Kim J. Gorissen

Local recurrence after stenting for obstructing left‐sided colonic cancer

Self‐expanding metallic stents (SEMS) may be used in acute obstructing left‐sided colonic cancers to avoid high‐risk emergency surgery. However, oncological safety remains uncertain. This study evaluated the long‐term oncological outcome of SEMS as a bridge to elective curative surgery versus emergency resection.

Laparoscopic ventral rectopexy for fecal incontinence associated with high-grade internal rectal prolapse.

BACKGROUND: The role of internal rectal prolapse in the origin of fecal incontinence remains to be defined. In our institution, laparoscopic ventral rectopexy is offered to patients with high-grade internal prolapse and fecal incontinence. OBJECTIVE: The present study was designed to evaluate the functional outcome after laparoscopic ventral rectopexy in patients with fecal incontinence associated with high-grade internal rectal prolapse. DESIGN: This study was designed as a prospective observational study. SETTINGS: The study took place in a university hospital. PATIENTS: Between 2009 and 2011, 72 patients with fecal incontinence not responding to maximum medical treatment (including biofeedback) were included. All patients had a grade III or grade IV rectal prolapse. INTERVENTION: Laparoscopic ventral rectopexy was performed. MAIN OUTCOME MEASURES: Preoperative endoanal ultrasonography and anorectal manometry were performed. Fecal continence was evaluated by using the Rockwood Fecal Incontinence Severity Index score before and 1 year after surgery. RESULTS: The median fecal incontinence severity index score 1 year after surgery was lower than the median score before surgery (15 versus 31; p < 0.01), representing an improvement in fecal continence. LIMITATIONS: This was a preliminary observational study with no control group, no postoperative proctography, and no postoperative anal physiology. CONCLUSION: Laparoscopic ventral rectopexy can improve symptoms of fecal incontinence in patients with a high-grade internal rectal prolapse. Internal rectal prolapse contributes to the multifactorial origin of fecal incontinence.

Erratum to: Sacral neuromodulation for faecal incontinence: is the outcome compromised in patients with high-grade internal rectal prolapse?

Background High-grade internal rectal prolapse appears to be one of the contributing factors in the multifactorial origin of faecal incontinence. Whether it affects the outcome of sacral neuromodulation is unknown. We compared the functional results of sacral neuromodulation for faecal incontinence in patients with and without a high-grade internal rectal prolapse.

Sacral neuromodulation for persistent faecal incontinence after laparoscopic ventral rectopexy for high-grade internal rectal prolapse.

Internal rectal prolapse is recognized as an aetiological factor in faecal incontinence. Patients found to have a high‐grade internal rectal prolapse on routine proctography are offered a laparoscopic ventral rectopexy after failed maximum medical therapy. Despite adequate anatomical repair, faecal incontinence persists in a number of patients. The aim of this study was to evaluate the outcome of sacral neuromodulation in this group of patients.

Sacral nerve stimulation for faecal incontinence due to imperforate anus in VATER/VACTERL association

Dear Editor: The VATER/VACTERL association is a rare condition of random co-occurrence of vertebral defects, anorectal malformations, cardiac defects, tracheaoesophageal fistula, renal anomalies and limb abnormalities [1]. Treatment of the anal atresia will usually consist of a direct postnatal doubleloop colostomy formation, followed later by a pull-through reconstructive operation and re-anastomosis of the colostomy. Long-term results for this operation show a normal bowel function in less than half of the patients, with constipation and soiling as main complaints [2]. Sacral nerve stimulation (SNS) is an effective treatment for patients suffering faecal incontinence, benefitting patients with sphincter lesions and incontinence due to neurological disorders also [3]. We report on the result of SNS in a patient suffering obstructive defecation and faecal incontinence related to VATER/VACTERL association, with (among other) imperforate anus and rectovaginal fistula at birth, treated by corrective surgical interventions at early age.

No benefit of ultrasound-guided transversus abdominis plane blocks over wound infiltration with local anaesthetic in elective laparoscopic colonic surgery: results of a double-blind randomized controlled trial

Advances in laparoscopic techniques combined with enhanced recovery pathways have led to faster recuperation and discharge after colorectal surgery. Peripheral nerve blockade using transversus abdominis plane (TAP) blocks reduce opioid requirements and provide better analgesia for laparoscopic colectomies than do inactive controls. This double‐blind randomized study was performed to compare TAP blocks using bupivacaine with standardized wound infiltration with local anaesthetic (LA).

Dynamic Article: Permanent Sacral Nerve Stimulation Under Local Anesthesia: Feasibility, Best Practice, and Patient Satisfaction.

BACKGROUND: The increasing incidence of fecal incontinence and the use of sacral neuromodulation have an increasing impact on health care providers and health care costs. OBJECTIVE: The purpose of this study was to investigate the technical and clinical success rates, complications, and patient satisfaction of the implantation of permanent sacral nerve stimulation under local anesthesia. DESIGN: A cohort analysis of consecutive patients with sacral nerve stimulation for fecal incontinence over a period of 1 year was performed. SETTINGS: This study was conducted at a specialized pelvic floor unit in a tertiary care center. PATIENTS: Sixty-one patients were available for the assessment after 1-year follow-up. MAIN OUTCOME MEASURES: Technical success, procedural time, and complications were noted. Clinical outcome (including Fecal Incontinence Severity Index, Fecal Incontinence Quality of Life scale, and Gastrointestinal Quality of Life Index were collected prospectively before and after treatment. RESULTS: All procedures were successfully completed under local anesthesia, with a median total procedural time of 50 minutes (range, 26–72 minutes). All patients were discharged on the day of their procedure. Postoperative complications occurred in 3 patients (4.9%). At 3 months follow-up, the median Fecal Incontinence Severity Index score was reduced from 37 to 27 (p = 0.001). Both the Fecal Incontinence Quality of Life scale and the Gastrointestinal Quality of Life Index had improved from 63 to 82 (p < 0.001) and 72 to 90 (p = 0.012). At a mean follow-up of 13 months, both the Fecal Incontinence Quality of Life scale and the Gastrointestinal Quality of Life Index improved further to 90 (p < 0.001) and 94 (p < 0.001). All patients would recommend the procedure under local anesthesia to other patients. No patients experienced leg pain during follow-up. LIMITATIONS: This study involved a relatively small group of patients, and patient satisfaction was only recorded for the last 22 patients. No exact cost calculations were made. CONCLUSIONS: Permanent sacral nerve stimulation implantation under local anesthesia has high technical and clinical success rates. It is safe, well tolerated by patients, and has obvious logistical and financial benefits.

A Twist in the Tale

We present the case of a 70-year-old gentleman who was referred to our Surgical Emergency Unit with signs and symptoms of large bowel obstruction on a background of long-standing constipation. Computed tomography confirmed sigmoid volvulus. Endoscopic decompression was unsuccessful. Although there were no findings suggestive of ischaemia or perforation, abdominal dissention and absolute constipation persisted. He underwent diagnostic laparoscopy and untorting of his sigmoid colon. In view of multiple medical comorbidities and a strong wish of the patient to avoid a stoma, the decision was taken not to perform a resection but to a laparoscopic sigmoidopexy. The sigmoid colon was fixed over its entire length to the abdominal wall with permanent metal tacks (Protack, Covidien) in an effort to prevent future volvulus. The patient made an uneventful recovery and was discharged on the third postoperative day. He presented again 5 months later with an identical clinical picture of abdominal distension, pain, vomiting, and absolute constipation. Computed tomography again confirmed the presence of a sigmoid volvulus. Tube decompression was initially successful, but the volvulus reoccurred just 4 days later. In view of recurrence, the decision was taken to perform another endoscopic desufflation, but followed by immediate laparoscopic sigmoid resection and primary anastomosis. At the time of laparoscopy, the following view was encountered (Image 1). The patient made and uneventful recovery and was discharged home on the day five post-operatively. He was asymptomatic at routine follow-up (24 months). The procedure of (temporary) sigmoidopexy with metal tacks is often utilized as part of laparoscopic ventral mesh rectopexy, and occasionally metal tacks are not removed at completion of the procedure. The concern is that, especially in a thin abdominal wall, these could predispose to chronic pain. In this case, after sigmoidopexy, the patient experienced a pulling pain that only occurred at reaching for the top

Pregnancy after Laparoscopic Ventral Mesh Rectopexy: Implications and Outcomes

Surgical management of rectal prolapse varies considerably. Most surgeons are reluctant to use ventral mesh rectopexy in young women until they have completed their family. The aim of the present study was to review outcomes of pregnancy following laparoscopic ventral mesh rectopexy from a tertiary referral centre over a 10‐year period (2006–2016) and to review the impact on pelvic floor symptoms.

Laparoscopic re-do rectopexies – video vignette

Laparoscopic ventral mesh rectopexy is the gold standard treatment for rectal prolapse and yields very good functional results. Unfortunately, however, recurrences do occur. In this video, we will present three cases, discussing tips, tricks and pitfalls based on laparoscopic footage. This article is protected by copyright. All rights reserved.