Postoperative recurrence after ileocaecal resection for fibrostenotic terminal ileal Crohn's disease is a significant issue for patients as it can result in symptom recurrence and requirement for ...further surgery. There are very few modifiable factors, aside from smoking cessation, that can reduce the risk of postoperative recurrence. Until relatively recently, the surgical technique used for resection and anastomosis had little or no impact on postoperative recurrence rates. Novel surgical techniques such as the Kono-S anastomosis and extended mesenteric excision have shown promise as ways to reduce postoperative recurrence rates. This manuscript will review and discuss the evidence regarding a range of surgical techniques and their potential role in reducing disease recurrence. Some of the techniques have been shown to be associated with significant benefits for patients and have already been integrated into the routine clinical practice of some surgeons, while other techniques remain under investigation. Current techniques such as resection of the mesentery close to the intestine and stapled side to side anastomosis are being challenged. It is looking more likely that surgeons will have a major role to play when it comes to reducing recurrence rates for patients undergoing ileocaecal resection for Crohn's disease.
Minimally invasive esophagectomy (MIE) has been increasingly performed to treat esophageal cancer. Studies published between 1990 and 2012 that described the use of MIE for cancer in at least 50 ...patients were included for systematic review. The literature search retrieved 34 publications comprising 18 case series, 15 comparative studies, and 1 randomized control trial. Results revealed a wide variability in surgical techniques and perioperative outcomes with a lack of standardized definitions of postoperative complications. In most studies, radical formal lymphadenectomy was not performed and the lymph node harvest fell below the minimum number recommended to achieve survival benefits. There is a need to reach a consensus regarding surgical approaches in MIE, the definition of postoperative complications and the extent of lymphadenectomy before embarking on further randomized controlled trials comparing MIE vs. open approach.
Background
Due to the significant contribution of anastomotic leak, with its disastrous consequences to patient morbidity and mortality, multiple parameters have been proposed and individually ...meta-analyzed for the formation of the ideal esophagogastric anastomosis following cancer resection. The purpose of this pooled analysis was to examine the main technical parameters that impact on anastomotic integrity.
Methods
Medline, Embase, trial registries, and conference proceedings were searched. Technical factors evaluated included hand-sewn versus stapled esophagogastric anastomosis (EGA), cervical versus thoracic EGA, minimally invasive versus open esophagectomy, anterior versus posterior route of reconstruction and ischemic conditioning of the gastric conduit. The outcome of interest was the incidence of anastomotic leak, for which pooled odds ratios were calculated for each technical factor.
Results
No significant difference in the incidence of anastomotic leak was demonstrated for the following technical factors: hand-sewn versus stapled EGA, minimally invasive versus open esophagectomy, anterior versus posterior route of reconstruction and ischemic conditioning of the gastric conduit. Four randomized, controlled trials comprising 298 patients were included that compared cervical and thoracic EGA. Anastomotic leak was seen more commonly in the cervical group (13.64 %) than in the thoracic group (2.96 %). Pooled analysis demonstrated a significantly increased incidence of anastomotic leak in the cervical group (pooled odds ratio = 4.73; 95 % CI 1.61–13.9;
P
= 0.005).
Conclusions
A tailored surgical approach to the patient’s physiology and esophageal cancer stage is the most important factor that influences anastomotic integrity after esophagectomy.
Background
Advanced bipolar radiofrequency (RF) energy-based devices are increasingly used for non-vascular tissue sealing, transection and anastomosis. Although the potential to further develop this ...technology is clear, the limitations of commercially available devices are poorly understood. This systematic review examines the current utilisation of advanced bipolar RF fusion technology for non-vascular applications in thoracic and abdominal tissues and organs.
Methods
Medline, Embase, Web of Science and Cochrane library databases were searched. Studies examining the non-vascular application of advanced bipolar RF technology in the abdomen and thorax were assessed. Measurement of seal sufficiency and the extent of tissue injury induced by bipolar RF energy application were the main outcomes of interest.
Results
Forty-six animal and human studies conducted in and ex vivo across a range of tissue types, met the inclusion criteria. The diversity of study protocols together with the heterogeneity of their outcomes prevented pooled analysis. However, the experimental animal studies assessed suggest that bipolar RF fusion devices are capable of effectively sealing most tissue types with the notable exception of large caliber bronchi (>4 mm) and bile ducts, where the rate of seal failure was unacceptably high. Human studies were additionally found to predominantly use bipolar RF technology as a means of parenchymal and ductal occlusion. A similar trend was seen amongst animal studies with only a handful of papers examining bipolar RF energy use for (bowel) anastomosis.
Conclusion
Bipolar RF fusion devices are capable of safely sealing a variety of thoracic and anterior abdominal tissues with an injury and leakage profile comparable to established technologies. Although thermal monitoring is increasingly sophisticated and multimodal, consistent real time tracking of a multitude of parameters is necessary in order to expand RF fusion technology utilisation to complete an array of tasks such as vessel ligation, ductal obliteration and anastomosis in the open and laparoscopic environments.
Intraoperative monitoring of tissue oxygen saturation (StO2 ) has potentially important applications in procedures such as organ transplantation or colorectal surgery, where successful reperfusion ...affects the viability and integrity of repaired tissues. In this paper a liquid crystal tuneable filter-based multispectral imaging (MSI) laparoscope is described. Motion-induced image misalignments are reduced, using feature-based registration, before regression of the tissue reflectance spectra to calculate relative quantities of oxy- and deoxyhaemoglobin. The laparoscope was validated in vivo, during porcine abdominal surgery, by making parallel MSI and blood gas measurements of the small bowel vasculature. Ischaemic conditions were induced by local occlusion of the mesenteric arcade and monitored using the system. The MSI laparoscope was capable of measuring StO2 over a wide range (30-100%) with a temporal error of ± 7.5%. The imager showed sensitivity to spatial changes in StO2 during dynamic local occlusions, as well as tracking the recovery of tissues post-occlusion.
Background
The reasons underlying prolonged waiting lists for surgery in Ireland are multifactorial. Patient-related factors including non-attendances contribute in part to the current waiting times.
...Aims
To determine the rate of short notice cancellation for day case surgery in a model 2 HSE hospital over a 1-month period and to implement an intervention to try and reduce the rate of cancellation.
Methods
The cancellation rate was documented over a 1-month period in the hospital. An intervention was then implemented, involving a phone call to the patient from a member of the surgical team to attempt to reduce the cancellation rate. Cancellations were re-audited after the implementation of the phone intervention.
Results
The initial audit revealed a cancellation rate of 39.7% during the first month prior to implementation of the phone intervention. A phone call intervention from a member of the surgical team was associated with a decrease in cancellations from 39.7 to 14.6% (
p
< 0.01).
Conclusions
While cancellations remained high even after our intervention, a simple phone call was effective and more than halved our cancellation rate. Future efforts need to focus on increasing awareness of patient responsibility for attending scheduled appointments and procedures.
Purpose
Recovering tissue deformation during robotic-assisted minimally invasive surgery procedures is important for providing intra-operative guidance, enabling in vivo imaging modalities and ...enhanced robotic control. The tissue motion can also be used to apply motion stabilization and to prescribe dynamic constraints for avoiding critical anatomical structures.
Methods
Image-based methods based independently on salient features or on image intensity have limitations when dealing with homogeneous soft tissues or complex reflectance. In this paper, we use a triangular geometric mesh model in order to combine the advantages of both feature and intensity information and track the tissue surface reliably and robustly.
Results
Synthetic and in vivo experiments are performed to provide quantitative analysis of the tracking accuracy of our method, and we also show exemplar results for registering multispectral images where there is only a weak image signal.
Conclusion
Compared to traditional methods, our hybrid tracking method is more robust and has improved convergence in the presence of larger displacements, tissue dynamics and illumination changes.
Polarisation imaging has the potential to provide enhanced contrast based on variations in the optical properties, such as scattering or birefringence, of the tissue of interest. Examining the signal ...at different wavebands in the visible spectrum also allows interrogation of different depths and structures. A stereo endoscope has been adapted to allow snapshot acquisition of orthogonal linear polarisation images to generate difference of linear polarisation images. These images are acquired in three narrow bands using a triple-bandpass filter and pair of colour cameras. The first in vivo results, acquired during a surgical procedure on a porcine subject, are presented that show wavelength dependent variations in vessel visibility and an increase in contrast under polarised detection.
Background
Bipolar radiofrequency (RF) induced tissue fusion is believed to have the potential to seal and anastomose intestinal tissue thereby providing an alternative to current techniques which ...are associated with technical and functional complications. This study examines the mechanical and cellular effects of RF energy and varying compressive pressures when applied to create ex vivo intestinal seals.
Methods
A total of 299 mucosa-to-mucosa fusions were formed on ex vivo porcine small bowel segments using a prototype bipolar RF device powered by a closed-loop, feedback-controlled RF generator. Compressive pressures were increased at 0.05 MPa intervals from 0.00 to 0.49 MPa and RF energy was applied for a set time period to achieve bowel tissue fusion. Seal strength was subsequently assessed using burst pressure and tensile strength testing, whilst morphological changes were determined through light microscopy. To further identify the subcellular tissue changes that occur as a result of RF energy application, the collagen matrix in the fused area of a single bowel segment sealed at an optimal pressure was examined using transmission electron microscopy (TEM).
Results
An optimal applied compressive pressure range was observed between 0.10 and 0.25 MPa. Light microscopy demonstrated a step change between fused and unfused tissues but was ineffective in distinguishing between pressure levels once tissues were sealed. Non uniform collagen damage was observed in the sealed tissue area using TEM, with some areas showing complete collagen denaturation and others showing none, despite the seal being complete. This finding has not been described previously in RF-fused tissue and may have implications for in vivo healing.
Conclusions
This study shows that both bipolar RF energy and optimal compressive pressures are needed to create strong intestinal seals. This finding suggests that RF fusion technology can be effectively applied for bowel sealing and may lead to the development of novel anastomosis tools.
Anastomosis is the critical step in restoring gastrointestinal continuity following bowel resection and has traditionally been accomplished using suture and stapling techniques. However, both ...technologies can be associated with complications and are particularly difficult to perform in the laparoscopic environment. As a result there has been an increasing interest in developing novel tools and techniques which would permit safe and reliable intestinal anastomoses to be performed whilst minimising potential complications. In recent years, advanced bipolar radiofrequency (RF) energy powered devices, developed to enable more consistent vascular haemostasis, have been proposed as an alternative method for anastomotic construction and is the basis for the research presented. This thesis investigates: (i) the parameters required to form bowel seals with sufficient mechanical strength to withstand physiological pressures; (ii) methods for monitoring the viability of seals and (iii) the ability to construct functional radiofrequency induced small bowel anastomoses. The role of varying electrical parameters and compressive pressures has been investigated and characterised both in vitro and in vivo. Mucosa-to-mucosa and serosa-to-serosa small bowel seals were formed using both commercial and prototype applicator devices powered by a research based electrical generator and bespoke programmable algorithms. The mechanical strength of bowel seals was assessed through ex vivo burst pressure measurements. This demonstrated seals to be capable of withstanding physiological luminal pressures (>25mmHg) before rupturing. Tissue effects of fusion have been examined microscopically through histological assessment. The viability of fused tissue in vivo was determined utilising a multispectral imaging (MSI) system, which measured tissue oxygenation in the peri-fusion areas and allowed for the calculation of relative concentrations of oxy- and deoxyhaemoglobin and hence, overall bowel oxygen saturation (SaO2). The results of these monitoring tools have suggested that the tissue remains viable in the short term using a specific combination of electrical and mechanical parameters. These ex vivo and acute in vivo findings were applied to construct a series of chronic porcine anastomoses, where animals were recovered for a median of seven days, to compare the macro- and microscopic effects of the novel and gold standard techniques. Fifteen small bowel anastomoses were formed using a commercial and prototype radiofrequency sealer in individual animals. In addition five hand-sewn end-to-end and five stapled side-to-side anastomoses were also constructed in individual animals. Three animals in the radiofrequency anastomosis group were terminated early due to clinical evidence of anastomotic leak. Microscopically, the fused bowel showed evidence of healing at the mucosal and sub-mucosal collagen levels, which was comparable to findings using the gold standard methods. The studies performed demonstrate a method for the formation and assessment of radiofrequency induced bowel fusion and confirm its potential to be ultimately used for both bowel resection and anastomosis.
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