Colin Peirce

The use of minimally invasive surgery in the management of idiopathic omental torsion: The diagnostic and therapeutic role of laparoscopy.

Omental torsion is an unusual and infrequently encountered cause of acute abdominal pain in adults. Computed tomography (CT) is a useful adjunct to clinical history and examination in establishing the diagnosis; however, definitive diagnosis is frequently established at the time of exploratory surgery. Treatment may be conservative or operative, with laparoscopic resection the surgical approach of choice. We report the case of a 60-year-old man who presented with a 3-day history of severe right-sided abdominal pain. Abdominal CT scan revealed a right upper quadrant mass with a whirl-like appearance, suspicious for omental infarction. Diagnostic laparoscopy was undertaken, the diagnosis confirmed and the diseased omentum resected. The patient was discharged the following day and made an uncomplicated recovery.

Prophylactic Negative Pressure Dressing Use in Closed Laparotomy Wounds Following Abdominal Operations: A Randomized, Controlled, Open-label Trial

Objective: A randomized controlled trial was undertaken to investigate the effect of prophylactic negative pressure dressings on postoperative surgical site infection (SSI) rates in closed laparotomy wounds. Summary of Background Data: Laparotomy wounds are associated with high rates of SSI. The effect of prophylactic negative pressure dressing of closed incisional wounds on SSI rate is unknown. Methods: A randomized, controlled, open-label trial was conducted (clinicaltrials.gov registration number NCT02780453). Fifty patients undergoing open abdominal surgery were included, with 25 patients randomized to the negative pressure dressing group and 25 to the standard dressing group. The primary endpoint was SSI incidence at 30 days postoperatively. Secondary endpoints included SSI incidence at 4 days, length of stay, cosmetic outcome, and patient satisfaction. Statistical analysis was performed on a per-protocol basis using SPSS version 23.0. Results: The incidence of SSI at 30 days postoperatively was significantly reduced in the treatment group compared with the control group [8.3% vs 32.0%, P = 0.043 (1-sided), P = 0.074 (2-sided)]. There was no difference in SSIs at 4 days postoperatively [4.1% vs 8.0%, P = 0.516 (1-sided), P = 1.0 (2-sided)]. Analysis of predictors of wound infection identified standard wound dressings as the only significant predictor of SSI development. Length of stay was significantly reduced in the negative pressure dressing group [6.1 vs 14.7 days, P = 0.019 (2-sided)]. Cosmetic outcome and patient satisfaction did not show any difference between the 2 groups. Conclusions: Prophylactic use of negative pressure dressings for closed laparotomy wounds significantly reduces the incidence of SSI at 30 days postoperatively.

Management of the Perineal Defect after Abdominoperineal Excision.

The optimal management of the perineal defect following abdominoperineal excision for anorectal malignancy remains a source of debate. The repopularization of extralevator resection means colorectal surgeons are confronted with larger perineal wounds. There are several surgical options available-primary perineal closure and drainage, omentoplasty, biological or synthetic mesh placement, musculocutaneous flap repair, and negative wound pressure therapy. These options are discussed along with the potential benefits and complications of each. There remains no consensus on which management strategy is superior; thus, each case must be tailored for each individual patient. Surgical expertise and availability of a multidisciplinary team approach are important considerations.

Inclusion of the Mesentery in Ileocolic Resection for Crohn’s Disease is Associated With Reduced Surgical Recurrence

Abstract Background and Aims Inclusion of the mesentery during resection for colorectal cancer is associated with improved outcomes but has yet to be evaluated in Crohn’s disease. This study aimed to determine the rate of surgical recurrence after inclusion of mesentery during ileocolic resection for Crohn’s disease. Methods Surgical recurrence rates were compared between two cohorts. Cohort A [n = 30] underwent conventional ileocolic resection where the mesentery was divided flush with the intestine. Cohort B [n = 34] underwent resection which included excision of the mesentery. The relationship between mesenteric disease severity and surgical recurrence was determined in a separate cohort [n = 94]. A mesenteric disease activity index was developed to quantify disease severity. This was correlated with the Crohn’s disease activity index and the fibrocyte percentage in circulating white cells. Results Cumulative reoperation rates were 40% and 2.9% in cohorts A and B [P = 0.003], respectively. Surgical technique was an independent determinant of outcome [P = 0.007]. Length of resected intestine was shorter in cohort B, whilst lymph node yield was higher [12.25 ± 13 versus 2.4 ± 2.9, P = 0.002]. Advanced mesenteric disease predicted increased surgical recurrence [Hazard Ratio 4.7, 95% Confidence Interval: 1.71–13.01, P = 0.003]. The mesenteric disease activity index correlated with the mucosal disease activity index [r = 0.76, p < 0.0001] and the Crohn’s disease activity index [r = 0.70, p < 0.0001]. The mesenteric disease activity index was significantly worse in smokers and correlated with increases in circulating fibrocytes. Conclusions Inclusion of mesentery in ileocolic resection for Crohn’s disease is associated with reduced recurrence requiring reoperation.

Digital sculpting in surgery: a novel approach to depicting mesosigmoid mobilization.

BackgroundThe aim of the present study was to develop a unique anatomic replica of the mesocolon using digital graphical software in order to provide an educational template for mesosigmoidectomy.MethodsThe colon and mesocolon were fully mobilized from ileocecal to mesorectal levels in a cadaver. Both colon and mesocolon provided a template from which to generate a three dimensional replica in ZBrush. The model was deformed in ZBrush, to compare and contrast current and classic interpretations of mesosigmoidal topography. An animation was developed in which the replica was deformed to mimic operative mobilization. Contiguous shape changes were captured in two-and-a-half-dimensional (2.5D) screen snapshots. This was repeated for medial to lateral and lateral to medial mobilization of the mesosigmoid.ResultsTopographic differences between classic and current appraisals of mesocolic anatomy were evident in 2.5D format. Using the model generated, contiguous shape changes during mesosigmoidal mobilization (i.e., between the left mesocolon, mobile/apposed mesosigmoid, and mesorectum) were replicated in animation format. By extracting and compiling 2.5D screen grabs a pictorial chronology of mobilization was developed.ConclusionsRecent advances in mesocolic topography can be captured and rendered using advanced digital sculpting software with high-end graphics capabilities. This approach permits a depiction of contiguous changes in mesosigmoidal topography during mesosigmoidal mobilization. A compilation of images in either animation or screen grab format obviates the interpolation of shape changes required using standard educational approaches.

Operative Strategy, Risk Factors for Leak, and the Use of A Defunctioning Ileostomy with Ileal Pouch-Anal Anastomosis: Let’s Not Divert from Diversion and the Traditional 3-Stage Approach for Inflammatory Bowel Disease

Operative strategy, risk factors for leak and the use of a defunctioning ileostomy with ileal pouch-anal anastomosis: let’s not divert from diversion and the traditional 3-stage approach for inflammatory bowel disease. Two articles are reviewed. The first paper, ‘Modified 2-stage ileal pouch-anal anastomosis results in lower rate of anastomotic leak compared to traditional 2-stage surgery for ulcerative colitis’, is an informative single-institution retrospective review of 2-stage ileal pouch-anal anastomosis [IPAA] procedures, the traditional versus the modified, over a 13-year period. The outcome of interest was anastomotic leak following pouch creation and was defined as ‘a clinical or radiographic leak originating from the ileo-anal anastomosis or the top of the J-pouch’. The authors report a significantly reduced and impressive leak rate in the modified 2-stage group, 4.6% vs 15.7%, along with a significantly reduced length of stay albeit at 9.5 days. The sequelae and morbidity of an ileal pouch-anal anastomotic leak are not necessarily comparable to those of a tip of the J-pouch leak, with or without a diverting ostomy. The exact sites of the 46 leaks across both groups are not reported here. We are told the ‘pouch failure’ rate in the study was 0.7%, that is three patients, but it is not readily apparent what this means. Furthermore, there are no data reported on the remaining 43 patients with leaks, i.e. pouch salvage, pouch excision, temporary or permanent pouch diversion. The predominant symptom following either site of leak is poor pouch function with a direct impact on the quality of life, and these data are often impossible to glean in the current retrospective setting. However, it would be widely agreed upon that pouch function following a leak is suboptimal in comparison with pouch function with no leak. We agree, as is clearly demonstrated here in terms of outcome, that … Both authors contributed equally to this work. Corresponding author: Dr F.H. Remzi, MD, FASCRS, Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA. Tel: 12164455020; fax: 12164458627; Email: remzif{at}ccf.org

Coexistent widespread small intestinal and colonic diverticular disease

A 73-year-old woman with a history of multiple abdominal surgery and sigmoid diverticulosis presented with severe constipation refractory to conservative management. As a result, she had developed food aversion and cachexia. Patient opted for laparotomy and defunctioning ileostomy to improve quality of life. At laparotomy, extensive diverticulae involving the small and large bowels were identified. Defunctioning ileostomy was performed. The patient regained her quality of life and reinstituted normal diet. Histology revealed marked serosal fibrosis and pulsion diverticulae.