M. Ferron

Operative Results and Quality of Life After Gracilis Muscle Transposition for Recurrent Rectovaginal Fistula

PURPOSE: The aim of this study was to assess the efficacy of gracilis muscle transposition for recurrent rectovaginal fistula. METHODS: Gracilis muscle transposition for recurrent rectovaginal fistula was performed in eight patients. Causes of fistulas included Crohns disease (n = 5), perineal surgery (n = 2), and obstetrical injury (n = 1). All patients underwent a mean of three (range, 1–6) previous repairs. Fecal diversion was performed in all cases. RESULTS: Six of eight patients (75%) healed after gracilis muscle transposition alone. The other two patients required a second gracilis. These two patients failed with another recurrence and one of them underwent laparotomy with successful omental interposition. Thus, after a median follow-up of 28 (range, 4–55) months, the per-gracilis muscle transposition healing rate was 60% (6/10) and the overall healing success rate after gracilis muscle transposition and other procedures was 88% (7/8). For patients with Crohns disease, four of five (80%) presented no recurrent rectovaginal fistula. Seven of eight patients underwent ileostomy closure after gracilis, but two required subsequent stomas, one for a late recurrence. Overall, five of eight patients are stoma-free. Despite healing, postoperative quality of life and sexual activity remained significantly altered. CONCLUSION: Gracilis muscle transposition can be proposed in cases of recurrent rectovaginal fistula. The procedure has a good success rate, especially in Crohns disease patients.

T4 colorectal cancer: is laparoscopic resection contraindicated?

Aim  T4 colorectal cancer remains a contraindication for laparoscopy. It is argued that the risk of incomplete resection could be higher than in open surgery. Furthermore, difficulty in dissection could lead to a very high rate of conversion. There is little information on this. The study aimed at assessing feasibility and operative and oncologic results of laparoscopic resection for T4 colorectal cancer.

Conservative management is associated with a decreased risk of definitive stoma after anastomotic leakage complicating sphincter-saving resection for rectal cancer.

Aim  Anastomotic leakage (AL) after sphincter‐saving resection (SSR) for rectal cancer can result in a definitive stoma (DS). The aim of the study was to assess risk factors for DS after AL‐complicating SSR.

Functional disorders after rectal cancer resection: does a rehabilitation programme improve anal continence and quality of life?

Aim  A poor functional outcome is often reported after total mesorectal excision (TME) for rectal cancer, especially when sphincter‐saving resection with intersphincteric dissection is performed for low tumours. Anal sphincter rehabilitation is widely proposed for faecal incontinence. Very few studies have reported results to improve anal dysfunction following rectal surgery. This prospective study aimed to assess the benefits of sphincter training after TME in terms of functional outcome and quality of life.

Single-incision laparoscopic colonic surgery

Aim  SILS is an area of growing interest in colorectal surgery. We report our preliminary experience of 13 consecutively selected patients undergoing colonic surgery using SILS.

Effects of a Multimodal Management Strategy for Acute Mesenteric Ischemia on Survival and Intestinal Failure

BACKGROUND & AIMS Acute mesenteric ischemia (AMI) is an emergency with a high mortality rate; survivors have high rates of intestinal failure. We performed a prospective study to assess a multidisciplinary and multimodal management approach, focused on intestinal viability. METHODS In an Intestinal Stroke Center, we developed a multimodal management strategy involving gastroenterologists, vascular and abdominal surgeons, radiologists, and intensive care specialists; it was tested in a pilot study on 18 consecutive patients with occlusive AMI, admitted to a tertiary center from July 2009 to November 2011. Patients with left ischemic colitis, nonocclusive AMI, chronic mesenteric ischemia, and other emergencies were excluded. Patients received specific medical management: revascularization of viable small bowel and/or resection of nonviable small bowel; 12 patients received arterial revascularization. We evaluated the percentages of patients who survived for 30 days or 2 years, the number with permanent intestinal failure, and morbidity. Lengths and rates of intestinal resection were compared with or without revascularization, and in patients with early or late-stage disease. RESULTS Patients were followed up for a mean of 497 days (range, 7-2085 d); 95% survived for 30 days, 89% survived for 2 years, and 28% had morbidities within 30 days. Intestinal resection was necessary for 7 cases (39%), with mean lengths of intestinal resection of 30 cm and 207 cm, with or without revascularization, respectively (P = .03). Among patients with early or late-stage AMI, rates of resection were 18% and 71%, respectively (P = .049). Patients with early stage disease had shorter lengths of intestinal resection than those with late-stage disease (7 vs 94 cm; P = .02), and spent less time in intensive care (2.5 vs 49.8; P = .02). CONCLUSIONS A multidisciplinary and multimodal management approach might increase survival of patients with AMI and prevent intestinal failure.

Redo surgery for failed colorectal or coloanal anastomosis: A valuable surgical challenge

BACKGROUND Redo surgery (RS) in patients with failed anastomosis is a rare procedure, and data about this surgery are lacking. The aim of this study was to examine the operative results and long-term outcomes of RS. METHODS All patients who underwent RS between 1999 and 2008 were included. Data were analyzed from a prospective colorectal database. Failure of the procedure was defined as the inability to perform the RS or the inability to close the defunctioning stoma. RESULTS Thirty-three patients (22 men) underwent the first surgery at a mean age of 53.4 years. Twenty-four had a colorectal anastomosis (CRA) and nine a coloanal anastomosis (CAA). The reasons for performing RS were stricture (n = 17), prior Hartmann procedure for complication on initial anastomosis (n = 6), chronic fistula (n = 5) or miscellaneous (n = 5). RS was impossible for 2 patients due to extensive adhesions. The mean operating time was 279 min (133-480) and the overall postoperative morbidity rate was 55%. The rate of anastomotic leakage and/or isolated pelvic abscess was 27%. After a mean delay of 3.9 months (0.3-16), 26 patients (79%) had a stoma closure. The mean number of stools per day was 3.2. The failure rates after new handsewn CAA and new stapled CRA were 33% (4/12) and 5% (1/19), respectively (P = .0385). The type of the former anastomosis influenced the success rate of restoring the intestinal continuity: failure rate after prior CAA was 56% and 8% after prior CRA (P = .0031). CONCLUSION Redo surgery for failure of previous CRA or CAA is feasible but requires a demanding surgical procedure with high short-term morbidity.

Single port access proctectomy with total mesorectal excision and intersphincteric resection with a primary transanal approach

Aim  Minimally invasive surgery is advancing with single port access (SPA). We describe a technique for a SPA transabdominal combined with transanal approach to perform laparoscopic proctectomy with total mesorectal excision (TME) and intersphincteric resection of low rectal adenocarcinoma.

Rectovaginal Fistula: What Is the Optimal Strategy?: An Analysis of 79 Patients Undergoing 286 Procedures.

OBJECTIVES The aim of this study was to assess results of surgery for rectovaginal fistula (RVF) and prognostic factors for success. BACKGROUND DATA Management of RVF remains challenging and numerous surgical options are available. Few large reports of RVF are available and success prognostic factors remain unknown. METHODS All patients operated for RVF from 1996 to 2014 were included. RESULTS Seventy-nine patients presented RVF due to Crohn disease in 34 (43%), postoperative in 25 (32%), obstetrical in 7 (9%), radiation proctitis in 4 (5%), and miscellaneous in 9 (11%). A total of 286 procedures (132 with associated stoma, 46%) were performed including 217 conservative (76%) [seton drainage (n = 59; 21%), vaginal (n = 49, 17%) or rectal advancement flap (n = 46; 16%), diverting stoma only (n = 27; 9%), plug (n = 15; 5%), glue (n = 13; 5%), or others (n = 8, 3%)]; and 69 major procedures (24%) [gracilis muscle interposition (n = 32; 11%), coloanal or colorectal anastomosis (n = 19; 7%) including 11 delayed anastomosis with colonic pull-through, biomesh interposition (n = 9, 3%), and abdominoperineal resection (n = 9; 3%)]. After a mean follow-up of 33 months, overall success rate was 57 of 79 (72%). Per-procedure-based multivariate analysis identified major procedure [odds ratio (OR): 6.4 (2.9-14.2); P < 0.001], diverting stoma [OR: 3.5 (1.4-8.7); P = 0.009], less than 9 months between diagnosis and first surgery [OR: 2.3 (1.1-5.3); P = 0.046], and first surgery in our institution [OR: 3.2 (1.5-6.9); P = 0.003], as independent factors for success. CONCLUSIONS Our study suggested that aggressive surgical treatment of RVF, including early use of temporary stoma and major procedure in case of failure of previous local treatment, leads to high success rates.

Perineal or Abdominal Approach First During Intersphincteric Resection for Low Rectal Cancer: Which Is the Best Strategy?

BACKGROUND: Intersphincteric resection during total mesorectal excision for low rectal cancer can be performed through a primary abdominal or a primary perineal approach. OBJECTIVE: The purpose of this study was to compare the results of a primary perineal approach with those of a primary abdominal approach in patients undergoing laparoscopic total mesorectal excision for low rectal cancer. DESIGN: This was a case-matched retrospective study from a prospectively maintained database. SETTING: The study was conducted at a tertiary colorectal surgery referral center. PATIENTS: From 2005 to 2013, among 138 patients with low rectal cancer who underwent total mesorectal excision with intersphincteric resection, 34 patients with a primary abdominal approach (abdominal group) were matched with 51 identical patients with a primary perineal approach (6-cm perineal dissection along the mesorectal plane; perineal group), according to TNM stage, sex, BMI, and age. MAIN OUTCOMES MEASURES: Postoperative morbidity, oncologic outcomes, and 3-year overall and disease-free survivals were measured. RESULTS: The operative time was significantly shorter in the perineal group (269 minutes in perineal vs 240 minutes in abdominal group; p = 0.01). Overall morbidity (47% vs 47%; p = 1.00), severe morbidity (16% vs 15%; p = 0.90), and clinical anastomotic leakage (24% vs 12%; p = 0.17) rates showed no differences when comparing the 2 groups. The overall R1 resection rate was similar in the 2 groups (16% vs 9%; p = 0.36), including a 10% vs 9% positive circumferential margin (p = 0.88) and a 8% vs 0% positive distal margin (p = 0.15). After a median follow-up of 39 months, 3-year overall (100% vs 93% (95% CI, 88%–98%); p = 0.26) and disease-free (63% (95% CI, 56%–71%) vs 62% (95% CI, 53%–71%); p = 0.58) survival rates showed no differences between the 2 groups. LIMITATIONS: The study was limited by its nonrandomized nature and limited sample size. CONCLUSIONS: In cases of laparoscopic total mesorectal excision with intersphincteric resection for low rectal cancer, the primary perineal approach appears to reduce operative time and is associated with similar short- and long-term outcomes as compared with the primary abdominal approach. The primary perineal approach should thus be considered as the standard strategy.