Search

Background Advances in sphincter-saving procedures improved the quality of life of patients with rectal cancer. However, many of them experienced functional disturbances after surgery, including low anterior resection syndrome. Objective The aim of this study was to evaluate the severity of low anterior resection syndrome after transanal total mesorectal excision and compare it with the conventional transabdominal, top-to-bottom, total mesorectal excision. Design This was a single-center, retrospective analysis. Settings The study was conducted at a tertiary academic institution. Patients This study analyzed patients who underwent total mesorectal excision for mid to low rectal cancer from January 2016 to April 2018. Cases were matched one-to-one according to the tumor height and history of pelvic irradiation using the propensity score. Main outcome measures The primary outcome measured was the severity of low anterior resection syndrome and fecal incontinence at 3, 6, and 12 months after surgery or stoma reversal, whichever was later. Results There were 35 patients in each group after matching; 67.1% were male, and 41.4% had neoadjuvant radiotherapy. At 3 months, the median low anterior resection syndrome score was 37 after transanal total mesorectal excision, which was significantly higher than the conventional approach, 32 (p = 0.045). Apart from this, the low anterior resection syndrome score, severity grading, and the Wexner score were comparable at 6 and 12 months. Limitations A difference between the 2 groups might not be detected because of the study's small sample size and because of its retrospective nature. Conclusions A higher low anterior resection syndrome score was observed after transanal total mesorectal excision at the initial 3-month period, but such a difference was not observed thereafter. This study showed that both surgical techniques had similar anal and bowel functional outcomes in the long run. However, because of the limited case number and study design, further study is needed to prove this. See Video Abstract at http://links.lww.com/DCR/B146. SINDROME DE RESECCION ANTERIOR BAJA DESPUES DE LA ESCISION MESORRECTAL TOTAL TRANSANAL: UNA COMPARACION CON EL ABORDAJE CONVENCIONAL DE SUPERIOR A INFERIOR: Los avances en los procedimientos para salvar esfinteres mejoraron la calidad de vida de los pacientes con cancer rectal. Sin embargo, muchos de ellos sufrieron trastornos funcionales despues de la cirugia, incluyendo el sindrome de reseccion anterior baja.El objetivo de este estudio fue evaluar la gravedad del sindrome de reseccion anterior baja despues de la escision mesorrectal total transanal y comparar con la escision mesorrectal total convencional transabdominal, de arriba a abajo.El estudio se realizo en una institucion academica terciaria.Este fue un analisis retrospectivo de un solo centro de pacientes que se sometieron a una escision mesorrectal total por cancer rectal medio a bajo desde enero de 2016 hasta abril de 2018. Los casos fueron emparejados uno a uno de acuerdo con la altura del tumor y los antecedentes de irradiacion pelvica con puntaje de propension.La gravedad del sindrome de reseccion anterior baja y la incontinencia fecal a los 3, 6 y 12 meses despues de la cirugia o la reversion del estoma, lo que ocurriera mas tarde.Hubo 35 pacientes en cada grupo despues del emparejamiento. El 67.1% eran hombres. El 41,4% tenia radioterapia neoadyuvante. A los tres meses, la puntuacion media del sindrome de reseccion anterior baja fue de 37 despues de la escision mesorrectal transanal total, que fue significativamente mayor que el enfoque convencional, 32 (p = 0.045). Aparte de esto, la puntuacion baja del sindrome de reseccion anterior, la clasificacion de gravedad y la puntuacion de Wexner fueron comparables a los 6 y 12 meses.Es posible que no se detecte una diferencia entre los dos grupos debido al pequeno tamano de la muestra del estudio. La naturaleza retrospectiva del estudio.Se observo una puntuacion mas alta en el sindrome de reseccion anterior baja despues de la escision mesorrectal total transanal en el periodo inicial de tres meses, pero dicha diferencia no se observo posteriormente. Este estudio mostro que ambas tecnicas quirurgicas tuvieron resultados similares de funcionamiento anal e intestinal a largo plazo. Sin embargo, debido al numero limitado de casos y al diseno del estudio, es necesario realizar mas estudios para demostrarlo. Consulte Video Resumen en http://links.lww.com/DCR/B146.

Background There are no data comparing the use of self-gripping mesh with standard mesh in total extraperitoneal repair (TEP). In this prospective study we aim to study the incidence of chronic pain between Progrip (PG) and standard mesh fixed by fibrin sealant (FS). Materials and methods Under Institutional Review Board approval, from April 2016 to May 2017, patients with primary unilateral or bilateral inguinal hernia eligible for TEP were recruited. Before mesh insertion they were randomized into PG or FS (Tisseel). Demographics, intraoperative, and postoperative data were recorded. Patients were followed up for at least 1 year. Visual Analog Scale was used to record pain scores. Primary outcome was the incidence of chronic pain at 3 months after surgery. Results One hundred fifty patients were randomized. Of the 150 patients (193 hernias), 76 were randomized to PG and 74 randomized to FS. Demographic data such as age, presence of comorbidities, smoking history, mean body mass index was comparable in both groups. Bilateral hernias occurred in 25 (32.9%) and 18 (24.3%) patients in PG and FS group, respectively. Mean mesh deployment time was 283.7 seconds (range, 140 to 720 s) in PG group and 301.9 seconds (range, 67 to 1006 s) in FS group (P=0.30). A total of 5 patients were lost at follow-up and they were excluded from subsequent data analysis. Seroma occurred in 15 (20.3%) and 16 (22.5%) patients in PG and FS group, respectively (P=0.45). Mean Visual Analog Scale at 2 weeks (cough) was highest at 1.05 and 1.02 in PG and FS group, respectively (P=0.62). Eight (12.3%) and 15 (23.4%) patients in PG and FG group, respectively, reported pain at 3-month follow-up (P=0.1). Of those who experienced pain, majority was mild pain which did not affect activities of daily living. At a mean follow-up of 13.1±5.4 months, no recurrence was detected. Conclusions There was no significant difference in terms of chronic pain between PG and FS group. The use of PG is effective in TEP.

Introduction: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is increasingly used to treat peritoneal metastases from appendiceal or colorectal origin. We evaluate our institution's experience and survival outcomes with this procedure, and its efficacy in symptom relief. Methods: This is a single-centre retrospective observational study on patients with peritoneal metastases (PM) from appendiceal neoplasm or colorectal cancer who underwent CRS/HIPEC in Queen Mary Hospital. Our primary endpoints were overall survival (OS) and morbidity and mortality of this procedure; secondary endpoints included disease-free survival (DFS) and symptom-free survival. Results: Between 2006 and 2018, thirty CRS/HIPEC procedures were performed for 28 patients – 17 (60.7%) had appendiceal PM while 11 (39.9%) had colorectal PM. The median peritoneal cancer index was 20; complete cytoreduction was achieved in 83.3% patients. High-grade morbidity occurred in 13.3% cases. There was no 30-day mortality. Two-year OS were 71.6% and 50% for low-grade appendiceal PM and colorectal PM patients (p = 0.20). Complete cytoreduction improved OS (2-year OS 75.4% vs 20%, p = 0.04). Median DFS was 11.8 months. Median symptom-free duration was 36.8 months; patients with complete cytoreduction were more likely to remain asymptomatic (82.9% at 1 year, vs 60% in incomplete cytoreduction group, p

INTRODUCTION Spigelian hernia (SH) is uncommon. Clinical diagnosis may be difficult, but computed tomography (CT) can help to establish the diagnosis. Laparoscopic repair is increasingly performed because it is associated with low morbidity rates. Laparoscopic approaches include transabdominal preperitoneal (TAPP), intraperitoneal onlay mesh (IPOM), and totally extraperitoneal (TEP). Here, we report our experiences of TEP repair for SH. METHODS A retrospective review was performed on all patients with SH who underwent elective laparoscopic TEP repair from 2007 to 2017 at Tung Wah Hospital, Hong Kong. RESULTS Four patients with SH were identified in the study period: three with a preoperative diagnosis of SH confirmed by CT scan and one diagnosed incidentally during TEP repair for inguinal hernia. The patients' mean age was 66.8 years (range, 55.0-82.0 years). The mean BMI was 22.8 kg/m2 (range, 20.8-23.6 kg/m2 ). The mean size of the SH defect was 2.0 cm (range, 0.5-3.0 cm). The mean operative time was 59 min (range, 40-86 min). Concomitant direct inguinal hernia was found in one patient and repaired simultaneously. All patients were discharged on postoperative day 1. One patient developed seroma, which subsided on conservative management. At a mean follow-up of 36 months (range, 2-108 months), there was no recurrence. CONCLUSION Laparoscopic repair for SH is preferred over the open approach as it is associated with a low morbidity rate and a short hospital stay. In our experience, TEP technique is safe and effective in laparoscopic SH repair.

Inguinal omental fibromatosis is a rare disease entity that could mimic incarcerated inguinal hernia clinically. In the present study, we review the incidence of inguinal omental fibromatosis at our centre. From 1 January1996 to 30 June 2016, all hernia operations performed in all the affiliated hospitals of the University of Hong Kong were reviewed retrospectively; data were retrieved from patient records. A total of 7039 hernia operations were carried out during the period, in which 564 were incarcerated or strangulated hernia operations, and two were omental fibromatosis, accounting for an incidence of 0.028 per cent of groin explorations. In the present study, we report the second case at our centre. A 26-year-old man was admitted with a history of reducible right groin mass from birth. The mass had become irreducible for 2 months. The patient had no symptoms of bowel obstruction. On palpation, a firm mass was found in the right groin extending to the right scrotum, and could not be reduced completely. Bilateral testes in the scrotum were palpable. Computed tomography scan of pelvic cavity showed that there was a herniated omentum in the right scrotum. The omental mass was completely resected and free-tension repair was performed. The histopathological examination revealed that the tumour consisted of spindle-shaped cells that were consistent with fibromatosis. Inguinal omental fibromatosis is rare and could present as incarcerated hernia clinically. Fibromatosis could be part of a syndromal disease presentation, such as Gardner syndrome. Recurrence is higher than in sporadic cases, despite radical surgery.

Colonic perfusion is crucial for anastomotic healing and this could be evaluated intraoperatively using indocyanine-green fluorescence imaging (ICG FI). The aim of this study was to ascertain whether the use of ICG FI resulted in the reduction of anastomotic complications, i.e. AL and anastomotic stricture. Consecutive patients who underwent anterior resections or low anterior resections at our institution in the period from January 1st 2013 to December 31st 2018 were retrospectively reviewed. Surgery performed during the period from January 1st 2013 to December 31st 2015 did not involve the use of ICG FI (ICG−) while surgery during the period from January 1st 2016 to December 31st 2018 was performed with the use of ICG FI (ICG+). The anastomotic leakage rates of the two groups were compared after propensity score matching, taking into account the height of the anastomosis and any history of pelvic irradiation. There was a total of 258 and 317 patients who had surgery with and without ICG FI, respectively. There were 253 patients in each group after propensity score matching. The overall anastomotic leakage rate was 3.6% and 7.9% for ICG+ and ICG−, respectively, (p = 0.035). Subgroup analysis showed that the use of ICG FI was significantly associated with a lower anastomotic leakage rate in total mesorectal excision (TME), 4.7% versus 11.6%, p = 0.043, but not in non-TME resections, 3.5% versus 2.4%, (p = 0.612). ICG FI, together with sex and anastomotic height, were independent predictors of anastomotic leakage. The routine use of ICG FI was associated with a lower anastomotic leakage rate in anterior resections. The reduction in anastomotic leakage rate was mainly seen in TME.

Background T4 hepatocellular carcinoma (HCC) with invasion to adjacent structure(s) may require resection of not only the tumor but also the invaded structure(s). This study aims to assess whether such combined resection for T4 HCC is justifiable. Methods Adult patients with T4 HCC were divided into three groups. Group 1: tumors and invaded adjacent structures were resected together if histopathologically confirmed tumor invasion; group 2: same as group 1 but histopathologically confirmed tumor adhesion; group 3: tumor resection only. Group comparisons were made. Results Totally 144 patients were included in the study. There were 71, 14 and 59 patients in groups 1, 2 and 3, respectively. The groups were comparable in demographics, complication and survival. Ten hospital deaths occurred (5, 0 and 5 in groups 1, 2 and 3, respectively; P =0.533). The 5-year overall survival (hospital mortality excluded) was 17.8% in group 1, 14.3% in group 2, and 28.9% in group 3 ( P =0.191). The 5-year disease-free survival was 10.4% in group 1 and 14.5% in group 3 (no data for group 2 yet) ( P =0.565). On multivariate analysis, macrovascular invasion and poor differentiation were risk factors for survival whereas combined resection did not impact patients' survival. Conclusions Combined resection achieved survival outcomes similar to tumor resection only. Patients with tumor invasion and those with tumor adhesion had comparable survival after combined resection. At centers with the required expertise, combined resection should be attempted to treat T4 HCCs with clinically suspected invasion of adjacent structures.

Background Perfusion plays an important role in anastomotic healing. Indocyanine-green fluorescence angiogram allows objective bowel perfusion assessment. This study aimed to investigate the impact of perfusion assessment on intraoperative decision during left-sided colorectal resections. Method This was a prospective, single-centre, observational study recruiting patients with left-sided colorectal resections. Perfusion of bowel segment was assessed with ICG fluorescence angiogram prior to resection and anastomosis intra-operatively. The planned transection site and the actual transection site after perfusion assessment were compared. The decision for diversion stoma was also evaluated. Results 110 patients with cancer of the sigmoid colon (29.1%) and rectum (70.9%) were recruited. Total mesorectal excision was performed in 51.8% of patients. The transection site was revised in 34.5% of cases: 30.9% more proximally and 3.6% more distally. The median distance between the intended and actual transection sites was 2 cm (range 1–17 cm). A proximal revision in the transection site was more likely seen in rectal cancers (p = 0.036, OR 3.58, 95% CI 1.09–11.78) and relatively under-perfused left colon (p = 0.036, OR 1.01, 95% CI 1.01–1.02). Three (2.7%) patients were spared from a diversion stoma. The overall anastomotic leakage rate was 5.5%. Conclusion ICG fluorescence angiogram altered operative decisions in a significant proportion of cases. The impact on transection site was more pronounced in patients with rectal cancers and those with relatively under-perfused colon.

INTRODUCTION The advantages of laparoscopic surgery for ventral hernia repairs are well documented, but its application for small paraumbilical hernias has been less studied. There is no consensus regarding the best technique. METHODS All patients who had open (suture or mesh) and laparoscopic repair of primary paraumbilical hernia between September 2007 and September 2017 in a single center were identified. Hernial defects of 2 cm or less were included; recurrent hernias were excluded. Primary outcomes included operative time, length of hospital stay, and surgical complications. RESULTS Seventy-seven patients were recruited: 54 (70.1%) had open repair and 23 (29.9%) had laparoscopic repair. Forty-six patients (85%) in the open group had primary suture repair. The mean operative time was significantly shorter in the open group than in the laparoscopic group (27.2 vs 56.1 min, P

Spigelian hernia (SH) is uncommon. Clinical diagnosis may be difficult, but computed tomography (CT) can help to establish the diagnosis. Laparoscopic repair is increasingly performed because it is associated with low morbidity rates. Laparoscopic approaches include transabdominal preperitoneal (TAPP), intraperitoneal onlay mesh (IPOM), and totally extraperitoneal (TEP). Here, we report our experiences of TEP repair for SH.A retrospective review was performed on all patients with SH who underwent elective laparoscopic TEP repair from 2007 to 2017 at Tung Wah Hospital, Hong Kong.Four patients with SH were identified in the study period: three with a preoperative diagnosis of SH confirmed by CT scan and one diagnosed incidentally during TEP repair for inguinal hernia. The patients' mean age was 66.8 years (range, 55.0-82.0 years). The mean BMI was 22.8 kg/mLaparoscopic repair for SH is preferred over the open approach as it is associated with a low morbidity rate and a short hospital stay. In our experience, TEP technique is safe and effective in laparoscopic SH repair.

Background Post-thyroidectomy hypocalcemia is a major contributing factor in delayed hospital discharge and dissuading surgeons from ambulatory thyroidectomy. We prospectively evaluated the accuracy and reliability of quick parathyroid hormone level measurement at skin closure (PTH-SC) in predicting clinically relevant hypocalcemia (i.e., patients requiring calcium ± calcitriol supplements on hospital discharge). Methods Of the 117 patients who underwent a total or completion total thyroidectomy and PTH-SC, 17 (14.5 %) had hypocalcemic symptoms or adjusted calcium 1 pmol/L) had a higher specificity (95.0 %) and AUC (0.887) than serial calcium monitoring or PTH-D1 alone. Although 3/98 of patients with PTH-SC >1 pmol/L required calcium supplements on discharge, they required only the minimum amount to maintain normocalcemia. Conclusion PTH-SC is an accurate and reliable means of predicting clinically relevant hypocalcemia. It would be reasonable to discharge those with PTH-SC >1 pmol/L on the same operative day as the risk of life-threatening hypocalcemia would seem unlikely.

Electron-hole pair excitations in the insulating cuprates $Sr_2CuO_2Cl_2$ were investigated by angle-resolved electron energy loss spectroscopy. The optically allowed and optically forbidden transitions were observed to be strongly anisotropic in $Cu-O_2$ plane. The former show a large energy dispersion $\sim 1.5$eV along [110], and the latter appear at a higher energy position ($\sim 4.5$eV) only along [100], but not along [110]. We interpret these results as transitions involving excitons. A small exciton model is examined to explain both the observed features.