Pain, gastrointestinal function and fertility outcomes of modified nerve-vessel sparing segmental and full thickness discoid resection for deep colorectal endometriosis - A prospective cohort study

INTRODUCTION

There is an ongoing debate on surgical techniques for colorectal deep endometriosis (DE) and their effects on gastrointestinal (GI) function. The aim of this study was to prospectively investigate the differences in pre- and postsurgical GI function, health profiles and pain symptoms in women undergoing colorectal surgery for symptomatic DE either with a modified segmental resection technique, so-called nerve-vessel sparing segmental resection (NVSSR), or full thickness discoid resection (FTDR). Complication rates and fertility outcomes were also evaluated.

MATERIAL AND METHODS

A total of 162 consecutive patients, 125 (77.2%) of whom underwent NVSSR and 37 (22.8%) FTDR, were evaluated regarding complication rates. Furthermore a lower anterior resection syndrome (LARS) scores, gastrointestinal function-related quality of life index (GIQLI), pain symptoms, endometriosis health profile (EHP-30) parameters were analyzed pre- and post-surgery in a final cohort of 121 patients.

RESULTS

There was no difference between postsurgical prevalence of LARS in either surgery group (14/98, 14.1% NVSSR; 2/23, 8.6% FTDR), with significantly decreased LARS scores and increased GIQLI values before vs after surgery in both groups (P < 0.001). The overall grade III complication rate was 7/162 (4.3%) with no significant differences between NVSSR and FTDR groups. Overall, EHP-30 and pain scores significantly decreased after a median follow-up of 41 (± 17.6) months (EHP-30 51.1, SD 21.5 vs 12.7, SD 19.3, P < 0.001; dysmenorrhea, dyspareunia, dyschezia all P < 0.001 both cohorts, respectively). The overall life birth rate and postsurgical pregnancy in infertile patients undergoing NVSSR and FTDR was respectively 58.1% in 25/43 patients; 55.6% in 5/9 patients; 56.0% in 14/25 patients and 100% in 5/5 patients.

CONCLUSIONS

NVSSR and FTDR for symptomatic colorectal DE confer a significant amelioration of GI function reflected by decreased LARS symptoms and increased GIQLI scores with no differences in postsurgical function in between the two techniques. Both techniques confer similar complication rates and effects on pain reduction and health profiles.

A Novel No Foil-to-Skin Contact Technique for Vacuum-assisted Wound Closure in Patients with Sensitive Skin

In some patients with chronic wounds, the surrounding skin is so injured due to various underlying conditions that negative pressure dressing cannot be applied or cannot function properly. Having faced this problem in our everyday practice, we developed a new skin-sparing technique for vacuum-assisted wound closure, which ensures that the peri-wound skin does not come into contact with the transparent adhesive films.

Methods

For 9 months (April-December 2022), we performed 32 vacuum wound dressings with the newly developed technique using the 3M ActiV.A.C. Therapy Unit and accessories, and Convatec's VARIHESIVE, avoiding skin contact with the adhesive films.

Results

Seven patients with 11 wounds who had sensitive skin or allergy to the conventionally used adhesive films were successfully treated with the new technique. The negative pressure wound dressings remained intact and functioned properly for up to 168 hours without compromising patients' daily activities and therapy.

Conclusion

The novel "no foil-to-skin contact" technique for vacuum-assisted wound closure can successfully be incorporated in the treatment of patients in whom conventional negative pressure dressings are otherwise not applicable.

Long-term surgical outcomes of nerve-sparing discoid and segmental resection for deep endometriosis

INTRODUCTION

The aim of this study was to investigate long-term outcomes in terms of pain, quality of life (QoL), and gastrointestinal symptoms in women following colorectal surgery for deep endometriosis.

MATERIAL AND METHODS

In this historical cohort, women who underwent surgical treatment for deep endometriosis by either nerve-sparing full-thickness discoid resection (DR) or colorectal segmental resection (SR) between March 2011 and August 2016 were re-evaluated through telephone interviews about their long-term pain symptoms, subjective overall QoL as rated using a score from 0 (worst) to 10 (optimal), and gastrointestinal outcomes reflected by lower anterior resection syndrome (LARS) following a first postsurgical evaluation (visit 1) published previously and a long-term follow-up evaluation (visit 2).

RESULTS

The median long-term follow-up time was 35.4 months at visit 1 and 86 months at visit 2. Of 134 patients, 77 were eligible for final analysis and 57 were lost to follow-up. Compared with presurgical values, QoL scores were significantly increased at both postsurgical evaluation visits in both the SR cohort (scores of 3, 8.5, and 10 at the presurgical visit, visit 1, and visit 2, respectively; p < 0.001) and the DR cohort (scores of 3, 9, and 10, respectively; p < 0.001). Pain scores for dysmenorrhea (SR group scores of 8, 2, and 2, respectively; p < 0.001; DR group scores of 9, 2, and 1, respectively; p < 0.001), dyspareunia (SR group scores of 4, 0, and 0, respectively; p < 0.001; DR group scores of 5, 0, and 1, respectively; p = 0.003), and dyschezia (SR group scores of 8, 2, and 2, respectively; p < 0.001; DR group scores of 9, 2, and 1, respectively; p < 0.001) significantly decreased after surgery and remained stable in both cohorts over the follow-up period. Minor and major LARS, reflecting gastrointestinal function, was observed in 6.5% and 8.1% of the SR group and in 13.3% and 6.7% of the DR group, respectively, at visit 1 and in 3.2% and 3.2% of the SR group and 0% and 0% of the DR group, respectively, at visit 2, without significant differences between the SR and DR groups.

CONCLUSIONS

Colorectal surgery for deep endometriosis, either by DR or SR, provides stable and long-term pain relief with low rates of permanent gastrointestinal function impairment.

Different segmental resection techniques and postoperative complications in patients with colorectal endometriosis: A systematic review

INTRODUCTION

The aim of this study was to analyze the available literature by conducting a systematic review to assess the possible effects of nerve-sparing segmental resection and conventional bowel resection on postoperative complications for the treatment of colorectal endometriosis.

MATERIAL AND METHODS

Pubmed, Clinical Trials.gov, Cochrane Library, and Web of Science were comprehensively searched from 1997 to 2021 in order to perform a systematic review. Studies including patients undergoing segmental resection for colorectal endometriosis including adequate follow-up, data on postoperative complications and postoperative sequelae were enrolled in this review. Selected articles were evaluated and divided in two groups: Nerve-sparing resection (NSR), and conventional segmental resection not otherwise specified (SRNOS). Within the NSRs, studies mentioning preservation of the rectal artery supply (artery and nerve-sparing SR - ANSR) and not reporting preservation of the artery supply (NSR not otherwise specified - NSRNOS) were further analyzed.

PROSPERO ID

CRD42021250974.

RESULTS

A total of 7549 patients from 63 studies were included in the data analysis. Forty-three of these publications did not mention the preservation or the removal of the hypogastric nerve plexus, or main rectal artery supply and were summarized as SRNOS. The remaining 22 studies were listed under the NSR group. The mean size of the resected deep endometriosis lesions and patients' body mass index were comparable between SRNOS and NSR. A mean of 3.6% (0-16.6) and 2.3% (0-10.5%) of rectovaginal fistula development was reported in patients who underwent SRNOS and NSR, respectively. Anastomotic leakage rates varied from 0% to 8.6% (mean 1.7 ± 2%) in SRNOS compared with 0% to 8% (mean 1.7 ± 2%) in patients undergoing NSR. Urinary retention (4.5% and 4.9%) and long-term bladder catheterization (4.9% and 5.6%) were frequently reported in SRNOS and NSR. There was insufficient information about pain or the recurrence rates for women undergoing SRNOS and NSR.

CONCLUSIONS

Current data describe the outcomes of different segmental resection techniques. However, the data are inhomogeneous and not sufficient to reach a conclusion regarding a possible advantage of one technique over the other.

Interim analysis of neoadjuvant chemoradiotherapy with sequential ipilimumab and nivolumab in rectal cancer (CHINOREC): A prospective randomized, open-label, multicenter, phase II clinical trial

e15604

Background: Immune checkpoint inhibitors (ICI) do not seem to be effective in solid cancers, which lack an immunogenic priming. Radiotherapy (RT) can induce an immunogenic cell death (ICD) and thereby restore the susceptibility to ICI, especially in microsatellite stable (MSS) cancers. This study evaluates safety, tolerability and feasibility of neoadjuvant chemoradiotherapy (CRT) with concomitant ipilimumab (IPI) and nivolumab (NIVO) in locally advanced rectal cancer (LARC). Here we present the first requisite interim analysis. Methods: This is a prospective, randomized, open-label, multicenter, phase II investigator- initiated trial (IIT). Key eligibility criteria are patients with LARC and the medical need for a neoadjuvant CRT, without metastatic disease that is considered incurable by local therapies. In total 80 patients will be randomized (ratio 30:50) to receive either neoadjuvant CRT alone (50 Gy in 2 Gy fractions over 25 working days + concurrent capecitabine 1650 mg/m2/d PO) or in combination with a single dose of IPI 1 mg/kg IV at day 7, following 3 cycles of NIVO 3 mg/kg IV Q2W, starting on day 14. Patients undergo surgery within 10-12 weeks post CRT. The primary endpoint is safety of neoadjuvant CRT with sequential IPI and NIVO following surgical resection. Surgical complications are graded by the “Clavien-Dindo Classification” v2.0 and treatment-related adverse events (TRAEs) by the Common Terminology Criteria of Adverse Events (CTCAE) v5.0. Interim analyses for the surgical complication “reoperation” will be assessed after every 10th patient in the IPI/NIVO treatment arm. Reoperation numbers are compared to historically known and published ratios. If the observed case numbers are above the calculated upper 95% confidence interval (95% CIup), the study will be terminated. Results: From 06/2020-02/2022, 36 patients have been accrued, of whom 23 were randomized to the CRT+IPI/NIVO arm. Of these, the first 10 patients who underwent successful surgery were used for the present interim analysis. No patient experienced a surgical complication with the need for a reoperation (3Grade IIIb). Any surgical complication occurred in 8 (80%) patients, with the most common being Grade I (70%) and Grade II (50%) events. Conclusions: The addition of sequentially applied IPI and NIVO to neoadjuvant CRT does not increase the number of surgical reoperation rates. The study meets it’s interim analysis criteria to be safe to continue accrual. Clinical trial information: NCT04124601.

Transvaginal sonography determines accurately extent of infiltration of rectosigmoid deep endometriosis

OBJECTIVE

To investigate the agreement of measurements of the three diameters of rectosigmoid deep endometriosis (DE) lesions between presurgical evaluation using transvaginal sonography (TVS) and postsurgical specimen measurement (PSM).

METHODS

This was a prospective observational multicenter study including symptomatic women undergoing surgical treatment for DE involving the rectosigmoid, by either discoid or segmental resection, from April 2017 to December 2019. TVS was performed presurgically to evaluate lesion size (craniocaudal-midsagittal length, anteroposterior thickness and transverse diameter), in accordance with the International Deep Endometriosis Analysis (IDEA) group consensus statement, and was compared with PSM. The agreement of lesion dimensions between the two methods was assessed by Bland-Altman plots and limits of agreement and additionally by the intraclass correlation coefficient (ICC) and Pearson's correlation coefficient. Systematic and proportional bias was assessed using the paired t-test.

RESULTS

A total of 207 consecutive women were eligible for inclusion. Forty-one women were excluded, leaving 166 women for final analysis. A total of 123 segmental resections and 46 discoid resections were performed (both procedures were performed in three women). The mean difference between TVS and PSM was 0.90 (95% CI, 0.85-0.95) mm for lesion length measurements, 1.03 (95% CI, 0.98-1.09) mm for lesion thickness measurements and 0.84 (95% CI, 0.79-0.89) mm for transverse diameter measurements. Bland-Altman analysis demonstrated good agreement between the two methods for measurements of lesion length. Furthermore, there was good reliability and correlation between TVS and PSM for lesion length measurements, as demonstrated by an ICC of 0.82 (95% CI, 0.75-0.87) and Pearson's correlation coefficient of 0.72 (95% CI, 0.62-0.80), moderate-to-good reliability and correlation for lesion thickness measurements, with an ICC of 0.76 (95% CI, 0.67-0.82) and Pearson's correlation coefficient of 0.61 (95% CI, 0.51-0.70), and poor-to-moderate reliability and correlation for transverse diameter measurements, with an ICC of 0.58 (95% CI, 0.39-0.71) and Pearson's correlation coefficient of 0.46 (95% CI, 0.33-0.58).

CONCLUSION

Preoperative TVS determines accurately rectosigmoid DE lesion length. TVS can thereby contribute to optimal planning of surgical treatment options in women with rectosigmoid DE. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Obsidian ASG® Autologous Platelet-Rich Fibrin Matrix and Colorectal Anastomotic Healing: A Preliminary Study

INTRODUCTION

Anastomotic leakage (AL) following colorectal resection is a devastating complication affecting morbidity, mortality, and quality of life of patients in the long term. Different tissue sealants and biologic glues were tested showing conflicting results regarding their influence on anastomotic healing and leak prevention. Application of autologous platelet-rich fibrin (Vivostat A/S, Alleroed, Denmark), which acts as a source of angiogenic growth factors and cytokines, showed promising results in an in-vivo porcine model. Herein, we present the first human study of stapled colorectal anastomoses supplemented with an autologous-derived platelet-rich fibrin matrix (Obsidian ASG®, Rivolution GmbH, Rosenheim, Germany and Vivostat A/S, Alleroed, Denmark).

MATERIALS AND METHODS

A retrospective analysis of prospectively accumulated data was performed in two colorectal centers (Linz, Vienna) on patients undergoing left-sided colorectal or coloanal stapled anastomosis between October 2018 and December 2019. The Obsidian ASG® Matrix was applied to the rectal stump, and after closure with the circular stapling device, at the circumference of anastomosis in every single case. Anastomoses were supplemented with intra- and extra-anastomotic application (IAA-intra-anastomotic application developed by Rivolution GmbH, Rosenheim, Germany) of Obsidian ASG® Matrix. The primary endpoints were incidence of perioperative complications and anastomotic leak rate.

RESULTS

Two-hundred-sixty-one (138 female) patients underwent left-sided colonic (n=177) or rectal resection (n=84). In 253 (96.9%) cases, a laparoscopic or robotic-assisted approach was used. There were no complications attributable to the intraoperative application of the Obsidian ASG® Matrix. All intraoperative leak tests were negative. Overall, anastomotic leak rate accounted for 2.3% (6/261). AL following colonic and rectal resection was seen in 2.3% (4/177) and 2.4% (2/84), respectively. Complication and leak rate was similar in the two participating centers. Postoperative fever and elevated CRP levels were significantly correlated to AL. There was no significant risk factor for AL on multivariate analysis.

CONCLUSION

Application of an autologous-derived platelet-rich fibrin matrix (Obsidian ASG®) at anastomotic site following colorectal resection is safe and associated with a low rate of anastomotic leakage.

Neoadjuvant chemoradiotherapy with sequential ipilimumab and nivolumab in rectal cancer (CHINOREC): A prospective randomized, open-label, multicenter, phase II clinical trial

TPS3623

Background: Immune checkpoint inhibitors (ICI), such as ipilimumab (anti-cytotoxic T-lymphocyte-associated protein 4) or nivolumab (anti-programmed cell death protein 1) have been proven to be an effective strategy in solid cancers. However, ICI seem not to be effective in microsatellite stable (MSS) cancers. As they might lack an immunogenic priming, radiotherapy (RT) is capable to induce an immunogenic cell death (ICD) and subsequently an immunogenic tumor immune microenvironment (TIME). Thus, RT might restore the susceptibility of MSS tumors to ICI and consequently leading to an effective anti-tumor immune response. Methods: This is a prospective, randomized, open-label, multicenter, phase II investigator-initiated clinical trial (IIT), including patients with locally advanced rectal cancer (LARC). Patients receive either neoadjuvant chemoradiotherapy (CRT) alone (50 Gy in 2 Gy fractions over 25 working days + capecitabine 1650 mg/m2/d PO) or in combination with ipilimumab (1 mg/kg IV on day 7) and nivolumab (3 mg/kg IV on day 14, 28 and 42). Patients will undergo surgery within 10-12 weeks post CRT. The primary endpoint is incidence of treatment-emergent adverse events (AEs) assessed by the Clavien-Dindo classification of surgical complications and the common terminology criteria of adverse events (CTCAE). Secondary objectives are radiographic and pathological therapy response. Serial liquid (plasma, serum and peripheral blood mononuclear cells) and tissue biopsies will be taken before, during and after neoadjuvant treatment. Genomic, transcriptomic, epigenomic and proteomic pattern of liquid and tissue biopsies, as well as the immune cell infiltrate of resected specimen, will be correlated with therapy response and clinical outcome. Currently 8 of planned 80 patients have been enrolled. Registration numbers: NCT no. NCT04124601, EudraCT no. 2019-003865-17. Clinical trial information: NCT04124601.

Low anterior resection syndrome following different surgical approaches for low rectal endometriosis: A retrospective multicenter study

INTRODUCTION

There is increasing evidence that intermediate and long-term bowel dysfunction may occur as a consequence of radical surgery for rectal deep endometriosis (DE). Typical symptoms include constipation, feeling of incomplete evacuation, clustering of stools, and urgency. This is described in the colorectal surgical literature as low anterior resection syndrome (LARS). Within this, several studies suggested that differences regarding functional outcomes could be favorable to more conservative surgical approaches, that is, excision of endometriotic tissue with preservation of the luminal structure of the rectal wall when compared with classical segmental resection techniques for DE, especially when performed for low DE.

MATERIAL AND METHODS

A total of 211 patients undergoing rectal surgery for low DE (≤7 cm from the anal verge) in three different tertiary referral centers between October 2009 and December 2018 were retrospectively reviewed regarding major complications and LARS. From the 211 eligible patients, six women were excluded because of loss to follow-up. Finally, a total number of 205 patients were enrolled for the statistical analysis; 139 with nerve- and vessel-sparing segmental resection (NVSSR) and 66 operated for laparoscopic-transanal disk excision (LTADE) were included. Gastrointestinal functional outcomes of the two procedures were compared using the validated LARS questionnaire. The median follow-up time was 46 ± 11 months. As a secondary outcome, the surgical sequelae were examined.

RESULTS

We found no statistically significant difference between the incidence of LARS (31.7% and 37.9%, respectively) among patients operated by LTADE when compared with NVSSR (P = .4). The occurrence of LARS was positively associated with the use of protective ileostomy or colostomy (P = .02). A higher rate of severe complications was observed in women undergoing LTADE (19.7%) when compared with patients with NVSSR (9.0%, P = .029).

CONCLUSIONS

LARS is not more frequent after NVSSR when compared with a more conservative approach such as LTADE in patients undergoing rectal surgery for low DE. To confirm our findings prospective studies are required.

Transvaginal sonography accurately measures lesion-to-anal-verge distance in women with deep endometriosis of the rectosigmoid

OBJECTIVES

First, to investigate the accuracy of transvaginal sonography (TVS) for presurgical evaluation of the distance between the most caudal part of the endometriotic lesion and the anal verge (lesion-to-anal-verge distance (LAVD)) in women with rectosigmoid deep endometriosis (DE), compared with intraoperative measurement (IOM). Second, to assess the agreement between anastomosis height and LAVD measured using TVS.

METHODS

This was a prospective observational multicenter study of symptomatic women who were scheduled for surgical treatment of rectosigmoid DE, by either discoid or segmental resection, between April 2017 and September 2019. Presurgical TVS was performed to evaluate the LAVD in two ways, depending on the level of the lesion. Method 1: for lesions at the level of the rectovaginal septum (RVS), the caudal part of the lesion was identified on TVS and an index finger was placed on the TVS probe at the level of the anal verge. The probe was withdrawn and the distance from the tip of the TVS probe down to the index finger was measured using a ruler, representing the LAVD. Method 2: for lesions above the RVS, the distance between the caudal part of the lesion and the lower lip of the posterior cervix was measured in a frozen image (LAVD-1), and the distance between the lower lip of the posterior cervix and the anal verge (LAVD-2) was measured using Method 1. These two measurements (LAVD-1 and LAVD-2) were added together and the result represented the total LAVD. During surgery, a rectal probe was used to perform IOM of LAVD, which was considered as the gold standard test. Agreement between LAVD measured using TVS and the IOM was assessed using Bland-Altman analysis. The intraclass correlation coefficient (ICC) for absolute agreement and Spearman's correlation coefficient were also calculated. Systematic and proportional bias were tested for significance using the paired t-test. Similar analysis was performed to assess agreement between LAVD measured using TVS and anastomosis height.

RESULTS

A total of 147 consecutive women were considered eligible for inclusion. Fourteen women were excluded initially. Thirty-four discoid resections and 102 segmental resections were performed; both procedures were performed in three women. Two more women were excluded from the final analysis because the measurements represented extreme outliers. The mean LAVD measured using TVS was 114.8 ± 36.5 mm and the mean IOM was 116.9 ± 42.3 mm. There was no statistically significant difference between LAVD measured using TVS and IOM (mean difference, -2.12 mm (95% CI, -6.33 to 2.05 mm); P = 0.32). Bland-Altman analysis showed that there was good agreement between the two methods. The ICC was 0.81 (95% CI, 0.74-0.86) and Spearman's correlation coefficient was 0.68 (95% CI, 0.56-0.77). The mean difference between LAVD measured using TVS and anastomosis height was statistically, but not clinically, significant (mean difference, 10.25 mm (95% CI, 5.94-14.32 mm); P = 0.0005), and the ICC was 0.78 (95% CI, 0.66-0.85).

CONCLUSIONS

There is good agreement between the LAVD measured using TVS and the IOM in women with rectosigmoid DE. As a consequence, TVS could be useful for estimation of the height of the final surgical anastomosis in women undergoing full-thickness resection for rectosigmoid DE. This is of pivotal importance in reducing the risk of complications and need for a temporary stoma, and could improve patient counseling. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Robotic-assisted repair of complex ventral hernia: can it pay off?

Pressure on health care providers is growing due to capping of remuneration for medical services in most Western European countries. We wanted to investigate, if robotic-assisted ventral hernia repair is reasonable from an economic point of view in our setting. Patients undergoing open or robotic-assisted repair for complex abdominal wall hernia using a Transversus Abdominis Release (TAR) between September 2017 and January 2019 were included. Procedure-related costs were calculated exact to the minute and cost unit accounting for the postoperative in-patient stay was done. Abdominal wall reconstruction using the TAR-technique was done in a total of 26 (10 female) patients via an open (n = 10) or robotic-assisted (n = 16) approach. No significant difference was seen in regard to age, BMI and ASA scores between subgroups. Time for operation was longer (253.5 vs 211.5 min; p = 0.0322), while postoperative hospital stay was shorter for patients operated with a robotic-assisted approach (4.5 vs 12.5 days; p < 0.005). Procedure-related costs were 2.7-fold higher when a robotic-assisted reconstruction was done (EUR 5397 vs. 1989), while total costs for in-patient stay were about 60% lower (EUR 2715 vs 6663). Currently, revenues by national insurance account for a total of EUR 9577 leading to a profit of EUR 1465 and 925 for the robotic-assisted and open myofascial release, respectively. In addition, 30-day re-admission rate was in favor of the robotic-assisted approach as well (6.3% vs 20%). From an economic point of view, robotic-assisted TAR for complex ventral hernia repair is a viable option in our setting. Higher procedure-related costs are offset by a significant shorter hospital stay. The economic advantage goes along with improvement in outcome of patients.

Association between disease extent and pain symptoms in patients with deep infiltrating endometriosis

RESEARCH QUESTION

The study aimed to assess the associations between pre-operative symptoms in patients with deep infiltrating endometriosis (DIE) and intraoperatively determined extent of disease as described by the revised ENZIAN score.

DESIGN

This was a retrospective data analysis of women who underwent surgery for DIE between 2014 and 2018 at the Department of Gynecology, Hospital St. John of God, Vienna (a tertiary referral centre for endometriosis).

RESULTS

Data from 245 women were analysed. Statistically significant associations were found between involvement of ENZIAN compartment B (uterosacral ligaments, parametrium) and presence of dyspareunia (P = 0.002), ENZIAN compartment C (rectum, sigmoid colon) and dyschezia (P < 0.001), and ENZIAN compartment FB (urinary bladder) and dysuria (P < 0.001, Fisher's exact test). Statistically significant correlations were also detected between symptom severity of dyschezia and lesion size in ENZIAN compartment C (r_s = 0.334, P < 0.001), and severity of dyspareunia and lesion size in ENZIAN compartment B (r_s = 0.127, P = 0.046). Severity of dysmenorrhoea was correlated with lesion size in ENZIAN compartment A (r_s = 0.244, P < 0.001) and was associated with the presence of adenomyosis (compartment FA; P = 0.005, Mann-Whitney U-test). Additionally, the number of affected compartments (A, B, C and FA) correlated with the severity of dysmenorrhoea (r_s = 0.256, P < 0.001) and dyschezia (r_s = 0.161, P = 0.012).

CONCLUSION

In contrast to previous studies evaluating disease extent based on the revised American Society for Reproductive Medicine (rASRM) score, disease localization and extent as described by the revised ENZIAN score was associated and correlated with the presence and severity of different pre-operative symptoms. These explorative findings suggest that it may be important to evaluate the extent of DIE using the revised ENZIAN score in addition to the rASRM score.

Influence of multiple stapler firings used for rectal division on colorectal anastomotic leak rate

BACKGROUND

Anastomotic leakage following colorectal resection remains one of the most significant complications with relevant morbidity and mortality. There is evidence that a higher number of stapler firings for rectal division can affect the leak rate in double stapling anastomosis. However, there are no data concerning compression anastomosis. We present our institutional experience addressing this issue.

DESIGN

This is a retrospective review of a prospective institutional database of patients undergoing colonic and rectal resection for benign and malignant indications between January 2008 and December 2014 at the surgical department of the St. John of God Hospital, Vienna. Inclusion criteria were rectal division with linear stapling devices and construction of anastomosis to the rectal stump using a circular stapler or compression device.

RESULTS

Three hundred eighty two (196 female; 51.3%) patients were included. Mean age was 65.8 years (range: 18-95) Indications for the operation included diverticular disease (44.8%), colorectal carcinoma (51.6%), inflammatory bowel disease (1.8%), and adenoma (1.8%). A laparoscopic approach was employed in 334 cases (87.4%); in 170 patients (44.9%), a compression anastomosis was created. One, two, and three or more stapler cartridges were used for rectal division in 58.4, 33.5, and 8.1%, respectively. Male gender, neoadjuvant therapy, rectal cancer as an underlying disease, laparoscopic surgical approach, and duration of operation longer than 200 min are leading causes for the usage of more than one stapler cartridge. Overall leak rate was 4.7% (18/382). The only factor associated with the occurrence of leakage was the use of three or more stapler cartridges for the closure of the rectal stump (p = 0.002).

CONCLUSION

Our data support that multiple stapler firings for rectal division following colorectal resection has a major impact on anastomotic leak rate. Especially in laparoscopic surgery efforts should be made to minimize the number of stapler cartridges used.

Influence of multiple stapler firings used for rectal division on colorectal anastomotic leak rate

BACKGROUND

Anastomotic leakage following colorectal resection remains one of the most significant complications with relevant morbidity and mortality. There is evidence that a higher number of stapler firings for rectal division can affect the leak rate in double stapling anastomosis. However, there are no data concerning compression anastomosis. We present our institutional experience addressing this issue.

DESIGN

This is a retrospective review of a prospective institutional database of patients undergoing colonic and rectal resection for benign and malignant indications between January 2008 and December 2014 at the surgical department of the St. John of God Hospital, Vienna. Inclusion criteria were rectal division with linear stapling devices and construction of anastomosis to the rectal stump using a circular stapler or compression device.

RESULTS

Three hundred eighty two (196 female; 51.3%) patients were included. Mean age was 65.8 years (range: 18-95) Indications for the operation included diverticular disease (44.8%), colorectal carcinoma (51.6%), inflammatory bowel disease (1.8%), and adenoma (1.8%). A laparoscopic approach was employed in 334 cases (87.4%); in 170 patients (44.9%), a compression anastomosis was created. One, two, and three or more stapler cartridges were used for rectal division in 58.4, 33.5, and 8.1%, respectively. Male gender, neoadjuvant therapy, rectal cancer as an underlying disease, laparoscopic surgical approach, and duration of operation longer than 200 min are leading causes for the usage of more than one stapler cartridge. Overall leak rate was 4.7% (18/382). The only factor associated with the occurrence of leakage was the use of three or more stapler cartridges for the closure of the rectal stump (p = 0.002).

CONCLUSION

Our data support that multiple stapler firings for rectal division following colorectal resection has a major impact on anastomotic leak rate. Especially in laparoscopic surgery efforts should be made to minimize the number of stapler cartridges used.

Diagnosis, management and outcome of early anastomotic leakage following colorectal anastomosis using a compression device: is it different?

AIM

Compression anastomosis has proved to be safe for rectal reconstruction with leak rates comparable to those observed using circular stapling devices. However, there are no data on whether the metallic compression ring alters the ease of diagnosis or the treatment in cases of leakage. In this study, we present our experience with early leakage following compression anastomosis.

METHOD

A prospective registry was used for data review. Patients with anastomotic leakage following compression anastomosis between November 2008 and September 2013 were included.

RESULTS

In all, 197 (92 female) patients were operated using a novel compression device. Early leakage was found in 10 (5.1%) patients after a median of 5 (3-14) days. The radiologist was able to detect leakage using CT in nine out of 10 cases unequivocally. Removal of the ring was necessary in eight of the 10 cases, and salvage of the anastomosis was feasible on six occasions. In all diverted cases with a low anastomosis, a transanal repair of the defect was feasible in three cases, including a single patient with complete separation of the anastomosis.

CONCLUSION

Artefacts on the CT scan caused by the compression ring did not hamper the diagnosis of anastomotic leakage. Removal of the ring in the early postoperative period is not associated with complete separation of the bowel ends. Salvage of anastomosis is feasible in most cases.

Hedgehog inhibition reduces angiogenesis by downregulation of tumoral VEGF-A expression in hepatocellular carcinoma

BACKGROUND

Dysregulation and activation of Hedgehog (Hh) signalling may contribute to tumorigenesis, angiogenesis, and metastatic seeding in several solid tumours.

OBJECTIVE

We investigated the impact of Hh inhibition on tumour growth and angiogenesis using in-vitro and in-vivo models of hepatocellular carcinoma (HCC).

METHODS

The effect of the Hh pathway inhibitor GDC-0449 on tumour growth was investigated using an orthotopic rat model. Effects on angiogenesis were determined by immunohistochemical staining of von Willebrand factor antigen and by assessing the mRNA expression of several angiogenic factors. In vitro, HCC cell lines were treated with GDC-0449 and evaluated for viability and expression of vascular endothelial growth factor (VEGF). Endothelial cells were evaluated for viability, migration, and tube formation.

RESULTS

In the orthotopic HCC model, GDC-0449 significantly decreased tumoral VEGF expression which was accompanied by a significant reduction of microvessel density and tumour growth. In HCC cells, GDC-0449 had no effect on cell growth but significantly reduced target gene regulation and VEGF expression while having no direct effect on endothelial cell viability, migration, and tube formation.

CONCLUSIONS

Hh inhibition with GDC-0449 downregulates tumoral VEGF production in vitro and reduces tumoral VEGF expression, angiogenesis, and tumour growth in an orthotopic HCC model.

Anastomotic leakage after low anterior resection for rectal cancer: comparison of stapled versus compression anastomosis

PURPOSE

Surgical technique and perioperative management in rectal cancer surgery have been substantially improved and standardized during the last decades. However, anastomotic leakage following low anterior resection still is a significant problem. Based on animal experimental data of improved healing of compression anastomosis, we hypothesized that a compression anastomotic device might improve healing rates of the highest-risk anastomoses.

METHODS

All low anterior resections for rectal cancer performed or directly supervised by the senior author between January 2004 and June 2012 were analyzed. Only patients with a stapled or compression anastomosis located within 6 cm from the anal verge were included. Until December 2008, circular staplers were employed, while since January 2009, a novel compression anastomotic device was used for rectal reconstruction exclusively.

RESULTS

Out of 197 patients operated for rectal cancer, a total of 96 (34 females, 35.4 %) fulfilled inclusion criteria. Fifty-eight (60.4 %) were reconstructed with circular staplers and 38 (39.6 %) using a compression anastomotic device. Significantly, more laparoscopic procedures were recorded in the compression anastomosis group, but distribution of gender, age, body mass index, American Society of Anaesthesiologists score, rate of preoperative radiotherapy, tumor staging, or stoma diversion rate were similar. Anastomotic leakage was observed in seven cases (7/58, 12.1 %) in the stapled and twice (2/38, 5.3 %) in the compression anastomosis group (p = 0.26).

CONCLUSIONS

In this series, rectal reconstruction following low anterior resection using a novel compression anastomotic device was safe and (at least) equally effective compared to traditional circular staplers concerning leak rate.

Repeat endorectal advancement flap after flap breakdown and recurrence of fistula-in-ano--is it an option?

AIM

Endorectal advancement flaps are an established treatment for high transsphincteric and suprasphincteric fistulae. The outcome of a repeat procedure in the case of flap breakdown and fistula recurrence remains unclear. The aim of the study was to analyse the outcome of repeat endorectal advancement flaps.

METHODS

We retrospectively analysed patients with a repeat endorectal advancement flap procedure after flap breakdown and recurrence of fistula-in-ano of cryptoglandular origin who had been treated in our unit between 1994 and 2010.

RESULTS

In all, 97 patients underwent an endorectal advancement flap procedure for fistula-in-ano and, of these, nine patients (five men, four women, 9.3%) subsequently underwent a repeat procedure due to flap breakdown. Median age was 40 years (range 25-60). Median follow-up time was 85 months (range 26-136). Seven full-thickness and two mucosal flap repeat procedures were performed because of eight transsphincteric and one suprasphincteric fistulae. The repeat procedure was successful in seven (78%) patients. In one of the two patients with repeat flap failure, a third flap procedure failed again. Disturbances of postoperative faecal incontinence were observed in five (55%) patients. Overall, the median postoperative Vaizey faecal incontinence score was 1 (range 0-4).

CONCLUSION

Repeat endorectal advancement flap procedures are feasible and associated with a low recurrence rate and mild postoperative faecal incontinence. Therefore, a repeat procedure is a viable option in the case of a flap breakdown and fistula recurrence.

Erlotinib and sorafenib in an orthotopic rat model of hepatocellular carcinoma

BACKGROUND & AIMS

The combination of erlotinib with sorafenib is currently being investigated in a phase III RCT. We studied the effect of erlotinib and sorafenib on HCC in a preclinical model.

METHODS

The Morris Hepatoma (MH) and HepG2 cells were treated in vitro with sorafenib (1-10 μM) and erlotinib (1-5 μM) and evaluated for tumor cell viability, apoptosis, and target regulation. Antiangiogenic effects were studied by measuring VEGF levels, endothelial cell viability, apoptosis, migration, and the aortic ring assay. In vivo, MH cells were implanted into the liver of syngeneic rats and treated with vehicle, sorafenib 5-10mg/kg, erlotinib 10mg/kg, and respective combinations.

RESULTS

In vitro, erlotinib downregulated p-ERK but showed no significant effect on tumor cell viability in MH and HEPG2 cells. Despite a similar target regulation, sorafenib significantly reduced cell viability of HCC cells by induction of apoptosis, in a dose-dependent manner (11 ± 5%; 20 ± 10%; 51 ± 5% for sorafenib 1, 5, 10 μM). No additional effect was observed upon combination with erlotinib. Of note, erlotinib treatment resulted in endothelial cell migration and vascular sprouting of aortic rings through induction of VEGF mRNA and protein levels in endothelial and tumor cells, which was blocked by sorafenib. In vivo, erlotinib had no single agent antitumor activity, raised serum-VEGF levels, and lacked a synergistic effect in combination with sorafenib.

CONCLUSIONS

Erlotinib had no antitumor effect on HCC in vitro nor in vivo, but induced VEGF, which may reflect a resistance mechanism to erlotinib monotherapy. No improvement of sorafenib efficacy was observed upon combination with erlotinib.

Bridging the gap with an ileocolonic graft after extensive colorectal resections

BACKGROUND

Ileocecal interposition (ICI) for first-line reconstruction after low anterior colorectal resection was introduced by von Flüe and Harder in 1994 (Dis Colon Rectum 37:1160-1162, 1994). We report our experience using this technique to bridge colonic gaps after significant loss of bowel length.

PATIENTS AND METHODS

Between 1999 and 2009 the left-sided colon was too short for traditional isoperistaltic reconstruction in six patients treated in our hospital. Reasons for extensive bowel loss were a deficient (n = 3) or torn (n = 1) marginal artery with ischemia or repeat colorectal resections (n = 2). An ICI was done to bridge the gap and enable restoration of intestinal continuity.

RESULTS

No patient died. Whenever performing a coloanal anastomosis (4/6) a loop ileostomy was raised. One patient with colonic diversion experienced graft-related complications: ischemic colitis of the interposed colonic segment, anastomotic stenosis, and a presacral sinus were observed and managed nonoperatively. Subsequent closure of the stoma was possible in all cases. A median Vaizey incontinence score of 9 (range: 4-14) was recorded in the patient with coloanal anastomosis. The average number of bowel movements per day was 1.5 (range: 0.5-6).

CONCLUSIONS

When the descending colon does not reach the rectal stump or anal canal in reoperative cases or after vascular complication, ICI is a useful salvage procedure resulting in good bowel function.

Traction-assisted endoscopic mucosal resection for polypectomy in the large intestine

AIM: To evaluate if traction-assisted endoscopic mucosal resection (TA-EMR) is feasible and if it enables en bloc resection of colorectal lesions.

METHODS: Seven patients with a total of 12 colorectal adenomas were prospectively enrolled. All lesions were removed by TA-EMR: one hemostatic clip tied to a white silk suture was applied to the base of the lesion to allow traction through the working channel of the colonoscope. A conventional polypectomy snare was mounted over the suture and the lesion was pulled into the snare and resected in one piece.

RESULTS: All 12 lesions (nine sessile) were resected en bloc with free lateral and vertical margins by using this novel technique, including five lesions (5/12, 41.6%) in less-accessible positions, where TA-EMR enabled complete visualization of the base before resection. Mean longest lesion and specimen sizes were 9 mm (range: 6-25 mm) and 11 mm in diameter (range: 7-17 mm), respectively. No serious procedure-related complications were observed.

CONCLUSION: TA-EMR through the endoscope using a hemostatic clip and suture material is technically feasible. Visualization of colorectal lesions in less-accessible locations can be improved.

Recurrent abscess after primary successful endo-sponge treatment of anastomotic leakage following rectal surgery

AIM: To assess long-term efficacy of initially successful endo-sponge assisted therapy.

METHODS: Between 2006 and 2009, consecutive patients who had undergone primary successful endo-sponge treatment of anastomotic leakage following rectal cancer surgery were enrolled in the study. Patients were recruited from 6 surgical departments in Vienna. Clinical and oncologic outcomes were assessed through routine endoscopic and radiologic follow-up examination.

RESULTS: Twenty patients (7 female, 13 male) were included. The indications for endo-sponge treatment were anastomotic leakage (n = 17) and insufficiency of a rectal stump after Hartmann’s procedure (n = 3). All patients were primarily operated for rectal cancer. The overall mortality rate was 25%. The median follow-up duration was 17 mo (range 1.5-29.8 mo). Five patients (25%) developed a recurrent abscess. Median time between last day of endo-sponge therapy and occurrence of recurrent abscess was 255 d (range 21-733 d). One of these patients was treated by computed tomography-guided drainage and in 3 patients Hartmann’s procedure had to be performed. Two patients (10%) developed a local tumor recurrence and subsequently died.

CONCLUSION: Despite successful primary outcome, patients who receive endo-sponge therapy should be closely monitored in the first 2 years, since recurrence might occur.