Abstract:

Gastrointestinal resections and anastomoses are commonly performed using stapling devices in a wide range of open and laparoscopic procedures. Whether they are hand-sewn or stapled, anastomoses have an associated leak rate that can impart significant morbidity or mortality to a procedure. In addition, bleeding from staple lines can cause additional complications. Staple line reinforcement is one intervention that has been postulated to reduce both the leak rate and associated bleeding risk. This can be accomplished with either material applied exogenously to the staple line, as in an engineered absorbable biomaterial, or it may use a material - either absorbable or nonabsorbable - that is incorporated into the staple line. A number of reinforcements are currently available but all add time and cost to the procedures in which they are used. However, preventing the complications associated with leak and hemorrhage from staple lines may justify the added cost of these devices. A review of the available published literature was performed to review the current data pertaining to the reinforcement of living tissue and anastomoses with these various reinforcements available to surgeons.

Authors:

Douglas M. Downey, M.D., Wright State University School of Medicine, Dayton, OH, USA; Sophia Ali, B.S., Notheastern Ohio Universities College of Medicine, Rootstown, OH, USA; Matthew I. Goldblatt, M.D., Wright State University School of Medicine, Dayton, OH, USA; Jonathan M. Saxe, M.D., Wright State University School of Medicine, Dayton, OH, USA; James P. Dolan, M.D., Keesler Medical Center, Biloxi, MS, USA

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Abstract:

Endoluminal resection in the gastrointestinal tract is limited to resection of the lamina mucosa and lamina submucosa. The integrity of the gastric wall, represented by the lamina muscularis propria, must be maintained, because no safe endoscopic methods of ensuring adequate closure of the gastric wall are currently available. With the flexible stapling system SurgAssistTM (Power Medical Interventions ([Power Medical Interventions Deutschland GmbH, Hamburg, Germany]), for the first time, a stapling device is available that can be introduced transorally into the gastric area together with a gastroscope. After performing appropriate animal experiments, full-thickness inverted resection of a tumorous section of the gastric wall was done in two patients with early gastric adenocarcinoma. In both patients, the authors were able to resect full-thickness sections of the gastric wall with a diameter of approximately 4 x 4 cm. A gastroscope was used for control of the resected areas in the stomach; one patient required endoscopic hemostasis. The further postoperative course was uneventful in both patients. The method presented herein offers, for the first time, an exclusively transoral, surgical procedure for full-thickness resection of the gastric wall. In addition to early gastric adenocarcinoma with incipient infiltration of the submucosa, possible indications for this procedure include gastrointestinal stromal tumors

Authors:

Georg F.B.A. Kähler, M.D., Peter H. Collet, M.D., Rainer Grobholz, M.D., Ph.D., Stefan Post, M.D., Ph.D., Professor, University Hospital Mannheim, University of Heidelberg, Manheim, Germany

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Abstract:

The objective of this study was to evaluate the efficiency of tumor detection in parenchymal organs and their resection by use of a micromagnetic needle detection system (MNDS). A micromagnetic needle (maximum magnetic flux density = 120 mT) and a micromagnetic needle-setting device were used. An in vitro laboratory study with a gumball within gelatin representing a tumor was conducted to calculate detection rates and to measure the time required for resection by MNDS. An animal study with the cervical lymph nodes of pigs representing tumors was conducted to measure the time required for lymph node resection. The removal rate of the target lymph node was 100% with MNDS. Results show that MNDS may be useful for tumor resection in the presence of air and for the resection of tumors that are difficult to detect by ultrasonography.

Authors:

Takeshi Ohdaira, M.D., F.S.A.G.E.S., Shigeto Ogura, M.D., AHideo Nagai, M.D., Jichi Medical University, Tochigi, Japan

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Abstract:

The use of laparoscopic surgery in managing liver malignancies has been developed only recently because of the complexity of liver surgery. Diagnostic laparoscopy is useful in staging liver malignancies before resection. The need for laparoscopic staging of colorectal liver metastasis has diminished as a result of better imaging technology such as positron emission tomography (PET). Laparoscopy still plays an important role in the staging of hepatocellular carcinoma because of the high incidences of multifocal tumors and venous invasion. Recently, laparoscopic liver resection was possible with the availability of new instruments that allow relatively bloodless liver transection. Small series have reported a conversion rate of 10% to 20%, and the complication rate and transfusion rate appeared to be comparable with open surgery in a few retrospective case-control studies. Limited data also suggest that oncological clearance and long-term outcome were not compromised. However, the role of laparoscopic liver resection is confined mainly to wedge or segmental resection of anterior segments of the right lobe and left lateral segments. Although successful laparoscopic hemihepatectomy and resections of segments VII and VIII have been reported at the time of this writing, these should be attempted only in centers that have already acquired wide experience with laparoscopic liver resection. Another application of laparoscopic surgery for the management of liver malignancies is laparoscopic radiofrequency ablation, which is gaining popularity because of its well-documented safety and efficacy. With further developments in technology, that laparoscopic surgery will have a greater impact on the management of liver malignancies is foreseeable in the near future.

Authors:

Ronnie T. Poon, M.B.B.S., M.S., F.R.C.S. (Edin), F.A.C.S., F.H.K.C.S., F.H.K.A.M. (Surgery), University of Hong Kong, Queen Mary Hospital, Hong Kong, China

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Abstract:

Laparoscopic minimally invasive procedures have become feasible and safe alternatives to open surgery in the management of esophageal and gastric leiomyomas. There are two major indications for the surgical management of these benign tumors: the presence of symptoms and the need for histopathologic confirmation if the biological behavior is unclear. The approach of choice for leiomyomas located in the very distal esophagus or gastroesophageal junction is the laparoscopic enucleation of the tumor. For the resection of gastric leiomyomas, three surgical procedures are primarily performed: the laparoscopic wedge resection without gastrotomy for tumors of the anterior gastric wall, lesser/greater curvature, and fundus; the laparoscopic wedge resection with gastrotomy for tumors of the posterior gastric wall ("transgastric approach"); and the laparoscopic intragastric resection for tumors of the posterior gastric wall ("intragastric approach"). This chapter summarizes these minimally invasive techniques and provides an update of the most recent clinical data that is available.

Authors:

D. Vallböhmer, M.D., A.H. Hölscher, M.D.,University of Cologne, Germany

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Abstract:

The most prominent and severe complication after a total gastrectomy is severe reflux esophagitis. We have developed a procedure involving jejunal pouch-esophagostomy to avoid such postoperative reflux. The novel procedure reported here initially involves folding a jejunal segment of approximately 35 cm in length. A side-to-side jejuno-jejunostomy at the anti-mesenteric side was then affected using a 100-mm linear stapler. This resulted in a jejunal pouch, 10 cm in length, and a 7-cm apical section of unstapled jejunal loop. Finally, an esophago-jejuno end-to-side anastomosis (pouch-esophagostomy) was formed at the right anterior wall of the apical bridge using a circular stapler. We have therefore introduced a "partial posterior fundoplication"-like wrapping technique to the standard gastrectomy using the apical bridge of the jejunal pouch. Only a little postoperative reflux was revealed by barium meal testing - even in the Trendelenburg's position - in patients treated with the described anti-reflux anastomosis procedure. Jejunal pouch reconstruction with partial posterior wrapping is a useful procedural addition for minimizing reflux esophagitis following a total gastrectomy.

Authors:

Michiya Kobayashi, M.D., Ph.D., Kochi Medical School, Nankoku, Japan; Ken Okamoto, M.D.; Kochi Medical School, Nankoku, Japan; Takehiro Okabyashi, M.D., Ph.D., Kochi Medical School, Nankoku, Japan, Toyokazu Akimori, M.D., Kochi Medical School, Nankoku, Japan, Tsutomu Namikawa, M.D., Ph.D., Kochi Medical School, Nankoku, Japan; Junichi Sakamoto, M.D., Ph.D., Nagoya University Graduate School of Medicine, Nagoya, Japan; Kazuhiro Hanazaki, M.D., Ph.D., Kochi Medical School, Nankoku, Japan

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Abstract:

Laparoscopic appendectomy (LA) was introduced into clinical practice by Kurt Semm in 1983. Since then, a number of methods for performing LA have emerged in the literature. However, the majority of these modifications require costly equipment. In this short technical chapter, we describe a very simple and inexpensive method of performing this procedure without resorting to any additional expensive paraphernalia.

Authors:

Francis R. D'Souza, F.R.C.S., Muzaffar A. Anwar, M.B.B.S., Riccardo A. Audisio, M.D., F.R.C.S., Muhammed Ashraf Memon, F.R.C.S., Whiston Hospital, Prescot, Merseyside, UK

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Abstract:

Surgery is the main modality in the therapy of retroperitoneal soft-tissue sarcomas (RSTS). A retrospective study was undertaken to evaluate the results of aggressive surgical treatment in a series of patients of primary and recurrent retroperitoneal sarcomas. A review of 166 consecutive patients with RSTS operated on at the Institute of Oncology in Ljubljana from 1975 through 2005 were reviewed. A total of 269 operations were performed on 166 patients. The five- and ten-year survival rates of patients with localized sarcoma were 52% and 38%, respectively. Factors that influenced the survival were distant metastases, tumor grade, and type of resection. The patients with R0 resections had a five-year survival rate of 75% and a ten-year survival rate of 65%; the respective rates for the patients with R1 resections were 25% and 7% (p < 0.00001). When only R0 resection was considered, referral status (primary, residual, recurrent RSTS) influenced survival (p = 0.004). The quality of initial surgery is a crucial prognostic factor to predicting survival in patients with RSTS. Complete surgical resection without microscopic residuum and contamination is likely to offer the best chances for long-term survival. Unless no other treatment modalities are available, aggressive surgery for recurrent sarcoma is recommended.

Authors:

Darja Erzen, M.D., M.Sc., Janez Novak, M.D. Marko Spiler, M.D., Mojca Sencar, M.D., Institute of Oncology, Ljubljana, Slovenia

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Abstract:

Endoscopic mucosal resection and endoscopic submucosal dissection have become more common in treatment of flat superficial tumors of the gastrointestinal tract. Submucosal injection is used to try to avoid complications and improve the technical feasibility of the procedure. However, the method has its limitations, particularly when treating extensive flat tumors in the colon. The water-jet dissector has already demonstrated its capacity for selective cutting with the dissection of parenchymatous. This chapter addresses a new indication, transmucosal mucosal elevation, together with first clinical results. After carrying out animal experiments into the physical properties using animal preparations and freshly resected human specimens from operations, our work group investigated and compared the applicability of the procedure using different carrier fluids. Six test substances-hydroxyethyl starch (HES), Gelafusal, Infukoll, Glucose 50 und isotonic saline solution-were injected into six anesthetized pigs; the height of the submucosal fluid cushion created by the injection was measured endosonographically over a period of 45 minutes. Endoscopic mucosal resection was subsequently carried out, and the resected specimen together with the area it was taken from were assessed histologically. Using commercially available NaCl cartridges, applied by the way of endocapillaries, 18 lesions were elevated in a series of 12 patients and subsequently resected endoscopically. All investigated substances could be applied without difficulty using the Helix HydroJet® (Erbe Elektromedizin GmbH, Waldhörnle-Str., Tübingen, Germany). The plasma expanders (HES and Gelafundin® 4%, B. Braun Melsungen AG, Melsungen, Germany) produced longer lasting fluid cushions than the isotonic solutions. Mucosal resections could be carried out in all cases with all of the solutions. Histological investigation confirmed the selective nature of the fluid accumulation in the submucosal tissue, which spared the lamina mucosae and lamina muscularis propria. The first clinical applications were successful. The technique of selective fluid accumulation in the submucosa by pressure injection, selective tissue elevation by pressure injection (STEP), presented herein for the first time in a clinical setting, makes it easier to carry out endoscopic mucosal resections and expands the use of this technique to treatment of extended lesions. The manufacturer has announced his intention of combining this technology with an IT-knife, so further improvements can be expected.

Authors:

Georg F.B.A. Kähler, M.D., Moritz G. Sold, Stefan Post, M.D., Ph.D., Surgical University Hospital Mannheim, University of Heidelberg, Manheim, Germany; Klaus Fischer, Markus D. Enderle, M.D., Ph.D., Erbe Elektromedizin, GmbH, Tübingen, Germany

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