Transanal total mesorectal excision: dissection tips using 'O's and 'triangles'

PURPOSE

Transanal total mesorectal excision (taTME) requires specific technical expertise, as it is often difficult to ascertain the correct dissection plane. Consequently, one can easily enter an incorrect plane, potentially resulting in bleeding (sidewall or presacral vessels), autonomic nerve injury and urethral injury. We aim to demonstrate specific visual features, which may be encountered during surgery and can guide the surgeon to perform the dissection in the correct plane.

METHOD

Specific features of dissection in the correct and incorrect planes are demonstrated in the accompanying video.

RESULTS

The 'triangles' created using appropriate traction can aid in performing a precise dissection in the correct plane. Recognition of features described as 'O's can alert surgeons that they are entering a new fascial plane and can avoid incursion into an incorrect plane.

CONCLUSION

Understanding and recognizing the described features which can be encountered in taTME surgery, a safe and accurate TME dissection can be facilitated.

Critical concepts and important anatomic landmarks encountered during transanal total mesorectal excision (taTME): toward the mastery of a new operation for rectal cancer surgery

Over the past 3 years, colorectal surgeons have begun to adapt the technique of transanal total mesorectal excision. As international experience has been quickly forged, an improved recognition of the pitfalls and the practical details of this disruptive technique have been realized. The purpose of this technical note was to express the various nuances of transanal total mesorectal excision as learned during the course of its clinical application and international teaching, so as to rapidly communicate and share important insights with other surgeons who are in the early adoption phase of this approach. The technical points specific to transanal total mesorectal excision are addressed herein. When correctly applied, these will likely improve the quality of surgery and decrease morbidity attributable to inexperience with the transanal approach to total mesorectal excision.

Real-time tablet-based resuscitation documentation by the team leader: evaluating documentation quality and clinical performance

Background

Precise and complete documentation of in-hospital cardiopulmonary resuscitations is important but data quality can be poor. In the present study, we investigated the effect of a tablet-based application for real-time resuscitation documentation used by the emergency team leader on documentation quality and clinical performance of the emergency team.

Methods

Senior anaesthesiologists either used the tablet-based application during the simulated resuscitation for documentation and also used the application for the final documentation or conducted the full documentation at the end of the scenario using the local hospital information system. The latter procedure represents the current local documentation method. All scenarios were video recorded. To assess the documentation, we compared the precision of intervention delivery times, documentation completeness, and final documentation time. To assess clinical performance, we compared adherence to guidelines for defibrillation and adrenaline administration, the no-flow fraction, and the time to first defibrillation.

Results

The results showed significant benefits for the tablet-based application compared to the hospital information system for precision of the intervention delivery times, the final documentation time, and the no-flow fraction. We observed no differences between the groups for documentation completeness, adherence to guidelines for defibrillation and adrenaline administration, and the time to first defibrillation.

Discussion

In the presented study, we observed that a tablet-based application can improve documentation data quality. Furthermore, we demonstrated that a well-designed application can be used in real-time by a member of the emergency team with possible beneficial effects on clinical performance.

Conclusion

The present evaluation confirms the advantage of tablet-based documentation tools and also shows that the application can be used by an active member of an emergency team without compromising clinical performance.

Current status of trans-anal total mesorectal excision (TaTME) following the Second International Consensus Conference

This article documents the consensus of an expert group of surgeons from the Second International Trans-anal Total Mesorectal Excision (TaTME) Conference held in Paris in July 2014. It outlines three facets of the TaTME procedure: (i) the technique and its indications, (ii) training and adoption, and (iii) data collection and the TaTME registry.

Quadruple Valve Reoperation after the Ross Procedure

Reoperations after the Ross procedure are rare, with autograft as well as homograft failure being the dominant causes for redo cardiac procedures. Due to increasing experience with valve-sparing aortic valve procedures, more valves can be preserved during redo surgery. Herein are reported the details of a patient who underwent quadruple valve reoperation comprising redo with a reconstructive approach after the short-term failure of pulmonary autograft and homograft with concomitant mitral and tricuspid regurgitation.

Results and Quality of Life after Minimally Invasive Ross Procedure

BACKGROUND AND AIM OF THE STUDY

Based on superior long-term results, an increasing interest in the Ross procedure for young adult patients can be observed. After the first publication of this challenging procedure through a minimally invasive access, this operation has become an alternative to conventional sternotomy at the authors' department. This analysis compares the results and quality of life of the conventional and the minimally invasive Ross procedures.

METHODS

By April 2013, a total of 136 patients had undergone the Ross procedure at the authors' institution. Preoperative parameters did not differ between the conventional group (C-group; n = 58; mean age 49 years) and the minimally invasive group (M-group; n = 78; mean age 50 years). Only the aortic cross-clamp time was longer for the M-group (151 versus 140 min).

RESULTS

One C-group patient died on the day of operation. Consecutively, survival was 99% for the follow up period of 1,093 ± 601 days. Valve-related reoperations were necessary for four patients. One C-group patient developed a distal pulmonary stenosis due to fibrotic scar tissue. Two M-group patients showed fistulas after early endocarditis, but the native valves could be preserved in these cases. One C-group patient with recurrent severe aortic regurgitation showed holes in two of three cusps. The SF-36 questionnaire detected better physical parameters (physical function, physical role function) for patients after minimally invasive access.

CONCLUSION

The minimally invasive Ross procedure allows the same excellent clinical outcome as the conventional technique. However, the physical quality of life is better with the minimally invasive procedure, in addition to an improved cosmetic result.

A multicentre evaluation of the autograft procedure for young patients undergoing aortic valve replacement: update on the German Ross Registry†

OBJECTIVES

Conventional aortic valve replacement (AVR) in young, active patients represents a suboptimal solution in terms of long-term survival, durability and quality of life. The aim of the present work is to present an update on the multicentre experience with the pulmonary autograft procedure in young, adult patients.

METHODS

Between 1990-2013, 1779 adult patients (1339 males; 44.7 ± 11.6 years) underwent the pulmonary autograft procedure in 8 centres. All patients underwent prospective clinical and echocardiographic examinations annually. The mean follow-up was 8.3 ± 5.1 years (range 0-24.3 years) with a total cumulative follow-up of 14 288 years and 662 patients having a follow-up of at least 10 years.

RESULTS

The early (30-day) mortality rate was 1.1% (n = 19). Late (>30 day) survival of the adult population was comparable with the age- and gender-matched general population (observed deaths: 101, expected deaths: 91; P = 0.29). Freedom from autograft reoperation at 5, 10 and 15 years was 96.8, 94.7 and 86.7%, respectively, whereas freedom from homograft reoperation was 97.6, 95.5 and 92.3%, respectively. The overall freedom from reoperation was 94.9, 91.1 and 82.7%, respectively. Longitudinal modelling of functional valve performance revealed a low (<5%) probability of a patient being in higher autograft regurgitation grades throughout the first decade. Similarly, excellent homograft function was observed throughout the first 15 years.

CONCLUSION

The autograft principle results in postoperative long-term survival comparable with that of the age- and gender-matched general population and reoperation rates within the 1%/patient-year boundaries and should be considered in young, active patients who want to avoid the shortcomings of conventional prostheses.

[Pulmonary hyalinizing granuloma]

Benign lesions as pulmonary hyalinizing granuloma may mimic a malign disease. A 63-year old patient complained dyspnea and a weight loss of 30 kg. CT-thorax scans showed a destructive and infiltrative pulmonary process with pleural thickening. Histologic examination of transbronchial and transthoracic biopsies as well as of biopsies taken by minithoracotomy was not conclusive. Due to further progression the patient underwent a left-sided pleuropneumonectomy despite a VO2 peak of 9 ml/kg/min. Histology revealed DIP-like infiltrations, a histiocytic reaction and hyaline granulomas. Among less than 100 published cases of pulmonary hyaline granuloma a comparable rapid progression with a total functional loss of the affected lung is not reported. Mostly hyalinizing granuloma presents with infiltrations, which may mimic lung cancer, or nodular lesions, partly with cavitations or calcifications. The etiology is unknown, a persistent immunologic response to an antigenic stimulus is discussed. Associations with infections, lymphomas, amyloidosis or IgG4-related disease are reported. Some cases have features of multifocal fibrosis. In the case reported none of these associations could be found. The prognosis of pulmonary hyaline granuloma is regarded as benign. There is no effective treatment yet. Once the diagnosis has been established a conservative approach as well as a resection of nodules and a therapeutic attempt with steroids are an option. Extensive resections as pleuropneumonectomy are an exception.

A human morphologically normal spermatozoon may have noncondensed chromatin

According to numerous assisted reproductive medicine practitioners, semen with normal characteristics might not require further investigation. However, on the scale of the individual spermatozoon, it is well known that normal morphology does not guarantee optimal nuclear quality. Here, for 20 patients with normal sperm characteristics and a high proportion of spermatozoa with noncondensed chromatin, we subsequently assessed chromatin condensation status (aniline blue staining) and morphology (Papanicolaou staining) of the same 3749 spermatozoa. Although the overall proportion of morphologically normal spermatozoa was not correlated with the overall proportion of spermatozoa with noncondensed chromatin, an individual spermatozoon's morphology appeared to be closely related to its chromatin condensation status. Morphologically normal spermatozoa with noncondensed chromatin were seen in all patients; the proportion averaged 23.3% [min 10.9%-max 44.4%]. Morphologically abnormal spermatozoa were more likely to have noncondensed chromatin than morphologically normal ones (P < 0.0001). Small-, large- or multiple-headed spermatozoa presented the highest degree of noncondensation (>80% for each type), and more than half the vacuolated spermatozoa also presented noncondensed chromatin. However, a morphologically normal spermatozoon may also have a noncondensed chromatin.

Transanal minimally invasive surgery for total mesorectal excision (TAMIS-TME): results and experience with the first 20 patients undergoing curative-intent rectal cancer surgery at a single institution

BACKGROUND

Transanal TME is a new approach to performing minimally invasive rectal resection. It is particularly well suited for patients with locally advanced distal rectal cancer and obesity, where the abdominal approach is challenging. Transanal TME can be performed with either TAMIS or TEM. Here, we report our initial experience with transanal TME using TAMIS (TAMIS-TME).

METHODS

Patients were selected to undergo transanal TME using the TAMIS platform (TAMIS-TME) primarily for malignant disease, but also for select cases of benign disease. Transanal TME defines a "bottom-up" approach to en bloc rectal cancer resection. Transanal TME requires abdominal access for proximal colonic mobilization and is often done in conjunction with a laparoscopic approach.

RESULTS

During a 32-month period, 20 patients underwent TAMIS-TME with curative intent. The primary indication for transanal TME was distal, locally advanced rectal cancer. The median age of rectal cancer patients at the time of surgery was 57 years (range 36-73 years) with 30% (6) female and 70% (14) male. The median body mass index (BMI) measured was 24 kg/m(2) (range 18-41 kg/m(2)); this included six patients (30%) with obesity (BMI ≥ 30 kg/m(2)). Mean operating time was 243 min (range 140-495 min) with blood loss averaging 153 ml. Postoperative length of stay averaged 4.5 days (range 3-24 days). There was no 30-day postoperative mortality. Surgical complications included wound infection (n = 2), pelvic abscess (n = 4), and prolonged ileus (n = 4). The anastomotic leak rate was 6.7% (1/15). Of the 20 patients who underwent resection, 90% (18/20) had negative margins. Pathologic grading of the TME specimen revealed that 85% (17/20) of transanal TME specimens were found to have "completely" or "near-completely" intact mesorectal envelopes. Data collected during the 6-month median follow-up period revealed that only one patient had developed distant metastasis. There was no locoregional recurrence in any of the patients.

CONCLUSIONS

Transanal TME is a feasible method for oncologic resection of locally advanced mid- and distal-rectal cancer with curative intent. It has special application for patients with obesity and anatomic constraints such as a narrow male pelvis.

High-magnification selection of spermatozoa prior to oocyte injection: confirmed and potential indications

Intracytoplasmic morphologically selected sperm injection (IMSI) involves the use of differential interference contrast microscopy at high magnification (at least ·6300) to improve the observation of live human spermatozoa (particularly by showing sperm head vacuoles that are not necessarily seen at lower magnifications) prior to intracytoplasmic sperm injection (ICSI) into the oocyte. However, a decade after IMSI’s introduction, the technique’s indications and ability to increase pregnancy and/or birth rates (relative to conventional ICSI) are subject to debate. In an attempt to clarify this debate, this work performed a systematic literature review according to the PRISMA guidelines. The PubMed database was searched from 2001 onwards with the terms ‘IMSI’, ‘MSOME’ and ‘high-magnification, sperm’. Out of 168 search results, 22 relevant studies reporting IMSI outcomes in terms of blastocyst, pregnancy, delivery and/or birth rates were selected and reviewed. The studies’ methodologies and results are described and discussed herein. In view of the scarcity of head-to-head IMSI versus ICSI studies, the only confirmed indication for IMSI is recurrent implantation failure following ICSI. All other potential indications of IMSI require further investigation.

Robotic-assisted transanal surgery for total mesorectal excision (RATS-TME): a description of a novel surgical approach with video demonstration

A new era has emerged in rectal cancer surgery--transanal total mesorectal excision (TME). Various platforms have been used to facilitate this novel approach, including transanal minimally invasive surgery (TAMIS) and transanal endoscopic microsurgery. We have previously reported the use of TAMIS-TME. This is a report of the first human case of robotic-assisted transanal surgery for TME.

Tomonaga-Luttinger physics in electronic quantum circuits

In one-dimensional conductors, interactions result in correlated electronic systems. At low energy, a hallmark signature of the so-called Tomonaga–Luttinger liquids is the universal conductance curve predicted in presence of an impurity. A seemingly different topic is the quantum laws of electricity, when distinct quantum conductors are assembled in a circuit. In particular, the conductances are suppressed at low energy, a phenomenon called dynamical Coulomb blockade. Here we investigate the conductance of mesoscopic circuits constituted by a short single-channel quantum conductor in series with a resistance, and demonstrate a proposed link to Tomonaga–Luttinger physics. We reformulate and establish experimentally a recently derived phenomenological expression for the conductance using a wide range of circuits, including carbon nanotube data obtained elsewhere. By confronting both conductance data and phenomenological expression with the universal Tomonaga–Luttinger conductance curve, we demonstrate experimentally the predicted mapping between dynamical Coulomb blockade and the transport across a Tomonaga–Luttinger liquid with an impurity.

When physicists study the characteristics of quantum conductors they usually take great pains to limit the resistance of other elements in the system. But Jezouin et al. show that when a single quantum channel is measured in series with a resistor, it exhibits analogous characteristics to a Tomonaga–Luttinger liquid.

Protective effect of CV247 against cisplatin nephrotoxicity in rats

CV247 (CV), an aqueous mixture of copper (Cu) and manganese (Mn) gluconates, vitamin C and sodium salicylate increased the antitumour effects of cisplatin (CDPP; cis-diamminedichloroplatinum) in vitro. We hypothesized that the antioxidant and cyclooxygenase-2 (COX-2; prostaglandin-endoperoxide synthase 2) inhibitory components of CV can protect the kidneys from CDPP nephrotoxicity in rats. CDPP (6.5 mg/kg, intraperitoneally) slightly elevated serum creatinine (Crea) and blood urea nitrogen (BUN) 12 days after treatment. Kidney histology demonstrated extensive tubular epithelial damage and COX-2 immunoreactivity increased 14 days after treatment. A large amount of platinum (Pt) accumulated in the kidney of CDPP-treated rats. Furthermore, CDPP decreased renal iron (Fe), molybdenum (Mo), zinc (Zn), Cu and Mn concentrations and increased plasma Fe and Cu concentrations. CDPP elevated plasma free radical concentration. Treatment with CV alone for 14 days (twice 3 ml/kg/day orally) did not influence these parameters. Chronic CV administration after CDPP reduced renal histological damage and slightly decreased COX-2 immunoreactivity, while failed to prevent the increase in Crea and BUN levels. Blood free radical concentration was reduced, that is, CV improved redox homeostasis. CV restored plasma Fe and renal Fe, Mo and Zn, while decreased Pt and elevated Cu and Mn concentrations in the kidney. Besides the known synergistic antitumour effects with CDPP, CV partially protected the kidneys from CDPP nephrotoxicity probably through its antioxidant effect.

Towards realistic estimates of HCV incidence in Egypt

Accurate incidence estimates are essential for quantifying hepatitis C virus (HCV) epidemic dynamics and monitoring the effectiveness of public health programmes, as well as for predicting future burden of disease and planning patient care. In Egypt, the country with the largest HCV epidemic worldwide, two modelling studies have estimated age-specific incidence rates that, applied to the age pyramid, would correspond to more than 500 000 Egyptians getting infected annually. This is in contrast to figures of the Egyptian Ministry of Health and Population that estimates new infections to be approximately 100 000 per year. We performed new analyses of nationwide data to examine the modelling assumptions that led to these estimates. Thus, we found that the key assumption of these models of a stationary epidemic is invalid. We propose an alternate approach to estimating incidence based on analysing cohort data; we find that the number of annual new infections is <150 000.

Trapping of topological-structural defects in Coulomb crystals

We study experimentally and theoretically structural defects which are formed during the transition from a laser cooled cloud to a Coulomb crystal, consisting of tens of ions in a linear radio frequency trap. We demonstrate the creation of predicted topological defects ("kinks") in purely two-dimensional crystals and also find kinks which show novel dynamical features in a regime of parameters not considered before. The kinks are always observed at the center of the trap, showing a large nonlinear localized excitation, and the probability of their occurrence saturates at ∼0.5. Simulations reveal a strong anharmonicity of the kink's internal mode of vibration, due to the kink's extension into three dimensions. As a consequence, the periodic Peierls-Nabarro potential experienced by a discrete kink becomes a globally confining potential, capable of trapping one cooled defect at the center of the crystal.

Quantum heat fluctuations of single-particle sources

Optimal single electron sources emit regular streams of particles, displaying no low-frequency charge current noise. Because of the wave packet nature of the emitted particles, the energy is, however, fluctuating, giving rise to heat current noise. We investigate theoretically this quantum source of heat noise for an emitter coupled to an electronic probe in the hot-electron regime. The distribution of temperature and potential fluctuations induced in the probe is shown to provide direct information on the single-particle wave function properties and display strong nonclassical features.

Transanal minimally invasive surgery (TAMIS): applications beyond local excision

Transanal minimally invasive surgery (TAMIS) is a new technique for the local excision of rectal neoplasia. This platform employs ordinary laparoscopic instruments to achieve high-quality local excision. The TAMIS platform, however, is quite versatile. Described here are applications of TAMIS beyond local excision, ranging from repair of a rectourethral fistula to reverse proctectomy.

Intérêt de la ponction épididymaire et de la biopsie testiculaire systématique dans la prise en charge de l’azoospermie obstructive

Introduction

Dans l’azoospermie obstructive (AO), les taux d’extraction chirurgicale de spermatozoïdes sont élevés. Cependant, en ce qui concerne les issues des ICSI (Intra cytoplasmic Sperm Injection) chirurgicales, les données de la littérature divergent. Quels sont, dans notre équipe, les taux d’extraction de spermatozoïdes après aspiration épidydimaire (MESA) et après extraction testiculaire (TESE) dans l’AO ? Les taux de grossesses, les taux de fausses couches spontanées et d’accouchements diffèrent-ils en fonction de l’origine du sperme ?

Matériels et méthodes

L’étude a rétrospectivement inclus 48 couples dont l’homme présente une azoospermie obstructive pure et ayant bénéficié d’un prélèvement chirurgical de spermatozoïdes associant systématiquement MESA et TESE. Les ICSI ont été réalisées de manière asynchrone. À chaque fois que cela était possible, la première ICSI a été réalisée avec des spermatozoïdes épididymaires.

Résultats

Pour les 48 couples, 99 ICSI ont été réalisées. Quinze couples ont réalisé 24 ICSI-TESE car l’aspiration épididymaire était négative. Onze couples ont réalisé 20 ICSI-TESE car la qualité du prélèvement épididymaire n’était pas satisfaisante (vitalité spermatique réduite le plus souvent). Vingt-deux couples ont réalisé 22 ICSI-MESA en première intention puis en cas d’échec, 11 couples ont réalisé 12 ICSI-MESA et dix couples ont réalisé 20 ICSI-TESE. Alors que les nombres d’ovocytes injectés (7,1±4,1 vs 6,9 ±3,6 P: 0,8) et d’embryons obtenus (4,5±3,0 vs 4,7±2,7; P: 0,7) ne sont pas significativement différents dans les deux groupes d’ICSI, les nombres d’embryons de top qualité (2,4±1,9 vs 3,6±2,0 P: 0,005) et d’embryons congelés (0,9±1,8 vs 1,7±1,9 P: 0,04) sont significativement supérieurs dans le groupe TESE. Le nombre de grossesse par ponction est supérieur dans le groupe TESE (58,5 % vs 26,5 %, P: 0,002).

Conclusion

L’approche de notre centre a la particularité d’associer systématiquement un prélèvement testiculaire au prélèvement épididymaire chez tout homme présentant une azoospermie obstructive alors que la plupart des autres études rapportées se limitent à l’exploration épididymaire si cette dernière est positive lors de l’examen extemporané. Alors que classiquement, on rapporte 100% de positivité lors du prélèvement épididymaire chez l’homme atteint d’une azoospermie obstructive, dans notre étude, plus de la moitié des explorations épididymaires s’est avérée inexploitable. La qualité embryonnaire et les taux de grossesses sont meilleurs avec des spermatozoïdes testiculaires. L’association de ces 2 sites de prélèvement (MESA et TESE) peut être complémentaire et utile pour le couple et l’issue de sa prise en charge en AMP sans pour autant entraîner un sur-risque pour l’homme dans les suites de la chirurgie.

The technical approach to laparoscopic colectomy in patients who have undergone prior abdominoplasty

BACKGROUND

For those patients undergoing laparoscopic colorectal surgery who have had prior abdominoplasty, cosmetic outcome is important and the technical considerations for laparoscopy in post-abdominoplasty patients have not been previously addressed. The aim of the present study was to define the technical approach to the post-abdominoplasty patient undergoing laparoscopic colorectal surgery after abdominoplasty.

METHODS

Utilizing the technical approach described, eleven patients underwent laparoscopy after prior abdominoplasty over a 7-year period.

RESULTS

The majority of patients (10/11) felt their laparoscopic colorectal resection had no adverse effect on the aesthetics of their prior abdominoplasty. From a surgeon's standpoint, the only significant challenge was due to the loss of abdominal wall compliance.

CONCLUSIONS

The surgical approach to laparoscopic colectomy in the post-abdominoplasty patient requires careful planning. Cosmetic outcome is a particularly important consideration for this subset of patients, and this should be appreciated by the operating surgeon.

Impact of a preventive programme on the occurrence of incidents during the transport of critically ill patients

OBJECTIVE

Incidents related to transport of critically ill patients have been extensively reported. The objective of this study was to determine the effect of an interdisciplinary preventive programme used by all intensive care unit team members involved in patients' transport on the rate of these incidents.

METHODS

A clinical quality improvement audit using a prospective pre and post intervention design was performed among medical and surgical patients hospitalised in intensive care who required intra or inter-hospital transport.

RESULTS

A total of 180 transports occurred in the pre-implementation phase of the study and 187 transports in the post-implementation phase. A 20% absolute reduction of incidents was observed (57.2% vs. 37.4%, p<0.001). Statistically significant reductions were obtained for the technical problems category of incidents (25% vs. 7.5%, p<0.001) as well as the problems related to patient's mobilisation category (14.4% vs. 7.5%, p=0.05). Clinically significant trends were also observed for the clinical deterioration (24.4% vs. 17.1%, p=0.11) and undesired delay before test (23.9% vs. 17.6%, p=0.14) categories but did not reach statistical significance.

CONCLUSIONS

A preventive programme applied by all care providers involved in transport of critically ill patients was associated with a reduction of incidents. The application of such a programme should be acknowledged as a standard of care considering the risks inherent to the transportation of ICU patients.

Excision of a rectal neoplasm using robotic transanal surgery (RTS): a description of the technique

The approach to local excision of benign and early-stage, well-selected neoplasms of the rectum continues to evolve. We demonstrate here that local excision of a rectal neoplasm using the da Vinci Robotic Surgical System can be successfully performed. To our knowledge, this is the first time robotic transanal surgery (RTS) has been used in this manner.