A new endoscopic tattooing technique for identifying the location of colonic lesions during laparoscopic surgery: a comparison with the conventional technique

Colon polypectomy: a review of routine and advanced techniques

The value of performing comprehensive screening colonoscopy with complete colon polypectomy is widely accepted. Colon cancer is a significant cause of worldwide mortality and prospective studies have proven that colonoscopic polypectomy reduces both the incidence and mortality related to this disease. Over the past few decades the array of instruments and techniques have greatly expanded to assist with the safe endoscopic removal of colon polyps. This article will review the published literature regarding efficacy and safety of standard polypectomy techniques such as snare polypectomy, electrocautery, and endoscopic mucosal resection along with newer techniques such as endoscopic submucosal dissection and combined laparoscopic techniques.

Laparoscopic resection of colonic lipomas: When and why?

PATIENT

Male, >60 FINAL DIAGNOSIS: Colonic lipoma Symptoms: Rectal bleeding • abdominal pain • fatique • abdominal distention

MEDICATION

- Clinical Procedure: Laparoscopic resection Specialty: General surgery.

OBJECTIVE

We aimed to review and discuss the clinical picture and management of 4 patients who underwent laparoscopic colonic resection with a definitive pathology of colonic lipoma.

BACKGROUND

Colonic lipomas are rare benign nonepithelial tumors of the colon. They begin to be symptomatic when they reach a certain size, although the presentation can vary. Different endoscopic and surgical treatment strategies have been reported in the literature.

CASE REPORTS

Four male patients who underwent laparoscopic colonic resection and had definitive diagnosis of colonic lipoma were included in this report. All patients were over 60 years old. The first case presented with massive rectal bleeding. Obstructive symptoms and intermittent bleeding were prominent in the second and third cases. Abdominal pain and discomfort was present in the forth case. In the first 2 cases, abdominal CTs were suggestive of colonic lipoma and laparoscopic ileocecal resection was performed. However, malignancy could not be ruled out in the other 2 cases due to large size and heterogeneous appearance of the lesions and inconclusive endoscopic biopsies consisted of ulcer with exudate and inflammatory cells. Laparoscopic left and right hemicolectomy was performed in the third and forth cases, respectively. There were no complications in any patients.

CONCLUSIONS

Laparoscopic resection can be the first choice in treatment of colonic lipomas with various presentations. Wider resections should be considered in cases with uncertain diagnosis.

Efficacy of intraoperative gastroscopy for tumor localization in totally laparoscopic distal gastrectomy for cancer in the middle third of the stomach

BACKGROUND

Determining resection margins for gastric cancer, which generally is not exposed to the serosal surface of the stomach, is the most important priority during totally laparoscopic gastrectomy (TLG). This study aimed to evaluate the usefulness of intraoperative gastroscopy for direct marking of tumors during TLG for gastric cancer in the middle third of the stomach.

METHODS

From May 2011 through July 2012, 20 patients with a diagnosis of adenocarcinoma in the middle third of the stomach were enrolled in this case series. Preoperative gastroscopy for tumor localization was not performed for these patients. After the first portion of the duodenum was mobilized from the pancreas and clamped with a laparoscopic intestinal clamp, 2-3 ml of indigo carmine was administered through an endoscopic injector into the gastric muscle layer at the proximal margin of the tumor.

RESULTS

Based on intraoperative gastroscopic findings, distal subtotal gastrectomy was performed for 18 patients, with the authors deciding to perform total gastrectomy for two patients. A specimen was extracted after distal gastrectomy to confirm sufficient distance from the resection margin to the tumor before reconstruction. All the patients had tumor-free margins and required no additional resection. No morbidity related to gastroscopic procedure occurred, and the time required has been gradually decreased to about 5 min.

CONCLUSIONS

Intraoperative gastroscopy for tumor localization is an accurate and comfortable method for gastric cancer patients undergoing totally laparoscopic distal gastrectomy.

Endoscopic tattooing of gastrointestinal and pancreatic lesions

The intraoperative identification of the lesions found at endoscopic examination is often difficult, especially during laparoscopic surgery. At present, the most used technique for the intraoperative detection of pathological lesions is endoscopic tattooing. The large majority of studies carried out concern colorectal lesions; however, endoscopic tattooing has also been described for esophageal, gastric, small bowel and, more recently, pancreatic lesions. In this review, the authors evaluated indications, substances used, injection techniques, accuracy, safety and, finally, the risk of complications related to this procedure.

Clinical impact of tumor infiltration at the transected surgical margin during gastric cancer surgery

BACKGROUND

When transected surgical margins are involved by tumor cells during gastrectomy for gastric cancer, dissemination of tumor cells to the peritoneal cavity may be a concern.

OBJECTIVES

The aim of this study is to evaluate the prognostic value of tumor infiltration at the transected surgical margin during gastrectomy.

METHODS

A total of 1,717 patients with gastric cancer who underwent R0 gastrectomy were included. The relationship between positive margins on frozen biopsy during gastrectomy and clinicopathologic data was examined. The prognostic impact of this intraoperative event was evaluated by univariate and multivariate analysis.

RESULTS

The intraoperative positive resection margin occurred in 69 patients (4.01%). Tumor size >5 cm, tumor located in the upper third or whole stomach, Bormann type IV gastric cancer, and signet ring cell histology were independent factors associated with that intraoperative event. pT and pN stages were significant prognostic factors associated with locoregional and/or peritoneal recurrence and overall recurrence. Tumor infiltration at the transected margin was not an independent prognostic factor associated with any recurrence.

CONCLUSIONS

Microscopic tumor involvement at the margin during gastric cancer surgery does not increase locoregional and/or peritoneal recurrence or overall recurrence independently if R0 resection is achieved by re-resection of the margin.

Novel technique for intraoperative tumor localization during totally laparoscopic distal gastrectomy: endoscopic autologous blood tattooing

BACKGROUND

Knowledge of the intraoperative location of lesions is a prerequisite for deciding the proper extent of gastric resection or the choice of anastomosis technique during totally laparoscopic distal gastrectomy (TLDG) for early gastric cancer (EGC). In this study we introduce a novel tumor localization method for TLDG: endoscopic blood tattooing.

METHODS

Twenty-three consecutive patients scheduled for TLDG for EGC were enrolled in this prospective study. The day before surgery, 2-3 ml of autologous blood was injected into the gastric muscle layer at 3-4 cm proximal to the lesion during endoscopy.

RESULTS

The study subjects consisted of 15 males and 8 females with a mean age of 61 ± 10.4 years. During surgery, the endoscopic blood tattooed sites were successfully identified in all 23 patients. No complications associated with the procedure occurred, and no patient had microscopic residual tumor cells at the proximal resection margin, with a mean proximal margin length of 3.3 ± 2.7 cm. Eighteen patients underwent TLDG with Billroth II anastomosis, four patients with Roux-en-Y gastrojejunostomy, and one patient with laparoscopic total gastrectomy. At final pathologic examinations, 20 patients were of stage IA and 3 were of stage IB according to the UICC TNM classification (6th ed.).

CONCLUSIONS

Endoscopic blood tattooing provides a simple and useful means of localizing lesions during TLDG for EGC. Although the superiority of this technique over other localization methods needs to be evaluated further, the authors recommend endoscopic blood tattooing as an alternative to other intraoperative localization methods for laparoscopic surgery for EGC.

Endoscopic tattooing of colorectal lesions: Is it a risk-free procedure?

Endoscopic tattooing is one of the most useful tools for the localization of small colorectal lesions especially in the laparoscopic setting. This is a minimally invasive endoscopic procedure without risk of major complications. However, many studies have revealed complications resulting from this procedure. In this article, several topics are reviewed including the accuracy, substance preparation, injected techniques and complications related to this procedure.

Leaving a mark: the frequency and accuracy of tattooing prior to laparoscopic colorectal surgery

AIM

Intra-operative localization of small cancers and polyps during laparoscopic colorectal surgery is difficult due to reduced tactile feedback. The consequences of failing to identify the lesion for resection can result in open conversion or removal of the wrong segment of bowel.

METHOD

Data were collected from a prospectively-kept database over a 12-month period from April 2008 to March 2009 and analysed retrospectively. Details concerning the documentation, visibility and accuracy of tattoos were recorded.

RESULTS

Eighty-five patients (88 lesions) underwent laparoscopic resection for a benign or malignant colorectal tumour during 1 year from April 2008. Eighty-one patients underwent endoscopic visualization of the tumour as a first or second procedure. Of these 81 patients, 83 lesions were visualized endoscopically and 54 (65.1%) were tattooed in 52 patients. In the 52 patients, 36 (69%) of the tattoos were carried out on the first endoscopy. At operation the tattoo was judged to be visible and accurate in 70%, visible but inaccurate in 7% and not visible in 15%. It was significantly easier to see the tattoo in women (19/21 women vs 21/29 men; P=0.03) but there was no relationship between tattoo visibility and BMI. An accurate tattoo did not reduce the conversion rate (P=0.71). No tattoo-related complications were encountered.

CONCLUSION

The practice of tattooing colorectal cancers is variable in frequency, technique and accuracy. We advocate that all colonic lesions suspicious for cancer should be tattooed during endoscopy at a defined distance below the tumour, adhering to a departmental protocol in case surgery is required.

A novel endoscopic fluorescent clip for the localization of gastrointestinal tumors

BACKGROUND

Accurate tumor localization is essential for gastrointestinal surgery, especially in cases of early cancer. This study was designed to develop a novel fluorescent clip for rapid and exact visualization of tumor sites.

METHODS

A transparent polymer matrix containing highly bright fluorochromes was coated on the front end of endoscopic clips. The fluorescent clips were placed on the mucosal surface of a porcine colon and stomach, and the operator then attempted to identify the fluorescent clips from the outer serosal side of the colon and stomach. A 532-nm diode laser and filter glass were used for visualizing the fluorescence signals through the colonic tissue. A 650-nm diode laser and a digital charge-coupled device (CCD) camera equipped with a bandpass emission filter were used for the imaging of the fluorescent clips through the thick stomach tissue.

RESULTS

When a green light from a 532-nm diode laser (power density=0.35 mW/cm2) was applied on the serosal surface of the porcine colon, we could identify all clips that had been placed endoscopically on the mucosal surface of the inner colonic wall. By using the light from a 650-nm diode laser (power density=0.7 mW/cm2), we identified all fluorescent clips through the stomach wall in real time. Similar results were also obtained with the filtered xenon lamp.

CONCLUSION

An endoscopic fluorescent clip can be useful for the rapid and exact localization of tumors, and this technique can also be useful during laparoscopic surgery.

Endoscopic tattooing

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through January 2010 for articles related to endoscopic tattooing by using the Keywords tattooing, colonic, endoscopic, India ink, indocyanine green in different search term combinations. Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Colonoscopy and computerized tomography scan are not sufficient to localize right-sided colonic lesions accurately

AIM

Accurate preoperative localization of colonic lesions is critical especially in laparoscopic colectomy where tactile localization is absent particularly in screen-detected tumours. The study aimed to evaluate the accuracy of colonoscopy and double-contrast computerized tomography (CT) scan to localize lesions treated by right hemicolectomy.

METHOD

A retrospective chart review was performed of patients treated by right hemicolectomy under the colorectal service between July 2003 and October 2006. Preoperative tumour location determined by CT scan and colonoscopy was compared with the intra-operative and histopathological findings.

RESULTS

Out of 101 patients, 73 (73%) were for adenoma or cancer, with a final diagnosis of adenocarcinoma in 59 (58%). Preoperative localization was inaccurate in 29% of lesions using both CT and colonoscopy. In the transverse colon, colonoscopy alone was only 37.5% accurate, increasing to 62.5% when information from the CT scan was added.

CONCLUSION

Preoperative localization of right-sided colon cancers using colonoscopy and CT scanning is unreliable in at least 29% of cases. Inaccurate localization of transverse colon tumours risks inadequate lymphadenectomy with an adverse cancer outcome. Preoperative abdominal CT scan improves accuracy but endoscopic tattoo localization should be employed routinely especially in patients undergoing laparoscopic resection.

Small-dose India ink tattooing for preoperative localization of colorectal tumor

INTRODUCTION

India ink tattooing is widely used for tumor localization; however, the tattooing procedure is not yet standardized. This study aims to evaluate the efficacy of small-dose tattooing with sterile India ink using a saline test-injection method.

PATIENTS AND METHODS

Between April 2009 and August 2009, 20 patients underwent colonoscopic tattooing with prepackaged sterile India ink before resection of colorectal tumor. We injected 0.5 cc of India ink at three circumferential sites at the distal tumor using a saline test-injection method. Observation and leakage of India ink were evaluated during laparoscopic surgery, and the diameter of tattooing in the specimen was assessed.

RESULTS

Tattoos were observed intraoperatively in 18 patients (90%). In 2 patients, tattoos were not observed on the serosal surface but were detected on the mucosal surface. Localized leakage of ink was identified during surgery in 1 patient (5%), without fever or abdominal pain. Mean tattoo diameter was 2.1 cm on the serosal surface and 2.0 cm on the mucosal surface.

CONCLUSIONS

Small-dose tattooing with sterile India ink using a saline test-injection method is effective for tumor localization.

Colonic tattooing in laparoscopic surgery - making the mark?

OBJECTIVE

Laparoscopic surgery for colorectal cancer is now widespread. Small lesions in the colon can be difficult to palpate and with lack of tactile sensation, it is essential to accurately localize them preoperatively. This is a review article on current methods of tattooing including the use of different agents and associated complications. Aim To review current techniques in preoperative tumour localization and methods used for colonic tattooing including agents used, dosage and potential complications.

METHOD

A literature search (Medline and Pubmed) was performed with manual cross referencing of all articles related to colonic tattooing.

RESULTS

Methods for localizing colonic tumours for laparoscopic resection include preoperative barium enema examination, CT colonography and intraoperative colonoscopy. The most effective method is, however, by tattooing with India ink performed endoscopically before surgery.

CONCLUSION

India ink is a reliable method of marking tumour location within the colon as prelude to laparoscopic resection. Surgeons must, however, be aware of potential complications associated with this technique.

Colonoscopic preoperative localization using submucosal injection of radiolabelled colloid

Malignant colonic polyps can be removed endoscopically but surgical resection is sometimes required. However, the polypectomy site can be difficult to locate. Current methods use various tattooing agents, with varying degrees of success. A new technique using preoperative injection of technetium-99m-labelled antimony colloid, with intraoperative localization using a handheld gamma probe, is described. Although unsuccessful in terms of localizing a previously partially resected polyp, the technique itself proved safe and simple, and has some advantages over other endoscopic approaches.

Intraoperative colonoscopy for anastomosis assessment in laparoscopically assisted left-sided colon resection: is it worthwhile?

BACKGROUND

The aim of our study was to evaluate the use of intraoperative colonoscopy in laparoscopically assisted left-sided colon resection for the assessment of anastomosis.

MATERIALS AND METHODS

All consecutive laparoscopically assisted left-sided colon resections performed at our department between May 2001 and February 2006 were included in this study. After colon resection and reanastomosis, an intraoperative colonoscopy was performed to detect anastomosis risk.

RESULTS

A total of 122 patients were enrolled in this study. In 73 patients (59.84%), the anastomosis was checked via colonoscopy (the study group, (SG), whereas the control group (CG) consisted of 49 (40.16%) patients without colonoscopy. Of the 122 patients, 65 (53.28%) underwent a laparoscopically assisted sigmoid resection, 45 (36.89%) a laparoscopically assisted sigmoid rectum resection, 4 (3.28%) a laparoscopically assisted anterior rectum resection, and 8 (6.56%) a laparoscopically assisted left hemicolectomy. In the study group, 5 (6.85%) anastomotic leakages were intraoperatively detected and oversewn. A total of 6 (4.92%) anastomotic leakages occurred in the early postoperative period (SG: 4 [5.47%] vs. CG: 2 [4.08%]; P = 0.541).

CONCLUSIONS

Intraoperative evaluation of anastomosis prevents early anastomotic insufficiency because intraoperative identification of leaks allows for repair during surgery. Nevertheless, a certain rate of anastomotic dehiscence occurs in every kind of colon resection. The sometimes increased rate of dehiscence in laparoscopic-assisted colon resection can be reduced by intraoperative colonoscopy.

Surgical usefulness of indocyanine green as an alternative to India ink for endoscopic marking

BACKGROUND

India ink has been commonly used for preoperative colonic tattooing, but various complications have been reported. This study aimed to evaluate the usefulness of indocyanine green (ICG) marking as a replacement for India ink.

METHODS

This study enrolled 40 patients who between January 2005 and February 2006 underwent laparoscopic or open surgery for colorectal lesions considered difficult to locate intraoperatively. Because one patient had a history of allergy to iodinated contrast material, metal clipping was used instead of ICG to mark the lesion. Endoscopists injected 5 ml of ICG suspension and saline solution adjacent to the lesion at duplicate locations to evaluate the visibility, duration, and adverse effects of the dye. For 39 patients, the date of the preoperative colonoscopy was not set for examination of the appropriate interval between endoscopic marking and the surgical operation.

RESULTS

The median interval between ICG marking and surgery was 4 days (range, 1-73 days). All 29 patients who underwent surgery within 8 days after marking had positive green ICG staining at the time of surgery. After 9 days or more, however, positive staining was seen clearly in only two of the remaining 10 patients. The staining tended to grow weaker and fainter over the time course, eventually dissipating. No perioperative adverse reactions to the dye were observed.

CONCLUSION

This study supports the use of ICG as a safe technique that can be identified reliably during operations performed within 8 days after endoscopic injection.

The usefulness of preoperative colonoscopic tattooing using a saline test injection method with prepackaged sterile India ink for localization in laparoscopic colorectal surgery

BACKGROUND

Laparoscopic surgery for colorectal neoplasm requires precise tumor localization. The authors have assessed the safety and efficacy of colonoscopic tattooing using a saline test injection method with prepackaged sterile India ink for tumor localization in laparoscopic colorectal surgery.

METHODS

Between July 2004 and January 2007, 63 patients underwent colonoscopic tattooing using prepackaged sterile India ink before laparoscopic surgery of colorectal tumors. Patient medical records and operation videos were retrospectively assessed.

RESULTS

Tattoos were visualized intraoperatively in 62 (98.4%) of the 63 patients, and colorectal tumors were accurately localized in 61 patients (96.8%). In one patient, the tattoo could not be detected, whereas in another patient, it was visualized but the serosal surface of the rectosigmoid colon was stained diffusely. Both of these patients underwent intraoperative colonoscopy. Localized leakages of ink were identified in six patients (9.5%) during surgery. However, five of these patients had no symptoms, and the sixth patient, who underwent polypectomy and tattooing simultaneously, felt mild chilling without fever or abdominal pain.

CONCLUSIONS

Preoperative colonoscopic tattooing using a saline test injection method with prepackaged sterile India ink is a safe and effective method for tumor localization in laparoscopic colorectal surgery.

Risk for high-grade dysplasia or invasive carcinoma in colorectal flat adenomas in a Spanish population

AIM

to determine the frequency and malignancy risk of colonic flat adenomas among patients with colorectal polyps in a Spanish population.

METHODS

1300 consecutive colonoscopic examinations were reviewed; 640 polyps were detected and removed endoscopically in 298 patients. Chromoendoscopy with 0.2% indigo carmine was applied to clarify the macroscopical appearance of flat lesions. The following data was collected for flat and protruding polyps: size, location (proximal or distal to splenic flexure), histology (neoplastic or non neoplastic), high grade dysplasia (HGD) and submucosal invasive carcinoma (SIC) or beyond.

RESULTS

490 polyps (76.6%) were adenomas and 150 (23.4%) hyperplastic; 114 (23.3%) adenomas were flat (3 flat-depressed) whereas 376 (76.7%) were protruding. The diameter of flat and protruding adenomas was 9.2 +/- 7.9. mm and 7.0 +/- 5.9 mm, respectively (p < 0.001). A proximal location was more frequent for flat (63.1%) than for protruding adenomas (48.7%) (p = 0.003). The rate of HGD or SIC was significantly higher in flat than in protruding adenomas (7.0 vs 2.6%; p < 0.04). Two of the 3 flat-depressed lesions (both <or= 10 mm in diameter) were carcinomas (T1 and T2, respectively). Flat adenomas had an increased risk for HGD or SIC (OR = 2,7; CI, 1,04-7,04; p < 0.05).

CONCLUSIONS

In a Spanish population, flat adenomas represent nearly one quarter of all colorectal neoplastic polyps, their most frequent location being the right colon and they bear a higher risk of malignancy than protruding adenomas, especially for the flat depressed type.

Tumor localization for laparoscopic colorectal surgery

BACKGROUND

Because palpating colonic tumors during laparoscopy is impossible, the precise location of a tumor must be identified before operation. The aim of this study was to evaluate the accuracy of various diagnostic methods that are used to localize colorectal tumors and to propose an adequate localization protocol for laparoscopic colorectal surgery.

METHODS

A total of 310 patients underwent laparoscopy-assisted colectomy between April 2000 and March 2006. We investigated if the locations of the tumors that were estimated preoperatively were consistent with the actual locations according to the operation.

RESULTS

All the tumors were correctly localized and resected. Altogether, 203 patients had complete endoscopic reports available. Colonoscopy was inaccurate for tumor localization in 23 cases (11.3%). In total, 104 patients (33.5%) underwent barium enema; five tumors (4.8%) were not visualized, and three tumors were incorrectly localized. Another group of 94 patients (30.3%) underwent computed tomography (CT) colonography, which identified 91 of 94 lesions (96.8%). Finally, 96 patients (31.0%) underwent endoscopic tattooing; 2 patients (2.1%) did not have tattoos visualized laparoscopically and required intraoperative colonoscopy to localize their lesions during resection. Dye spillage was found in six patients intraoperatively, but only one patient experienced clinical symptoms. Intraoperative colonoscopy was performed in four patients; two of the four were followed by endoscopic tattooing, and the other two underwent intraoperative colonoscopy for localization. All lesions were correctly localized by intraoperative colonoscopy. The accuracy of tumor localization was as follows: colonoscopy (180/203, 88.7%), barium enema (97/104, 93.3%), CT colonography (89/94, 94.7%), endoscopic tattooing (94/96, 97.9%), and intraoperative colonoscopy (4/4, 100%).

CONCLUSIONS

With a combination of methods, localization of tumors for laparoscopic surgery did not seem very different from that during open surgery. Preoperative endoscopic tattooing is a safe, highly effective method for localization. In the case of tattoo failure, intraoperative colonoscopy can be used for accurate localization.

The Use of Preoperative Endoscopic Tattooing in Laparoscopic Colorectal Cancer Surgery for Endoscopically Advanced Tumors: A Prospective Comparative Clinical Study

BACKGROUND

Endoscopic India ink marking techniques are often used for the intraoperative location of colonic polyps and early stage neoplasms. The aim of this study was to compare how effective this technique is compared with conventional localization methods, as well as its influence on the results of colorectal laparoscopy (LSCRC) for endoscopically advanced tumors.

METHODS

From January 2003 to January 2005, 47 patients with colorectal carcinomas were included in the study. In one group, lesions were localized preoperatively by endoscopic India ink tattooing (n = 21; tattooed group, TG), while conventional methods were used in the others (n = 26; non-tattooed group, NTG). Patients' perioperative clinical and pathoanatomical data were prospectively collected.

RESULTS

Both groups were comparable in age, sex distribution, American Society of Anesthesiologists (ASA) score, body mass index (BMI), technique performed, tumor size and proportion of patients who had previous abdominal surgery. Three patients presented ink spillage without clinical repercussions. Visualization of the correct resection site was higher in the TG (100% vs. 80.8%, P = 0.03). Operative time (147.3 +/- 46.2 vs. 187.0 +/- 52.7 minutes, P = 0.02) and blood loss (99.3 +/- 82.8 vs. 163.6 +/- 96.6 cc, P = 0.03) were lower in the TG. There were no differences between groups regarding peristalsis, introduction of oral intake, hospital stay or intra- and postoperative complication rates. No differences were observed amongst pathoanatomical data studied.

CONCLUSIONS

Preoperative endoscopic tattooing is a safe and effective technique for intraoperative localization of advanced colorectal neoplasms, improving the operative results of LSCRC.

Colonoscopic-assisted laparoscopic resection of a colon lipoma

We report the case of a 51-year-old man who had abdominal distension and intermittent cramping pain for 4 months. A lower gastrointestinal double-contrast study revealed a protruding mass at the transverse colon. Endoscopic ultrasonography showed a lesion arising from the submucosal layer. Instead of a laparotomy, the lesion was removed laparoscopically with the assistance of a colonoscope. No operative morbidity was noted. With future improvements of this technique, tumors that are difficult to remove with colonoscopy can be excised laparoscopically without the aid of an endoscopic stapler. In our case, the tumor was localized intraoperatively and extracted using the intraoperative colonoscopy. This double-scope technique is safe and cost-effective for some difficult colonic lesions.

Usefulness of endoscopic marking for determining the location of transanal endorectal pull-through in the treatment of Hirschsprung's disease

In the treatment of Hirschsprung's disease, transanal endorectal pull-through (TEPT) is being performed without laparoscopic assistance or laparotomy for short-segment aganglionosis. Preoperative ascertainment of the extent of aganglionosis is required, as this affects the planning for TEPT. The present study investigated the usefulness of preoperative endoscopic marking as an intraoperative marker of the location of pull-through. Since 1998, we have performed TEPT using a prolapsing technique for the treatment of Hirschsprung's disease. Subjects comprised 17 patients with short-segment aganglionosis and 2 patients with long-segment aganglionosis in whom endoscopic marking was performed preoperatively. Median age at time of surgery was 2.7 months. The relationship between pathologic findings at the marked area and location of actual pull-through was investigated. For endoscopic marking, each patient was sedated using intravenous ketamine hydrochloride. The junction between normal bowel with peristalsis and aganglionic bowel without peristalsis ("shorebreak" finding) was marked by either tattooing or clipping. Normal ganglion cells were seen in the marked area of 14 patients, and pull-through was performed at the marked area in each of these patients. In three patients, ganglion cells existed in the marked area, but the number of ganglion cells was considered insufficient. Additional frozen sections were thus prepared to ascertain the area with normal ganglion cells, showing that normal ganglion cells were seen 1, 3 or 5 cm proximal to the marked area. In one patient, no ganglion cells were seen in the marked area, but were present 5 cm proximal to the marked area. In the remaining one patient, normal ganglion cells were seen 7 cm distal to the marked area. Pathologic findings revealed ganglion cells at the shorebreak finding in 17 of the 19 patients (89.5%), suggesting that this junction basically matches the distribution of ganglion cells. Endoscopic marking of the junction is very useful for determining the tip of pull-through.

Laparoscopic resection of colon Cancer: Consensus of the European Association of Endoscopic Surgery (EAES)

BACKGROUND

The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on the laparoscopic resection of colon cancer during the annual congress in Lisbon, Portugal, in June 2002.

METHODS

A systematic review of the current literature was combined with the opinions, of experts in the field of colon cancer surgery to formulate evidence-based statements and recommendations on the laparoscopic resection of colon cancer.

RESULTS

Advanced age, obesity, and previous abdominal operations are not considered absolute contraindications for laparoscopic colon cancer surgery. The most common cause for conversion is the presence of bulky or invasive tumors. Laparoscopic operation takes longer to perform than the open counterpart, but the outcome is similar in terms of specimen size and pathological examination. Immediate postoperative morbidity and mortality are comparable for laparoscopic and open colonic cancer surgery. The laparoscopically operated patients had less postoperative pain, better-preserved pulmonary function, earlier restoration of gastrointestinal function, and an earlier discharge from the hospital. The postoperative stress response is lower after laparoscopic colectomy. The incidence of port site metastases is <1%. Survival after laparoscopic resection of colon cancer appears to be at least equal to survival after open resection. The costs of laparoscopic surgery for colon cancer are higher than those for open surgery.

CONCLUSION

Laparoscopic resection of colon cancer is a safe and feasible procedure that improves short-term outcome. Results regarding the long-term survival of patients enrolled in large multicenter trials will determine its role in general surgery.

Laparoscopic resection of colonic cancer

Laparoscopic resection of colonic cancer can be regarded as a safe and efficacious procedure. Short-term outcome is better after laparoscopic colectomy than after open colectomy. Long-term results of the first published randomized clinical trial indicate improved cancer related survival following laparoscopic resection of colonic cancer. However, patients included in this single center study were operated on by highly experienced laparoscopic surgeons and included relative small numbers of patients. Results of other large randomized controlled trials have to be awaited before laparoscopic resection can be recommended for colonic cancer. Higher in-hospital costs and a long learning curve hinder rapid implementation of laparoscopic colectomy into general surgical practice. Integration of laparoscopic surgery into surgical training programs is mandatory.