Oncological adequacy of laparoscopic rectal cancer resection: An audit in Indian perspective.

BACKGROUND: Laparoscopic resection for rectal cancer (LRR) has gained popularity because of better short-term outcomes and less post-operative morbidity. However, LRR is still not endorsed as a standard of care mainly due to concerns centred on oncological safety in comparison with open approach. Moreover, two recent randomised trials (Australian Laparoscopic Cancer of the Rectum [ALaCaRT] and the American College of Surgeons Oncology Group [ACOSOG] Z6051) have failed to prove that LRR is non-inferior to open resection. Studies on oncological adequacy of LRR in the Indian population in terms of quality of mesorectal excision are scarce. In this article, we aim to audit the oncological adequacy of LRR in our centre and thereby critically analyse the reliability of extrapolation of results of ALaCaRT and ACOSOG trials to the Indian population. METHODS: We retrospectively analysed the oncological adequacy of LRR in terms of completeness of total mesorectal excision (TME), distal and circumferential resection margin (CRM) status and nodal harvest in patients with rectal cancer who underwent LRR between January 2016 and June 2018 at our centre. RESULTS: Of 157 patients included in this study, a complete TME was achieved in 148 (94.26%) patients and nearly complete in 7 (4.46%) patients. A safe CRM (≥1 mm) was obtained in 151 (96.18%) patients. Distal margin results were negative in 155 (98.73%) patients. Average nodal harvest was 19.86 ± 9.28. Overall surgical success, calculated as a composite measure of negative distal margin and negative CRM and complete TME was 95.54%. CONCLUSION: Good quality rectal cancer resection can be achieved by experienced laparoscopic surgeons without compromising oncological safety.

Exploring minimally invasive options: Laparoscopic transabdominal levator transection for low rectal cancers.

Extralevator abdominoperineal excision (ELAPE) of the rectum offers wider circumferential margin and decreased rate of intraoperative tumour perforation. However, the need to change the position of the patient in between abdominal and perineal stages of the procedure and extended perineal resection result in increased morbidity and operative time. Evolving technique of laparoscopic transabdominal controlled division of levator ani muscles under direct vision could address these issues while providing all benefits of ELAPE for patients with low rectal cancers.

Rare Case of Ileocecal Obstruction Secondary to Endometriosis Presenting for the First Time.

Though endometriosis involving the intestines is well known, it causing ileocecal obstruction is a rare presentation. Etiology for ileocecal obstruction may not be known in all the cases preoperatively and may sometimes need resection and histopathology for diagnosis. Here we present a case of endometriosis presenting for the first time as an ileocecal obstruction in a 39-year-old lady who presented to us with complaints of intermittent abdominal pain. Contrast CT scan of the abdomen showed terminal ileal stricture and wall thickening. She underwent diagnostic laparoscopy, which showed dilated distal small bowel loops with suspicious stricturing growth at the terminal ileum and ileocecal valve region. A formal laparoscopic right hemicolectomy was done and post-operative histopathology revealed endometriosis with fibrosis, causing a luminal obstruction. In conclusion, endometriosis should be considered as a rare differential in patients presenting with ileocecal obstruction and having inconclusive features on imaging, endoscopic or biopsy, especially in women of childbearing age.

Ligation of symptomatic celiac artery aneurysm without vascular reconstruction: Utilizing the natural collateral circulation of the celiac axis: A case report.

INTRODUCTION: Celiac artery aneurysm is very rare visceral artery aneurysm. Symptomatic and ≥ 2.5 cm sized aneurysm requires treatment. Excision and revascularization is the most commonly employed procedure. CASE PRESENTATION: We report a case of ligation and excision of celiac artery aneurysm extending onto the splenic and hepatic arteries without vascular reconstruction. The patient was a 52 year old lady who was evaluated for abdominal pain and was found to have a celiac artery aneurysm involving the hepatic and splenic arteries. She was evaluated with computerized tomography and digital subtraction angiography of the abdominal vessels. These confirmed good natural collaterals from the branches of superior mesenteric artery supplying the liver, stomach and spleen. We performed ligation and excision of the aneurysm and ligation and division of hepatic, splenic and left gastric arteries as the aneurysm was extending on to these vessels, without any vascular reconstruction, utilizing the natural collaterals from the superior mesenteric artery. DISCUSSION: Ligation of celiac artery aneurysm without revascularization is often done in emergency situations. Excision and revascularization is the treatment of choice to ensure adequate blood supply to liver, spleen and stomach. We could utilize the natural collateral circulation of celiac artery from superior mesenteric artery avoiding a complex procedure of revascularization. CONCLUSION: We present this because of the rarity of the disease as well as rarity of the technique of not performing vascular reconstruction. We emphasize on the pre-operative and operative evaluation of collateral circulation with conventional angiography and intraoperative Doppler respectively.

Voluntary perioperative colorectal cancer registry from Kerala-An initial overview.

BACKGROUND: Although colorectal cancer (CRC) may not be uncommon in India, accurate data regarding its demographics and surgical outcomes is sparse. METHODS: With an aim to assess demographics and perioperative outcomes of CRC in Kerala, all members of Association of Surgical Gastroenterologists of Kerala (ASGK) were invited to participate in a registry. Data of operated cases of CRC were entered on a web-based questionnaire by participating members from January 2016. Analysis of accrued data until March 2018 was performed. RESULTS: From 25 gastrointestinal surgical centers in Kerala, 15 ASGK member hospitals contributed 1018 CRC cases to the database (M:F 621:397; median age-63.5 years [15-95 years]). Rectum (39.88%) and rectosigmoid (20.33%) cancers comprised the majority of the patients. Among them, preoperative bowel preparation was given to 37.68%, minimally invasive surgery (MIS) was performed in 73%, covering stoma in 47% and had an overall leak rate of 3.58%. In colonic malignancies, MIS was performed in 56.74%, covering stoma created in 13% and had a leak rate of 2.71%. Of 406 patients with rectal cancers, neo-adjuvant radiotherapy/chemoradiotherapy was given to 51.23%. The mean hospital stay for MIS in both rectal and colonic cancer patients was significantly shorter than open approach (10.46 ± 5.08 vs. 12.26 ± 6.03 days; p = 0.001and 10.29 ± 4.58 vs. 12.46 ± 6.014 days; p = <0.001). Mortality occurred in 2.2% patients. CONCLUSION: A voluntary non-funded registry for CRC surgery was successfully created. Initial data suggest that MIS was performed in majority, which was associated with shorter hospital stay than open approach. Overall mortality and leak rate appeared to be low.

Surgical treatment for small bowel Crohn's disease: an experience of 28 cases.

BACKGROUND: Crohn's disease is increasingly encountered in India. This paper reviews our experience with surgery for small bowel involvement in Crohn's disease. METHODS: Retrospective analysis of prospectively collected data of patients who underwent surgical resection for Crohn's disease during a period of 8.8 years from 1997-2006 at a tertiary care center. RESULTS: Twenty-eight patients (mean age 31.2 years; 18 men) underwent surgical treatment for Crohn's disease. The diagnosis was made only after surgery in 17 patients; 5 of them were receiving anti-tuberculosis treatment. The most common indication for elective surgery was subacute intestinal obstruction (n=15) followed by enterocutaneous fistula (3) and protein-losing enteropathy (2). Emergency surgery was performed in 4 patients who presented with perforation and peritonitis. Resection of the maximally involved segment and primary anastomosis was done in all elective cases. Resection and exteriorization of resected ends was done in patients who presented with peritonitis. Multiple strictureplasties combined with resection were done in 9 patients. Predominant colonic involvement was observed in 2 patients. The type of small bowel involvement included strictures (n=25), fistulizing disease (8) and perforation (6); 11 patients had more than one pathology. Postoperative morbidity was observed in nine patients; 6 patients underwent re-operation for anastomotic leak. Stoma had to be created in 11 patients either primarily or at re-operation, which could be closed after a median interval of 3.2 months. During a median follow up of 29 months, 3 patients required more than one hospital admission for abdominal symptoms. Pre-operative anemia, malabsorption and/or growth retardation, steroid and/or immunosuppressant therapy and mid small bowel resection had a negative impact on anastomotic integrity leading to anastomotic dehiscence. Indication for surgery, the type or extent of disease did not have any impact on postoperative morbidity. CONCLUSION: This retrospective analysis from a tertiary referral center indicates that sub-acute intestinal obstruction and perforation-peritonitis were the most common indications for surgery in Crohn's disease. Pre-operative anemia, malabsorption state, steroid/immunosuppressant and mid small bowel resection were associated with higher postoperative morbidity.

Total extraperitoneal robot assisted laparoscopic renal transplant recipient surgery.

INTRODUCTION: Renal transplant recipient surgery is conventionally performed using open technique which is total extra-peritoneal in approach whereas robot assisted renal transplant recipient surgery is performed through a transperitoneal approach. We present a case where a total extraperitoneal robot assisted renal transplant recipient surgery was performed. MATERIALS AND METHODS: A 30 year old gentleman with Ig A nephropathy and diffuse glomerulosclerosis underwent total extra-peritoneal robot assisted renal transplant recipient surgery (TERT) with sister as donor. Renal allograft was introduced through Pfannensteil incision. Alexis wound retractor was used to minimize trauma while positioning the allograft. RESULTS: There was good urine output on release of vascular clamps. Nadir creatinine was attained in three days. Patient was discharged on post-operative day six. CONCLUSION: TERT is a technically demanding procedure that closely resemble open technique while imparting the benefits of minimally invasive surgery to the patient.

[Liver hanging maneuver in the course of right hemihepatectomy: advantages and limitations]. / Liver hanging maneuver in corso di emiepatectomia destra: vantaggi e limiti.

Belghiti's liver hanging maneuver is now widely used for right hemihepatectomy or donor operation in living-related liver transplantation. This technique allows parenchymal transection to be performed without liver mobilization and avoiding tumour spread. On the basis of the first few years of world-wide experience we can now assess the advantages and limitations of this technique.

A Technique for Localizing Perforated Duodenal Ulcer During Laparoscopic Repair.

Laparoscopic repair of duodenal ulcer perforation has certain advantages over open repair. However, the conversion rate to open surgery is still high. The most common reason for conversion is inadequate localization of the ulcer perforation site during laparoscopy. Here, a technique is described which will aid in localizing the perforation, make suturing and repair easier, and helps in checking the integrity of the repair at the end of the procedure. This is done by compressing the gall bladder with an instrument like a laparoscopic fan retractor and simultaneously depressing the first part of the duodenum with another instrument. This results in bile flowing out through the perforation and simultaneously depressing the duodenum downward, making it more easily visible and making identification easier. Suturing is easier due to the liver also getting retracted simultaneously and more space being available consequently. Integrity of the anastomoses is also easily ascertained by this maneuver.

Octreotide Does Not Prevent Pancreatic Fistula Following Pancreatoduodenectomy in Patients with Soft Pancreas and Non-dilated Duct: A Prospective Randomized Controlled Trial.

BACKGROUND: Whether octreotide prevents pancreatic fistula following pancreatoduodenectomy is controversial and it is believed to be beneficial in soft glands and normal-sized ducts. The aim of this study is to assess the potential value of octreotide in reducing the incidence of pancreatic fistula, postoperative complications, morbidity and hospital stay in patients with soft pancreas and non-dilated ducts. METHODS: A total of 109 patients undergoing elective pancreatoduodenectomy with soft pancreas and non-dilated duct were randomized to octreotide group versus no octreotide-the control group. Surgical steps were standardized and incidences of pancreatic fistula, complications, death and hospital stay were assessed. RESULTS: There were 55 patients in octreotide group and 54 in the control group. Demographic features and pancreatic duct diameter of the groups were comparable. The rates of clinically significant pancreatic fistulae (grades B and C) were 10.9 and 18.5 % (p = ns), and morbidity was 18 and 29.6 % (p = ns), respectively. Patients who received octreotide resumed oral diet early and had a shorter hospital stay. CONCLUSION: This study demonstrated no statistical difference in pancreatic fistulae with the use of octreotide, though there was a trend towards fewer incidences of pancreatic fistulae, morbidity and shorter hospital stay. ClinicalTrials.gov Identifier: NCT01301222.

Biliary access loops for intrahepatic stones: results of jejunoduodenal anastomosis.

BACKGROUND: Patients with intrahepatic calculi require multiple interventions following successful surgical stone clearance for recurrent stones and cholangitis. The present paper describes the results of a technique of in-continuity side-to-side jejunoduodenal anastomosis (JDA) that provides endoscopic access to the hepaticojejunostomy and intrahepatic ducts. This operation is compared to other techniques in a critical appraisal of various biliary access procedures described for long-term management of intrahepatic -calculi. METHODS: A retrospective analysis of clinical data of 13 patients who underwent biliary drainage procedures with access loops for intrahepatic calculi during the period March 1990 to December 2000 was performed. The postoperative course of patients and the feasibility of postoperative endoscopic access to the hepaticojejunostomy and intrahepatic ductal system in treatment of recurrent cholangitis were assessed. Nine patients underwent JDA, two underwent permanent-access hepaticojejunostomy (PAH) and two others underwent an interposition hepaticojejunoduodenostomy (IHJ). RESULTS: The analysis revealed no major procedure-related complications or mortality. Endoscopic access (using forward-viewing gastroscope) was possible in 100% of cases following JDA, and with difficulty in both cases after PAH. Endoscopic access in the two patients with IHJ failed because of technical reasons. Recurrent cholangitis was seen in seven patients (54%) - two out of two patients in the PAH group, one out of two in the IHJ group and four out of nine in the JDA group. This required 12 endotherapy sessions (mean: 1.5 procedures per patient). CONCLUSION: In-continuity side-to-side JDA allows easy access of conventional gastroduodenoscopes to the biliary tree for removal of recurrent/residual intrahepatic stones. The technique has advantages over other access loop procedures in the long term management of recurrent intrahepatic stones.

Ileal ganglioneuromatosis with adenocarcinoma in a patient with multiple neurofibromatosis.

Von Recklinghausen's disease or type 1 neurofibromatosis is an autosomal dominant disease characterized by mucocutaneous neurofibromas, café-au-lait spots and involves many organs including gastrointestinal tract. Gastrointestinal involvement in neurofibromatosis is uncommon and is seen 25% patients and nearly 5% of them are only symptomatic (Shekitka and Sobin, Am J Surg Pathol 18:250-257, 1994; Tomita et al., Int J Colorectal Dis 21: 89-91, 2006).

Laparoscopic colonic resection for rectosigmoid colonic tumours: a retrospective analysis and comparison with open resection.

Laparoscopic approach for treatment of colorectal malignancy is gaining acceptance gradually; however the benefits of laparoscopic surgery in colonic and rectal tumours is still open to debate. This study aims at a retrospective analysis of operative and short term outcome of patients with rectosigmoid tumours. A retrospective analysis of operative, postoperative and short-term outcome of 62 patients who underwent laparoscopic colorectal resection for cancer of rectosigmoid region were compared with a same number of parameters-matched patients who underwent open colorectal resection. Blood transfusion requirement was significantly more in the open group compared to the laparoscopy group (38.7% versus 6.4%, p = 0.001). ICU stay was less in the laparoscopy group (p = <0.05) and they were started on oral liquid diet earlier (p = 0.013). The number of the lymph nodes retrieved, positive distal margin and radial involvement were similar in both groups. The hospital stay was significantly shorter in laparoscopy group (8.4 versus 13.8 days, p < 0.05). Radical operation for rectosigmoid tumors is technically feasible with laparoscopic surgery. Laparoscopic approach is associated with less blood loss, transfusion and significantly less ICU stay. Laparoscopic group recovers early and needs less hospital stay.

Outcome of pancreatic ascites in patients with tropical calcific pancreatitis managed using a uniform treatment protocol.

Pancreatic ascites or internal pancreatic fistula is a known complication of chronic pancreatitis. This condition is associated with considerable morbidity and mortality. The management approach of pancreatic ascites in tropical calcific pancreatitis is infrequently reported owing to the low incidence of this condition. Between December 2005 and June 2007, 11 patients with pancreatic ascites with tropical calcific pancreatitis (male:female 7:4, mean age 29.5 [14.2] years) were treated. A retrospective analysis of patients who underwent endotherapy and surgery for this condition based on an institutional protocol was performed. The end point was resolution of pancreatic ascites and relief of symptoms. All patients had pancreatic ascites, and one patient also had pancreatic pleural effusion. Endoscopic transpapillary stenting was possible in nine patients (81%). Identification of site of leak and placement of an endoscopic stent across the PD disruption was possible in five (45%) patients. All these patients had relief of ascites. Mean number of endotherapy sessions required before control of ascites was 1.8. Among the remaining four (36.6%) patients who had ERCP, placement of stent across the leak was unsuccessful; however stenting helped stabilize the general condition and nutritional status. These four patients and two patients who failed ERP underwent lateral pancreatojejunostomy surgery. Morbidity was observed in three patients who underwent surgery and one patient died due to sepsis and hemorrhage. All patients who had surgical drainage had complete relief of ascites and symptoms. In patients with pancreatic ascites in tropical calcific pancreatitis endotherapy and transpapillary stenting helps in resolution of ascites in nearly half of the patients. In the remaining patients preliminary conservative management followed by surgical pancreatic ductal drainage provides good relief of symptoms.

Two hundred liver hanging maneuvers for major hepatectomy: a single-center experience.

OBJECTIVE: To establish the indications of the liver hanging maneuver for major hepatectomy. SUMMARY BACKGROUND DATA: The liver hanging maneuver, which is a technique of passing a tape along the retrohepatic avascular space and suspending the liver during parenchymal transection, facilitates anterior approach of major hepatectomy. However, the feasibility and limits of this maneuver have never been established in patients with different clinical backgrounds. METHODS: Medical records of 242 consecutive patients considered for major hepatectomy using the hanging maneuver were reviewed. RESULTS: Among 242 patients, 14 patients (6%) were considered to have contraindication for this maneuver preoperatively because of tumor infiltration to anterior surface of retrohepatic inferior vena cava (IVC). It was successful in 201 patients with overall feasibility of 88%. The feasibility increased significantly in the recent years as compared with the initial years (94% in 2003-2005 vs. 76% in 2000-2002, P < 0.0001). Bleeding during the retrohepatic dissection occurred in 5 patients (2%), which was minor due to injury of hepatic capsule in 3 (1%) and major due to injury of short hepatic vein in 2 (1%). In all cases, bleeding stopped spontaneously. The maneuver was abandoned in 27 patients, including 15 related to severe adhesion between liver and IVC. Univariate analysis showed that adhesion between IVC and liver was the only significant negative predictor affecting the feasibility. Cirrhosis, large tumor, preoperative radiologic treatments did not influence on the feasibility. CONCLUSIONS: The liver hanging maneuver has 94% feasibility in recent years. Absolute contraindication is tumor infiltration to the retrohepatic avascular space. Adhesion between the IVC and liver has a negative impact of the feasibility. According to this indication, the hanging maneuver is easily achievable without risk of the major bleeding during the retrohepatic dissection.

A prospective analysis of living-liver donation shows a high rate of adverse events.

Donor risk is the main obstacle in the development of living-donor liver transplantation in Western countries. The knowledge of a wide and uneven range of donor morbidity has come mainly from various retrospective analyses of complications in the literature. Donor outcomes have not been prospectively analyzed. From 1995, the intra- and postoperative courses of 127 living-donor hepatectomies were prospectively analyzed and recorded. All adverse events were classified and stratified according to the extent of surgery, including 45 left-lateral sectionectomies (LLS); 25 left hepatectomies (LH), and 57 right hepatectomies (RH). There was no donor death. The overall rate of significant complications was 20%, ranging from 8% after LH to 32% after RH. The overall incidences of surgical complications, reoperations, and hospital readmissions were 8%, 3%, and 5%, respectively. However, the prospective accumulation of all adverse events revealed an overall postoperative morbidity of 51%, ranging from 32% after LH to 66% after RH. In conclusion the incidence of postoperative adverse events after living donation is nearly 50% as revealed by prospective screening. These results allow more accurate information for potential donors. This study confirms that right hepatectomy carries three times higher risk of morbidity as compared to left-sided resections, leading to reappraisal of the use of left grafts in adults.