Doppler-guided hemorrhoidal dearterialization with laser (HeLP): indications and clinical outcome in the long-term. Results of a multicenter trial.

BACKGROUND: Doppler-guided hemorrhoidal laser procedure consists of sutureless closure of terminal branches of the superior hemorrhoidal artery by laser energy. Clinical results of patients treated with this procedure were analyzed at the completion of 2-year follow-up. Primary endpoint was resolution of symptoms and secondary endpoints were recurrence rate, type of recurrences, re-operation rate, and potential predictive factors for failure. METHODS: Bleeding was assessed on a score from 0 to 4 (none = 0; < 1/month = 1; 1/week = 2; > 1/week = 3; 3-4/week = 4), frequency of hemorrhoid-related symptoms with a score of 0-3 (2/year = 1; 3-5/year = 2; < 5/year = 3). Constipation and fecal incontinence were assessed by means of validated scores. Quality of life and pain at defecation were assessed using a visual analog scale of 0-10 (0 = worst possible-10 = best possible quality of life and 0 = no pain-10 = worst pain imaginable, respectively). Recurrence rate and need for re-operation were reported. Potential predictive factors of failure were analyzed by means of univariate analysis. RESULTS: Two-hundred-eighty-four patients (183 males, 101 females; mean age: 47.5 years) were included in the trial; 8 patients were lost at follow-up. Analysis of 276 patients who completed the 2-year follow-up showed an overall resolution of symptoms in 89.9% (248/276) of patients. Statistically significant improvement of quality of life, pain reduction, bleeding and frequency of acute symptoms were reported. Of 28 patients with persistent or recurrent symptoms, 12 had pain (4.35%), 10 had bleeding (3.6%) and 6 had increasing prolapse at defecation (2.2%). Eleven out of twenty-eight patients required additional surgery. Constipation and III-IV grade hemorrhoids were associated with statistically significant higher failure rates (p = 0.046 and 0.012, respectively). Better results were reported in patients reporting preoperative high-grade pain at evacuation. CONCLUSIONS: The Doppler-guided hemorrhoidal laser procedure showed efficacy at long-term follow-up. It can be considered as 'first-line' treatment in patients with low-grade hemorrhoids suffering from bleeding, pain and recurrent acute symptoms in whom conservative treatment failed.

Intraoperative angiography with indocyanine green to assess anastomosis perfusion in patients undergoing laparoscopic colorectal resection: results of a multicenter randomized controlled trial.

BACKGROUND: Insufficient vascular supply is one of the main causes of anastomotic leak in colorectal surgery. Intraoperative indocyanine-green (ICG) angiography has been shown to provide information on tissue perfusion, identifying a well-perfused location for colonic and rectal transections, and thus possibly reducing the leak rate. Aim of this study was to evaluate the usefulness of intraoperative assessment of anastomotic perfusion using ICG angiography in patients undergoing left-sided colon or rectal resection with colorectal anastomosis. METHODS: This randomized trial involved 252 patients undergoing laparoscopic left-sided colon and rectal resection randomized 1:1 to intraoperative ICG or to subjective visual evaluation of the bowel perfusion without ICG. The primary aim was to assess whether ICG angiography could lead to a reduction in anastomotic leak rate. Secondary outcomes were possible changes in the surgical strategy and postoperative morbidity. RESULTS: After randomization, 12 patients were excluded. Accordingly, 240 patients were included in the analysis; 118 were in the study group, and 122 in the control group. ICG angiography showed insufficient perfusion of the colic stump, which led to extended bowel resection in 13 cases (11%). An anastomotic leak developed in 11 patients (9%) in the control group and in 6 patients (5%) in the study group (p = n.s.). CONCLUSIONS: Intraoperative ICG fluorescent angiography can effectively assess vascularization of the colic stump and anastomosis in patients undergoing colorectal resection. This method led to further proximal bowel resection in 13 cases, however, there was no statistically significant reduction of anastomotic leak rate in the ICG arm. CLINICAL TRIAL: ClinicalTrials.gov NCT02662946.

A prospective, randomized trial comparing the short- and long-term results of doppler-guided transanal hemorrhoid dearterialization with mucopexy versus excision hemorrhoidectomy for grade III hemorrhoids.

BACKGROUND: Few randomized trials have compared the results of Doppler-guided transanal hemorrhoid dearterialization with mucopexy and excisional open hemorrhoidectomy. Few studies have reported long-term results. OBJECTIVE: The aim of this study is to evaluate the results of Doppler-guided transanal hemorrhoid dearterialization with mucopexy compared with excisional open hemorrhoidectomy in patients with grade III hemorrhoids. DESIGN: This is a prospective randomized study registered at clinicaltrials.gov (NCT01263431). A power analysis assessed the study's sample size. Patients were randomly assigned to undergo either hemorrhoidectomy or Doppler-guided hemorrhoid dearterialization plus mucopexy. The χ test, Mann-Whitney U test, Student t test, and a regression model were used, as appropriate. SETTINGS: This study was conducted at the Department of Surgery, San Raffaele Scientific Institute, Milan, Italy. PATIENTS: Fifty consecutive patients were treated for grade III hemorrhoids from July to November 2010. MAIN OUTCOME MEASURES: The primary outcome was postoperative pain. The secondary outcomes included postoperative morbidity, the resumption of social and/or working activity, patient satisfaction, and the relapse of symptoms at 1 and 24 months. RESULTS: No major complications occurred in either group. The median visual analog scale scores for pain in the hemorrhoidectomy and Doppler-guided dearterialization plus mucopexy groups on days 1, 7, 14, and 30 were 7 vs 5.5, 3 vs 2.5, 1 vs 0, and 0 vs 0 (p> 0.05). The median work resumption day was the 22nd in the hemorrhoidectomy group and the 10th in the Doppler-guided dearterialization plus mucopexy group (p = 0.09). Patient satisfaction at 1 and 24 postoperative months, with the use of a 4-point scale, was 3 vs 4 and 4 vs 4 (p > 0.05). During the follow-up, 2 patients in the dearterialization group required ambulatory treatment, and 1 patient in each group required further surgery for symptom relapse. LIMITATIONS: Nonvalidated questionnaires were used in the follow-up. Cost analysis was not performed. CONCLUSION: Compared with hemorrhoidectomy, dearterialization with mucopexy resulted in similar postoperative pain and morbidity, and a similar long-term cure rate.

Laparoscopic TME with APPEAR (Anterior and Perineal PlanE for ultra-low Anterior Resection of the Rectum) technique for distal rectal cancer.

BACKGROUND: Laparoscopic sphincter saving rectal resection for low rectal cancer is hampered by narrow pelvis and limitations of current stapling devices. The APPEAR (Anterior Perineal PlanE for Ultra-low Anterior Resection of the Rectum) was proposed by Williams et al. as an alternative to the abdominal-perineal resection to perform very low rectal resection and anastomosis through a perineal wound. We adapted the original technique to the laparoscopic approach, avoiding any other abdominal incision. METHODS: Between December 2011 and April 2012, five patients (2 females; median age 72 years (range 60-78)) with rectal cancer not involving the sphincters underwent laparoscopic total mesorectal excision (TME) with APPEAR. Mean distance of the tumor from anal verge was 3.2 ± 1.1 cm (range 2-5). RESULTS: All of the procedures were completed laparoscopically. All of the anastomoses were stapled, and a protective stoma was always constructed. The surgical specimens were retrieved from the perineal wound, and the stoma performed through one of the port sites, without any further abdominal incision. Mean operative time was 333 ± 47 min (range 295-405), postoperative stay 12 ± 5 days (range 6-17). Perineal wound infection was observed in three patients, two of whom also had anastomotic fistula, and was treated conservatively with prolonged suction drainage. Histological examination showed three pT3N+, one T2N0, and one complete response after neoadjuvant radiochemotherapy, with a mean distal clear margin of 1.27 ± 0.5 cm (range 0.5-1.7). After a median follow-up of 9 months (range 8-12), one stoma reversal has been performed and the patient is fully continent. CONCLUSIONS: Our experience shows the feasibility of the APPEAR technique with laparoscopic TME, without any other abdominal incision. This technique offers advantage over the limitations of current laparoscopic stapling devices and their scanty maneuverability in the pelvis, allowing resection and anastomosis under direct vision, with adequate distal clearance, while sparing the anal sphincters.

Surgeons' practice and preferences for the anal fissure treatment: results from an international survey.

The best nonoperative or operative anal fissure (AF) treatment is not yet established, and several options have been proposed. Aim is to report the surgeons' practice for the AF treatment. Thirty-four multiple-choice questions were developed. Seven questions were about to participants' demographics and, 27 questions about their clinical practice. Based on the specialty (general surgeon and colorectal surgeon), obtained data were divided and compared between two groups. Five-hundred surgeons were included (321 general and 179 colorectal surgeons). For both groups, duration of symptoms for at least 6 weeks is the most important factor for AF diagnosis (30.6%). Type of AF (acute vs chronic) is the most important factor which guide the therapeutic plan (44.4%). The first treatment of choice for acute AF is ointment application for both groups (59.6%). For the treatment of chronic AF, this data is confirmed by colorectal surgeons (57%), but not by the general surgeons who prefer the lateral internal sphincterotomy (LIS) (31.8%) (p = 0.0001). Botulin toxin injection is most performed by colorectal surgeons (58.7%) in comparison to general surgeons (20.9%) (p = 0.0001). Anal flap is mostly performed by colorectal surgeons (37.4%) in comparison to general surgeons (28.3%) (p = 0.0001). Fissurectomy alone is statistically significantly most performed by general surgeons in comparison to colorectal surgeons (57.9% and 43.6%, respectively) (p = 0.0020). This analysis provides useful information about the clinical practice for the management of a debated topic such as AF treatment. Shared guidelines and consensus especially focused on operative management are required to standardize the treatment and to improve postoperative results.

Italian multi-society modified Delphi consensus on the definition and management of anastomotic leakage in colorectal surgery.

INTRODUCTION: The incidence of anastomotic leak (AL) has not decreased over the past decades and some important grey areas remain in its definition, prevention, and management. The aim of this study was to reach a national consensus on the definition of AL and to identify key points to be applied in clinical practice. METHODS: A 3-step modified Delphi method was used to establish consensus. Ten representative members of the major Italian surgical scientific societies with proven colorectal expertise were selected after a call to action. After a comprehensive literature search, each expert drew a list of evidence-based statements which were voted in round one by the scientific board. Panel members were asked to mark "totally disagree", "partially agree" or "totally agree" for each statement and provide comments. The same voting method was used for round 2. Round 3 consisted of a final face-to-face meeting. RESULTS: Thirty-three statements (clustered into 14 topics) were included in round 1. Following the third voting round, a final list of 16 items was formulated, which encompass the following 9 topics: AL definition, patient- and operative-related risk factors, prevention measures, bowel preparation, surgical technique, intraoperative assessment, early diagnosis, radiological diagnosis and management of specific patterns of AL. The overall response rate was 100% for all items in all the three rounds. CONCLUSIONS: This Delphi survey identified items that expert colorectal surgeons agreed were important to be applied in the prevention, diagnosis, and management of AL. This represents the first consensus involving all relevant national scientific societies, defining important and shared concepts in the diagnosis and management of AL.

Laparoscopic treatment of deep pelvic endometriosis with rectal involvement.

PURPOSE: Our study aimed to evaluate the feasibility and outcome of laparoscopic excision of deep pelvic endometriosis with extensive rectal involvement causing severe symptoms. METHODS: Ten patients, mean age 32 years (range, 27-43), with deep pelvic endometriosis and rectal wall involvement, requiring surgical resection, were studied since January 2004. Prior to surgery and 6 months postsurgery, patients completed a 100-point rank questionnaire on intensity of intestinal and extraintestinal symptoms. A laparoscopic approach was performed by a team of a gynecologist and colorectal surgeons. RESULTS: At surgery, complete excision of infiltrating endometriosis was achieved, with 7 low rectal resections, 2 rectosigmoid resections, and 1 proctectomy with coloanal anastomosis. Additional procedures were: ureter resections (n = 2) with one reimplantation in the bladder, left ovariectomies (n = 2), ovarian endometrioma resections (n = 4), and laser ablation of superficial peritoneal lesions (n = 4). In four cases, a laparotomic conversion was needed. Mean follow-up was 27.6 months (range, 18-37). Neither intraoperative nor postoperative serious complications were observed. All the patients experienced significant improvement of intestinal and extraintestinal symptoms. CONCLUSIONS: Laparoscopic resection of deep pelvic endometriosis with rectal involvement can be successful in improving digestive and gynecologic symptoms; however, this approach is challenging with a high rate of laparotomic conversion.