Laparoscopic Total Mesorectal Excision After 450 Cases

INTRODUCTION: The laparoscopic technique is widely adopted in the surgical treatment of colorectal carcinoma. Thus, patients benefit from the usual short-term advantages of minimally invasive surgery over classical open surgery, with comparable long-term oncological results.AIM: The study presents the experience of the Clinic for General and Endoscopic Surgery of St. Ivan Rilski University Hospital in Sofia, with laparoscopic radical rectal resections for rectal carcinoma over a 14-year period and more than 450 completed laparoscopic interventions.MATERIALS AND METHODS: From January 2009 until December 2022, 454 laparoscopic curative rectal resections for rectal carcinoma were performed. Only patients with cT1–cT3 tumors, without distant metastases, were included in the study.RESULTS: The studied group included 301 (66.3%) men and 153 (33.7%) women, aged between 34 and 86 years, with an average BMI of 26 kg/m2 (21–32 kg/m2). According to the localization of the tumor in the rectum, the patients were divided as follows: proximal 1/3 (10–15 cm)—148 (32.6%); middle 1/3 (5 < 10 cm)—203(44.7%), and distal 1/3(< 5 cm)—103 (22.7%). A total of 277 (61%) patients underwent neoadjuvant chemoradiation. Eighty-five (18.7%) of the operated were in the 1st stage, 159 (35%)—in the 2nd stage, 219 (46.3%)—in the 3rd stage. Conversion was necessary in 23 cases (5.1%). The average duration of the operative intervention was 180 minutes. (120–420 min), and the blood loss was 80 mL (20–800 mL). Intestinal passage was restored on average on the 2nd postoperative day (1–7 days). The average postoperative hospital stay was 5 days (3–17 days). Complications occurred in 35 patients (7.7%). The operated patients were followed up for an average of 36 months (3–60). The overall recurrence rate was 15.6%.CONCLUSION: Laparoscopic rectal resections for carcinoma are safe interventions, characterized by less postoperative pain, less blood loss, faster bowel recovery, shorter hospital stay, and excellent cosmetic results with comparable to open surgery oncological outcomes

Thyroglossal duct cyst carcinoma

Not required for Clinical Vignette

High Versus Low Inferior Mesenteric Artery Ligation in Rectal Cancer Surgery. A Retrospective Analysis and Review of the Literature

Introduction: Colorectal cancer is the leading cause for cancer-related mortality in both sexes worldwide. Around 30% of all colorectal cancers are situated in the rectum. They have worse clinical outcomes. Laparoscopic total mesorectal excision (TME), described first by Heald et al. in 1982, is a gold standard of treatment for rectal cancer. During the procedure the inferior mesenteric artery (IMA) should be ligated. However, whether high or low, the ligation is still controversial. Aim: The aim of this article is to investigate the advantages and disadvantages of both low and high IMA ligation during laparoscopic TME for rectal cancer treatment.Materials and Methods: We conducted a retrospective study of 77 patients operated in our department for a period of 1 year, between January 2021 and January 2022. We gathered data for gender, hospital stay, pathology findings, and perioperative complications, including anastomotic leakage, anastomotic stricture, genitourinary dysfunction, survival. We conducted a literature review and compared the results with our own experience.Results: We performed laparoscopic TME with high IMA ligation in 53 men and 24 women. The mean operative time was 270 min. The mean hospital stay was 5 days. During the period we detected anastomotic leakage in 2 patients and no strictures of the anastomosis were identified 30 days after the procedure. Conclusion: High IMA ligation is a safe and effective enough operative technique in rectal cancer treatment, which, when properly performed, does not lead to more perioperative complications than low IMA ligation, except for some anatomically related reasons

Modification of Longo procedure for high grade hemorrhoids with immediately reduction of the residual prolapse

Introduction:Hemorrhoidal disease is a common condition in humans, affecting between 4.4% and 36.4% of the general population and has been known for thousands of years. It was even described in Egyptian papyruses.The most common symptoms are prolapse, bleeding, pain, pruritus, itching, and, in some cases, incontinence.The hemorrhoid management algorithm depends mainly on the stage of the condition and the patient’s complaints. In early stages most patients just have to change their lifestyle and dietary habits. Some patients with grade I, II, and sometimes grade III hemorrhoids might need ligation, sclerotherapy, or coagulation with different devices. Surgical treatment in hemorrhoids is only needed in grade III and IV. The most popular technique, open hemorrhoidectomy, was described in 1937 by Milligan et al. Its main disadvantage is postoperative pain because of the presence of open wounds. In 1998 Longo proposed an innovative for its time technique that can deal with the postoperative pain. The problem with this procedure is the residual prolapse. Aim:The aim of this article is to present our experience with the Longo procedure for grade III and IV hemorrhoids with a modification of the technique in order to remove the postoperative residual prolapse.Materials and Methods:We present a retrospective study of 91 patients with grade III and IV hemorrhoids for a period of 1 year, between January 2021 and January 2022. All patients were operated on using a modification of the Longo procedure we present, performed by the same team. Standard parameters, like operative time, postoperative pain, hospital stay, residual prolapse, recurrence rate, and other perioperative complications were analyzed.Results:The mean operative time was 27 minutes. We used patient-controlled analgesia (PCA) in all patients and the percentage of additional postoperative pain killers was low. The mean hospital stay was 3 days. There was no residual prolapse detected immediately after the procedure.Conclusion:With this modification we solve one of the biggest disadvantages of the Longo procedure—residual prolapse. This allows us to combine the advantages of open hemorrhoidectomy techniques and stapler hemorrhoidopexy, which leads to high satisfaction rate in patients

Surgical treatment of gastrointestinal stromal tumors of the duodenum. A literature review

Background: Gastrointestinal stromal tumors (GIST) are the most frequent mesenchymal tumours in the digestive tract. The duodenal GIST (dGIST) is the rarest subtype, representing only 4–5% of all GIST, but up to 21% of the resected ones. The diagnostic and therapeutic management of dGIST may be difficult due to the rarity of this tumor, its anatomical location, and the clinical behavior that often mimic a variety of conditions; moreover, there is lack of consent for their treatment. This study has evaluated the scientific literature to provide consensus on the diagnosis of dGIST and to outline possible options for surgical treatment. Methods: An extensive research has been carried out on the electronic databases MEDLINE, Scopus, EMBASE and Cochrane to identify all clinical trials that report an event or case series of dGIST. Results: Eighty-six studies that met the inclusion criteria were identified with five hundred forty-nine patients with dGIST: twenty-seven patients were treated with pancreatoduodenectomy and ninety-six with only local resection (segmental/wedge resections); in four hundred twenty-six patients it is not possible identify the type of treatment performed (pancreatoduodenectomy or segmental/wedge resections). Conclusions: dGISTs are a very rare subset of GISTs. They may be asymptomatic or may involve symptoms of upper GI bleeding and abdominal pain at presentation. Because of the misleading clinical presentation the differential diagnosis may be difficult. Tumours smaller than 2 cm have a low biological aggressiveness and can be followed annually by endoscopic ultrasound. The biggest ones should undergo radical surgical resection (R0). In dGIST there is no uniformly adopted surgical strategy because of the low incidence, lack of experience, and the complex anatomy of the duodenum. Therefore, individually tailored surgical approach is recommended. R0 resection with 1–2 cm clear margin is required. Lymph node dissection is not recommended due to the low incidence of lymphatic metastases. Tumor rupture should be avoided

Cystic Echinococcosis of the Breast - Diagnostic Dilemma or just a Rare Primary Localization

Introduction: Although the liver and lung are the most frequently affected organs in cystic echinococcosis, the cysts may develop in any viscera and tissues. Breast is a rare primary localization with few cases described in the literature. We present an updated and systematic review and discuss the possible mechanisms of spreading, diagnostic and treatment options.Materials and methods: We performed a literature search in PUBMED using the key words &lsquo;hydatid disease&rsquo;, &lsquo;cystic echinococcosis&rsquo; and &lsquo;breast echinococcosis&rsquo; without time limitation. Only studies reporting breast cystic echinococcosis were included.Results: Overall, 121 cases with cystic echinococcosis and 2 with alveolar echinococcosis were reported. A total of 52 cases were included in the analysis. The mean size of cysts was 5.5 cm (range 1.7-12). The most common clinical presentation was painless lump presented from 4 months to 19 years before the final diagnosis. Most cases had isolated breast CE, few cases had synchronous localizations &ndash; femoral, thigh and lung, and previous liver CE. Most were active CL and CE1-2 cysts (72%). Ultrasound was used in 83%, followed by mammography (35%). Fine needle aspiration was reported in 27 cases with positive finding in 59%.Conclusions: In cases with cystic breast lesions from endemic regions we recommend the US as a gold standard. CT and MRT are more accurate but expensive tools without the potential to change the surgical tactic. In contrast to the other localizations of CE, complete excision of the cysts is the best diagnostic and treatment approach

Temporary abdominal closure techniques in open abdomen – a word of caution

The present work represent a short commentary of the article of Coccolini et al. “IROA: International Register of Open Abdomen, preliminary results” published recently in the February issue of WJES. We provide for a succinct commentary of their article and make certain useful suggestions

A CASE OF LAPAROSCOPIC-ASSISTED TREATMENT OF SMALL BOWEL INTUSSUSCEPTION DUE TO METASTASES FROM MALIGNANT MELANOMA - A WORD OF CAUTION

During the last four decades the laparoscopic surgery gradually underwent a full recognition and nowadays it is a “gold standard” treatment for many elective conditions and recently in wide variety of emergent conditions. However, its use in bowel obstruction is still under debate and high-level evidence are lacking. Herein we present a case of 36-year-old man with small bowel intussusception due to metastases from melanoma initially treated laparoscopically. Diagnostic challenges and pitfalls of laparoscopic treatment are discussed. Multiple gastrointestinal metastases should be considered in all cases with small bowel obstruction and a history of melanoma. Although laparoscopy is increasingly used in emergency setting and appears to be feasible and safe treatment of small bowel obstruction it should be used with a caution in cases with suspected metastasized malignant melanoma