Clinical outcome of laparoscopic right hemicolectomy with transvaginal resection, anastomosis, and retrieval of specimen

PURPOSE

The goal of this study is to evaluate the technical feasibility, safety, and clinical outcomes of totally laparoscopic colectomy with transvaginal anastomosis and extraction of specimen in female patients with right-sided colon cancer.

METHODS

A review of prospectively collected database at the Kyungpook National University Hospital from April 2007 to December 2007 revealed a series of 14 consecutive patients affected by right colon cancer were operated by use of the totally laparoscopic colectomy with transvaginal anastomosis and extraction of specimen approach. For this approach, the bowel was fully mobilized and a D3 lymphadenectomy was performed with established laparoscopic technique, followed by transvaginal anastomosis and removal of the resected specimen. Data regarding clinicopathological outcomes, surgical morbidity, and short-term oncologic results were analyzed.

RESULTS

No case required an open conversion, but in 2 patients the planned transvaginal retrieval of the specimen was aborted because of inadequate posterior colpotomy. The median operative time was 150.0 minutes (range, 110-330 min) and the median blood loss was 50.0 mL (range, 20.0-115 mL). The median tumor size was 4.0 cm and the number of harvested lymph nodes was 36.0 (range, 13-65). There was no surgical mortality or major morbidity, except one case of postoperative ileus that was conservatively managed. No patient experienced complications directly associated the transvaginal approach; nor did any patient have infection or prolonged spotting from the extraction site postoperatively. Recovery after the procedure was rapid and the median hospital stay was 7.0 days (range, 6-12 d). With a median follow-up 34 months, one patient experienced distant metastasis (7.1%).

CONCLUSIONS

In selected cases, totally laparoscopic colectomy with transvaginal anastomosis and extraction of specimen is feasible and reproducible and may be an alternative technique for treatment of women with right colon cancer. This approach may provide both an attractive way to increase patient comfort and a bridge to "pure" natural orifice colon surgery.

Robotic-assisted versus laparoscopic surgery for low rectal cancer: case-matched analysis of short-term outcomes

PURPOSE

The aim of this study is to compare short-term outcomes and surgical quality of robot-assisted (RAP) and laparoscopic (LAP) total mesorectal excision (TME) in patients with low rectal cancer.

METHODS

From December 2007 to June 2009, 41 consecutive patients with low rectal cancer underwent TME by robot-assisted procedures. The lowest tumor margins were below peritoneal reflection and 1.0-8.0 cm above the anal verge. These patients were matched 1:2 by age, gender, body mass index, date of surgery, American Society of Anesthesiologists score, and tumor stage, with 82 patients who underwent conventional LAP. Macroscopic quality of the specimens and operative and postoperative outcomes were compared.

RESULTS

Mean operation time was 168.0 ± 49.3 min for LAP group and 231.9 ± 61.4 min for RAP group (P < 0.001). Time to regular diet (RAP, 6.7 days vs. LAP, 6.6 days) and length of stay (RAP, 9.9 days vs. LAP, 9.4 days) were similar. The proportion of surgeries performed with the modified natural orifice techniques (totally intracorporeal procedures with transanal or transvaginal retrieval of specimens) was significantly higher in the RAP group (RAP, 48.8% vs. LAP, 13.4%; P < 0.001). There were no between-group differences in specimen quality, including distal resection margins, harvested lymph nodes, and circumferential margins. The overall major complication rates were similar (RAP, 9.8% vs. LAP, 7.3%; P = 0.641).

CONCLUSIONS

RAP was safe and effective for patients with low rectal cancer. Furthermore, the technical advantages of robot surgical systems may allow a novel approach using hybrid natural orifice surgery.

S052: a comparison of robot-assisted, laparoscopic, and open surgery in the treatment of rectal cancer

BACKGROUND

In recent years, robot-assisted surgery using the da Vinci System® has been proposed as an alternative to traditional open or laparoscopic procedures. The aim of this study was to compare the short-term outcomes for open, laparoscopic, and robot-assisted rectal resection for cancer.

METHODS

Two hundred sixty-three patients with rectal cancer who underwent curative resection between 2007 and 2009 were included. Patients were classified into an open surgery group (OS, n = 88), a laparoscopic surgery group (LAP, n = 123), and a robot-assisted group (RAP, n = 52). Data analyzed include operating time, length of recovery, methods of specimen extraction, quality of total mesorectal excision, and morbidity.

RESULTS

The mean operating time was 233.8 ± 59.2 min for the OS group, 158.1 ± 49.2 min for the LAP group, and 232.6 ± 52.4 min for the RAP group (p < 0.001). Patients from the LAP and RAP groups recovered significantly faster than did those from the OS group (p < 0.05). The proportion of operations performed through a natural orifice (intracorporeal anastomosis with transanal or transvaginal retrieval of specimens) was significantly higher in the RAP group (p < 0.001). The specimen quality--with a distal resection margin, harvested lymph nodes, and circumferential margin--did not differ among the three groups. The overall complication rates were 20.5, 12.2, and 19.2% in the OS, LAP, and RAP groups, respectively (p = 0.229).

CONCLUSIONS

RAP and LAP reproduce the equivalent short-term results of standard OS while providing the advantages of minimal access. For the experienced laparoscopic colorectal oncologist, use of the da Vinci robot resulted in no significant short-term clinical benefit over the conventional laparoscopic approach.

Ectoparasite fauna of rodents and shrews from four habitats in Kuala Lumpur and the states of Selangor and Negeri Sembilan, Malaysia and its public health significance

A total of 204 rodents comprising 14 host species from four different habitats were examined. Nine rodent species were trapped from the forest and another five species were trapped from the coastal, rice field and urban habitats. Rattus rattus diardii (67%) was the predominant rodent species examined. Fifty six (47.3%) rodents and shrews were found to be infested with at least one of the 20 species of ectoparasite recovered. Mites belonging to the family Trombiculidae were the predominant ectoparasite species recovered. Ticks belonging to the family Ixodidae were recovered mainly from the forest dwelling rodents. Polyplax spinulosa and Hoplopleura pacifica were the common lice species found infesting the urban rodents. Xenopsylla cheopis was the only flea species recovered. The following ecto-parasites have been incriminated as important vectors or as mechanical carriers for the transmission of zoonotic diseases: Ixodes granulatus, Dermacentor sp. Haemaphysalis sp., Amblyomma sp. Ascoschoengastia indica, Leptotrombidium deliense, Ornithonyssus bacoti, Laelaps nuttalli, H. pacifica, P. spinulosa and Xenopsylla cheopis. Urban and forest rodents were significantly higher in ecto-parasitic infestation, compared to rats from the other two habitats. However, there was no significant statistical association between male and female rodents infested with ectoparasites.

Serum carcinoembryonic antigen monitoring after curative resection for colorectal cancer: clinical significance of the preoperative level

AIM

We evaluated preoperative serum carcinoembryonic antigen (CEA) as a prognostic factor for colorectal cancer and determined when surveillance of this marker was useful.

METHODS

Serum CEA was measured preoperatively in 1,263 patients who underwent curative resection for colorectal cancer at 3-month intervals for the first 2 postoperative years and at 6-month intervals thereafter. Mean follow-up was 48 months (range 1-156 months).

RESULTS

The 5-year disease-free survival was less in patients with a high preoperative serum CEA level (P<0.0001). Among patients with a tumor recurrence, 38.5% had high follow-up serum CEA levels. The number of patients with high postoperative serum CEA levels exceeded the number of patients with high preoperative levels. High preoperative and follow-up serum CEA levels were independent prognostic factors for tumor recurrence (P=0.003 and P<0.001, respectively). In patients with high preoperative serum CEA levels, CEA surveillance had a 92.3% positive predictive value (PPV) and a 96.1% negative predictive value (NPV). The mean interval between postoperative serum CEA elevation and the diagnosis of a tumor recurrence [diagnostic interval (DI)] was 2.5 months (range 5-17 months). The DI was 0 in 18.8% of patients with a tumor recurrence.

CONCLUSION

High serum CEA levels preoperatively and at follow-up are prognostic factors for colorectal cancer. Postoperative serum CEA surveillance is used most effectively when patients have high preoperative serum CEA levels. Considering the DI of 0 in 18.8% of the patients, the current CEA surveillance schedule might be changed.

Comparison of one-stage managements of obstructing left-sided colon and rectal cancer: stent-laparoscopic approach vs. intraoperative colonic lavage

PURPOSE

We evaluated the operative outcomes of laparoscopic surgery following self-expandable metallic stent compared to one-stage emergency surgical treatment.

METHODS

From April 1996 to October 2007, 95 consecutive patients with left-sided malignant colorectal obstruction were enrolled. Twenty-five patients were assigned to the preoperative stenting and elective laparoscopic surgical treatment group (SLAP) and 70 to the emergency open surgery with intraoperative colon lavage group (OLAV).

RESULTS

Among the 25 patients in the SLAP group, a primary anastomosis was possible in all patients and a diverting stoma was needed in one patient. The operative time was shorter in the SLAP group (198.53 vs. 262.17 min, P = 0.002). Tumor size, number of retrieved lymph nodes, and pathological stage were similar in both groups. The rate of anastomotic failure was similar and postoperative complications occurred less in the SLAP group (5.9% vs. 31.4%, P = 0.034). The passage of flatus and oral intake were resumed earlier in the SLAP group (2.88 vs. 3.68 days, P = 0.046 and 5.18 vs. 6.65 days, P < 0.001, respectively). The postoperative hospital stay was shorter in the SLAP group (10 vs. 15.4 days, P = 0.013).

CONCLUSIONS

In patients with left-sided malignant colon and rectal obstruction, laparoscopic surgery after SEMS could be safely performed with successful early postoperative outcomes.

Tobacco use, knowledge and attitude among Malaysians age 18 and above

This study aims to determine the level of knowledge and to understand their attitude towards smoking and secondly to determine how sociodemographic background, smoking status and knowledge on the health risks of smoking contribute toward the development of such attitude. A total of 10,545 respondents age 18 years and above across Malaysia were interviewed. Results indicated that level of knowledge and attitude varied by gender, education level, smoking status, age, ethnicity and smoker category. Smokers' low education, poor knowledge on the dangers of smoking and being males had more positive or greater impact on their attitudes towards smoking. Formulation and implementation of a holistic programme aimed at increasing knowledge and attitude change that accounts for sociodemographic background of the population is recommended in order to bring down smoking rates and thus reduce smoking related health problems in this country.

Endo-parasite fauna of rodents caught in five wet markets in Kuala Lumpur and its potential zoonotic implications

Rodents were collected from five wet markets (Chow Kit, Dato Keramat, Setapak, Jinjang and Kepong) in Kuala Lumpur, Federal Territory between March to April 2006. Ninety seven rats were trapped using wire traps measuring 29 x 22 x 50 cm baited with fruits, coconuts, dried fish or sweet potatoes. A total of 17 different species of parasites were identified from three species of rats out of which 11 (65%) were identified to be zoonotic. The helminths identified from the urban rats were nematodes- Capillaria hepatica, Gongylonema neoplasticum, Heterakis spumosa, Heterakis sp., Masterphorus muris, Nippostrongylus brasiliensis, Physolaptera sp., Pterogodermatis sp., Rictularia tani and Syphacia muris; cestodes- Hymenolepis nana, Hymenolepis diminuta, Hymenolepis sabnema, Hymenolepis sp., Raillietina sp. and Taenia taeniaeformis, and acanthocephalan- Moniliformis moniliformis. The following parasites are of potential medical importance: C. hepatica, G. neoplasticum, R. tani, S. muris, H. diminuta, H. nana, Raillietina sp. and T. taeniaeformis.

Lymph node metastasis patterns in right-sided colon cancers: is segmental resection of these tumors oncologically safe?

PURPOSE

The type of surgery and the extent of lymphadenectomy depend on the tumor location and should be based on the extent of lymphatic spread and the oncologic outcome. The aim was to analyze patterns of lymph node metastasis in patients with right-sided colon cancer.

METHODS

Between 1996 and 2007, a total of 419 patients underwent curative resection for right-sided colon cancer. Lymph nodes were grouped immediately after surgery on the basis of the location of the tumor.

RESULTS

There were 75, 208, 78, and 58 tumors in the cecum, ascending colon, at the hepatic flexure, and in the transverse colon, respectively. Of the 58 patients with transverse colon tumors, 43, 11, 3, and 1 underwent right hemicolectomies, transverse colectomies, left hemicolectomies, and a subtotal colectomy, respectively. Patients with cecal and ascending colon cancers most frequently had metastases in the ileocolic lymph nodes. Metastasis to the lymph nodes along the right branch of the middle colic artery occurred in 6.1% of patients with cecal cancer. In patients with hepatic flexure cancers, the epicolic lymph nodes along the right and middle colic arteries were most commonly metastatic lymph nodes. In transverse colon cancer, the middle colic node was the most commonly involved lymph node. Approximately 10% of patients had metastases to the right colic nodes.

CONCLUSIONS

Metastasis to lymph nodes along the right colic artery occurred in approximately 10% of the patients with transverse cancer, indicating the need for great care in deciding the extent of segmental resection for these patients.

Prevalence and factors related to smoking among secondary school students in Kota Tinggi District, Johor, Malaysia

Smoking among adolescent is a public health concern in Malaysia. Multiple studies on smoking prevalence and its related factors have been conducted in Malaysia, however, they were specific to either urban or rural areas alone. Studies in mixed settlement areas (urban, rural, land development area) had not been intensively investigated. This study reports the prevalence, demographic and factors related to smoking amongst form four students in the district of Kota Tinggi, Johor. A cross-sectional study of 16-year old secondary school students in Kota Tinggi district was conducted using two-stage stratified, proportionate sampling in July 2005. The study instrument used was a validated structured questionnaire on smoking and its related factors. Smoking prevalence was found to be 29.7%. More than 50% of male students were smokers. Prevalence was highest in FELDA (Federal Land Development Authority) settlement areas. Smoking was associated with having a brother or friend who smokes and poor academic performance. The study revealed that smoking prevalence was high, especially among male students in land development schemes. This situation will contribute to high smoking-related health problems in the future if proper preventive measures are not taken accordingly.

Depressive symptoms of type 2 diabetics treated with insulin compared to diabetics taking oral anti-diabetic drugs: a Korean study

OBJECTIVE

The purpose of this study was to examine the depressive symptoms of type 2 diabetic patients who were treated with insulin compared to those diabetics treated with oral anti-diabetic drugs in Korea.

METHODS

A total 204 outpatients with type 2 diabetes were invited to complete a questionnaire using the Beck depression inventory (BDI) to measure depressive symptoms. Age, gender, body mass index, serum lipid profile, and a social history including marital status, occupation and educational background were also assessed. The presence of diabetic complications was evaluated by examining the patients' medical records. Diabetic patients who were not treated with anti-diabetic drugs were excluded. All the study subjects were classified into two groups based on their mode of therapy: the oral drug group and insulin group. The insulin group included patients treated with insulin-oral drug combinations as well as those treated solely with insulin.

RESULTS

Overall, 32.4% of our diabetic subjects showed depressive symptoms with the criterion being a BDI score > or = 16. Compared to the oral drug group, the insulin group showed a significantly higher frequency of depressive symptoms (insulin group, 48.0%; oral drug group, 27.3%; p<0.01) and higher BDI scores (insulin group, 16.6+/-10.7; oral drug group, 12.6+/-8.7; p<0.01). Moreover, after an adjustment for social factors, the degree of hyperglycemia and the presence of diabetic complications, the insulin group showed a significantly higher frequency of depression (odds ratio 4.38, 95% CI 1.66-11.6, p=0.003), compared to the oral drug group.

CONCLUSIONS

The data showed that insulin treatment is related to the presence of depressive symptoms, and the importance of more careful psychological support of Korean insulin-treated type 2 diabetic patients is strongly suggested.

The medical alumni story

The Medical Alumni is unique in being the oldest alumni association with medical, dental and pharmacy graduates from our seminal medical school, that has now evolved into the faculties of medicine in 2 countries, namely Malaysia and Singapore. Founded in 1923, the medical alumni association has undergone several name changes with its evolution and activism. After the Japanese Occupation, it was given its present name in 1947, comprising 3 branches working under a common Constitution operating in 2 separate countries. It is also unique in being the only association recognised by the Registrar of Societies with membership in 2 countries. Following the development of medical professional and academic bodies, the medical alumni wound down its medico-political activities to concentrate on providing social and mutual support for its members and its alma mater.

The medical students' societies and medical students' publications

The rich corporate life of the medical student and the medical students' societies at our medical school (at the present National University of Singapore) is generally unappreciated by its graduates and regrettably, even more unknown to the medical student of today. The present generation of medical students of NUS do not know of their rich history. We have published documentation of student activities from the founding of the medical school in 1905 till the establishment of the then University of Malaya in 1950, reviewed herein. Materials presented after 1950 were gathered from personal communications from key players in the students' societies and from editors of the medical students' publications.

Acute myocardial infarction in the elderly--the differences compared with the young

OBJECTIVES

The aim of the study was to determine the differences in presentation, complications, management and outcome of elderly patients with acute myocardial infarction (AMI) compared to young patients.

MATERIALS AND METHODS

All case-notes with a discharge or death diagnosis ofAMI between January and July 1999 at a restructured hospital in Singapore were reviewed retropectively. Patients were categorised into those younger than 65 years (young) and those 65 years or older (elderly). Data on the demographic and clinical profile of patients were collected.

RESULTS

There were 112 young and 101 elderly AMI patients. Chest pain was the most common presentation in both age groups, but more likely in the young than the elderly (89.3% vs 66.3%; p < 0.001). Atypical presentations were more likely in the elderly, with shortness of breath as the most common presentation (20.8% vs 5.4%; p < 0.001). The elderly were more likely to have complications of cardiac failure (65.3% vs 25%; p < 0.001) and cardiogenic shock (8.9% vs 0.9%; p = 0.006). The elderly were less likely to receive thrombolytic therapy (35.8% vs 64.8%; p < 0.001) as they were more likely to have contraindications (34.5% vs 6.8%; p = 0.002). The elderly were also less likely to receive beta-blockers (21.8% vs 60.7%; p < 0.001). In-hospital mortality was higher in the elderly (20.8% vs 2.7%; p < 0.001). Cardiogenic shock complicating AMI was associated with high in-hospital mortality.

CONCLUSION

In AMI patients, chest pain was the most common presentation in both age groups, though less frequently in the elderly. Atypical presentations were more likely in the elderly, with shortness of breath as the most common atypical presentation. In elderly AMI patients, prevalence of cardiac failure was higher, use of beta-blockers was lower and in-hospital mortality was higher than young patients.

A four-dimensional study of the aortic root dynamics

OBJECTIVE

Although aortic root expansion has been well studied, its deformation and physiologic relevance remain controversial. Three-dimensional (3-D) sonomicrometry (200Hz) has made time-related 4-D study possible.

METHODS

Fifteen sonomicrometric crystals were implanted into the aortic root of eight sheep at each base (three), commissures (three), sinuses of Valsalva (three), sinotubular junction (three), and ascending aorta (three). In this acute, open-chest model, the aortic root geometric deformations were time related to left ventricular and aortic pressures.

RESULTS

During the cardiac cycle, aortic root volume increased by mean+/-1 standard error of the mean (SEM) 33.7+/-2.7%, with 36.7+/-3.3% occurring prior to ejection. Expansion started during isovolumic contraction at the base and commissures followed (after a delay) by the sinotubular junction. At the same time, ascending aorta area decreased (-2.6+/-0.4%). During the first third of ejection, the aortic root reached maximal expansion followed by a slow, then late rapid decrease in volume until mid-diastole. During end-diastole, the aortic root volume re-expanded by 11.3+/-2.4%, but with different dynamics at each area level. Although the base and commissural areas re-expanded, the sinotubular junction and ascending aorta areas kept decreasing. At end-diastole, the aortic root had a truncated cone shape (base area>commissures area by 51.6+/-2.0%). During systole, the root became more cylindrical (base area>commissures area by 39.2+/-2.5%) because most of the significant changes occurred at commissural level (63.7+/-3.6%).

CONCLUSION

Aortic root expansion follows a precise chronology during systole and becomes more cylindrical - probably to maximize ejection. These findings might stimulate a more physiologic approach to aortic valve and aortic root surgical procedures.

Analysis of alkali-soluble glucan produced by Saccharomyces cerevisiae wild-type and mutants

The alkali-soluble glucan of the yeast cell wall contains beta-(1,3)- and (1,6)-D-linkages and systemically enhances the immune system. To isolate Saccharomyces cerevisiae mutants producing glucan with a high degree of beta-(1,6)-D-glycosidic bonds, a wild-type strain was mutagenized with ultraviolet light. The mutants were then selected by treatment with 1.0 mg laminarinase, endo-beta-(1,3)-D-glucanase/ml. The alkali-soluble glucan was extracted by modified alkalysis followed by the Cetavlon method and concanavalin-A chromatography. The prepared alkali-soluble glucans from the wild-type and the mutants were compared with respect to yield and polymer structure using gas chromatography, 13C-NMR spectrometry, high performance liquid, and multi-angle laser light scattering and refractive index detectors. The results indicated that the S. cerevisiae mutants had ten-fold more alkali-soluble glucan than the wild-type. Structural analysis revealed that the alkali-soluble glucan from the mutants also had a higher degree of beta-(1,6)-D-linkage than that from the wild-type.

Aortic and pulmonary root: are their dynamics similar?

OBJECTIVES

The long-term behavior of the pulmonary autograft in the aortic position (Ross procedure) remains uncertain. Using three-dimensional (3D) sonomicrometry (200 Hz) we compared the dynamics of the aortic and pulmonary roots.

METHODS

Twenty-four crystals were implanted in each aortic (eight sheep) and pulmonary roots (six sheep) at: base (3 x 2), commissures (3 x 2), sinotubular junction (3 x 2), ascending aorta (3) and pulmonary trunk (3). Under stable hemodynamic conditions, geometric changes were time-related to left ventricular pressure (LV) and aortic pressure.

RESULTS

The expansion of the aortic root is twice that of the pulmonary root. During the cardiac cycle, the aortic root volume increased by 37.7 +/- 2.7% (mean +/- SEM) versus 20.9 +/- 1.0% for the pulmonary root. Both were cone-shaped at end diastole. Because expansion at commissures was twice that of the base, both roots became more cylindrical during ejection. Although both roots started to expand prior to ejection and reached maximal expansion during the first third of ejection, the commissural and sinotubular junction dynamics were different in each root. While in the aortic root, expansion at commissural and sinotubular junction levels was significantly different (63.7 +/- 3.6% versus 37.0 +/- 2.1%), in the pulmonary root, they were similar (29.0 +/- 1.3% versus 27.7 +/- 1.4%). Expansion of the three sinuses was also different (P<0.001). In the aortic root: the right expanded more than the left and more than the non-coronary sinus. In the pulmonary root: the right sinus expanded more than the anterior more than the left.

CONCLUSIONS

Dynamic differences might explain the global pulmonary root dilatation when subjected to systemic pressure, particularly at the level of the sinotubular junction which might result in the autograft failure. Differences in the asymmetrical expansion of the aortic and pulmonary roots should be considered for the implantation of the pulmonary autograft in the most physiological position.