A necktie fashion vascular loop seton tie may simplify the treatment of perianal fistula

Seton for treatment of perianal fistula can be of the cutting or a loose type. We adopted a simple technique for tighten the seton by applying a necktie shape tie on the vascular loop, hence it can be used for drainage on the beginning, and for cutting purpose later on. In this retrospective study we report our experience on this seton tie method.

Material and methods Patients operated for perianal fistula between 2012 and 2014 were reviewed.

Results Of 63 patients operated, 23 (35%) had a necktie-tie seton. There were 15 (65%) men. Age 34.1 ± 10.6. Six (26%) had a recurrent fistula, 2 (9%) with loose seton in place. The external opening: anterior four (17%), lateral fifteen (65%), posterior three (13%), one patient (4%) had two opening. The internal opening was identified: posterior seventeen (74%), anterior four (17%) and right posterior two (8%). Nineteen (82%) had a trans-sphenteric tract, four (17%) females had an anterior location. Operative time was 32 min (range 22–55). The seton was tightened 4 times (range 2–5) with 2 weeks interval. Healing was achieved in 7 weeks (range 5–11). In 24 months (range 12–35) follow-up, no reported anal incontinence. Recurrence was observed in one patient (4%).

Conclusion The necktie tightening of the vascular loop seton is a simple, safe, easily performed and may simplify the seton management of perianal fistulae.

Transanal Endoscopic Microsurgery Combined with Laparoscopic Colectomy for Synchronous Colorectal Tumors: A Word of Caution

BACKGROUND

The incidence of malignant synchronous colorectal tumors (SCRT) is between 2% and 5%, and the association of synchronous adenomatous polyps in colon cancer has been reported to be 15%-50%. Surgical resection is the primary treatment option for SCRT not amendable to endoscopic resection. Lesions in adjacent segments are usually treated with more extensive resection; however, there is still some controversy on how to best treat synchronous lesions in separate segments, especially when the rectum is involved. In this study, we aimed to report the outcome of patients with SCRT treated by laparoscopic colectomy combined with Transanal Endoscopic Microsurgery.

METHODS

Data pertaining patients undergoing combined colectomy and Transanal Endoscopic Microsurgery (TEM) between 2004 and 2014 were retrospectively collected.

RESULTS

141 TEM performed in the study period, 9 (6.5%) with combined laparoscopic colectomy were included. Mean age was 69.1 ± 10.6 years. There were 6 (66%) right, 2 (22%) left, and one (11%) sigmoid colectomy. All rectal lesions were benign adenomas, with mean tumor size 2.5 cm, and distance from the verge 9 ± 2.5 cm. Lesions were located in lateral rectal wall in 4, posterior in 4, and anterior in one case. Seven patients had the colectomy before TEM, and 2 had the TEM first. Mean operative time was 245 minutes (range 185-313) for the combined procedures. Median time of hospitalization was 6 days (range 4-11). Six patients (66%) had prolonged postoperative diarrhea. The final rectal pathology reports were adenoma with high-grade dysplasia (HGD) in 5 patients and adenoma with low-grade dysplasia in four cases. The colon pathology was T1 N0 in 3, T2 N0 in one, T3 N1 in one, adenoma with HGD in 2, and no residual tumor in 2 patients. Two patients underwent re-TEM for recurrent adenoma of rectum at 14 and 18 months postoperatively.

CONCLUSION

The combination of TEM with laparoscopic colectomy is feasible and should be kept in mind as an alternative procedure in case of SCRT. However, more strict selection criteria should be considered and the disadvantages should be discussed with the patient.

Long-Term Outcome of Laparoscopic Totally Extraperitoneal Repair of Bilateral Inguinal Hernias with a Large Single Mesh

BACKGROUND

A totally extraperitoneal (TEP) approach is currently the technique of choice for the laparoscopic repair of bilateral inguinal hernias in our institution. Most other surgeons use two meshes for the TEP repair, one for each side. We prefer a large single mesh when possible since it allows for easier correct placement of the mesh in one stage. We compared our long-term results of both techniques in terms of late complications and recurrence rates.

METHODS

This study retrospectively evaluated the medical records of 108 patients who underwent bilateral laparoscopic TEP repair in our institution between January 2002 and December 2003. Excluded were patients who had a conversion to a transabdominal preperitoneal or open approach. A total of 73 (67 %) patients fulfilled study entrance criteria and were enrolled: 39 had undergone single mesh repair and 34 had undergone double mesh repair.

RESULTS

There were no significant group differences in demographics, operating time, postoperative morbidity, or hospital stay. Likewise, after a median follow-up of 102 months (range 94–115 months), there were no significant group differences between the single and double mesh groups in persistent pain (5.8 vs 2.5 %, respectively; p = 0.476) and recurrence (7.6 vs 8.8 %, respectively; p = 0.55).

CONCLUSION

The use of a large single mesh is an effective and safe alternative technique for TEP repair of bilateral inguinal hernias, and is technically easy to perform.

Transanal Endoscopic Microsurgery After Neoadjuvant Chemoradiotherapy for Rectal Cancer

BACKGROUND

Radical rectal resection following neoadjuvant chemoradiation therapy (CRT) for locally advanced rectal cancer is accompanied by relatively high morbidity. Local excision of rectal cancer may be more appropriate for some frail patients with severe comorbidities. Transanal endoscopic microsurgery (TEM), consisting of local excision of selected rectal cancers, has been associated with low rates of postoperative complications. Because neoadjuvant CRT for rectal cancer may be associated with increased complications, the suitability of TEM following CRT is still unclear. In this study we aimed to assess the clinical outcomes of patients undergoing TEM following neoadjuvant CRT.

PATIENTS AND METHODS

This study retrospectively analyzed all patients undergoing TEM for malignant rectal tumor in our institution between 2004 and 2010. They were divided into those who received CRT (CRT group) and those without CRT (non-CRT group). Demographics and clinical data were compared.

RESULTS

Forty-four of 97 patients who underwent TEM were included: 13 CRT and 31 non-CRT. Age, comorbidities, and the duration of the procedure were similar for both groups. There were no significant group differences in tumor diameter (2.1 cm [range, 0.5-3.5 cm] and 2.9 cm [range, 0.5-4.2 cm], respectively; P=.125) or distance of the lower part of the tumor from the anal verge (6.7 cm [range, 5-10 cm] and 7.7 cm [range, 5-15 cm], respectively; P=.285). Two non-CRT patients had peritoneal entry, and 1 of them underwent protective ileostomy because of insecure rectal defect closure. One non-CRT patient underwent a re-operation for postoperative bleeding. The other perioperative complications were minor and included urinary retention requiring catheter placement (2 patients in each group), pulmonary edema (1 non-CRT patient), and pneumonia (1 non-CRT patient). All complications were managed conservatively. There was no wound disruption, major complication, or mortality in either group.

CONCLUSIONS

With proper patient selection, TEM can be performed safely following CRT, without major complication or increased postoperative morbidity.

Long-term outcome of local excision after complete pathological response to neoadjuvant chemoradiation therapy for rectal cancer

BACKGROUND

Neoadjuvant chemoradiotion therapy (CRT) for advanced rectal cancer has improved local disease. Complete rectal wall tumor regression may be associated with the absence of viable cancer cells in the mesorectum, and thus local excision (LE) of such lesions as an alternative to radical surgery has recently gained interest. We report the long-term outcome of LE in patients with a mural pathological complete response (ypT0) after CRT.

METHODS

A retrospective review of patients with rectal cancer treated by CRT and followed by LE with pathological complete response in the specimen between 1998 and 2009 was performed.

RESULTS

A total of 174 patients had neoadjuvant CRT, and 68 (39 %) showed complete clinical response (cCR). Thirty-one of the cCR patients underwent LE; 23 of them resulted in ypT0 and 8 had residual disease. The ypT0 group included 12 men and 11 women with a median age of 66. The pretreatment stage was T3N1 in 4 (17 %) patients, T3N0 in 11 (48 %), T2N1 in 3 (13 %), and T2N0 in 5 (22 %). The median tumor distance from the anal verge was 6 cm. Sixteen patients (70 %) underwent transanal excision, and 7 (30 %) were treated by transanal-endoscopic microsurgery. Three patients died: one of pneumonia, one of melanoma of the rectum, and one of lung carcinoma. No local or distant recurrences were detected in the remaining 20 patients. The median follow-up was 87 months.

CONCLUSIONS

Although radical rectal resection is the treatment of choice, LE of complete rectal tumor regression could be a safe alternative with an acceptable result in selected patients.

Simultaneous repair of bilateral inguinal hernias: a prospective, randomized study of single versus double mesh laparoscopic totally extraperitoneal repair

The aim of this study was to compare the double and the single mesh techniques, both used in the laparoscopic totally extra peritoneal (TEP) repair of bilateral inguinal hernia. Sixty-five patients with bilateral inguinal hernia were enrolled in a prospective, randomized trial comparing the single and the double mesh techniques. The single and the double mesh techniques compared favorably in terms of operating time, long-term morbidity, hospital stay, time for return to work, postoperative quality of life and recurrence rate. However, the cost of a single, large prosthesis was 38% to 40% lower than that of 2 small ones. The laparoscopic TEP repair of bilateral inguinal hernia with a large, single prosthetic mesh is a technically simple and safe procedure, which offers clear cost savings and a potentially shorter operating time over the double mesh repair. It is strongly recommended for the routine, laparoscopic TEP repair of bilateral inguinal hernias.

Inguinal hernia: Challenging the traditional indication for surgery in asymptomatic patients

BACKGROUND

It is generally accepted that most inguinal hernias should be operated on electively in order to avoid the high morbidity and mortality associated with incarceration and small bowel obstruction. The present study reassesses the indication for surgery in asymptomatic inguinal hernia patients.

METHODS

We analyzed profiles, separately, for elective and emergency inguinal herniorrhaphies and compared the morbidity and mortality rates.

RESULTS

Two hundred randomly selected elective hernia repairs were compared with 67 incarcerated cases. Postoperative complications were more common following emergency (23.9%) than elective repair (10.5%); however, in both groups, minor complications predominated. The mortality rate in the incarcerated group (6%) was clearly linked with a high preoperative American Society of Anesthesiologists (ASA) score. A bowel resection rate of 4.5% was found in the incarcerated cases, which was not correlated with mortality.

CONCLUSIONS

Patients with asymptomatic inguinal hernia and unfavorable medical conditions should be recommended an elective repair, preferably under local anesthesia, to avoid the high mortality associated with an emergency operation.

Adenocarcinoma of the appendix: an unusual disease

OBJECTIVE

To describe our experience with primary appendiceal tumours.

DESIGN

Retrospective study.

SETTING

University hospital, Israel.

SUBJECTS

2520 patients who had appendectomies during the 14 years, January 1982-December 1996.

RESULTS

22 patients 5 male and 17 female, mean age 56.2 years, had primary neoplasms; 14 were carcinoid tumours and villous adenomas and were treated by appendicectomy only. Adenocarcinoma was diagnosed in 8 patients (0.3%), 5 after appendicectomy (0.2%) which is twice the reported incidence. They were all treated by right hemicolectomy. Seven of the patients were classified as Dukes' B and one as Dukes' C. All patients were alive and disease-free after a mean follow-up period of 57.4 months.

CONCLUSION

Right hemicolectomy is the treatment of choice for adenocarcinoma of the appendix.

Surgery in chronic dialysis patients

During recent years there has been a continuous increase in the number of patients with end-stage renal failure who require long-term dialysis. The purpose of this retrospective work was to look at the number and type of operations performed and the postoperative outcome and complications that may be typical for these patients. This report details our experience with surgery in chronic dialysis patients, focusing mainly on major surgical procedures. During 21 years (1972-93) 22 patients on long-term hemodialysis or peritoneal dialysis underwent 44 operations. All access operations and parathyroidectomies were excluded. Each patient underwent between 1 and 6 operations; 27 (61.4%) operations were elective and 17 (38.6%) were emergencies. The most common type of operation performed was abdominal surgery and hernia repair; the others, in decreasing order, were urological operations, amputations, and vascular surgery. Postoperative complications occurred in 54% of the operations, the most common being hyperkalemia in 32%, infectious complications in 16%, and bleeding in 11%. One patient (2%) died postoperatively; the cause was most probably secondary to hyperkalemia and a fatal arrhythmia. From a review of the literature and from the results of our study it appears that surgery in uremic patients can be performed with acceptable results in terms of morbidity and mortality rates. Complications, such as hyperkalemia, a fall in blood pressure, and bleeding, are expected and preventive measures should therefore be taken. Perioperative measures are recommended to minimize complications.

Laparoscopic removal of an abdominal pregnancy adherent to the appendix after ovulation induction with human menopausal gonadotrophin

The laparoscopic management of tubal pregnancies has become a standard form of treatment. We present, for the first time, a successful laparoscopic approach in the management of early abdominal pregnancy. Although it is difficult to reach conclusions from such limited published experience, it nevertheless appears that early abdominal pregnancies can be treated via operative laparoscopy. The possible advantages of such a therapeutic approach include lower morbidity and mortality, and a better fertility prognosis.

Heterotopic abdominal pregnancy following in-vitro fertilization/embryo transfer presenting as massive lower gastrointestinal bleeding

We present a case that, as far as we know, is the first report of lower gastrointestinal haemorrhage as a complication of heterotopic pregnancy induced by artificial reproductive technology. The heterotopic abdominal pregnancy caused erosion of the intestinal wall and massive rectal bleeding, 8 weeks after in-vitro fertilization/embryo transfer. The source of the bleeding could not be identified despite comprehensive investigation including gastroscopy, ultrasonography, sigmoidoscopy, 99Tc (technetium) scanning and angiography. Tagged-erythrocyte isotope scanning revealed an abnormal concentration in the left lower quadrant, compatible with active bleeding in the area of the terminal ileum. Laparotomy disclosed a heterotopic abdominal pregnancy, causing erosion of the intestinal wall at this site. As assisted reproductive technologies become more and more common this rare complication of intestinal erosion should be kept in mind in case of lower gastrointestinal bleeding.

Primary appendiceal neoplasms

A retrospective review of the files of 1,740 appendectomies performed during a 10-year period disclosed 13 patients (0.7%) with primary appendiceal tumors. Adenocarcinoma of the appendix was diagnosed in 6 patients (0.3%), which is a two- to four-fold higher incidence than reported in the literature. The other seven patients had benign tumors and only appendectomy was performed. The female to male ratio of adenocarcinoma was 5:1. All six adenocarcinoma patients, classified histologically as Dukes' B stage, underwent right hemicolectomy, and were disease free following a mean follow-up of 35 months. The results of our policy, also recommended by others, confirmed the benefit of right hemicolectomy in all patients with confirmed primary appendiceal carcinomas.

[Rectosigmoid carcinoma in an adolescent girl]

Carcinoma of the colon and rectum is very rare in childhood and adolescence. We describe a 16.5-year-old girl with rectal bleeding and constipation. She had been treated symptomatically for 6 months without being properly examined. Only with onset of weight loss was rectal examination performed. After workup a diagnosis of locally advanced carcinoma of the rectosigmoid with multiple lung metastases was reached. From review of the literature and our own case, it seems that the unfavorable prognosis in young patients is mainly due to lack of awareness of such a possibility, resulting in delayed diagnosis and treatment. An additional factor is the invasive nature of most colon cancers in this age group.

Prospective comparative study of magnetic resonance imaging versus transrectal ultrasound for preoperative staging and follow-up of rectal cancer. Preliminary report

The efficiency of magnetic resonance imaging (MRI) and that of transrectal ultrasound (TRUS) were compared in preoperative staging of 15 patients with rectal cancer and in postoperative follow-up of 12 patients. Thirteen of the 15 patients evaluated for preoperative staging were operated on. Preoperative staging and pathologic finding were identical in 11 patients (84.6 percent) examined by TRUS and in 10 patients (76.9 percent) examined by MRI. Recurrent cancer was detected in 3 of 12 patients in the follow-up group. MRI was able to diagnose correctly 10 of 12 patients (83.2 percent), one patient was misdiagnosed, and in one patient the MRI could not distinguish between fibrous tissue and recurrent cancer. TRUS diagnosed correctly only 5 of 12 patients (41.6 percent). One was falsely diagnosed, and, in 6 patients (50 percent), this examination could not differentiate between fibrous tissue and recurrent tumor. According to our results, both MRI and TRUS have a place in the preoperative staging of patients with rectal cancer. The main differences between the two methods were in the differential diagnoses of fibrous tissue and recurrent cancer. MRI being more specific in detection of recurrence.

Free perforation of small intestine in adults

In a 14-year period 15 cases of free perforation of the small bowel in adults were treated in our department. In two patients perforation was caused by a foreign body and in six by each of the following: duplication of the small bowel, Hodgkin's lymphoma, vasculitis and steroid treatment, intussusception, adhesions, diverticulum. All patients presented with the signs of diffuse peritonitis. One patient died before surgery. Of the 14 patients operated upon, 10 underwent resection and primary anastomosis and four suturing of the perforation. In six cases the etiology remains unknown even after surgical intervention and pathological examination. The mortality rate of the 14 operated patients was 7.1%. 78.5% of the patients were operated on within 24 hours of onset of symptoms, and early surgery is considered to be the most important factor in the low mortality rate achieved in this series.

Intramural hematoma of duodenum following endoscopic intestinal biopsy

We present the fourth case to be reported in the literature of intramural hematoma of the duodenum following endoscopic small bowel biopsy. It is the first reported to have been diagnosed by ultrasonography and confirmed by contrast roentgenograms. Conservative treatment was effective in achieving satisfactory resolution of the obstruction within seven days, as evidenced by barium meal examination. The mechanism of trauma, in light of the other cases reported in the literature, is discussed.