Mostafa Shalaby

Sensitivity and specificity of indocyanine green near-infrared fluorescence imaging in detection of metastatic lymph nodes in colorectal cancer: Systematic review and meta-analysis.

This review aimed to determine the overall sensitivity and specificity of indocyanine green (ICG) near‐infrared (NIR) fluorescence in sentinel lymph node (SLN) detection in Colorectal cancer (CRC). A systematic search in electronic databases was conducted. Twelve studies including 248 patients were reviewed. The median sensitivity, specificity, and accuracy rates were 73.7, 100, and 75.7. The pooled sensitivity and specificity rates were 71% and 84.6%. In conclusion, ICG‐NIR fluorescence is a promising technique for detecting SLNs in CRC.

Synthetic Versus Biological Mesh-Related Erosion After Laparoscopic Ventral Mesh Rectopexy: A Systematic Review

Purpose This review reports the incidence of mesh-related erosion after ventral mesh rectopexy to determine whether any difference exists in the erosion rate between synthetic and biological mesh. Methods A systematic search of the MEDLINE and the Ovid databases was conducted to identify suitable articles published between 2004 and 2015. The search strategy capture terms were laparoscopic ventral mesh rectopexy, laparoscopic anterior rectopexy, robotic ventral rectopexy, and robotic anterior rectopexy. Results Eight studies (3,956 patients) were included in this review. Of those patients, 3,517 patients underwent laparoscopic ventral rectopexy (LVR) using synthetic mesh and 439 using biological mesh. Sixty-six erosions were observed with synthetic mesh (26 rectal, 32 vaginal, 8 recto-vaginal fistulae) and one (perineal erosion) with biological mesh. The synthetic and the biological mesh-related erosion rates were 1.87% and 0.22%, respectively. The time between rectopexy and diagnosis of mesh erosion ranged from 1.7 to 124 months. No mesh-related mortalities were reported. Conclusion The incidence of mesh-related erosion after LVR is low and is more common after the placement of synthetic mesh. The use of biological mesh for LVR seems to be a safer option; however, large, multicenter, randomized, control trials with long follow-ups are required if a definitive answer is to be obtained.

Transanal Minimally Invasive Surgery for Rectal Lesions.

Background and Objectives: Transanal minimally invasive surgery (TAMIS) has emerged as an alternative to transanal endoscopic microsurgery (TEM). The authors report their experience with TAMIS for the treatment of mid and high rectal tumors. Methods: From November 2011 through May 2016, 31 patients (21 females, 68%), with a median age of 65 years who underwent single-port TAMIS were prospectively enrolled. Mean distance from the anal verge of the rectal tumors was 9.5 cm. Seventeen patients presented with T1 cancer, 10 with large adenoma, 2 with gastrointestinal stromal tumor (GIST) and 2 with carcinoid tumor. Data concerning demographics, operative procedure and pathologic results were analyzed. Results: TAMIS was successfully completed in all cases. In 4 (13%) TAMIS was converted to standard Parks transanal technique. Median postoperative stay was 3 days. The overall complication rate was 9.6%, including 1 urinary tract infection, 1 subcutaneous emphysema, and 1 hemorrhoidal thrombosis. TAMIS allowed an R0 resection in 96.8% of cases (30/31 cases) and a single case of local recurrence after a large adenoma resection was encountered. Conclusion: TAMIS is a safe technique, with a short learning curve for laparoscopic surgeons already proficient in single-port procedures, and provides effective oncological outcomes compared to other techniques.

Endoscopic Pilonidal Sinus Treatment: Long-Term Results of a Prospective Series

Background and Objectives: Pilonidal sinus is a common problem in the sacrococcygeal region, especially in obese, sedentary young men. The ideal surgical solution is still under debate, and there is a high rate of recurrence. In the present study, we analyzed the long-term results of a video-assisted minimally invasive technique for the treatment of sacrococcygeal pilonidal disease: endoscopic pilonidal sinus treatment (EPSiT). Methods: From October 2013 through November 2015, a total of 77 consecutive patients (69 Males and 8 Females, median age: 23 y) were referred to our colorectal units. Sixty-eight patients had a primary sacrococcygeal pilonidal sinus, and 9 had recurrent pilonidal sinus; all underwent EPSiT. A fistuloscope was introduced through an external opening and the sinus cavity was completely ablated under direct vision. Postoperative complications, wound infection rate, recurrence rate, time until return to work, and patient satisfaction score were recorded during follow-up or at the last interview. Clinical data were obtained at 7, 15, and 30 days and at 6, 12, and 24 months after surgery. Results: All patients completed the follow-up (median follow-up was 25 (range, 17–40) months. Median operative time was 18 (range, 12–30) minutes. The median hospital stay was 6.5 (range, 5–9) hours, and the median time to return to work was 5 days. Median healing time was 26 (range, 15–45) days. There were no major or minor complications. Six patients experienced recurrence. The overall satisfaction rate was 97%. Conclusions: The ideal surgical treatment for pilonidal sinus disease should be simple and effective. In our experience, EPSiT can be performed as a day surgery, with early return to daily activities. This technique is an uneventful procedure, with good aesthetic results and a low recurrence rate.

Perineal resectional procedures for the treatment of complete rectal prolapse: A systematic review of the literature

BACKGROUND AND AIM Several procedures for the treatment of complete rectal prolapse (CRP) exist. These procedures are performed via the abdominal or perineal approach. Perineal procedures for rectal prolapse involve either resection or suspension and fixation of the rectum. The present review aimed to assess the outcomes of the perineal resectional procedures including Altemeier procedure (AP), Delorme procedure (DP), and perineal stapled prolapse resection (PSR) in the treatment of CRP. PATIENTS AND METHODS A systematic search of the current literature for the outcomes of perineal resectional procedures for CRP was conducted. Databases queried included PubMed/MEDLINE, SCOPUS, and Cochrane library. The main outcomes of the review were the rates of recurrence of CRP, improvement in bowel function, and complications. RESULTS Thirty-nine studies involving 2647 (2390 females) patients were included in the review. The mean age of patients was 69.1 years. Recurrence of CRP occurred in 16.6% of patients. The median incidences of recurrence were 11.4% for AP, 14.4% for DP, and 13.9% for PSR. Improvement in fecal incontinence occurred in 61.4% of patients after AP, 69% after DP, and 23.5% after PSR. Complications occurred in 13.2% of patients. The median complication rates after AP, DP and PSR were 11.1%, 8.7%, and 11.7%, respectively. CONCLUSION Perineal resectional procedures were followed by a relatively high incidence of recurrence, yet an acceptably low complication rate. Definitive conclusions on the superiority of any procedure cannot be reached due to the significant heterogeneity of the studies.

Small-Bowel Obstruction Secondary to Adhesions After Open or Laparoscopic Colorectal Surgery

Background and Objectives: Small-bowel obstruction (SBO) is a common surgical emergency that occurs in 9% of patients after abdominal surgery. Up to 73% are caused by peritoneal adhesions. The primary purpose of this study was to compare the rate of SBOs between patients who underwent laparoscopic (LPS) and those who had open (OPS) colorectal surgery. The secondary reasons were to evaluate the rate of adhesive SBO in a cohort of patients who underwent a range of colorectal resections and to assess risk factors for the development of SBO. Method: This was a retrospective observational cohort study. Data were analyzed from a prospectively collected database and cross checked with operating theater records and hospital patient management systems. Results: During the study period, 707 patients underwent colorectal resection, 350 of whom (49.5%) were male. Median follow-up was 48.3 months. Of the patients included, 178 (25.2%) underwent LPS, whereas 529 (74.8%) had OPS. SBO occurred in 72 patients (10.2%): 20 (11.2%) in the LPS group and 52 (9.8%) in the OPS group [P = .16; hazards ratio (HR) 1.4 95% CI 0.82–2.48] within the study period. Conversion to an open procedure was associated with increased risk of SBO (P = .039; HR 2.82; 95% CI 0.78–8.51). Stoma formation was an independent risk factor for development of SBO (P = .049; HR, 0.63; 95% CI 0.39–1.03). The presence of an incisional hernia in the OPS group was associated with SBO (P = .0003; HR, 2.85; 95% CI 1.44–5.283). There was no difference in SBO between different types of procedures: right colon, left colon, and rectal surgery. Patients who developed early small-bowel obstruction (ESBO) were more often treated surgically compared to late SBO (P = .0001). Conclusion: The use of laparoscopy does not influence the rate of SBO, but conversion from laparoscopic to open surgery is associated with an increased risk of SBO. Stoma formation is associated with a 2-fold increase in SBO. Development of ESBO is highly associated with a need for further surgical intervention.

Biological mesh extrusion months after laparoscopic ventral rectopexy

Laparoscopic ventral mesh rectopexy (LVR) is gaining wider acceptance as the preferred procedure to correct internal as well as external rectal prolapse associated with obstructed defecation syndrome (ODS) and/or fecal incontinence. Very few reports exist on the use of biological mesh for LVR [1]. We report a case of a mesh extrusion after 9 months after an uneventful laparoscopic mesh rectopexy performed with a biological mesh. The patient was a 62-year-old female with a IV internal rectal prolapse according to the Oxford prolapse grading system. Surgery was conducted laparoscopically as previously described [2]. Briefly, an anterolateral dissection was carried out between the rectum and the vagina starting from the sacral promontory, down to the levator ani muscle. A 3 9 15 cm tailored strip of biological mesh of bovine cross-linked pericardium (BioIntegral Surgical, Inc, Canada) was positioned in this pocket at the level of the levator ani muscle and sutured to the anterior wall of the rectum using two parallel rows of non-absorbable 2-0 sutures (Tycron, Covidien, UK). The mesh was then secured on the sacral promontory using the ProTack device (Autosuture, Covidien, UK), and the vaginal vault (or cervix) was fixed to the mesh without traction by two additional absorbable sutures (vicryl 2-0). The postoperative course was uneventful, but 7 months after surgery the patient noticed ‘something’ protruding through the vagina during straining. She removed it using her fingers and after contacting the surgeon she preserved it. Figure 1 shows the mesh that was implanted months before which conserves the shape, the tacks used for the proximal fixation as well as the majority of the non-absorbable 2-0 stitches for rectal fixation. Two days later she was seen as outpatient. She did not present any symptom, but minimal serosal discharge from the vagina. Gynecological examination revealed a 1-cm defect at the level of the posterior vaginal vault with the presence of minimal fibrin deposition. The patient was treated with oral antibiotic for 5 days. Her recovery was uneventful, and at the 2-weeks follow-up visit the defect had closed. The patient remains asymptomatic in terms of constipation after 1 year from this event. In order to evaluate the microscopic remodeling process of the mesh, a part of it was sent for pathology. Microscopic examination of a haematoxilyn and eosin-stained section revealed an amorphous acellular

Hiatal hernia, mitral valve prolapse and defecatory disorders: An underlying rectal prolapse?

The treatment of rectal prolapse (RP) remains a surgical challenge with a recurrence rate as high as 30 %, being usually between 10 and 20 %. These results lead to a continuous search for the ideal surgical treatment. The majority of failures might be secondary to patients’ selection among what is probably an excessively large number of surgical options. The aim is a tailored surgical approach that, addressing all the anatomical changes associated with rectal prolapse, may reduce recurrence rates. Clinical experience shows that sometimes even when surgical results are good with satisfactory anatomical restoration, functional results are not. Ultra-structural changes might exist due to chronic straining as well as pre-existing disorders leading to general pelvic floor weakness. If these factors are recognized before surgery, they might affect the patient’s choice of procedure thus reducing recurrence. Recently, we evaluated longer-term results of 183 patients who underwent laparoscopic ventral mesh rectopexy (LVR) for both internal and external rectal prolapse. Median follow-up was 24 months, and 21 patients experienced recurrence (11 %). Reviewing our data, we observed a higher incidence of hiatal hernia (HH) in patients with recurrence. Briefly, data on previous upper-gastrointestinal endoscopy were available for 86 patients out of 183. Of those, 32 had a documented HH (35 % considering only those with documentation) before surgery. HH was more common in patients with RP recurrence: 14 out of 21 (66.7 %). Analyzing comorbidities in this cohort of patients with recurrence, we observed that 8 patients (38 %) had also mitral valve prolapse (MVP). Overall the MVP was reported in 19 out of 183 patients (10 %). However, this percentage is obviously underestimated being obtained from retrospective information about patients who had undergone cardiac evaluation in the past. We decided to assess whether this apparently strong association between HH and MVP among patients with recurrent RP after LVR might exist in a cohort of patients with a proven HH. From a prospectively kept database, we identified female patients with an endoscopically proven HH. To reduce bias in patient selection, only patients with a body mass index \30 kg/cm were considered. Patients with previous cardiothoracic, abdominal (other than appendectomy or cholecystectomy), or pelvic floor surgery were excluded. Patients with chronic pulmonary disease as well as neoplastic or inflammatory bowel disease were also excluded. Patients suitable for the study were studied for defecatory disorders (DDs) including constipation and incontinence. DDs were evaluated using the Wexner Constipation Score (WCS) and the Fecal Incontinence Severity Index (FISI). A WCS C5 and a FISI C10 were considered clinically relevant. Patients with abnormal scores underwent proctological examination and a proctogram. The prolapse was graded after the proctogram using the Oxford Prolapse Grading System (internal rectal prolapse: I–IV; external rectal prolapse: V) and considering severe a prolapse grade[III. & P. Sileri piersileri@yahoo.com

Outcome of Colorectal Surgery in Elderly Populations

Purpose The aim of this study is to investigate the impact of age on short-term outcomes after colorectal surgery in terms of the 30-day postoperative morbidity and mortality rates. Methods The subjects for the study were patients who had undergone colorectal surgery. Patients were divided into 2 groups according to age; groups A and B patients were ≥80 and <80 years old of age, respectively. Both groups were manually matched for body mass index, American Society of Anesthesiologists score, Charlson Comorbidity Index and procedure performed. Results A total of 200 patients, 91 men (45.5%) and 109 women (54.5%), were included in this retrospective study. These patients were equally divided into 2 groups. The mean ages were 85 years in group A (range, 80 to 104 years) and 55.3 years in group B (range, 13 to 79 years). The overall 30-day postoperative mortality rate was 1% of total 200 patients; both of these 2 patients were in group A. However, this observation had no statistical significance. No intraoperative complications were encountered in either group. The overall 30-day postoperative morbidity rate was 27% (54 of 200) for both groups. The 30-day postoperative morbidity rates in groups A and B were 28% (28 of 100) and 26% (26 of 100), respectively. However, these differences between the groups had no statistical significance importance. Conclusion Age alone should not be considered to be more of a contraindication or a worse predictor than other factors for the outcome after colorectal surgery on elderly patients.

Transanal Inspection and Management of Low Colorectal Anastomosis Performed With a New Technique: the TICRANT Study:

Background: Anastomotic leakage is one of the most serious complications after rectal cancer surgery. Method: A prospective multicenter interventional study to assess a newly described technique of creating the colorectal and coloanal anastomosis. The primary outcome was to access the safety and efficacy of this technique in the reduction of anastomotic leak. Result: Fifty-three patients with rectal cancer who underwent low or ultra-low anterior resection were included in the study. There were 35 males and 18 females, with a median age of 68 years (range = 49-89 years). The median tumor distance from the anal verge was 8 cm (range = 4-12 cm), and the median body mass index was 24 kg/m2 (range = 20-35 kg/m2). Thirty patients underwent open, 16 laparoscopic, and 7 robotic surgeries. Multiple firing (2-charges) was required in 30 patients to obtain a complete rectal division. Forty-five patients had colorectal anastomosis, and 8 patients had coloanal anastomosis. The protective ileostomy was created in 40 patients at the time of initial surgery. There was no mortality in the first 30 days postoperatively, and only 10 (19%) patients developed complications. There were 3 anastomotic leakages (6%); 2 of them were subclinical with ileostomy created at initial operation and both were treated conservatively with transanal drainage and intravenous antibiotics. One patient required reoperation and ileostomy. The median length of hospital stay was 10 days (range = 4-20 days). Conclusion: Our technique is a safe and efficient method of creation of colorectal anastomosis. It is also a universal method that can be used in open, laparoscopic, and robotic surgeries.