Intraoperative localization of occult colorectal tumors during laparoscopic surgery by magnetic ring markers-a pilot study

Intraoperative localization of gastrointestinal tumors by magnetic tracer technique during laparoscopic-assisted surgery (with video)

BACKGROUND

Laparoscopic localization of gastrointestinal tumors has long been an important objective. This study aimed to evaluate the clinical application of a magnetic tracer technique during laparoscopic-assisted surgery.

METHODS

Fifty-seven patients with gastrointestinal tumors, who voluntarily underwent endoscopic marking between May 2019 and May 2020, were enrolled. A magnetic ring was clamped onto tissues adjacent to the lesion and released during preoperative endoscopy. Then, another magnet ring or laparoscopic instrument was delivered to the wall of the digestive tract contralateral to the lesion and attracted, thus achieving accurate intraoperative localization. Observational evaluation included data regarding preoperative marking, intraoperative localization, operation, and safety.

RESULTS

Fifty-six of the 57 (98.2%) patients with gastric tumors (n = 35), duodenal tumors (n = 1), and colorectal tumors (n = 20), successfully underwent marking, localization, and resection. The mean margins of proximal and distal resection of colorectal tumors were 106 and 78 mm, respectively. The mean (± SD) duration of endoscopic marking and laparoscopic localization for gastric/duodenal and colorectal tumors were 5.3 ± 0.3, 1.0 ± 0.1, 5.5 ± 0.4, and 1.0 ± 0.1 min, respectively. No complications occurred in 56 of the 57 patients.

CONCLUSIONS

The magnetic tracer technique demonstrated promising potential as a localization method for gastrointestinal tumors, with superior safety, effectiveness, rapidity, and convenience.

Tattooing or Metallic Clip Placement? A Review of the Outcome Surrounding Preoperative Localization Methods in Minimally Invasive Anterior Resection Performed at a Single Center

BACKGROUND

For minimally invasive colorectal surgery, preoperative localization is a typical procedure. We here aimed to analyze compared 2 different localization methods in terms of short-term outcomes, like the operative outcome and postoperative complication rates based on real-world data.

MATERIALS AND METHODS

This was a retrospective analysis study conducted at a medical center. We enrolled patients who were presented with colonic tumor between January 1, 2016, and December 31, 2019, and they had undergone laparoscopic anterior resection in a single institution. Data included patient characteristics, operative outcome, length of hospital stay, and postoperative complications.

RESULTS

The preoperative localization group had a better resection margin (4 vs. 3 cm; P<0.001) and fewer procedures of intraoperative colonoscopy (4.67% vs. 18.22%; P=0.002). Lymph node harvest occurred more in patients with endoscopic tattooing procedures than with metallic clip procedures (25 vs. 20; P=0.031). No significant difference was found regarding postoperative complications and the length of hospital stay.

CONCLUSIONS

Preoperative localization in a laparoscopic anterior resection led to better surgical planning and resection margin. The metallic clip placement was helpful in the preoperative localization and setting. The endoscopic tattooing method had a larger lymph node harvest and with fewer intraoperative colonoscopy.

Endoscopic clips allow for accurate pre-operative localisation of colorectal cancer

BACKGROUND

Colorectal cancer is a major cause of morbidity and mortality worldwide. Optimal management of this disease relies upon accurate pre-operative localisation to allow multidisciplinary discussion and treatment planning. Current pre-operative localisation methods consist of colonoscopy and computed tomography (CT), which are only 79%-85% accurate. To minimise this error, colonoscopy tattooing is a routine practice to facilitate operative localisation. The aim of this study is to investigate if endoscopic radiopaque clips can more accurately localise the lesions pre-operatively.

METHODS

A retrospective case-control study was conducted of patients diagnosed with colorectal cancer at a tertiary hospital between 2017 and 2019. Visualisation rates and accurate localisation rates were compared between patients receiving radiopaque clips and those who had colonoscopy alone. All patients received a tattoo distal to the tumour and a staging CT. Data on patient demographics, tumour demographics, post-procedure complications and changes to surgical management were collected.

RESULTS

Of 285 patients, 245 had tumour localisation with colonoscopy alone and 40 had additional clip localisation. Groups had comparable patient demographics. For patients receiving clips and follow-up CTs within 14 days, 92% of lesions were visualised and 100% of these lesions were accurately localised. In contrast, colonoscopy only accurately localised 77% of lesions (p < 0.01). This resulted in 1.2% of patients requiring an altered operation due to incorrect localisation. No clip-related complications were reported.

CONCLUSION

Radiopaque clips are a highly accurate and cost-effective method for localising colorectal cancer with a pre-operative accuracy rate over 92%.

The Usefulness of Preoperative Colonoscopic Tattooing with Autologous Blood for Localization in Laparoscopic Colorectal Surgery

Purpose

In colorectal cancer surgery, it is important to have accurate resection margins. However, it is challenging to localize lesions during laparoscopy. Therefore, to reduce surgical errors, many preoperative localizing methods have been introduced. In this study, we aimed to assess the preoperative feasibility and safety of autologous blood tattooing.

Methods

A total of 11 patients underwent preoperative colonoscopic autologous blood tattooing from August 2017 to February 2020. At the start of the surgery, the surgeon assessed the patients for the precision of visibility and other complications such as abscess or spillage. The patients’ characteristics, outcomes, and complications were collected retrospectively.

Results

The study comprised 8 men and 3 women, with an average age of 63 years. Ten patients showed precise visibility, and no localization errors were observed during surgery. No complication was observed in all patients.

Conclusion

Preoperative autologous blood tattooing is a very useful and safe technique because it has high visibility with no complications. This method does not require additional agents or facilities. A large-scale study will be required to develop standard guidelines.

Endoscopic Preoperative Tattooing and Marking in the Gastrointestinal Tract: A Systematic Review of Alternative Methods

Background: An accurate and reliable localization of endoluminal gastrointestinal (GI) lesions is crucial, particularly during minimally invasive surgery. As an extreme consequence, a misdetected GI lesion can lead to the resection of the wrong segment, especially in colorectal surgery. A preoperative endoscopic marking is recommended in case of GI lesions, which are expected to be difficult to detect from the serosal side. In clinical practice, three preoperative endoscopic marking methods are currently used: India ink, SPOT™, and endoclips with intraoperative fluoroscopy. All of them have substantial limitations. This has encouraged research on alternative solutions. Methods: In the current systematic review, animal and clinical studies about alternative preoperative endoscopic marking methods of GI lesions were analyzed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Thirty studies were found using PubMed/MEDLINE, EMBASE/Ovid, and the Cochrane Library for the qualitative analysis. Conclusion: Although several smart solutions have been proposed and tested successfully, all of them seem to have a substantial drawback related either to scarce stability on the marking site or potential spreading on the bowel wall or diffusion into the surgical planes.

Endoscopic applications of magnets for the treatment of gastrointestinal diseases

Endoscopic treatment of gastrointestinal diseases has developed rapidly in recent years, due to its minimally invasive nature. One of the main contributing factors for this progress is the improvement of endoscopic instruments, which are essential for facilitating safe and effective endoscopic interventions. However, the slow learning curve required in the implementation of many advanced endoscopic procedures using standard devices is associated with a high risk of complications. Other routine procedures may also be complicated by unexpected difficulties. Based on the ferromagnetic properties of many objects, both internal and external magnetic devices have been developed and applied for multiple endoscopic interventions. The applications of magnets, mainly including compression, anchoring and traction, facilitate many difficult procedures and make it feasible to operate procedures that were previously impossible. Other novel endoscopic applications, such as magnetic nanoparticles, are also under development. In this article, we reviewed published studies of endoscopic applications of magnets for the treatment of gastrointestinal diseases such as precancerous lesions and cancer, obstruction, stricture, congenital and acquired malformations, motility disorders, and ingestion of foreign bodies. Since several endoscopic applications of magnets may also be relevant to surgery, we included them in this review.

The use of neodymium magnets in healthcare and their effects on health

The strong magnetic field properties of magnets have led to their use in many modern technologies, as well as in the fields of medicine and dentistry. Neodymium magnets are a powerful type of magnet that has been the subject of recent research. This review provides a brief explanation of the definition, history, and characteristics of rare earth magnets. In addition, a broad overview of results obtained in studies performed to date on the effects of magnets, and neodymium magnets in particular, on body systems, tissues, organs, diseases, and treatment is provided. Though they are used in the health sector in various diagnostic devices and as therapeutic tools, there is some potential for harmful effects, as well as the risk of accident. The research is still insufficient; however, neodymium magnets appear to hold great promise for both diagnostic and therapeutic purposes.

Preoperative endoscopic titanium clip placement facilitates intraoperative localization of early-stage esophageal cancer or severe dysplasia

Background

Accurate intraoperative localization of esophageal lesions is essential for successful surgical resection. We tested whether preoperative endoscopic placement of titanium clips could facilitate intraoperative localization of early-stage esophageal cancer or severe dysplasia.

Methods

A prospective randomized clinical trial was performed between May 2012 and July 2014. All enrolled patients received preoperative endoscopy and esophageal endoscopic ultrasound, as well as pathological study on the biopsy specimen, to confirm early stage esophageal cancer or severe dysplasia. One day before the surgical operation, patients in the experimental group received the preoperative endoscopic titanium labeling of esophageal lesions. Then, during the surgical operation, palpitation of titanium clips was used to localize the lesions in these patients. In patients in the control group, palpitation of nodules or esophageal wall mucosal thickening, together with the consideration of the results from preoperative endoscopic and ultrasound studies, was applied to estimate the location of the esophageal lesions. Study outcomes included the proportions of patients having successful intraoperative pre-resection lesion localization, post-esophagectomy lesion visualization, negative upper surgical margin, change of surgical approaches, and positive postoperative pathological diagnosis.

Results

A total of 27 patients were enrolled into the study, with 14 in the experimental group and 13 in the control group. Compared to the patients in the control group, a higher proportion of patients in the experimental group had statistically significant successful intraoperative esophageal lesion localization (100 versus 15.3% in the experimental versus control group).

Conclusions

Preoperative endoscopic titanium clip placement could facilitate intraoperative localization of early-stage esophageal cancer or severe dysplasia.

Trial registration

Current study was registered in Chinese Clinical Trial Registry and World Health Organization International Clinical Trials Registry Platform, ChiCTR-INR-17010949. Registered 22 March 2017, retrospectively registered.

Preoperative localization of colorectal cancer: a systematic review and meta-analysis

BACKGROUND

Preoperative colorectal tumor localization is crucial for appropriate resection and treatment planning. As the localization accuracy of conventional colonoscopy is considered to be low, several localization techniques have been developed. We systematically reviewed the tumor localization error rates of several preoperative endoscopic techniques and synthesized information on risk factors for localization errors and procedure-related adverse events.

METHODS

MEDLINE, EMBASE, the Cochrane Library, and the grey literature were searched. Studies were included if they reported tumor localization errors in patients with colorectal cancer undergoing resection with curative intent. Using random-effects models, pooled incidence of tumor localization errors were derived for conventional colonoscopy and colonoscopic tattooing. Due to the lack of comparative studies, a direct comparison of the pooled estimates was performed. Procedure-related adverse events, risk factors for localization errors, and the localization outcomes of other techniques such as colonoscopic clip placement, radioguided occult colonic lesion identification, and the use of magnetic endoscope imaging were also synthesized.

RESULTS

A total of 38 non-randomized controlled and observational studies were included in this review (2578 patients underwent conventional colonoscopy and 643 colonoscopic tattooing). The pooled incidence of localization errors with conventional colonoscopy was 15.4 % (95 % CI 12.0-18.7), whereas that of colonoscopic tattooing was 9.5 % (95 % CI 5.7-13.3), mean difference 5.9 % (95 % CI 0.65-11.14, p = 0.03). Adverse events secondary to tattooing were infrequent, and most were cases of ink spillage. Limited information was available for other localization techniques.

CONCLUSION

Conventional colonoscopy has a higher incidence of localization error compared to colonoscopic tattooing for localization of colorectal cancer. Colonoscopic tattooing is safe and leads to fewer tumor localization errors. Given the widespread adoption of laparoscopic resections for colorectal cancer, routine colonoscopic tattooing should be adopted. However, studies directly comparing different localization techniques are needed.