Toward less invasive coloproctology: The future is out there

Medical care has undergone remarkable improvements over the past few decades. One of the most important innovative breakthroughs in modern medicine is the advent of minimally and less invasive treatments. The trend towards employing less invasive treatment has been vividly shown in the field of gastroenterology, particularly coloproctology. Parallel to foregut interventions, colorectal surgery has shifted towards a minimally invasive approach. Coloproctology, including both medical and surgical management of colorectal diseases, has undergone a remarkable paradigm shift. The treatment of both benign and malignant colorectal conditions has gradually transitioned towards more conservative and less invasive approaches. An interesting paradigm shift was the trend to avoid the need for radical resection of rectal cancer altogether in patients who showed complete response to neoadjuvant treatment. The trend of adopting less invasive approaches to treat various colorectal conditions does not seem to be stopping soon as further research on novel, more effective and safer methods is ongoing.

Long-term changes in psoas muscle mass after lobectomy and segmentectomy for early-stage lung cancer

BACKGROUND

Segmentectomy is considered a less invasive procedure than lobectomy for patients with non-small cell lung cancer (NSCLC); however, little is known about the physiological mechanism underlying the lower invasiveness of segmentectomy. This study is aimed to compare the differences in the long-term changes in the psoas muscle mass after segmentectomy and lobectomy in patients with NSCLC.

METHODS

Overall 315 recurrence-free patients who underwent segmentectomy (n = 93) or lobectomy (n = 222) for clinical stage 0-I NSCLC between January 2016 and December 2018 and underwent computed tomography during the entire period of 6 months ≤ postoperative year (POY) 0.5 < 12 months, 12 months ≤ POY 1 < 24 months, 24 months ≤ POY 2 < 36 months, and 36 months ≤ POY 3 < 48 months were included. Bilateral psoas muscle area (PMA) at the L3 level was measured using each cross-sectional computed tomography scan. Differences between the segmentectomy and lobectomy groups in the mean change of postoperative PMA from the preoperative period were analysed using Student's t-test and mixed analysis of variance. Multivariable analysis was performed to identify the risk factors for PMA loss on POY 3 using logistic regression analysis.

RESULTS

The lobectomy group had a significantly larger PMA change than the segmentectomy group during each postoperative period (P < 0.001). Mixed analysis of variance revealed that the mean PMA change was significantly smaller in the segmentectomy group than in the lobectomy group during the observation period (P < 0.001). The mean change in the PMA was significantly larger from POY1 (-2.5%) to POY2 (-3.9%) and POY3 (-4.7%) in the lobectomy group (P = 0.003 and P < 0.001). However, PMA remained unchanged during the postoperative observation period in the segmentectomy group. In the multivariable analysis, the risk factors for PMA change ≤-3.3% (cut-off: mean change of PMA) at POY3 included lobectomy [odds ratio (OR), 3.32; 95% confidence interval (CI), 1.90-5.82; P < 0.001], male sex (OR, 1.92; 95% CI, 1.02-3.62; P = 0.044) and open thoracotomy (OR, 1.84; 95% CI, 1.11-3.05; P = 0.017). After propensity score matching, the mean change in PMA was smaller in the segmentectomy group (n = 75) than in the lobectomy group (n = 75) during the postoperative observation period (P < 0.001).

CONCLUSIONS

Psoas muscle mass was better maintained during the postoperative period by segmentectomy than by lobectomy. Psoas muscle mass reduction progressed over a long postoperative period after lobectomy. Segmentectomy via complete video-assisted thoracic surgery is associated with a lower likelihood of sarcopenia progression.

Three-dimensional printed cast assisted screw fixation of calcaneal fractures: a prospective study

BACKGROUND

Treatment of displaced intra-articular calcaneal fractures (DIACFs) with percutaneous screw fixation remains defective in some aspects. A novel three-dimensional (3D) printed cast was devised to assist screw placement. This study assessed the radiological and functional outcomes of 3D-printed cast assisted screw fixation for patients with DIACFs.

METHODS

Patients with unilateral Sanders type II or III DIACFs admitted to a single-centre hospital underwent either 3D-printed cast assisted screw fixation (3D group) or minimally invasive plate fixation (control group) from September 2020 to November 2022. All patients were assessed at one, two, three, and six months of follow-up. Comparison between groups was conducted in operative duration, fluoroscopic times, radiographic measurements of the calcaneus, and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score.

RESULTS

A total of 32 patients were enrolled (19 in the 3D group versus 13 in the control group). Significant differences were detected between the 3D group and control group in operative duration (53.63±8.95 min, 95.08±8.31 min, P <0.001), fluoroscopic times (7.37±1.21, 16.85±1.57, P <0.001). At a follow-up of six months, the 3D group showed better restoration than the control group in calcaneal width, height, Bohler angle, and AOFAS Ankle-Hindfoot scores (all P <0.001). No significant differences were shown in calcaneal length and Gissane angle (P >0.05). No wound-related complications occurred in either group.

CONCLUSION

The 3D-printed cast assisted screw fixation has shown superiority over minimally invasive plate fixation in the operative duration, fluoroscopic exposure, morphological restoration of the calcaneus, and functional outcomes in the treatment of DIACFs.

Less invasive, simultaneous, and continuous measurements of locomotor activity and body temperature using the nano tag® small accelerometer device in cynomolgus monkeys

Locomotor activity and body temperature evaluations of cynomolgus monkeys are useful to understand the effects of drugs on the central nervous system. Here, we describe a simple, inexpensive, and less invasive evaluation method using the nano tag® (KISSEI COMTEC Co., Ltd.), a small three-axis accelerometer device with a temperature sensor. Nano tags® were subcutaneously implanted in four cynomolgus monkeys that had been intraperitoneally implanted with a telemetry transmitter. Then, body temperature and locomotor activity counts were simultaneously and continuously measured by both the nano tag® and telemetry transmitter for 14 days after nano tag® implantation. The invasiveness of the implantation surgery was evaluated by recovery after surgery, and the validity of each nano tag® parameter was evaluated by comparison with the telemetry system data. Additionally, locomotor activity and body temperature changes induced by treatment with ketamine, a noncompetitive N-methyl-d-aspartate receptor antagonist, were evaluated by the nano tag®. Recovery from nano tag® implantation surgery was observed at 7 days postoperative, indicating that nano tag® was less invasive than a telemetry transmitter. Both of the parameter profiles measured by nano tag® were approximately comparable to those of the telemetry system. Moreover, the nano tag® could detect ketamine-induced pharmacological changes of decreases in both parameters. The present study demonstrates that nano tag® is an effective, simple, and less invasive tool for locomotor activity and body temperature evaluations in cynomolgus monkeys. This proposed easier method could help researchers evaluate central nervous system effects in cynomolgus monkeys.

Less-Invasive Diagnostic Approaches for Infants with Suspected Differences of Sex Development: A Case Report of a 297-g Neonate with Ambiguous Genitalia

Less-invasive diagnostic approaches for low-birthweight preterm neonates with suspected differences of sex development have not been established. Herein, we describe our diagnostic approaches for a 297-g neonate with ambiguous genitalia. Using a fiberscope, the external genitalia were inspected in an incubator to minimize the risk of hypothermia and infection. Endotracheal aspirate, collected during routine care, was used for genetic testing to avoid anemia and vital signs fluctuations caused by peripheral blood sampling. Array comparative genomic hybridization indicated a 46,XY karyotype. No pathogenic variants of AR and SRD5A2 were found. Endocrinological data could not be evaluated owing to the absence of reference data. Identification and structural evaluation of the internal genitalia and gonads were difficult. On postnatal day 42, the parents assigned their baby's sex as male. Our less-invasive diagnostic approaches of inspection and genetic testing are useful for management, including sex assignment in extremely low-birthweight preterm neonates with ambiguous genitalia.

The dataset on the clipped cerebral aneurysm and their radiological findings in three-dimensional computed tomography, time-of-flight magnetic resonance angiography (TOF-MRA), and Pointwise Encoding Time Reduction with Radial Acquisition (PETRA)-MRA

These data present the 141 intracranial arterial branches' visibilities near the 72 cerebral aneurysms in postoperative 58 patients treated with titanium or cobalt-chromium-nickel-molybdenum (CCNM) alloy clips. The visibilities were evaluated using time-of-flight magnetic resonance angiography (TOF-MRA), pointwise encoding time reduction with radial acquisition (PETRA)-MRA, which uses MRA with ultrashort echo time (UTE-MRA) and subtraction technique between saturated and non-saturated images, and three-dimensional computed tomography angiography (3DCTA). We retrospectively acquired the data from the medical records of Suwa Red Cross Hospital. Each method's appearance was compared, and associations between visibility on PETRA-MRA, arterial diameter, clip numbers, clip shapes, clip materials, and amounts of hematoma were summarized. Our article on PETRA-MRA's usefulness for proximal and branched arteries evaluation after cerebral aneurysm clipping [1] was based on these data. This dataset would be useful for reference value for other neurosurgeons or radiologists for further analysis on PETRA-MRA and another UTE-MRA like SILENT-MRA after cerebral aneurysm clipping.

Thoracoscopy-thoracotomy approach for an aortoesophageal fistula: a case report

An aortoesophageal fistula is often fatal, and standard radical surgery is highly invasive because both bilateral thoracotomy and laparotomy are required. We successfully incorporated thoracoscopic esophagectomy into this procedure for a 43-year-old man with an aortoesophageal fistula. After detaching the esophagus from the adjacent tissue, and leaving just the fistula in the right thoracoscopic procedure, we performed an open aortic graft replacement. Subsequently, we created an omental pedicle graft and wrapped it over the graft. Through this thoracoscopy-thoracostomy approach, minimal destruction of the right thoracic wall was achieved and the successful dissection of the diseased esophagus could be carried out while reducing the amount of bleeding during anticoagulation for cardiopulmonary bypass, and the field of view for the aortic replacement was not disturbed during left thoracotomy. Four months later, we reconstructed the esophagus by a pedunculated small intestinal graft through the ante-thoracic route. A thoracoscopy-thoracotomy approach is therefore considered to be effective and useful for treating a patient with an aortoesophageal fistula.

Magnetic resonance angiography with ultrashort echo time evaluates cerebral aneurysm with clip

Contrast-enhanced computed tomography angiography is usually valuable for the evaluation of clipped cerebral aneurysm, but it has side effects of contrast medium. Time-of-flight magnetic resonance angiography (MRA) is a non-invasive and fast method. However, clip-induced artifact limits assessment of the artery in the vicinity of a clip. MRA with ultrashort echo time (TE) reduces metal artifact. We use MAGNETOM Aera 1.5T (SIEMENS, München, Germany) and perform pointwise encoding time reduction with radial acquisition (PETRA)-MRA using ultrashort TE for the assessment of the cerebral aneurysm after clipping. We, herein, presented two representative cases with a clipped aneurysm which could be evaluated by PETRA- MRA. Especially in one of them, the neck remnant was revealed by PETRA-MRA. PETRA-MRA can reduce the time and the invasiveness and may be helpful for the usual follow-up of the clipped aneurysm with the development of MRA technology in the future.

Contemporary less invasive spinal instrumentation for AO C-type posterior pelvic ring injuries

OBJECTIVE

This study evaluates efficacy and safety of contemporary spinal instrumentation for AO/type C posterior pelvic ring (PPR) injuries.

METHODS

Twenty-two consecutive patients, aged 36 ± 17 years, were managed with spinal instrumentation with spinopelvic fixation (SPF) or non-spinopelvic fixation (NSPF) and less invasive surgery. There were 16 vertically unstable sacral fractures and six iliosacral dislocations. Matta score was used for fragment diastasis and Majeed's score for functional outcome evaluation.

RESULTS

All patients were followed for 61 ± 8 months postoperatively. The operative time was less in NSPF (P < 0.001). SPF was applied in six cases and NSPF in 16 cases. Postoperatively, fragment diastasis was reduced from 16 ± 13 to 2.6 ± 3.8 mm (P < 0.000). There was no statistically significant difference in fracture reduction between SPF and NSPF (P = 0.16). Majeed score was 83 ± 16 postoperatively. There was a significant correlation between Matta score and Majeed score (P = 0.013). There were two cases with spinal instrumentation failure. Low-grade infection occurred in one patient, without hardware failure, that was eradicated after hardware removal. From ten patients with incomplete neurologic impairment on admission, eight showed postoperatively full and two partial recovery without direct sacral decompression. Patients with preoperative neurologic impairment showed lower postoperative Majeed score than those without neurologic impairment (P = 0.027). There was no correlation between neurologic impairment and recovery and type of PPR injury.

CONCLUSIONS

SPF and NSPF with contemporary spinal instrumentation for C AO-type PPR injury with less invasive methods are safe and effective techniques that reduce and maintain PPR disruption allowing early mobilization, neurologic recovery and improved Majeed score. These slides can be retrieved under electronic supplementary material.

A unilateral less invasive posterolateral approach for disc debridement and titanium cage insertion supplemented by contralateral transfascial screw fixation for high-morbidity patients suffering from septic thoracolumbosacral spondylodiscitis

PURPOSE

This case series reports on the efficacy and safety of a less invasive posterolateral approach for septic thoracolumbosacral spondylodiscitis in high-morbidity patients.

METHODS

Twenty consecutive severe sick (ASA > III) patients (14 men and 6 women), with an average age of 64 ± 14 years, suffering from septic subacute and chronic thoracolumbosacral spondylodiscitis were selected to undergo a one-stage less invasive unilateral posterolateral disc space debridement, supplemented by an ipsilateral titanium cage implantation and pedicle screw fixation plus a contralateral transfascial pedicle screw fixation.

RESULTS

Two high-risk patients with severe comorbidities (ASA stage IV and V, respectively) died on days 1 and 8 postoperatively because of non-surgical complications such as massive lung embolism and acute myocardial infract, respectively. Three patients with incomplete paraplegia (ASIA C) preoperatively were improved after the surgery to ASIA D (two patients) and E (one patient), respectively, while there was no neurological deterioration in any patient postoperatively. From the 18 patients that survived, ten patients were available for the final follow-up 8.8 ± 2.7 years postoperatively. In two patients with spondylodiscitis caused by gram(-) bacteria, the posterior instrumentation was finally removed because of asymptomatic fistula emerging from posterior instrumentation solely, 15 and 19 months after surgery. The survivals at 2.5 and 10 years with revision as end point was 87.4% (95% CI 58.1-96.7); while in the "worst case scenario" the survivals at 2.5 and 10 years were: 66.7% (95% CI 40.4-83.4%); 47.7% (95% CI 23.2-68.8%) and 47.7% (95% CI 23.2-68.8%), respectively.

CONCLUSIONS

The less invasive posterolateral approach for disc debridement and titanium cage insertion seems to be an alternative surgery for severe sick adult immunosuppressed patients with septic thoracolumbosacral spondylodiscitis that cannot tolerate traditional open transthoracic, thoracolumbar, retroperitoneal or combined approaches. The study has been registered in the Public Registry ClinicalTrials.gov PRS with the ID: NCT03472131.

Sinus Tarsi Approach with Screws-Only Fixation for Displaced Intra-Articular Calcaneal Fractures

Treatment of displaced intra-articular calcaneal fractures has changed numerous times in the last decades. Currently, less invasive surgery has reemerged and is increasingly used. The sinus tarsi approach is most commonly used. It combines the open approach to the subtalar joint with percutaneous reduction of the overall shape of the calcaneus. The results in the literature show overall similar functional outcome compared with the extended lateral approach, however with a significant reduction in wound complications. This article deals with the sinus tarsi approach in which the reduction is fixated using screws only. Indications, surgical technique, and possible pitfalls are discussed.

Cortical Bone Trajectory Screw Fixation in the Upper and Middle Thoracic Spine (T1-T8): An Anatomic and Radiographic Assessment

OBJECTIVE

To assess an alternative method of cortical bone trajectory (CBT) screw placement in the thoracic spine from T1 to T8 and to investigate the proper entry point, screw insertion angle, screw length, and diameter.

METHODS

Computed tomography images of 80 patients were used to measure all related parameters. Ten cadaveric spines were studied and 4.5-mm screws were inserted into both sides of the vertebrae. Computed tomography of all vertebrae previously inserted with CBT screws was performed and lateral or medial pedicle wall violation was checked.

RESULTS

Of the inserted 160 CBT screws, 41.25% (66/160) penetrated the lateral pedicle wall, and the proportion of medial pedicle wall violation accounted for 0.625% (1/160). Maximal screw length tended to gradually increase from T1 to T8 (from 24.54 mm at T1 to 29.53 mm at T8). Compared with T4 and T5, maximal screw diameters of other thoracic levels were wider, ranging from 4.63 mm at T4 to 5.53 mm at T8. The greatest lateral angle was 8.66° in men and 8.39° in women at T8, whereas the smallest lateral angle was 4.97° in men and 4.67° in women at T1. The cephalad angle ranged from 17.23° at T7 to 31.50° at T1 and it was significantly larger in men at T7 (P < 0.05), T6 and T8 (P < 0.01).

CONCLUSIONS

Based on the results of this study, we suggest that patients could be placed with 4.5 × 25.0-30.0 mm CBT screws from T1 to T8 through the pedicle or pedicle rib unit.

Bikini Line Sleeve Gastrectomy: Initial Report

BACKGROUND/INTRODUCTION

Several reports have discussed the potential for reducing port access in laparoscopic sleeve gastrectomy (LSG); however, each approach had its innate setbacks. Aiming at improving the aesthetic outcome, we report a novel approach to the LSG where we place the trocars at the bikini line in what we described as bikini line sleeve gastrectomy (BLSG).

METHODS

The present work is a prospective, pilot study on the use of BLSG in patients, during the period between April and October 2016. Exclusion criteria included the following: large hiatal hernia, upper abdominal surgery, and xiphi-umbilical, xiphi-symphysis pubis, and xiphi-anterior superior iliac spine distances of > 25,36 and 33 cm, respectively. Four trocars were used: one at the umbilicus and three at the bikini line. All laparoscopic graspers were bariatric length instruments (43 cm). However, camera telescope, endoscopic stapler, and bipolar dissectors were standard length.

RESULTS

Twenty eight patients underwent BLSG. The mean age was 34.6 ± 3.7 years with a mean BMI of 42.46 kg/m² ± 3. There were no major intra- or postoperative complications and no conversion to conventional port site placement. Patient's scar satisfaction was favorable. The mean postoperative BMI and weight at 6 m were 28.5 ± 1 kg/m² and 79.8 kg ± 2, respectively. The mean percentage excess weight loss at 3, 6, and 12 months were 39.5 ± 4.6, 64.5 ± 5, and 69.8 ± 6%, respectively.

CONCLUSION

BLSG was found to be potentially safe, feasible, and effective with a favorable aesthetic outcome; it could possibly be offered to a select group of patients that are conscious about their scar appearance.

Transpedicular direct osteosynthesis of hangman's fracture from a mini-open exposure as a less invasive procedure: A technical note

This surgical technical case report presents initial clinical experience and preliminary results with a less invasive surgical solution for selected hangman's fracture. A well-known stabilization technique (i.e. direct transpedicular osteosynthesis) was applied through a minimally invasive small incision transmuscular posterior approach guided by a standard C-arm fluoroscopy. This mini-open approach to C2 vertebra allows similar dissection, visualization of the bony landmarks, visual control of the transpedicular screw path drilling, tapping and screw insertion to the standard posterior cervical spine approach. At the same time it has the benefits of less invasive procedures.

Left Ventricular Assist Device Therapy for Destination Therapy: Is Less Invasive Surgery a Safe Alternative?

INTRODUCTION AND OBJECTIVES

The number of older patients with congestive heart failure has dramatically increased. Because of stagnating cardiac transplantation, there is a need for an alternative therapy, which would solve the problem of insufficient donor organ supply. Left ventricular assist devices (LVADs) have recently become more commonly used as destination therapy (DT). Assuming that older patients show a higher risk-profile for LVAD surgery, it is expected that the increasing use of less invasive surgery (LIS) LVAD implantation will improve postoperative outcomes. Thus, this study aimed to assess the outcomes of LIS-LVAD implantation in DT patients.

METHODS

We performed a prospective analysis of 2-year outcomes in 46 consecutive end-stage heart failure patients older than 60 years, who underwent LVAD implantation (HVAD, HeartWare) for DT in our institution between 2011 and 2013. The patients were divided into 2 groups according to the surgical implantation technique: LIS (n = 20) vs conventional (n = 26).

RESULTS

There was no statistically significant difference in 2-year survival rates between the 2 groups, but the LIS group showed a tendency to improved patient outcome in 85.0% vs 69.2% (P = .302). Moreover, the incidence of postoperative bleeding was minor in LIS patients (0% in the LIS group vs 26.9% in the conventional surgery group, P < .05), who also showed lower rates of postoperative extended inotropic support (15.0% in the LIS group vs 46.2% in the conventional surgery group, P < .05).

CONCLUSIONS

Our data indicate that DT patients with LIS-LVAD implantation showed a lower incidence of postoperative bleeding, a reduced need for inotropic support, and a tendency to lower mortality compared with patients treated with the conventional surgical technique.

Navigated Pin-Point Approach to Osteoid Osteoma Adjacent to the Facet Joint of Spine

Osteoid osteoma (OO) is a benign osteoblastic tumor. Its curative treatment is complete removal of the nidus, where intraoperative localization of the nidus governs clinical results. However, treatment can be difficult since the lesion is often invisible over the bony surface. Accordingly, establishment of an ideal less invasive surgical strategy for spinal OO remains yet unsettled. We illustrate the efficacy of a computed tomography (CT)-based navigation system in excising OO located adjacent to the facet joint of spine. In our 2 cases, complete and pin-point removal of the nidus located close to the facet joint was successfully achieved, without excessive removal of the bone potentially leading to spinal instability and possible damage of nearby neurovascular structures. We advocate a less invasive approach to spinal OO, particularly in an environment with an available CT-based navigation system.

Mini Open Foraminotomy for Cervical Radiculopathy: A Comparison of Large Tubular and TrimLine Retractors. Asian Spine J. 2015;9:548-552. [PMID: 26240713 PMCID: PMC4522444 DOI: 10.4184/asj.2015.9.4.548]

Study Design

Retrospective chart review.

Purpose

A comparison of mini open foraminotomy (MOF) for cervical radiculopathy using either large tubular (LT) or TrimLine (TL) retractors.

Overview of Literature

Posterior foraminotomy relieves compression of the cervical nerve root in radiculopathy patients. However, invasion of the paravertebral muscle may cause major problems in these patients. To address these problems, we performed MOF.

Methods

Twenty cervical radiculopathy patients (16 male and 4 female) who underwent MOF between May 2004 and August 2011 were assigned to LT and TL groups. Each group contained 10 subjects. Surgical and clinical outcomes were compared.

Results

The average operating time in the TL group was significantly shorter than that in the LT group. The final follow-up mean neck disability indices significantly improved compared to the preoperative values (LT group, 12.0±7.8 vs. 28.0±9.4; TL group, 6.0±5.9 vs. 21.9±10). The final follow-up neck pain visual analog scale (VAS) scores also decreased significantly from the preoperative of 8.0±1.5 and 2.5±2.5 to the final follow-up values of 2.2±2.2 and 1.0±2.5 in the LT and TL groups, respectively. The recovery rate for the neck pain VAS score was 70.0±31.9 in the LT group and 87.0±32.0 in the TL group, thus suggesting no significant difference between the two groups.

Conclusions

MOF with the TL retractor is an easy and safe procedure. Furthermore, the use of the TL retractor allows for a minimally invasive and effective surgical treatment of cervical radiculopathy patients.