Selected publications from PubMed
The impact of fluorescence angiography on anastomotic leak rate following transanal total mesorectal excision for rectal cancer: a comparative study.
Otero-Piñeiro AM, de Lacy FB, Van Laarhoven JJ, Martín-Perez B, Valverde S, Bravo R, Lacy AM
Surg Endosc. 2021 Feb;35(2):754-762 doi: 10.1007/s00464-020-07442-6.
Evolution of transanal total mesorectal excision for rectal cancer: From top to bottom.
Emile SH, de Lacy FB, Keller DS, Martin-Perez B, Alrawi S, Lacy AM, Chand M
World J Gastrointest Surg. 2018 Mar 27;10(3):28-39 doi: 10.4240/wjgs.v10.i3.28.
The present and future of surgical education - a video vignette.
Lacy AM, Martin-Perez B, Diaz-DelGobbo G, DeLacy H, Cahill R, Wexner SD
Colorectal Dis. 2017 Mar;19(3):303-304 doi: 10.1111/codi.13617.
1. HPV (Human Papillomavirus) and anal squamous cell carcinoma (ASCC) Although still rare, the incidence of anal carcinoma has been increasing, having doubled in the last two decades. More than 90% of anal squamous cell carcinoma (ASCC) is caused by HPV infection . There are more than 100 subtypes of HPV, but some were demonstrated to be more carcinogenic, especially 16 and 18. Populations at higher risk for ASCC are: HIV infected patients, men who have sex with men, patients who perform anal receptive intercourse, tobacco smokers, patients with chronic immunosuppression and women with cervical dysplasia. 2. Physiopathology of precursor lesions Most of what is known about the physiopathology of anal dysplasia comes from what is known about cervical dysplasia. Similarly to cervical cancer, which occurs in a transformation zone in the cervix, ASCC also occurs in a transformation zone, the ATZ (anal transformation zone), where the mucosa transitions to nonkeratinized squamous epithelium. The ATZ is located proximal to the dentate line and extends for 0.5 to 1.5 cm distally. Because constant transformation of columnar cells into squamous cells is occurring in this area, this region is very susceptible to HPV infection. The HPV virus integrates into the DNA of the host, disrupting the gene E2, which inhibits proteins E6 and E7, and, consequently, the tumor suppressor gene p53, leading to dysplasia. This dysplasia can be: - initially very mild or mild - and these lesions are called low-grade squamous intraepithelial lesion (LSIL) - or they can evolve to moderate or severe dysplasia or even in situ carcinoma. These lesions are called high-grade squamous intraepithelial lesions (HSIL) . These lesions were initially classified as anal intraepithelial neoplasia (AIN) grades I, II, and III. However, as this led to uncertainty regarding the significance of AIN II lesions, a new standardization was made, in which AIN I corresponds to LSIL and AIN II, IIIand in situ carcinoma, to HSIL. It is believed that treating HSIL may prevent its evolution to invasive carcinoma. 3. Surveillance and screening methods Early detection of ASCC is correlated with higher survival and since precursor lesions can be diagnosed and treated, it is believed that this disease is potentially preventable with adequate preventive measures, as it has been occurring with cervical carcinoma - deaths from cervical carcinoma have decreased remarkably since the introduction of screening methods and, more recently, vaccination. There is actually no consensus regarding what patients should be enrolled in an intensive screening program, but risk factors must be assessed individually, and the following populations should be considered for anal cancer screening: HIV-positive men aged >25 y regardless of sexual orientation HIV-positive women aged >25 y HIV-negative MSM aged >40 y Women with high-grade cervical or vulvar lesions or cancer aged >40 y All men and women with perianal condyloma/high-grade squamous intraepithelial lesion aged >25 y Solid organ transplantation recipients and patients with other forms of immunosuppression aged >25 y Currently, there are some methods employed for screening: Anal Pap smear or anal cytology: is one of the most available methods to identify individuals who might benefit from a more intensive screening program. Sensitivity and specificity of anal cytology is quite limited (50–80% of sensitivity and 40-60% of specificity), but it is a simple and inexpensive method, being justifiable as screening tool for high-risk populations for its cost-effectiveness. Anal cytology can present with 4 different results: normal LSIL HSIL ASCUS (atypical squamous cells of undetermined significance) Patients with all results except for normal should be referred to high resolution anoscopy. High resolution anoscopy (HRA): is performed with a colposcope either in the office or in the operating room and allows visualization of lesions that would go unnoticed under conventional anoscopy. Biopsy guided by HRA is considered the gold-standard method for identifying HSIL. The advantage of this method is that it allows treating the lesions under direct vision at the moment of the exam. HPV testing: The presence of HPV, especially subtypes 16 and 18, is associated with the majority of anal cancers, so screening for the presence of high-risk HPV might estimate the risk for dysplasia. However, due to the high prevalence of various types of HPV among high-risk populations, this strategy is quite limited. 4. Assessing precursor lesions Fortunately the rate of progression of HSIL to invasive carcinoma is relatively low, about 1.3-2% per year and around 10% in a 5-year period. For this reason, it is still debatable whether HSIL lesions should always be treated or if expectant management with close follow-up is acceptable in specific situations. Treatment options include ablative therapy and use of topical agents (imiquimod, fluoracil, trichloroacetic acid). There are various algorithms for anal cancer screening, as the University of California San Francisco Anal Neoplasia Clinic, Research, and Education Center (ANCRE). 5. Vaccination The vaccines currently available protect against either two, four or nine types of HPV. All of them protect against types 16 and 18, the most carcinogenic ones. The Centers for Disease Control and Prevention (CDC) recommends: Two doses of the HPV vaccine for all boys and girls at ages 11-12; Vaccination through age 26 for women, 21 for men, if they did not get vaccinated when they were younger. Vaccination of people through age 26, if they did not get vaccinated when they were younger: Young men who have sex with men Young adults who are transgender Young adults with weakened immune systems Although the vaccines are for some specific types of HPV, many studies suggest that crossed-protection against other types of HPV are developed with vaccination. Also, some studies have shown that the nonavalent HPV vaccine may be helpful in preventing recurrent HSIL and the progression to anal SCC, so vaccination might also have a role in secondary prevention of anal cancer.
Published
Sep 2019
To begin the procedure, pneumoperitoneum is created in the abdominal cavity. Our team uses a Veress needle in the left upper quadrant. Once the abdominal pressure reaches 15 mm Hg, trocars are placed in the abdomen. A 12 mm trocar is placed supraumbilically, and 5 mm trocars are placed in the right flank, the right lower quadrant, and the left lower quadrant. The camera is introduced and the abdominal cavity is assessed. The surgeon must look for peritoneal implants,and assess the length of the sigmoid colon and the need to mobilize the splenic flexure, as well as any other findings. The patient is placed in the litothomy position, in Trendelenburg, and tilted to the right. Two teams are working simultaneously at this time. The transanal team includes the main surgeon sitting between the patient’s legs, the assistant to the left and the scrubbed nurse to the right. The abdominal surgeon is to the patient’s right, the first assistant to his left, the scrubbed nurse to the right and a second assistant at the patient’s left side. The transanal platform is then placed. First, the Lone Star retractor is used to locate the dentate line. We use anal dilators to facilitate placement of the gel point platform. The platform is folded in a U-shaped manner to facilitate its introduction in the lubricated anal canal. The device is adjusted with the introducer over the levators and 2 stitches at 3 and 9 o’clock are placed to fix it. Trocars are placed in the gel path cap at 2, 6 and 11 o’clock. If a continuous insufflation system is used, the trocar is usually placed at 2 o’clock. The cap is then placed on the transanal platform and the lid is closed. The pursestring suture is used to close the rectal cavity below the tumor, ensuring an oncologic margin: 5 cm for high rectal cancer, 2 cm for mid-rectal cancer and in the free macroscopic margin in low tumors. A 0 PDS or prolene suture on a 26 mm needle is used, starting at 12 o’clock and continuing clockwise with a 1-2 mm space between stitches. In women, the anterior stitches must be carefully placed to avoid grasping the vaginal wall. While performing this step, the abdominal team clamps the colon at the level of the rectosigmoid junction to prevent colonic distension. TaTME allows for clear identification of the distal edge of the tumor; then, at the desired distance, the pursestring suture is placed in order to achieve a clear distal resection margin. Once completed, it should be tied down either intraluminally with a knot-pusher or outside after removing the platform cap. Once the pursestring is tied down, the cap is placed back on the platform and the pneumorectum is established. With the help of the electrocautery, the rectal mucosa is marked circumferentially, about 1 cm from the pursestring knot, where the mucosal folds end. Small tattoos are then made that will be connected once the marks are completed. The mucosal dissection will progress from partial to full thickness, transecting the rectal wall to continue along the mesorectum. Dissection should progress circumferentially, avoiding creating a funnel. Posteriorly, the dissection will continue to the presacral fascia level. If the dissection continues too posterior, the presacral vessels can be injured with the subsequent bleeding. At the lateral side, the parietal fascia should be our landmark, for if we go too lateral into the lateral wall, nerves and vessels can be injured. Anteriorly, the rectovaginal wall has to be carefully dissected. Placing a vaginal retractor or by digital exam, the border with the vagina is localized and gently dissected. In males, the prostate should be left anteriorly, to avoid any prostatic bleeding, or an even worse complication such as urethral injury. The abdominal team should be working simultaneously on the dissection of the inferior mesenteric vessels and the dissection of the upper part of the rectum. The two teams’ rendezvous is usually anterior at the level of the Douglas pouch. Once both teams connect, the dissection will be completed circumferentially. At this point, the specimen can be extracted transabdominally or transanally. If needed, the splenic flexure can be mobilized. The inferior mesenteric vein is located at the Treitz angle and dissected. The pancreas is visualized and the dissection continues into the lesser sac, toward the splenic flexure to completely mobilize the flexure. Then it is time for the anastomosis. The proximal colon should reach the pelvis with no tension and no torsions. The proximal colon is prepared; all extraneous fat and tissue is removed and the vascular supply is assessed. After vascular assessment, the proximal colon is prepared with the pursestring device. The EEA detachable anvil is introduced into the proximal colon and secured with the pursestring suture. A distal pursestring is made in the rectal stump through the transanal port. Then the EEA stapler is gently introduced into the anal canal and the remaining rectum. The EEA spike is guided through the distal pursestring with a plastic tube, and pulled transabdominally until the spike has gone completely through the pursestring. The distal pursestring is tied down. The anvil is then attached to the spike under abdominal monitoring. Once the anvil and the head are attached to each other, two circular rows of staggered staples are applied and a circular blade cuts out the interior tissue, communicating both lumens. The technique is the same for end-to-end and side-to-side anastomosis, with only the way in which the head is positioned in the graft changing. Injecting Indocyanine Green allows us to perform a real-time intraoperative assessment of the colonic perfusion, helping in the decision on where to locate the proximal colonic transection point. Finally, a loop ileostomy is created if indicated and the abdominal wall ports are closed.
Published
Nov 2018
Clinical Case Today, experts estimate that all human medical knowledge doubles every 18 months. The pace of progress in surgical innovation is so fast that some surgeons have expressed serious concern about patient safety as technology diffuses throughout keeping hospital organization up with surgical innovation is imperative for growth, but surgical programs can be slow to adopt because new technology may result in poor patient outcomes early in the adoption cycle. Because of these fears, the idea of telementoring is born, so that one surgeon can guide another in the distance, using telecommunications, through audio and video telestration. This valuable tool can help your surgeons and clinical teams feel comfortable adopting the latest procedures But before continuing talking, we should know… What is the difference between the different concepts of telemedicine? Telemedicine: The use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status. Teleconferencing: Interactive electronic communication among multiple users at two or more sites that facilitates voice, video and/or data transmission systems: audio, graphics, computer and video systems. Telemonitoring: The process of using audio, video and other telecommunications and electronic information processing technologies to monitor the health status of a patient from a distance. Telepresence: The use of a set of technologies that allows individuals to feel as if they were present, to give the appearance of being present, or to have an effect at a place other than their true location. Teleconsultation: Consultation between a provider and specialist at distance using either store and forward telemedicine or realtime videoconferencing. Telementoring: telementoring is a relationship, facilitated by telecommunication technology, in which an expert (Mentor) provides guidance to a less experienced learner (Mentee) from a remote location. Telestration: a technique for drawing freehand annotations over a still image or video. The Mentor/telementor is an expert surgeon who undertakes to impart his/her clinical knowledge and skills in a defined setting to a mentee. The mentor must be appropriately privileged, skilled, and experienced in the procedure and or technique in question. The telementor, by definition, does not have the ability to physically intervene onsite in the primary activity without the telecommunications interface. The Mentee/trainee is a surgeon with appropriate basic knowledge and experience seeking individual training in skills and/or procedures not previously learned in prior formal residency or fellowship training. The mentee must have appropriate background knowledge, basic skills, and clinical experience relevant to the proposed curriculum. Telementoring differs from teleconsultation in three precise ways: Telementoring requires an established relationship between the mentor and mentee in which the skills and knowledge of both are understood through a relationship developed prior to the telementoring event. Telementoring is performed with a competent mentee who is capable of managing the patient’s disease, as if the mentor were not telepresent, although likely using a different technique or technology. Telementoring occurs within an educational framework through which both the mentor and mentee have worked to prepare for the mentoring experience. Modern technology has allowed for numerous advances in the utilization of telementoring. Early telementoring systems were limited by low transmission rates, raising concerns of the deleterious effects that a time delay may have on surgical performance. Current telecommunication systems allow for dramatically increased transmission speeds, permitting a considerably decreased time delay. In addition, the high resolution associated with modern high definition cameras has enhanced the remote surgeon’s ability to zoom and visualize small anatomic details. Wearable technology, such as Virtual Reality Glasses, and methods of augmented reality telementoring have also been implemented and have had some success. Specially designed telemedical robotic platforms have been developed also and may play a role in further increasing the remote surgeon’s presence in the operating room. But one of the most important advances in telementoring systems was the application interactive additions such as laser pointing capabilities, telestration, or increased remote control of the visual field playing a role in enriching the teaching capabilities of the remote surgeon. These different strategies for realizing telementoring have numerous advantages that have been increasing to the present. Telestration enables a trainer to point or draw freehand sketches over a video for the trainees to see. This method can improve the trainees performance, in terms of economy of movement, after the initial mastery has been attained. The improved use of laparoscopic video results in more direct instrument movement. The telestration systemns benefits the trainees in the adoption of professional vision, which would further enhance the trainees technical skills and understanding of the procedure. Telestration reduces travel and time away from work for both surgeons involved in training a major rate limiting factor in surgeon upskilling. In addition, the hospital benefits from performing more cases at their facility and ensuring that the surgeon has the expert support needed to deliver high quality care early in their post-training learning curve. The patient, meanwhile, gets the comfort of knowing that their surgeon will be supported by additional experts. As the technology required to implement surgical telestration is currently readily available to many physicians, the advancement of tit is now dependent on several other hurdles limiting its expansion. Additionally, despite numerous studies demonstrating the utility and safety of telementoring and telestration, the literature is limited by small sample sizes, variation in telementoring platforms, procedure, and the experience of the onsite surgeon. These limitations provide some confusion regarding the optimal use of this technology. Future studies evaluating clinical and educational outcomes with large sample sizes that span numerous procedures may be necessary to validate its utility and appropriate indications for use. The skill set and experience of the onsite surgeon likely has a large impact on the success the telementored procedure. However, some studies have began investigating its potential to be used in “worst-case scenarios”, in which the mentored onsite healthcare professionals have very limited experience or training in the procedure they are required to perform. Future studies are needed in order to determine the feasibility of telementoring in guiding inexperienced healthcare professionals. Determining a minimum set of qualifications and skillsets is another factor that may better define the best application of telementoring and its future success. The main benefit is that it has to potential to distribute specialized surgical knowledge and guidance through a relatively convenient and low cost method as compared to traditional mentoring. The development of platforms that optimize patient outcomes and the educational value of that training, while maintaining appropriate cost effectiveness, carry great potential to mitigate the shortage of surgeons around the world. The Hospital Clinic of Barcelona, a reference center in laparoscopic and minimally invasive surgery, will now have this innovative tool, thus breaking the barriers of surgical training, and can bring new knowledge to all types of hospitals around the world, thus improving the development of the surgeons surgical skills and consequently, favoring the treatment of patients and their results.
Published
Jun 2018
Case A 73-year-old male presented with a local recurrence for rectal cancer. Initially, the patient had a cT4N1 3 cm from the anal verge, received neoadjuvant treatment and underwent a transanal intersphincteric resection (ypT3N0). No adjuvant treatment was indicated. A year later he presented with a pulmonary metastatic nodule, which was resected followed by chemotherapy. Three years later, a perianal nodule below the anastomosis was detected, associated with elevated CEA levels, positive imaging, and positive pathology for malignancy. An abdominoperineal resection by a two-team approach (Cecil approach) was then indicated. Treatment The patient is placed in the lithotomy position, and a Foley catheter is inserted. First the anus is closed and the perianal skin is scored circumferentially with a cautery. Extraelevator dissection is not performed in our center. The dissection is continued from the skin into the subcutaneous tissue circumferentially, creating a skin flap to place the Lonestar retractor. Further open resection is carried out through the fatty tissue in order to create enough space for the transanal platform to sit. At this point, a purse-string is created along the skin border so that, whenever the transanal platform is placed, the perianal skin can be adjusted around the platform. A continuous running silk suture is used, removing the Lonestar as the purse-string progresses. Different transanal platforms are available. For abdominoperineal resections, a plastic flexible platform may adjust more adequately to the skin, tying the purse-string around it (GelPOINT mini®, Applied Medical, Inc). Trocars are placed on the gel platform lid, one of them for the continuous flow insufflation device (Airseal®, Conmed). The lid is adjusted onto the transanal platform and a pneumorectum is created. A laparoscopic 3D flexible tip camera, a hook cautery and a grasper are used through the transanal platform in order to continue the mesorectal dissection. Operative time was 150 minutes. The post-operative period was uneventful and the patient was discharged on 4th post-operative day. Outcome In conclusion, the transanal approach to abdominoperineal resection is a safe and feasible technique in our experience. Technical steps are critical in order to perform this technique transanally as the available instruments are adapted for the procedure.
Published
Mar 2018
Clinical Case Trocar site hernias (TSH) tend to develop more frequently – around 25% of them - at umbilical and midline port sites due to a natural weakness of the linea alba. Most hernias develop in the first month after surgery, especially during the first 10 days. About 70-80% of trocar site hernias require surgical management and one of the most feared complications of trocar site hernias is small bowel strangulation. Ritcher’s hernia is particularly frequent in TSH. It is defined by a protrusion of the antimesenteric wall of the intestine through a defect in the abdominal wall, so it can cause small bowel strangulation without causing obstructive symptoms. The incidence of Ritcher’s hernia reaches 47.6% in early onset TSH. About 80-90% of trocar site hernias occur at incisions that are 10 mm or larger, so an incision size larger than or equal to 10 mm is a significant risk factor. Other associated risk factors are: prolonged surgical time manipulation of the incision number of trocars incomplete closure of fascia at the trocar site midline trocars organ retrieval through the trocar site partial vacuum during port withdrawal, drawing the omentum and intestine into the fascial defect wound infection at trocar site reinsertion of the port host factors: obesity, poor nutrition, advanced age, gender, diabetes, steroid therapy The clinical presentation of TSH is variable, as is the time of onset. Usually, it presents as swelling and pain at the incision site and may be hard to differentiate from a hematoma or wound infection, especially in the first post-operative days. Especially in obese patients, diagnosis by physical examination can be tricky, so CT scans can be helpful. Careful postoperative management is recommended, especially in patients with the risk factors mentioned. Bowel occlusion is often insidious, as in the case of a partial Richter's hernia, which typically presents with vomiting or nausea and a distended and painful abdomen, especially in the first 14 days after surgery. When resolution of postoperative ileus after laparoscopic surgery is not achieved after 7–14 days, a differential diagnosis with mechanical occlusion should be obtained by means of a CT scan. TSHs are classified into 3 types , originally described by Tanouchi: Type 1, early-onset: indicates dehiscence of the anterior fascial plane, posterior fascial plane, and peritoneum. It often presents as a small-bowel obstruction. Type 2, late-onset: develops several months after surgery and is frequently related to complications of the trocar insertion. It indicates dehiscence of the anterior fascial plane and posterior fascial plane. The hernia sac of the late-onset type is in the peritoneum. Type 3, special type: indicates dehiscence of the whole abdominal wall, with protrusion of the intestine and other tissue (eg, greater omentum). Trocar site hernias are directly related to the size of the trocar, being more common at > 10mm sizes rather than in 5mm. Therefore, it is recommended that all incisions > 10mm be closed, if possible. When active manipulation through a 5-mm port has occurred during prolonged procedures, the fascial defect should be closed to avoid complications. Many authors have recommended the deflation of the pneumo-peritoneum prior to port removal , so the omentum and intestines are not drawn into the fascial defect. According to most authors, despite the evidence that some types of trocars or incisions may prevent or are better at avoiding trocar site herniation, closure of both the fascia and the peritoneum should be performed when possible.
Published
Feb 2018
Clinical Case A parastomal hernia (PH) is defined as the herniation of any abdominal cavity content other than the ostomy itself through the ostomy orifice. It should be distinguished, however, from mucosal prolapse, which is a full-thickness protrusion of intestine through the stoma. Parastomal hernias are a fairly common complication in patients with a definitive stoma, being observed in 30-50% of them. Thus they are more frequent overall than incisional ventral hernias . Most parastomal hernias occur within the first years after their stoma is created, but may arise much later, as the patients grow older and the abdominal wall may become weaker. Parastomal hernias occur as a result of weakness in the abdominal wall which may or may not be associated with elevated intraabdominal pressure, or be due to a technical failure when the stoma is created. Consequently, the main risk factors for parastomal hernias are: Advanced age Obesity Malnutrition Steroid use or other immunodeficience Smoking and/or COPD Wound infection The diagnosis is established on the basis of clinical history and physical examination . The most frequent complaints are discomfort and difficulty in adapting ostomy appliances. The physical examination will show a bulge under the skin beside the ostomy, which is increased by Valsalva’s maneuver and may be completely or partially reducible. In obese patients, the diagnosis of parastomal hernias by physical examination may be difficult. In these cases, when there is a complaint, a CT scan or ultrasound can be helpful for diagnosis. Moreover, these exams are helpful in evaluating the size of the hernia, as well as its contents. Several classifications have been created over the years, until in 2014, the European Hernia Society created a consensus classification in order to improve the ability to compare different studies and their results, in addition to facilitating data collection. The classification divides hernias into four types and distinguishes between primary and recurrent hernias. Hernias are rated according to size ( ≤ or > 5 cm) and presence or not of incisional hernia (cIH). Type I: PH ≤5 cm with no cIH. Type II: PH ≤5 cm with cIH. Type III: PH >5 cm with no cIH. Type IV: PH >5 cm with cIH. P: primary PH. R: recurrence after previous PH treatment. There is no consensus on the timing of elective surgical treatment for parastomal hernias. Treatment should be tailored according to the patient’s symptoms and complaints and should take into consideration the patient’s comorbidities, quality of life and clinical status, as well as the risk associated with watchful waiting. The main symptoms leading to surgery are discomfort, pain, bowel obstruction and/or strangulation, and difficulty in proper fixation of ostomy appliances, leading to peristomal dermatitis and physical deformity. There are some clinical measures that can be taken to minimize symptoms, such as use of support garments, losing weight and follow-up with stomal nurses. Many techniques have been proposed, from Sugarbaker to repositioning of the colostomy, open vs laparoscopic, biological or synthetic mesh vs no mesh. One of the most frequently employed techniques is the Sugarbaker technique, which consists of applying an intraperitoneal mesh covering the ostomy. There are some intra and post-operative measures that can help to prevent the development of parastomal hernias, such as: Correct positioning, placing the orifice through the rectus muscle Avoiding excessive opening of the fascia (as small as possible, as long as it doesn’t compromise stoma perfusion) Wearing a support garment (belt or underwear) Avoiding heavy lifting and straining Avoiding being overweight and maintaining a normal body mass index when possible – being overweight can place additional strain on your abdominal muscles.
Published
Feb 2018
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