Light-Activated Chemically Reactive Fibrous Patch Revolutionizes Wound Repair Through the Prevention of Postoperative Adhesion.

A light-activated chemically reactive fibrous patch (ChemPatch) with tissue adhesion and wound healing activity was developed for preventing postoperative peritoneal adhesion. ChemPatch was constructed by an integrative electrospinning fabrication strategy, generating multifunctional PCL-NHS fibers encapsulating antioxidant curcumin and MnO2 nanoparticles. ChemPatch exhibited excellent photothermal conversion, which not only reformed the physical state to match the tissue but also improved conjugation between ChemPatch and tissues, allowing for strong attachment. Importantly, ChemPatch possessed good antioxidant and radical scavenging activity, which protected cells in an oxidative microenvironment and improved tissue regeneration. Particularly, ChemPatch acted as a multifunctional barrier and could not only promote reepithelialization and revascularization in wound defect model but simultaneously ameliorate inflammation and prevent postoperative peritoneal adhesion in a mouse cecal defect model. Thus, ChemPatch represents a dual-active bioadhesive barrier for reducing the incidence and severity of peritoneal adhesions.

The Gordian knot of hydrocephalus: constrictive entanglement of distal ventriculoperitoneal shunt catheter.

We recently cared for a patient with a distal ventriculoperitoneal shunt malfunction. The peritoneal catheter was coiled in a scarred pseudocyst, and we encountered strong resistance while attempting to remove the distal shunt catheter. The catheter was successfully removed under laparoscopic guidance and was found to be tightly coiled in a constrictive knot. We describe a technique for managing this unusual presentation to minimize the risk of complications.

Surgical enlargement of the epiploic foramen in horses.

OBJECTIVE: To assess the safety and efficacy of a method for digitally enlarging the caudal aspect of the epiploic foramen (EF). STUDY DESIGN: Healthy horses and clinical cases of EF entrapment (EFE). ANIMALS: Fourteen healthy horses and three clinical cases. METHODS: Through a ventral midline celiotomy under general anesthesia, the EF was enlarged by digital separation of the caudal attachments of the caudate lobe of the liver from right dorsal colon, right kidney, gastropancreatic fold, and pancreas. Healthy horses were euthanized under anesthesia, and the enlarged EF was measured at necropsy. RESULTS: The method used for enlarging the EF did not cause clinically relevant hemorrhage, as determined by visual inspection of the EF in 14 horses at necropsy and by vital parameters under anesthesia in all horses. In clinical cases, EFE was reduced following enlargement of the EF, and no intraoperative complications were encountered. In one clinical case, necropsy at 30 days confirmed partial closure of the enlarged EF. CONCLUSION: The method proposed enlarged the EF safely and effectively. Limitations of the study include the small number of clinical cases and the lack of postoperative follow-up on the healthy horses. CLINICAL SIGNIFICANCE: Enlargement of the EF at its caudal extent should be considered in selected cases of EFE in which manual reduction is difficult or protracted. Although the procedure was safe in this study, knowledge of the anatomy, practice on cadavers, and careful selection of cases with greatest need are recommended before clinical use.

ASYMPTOMATIC SHUNT FRACTURE IN A PATIENT WITH HISTORY OF TUBERCULOUS MENINGOENCEPHALITIS: A CASE REPORT.

Ventriculoperitoneal (VP) shunt is the most frequently performed procedure in patients with hydrocephalus, but can cause seri¬ous complications. Shunt fractures, is a rare complication of VP shunt and can be damage for patient. The question of whether asymptomatic patients should or should not be operated on remains to be answered. The authors report a case of a pediatric patient who had an asymptomatic shunt fracture with a history of tuberculous menin¬goencephalitis (TBM). We report the case of a 7-year-old girl with a shunt fracture and a history of hydrocephalus due to TBM. She presented to the hospital in 2021 without symptoms of increased intracranial pressure and was fully conscious. Three weeks later, the patient experienced a gradual loss of consciousness. The result of the examination revealed that the hydrocephalus had become larger than before the operation in 2015. The peritoneal shunt had completely migrated into the peritoneal cavity. An emergency shunt revision was performed at the left Kocher point. After the operation, the patient regained consciousness and lived life without any complications. Although the decision to re-operate in an asymptomatic patient with a shunt fracture is debatable, shunt revision should be con¬sidered. Early revision of the shunt fracture does not pose a serious hazard to the patient.

Fenestrated endovascular aortic aneurysm repair promotes positive infrarenal neck remodeling and greater sac shrinkage compared with endovascular aortic aneurysm repair.

OBJECTIVE: Endovascular aortic aneurysm repair (EVAR) has become the standard of care for abdominal aortic aneurysms (AAAs) in the modern era. Although numerous devices exist for standard infrarenal AAA repair, fenestrated EVAR (fEVAR) offers a minimally invasive alternative to traditional open repair for patients with a short infrarenal neck. Over time, aortic neck dilation can occur, leading to loss of the proximal seal, endoleaks, and AAA sac growth. In the present study, we analyzed aortic remodeling after EVAR vs fEVAR and further evaluated whether fEVAR confers a benefit in terms of sac shrinkage. METHODS: A retrospective review of prospectively collected data from 120 patients who had undergone EVAR was performed. Of these 120 patients, 30 had been treated with fEVAR (Zenith fenestrated; Cook Medical Inc, Bloomington, IN) and 90 patients were treated with EVAR devices (30 each with Endurant [Medtronic, Dublin, Ireland], Excluder [W.L. Gore & Associates, Flagstaff, AZ], and Zenith [Cook Medical Inc]). The demographic data were recorded. Also, anatomic measurements were performed for each patient preoperatively, at 30 days postoperatively, and at the longest follow-up point using three-dimensional reconstruction software. RESULTS: No significant differences were found in demographic data between the four groups. fEVAR had been used more often in aortas with large necks and irregular morphology (P = .004). At the longest follow-up, the suprarenal aorta encompassing 5, 10, and 15 mm above the lowest renal artery had dilated the most for the fEVAR group vs all EVAR groups. However, the infrarenal segment had tended to increase the least, or to even have regressed, for fEVAR compared with all three EVAR groups and was associated with the overall greatest proportion of sac shrinkage for the fEVAR group compared with the Medtronic, Gore, and Cook devices (-13.90% vs -5.75% vs -2.31% vs -4.68%, respectively; P = .025). CONCLUSIONS: Compared with EVAR, the patients treated with fEVAR had experienced greater suprarenal dilation over time, consistent with an overall greater burden of disease in the proximal native aorta. However, the infrarenal segment had dilated significantly less over time in the fEVAR group compared with all three EVAR groups, suggesting that fEVAR might stabilize the infrarenal neck, promoting positive sac remodeling, which was evidenced by the greatest degree of decrease in the largest AAA diameter in the fEVAR group.

Five-year follow-up of a randomized clinical trial comparing bursectomy and omentectomy alone for resectable gastric cancer (JCOG1001).

BACKGROUND: Bursectomy, the total resection of the bursa omentalis, is a standard procedure in gastrectomy for resectable gastric cancer. A phase III trial (JCOG1001) comparing bursectomy and omentectomy alone was terminated early at the interim analysis. The final results of the updated analysis after a minimum follow-up of 5 years are reported here. METHODS: Patients with histologically proven adenocarcinoma of the stomach (cT3-T4a) were randomized (1 : 1) during surgery to bursectomy or omentectomy-alone groups and then underwent D2 gastrectomy. The primary endpoint was overall survival, analysed on an intention-to-treat basis. RESULTS: A total of 1204 patients (602 bursectomy and 602 omentectomy alone) were enrolled between June 2010 and March 2015. The bursectomy group had a significantly higher incidence of Clavien-Dindo grade III-IV intra-abdominal abscess than the omentectomy-alone group (5.5 versus 2.5 per cent respectively; P = 0.008). The updated 5-year overall survival rates were 74.9 (95 per cent c.i. 71.2 to 78.2) per cent in the bursectomy group and 76.5 (72.8 to 79.7) per cent in the omentectomy-alone group; the adjusted HR for death in the bursectomy group was 1.03 (95 per cent c.i. 0.83 to 1.27) (1-sided P = 0.598). Bursectomy did not decrease peritoneal recurrence (12.1 versus 12.3 per cent respectively; P = 1.000). In a multivariable analysis, old age (above 65 years), tumour located in the lower third or posterior wall of the stomach, macroscopic type 3/5, total gastrectomy, and cT4a were independent predictors of poor overall survival, but omentectomy alone was not. CONCLUSION: In D2 gastrectomy, bursectomy is not recommended as a standard procedure for cT3-T4a gastric cancer. Registration number: UMIN000003688 (https://www.umin.ac.jp/ctr/).

Development of a clinically relevant ovarian cancer model incorporating surgical cytoreduction to evaluate treatment of micro-metastatic disease.

OBJECTIVES: Mouse models of ovarian cancer commonly transfer large numbers of tumor cells into the peritoneal cavity to establish experimental metastatic disease, which may not adequately model early metastatic spread from a primary tumor site. We hypothesized we could develop an ovarian cancer model that predictably represents micro-metastatic disease. METHODS: Murine ID8VEGF ovarian cancer cells were transduced to express enhanced luciferase (eLuc) to enable intravital detection of microscopic disease burden and injected beneath the ovarian bursa of C57Bl/6 mice. At 6 or 10 weeks after orthotopic injection, when mice had detectable metastases, hysterectomy and bilateral salpingo-oophorectomy was performed to remove all macroscopic disease, and survival monitored. Immunohistochemistry and gene expression profiling were performed on primary and metastatic tumors. RESULTS: eLuc-transduced ID8VEGF cells were brighter than cells transduced with standard luciferase, enabling in vivo visualization of microscopic intra-abdominal metastases developing after orthotopic injection. Primary surgical cytoreduction removed the primary tumor mass but left minimal residual disease in all mice. Metastatic sites that developed following orthotopic injection were similar to metastatic human ovarian cancer sites. Gene expression and immune infiltration were similar between primary and metastatic mouse tumors. Surgical cytoreduction prolonged survival compared to no surgery, with earlier cytoreduction more beneficial than delayed, despite micro-metastatic disease in both settings. CONCLUSIONS: Mice with primary ovarian tumors established through orthotopic injection develop progressively fatal metastatic ovarian cancer, and benefit from surgical cytoreduction to remove bulky disease. This model enables the analysis of therapeutic regimens designed to target and potentially eradicate established minimal residual disease.

Surgical complications comparing extraperitoneal vs transperitoneal laparoscopic aortic staging in early stage ovarian and endometrial cancer.

OBJECTIVE: To determine whether the extraperitoneal approach for paraaortic staging lymphadenectomy results in a lower rate of surgical complications compared to the transperitoneal approach, without compromising oncological outcomes. METHODS: Prospective randomized multicenter study of patients with early endometrial or ovarian cancer undergoing paraaortic lymphadenectomy in 2010-2019. Patients were randomized to minimally invasive surgery (laparoscopy or robotic-assisted) using an extraperitoneal or a transperitoneal approach. The primary end point measure was a composite outcome that included developing one or more of the following surgical complications: bleeding during paraaortic lymphadenectomy ≥500 mL, any intraoperative complication related to paraaortic lymphadenectomy, severe postoperative complication (Dindo ≥ IIIA), impossibility to complete the procedure, or conversion to laparotomy. RESULTS: There were 103 patients in the extraperitoneal group and 100 in the transperitoneal group. Differences in the composite outcome (transperitoneal 26.0% vs, extraperitoneal 18.4%; P = 0.195) were not found. Differences in the operative time, conversion to laparotomy, intraoperative bleeding, or survival were not observed. A higher number of lymph nodes were retrieved through the extraperitoneal approached (median, interquartile range [IQR] 12 [7-17] vs, 14 [10-19]: P = 0.026). Older age and greater body mass index (BMI) or waist-to-hip ratio (WHR) increased the risk for surgical complications independently of the laparoscopic approach. CONCLUSIONS: The extraperitoneal approach did not show differences regarding surgical and oncological parameters compared with the transperitoneal approach, although the number of aortic nodes retrieved was higher. The decision to use one or another laparoscopic route is a matter of the surgeon preference. Trial registration ClinicalTrials.gov.identifier: NCT02676726.

Single-site laparoscopic burnia for inguinal hernias in girls: comparison with open repair.

BACKGROUND: Burnia is a suturless repair for inguinal hernias in girls. It is performed under laparoscopy by grabbing the sac, inverting it into the peritoneal cavity, and cauterizing. The aim of this study is to report our experience with single-site laparoscopic burnia (BURNIA) and compare them with open repair (OPEN). METHODS: With IRB approval, pediatric female patients younger than 18 years of age who underwent inguinal hernia repair between January 2015 and December 2017 were enrolled. Medical records were retrospectively reviewed. The patients were divided into two groups, BURNIA and OPEN. RESULTS: 198 patients were included. In BURNIA, 49 patients underwent bilateral repairs, and 50 patients underwent 51 unilateral repairs (one patient had metachronous contralateral hernia). In OPEN, 27 patients underwent bilateral repairs, and 72 patients underwent 77 unilateral repairs (five patients had metachronous contralateral hernias). The mean age of BURNIA was similar to OPEN for bilateral repairs (49.1 ± 36.6 vs. 43.7 ± 26.4 months, p = 0.46), but significantly older for unilateral repairs (54.6 ± 29.8 vs. 29.0 ± 31.4, p < 0.01). The mean operation time of BUNIA was similar to OPEN for bilateral repairs (24.2 ± 7.6 vs. 22.4 ± 8.6 min, p = 0.35), but significantly longer for unilateral repairs (19.2 ± 7.0 vs, 13.6 ± 8.8 min, p < 0.01). The mean follow-up duration of BURNIA was significantly shorter than OPEN for bilateral and unilateral repairs, respectively (32.5 ± 8.8 vs. 45.4 ± 4.8 months, p < 0.01) (30.2 ± 8.8 vs. 39.1 ± 9.6 months, p < 0.01). No conversion was required in BURNIA. There were no complications and no recurrence in all patients. CONCLUSIONS: Single-site laparoscopic burnia is technically feasible, and as safe and effective as open inguinal hernia repair.

Extended View: Totally Extra Peritoneal (e-TEP) Approach for Ventral and Incisional Hernia-Early results from a single center.

BACKGROUND: Laparoscopy for ventral hernia repair is now an established technique with its proven benefits of less pain, early recovery, low-recurrence rate as compared to open repair. Several techniques have been described such as IPOM, MILOS, TES, EMILOS, SCOLA, e-TEP. e-TEP was originally conceptualized as an alternative approach to inguinal hernia in difficult cases (obese, previous scars) and for training surgery residents. Application of this approach for ventral hernia repair has recently been reported by few surgeons. We present our experience of e-TEP approach for ventral hernia from a tertiary care center in South India over one year duration. MATERIALS AND METHODS: Electronically maintained data of patients who underwent e-TEP for ventral hernia during a period of November 2017 to November 2018 was reviewed retrospectively. Their demographic data, intraoperative details, postoperative complications and follow up data for a period of 6 months was noted. RESULTS: 171 patients underwent e-TEP approach ventral hernia repair. Mean age was 49.34 ± 10.75 years with hypertension being most common comorbidity. Mean BMI was 29.2 ± 4.1 kg/m2. Mean defect area was 51.35 ± 45.09 cm2 and mean mesh size used was 397.56 ± 208.83 cm2. Fifty patients required TAR. Mean duration of surgery was 176.75 ± 62.42 min and blood loss was 78.7 ± 24.4 ml. Mean length of stay was 2.18 ± 1.27 days. Seven cases had paralytic ileus, 5 cases had surgical site infection, and 3 cases had recurrence at 6 months follow up. CONCLUSION: e-TEP is a minimally invasive approach which is safe, feasible and also avoids placement of mesh in peritoneal cavity. Since it is a relatively new approach it requires further studies for standardization of techniques, criteria for patient selection and to study long-term outcomes.

Is Youtube a potential training source for total extraperitoneal laparoscopic inguinal hernia repair?

BACKGROUND: The aim of this study is to evaluate the quality of the most commonly viewed total extraperitoneal laparoscopic inguinal hernia repair (TEP) videos on Youtube, which is the largest social and medical media broadcasting service, concerning educational purposes. METHOD: A search with the keyword "total extraperitoneal laparoscopic inguinal hernia repair" was performed on Youtube. The first 120 videos among the search results were downloaded and 55 of them were included in the study. A scoring system developed by the authors according to the recent literature was utilized for evaluation of the videos. Video demographics were evaluated for the quality and upload source. RESULTS: Among the enrolled videos, video quality was rated as good in 13 (23.6%), as moderate in 22 (40%), and as poor in 20 (36.4%). Video length, presence of narration, number of likes, and comments were significantly higher in the good group. Upload source was an academic center in 14 (25.5%), a community hospital in 22 (40.0%), and a physician in 19 (34.5%). The mean video score of the academic center group (8 ± 4.095) and community hospital group (8.64 ± 3.259) was significantly higher than the physician group (5.47 ± 2.632) (p = 0.010). Video quality was not correlated with total views or views per day. CONCLUSION: Total extraperitoneal laparoscopic inguinal hernia repair procedure videos uploaded to Youtube demonstrate considerable heterogeneity in terms of educational quality and the number of good quality videos is significantly low. This heterogeneity is attributed to the lack of peer review process for the evaluation of educational quality of the videos. Therefore, a physician intending to learn and practice a surgical procedure properly (TEP repair in this situation) should not consider a broadcasting service without a peer review process as a reliable training source.

Posterior Retroperitoneoscopic Versus Laparoscopic Transperitoneal Adrenalectomy: A Systematic Review by an Updated Meta-Analysis.

BACKGROUND: Two main minimal access adrenalectomy techniques are available: laparoscopic transperitoneal (LTA) and posterior retroperitoneoscopic adrenalectomy (PRA). This study aims to compare these approaches in an updated meta-analysis of randomised controlled (RCT) and non-randomised comparative (NRT) trials. METHODS: A systematic search of comparative LTA and PRA studies was performed. Standard demographic and surgical data were recorded. Outcome measures compared included: operative time, estimated blood loss (EBL), conversion to open, post-operative pain, time to oral intake and ambulation, early morbidity, hospital length of stay (HLOS) and mortality. Quality of RCTs and NRTs was assessed using Cochrane and ROBINS-I, respectively, and heterogeneity using the I2 test. Dichotomous and continuous variables were compared using odds ratios and mean/standard difference. Studies were then combined using the Mantel-Haenszel method. Meta-analysis was performed by fixed- and random-effect models. RESULTS: Following exclusions, 12 studies were included in the analysis: 3 RCTs and 9 NRTs. These reported a total of 775 patients: 341 (44%) PRA and 434 (56%) LTA. Demographics were similar except for tumour size which was smaller (by 0.78 cm) in PRA (p = 0.003). Significant differences in outcome were seen in EBL (18 mls less in PRA, p = 0.006), time to oral intake (3.4 h sooner in PRA p = 0.009) and HLOS (shorter in PRA by 0.84 day, p = 0.001). CONCLUSIONS: This analysis demonstrates that while PRA tends to be performed for smaller tumours it allows for less EBL, earlier post-operative oral intake and shorter hospital stays. In appropriately selected patients, it represents an invaluable tool in the endocrine surgeon's armamentarium.

Passive Versus Active Intra-Abdominal Drainage Following Pancreaticoduodenectomy: A Retrospective Study Using The American College of Surgeons NSQIP Database.

BACKGROUND: Prophylactic drainage following pancreaticoduodenectomy (PD) reduces morbidity and mortality. Little evidence exists to advise on whether passive gravity (PG) or active suction (AS) drainage systems result in superior outcomes. This study examines the relationship between drainage system and morbidity following PD. METHODS: All patients undergoing elective PD with an operatively placed drain in the 2016 ACS-NSQIP database were included. Pre- and intra-operative factors were examined. Multivariable logistic regression and coarsened exact matching (CEM) were used to assess for an association between drainage system (PG vs. AS) and morbidity. The primary outcome was postoperative pancreatic fistula (POPF). RESULTS: In total, 3430 patients were included: 563 (16.4%) with PG and 2867 (83.6%) with AS drainage system. On multivariable regression, 1787 patients were included. Drainage type was not associated with POPF, surgical site infection, delayed gastric emptying, or re-operation. AS drainage was protective against percutaneous drain insertion (OR 0.65, 95% CI 0.44-0.96, p = 0.033). In the CEM cohort (n = 268), superficial SSI was higher in the AS group (0.8% vs. 6.0%, p = 0.036). There was a trend toward higher rates of composite total SSI (PG 15.7%, AS 23.9%, p = 0.092) and organ space SSI (PG 14.2%, AS 20.2%, p = 0.195) in the AS group; this did not demonstrate statistical significance. CONCLUSIONS: The findings of this study suggest that AS drainage is protective against percutaneous drain insertion, but may be associated with increased risk of SSI. There was no relation between drainage type and POPF. A prospective, randomized controlled trial is warranted to further explore these findings.

MIEO: a micro-invasive endoscopic operation port system for transluminal interventions-an acute and survival porcine study.

BACKGROUND: A reliable and sterile access through the intestinal wall to ease flexible endoscopic transluminal interventions is still appealing but lacks a suitable port system. METHODS: In a granted industry cooperation, we developed the MIEO-Port, a flexible three components overtube system that provides a temporary hermetic sealing of the intestinal wall to allow endoscopic disinfection and manipulation to gain access to the abdominal cavity. The port features an innovative head part which allows for coupling the port to the intestinal wall by vacuum suction and for controlled jetting the isolated intestinal surface with a disinfectant. The device was tested in vivo in 6 pigs for acute and long-term usability. All animal tests were approved by the local ethics committee. RESULTS: In the acute experiment, the port system supported sealed endoscopic mucosa resection and transluminal cholecystectomy. In the survival study on 5 animals, the MIEO-Port proved its reliability after transcolonic peritoneoscopy. In one animal, a port dislocation occurred after extensive retroperitoneal preparation, one animal revealed bacterial contamination at necropsy; however, all animals showed a favourable course over ten days and offered no signs of peritonitis or abscedation during post-mortem examination. DISCUSSION: To the best of our knowledge, the MIEO-Port system is the first device to provide a reliable and sterile flexible access to the peritoneal cavity that can be used throughout the entire gastrointestinal tract regardless of the access route and which combines hermetic sealing with local sterilization. Further studies are warranted.

Surgical technique for placement of the automated low flow ascites pump (Alfapump).

Approximately 10% of patients with ascites associated with cirrhosis fail to respond to dietary rules and diuretic treatment and therefore present with refractory ascites. In order to avoid iterative large-volume paracentesis in patients with contraindication to TIPS, the automated low flow ascites pump system (Alfapump) was developed to pump ascites from the peritoneal cavity into the urinary bladder, where it is eliminated spontaneously by normal micturition. This manuscript reports the surgical technique for placement of the Alfapump.

Feasibility of a Portable Abdominal Insufflation Device for Controlling Intraperitoneal Bleeding After Abdominal Blunt Trauma.

Uncontrolled bleeding contributes to 30% to 40% of trauma-related deaths and is the leading cause of potentially preventable deaths. Currently, there is no effective method available to first responders for temporary control of noncompressible intraabdominal bleeding while patients are transported to the hospital. Our previous studies demonstrated that abdominal insufflation provides effective temporary bleeding control. The study aims to prove the feasibility (insufflation to a target pressure) and safety (cardiovascular and respiratory effects) of a novel portable abdominal insufflation device (PAID) designed to control the intraperitoneal bleeding caused by abdominal trauma. The PAID prototype is based on a patented design and manufactured via additive manufacturing. PAID contains a 16-g CO2 cartridge and an electronic pressure transducer. PAID was tested on a bench top and a swine animal model. For the animal model study, the intraperitoneal pressure as well as cardiorespiratory parameters (hearth rate, SpO2 [peripheral capillary oxygen saturation], and blood pressure) were continuously monitored during the insufflation procedure. The prototype functioned according to specifications on both bench top and animal models. CO2 insufflation of the peritoneal cavity was delivered up the target 20 mm Hg and maintained for 30 minutes from 1 or 2 cartridges in the swine model. No intraoperative incidents were registered, and all the recorded physiological parameters were within normal limits. The PAID prototype is a feasible, easy to use device that provides quick, controlled, and safe insufflation of the peritoneal cavity. Future studies will focus on testing the next-generation, semiautomatic PAID prototype in a severe intraabdominal injury model.

[A Case of Laparoscopic Abdominoperineal Resection for Rectal Cancer with Left-Sided Inferior Vena Cava].

A 66-year-old-man was hospitalizedfor the treatment of rectal cancer. Preoperative contrast-enhancedcomputedtomography revealedrectal cancer, left-sided inferior vena cava, and distant metastasis. He was diagnosed with cStage Ⅳb rectal cancer. Laparoscopic abdominoperineal resection with standard lymph node dissection was performed. There have been a few reports on laparoscopic colorectal resection for patients with left-sided inferior vena cava. We report a case of laparoscopic abdominoperineal resection for a patient with left-sided inferior vena cava.

Peritoneal microdialysis as a tool for detecting anastomotic leakage in patients after left-side colon and rectal resection. A systematic review.

OBJECTIVE: The objective was to evaluate peritoneal microdialysis in the detection of clinical anastomotic leakage after left-sided colon and rectal resection through a systematic review. METHODS: A systematic review (PRISMA guidelines) based on a systematic search through PubMed, Cochrane Library, and EMBASE (1 February 2017) was performed. Methodological index of non-randomised studies score was selected to assess the methodological quality. Patient demographics and raw data for intraperitoneal microdialysis concentrations of glucose, lactate, glycerol and pyruvate for 5 d postoperative were obtained from the respective study groups. RESULTS: Ten studies with a total of 128 patients were included. Thirty (23%) patients developed clinical anastomotic leakage. The area under the curve for intraperitoneal lactate concentration was significant higher in patients with anastomotic leakage (58.2; 95% CI 39.2, 77.2) compared with the no leakage group (41.0; 95% CI 35.2, 46.1; p = .007). Receiver operating characteristic curve analysis of the maximum measured lactate concentration demonstrated 25% sensitivity, 88% specificity and 74% accuracy for AL at a cut-off value of 9.8 mmol/L. The odds ratio for a 5 mmol/L increase in lactate in relation to the risk of AL was 2.9 (CI 1.1, 8.0). CONCLUSIONS: Increased intraperitoneal lactate concentration within the first 5 d postoperative was significantly associated with clinical anastomotic leakage, but with low predictive values. The microdialysis method is not yet ready for clinical implication before large prospective studies have defined cut off values for a biologic marker in the setting of a clear definitions of leakage.

Metastatic Involvement of Lesser Sac in Advanced Epithelial Ovarian Cancer.

OBJECTIVES: In advanced epithelial ovarian cancer (AOC), lesser sac (LS) metastasis particularly to the supragastric LS (SGLS) may be overlooked, resulting in unrecognized residual disease. We aimed to identify the frequency, distribution, and predictors of LS metastasis using laparoscopic evaluation at laparotomy and perioperative surgical complications associated with evaluation and resection/ablation. METHODS: Prospective observational study in consecutive patients with AOC undergoing laparotomy for primary or interval cytoreductive surgery in 2 centers between November 2013 and December 2016. RESULTS: Of 182 AOC patients undergoing laparotomy, 150 were eligible for metastasis distribution analysis; 96/150 (64%) had LS metastasis with 90/150 (60%) involving the SGLS, including lesser omentum (47.3%), floor (42%), upper recess (24.6%), and caudate lobe (22.6%), with 62/90 (68.8%) being less than 1 cm in dimension. Of 144 undergoing cytoreductive surgery, 92 (64%) had LS metastasis, which was completely resected/ablated in 77/92 (83.6%).The strongest multivariate predictors of LS metastasis were involvement of Morison pouch (P < 0.001) and peritoneal cancer index of 17 or greater (P < 0.001). The LS metastasis was significantly associated with diaphragmatic surgery (84% vs 54%), cholecystectomy (33% vs 2%), splenectomy (50% vs 14%), retroperitoneal nodal metastasis (75% vs 49%), and surgical complexity score of 8 or higher (75% vs 35%). Morbidity related to treatment of LS metastasis was minimal. CONCLUSIONS: Lesser sac metastasis and SGLS metastasis are present in almost two thirds of cases of AOC and often small in size. Systematic exploration is necessary to detect and treat metastases to LS to prevent unrecognized incomplete cytoreduction.

Laparoscopic radical cystectomy with pelvic re-peritonealization: the technique and initial clinical outcomes.

BACKGROUND: Delayed bowel function recovery and postoperative ileus are relatively serious complications of laparoscopic radical cystectomy (LRC). Our study aimed to determine whether performing pelvic re-peritonealization reduces the incidence of these complications. METHODS: Clinical data of 78 patients who had undergone LRC with pelvic re-peritonealization from August 2015 to December 2017 were retrospectively collected and compared with those of 92 patients who had undergone LRC alone between January 2013 and July 2015 in our institution. Differences in duration of surgery, estimated blood loss, time to recovery of bowel function, the complications of intestinal and blood vessel injury, and incidence of postoperative ileus between the two groups were analyzed. RESULTS: Baseline characteristics such as age, sex and BMI were balanced between the two groups. There were no significant differences in duration of surgery (P = 0.072), estimated blood loss (P = 0.717), or incidence of intestinal obstruction (P = 0.225) between the two groups. Interestingly, patients who had undergone pelvic re-peritonealization recovered bowel function more rapidly than those had not (2.79 d vs. 3.72 d, P = 0.001). Additionally, hospitalization stay was significantly shorter for patients with re-peritonealization than for those without (5.46 d vs. 6.68 d, P = 0.029). CONCLUSIONS: Compared with LRC alone, LRC with pelvic re-peritonealization as described in the present study had comparable perioperative complications, but was associated with more rapid gastrointestinal recovery and shorter hospitalization stay.