Neoplasias Intestinais/patologia , Neoplasias Intestinais/fisiopatologia , Neoplasias Intestinais/cirurgia , Intestinos/diagnóstico por imagem , Intestinos/patologia , Intestinos/cirurgia , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento
17.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(7): 668-672, 2019 Jul 25.
Artigo em Chinês | MEDLINE | ID: mdl-31302966

RESUMO

Objective: To investigate the feasibility and safety of the medial approach "four-step method" in the laparoscopic mobilization of splenic flexure. Methods: A retrospective cohort study was performed. Clinical data of 157 colorectal cancer patients undergoing the medial approach "four-step method" in the laparoscopic mobilization of splenic flexure at Gastrointestinal Surgical Department of Guangdong Provincial People's Hospital from July 2015 to June 2018 were retrospectively analyzed. Of 157 cases, 17 were transverse colon cancer, 94 were descending colon cancer, 25 were sigmoid cancer and 21 were rectal cancer; 89 were male and 68 were female; mean age was (61.8±10.3) years and mean body mass index was (23.2±3.7) kg/m(2). The medial approach "four-step method" in the laparoscopic mobilization of splenic flexure was performed as follows: (1) The root vessels were treated with the "provocation" technique to expand the Toldt's gap. This expansion was extended from the lateral side to the peritoneum reflex of left colonic sulcus, from the caudal side to the posterior rectal space, and from the cephalad side to the lower edge of pancreas. (2) The left colonic sulcus was mobilized, converging with the posterior Toldt's gap. Mobilization was carried out from cephalad side to descending colon flexure, freeing and cutting phrenicocolic ligament and splenocolic ligament, and from caudal side to peritoneal reflex. (3) Gastrocolic ligament was moblized. Whether to enter the great curvature of stomach omentum arch when the gastrocolic ligament was cut, that was, whether to clean the fourth group of lymph nodes, should be according to the tumor site and whether serosal layer was invaded. (4) Transverse mesocolon was moblized and transected at the lower edge of the pancreatic surface, merging with the posterior Toldt's gap, and from lateral side to lower edge of the pancreatic body, merging with the lateral left paracolonic sulcus. Safety and short-term clinical efficacy of this surgical procedure was summarized. Results: All the patients completed this procedure. During operation, 3 cases were complicated with organ injury, including 1 case of colon injury, 1 case of spleen injury and 1 case of pancreas injury. No operative death and conversion to open surgery was found. The average operation time was (147.5±35.1) minutes, the average intra-operative blood loss was (40.8±32.7) ml and the average number of harvested lymph node was (16.1±5.8), including (4.0±2.3) of positive lymph nodes. The first exhaust time after surgery was (41.3±20.6) hours, the fluid intake time was (1.5±1.3) days, the postoperative hospital stay was (5.2±2.3) days. Eight (5.1%) cases developed postoperative complications, and all were improved and discharged after conservative treatments. According to the TNM classification system, postoperative pathology revealed that 31 patients were stage I, 51 were stage II, 53 were stage III, 22 were stage IV. Conclusion: The medial approach "four-step method" is safe and feasible, which can effectively decrease the operation difficulty of the laparoscopic mobilization of the splenic flexure.


Assuntos
Colectomia/métodos , Colo Transverso/cirurgia , Neoplasias do Colo/cirurgia , Laparoscopia/métodos , Neoplasias Retais/cirurgia , Idoso , Anastomose Cirúrgica , Estudos de Viabilidade , Feminino , Humanos , Masculino , Mesentério/cirurgia , Pessoa de Meia-Idade , Peritônio/cirurgia , Estudos Retrospectivos , Resultado do Tratamento
19.
Dis Colon Rectum ; 62(7): 894-897, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31188192

RESUMO

INTRODUCTION: There is growing evidence supporting complete mesocolic excision as the optimal surgical approach for right-sided colon cancer to improve oncologic outcomes in comparison with conventional surgical resection. Although the feasibility of a minimally invasive approach to complete mesocolic excision has been reported, obesity has been associated with increased difficulty for finding the correct plane for dissection and delineating the vascular anatomy. We describe a novel approach with early identification of and dissection along the superior mesenteric vein during robotic complete mesocolic excision surgery, for all patients, regardless of BMI. TECHNIQUE: The dissection is initiated with identification of the superior mesenteric vein as the starting point. Then, the vascular dissection is performed along the anterior superior mesenteric vein plane while observing complete mesocolic excision principles. The anterior superior mesenteric vein plane is an optimal and safe dissection plane because there are no anterior tributaries. The ileocolic vein and artery are ligated separately at their junction with the superior mesenteric vein and superior mesenteric artery. The dissection is then continued cephalad along the superior mesenteric vein, identifying additional colic arteries, including the middle colic arterial trunk as well as the venous tributaries to the superior mesenteric vein such as the gastrocolic trunk. The superior right colic vein is then ligated at the gastrocolic confluence and the middle colic vessels are ligated. After the vascular dissection is completed, the colon is then mobilized. RESULTS: A total of 66 patients received the "superior mesenteric vein-first" approach for robotic colectomy between 2013 and 2018, including 40.9% patients with BMI >30 kg/m. Median lymph node yield was 32 (interquartile range, 25-40). The median distance to the high vascular tie was 12 cm (interquartile range, 7-19). Median estimated blood loss was 33 mL (interquartile range, 25-50). Overall rate of grade ≥3 complications was 3.0%. CONCLUSIONS: Using the superior mesenteric vein-first approach, robotic complete mesocolic excision for right colectomy can be performed on patients with high or low BMI with excellent short-term oncologic outcomes and acceptable morbidity. See Video Abstract at http://links.lww.com/DCR/A960.


Assuntos
Colectomia/métodos , Neoplasias do Colo/cirurgia , Veias Mesentéricas/cirurgia , Mesocolo/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Dissecação , Feminino , Humanos , Excisão de Linfonodo , Masculino , Pessoa de Meia-Idade
20.
Gastroenterology ; 157(4): 967-976.e1, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31158369

RESUMO

BACKGROUND & AIMS: The efficacy of prophylactic placement of hemoclips to prevent delayed bleeding after removal of large colonic polyps has not been established. We conducted a randomized equivalence study to determine whether prophylactic placement of hemoclips affects incidence of delayed post-polypectomy bleeding (PPB). METHODS: During elective colonoscopy performed at 4 Veterans Affairs Medical Centers, 1098 patients who had polyps ≥1 cm removed were randomly assigned to groups that received prophylactic hemoclips (n = 547) or no hemoclips (n = 551), from September 2011 through September 2018. Data on PPB (rectal bleeding resulting in hemoglobin decreases ≥2 g/dL, hemodynamic instability, colonoscopy, angiography, or surgery) within 30 days of colonoscopy (called delayed PPB) were collected during telephone interviews or hospital visits 7 and 30 days after colonoscopy. The primary outcome was the incidence of important post-polypectomy bleeding. RESULTS: Twelve patients in the hemoclip group (2.3%) and 15 patients in the no hemoclip group (2.9%) had important delayed PPB. There were no deaths, and no patients in either group required angiography or surgery. In intention-to-treat analysis, two 1-sided test's lower and upper confidence interval limits were -2.07 and 1.01, indicating that the data approached but did not meet equivalence criteria. On multiple logistic regression analysis, significant predictors of PPB included use of warfarin with bridging, thienopyridines, polyp size, and polyp location, but hemoclip placement did not associate with important delayed PPB. CONCLUSIONS: In a randomized trial, we found that prophylactic placement of hemoclips after removal of large colon polyps does not affect the proportion of important delayed PPB events, compared with no hemoclip placement. These findings call into question the widespread, expensive practice of routinely placing prophylactic hemoclips after polypectomy. ClinicalTrials.gov ID: NCT01647581.


Assuntos
Colectomia/efeitos adversos , Pólipos do Colo/cirurgia , Colonoscopia/efeitos adversos , Técnicas Hemostáticas/instrumentação , Hemorragia Pós-Operatória/prevenção & controle , Instrumentos Cirúrgicos , Colectomia/métodos , Pólipos do Colo/patologia , Desenho de Equipamento , Feminino , Técnicas Hemostáticas/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/etiologia , Estudos Prospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , United States Department of Veterans Affairs
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