Albert Wolthuis

Anal Fistula Plug for Closure of Difficult Anorectal Fistula: A Prospective Study

PurposeComplex high and recurrent fistulas remain a surgical challenge. Simple division, i.e., fistulotomy, will likely result in fecal incontinence. Various surgical treatment options for these fistulas have shown disappointing results. Recently a biologic anal fistula plug was developed to treat these high transsphincteric fistulas. To assess the results of the anal fistula plug in patients with complex high perianal fistulas, a prospective, two-center, clinical study was undertaken.MethodsBetween April 2006 and October 2006, a consecutive series of patients with difficult therapy-resistant high fistulas were enrolled. During surgery, the internal fistula tract opening was identified. A conical shaped collagen plug was pulled through the fistula tract. Any remaining portion of the plug that was not implanted in the tract was removed. The plug was fixed at the internal opening with a deep 3/0 polydioxanone suture.ResultsSeventeen patients with a median age of 45 (range, 27–75) years were included. Of these patients, 71 percent (12/17) were male. At a median length of follow-up of 7 (range, 3–9) months, 7 of 17 fistulas had healed (41 percent). In ten patients, the fistula recurred.ConclusionsIn these small series of 17 patients with difficult high perianal fistulas, a success rate of 41 percent is noted. Larger series, preferably in trial setting, must be performed to establish the efficacy of the anal fistula plug in perianal fistula.

Clinical outcome after radical excision of moderate-severe endometriosis with or without bowel resection and reanastomosis: a prospective cohort study.

Objective:To assess the clinical outcome of women requiring laparoscopic excision of moderate-severe endometriosis in women with and without bowel resection and reanastomosis. Methods:Two hundred three patients with laparoscopically excised moderate (n = 67) or severe (n = 136) endometriosis (rAFS: revised endometriosis classification of the American Fertility Society) were prospectively followed during a median of 20 months (1–45 months) using a CONSORT-inspired checklist. Patients completed the EHP30 Quality-of-Life Questionnaire and visual analogue scales (VAS) for dysmenorrhea, chronic pelvic pain, and deep dyspareunia and answered questions about postoperative complications, reinterventions/recurrences, and fertility outcome 1 month before and 6, 12, 18, and 24 months after surgery. Clinical outcome was compared between women with deeply infiltrative endometriosis undergoing CO2 laser ablative surgery with bowel resection (study group, 76/203; 37%) and without bowel resection (control group, 127/203; 63%). Results:Both groups were similar with respect to population characteristics and clinical outcome, except for mean rAFS score [higher in study group (73 ± 31) than in control group (48 ± 26)] and minor complication rate [higher in study group (11%) than in control group (1%)]. In both groups, mean VAS and EHP30 scores improved significantly and remained stable for 24 months after surgery, with a pregnancy rate of 51%. Within 1, 2, and 3 years follow-up, the cumulative reintervention rate was 1%, 7%, and 10%, respectively, and the cumulative endometriosis recurrence rate was 1%, 6%, and 8%, respectively. Conclusions:Clinical outcome after CO2 laser laparoscopic excision of moderate-severe endometriosis was comparable in women with or without bowel resection and reanastomosis, except for a higher minor complication rate occurring in women with bowel resection and reanastomosis (NCT00463398).

The use of Oxaliplatin or Mitomycin C in HIPEC treatment for peritoneal carcinomatosis from colorectal cancer: A comparative study

Oxaliplatin and Mitomycin C (MMC) are both suitable as intraperitoneal chemotherapy agents in HIPEC for peritoneal carcinomatosis (PC) of colorectal cancer (CRC).

Outcomes for case-matched single-port colectomy are comparable with conventional laparoscopic colectomy

Aim  With the introduction of single‐port surgery, expected advantages are improved cosmesis, decrease of pain and shorter length of stay. The aim of this study was to compare early outcomes of single‐port colectomy with those of conventional laparoscopic colectomy.

Incidence of Prolonged Postoperative Ileus after Colorectal Surgery: a systematic review and meta‐analysis

Prolonged postoperative ileus (PPOI) after colorectal surgery remains a leading cause of delayed postoperative recovery and prolonged hospital stay. Its exact incidence is unknown. The aim of this systematic review is to investigate the definitions and incidence of PPOI previously described.

The impact of frailty on postoperative outcomes in individuals aged 65 and over undergoing elective surgery for colorectal cancer: A systematic review

Colorectal cancer surgery is frequently performed in the older population. Many older persons have less physiological reserves and are thus more susceptible to adverse postoperative outcomes. Therefore, it seems important to distinguish the fit patients from the more vulnerable or frail. The aim of this review is to examine the evidence regarding the impact of frailty on postoperative outcomes in older patients undergoing surgery for colorectal cancer. A systematic literature search of Medline Ovid was performed focusing on studies that examined the impact of frailty on postoperative outcomes after colorectal surgery in older people aged ≥65years. The methodological quality of the studies was evaluated using the MINORS quality assessment. Five articles, involving four studies and 486 participants in total, were included. Regardless of varying definitions of frailty and postoperative outcomes, the frail patients had less favourable outcomes in all of the studies. Compared to the non-frail group, the frail group had a higher risk of developing moderate to severe postoperative complications, had longer hospital stays, higher readmission rates, and decreased long-term survival rates. The results of this systematic review suggest the importance of assessing frailty in older persons scheduled for colorectal surgery because frailty is associated with a greater risk of postoperative adverse outcomes. We conclude that, although there is no consensus on the definition of frailty, assessing frailty in colorectal oncology seems important to determine operative risks and benefits and to guide perioperative management.

Laparoscopic sigmoid resection with transrectal specimen extraction: a novel technique for the treatment of bowel endometriosis

BACKGROUND Multidisciplinary laparoscopic treatment is the standard of care for radical treatment of deep infiltrating pelvic endometriosis. If bowel resection is necessary, a muscle-split or Pfannenstiel incision is also required. The avoidance of any laparotomy could decrease surgical stress response, give a faster return to normal bowel function, decrease post-operative pain and reduce wound complications and incisional hernias. We assessed post-operative outcome after a full laparoscopic sigmoid resection for bowel endometriosis. PATIENTS AND METHODS Twenty-one patients who underwent elective full laparoscopic sigmoid resection for bowel endometriosis from September 2009 to September 2010 were matched for age, American Society of Anesthesiologists class and BMI to 21 patients who underwent a conventional laparoscopic sigmoid resection. Groups were compared for peri-operative factors, complications, length of hospital stay, post-operative pain (Visual Analog Scale: VAS), analgesics consumption and inflammatory response (plasma C-reactive protein: CRP). RESULTS Median operating time was 15 min shorter with transrectal specimen extraction (P = 0.003). VAS-scores and use of analgesics were higher in the conventional laparoscopic group (P = 0.0005). Mean CRP-level tended to be higher in the transrectal specimen extraction group (38%, P = 0.054) but there was no difference in increase in CRP level between groups (P = 0.15). There were no anastomotic leaks or reinterventions in either group, and the median hospital stay was similar. At follow-up, no wound infections or incisional hernias were observed and no patients reported anal dysfunction. CONCLUSION Full laparoscopic sigmoid resection reduced operating times and decreased post-operative VAS-scores and analgesic requirements compared with the conventional laparoscopic sigmoid resection for bowel endometriosis.

Laparoscopic sigmoid resection with transrectal specimen extraction: a systematic review.

Aim  A systematic review was performed to identify differences in surgical technique, postoperative morbidity, length of hospital stay and safety for procedures involving left‐sided laparoscopic colectomy with natural orifice specimen extraction.

Specific members of the predominant gut microbiota predict pouchitis following colectomy and IPAA in UC

Objective Pouchitis is the most common complication after colectomy with ileal pouch-anal anastomosis (IPAA) for UC and the risk is the highest within the 1st year after surgery. The pathogenesis is not completely understood but clinical response to antibiotics suggests a role for gut microbiota. We hypothesised that the risk for pouchitis can be predicted based on the faecal microbial composition before colectomy. Design Faecal samples from 21 patients with UC undergoing IPAA were prospectively collected before colectomy and at predefined clinical visits at 1 month, 3 months, 6 months and 12 months after IPAA. The predominant microbiota was analysed using community profiling with denaturing gradient gel electrophoresis followed by quantitative real-time PCR validation. Results Cluster analysis before colectomy distinguished patients with pouchitis from those with normal pouch during the 1st year of follow-up. In patients developing pouchitis, an increase of Ruminococcus gnavus (p<0.001), Bacteroides vulgatus (p=0.043), Clostridium perfringens (p=0.011) and a reduction of two Lachnospiraceae genera (Blautia (p=0.04), Roseburia (p=0.008)) was observed. A score combining these five bacterial risk factors was calculated and presence of at least two risk factors showed a sensitivity and specificity of 100% and 63.6%, respectively. Conclusions Presence of R. gnavus, B. vulgatus and C. perfringens and absence of Blautia and Roseburia in faecal samples of patients with UC before surgery is associated with a higher risk of pouchitis after IPAA. Our findings suggest new predictive and therapeutic strategies in patients undergoing colectomy with IPAA.

AirSeal system insufflator to maintain a stable pneumorectum during TAMIS.

Abstract Transanal minimally invasive surgery (TAMIS) is typically used for treating intraluminal rectal tumors. Other applications have recently been described. We here present the use of TAMIS as a tool to treat a chronic anastomotic fistula after restorative rectal resection. A new insufflation device expected to solve the problem of maintaining a stable pneumorectum is described.