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Heimberger M, Stocchi L, Brennan E, Spaulding A, DeLeon M, Merchea A, Dozois E, Colibaseanu D. Can preoperative ureteral stent placement help in the intraoperative identification of iatrogenic ureteral injury? J Gastrointest Surg 2024; 28:903-909. [PMID: 38555016 DOI: 10.1016/j.gassur.2024.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 03/05/2024] [Accepted: 03/24/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND The benefits of prophylactic ureteral stent placement during colorectal surgery remain controversial. This study aimed to determine the incidence of ureteral injury in colorectal operations, assess the complications associated with stent usage, and determine whether their use leads to earlier identification and treatment of injury. METHODS This was a retrospective study of patients undergoing colorectal abdominal operations between 2015 and 2021. Variables were examined for possible association with ureteral stent placement. The primary study endpoint was ureteral injury identified within 30 days postoperatively. RESULTS Of 6481 patients who underwent colorectal surgery, 970 (15%) underwent preoperative ureteral stent placement. The use of stents was significantly associated with a higher American Society of Anesthesiologists classification, wound classification, and longer duration of surgery. A ureteral injury was identified in 28 patients (0.4%). Of these patients, 13 had no stent, and 15 had preoperative stents placed. After propensity matching, stent use was associated with an increased risk of hematuria and urinary tract infection. Ureteral injury was identified intraoperatively in 14 of 28 patients (50.0%) and was not associated with ureteral stent use (P = .45). CONCLUSION Iatrogenic ureteral injury was uncommon, whereas preoperative stent placement was relatively frequent. Earlier recognition of iatrogenic ureteral injury is not an expected advantage of preoperative ureteral stent placement.
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Affiliation(s)
- Mark Heimberger
- Department of Surgery, Mayo Clinic Florida, Jacksonville, Florida, United States
| | - Luca Stocchi
- Department of Colon and Rectal Surgery, Mayo Clinic Florida, Jacksonville, Florida, United States.
| | - Emily Brennan
- Department of Health Sciences Research, Mayo Clinic Florida, Jacksonville, Florida, United States
| | - Aaron Spaulding
- Department of Health Care Delivery Research, Mayo Clinic Florida, Jacksonville, Florida, United States
| | - Michelle DeLeon
- Department of Colon and Rectal Surgery, Mayo Clinic Florida, Jacksonville, Florida, United States
| | - Amit Merchea
- Department of Colon and Rectal Surgery, Mayo Clinic Florida, Jacksonville, Florida, United States
| | - Eric Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic Minnesota, Rochester, Minnesota, United States
| | - Dorin Colibaseanu
- Department of Colon and Rectal Surgery, Mayo Clinic Florida, Jacksonville, Florida, United States
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Brollo PP, Puggioni A, Tumminelli F, Colangelo A, Biddau C, Cherchi V, Bresadola V. Preventing iatrogenic ureteral injury in colorectal surgery: a comprehensive and systematic review of the last 2 decades of literature and future perspectives. Surg Today 2024; 54:291-309. [PMID: 36593285 DOI: 10.1007/s00595-022-02639-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 12/19/2022] [Indexed: 01/03/2023]
Abstract
Iatrogenic ureteral injury (IUI) during colorectal surgery is a rare complication but related to a serious burden of morbidity. This comprehensive and systematic review aims to provide a critical overview of the most recent literature about IUI prevention techniques in colorectal surgery. We performed a comprehensive and systematic review of studies published from 2000 to 2022 and assessed the use of techniques for ureteral injury prevention and intraoperative localization. 26 publications were included, divided into stent-based (prophylactic/lighted ureteral stent and near-infrared fluorescent ureteral catheter [PUS/LUS/NIRFUC]) and fluorescent dye (FD) groups. Costs, the percentage and number of IUIs detected, reported limitations, complication rates and other outcome points were compared. The IUI incidence rate ranged from 0 to 1.9% (mean 0.5%) and 0 to 1.2% (mean 0.3%) in the PUS/LUS/NIRFUC and FD groups, respectively. The acute kidney injury (AKI) and urinary tact infection (UTI) incidence rate ranged from 0.4 to 32.6% and 0 to 17.3%, respectively, in the PUS/LUS/NIRFUC group and 0-15% and 0-6.3%, respectively, in the FD group. Many other complications were also compared and descriptively analyzed (length-of-stay, mortality, etc.). These techniques appear to be feasible and safe in select patients with a high risk of IUI, but the delineation of reliable guidelines for preventing IUI will require more randomized controlled trials.
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Affiliation(s)
- Pier Paolo Brollo
- General Surgical Oncology Department, IRCCS CRO di Aviano (Istituto Nazionale Tumori), Aviano, Italy.
- General Surgery Department and Simulation Center, Department of Medicine, Academic Hospital of Udine, University of Udine, Udine, Italy.
| | - Alessandro Puggioni
- General Surgery Department and Simulation Center, Department of Medicine, Academic Hospital of Udine, University of Udine, Udine, Italy
| | - Francesco Tumminelli
- General Surgery Department and Simulation Center, Department of Medicine, Academic Hospital of Udine, University of Udine, Udine, Italy
- General Surgery Department, Hospital of Pordenone, Pordenone, Italy
| | - Antonio Colangelo
- General Surgery Department and Simulation Center, Department of Medicine, Academic Hospital of Udine, University of Udine, Udine, Italy
- General Surgery Department, Hospital of Pordenone, Pordenone, Italy
| | - Carlo Biddau
- General Surgery Department, Hospital of Pordenone, Pordenone, Italy
| | - Vittorio Cherchi
- General Surgery Department and Simulation Center, Department of Medicine, Academic Hospital of Udine, University of Udine, Udine, Italy
| | - Vittorio Bresadola
- General Surgery Department and Simulation Center, Department of Medicine, Academic Hospital of Udine, University of Udine, Udine, Italy
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Chen KA, Joisa CU, Stem JM, Guillem JG, Gomez SM, Kapadia MR. Prediction of Ureteral Injury During Colorectal Surgery Using Machine Learning. Am Surg 2023; 89:5702-5710. [PMID: 37133432 PMCID: PMC10622328 DOI: 10.1177/00031348231173981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
BACKGROUND Ureteral injury (UI) is a rare but devastating complication during colorectal surgery. Ureteral stents may reduce UI but carry risks themselves. Risk predictors for UI could help target the use of stents, but previous efforts have relied on logistic regression (LR), shown moderate accuracy, and used intraoperative variables. We sought to use an emerging approach in predictive analytics, machine learning, to create a model for UI. METHODS Patients who underwent colorectal surgery were identified in the National Surgical Quality Improvement Program (NSQIP) database. Patients were split into training, validation, and test sets. The primary outcome was UI. Three machine learning approaches were tested including random forest (RF), gradient boosting (XGB), and neural networks (NN), and compared with traditional LR. Model performance was assessed using area under the curve (AUROC). RESULTS The data set included 262,923 patients, of whom 1519 (.578%) experienced UI. Of the modeling techniques, XGB performed the best, with an AUROC score of .774 (95% CI .742-.807) compared with .698 (95% CI .664-.733) for LR. Random forest and NN performed similarly with scores of .738 and .763, respectively. Type of procedure, work RVUs, indication for surgery, and mechanical bowel prep showed the strongest influence on model predictions. CONCLUSIONS Machine learning-based models significantly outperformed LR and previous models and showed high accuracy in predicting UI during colorectal surgery. With proper validation, they could be used to support decision making regarding the placement of ureteral stents preoperatively.
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Affiliation(s)
- Kevin A. Chen
- Department of Surgery, University of North Carolina at Chapel Hill, NC, USA
| | - Chinmaya U. Joisa
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, NC, USA
| | - Jonathan M. Stem
- Department of Surgery, University of North Carolina at Chapel Hill, NC, USA
| | - Jose G. Guillem
- Department of Surgery, University of North Carolina at Chapel Hill, NC, USA
| | - Shawn M. Gomez
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, NC, USA
| | - Muneera R. Kapadia
- Department of Surgery, University of North Carolina at Chapel Hill, NC, USA
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de'Angelis N, Schena CA, Marchegiani F, Reitano E, De Simone B, Wong GYM, Martínez-Pérez A, Abu-Zidan FM, Agnoletti V, Aisoni F, Ammendola M, Ansaloni L, Bala M, Biffl W, Ceccarelli G, Ceresoli M, Chiara O, Chiarugi M, Cimbanassi S, Coccolini F, Coimbra R, Di Saverio S, Diana M, Dioguardi Burgio M, Fraga G, Gavriilidis P, Gurrado A, Inchingolo R, Ingels A, Ivatury R, Kashuk JL, Khan J, Kirkpatrick AW, Kim FJ, Kluger Y, Lakkis Z, Leppäniemi A, Maier RV, Memeo R, Moore EE, Ordoñez CA, Peitzman AB, Pellino G, Picetti E, Pikoulis M, Pisano M, Podda M, Romeo O, Rosa F, Tan E, Ten Broek RP, Testini M, Tian Wei Cheng BA, Weber D, Sacco E, Sartelli M, Tonsi A, Dal Moro F, Catena F. 2023 WSES guidelines for the prevention, detection, and management of iatrogenic urinary tract injuries (IUTIs) during emergency digestive surgery. World J Emerg Surg 2023; 18:45. [PMID: 37689688 PMCID: PMC10492308 DOI: 10.1186/s13017-023-00513-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 08/21/2023] [Indexed: 09/11/2023] Open
Abstract
Iatrogenic urinary tract injury (IUTI) is a severe complication of emergency digestive surgery. It can lead to increased postoperative morbidity and mortality and have a long-term impact on the quality of life. The reported incidence of IUTIs varies greatly among the studies, ranging from 0.3 to 1.5%. Given the high volume of emergency digestive surgery performed worldwide, there is a need for well-defined and effective strategies to prevent and manage IUTIs. Currently, there is a lack of consensus regarding the prevention, detection, and management of IUTIs in the emergency setting. The present guidelines, promoted by the World Society of Emergency Surgery (WSES), were developed following a systematic review of the literature and an international expert panel discussion. The primary aim of these WSES guidelines is to provide evidence-based recommendations to support clinicians and surgeons in the prevention, detection, and management of IUTIs during emergency digestive surgery. The following key aspects were considered: (1) effectiveness of preventive interventions for IUTIs during emergency digestive surgery; (2) intra-operative detection of IUTIs and appropriate management strategies; (3) postoperative detection of IUTIs and appropriate management strategies and timing; and (4) effectiveness of antibiotic therapy (including type and duration) in case of IUTIs.
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Affiliation(s)
- Nicola de'Angelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, Clichy, Paris, France
- Faculty of Medicine, University of Paris Cité, Paris, France
| | - Carlo Alberto Schena
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, Clichy, Paris, France.
| | - Francesco Marchegiani
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, Clichy, Paris, France
| | - Elisa Reitano
- Department of General Surgery, Nouvel Hôpital Civil, CHRU-Strasbourg, Research Institute Against Digestive Cancer (IRCAD), 67000, Strasbourg, France
| | - Belinda De Simone
- Department of Minimally Invasive Surgery, Guastalla Hospital, AUSL-IRCCS Reggio, Emilia, Italy
| | - Geoffrey Yuet Mun Wong
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, NSW, 2065, Australia
| | - Aleix Martínez-Pérez
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Fikri M Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, UAE
| | - Vanni Agnoletti
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, Cesena, Italy
| | - Filippo Aisoni
- Department of Morphology, Surgery and Experimental Medicine, Università Degli Studi Di Ferrara, Ferrara, Italy
| | - Michele Ammendola
- Science of Health Department, Digestive Surgery Unit, University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Luca Ansaloni
- Department of General Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Miklosh Bala
- Acute Care Surgery and Trauma Unit, Department of General Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem Kiriat Hadassah, Jerusalem, Israel
| | - Walter Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Graziano Ceccarelli
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Italy
| | - Marco Ceresoli
- General and Emergency Surgery, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Osvaldo Chiara
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Massimo Chiarugi
- General, Emergency and Trauma Department, Pisa University Hospital, Pisa, Italy
| | - Stefania Cimbanassi
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Department, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- Riverside University Health System Medical Center, Riverside, CA, USA
| | - Salomone Di Saverio
- Unit of General Surgery, San Benedetto del Tronto Hospital, av5 Asur Marche, San Benedetto del Tronto, Italy
| | - Michele Diana
- Department of General Surgery, Nouvel Hôpital Civil, CHRU-Strasbourg, Research Institute Against Digestive Cancer (IRCAD), 67000, Strasbourg, France
| | | | - Gustavo Fraga
- Department of Trauma and Acute Care Surgery, University of Campinas, Campinas, Brazil
| | - Paschalis Gavriilidis
- Department of HBP Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Angela Gurrado
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery "V. Bonomo", University of Bari "A. Moro", Bari, Italy
| | - Riccardo Inchingolo
- Unit of Interventional Radiology, F. Miulli Hospital, 70021, Acquaviva Delle Fonti, Italy
| | - Alexandre Ingels
- Department of Urology, Henri Mondor Hospital, University of Paris Est Créteil (UPEC), 94000, Créteil, France
| | - Rao Ivatury
- Professor Emeritus, Virginia Commonwealth University, Richmond, VA, USA
| | - Jeffry L Kashuk
- Department of Surgery, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jim Khan
- Department of Colorectal Surgery, Queen Alexandra Hospital, University of Portsmouth, Southwick Hill Road, Cosham, Portsmouth, UK
| | - Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, EG23T2N 2T9, Canada
| | - Fernando J Kim
- Division of Urology, Denver Health Medical Center, Denver, CO, USA
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Zaher Lakkis
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, University Hospital of Besançon, Besançon, France
| | - Ari Leppäniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ronald V Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Riccardo Memeo
- Unit of Hepato-Pancreato-Biliary Surgery, General Regional Hospital "F. Miulli", Acquaviva Delle Fonti, Bari, Italy
| | - Ernest E Moore
- Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Carlos A Ordoñez
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
| | - Gianluca Pellino
- Colorectal Surgery Unit, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Manos Pikoulis
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Michele Pisano
- 1st General Surgery Unit, Department of Emergency, ASST Papa Giovanni Hospital Bergamo, Bergamo, Italy
| | - Mauro Podda
- Department of Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | | | - Fausto Rosa
- Emergency and Trauma Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery "V. Bonomo", University of Bari "A. Moro", Bari, Italy
| | | | - Dieter Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Emilio Sacco
- Department of Urology, Università Cattolica del Sacro Cuore Di Roma, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Alfredo Tonsi
- Digestive Diseases Department, Royal Sussex County Hospital, University Hospitals Sussex, Brighton, UK
| | - Fabrizio Dal Moro
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, Cesena, Italy.
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Cirocco WC. Trends and benefits of prophylactic ureter catheters in the era of minimally invasive surgery. Am J Surg 2023; 225:577-582. [PMID: 36509589 DOI: 10.1016/j.amjsurg.2022.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 11/10/2022] [Accepted: 11/29/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND The recent spike in ureter injury (UI) amidst the rise of minimally invasive surgery (MIS) has focused attention on the propriety of prophylactic ureter catheters (PUCs) for abdominopelvic operations. METHODS A retrospective review of PUCs for rectal cancer resection following neoadjuvant therapy, combined with a comprehensive literature review. RESULTS There were zero UI in the current study. Literature review revealed a nationwide spike in PUCs in the last 30 years, dependent on operation: 1) colorectal resection-increased from 1.1% to 4.4%, 2) sigmoid colectomy for diverticulitis-increased from 6.7% to 16.3%. This 2-4 fold increase parallels the rise of MIS: 15 of the 20 latest studies (75%) either combined open operations and MIS (4 studies) or focused solely on MIS (11 studies). Medial-to-lateral dissection identified as a UI risk factor. Only 20-30% of UI identified intraoperatively. CONCLUSIONS Intraoperative UI is missed in 70-80% of cases. The prevention, identification, ease of ureter repair, and net decrease in operative time support the use of PUCs. Medial-to-lateral dissection is identified as a potential contributing factor to UI.
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6
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Joosten JJ, Sharabiany S, Musters GD, Beerlage HP, Tanis PJ, Bemelman WA, Hompes R. Iatrogenic injury of the urinary tract during salvage procedures for pelvic sepsis: Experience of a national referral centre. Colorectal Dis 2022; 24:1397-1404. [PMID: 35698898 PMCID: PMC9796761 DOI: 10.1111/codi.16221] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/21/2022] [Accepted: 06/06/2022] [Indexed: 01/07/2023]
Abstract
AIM This study aimed to determine the incidence, consequences and outcomes of iatrogenic urinary tract injury (IUI) during salvage surgery for pelvic sepsis. METHOD Patients who underwent salvage surgery for pelvic sepsis after prior low anterior resection or Hartmann's procedure for rectal cancer were prospectively maintained in a database between 2010 and 2020 and reviewed retrospectively. The primary endpoint was the incidence of IUI. Secondary endpoints were timing of diagnosis (intra- vs. postoperative), reinterventions related to the IUI and healing of IUI. RESULTS In total 126 consecutive patients were included, and IUI occurred in 13 patients (10%). A ureteric injury occurred in eight patients, bladder injury in four patients and a urethral injury in one patient. All patients with an IUI had radiotherapy as neoadjuvant treatment. The IUI was diagnosed postoperatively in 63% (n = 8/13) with a median duration between surgery and diagnosis of the IUI of 10 days (IQR: 6-15). The median number of reinterventions was five (range 1-31) in the group with a postoperative diagnosis and one (range 0-1) in the group with an intraoperative diagnosis. Four patients required a surgical reintervention, all concerning injuries diagnosed postoperatively. At the end of follow-up, 85% of patients (n = 11/13) had a healed IUI. CONCLUSION Iatrogenic urinary tract injury is not uncommon in salvage procedures for pelvic sepsis, even in an experienced tertiary referral centre. Most injuries were diagnosed postoperatively which affects the severity of these complications, emphasising the need to improve intraoperative diagnostic modalities.
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Affiliation(s)
- Johanna J. Joosten
- Department of Surgery, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Sarah Sharabiany
- Department of Surgery, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Gijsbert D. Musters
- Department of Surgery, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Harrie P. Beerlage
- Department of Urology, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Pieter J. Tanis
- Department of Surgery, Amsterdam UMC, Cancer Centre AmsterdamUniversity of AmsterdamAmsterdamThe Netherlands,Department of Surgical Oncology and Gastrointestinal SurgeryRotterdamThe Netherlands
| | | | - Roel Hompes
- Department of Surgery, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
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Napier-Hemy TP, Floyd MS, Samsudin A. The Whiston Snare Technique for Loop Extraction of Stents (WHISTLES): A novel technique for the intraureteric assembly of a loop snare for the retrograde extraction of a migrated ureteric stent. JOURNAL OF CLINICAL UROLOGY 2022. [DOI: 10.1177/20514158221081305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: While ureteric stent removal remains a frequently performed endourological procedure stent migration either proximally or distally can present the endourologist with a significant intraoperative dilemma. In cases where the stent is of large calibre or impacted into the mucosa of the ureter, retrieval may prove refractory to traditional approaches. Objective: To present a further novel procedure: The Whiston Snare Technique for Loop Extraction of Stents (WHISTLES) which allows for intraureteric assembly of a tightening loop through a ureteric catheter thus permitting safe retrieval of a migrated stent. Methods: We describe the procedure as it was performed and have recreated the steps in a laboratory environment. This demonstrates an adaptation of existing materials readily found in most urological theatres and is not a prototypical device. Results: The procedure was successfully performed to allow extraction of the migrated ureteric stent. Conclusion: WHISTLES is a reproducible method for the retrieval of migrated ureteric stents where traditional techniques have failed. Level of evidence: 5
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Affiliation(s)
- Timothy Peter Napier-Hemy
- Department of Urology, Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Foundation Trust, Prescot, UK
| | - Michael S Floyd
- Department of Urology, Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Foundation Trust, Prescot, UK
| | - Azizan Samsudin
- Department of Urology, Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Foundation Trust, Prescot, UK
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8
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Mazzarella G, Muttillo EM, Picardi B, Rossi S, Rossi Del Monte S, Muttillo IA. Real-Time Intraoperative Ureteral Identification in Minimally Invasive Colorectal Surgery: A Systematic Review. J Laparoendosc Adv Surg Tech A 2021; 32:627-633. [PMID: 34669486 DOI: 10.1089/lap.2021.0292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Although colorectal surgery (CRS) has currently almost entirely standardized surgical procedures, it can still show pitfalls such as the intraoperative ureteral injury. Intraoperative ureteral identification (IUI) could reduce the ureteral injuries rate but evidence is still lacking. We aimed to analyze the utility and the effectiveness of real-time IUI in minimally invasive CRS. Materials and Methods: A systematic review was performed examining available data on randomized and nonrandomized studies evaluating the utility of intraureteral fluorescence dye (IFD) and lighted ureteral stent (LUS) for intraoperative identification of ureters in CRS, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards. Primary endpoint was ureteral injuries rate. Secondary endpoints included acute kidney injury, hematuria, urinary tract infections (UTI), and fluorescence assessment. Results: After literature search, 158 studies have been recorded, 36 studies underwent full-text reviews and 12 studies met inclusion criteria. Overall, out of a total of 822 patients who successfully received IUI, 3 (0.33%) patients experienced ureteral injury. Hematuria was reported in 689 (97.6%) of patients following LUS-guided surgery and in 1 (2%) patient following IFD-guided surgery, although transient in all cases. UTI was reported in 15 (3.3%) LUS-guided resections and in 1 (2%) IFD-guided resections. Acute kidney injury occurred in 23 (2.5%) LUS-guided surgery and 1 (1%) IFD-guided surgery. Conclusions: Real-time ureteral identification techniques could represent a valid solution in complex minimally invasive CRS, safely, with no time consuming and always reproducible by surgeons. Prospective studies will be needed to confirm these findings.
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Affiliation(s)
- Gennaro Mazzarella
- Department of General and Emergency Surgery, San Filippo Neri Hospital, Rome, Italy.,Department of Emergency Surgery, Sapienza University of Rome, Rome, Italy
| | - Edoardo Maria Muttillo
- Department of General and Emergency Surgery, San Filippo Neri Hospital, Rome, Italy.,Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Biagio Picardi
- Department of General and Emergency Surgery, San Filippo Neri Hospital, Rome, Italy
| | - Stefano Rossi
- Department of General and Emergency Surgery, San Filippo Neri Hospital, Rome, Italy
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9
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Iatrogenic Ureteral Injury and Prophylactic Stent Use in Veterans Undergoing Colorectal Surgery. J Surg Res 2021; 265:272-277. [PMID: 33964637 DOI: 10.1016/j.jss.2021.03.054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 03/24/2021] [Accepted: 03/29/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Iatrogenic ureteral injury (IUI) is an uncommon complication in colorectal surgery. Prophylactic ureteral stenting (PUS) gained acceptance to aid in intraoperative identification of the ureter. Despite its use, the benefit of pus to avoid IUI remains debatable. We sought to analyze the rates of IUI after colorectal surgery in veterans and to compare the outcomes after PUS using a large matched cohort. METHODS The veterans affairs surgical quality improvement program database was queried for patients who underwent colorectal surgery from 2008-2015. To analyze the outcomes of PUS, we created two matched groups using propensity-score matching accounting for demographical and clinical cofactors to assess variable outcomes. Cross-tabulation was used to calculate rates of IUI and univariate and multivariate analyses were performed to evaluate risk factors associated with IUI. RESULTS 27,448 patients were identified and 458 underwent PUS placement (1.6%). The majority of procedures were performed electively and with an open approach. Mean age was 65 y, 96.3% were male, and colorectal cancer was the most common indication. 45 patients (0.2%) were diagnosed with IUI. IUI incidence was higher in female patients, after left-sided colorectal resection, and in those undergoing open procedures. After matching, PUS use was associated with longer length of stay and operative time and increased creatinine levels from baseline. CONCLUSION We demonstrated that the use of PUS is independently associated with increased operative time and change in creatinine levels. Although no IUI occurred in the PUS group, this finding was not statistically significant. The risk and/or benefit ratio of PUS should be considered for each individual case, with its selective use based on the presence of risk factors for IUI, such as female patients and left-sided resections.
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10
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Wilson RRA, Thomas G, Edge C, Scarff G, Pathak RA. Prophylactic Ureteral Localization Stent with Guidewire Assistance Decreases Urologic-Induced Complication Rates: Quality Improvement Initiative and Review of Literature. J Laparoendosc Adv Surg Tech A 2021; 32:118-124. [PMID: 33567230 DOI: 10.1089/lap.2020.0865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: We previously reported a 2% Clavien IIIb urologic-induced complication rate associated with blind (no guidewire, no fluoroscopy) prophylactic ureteral localization stent (PULSe) placement. As part of a quality improvement initiative, mandatory guidewire placement before PULSe was performed and urologic-induced Clavien IIIb or greater complication rates were evaluated. A systematic review was performed to elicit the overall urologic-induced complication rate in the literature. Materials and Methods: A retrospective review of all patients who underwent guidewire-assisted PULSe placement before colorectal surgery was performed. The contemporary cohort was compared with those in the prior cohort using age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, preoperative creatinine, postoperative creatinine, pre-/postoperative creatinine difference, and Clavien IIIb urologic-induced complication rates. A review of literature from 1982 to 2019 was performed using 14 unique search terms. Of 38 studies reviewed, 18 met predetermined inclusion criteria. Results: One hundred thirty-two patients underwent bilateral PULSe placement with mandatory guidewire utilization. Mean age and BMI were 55.78 (18-89) and 27.02, respectively, with zero Clavien IIIb complications, compared with a rate of 2% (P < .001) in our prior study. Our contemporary cohort yielded a more favorable postoperative creatinine (P < .022) and pre-/postoperative creatinine difference (P < .003). A review of literature identified a mean Clavien IIIb complication rate of 0.38%. Conclusions: Mandatory guidewire utilization before PULSe placement reduced the Clavien IIIb complication rate to zero, compared with a rate of 2% from our prior cohort. Guidewire utilization can decrease Clavien IIIb urologic-induced complication rates. A review of the literature shows a lack of uniformity concerning the technique of PULSe placement.
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Affiliation(s)
- Robert R A Wilson
- Wake Forest University School of Medicine, Department of Urology, Winston-Salem, North Carolina, USA
| | - Garrett Thomas
- Wake Forest University School of Medicine, Department of Urology, Winston-Salem, North Carolina, USA
| | - Carl Edge
- Wake Forest University School of Medicine, Department of Urology, Winston-Salem, North Carolina, USA
| | | | - Ram A Pathak
- Wake Forest University School of Medicine, Department of Urology, Winston-Salem, North Carolina, USA
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11
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Coakley KM, Davis BR, Kasten KR. Complicated Diverticular Disease. Clin Colon Rectal Surg 2020; 34:96-103. [PMID: 33642949 DOI: 10.1055/s-0040-1716701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The modern management of colonic diverticular disease involves grouping patients into uncomplicated or complicated diverticulitis, after which the correct treatment paradigm is instituted. Recent controversies suggest overlap in management strategies between these two groups. While most reports still support surgical intervention for the treatment of complicated diverticular disease, more data are forthcoming suggesting complicated diverticulitis does not merit surgical resection in all scenarios. Given the significant risk for complication in surgery for diverticulitis, careful attention should be paid to patient and procedure selection. Here, we define complicated diverticulitis, discuss options for surgical intervention, and explain strategies for avoiding operative pitfalls that result in early and late postoperative complications.
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Affiliation(s)
- Kathleen M Coakley
- Department of Surgery, Carolinas HealthCare System, Charlotte, North Carolina
| | - Bradley R Davis
- Department of Surgery, Carolinas HealthCare System, Charlotte, North Carolina
| | - Kevin R Kasten
- Department of Surgery, Carolinas HealthCare System, Charlotte, North Carolina
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12
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Fugazzola P, Coccolini F, Tomasoni M, Cicuttin E, Sibilla MG, Gubbiotti F, Lippi A, Improta M, Montori G, Ceresoli M, Pisano M, Ansaloni L. Routine prophylactic ureteral stenting before cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: Safety and usefulness from a single-center experience. Turk J Urol 2019; 45:372-376. [PMID: 31509510 DOI: 10.5152/tud.2019.19025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 07/25/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVE There are very few evidences about safety and usefulness of routine prophylactic ureteral stenting (PUS) before cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). MATERIAL AND METHODS An analysis of prospectively collected data about patients who underwent CRS and HIPEC for different sites of primary disease was carried out focusing on ureteral complications. RESULTS A total of 138 patients who underwent CRS and HIPEC between December 2010 and June 2017 were considered. All patients underwent PUS before CRS and HIPEC. Of them, 91 (66.4%) patients received pelvic peritonectomy, 49 (35.8%) pelvic lymphadenectomy, 31 (22.6%) left hemicolectomy, 44 (32.4%) right hemicolectomy, 46 (33.6%) rectal resection, 56 (40.9%) hysteroannessiectomy, and 39 (28.5%) appendectomy. There was one (0.7%) postoperative ureteral fistula. The cumulative risk of ureteral stent-related major complications was 4.3% (two patients (1.4%) had protracted gross hematuria, two patients (1.4%) had urinary sepsis, and three patients (2.9%) developed hydronephrosis after a period from removing ureteral stents and required restenting. Morbidity due to ureteral stenting was associated with a longer length of stay (LOS) (p=0.053). A total of 52 patients (44.1%) developed renal dysfunction according to the RIFLE (Risk, Injury, Failure, Loss of kidney function, End-stage kidney-disease) criteria: 19.5% were in risk class, 10.2% in acute renal injury class, and 14.4% in acute renal failure class. CONCLUSION PUS could be a useful tool for reducing iatrogenic ureteral injury, but it is associated with a non-negligible morbidity, which implies longer LOS. A more accurate patient selection for PUS is necessary.
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Affiliation(s)
- Paola Fugazzola
- Department of General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Federico Coccolini
- Department of General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Matteo Tomasoni
- Department of General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Enrico Cicuttin
- Department of General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | | | - Francesca Gubbiotti
- Department of General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Andrea Lippi
- Department of General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Mario Improta
- Department of General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Giulia Montori
- Department of General and Emergency Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Marco Ceresoli
- Department of General and Emergency Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Michele Pisano
- Department of General and Emergency Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Luca Ansaloni
- Department of General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
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13
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The sentinel stent? A systematic review of the role of prophylactic ureteric stenting prior to colorectal resections. Int J Colorectal Dis 2019; 34:1161-1178. [PMID: 31175421 DOI: 10.1007/s00384-019-03314-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE 'Prophylactic' ureteric stents potentially reduce rates, and facilitate intraoperative recognition, of iatrogenic ureteric injury (IUI) during colorectal resections. A lack of consensus surrounds the risk-benefit equation of this practice, and we aimed to assess the evidence base. METHODS A systematic review was performed according to PRISMA guidelines. MEDLINE, Scopus, EMBASE and Cochrane databases were searched using terms 'ureteric/ureteral/JJ/Double J stent' or 'ureteric/ureteral catheter' and 'colorectal/prophylactic/resection/diverticular disease/diverticulitis/iatrogenic injury'. Primary outcomes were rates of ureteric injuries and their intraoperative identification. Secondary outcomes included stent complication rates. RESULTS We identified 987 publications; 22 papers met the inclusion criteria. No randomised controlled trials were found. The total number of patients pooled for evaluation was 869,603 (102,370 with ureteric stents/catheters, 767,233 controls). The most frequent indications for prophylactic stents were diverticular disease (45.38%), neoplasia (33.45%) and inflammatory bowel disease (9.37%). Pooled results saw IUI in 1521/102,370 (1.49%) with, and in 1333/767,233 (0.17%) without, prophylactic ureteric stents. Intraoperative recognition of IUIs occurred in 10/16 injuries (62.5%) with prophylactic stents, versus 9/17 (52.94%) without stents (p = 0.579). The most serious complications of prophylactic stent use were ureteric injury (2/1716, 0.12%) and transient ureteric obstruction following stent removal (13/666, 1.95%). CONCLUSIONS Placement of prophylactic ureteric stents has a low complication rate. There is insufficient evidence to conclude that stents decrease ureteric injury or increase intraoperative detection of IUIs. Apparently higher rates of IUI in stented patients likely reflect use in higher risk resections. A prospective registry with harmonised data collection points and stratification of intraoperative risk is needed.
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14
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Douissard J, Meyer J, Ris F, Liot E, Morel P, Buchs NC. Iatrogenic ureteral injuries and their prevention in colorectal surgery: results from a nationwide survey. Colorectal Dis 2019; 21:595-602. [PMID: 30624852 DOI: 10.1111/codi.14552] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 01/03/2019] [Indexed: 12/13/2022]
Abstract
AIM Iatrogenic ureteral injury (IUI) occurs rarely during colorectal surgery but is associated with significant mortality, morbidity and medicolegal issues. Few cases are reported, and recommendations regarding prevention are lacking. The aim of this study is to describe the current state of practice regarding IUI and its prevention among general surgeons in Switzerland. METHOD All Swiss general surgeons who are members of either the Swiss Association of Laparoscopic and Thoracoscopic Surgery or the Swiss Surgical Society were invited to participate in an anonymous online survey. Demographics, surgical practice, rate of IUI and methods used to prevent IUI were investigated. RESULTS All participants were board-certified general surgeons, 63.4% were certified visceral surgeons and 17.9% were certified colorectal surgeons. The mean level of experience in colorectal surgery was 15.6 ± 9.2 years. Formal ureter identification was considered mandatory during sigmoid or rectal surgery by 83.7% of participants, and 31.7% considered identification of the right ureter during right colectomy to be mandatory. In total, 61.8% of the participants and 78.4% of surgeons with more than 20 years of experience had encountered at least one IUI. Prophylactic ureteral stenting was considered useful in complex procedures by 93.5% of participants, and 56.9% had used stents at least once in the past 12 months. Noninvasive techniques for identifying ureters would be considered in regular daily practice by 54.5% of the participants. CONCLUSION Most general surgeons experience IUI. Ureter identification is widely integrated in colorectal procedures. Prophylactic stenting is widely used for difficult cases. Noninvasive methods to improve ureter identification are now needed.
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Affiliation(s)
- J Douissard
- Visceral Surgery Department, University Hospital of Geneva and School of Medicine, Geneva, Switzerland
| | - J Meyer
- Visceral Surgery Department, University Hospital of Geneva and School of Medicine, Geneva, Switzerland
| | - F Ris
- Visceral Surgery Department, University Hospital of Geneva and School of Medicine, Geneva, Switzerland
| | - E Liot
- Visceral Surgery Department, University Hospital of Geneva and School of Medicine, Geneva, Switzerland
| | - P Morel
- Visceral Surgery Department, University Hospital of Geneva and School of Medicine, Geneva, Switzerland
| | - N C Buchs
- Visceral Surgery Department, University Hospital of Geneva and School of Medicine, Geneva, Switzerland
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15
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Trujillo CG, Domínguez C, Robledo D, Caicedo JI, Bravo-Balado A, Cataño JG, Cortés N, Parra L, Riaño W, Londoño-Schimmer E, Otero J, Herrera G, Arias F, Plata M. Urological approach for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a clinical care center. Acta Chir Belg 2018; 118:348-353. [PMID: 29475412 DOI: 10.1080/00015458.2018.1436797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is associated with significant manipulation of the urinary tract (UT). We aim to describe the urological events and their management in patients who underwent CRS-HIPEC. METHODS Clinical records of patients who underwent treatment between 2007 and 2015 were reviewed. Urological events and their multidisciplinary management were analyzed. Descriptive statistics were calculated. RESULTS A total of 103 patients were included. Mean age was 51 years (SD ± 11.8). Mean peritoneal cancer index (PCI) was 20.4 (SD ± 10.1). Primary tumors included appendicular (64%), gynecological (16%), colorectal (10%), and peritoneal mesotheliomas (9%). Ninety-three percent of patients had bilateral ureteral catheters inserted prior to surgery, without complications. Intraoperative UT injuries occurred in 7% of patients. In 5% of patients, tumor invasion of the bladder was evident at surgery and partial resection and primary repair of the bladder wall was performed. Urological complications included urinary tract infection (UTI) (21%) acute post-renal failure (4%), urinary fistulae (4%), and acute urinary retention (AUR) (1%). CONCLUSIONS In our study, intraoperative UT events and postoperative complications, although not neglectable, were infrequent. Due to the high complexity of these cases, a multidisciplinary approach is mandatory. However, randomized clinical trials are necessary to clarify current data on the need and efficacy of prophylactic ureteral catheterization in patients undergoing CRS-HIPEC.
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Affiliation(s)
- Carlos Gustavo Trujillo
- Department of Urology, Hospital Universitario Fundación Santa Fe de Bogotá and Universidad de los Andes School of Medicine, Bogotá, Colombia
| | - Cristina Domínguez
- Department of Urology, Hospital Universitario Fundación Santa Fe de Bogotá and Universidad de los Andes School of Medicine, Bogotá, Colombia
| | - Daniela Robledo
- Department of Urology, Hospital Universitario Fundación Santa Fe de Bogotá and Universidad de los Andes School of Medicine, Bogotá, Colombia
| | - Juan Ignacio Caicedo
- Department of Urology, Hospital Universitario Fundación Santa Fe de Bogotá and Universidad de los Andes School of Medicine, Bogotá, Colombia
| | - Alejandra Bravo-Balado
- Department of Urology, Hospital Universitario Fundación Santa Fe de Bogotá and Universidad de los Andes School of Medicine, Bogotá, Colombia
| | - Juan Guillermo Cataño
- Department of Urology, Hospital Universitario Fundación Santa Fe de Bogotá and Universidad de los Andes School of Medicine, Bogotá, Colombia
| | - Natalia Cortés
- Department of Surgery, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Lina Parra
- Department of Surgery, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Wilson Riaño
- Department of Surgery, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Eduardo Londoño-Schimmer
- Department of Surgery, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
- Clinical Care Center for Peritoneal Neoplasms, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Jorge Otero
- Clinical Care Center for Peritoneal Neoplasms, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
- Department of Oncology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Gabriel Herrera
- Department of Surgery, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
- Clinical Care Center for Peritoneal Neoplasms, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Fernando Arias
- Department of Surgery, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
- Clinical Care Center for Peritoneal Neoplasms, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Mauricio Plata
- Department of Urology, Hospital Universitario Fundación Santa Fe de Bogotá and Universidad de los Andes School of Medicine, Bogotá, Colombia
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16
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Luks VL, Merola J, Arnold BN, Ibarra C, Pei KY. Prophylactic Ureteral Stenting in Laparoscopic Colectomy: Revisiting Traditional Practice. J Surg Res 2018; 234:161-166. [PMID: 30527469 DOI: 10.1016/j.jss.2018.09.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/28/2018] [Accepted: 09/12/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Prophylactic placement of ureteral stents is performed during open colectomy to aid in ureteral identification and to enhance detection of injury. The effects of this practice in laparoscopic colectomy are unknown. This study compares outcomes of patients undergoing laparoscopic colectomy with and without prophylactic ureteral stenting. METHODS A retrospective cohort study at a tertiary academic medical center was performed. The primary outcome measure was the incidence of ureteral injury. Secondary outcomes evaluated included mortality, length of stay, procedural duration, and new-onset urinary complication (hematuria, dysuria, and urinary tract infection). RESULTS In 702 consecutive patients undergoing elective laparoscopic colectomy from 2013 to 2016, prophylactic stents were placed in 261 (37%) patients. Two ureteral injuries occurred (0.3%), both in patients who underwent ureteral stent placement (P = 0.07) and were found and repaired intraoperatively. There was no in-hospital mortality. When accounting for age-adjusted Charlson comorbidity score, procedural indication, gender, BMI, and extent of resection, no difference in hospital length of stay (P = 0.79) was noted comparing patients with and without stenting. However, stent placement prolonged operating time (P = 0.03) and increased the risk of new-onset urinary complications (P = 0.04). CONCLUSIONS In this study, ureteral injuries only occurred in those with stent placement. Prophylactic ureteral stents in laparoscopic colectomy are associated with increased operative time and urologic morbidity. Owing to the low prevalence of ureteral injury in the elective setting and the increased risk of urinary complications, use of prophylactic ureteral stenting should be highly selective.
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Affiliation(s)
- Valerie L Luks
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Jonathan Merola
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Brian N Arnold
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | - Kevin Y Pei
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
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17
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van Manen L, Handgraaf HJM, Diana M, Dijkstra J, Ishizawa T, Vahrmeijer AL, Mieog JSD. A practical guide for the use of indocyanine green and methylene blue in fluorescence-guided abdominal surgery. J Surg Oncol 2018; 118:283-300. [PMID: 29938401 PMCID: PMC6175214 DOI: 10.1002/jso.25105] [Citation(s) in RCA: 184] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 04/21/2018] [Indexed: 12/14/2022]
Abstract
Near-infrared (NIR) fluorescence imaging is gaining clinical acceptance over the last years and has been used for detection of lymph nodes, several tumor types, vital structures and tissue perfusion. This review focuses on NIR fluorescence imaging with indocyanine green and methylene blue for different clinical applications in abdominal surgery with an emphasis on oncology, based on a systematic literature search. Furthermore, practical information on doses, injection times, and intraoperative use are provided.
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Affiliation(s)
- Labrinus van Manen
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Michele Diana
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,IRCAD, Research Institute against Cancer of the Digestive System, Strasbourg, France.,Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - Jouke Dijkstra
- Division of Image Processing, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Takeaki Ishizawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | | | - Jan Sven David Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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18
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Hassinger TE, Mehaffey JH, Mullen MG, Michaels AD, Elwood NR, Levi ST, Hedrick TL, Friel CM. Ureteral stents increase risk of postoperative acute kidney injury following colorectal surgery. Surg Endosc 2018; 32:3342-3348. [PMID: 29340810 DOI: 10.1007/s00464-018-6054-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 01/11/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Ureteral stents are commonly placed before colorectal resection to assist in identification of ureters and prevent injury. Acute kidney injury (AKI) is a common cause of morbidity and increased cost following colorectal surgery. Although previously associated with reflex anuria, prophylactic stents have not been found to increase AKI. We sought to determine the impact of ureteral stents on the incidence of AKI following colorectal surgery. METHODS All patients undergoing colon or rectal resection at a single institution between 2005 and 2015 were reviewed using American College of Surgeons National Surgical Quality Improvement Program dataset. AKI was defined as a rise in serum creatinine to ≥ 1.5 times the preoperative value. Univariate and multivariate regression analyses were performed to identify independent predictors of AKI. RESULTS 2910 patients underwent colorectal resection. Prophylactic ureteral stents were placed in 129 patients (4.6%). Postoperative AKI occurred in 335 (11.5%) patients during their hospitalization. The stent group demonstrated increased AKI incidence (32.6% vs. 10.5%; p < 0.0001) with bilateral having a higher rate than unilateral stents. Hospital costs were higher in the stent group ($23,629 vs. $16,091; p < 0.0001), and patients with bilateral stents had the highest costs. Multivariable logistic regression identified predictors of AKI after colorectal surgery including age, procedure duration, and ureteral stent placement. CONCLUSIONS Prophylactic ureteral stents independently increased AKI risk when placed prior to colorectal surgery. These data demonstrate increased morbidity and hospital costs related to usage of stents in colorectal surgery, indicating that placement should be limited to patients with highest potential benefit.
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Affiliation(s)
- Taryn E Hassinger
- Department of Surgery, University of Virginia, Charlottesville, VA, USA. .,University of Virginia Health System, P.O. Box 800300, Charlottesville, VA, 22908-0709, USA.
| | - J Hunter Mehaffey
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Matthew G Mullen
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Alex D Michaels
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Nathan R Elwood
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Shoshana T Levi
- Department of Surgery, University of Virginia, Charlottesville, VA, USA.,Department of Surgery, Christiana Care Health System, Wilmington, DE, USA
| | - Traci L Hedrick
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Charles M Friel
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
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19
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Prophylactic Ureteral Catheters for Colectomy: A National Surgical Quality Improvement Program-Based Analysis. Dis Colon Rectum 2018; 61:84-88. [PMID: 29215477 DOI: 10.1097/dcr.0000000000000976] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Despite improvement in technique and technology, using prophylactic ureteral catheters to avoid iatrogenic ureteral injury during colectomy remains controversial. OBJECTIVE The aim of this study was to evaluate outcomes and costs attributable to prophylactic ureteral catheters with colectomy. DESIGN This was a retrospective study. SETTINGS The study was conducted at a single tertiary care center. PATIENTS The colectomy-targeted American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2014 was queried. MAIN OUTCOME MEASURES The primary end point was the rate of 30-day ureteral injury after colectomy. Univariate and multivariate analyses determined factors associated with ureteral injury and urinary tract infection in patients undergoing colectomy. RESULTS A total of 51,125 patients were identified with a mean age of 60.9 ± 14.9 years and a BMI of 28.4 ± 6.7 k/m; 4.90% (n = 2486) of colectomies were performed with prophylactic catheters, and 333 ureteral injuries (0.65%) were identified. Prophylactic ureteral catheters were most commonly used for diverticular disease (42.2%; n = 1048), with injury occurring most often during colectomy for diverticular disease (36.0%; n = 120). Univariate analysis of outcomes demonstrated higher rates of ileus, wound infection, urinary tract infection, urinary tract infection as reason for readmission, superficial site infection, and 30-day readmission in patients with prophylactic ureteral catheter placement. On multivariate analysis, prophylactic ureteral catheter placement was associated with a lower rate of ureteral injury (OR = 0.45 (95% CI, 0.25-0.81)). LIMITATIONS This was a retrospective study using a clinical data set. CONCLUSIONS Here, prophylactic ureteral catheters were used in 4.9% of colectomies and most commonly for diverticulitis. On multivariate analysis, prophylactic catheter placement was associated with a lower rate of ureteral injury. Additional research is needed to delineate patient populations most likely to benefit from prophylactic ureteral stent placement. See Video Abstract at http://links.lww.com/DCR/A482.
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20
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Chiu AS, Jean RA, Gorecka J, Davis KA, Pei KY. Trends of ureteral stent usage in surgery for diverticulitis. J Surg Res 2017; 222:203-211.e3. [PMID: 29100586 DOI: 10.1016/j.jss.2017.09.050] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 09/08/2017] [Accepted: 09/29/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Many believe that the use of ureteral stents in colorectal surgery for diverticulitis aids prevention and easier identification of ureteral injuries; others argue that the added time, cost, and risks of stent placement negate potential benefits. Even among providers who use stents, selective use is common. Among unclear consensus, it remains unknown if the use of stents is growing. MATERIALS Patients in the National Inpatient Sample who underwent a partial colectomy or anterior rectal excision for diverticulitis between 2000 and 2013 were included (n = 811,071). Trends in ureteral stent use, multivariate logistic regression of factors influencing stent placement, and linear regression of length of stay (LOS) and costs associated with stent use were examined. RESULTS Usage of ureteral stents increased from 6.66% in 2000 to 16.30% in 2013 (P < 0.0001). Rates of stent usage were higher with laparoscopic surgery (19.31% versus 12.31% open, P < 0.0001). Regression demonstrated patients in the Northeast (Midwest odds ratio (OR) 0.49 [0.37-0.66] P < 0.0001, South OR 0.60 [0.45-0.80] P = 0.0004, West OR 0.30 [0.22-0.41], P < 0.0001), and those whose admission was elective (OR 2.37 [2.08-2.69], P < 0.0001) were more likely to receive stents. Stent use was associated with an increased LOS (0.55 days, P < 0.0001) and cost ($1,983, P < 0.0001). CONCLUSIONS The use of ureteral stents in surgery for diverticulitis has steadily increased since 2000, despite the lack of consensus of their overall benefit. Stent usage is associated with laparoscopic surgery and varies widely among regions of the country. Further studies are required to truly understand the risk-benefit ratio of ureteral stenting and to determine if its increased use is warranted.
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Affiliation(s)
- Alexander S Chiu
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut; National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jolanta Gorecka
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Kimberly A Davis
- Section of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Kevin Y Pei
- Section of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
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Boyan WP, Lavy D, Dinallo A, Otero J, Roding A, Hanos D, Dressner R, Arvanitis M. Lighted ureteral stents in laparoscopic colorectal surgery; a five-year experience. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:44. [PMID: 28251123 DOI: 10.21037/atm.2017.02.01] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ureteral injuries during colorectal surgery are a rare event, ranging in the literature from 0.28-7.6%. Debate surrounds the use of prophylactic lighted ureteral stents to help protect the ureter during laparoscopic surgery. It has been suggested that they help to identify injuries but do not prevent them. The authors look to challenge this. METHODS Over 66 months, every laparoscopic or colectomy involving ureteral stents was recorded. Researchers documented any injury to the ureter intraoperatively. The chart was also reviewed for the complications of urinary tract infection (UTI) and urinary retention post-operatively. RESULTS During the 66 months, 402 laparoscopic colon resections were done. There were no ureteral injuries. The lighted ureteral stent was identified during every case in the effort to prevent injury during dissection and resection. No catheter associated UTIs were identified, while 14 (3.5%) suffered from post-operative urinary retention. CONCLUSIONS The authors of this study present a large series of colon resections with no intraoperative ureteral injuries. In addition, these catheters were not associated with any UTIs and a rate of urinary retention similar to that of the at large data. This series provides compelling data to use lighted ureteral stents during laparoscopic colon surgery.
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Affiliation(s)
| | - Daniel Lavy
- Monmouth Medical Center, Long Branch, NJ, USA
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Pérez-Sánchez LE, Burneo-Esteves M, Rosat-Rodrigo A, Baz-Figueroa C, Pérez-Álvarez AD, Barrera-Gómez MÁ. [Crossed renal ectopia in a patient with a complicated sigma neoplasia]. CIR CIR 2016; 85 Suppl 1:72-75. [PMID: 28012556 DOI: 10.1016/j.circir.2016.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 10/26/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Crossed renal ectopia is a rare pathology that is often asymptomatic. Intraoperative detection with a sigma complicated neoplasia is more infrequent and requires correct management to avoid a renal ureteral injury. AIM To present a case report of a patient with a sigma complicated neoplasia and a crossed renal ectopia detected incidentally. CASE REPORT We present the case of a 62-year-old man that was submitted for emergency surgery for a sigma perforated neoplasm, and who presented with a previously undiagnosed left-side CRE. During surgery there was a need to insert 2-double-J stents as a guide to both ureters and to avoid any injury to them. DISCUSSION Crossed renal ectopia is a rare, often asymptomatic entity, the diagnosis of which is usually incidental. In our case, the detection of a concomitant complicated neoplasm, required identification of both ureters due the anatomic doubt of its localization and to avoid them being injured. In conclusion, upon finding a casual crossed renal ectopia during an emergency surgery of sigma, we recommend the identification of the ureters to facilitate its location and to avoid any injury to the ureters.
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Affiliation(s)
- Luis Eduardo Pérez-Sánchez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Tenerife, España.
| | - Mauricio Burneo-Esteves
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Tenerife, España
| | - Adriá Rosat-Rodrigo
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Tenerife, España
| | - Caleb Baz-Figueroa
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Tenerife, España
| | - Antonio Dámaso Pérez-Álvarez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Tenerife, España
| | - Manuel Ángel Barrera-Gómez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Tenerife, España
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Al-Taher M, van den Bos J, Schols RM, Bouvy ND, Stassen LPS. Fluorescence Ureteral Visualization in Human Laparoscopic Colorectal Surgery Using Methylene Blue. J Laparoendosc Adv Surg Tech A 2016; 26:870-875. [PMID: 27575463 DOI: 10.1089/lap.2016.0264] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Ureteral injury during laparoscopic surgery is rare, but when it occurs, it can be a serious problem. Near-infrared fluorescence (NIRF) with methylene blue (MB) administration is a promising technique for easier and potentially earlier intraoperative visualization of the ureter. Aim of this prospective study was to assess the feasibility of NIRF imaging of the ureter during laparoscopic colorectal surgery, using MB. METHODS Patients undergoing laparoscopic colorectal surgery were included and received intravenous injection of MB preoperatively. The ureter was visualized using a laparoscope, which offered both conventional and fluorescence imaging. Intraoperative recognition of the ureter was registered. The precision of ureter distinction with MB imaging was compared to the conventional laparoscopic view. RESULTS Ten patients were included. All procedures were initially performed using a laparoscopic approach. Dose per injection ranged between 0.125 mg/kg and 1.0 mg/kg bodyweight. There were no adverse effects attributable to MB administration. The ureter was successfully detected in five patients, with highest contrast between ureter and surrounding tissue at an administered dose of 0.75-1.0 mg/kg. The fluorescent signal was only picked up after the ureter was already visible in the conventional white light mode. CONCLUSION Ureteral fluorescence imaging using MB proved to be safe and feasible. However, the present technique does not provide practical advantage over conventional laparoscopic imaging for identification of the ureter during laparoscopic colorectal surgery. Future research is necessary to explore more extensive dose finding, alternative fluorescent dyes, or improvement of the imaging system to make this application clinically beneficial.
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Affiliation(s)
- Mahdi Al-Taher
- Department of Surgery, Maastricht University Medical Center , Maastricht, The Netherlands
| | - Jacqueline van den Bos
- Department of Surgery, Maastricht University Medical Center , Maastricht, The Netherlands
| | - Rutger M Schols
- Department of Surgery, Maastricht University Medical Center , Maastricht, The Netherlands
| | - Nicole D Bouvy
- Department of Surgery, Maastricht University Medical Center , Maastricht, The Netherlands
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Center , Maastricht, The Netherlands
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Althumairi AA, Efron JE. Genitourinary Considerations in Reoperative and Complex Colorectal Surgery. Clin Colon Rectal Surg 2016; 29:145-51. [PMID: 27247540 PMCID: PMC4882184 DOI: 10.1055/s-0036-1580629] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Genitourinary structures are at risk of injury during colorectal surgery. The incidence of injury is low; however, the risk is higher in cases involving severe inflammatory or infectious processes, locally advanced or recurrent cancer, previous radiation, and reoperation. Consideration of the anatomical relationship between the genitourinary system, and the colon and rectum is crucial to avoid injuries. Intraoperative diagnostic techniques such as intravenous pyelogram (IVP), fluoroscopic cystogram, or retrograde urethrogram can aid in identifying suspected injuries. Early recognition and repair of injuries decrease the morbidity of an injury. Repair of injuries depends on the location and extent of the injury. Simple injuries may be repaired primarily, while complex injuries may require more advanced repairs such as a flap reconstruction.
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Affiliation(s)
- Azah A. Althumairi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan E. Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Hidaka E, Nakahara K, Maeda C, Takehara Y, Ishida F, Kudo SE. Laparoscopic surgery for sigmoidocutaneous fistula due to diverticulitis: A case report. Asian J Endosc Surg 2015; 8:340-2. [PMID: 26303733 DOI: 10.1111/ases.12189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 03/09/2015] [Indexed: 11/29/2022]
Abstract
Sigmoidocutaneous fistulas due to sigmoid colon diverticulitis are very rare. Here we report a case in which laparoscopic sigmoidectomy was used to successfully treat a sigmoidocutaneous fistula due to diverticulitis. A 41-year-old man was admitted to our hospital because of redness and swelling of the left inguinal skin. Enhanced abdominal CT revealed a subcutaneous abscess in the left lower abdomen. Percutaneous drainage was performed, and fistulography revealed a fistula between the sigmoid colon and left inguinal skin. Therefore, a sigmoidocutaneous fistula was diagnosed, and laparoscopic sigmoidectomy and fistulectomy were performed. The sigmoid colon had several diverticula, and a pathological examination revealed that the sigmoidocutaneous fistula was due to diverticulitis. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. In cases of sigmoidocutaneous fistula, laparoscopic treatment can be safely performed.
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Affiliation(s)
- Eiji Hidaka
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Kenta Nakahara
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Chiyo Maeda
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Yusuke Takehara
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Fumio Ishida
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Shin-ei Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
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Application of a new dye for near-infrared fluorescence laparoscopy of the ureters: demonstration in a pig model. Dis Colon Rectum 2014; 57:407-11. [PMID: 24509470 DOI: 10.1097/dcr.0000000000000055] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Ureteral injury during laparoscopic colorectal surgery is a rare but serious complication with a reported incidence rate of 0.66%. The early detection and prevention of ureteral injury is clinically relevant and important. The successful use of preclinical near-infrared fluorophore CW800-CA for real-time intraoperative identification of the anatomical course of the ureters with the use of a laparoscopic fluorescence imaging system is reported. METHODS The usefulness of this new imaging technique was explored in two 35-kg pigs. Intravenous CW800-CA was administered 10 minutes before fluorescence imaging was conducted with the use of a commercially available laparoscopic fluorescence imaging system. RESULTS A dose of 1 mg/mL CW800-CA (bolus injection of 3 mL) provided clear delineation of the course of both ureters by using the fluorescence mode of the laparoscope. There were no adverse reactions to the injected dye. CONCLUSION Near-infrared fluorescence laparoscopy of the ureters, following intravenous CW800-CA administration, is easily applicable and provides real-time identification of the course of the ureters.
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