Stable pneumorectum using an inline glove - a cost-effective technique to facilitate transanal total mesorectal excision

AIM

Transanal total mesorectal excision (taTME) is a novel approach for resection of the rectum. Use of a standard insufflator to create pneumorectum, however, results in bellowing-large heaving motions from insufflation of air that can frustrate surgery. We report the successful application of our technique, stable pneumorectum using an inline glove (SPRING), for the performance of transanal rectal excision in a series of 17 patients using a standard laparoscopic insufflator.

METHOD

A retrospective review of 17 patients using the SPRING technique was performed between October 2015 and October 2016. Characteristics of these patients were evaluated, and technique-related short-term outcome was reviewed.

RESULTS

The SPRING technique was successfully used in patients who underwent both minimally invasive (n = 14) and open (n = 3) approaches in the abdominal stage of the surgery. In the 12 patients who had rectal cancer for whom SPRING was used to facilitate taTME there were no conversions to an alternative access for rectal resection, the median duration of the TME part of the operation was 95 min (62-147) and there was one R1 resection (8%). Billowing was not a significant problem in any of the 17 patients during the surgery.

CONCLUSION

In this case series we have successfully shown the feasibility of the SPRING technique as a practical and cost-effective solution to the problem of billowing during taTME.

Apical lymph node dissection of the inferior mesenteric artery

AIM

It is controversial whether a high or low ligation of the inferior mesenteric artery (IMA) is superior. The former allows an extended lymph node clearance whereas the latter preserves the distal vascular supply via the left colic artery (LCA). Apical lymph node dissection of the IMA (ALMA) harvests nodal tissue along the IMA proximal to the LCA whilst performing a low ligation. This anatomically replicates the oncological benefit of high ligation and the vascular preservation of low ligation. Our study evaluates the nodal yield of ALMA and the short-term outcome of this technique.

METHOD

We retrospectively studied 19 patients with sigmoid or rectal cancer who underwent curative surgical resection with ALMA. All ALMAs were performed with a standard technique previously described (Kobayashi et al., Surg Endosc 2005, 20:563-9; Sekimoto et al. Surg Endosc 2010, 25:861-6) . The lymph node yield from the dissection (the ALMA specimen) was compared with the total lymph node yield. Data on the LCA anatomy, time required to perform ALMA, complications and postoperative recovery were evaluated.

RESULTS

ALMA was successful in 18 patients. Median postoperative hospitalization was 5 (2-26) days without ALMA-related morbidity or mortality. The median lymph node yield was 20 (9-41) and a median of 14.3 (0-80)% were harvested with ALMA. Two patients not having neoadjuvant chemoradiotherapy had fewer than 12 lymph nodes, excluding nodes harvested from ALMA. The average time required for ALMA was 18 min.

CONCLUSION

ALMA is a safe and feasible technique, allowing extended lymphadenectomy without sacrificing the LCA. In this small group of patients none were upstaged due to cancerous involvement of the proximal nodes.

Laparoscopic excision of retrorectal tumours

AIM

The aim of this study was to demonstrate a laparoscopic technique for the excision of retrorectal tumours.

METHOD

A retrospective review of cases identified from a prospectively maintained database was undertaken.

RESULTS

Ten patients (seven female; median age 45 years (range 23-79) underwent successful laparoscopic excision with no significant morbidity or intra-operative mishaps.

CONCLUSION

The procedure was deemed to be safe and we include a video to show the operative technique.

Inflammatory myofibroblastic tumour of the duodenum

Inflammatory myofibroblastic tumours (IMTs) of the duodenum and head of the pancreas are rare. They are of probable immunological aetiology and preoperatively indistinguishable from adenocarcinomas of the pancreatic head. We describe a patient with duodenal IMT and gastric outlet obstruction, and present a review of pancreatic head and duodenal IMTs in the literature. IMTs of the pancreatic head present as obstructive jaundice, while those of the duodenum present as gastric outlet obstruction. Surgery is the primary modality of treatment. Adjuvant chemotherapy and radiotherapy are controversial and reserved for incomplete resections and IMTs of a pathologically aggressive nature. Otherwise, recurrence is uncommon and surgery curative.

Chronic anastomotic sinus after low anterior resection: when can the defunctioning stoma be reversed?

AIM

Anastomotic leakage after low anterior resection may incompletely resolve, resulting in sinus tracts that persist on repeated contrast studies. This case series evaluated the factors that may contribute to sinus healing or to safe reversal of the defunctioning ileostomy.

METHOD

All patients (n = 8) who developed an anastomotic sinus after low anterior resection over an 8-year period were identified from a prospective database.

RESULTS

All patients had been treated with low anterior resections with defunctioning stomas for rectal carcinoma [median follow up 43.5 (13-84) months]. Two patients with an unhealed subclinical leak had the stoma reversed successfully. Of the six patients with clinical leakage, two healed spontaneously, one healed after application of fibrin glue, one developed an anastomotic stricture that was successfully treated by dilatation with subsequent stoma reversal, and one developed recurrent cancer and was not reversed. One patient underwent reversal, despite persistence of the sinus, followed by rectal perforation requiring laparotomy and faecal diversion. Bowel function was satisfactory where the sinus healed spontaneously, but poor where reversal was carried out without sinus healing.

CONCLUSION

Tracks that persist for longer than 1 year are unlikely to heal, but the stoma can be reversed if there had been a subclinical leak previously. A persistent anastomotic sinus leading to a cavity may not be suitable for stoma closure.

The changing trend of diverticular disease in a developing nation

AIM

Left-sided diverticular disease (LDD) is associated with reduced dietary intake, whereas right-sided diverticular disease (RDD) is more common amongst Oriental populations. We aimed to determine whether the prevalence, site and distribution of diverticular disease in our Oriental population has changed over the past two decades.

METHOD

A total of 1663 barium enema studies performed between January 2001 and August 2002 were reviewed retrospectively. The site of disease was correlated with age, gender and ethnicity of the patient.

RESULTS

Forty-five per cent of patients in the study population had diverticular disease. Older patients were more likely to have LDD, whereas the Chinese ethnic group was more likely to have RDD. Right-sided diverticular disease peaks at in the sixth decade, while for LDD this occurred in the seventh and eighth decades. Right-sided diverticular disease was more common in all age groups overall. When compared with two barium enema studies carried out in Singapore two decades earlier, there was a statistically significant increase in the incidence of RDD and LDD.

CONCLUSION

There is a positive association of RDD and LDD with Chinese race and increasing age. There is an increasing incidence of both LDD and RDD compared with two decades previously.

Comparison of chondrogensis in static and perfused bioreactor culture

As a result of the low yield of cartilage from primary patient harvests and a high demand for autologous cartilage for reconstructive surgery and structural repair, primary explant cartilage must be augmented by tissue engineering techniques. In this study, chondrocytes seeded on PLLA/PGA scaffolds in static culture and a direct perfusion bioreactor were biochemically and histologically analyzed to determine the effects of fluid flow and media pH on matrix assembly. A gradual media pH change was maintained in the bioreactor within 7.4-6.96 over 2 weeks compared to a more rapid decrease from 7.4 to 6.58 in static culture over 3 days. Seeded scaffolds subjected to 1 microm/s flow demonstrated a 118% increase (p < 0.05) in DNA content, a 184% increase (p < 0.05) in GAG content, and a 155% (p < 0.05) increase in hydroxyproline content compared to static culture. Distinct differences were noted in tissue morphology, including more intense staining for proteoglycans by safranin-O and alignment of cells in the direction of media flow. Culture of chondrocyte seeded matrices thus offers the possibility of rapid in vitro expansion of donor cartilage for the repair of structural defects, tracheal injury, and vascularized tissue damage.

The cutometer and ultrasonography in the assessment of postburn hypertrophic scar--a preliminary study

Sixteen patients with various degrees of postburn hypertrophic scars were evaluated by ultrasonography and elastometry. An Aloka Echo Camera (SSD-500) with a 7.5 MHz probe and a Cutometer SEM 575 skin elastometer were used. Serial monthly examinations were performed using both pieces of equipment. In some patients, more than one scar was assessed. The assessments were correlated with clinical grading of the progress of the scars. It was noted that ultrasonography was very sensitive in the localization of scar tissues, distinguishing them from normal skin, assessment of thickness and also delineation of the extent of scar tissues. The subcutaneous part of the scar could be assessed. Cutometer SEM 575 is a new machine that applies a gentle suction to the skin to measure its viscoelasticity. It is sensitive, the inter-observer variation is low, and it could be used for the grading of a scar. These two assessment techniques compliment other methods of scar assessment and will prove useful when assessment of response to treatment is required.

Monoclonal antibodies specific for the M- and N-forms of human glycophorin A

Four mouse monoclonal antibodies directed against the red cell membrane protein glycophorin A have been isolated and characterized. They are produced by hybridomas derived from SP2/0 myeloma cells and spleen cells from Biozzi mice immunized with a mixture of human erythrocytes from homozygous blood group M and N individuals. These antibodies recognize and bind to purified glycophorin A and to glycophorin on the red cell surface. All are of the IgGl, kappa light chain subclass and bind to determinants presented on the 39 amino acid, trypsin-sensitive, N-terminal peptide of glycophorin A. Three display differential specificities for the two allelic forms of glycophorin A; two are exquisitely specific for the M-form and one preferentially binds the N-form. Treatment of red cells with neuraminidase, which removes N-acetylneuraminic acid from glycophorin A, abolishes the binding of these three antibodies. The binding of the N-specific antibody is also sensitive to modification of the amino-terminal residue of the antigen. The fourth antibody binds equally well to both the M- and N-forms as well as to neuraminidase-treated red cells; thus it recognizes a public, N-acetylneuraminic acid independent glycophorin A determinant.