Retrospective study of the functional and oncological outcomes of conformal sphincter preservation operation in the treatment of very low rectal cancer

BACKGROUND

Conformal sphincter preservation operation (CSPO) is a new surgical procedure for very low rectal cancers (within 4-5 cm from the anal verge). CSPO preserves more of the dentate line and distal rectal wall and also avoids injuring nerves in the intersphincteric space, resulting in satisfactory anal function after resection. The aim of this study was to analyze the short-term surgical results and long-term oncological and functional outcomes of CSPO.

METHODS

Consecutive patients with very low rectal cancer, who had CSPO between January 2011 and October 2018 at Changhai Hospital, Shanghai were included. Patient demographics, clinicopathological features, oncological outcomes and anal function were analyzed.

RESULTS

A total of 102 patients (67 men) with a mean age of 56.9 ± 10.8 years were included. The median distance of the tumor from the anal verge was 3 (IQR, 3-4) cm. Thirty-five patients received neoadjuvant chemoradiation (nCRT). The median distal resection margin (DRM) was 0.5 (IQR, 0.3-0.8) cm. One patient had a positive DRM. All circumferential margins were negative. There was no perioperative mortality. The postoperative complication rate was 19.6%. The median duration of follow-up was 28 (IQR, 12-45.5) months. The local recurrence rate was 2% and distant metastasis rate was 10.8%. The 3-year overall survival and disease-free survival rates were 100% and 83.9%, respectively. The mean Wexner incontinence and low anterior resection syndrome scores 12 months after ileostomy reversal were 5.9 ± 4.3, and 29.2 ± 6.9, respectively.

CONCLUSIONS

For patients with very low rectal cancers, fecal continence can be preserved with CSPO without compromising oncological results.

Risk factors for non-closure of an intended temporary defunctioning stoma after emergency resection of left-sided obstructive colon cancer

PURPOSE

A substantial part (21-35%) of defunctioning stomas created during resection for colorectal cancer will never be reversed. Known risk factors for non-closure are age, peri- or postoperative complications, comorbidity, and tumor stage. However, studies performed to identify these risk factors mostly focus on rectal cancer and include both preoperative and postoperative factors. This study aims to identify preoperative risk factors for non-reversal of intended temporary stomas created during acute resection of left-sided obstructive colon cancer (LSOCC) with primary anastomosis.

METHODS

All patients who underwent emergency resection for LSOCC with primary anastomosis and a defunctioning stoma between 2009 and 2016 were selected from the Dutch ColoRectal Audit, and additional data were collected in the local centers. Multivariable analysis was performed to identify independent preoperative factors for non-closure of the stoma.

RESULTS

A total of 155 patients underwent acute resection for LSOCC with primary anastomosis and a defunctioning stoma. Of these, 51 patients (32.9%) did not have their stoma reversed after a median of 53 (range 7-104) months of follow-up. In multivariable analysis, hemoglobin < 7.5 mmol/L (odds ratio (OR) 4.79, 95% confidence interval (95% CI) 1.60-14.38, p = 0.005), estimated glomerular filtration rate (eGFR) ≤ 45 mL/min/1.73 m² (OR 4.64, 95% CI 1.41-15.10, p = 0.011), and metastatic disease (OR 6.12, 95% CI 2.35-15.94, p < 0.001) revealed to be independent predictors of non-closure.

CONCLUSIONS

Anemia, impaired renal function, and metastatic disease at presentation were found to be independent predictors for non-reversal of intended temporary stomas in patients who underwent acute resection for LSOCC. In patients who have an increased risk of non-reversal, the surgeon should consider a Hartmann's procedure.

[Late recognition of intestinal malrotation]

BACKGROUND

Intestinal malrotation is a congenital intestinal abnormality caused by abnormal intestinal rotation during foetal development.

CASE DESCRIPTION

We describe a 20-year-old woman with many years' history of abdominal symptoms and eating disorders that were labelled as psychosomatic following repeated and extensive investigations. The diagnosis of malrotation was only made after an emergency laparotomy, with right hemicolectomy for intestinal necrosis.

CONCLUSION

The reason that diagnosis was missed in this patient was probably not only because malrotation is accompanied by non-specific symptoms. The cognitive strategies used by doctors to make a diagnosis on the basis of symptoms may also have led to ignoring details that did not fit, and to clinging to earlier diagnoses. Furthermore, eating disorders and gastrointestinal disorders are sometimes difficult to distinguish and are often linked. Even with extra vigilance a misdiagnosis cannot always be avoided.

Local administration of gentamicin collagen sponge in surgical excision of sacrococcygeal pilonidal sinus disease: a systematic review and meta-analysis of the literature

Surgical site infections occur in up to 24 % of patients after surgical excision of sacrococcygeal pilonidal sinus disease with primary wound closure. Local administration of antibiotics by a gentamicin collagen sponge could reduce this infection rate. The objective of this systematic review and meta-analysis was to evaluate the effect of a gentamicin collagen sponge on outcome after surgical excision in patients with sacrococcygeal pilonidal sinus disease. A structured literature search was performed in the PubMed, Embase, The Cochrane Library, and Scopus databases. Studies comparing surgical excision of sacrococcygeal pilonidal sinus disease with versus without a gentamicin collagen sponge were included. Outcome measures were surgical site infection, wound healing, and recurrence. The search strategy yielded six studies with a total of 669 patients. Three randomized controlled trials, comparing excision of pilonidal sinus disease and primary wound closure with versus without gentamicin collagen sponge, were eligible for inclusion in the meta-analysis (319 patients), demonstrating a trend towards reduced surgical site infections after administration of gentamicin collagen sponge [absolute risk reduction 20 %, 95 %-confidence interval (CI) 1-41 %, p = 0.06]. The wound healing (absolute risk reduction 22 %, 95 % CI 32-77 %, p = 0.42) and recurrence rate (absolute risk reduction 8 %, 95 % CI 7-22 %, p = 0.30) were not significantly different between both groups. Administration of a gentamicin collagen sponge after surgical excision of sacrococcygeal pilonidal sinus disease showed no significant influence on wound healing and recurrence rate, but a trend towards a reduced incidence of surgical site infections. Therefore, additional larger well-designed randomized controlled trials are required.

Laparoscopic Nissen fundoplication after failed EsophyX fundoplication

BACKGROUND

Reflux control may be ineffective in a substantial number of patients after endoluminal EsophyX fundoplication for gastro-oesophageal reflux disease. Subsequent laparoscopic Nissen fundoplication (LNF) might be required to relieve symptoms. The aim of this study was to evaluate the outcome of LNF after previous EsophyX fundoplication.

METHODS

EsophyX failure was defined as recurrence or persistence of typical symptoms, with or without anatomical failure of the wrap or persisting pathological oesophageal acid exposure. Consecutive patients who underwent LNF after failed EsophyX fundoplication were identified. Symptomatic outcome was obtained by standardized questionnaire, and objective outcome by endoscopy, oesophageal manometry and pH monitoring.

RESULTS

Eleven patients were included. During LNF, intraoperative gastric perforation occurred in two patients and one developed a subphrenic abscess after operation. Daily heartburn was present in one patient after LNF and three had troublesome daily dysphagia. General quality of life after LNF was not significantly better than that before EsophyX fundoplication. Oesophageal acid exposure was normalized in all patients after surgery. Oesophagitis was absent after LNF in all except one patient who had persisting grade A oesophagitis.

CONCLUSION

Symptomatic and objective reflux control are satisfactory after LNF for a failed EsophyX procedure. Previous EsophyX fundoplication, however, is associated with a risk of gastric injury during LNF and a relatively high rate of postfundoplication dysphagia.

Predictors of symptomatic and objective outcomes after surgical reintervention for failed antireflux surgery

BACKGROUND

Recurrent gastro-oesophageal reflux disease (GORD) and troublesome dysphagia after primary antireflux surgery are treated successfully by reoperation in 70 per cent of patients. Identifying predictors of outcome could allow selection of patients likely to benefit from further surgery. The aim was to identify such predictors in patients reoperated on for recurrent GORD or troublesome dysphagia.

METHODS

Between 1994 and 2005, 83 patients (mean(s.d.) age 47.2(14.4) years; 47 men) with recurrent GORD and 47 (aged 50.7(13.4) years; 18 men) with troublesome dysphagia had further surgery. The predictive values of demographic, anatomical and manometric variables, and 24-h pH monitoring were analysed with respect to symptomatic and objective outcomes in each group.

RESULTS

None of the factors included in a multivariable analysis predicted outcome after surgery for recurrent GORD. Independent predictors of symptomatic outcome after reoperation for dysphagia were amplitude of distal oesophageal contractions (odds ratio (OR) 1.613 (95 per cent confidence interval (c.i.) 1.087 to 2.393); P = 0.017), intrathoracic wrap migration (OR 0.077 (0.003 to 1.755); P = 0.108) and an abdominal approach (OR 0.012 (0.001 to 0.337); P = 0.009).

CONCLUSION

Low-amplitude distal oesophageal contractions, intrathoracic wrap migration and an abdominal approach were significant predictors of an unsuccessful symptomatic outcome after reoperation for troublesome dysphagia.