Near infra-red fluorescence identification of the thoracic duct to prevent chyle leaks during oesophagectomy.

BACKGROUND: Chyle leaks following oesophagectomy are a frustrating complication of surgery with considerable morbidity. The use of near infra-red (NIR) fluorescence in surgery is an emerging technology and the use of fluorescence to identify the thoracic duct has been demonstrated in animal work and early human case reports. This study evaluated the use mesenteric and enteral administration of indocyanine green (ICG) in humans to identify the thoracic duct during oesophagectomy. METHODS: Patients undergoing oesophagectomy were recruited to the study. Administration of ICG via an enteral route or mesenteric injection was evaluated. Fluorescence was assessed using a NIR fluorescence enabled laparoscope system with a visual scoring system and signal to background ratios. Visualisation of the thoracic duct under white light and NIR fluorescence was compared as well as any identification of active chyle leak. Patients were followed up post-operatively for adverse events and chyle leak. RESULTS: 20 patients received ICG and were included in the study. The enteral route failed to fluoresce the thoracic duct. Mesenteric injection (17 patients) identified the thoracic duct under fluorescence prior to white light in 70% of patients with a mean signal to background ratio of 5.35. In 6 participants, a possible active chyle leak was identified under fluorescence with 4 showing active chyle leak from what was identified as the thoracic duct. CONCLUSION: This study demonstrates that ICG administration via mesenteric injection can highlight the thoracic duct during oesophagectomy and may be a potential technology to reduce chyle leak following surgery. CLINICAL TRIAL REGISTRATION: Clinical trials.gov (NCT03292757).

Methylene blue fluorescence of the ureter during colorectal surgery.

BACKGROUND: Iatrogenic ureteric injury is a serious complication of colorectal surgery. Incidence is estimated to be between 0.3 and 1.5%. Of all ureteric injuries, 9% occur during colorectal procedures. Ureteric stents are utilised as a method to reduce the risk of injury; however, these are not without risk and do not guarantee prevention of injury. Fluorescence is a safe and effective alternative for intraoperative ureteric localisation. This proof of principle study aims to assess the use of methylene blue to fluoresce the ureter during colorectal surgery. METHOD: Patients undergoing elective colorectal surgery were included in this open label, non-randomised study. Methylene blue was administered intravenously at varying doses (0.25-1 mg/kg) over 5 min, 10-15 min prior to entering 'ureteric territory.' Fluorescence was assessed using the PINPOINT Deep Red laparoscopic system at fixed time points by the surgeon and an independent observer. RESULTS: 42 patients received methylene blue; 2 patients were excluded from analysis. Of the 69 ureters assessed, 64 were seen under fluorescence. Of these, 14 were not visible under white light. 50 ureters were observed with both fluorescence and white light with 14 of these being seen earlier with fluorescence. In ten cases, fluorescence revealed the ureter to be in a different location than suspected. CONCLUSION: Fluorescence is a promising method to allow visualisation of the ureter, where it is not identified easily under standard operative conditions, thereby improving safety and reducing operative time and difficulty.

Fissurectomy Combined with High-Dose Botulinum Toxin Is a Safe and Effective Treatment for Chronic Anal Fissure and a Promising Alternative to Surgical Sphincterotomy.

BACKGROUND: There is paucity of data on the long-term outcome of the combination of fissurectomy and botulinum toxin A injection for the management of chronic anal fissure. OBJECTIVES: The aim of this study is to assess the safety, efficacy, and long-term outcome of the combination of fissurectomy and botulinum toxin A injection. DESIGN: This is a nonrandomized prospective cohort study. SETTINGS: This study was conducted at a district general hospital in the United Kingdom. PATIENTS: The cohort included all patients treated with fissurectomy and botulinum toxin A for chronic anal fissure between September 2008 and March 2012. INTERVENTION: The patients were treated with a combination of fissurectomy and botulinum toxin A injection. MAIN OUTCOME MEASURES: Symptomatic relief, fissure healing, complications, recurrence, and the need for further surgical intervention. RESULTS: One hundred and two patients received fissurectomy and botulinum toxin A injection for chronic anal fissure. At 12-week follow-up, 68 patients had resolution of symptoms and complete healing of chronic anal fissure, 29 patients had improvement of symptoms but incomplete healing and had further topical or botulinum toxin A treatment with subsequent complete healing. Ninety-five patients (93%) reported no postoperative complications. Seven patients reported a degree of incontinence in the immediate postoperative period. All reported normal continence at12-week follow-up. No local complications were observed or reported. At the mean follow-up of 33 months, there was no evidence of recurrence. Twelve-month follow-up was conducted via telephone interview only. LIMITATIONS: This study is nonrandomized and did not examine the dose response of Botulinum Toxin A. CONCLUSIONS: Fissurectomy combined with high-dose botulinum toxin A is a safe, effective, and durable option for the management of chronic anal fissure and a promising alternative to surgical sphincterotomy.

Laparoscopic Spigelian Hernia Repair: A Systematic Review.

PURPOSE: Spigelian hernias (SHs) account for 1% to 2% of abdominal wall hernias. Traditionally they have been repaired using an open technique. Since 1992, laparoscopic methods have become increasingly popular with various techniques being described in the literature. This systematic review aims to represent the current trends in laparoscopic repair of SHs. MATERIALS AND METHODS: The databases MEDLINE and EMBASE were searched for appropriate terms regarding SH repair. Papers describing laparoscopic repair of SH were included. RESULTS: Fifty articles were identified for the final review. No randomized controlled trials comparing laparoscopic techniques were identified. Two hundred thirty-seven SHs were repaired by various techniques. Intraperitoneal onlay mesh technique was the most popular repair method with minimal complications and recurrences reported in all techniques. CONCLUSIONS: There are a number of laparoscopic techniques available to the surgeon repairing a SH. Overall, laparoscopic repair of the SH is a safe and acceptable method.

Laparoscopic transabdominal preperitoneal repair of spigelian hernia-closure of the fascial defect is not necessary.

INTRODUCTION: Spigelian hernia (SH) is rare and is traditionally repaired using an open technique. There has been an increasing popularity of laparoscopic methods, with transabdominal preperitoneal (TAPP) repair being one of the popular techniques. Currently, most surgeons using the TAPP technique close the fascial defect prior to mesh placement. Here we report our experience with a TAPP repair that deliberately excludes approximation of the fascial defect. SUBJECTS AND METHODS: Prospective data were collected on consecutive patients undergoing elective SH repair under the care of a single surgeon between 2001 and 2012. Diagnosis was confirmed preoperatively using ultrasonography or computerized tomography. A laparoscopic TAPP repair was used without closing the defect. Following discharge all patients were followed up at 3 and 12 months. The clinical records were reviewed at the time this article was written. The technique, epidemiological characteristics, operative findings, hospital stay, morbidity, and follow-up are presented. RESULTS: Twenty-six patients (16 males) with a median age of 63 years were operated on. The follow-up period ranged between 6 months and 11 years (median, 4 years). Hernia defect size ranged from 2 to 10 cm. Mean operating time for unilateral defects was 45 minutes; that for bilateral defects was 70 minutes. Twenty-two patients were discharged on the same day. There were no postoperative complications or recurrences. CONCLUSIONS: Laparoscopic TAPP repair of SH without closing the defect is safe, effective, and durable. There is no additional benefit from routine closure of the fascial defect. On the contrary, there may be potential advantages in leaving the defect unopposed.