P. De Nardi

Impact of previous abdominal surgery on the outcome of laparoscopic colectomy: a case-matched control study

BackgroundAdhesions are a major risk for visceral injury and can increase the difficulty of both laparoscopic and open colectomy. The aim of the present study was to evaluate the impact of previous abdominal surgery on laparoscopic colectomy in terms of early outcome.MethodsWe performed a case-control study of patients who underwent laparoscopic colectomy for colorectal disease. The case group comprised 91 patients with a history of prior abdominal surgery, while the 91 controls had no such history. Case and controls were matched for age, gender, site of primary disease, comorbidity on admission and body mass index.ResultsThe two groups were homogeneous for demographic and clinical characteristics. Conversion rate was 16.5% in the case group and 8.8% in the control group (p=0.18). Of the 7 patients who underwent conversion because of adhesions, six had prior surgery (cases) and one did not (p=0.001). Operative time was 26 minutes longer in the case group than in the control group (p=0.001). Morbidity rate was 25.3% among cases and 23.1% for controls. Patients in the two groups experienced a similar time to recovery of bowel function, length of postoperative stay, and 30-day readmission rate.ConclusionsLaparoscopic colectomy in previously operated patients is a time-consuming operation, but it does not appear to affect the short-term postoperative outcome.

Proctalgia in a patient with staples retained in the puborectalis muscle after STARR operation

Stapled transanal rectal resection (STARR) is a novel surgical technique for the treatment of intussusception and rectocele causing obstructed defecation. In this procedure, a double full-thickness rectal resection is performed transanally using two circular staplers. We describe the case of a patient complaining of persistent pain, tenesmus and fecal urgency after STARR. The patient also had an external rectal prolapse requiring an Altemeier rectosigmoid resection; during this operation we found and removed several staples that had stuck to the puborectalis muscle during STARR. Some degree of muscle inflammation was found at histological analysis. The patient recovered fully after this reintervention. Among the complications reported after STARR, the present one had not previously been described. The retained staples might have caused proctalgia in this patient.

Evaluation and management of perianal abscess and anal fistula: a consensus statement developed by the Italian Society of Colorectal Surgery (SICCR)

Perianal sepsis is a common condition ranging from acute abscess to chronic fistula formation. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. The key to successful treatment is the eradication of the primary track. As surgery may lead to a disturbance of continence, several sphincter-preserving techniques have been developed. This consensus statement examines the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.

Fecal incontinence after stapled transanal rectotomy managed with Durasphere injection

A 47-year-old multiparous woman complained of minor daily fecal soiling. 1 Rubber band ligation of recurrent rectal internal mucosa prolapse after STARR operation for obstruction defecation. Retained stapled and surgical wound polypoid granuloma (arrow). 2 Injection of the bulking agent Durasphere under local anesthesia. 3 Closed anus on traction after the injection. 4 Preoperative anal ultrasound showed two interruptions of the internal sphincter (hypoechoic ring, posterior aspect). 5 Two weeks later, the perisphinteric Durasphere (hyperechogenic area) was detectable at anal US (arrow). The patient was fully continent 1 2

Anal endosonography: a survey of equipment, technique and diagnostic criteria adopted in nine Italian centers.

BackgroundAnal endosonography (AES) has become an essential part of the pre-operative diagnostic workup in both organic and functional anal diseases.MethodsNine Italian centres with an average volume activity of >10 exams/week each were surveyed with the aim of determining the concordance with respect to indications for the procedure and interpretation of the results.ResultsOverall, anal sepsis, faecal incontinence and anorectal tumours were the more common indications for AES while evacuation dysfunctions and anal pain were not always considered indications. All centres use the same diagnostic criteria for simple and complicated perirectal sepsis and sphincteric defects, but adopt different classifications for stage 1 and stage 2 anal tumours. Participants agreed in that lymph-node staging by AES is less precise than tumour staging, especially after chemoradiation therapy.ConclusionsA list of recommendations and guidelines based on the groups’s experience has been produced for those radiologists and coloproctologists interested in the use of AES and accreditation of their centres.

Prospective trial evaluating new circular and linear stapler devices for gastrointestinal anastomosis: preliminary data

Several commercial models of stapler devices are available. This study evaluated the ease of use, effectiveness and safety of new commercial stapling devices for gastrointestinal anastomosis. A total of 11 patients (5 men) requiring surgical therapy for benign or malignant disease of the digestive tract were recruited between July and October 2006. Eleven patients were treated with KYGW circular stapler or KYFB linear stapler (Changzhou Kangdi Medical Stapler). In these patients, 14 staplers were used and 21 stapled sutures (16 linear, 5 circular) were performed. Number of anastomoses successfully completed, postoperative anastomotic fistula or dehiscence, days to take fluid and normal diet, length of hospital stay and anastomotic stenosis were recorded. A 10-point questionnaire enquiring about the instrument and anastomotic features was administered to surgeons immediately after the operation in the study group and in 10 control patients treated with standard CDH circular and SDH linear staples (Ethicon Endo-Surgery). Mean scores on the questionnaire for the experimental and control groups were good (>7.5) and did not significantly differ for handling, closing ease, bleeding, and overall satisfaction. No case of intra-abdominal sepsis, leakage or intestinal obstruction was recorded in the study group. In the 5 patients with colorectal anastomosis, the anastomotic lumen at 15 days was wide open and at 3 months there were no strictures. These new instruments are valuable for performing gastrointestinal anastomosis and are in conformity with clinical requirements; their use is simple and seems to be safe.

A postgraduate teaching course in laparoscopic surgery

A teaching course in laparoscopic surgery was addressed to 21 young postgraduates as a part of their general surgery program with the aim of making them familiar with the basic principles of laparoscopic surgery. The methodology was based on tutorial teaching and ‘learning by problems’; the students worked in little groups elaborating check lists, discussing problems, and practising with laparoscopic training devices. Theoretical learning, practical abilities, and efficacy of tutorial teaching were investigated at the end of the course: the participants understanding of instrument function, mastering of equipment, and solutions to clinical problems were good, as were the efficiency and pleasantness of the didactic method. Tutorial teaching seems to be a valid model for basic training in laparoscopic surgery in a modern medical education program.

The ProTect device in the treatment of severe fecal incontinence: preliminary results of a multicenter trial

BackgroundPatients suffering from severe fecal incontinence (FI) in whom surgical treatment has either failed or is inappropriate due to high operative risks and those who refuse to undergo surgery are condemned to living with their embarrassing symptoms, often responsible for progressive social isolation. ProTect is a new, relatively simple, medical device intended for selected patients suffering from severe FI. It consists of a pliable, silicone catheter with an inflatable balloon that seals the rectum at the anorectal junction, acting like an anal plug. The proximal part of the catheter incorporates two contacts that monitor the rectum for the presence of feces. The patient is alerted to an imminent bowel movement and, hence, a potential fecal accident, through a beeper.MethodsA multicenter trial has been set up to assess the reliability of the device in preventing episodes of FI and to evaluate its impact on quality of life. Patients with significant FI (CCF>10) were prospectively entered into this 14-day study. Two quality of life questionnaires and a daily log of bowel activity and incontinent episodes were completed before and during the study.ResultsCurrently, the study enrolled 17 patients and 11 patients (9 women, 2 men) with a mean age of 66 years (range, 46–85) completed the trial. In these 11 subjects, there was an overall significant improvement in the quality of life (p<0.05) and a significant reduction in incontinence scores (p<0.001) while using ProTect compared to baseline.ConclusionsThe ProTect is a safe non-surgical device that is able to prevent episodes of FI. It is unique because it can be used according to a patient’s needs without interfering with activities of daily living.

T1 colon cancer in the era of screening: risk factors and treatment.

BackgroundThe aim of this study was to identify risk factors for lymph node positivity in T1 colon cancer and to carry out a surgical quality assurance audit.MethodsThe sample consisted of consecutive patients treated for early-stage colon lesions in 15 colorectal referral centres between 2011 and 2014. The study investigated 38 factors grouped into four categories: demographic information, preoperative data, indications for surgery and post-operative data. A univariate and multivariate logistic regression analysis was performed to analyze the significance of each factor both in terms of lymph node (LN) harvesting and LN metastases.ResultsOut of 507 patients enrolled, 394 patients were considered for analysis. Thirty-five (8.91%) patients had positive LN. Statistically significant differences related to total LN harvesting were found in relation to central vessel ligation and segmental resections. Cumulative distribution demonstrated that the rate of positive LN increased starting at 12 LN harvested and reached a plateau at 25 LN.ConclusionsSome factors associated with an increase in detection of positive LN were identified. However, further studies are needed to identify more sensitive markers and avoid surgical overtreatment. There is a need to raise the minimum LN count and to use the LN count as an indicator of surgical quality.

Intestinal obstruction following a hemorrhoid laser procedure (HeLP)

We read the article published in the latest online issue of Techniques in Coloproctology by Gallo et al. [1]. We agree with the authors that there are potential complications associated with reinterventions for hemorrhoids; however, we have some comments to make about the case described. The authors present a young male patient who had undergone a PPH procedure 15 years earlier and a HeLP procedure 18 months prior to developing an intestinal obstruction due to an intramural hematoma of the rectum. The authors assume the hematoma causing the obstruction was the result of the HeLP procedure that was indicated for the persistence of symptoms related to hemorrhoids. The authors did not describe the symptoms reported by the patient after the two operations and did not report any intraand postoperative complication related to the procedures. In particular, it was not specified if the patient also had chronic constipation which might have required invasive maneuvers such as self-administered enemas or digitation. PPH has been considered a good procedure for treating mucosal prolapse related to hemorrhoids. However, a few papers have described serious postoperative complications including retropneumoperitoneum, closure of the rectal lumen, and hematomas. The nature of the procedure, a ‘‘blind,’’ full thickness resection of approximately 3 cm of prolapsing tissue, explains the occurrence of these rare complications. The HeLP procedure consists of the closure of terminal branches of the superior rectal artery approximately 3 cm above the dentate line by means of a diode laser. This procedure is performed under direct vision of the anal canal. The diode laser is set at the wavelength of 980 nm, and the laser beam is delivered at the energy of 13 W in a pulsed mode. With these settings, the interaction of the laser energy with the human tissues causes a shrinkage of only 4 mm of the underlying tissue which includes the arteries previously identified with a Doppler probe. In addition, the 980 nm wavelength is selective for the chromophores of hemoglobin thus focusing the coagulating effect on the submucosal vessels. Therefore, from a technical point of view, it seems very unlikely that a HeLP procedure could cause a hematoma outside the rectal wall as shown in the ultrasound image. The effects of laser on the rectal mucosa have been described in detail in the first prospective study published on this procedure [2]. No hematomas have been described after this procedure in other papers, even in the long term [3–5]. Based on our personal experience with more than 400 cases, intrarectal or extrarectal hematoma should not be included in the possible adverse events related to this procedure. As a further consideration, according to the article, the patient underwent an Hartmann procedure. However, in the picture showing the anatomical pattern after surgery, a lateral colostomy is shown. Moreover, since an endorectal ultrasound encompassing the stenosis was feasible, we believe that a more conservative treatment could have been appropriate, such as endoscopic dilatation. & P. De Nardi denardi.paola@hsr.it