Postoperative complications and waiting time for surgical intervention after radiologically guided drainage of intra-abdominal abscess in patients with Crohn's disease

BACKGROUND

In patients with active Crohn's disease (CD), treatment of intra-abdominal abscess usually comprises antibiotics and radiologically guided percutaneous drainage (PD) preceding surgery. The aim of this study was to investigate the risk of postoperative complications and identify the optimal time interval for surgical intervention after PD.

METHODS

A multicentre, international, retrospective cohort study was carried out. Details of patients with diagnosis of CD who underwent ultrasonography- or CT-guided PD were retrieved from hospital records using international classification of disease (ICD-10) diagnosis code for CD combined with procedure code for PD. Clinical variables were retrieved and the following outcomes were measured: 30-day postoperative overall complications, intra-abdominal septic complications, unplanned intraoperative adverse events, surgical-site infections, sepsis and pathological postoperative ileus, in addition to abscess recurrence. Patients were categorized into three groups according to the length of the interval from PD to surgery (1-14 days, 15-30 days and more than 30 days) for comparison of outcomes.

RESULTS

The cohort comprised 335 CD patients with PD followed by surgery. Median age was 33 (i.q.r. 24-44) years, 152 (45.4 per cent) were females, and median disease duration was 9 (i.q.r. 3.6-15) years. Overall, the 30-day postoperative complications rate was 32.2 per cent and the mortality rate was 1.5 per cent. After adjustment for co-variables, older age (odds ratio 1.03 (95 per cent c.i. 1.01 to 1.06), P < 0.012), residual abscess after PD (odds ratio 0.374 (95 per cent c.i. 0.19 to 0.74), P < 0.014), smoking (odds ratio 1.89 (95 per cent c.i. 1.01 to 3.53), P = 0.049) and low serum albumin concentration (odds ratio 0.921 (95 per cent c.i. 0.89 to 0.96), P < 0.001) were associated with higher rates of postoperative complications. A short waiting interval, less than 2 weeks after PD, was associated with a high incidence of abscess recurrence (odds ratio 0.59 (95 per cent c.i. 0.36 to 0.96), P = 0.042).

CONCLUSION

Smoking, low serum albumin concentration and older age were significantly associated with postoperative complications. An interval of at least 2 weeks after successful PD correlated with reduced risk of abscess recurrence.

Chirurgie des maladies inflammatoires chroniques de l’intestin et COVID-19 : étude européenne multicentrique (COVIBD-SURG)

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Méthodes

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Conclusions

Surgical management of complex ileocolonic Crohn's disease: a survey of IBD colorectal surgeons to assess variability in operative strategy

INTRODUCTION

To explore the reported variability in the surgical management of ileocolonic Crohn' s disease and identify areas of standard practice, we present this study which aims to assess how different colorectal surgeons with a subspecialty interest in inflammatory bowel disease (IBD) surgery may act in different clinical scenarios of ileocolonic Crohn's disease.

METHODS

Anonymous videos demonstrating the small bowel walkthrough and anonymised patients' clinical data, imaging and pathological findings were distributed to the surgeons using an electronic tool. Surgeons answered on operative strategy, bowel resections, management of small bowel mesentery, type of anastomosis and use of stomas.

RESULTS

Eight small bowel walkthrough videos were registered and 12 assessors completed the survey with a questionnaire completion rate of 87.5%. There was 87.7% agreement in the need to perform an ileocolonic resection. However, the agreement for the need to perform associated surgical procedures such as strictureplasties or further bowel resections was only 57.4%. When an anastomosis was fashioned, the side to side configuration was the most commonly used. The preferred management of the mesentery was dissection close to the bowel.

CONCLUSIONS

The decision on the main procedure to be performed had a high agreement amongst the different assessors, but the treatment of multifocal disease was highly controversial, with low agreement on the need for associated procedures to treat internal fistulae and the use of strictureplasties. At the same time, there was significant heterogeneity in the decision on when to anastomose and when to fashion an ileostomy.

Segmental Colectomy for Ulcerative Colitis: Is There a Place in Selected Patients Without Active Colitis? An International Multicentric Retrospective Study in 72 Patients

BACKGROUND AND AIMS

The aim of this study was to report a multicentric experience of segmental colectomy [SC] in ulcerative colitis [UC] patients without active colitis, in order to assess if SC can or cannot represent an alternative to ileal pouch-anal anastomosis [IPAA].

METHODS

All UC patients undergoing SC were included. Postoperative complications according to ClavienDindo's classification, long term results, and risk factors for postoperative colitis and reoperation for colitis on the remnant colon, were assessed.

RESULTS: A TOTAL OF

72 UC patients underwent: sigmoidectomy [n = 28], right colectomy [n = 24], proctectomy [n = 11], or left colectomy [n = 9] for colonic cancer [n = 27], 'diverticulitis' [n = 17], colonic stenosis [n = 5], dysplasia or polyps [n = 8], and miscellaneous [n = 15]. Three patients died postoperatively and 5/69 patients [7%] developed early flare of UC within 3 months after SC. After a median followup of 40 months, 24/69 patients [35%] were reoperated after a median delay after SC of 19 months [range, 2-158 months]: 22/24 [92%] underwent total colectomy and ileorectal anastomosis [n = 9] or total coloproctectomy [TCP] [n = 13] and 2/24 [8%] an additional SC. Reasons for reoperation were: colitis [n = 14; 20%], cancer [n = 3] or dysplasia [n = 3], colonic stenosis [n = 1], and unknown reasons [n = 3]. Endoscopic score of colitis before SC was Mayo 23 in 5/5 [100%] patients with early flare vs 15/42 without early flare [36%; p = 0.0101] and in 9/12 [75%] patients with reoperation for colitis vs 11/35 without reoperation [31%; p = 0.016].

CONCLUSIONS

After segmental colectomy in UC patients, postoperative early colitis is rare [7%]. Segmental colectomy could possibly represent an alternative to IPAA in selected UC patients without active colitis.

Biological mesh reconstruction versus primary closure for preventing perineal morbidity after extralevator abdominoperineal excision: a multicentre retrospective study

AIM

The aim of the study was to compare the incidence of perineal hernia and the perineal wound morbidity following extralevator abdominoperineal excision (ELAPE) between two groups - primary perineal closure and reconstruction with a biological mesh.

METHOD

One hundred and forty-seven consecutive patients who underwent ELAPE for primary rectal cancer between January 2007 and December 2018 in two tertiary referral centres were retrospectively identified from prospective databases. Perineal closure was carried out via primary closure or with a biological mesh (porcine dermal collagen mesh). Outcome measures were perineal hernia and perineal wound morbidity (infection, dehiscence, persistent sinus and chronic pain).

RESULTS

A total of 139 patients were included in the study. A prophylactic mesh was used in 80 (57.5%) and primary closure was practised in 59 (42.4%) patients. The median follow-up was 30 (interquartile range 46.88) months. Thirty patients (21.6%) developed perineal hernia. No significant differences were found between prophylactic mesh and primary closure (16.3% vs 23.3%, P = 0.07). The median period between surgery and hernia diagnosis was 8 months in the primary closure group and 24 months in the mesh group (P < 0.01). Perineal wound morbidity was significantly higher in the prophylactic mesh group (55% vs 33.9%, P < 0.01).

CONCLUSION

In our study, the use of a biological mesh did not reduce the rate of perineal hernia, although it did delay its appearance. Perineal closure using a biological mesh may increase perineal morbidity, both acute and chronic.

Video-laparoscopic assessment of the small bowel in Crohn's disease: a comparative study to evaluate surgeons' inter-observer variability

BACKGROUND

Assessment of the entire small bowel is advocated during Crohn's disease (CD) surgery, as intraoperative detection of new lesions may lead to change in the planned procedure. The aim of this study was to evaluate the inter-observer variability in the assessment of extent and severity of CD at the small bowel laparoscopic "walkthrough".

METHODS

A survey on laparoscopic assessment of the small bowel in patients with CD, including items adapted from the MREnterography or ultrasound in Crohn's disease (METRIC) study and from the classification of severity of mesenteric disease was developed by an invited committee of colorectal surgeons. Anonymous laparoscopic videos demonstrating the small bowel "walkthrough" in ileocolonic resection for primary and recurrent CD were distributed to the committee members together with the anonymous survey. The primary outcome was the rate of inter-observer variability on assessment of strictures, dilatations, complications and severity of mesenteric inflammation.

RESULTS

12 assessors completed the survey on 8 small bowel walkthrough videos. The evaluation of the small bowel thickening and of the mesenteric fat wrapping were the most reliable assessments with an overall agreement of 87.1% (k = 0.31; 95% CI - 0.22, 0.84) and 82.7% (k = 0.35; 95% CI - 0.04, 0.73), respectively. The presence of strictures and pre-stenotic dilatation demonstrated agreement of 75.2% (k = 0.06: 95% CI - 0.33, 0.45) and 71.2% (k = 0.33; 95% CI 0.15, 0.51), respectively. Evaluation of fistulae had an overall agreement of 75.3%, while there was a significant variation in the evaluation of mild, moderate and severe mesenteric disease with overall agreement ranging from 33.3 to 100%.

CONCLUSION

Laparoscopic assessment of the small bowel thickening and of the presence of mesenteric fat wrapping is reliable for the intraoperative evaluation of CD with high inter-rater agreement. There is significant heterogeneity in the assessment of the severity of the mesenteric disease involvement.

Risk factors for leak, complications and mortality after ileocolic anastomosis: comparison of two anastomotic techniques

INTRODUCTION

There are no definitive data concerning the ideal configuration of ileocolic anastomosis. Aim of this study was to identify perioperative risk factors for anastomotic leak and for 60-day morbidity and mortality after ileocolic anastomoses (stapled vs handsewn).

MATERIALS AND METHODS

This is a STROBE-compliant study. Demographic and surgical data were gathered from patients with an ileocolic anastomosis performed between November 2010 and September 2016 at a tertiary hospital. Anastomoses were performed using standardised techniques. Independent risk factors for anastomotic leak, complications and mortality were assessed.

RESULTS

We included 477 patients: 53.7% of the anastomoses were hand sewn and 46.3% stapled. Laterolateral anastomosis was the most common configuration (93.3%). Anastomotic leak was diagnosed in 8.8% of patients and 36 were classified as major anastomotic leak (7.5%). In the multivariate analysis, male sex (P = 0.014, odds ratio, OR, 2.9), arterial hypertension (P = 0.048, OR 2.29) and perioperative transfusions (P < 0.001, OR 2.4 per litre) were independent risk factors for major anastomotic leak. The overall 60-day complication rate was 27.3%. Male sex (31.3% vs female 22.3%, P = 0.02, OR 1.7), diabetes (P = 0.03 OR 2.0), smoking habit (P = 0.04, OR 1.8) and perioperative transfusions (P < 0.001, OR 3.3 per litre) were independent risk factors for postoperative morbidity. The 60-day-mortality rate was 3.1% and no significant risk factors were identified.

CONCLUSION

Anastomotic leak after ileocolic anastomosis is a relevant problem. Male sex, arterial hypertension and perioperative transfusions were associated with major anastomotic leak. Conversion to open surgery was more frequently associated with perioperative death.

Accuracy of CT colonography in the preoperative staging of colon cancer: a prospective study of 217 patients

AIM

The purpose of the present study was to evaluate the accuracy of computed tomography colonography (CTC) in the preoperative localization and TN staging of colon cancer. CTC can be an effective technique for preoperative evaluation of colon cancer and could facilitate the selection of high-risk patients who may benefit from neoadjuvant chemotherapy.

METHOD

This was a prospective observational study conducted at a single tertiary-care centre. It involved 217 patients (225 tumours) who had colon cancer and underwent preoperative CTC and elective colectomy. The radiologist determined the TNM stage using postprocessing software with multiplanar images and virtual colonoscopy. The following criteria were analysed for every colon tumour: location, size and signs of direct colon wall invasion. The histopathological findings of the surgical colectomy specimens served as the reference standard for local staging.

RESULTS

CTC detected all tumours and achieved an exact location in 208 cases (92.4%). CTC findings changed the surgical plan in 31 patients (14.3%) following colonoscopy. The accuracy in differentiating T3/T4 vs T1/T2 tumours was 87.1%, with a sensitivity and specificity of 88.5% and 84.1%, respectively (kappa = 0.71). For high-risk tumours (T3 ≥ 5 mm and T4), CTC showed an accuracy, sensitivity and specificity of 82.7%, 86% and 80%, respectively (kappa = 0.65). The accuracy of N-stage evaluation was 69.3%, the sensitivity 74% and the specificity 67.1% (kappa = 0.37).

CONCLUSION

CTC provides accurate information for the assessment of tumour localization and T staging, allowing better surgical planning and also allows the selection of locally advanced tumours that may benefit from new treatments such as neoadjuvant chemotherapy.

Predictors of complications and mortality following left colectomy with primary stapled anastomosis for cancer: results of a multicentric study with 1111 patients

AIM

Reports detailing the morbidity-mortality after left colectomy are sparse and do not allow definitive conclusions to be drawn. We aimed to identify risk factors for anastomotic leakage, perioperative mortality and complications following left colectomy for colonic malignancies.

METHOD

We undertook a STROBE-compliant analysis of left colectomies included in a national prospective online database. Forty-two variables were analysed as potential independent risk factors for anastomotic leakage, postoperative morbidity and mortality. Variables were selected using the 'least absolute shrinkage and selection operator' (LASSO) method.

RESULTS

We analysed 1111 patients. Eight per cent of patients had a leakage and in 80% of them reoperation or surgical drainage was needed. A quarter of patients (24.9%) experienced at least one minor complication. Perioperative mortality was 2%, leakage being responsible for 47.6% of deaths. Obesity (OR 2.8, 95% CI 1.00-7.05, P = 0.04) and total parenteral nutrition (TPN) (OR 3.7, 95% CI 1.58-8.51, P = 0.002) were associated with increased risk of leakage, whereas female patients had a lower risk (OR 0.36, 95% CI 0.18-0.67, P = 0.002). Corticosteroids (P = 0.03) and oral anticoagulants (P = 0.01) doubled the risk of complications, which was lower with hyperlipidaemia (OR 0.3, P = 0.02). Patients on TPN had more complications (OR 4.02, 95% CI 2.03-8.07, P = 0.04) and higher mortality (OR 8.7, 95% CI 1.8-40.9, P = 0.006). Liver disease and advanced age impaired survival, corticosteroids being the strongest predictor of mortality (OR 21.5, P = 0.001).

CONCLUSION

Requirement for TPN was associated with more leaks, complications and mortality. Leakage was presumably responsible for almost half of deaths. Hyperlipidaemia and female gender were associated with lower rates of complications. These findings warrant a better understanding of metabolic status on perioperative outcome after left colectomy.

Accuracy of magnetic resonance enterography in the preoperative assessment of patients with Crohn's disease of the small bowel

AIM

To assess the accuracy of magnetic resonance enterography in predicting the extension, location and characteristics of the small bowel segments affected by Crohn's disease.

METHOD

This is a prospective study including a consecutive series of 38 patients with Crohn's disease of the small bowel who underwent surgery at a specialized colorectal unit of a tertiary hospital. Preoperative magnetic resonance enterography was performed in all patients, following a homogeneous protocol, within the 3 months prior to surgery. A thorough exploration of the small bowel was performed during the surgical procedure; calibration spheres were used according to the discretion of the surgeon. The accuracy of magnetic resonance enterography in detecting areas affected by Crohn's disease in the small bowel was assessed. The findings of magnetic resonance enterography were compared with surgical and pathological findings.

RESULTS

Thirty-eight patients with 81 lesions were included in the study. During surgery, 12 lesions (14.8%) that were not described on magnetic resonance enterography were found. Seven of these were detected exclusively by the use of calibration spheres, passing unnoticed at surgical exploration. Magnetic resonance enterography had 90% accuracy in detecting the location of the stenosis (75.0% sensitivity, 95.7% specificity). Magnetic resonance enterography did not precisely diagnose the presence of an inflammatory phlegmon (accuracy 46.2%), but it was more accurate in detecting abscesses or fistulas (accuracy 89.9% and 98.6%, respectively).

CONCLUSION

Magnetic resonance enterography is a useful tool in the preoperative assessment of patients with Crohn's disease. However, a thorough intra-operative exploration of the entire small bowel is still necessary.

Dielectric characterization of healthy and malignant colon tissues in the 0.5-18 GHz frequency band

Several reports over the last few decades have shown that the dielectric properties of healthy and malignant tissues of the same body organ usually show different values. However, no intensive dielectric studies of human colon tissue have been performed, despite colon cancer's being one of the most common types of cancer in the world. In order to provide information regarding this matter, a dielectric characterization of healthy and malignant colon tissues is presented. Measurements are performed on ex vivo surgery samples obtained from 20 patients, using an open-ended coaxial probe in the 0.5-18 GHz frequency band. Results show that the dielectric constant of colon cancerous tissue is 8.8% higher than that of healthy tissues (p  =  0.002). Besides, conductivity is about 10.6% higher, but in this case measurements do not have statistical significance (p  =  0.038). Performing an analysis per patient, the differences in dielectric constant between healthy and malignant tissues appear systematically. Particularized results for specific frequencies (500 MHz, 900 MHz, 2.45 GHz, 5 GHz, 8.5 GHz and 15 GHz) are also reported. The findings have potential application in early-stage cancer detection and diagnosis, and can be useful in developing new tools for hyperthermia treatments as well as creating electromagnetic models of healthy and cancerous tissues.

Colonic prolapse after intersphincteric resection for very low rectal cancer: a report of 12 cases

BACKGROUND

There are no published data concerning management of patients with exteriorized colonic prolapse (CP) after intersphincteric rectal resection (ISR) and side-to-end coloanal manual anastomosis (CAA) for very low rectal cancer. The aim of the present study was to report our experience in 12 consecutive cases of CP following ISR with CAA.

METHODS

From 2006 to 2014, all patients with very low rectal cancer who developed CP after ISR and CAA were reviewed. Demographic and surgical data, prolapse symptoms and treatment were recorded. Postoperative morbidity, functional outcomes and results after prolapse surgery were recorded.

RESULTS

Twelve out of 143 patients (8 %) who underwent ISR with side-to-end CAA for low rectal cancer presented CP: 7/107 ISR (7 %) with partial resection of the internal anal sphincter (IAS) and 5/36 ISR (14 %) with subtotal or total resection of the IAS (NS). CP was diagnosed after a median of 6 months (range 2-72 months) after ISR. All patients with CP suffered from pain and fecal incontinence. Median Wexner fecal incontinence score before surgery was 16.5 (range 12-20). Three patients refused reoperation. Nine patients underwent transanal surgery with prolapse resection (including colonic stump and side-to-end anastomosis) and new end-to-end CAA (with posterior myorraphy in 4 cases). After a median follow-up of 30 months (range 8-87 months), 3/9 patients (33 %) had CP recurrence: One with very poor function was treated by abdominoperineal resection and definitive stoma. The 2 others were successfully reoperated on transanally. Median Wexner fecal incontinence score after CP surgery was 9 (range 0-20). No CP recurrence was noted for the 6 other patients, and function improved in all cases. Thus, at the end of follow-up, 8/9 patients (89 %) had no recurrence after surgery.

CONCLUSIONS

We believe surgery must be attempted in these patients who develop CP after ISR with CAA for very low rectal cancer in order to improve function and symptoms. A transanal approach with CP resection and new end-to-end anastomosis appeared to be safe and effective. Larger studies are needed to confirm our results.

Anastomotic leakage after colon cancer resection: does the individual surgeon matter?

AIM

Anastomotic leakage is one of the most feared complications after colonic resection. Many risk factors for anastomotic leakage have been reported, but the impact of an individual surgeon as a risk factor has scarcely been reported. The aim of this study was to assess if the individual surgeon is an independent risk factor for anastomotic leakage in colonic cancer surgery.

METHOD

This was a retrospective analysis of prospectively collected data from patients who underwent elective resection for colon cancer with anastomosis at a specialized colorectal unit from January 1993 to December 2010. Anastomotic leaks were diagnosed according to standardized criteria. Patient and tumour characteristics, surgical procedure and operating surgeons were analysed. A logistic regression model was used to discriminate statistical variation and identify risk factors for anastomotic leakage.

RESULTS

A total of 1045 patients underwent elective colon cancer resection with primary anastomosis. Anastomotic leakage occurred in 6.4% of patients. Ileocolic anastomosis had an anastomotic leakage rate of 7.2%, colo-colonic/colorectal anastomosis 5.2% and ileorectal anastomosis 12.7%, with intersurgeon variability. The independent risk factors associated with anastomotic leakage were the use of perioperative blood transfusion (OR 2.83, CI 1.59-5.06, P < 0.0001) and the individual surgeon performing the procedure (OR up to 8.44, P < 0.0001).

CONCLUSION

In addition to perioperative blood transfusion, the individual surgeon was identified as an important risk factor for anastomotic leakage. Efforts should be made to reduce performance variability amongst surgeons.

Is biological mesh interposition a valid option for complex or recurrent rectovaginal fistula?

AIM

Many surgical techniques are available for the treatment of rectovaginal fistula (RVF). There is hitherto little information on its treatment by biological mesh interposition. The aim of the present study was to analyse our results of RVF treatment using biological mesh interposition.

METHOD

Patients with RVF undergoing biological mesh interposition were identified. Success was defined by the absence of a diverting stoma and/or any vaginal discharge of faeces, flatus or mucous discharge.

RESULTS

Ten women [median age 39 (24.5-65) years] were included. Nine (90%) had recurrent RVF, and the median number of previous attempts at closure was 2.5 (0-8). The main cause of RVF was Crohn's disease (40%). All patients had faecal diversion. No intra-operative complications occurred from mesh interposition. Seven (70%) patients developed postoperative morbidity which was major (Dindo III) in two (20%). The primary success rate was 20% (2/10) but final success rate was achieved in 70% after reoperation with other procedures at 11.1 (2.7-13.1) months of follow-up.

CONCLUSION

The study has shown disappointing results with biological mesh interposition for RVF with a healing rate lower than achieved by gracilis muscle interposition.

Rectal cancer threatening or affecting the prostatic plane: is partial prostatectomy oncologically adequate? Results of a multicentre retrospective study

AIM

The management of rectal cancer threatening or affecting the prostatic plane is still under debate. The role of preoperative chemo radiotherapy and the extent of prostatectomy seem to be key points in the treatment of these tumours. The aim of the present study was to evaluate the pathological circumferential margin status and the local recurrence rate following different therapeutic options.

METHOD

A multicentre, retrospective study was conducted of patients with rectal cancer threatening or affecting the prostatic plane, but not the bladder, judged by magnetic resonance imaging (MRI). The use of preoperative chemoradiotherapy and the type of urologic resection were correlated with the status of the pathological circumferential resection margin (CRM) and local recurrence.

RESULTS

A consecutive series of 126 men with rectal cancer threatening (44) or affecting (82) the prostatic plane on preoperative staging and operated with local curative intent between 1998 and 2010 was analysed. In patients who did not have chemoradiotherapy but had a preoperative threatened anterior margin the CRM-positive rate was 25.0%. In patients who did not have preoperative chemoradiotherapy but did have an affected margin, the CRM-positive rate was 41.7%. When preoperative radiotherapy was given, the respective CRM infiltration rates were 7.1 and 20.7%. In patients having preoperative chemoradiotherapy followed by prostatic resection the rate of CRM positivity was 2.4%. Partial prostatectomy after preoperative chemoradiotherapy resulted in a free anterior CRM in all cases, but intra-operative urethral damage occurred in 36.4% of patients who underwent partial prostatectomy, resulting in a postoperative urinary fistula in 18.2% of patients.

CONCLUSION

Preoperative chemoradiation is mandatory in male patients with a threatened or affected anterior circumferential margin on preoperative MRI. In patients with preoperative prostatic infiltration, prostatic resection is necessary. In this group of patients partial prostatectomy seems to be oncologically safe.

The use of an endostapler in the treatment of supralevator abscess of intersphincteric origin

AIM

This technical note describes the use of an endostapler for the definitive treatment of supralevator abscess upward from an intersphincteric origin.

METHOD

A two-stage treatment was performed. First an endoanal drainage was performed by inserting a mushroom catheter in the supralevator abscess cavity. In the second stage transanal unroofing of the fistula was performed with an endostapler.

RESULTS

Since 2011, three patients have been treated in this way. After 2 years of follow up, none of the patients had recurrence of the abscess or been referred for anal incontinence.

CONCLUSION

The use of an endostapler in the treatment of supralevator abscess of intersphincteric origin may be an alternative to decrease the risk of recurrence and incontinence.

Prospective evaluation of intraoperative peripheral nerve injury in colorectal surgery

AIM

Intraoperative peripheral nerve injury can have permanent neurological consequences. Its incidence is not known and varies according to the location and the surgical specialty. This study was a prospective analysis of intraoperative peripheral nerve injury as a complication of abdominal colorectal surgery.

METHOD

All patients who underwent major colorectal abdominal surgery in our Colorectal Unit between 1996 and 2009 were analyzed. Data on nerve injury were prospectively collected.

RESULTS

There were 2304 patients, of whom eight (0.3%) experienced intraoperative peripheral nerve injury. This occurred in 5/2211 (0.2%) open procedures and in 3/93 (3%) laparoscopic procedures. There was no association between intraoperative peripheral nerve injury and age, gender, body mass index, surgeon, operation time, American Society of Anesthesiology (ASA) score and urgent surgery. The use of Allen-type stirrups and a vacuum bag (in laparoscopic surgery) seemed to be protective for nerve injury in the lower and upper limbs respectively.

CONCLUSION

Adequate positioning and the use of pressure-free positioning devices may prevent intraoperative peripheral nerve injury, particularly during laparoscopy.

Randomized clinical trial of laparoscopic versus open left colonic resection

BACKGROUND

The main aim of this study was to compare short-term results and long-term outcomes of patients undergoing laparoscopic versus open left colonic resection.

METHODS

Between February 2000 and December 2004, all adult patients undergoing elective left colonic resection were assessed for eligibility to the study. The protocol for postoperative care was the same in both groups. Cost-benefit analysis was based on hospital costs. Quality of life, long-term morbidity and 5-year survival were also evaluated.

RESULTS

Some 268 patients undergoing left colonic resection were assigned randomly to the laparoscopic (n = 134) or open (n = 134) approach. The short-term morbidity rate was 20.1 per cent in the open group and 11.9 per cent in the laparoscopic group (P = 0.094). Hospital stay was longer in the open group (8.7 versus 7.0 days for the laparoscopic approach; P = 0.002). Cost-benefit analysis showed an additional cost of euro66 per patient randomly allocated to the laparoscopic group. Quality of life was significantly improved in the laparoscopic group 6 months after surgery, but no difference was found subsequently. The long-term morbidity rate was 11.9 per cent in the open group and 7.5 per cent in the laparoscopic group (P = 0.413). The 5-year survival rate of patients with cancer was 66 and 72 per cent for open and laparoscopic groups respectively (P = 0.321).

CONCLUSION

Laparoscopic left colonic resection resulted in an earlier recovery after surgery. As cost-benefit analysis and long-term follow-up showed similar results, the laparoscopic approach should be preferred to open surgery.

[Laparoscopic-assisted versus open surgery for colorectal cancer: postoperative morbidity in a single center randomized trial]

AIM

The primary objective of the study was to compare the effect of laparoscopic-assisted (LPS) versus open surgery (LPT) for colorectal cancer on postoperative morbidity. The secondary objectives were to evaluate immune response and intestinal wall oxygen perfusion.

METHODS

A total of 610 patients with colorectal cancer were randomly assigned to receive colon resection by either LPS (n=306) or LPT (n=304). Four surgical staff members not involved in the study recorded postoperative complications up to 30 days after the operation. Immune response was evaluated by measuring lymphocytic proliferation after challenge with Candida albicans and phytohemoagglutinin before, at 3 and 15 days after the operation. Intestinal wall oxygen perfusion was continuously monitored using a probe.

RESULTS

The conversion rate was 4.6% in the LPS group. Morbidity was 18.6% in the LPS group and 34.5% in the LPT group (P<0.0005). Infections developed in 9.1% of LPS-treated patients and in 20.2% of LPT-treated patients (P<0.0005). The mean length of stay was 9.7+/-2.6 days in the LPS group and 12.2+/-4.2 days in the LPT group (P<0.0001). In both groups lymphocytic proliferation was low at 3 days postoperative but returned to normal range at 15 days only in the LPS group. Interoperative intestinal oxygen perfusion values were higher in the LPS group.

CONCLUSIONS

Laparoscopic colorectal surgery reduced both postoperative morbidity and length of stay. Lymphocytic proliferation and intestinal wall oxygen perfusion were higher in patients who underwent laparoscopic-assisted surgery.

Glial cell line-derived neurotrophic factor induces histologic and functional protection of rod photoreceptors in the rd/rd mouse

PURPOSE

To evaluate the neuroprotective potential of glial cell line-derived neurotrophic factor (GDNF) in the retinal degeneration (rd/rd) mouse model of human retinitis pigmentosa.

METHODS

Subretinal injections of GDNF were made into rd/rd mice at 13 and 17 days of age and electroretinograms (ERGs) recorded at 22 days. Control mice received saline vehicle injections or underwent no procedure. At 23 days of age, retinas from treated and control mice were fixed and processed for wholemount immunohistochemistry using an anti-rod opsin antibody, and rod numbers were estimated using an unbiased stereological systematic random approach. Subsequent to counting, immunolabeled retinas were re-embedded and sectioned in a transverse plane and the numbers of rods recalculated.

RESULTS

Although ERGs could not be recorded from sham-operation or nonsurgical rd/rd mice at 22 days of age, detectable responses (both a- and b-waves) were observed in 4 of 10 GDNF-treated mice. Stereological assessment of immunolabeled rods at 23 days showed that control rd/rd retinas contained 41,880+/-3,890 (mean +/- SEM; n = 6), phosphate-buffered saline (PBS)-injected retinas contained 61,165+/-4,932 (n = 10; P < 0.001 versus control retinas) and GDNF-injected retinas contained 89,232+/-8,033 (n = 10; P < 0.001 versus control retinas, P < 0.002 versus PBS). This increase in rod numbers after GDNF treatment was confirmed by cell counts obtained from frozen sections.

CONCLUSIONS

GDNF exerts both histologic and functional neuroprotective effects on rod photoreceptors in the rd/rd mouse. Thus rescue was demonstrated in an animal model of inherited retinal degeneration in which the gene defect was located within the rods themselves, similar to most forms of human retinitis pigmentosa. GDNF represents a candidate neurotrophic factor for palliating some forms of hereditary human blindness.

Retinitis pigmentosa: rod photoreceptor rescue by a calcium-channel blocker in the rd mouse

Retinitis pigmentosa is an inherited degenerative disease of photoreceptors leading to blindness. A well-characterized model for this disease is provided by the retinal degeneration mouse, in which the gene for the rod cGMP phosphodiesterase is mutated, as in some affected human families. We report that D-cis-diltiazem, a calcium-channel blocker that also acts at light-sensitive cGMP-gated channels, rescued photoreceptors and preserved visual function in the retinal degeneration mouse. The long record of diltiazem prescription in cardiology should facilitate the design of clinical trials for some forms of retinitis pigmentosa.

Cellular retinol-binding protein I is essential for vitamin A homeostasis

The gene encoding cellular retinol (ROL, vitA)-binding protein type I (CRBPI) has been inactivated. Mutant mice fed a vitA-enriched diet are healthy and fertile. They do not present any of the congenital abnormalities related to retinoic acid (RA) deficiency, indicating that CRBPI is not indispensable for RA synthesis. However, CRBPI deficiency results in an approximately 50% reduction of retinyl ester (RE) accumulation in hepatic stellate cells. This reduction is due to a decreased synthesis and a 6-fold faster turnover, which are not related to changes in the levels of RE metabolizing enzymes, but probably reflect an impaired delivery of ROL to lecithin:retinol acyltransferase. CRBPI-null mice fed a vitA-deficient diet for 5 months fully exhaust their RE stores. Thus, CRBPI is indispensable for efficient RE synthesis and storage, and its absence results in a waste of ROL that is asymptomatic in vitA-sufficient animals, but leads to a severe syndrome of vitA deficiency in animals fed a vitA-deficient diet.

Differential distribution of dystrophins in rat retina

PURPOSE

Duchenne muscular dystrophy is frequently associated with a reduced amplitude of b-wave under scotopic conditions in the electroretinogram. This suggests that the dystrophin gene-encoded proteins play a role in retinal neurotransmission. The abnormal neurotransmission has been attributed to altered expressions of C-terminal products of the dystrophin gene in the outer plexiform layer, where photoreceptor cells form synapses with secondary neurons. The present study was undertaken to determine the cellular distribution of each member of the dystrophin superfamily in rat retina.

METHODS

Examined in the study were the developmental pattern of dystrophins in rat retinae that exhibit inherited progressive photoreceptor degeneration; dystrophins messengers expression in the outer and the inner retina of normal rats, prepared by mechanical fractionation through the outer plexiform layer; and immunolocalization of dystrophin proteins and utrophin in normal and degenerated adult rat retinae, with several antibodies prepared against specific regions of the dystrophin superfamily.

RESULTS

The results showed that Dp260 is exclusively localized in photoreceptor cells; Dp140 seems to be present in perivascular astrocytes; the exon 78 spliced isoform of Dp71 and the unspliced form are located in Müller glial cells and in perivascular astrocytes, respectively. Müller glial cells also contain utrophin.

CONCLUSIONS

Although the role of these membrane cytoskeletal proteins remains to be elucidated in retina, the results support the hypothesis that b-wave reduction may be caused by molecular anomalies of C-terminal products of the dystrophin gene expressed in both neuron and glial cells.

Benefit of against-the-rule astigmatism to uncorrected near acuity

PURPOSE

To determine whether with-the-rule (WTR) or against-the-rule (ATR) astigmatism gives a better visual outcome after cataract and intraocular lens (IOL) implantation surgery by comparing the uncorrected distance and near visual acuities in eyes with low, simple, myopic residual astigmatism.

SETTING

S. Geraldo Eye Hospital, Federal University of Minas Gerais, Belo Horizonte, Brazil.

METHODS

Two groups of 10 eyes each, one with WTR and the other with ATR simple, myopic astigmatism, were studied after uneventful cataract and IOL implantation surgery. All patients had an uncorrected distance visual acuity of 20/40 or better. The negative cylinder ranged from 1.00 to 1.50 diopters (D). The uncorrected distance and near visual acuities of the two groups were compared.

RESULTS

There was no statistically significant between-group difference in uncorrected distance visual acuity. However, for uncorrected near, the difference between groups was highly statistically significant (P < .001). Patients with ATR astigmatism had much better uncorrected near acuity than those with WTR astigmatism.

CONCLUSION

In pseudophakia, low, simple, ATR myopic astigmatism is better than WTR astigmatism because it provides superior uncorrected near visual acuity.

Osteoid osteoma of the vertebral body. A case report

The authors describe a case of osteoid osteoma localised in the body of a lumbar vertebra. This rare localisation--the tenth case described in the literature--and its associated drug-dependency and serum positivity for HTL3 justify its addition to the literature. In addition to an accurate history, the diagnosis requires scintigraphy with Tc 99 and CT scan. The latter is needed so that a correct surgical approach may be planned.