Resection of polyps involving the appendiceal orifice by combined endo-laparoscopic surgery: Two case reports

BACKGROUND The management of polyps involving the appendiceal orifice(AO)presents notable challenges.Endoscopic resection is frequently hindered by operational complexities,a heightened risk of incomplete removal,and an elevated risk of procedural complications,including appendicitis.Conversely,surgical resection may entail unnecessary excision of intestinal segments,leading to potential morbidity.CASE SUMMARY Here,we reported two patients who presented with polyps deeply situated within the AO,with indistinct boundaries making it challenging to ensure completeness using traditional endoscopic resection.To overcome these challenges,we em-ployed combined endo-laparoscopic surgery(CELS),achieving curative resection without postoperative complications.CONCLUSION The application of CELS in managing polyps involving the AO is emerging as a safe and effective treatment modality.

Robotic vs laparoscopic abdominoperineal resection for rectal cancer:A propensity score matching cohort study and metaanalysis

BACKGROUND Robotic surgery(RS)is gaining popularity;however,evidence for abdominoperineal resection(APR)of rectal cancer(RC)is scarce.AIM To compare the efficacy of RS and laparoscopic surgery(LS)in APR for RC.METHODS We retrospectively identified patients with RC who underwent APR by RS or LS from April 2016 to June 2022.Data regarding short-term surgical outcomes were compared between the two groups.To reduce the effect of potential confounding factors,propensity score matching was used,with a 1:1 ratio between the RS and LS groups.A meta-analysis of seven trials was performed to compare the efficacy of robotic and laparoscopic APR for RC surgery.RESULTS Of 133 patients,after propensity score matching,there were 42 patients in each group.The postoperative complication rate was significantly lower in the RS group(17/42,40.5%)than in the LS group(27/42,64.3%)(P=0.029).There wasno significant difference in operative time(P=0.564),intraoperative transfusion(P=0.314),reoperation rate(P=0.314),lymph nodes harvested(P=0.309),or circumferential resection margin(CRM)positive rate(P=0.314)between the two groups.The meta-analysis showed patients in the RS group had fewer positive CRMs(P=0.04),lesser estimated blood loss(P<0.00001),shorter postoperative hospital stays(P=0.02),and fewer postoperative complications(P=0.002)than patients in the LS group.CONCLUSION Our study shows that RS is a safe and effective approach for APR in RC and offers better short-term outcomes than LS.

Machine learning as a tool predicting short-term postoperative complications in Crohn’s disease patients undergoing intestinal resection: What frontiers?

The recent study,“Predicting short-term major postoperative complications in intestinal resection for Crohn’s disease:A machine learning-based study”invest-igated the predictive efficacy of a machine learning model for major postoperative complications within 30 days of surgery in Crohn’s disease(CD)patients.Em-ploying a random forest analysis and Shapley Additive Explanations,the study prioritizes factors such as preoperative nutritional status,operative time,and CD activity index.Despite the retrospective design’s limitations,the model’s robu-stness,with area under the curve values surpassing 0.8,highlights its clinical potential.The findings align with literature supporting preoperative nutritional therapy in inflammatory bowel diseases,emphasizing the importance of compre-hensive assessment and optimization.While a significant advancement,further research is crucial for refining preoperative strategies in CD patients.

Novel prognostic factors after radical resection of hepatocellular carcinoma: Updating an old issue

In this editorial,I comment on the article by Li et al published in the recent issue of the World Journal of Gastrointestinal Surgery in 2023,investigating the role of some novel prognostic factors for early survival after radical resection of liver cancer.Liver cancer is an important burden among Asian and Western popu-lations,despite recent advances in both medicine(from virus eradication to systemic target therapies)and surgery.However,survival after proven radical surgery remains poor,with recurrences being the rule.Many prognostic scores have been developed and validated to select those patients who will best benefit from radical liver surgery,although the final general and oncological outcomes continue to be highly jeopardized.Unfortunately,no single biomarker can resolve all these issues for hepatocellular carcinoma,and it remains to be proven whether some of them main-tain predictive power in the long-term follow-up.In the ongoing era of“preci-sion”medicine,the novel prognostic markers,including immune inflammatory and nutritional indexes could be of great help in better stratify surgical candi-dates.

Robotic natural orifice specimen extraction surgery I-type F method vs conventional robotic resection for lower rectal cancer

BACKGROUND Robotic resection using the natural orifice specimen extraction surgery I-type F method(R-NOSES I-F)is a novel minimally invasive surgical strategy for the treatment of lower rectal cancer.However,the current literature on this method is limited to case reports,and further investigation into its safety and feasibility is warranted.AIM To evaluate the safety and feasibility of R-NOSES I-F for the treatment of low rectal cancer.METHODS From September 2018 to February 2022,206 patients diagnosed with low rectal cancer at First Affiliated Hospital of Nanchang University were included in this retrospective analysis.Of these patients,22 underwent R-NOSES I-F surgery(RNOSES I-F group)and 76 underwent conventional robotic-assisted low rectal cancer resection(RLRC group).Clinicopathological data of all patients were collected and analyzed.Postoperative outcomes and prognoses were compared between the two groups.Statistical analysis was performed using SPSS software.RESULTS Patients in the R-NOSES I-F group had a significantly lower visual analog score for pain on postoperative day 1(1.7±0.7 vs 2.2±0.6,P=0.003)and shorter postoperative anal venting time(2.7±0.6 vs 3.5±0.7,P<0.001)than those in the RLRC group.There were no significant differences between the two groups in terms of sex,age,body mass index,tumor size,TNM stage,operative time,intrao-perative bleeding,postoperative complications,or inflammatory response(P>0.05).Postoperative anal and urinary functions,as assessed by Wexner,low anterior resection syndrome,and International Prostate Symptom Scale scores,were similar in both groups(P>0.05).Long-term follow-up revealed no significant differences in the rates of local recurrence and distant metastasis between the two groups(P>0.05).CONCLUSION R-NOSES I-F is a safe and effective minimally invasive procedure for the treatment of lower rectal cancer.It improves pain relief,promotes gastrointestinal function recovery,and helps avoid incision-related complications.

Accurate resection of hilar cholangiocarcinoma using eOrganmap 3D reconstruction and full quantization technique

BACKGROUND For treatment of hilar cholangiocarcinoma(HCCA),the rate of radical resection is low and prognosis is poor,and preoperative evaluation is not sufficiently accurate.3D visualization has the advantage of giving a stereoscopic view,which makes accurate resection of HCCA possible.AIM To establish precise resection of HCCA based on eOrganmap 3D reconstruction and full quantification technology.METHODS We retrospectively analyzed the clinical data of 73 patients who underwent HCCA surgery.All patients were assigned to two groups.The traditional group received traditional 2D imaging planning before surgery(n=35).The eOrganmap group underwent 3D reconstruction and full quantitative technical planning before surgery(n=38).The preoperative evaluation,anatomical classification of hilar hepatic vessels,indicators associated with surgery,postoperative complications,liver function,and stress response indexes were compared between the groups.RESULTS Compared with the traditional group,the amount of intraoperative blood loss in the eOrganmap group was lower,the operating time and postoperative intestinal ventilation time were shorter,and R0 resection rate and lymph node dissection number were higher(P<0.05).The total complication rate in the eOrganmap group was 21.05%compared with 25.71%in the traditional group(P>0.05).The levels of total bilirubin,Albumin(ALB),aspartate transaminase,and alanine transaminase in the eOrganmap group were significantly different from those in the traditional group(intergroup effect:F=450.400,79.120,95.730,and 13.240,respectively;all P<0.001).Total bilirubin,aspartate transaminase,and alanine transaminase in both groups showed a decreasing trend with time(time effect:F=30.270,17.340,and 13.380,respectively;all P<0.001).There was an interaction between patient group and time(interaction effect:F=3.072,2.965,and 2.703,respectively;P=0.0282,0.032,and 0.046,respectively);ALB levels in both groups tended to increase with time(time effect:F=22.490,P<0.001),and there was an interaction effect between groups and time(interaction effect:F=4.607,P=0.004).In the eOrganmap group,there was a high correlation between the actual volume of intraoperative liver specimen resection and the volume of preoperative virtual liver resection(t=0.916,P<0.001).CONCLUSION The establishment of accurate laparoscopic resection of hilar cholangiocarcinoma based on preoperative eOrganmap 3D reconstruction and full quantization technology can make laparoscopic resection of hilar cholangiocarcinoma more accurate and safe.

Simultaneous laparoscopic multi-organ resection combined with colorectal cancer:Comparison with non-combined surgery

AIM: To access the short-term outcomes of simultaneous laparoscopic surgery combined with resection for synchronous lesions in patients with colorectal cancer. METHODS: Between March 1996 and April 2010 prospectively collected data were reviewed from 93 consecutive patients who had colorectal cancer and underwent simultaneous multiple organ resection (combined group) and 1090 patients who underwent conventional laparoscopic right hemicolectomy or laparoscopic low/ anterior resection for colorectal cancer (non-combined group). In the combined group, there were nine gastric resections, three nephrectomies, nine adrenalectomies, 56 cholecystectomies, and 21 gynecologic resections. In addition, f ive patients underwent simultaneous laparoscopic resection for three organs. The patient demographics, intra-operative outcomes, surgical morbidity, and short-term outcomes were compared between thetwo groups (the combined and non-combined groups). RESULTS: There were no signifi cant differences in the clinicopathological variables between the two groups. The operating time was signifi cantly longer in the combined group than in the non-combined group, regardless of tumor location (laparoscopic right hemicolectomy and laparoscopic low/anterior resection groups; P = 0.048 and P < 0.001, respectively). The other intraoperative outcomes, such as the complications and open conversion rate, were similar in both groups. The rate of post-operative morbidity in the combined group was similar to the non-combined group (combined vs non-combined, 15.1% vs 13.5%, P = 0.667). Oncological safety for the colon and synchronous lesions were obtained in the combined group. CONCLUSION: Simultaneous laparoscopic multiple organ resection combined with colorectal cancer is a safe and feasible option in selected patients.

Hybrid natural orifice transluminal endoscopic surgery for ileocecal resection

Although laparoscopic colectomy is commonly performed around the world,an operative wound formed during the surgery is large but not sufficient enough to convert for the majority of open surgery.Thus,a certain sized skin incision is required to remove the resected colon.Here we report the case of a pure laparoscopic ileocecal resection which involves transanal specimen extraction.We present a case characterized by a laterally spreading type of tumor of the cecum.We performed a pure laparoscopic ileocecal resection and the resected specimen was removed transanally using colonoscopy.Intracorporeal functional anastomosis was then performed using a flexible linear stapling device under supporting barbed suture traction.The patient was discharged without complications on postoperative day 4.Laparoscopic colectomy performed with minimal incision could essentially increase the usage of this surgical technique.Although our method is restricted to flat or small lesions,we think it is a feasible and realistic solution for minimization of operative invasion because it involves specimen extraction through a natural orifice.

“En bloc ” caudate lobe and inferior vena cava resection following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal and liver metastasis of colorectal cancer

There are diverse protocols to manage patients with recurrent disease after primary cytoreductive surgery(CRS) with hyperthermic intraperitoneal chemotherapy(HIPEC) for peritoneal carcinomatosis. We describe a case of metachronous liver metastasis after CRS and HIPEC for colorectal cancer, successfully treated with a selective metastectomy and partial graft of the inferior vena cava. A 35-year-old female presented with a large tumour in the cecum and consequent colonic stenosis. After an emergency right colectomy, the patient received adjuvant chemotherapy. One year later she was diagnosed with peritoneal carcinomatosis, and it was decided to carry out a CRS/HIPEC. After 2 years of total remission, an isolated metachronous liver metastasis was detected by magnetic resonance imaging surveillance. The patient underwent a third procedure including a caudate lobe and partial inferior vena cava resection with a prosthetic graft interposition, achieving an R0 situation. The postoperative course was uneventful and the patient was discharged on postoperative day 17 after the liver resection. At 18-mo follow-up after the liver resection the patient remained free of recurrence. In selected patients, the option of re-operation due to recurrent disease should be discussed. Even liver resection of a metachronous metastasis and an extended vascular resection are acceptable after CRS/HIPEC and can be considered as a potential treatment option to remove all macroscopic lesions.

Global scientific production of robotic liver resection from 2003 to 2022:A bibliometric analysis

Objective:With the widespread application of robotic liver surgery,the body of literature related to robotic liver resection is growing.However,there is a lack of understanding of the publication activities surrounding robotic liver resection research.This bibliometric study aimed to detect the global publication distributions of robotic liver resection research over the past 20 years.Methods:Articles on robotic liver resection published from January 1,2003 to August 31,2022 were extracted from the Web of Science Core Collection database.The publication language was restricted to English.Literature distribution analyses were performed at the country/region,institution,author,and journal levels.In addition,each author's productivity was assessed with Lotka's law.Academic influence was assessed by local citation score and global citation score.The keywords evolution was also analyzed.R software and HistCite were applied for the analyses.Results:A total of 685 articles were identified,with 4107 local citations and 9458 global citations.These articles were published in 156 journals and written by 2449 authors from 785 institutions in 49 countries/regions.The cumulative publication number of the last 5 years accounted for 66.3%(454/685)of the total publication number.The USA played a leading role in the publication output(212,30.9%),followed by Italy(120,17.5%)and China(104,15.2%).The three countries also had the most citations.Yonsei University from South Korea had the highest publication number(30,4.4%).The Asian Journal of Surgery published the most articles(51,7.4%),and Surgical Endoscopy and Other Interventional Techniques had the most local citations(575)and global citations(1115).Sucandy published 44 articles,ranking first in productivity.Choi had many more citations than other scholars,with 465 local citations and 1253 global citations.Lotka's law reflected that the majority of the authors(1783,72.8%)wrote one document.The top 5 most prominent keywords were“surgery”,“hepatocellular-carcinoma”,“outcomes”,“hepatectomy”,and“experience”.Conclusion:The number of publications on robotic liver resection research has been rapidly increasing over the last 20 years.The most prolific countries/regions and institutions also had strong academic influence.The articles,institutions and authors with high citations mainly came from USA,China,South Korea,Italy,and Singapore.The research hotspots shifted from survival to complications,mortality,and augmented reality.

Case Report:Pulmonary actinomycosis:a case undergoing resection through video-assisted thoracic surgery (VATS)

Actinomycosis is an uncommon disease, which is usually manifested as cervicofacial infection; related to poor oral hygiene or compromised immune function. Pulmonary actinomycosis is rare, but its diagnosis is changing due to its variable presentation; the similarity in appearance to other intrapulmonary diseases. Here we report an 80-year-old man with a solitary pulmonary nodule over the left upper lobe. Pulmonary neoplasm was highly suspected in this patient; thus resection of the mass was undertaken through video-assisted thoracic surgery (VATS). Histopathological examination demonstrated this patient had an Actinomyeces infection. While the application of VATS in patients with pulmonary actinomycosis has rarely been reported in literature, we conclude that VATS is valuable for the diagnosis; treatment of patients with undetermined pulmonary nodule(s).

Long-term outcomes and failure patterns after laparoscopic intersphincteric resection in ultralow rectal cancers

BACKGROUND Intersphincteric resection(ISR),the ultimate anus-preserving technique for ultralow rectal cancers,is an alternative to abdominoperineal resection(APR).The failure patterns and risk factors for local recurrence and distant metastasis remain controversial and require further investigation.AIM To investigate the long-term outcomes and failure patterns after laparoscopic ISR in ultralow rectal cancers.METHODS Patients who underwent laparoscopic ISR(LsISR)at Peking University First Hospital between January 2012 and December 2020 were retrospectively reviewed.Correlation analysis was performed using the Chi-square or Pearson's correlation test.Prognostic factors for overall survival(OS),local recurrence-free survival(LRFS),and distant metastasis-free survival(DMFS)were analyzed using Cox regression.RESULTS We enrolled 368 patients with a median follow-up of 42 mo.Local recurrence and distant metastasis occurred in 13(3.5%)and 42(11.4%)cases,respectively.The 3-year OS,LRFS,and DMFS rates were 91.3%,97.1%,and 90.1%,respectively Multivariate analyses revealed that LRFS was associated with positive lymph node status[hazard ratio(HR)=5.411,95%confidence interval(CI)=1.413-20.722,P=0.014]and poor differentiation(HR=3.739,95%CI:1.171-11.937,P=0.026),whereas the independent prognostic factors for DMFS were positive lymph node status(HR=2.445,95%CI:1.272-4.698,P=0.007)and(y)pT3 stage(HR=2.741,95%CI:1.225-6.137,P=0.014).CONCLUSION This study confirmed the oncological safety of LsISR for ultralow rectal cancer.Poor differentiation,(y)pT3 stage,and lymph node metastasis are independent risk factors for treatment failure after LsISR,and thus patients with these factors should be carefully managed with optimal neoadjuvant therapy,and for patients with a high risk of local recurrence(N+or poor differentiation),extended radical resection(such as APR instead of ISR)may be more effective.

Short- and long-term results of open vs laparoscopic multisegmental resection and anastomosis for synchronous colorectal cancer located in separate segments

BACKGROUND It remains unclear whether laparoscopic multisegmental resection and ana-stomosis(LMRA)is safe and advantageous over traditional open multisegmental resection and anastomosis(OMRA)for treating synchronous colorectal cancer(SCRC)located in separate segments.AIM To compare the short-term efficacy and long-term prognosis of OMRA as well as LMRA for SCRC located in separate segments.METHODS Patients with SCRC who underwent surgery between January 2010 and December 2021 at the Cancer Hospital,Chinese Academy of Medical Sciences and the Peking University First Hospital were retrospectively recruited.In accordance with the RESULTS LMRA patients showed markedly less intraoperative blood loss than OMRA patients(100 vs 200 mL,P=0.006).Compared to OMRA patients,LMRA patients exhibited markedly shorter postoperative first exhaust time(2 vs 3 d,P=0.001),postoperative first fluid intake time(3 vs 4 d,P=0.012),and postoperative hospital stay(9 vs 12 d,P=0.002).The incidence of total postoperative complications(Clavien-Dindo grade:≥II)was 2.9%and 17.1%(P=0.025)in the LMRA and OMRA groups,respectively,while the incidence of anastomotic leakage was 2.9%and 7.3%(P=0.558)in the LMRA and OMRA groups,respectively.Furthermore,the LMRA group had a higher mean number of lymph nodes dissected than the OMRA group(45.2 vs 37.3,P=0.020).The 5-year overall survival(OS)and disease-free survival(DFS)rates in OMRA patients were 82.9%and 78.3%,respectively,while these rates in LMRA patients were 78.2%and 72.8%,respectively.Multivariate prognostic analysis revealed that N stage[OS:HR hazard ratio(HR)=10.161,P=0.026;DFS:HR=13.017,P=0.013],but not the surgical method(LMRA/OMRA)(OS:HR=0.834,P=0.749;DFS:HR=0.812,P=0.712),was the independent influencing factor in the OS and DFS of patients with SCRC.CONCLUSION LMRA is safe and feasible for patients with SCRC located in separate segments.Compared to OMRA,the LMRA approach has more advantages related to short-term efficacy.

Enhanced recovery after surgery in laparoscopic major liver resection: A propensity score matching analysis

Objective:Even though enhanced recovery after surgery(ERAS)has been applied to liver resection worldwide,there is a lack of evidence covering its feasibility in laparoscopic major hepatectomy.This study aimed to preliminarily evaluate the superiority of ERAS in major liver resection.Methods:The data were collected from patients who underwent laparoscopic major hepatectomy from July 2014 to November 2020 in Sir Run Run Shaw Hospital,Zhejiang University School of Medicine.The baseline characteristics,pathological features,surgical outcomes,medical costs,and postoperative pain scores were compared before and after propensity score matching(PSM).The patients were divided into the ERAS group and the routine group based on the treatment protocols.Results:Eighty-one patients who underwent laparoscopic major hepatectomy were retrospectively enrolled in the study.Before PSM,there were differences in pathology(p¼0.037)and surgical extent(p¼0.011)between the ERAS group(n¼42)and routine group(n¼39).After PSM,26 patients from each group were matched.For surgical outcomes,patients in the ERAS group had a significantly lower postoperative complication incidence than patients in the routine group(28.6%vs.53.8%,RR:0.531[0.303,0.929],p¼0.021)before PSM.However,after PSM,superiority was not observed in the ERAS group(30.8%vs.53.8%,RR:0.571[0.290,1.13],p¼0.092).The duration of abdominal tube retention(before PSM:5.0 d vs.10.0 d,p<0.001;after PSM:6.0 d vs.9.0 d,p¼0.001),the duration of urinary tube retention(before PSM:1.0 d vs.2.0 d,p<0.001;after PSM:1.0 d vs.2.0 d,p¼0.002),and hospital stay(before PSM:6.0 d vs.11.0 d,p<0.001;after PSM:7.0 d vs.11.5 d,p<0.001)was significantly shorter in the ERAS group than in the routine group.A significant benefit on postoperative day 3(2 vs.3,p¼0.038)was observed with respect to the alleviation of pain after PSM.Conclusions:Our preliminary study revealed the superiority of ERAS in the setting of major liver resection,although further investigations in a large number of patients from multiple institutions are needed to evaluate the feasibility of ERAS.

Robotic surgery in living liver donors and liver recipients

There have been nearly 60 years since Thomas Starzl’s first liver transplant.During this period,advancements in medical technology have progressively enabled the adoption of new methods for transplantation.Among these innovations,robotic surgery has emerged in recent decades and is gradually being integrated into transplant medicine.Robotic hepatectomy and liver implantation represent significant advancements in the field of transplant surgery.The precision and minimally invasive nature of robotic surgery offer substantial benefits for both living donors and recipients.In living donors,robotic hepatectomy reduces postoperative pain,minimizes scarring,and accelerates recovery.For liver recipients,robotic liver implantation enhances surgical accuracy,leading to better graft positioning and vascular anastomosis.Robotic systems provide more precise and maneuverable control of instruments,allowing surgeons to perform complex procedures with greater accuracy and reduced risk to patients.This review encompasses publications on minimally invasive donor liver surgery,with a specific focus on robotic liver resection in transplantation,and aims to summarize current knowledge and the development status of robotic surgery in liver transplantation,focusing on liver resection in donors and graft implantation in recipients.

Beyond total mesorectal excision: The emerging role of minimally invasive surgery for locally advanced rectal cancer

Multivisceral resection and/or pelvic exenteration represents the only potential curative treatment for locally advanced rectal cancer(LARC);however,it poses significant technical challenges,which account for the high risk of morbidity and mortality associated with the procedure.As complete histopathologic resection is the most important determinant of patient outcomes,LARC often requires an extended resection beyond the total mesorectal excision plane to obtain clear re-section margins.In an era when laparoscopic surgery and robot-assisted surgery are becoming commonplace,the optimal approach to extensive pelvic inter-ventions remains controversial.However,acceptance of the suitability of mini-mally invasive surgery is slowly gaining traction.Nonetheless,there is still a lack of evidence in the literature about minimally invasive approaches in multiple and extensive surgical resections,highlighting the need for research studies to explore,validate,and develop this issue.This editorial aims to provide a critical overview of the currently available applications and challenges of minimally invasive abdo-minopelvic surgery for LARC.Furthermore,we discuss recent developments in the field of robotic surgery for LARC,with a specific focus on new innovations and emerging frontiers.

Vascular resections in minimally invasive surgery for pancreatic cancer

Pancreatic ductal adenocarcinoma(PDAC)is characterised by poor oncological outcome and is the seventh cause of cancer-related deaths worldwide.With the advances in surgical technology,oncological treatment,and critical care,extended pancreatic resections including vascular resections have become more frequently performed in specialised centres.Furthermore,the boundaries of resectability continue to be pushed in order to achieve a potentially curative approach in selected patients in combination with neoadjuvant and adjuvant treatment strategies.This review gives an overview on the current state of venous and arterial resections in PDAC surgery with particular attention given to the minimally invasive approach.

Transanal minimally invasive surgery to rescue anastomosis following leak after low anterior resection: A case report

Restorative low anterior resection(LAR)for rectal cancer carries a significant risk of anastomotic leak:One of the most feared complications in colorectal surgery.Operative management may include takedown of the anastomosis and end colostomy which,in some cases,is permanent.Other contemporary operative measures include over the scope clips and Endosponge.Recently,there have been case reports and a Society of American Endoscopic and Gastrointestinal Surgeons video on the novel use of transanal minimally invasive surgery(TAMIS)in the management of anastomotic leak.We present a 59-year-old female who underwent LAR after declining radiotherapy for a bulky 9 cm rectal tumour 9-10 cm from the anal verge.Following clinical deterioration,computed tomography demonstrated an anastomotic leak communicating with a 5-cm pelvic collection containing gas.At laparoscopy,pus and faeculent material were washed from the pelvic cavity and drains were placed.Intra-operative endoscopy demonstrated a 7-8 mm dehiscence at the anastomosis.The defect(approximately 7 cm from the anal verge)was successfully closed using TAMIS and a running V-lock suture.The patient recovered well and was discharged home on post-operative day 20.In this case,a low colorectal anastomotic leak was successfully rescued with TAMIS.This novel technique may be useful in the armamentarium of colorectal surgeons experienced in TAMIS.

Abdominoperineal Resection in Rectal Cancer in General Surgery Department at Gabriel Toure University Hospital

The objectives: Were to determine the hospital frequency of abdominoperineal resection (APR);to determine mortality and morbidity rates and to assess oncologic outcomes. Method and patients: We performed a retrospective study between 2008 and 2013 in general surgery department at Gabriel Toure University Hospital (UH) which included all patients admitted for rectal cancer confirmed by pathological examination, and having undergone an APR. Results: We have collected 17 cases which accounted for 65.38% of curative resections of rectal cancer. The sex-ratio was 0.89 and the averageage was 49.53 years. The average tumor distance from the anal verge was 4.59 ± 1.7 cm. All patients had adenocarcinoma of the rectum. The histopathologic grade was well in 7 cases, moderate and poor in 5 cases each. According to the pathologic TNM classification, 13 patients were classified T4, 14 patients N+. APR was associated with hysterectomy and partial colpectomy in 4 cases. The average duration of interventions was 202.06 ± 25.68 minutes. The average duration of hospitalization was 18.24 ± 04.89 days. The postoperative mortality and morbidity rates were 5.88% and 29.42%, respectively. Local recurrence was observed in 6 patients and liver metastasis in 2 patients. The overall survival rate was 37.5% at 2 years and 18.75% at 5 years. Conclusion: APR still occupies an important place in our practice. Our results could be improved by the recent introduction of neoadjuvant radio chemotherapy in Mali.

Limited resection for duodenal gastrointestinal stromal tumors:Surgical management and clinical outcome

AIM:To analyze our experience in patients with duodenal gastrointestinal stromal tumors(GIST) and review the appropriate surgical approach.METHODS:We retrospectively reviewed the medical records of all patients with duodenal GIST surgically treated at our medical institution between 2002 and 2011.Patient files,operative reports,radiological charts and pathology were analyzed.For surgical therapy open and laparoscopic wedge resections and segmental resections were performed for limited resection(LR).For extended resection pancreatoduodenectomy was performed.Age,gender,clinical symptoms of the tumor,anatomical localization,tumor size,mitotic count,type of resection resectional status,neoadjuvant therapy,adjuvant therapy,risk classification and follow-up details were investigated in this retrospective study.RESULTS:Nine patients(5 males/4 females) with a median age of 58 years were surgically treated.The median follow-up period was 45 mo(range 6-111 mo).The initial symptom in 6 of 9 patients was gastrointestinal bleeding(67%).Tumors were found in all four parts of the duodenum,but were predominantly located in the first and second part of the duodenum with each 3 of 9 patients(33%).Two patients received neoadjuvant medical treatment with 400 mg imatinib per day for 12 wk before resection.In one patient,the GIST resection was done by pancreatoduodenectomy.The 8 LRs included a segmental resection of pars 4 of the duodenum,5 wedge resections with primary closure and a wedge resection with luminal closure by Roux-Y duodeno-jejunostomy.One of these LRs was done minimally invasive;seven were done in open fashion.The median diameter of the tumors was 54 mm(14-110 mm).Using the Fletcher classification scheme,3/9(33%) tumors had high risk,1/9(11%) had intermediate risk,4/9(44%) had low risk,and 1/9(11%) had very low risk for aggressive behaviour.Seven resections showed microscopically negative transsection margins(R0),two showed positive margins(R1).No patient developed local recurrence during follow-up.The one patient who underwent pancreatoduodenectomy died due to progressive disease with hepatic metastasis but without evidence of local recurrence.Another patient died in complete remission due to cardiac disease.Seven of the nine patients are alive disease-free.CONCLUSION:In patients with duodenal GIST,limited surgical resection with microscopically negative margins,but also with microscopically positive margins,lead to very good local and systemic disease-free survival.