Recurrence Rates and Risk Factors in Altemeier Procedure for Rectal Prolapse: A Multicenter Study.

BACKGROUND: Perineal proctosigmoidectomy (Altemeier) is a surgical procedure that is commonly utilized for the treatment of rectal prolapse. However, there is a diverse range of recurrence rates following the Altemeier procedure repair that have been reported in the literature. OBJECTIVE: We aimed to identify primary and subsequent recurrence rates following perineal proctosigmoidectomy, as well as to define potential risk factors for recurrence. DESIGN: Cohort study. SETTINGS: Conducted at 6 hospitals affiliated with the Cleveland Clinic. PATIENTS: Included patients older than 18 years who were treated with Altemeier procedure for rectal prolapse between 2007 and 2022. MAIN OUTCOME MEASURES: Primary outcomes were rates of primary and subsequent recurrences. Secondary outcomes included potential risk factors for recurrence previously mentioned in the literature. RESULTS: We identified 182 patients, of whom 95.1% were female with a mean age of 79 years (SD 11.4). Overall, 92.1% were elective, and 14.3% had previously undergone prolapse repairs (Delorme, Thiersch, abdominal suture rectopexy, and abdominal mesh rectopexy). At a mean follow-up period of 27.5 months (SD 45.7), 37.9% of patients experienced recurrence, with 16.5% of patients having multiple recurrences. A subsequent Altemeier procedure was performed in 72.5% of instances. Other treatments included Delorme, abdominal suture rectopexy, abdominal mesh rectopexy, or conservative management. This study identified connective tissue disorders and time since surgery as significant risk factors for recurrence. LIMITATIONS: Retrospective design and varying follow-up periods. CONCLUSION: Perineal proctosigmoidectomy is associated with a significant risk of recurrence. The risk of recurrence increased with the presence of a connective tissue disorder and in proportion to the elapsed time since surgery. These discoveries assist healthcare professionals in counseling and managing patients who undergo perineal proctosigmoidectomy for rectal prolapse. See Video Abstract.

Crohn's disease-related versus sporadic colorectal cancer: A stage-matched case-control study based on four decades of experience.

BACKGROUND AND OBJECTIVES: This study compares surgical and oncological outcomes in patients with Crohn's disease (CD)-related colorectal cancer (CRC) to those with sporadic CRC. METHODS: Patients treated between 1983 and 2013 were matched by stage, age, gender, American Society of Anesthesiologists (ASA), cancer site, and adjuvant chemotherapy. RESULTS: For stages I and II, 107 patients were matched (58.9% male, mean age 59 years, 59.8% with ASA score 3). Tumor sites included the right (17.7%), transverse (4.7%), left colon (15.9%), and rectum (61.7%). CD patients exhibited longer operative times, higher pT stages, and 2.60 times the odds of postoperative complications (p = 0.03). Overall and disease-free survival were similar. For stage III, 54 patients were matched (57.4% male, mean age 54 years, 46.3% with ASA score 3). The cancer site distribution was right (29.7%), transverse (3.7%), left colon (18.5%), and rectum (48.1%). CD patients had longer operative times, increased blood loss, more involved lymph nodes, higher pT- and pN-stages. The rates of postoperative complications were not different (p = 0.19). CD-related CRC patients had similar overall (p = 0.06), and local recurrence-free survival (p = 0.07). CONCLUSIONS: Despite facing worse perioperative and pathological characteristics, survival differences in stages I-III CD-related CRC compared with sporadic CRC patients were not significantly different.

Evaluating Complete Response Rates and Predictors in Total Neoadjuvant Therapy for Rectal Cancer.

INTRODUCTION: In the management of locally advanced rectal cancer (LARC), there is a paradigm shift from conventional neoadjuvant treatment to total neoadjuvant therapy (TNT). Despite its growing acceptance, there are limited studies have examined its effects on disease presentation. It is also important to determine the factors that play a role in complete response (CR). Our previous data with 119 patients revealed that the CR rate was 37%, and low rectal tumors and the absence of extramural vascular invasion (EMVI) were predictors of CR. Unfortunately, there continues to be a lack of data, and reliable markers are still needed to consistently identify the best respondents. Therefore, we aimed to determine factors associated with CR. We hypothesized that due to the growing patient population, both predictive factors and CR ratio might evolve over time. METHODS: A retrospective analysis of patients who completed TNT for LARC at our tertiary care center between 2015 and 2022 was performed. Our primary outcome was to determine predictors of CR. As a secondary outcome, we evaluated the 2-year disease-free and overall survival rates. CR consists of patients who sustained clinical CR (cCR) for at least 12 months under WW or had pathological CR (pCR) after surgery. RESULTS: Out of 339 patients with LARC, 208 (61.3%) successfully completed TNT. Among them, 57 (27.4%) patients achieved cCR, and 80% sustained without tumor regrowth after a year. The remaining 151 (72.6%) patients underwent surgery, and 42 had pCR. The final CR rate was 42.3%. The median age of the patients was 56 (49-66), and 63.5% of the participants were male (n=132), while 36.5% were female (n=76). The median tumor size was 4.95cm (3.6-6.43), with most tumors in the low rectum (119, 57.2%). The MRF involvement rate was 25% (n=52), and EMVI was observed in 20.7% of patients (n=43). based on MRI findings. Low rectal tumors, the absence of MRF involvement, and the absence of EMVI were predicted CR. With a median follow-up of 24.7 months, 2-year disease-free survival and overall survival were significantly higher among patients with CR (91.3% vs 71%, p<0.01 and 98.8% vs 90.2% p=0.03, respectively). CONCLUSION: In our updated dataset, we observed an increasing CR rate compared to our previous study. In addition to previously identified predictors, low tumor location and the absence of EMVI, we also found the absence of MRF involvement as a predictor of CR. These findings offer valuable insights for clinical practice, helping clinicians set clear expectations when counseling patients.

Multidisciplinary surgical management of severe posterior compartment endometriosis.

BACKGROUND: Endometriosis is a chronic, inflammatory, and hormone-dependent disease that affects approximately 10% of women in reproductive age. Endometriosis is categorized into different types, as superficial, deep, and ovarian endometriosis. When deep endometriosis occurs, the sigmoid and rectum are often affected (Becker et al. in Hum Reprod Open, 2022, https://doi.org/10.1093/hropen/hoac009 ). In the following article, we aim to demonstrate stepwise surgery for stage IV endometriosis involving the anterior rectosigmoid. METHODS: We present the case of a 26-year-old obese (BMI 35.87) woman with severe posterior pelvic compartment endometriosis, persistent abdominal pain, and constipation. On preoperative MRI of the pelvis, a 13 cm conglomerate incorporating both ovaries (kissing ovaries), uterine serosa, and the anterior rectosigmoid was observed (Fig. 1). Accordingly, interdisciplinary laparoscopic surgery with a gynecologist and colorectal surgeon was planned. RESULTS: The total laparoscopic approach is demonstrated step by step in the video. CONCLUSIONS: Deep endometriosis is a rare condition. When involvement of other organs (e.g., the bowel) is suspected, preoperative endometriosis-specific imaging should be performed for optimal surgical planning. Experienced endometriosis multidisciplinary surgical teams can provide specialized and high-quality care for patients suffering from this debilitating disease (Luna Russo et al. in Minerva Ginecol, 2020, https://doi.org/10.23736/S0026-4784.20.04544-X ).

Ventral mesh rectopexy for recurrent rectal prolapse after Altemeier perineal proctosigmoidectomy: feasibility and outcomes.

PURPOSE: Recurrence of rectal prolapse following the Altemeier procedure is reported with rates up to 40%. The optimal surgical management of recurrences has limited data available. Ventral mesh rectopexy (VMR) is a favored procedure for primary rectal prolapse, but its role in managing recurrences after Altemeier is unclear. VMR for recurrent prolapse involves implanting the mesh on the colon, which has a thinner wall, more active peristalsis, no mesorectum, less peritoneum available for covering the mesh, and potential diverticula. These factors can affect mesh-related complications such as erosion, migration, or infection. This study assessed the feasibility and perioperative outcomes of VMR for recurrent rectal prolapse after the Altemeier procedure. METHODS: We queried our prospectively maintained database between 01/01/2008 and 06/30/2022 for patients who had experienced a recurrence of full-thickness rectal prolapse following Altemeier's perineal proctosigmoidectomy and subsequently underwent ventral mesh rectopexy. RESULTS: Ten women with a median age of 67 years (range 61) and a median BMI of 27.8 kg/m2 (range 9) were included. Five (50%) had only one Altemeier, and five (50%) had multiple rectal prolapse surgeries, including Altemeier before VMR. No mesh-related complications occurred during a 65-month (range 165) median follow-up period. Three patients (30%) experienced minor postoperative complications unrelated to the mesh. Long-term complications were chronic abdominal pain and incisional hernia in one patient, respectively. One out of five (20%) patients with only one previous prolapse repair had a recurrence, while all patients (100%) with multiple prior repairs recurred. CONCLUSION: Mesh implantation on the colon is possible without adverse reactions. However, high recurrence rates in patients with multiple previous surgeries raise doubts about using VMR for secondary or tertiary recurrences.

Epidemiology and age-related trends in surgical outcomes for sigmoid volvulus: a 17-year analysis.

BACKGROUND: Sigmoid volvulus, a gastrointestinal disorder characterized by twisted bowel, often requires medical intervention, either through endoscopic or surgical means, to avoid potentially severe outcomes. This study examined the challenges elderly patients face in undergoing surgical treatment, encompassing both mortality and morbidity. Furthermore, it aimed to determine how medical practices and outcomes have changed over a period of 17 years. METHODS: We utilized data from the National Surgical Quality Improvement Project, which covers the period from 2005 to 2021, to identify patients who underwent left hemicolectomy for colonic volvulus. The patients were categorized into three age groups: < 60 years, 60-75 years, and > 75 years. We performed a meticulous logistic regression analysis, carefully adjusted for risk factors, to compare mortality, morbidity, and types of surgical treatment administered among the different age groups. RESULTS: Our study included 6775 patients. The breakdown of the patient population was as follows: 2067 patients were < 60 years of age, 2239 were between 60 and 75 years of age, and 2469 were > 75 years of age. The elderly cohort, those aged above 75 years, were predominantly male, had lower BMIs, underwent fewer laparoscopic surgeries, required more diverting stomas and end-ostomies, and had longer hospital stays. Notably, the elderly population faced a mortality risk that was 5.67 times (95% CI 3.64, 9.20) greater than that of their youngest counterparts, with this risk increasing by 10% (95% CI 1.06, 1.14) for each additional year of age. Furthermore, the odds of mortality associated with emergency surgery were 1.63 times (95% CI 1.21, 2.22) higher than those associated with elective surgery. The postoperative morbidity odds were also elevated for emergency surgeries, 1.30 times (95% CI 1.08, 1.58) greater than that for elective cases. Over the 17-year period, we observed a decline in mortality rates, an increase in the utilization of laparoscopic procedures, and overall stability of morbidity rates. CONCLUSION: Our findings highlight the increased vulnerability of patients over 75 years of age, who are not only at an elevated risk of mortality compared to their younger counterparts, but also a continuously increasing risk with age. By focusing on elective surgeries for younger patients and minimizing emergency surgeries for the elderly, it may be possible to reduce the mortality risk associated with surgical interventions in this population.

Giant rectal vascular malformation: a rare differential diagnosis in rectal bleeding.

Investigations in a woman with prolonged symptoms of laxative-resistant constipation and recurrent rectal bleeding revealed a giant rectal vascular malformation. Colonoscopy and MRI were performed to rule out malignancy and determine differential diagnoses. Repeated tests were necessary due to inconclusive results. After a definite diagnosis, image-guided, transcutaneously administered sclerotherapy was used. The intervention and postoperative course were uneventful. A minimally invasive procedure relieved symptoms and improved quality of life.

Global Irradiation in Children Treated for Hydrocephalus and Its Change over Time-A Single Institutional Analysis.

Radiation exposure early in life is associated with greater incidences of malignancy. Our goal was to quantify radiation exposure in shunt-treated hydrocephalus patients and study changes in the diagnostic modalities used. A single-center, retrospective analysis was performed, and 41 children treated for hydrocephalus using an adjustable ventriculoperitoneal shunt were identified. Diagnostics associated with hydrocephalus and other comorbidities were analyzed and radiation exposure was calculated. During 330.09 total shunt years, patients were exposed to a mean hydrocephalus-associated radiation dose of 3.93 mSv (range: 0-24.38 mSv), which amounted to a mean rate of 0.49 mSv per shunt year, respectively. Radiation exposure was greatest after shunt insertion in the first year of life. A continuous change from CT scans to MRIs could be seen over the study period, such that patients who underwent shunt insertion after 2017 were not exposed to additional hydrocephalus-associated radiation during their first year of life. Nevertheless, our patients, and a few individuals especially, seemed to be at higher risk for radiation sequelae. Our results suggest that CT scans should be substituted with MRIs, which decrease overall radiation exposure and can lead to zero additional radiation exposure during the first year of life after shunt insertion.

Volatile Organic Compounds, Bacterial Airway Microbiome, Spirometry and Exercise Performance of Patients after Surgical Repair of Congenital Diaphragmatic Hernia.

The aim of this study was to analyze the exhaled volatile organic compounds (VOCs) profile, airway microbiome, lung function and exercise performance in congenital diaphragmatic hernia (CDH) patients compared to healthy age and sex-matched controls. A total of nine patients (median age 9 years, range 6-13 years) treated for CDH were included. Exhaled VOCs were measured by GC-MS. Airway microbiome was determined from deep induced sputum by 16S rRNA gene sequencing. Patients underwent conventional spirometry and exhausting bicycle spiroergometry. The exhaled VOC profile showed significantly higher levels of cyclohexane and significantly lower levels of acetone and 2-methylbutane in CDH patients. Microbiome analysis revealed no significant differences for alpha-diversity, beta-diversity and LefSe analysis. CDH patients had significantly lower relative abundances of Pasteurellales and Pasteurellaceae. CDH patients exhibited a significantly reduced Tiffeneau Index. Spiroergometry showed no significant differences. This is the first study to report the VOCs profile and airway microbiome in patients with CDH. Elevations of cyclohexane observed in the CDH group have also been reported in cases of lung cancer and pneumonia. CDH patients had no signs of impaired physical performance capacity, fueling controversial reports in the literature.