Estudio de casos y controles entre anastomosis intra y extracorpórea en pacientes intervenidos de hemicolectomía derecha laparoscópica

Introduction: There is still insufficient scientific evidence on which is the best technique to perform the anastomosis -intracorporeal (IC) or extracorporeal (EC)- in right laparoscopic hemicolectomy. The objective of the present study is to determine whether there are differences to compare in both techniques. Material and methods: A study was performed on a prospective patient series subjected to right laparoscopic hemicolectomy in our Hospital. The preoperative and the postoperative variables associated with complications recorded depending on the type of anastomosis. Results: A total of 60 patients were intervened form June 2004 to June 2010 (35 IC; 25 EC). There were no significant differences between both groups as regards baseline preoperative characteristics or associated comorbidities. The median operation time was 212 minutes (142-305 min), with no significant difference between both techniques. The number of lymph nodes removed was higher in the IC group (21 versus 14; p = 0.03). The beginning of oral tolerance and the first bowel movement were significantly earlier in the IC group. The complications rate was similar for both groups (14% IC; 16% EC; p = 0.89). Three patients in the IC group had anastomosis dehiscence. The mortality rate was 2.8% (one patient in each group). Conclusion: Intracorporeal versus extracorporeal anastomosis in right laparoscopic hemicolectomy can obtain a higher number of resected lymph nodes and an earlier oral tolerance and intestinal transit

Fluorescence-guided surgical sampling of glioblastoma identifies phenotypically distinct tumour-initiating cell populations in the tumour mass and margin.

BACKGROUND: Acquiring clinically annotated, spatially stratified tissue samples from human glioblastoma (GBM) is compromised by haemorrhage, brain shift and subjective identification of 'normal' brain. We tested the use of 5-aminolevulinic acid (5-ALA) fluorescence to objective tissue sampling and to derive tumour-initiating cells (TICs) from mass and margin. METHODS: The 5-ALA was administered to 30 GBM patients. Samples were taken from the non-fluorescent necrotic core, fluorescent tumour mass and non-fluorescent margin. We compared the efficiency of isolating TICs from these areas in 5-ALA versus control patients. HRMAS (1)H NMR was used to reveal metabolic alterations due to 5-ALA. We then characterised TICs for self-renewal in vitro and tumorigenicity in vivo. RESULTS: The derivation of TICs was not compromised by 5-ALA and the metabolic profile was similar between tumours from 5-ALA patients and controls. The TICs from the fluorescent mass were self-renewing in vitro and tumour-forming in vivo, whereas TICs from non-fluorescent margin did not self-renew in vitro but did form tumours in vivo. CONCLUSION: Our data show that 5-ALA does not compromise the derivation of TICs. It also reveals that the margin contains TICs, which are phenotypically different from those isolated from the corresponding mass

Long splenic flexure carcinoma requiring laparoscopic extended left hemicolectomy with CME and transverse-rectal anastomosis. technique for a modified partial Deloyers in 5 steps to achieve enough reach and preserving middle colic vessels

Introduction: This How-I-Do-It article presents a modified Deloyers procedure by mean of the case of a 67-year-old female with adenocarcinoma extending for a long segment and involving the splenic flexure and proximal descending colon who underwent a laparoscopic left extended hemicolectomy (LELC) with derotation of the right colon and primary colorectal anastomosis. Background: While laparoscopic extended right colectomy is a well-established procedure, LELC is rarely used (mainly for distal transverse or proximal descending colon carcinomas extending to the area of the splenic flexure). LELC presents several technical challenges which are demonstrated in this How-I-Do-It article. Technique and methods: Firstly, the steps needed to mobilize the left colon and procure a safe approach to the splenic flexure are described, especially when a tumor is closely related to it. This is achieved by mobilization and resection of the descending colon, while maintaining a complete mesocolic excision to the level of the duodenojejunal ligament for the inferior mesenteric vein and flush to the aorta for the inferior mesenteric artery. Subsequently, we depict the adjuvant steps required to enable a primary anastomosis by trying to mobilize the transverse colon and release as much of the mesocolic attachments at the splenic flexure area. Finally, we present the rare instance when a laparoscopic derotation of the ascending colon is required to provide a tension-free anastomosis. The resection is completed by delivery of the fully derotated ascending colon and hepatic flexure through a suprapubic mini-Pfannenstiel incision. The primary colorectal anastomosis is subsequently fashioned in a tension-free way and provides for a quick postoperative recovery of the patient. Results: This modified Deloyers procedure preserves the middle colic since the fully mobilized mesocolon allows for a tension-free anastomosis while maintaining better blood supply to the mobilized stump. Also, by eliminating the need for a mesenteric window and the transposition of the caecum, we allow the small bowel to rest over the anastomosis and the mobilized transverse colon and reduce the possibility of an internal herniation of the small bowel into the mesentery. Conclusions: Laparoscopic derotation of the right colon and a partial, modified Deloyers procedure preserving the middle colic vessels are feasible techniques in experienced hands to provide primary anastomosis after LELC with improved functional outcome. Nevertheless, it is important to consider anatomical aspects of the left hemicolectomy along with oncological considerations, to provide both a safe oncological resection along with good postoperative bowel function

Protective ileostomy creation after anterior resection of the rectum: shared decision-making or still subjective?

The choice to perform protective ileostomy (PI) after anterior resection (AR) is mainly guided by risk factors (RFs) responsible for anastomotic leakage (AL) development. However, clear guidelines about PI creation are still lacking in the literature and this is often decided according to the surgeon's preferences, experiences, or feelings. This qualitative study aims to investigate by an open-ended question survey, the individual surgeon's decision-making process regarding PI creation after elective AR. Fifty-four colorectal surgeons took part in an electronic survey to answer the questions and describe what usually led their decision to perform PI. A content analysis was used to code the answers. To classify answers, five dichotomous categories (In favour/Against PI, Listed/Not listed RFs, Typical/Atypical, Emotions/Non-emotions, Personal experience/No personal experience) have been developed. Overall, 76% of surgeons were in favour of PI creation and 88% considered listed RFs in the question to perform PI. Atypical answers were reported in 10% of cases. Emotions and personal experience influenced surgeons' decision-making process in 22% and 49% of cases, respectively. The most frequent considered RFs were the distance of the anastomosis from the anal verge (96%), neoadjuvant chemoradiotherapy (88%), positive intraoperative leak test (65%), blood loss (37%), and immunosuppression therapy (35%). The indications to perform PI following rectal cancer surgery lack standardization and evidence-based guidelines are required to inform practice. Until then, experts' opinions can be helpful to assist the decision-making process in patients who underwent AR for adenocarcinoma